HomeMy WebLinkAboutROLLING HILLS VIEW ESTATES BLK 4 LT 1Rolling Hill
View
states
lock 4
Lot I
050- 322
-15
Permit Number:
Tax Code Number:
Work Type:
On-Site Wastewater Disposal System Permit
OSPl11012
05032215000
Septic
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 EImore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Upgrade
Permit Effective Dates: February 24, 2011 to February 24, 2012
Design Engineer: PANNONE ENGINEERING SERVICE
Subdivision: ROLLING HILLS VIEW ESTATES
Site Legal Address: ROLLING HILLS VIEW ESTATES BLK 4 LT 1 G:0254
Owner/Address: ADAMS ENOCH L & MARY ALICE
19117 UPPER MC CRARY RD EAGLE RIVER AK 995772505
Site Mailing Address: 19117 UPPER MC CRARY RD, Eagle River
Lot Size in Sq Ft: 40946
Total Bedrooms: 3
This permit is for the construction of:
Y Disposal Field Y SepticTank N Holding Tank N Privy N Private Well N Water Storage
All construction must be in accordance with: 1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater
Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80).
3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received
Issued By:
Date:
Date:
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/onsite
(907) 343-7904
ON-SITE SEWERA/VE~ERMIT APPLIC~
FOR A SINGLE F~NG
O$¢tllOla'
Parcel I.D. 050-322-15
Property owner(s) Enoch & Man/Alice Adams
Mailing address19117 Upper McCraw Rd
Site address 19117 Upper McCrary Rd
Legal description (Sub'd., Block & Lot)
Legal description (Township, Range & Section)
Lot Size 40,946 Sq. Ft.
Rolling Hills View Est, Block 4 Lot 1
Number of Bedrooms
Day phone
Zip Code 99577
Zip Code 99577
THIS APPLICATION IS FOR ([~ all that apply):
Absorption Field []
Septic Tank []
Holding Tank []
Privy []
Private Well []
Water Storage []
THIS APPLICATION IS AN:
Initial []
Upgrade []
Renewal []
I 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.
Pannone Engineering Services, LLC.~~/~'~
(Signature of property owner or authorized agent)
Permit,, ,us,, ~Fees:
Date of Payment:
Receipt Number:
(Rev. 11/05)
Waiver Fees:
Date of Payment:
Receipt Number:
Pannone Engineering Services LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E-maih steve@panengak.com
February l4,2011
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
4700 S. Bragaw Street
P. O. Box 196650
Anchorage, Alaska 99519
Subject:
Rolling Hills View Estates, Block 4 Lot 1
Septic System Permit Upgrade Request
Conditional COSA Request
Ladies and Gentlemen:
I am writing to request a permit to construct an upgraded septic system be issued for this property as well as
the issuance of a conditional COSA for an upcoming sale. The proposed systems will serve an existing
three-bedroom house. Currently the lot is developed. The lot is served by a private water supply. The
existing septic system shall be reused. The surrounding developed lots are served by private water systems.
The private wells are located over 100 feet from the proposed soil absorption system.
1. COSA. The Owner is in the process of selling this property. The existing system was located and
inspected. The system was tested for operation and was found that it could not accept the required 150
gallons per bedroom per day (450 gpd). The system is able to absorb approximately 200 gallons per day. The
intent is to install an upgraded septic system in the spring of 2011 by July 15, 2011.
2. Soils. A single test hole was excavated by Pannone Engineering Service in February of2011. See the
soil log attached. Ground water was monitored for seven days. No ground water was monitored to a depth
of 15 feet below ground level after the monitoring period. Bedrock was not encountered in the test hole. It is
my opinion, based on the results of the percolation tests and overall soils appearance; an application rate of
0.8 gallons/day/square feet should be used, using a conventional wastewater treatment system.
Soil Absorption System Design.
a. See Sheet 2 of the design package
4. Surface Water: There is no surface water within 100 feet of the proposed septic tank and the
existing drain field. The proposed drain field upgrade will maintain at least 100 feet from all surface water
and drainage ditches.
Page 2 of 2
5. Topography: The average topography in the area of the proposed septic system is approximately 5
percent based on the survey information. The proposed upgrade is located in a flat spot on the southern
portion of the lot, adjacent to the road. The proposed installation will be greater than 50 feet from the
shoulder of the steep slopes.
6. Drawing Markings: The Drawings are marked "For MoA Review Only". When written notification
that the review is complete and that there are no further comments is received from MoA On-Site
Department, the note will be removed and "Issued for Construction" drawings will be issued.
The proposed installation will not affect the future development of the surrounding or existing lots. There
are no wells or septic systems within 100 feet of the proposed septic location.
If you have any questions or concerns, please contact me at 272-8218.
Sincerely,
Steven R. Pannone, P.E.
Owner/Civil Engineer
Attachments:
Maiiit"~3~:~ ?,O~ Box 500227~ Anchoa"a6e~ A!{ 995J~0-C1257
61.5 i¢}.ast 82® Ave~ 5uit:e ~6~ Anc{~o:'ase~ AK 99503
Telephone: (907) 272.--8218 FAX: (907) 272-8225
~OL~-x~ ~-~x~ W, ~'~ ~~ ~
~ 1250g SE~C TANK (P) / ~ ~,
, ~ W/ DOUBLE CLEANOUf ~
~ ~ AND DIVERTER VALVE ~
NOTES: P~O~ ~G ~C, L~
~/~/~
,FOR CONSTRUCTION P.O. 80X ~00217 ANCHORAGE, AK 99~10 ~"' ~f~?~ Sc~l~
~o~z (~o~) ~-~ ~Ax (~o~) ~-~
' ": P.I.D. NO
ROLLING HILLS VIEW EST. BLOCK 4, LOT 1 -:~~~ ~....~ .... ~ 050-322-15
~ u~ ~oC~A~ ~OA~ ~,~.. ..~Z~ OS~l~O~
PLAN EAGLE RIVER, AK 99577
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF
ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF
ON-SITE WASTEWATER DISPOSAL SYSTEMS.
2. ALL WORK SHALL BE IN ACCORDANCE WITH THE Al-i-ACHED SPECIFICATIONS.
5. SCOPE OF WORK: INSTALL NEW 1000 GALLON SEPTIC TANK AND NEW SOIL ABSORPTION SYSTEM.
4. NO GROUNDWATER WAS OBSERVED AS EVIDENCED BY THE SOIL TEST HOLE. IF AN APPARENT WATER TABLE IS
OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 14.0 FEET BELOW EXISTING GRADE, NOTIFY THE ENGINEER
IMMEDIATELY.
TH1
3i5 o.5
sM 4.0
I
7.0
-15 SOH
No groundwoter
monitored
o ~ ~ o
o~
~ - _ _
4.0 ~4" Dia Peff Pipe
-" ~NEW1250g ~ -- · ,--
/
SEPTIC~
TANK
TRENCH 60 LONG, 4' DEEP, 8' T.D.
PROFILE
PRIMARY/RESERVE SEPTIC SYSTEM AB B R EVIATI 0 N S LEG END
NO. BEDROOM: 5 (~50 gpd) CU COPPER ~ W WATER LINE/
TANK SIZE: l O00g DIP DUCTILE IRON PIPE WELL RADIUS
PERC RATE = 6-15 MPI TH TEST HOLE
SOIL RATING: 0.8 GPD/SF FC FOUNDATION CLEAN OUT ~ SS ~ NEW SEPTIC
AREA RQD: 562.5 SF T~ TANK CLEAN OUT NO.
SYS. ~PE: WIDE TRENCH ~.0' E.D. C~ CLEAN OUT NO.
RF=0.50 MIN LENGTH: 56.25 LF
M~ MONITOR TUBE NO.
USE: R.I. RIGID INSU~TION
60 LF X 5' WIDE, 4' E.D., DCO DOUBLE CLEAN OUT
8' TD DV DIVERTER VALVE
TOTAL AREA: 600 SF FS FLOW SPLICER
NOTES:
,ox lOO 1Z
Scale
NTS
ROLLING HILLS VIEW EST. BLOCK 4, LOT 1~ -050-322-15
~tev~ R. P~nno~e
MARY ADAMS 'Iii~;.~ CE 8149...k~ PERMIT NO.
19117 UPPER McCRARY ROAD ~ ~". ..' ~ 0SPl11012
DESIGN DETAILS EAGLE RIVER, AK 99577 Il ~td ....... ~x~ Sheet
SOILS LOG ~ PERCOLATION TEST
TEST HOLE 1
ROOT MASS SLOPE / ~/ SITE ~
1-- OR ORGANICS ~%.~?~ '~~ ~
2 ~ BRO~ SlL~
SP/SM SAND
SM SIL~ SAND
7~
x
8 I TH
9
TH- ~0 ~
12 ~ GP/SM SlL~ SAND
W/COBBLES
13 --
WAS GROUND WATER SLOPE
~4 -- ENCOUNTERED? N
15
BOH IF YES, AT WHAT TH
16 ~ DEPTH? -0-' X
17 -- DEPTH TO WATER AFTER
MONITORING? -DRY-
18 DATE: 2/15/11
; WATER
DATE PERFORMED: 2/8/11 R~DING CATE CLOCK
TIME NET TIME LEVEL NET CROP
R~DING
~ 2/8/11 11:16 --- 2.05 ---
2 11:26 10 MIN 3.13 1.08
a 11:27 --- 2.05 ---
4 11:37 10 MIN 3.10 1.05
s 11:38 -- 2.05 --
~ 11:48 10 MIN 3.07 1.02
PERO~TION ~TE 9.8 (min/inch) PERC HOLE DIAMETER 6 inches
TEST RUN BE~EEN 4.5 FTAND 5.5 FT
CO~MBN~S: Test ~o]e excavated by SOU~ ~OR~ CONSTRUCTION. ~ec ~ole ~as p~eso~ed.
·est ~ fo~ o~e Ao~. ~ast 3 read1~gs ~epo~ted
~BR~ORMBD BY: Ste~e~ R. P~o~e~ P.~. ~ CBR~]PY THAT ~H~S ~BST WAS PBR~ORMBD ~N ACCORD~CB
W~ AgU S~A~ AND MUN]C~Ag GU~DU~N~S ~N BFFBC~ ON ~ DAT~ OF ~H~S TBS~.
NOTES: p~o~ ~G ~C, L~
P,0~[ (~07) 272-8218 [~X (~07) 272-8211 Sco,~
ROLLING HILLS VIEW EST. BLOCK 4, LOT 1~ 050-322-15
MAmY ADAMS ~. ~ ~ -':*~ o~o~
SOILS LOG EAGLE RIVER, AK 99577
READING DATE CLOCK WATER
TIME NET TIME LEVEL NET DROP
READING
~ 2/8/11 11:16 --- 2.05 ---
2 11:26 10 MIN 3.13 1.08
3 11:27 --- 2.05 ---
4 11:37 10 MIN 3.10 1.05
5 11:38 ___ 2.05 __
6 11:48 10 MIN 3.07 1.02
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
N-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME IPHONE ~NEW
MAi LING ADDRESS
LOCATION ~ NO. OF BEDROOMS
~ DISTANCE TO: IWej'/~' ~ Absorption area. X' Dwelling ~/
~ ~ Z ( Manufacturer~ Material No. of~ ~artments
~ Well DweJling PERMIT NO.
DISTANCE
TO:
~ ~ ~ Manufacturer Material Liquid capacity in gallons
DISTANCE TO: iOO t.+ FounOatio~, Nearest lot li~o PERMI~~,, ¢, ,
~ z ~ No. of ~ne Total le~4irs Trench ~ inches
~. Top of tile to finish grade ~/ Materia]ben,athtile ~ inches Total eff~g~sorption area
Length Width Depth PERMIT NO.
~ N Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation .Nearest lot line
~ DISTANCE TO:
Class Depth Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
DISTANCE
TO:
- / /
APPR DATE LEGAL
. _.�. ..�. ._... .. ,...la•re..rrc-�:].+.a'^��....wr�w+-.........••.�—....-..—w........,��,,.:"`r''i:: r..+siY�'�
�xitlt r
by
DOC Co. CCa -
SULLIVAN MATER WELLS
P.O. BOX 272, CHUG IAK, ALASKA 99567 • TELEPHONE 6882759
OWNER OF LAND c DEPTH OF WELL U
ADDRESS `(^t T '�1. c fC S r +. +c r� `l j'• CrSTATIC LEVEL OF WATER FT. _I 'q J
LEGAL DESCRIPTIOit -' 11
rl o :1.. , % L!i<c S u 6AA WN FT. .
DATE -Started z. -fir- Ended GALS. PER HR J�
PERMIT NUMBER KIND OF CASING aS 7
KIND OF FORIIATION:
From n Ft. toFt.
From
Ft. to
Ft.
From Ft. to I.
From
Ft. to
Ft.
From Ft. to a .? Ft.
LSA Y7 4- From
Ft. to
Ft.
From - Ft. to lE * Ft.
• 1 �`" �,) r v .r _, From
Ft to
Ft
From f Ft. to—'=, Ft.
C <+4 `' e?,A� -'< From
Ft. to
Ft
From < Ft. to ? ' % S~Ft.
(� r el •tf U c /< 0100 vf rom
Ft. to
Ft.
From Ft. to Ft.
1=d'�gc>ti�r `r From
Ft. to
Ft.
From Ft. to_2LS__ Ft.
w +ti • From
Ft. to
Ft.
From Ft. to Ft
f l:%•- •= • f/ G t ! from
Ft. to
Ft
From Ft. to—FL
„ �!i I From
-Ft. to
Ft.
From -a Ft. to 7 2J Ft. / r.f > r • •'
From Ft. toFt.
..y i
From Ft. to Ft.
From Ft. to Ft.
From FL to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft. From Ft. to Ft.
From FL to • Ft. From Ft. to Ft
NIISCL• INFORMATION-
.. /+ �+ sinJG
DRILLER'SNAME
WATER W LL$
P. O. BOX 272, CHUGIAK, ALASKA 99567' · TELEPHONE 688 2759
. .~ //~'~
KIND OF CASING
,
KIND OF FORbtATION:
From FI. to III Ft.
From I -- Ft. lO, L Ft. Il
From Ft. to_ Ft.
From , i Ft. lo_
From Ft. lo ·
MISCL. INFORMATION:
FI.
FI,.
// ,
From__FI. to I Il FI
From IlL Ft. to Ft.
From Ft. to Fl,
From Fl-lOll Ft.l
From Ft. to.. Ft.__
From ..... FI. loFt_
MUNICIPALITY OF ANCHORAGE
Health
Department/~%f and Environmenta~rotection
. 825 ~ Street, Anchorage, AK. j9501 '
Permft ~' ' J-~'~ WELL AND/OR ON-SITE SEWER PERMIT ;E>'~ ///~::
Applicant: ~_ ~~'~ . Mailing Address=
Location: ~D~ ~ ~ Phone Nu~er:
0 scr on:
Type of Soil ~s~ption System Is: ~
Trench: ~ Drainfield. Seepage Bed: ~ Holding Tank:
Maxim~ N~ber of Bedrooms: ~ Soil Rating(sq.ft/br)
The Required Size of the Soil ~sorption System IS: '
DEPTH ~ LENGTH ~'
. GRAVEL DEPTH WIDTH
The length dimension is the length(in feet) of the trench or drainfield, The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet), There is no set width for trenches,
The gravel depth is the minim~ depth of gravel between the outfall pipe and
the bottom of the excavation(in feet),
~ ~ REQUIRED SEPTIC(HOLDING) TANK SIZE = / ~ GALLONS
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the wei1 wii1 serve,
~ ~ ~ TWO(2) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection and approval by this department
wiiI be subject to prosecution,
Minim~ distance between a weli and any on-site sewage disposal system is IO0 feet~
for a private well or i50 to 200 feet from a pubiic weli depending upon the type
of pubiic weli, Einim~ distance from a private wei1 to a private sewer iine
is 25 feet and to a co~unity sewer line is 75 feet, Well logs are required
and must be returned to this department within 30 days of the weii completion,
Other requirements may apply, specifications and construction diagrams are
avaiiabie to insure proper installation,
~ ' ' PERMIT EXPIRES DECEMBER ~1~ 1 g ~ 3
I certify that:
(i) I am f~iiiar with the requirements for on-site sewers and weiis as
set forth by the Municipality of ~chorage,
(2) I wiIi instali the system in accordance with codes,
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 b~rooms,
Applicant
SWP/024 (1/81)
IVlUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
SOILS LOG
2
5
6
7
9
PERCOLATION
TEST
DATE PERFORMED: ~'~ ' '
SLOP~ SITE PLAN
10
11
14
20-
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT wHAT
DEPTH?
I
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE I'minutes/inch)
December 29, 1978
9780284
R.S. Hill
Box 436
Chugiak, Alaska 99567
Subject: Lot 1 Block 4 Rolling Hills View Estates Subdivision
A permit issued by this department for well and/or
sewer system has expired.
Permits are issued on a calendar year basis, as stated
on the permit, by authority of Municipal ordinance.
If you have drilled the well, a well log should be
sent to this department to document the installation
date°
If there are any further questions, please contact
this office at 264-4720.
Sincerely,
Les
Senior Environmental Specialist
'-- ~ t,. r:,,, ....... ::i..4E.~
THE ~:;,m':~,..,.... .... T :':. ........... FF' ¢~; Z ;::~E: OF' THE 'E;O Z L ¢:,Fr;;F N'~:'"t", . .T .IN ........TE,. ~ ::, '
..... ,~'; LEN::iTH DIMEN:~4;iON IS '"'HE LENGTH ,::iN FEET) 'IF THE T~'EN]:H OR
~ ~.4c. ~... 1:.1'. ~ I t-iF Fi TREN(]:H t:;I[;;: F'Z i T ,::: "['HF 2 ] ::-'"R ",IE:F F ET ,.iEEN THE '::;
":iPOi IN[':' FI~',~[:' THE BOTTOM I...i[- ] ,.~[:. ~:'::-, '" ff,/i::IT ]' '" ~-I "]' N ......... ~ ....
THFPE T'E; N] SET N ZE:'TH ~'. r'~ TRENCHES.
]"!'"t~; ij~*:Pi',?~i]._. L-Er Fl- f';:: THE M]:NIMUM I}EPTH '"F' ]jRFt'v'EL s,~:.,!.,E~.,4 .r4~:. OU]¥:'FI[...L !::'iPE
......... -,'"~'c.~ i)'H FEET).
R?.,![) THE E~(]TT(]M ]P' 'T'kE ~:,...,LI'~, h! ......
. r,.z,!.-cL., ¢. L,,-,!.:;, , , ?i?'4'T' HELLS ::il;: J'~::~E.El},r¥ TO TH);I'.S l'-r~:_-f'~:t T r t::It".![:' Ir!t:
NU!"IE;ER '" I::' RIE';'!; ! i}E,NCES THi:::FF THi]:' i,.IEI...L !.,.l'IL .L. '~:: ERVE.
BRCKF' ! LL. ! NEi OF iEt?',!"r' .t:~;'T'STEM i4 Z 'T'!'4,(]UT F t NR .... Z NSPECT ): 0i'.,I fiND
[)EF'RRTHENT (.,41 L 1 BE ..... '" 'F'"'-''~''
' .._ .u, ..,'c,... C~L. Ti]:! PROSECUT T.
M :(N :[ MUM [" i S"FF!?',E)E BE"FHEEf",! Fl i.,iEL. L. RN[:' R.I'.¢T' ON-S l T'E SEt,.!F~GE D I SPOSt::!i.. S¥STE:M ! S
¢.iZ!8 FEET FOR R F:'R!VF!]"E !4E[...L.~ OR
:i. 58 TO ;3(~:.~E~ FEET FROM Fi t::'t..I!~L..];C HELL DEF'ENE:'IN[ii UPO?.,I THE T'.¢PE OF PUBLIC I.,.iEL.! .....
I,tEI...[. LOGS F:IRE REQUIRED BND MLiS;T BE RETURNED TO THE DEF'RRThiENT !.,.l!"f'H):hl
OF THIE I.,.IELL.. COMPLET'iON.
OTHER P. EQU!f;'.EME]NTS Mt::f? F!Pt::'L'T'. SPEC!F'iE;!~TIONS RND i:':O~.,i:~Li]'I:;~:I_I(]]:T]:Oi'.,! [:, :i: RGRi:~?E; i::tRE
ff,;,'R i I....RSL. E TO Z NSLtRE PROPER t NS"FRLL!:::iT Z
i Cii~:]R'!" i F? THFI'T
:!.; I FiM FRMIL!FiR HI'TH 'T'HE RE(;:!Ui~;~:E!'qENT:'~; FOF,.': ON-:i!i;!'T'E SEWERS FIND
I:::'ORTi..i 8? ]"HE ,~4L!IqtOIPF!I....ZT'¥ OF' FIhE:HORR6E.
2: I HIM_ INSTF:ILL T'HE S'¢S]"EM ]'.lq FiCCOP.[:,FtNCE WiTH THE CODES.
:?: I t..IN[:,ERSTF!N[:, 'f'HRT THE ON-.SITE SIE!.,.IER S'.¢STt:ZM
~;~'~;:"::; ~: I':,F~¢CE I S REMODEL~"F(} I NCLUt}E MORE "FHF!N 4 BEI]:,R(]OMS.
RF'PL ): CF!t'-,!T R.S. H ILL
...-¢ .:. ~ L.' B"?. . ............ DFI'FE ....
O ~ E GEC. 'ECHNICAL 8 DEVEL,~'PMENT CO.
Box 90, Davis St,, Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster
694-2774
Soils Et FoundatiOns
Performed for:
Legal Description:
SOIL LOG
Name: ,/Y/¢~. ~
Hatllng Address: ~-~.~
Depth (feet)
Sotl Charectertsttc~
Earl Ellis
688-2280
Land Development
Tel. No.
lO
11
12
15,
16
Ground Water Encountered: Yes~
Proposed Installation: Seepage Pit
Comments:
No ,~'~ If yes, what dapth
Drain Field ~/'~
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/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-322-15
COSA # ~:) ~, C.~ / / / ~ ~//-/
Expiration Date: ,/<2~ -- ] y -//
GENERAL INFORMATION
Complete legal description Rollin.q Hills View Estates, Block 4, Lot 1
Location (site address) 19117 Upper McCrary Road
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Mary Adams
19117 Upper McCrary Road
Day phone
Day phone
Real Estate Agent
. Craig Nu,qanst / Great Land Realty
Day phone 529-9084
Mailing Address
Unless othetWis~,=hdq[Jested, COSA will be held by DSD for pickup.
NUMB'~"R OF BEDRO0'N~'S: 3
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
CommunitYCla'ss . Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] Individual Holding Tank []
[] Community On-site []
[] 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 On-Site 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 On-Site Systems Approval
are valid for 90 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, 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 Pannone Enqineerin.q Services, LLC Phone 272-8218
Address P.O. Box 100217, Anchora,qe, AK 99510
Engineer's Printed Name Steven R. Pannone, P.E. Date 7/13/2011
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & 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. PES can therefore not provide any warranty for future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed
above. Any reliance upon or use of this report by any other person or party is not authorized nor will it
confer any legal right whatsoever.
5. DSD SIGNATURE
t,/'/ Approved for '~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
By: //
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
[~,,,/,/4, /~~riginal Certificate Date: ~/L/--//
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P,O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Rollincj Hills View Estates, Block ~t, Lot a
If A, B, or C provide PWSID #
Sanitary seal (Y/N)Y
Cased to n8.?F ff.
Legal Description:
A. WELL DATA
Well type Private
Date completed 61aF/a98=}
Total depth a=o ft.
FROM WELL LOG
61aFla98n.
g.p.m.
Date of test
Static water level =4=}
Well production a
WATER SAMPLE RESULTS:
Coliform Ne§ colonies/100mL
Arsenic: .ND ug/I
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Anchoracje Tank I Steel
Nitrate =}.aa mglL
Date of sample:
Tank size aooo gal.
Foundation cleanout (Y/N) Y
Date of pumping '~Ttt~/t(
C. ABSORPTIOrN FIELD DATA
Date installed 71aalaoaa Soil rating
Number of comPartments
Depression over tank (Y/N) N
Pumper
Parcel ID: o5o-~,~-*,5
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) aa
AT INSPECTION
a6a ff.
=}-7 g.p.m.
Length 60 ft. Width .5 ft.
Total depth _8 ft. Eft. absorption area 600 ~ Monitoring tube Y
Date of adequacy test ~_2~.~1' Results (Pass/Fail).
Fluid depth in absorption field before test in. Water added
Elapsed Time: __ min. Final fluid depth in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Date installed ?laalaeaa
' Cleanbuts (Y/N)Y
(g.p.d./ft= or ~/bdrm) 0.8 GPDISF
High water alarm (Y/N) N
System type Wide Trench
Gravel below pipe .zr ft.
Depression over field N
For __~ bedrooms
gal. New depth., in.
Absorption rate >= g.p.d.
If yes, give date
Other bacteria Necj coloniesll00 mL
Collected by: Pannone Engineering
LIFT STATION
Date installed Size in gallons
"Pump on" level at ~ in. "Pump off" level at ~
Datum Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot ~.2~.8
Absorption field on lot ~.:~,..?
Public sewer main 75+
Sewer/septic service line 25+
Animal containment areas 5o+
in.
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots ~.oo+
On adjacent lots ~.oo+
Public sewer manhOle/cleanout =oo+
Holding tank ~.oo+
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~-.9 Property line ~8./~
Water main ~.o+ Water service line 25+
Wells on .adjacent lots ~.oo+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~.? Building foundation ~?.F
Water Service line 25+ Surface water ~oo+
Curtain'drain 50+ Wells on adjacent lots ~oo+
F. COMMENTS
NewSASj '~'~.e~ta,,~' 01,~. ~e,'O't~"T-/OA),A/.,. ~...~
Absorption field 9.1
Surface water ~.oo+
lOO+
Water main 75+
Driveway, parking/vehicle storage ~.o+
in.
Receipt Number ~-)2[ '~',~' o~ Receipt Number
(Rev. 11/05)
·
I certify that I have determined through field inspections and
~view of Municipal ~co~s that the above systems 'a~ in
conformance w~th MOA COSA guidelines ~n effect on th~s date.
Engineers PHnted Name Steven R Pannone P E
· , · .
Date
$~~~ ~~ Waiver
COSA
Fee
Date °f Paym~
Date of Payment 7~ /
Lot 2
Lof 1
x 7.8' SHED
CLEANOUTS
DECK ABOVE
SEP~C
60.00,
N 89'57'40'W 1~
UPPER McCRARY ROAD
2 STORY
DOME
NOTES:
THE PLAT OF ROLUNG HILLS VIEW ESTATES SUBD. IS MISSING DATA FOR THE CURVE AT THE SOUTH WEST CORNER OF
LOTS 1 AND 2, BLOCK 4. THE ARC LENGTH SHOWN IS COMPUTED. THE RECORD BEARING WAS HELD FOR THE WEST
PROPERTY LINE (BETWEEN LOTS 1 AND 2, BLOCK 4) AND THE COMPUTED DISTANCE IS SHOWN.
2. THE RECORD AREA FOR LOT 1, BLOCK 4 IS .940 ACRES. OUR COMPUTED AREA FOR LOT 1, BLOCK 4 IS 1.062 ACRES.
PLOT PLAN AS BUILT X SCALE 1" = 40' GRID NW 254 PraJecf No. 11-017
LQ n g (907) 5z2-6476
Reglsfered Lend Surveyors (907) 522-4625
kglangls~,alaska.nef / Jclangls~,alaska.nef
& Associafes, inc. 1~500 Daryl Avenue, Anchorage, Alaska 99515-5049
Phone
Fax
I hereby certify fhaf I have surveyed the following described properly:
I.of 1, Block 4, Rolling Hills View Esfafes Subd. (Plaf No. P-624)
Anchorage Recording Dlsfrlcf, Alaska, and fhaf fhe Improvemenfs slfuafed fhereon are
wlfhln fhe properly lines and do nor encroach onfo fhe properly adJacenf fherefo, fhaf
no Improvemenfs on fhe properly lying adJacenf fherefo encroach on fhe surveyed
premises and fhaf fhere are no roadways, fransmlsslon lines or ofher vlsible
easemenfs on sald properly excepf aa lndlcafed hereon.
Dared fhls fhe I~~ Day of ~"L//~ , ~C~ , af Anchorage, Alaska
If Ia fhe responslbillty of fhe owner fo defermlne fhe exlsfence of any easemenfs,
covenanfs, or resfrlcflons which do nor appear on fhe recorded subdlvlslon plaf.
................ S,G,S' .............
SGS Ref.# 1110363001
Client Name Pannone Eng. Sty. Printed Date/Time 02/08/2011 15:44
Project Name/# 19117 Upper McCrary Rd Collected Date/Time 02/02/2011 15:30
Client Sample ID 19117 Upper McCrary Rd Received Date/Time 02/02/2011 16:50
Matrix Drinking Water Technical Director Stel~hen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic
ND 5.00 ug/L EP200.8 C (<I 0) 02/04/11 02/07/11 NRB
Waters Department
Total Nitrate/Nitrite-N
3.21 0.100 mg/L SM20 4500NO3-F B (<10) 02/03/11 AYC
Microbiolog~f Laboratory
E. Coli
Total Coliform
Negative I 100mL SM20 9223B A 02/02/11 SDP
Negative I 100mL SM20 9223B A 02/02/11 SDP
SSl/~AS/OV20ii ii'52 S^X No. e. OOi/OOi
. ":~1~' - -189191
omestate. · -
~g. age Company
J X~ans ~ Work For You
~801 Ce~e~oint D~ve, ~Ulte l~' / Ancho~ge, ~K / 99503
'~ce: 762-5890/F~: 762-5899
March 3,201!
Re: 19117 UpperMcCrary Road, Eagle River, AK
When Homestate closes on this transaction will be holding and escrow for the new septic system. We
will be holding 1.5 times the cost of the highest bid 12740 x 1.5 = 19110.00. We will require a
conditional COSA prior to closing.
,
uonna Nail ,I
Operations'Manager
Homestate Mortgage Company
#189191
,iRs Pumping
PL") Box 773415
Eagle FJver, .A~ 99577
(907) 694-6454
[-BIIlln~__!nfo ~.r~..._.a_.tl o n
Pannone Engineering
Po Box 100217
Anchorage, AK 99510-0217
(907) 272-8248
Office #
[Job 8its Information
Job Description:
P.O. Number:
Terms:
Sales~ep:
Map
Cross Streets:
Job Comments:
Dan
19117 Upper McCrary Rd
Eagle River, AK 99577
(907) 272-8218
1000g
Net 30
Dawn-Dawn
N Eagle River Loop
Service Agreement
Number: 032829
Order Date: 31-Jan-2011
Service Date: 01-Feb-2011 12:00
Technician: Dan
Tax %: 0
Job Type: Repeat
Map Grid: 87 - -
Last Serv 09'16'2009
Cked & Pumped Tank
Tank L's Normal
B/F - 2 X's
lO00g
Additional Location Comments
Corner home on McCrary Rd-
Dome shape home
~'s start ~ dw on news paper
box
Enter sepdc ~ 2nd dw
Diagram: '~'~1 ra ".~3.b Gallons Planned; 1000
Gal. Actual: ,
Hose Length;
.e Double Tank: [] ......
Pump System: [] _
Baffles Inlet: [] ,,
Baffles Outlet: [] ....._
Service Type
Septic Serv 1000K
Qty Price Each Tax?
1 $185,00 No
Extension Actual
$185.00
Estimated Charges:
NonTaxable Total Taxable Total Tax Total Grand Total
$185.00 $0.00 $0.00 $185.00
Actual Charges; ~ __
Customer agrees to the terms and conditions shown, THIS IS A BINDING AGREEMENT.
[ [ I
Signature and Title of Customer R epressntative
Date
Accepted by JRs Pumping Date Accepted
For your added convenience we accept; American Express, Dlcover, Visa and Master Card payments over the phone.
Aller 30 Days account will be turned over to COLLECTIONS, $30,00 For NSF cheeks Returned.
JR 'S SEPTIC PUMPING
DBA
FLINTS TONE ENTERPRISES
Date: 2/15/11
P.O. BOX 773415
EAGLE, RIVER ALASKA
99577
Phone: 694-6454
Fax: $44-9821
,~ubmi~¢d ~o:
Mary Adams
PROPOSAL
Photte;
Cell:
.lob Location:
19117 Upper McCrory Road
Install New Septic ,~ystem ~ per Engineering Design
Prgce~ lnclstdes:
New IL~O gal Steel Septic Tank
2, Pump existing Tank
3. Abandon old Tank as per M,A.O, code
4. Clean line existing line from house to new Tank
5. Install new leach field 60 foot long 5 feet wide with 4.5 foot of septic rock
6. Grade all disturbed area's
_Cost for above work ~ t~, " ,,,
NOTE: 14711provide a Top Soil price at owners request after installation of system.
Prices Does Not Include:
1. Engineering
2. Permits
$. Landscaping Top Soil and Seeding
4. Utilities not located by located center
5. Removal of any material from site
FRI/FEB/18/2011 11'04 FAX No, P. 002
Pacific Services -G UALITY EARTHWORKS-
P.O. Box 770483 Eagle River, AK 99577 TellFax(907)830-0861
Proposal submitted to: Pannone Engineering Services
Address: 3701 E. Tudor Road, Suite 101
Date:2/1512011
Legal Description: Upper McCrary 19117
Contact: Dan Client Job #11-01
Date of Permit/Engineer: Telephone/Fax: (907)272-8218 Fax 272-8211
We hereby Submit Specifications For. Existing home septic installation up-grade
Excavation & Grading Services to include:
-Work to be performed includes- Installation of new septic system up-grade for existing home by design of Pannone
Engineering group. Design includes new 1250 gallon steel septic tank, 2" moa septic rock, moa approved septic parts
and pipe, high quality filter fabdc, and a flow diverter. Septic trench design is 60' feet long X 4' feet wide X 4' feet in
effective elevation, and monitor tubes will be placed on both ends of the leach field.
Estimate:
-Mobilization and demobilization of building material, tools and equipment
-Materials- 1250 gallon septic tank, septic rock, new pipe and parts, fabric, and flow diverter
-Existing septic tank haul off, disposal fee, and pumping fees
-Excavation
-Installation of system with flow diverter to existing leach field
-Backfill with final grade
Totals
$ 700.00
$5,900.00
$ 600.00
$1,600.00
$I,000.00
$1,100.00
$10,900.00
-Additional work as directed by client/general contractor will be accomplished on a time and materials basis including
mobilization of more equipment.-
Conditions:
-Contractor I Home owner ta In charge of building permits, and surveying of proposed structures.
-Pacific Services includes no landscaping.
-Price does not include extra material for leach field coverage or topsoil
-Pacific Servicas includes no insulation in this pHca.
-Pacific Sewices is to do work by design of Pannone Engineering Services
We are licensed, bonded, insured & certified for the work listed above.
We-Propose hereby to fumish material and labor - complete accordance with above specifications, for the sum of:.
The amount listed above. $10,900.00
Payment to be made as follows:
Payment: An initial deposit of 50%, and the remainder upon completion of work. Any past due balance at 1.5% per month
after 30 days.
Acceptance of proposal - The above prices,
Specifications and conditions are satisfactory and are hereby
Accepted. You are authorized to do work as specified. Payment
Willbe made as outlined above. We acknowledge the right to lien the property.
Date of acceptance: Signature:
Alaska Divers & Underwater Salvage, Inc.
PO Box 773253
Eagle River, AK 99577
Name / Address
Pannone Engineering Services, LLC
P.O. Box 102954
Anchorage, AK. 99510
REF: Mary Adams
PROPOSAL
Date Quote #
2/19/2011 447
Project Cf
Description Cost Qty Total
-'~1 .ASKA DIVEP, S & UNDERWATER SALVAGE, INC 12,740.00 l 2,740.00
PROPOSES TO PROVIDE ALL LABOR AND EQUIPMENT TO
INSTAl .1. THE SEI~I'IC SYSTEM AS DESIGNED LOCATED AT
19117 UPPER MCCRARY ROAD EAG1.E RIVER, AK
David L Mallars -230-2991
Total ,1:,74o.oo
Signature
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-472O
Application Date
GENERAL INFORMATION ,/~,.~2~ 9/ / ~
(a) Legal Description (include lot, block, subdivision, section, township, range)
f,(~t I Rlonk 4 Roll'ing
Location (address or directions)
Applicant Name ~_l,_ Adam~
Applicant Address P.O. BO~ 2505
August 29, 1986
/~,~,
Hqql,q Estate,~ W]2N 1W See.. 6
(b) Telephone: Home N/A Business 561-1318
Eagle River, Alaska 99577
(c) Applicant is (check one): Lending institution []; Owner/builder []; Buyer []; Other r-I (explain);
(d) Lending Institution Ak Mortgage & Escrow Telephone 562-r, 626
Address' 4791 Business Park Blvd. Suite ~ Anchorage: Alaska 99503
(e) Real Estate Company and Agent N/A
Address N/A
(f)
Telephone N/A
Mail the HAA to the following address:
pick-up by angin~=aT'
TYPE OF RESIDENCE
Single-Family [] Multi-Family []
Number of Bedrooms 3
Other
WATER SUPPLY
ndividual Well [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation d~te shown below, I verify that my nvestigation of this Health
Authority Approval 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 alt Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm
Address
Date
EA6LE ~!VE~ EN6!NE~!u~ RFRVlCES
EAGLE RIVER, AK 99577
P. 0. BOX 773294
~94-5195
Telephone
ADpHpEr:vAe:~oRrOV'~~ bedrooms by ~~'~~
ate
Approved /~ Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
Page 2 of 2
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICIP^UIY OF ^NCHOP, AGE 264-4720
DEPT. OF HEAL'IH &
EI~IRONMENTAL PROTECTION Legal Description: ~/~'-//
sEPt
R~J~V~rD I, A, B, O, D.E.C. Approved (Y/N)
Well Classification
Well Log Present (Y/N) /Y Date Completed ~',~/J-//'¢$ Yield
Total Depth ¢,~ P-o / Cased to '~"-~ C'~'/' Depth of Grouting ,'~,/'//4
Static Water Level /,~.~, t ,~ /.~ ,,~ d.~,r~--/.c Pump Set At
Casing Height Above Ground /~ ¢' Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) 'Y Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot //~/
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
; On Adjoining Lots .¢':'/'¢,0 t
//¢'~'" ; On Adjoining Lots ~"~'~-2"
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ~ ~
~ ~ ~-~ P~F'~; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) /Y Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N) /v'/,,~
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
Size ,/,w~6~.~ / NO. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
; for -
Temporary Holding Tank Permit (Y/N)~,~-'/~'
To Water-Supply Well '//¢ /
To Property Line ~ ¢ /'
To Water Main/Service Line ~'~ /'
Course ~' '/¢0 '
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Dra!nage
Comments
Page I of 2
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field '~ /
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test ~',~
Separation Distance from Absorption Field:
To Water-Supply Well //---~ /
To Building Foundation ~/
Lot
To Water Main/Service Line ~"'/~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field ~ /
Depth of Field -~ /
Gravel Bed Thickness
Standpipes Present (Y/N) ,Y
Date of Last Adequacy Test
To Property Line ,~-O"
To Existing or Abandoned System on
; On Adjoining Lots ;~"--Y~/'
To Cutbank (if present) '~'//~'
D. LIFT STATION ~/~
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I hav~p..~he~ed, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Y~'"'~ Date
Company ~.¢=---~" MOA No.
Receipt No./~/ ~ ~
Dateof Payment ~//
A oun,: Sea,
Page 2 of 2
72-026 (11/84)
MUNICIPALZTY OF ~qCHORAGE
DIVISION OF F~VIRONME~fAL HEALTH
DEPARTMENT OF HF2aJ~TH ~D 5/%B;IR(INMENTAL PROTECTION
APPLICATION POR HFJtLI~t AOXFHORI'Iif APPROVAL CERTIFICATE
1~ GeP~al inform~tion Application Date ~ ~ .j~L_~~
(a) I£3gai [~a~ipti~ (include lot~ block, subdivision, section, toNnship, range)
Loc~tion (add~ess o~ directions)
(b) Applicants Na ~ ' ~' ,, '
(c)Applicant .is (ched~ one) lending Institution ~ I C~ner/tx~ilder ~. l
Buyer Eli ; Other L-~ (exp. lain) ~
(d) lending Institution Tel~hone
Address
(e) Real Estate Co. & Agent
Address
Te le phons
2. Type_ of '~esidence
Single-Family ~Pi Multi-Family ~ Othe= (~s~i~)
3. ~te~ ~.
Note: If ax~nity ~11 system, ~St ha~ ~itten ~nf~tion ~m~ ~e State
~=~nt of ~viron~ntal Con~r~tion attesting to t~ legality ~d status.
Is the ~11 adequa~ f~ the n~r of ~s s~cified in this ~ (Y~) ~
Is the wastewater dis~al sys~m a~quate f~ ~ ~r of ~ (Y,~) ~
[Page 1 of 2]
2-15-84
~~Firm P~ovid%n~- s Tes- ?s, Data and .I.nformation
I o~tify that I have checked~ verified, o~ conformed to all MOA HAA Guid~lirss in
effect on the date of this inspection.
(ENGINEER SF2%L)
6. D~l%q~ Approval
App~o~d for -~ bedrooms
Approved ~ Disapp~o~d ~--U
Te~u~ of Conditional Approval ......
Conditional
The Municipality of Anchorage Dapa~tu~nt of ~l~alth and Environmental P~otection does
not guarantee the continued satisfactory perfc~manc~ of the water supply and/c~ the
wastewater disposal system. This app,.oval indicates that, as of the validation date
sheen above~ based on the data and inf(E~ation fu~nishe~ by an engi~e~ ~egistered in
the State of Alaska, the w~ter supply and wastewate~ disposal system is safe and func-
tional for the numbe~ of bedrooms and type of structure indicated.
(DHEP SEAL)
7. Mail th~ HAA to the following add~ess: /~f,~-~~
KB2/d5/s
[Page 2 of 2]
2-15-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
Well Classification ~6JDIL) ID~)A L-
Well Log P~esent (Y/N)
Total Depth ~-20 / cased to
Static Water Level 14.$ ' Pump Set At
Casing Height Above Ground I,~x
Electrical Wiring in Conduit (Y/N) y~ S
Separation Distances f~cm Well:
To Septic/Holding Tank on Lot I{ ~ x
To Nearest Edge of Absorption Field on Lot
MUNICIPALITY OF ANCHOP, AG~
DEPT. OF HEALTH &
~:NVIRONMSNTAL PROTECTION
CHECKLIST - FEBRUARY 1984
Legal Description: ~-~"i- i [~O~J~J ~'~ D
If A, B, ~ C, D.E.C. ~o~d(Y~) ~/~
~te ~leted ~ :' A 5
.~, ~ ,x ~pth of ~outing/V
160 '
Sanitary Seal on casing (Y/N)'¥F.G
Depression A~ound Wellhead (Y/N) A~O
; On Adjoining Lots > 17
.; On Adjoining Lots ~
To Neacest Public Sewer Line AJ,/~ To Nearest Public Sewer
Cleanout/MaDlaole A)//~ To Nearest Se~r Service Line on LOt
Water Sample Collected By /9]~ ; Date j~JL~--~'~ ~ 4~
Water Sample Test Results
B. SEPTIC~ TANK DATA
Date Installed 10/17 /,f-'rJ.~ Size 1~.~'-~) . NO. of Co,~a~tments
Standpipes (Y/N) y~ Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N)~S
Depression ove~ Tank (Y/N) ~JC) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N)/Q/~.....; for .~.]z/'
Holding Tank High-Wate~ Alarm (Y/N) /~,/~ Temporary Holdi~ Tank Permit (Y/N) O./~
Separation Distances f~om Septic/Holding Tank:
TO Water-Supply Well
To opert¥ Line
TO Water Main/Service Line
Course /~/~
To Building Foundation ~ I /
TO Disposal Field
To Stream, Pond, Lake, c~ Major D~ainage
[Page 1 .of 2] 2-15-84
Ct
ABSORPTIO~ FIELD DATA
Soils Rating in Absorption St=ara /~O ~/~ ~ Type of System Design
Date Installed ~>/l~ / ~ / Length of Field ~--q !
Width of Field 4~" Depth of Field q /
~1 Bed Thickness 4/
Squa=e Feet of Absorption A~ea ~3Z [~/] 4 Standpipes Present (Y/N) ~..c~
Depression over Field (Y/N) ~_(O ~)ate of La.s~ Adequacy Test
Results of Last Adequacy Test /~-P_~3
Separation Distance from Absc~tption Field:
To Wate=-Suppiy Well IZ4' To P~operty Line ~S/,~.) %0'
TO Building FoundatiOn . ~ / To Existing or Abandoned System cn
Lot .~;/~ ' ; On Adjoining Lots >EO'
To Water ~ain/Bervice Line ~]O / To Cutbank(if present) ~/~
To Stream/Pond/Lake/c~ Ma3o= D=ainage Ccurse . /~../~
To D=iveway, Pa~king A=ea, c~ Vehicle Sto~age Area ~6>F
D. LIFT STATION ~
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested fo=
Electrical Codes (Y/N)
C~t~nts
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent !Y/N)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
** Check Permitted Bedroom Rating Against HAA Request
I certify that I have checked, verified, o~ conformed to all MOA HAA
on the date of this inspection.
KB1/dL/s
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