HomeMy WebLinkAboutHILLSIDE PARK PUD LT 6Hillside Park
Lot 6
#015-122-45
Municipality of Anchorage
On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211060 PID Number: 015-122-45
Dwelling: RE Single Family (SF) R with ADU R Duplex (D) R Two Single Family Project: ❑ New RE Upgrade
Name
JAMIHANSEN
ABSORPTION FIELD
R Deep Trench R Wide Trench El 133edound
Z
Site Address
7241 TREE TOP CIRCLE -ANCHORAGE, AK 99507
El Other
Phone
Number of Bedrooms
Soil Rating
Total depth original grade
907-229-3614
4
GPD/SF
Ft.
LEGAL DESCRIPTION
original grad
Depth to pipe invert from ;P
Ft.
:;1
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
HILLSIDE PARK PUD; LOT 6
Fill added above original
Ft.
Gravel length
R.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total rption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft2
Ft.
Well
N/A
TANK 9 Septic [I S.T.E.P. El Holding Ej Other
Manufacturer
GREER TANK
Capacity
1250 Gal.
Surface Water
100'+
Material
Number of compartments
Lot Line
51+
NA
HDPE
2
Foundation
10'+
LIFT STATION
Manufacturer
Capacity
Remarks OLD TANK DECOMMISSIONED PER UPC
Gal.
Electrical installed by
PER CONTRACTOR
Alarm location
Installer
PIPE MATERIAL House to tank EXISTIhdrainfield Tankto D3034
A+ HOME SERVICES
Drainfield EXISTING CO/MTD3034
Inspector TIM ECKLUND AND GEG
BENCH MARK (Assumed elevation) 97.98 ft
Inspdates: ection 1s' 7/26/21
Location and description
nd
2
TOP OF MH
3rd 4"'
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineers Stamp
Conditional Approval: Date
IN
Septic System
Approved Date
J fr y Garn ss.-
-79
CE
O
Note: this approval does not include well permit requirements.
#AECC88of e s s"01"\ 'i�
4 N�' z>Z1
k &VU-J1Vf11Q)
PERMIT NUMBER:
0SP211060 RECORD DRAWING
l0l
MH 23.8 19.9
ST1
28.2
23.7
DBL3
29.9
24.2
DBL4
30.5
24.1
C01
41.5
27.0
MTI
42.7
, 27.9
EXISTING OF
INSTALLED AT
IGOLDEN HILLS; BLOCK 1, LOT 4 1
NEW 1250 GALLON HDPE GREER T
NEW C/O AND MT
3T END OF TRENC
I PUBLIC WATER
HILLSIDE PARK; PUD LOT 5
IGOLDEN HILLS; BLOCK 1, LOT 3 1
EXISTING 4
4-14 A
kff ARNESS EN(N-11NEERINIG1
(3ROYTp w
%j 9 Ltd
ENGINEERING ;° SALES- CONSULTING
3701 E. TUDOR ROAD, SUITE 101 -ANCHORAGE,AK99507* PHONE (907)337,6179- FAX (907)338-3246*WEBSITE: v ,gamessengmeemg,c,,,
PREPARED FOR:
PHONE NUMBER:
PAGE NUMBER:
JAMIE HANSEN
907-229-3614
2 OF 3
LEGAL DESCRIPTION:
DRAWN BY:
HILLSIDE PARK PUD; LOT 6
D.J.G.
TYPE OF WORK:
DATE:
II, -SEPTIC TANK RECORD DRAWINGS
8/10/2021
64
PARCEL ID NUMBER:
015-122-45
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SCALE:
1"=40'
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40
Ar
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IT
POSP211060 RECORD DRAWING PARCEL 015-1 2 NUMBER:
22-45
TOP OF MANHOLE = 97.98
FINAL GRADE = 97.4-97.6
MH1 ST1
2" INSULATION PER CONTRACTOR
TOP OF TANK AT INTLET = 93.98 TOP OF TANK AT OUTLET = 93.97
INVERT OF BUNG AT INLET = 93.31 INVERT OF BUNG AT OUTLET = 93.19
NEW 1250 GALLON
H.D.P.E. SEPTIC TANK
.���►��� t,,
OF
#i
ENGINEERING ?, SALES CONSULTING _ ..5 _�..
3707 E. TUDOR ROAD, SUITE 707 'ANCHORAGE, AK 98507' PHONE (907) 337-6779FAX (907) 33&3246' WEBSITE: —gam—ng.eenng-m
....1. .......:....
PREPARED FOR:♦ PHONE NUMBER: PAGE NUMBER.
-
♦ � e rey A. Gamess
JAMI HANSEN 907-229-3614 3 OF 3 �j� CE -7973 �^�'�
•��•• l 'ter
LEGAL DESCRIPTION: DRAWN BY: �♦ l Z / �.���
HILLSIDE PARK PUD; LOT 6 D.J.G.
U
OF WORK: DATE: ♦�•••••,,•''•EPTIC TANK PROFILE 8/9/2021 #AECC884,,�� LIL
N 89 59'00" W 196.22
NOTE :
THE EAST 10 FEET IS AFFECTED BY AN EASEMENT
IN FAVOR OF GC/ CORP. AS RECORDED AT BOOK 2162, PAGE 646.
000OO�DO
OF
49 TH
o� �a
�Oa�r SHANE A. HOLT O
A
�n LS -6914 ci��0
�1 rofessiona\ foo
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINE5.
EASEMENTS OF RECORD, OTHER THAN TH05E APPEARING ON THE RECORD PLAT, ARE NOT SHOWN
HEREON ( UNLE55 INDICATED)
NOTE: FENCELINE5 THAT MAY APPEAR ON THI5 DRAWING ARE NOT TO BE USED TO DETERMNE
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCE55IVE SNOW AND/OR ICE.
fol x fol
C.E.A. EASEMENT
AS -BUILT SURVEY 1" =20'
NO CORNERS SET THIS DATE
ASPHALT
Lo
9
I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
LOT 6, HILLSIDE PARK P.U.D. SUB.
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EXIST OTHER THAN NOTED.
DATED AT ANCHORAGE,ALASKA THIS _29 TH DAY OF
NOVEMBER . 2021.
12276, 159-43, SCAN,219-50
HOLT LAND SURVEYING
93og GROVER DRIVE
ANCHORAGE,AK 99507
907.223.8615
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
POBox 19GasO ^7ooElmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
On -Site WastewaterD~sposal SystemPermit
Permit Number: OSP211060
Work Type: SapUnTankUpgnode
Tax Code Number: 01512245000
Site Legal Address: HILLSIDE PARK PUD LT 6 G:2539
Site Mailing Address: 7241TREE TOP C|F(Anchorage
Design Engineer: GARNESS ENGINEERING GROUP LTD
This permit is for the construction of:
Effective Date:
Expiration Date
Lot Size in Sq Ft:
Total Bedrooms:
3/16/2021
3/16/2022
[] Disposal Field 21 Septic Tank EIHolding Tank 171 Privy [] Private Well [lWater Storage
All construction shall beinaccordance with:
1. The attached approved design.
2, All requirements specified inAnchorage Municipal code Chapters 1555 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (I 8AAC72) and Drinking Water Regulations (1 8AAC80)
-. The wastewater code requires "inspections during uthe installation. ///e engineer shall notify the Development
Services Department per AMC 15.O5.Provide notification bycalling (QO7)343-7QU4(24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall baeither:
a. Opened and Closed onthe same day, or
b. Covered, sealed, and heated to prevent freezing
Received
Issued By
Date:
� Date:
^^
/
ILI
Community Development Department Phone: 907-343-7904
Development Services Fax: 907- 343-7997
On -Site Water & Wastewater Program
Mayor Dan Sullivan
On -Site Sewer/Well Permit Application
For A Single Family Dwelling
Parcel I.D. 015-122-45
Property owner(s) JAMIE HANSEN
Mailing address 7241 TREE TOP CIRCLE *ANCHORAGE, AK 99507
Site address 7241 TREE TOP CIRCLE *ANCHORAGE, AK 99507
Legal description (Sub'd, Block & Lot) HILLSIDE PARK PUD; LOT 6
Legal description (Township, Section & Range)
Day phone
Lot Size
Sq.Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DEWELLING:
(® all that apply)
Absorption Field ❑
Initial ❑
Single Family (SF)
Septic Tank ®
Upgrade
(w/wo ADU)
Renewal ❑
Duplex (D)
❑
Holding Tank ❑
Multiple Dwellings
❑
Privy ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR:
NIA
Distance: -
I certify that the above information is correct. I further certify that this
is in accordance with
applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd.
(Signature of property owner or authorized agent)
Permit/Rush Fees: $225 Waiver Fees:
Date of Payment:'', Date of Payment:
Receipt Number: 42 .22_7 7_(�Z Receipt Number:
Permit No. OSP211060 Waiver No.
(Rev. 01111)
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211060, Deb Wockenfuss, 03/16/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211060, Deb Wockenfuss, 03/16/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211060, Deb Wockenfuss, 03/16/21
MUNICIPALITY OF ANCHORAGE
O DEPARTMENT OF HEALTH & ENVIRONMENTAL_ PROTECTION
ENVIRONMENTAL_ ENGINEERING DIVISION
82.5 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL_ SYSTEM AND/OR WELL INSPECTION REPORT
- -j—�
NAME
j_J }{-- I' ��iv�
PHONE -7
� 3 _Jj -�/y
NEW
❑UPGRADE
MAILING ADDRE6SS•^^��l/N✓ ,/
LEGAL DESCRIPTION /J� n /J
LOCATION
NO. q.F BEDV300MS
- Adv. .y.`C`
U
DISTANCE TO:
W II
� " /IA_-.
Absorption arga r
(�
Dwelling /
` 6 RC1._
PERMIT rR
arC 48 7
y
F- Z
w
Manufacturer
Mate ial �J' f
No. of comp orients
V)
Liq. capacity in gams
IF HOMEMADE:
Inside length _
Width_
Liquid depth
O Y
J U`Z
DISTANCE TO•
Well
Dwelling
PERMIT NO.
_ = <
Manufactur
M
capaci in ns
O
J =
DISTANCE TO:
Well
-yy,,U�vZ/
Fou ndat n
Nearest tline
o ID
PERMIT NO. y
U � oo) 7
LU E U
J W
P:Z
No. c¢}� lirL2s
Len th of each,{ne
g G>L
Total len th of lines
9 ,.'
Trench wid+r-h7
L") inches
Distance betwe g li es
1 Vii_
F
O
Top of tile to finish grade r'".�/
(
Material beneath the `t-
+riches
Total effective absorption area
LU
Length
Width
Depth
PERMIT NO.
0
a 1-
wa
Type of crib
rib dia ete�
Cri epth
effect' rption are
w
`n
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
W
3:
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING ,y.
Cn
INSTALL
6
REMARKS �
APPR V/E�D/ �,,�f/'� ,y� DATE /LEGAL
/ 1 ��-.-X . !/� l.�l/Vl._&: %�. w A � M � 0ll1 l Y76
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SO FT/BR).- 100
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
r-"- F_ -"F-" 7-"-- :JL 2- L_ E r -4 17A -r " � -a 05 Cl Fc n 846 F= I C -s F= F=11 -r
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 MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
F-. f---! LJ I IR F= C-4 OF. Er F- -r 11::- 7r f =%" l< "E. I 2EEE= -1 Z-2!5- 0 0 F=l I I CK t-4
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.
--- -rw"- ff: :=- > I ":s F" a 0 _r I ID " _ Fl F;;?., a Fe a "1 I F-: a E-0 - - —
BA: KF I LL I P•dG
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO.PR'OSECUTION,
i
MINIMUM 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.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
I CERTIFY T14AT
1: 1 AN FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: 1 MILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: 1 UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
SIGNED:--------------------------.
APPL I CANT
IGNED:---------------------------
APPLICANT L H CONST. INC.
ISSUED BY_�
V4. 0
twl k -1 ®-A 10 1 F-"F:W I -r '-e C -I F=
DEPARTMENT i HEALTH
AND ENVIRONMENTAL `QTECTION
825 ;L STREET:
ANCHORAGE: AK. 99*-ol
264-4720
-3,0
0 r-4 3: -F FE
FE W F= Fe- F=DF= F, rl I "T
PERMIT NO.
< 800287 )
APPLICANT L
H CONST. INC:.
3220 CAMPBELL AIRSTRIP
333-8742
LOCATION
LEGAL L6
HILLSIDE PARK
LOT SIZE 30000 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SO FT/BR).- 100
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
r-"- F_ -"F-" 7-"-- :JL 2- L_ E r -4 17A -r " � -a 05 Cl Fc n 846 F= I C -s F= F=11 -r
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 MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
F-. f---! LJ I IR F= C-4 OF. Er F- -r 11::- 7r f =%" l< "E. I 2EEE= -1 Z-2!5- 0 0 F=l I I CK t-4
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.
--- -rw"- ff: :=- > I ":s F" a 0 _r I ID " _ Fl F;;?., a Fe a "1 I F-: a E-0 - - —
BA: KF I LL I P•dG
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO.PR'OSECUTION,
i
MINIMUM 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.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
I CERTIFY T14AT
1: 1 AN FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: 1 MILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: 1 UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
SIGNED:--------------------------.
APPL I CANT
IGNED:---------------------------
APPLICANT L H CONST. INC.
ISSUED BY_�
V4. 0
!?Ti1 tT W-ALM ANDI3 4t Ted Y#t .tT7b i t CN
'264-4,720
-'=. •T I T
PERM # T M.
i*"- it -w r ,.L H CL Mc. ? ' 3 ClMPLRELL #i t STR fP I
tr013AT T m.#I
t-F-r l HILLSItC PARS Lor SI-aix-fm
t! Ipy-fti t,gyq-M .R QF SCORMNS =4 '501L R TfPb3 <7;0 Ft`/Mlm M89
T; 4 3Ii
--;LZF. OV r '-SOIL 8W5G Ti% T lysroi {a'
I:_
T L iTAT�T It T t d I.3 rW LEM3TH (IN SEE T) E t T �# s7 DRAitFIEL_0
r148 CW-PrH OF 8 TRerJ4 OR PIT P; TK 015rWZE BETWEEN THE '5t
i1qsAkilD f10 THE GOT T; 4 QF T +:;WAT tit (IN PE+'ET` .
I` a � ov---r# is TtqE nErar iti OEP— 4 t r'�#�I�, ii+ ii THE t14 T�t�_I �I
THE TP 'Yf i W ��'�'t�TTt�t t its FEET).
Tor1-1-AF13M
€ W WELLS .3 JACGt T F M I'? M ry, AM rw
1-#.4#4$jZR, tX7 RES TMT THE T-O. L HILL,5ER
SOC
KFIL.LU40 f I-W SYSTIEM 14MMT APPRiNAL BY T141S
t4 Iii I T €? I a F BET1 EEN R WELL 40 #� �! � f T SePME 0I s.POSAL SYSTEM IS
tffjo FEET FOR t4 .PRfVRM. t-O-L OR T:-%3 F PRON A PUBLIC IC;' WELL OEPsw l tlu
ttPttAt tBT C t T'� PRi` T R PR'IVOT SEIMP. LE I`5 T T
TO 14 C#3t* POM i T l *,;�R LINE V3 75 FIEC T.
I AM F�±R� IL I ` T4 t rH r t 2ti E ` t-T is t -`s I Te s 4D id t...us t4' T
# rff By T"-O--
{ }tet r F � ftpT T TW- C -S t r 5,94ER .: T' 1 PMsate 1 9A�OeWJ) t` If
I€k tls Ii Rpt} � p) EpjrLlJM MIME TTS 4 CtMXMS-
`�:L `iNED t ------ .a- a
PERMIT NO.
M ki F-1 rA 0 F-1 Y..4 F.? 0=1 KaL
DEPARTMENT f-71-JEALTH AND ENVIR.ONMEN-rAL. " '-'CT I ON
825 't STREET., ANCHORAGE, AK 99-,,,' 1
;-.--.,.64---4720
1 _F....E- E .t4
800287 )
APF"LICANT L H C'ONST. INC. 3220 CAMPBELL AIRSTRIP 333-8742
L f.) (' "Al" I ON
LEGAL L6 HILLSIDE PARK LOT SIZE "---,'0000 SQUARE FEET
TYF,E OF.' 5501L. ABSORPTION SYSTEM IS: TRENCH
1flfl.`-`ItlJM NUMBER OF BEDROOMS = 4 SOIL RATING <SQ, f--T/BR)nm 1.00
'THE: RECIL)IF:ED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
I—EEP-4urn 7'"== .-2!5 NEES
J'HE LENGTH [)IMENl---,ION 15 THE LENGTH (IN FEET) OF' THE TRENCH OR DRAINFIELD.
THE-, DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUt--11) AND THE BOTTOM OF THE EXCAVATION (.'T.N FEET).
THERE 15 NO -SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF' GRAVEL BETWEEN THE OUTFALL. PIPE
AND I'HE BOTTOM OF THE EXCAVATION (.IN FEET'.).
F"OE-7-C-Al.j I F :ZE-EF=01- I #:Z= -r n -P -4t< I
PERMIT APPLICANT HAS THE
RESPONSIBILITY
TO INFORM
THIS DEPARTMENT DURING THE
IOS
INSTALLATION INSPECt 'N
Y WELLS JACENT TO
))F ANAD
71-11S PROPERTY AND THE
1,1UMf.':tiER OF RESIDENCES THAI'
THE WELL WILL
SERVE.
< F� F -?E -E F. - OF---- -, U I F --r-.
BACKFILL. ING f.)F ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
L:-EF`ARTM[-NT WILL BE SUE-:JECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
:;L6 ti -'I FEET FOR 1-1 PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WEI L DEPENDING
LSF" C.'IN THE TYPE OF PUBLIC WEL.L.
MINIMUM DISTANCE FROM A PRIVATE WELL TO FI PRIVATE SEWER LINE IS 25 FEET AND
TO 1-1 1--.'OMMUNITY SE14ER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPL%,'. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
7*0 INSURE PROPER INSTALLATION.
F-" 9E:_' Fe M .R.. 0- EE » « F� 1 F -c r> EE vZ: EE fwi E" F -r-,:# ,'I_ f=-4 ".p
I ("ERTIFY THAT
.J.: I Fill FAMILIFIR WITH THE RE15"!UIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUP41CIPAL ITY OF ANCHORAGE.
2: 1 WILL ithsTALL. THE SYSTEM IN ACCORDANCE WITH THE CODES. HE
I UNDERSTAND THAT THF.", Ot-J-SITE SEWER SYSTEM MAY REOUIRE ENL.AF"-,'GEMENI
T IF
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
I GNED:
APPLICANT L 14 CONST. INC.
V4, 0
ISSUED BY . ..... �-,,ATE ... . ........
TEST PERFORMED BY: Bob Peters DATA CERTIFIED BY: James
DATE:
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•® 1 E w 1 1 : • ••
TEST PERFORMED BY: Bob Peters DATA CERTIFIED BY: James
DATE:
pE B
• Municipality of Anchor
On -Site Water and Wastewater Progr n) ;1 X\ 1
(907) 343_ 7904 s ^ E
a� N0V0 9 20 113 I l
Certificate of On -Site Systems Aja; roval
4, �� .,
Parcel I.D. 015-122-45-000 Expiration DILL:
1. GENERAL INFORMATION
Complete legal description Hillside Park PUD, Lot 6
Location (site address) 7241 Tree Top Circle, Anchorage, AK 99507
Current Property owner(s) Scott & Rebekah Hayden Day phone
Mailing address 7241 Tree Top Circle, Anchorage, AK 99507
Real Estate Agent Sherilynn Bare Day phone 907-230-9936
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
WaiverNariance request for:
COSA to be released
unless otherwise requested by the engineer.
Date: l09 l4
COSA Fee $ 5^2-Kq o d Waiver Fee $
Date of Payment �� rf �k/, Date of Payment
Receipt Number
COSA# OSCl6/SYa
Receipt Number
Waiver #
4
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual
Q
Individual Water Storage
❑
Holding Tank
❑
Community Class A Well
Q
Community
❑
Public Water System
❑
Public Sewer
❑
WaiverNariance request for:
COSA to be released
unless otherwise requested by the engineer.
Date: l09 l4
COSA Fee $ 5^2-Kq o d Waiver Fee $
Date of Payment �� rf �k/, Date of Payment
Receipt Number
COSA# OSCl6/SYa
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Anderson Engineering
Address PO Box 240773, Anchorage, AK 99524
Engineer's Printed Name Benjamin Schiller
6. DSD SIGNATURE
4— System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Phone 522-7773
Date 11-8-2[[0'' 16
�1j
so
:V •9TH
4zft',�:iaeja;��}r-1iSa;hi!'e7o .;=®
�r°° Ce e2-92
,t°°,e Flo
Conditional approval for bedrooms, with the following stipulations
BY vLt� Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet ! c
If more than 1 septic system is on the lot:
COSA Checklist # of _
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description
Hillside Park PUD, Lot 6
A. WELL DATA
Well type Class A
Date completed
Total depth ft.
If A, B, or C provide PWSID # 21 2461
Sanitary seal (Y/N)
Cased to ft.
FROM WELL LOG
Date of test
Static water level ft.
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic ug/L Date of sample:
B. SEPTIC/HOLDING TANK DATA
Parcel ID: 015-122-45-000
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground) in.
AT INSPECTION
Collected by:
FIN
Tank Type/Material Septic/Steel Date installed 7/1 1 /80*
Tank size 1 250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/Ni) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 11/8/2016 Pumper Isaac's Pumping Service
C. ABSORPTION.FIELD DATA
Date installed 7/11/80 Soil rating (g.p.d./ft2 or ft2/bdrm) 100 SF/bdrm System type Trench
Length 25:. 0 'ft... Width 3 ft. Gravel below pipe 8 ft.
Total,depth. • -2 ft` +Eff. absorption area 400 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 1 /316 Results (Pass/Fail) PASS For 4 bedrooms
29.5 600 57.5
Fluid depth.in'absorpticn field before test in. Water added gal. New depth in.
A�cm+1440 ' :'• > 29.5 600
Elapsed,Time -•• mFinal fluid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NO If yes, give date
'Septic Tank is more than 30 years old and nearing the end of its useful life.
D. LIFT STATION
Date installed
"Pump on" level at in.
Datum
E. SEPARATION DISTANCES
WELL ON LOT TO:
Size in gallons
"Pump off"level at
Cycles tested
Septic tank/lift station on lot N/A
Absorption field on lot N/A
Public sewer main N/A
Sewer /septic service line N/A
Animal containment areas N/A
SEPTIC/HOLDING TANK ON LOT TO:
>5'
Manhole/Access (Y/N)
in. High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots N/A
On adjacent lots N/A
Public sewer manhole/cleanout N/A
Holding tank N/A
Manure/animal excrete storage areas N/A
>51
Building foundation Property line
Water main >10 Water service line >10'
Wells on adjacent lots > 10 0,
ABSORPTION FIELD ON LOT TO:
r ,
Property line Building foundation >10
Water Service line >10'
Curtain drain None Noted
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Surface water >100'
Wells on adjacent lots >100'
l certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Benjamin Schiller, P.E.
Date I, —a-16
COSA brown sheet 10-10-12.doc
Absorption field >5
Surface water > 100'
Water main >10,
Driveway, parking/vehicle storage > 10'
yZYEA
.� Ott °• sd.i+r.
92 Vm
in.
N 89 59' 00" W 196.22
Seco
O
an>11:
NOTE :
THE EAST 10 FEET 1S AFFECTED BY AN EASEMENT
1N FAVOR OF GC1 CORP. AS RECORDED AT BOOK 2162, PAGE 546,
OF A
49 TH
SHANE A. HOLT
LS -6914
..........
�ofessioW Lo
THE INFORMATION HEREON I5 FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES.
EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT, ARE NOT SHOWN
HEREON ( UNLESS INDICATED)
NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE.
�t
=o
pJSE
ro1 :o'
CEA E4SEME/JI
AS -BUILT SURVEY 1" = 20'
NO CORNERS SET THIS DATE
S
k
ASPF LT
19
E
51'
n0
Sw
I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
LOT 6, HILLSIDE PARK P.U.D. SUB.
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EXIST OTHER THAN NOTED.
DATED AT ANCHORAGE,ALASKA THIS _7th DAY OF
NOVEMBER , 2016.
12276.
HOLT LAND SURVEYING
600 HIGHVIEW DRIVE
ANCHORAGEAK 99515
345-5513
'�-�'-v~xcrsv�p sus':';: �.:�»,.*ms"-..,.. w �,✓r r "i r—
"A►NDERSN INEERING:
1 Al2P O BOX 240773
�,'ANCHORAGE'AK
4A22 _7773 : s 677_7766 FAX
November 16, 2016
Municipality of Anchorage_
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 6„Hillside Park PUD Subdivision, OSC161540
Septic Tank
Dear Onsite Services Engineer:
According to municipality records, the single-family home at the above lot had a septic
system .installed in: 1980. This included a 25' long trench at 8' effective, depth and a
1,250 gallon septic.tank. When the lot was.sold in 2013, the paperwork indicated that
the same system appeared to be in operation. The paperwork included an as -built from
1987.
However, the most recent as -built shows more.cleanouts, indicating that the septic tank
may have been replaced at some time,in the, past 30 •years. Thiis would, be a logical
conclusion, since the life expectancy of a septic tank is typically closer`to 20 years. If
this is the case, it was,done without`any paperwork or submittal to on-site services. We
do not have a way to verify this without excavating the tank.
We have no knowledge of a tank replacement on this property, and the owners
currently selling th b,oroperty also know, nothing about this, If it was done, it was done
before they bought the property in 2013.
Sincerely,
• Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. o 13 7- 1 22 -
Expiration Date: 1�11 .— % :Z." I
1.
GENERAL INFORMATION
Complete legal description i.
v t 6� H I !s o/Q �a r + - ff • u . fl
Location (site address) 7 2.'1/
717ey e Ta v
.. .
,, Current Proper.ty owners) ft -a r�e
It Sarre A-- A o tai Day phone' 3.'/,!(-
Mailing address 7 2y /
T To.V C re le A rh a�
'Real Estate Agent 0" Re hax Dayp6one, 72-7
2,:
TYPE OF DWELLING:
ala Fe: Pleere C' _T a,l bwnt� cit
Single Family. (w/Wo ADU)
ex P, Ca LO u ct A , :alar ka. ¢olcc
❑ Duplex
i2ne o�7s o �''9'" eer
.❑ Multiple Dwellings (Single Family and/or Duplex) @ f'
rtC(e u� y� tuner pi.mil�r mai
3.
NUMBER OF BEDROOMS:
4..
TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑ Individual
Individual Water Storage
❑ Holding Tank ❑
Community Class _ A Well
® Community ❑
Public Water System
❑ Public Sewer ❑
.COSA to be released to the engineer, unless otherwise requested
COSA Fee $ t/q ) , W WaiverFee $
Date of Payment 612%/ 3 Date of Payment
Receipt Number 65-5-606 Receipt Number
COSAWaiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As-cerfified by my seal affixed hereto and as- of the validation data shown below, l verify that my investigation,
:based :on procedures outlined In the. Certificate of Oh -.Site Systems Approval Guidelines for. this application;
shows that the onsite 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 Municipaiity of Anchorage files and, from my investigatieri and inspection, the on-site water
.supply and/or wastewater disposal system ts(are) In compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
NameofFirm_Ffat-Ane Phone .. 3w4'- 13 &-s'
Address IHS 3 G -moo 1;4nrc fFnf�ra-cr�n A'--q9s��
Engineer's Printed Name _Th no ,,Co .e P -too .e Date G 20
6 DSD S)GNATURE
System #7 Approved for bedrooms. A ti Gry V
BC66UCE�u @GC0 P
System #2 Approvedfor bedrooms. cif✓-�
Disapproved.
Conditional approval for bedrooms, with the following stipulations
By �� Original Certificate Date:
The cipa orege Development Services Division (DSD) Issues Certificates of Onsite 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 engineers we&
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
If more than 1 septic system is on the lot:
COSA Checklist #_of
Structure served by this system
S'rnflL .{Wm, I;y
..
Certificate of On -Site Systems Approval Checklist
Legal Description: _ L, o % If r! Lt 1!6f Pa r I- P. K A Parcel ID: O 1,9 - t 2Z - 105,
A. WELL DATA
Well type Clarc `k " If A, B, or C provide PWSID # 212 y6/ Well Log (YIN)
Date completed Sanitary seal (YIN) _ Wires properly protected (YIN)
Total depth ft Casedao ft.. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level g,
Well production g p.m.
WATER SAMPLE RESULTS:
Coliform : . colonles/1D0 mL , Nitrate mg/L
Arsenic ug/l Date of sample:
Collected by:
ft.
g:p:m. .
B. SEPTICIHOLDING TANK DATA
Tank Type/Material _e!r he. / Sf-se / Date installed 7/ if Age
Tank size 1250. gal. Number of Compartments ?_ Cleanouts (Y/N) `P
Foundation cleanout (Y/N) •Y Depression over tank (Y/N) .. n/ High water alarm (YIN) N
Date of pumping. /R / 13 Pumper =-V et'-- r
C. ABSORPTION FIELD DATA
Date installed /11 / Soil rating (g.p.d./Ie or ffzPodrm) IUO V,65,R,,System type 7, y
Length 2 S . ft Width 3 fL Gravel below pipe_ ft
Total depth 10 + ft. Eff. absorption area eO fe - .Monitoring tube Depression over field N
Date of adequacy test 2/7/83 _ Results (Pass/Fail) _Lew For Y bedrooms
Fluid depth in absorption field before test _'i V- in. Water added 8$9 7 gal.. New depth_2.2L in.
Elapsed Time: 63 min. Final fluid depth Si in. Absorption rate >= 606 g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) IV . If yes, give date Iv. .4.
D. LIFT STATION N: A.
Date installed
Size in.gallons •Man iolefAccess &IN)
`Pump cow level at in.
"Pump ofr level at in. High water alarm level at in.
Datum
Cycles tested Meets alarm & dreuit requirements?
' E. SEPARATION DISTANCES
WELL ON LOTTO: N .
Septic tank/lift station on lot
On adjacent lots
Absorption field on lot -
On adjacent lots -.
Public sewer main -
Public sewer manholeldeanout
Sewer /Septic service line
- Holding tank -
Animal containment areas
- Manurelaniinal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation r 0
Property line 3 0 Absorption field l o'
Water main >_ e0 'to'
Water service lime Surface water > too,
-Wells on adjacent lots 7 too > Loo f'..b_
ABSORPTION FIELD ON LOT
TO:
Property line 3 40'
Building foundation Z.G Water main > r o
Water Service line > t a '
rkin S o
Surface water > t ao Driveway, pa ghreNde storage
Curtain drain hio^e S49-011
Wells on adjacent lots roo P�f 7 zoo Pao .
F. COMMENTS
G. ENGINEER'S CERTIFICATION
certify that I have determined through .field inspections and
review of Municipal records that the above systems are in
confom7ance with MOA COSA guidelines in effect on this data.
Engineer's Printed Name
7he0clon9 r: r-revre
Date 5"y2-0/'3
COSA brown sheet -1 0-10-1 2.doc
STAIVIP., s ` s 16,1
0
m'
ti ti
CP
fur,
G=x 180
east
� L 1
I hereby certify that I have
surveyed the property shown
and described hereon, and
the improvements situated
therein ore within the
oroperty lines and do not
cverlap or encroach on
adtacent property, excepi
1 as indicated hereon.
Ecsemems of record,
other than those shown
the recorded plat,
not shown hereon.
1- , Ry.,.
E °fie vt BENCH
Profes<
rW Scale= , I, 01
A- 'gate Surveyed p
r e �� t' �—�— 7
p,,pyc _ Date Drawn:2-4-87
'�,+ obi81S 1
i$
9. Aree�. aea',yp•'6;�AFI Legal Descriptiorn
4Is' oFf3SI0P1 i.L `y'��
MARK INC.
I Land Surveyors
Drawn by
DCN
Checked by: R.E-
Grid:2530, 1 w.o87_01'.
Lot 5, Eillside ParkP.U.--. Suo;:,
D34-
J
SURVEY TYPE
�i
0\
I hereby certify that I have
surveyed the property shown
and described hereon, and
the improvements situated
therein ore within the
oroperty lines and do not
cverlap or encroach on
adtacent property, excepi
1 as indicated hereon.
Ecsemems of record,
other than those shown
the recorded plat,
not shown hereon.
1- , Ry.,.
E °fie vt BENCH
Profes<
rW Scale= , I, 01
A- 'gate Surveyed p
r e �� t' �—�— 7
p,,pyc _ Date Drawn:2-4-87
'�,+ obi81S 1
i$
9. Aree�. aea',yp•'6;�AFI Legal Descriptiorn
4Is' oFf3SI0P1 i.L `y'��
MARK INC.
I Land Surveyors
Drawn by
DCN
Checked by: R.E-
Grid:2530, 1 w.o87_01'.
Lot 5, Eillside ParkP.U.--. Suo;:,
c
J
SURVEY TYPE
SYMBOLS
❑ AS -BUILT - NO CORNERS SET
.-'
wc3 ASSUMED ELEV.
DRAINAGE
❑ PLOT PLAN - AS -BUILT -LOT SURVEY - TOPOGRA?r"Y
a G WOOD FENCE "r,,
WOOD DECK
ASPHALT
LAT SURVEY
---T-� CHAIN LINK PT�NfCE�o:-c.
CONCRETE
A RECERTIFICATION
NOTE: Fences are shown in their approximate
AS -BUILT - NO CORNERS
SET locations only.
t lsthe responsibility of the builder or owner, prior to
LEGEND hub & tack -found ❑ set
El
construction, to verify proposed building grade relative
Iran rebar -found p set
to finished grade and utility connections and to determine
iron pipe -found - O Set
•
O
the existence of any easements, covenants or restrictions
brass cap -found 0
which do not appear on the recorded subdivision plat.
set
alum. cap -found set
e
-
of Survev Cprtifinntirn
------A r...
I hereby certify that I have
surveyed the property shown
and described hereon, and
the improvements situated
therein ore within the
oroperty lines and do not
cverlap or encroach on
adtacent property, excepi
1 as indicated hereon.
Ecsemems of record,
other than those shown
the recorded plat,
not shown hereon.
1- , Ry.,.
E °fie vt BENCH
Profes<
rW Scale= , I, 01
A- 'gate Surveyed p
r e �� t' �—�— 7
p,,pyc _ Date Drawn:2-4-87
'�,+ obi81S 1
i$
9. Aree�. aea',yp•'6;�AFI Legal Descriptiorn
4Is' oFf3SI0P1 i.L `y'��
MARK INC.
I Land Surveyors
Drawn by
DCN
Checked by: R.E-
Grid:2530, 1 w.o87_01'.
Lot 5, Eillside ParkP.U.--. Suo;:,
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services 44
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 01,6' 122 YS V
1. GENERAL INFORMATION
HAA # ITIA C�')k C� Q
Complete legal description 6 Pork P u. D
Location (site address or directions) 7 2 Y r 7r --e P circ/C
Property owner
NariAg(
MtNc Z
Peher
Day phone 3
y6 -333 /
Address 3J�r "�"
Sf.
Mailing address
7 ZH J
Tv'ee
{cue C(re le Am orrxgrg,
�� 99,s /6'
Lending agency
Mailing add
Day phone
Agent f3ef� S�. ��,5�
D,,�aMtc 9.oy,ef
f,er
Day phone 279 - -76'11
Address 3J�r "�"
Sf.
Skle /ao
,¢„ch .4K
99s a3
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
V
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
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) Front MOAM21
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 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 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 FlahaW Terl7n ira/ S&n,«Pf Phone 3 ys - 13s-5—
Address 11IT30
gcn/lo
Engineer's signature
Date :�'47krm her is /99,C
6. DHHS SIGNATURE
Approved for d U %� bedrooms.
Disapproved.
Conditional approval for
Additional Comments
M
C,
r,
bedrooms, with the following stipulations:
Date l_ /9 ` 9 21
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 x21
M
r
Municipality of Anchorage 10 1999
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division ,w,jNiuVAu I Ui A[
825 L Street, Room 502 • Anchorage, Alaska 99501 • (9anS4354744''
Health Authority Approval Checklist
Legal Description: L -o f t4 Ns Ae PQ v k P• u• D. Parcel I.D.: O t S /Z2
A. WELL DATA
Well type C /asu �4 If A, B, or C, attach ADEC letter. ADEC water system number 2.01YC/
Log present(Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
Date completed
Cased to
FROM WELL LOG
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
Casing height (above ground)
Wires properly protected (Y/N)
Collected by:
AT INSPECTION
Other bacteria
g. p. m.
B. SEPTIC/HOLDING TANK DATA �-
Date installed '7 / 0 / do Tank size1 2� Number of Compartments *— Cleanouts (Y/N)
Foundation cleanout (Y/N) ,K Y Depression (Y/N) t_ High water alarm (Y/N) V-4
Date of Pumping 6/12/ q& Pumper No fh lam msApllt�t o.�
0f S e'4 A*C Awi Ora c t" e. -t c cV.r'
Iron ductiu C rid¢ rt�r/acct! cti,
C. ABSORPTION FIELD DATA D 3o3q i o bJ c•a• �nr1Gll r.� B/���9�
Date installed 7/11/90 Soil rating (g.p.d./ft2 or ft2/bdrm) loo a' System type Ti'c^c�
ORit
Length 25"' Width 3' Gravel thickness below pipe 19' Total depth
Effective absorption area Y06 1:7' Monitoring Tube present (Y/N) y Depression over field (Y/N) N
Date of adequacy test 6111/28 Results (Pass/Fail) Pasr For 4y bedrooms
rvr�"_
Fluid depth in absorption field before test (in.); 5-7 Immediately after BCCG gal. water added (in.): _ _ 6�.5't
Fluid depth 60.1' (ins) Minutes later: GG Absorption rate = > 600 g.p.d.
Peroxide treatment (past 12 months) (Y/N) N If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at* _
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO: N• A.
Septic/holding tank on lot
On adjacent lots
Absorption field on lot - On adjacent lots
Public sewer main
Sewer /septic service line
"Pump off" level at*
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation
Property line
Absorption
Water main/service line > to' Surface water/drainage �> loo' Wells on adjacent lots -> 2cr.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water > tao'
Building foundation
Water main/service line
Driveway, parking/vehicle storage area
Curtain drain nlvne soei Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal recgrds that the �boya systems are
HAA Fee $ 3a0 =`'
Date of Payment C A a 1w
Receipt Number_ ovOS/ 62E7
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
5. LEGAL DESCRIPTION
DATE RECEIVED
INSPECTION APPOINTMENTS
�r
TIME
TIME
TIME
6. TYPE OFRESIDENCE
NUMBER OF,BEDROOMS
DATE
DATE
DATE
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
INSPECTOR
INSPECTOR
INSPECTQR�
,�'Ci. 1 V
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTORIIRONMENTAL PFOTECTION
825 L Street - Anchorage, Alaska 99501
•
NOV 2 51900
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEV&1r LITIES"
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER .,
PHONE
'/7 p
MAILING ADDRESS
CR
® O.,_
PROPERTY RESSID NT (If differentlomm above)
PHONE
2. BUYER
PHONE
�...e -.
MAILING ADDRESS
3. LENDING INSTITU ON
PHONE
p
42C�_
MAILI G ADDRESS
4. REALTOR/AGENT
PHONE
MAI LIN ADDRESS
5. LEGAL DESCRIPTION
�r
STREET LOCATION
6. TYPE OFRESIDENCE
NUMBER OF,BEDROOMS
I] One AK Four ❑ Other
SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
❑ Three ❑ Six
7. WATER SUPPLY
❑ INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
�9. COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
M INDIVIDUAL/ON-SITE**
I7W49 YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLIC UTILITY
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
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
ED PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL T0:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
JI -��0
BY