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SILVER CREST BLK 2 LT 1
Silver Crest Block 2 Lot 1 #015-062-32 Municipality of Anchorage Development Services Department jCy: Building Safety Division On-Site Water and Wastewater Program. 4700 Bragaw SL /of 3 P.O. Box 190050 Anchorage. AK 995768650 Page www.d.anchorage.sk.us (907) 3437904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number. SW070156 PID Number. 015-062-32 Nr DON & KAREN LAMPRECHT Wastewater System: ❑ New Q Upgrade Ma... 9201 GROVER, ANCHORAGE, AK ABSORPTION FIELD F"01' Fwber to BFaaonM 4 D DW I wd D S M "7 - 0 D BW D Mona D cow LEGAL DESCRIPTION Sar RWq no change Gpowe T" D.pn Ian apnl v.a. Fl. ll "2 La 1 sk�� SILVER CREST DeoelwPv.eaea"Ma"WIM G� Owe,w P" FI. Fl Tm W Rrge S.ceal FM.aJM MMw OnprMlp0 Gn L/qal. Fl. Fl. Well: New ❑Upgrade r«.nrarw �� Fl. Ft cIHYMI9an (Pour.• A B. cF Tan DWftC.Ma to T.m.baplcn rM Pp MM private Fl. Fl Fr Orer DM. D� stl war L.wl. .eats« A+ Home Services, Inc. Dw.wr.a 723/07 Ft YM1a PMN SMw ""N's"..%. MowW TANK cw FI. Fl SEPARATION DISTANCES 0 Septic ❑ Holding ❑ S.T.E.P. ❑ Other: To From Septet Tank Absorption Field Uft Station Holding Tank lubWPOnle Se LM itl V. Anchorage Tank & Welding T 1250 G.1 MM M acaN.a,rn w.F 101 110 — — 86 STEEL 2 rWUWwn., too+ 100+ _ _ LIFT STATION La U" 70+ 13 — — GM •Pori Mwl.l -P" 'PMN WMWK Myrwr.lrm M. FOMibean 2Q+ 40+ _ _ h h h PMN MM. a Moats EMarrMl Inp«..anF prbnnU OY C~D% R«"r"'BENCH No work performed on drainfield, except a monitoring MARK LocMnn «q tube was installed. Tank was Insulated. Old tank was sliding glass door threshhold abandoned in place. v.ua• 100.00 Ft Engineees Stamp Inspections performed by: Cindy W. Ellis Dates: 1M 723/07 F 2"a P��,...R.......q�q r% Development Services Department Approval `9 49LN' Conditional Approval Date: Clio y W. Ellis CE•losn 7 Reviewed and approved by: e/'Date: - m.. ower 62A y'y, '�'FESSIOtiP•LG J AS -BUILT CO 2 DC01 C`2 ST1 C01 \ FC A 4BEDROOM HOUSE A Based upon an asbuilt survey by LanTech dated September 11, 2007 N90000'00' W 141.71' GROVER DRIVE W 0 0 0 0 0 0 Silver Crest Blk 2 Lot 1 Record Drawing P P9 of Septic Upgrade Q.F. At 0 Don &Karen Lamprecht 4" cO: LH o.: 49 Parcel ID:015-062-32 Watkins Engineering, Inc o.../ ................... Permit No: SW070156 Cindy W. Ellis, P.E. P.O. Box 110443 December 15, 2007 Anchorage, Alaska 99511-0443 Scale 1 Inch - 30 ft Phone: (907) 349-1851, Fax: (907) 349-1934 A B FCO 26.4 STI 40.0 34.0 ST2 43.5 42.0 DC01 41.8 45.9 DCO2 42.8 43.9 CO1 30.0 31.0 CO2 38.5 50.5 MT 48.5 67.0 SUMP 70.6 105.0 A Based upon an asbuilt survey by LanTech dated September 11, 2007 N90000'00' W 141.71' GROVER DRIVE W 0 0 0 0 0 0 Silver Crest Blk 2 Lot 1 Record Drawing P P9 of Septic Upgrade Q.F. At 0 Don &Karen Lamprecht 4" cO: LH o.: 49 Parcel ID:015-062-32 Watkins Engineering, Inc o.../ ................... Permit No: SW070156 Cindy W. Ellis, P.E. P.O. Box 110443 December 15, 2007 Anchorage, Alaska 99511-0443 Scale 1 Inch - 30 ft Phone: (907) 349-1851, Fax: (907) 349-1934 AS -BUILT Silver Crest Bik 2 Lot 1 Record Drawing of Septic Upgrade Don & Karen Lamprecht Watkins Engineering, Inc. Parcel ID:015-062-32 Permit No: SW070156 Cindy W. Ellis, P.E. P.O. Box 110443 December 13, 2007 Anchorage, Alaska 99511-0443 No Scale Phone: (907) 349-1851, Fax: (907) 349-1934 To Existing Drainfield OFA -app o> ...............1 49TH y� ............................ . E - 10577 'c MUNICIPALITY OF ANCHORAGE Development Services Department lO On -Site Water B Wastewater Program 4700 South Bragaw Street \0'( P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Date Issued: Jul 12, 2007 Expiration Date: Jul 11, 2008 Permit Number: SW070156 Parcel ID: 015-062-32 Legal Description: SILVER CREST BLK 2 LT 1 Design Engineer: 0844 WATKINS ENGINEERING Site Address: 009201 GROVER DR Owner Name: DON & KAREN LAMPRECHT Lot Size: 43961 SQ. FT. Owner Address: 9201 GROVER Total Bedrooms: 4 Permit Bedrooms: 4 ANCHORAGE. AK 99516 - This permit is for the construction of: ❑ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must be In accordance with: 1. The attached approved design. 2. All requirements specked 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 engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: Date: Date: z 7 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, Alaska 99519-6650 www.muni.org/onsfte (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-062-32 Property owner(s) Don & Karen Lamprecht Day phone Mailing address 9201 Grover Drive, Anchorage Zip Code 99507 Site address same Zip Code Legal description (Sub'd., Block & Lot) Silver Crest Block 2 Lot 1 Legal description (Township, Range & Section) Lot Size 43,961 Sq. Ft. THIS APPLICATION IS FOR (® all that apply): Absorption Field ❑ Septic Tank Q Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms 4 THIS APPLICATION IS AN: Initial ❑ Upgrade 0 Renewal ❑ certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. I 6;Ad4dV et_� 10 c. (Signature of property r><ylner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number. (Rev. 11105) f lM£ 9f t", 1 Waiver Fees: Date of Payment: Receipt Number. Watkins Engineering, Inc. P.0 Box 110443, Anchorage, AK 99511 (907)349-1851 cwellis®gcLnet July 10, 2007 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 RE: Silver Crest Block 2 Lot 1 Proposed Septic Tank Replacement To Whom It May Concern: Attached please find an application to install a new 1250 gallon steel septic tank at the referenced 4 bedroom house in Anchorage. The existing septic tank, installed in 1977, appears to have failed and will be abandoned in place. No work is proposed on the drainfield, as it passed an adequacy test performed on July 3, 2007. Thank you for consideration of this permit application. If you have any questions or need further information, please call me at 349-1851. Sincerely, Cindy W. Ilis, P.E. President BBOTT ROAD / ---- ---------- --------------------- --- 2 1 / 1 g 4 Existing Sep tank WELL WELL / to be aband ed in placeappro:imate Location Approximate E is2g d infield Location dd SeptioArea w rk oposed Prop se eatictank \ LISA CT._ 4A 1 8 N co W w Septic Area I t i I �l WELL 1 -------- ------------- �,1 -------- ------------- 8 N 0 2 Silver Crest Blk 2 lot 1 Site Plan for Tank Replacement Don & Karen Lamprecht Parcel ID:015-062-32 BLOCK 1 Septic Area BLOCK 2 J 65 WELL Septic Area WELL 1 Septic Area 6 5 7 — — — — I --------- _-----------� --- 8 I \ , Watkins Engineering, Inc P��" "-At- 49 T t-4978 Yd Cindy W. Ellis, P.E. P.O. Box 110443 app. `., 01a Y: July 10, 2007 Anchorage, AK 99511-0443 dpGE Scale: 1' =100' Phone: (907) 349-1851 Fax: (907) 349-1934 I I I i I I Property line is 64 ft north Install 10/4/77 drainfield MT 6 ft effective MT driven shallow 6/13/07 sump I 5 f minimum 1250 gal steeV septic tank, Installed 10/4!77 failed - to be abandoned in place Install DCO F_ CR M CO N H O Z oProposed new 1250 gal steel septic tank C1*19RU L=141.7 Silver Crest Bik 2 Lot 1 Proposed Septic Tank Replacement Watkins Engineering, Inc. Don & Karen Lamprecht Parcel ID:015-062-32 Cindy W. Ellis, P.E. P.O. Box 110443 July 10, 2007 Anchorage, Alaska 99511-0443 Scale 1 Inch - 30 ft Phone: (907) 349-1851, Fax: (907) 349-1934 100 ft 11UNICIPALITY OF ANCHORAGE Hea.' and Environmental Protec >n Fourth Floor West 825 L Street Anchorage, Alaska 99501 264-4720 --\— IN5PEC`CION REPORT ON 51TE SLS/tJI-_,GE DISI_'C_�--SAL SYSTUA c NAMFZ,-_---'��="�� MAILING ADDRESS�GCJ_%'Jc-' "(�`'..`a'__—PHONE1`` LOCATiON�`1_ Ptz t --- LEGAL DESCRIPTIONr��w7.-�"�"" �� �J 64[J SEPTIC TANK: DISTANCE`� NUMBER OF FROM W .LL _�T®� MANUFACTURER _'� � e � �'•1A7ERIAL �� 1 - COMPARTMENTS �— '`-I-N--S�IDDEE LENGTH____--.-_ __ INSIDE WIDTH_-- LIQUID DEPTH ___ LIQUID CAPACITY 4�--SG4I_LONS. J- TOTAL LENG7 DISTANCE FROM WELL /_'U `OFOUNDATION-3 -':'----NEAREST LOT LINE- _____rte_ OF LINE-- # Of Lines - - -- DISTANCE BETWEEN LINES N _-__TRENCH WIUTI-1� IN. TOTAL GFF6CTIVE ABSORPTION AREA __ l P O SQ, FT. LENGTH OF EACH LINE --- I DEPTH OF FILTER �/ DEPTII: TOP OF -TILE TO f=1NISH GRADE _ —MATERIAL BENEATH TILE IN. ABOVE TI LEN//IN. SEEPAGE PI r: DIiiMEfER __-._ OR WIDTH -_, LENGTH_ DEPTH Log Crib _Rings_ Crib Size: DIAMETER___-DEPTII._—DISTANCI= FROM: WELL TOTAL.. EFFECTIVE BUILDING FOUNDATION . , NEAREST LOT LINE--- . ABSORPTION AREA (WALL AREA) -SQ. FT. Well P Class: uG Depth: Well Distance To: Lot Line Bldg: Sewer Line: Pipe Materials: (Z� # of Bedroo - Installer: Remarks: DATE /0 .�_�APPROVEV _.-- ld•gnoJL9 'L� r. 1 -C- iucr�3� E. I i til -C= 1-_i_ I � -�— iI- i _NTI : III III�iC��iII �I DATE /0 .�_�APPROVEV _.-- ld•gnoJL9 ����, 0,k�A0-I P.. J. U `w A A -1 FRm-1 M. DFPHH|MEN| U) .|LHL|H HNo N U�5 'L' �|kEE|HNCHUHHGE, HK 9��W1 tot On h1 � ���� ������ �U`� o ����� ������ �0' ~`� P�KM1 [ NU ( 7781l ) / |1PPL1CHNlSA�.11 [KUC| y]N I810 L WOOD LUUP l492I16 LUCHllUN GHUvER DRlV6 LEGHL LU| 1 8L 2 SlLVEk UHI I:- 1 |YPE UF SU1L H8SOR8TIUN SYSlEM 1RENCH MHXlMUM N1.1M8ER 0F. 86DK4 SUlL kHllNG (SQ FT/B120 THE H�QUlR�D SlZE VF THE �OlL n�SUHPTlUN SYSTEM lS� ' 114 13 1^�� �fA_ 0 1111� � ' / N ~EE) OF THE TRENCH OR DRHlNFIELD lHE LENGTH DlMENSION I5JHE L£NGTH (I F | [HE DEPlH UF H TRENCH/OR. PlT IS |HE DlSlFIN CE BE[WEEN lHE SURFHCE UF I 1:-.: ' GROUNU HND THE BOTTOM OFIHE EXCHVHTlGIN (lN FEET) TH�R� lS NO SET WIDTH FUH THENCH�S TH� GRH;EL����TH lS THE MINIMUM DEPTH 1 [F. GRHVEL 8E[WEEN THE OUlFHLL PlPL:. HND lHE BU OM OF THE EXCHVHTIUN (IN 1- 6ET) \ �OR VA 1. 11 o..'.��� ����~K��� ^������ ����� nL��Y �����C���� . ' ` to" 101 CO u< ILI KJ W �I __ pit VVA - I' Rio OW, U`1 K -A V-4 ~~.... �����.... � H PHCKHGE PLHNT MHY BE lNSTHLLED Hl l4AE PERMlT��EE'S UPTIUN SUBJECT TO THE FULLOW1NG CONDlllONS� 1EllFill H CLFES S l UH I] NSF HPPRChi GD PLHNT MHY BE 1NSTHLLEI 2H COkiTINUUUS I'll HINTENHNCE HGREEMENl� 1� REQUIRED� IF H MHlNTENF�K�� HGREEMENllS NUT KEPl CURRENT YOU MHY 87: HEQU1R�D I ENLHRGE TH� �UlL HHSURP|ION SYSlEM HND/OR YOU MHY 8E 5UBJECT -1 (J PRI'S ECU[lON, _... ........ ��......... ����~__.��_��~~��_....... ��_.�~��������� �-- ��-.0 J: 1: CAN&, ��pc-n� 4 .: HL-� II.—If AL P.: -n P.L.,-, ~~� BHCKFlLLlNG OF HNY SYSTEM WITHOUlF FlNHL 1NSPECTI(�JHND HPPRUVML BY lHI� �� DEPHHTMEN| WILL BE SUBJ6CllU PROS�C@lON' I'll NlMUM DISlHNCE BElWEEN H WEL!, HND HN -r' IlE SEWHGE Dl5PUSHL L -M IS 100 FE�l FUR H PRIVHlE WELL OR 200 FEE| FOk H PU�LC WELL ` WELL LOGS HRE REQUlRED HND MUST 8E R2TURNED lO THE",DEPHRTMENT 1-11 1+111,1 HYS UF HE. WELL TION. � 0HER KEQUIREMENTS MHY HPPLY, SPECIFICHTIUNS HND 0]NSTkUCl1ON DlHGRHMS 1`11".., 1, � HVHIiHUL� |U lNSUR� PRUPEH 1N�[HLLH[IUN � '! / ~ 11`11 IL11 11 4,11 - -9 0 -.:! 4 ��R=_ 11-1 L i"- U�_ 0-o:! ���� l CERTlFY l'HHT 1 I HM FFill lLlFMR WlTH THL REG!UlREll ENVS FUR ON--SITE SEWER�o HND WELLS HS SET FORTH BY lHE MUNICIPHLITY OF HNCHORHGE. 2� I WlLL 1NSTFI) L -1 off:, SYSTEM lN HCCURDHNCE WITH THE CUb�S �� l UNDEk�THND |HHl THE SEWER SYSTEM MHY REQUIHE R6SlDENCE lS REMODELED TO lNCLUDE MURE lHHN 4 8�DHOOMS HPP `HNl STEPHENS 0aNSMUM IUN �. .� & ~W DRILLING, INC.( .\ /\v DRILLING LOG UseWell Owner .z(o`xu of Well Location (address of: Township, Iluu0o. Seotbon, if known; or distance main road V'� �/ Size of of Hole eet Cased to feet Static water level ft. (above) (below) land surface. Finish ofwell (check one) open end Screen Perforated ( � /i Describe aorceu or perforation Well ynnuDiog tent at � gallons per (hour) (minute) for � hours with t' of druvvdovvo from static level. Date ofcompletion ' Depth in feet from ground surface Give details *f formations penetrated, size odmaterial, color and hardness TO- TO— 0_--_---- ^ To— TO------- -_--�--_TO---�------ A.'! Si!L}r TO_�__ -_-_---'7O-_-_----- ---�-�-_,2[L-_-��---- �i 70 ---____-TC)--_-_---_ --���_--T0--_��---- ^^ )|/ | �~/ T[)-` '^` --_ --T0-_------_ -____---'------- /\Co1i|�i'idConbxrkm� ---_--__TO--__----_ TO______ IO______ -------- 2-6TATE Municipality of Anchorage G`t On -Site Water and Wastewater Program _ (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 015-062-32 1. GENERAL INFORMATION Complete legal description SILVER CREST BLOCK 2 LOT 1 Expiration Date: Location (site address) 9201 GROVER DRIVE, ANCHORAGE AK 99507 Current Property owner(s) HANK & MONIQUE BACA Day phone Mailing address Real Estate Agent 9201 GROVER DRIVE ANCHORAGE AK 99507 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 4 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 ❑ Received by:Date: COSA to be released toAhe engineer, unless otherwise requested by the engineer. t e� COSA Fee $ C 0# 3 Waiver Fee $ Date of Payment Date of Payment Receipt Number 0'4 585 i Receipt Number COSA # 0Se 13 tb 30► 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 ARCTERRA CONSULTING, INC. Phone 868-3791 Address _20441 PTARMIGAN BLVD., EAGLE RIVER AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date OT/04/2013 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and sepfic 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 inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. 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, ArcTerra can not give any estimate of how long a , system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen "' + OF y encroachments, deficiencies or discrepancies exist.,'} q 6. DSD SIGNATURE M The Municipality of q System #1 Approved for bedrooms. System #2 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Original Certificate 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 '• 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: SILVER CREST BLOCK 2 LOT 1 Parcel ID: 015-062-32 A. WELL DATA Well type PRVT If A. B, or C provide PWSID # Date completed 912311977 Sanitary seal (Y/N) Y Total depth 105 ft. Cased to 105 ft. FROM WELL LOG Date of test 912311977 Static water level 65 ft. Well production 6 g.p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/100 mL Nitrate 1.96 mg/L Arsenic: ND ug/L Date of sample: 12127112 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1250 gal. Number of Compartments 2 Foundation cleanout (YIN) Y Depression over tank (Y/N) N Date of pumping 12127112 Pumper A+ C. ABSORPTION FIELD DATA Well Log (Y/N) Wires properly protected (Y/N) Y Casing height (above ground) 24 in. AT INSPECTION 1212712012 ft. 2.8 g.p.m. Collected by: ARCTERRA Date installed 712312007 Cleanouts (Y/N) High water alarm (YIN) N Date installed 1010411977 Soil rating (g.p.d./ft2 or ftz/bdrm) 120 System type TRENCH Length 4 4l,� ft. Width 3 ft. Gravel below pipe 6 ft 5S2 Total depth 10.8 ft. (Measured 12/27/12) Eff. absorption area 480 ftz Monitoring tube Y Depression over field N Date of adequacy test 1212712012 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 46.8 in. Elapsed Time: 1440 min. Final fluid depth 46.6 in. Water added 600 gal. New depth 58.8 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at —in. Datum Size in gallons "Pump off' level at —in. Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption Feld on lot 1004 Public sewer main 75'+ Sewer/septic service line 25'+ Animal containment areas 50'+ SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank 100'+ Manurelanimal excrete storage areas 100'4- Building 00'+ 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'+ (NONE KNOWN) Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I 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 KENNETH M. DUFFUS Date 0110412013 COSA brown sheet 9-1-12.doc c t �axKsri � �4r c nea in. Municipality of Anchorage • Development Services Department Building Safety Division On. -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsfe (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. 015-062-32 1. GENERAL INFORMATION Complete legal description SILVER CREST BLK 2 LOT 1 COSA #_ C2jgL{ 4 Expiration Date: 3— 2 n •- C? R Location (site address) 9201 GROVER DR, ANCHORAGE, AK 99507 Current Property owner(s) DON d, KAREN IAMPRECHT Day phone Mailing address 9201 GROVER DR, ANCHORAGE, AK 99507 Lending agency Day phone Mailing address Real Estate Agent BILL BABYLON /PRUDENTIAL REAL ESTATE Day phone 907-273-7531 Mailing Address 3801 Centerpoint Dr., Suite 200 Anchorage, AK 99503 Unless otherwise requested, COSA wr71 be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well El Individual On-site 0 Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given In paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Onsite Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of Onsite Systems Approval are valid for 9D days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, Guidelines or that his investigation, on, based on procedures outlined in the Certificate of On -She Systems Approval shows that the on -she 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 Finn Watkins Engineering, Inc. Phone 907-349-1851 Address P.O. Box 110443, Anchorage. AK 99511.0443 Engineer's Printed Name Cindy W. Ellis, P.E. Date �Z' b% 6. DSD SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report [OIL�1 By, Original Certificate Date:ter)--0'7 (a«.11A5) a Municipality of Anchorage .. Development Services Department E Building Safety Division On -Ste Water & Wastewater Program : • ' •' '; 4700 Bregaw Street P.O. Box 196650 Anchorage, AK 9951943650 www.muni.orglonsRe (907) 343.7904 k CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SILVER CREST BLK 2 LOT 1 Parcel ID: 015-062-32 A. WELL DATA W80 type PRI K A B, or C provide PWSID >i _ Well Log (Y/N) YES Date completed 9/23!77 Sanitary seal (Y" AS Wires property protected (YIN) YES Total depth 105 ft.Cased to 105.8 R. Casing height (above ground) 4 `i In. I: FROM WELL LOO AT INSPECTION Date of test 9123/?7 7/3/07 Static water level 65 ft. 71 R. Well production 64 G 9.p -m. 2.3 9 -P.M. WATER SAMPLE RESULTS: Coliform 0 colonlea1100 ml. Nitrate 1.08 mglL Other bacteria 0 colonies/100 mL Arsenic: <0_005 mgA Date of sample: 1216107 Cotlected by: Rocky Tama / Madns Engr B. SEPTICIHOLDING TANK DATA Tank Type/Material STEEL Date installed 7123107 Tank size 1250 gal. Number of Compartments 2 Cleanouts (YIN) YES Foundation cleanout (YIN) YES Depression over tank (Y/N) NO High water alarm (YRS WA Date of pumping 6129/07 Pumper A+ HOME SERVICES C. ABSORPTION FIELD DATA Date installed 1014!77 Soil rating (g.p d.IR or fe/bdrrn)120 System type TRENCH Length 45 ft. Width 3 ft. Gravel below pipe 6 R. Total depth 10? R. ER. absorption area 180-11? Monitoring tube YES Depression over field No Data of adequacy test 7125!07 Results (PasslFaiq Pass For 4 bedrooms Fluid depth in absorption field before test 44.75 n. Water added15-0 gel. New depth 62.75 n. Elapsed Tare: 60 min. Final fluid depth 59.5 in. Absorption raft >- 600 g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN 3 type) No If yea, give date D. LIFT STATION Date installed NA Size in gallons 'Pump on' kml at _ in. 'Pump oft' level at _ in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septi tankAitt station on lot 101 Absorption field on lot 110 Public sewer main 100+ Sewer /septic service line 88 Animal containment areas 100+ Manhole/Access (YM) High water alarm level Meats alarm R circuit repuirrnents9 On adjacent lots 100'+ On adjacent kits100'+ Public sewer menhoWdeenout 100+ Holding tank 100+ Manure/animal excrete storage areas 100+ In. SEPARATION DISTANCES FROM SEP71CIHOLDING TANK ON LOT TO: Building foundation 20+ Property pine 70+ Absorption field 10+ Water main 100+ Water service line 50+ Surface water 100+ Wells on adjacent kris 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 13 Building foundation 40+ Water main 100+ Water Service line 70+ Surface water 100+ Driveway, moUlngIvehicle storage 80+ Curtain drain none lopwn Wells on adjacent loft 100'+ F. COMMENTS: A new monaoring tube was lolled in the dminbeld on 7r23W by axwvaeng to the top of are lateral and driving a perforated steel pipe to the bottom of the bench. Tank was moved ti It on 8129 to get outside the well radius, due to a survevino error. 0. ENGINEER'S CERTIFICATION 1 car* that 1 have determared through Bold inspectim and review of Municial records that the above systems are in corAamance with MOA COSA guidelines in elfed on this date. Engineers Printed Name Cindy W. Ellis, P.E. Date (2, 11 -o*7 COSA Fee S Waiver Fee $ _ Date of Psyment P, Date of payment Receipt Number ]%)3 Receipt Number (Rev. 11/05) W. Ellis SCS ReCN 1076405001 Client Name Watkins Engineering Project Name/4 Silver Crest Blk 2 Lot 1 Client Sample ID Silver Crest Blk 2 Lot 1 Matrix Drinking Water PR'SID 0 Sample Remarks: All Dates/flmes are Alaska Standard Time PrintedDatefime 12/132007 11:51 Collected DateMme 12/062007 16:09 Received DateMme 12/062007 16:40 Technical Director Stephen C. Ede Allowable Prep Analysis parameter Rcsults PQL Units Method Comaincr ID Limits Date Date Init Metals by ICF/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 12/07/0712/12/07 M11 Waters Department Total Nitmte(Nitrite-N 1.08 0.100 mg(L SM204500NO3-F B (<10) 12/07/07 LCP Microbiology Laboratory Total Coliform 0 coU100mL SM209222B A (<1) 12106107 SDP ABBOTT ROAD 0 0 to to S 8959'22" E 119.86' 3p,r4/ 10' TELEPHONE & ELECTRIC EASEMENT DO----------------- u ;yam O 2 _ LOT 1 Or ° OR 0 0 0) QI C; N LL1 n W ors `WLOT 2 o 31.1 }rx—x—x�% PSC PIPE 41.9 O _ N M O x O 3 c O 5,3 e N rn N lA 26.0 p to -� 25.3 EXISTING HOUSE o 34.8 0 Do ...... ............ A OF F. ..... 30 oo� 4 D �Jr' TH 0..... { Q pp3 :. . N90'00'00"W 141.71' Q OQ�. ;ant y on.. p 0 0 a� LS -9020 p� Z��oov M M — — �, GROVER DRIVE AS -BUILT NOTE: THIS DRAWING IS NOT TO BE MODIFIED FOR USE AS A PLOT PLAN. Legal Description: Ordered BY Dors Lamprecht 1, r] Lot 1/ Block 2e Silver Crest Subdivision Legend: septic Slandplpe05 :':'z:ASDhdt?:.".:>iN: Water Wei 0 ...:.Cona�la:- Fena.—X—x— ;;,;°avpl eng;l i;i; - D_eck SURVEY CERTIFICATION: TECHdroe has Conducted a physical survey the An on his rn encs Property he Mown on this drawing and certifies n of the encroachments thereen ore wlNh the property IMse and no encroochmenh exist ether t other then noted. — LAND & CONSTRUCTION SURVEYORS—PLANNERS—ENGINEERS EXCLUSIONARY NOTE: It Is the owners' responsibility to delenrnine the existence of ply soeenlents, covenants. restrictions or right—of—Way 440 West Benson Boulevard, Suite 200 Phone: 562-5291 taking, which do not appear on the recorded subdiAslon plot. Under no circumstances should any data hereon be used for constructlon• Anchorage, Alaska 99503 Fax: 561-6626 far establishing property lines. or for plot–plan purposes. Poe 77-176 Grid: 2439 Dale: September 11, 2007 lorown Sr. NRB Work Order. 20071-1 67A Fb/Pg 693/67 & Ref:071_195 Scols:1"se 40' lChecked By. APH uuun I %J v v sof A F F'ERt'i CT AND CERTIFICATE OF AP'PROP'RIATION I -AS 4763 THE STATE OF' ALASKA UNDER AS"46'.15,.THE . 'ALASKA .WATcR AND THE REGULATIONS AD.0PTED'UNDEF7 "-IT„ CRANTS TO::' DON E LAi1PRECHT 61), KAREN E LANF RECHT (Q 9201 GROVER ANCHORAGE, AK.•_995{6' 'THE RIGHT TO USE WATER .FROM JHE FOLLOWING;SOVRCE.: A) DRILLED iJEL� WI1fl A F'RIORITY`..DATE: PAGE 0655 USE ACT. OF 12/1/1905 500 4�GAL/DAY, FOR,SINGLE DWELLING JAN ,Q1,THRU DEC 31 r , THE LOCATION TO WH2C1I THIS'WATEFi RTGFIT AFPcFiTAITCS IS:, • LOT 1, BLOCK 2, SILVER' CRESTiSUBDIVISZON', rACCORDING TO PLAT,NO :.•,77-176 FILED IN THE ANCHORAGE'"RECORDING DISTRICT, SAID LOT LOCATED ~WITHIN NW1/4NE1/4 SECTION 14, TOWNSHIP S'2 NORTH, RANGE 3 WEST, SEWARA`; ':- MERIDIAN. THE LOCATION OF THE.WATFR SOURCE IS A DRILLED WELL, 105 FEET DEEP,' WITHIN THE ABOVE�DESCRIBED PARCEL OF PROPERTY. THE CONDITIONS THAT APPLY TO THIS APPROPRIATION ARE FOUND IN ATTACH- MENT A, ATTACHED HERETO AND MADE A FART HEREOF. THE WATER RIGHT IS GRANTED SUBJECT 'TO THE PERTINENT STATUTORY PROVISIONS IN AS 46.15, AND ADMINISTRATIVE REGULATIONS IN 11 AAC 93. PAGE fl A 'Wamr aighto PA ell, 1)65E: PERMIT AND CERTIFICATE OF APPROPRIATION LAS 4763 THIS CERT'IFICA-1.1� OF APPROPRIATION IS IS'S'UED BY AUTHORITY' OF' AS 46.15.120 AND 11 AAC 93.130 ON APPROVED: TITLE: --- S.j:._. DI.VISION F:LAND AND WAIER MANAGEMF'NT STATE OF ALASKA ) JUDICIAL.'DISTRICT) THAT ON l� THIS IS 1'0 CERTIFY 19$7_ BEFORE ME APPEARED�__-- ME TO BE THE DIRECTOR OR,AUTHORIZFD REPRESCNTAI'I'YE --------- OF' KNOWN BY VIS LAND AND WATER MANAGtMENT' DEPARTMENT DIVISION OF OF';I�ATURAL fiESOUFCES ACKNOWLEDGED TOjiE ;THAT THIS CERTIFICATE>OF-`AFPROPRIATZDPi S! TARILY EXECUTED` CIN BrzHALF •(1F" THE STATE .DF A4ASKF1. :.� ? r 1•`� ��. �- NOjARY .PUBLIC :IN AIlD FOFIT SI OF FlL.ASKA: MY; COMMISSION', XF IROS PURSUANT TO AS 46,15.160 AND;AF'F'LICABLE REGULATIONS THE Fj�TFf3 fjTC HOLDER SHALL_ NOl'IFY THE ALASKA DIVISION OF LAND AND WAFEh'HANr'iT�#alx UPON CHANGE OF ADDRESS,O—lRANSFO2 OF ANY REAL PROPERTY RELATES f''? THERETO. ¢ 1. PAGE _. JULlI I D n d PERMIT AND CERTIFICATE OF APPROPRIATION ATTACHMENT A - CO,IDITIONS: THE HOLDER OF THIS CERTIFICATE SHALL: PATE U.6 5 7 L.AS 4763 FOLLOW ACCEPTABLE ENGINEERING STANDARDS IN EXERCISTNG THE WATER RIGHT GRANTED BY THIS CERTIFI,CATE... ` DEFEND AND INDEMNIFY THE STATE'AGAINST,AND-HOLD I1' HARMLESS FROM ANY AND ALL CLAIMS, DEMANDS,�'LEGAL'.ACTIONS; LOSS, LIABILITY AND EXPENSE FOR INJURY TO OR'DEATH ,OF„PERSONS AND DAMAGES '10 OR LOSS OF PROPERTY ARISING"OUT".M OR CON NF_CTED WITH -THE EXERCISE OF THE WATER RIGHT GRANTED :liY:',fHIS."CERT IFICATE.'.:.. COMPLY WITH ALL AFPL:ICAFiLE LAWS,'REGULATIONS'.AND CONDITIONS. NOTIFY THE DIVISION OF;.JLAND-.AND.WA1''Efi MANAGEMENT,.. DEPARTMENT OF NATURAL RESOURCES OF-,;Ni4Y;;bHANGE;:'OF' ADDRESS ',OF ,THE .GRANTEE OR TRANSFER OF ANY -REAL'' P'RdPERTY' tDFN7't�T�n::;Tu :TWTC T%flf-1 IMr*XiT U15TRICT APR 9 19 PH IF Y _ lo Lopyl pl'eC1 - �'laUl . 6,eouek PAGE 3 rime Date Date Date Inspector Inspector Inspector Comments Conditional Approval % Date Sewer Installed Permit No. Septic Tank Size ,), 16 Holding Tank Size — Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property Owner L e P y Phone Mailing Address Buyer r to - Address Lending Institution. e 6 �J-<� p y �y o�w, Phone UX Address Realty Co. & Agent -_ -0 / lea t� -� (i .+ (_1 P -h 7� Address/- [ALJ° pi / Legal Desc)ipti6n ,i10 -:b Z ]<��h f•�L2a Street Lee tion Type pf Residence Single Family ❑ Multiple Family No. of Bedrooms ❑ Other Water Pupply 0Individual ATTACH WELL LOG. A well log is required for all wells drilled since June ❑ Community 1975. For wells drilled prior to that date, give well depth (attach log if ❑ Public Utility_ available.)_ Sew �q� Disposal ,�Y Individual Year Individual Installed: ❑ Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN RE INITIATE®. ALASKA MUIROWWAL C011TROL Scn IUSY Inc. Cngineerinq & 6nuironmental Studies 4/28/82 PARTICIA. & GARY ANDERSON SRA BOX 71—P ANCHORAGE AK 99507 SELLER — PARTICIA & GARY ANDERSON BUYER—DON & KAREN LAMPRECHT SUBDIVISION—SILVER CREST BLOCK -2 LOT -1 ADEQUACY TEST FOR SEWER SYSTEM THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 480 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 600 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 600 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 4 BEDROOM HOME. THE SEPTIC TANK WAS PUMPED ON 8/1.1/81 . SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR THIS 4 BEDROOM HOUSE. l'N LJ Ha° f -�19 eu6 �' d4j� (d+a °e euc ecs¢uee:�wuo e° � 11 • -. s a '.-d C. 50 .l est^�"u Lcro C. Raid, Jr.1+•✓,',i7 <.J�. , hla. 2251-C r,��,r�s,;�i=,,y� 1220 West 25th Auenue • Anchorage, Alaska 99503 e (901) 276-1361 7, 1.9111.0 Gar,y, CIII(I Atid( rrv,)-o (7/o 'v4ary mu,dor, C2.1. flotxc) 2 3 1. 1. v 0 Jr.' (--, r 0 ol A Y),-) r o v ; t I for. til c. i.; I i, v 10.1,1 .'11 rl e d ra 1- n I Id wa r o r f a 11.:1. t-., i no bo t I t n! k111 1 F,( -A lowinrl itemq bavI )eon co-inleter, r Jho waLor anal.,Mi.,s roi i porL tineris b.`2 sublait-ter, to t3lis -In Ch(lm all, 56'1:11 R Strf!et, j -,or mir -reviov.7. rt,fio soptic t -,"Ink T)w,11pnd wit.h Fk vc?ceipf- submittod t(.) tlli,- INIA atir,"naev tcot nocdri to Do peirforiniml, (-.)ri tbo 1(,'achin" vrea. Thi -S tV-St Will 1.?' -a i -. o accx)rd i nq to 1 fa t i ona tan(lar "fl, Ii. r3 t, i 11 q, f: private Y`Irms Y)f-.r.Forminq tlin. tost i�� enclosed. Fill uv. ro,-port- noed!-,, to N5 `mbxaitt-,Ofl t-) thiS OrN.00 ;FOr OM7 rev -.Lc -,v,,. Plnat-,o notify thi-s. rlo-partra6nit For a rc-Antpect-1-ort Own tlic! ell hrive c -or-- e v t e (I . T_" 1-1,orenrn. anv kurtlior cplc�sUicwts, plca.-,o call. Lhi-F, ofFi.rio it 264--4720. I Si.ncoroly IF Y4,)bort C. A s s a c is t c! Cl L—LA ryt / /,r!cIIOPAcc MUNICIPALITY OF ANCHORAGE-!:! ✓!ar,.rNTAL r:.crecTION DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION - Subdivision 825 L Street - Anchorage, Alaska 99501 - C` -- . r) 6805 Grover Drive (corner Grover Dr. and Homestead Trail ---NE coy. 6, TYPE OF RESIDENCE ENVIRONMENTAL ENGINEERING DIVISION 0(*) 264.4720 EIVED Telephone ® SINGLE FAMILY REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not he processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE Lloyd B. Oatis and Stephanie S Oatis 349-1768 MAILING ADDRESS - ❑ COMMUNITY SRA 77-P, Anchorage, AK 99507 ❑ PUBLIC UTILITY PROPERTY RESIDENT (If different from above) B. SEWAGE DISPOSAL SYSTEM - 6805 Grover Drive 349-1768 2. BUYER i _ 111 INDIVIDUAL/ON-SITE** PHONE MAILING ADDRESS If system is over two (2) years old an adequacy test is required 3. LENDING INSTITUTION _ by this Department. PHONE _ MAILING ADDRESS 4. REALTOR/AGENT _ _ PHONE Dynamic Realt /Petie Strant�_sJ;m Boudreaux270-7611 MAILING ADDRESS _ _ 501 W. Northern Lights, Anchorage, AK 99503 5. LEGAL DESCRIPTION Lot 11 Block 2 Silver Crest Subdivision STREET LOCATION 6805 Grover Drive (corner Grover Dr. and Homestead Trail ---NE coy. 6, TYPE OF RESIDENCE NUMBER OF BEDROOMS - ❑ One EA Four ❑ Other ® SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY EN INDIVIDUAL* ' ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) B. SEWAGE DISPOSAL SYSTEM - **If individual/on-site, give installation date19-1-)_. 111 INDIVIDUAL/ON-SITE** If system is over two (2) years old an adequacy test is required ❑ PUBLIC UTILITY by this Department. NOTE: THE -INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY ' INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 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 ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: lc ' If Tank is homemade give dimensions: SOILS RATING a �g 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 COY APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must ac pany certificate) Uk-DISAPPROVED le DATE /(\JQ S BY (Title)/\ LEGAL DESCRIPTION o -v iv tnev. ai ral MUNICIPALITY"OF ANCHORAGE DEPARTMENT F HEALTH AND ENVIRONMENTA: 'ROTECTION 825 L Street, Anchoracra, Alaska 99501 264-4720 Date Received: March 21, 1978 #1: Time 1:30 #2: Time #3: Time Date 3-22-78 Wed Date Date Insp Pratt Insp Insp REQUEST FOR APPROVAI, OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: Mailing Address: Phone: 2. Property Owner: Stephens Construction Phone: 349-4675 Mailing Address: Post Office Box 3-3772 ECB 3. Legal Description: Lot 1 Block 2 Silver Crest Subdivision 4: Single Family Residence: (x) Multiple Family Residence: ( ) Number of Bedrooms: Number of Bedrooms: Four 5. Well System: Individual Well (x) Community/Public System ( ) Permit # Depth of Well Well Log on File $xX Construction Bacterial Analysis 6. Sewage Disposal System: On-site System (x) Public Utility ( ) Permit # Installed 1977 Installer61 _ Septic Tank Size ManufacturerE✓ Absorption Area Soils Rate Material 7. Distances: Well to Septic Tank to Absorption Area _ to Sewer Line Nearest Lot line Absorption Area to Nearest Lot Line Page Two Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 1 Block 2 Silver Crest Subdivision Comments: Affadavit Attached: Approved: i Disapproved: Department Worksheet: Letter Attached: ( ) Date: J J Date: MUNICIPALITY OF ANCHORAGE Department of Health and Environmental Protection ©; ci 825 L Street, Anchorage, Alaska 99501 ± 4 ji �fG i 264-4720 request for Approval of Individual Sewer and Water Facilities ti. 1. Property Owner: 2. 3. 4, Mailing Address:\(')� �`\1� �_C-� Phone:��\�� Name of Buyer: Mailing Address: Lending Institution: Mailing Address: Realtor/Agent: Mailing Address: Phone: Phone: Phone: 5. Legal Description:�L� Street Location: 6 7. 8. Single Family Residence: Multiple Family Residence: (AY' Number of Bedrooms: ( ) Number of Bedrooms: Water Supply:, *Individual Well ( ) Public/Community System ( ) If Individual Well, well depth If Community System, name of system Sewage Disposal System: *"On-site System ( ) Public System ( ) If On-site System, date of installation: *NOTE: A well log is required on ALL wells drilled since 6/75. **If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fee of $25.00 must accompany each request before processing can be initiated. 3/77