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HomeMy WebLinkAboutPARADISE VALLEY BLK 4 LT 39AMunicipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON -SITE WASTEWATER INSPECTION REPORT Permit Number: OSP241011 PID Number: 020-411-33 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name SCOTT G FOXLEY ABSORPTION FIELD - EXISTING ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 18201 SPAIN DRIVE, ANCHORAGE ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot PARADISE VALLEY 4 39A Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width 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 Ftz Ft. Well 100'+ __ 25'+ TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal. Surface Water 100'+ -- Material HDPE Number of compartments 2 Lot Line 10'+ -- NA Foundation 8'+ __ LIFT STATION Manufacturer Capacity Gal. Remarks ST insulated w/ 4" of 40 PSI insulation w/ mounded cover & is outside soil bearing prism. MOA on -site at install. Alarm location Electrical installed by Installer Mike N Anderson (MNA) PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Drainfield CO/MT Inspector MNA & FWCS BENCH MARK (Assumed elevation) 100 ft Inspection Is` 2/14/2024 2 d 2/14/24 da Location and description 3rd 4`h TOP OF MANHOLE ON -SITE WATER AND WASTEWATER SECTION APPROVAL or— A • • �� Conditional Approval: Date ' .....•... �� • • • • Curtis Huffman �� c��,,•,• CE 128991 Septic System /� Approved - (' w Date Z Z� ZoZ •.•��`��f� �� s�� . p2/21/24• . •���AW O_ `l,��pROFESSIONP .� Note: this approval does not include well permit requirements. �\ROHSV kmev vaivu io) FIRST WATER CONSULTING PARADISE VALLEY BLOCK 4, LOT 39A PARADISE VALLEY BLOCK 4, LOT 39A AUSrRIA DRIVE I 1 / / / 10.3'x9.4' SHED ENCROACHES ONTO LOT 38 Lot 38' M J Lot 7 Lot 6 PLOT PLAN AS BUILT —.2L SCALE 1" = 50' GRID SW 3538 Project No. 24-020 Al 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone oQ�O (907) 522-4625 Fax a4 O F A. Professional Land Surveyors kenOlongsurvey.com v ... . ,q jonothanQlangsurvey.com OAP s QQ I hereby certify that I have surveyed the following described property: LOT 39A, BLACK 4, PARADISE VALLEY SUBDIVISION (PLAT No. 2001-112) 1-0 : 49TH 4� Anchorage Recording District, Alaska, and that the improvements situated thereon are "" " ' '•"""""' within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed a' KENN G. • promises and that there are no roadways, transmission lines or other visible QAA LANG easements on said property except as Indicated hereon. ri Dated this the Day of r F7u t , at Anchorage, Alaska �� ,off • • • •O� �44�S5100-���' If Is the responsibility of the owner to determine the existence of any easements, DO04� covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 PID:020-411-33 PERMIT:OSP241011 FIRST WATER CONSULTING PARADISE VALLEY BLOCK 4, LOT 39A MUNICIPALITY OF ANCHORAGE nr On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite v Delrirtment On -Site Wastewater Disposal System Permit Permit Number: OSP241011 Effective Date: 1/30/2024 Work Type: SepticTank Upgrade Expiration Date: 1/29/2025 Tax Code Number: 02041133000 Site Legal Address: PARADISE VALLEY BLK 4 LT 39A G:3538 Site Mailing Address: 18201 SPAIN DR, Anchorage Owner: FOXLEY SCOTT G Lot Size in Sq Ft: 37776 Design Engineer: FIRST WATER CONSULTING Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: l 5 S �i-- t-✓ C Date: Issued By: �n , �---- Date: 3"Z 20 Z y MUNICIPALITY OF ANCHORAGE Development Services Department " s p p Phone: 907-343-7904 On —Site Water & Wastewater Section Fax: 907-343-7997 ON -SITE SEPTICIWELL PERMIT APPLICATION Parcel I.D. 020-411-33 Property owner(s) SCOTT G FOXLEY Day phone Mailing address 18201 SPAIN DRIVE, ANCHORAGE, AK 99516 Site address 18201 SPAIN DRIVE, ANCHORAGE, AK 99516 Legal description (Sub'd., Block & Lot) PARADISE VALLEY BLOCK 4, LOT 39A Legal description (Township, Range & Section) Lot Size 37776 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) El Septic Tank 0 Upgrade M (w/wo ADU) (D) ElRenewal Holding Tank El Renewal❑ 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: Z Waiver Fees: Date of Payment: , 2oZY Date of Payment: Receipt Number: Permit No. `% SP Z 910 ft Receipt Number: Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / firstwaterAK@gmail.com ! !! January 26, 2024 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: PARADISE VALLEY BLOCK 4, LOT 39A The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic tank on the above referenced lot. We propose to install an IM-1060 plastic septic tank per the attached design to serve the existing 3-bedroom residence. Groundwater was noted in the MOA on-site file at 7’10” during monitoring on 8/1/1990 and believe it will not impact the proposed installation. The septic tank is to be bedded and buoyancy measures installed if necessary, per manufacture’s specs. The lot and area are served by private water and any encroaching wells, easements, … must be staked prior to construction. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241011, Curtis Townsend, 01/30/24 FIRST WATER CONSULTING PARADISE VALLEY BLOCK 4, LOT 39A DESIGN DETAILS: Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241011, Curtis Townsend, 01/30/24 1 1 � 11 N 1600'00"E—,,/ 1 12.52' !r I 1 r� AUSr � * R1� Lot 39A 10' UTILITY, T&E EASEMENTS DRIV 37.776 s.f. ' +� f Lot 6 Vo ' r 0 f SEPTIC PIPES I N 11 p f Or LLJ� 4.PORCH ` p / 00 \ 04 14 cv 2' 5.I I � ,9 f I! Ogi�Ah a8 J _ / 0 40.0 1.4'x1.` CANT I / Q , ' I 6-8'x18-4' CCVEREp DECK r 3.fl' PROW N ` Jf CL 8.2'x8.4' DECK WELL Iq Lot 7 p S $8'07'00"W +179.85' A 10.3'x9.4' SHED 1 1 ' 3, PO ENCROACHES ONTO LOT 38 1 j---� Lot 38' PLOT PLAN\ AS BUILT JL SCALE 1" = 50' GRID SW 3538 Project No. 19-014/A1 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates} inc. (907) 522-6476 Phone (907) 522-4625 fax 4oQQ A Professional Land Surveyors kenOlongsurvey.com = 3 .•,....... ,9 p jonothanOlangsurvey.com DOP I hereby certify that I have surveyed the following described property: V LOT 39A, BLOCK 4, PARADISE VALLEY SUBDIVISION (PLAT No. 2001-1 12) * ' ..49TH . '-�* dQ Anchorage Recording District, Alaska, and that the Improvements situated thereon are ' "' ." ' Q ............. within the properly lines and do not encroach onto the properly adjacent thereto, that no Improvements on the properly lying adjacent thereto encroach on the surveyed 0'.' ......... LAN • .:. aG promises and that there are no roadways, transmission lines or other visible �,KENErH rr easements on said properly except as Indicated hereon. Dated this the �Day of at Anchorage, Alaska ,0•—520. It is the responsibility of the owner to determine the existence of any easements, 044gq�a�' covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 Lot 41 A www.sullivanwaterwells.com Pump Installation Log Well Drilling Permit Number: SW Date of Issue Parcel Identification Number: Legal Description Property Owner Name & Address Paradise Valley Block 4 Lot 39A Scott Foxley 18201 Spain Drive Anchorage, AK 99516 Pump Installation Date: 11-10-20 Pump Intake Depth Below Top of Well Casing: 230 feet Pump manufacturer’s Name: F&W Pump Model: 4F07G10301S Pump Size: 1 hp Pitless Adapter Burial Depth: 10 feet Pitless Adapter Installer: Unknown Disinfected Upon Completion? yes no Method of Disinfection: Chlorine 50 PPM Comments: Pitless Manufacturer: Unknown Pump Installers Name: Sullivan Water Wells Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES · /~, O~k ~C::~. ~'~--'~"T' 0t'~C::>f'-~ ~ SEPTIC ABSORPTION WELL Address TANK FIELD ~ ~ ~ I ~ ~ 0~I~ LOT LINE ~ ~ownship, Ran~, Section ~[~ ~ ~ ~ , ~ ~ ~'~w~ ~Ja ~ Ir ~ ~c~,~ t ~h°w I°cati°n °f well' septic system' pr°pO~y lines' l°undati°n' TANKS TYPE OF SYSTEM ~ ~ ~ ~ ~ TRENCH ~ BED ~W. DRAIN ~ OTHER Depth t° p'pe b°tt°m fr°m / T°tal depth fr°m °rig[nal grade / original grade [ FT ~,~ ET Gravel length ~ ~ I [1-- Total absorption area ~ ~ SO FI ~ ~ FI Number of lines Soil rating . Pipe material ~ ~ Inst ~ .~ Date Installed WELLS ~RIVATE ~ OTHER {Identifv) To~a~ D~.th ] Ca~ ~o ClassifiCation (A~,C) REMARKS: Inspections I ~ ~ ~ ~_-~ oi,,=~ I ~n gm.A ~. ~-- ce~ify that this inspe~ion was pedormed acGording to all Health ~e?qment Approval Date' 72-013 (3/85) :'-~d~,ICHI:)RAGE, AK 995 t 7 Pa r' c>.'.:.~:, ]. ]] d ~ 0;;::0-4 I ].-'"05 Lot Le*.~:~::~ l a Subd :L v i. s :l. c,n: PARAD I SE VAL..L..EY L..cd:.. Sec::'L J.c,n :: ;!. ;L 'Fc:~**~nsh':~.p ~: ]. ].N Rar'~ge: 3W Lot S:Lz(<;., 24590 (~(::1,, ft,, ,:::m ac~'es) Hax ~;-;¢ ** (::1 ? ,::,(::),'n~,~, a Th :L s F:'er'm :i. 'L: 3 Tc4'..a Sliii]:::"T i C "f ANt.::Z ~: H i n :i. alum 'L crL a 1 sllel;;~'L i *.::: 'L an I< c;apac: :L ty ~ ~, 0()0 g a ]. ]. on s ,, Each ,iel::*'L J. c tank must have at. l(¢.:~ast 2 ~;;;cirrq]ar~'t]Filen'Ls, Depth to tol::* of sept:i.c 'l.;ar'tk (~i,) < ~'~;.:.~,:.~:~'~.. p¢:.H;;l~..~:i.r'(~:,~i~ J.~"i'~L.~].atJ. cirl civG~r' tar'il< (s) ,, ,L ,... ,.... ~*1 ;L 'L i..i i r'i .... ' ...... ¢'" i::'llii]::i:H ;ii 'f Ii!!; X P '.I: i::i'.iiii;S DI.:.}X]IiZMB!ER 3 ;I;, ;I. 99(), ....... ~.t~ ;};43"'"468 .I. NO ~".l.i-'f ,..* *~ "' !'"' °* , . ..... ('t!:::' ];!x!SI:::'I:::'C'T'ICiNS A'T' "'.'. ..... ' -* "?* ........ ,~. ~-u::t,L. I, . l'"hqVt;::. 50 c:;F'l" ;A";" TC) qi CF::'F: .::';db,i AI.J.Jt~. SI:::'A;i:N fc:,r'-I'..h I::)~,., tl",~:~.~ Hu.r'i:i.c:i.l:;).:;r~!:i~ty of Ar'tchcH".age (MC)A) ar'id 'it. he S'Late (::)i Alaska,, a.r'ld ;i. tq cot~lp}.;i..:i?,.r'ic:(~-~ ~4it. h i;. !"t ~i.'.~, des;i, gr'l c;t";i;'Lep;i..i:~,, of this C[ u,~*J.].], adhc-m~-~:.~ 'Lo ali. MOA and St.a'i'..e ,'.;)f Alaska !"eCILI;i.I'"E'IIIG:'~I"I'LS for' the %G:~t. back ~iii~;.:.})~,i~)'.~l"..;~:'~(;]ii.:.:i, ~Yy!i'i'i.'eill oi"l 't.l"~:i.*~ c:m any adjac:ent, c;,r. r'ts;,ar, by ........................ ...................................................................................................................... (O~.',il"li'!:')P) AK I..jf]~iA i:::'EZD L;RIED. ,A 0 / ~'~¥0S Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION:/~'~ ~:::~;~03l~d,,~"/--J[- ~ J~)~£~(.-- I)~°~wnship, Range. Section: ............ ~ SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O Deplh to Water After ~ ~t Monitoring? "~ ~0 Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~.0 (minutes/inch) PERC HOLE DIAMETER , ~'~ ~ I TEST RUN BETWEEN ~' FT AND ~' FT COMMENTS 17034 Eagle Ri~er L~ Road No, 2~ /~ PERFORMED BY: ........ -~/~d CERTIFY THAT THiS TEST WAS PERFORMED IN Eagle River, AMOK- z7~,, ~ ~ ACCORDANCE WITH ALL STATE AND M~NICIP~L GUIDEL~ [~[CT ON THiS ~ATE, ~TE: 72-008 (Rev, 4/85) PO, 'H 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit 9: 840026 January 31, 1985 TO: Permit Applicant SUBJECT; Lot 39 Block 4 Paradise Valley Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 19 84. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as-built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, ~~and~t, Su~pe ~i2or Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 DEPF:IR-PMENT OF" HERLTH RND EN',,,'IRONMENTRL PROTECTTON 825 L STREE]"., RNCHOF.:t'3GE., 26~-4720 .-.EF..MIT NO: E:,RTE I L= S E[:': HF F L. I CRNT - FI D D R E Si; S ' C .]NTRgT F:'HONE: L. EGFIL. DES(iR Z P: L.O T ::.:'~ I Z E: LOT LOC:FIT I ON ' I'"IF-D-:; BE[)ROOh1S: CECIL. S CLEMON:;5 8:~..'.t 0 PIONEER FtNCHORRGE., FIK E.~ ~ 5 0 4 _-'..': ]:8 :I. ]~:5 4 SUBD I',/I S I ON: PHRRD I SE VFILL. E'?' SECTION: 11. 'TOHNSHIF': /.iN ;.:..'.'E1000 ('_=;Q. FT. OR RE:RES) SPFII N STREET 4 LOT: ~:'a E, LU_.F,: 4 RRNGE: 3:14 L. ISTE[:, EEL3t,t FIRE THE: ...F II_N-'_.., H,,,HtL. ME, LE TO '-r'OU IN DESIGNING "¢OUR SEPTIC S"r'STEP1. C:HE~OSE THE: OPTIOI"4 'i'HRT BEST FI'T'S "¢OUF.': SITE. T' IF~.: EE fi'-.[ C: ~--~ ~2~ 'o ,,? E.'" E=. .... [... ". ~...!. .LC:.... F.,: DEPTH 'TO PIPE BOTTOM (FT.) GRRk,'E:L DEPTFI (FT TOTRL E:,EPTH (FT.) GRR'v'EL HIDTH ,::FT. GRR'v'EL LENGTH (FT .':, GRRVEL 'v'OLUME (CU. '.r'DS. ) 'TRNK S I ZE ,:: GR[._S ) SOIL F.'.RTING '::SLT-!. FT. ,-"'BR) 4.0 ~0 4.0 4.0 7.5 ~-~ 4.5 6.5 2. 5 ~.~ ,=':'°~. 0 5, 0 87. 0 ** _~O 42. 0 78. 0 ** ~2. 2 ~4. 2 4~. ~ 1,2~0.0 ** 1,250, 0 ** 1,250, 0 ** 152 152 152 _ ._ -"'.~ Fl', ERE:H) :+::+: GRR'v'EL. LENGTH :::' ":'E F'T REQUIRES MULTIPLE F..IJN.:, (NOT E':':'F"EE[:IMG ,'._ ...... MF HF. TMENT_, :+::+: TRNK M '~'r' HR',,,'E RT I.EFIST THO -'-' ':'-' ' c: I CE:RTIF'T' THRT. .I...I RM FRMIL...IRR HITH ]'HE REQUIREMENTS FOR ON-SITE SEWERS RND 14ELLS RS~'=;ET FORTH E:'¢ THE I"IUNICIPR[.IT'¢ OF FfNCHORRGE (MOm) FIND THE STRTE OF RLFISKR. :!. I HILL. INSTRLL ]"FIE S'¢STEM IN 8CCORDFINCE 14ITH RLL MOR CODES 8ND REGUL8TIONS,, RND iN COMPLIRNCE WiTH THE DESIGN CRiTERI8 OF THIS PERMIT. 3:. I HILL RDHERE TO BLt.. MOB RND ST8TE OF 8LRSKF4 REQUIREMENTS FOR THE SET BRCK DISTFINCES FROM RN'?' EXISTING HELL., 14RSTEWRTER DISPOSFIL S'¢STEM OR PUBLIC :SEI.4ERRGE S'Y'STEM ON THIS OR 8N'¢ FIDJRCENT OR NERRB'¢ LOT. 4. I UNDERST8ND THFI]" THIS PERMIT IS ',/8LID FOR ~ MR',:-::IMUM OF 4 BEDROOMS FiI",I'¢ ENI.LRRGEMENT HILL REQUIRE FIN RE:,DITIONRL PERMIT. IF R LIFT STRTION tS INSTRL. LED IN RN RRE8 COVERED B'¢ MOR BUIL[:,ING CODES., THEN (f) RN ELECTRICRL. PERMIT RN[:, INSPECTION MUST BE OBTRINEBu (2) RS-BUILTS' HILL NOT BE RPPROMED HITHOUT RN EL. ECTRICRL INSPECTION REPORT.~ RND (g) THE ELECTRICRL HORK MUST BE DONE E:'¢ R LICENSED ELECTRICIRN. ..... RPPLICRNT: CECIL S CLEMONS MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST .EREORMEO FOR: /:ti LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 SLOPE ! --GM ~AS GROUND WATER ~C) ~ k/,~ ENCOUNTER ED? O IF YES, AT WHAT .._.,--- DEPTH? r' DATE PERFORMED: 14 15 16 17 18 19 2O cO 72-008 (6/79) Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE · i J'~ .FT_ TEST RUN BETWEEN 37,Z ,;' FT AND by OOC Co. (:IDa SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2769 M~i~'LV ~) Del'TH OF WELL ~c~I~ ()~1~ A~' ~'STATIC LEVEL OF wATER FT. OWNER OF LAND ADDREss DATE - Started Ended PERMIT NUMBER' KIND OF FORMATION: From ~'~ Ft. to c:~ Ft. O__,~'£d~ ~rlC/4/O~O From From '~ Ft. to ~ Ft. {-)/-'/~/~d~g~-_~,~ From Ft. to . . Ft. to From ~ Ft. to,~ Ft. ,~/~.7'Y,~"'/~uaj~ -~;~~/q'd~Fr°m Et. to. From Ft. to Ft., ~"/~/- ~ ~ /.,~'0 t,d t~J From Ft. to /,F.r~m~Ft. to ~C~ Ft.-/CLi~/ ¢ ~6~/~u/~/., ~/i~rom Et. to _.om4C/ Ft. to~-~ .Ft. /~/~070/~~'') From__Ft. to From. q.~ Ft. to 1~ Ft. ff~t~Y/~/~] b~//~f3t~/~S From Ft. to From /O~ Ft. to/~/~ Ft.. lg,~,~ao~U f--~f From Ft. lo From ]~1' Ft. to ~ ,-.~" Ft. //'//~A~t~ ~gd'~ ~ From Ft. to From /_~._~ Ft. to ~'"'F.t. , ~_~,O/~D~/~ ~ ,.,O tn`/ From Ft. to From ~ ~" Ft. to ~c~¢~eFt. ~,~/~9~C~,~ ~g~ &) rJ From_ ~Ft. to_ From Ft. to Ft. F~/qCT'O t~ ~ O 7 5 ~)0/'/~ From Et. to From~,}~c/ Ft. to '~4'6 Et/ ~O~e,.,'t~,., ~'[~'~/~ From ~" FromC"~_4. ~ Et. to ~g'~ Ft.~ /,?~10~'}c''l<'~ ~*P/~:~""J From From__Et. to Ft.. ',-~/ ?,,O~fZ'' ~'(~/4~4~ From From . Ft. to Ft. ~ From From Ft. to Ft._ From Ft. Ft. Ft.. Et, Ft Ft. Ft. Ft. Ft. Ft. Ft. Ft. Ft"°-RE( tE Ivr'u Ft. ~o Ft FL to MAgt.1 1 199 F~ ~iqty et Anchorage ept. Health & Human Se~ic~ Ft. to Ft MISCL. INFORMATION: I tt DRILLER'S NAME MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES PO BOX 196650 ANCHORAGE, ALASKA 99519 343-4744 HAND WRITTEN PERMIT Permit Number: SWq}~c~Lb~ Permit Type:~ Date Issued:/-~-~/ .. Expiration Date:/-~Z' Design Engineer:Sf~f~,~w,~4 Owner Name: M~Yk~/~ oWner Address: 8~2q Parcel ID: Lot Legal: : ~ Township: Lot Size:~ (sq.ft. Max Bedrooms: This Permit: SEPTIC TANK: Minimum septic tank capaciky:~ gallons. Each septic tank must have at least 2 compartments, insulation is required if depth to top of septic tank(s) is less than 4.0' Lift stations require an appropriate electrical inspection. WELL LOG: A copy of the well log must be sent to DHHS within 30 days of the well's completion. Day Phone:~-f~Z I CERTIFY THAT: 1. I will install the on-site sewer system and/or well in accordance with all codes and regulations of the Municipality of Anchorage (MOA) and State of Alaska , and in compliance with the design criteria of this permit. 2. I will adhere to all MOA and State of Alaska requirements for separation distances from any existing well, septic system, or surface water on this or any adjacent or nearby lot. 3. I understand that this permit is valid for a single family dwelling with a maximum of ~ bedrooms. I also understand that any enlargement will require an additional permit. 4. I understand this permit is issued for 365 days and expires one year from the date of issue. 5. I will notify DHHS prior to all inspections by the engineer or well driller. ' /'J DATE' I'lO" ?l SIGNED ~ '~ - · db/ll5 L ": / I I I ~ 1 I I I I I I I I MUNICIPALITY OF ANCHORAGE Development Services Department c Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 020-411-33 Legal description PARADISE VALLEY BLK 4 LT 39A Site address 18201 SPAIN DR Anchorage AK Current property owner(s) FOXLEY Expiration Date: Z Y `,0 Z XThe On -site system(s) is/are approved for 3 bedrooms Conditional approval for Comments or advisories: M bedrooms, with the following stipulations: Original Certificate Date: ' Z V2 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory x Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 MUNICIPALITY OF ANCHORAGE o�� 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. 020-411-33 Complete legal description PARADISE VALLEY BLOCK 4 LOT 39A Location (site address) 18201 SPAIN DRIVE, ANCHORAGE, AK 99516 Current property owner(s) SCOTT G FOXLEY Day phone 2. ON -SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ® Plastic ❑ Concrete ❑ Fiberglass Age _NEW - 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 $ S— 0 Waiver Fee $ Date of Payment I 2 Z 2.0 2 Date of Payment COSA # -S C 2- `7 l ( Waiver # COSA Application.doc COSA Checklist.docx COSA Checklist Legal Description: PARADISE VALLEY BLOCK 4, LOT 39A Parcel ID: 020-411-33 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 3/1991 Total depth 260 ft Cased to 138 ft (MOA received log 3/11/92) Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 1/24/2024 Static water level at beginning of test 153 ft. Well production at time of test 1.9 gpm Water storage tank volume NA gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate *8.01 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date 12/04/2023 Comments *Higher nitrate levels indicative of the area’s aquifer & results was less than the last test of 9.58 mg/L on 9/16/2018 per MOA file. B. TANK DATA Measured operating fluid level in septic tank NA Date of pumping NEW TANK Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA – (*In order per trench “MT1, MT2, MT3 & MT4”) Which system tested (date installed) 10/24/1990 ALL standpipes present per record drawing Total measured depth from grade 8.7 ft (max) Measured depth to pipe invert from grade 5.0 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 *1.6’, 0.9’, 1.3’ & 1.5’ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced 2000 gallons 1/23/2024 date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date 1/24/2023 Results Pass Fluid depth prior to test *1, 3, 2 & 4 in Water added 780 gal New fluid depth *2, 6, 5 & 14 in Elapsed time 1440 min Final fluid depth *0, 0, 0 & 2 in Absorption rate 450 gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) 30 in (MOA 2.5’ ED) Effective depth used *11, 19, 14 & 14 in (Missing ED + Final Fluid Depth) Effective depth (ED) remaining *19, 11, 16 & 16 in Comments/Deficiencies: Approximate total measured depths from existing grade. Per elevation measured shots of the 4 trenches, the measurable ED appears approximate as follows: MT1 1.6’ or 19”, MT2 0.9’ or 11”, MT3 1.3’ or 16” & MT4 1.5’ or 18” of ED. This is a cascading absorption trench system. 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 *8 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 *Septic tank is outside the soil bearing prism. 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 2/20/2024 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 & 2/20/24 Nitrate Advisory Certificate of On -Site Systems Approval # OSC241041 Subdivision: Paradise Valley, Block: 4, Lot: 39A A water sample revealed a nitrate concentration of 8.01 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. rrM M ORRA =�� t s� Eyx - �a, sa ,� Mailing Address P � Box 196650 *kAnchorage;Alaska'99519 6650 * www muniorg � k t • •�� '� Municipality of Anchorage On-Site Water and Wastewater Program •: (907)343-7904 SA ®;� ,Y Certificate of On-Site Systems Approval 020-411-33 Parcel I.D. Expiration Date: I4-t 1. GENERAL INFORMATION Complete legal description Paradise Valley Block 4 Lot 39A Location (site address) 18201 Spain Dr. Anchorage, AK 99516 Current Property owner(s) Justin Mills Day phone Mailing address 18201 Spain Dr. Anchorage, AK 99516 Real Estate Agent Day phone 2. TYPE OF DWELLING: Q Single Family(w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received b • Pi4.I S m I i A Date: 972/06 COSA to be released to a nee, • -ss otherwise requested engineer. • COSA Fee $ 140 Waiver Fee $ Date of Payment 61 I i-Jti Date of Payment Receipt N umber O235-0.D Receipt Number COSA# O'C 1214n 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 andlor 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. In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system.These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system.The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone Date 9/13/2018 j*,,- • wu is 9*v 6. DSD SIGNATURE / ..0110 System#1 Approved for 3 bedrooms hririone . System#2 Approved for bedrooms T# 9 • CE-8149 Disapproved k /Rp 0i - • ♦� / `Conditional approval for bedrooms, with the following stipulations: Ave'to`j-P t f-PM c( c- c ph c I C t S 2_0 yrs o.i 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 Othedtk COSA blue sneel! .. If more than 1 septic system is on the lot: COSA Checklist# 1 of 1 Structure served by this system i Certificate of On-Site Systems Approval Checklist Legal Description: Paradise Valley Block 4 Lot 39A Parcel ID:020-411-33 A. WELL DATA Well type Private If A. B, or C provide PWSID# Well Log(Y/N) Y Date completed 03/11/1992 Sanitary seal (YIN) Y Wires properly protected(YIN) Y Total depth 260 ft. Cased to 138 ft. Casing height(above ground) 12 in. FROM WELL LOG AT INSPECTION Date of test 03/11/1992 4/6/2017 Static water level 150 ft. 88 ft. Well production 1.5 g.p.m. 1.4 g.p.m. WATER SAMPLE RESULTS: Coliform J\)-=G colonies/100 mL Nitrate C1,, ?.% mg/L • Arsenic I D ug/L Date of sample: 9!)Lo 1 ib Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 10/24/1990 Tank size 1000 gal. Number of Compartments 2 Cleanouts(Y/N) Y Foundation cleanout(YIN) Y Depression over tank(Y/INS)) N High water alarm(Y/N) N Date of pumping`-7/i i/ / Pumper A ' -brYlQ_ SCS vi(i2.c,1 1 NC_... C. ABSORPTION FIELD DATA Date installed 10/2411990 Soil rating (g.p.d./ft2 or ft2/bdrm) 225 SF/BR System type Shallow Trench Length 90 ft. Width 5 ft. Gravel below pipe 2.5 ft. Total depth 6.2 ft. Eff.absorption area 703 ft2 Monitoring tube Y Depression over field N Date of adequacy test 4/6/2017 Results Pass/Fail ( ) Pass For 3 bedrooms Fluid depth in absorption field before test 4 in. Water added 455 gal. New depth 9 in. Elapsed Time: 230 min. Final fluid depth 4 in. Absorption rate >= 450+ d 9•P• No Any rejuvenation treatment(past 12 mo.)(Y/N&type) If yes,give date • D. LIFT STATION Date installed Size in gallons Manhole/Access(YIN) "Pump on"level at in. "Pump off'level at in. High water alarm level at in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES • WELL ON LOT TO: Septic tank/lift station on lot 1 00+ On adjacent lots 100+ Absorption field on lot 100+ On adjacent lots 100+ Public sewer main 75+ Public sewer manhole/cleanout 100+ Sewer/septic service line 25+ Holding tank 100+ Animal containment areas 50+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Absorption field 5+ Water main 10+ Water service line 10+ Surface water 100+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water main 10+ Water Service line 10+ Surface water 100+ Driveway,parking/vehicle storage 1 0+ • Curtain drain 50+ Wells on adjacent lots 100+ • F. COMMENTS ,Sv-fZVe`? G. ENGINEER'S CERTIFICATIONOF AL `klk I certify that 1 have determined through field inspections and �P• `4•••��t review of Municipal records that the above systems are in fi' .• . d : y / !r conformance with MOA COSA guidelines in effect on this date. • •�� • � Steven R. Pannone Engineer's Printed Name .Sieve'12. •oririone Date 9/13/2018 ftp• CE-8149A� • COSA canary sheei_2-6-15.doc • • MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT l • 907-343-7904 On-Site Water and Wastewater Section Fax:343-7997 www.muni.org/onsite Septic Tank Advisory Certificate of On-Site Systems Approval # 0SC181488 Subdivision: Pardise Valley, Block: 4 , Lot: 39A Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 28 years old. Typical replacement costs range from $6,000 to $9,000. This advisory must be attached to all copies of the subject Certificate of On-Site Systems Approval. This is an example of what the metal of a 20 year old steel tank MAY look like. r. b r u .a / **At '-'mak �` :, r - .x y r rj _ n h. r, . "�►, ,, *- ‘`' ,.. . y fi3r r ` ::,,a,_,,r 20-5A22 :-., ,(„ , 4. iJ.„--a,'+o ., .rye _ t Mailing Address: P.0. Box 196650* Anchorage,Alaska 99519-6650 *www.muni.org ' - MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907-343-7904 On-Site Water and Wastewater Section Fax: 343-7997 www.muni.org/onsite Nitrate Advisory Certificate of On-Site Systems Approval # OSC181488 Subdivision: Pardise Valley, Block: 4 , Lot: 39A A water sample revealed a nitrate concentration of 9.58 milligrams per liter (mg/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On-Site Systems Approval. Mailing Address:P.0.Box 196650*Anchorage,Alaska 99519-6650*www.muni.org Nitrate Fact Sheet From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids,and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available,which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Mailing Address:P.O.Box 196650*Anchorage,Alaska 99519-6650*www.muni.org • • _� Municipality of Anchorage \,.`) On-Site Water and Wastewater Program , �� %Ll' (907) 343-7904 s A F _s• MAY 05 21 1111-Certificate of On-Site Systems Approval � ?,/'`" �w 020-411-33 ��° Parcel I.D. Expiration Date: f>� 1. GENERAL INFORMATION Complete legal description Paradise Valley, Block 4, Lot 39A Location (site address) 18201 Spain Dr Current Property owner(s) Alfred and Key Getty Day phone Mailing address 10975 Vosikof Place Anchorage AK 99507 Real Estate Agent Day phone 2. TYPE OF DWELLING: E Single Family (w/wo ADU) ❑ Duplex E Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: �/ t i Date: 5/15// 7- COSA to be released to the engineer, unless otherwise requested by the a !neer. COSA Fee $ 5g-t, Waiver Fee $ Date of Payment /57A Date of Payment Receipt Number V 9t4:47g§§ Receipt Number COSA# 641 ca t 1 cAs 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 infoffnation.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 installatl n. . „l In conducting an adequacy test, I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation dista,ricres,rwasured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition,grounidls ii ter I,¢ Is that may fluctuate during the year,and the water usage of the family being served by the system.These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone Date 5/4/2017 i�P�G OF ALQs�k� Al :, s •, Ne\�/. . . �/ 6. DSD SIGNATURE �] P `_ v System #1 Approved for _] bedrooms j . •She .0..,. a none ((( 6 -0,•. CE-8149 System #2 Approved for bedrooms • �4�gf•., i Disapproved �l�t�ENDFiSS� — Conditional approval for bedrooms, with the following stipulations: -ms `s ep ti L , ( ,,,,,k alat2,,, 4_,, 1:::, ON-SITE WATER AND r" m WASTEWATER o n PROCRAM `; O,o �� ��^rT,�'FC?�I,CV. By: u."-- k / Original Certificate Date: ,--(5 -( 7 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# 1 of ' Structure served by this system ' Certificate of On-Site Systems Approval Checklist Legal Description Paradise Valley, Block 4, Lot 39A Parcel ID: 020-411-33 A. WELL DATA Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y Date completed 03/11/1992 Sanitary seal (YIN) Y Wires properly protected (YIN) Y Total depth 260 ft Cased to 1 38 ft Casing height (above ground) 12 in. FROM WELL LOG AT INSPECTION Date of test 03/11/1992 4/6/2017 Static water level 150 ft. 88 ft. Well production 1 .5 g.p.m. 1 '4 g.p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/100 mL Nitrate 8.29 mg/L Arsenic ND ug/L Date of sample: 4/6/2017 Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 10/24/1990 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (Y/N) N Date of pumping 4/11/2017 Pumper A+ Home Services C. ABSORPTION FIELD DATA Date installed 10/24/1990 Soil rating (g.p.d./ft2 or ft2/bdrm) 225 SF/BR System type Shallow Trench Length 90 ft. Width 5 ft Gravel below pipe 2.5 ft Total depth 6.2 ft. Eff. absorption area 703 ft2 Monitoring tube Y Depression over field N Date of adequacy test 4/6/2017 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 4 in. Water added 455 gal. New depth 9 in. Elapsed Time: 230 min_ Final fluid depth 4 in. Absorption rate >= 450+ g.p.d. No Any rejuvenation treatment (past 12 ma) (Y/N & type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off" level at in. High water alarm level at in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100+ On adjacent lots 100+ Absorption field on lot 100+ On adjacent lots 100+ Public sewer main 75+ Public sewer manhole/cleanout 100+ Sewer/septic service line 25+ Holding tank 100+ Animal containment areas 50+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Absorption field 5+ Water main 10+ Water service line 10+ Surface water 100+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water main 10+ Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS U1/4)((\/ 0 137._. ���\\\\ G. ENGINEER'S CERTIFICATION AgkkSitk I certify that 1 have determined through field inspections and 6'4P _� . 97 6 review of Municipal records that the above systems are in Ff*; i' •,* conformance with MOA COSA guidelines in effect on this date. ,• • •• V41140— 0 • ••• 0 _� . � . A r Engineer's Printed Name Steven R. Pannone — /�' :•Sieveri IR. •onnone •' oiry ' 5/412017 t - CE-8149 Date �i}�4s�' _ ,�,r' % g44FE54130\�+ t\\1�� COSA canary sheet_2-6-15.doc Municipality of Anchorage K..j Development Services Department Building Safety Division . On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On-Site Systems Approval # OSC 171165 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 4, Lot 39A of Paradise subdivision. This inspection revealed a nitrate concentration of 8.29 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On- Site Systems Approval. Nitrate Fact Sheet From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ~----~'~ GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone ~% I~, ¢ Day phone Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front 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 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~'~t,4 ~C~l=-~ Address ~:b,~,~"~c~ /~/'2~?~ Engineer's signaturo~~'~ Phone Date DHHS SIGNATURE X Approved for ,j2 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date /¢ - 2~ ' ¢'~' I The Municipality of A~chorage 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. 72~25 (Rev. 1/91) Bac~ MOA ~'21 DEl 825 L~, Legal 1 A. WELL DATA ~ ' i Well type'-"~xoJ¥-v-~_~. ~ IfA B o~: C. attach ADEC h Log present (Y/N) · ~ Total depth Sanitary seal (y/N) Date of test Static Water level Well production WATER SAMPLE RESULTS: , -. ' ,. Coliform ' ' C:> --- Date of sample: - B. SEPTIC/HOLDING TANK DATA ~ . Date installed /O/2~/~'O Foundation cleanout (y/Iql C. ABSORPTION FIELD DATA ~!' ~ :: "' Date installed. ! 0 Length c~E>' Width Effective absorption area -z~.E Date of adequacy test ~I~ ~-~ ~ Results (Pass.ail) ~&~ For , . ~. " bedro0~s Fldd depth in abso~tion_field before [~st (in.);' / ,= ~ ~mme~ately ~er ~ g __ Fluiddepth [&~ (ihs.) Mlnutes :iater: Zq qo if AbS0~ti0n rate g-P-d. Peroxide treatment (past 12 months',) D. LIFT STATION Date installed Size in gallons Mauhole/Access (Y/N) "Pump off' level High water alarm level at* ~..~---~"~'- *Datum E. SEPARATION DISTANCES "Pump off' level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line ; On adjacent lots ', On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~ Property line ~,~ Absorption field Water main/service line ,9-~ Surface water/drainage g'c-~a>~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Surface water t' ~c9 f Curtain drain ENGINEER'S CERTIFICATION Water main/service line Driveway, parking/vehicle storage area '-'~'~_D Wells on adjacent lots ,/t:~9 t Property line ! certify that I have detertnined thrufield inspections and review of Municipal records in conformance with MOA HAA guidelines in effect on this date. Signature=_ Engineer's Name Date t'c>/r'~O[ HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.doc 12/19/96, 11:23 AM Steven R. Pannone, P.E. Consulting Engineer (907) 272-8218 Lot 39, Block 4 Paradise Valley Subdivision 18201 Spain Road Date Performed: November 28, 1996 Well Flow Data Time Water Meter Gallons Flow Level Reading Period Total Period Total 08:30 148 5635 0 0 08:35 155 5647 5 5 1.0 1.00 08:40 160 5662 6 11 1.2 1.10 08:45 167 5676 6 17 1.2 1.13 08:50 166 5691 7 24 1.4 1.20 09:O0 170 5721 13 37 1.3 1.23 09:15 168 5760 20 57 1.3 1,27 09:30 162 5801 19 76 1.3 1.27 10:00 164 5883 40 116 1.3 1.29 10:30 169 5967 38 154 1.3 1.28 11:00 167 6050 41 195 1,4 1.30 11:30 163 6129 39 234 1.3 1.30 12:00 170 6207 38 272 1.3 1.30 12:30 164 6287 40 312 1.3 1.30 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 CERTIFICATE OF HEALTH AUTHORITY. APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# /'~-J-~\\~ ("~-~ HAA# ~-~::~z3(~°~ 1. GENERAL INFORMATION Completelegaldescription LoT ~ ~'~ ~ : ~l~l~,$t~ Location (site address or directions) g Property owner Ma'i'~ing address Lending agency Mailing address Agent D~y phone Day phone Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well -.. PubJic water NOTE: ff 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 MOA#21 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 verifythat based on the information obtained from the Municipality of Anchorage files and from my invesfigatio, n, an..d 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 Address Engineers signature ~pprovod for ~odroom~. Di~pprowd. Oonditional approval for 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 DH HS does this as a courtesy to pumhasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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) Baok MOA#21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lo - A. Well Data Well type Log presont (W~) Total dopth 8anita~ saal (WR) Parcel i.D. If A, B, or C, attach ADEC letter. ADEC water system number ~ ~'..'.0 0 ' Cased to Date completed '~ Ic~ [ Driller ~'ULL&~/P~ Casing height Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot } ~:):,'~0 / Absorption field on lot I 0 ~ ! Public sewer main ~J I ~ Sewer service line I ~) '-~ I g.p.m. AT INSPECTION ; On adjacent lots'100'~ ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ~ I~ WATER SAMPLE RESULTS: Coliform O ¢o|o,~,~ /IOO ~LNitrate Date of sample: ~ ~ t O~, (~ ~ G._~ I~,,~/~._ Other bacteria /'~/~ Collected by: ~ o .~ T ~-]-~roe-~, ~,, ~,, B. SEPTIC/P~;;~i TANK DATA Date installed I O ' 7_ 4 - (~ O Tank size I OOO Compartments ~- Cleanouts (Y/N) YE'~ Foundation cleanout (Y/N) x'~iEc'~ Depression (Y/N) i~,,Jo~~ ~eM High water alarm (Y/N) ~%//~ Alarm tested (Y/N) ~.1 (iCi Date of pumping "~~~0-C1~-'-3 Pumper Ne~'~I.P~ 'Pu~P'~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(~ on lot I 0 TO property line qS Surface water/drainage On adjacent lots Absorption field Foundation ,~ I Water main/service line ~0 / CONTINUED ON BACK PAGE 72-026 (3/93)* Front C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at ,Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA .On adjacent lots Surface water Date installed ___~ O" Z Z~- ~ O Soil rating (GPD/FF) ~'Z ~ Length ~".~OI Width ,~ I Gravel thickness Total absorption area ~,~-~ ~C)Z'~ Cleanout present (Y/N) Date of adequacy test q* I O~ ~ % Results (pass/fail) Water level in absorption field before test ~;-~e_ ~ ~ ~ ~.~ Peroxide treatment (past 12 months) (Y/N) N O System type ~,-), Total depth Depression over field (Y/N) for %1--I 17.~ ~'-/_~.-- Bedrooms After test ~ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: on Well lot I0~ On adjacent lots I00$ IoJ~ r~ c~(~ Propertyline To building foundation ~'(-.~ ' To existing or abandoned system on lot jkd It"q} On adjacent lots Surface water Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. --- Signature~ ~~ ~~ .~:~ Engineers Name ~o~ ~ ~~ H~Fee$ ¢¢' ~ Waiver FeeS Date of Payment ~ ~-~/~ ~ Date of Payment Receipt Number / / ~ ~ ~ Receipt Number 72-026 (3/93)* Sack MUNICIPALITY OF ANCHORAGE MEMORANDUM WATER WELL ADVISORY HEALTH AUTHORITY APPROVAL During a recent Health Autherity Approval on-site inspection and test of the potable water /Suppzy welz on Lot 37 Subdlv!szon, the well s productivity was determined to be~,~ gallons per mlnut . The minimum well productivity required by this Department (AMC 15.55) for a ,~ bedroom residence is ~ ~ gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. JOHN T. FELTON, P.E. P.O. BOX 1504 PALMER, ALASKA 99645 ADEQUACY TEST FORM LOCATION: LoT DATE' INSPECTOR: ~ ~'~--~ TANK SIZE~ ~ O(f~ WORK ORDER: TEST RESULTS PASSED ~ , FAILED NO. of BEDROOMS: NO of BATHROOMS: CALC. PEAK LOAD: CALC. PEAK TIME: CALC. PEAK FLOW RATE MEAS. AVE. FLOW RATE NOTE; MEASUREMENTS ARE IN INCHES SEPTIC TANK LIQUID LEVEL-- ' RELATIVE RELATIVE TiME METER CUMULATIVE FLOW SEPTIC TANK READING VOLUME RATE LIQUID LEVEL SEPTIC TANK LEVEL S.A. S COMMENTS o TOT'ALS REVIEWED BY: LOAD = 150 GALLONS X NO. OF BEDROOMS DATE TIME = 2.5 MINUTES X NO. OF BEDRMS + NO, OF BATHROOMS ~c~ lq3I Zo~I 07-oo 0 io~" Dry 0 0 0 0 © 0 rf JOHN T. FELTON, P.E. ~" .'~ - P.O. BOX 1504 PALMER, ALASKA 99645 .... WELL FLOW TEST Date Work Order: " Well Depth: (ft.) ~ Inspector Static Water Level' [ ~ ~ {ft.) Casing Above Ground: ~ (ff.) Time Meter Volume Cum Flow Woler Comments Reoding (g~l,) Volume (gpm) Level (gal) Ave. (fl,) Static ~ ~ ~0~ ~1 ~ 441340* 1% ~ S~~ 0~ o~o5~Z~ Z[GL ~ II ~4SD 0 ~ This Well Produces On The Average For Tolal VOlume of Flow: ~ (gal,) Total Time of Flow: ~ ~'~ (mln,) Average Flow Rate: . ~ "~n (gpm) ~ Note: Aquifer I, ,ubject lo change over lime in some c~ses. / / SHEET of , ~_..~ ...... JOHN T. FELTON, P.E. . .... P.O, BOX 1504 PALMER, ALASKA 99645 %,,.. WELL 'FLOW TEST Date Work Order:. " _ Well Depth: ~0 ~4 (fL) ~, Inspector Slollc Woter Level: ~ ~ ..(ft.) Casing Above Ground: I (fl) ~P e Time Meter Volume Cum Flow Water Commenls Reading (gal.) Volume (gpm) Level (gal) Ave. (ft.) Slatic This Well Produces On TheAvemge ~i~'~''' (min.) Tolal Volume of Flow: ,,.(gal.) Total Time of FI Average Flow Role: . ~~~) REVIEWED BY: ~~~, x Note; Aquifer Is subjec* to chonge over time in some c~ses, SHEET 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot 39; Block 4; Paradis~ Valley Subdivision; Location (site address or directions) 18201 Spain Driv~ Property owner Ma~:;~d"~ ://' ':'': ~'' Day phone Mailing address 18201 Spain Drive Anchorage, Alaska 99516 Lending agency Mailing add'ress' Agent NATIONAL BANK OF ALASKA Day phone Day phone Address NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Unless otherwise requested, HAA will be held for pickup. NOTE: ×X Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 STATEi~IENT OF iNSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify [h~:~ my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposat 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 Address Engineer's signature Approved for ~'~-~ ~!/'~ bedrooms. Disapproved. Conditional approval for Phone Date bedrooms, with, the following stipulations: Additional Comments 7~ ~ ~ ~. ,.L ~/~_.. 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 & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. WELL DATA Well type ~2~,g Log present~) Total depth Sanitary seal ~N) Parcel I.D. ADEC water system number ~ - '~ ~, Driller ~ Casing height Wires properly protected (~N) If A, B, or C, attach ADEC letter. Date completed Cased to ~,'z2~ ~ FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~ c, c~ Absorption field on lot \ ~ Public sewer main Sewer service line On adjacentlots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~;) c.o~,~,~,.,~_. Nitrate Date of sample: '~"?"~ 'ClZ' / '~- [~ -~?-"- ?.... v~'~r-/~,.' Collected by: B. SEPTIC/HOLDING TANK DATA Other bacteria S & S ENGINEERING · .703~. E_-.~!e m,,~r I_~ep Road No. 204 Eagle River, Alaska 99577 Date installed Cleanouts (~N) High water alarm (Y,~ O Tank size Foundation cleanout(~/N) Alarm tested (Y/N) D~te of pumping ?~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \ c~o On adjacent lots ~, 'O~ ~"~ Compartments Depression (Y/I~ ~- ~'- To property line ~.o "~ Absorption field Surface water/drainage I c~ ~ \'~ Foundation Water main/service line 72-026 (Rev. 7/91) Front ' ' CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes ~ SEPARAT~ROM LIFT STATION TO: WL~on lot ' On adjacent lots Manufacturer Manh~---~ "Pump on" level at "Pump off" level at ~ Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed lO-'7~ -~:~ Length ~ ~;:>~ Width Total absorption area Depression over field ('~1~ ResUlts (pass/fail) Soil rating Gravel thickness ~-.~"' Cleanouts present Date of adequacy test for Total depth Peroxide treatment (past 12 months) (Y,~ ~ If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ C>c> ~ Property line To building foundation t o To existing or abandoned system on lot On adjacent lots "~ ~ \'~ Cutbank ~ Ip~ Water main/service line Surface water ~_~:>C.~ ~'¥- Driveway, parking/vehicle storage area Curtain drain ~1,~ , . E. ENGINEER'S CERTIFICATION On adjacent lots ~ c:~\~'- I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. S & $ ENGINEERING ~. . .' 4 Eagle River Loop Road No Engineer's Name HAA Fee $ /'?0 ~ o.,¢,- Date of Payment ~-~ ~2~. Receipt Number ~.~(~ ~ ~ ~ ~"~) · / 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number