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SLEEPY HOLLOW #2 BLK 1 LT 13
Sleep Hollow Block 1 Lot 13 #051-511-05 Municipality of Anchorage On -Site Water and Wastewater Program • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP131295 PID Number: 051-511-05 Dwelling: ® Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ® Upgrade Name: Silverberg/Burger Alaska Comm. Prop. Trust... ABSORPTION FIELD - EXISTING ® Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound Address 18854 Mountain Rd., Chugiak, AK 99567 ❑ 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 SLEEPY HOLLOW #2 1 13 Fill added above original grade -- Ft. Gravel length 1 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 -- Fe-- Ft. Well 100'+ 100'+ -- __ 25,+ TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer ANCHORAGE TANK Capacity 1 1000 Gal. Surface Water 100'+ 100'+ __ __ Material Number of compartments Lot Line 5'+ 10'+ __ __ STEEL 2 NA Foundation 5'+ 10'+ __ _ LIFT STATION Manufacturer Capacity Curtain Drain NA "50'+ NA -- ----------------- Gal. Remarks Existing septic tank decommissioned Pump on level at Pump off level at High water alarm at per code. New tank insulated. in. in. in. Pump make and model Electrical Inspections performed by Installer JRS PIPEMATERIAL House to tank dTnktoD3034 eld Drainfield -- CO/MT -- Inspector ARCTERRA BENCHMARK (Assumed elevation) 100 ft Inspectionts' 9/1/13 9/1/13 Location and description dates: 2'd 3m 4'^ Para a slab COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL �++1�►aq OF Al1 Conditional Approval: Date All jr ° T HtQM Y. D - [[ < ; Approved Date Inspection Report ST copy.doc A -C=16.4' B -C=10,7' A -D=21.6' B -D=9,5' AS -BUILT TANK DETAILS/SITE PLAN SLEEPY HOLLOW #2, BLK 1, LOT 13 ?S, Ker eox 2S. ❑ aN SEPTIC �� 4 TH * �` I` EENNETH M. D CE -7116 / }'A "�'ESSIOT3�'AV p�MT 'SUMP FCO SCALE, NTS LOT 13 BILK 1 EXISTING TRENCH PREPARED FOR: SILVERBERG/BURGER TRUST... 18854 MOUNTAIN ROAD CHUGIAK, AK 99567 FlELD BOOKS COMPUTED: SOUNDAxr.BOUNDARY o' BMW ""D' STAKING a clEo: KMD ASSUILT SLS DATE. 8/27/1 DWG. FILE GM.. NW1060 ACRD FlLE' FILE roe "a° 13179 Permit: OSP131� PID# 051-511-Oo On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP131295 Tax Code Number: 05151105000 Work Type: Septic Permit Effective Dates: August 30, 2013 to August 30, 2014 Design Engineer: ARC TERRA CONSULTING INC Subdivision: SLEEPY HOLLOW #2 Site Legal Address: SLEEPY HOLLOW #2 BLK 1 LT 13 G:1060 �- 13 Owner/Address: SILVERBERG/BURGER ALASKA COMMUNITY PROPERTY TRUST BURGER R A & SI PO BOX 6598 ITHACA NY 148516598 Site Mailing Address: 18854 MOUNTAIN RD, Chugiak Lot Size in Sq Ft: 63469 Total Bedrooms: 3 This permit is for the construction of: N Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage 01 3:ao 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 MUNICIPALITY OF ANCHORAGE as_-)� Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I. D. 051-511-05 Property owner(s) SILVERBERG/BURGER... PROP. TRUST.. Day phone Mailing address PO BOX 6598, ITHACA, NY 14851 Site address 18854 MOUNTAIN ROAD, CHUGIAK, AK 99567 Legal description (Sub'd., Block & Lot) SLEEPY HOLLOW #2, BLOCK 1, LOT 13 Legal description (Township, Range & Section) Lot Size 63469 So. Ft. Number of Bedrooms APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Single Family Absorption Field ❑ Initial ❑ (SF) Septic Tank 1� Upgrade F� (w/wo ADU) Duplex (D) ❑ Holding Tank ElRenewal ElMultiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / 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: b, Waiver Fees: _ Date of Payment: Date of Payment: Receipt Number: 60115 Receipt Receipt Number: Permit No. OSP I?;) ia'gS Waiver No. Permit App_9-1-12.doc o �RCTERRq „ »''ni LNG August 27, 2013 Arzc T miaA CONSUL TING, INC 212 E. 51' Ave, Anchorage, AK. 99503 Office (907) 868-3791, Fax (907) 868-3793 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: Septic Tank Upgrade Permit — Sleepy Hollow #2 Bl, L13 The owner has requested we proceed forward to obtain a septic permit to upgrade the failed septic tank on the subject lot. The proposed upgrade will serve the existing 3 -bedroom house. The adjacent delevoped lots are served by private and community water as noted on the design. There is no surface water within 100' of the proposed tank. We do not expect there to be any adverse effect on adjacent lots by the development of this tank. If you have any questions, please contact me at 868-3792/FAX 868- 3793. Respectfully submitted, ArcTerra Consulting, Inc. Kenneth M. Duffust P Attachments: On -Site Sewer Application Wastewater Absorption System Details/ Site Plan 20441 PTARMIGAN BLVD • EAGLE RIVER, AK 99577-8736 • PH (907) 868-3791 • FAX (907) 868-3793 WASTEWATER DISP❑SAL SYSTEM DETAILS/SITE PLAN SLEEPY HOLLOW #2, BLK 1, LOT 13 10 ps50 7 06 Q� 1 15 N. NO PUBLIC WELLS WITHIN 200' OF PROPOSED SYSTEM. NO PRIVATE WELLS WITHIN 200' OF PROPOSED SYSTEM EXCEPT AS NOTED. NO SEPTIC SYSTEMS WITHIN 200' OF PROPOSED WELL EXCEPT AS NOTED. �F\ *.4 THKE *+� -711'•�n'Essloo YAV s20 '14, xs150� w i - R ¢y� 97• R 173.43 ••7 1 12 9 :° °� 00 164.12 cw 13 _ J 14 Scale; 1"=160' PAGE 1 OF 2 DESIGN DETAILS DECOMMISSION EXISTING SEPTIC TANK PER CODE INSTALL NEW 1000—GALLON SEPTIC TANK INSTALL POST TANK COS — CONNECT TO EXISTING SYSTEM NOTES1 1. INSULATE TANK IF <4' COVER. 2. CONTRACTOR WILL ENSURE MINIMUM 2% SLOPE INTO SEPTIC TANK. 3. CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT WELLS & SEPTICS. PREPARED FOR1 SILVERBERG/BURGER TRUST... 18854 MOUNTAIN ROAD CHUGIAK, AK 99567 FlELD BOOKS COMPUTED: Somomy. BOUNDARY DRA°"` BMW sTmNa STAKING CH"'N"" KMD Air SPANGLER DA"': 8/271 0M°• P"E: GRID' NW10E ACAD "LE' FILE 'IOB "" 13179 oti �cTERR, r H� �r i % m I 4 ��F SUL8TI95r 0 5 6 ` WASTEWATER DISP❑SAL SYSTEM DETAILS SLEEPY HOLLOW #2, 'BLK 1, LOT 13 A Ex. S.T CAR PORT DECK OF AL�� * TH� * �0 ' KENNETH M. / CE 71 6 '$A/ 164.12 13 be CO PER CODE, INSTALL SX NEW 1000—GAL SEPTIC TANK &RECONNECT TO EXISTING FCO FIELD WITH POST TANK CO'S, MAINTAIN 5' SEPARATION FROM FOUNDATION & FIELD FLAG ALL WELL RADII, EASEMENTS & LOT LINES PRIOR TO CONSTRUCTION PREPARED FOR; SILVERBERG/BURGER TRUST... 18854 MOUNTAIN ROAD CHUGIAK, AK 99567 FIELD BOOKS Om'o sr: BOUND ST''1 M STAKIt ASWLT: SPANG DNC. FILE: Am RLE' FILE aawUim: DRAW BMW alcom: KMD DAIS: 8/27/13 GIM NW1060 ,as Nae 13179 Scale) 1'= 30' PAGE 2 OF 2 oti �CJERRq F i ~ $ m _ � TING. V fR' AK. 9951i�� MyN1CIPALITY OF ANCHORAGE Department of Health u Human Services O25 L Street, Anchorage, Alaska 99301 343-4720 DN - SITE WELL PERM]T Permit Number: 890074 0u�ulK��/ h�O/� /7/ "� Date Issued, 05/0O/89 Owner Name: RAYMOND A. BURGER Day Phone: Owner Address: HC79 BOX 6690 688-3835 CUUGIAK, AK 99567 Parcel [d: 051-511-05 Lot Legal: Subdivision: SLEEPY HOLLOW 02 Lot: 13 Block; 1 Section: 15 Township: 15N Range: 1W Lot Size 63469 (sq,ft" or acres) Max Bedrooms: This Permit: 0 Total Capacity: 3 WELL: Log most be submitted to Municipality of Anchorage Department of Health and Human Services within 30 days of well completion" THIS PERMIT /S lSGUED FOR THE EXISTING 3 BEDROOM SINGLE FAMILY DWELLING DNLY AND EXPIRES ON 12/31/89. I CERTIFY THAT: L. I am familiar with the requirements for on-site sewers and wells as seL forth by the Municipality of Anchorage (MOA) and the State of Alaska^ 2^ I will install the system in accordance with all MDA codes and regulations,, and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot" 4. I understand that this permit is valid for a maximum of 0 bedrooms, I also understand that the capacity of the total system is 3 bedrooms and any enlargement will require an additional permit.. Signed, DATE: (--/0-��7 /_e��.�e�_����_�__-_____-_ __------------ - (Owner) RAYMqN0 A. BUROBIR Issued By: DATE: Ci-UGiAK, AK 633-3199 DRELLMS C00 ?.O. BOX 670642 - C UGIAK, ALASKA 99567 OWNER OF LAND ....R2,y:no�.a..�-...3lirger ............................................. ADDRESS.r�._7°..-Box 6690 Chngiak Ak. 99567 IVELL - SITE Sleepy ... hoiiow 2 Lot 13 Blk.l DATE - STARTED. -5-18-89 ................................................................... DATE -- ENDED......6-..-89...................._........_........................................ KIND OF FORMATrON: FROM- ............. (.-. FT. TO ................. ... FT...Stub. Up ............... FROM ...............C.... ................ F T ................................. FT. T.0 . ..................... =4 FROA1....................... Crave' & Coble .. ...... F RON I ..............c..'..... i /. ...... .- F d . 14J ................`.C... 7 G .-..., C ➢ ......, R..l der �.......................... FROTvI ............. �.._ FT. TO ...............31 .. � i , s . Brown Sand ................................... FROM .............3.1.... FROM ....................... FT. T O .... .......... 3 .., FT.. Boiler................... r_ . itOM1..............32. .... -.T...............4�r ...8.. ........... n dy Silt ...................... somewaterFRO,'.!.............48....FT. i0 ................ 57 ...... _ Fs. .Gravel &Sand . .---........................... FROM ..............57... �[�P .... FT. TC ................�0.. FT...G-aY.. v Cla.. --- FROM ..............59.... FT -TC ..............112. .S...... FT...i�tdGravel .. FROM ............112... FT. TO ............. 170dpan .o _ Bolder .............. FROM ............i70... FT. TO ............. .J3.. FT. U.T.ay..sagd.... .......... II I ...................... FT. TG ...................... FT................................... CALL AL ASKA DEPTH OF WELL .... iN.. Ft. WASELLA, AK 376-3199 STATIC LEVEL OF RATER FT.. 40.. ft ............................................ DRAW DGWN FI'.175 ft. .................................................. GA S. PER ER. 45Q. GAr.St3ai .................................... .....liag.................... ... KIND OF CASING. 180. Ft. 6 in. A53-A.S.T.M. FROM ................173 r-7. TO ...............174.. FT Bolder .................. FROM ................174 FT. TO ................ ............. _7S... r i' Graver& Sand FROM 178 -- __ 1 80 �- BroaT Clay ....................... FT. kV ............ :.......... a I....................... FROM ....................... FT. TO ......................- FT.......................... FROM ..... ............. ..... FT. TO ........................ FT.......................... FROM ....................... FT. TO ........................ FT................................. FROM ....................... FT. TO--- ................ F T ................................. FROA1....................... FT. TO ........................ FT................................. FROM....................... FT. TO ...................,u. FZ................................ FROM ....................... FT. To ...................04S..... 17 �........... FROM....................... FT. TO .................... w� : Q�........... .... ........... D7 �— FROM....................... FT. TO .................... u.r �7........ �[�P .... ,. -:SCL.eNFORMATION:Drove Bolder down. from 174 ft, to 180 ft. 2� G.P.M. Perfrater well at 5i 0�55 2 hrs. with air rig 3 to 4 G.F.M. used bailer 4 hrs. bailing 7§ G.P.M. No warranty or no warranties imoiied DRILLER'S NAME.. ... Jay Williams ........................................................................... .P.M. pucp well L13, ell s�cc�r rfot-Lot l I /V WARRANTY DEED The Grantor, ,lack Kemp, Secretary of Housing and Urban Development, whose address is 605 W. 4th Avenue, Anchorage, Alaska 99501, his successors and assigns of Washington, D.C. for and in consideration of ten dollars ($10) in hand paid, the receipt of which is hereby acknowledged, and other good and valuable consideration conveys and warrants to: RAYMOND A. BURGER, GRANTEE(S), NUN MOUNTAIN ROAD, -EAGLE RIVER, ALASKA 99577, the following described real estate: LOT 'THIRTEEN (13), BLOCK ONE (1), SLEEPY HOLLOW SUBDIVISION NO. 2, according to Plat No. 73-086, Records of the Anchorage Recording District, Third Judicial District, State of Alaska. Located in the State of Alaska. SUBJECT TO reservations, exceptions, easements, covenants, conditions of record, if any. COMMONLY KNOWN AS: NHN MOUNTAIN ROAD, EAGLE RIVER, ALASKA 99577 Dated this 4th day of May, 1989. Secretary of Housing and Urban Development By: — —_ ................. Chief, Property Disposition Branch Anchorage Office STATE OF ALASKA ) )as Third Judicial District ) On May 4, 1989, before me, the undersigned Notary Public, in and for the State of Alaska, personally appeared Paul 0. Johnson, known to me to be the individual described in and who executed the within and foregoing deed, and who acknowledged before me that he was duly authorized to and did execute the same as his free and voluntary act and deed for the used and purposed therein mentioned. Witness my hand and seal on the date written above. Notary Public in and fo ` he State of Alaska My comnission expires October 15, 1989. MUNICIPALITY OF ANCHORAGE Q DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO'T'ECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/Oil WELL INSPECTION REPORT NAME P♦j H/CTNE �` p (fJF••, -V 13(S —NEW L� UPGRADE MAILINGADDRESS �—j ^r I SS/� /J ,fig (�J OY• ff If /"- 9 !? :5* 7F 7 �141< LEGAL DESCRIPTION ZO 74 LOCATION NO. OF BEDROOMS Wel tt AbsorptAion a(e DISTANCE TO: /yP4If/T Dwelling w'� Yf+r PERMIT NO. PZ Manufacturer Material No. of compartments n w la. H m Liu. cal) yin gallons IF HOMEMADE: Width Liquid depth Flnsidength PERMIT NO. = Z H Manufacturer Ma—teHia-1 Liquid capacity in gallons w= DISTANCE TO: Well Foundation W 25 Nearest lot line / PERMIT NO. 8 pe /9 x /° 2 7 J LL Z Z No. of lines / Length of each line Total length of lines Trend cjth Distance between lines w H (p inches /}�A{ hN. Top of the to finish grade Material beneath fila / Total effective aAb9sor tion area p T �%• [� inches Length Width Depth PERMIT NO. at 7 Q H o. — a- Type of crib Crib diameter Crib depth Total effective absorption arca w in DISTANCE T0: Well _ Building foundation Nearest lot line .a Depth Driller Distance to lot line PERMIT NO. LuBuilding [IDISTANCETO: foundation Sewer line Septic tank Absorption area(s) OTHER all 10 LL _ PIPE MATERIALS SOI L TEST RATI/NG` I -Ac' .s?"a� INSTALLER HJ 01 AI 4- REMARK �+ P-- �6� .L iYS RCTAOh /!'J ^,$(0^132 , �,v 1� �' "�• .� v�A/ li�.4 mac: �leaf7 S- 2 • �3 t ' o r -� sr 9 , ri u Sd' 1Qr >E A1"O • AS �W ira••��f"e°tlaBeeup°•'FI X11 �d q E0i60t°E¢u a 8f�' A9 )oY • —0 — N0.2113.E .r A P OV ED DATE LEGAL lm 7 4' !.3 7�1'tY13 (Rev. 3/719) // , 'x 0-'Y �������0�' I c- �U-0 if ��IU�;' �~^ DFPARTMENT OF HFALTH AND GNVIRONMENTA L PROTECTIDN F125 L STREI.E.T, ANCHnRAGG, AK 995C)1 ` C*.11 F—������ PERMIT NO: 85O385 DATE ISSUED: '07/03/85 APFLICANT: JOHN GROSS ADDRE.GS: P^O. ROX 772204 I.AGLE RIVER, AK 99577 CONTACT PHONE: 694`b219 LEGAL DF -SCRIP: SkDUIVISION, SLEEPY HOLLOW . ' LOT: 13 BLOCK1 5ECTION: 15 TgWNSHIP: 1�1\1 RANGF.: 1W LOT Ell ZE: 63469 (SQ.FT^ DR ACRES) MAX BEDROOMS: 3 Li�ted below are the options avai1able to you in designing your septii;. system" Choose the option that best your site. �F",Z. PA C; 11-- U NEX 1=1. 13 Lq'p J!"'), F;2' fr:'� J: DNA D�pTH TO PTPE BOTTOM (FT,) 4.0 4"0 4"0 GRAVEL DEPTH (FT") 13"0 0,5 �"5 TOTAL DEPTH (FT. } 12"0 4"5 7.5 �RAVEI- WIDTH (FT") 2"5 1B"0 5.0 GRAVEL LENGTH (FT.} 27.0 35"0 �6"0 GRAVEL VOLUME (CU.YUS.) 21^3 23^4 34^1 TANK SIZE (GALG) 1,000 1,000.0 ** 1,000"0 ** SOIL RATING (SQ"FT"MIR) 140 140 140 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS I �erti�y that: 1" I am [amiliar with the requirements for on-site sewers and wellc as set forth by the Municipality of Anchorage (MOA) and the Stateof Alaska" 2, I will install the system in accordance with all MOA codes and regulations, and in compliance wi,th the design criteria of this permit" 3. I will adhere to all MOA and ':.tate nf Alaska requirements for the set back distances from any existing well, wastewater disposal system or, public sewerage system on this or any adjacent or nearby 1ot° 4" I undvpstand that thiy peymit is valid for a maxiwum of 3 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS IN�TALLGD IN AN AREA COVERED BY MDA BUILDIN8 CODES, THEN (1) AN ELECTRICAL PERMIT AND INsPECTION MUST H2 OBTAINED; (2) AS-8U1LTS WILL`N0T BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DON� BY A LTCENSED ELECTRICIAN" SIGNED � DOJ E: APPLICANT: JCJFIN ORIASS IGSUED RY DHTE: .� 44— ����� ;.h [) A:' I ;[ 1, 1 01 III.AI.l11 "';J1) f' I _ r1 I'RWl I-'. (Permit #: 821127 January 31, 1983 TO: Permit Applicant Subject: Tot 13 Block 1 Sleepy Hollow Subdivision #2 A permit issued by this department for an individual. well and/or on-site sewer system has expired as of December 31, 1982. 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 needs to be sent to this department for documentation of the installation date and to close the permit. If a private engineer inspected the installation of the on-site sewer system, please have them send us the as-•builts for our files and documentation. If there are any further questions, please call this office at 264-4720. Sincerely Q c"Ji 6 Robert C. Pratt, R.S. Acting Program Manager Sewer and Water Program RCP/ljw enc: Copy of Permit SWP/057 7 c I [) A:' I ;[ 1, 1 01 III.AI.l11 "';J1) f' I _ r1 I'RWl I-'. (Permit #: 821127 January 31, 1983 TO: Permit Applicant Subject: Tot 13 Block 1 Sleepy Hollow Subdivision #2 A permit issued by this department for an individual. well and/or on-site sewer system has expired as of December 31, 1982. 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 needs to be sent to this department for documentation of the installation date and to close the permit. If a private engineer inspected the installation of the on-site sewer system, please have them send us the as-•builts for our files and documentation. If there are any further questions, please call this office at 264-4720. Sincerely Q c"Ji 6 Robert C. Pratt, R.S. Acting Program Manager Sewer and Water Program RCP/ljw enc: Copy of Permit SWP/057 TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = = SOIL RATING (SQ FT,'BR) = 140 THE REC.U.IIRE:D SIZE OF THE SOIL ABSORPTION SYSTEM IS: E -+ E E " -I" E-1 =-= -1-;2 1_ E_ r-4 Y:i -T" H- . ' e 13 F�' n%-* 1= L_ E.! F=_- F=' -1` E--1-- Eb THE LENGTH DIMENSION IS THE LENGTH CIN FEET? OF THE TRENCH OR DRAINFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET?. THERE 15 NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUT'FA_L. PIPE AND THE BOTTOM OF THE: EXCAVATION CIN FEET''. r -;z F=_ A`w M -o I F?' F= E-A =: F_ 1=" -E- Y A-_ -1E-' FA 1^•.1 F..: !3 x "-f EE == JL 17.10 0.1. - PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING TETE INSTALLATION INSPECTION_i OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. -I-1,-1 Y:1 a_ L 1^ J 1 E. e_ I"' Y 1D A'-1 =" F-1 FR EEn Fes_ E' CA Li 7L FN E (L::a _ BACKFILLING OF OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE 'SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM Is 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIE'UUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET FIND TO A COMMUNITY 'SEWER LINE 15 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE A'V'AILABLE TO INSURE PROPER INSTALLATION. F= E= Fe E l 3:'T' EE .- lF ^ 1: F<° 1_ - 0 E_ CD Er PI E": E E F2 _` w = _I_ _=A C5 I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELT._=, AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODE=S. _. I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN _ BEDROOMS. ------------------- /,�P�LOIICANT JOHN GROSS ISSUED BY--72� �1=�_`_��_=�-� _- �--G;ATF_:__LL�� 1�-� V4. 0 1 ^b B__Y 1'-a Y Y=' � F- r % 1-. 7C: '11 ''-r' A -•Y 1= 1-91'.� �" 1-6 B_• �� Y=# Yee E_ L:�EPAFTMENT OF' HEAW AND iTRt.�NMEEdTAL PE�:OTE�_TION 825 'L' STREET, ANCHORAGE, AK 9956E+1 264-4720 Y -11^-,E :C T' E= E 1 x-11=:. Int Fu " _ F;' r 1 g -IF PERMIT NO. C 821127 APPLICANT JOHN GROSS PO BOX 1161 E. R. 99577 694-9138 LOCATION LEGAL L.13 01 SLEEPY HOLLOW #2 LUT SIZE 999999 QUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = = SOIL RATING (SQ FT,'BR) = 140 THE REC.U.IIRE:D SIZE OF THE SOIL ABSORPTION SYSTEM IS: E -+ E E " -I" E-1 =-= -1-;2 1_ E_ r-4 Y:i -T" H- . ' e 13 F�' n%-* 1= L_ E.! F=_- F=' -1` E--1-- Eb THE LENGTH DIMENSION IS THE LENGTH CIN FEET? OF THE TRENCH OR DRAINFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET?. THERE 15 NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUT'FA_L. PIPE AND THE BOTTOM OF THE: EXCAVATION CIN FEET''. r -;z F=_ A`w M -o I F?' F= E-A =: F_ 1=" -E- Y A-_ -1E-' FA 1^•.1 F..: !3 x "-f EE == JL 17.10 0.1. - PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING TETE INSTALLATION INSPECTION_i OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. -I-1,-1 Y:1 a_ L 1^ J 1 E. e_ I"' Y 1D A'-1 =" F-1 FR EEn Fes_ E' CA Li 7L FN E (L::a _ BACKFILLING OF OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE 'SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM Is 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIE'UUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET FIND TO A COMMUNITY 'SEWER LINE 15 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE A'V'AILABLE TO INSURE PROPER INSTALLATION. F= E= Fe E l 3:'T' EE .- lF ^ 1: F<° 1_ - 0 E_ CD Er PI E": E E F2 _` w = _I_ _=A C5 I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELT._=, AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODE=S. _. I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN _ BEDROOMS. ------------------- /,�P�LOIICANT JOHN GROSS ISSUED BY--72� �1=�_`_��_=�-� _- �--G;ATF_:__LL�� 1�-� V4. 0 PERFORMED LEGAL DESCRII DEPTH (FEET) IK SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ❑ PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264.4720 SOILS LOG - PERCOLATION TEST 1 ri G 2 4 5 U 6 7 8 U 10 • .� U _.r --5* 1 J DATE PERFORMED:_ ,Ile� ✓ VN SITE 11 / Gross Time WAS GROUND WATER ?' S Net Drop (1 ENCOUNTERED? 0 12 / P ' IF YES, AT WHAT E U r DEPTH? 13 14 Y 16 ` r 7" Robert A t%/ d). Shaky a W 18-- �(,°,n No. 1457-E 19�ipAl �p"'°o, 20 PERCOLATION RATE TEST RUN BETWEEN —e_ FT AND Reading Date Gross Time Net Time Depth to Water Net Drop COMME=NTS PERFORMED 8Yt ' Ej JOB) au 72-008 (6/79) CERTIFIED (minutes/inch) s FT DATE:_ DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA 99601 DATE: PWS 1.0.#-Z /.� 5- z 2 - To Whom it May Concern: BILL SHEFFIELD, GOVERNOR Telephone: (907) Pf Address: I MUNICIPALITYV4pjj1t5{WGE DEPT. OF HEALTH & ,,,,,,NNCNTAL. 'RO"'-c"O" Jl)N ?, '7 1965 According to records on file in this office the go//0 w Water System is in compliance with the State Drinking Water Regulations Sincerely, MUNICIPALITY OF ANCHORAGE Development Services Department p p Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 051-511-05 Expiration Date: Z� 2 Legal description SLEEPY HOLLOW #2 BLK 1 LT 13 Site address 18854 MOUNTAIN RD Chugiak AK Current property owner(s) LUCORE X The On -site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 3/21 /2024 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 Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 MUNICIPALITY OF ANCHORAGE Development Services Department p p 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. 051-511-05 Complete legal description Sleepy Hollow #2 Block 1 Lot 13 Location (site address) 18854 Mountain Rd, Chugiak, AK Current property owner(s) Nicholas Lucore 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 11 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed V 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 $ 5 Waiver Fee $ Date of Payment 2 21 �- y Date of Payment COSA # S CZ `1 t O - Waiver # COSA Application —June 2022 Legal Description: Sleepy Hollow #2 Block 1 Lot 13 Parcel ID: 051-511-05 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) a pr Date illed Total depth ft Water storage tank volume NA gallons Cased to ft Well disinfected for coliform test? ❑ Yes ✓❑ No ❑ Sanitary seal is ctioning correctly 0 Coliform bacteria is Negative El Wires are properly pr cted Nitrate 4.91 mg/L ❑ Nitrate less than MRL (ND) Casing height (above ground) in. Arsenic ug/L ✓❑ Arsenic less than MRL (ND) Date of flow test for COSA Collected by Arcterra Consulting Static water level at beginning of test ft. Date 1/18/24 Comments Community well B. TANK DATA Measured operating fluid level in septic tank 49" Date of pumping 1/16/24 ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 2/24/83 W ALL standpipes present per record drawing Total measured depth from grade 12.4 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ✓❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Qeficiencies; On 3/19/24 repaired existing MT. IFT STATION ❑ Require 'ntenance completed Age of lift station rs Lift station material \� Comments: Adequacy test date 3/19/24 Results 0 Pass Fluid depth prior to test 0 in Water added 450 gal New fluid depth 0 in Elapsed time 1 min Final fluid depth 0 in Absorption rate 450+ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 96 in Effective depth used 0 in Effective depth remaining 96 in COSA Checklist June 2022 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' Community Sewer Manhole/Cleanout > 100' ❑Yes if No ft ❑ Yes if No ft Neighboring Tank > 100' Yes if No ft Private Sewer/Septic Line > 25' Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' ❑ Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' Yes if No ft ❑ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑Yes if No ft Q Yes if No ft 91 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 ft Surface Water > 100' 21 Yes if No ft Tank to Property Line > 5' Yes Field to Property Line > 10' Yes Water Main > 10' [✓] Yes Water Service Line > 10' ✓� Yes F. ENGINEER'S COMMENTS if No ft Wells on Adjacent Lots: if No ft Private Wells > 100' if No ft Community Wells > 200' 0 Yes if No ft © Yes if No ft if No ft If tank or field is under driveway comment below 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 Areterra Consulting Phone (907)-696-6111. Engineer's Printed Name Kenneth Duffus Date -W 2C( Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 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, AreTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can AreTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. COSA Checklist June 2022 Parcel I.D. 051 511 05 Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval Expiration Date 1. GENERAL INFORMATION Complete legal description Sleepy Hollow #2 Block 1 Lot 13 Location (site address) 18854 Mountain Road Current Property owner(s) Shane Stragier Mailing address Real Estate Agent 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 EPLAkis- bp -c- 1a, 'aO19 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well El Individual rx-1 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ JT a4�1 Waiver Fee $ Date of Payment I/ I a g h y Date of Payment Receipt Number COSA # 056 l9/ a� Receipt Number Waiver # Aacertified bymyseal affixed hereto and as of the validation date shown below, |verify that myinvestigation, based on procedures outlined in the Cadificoba of On -Site SystemsAppnzva| Guidelines for this ap[dication, shows that the on-site water supply and/or wastewater diypnoo| system is (are) mefe, 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, nvdinencea, and regulations in effect otthe time ofinstallation. Name OfFirm C&MENGINEERING Address 20182TULVVAF( Engineer's Printed Name CHARLES BALZAR|M| 6. DSD SIGNATURE System #1 Approved for bedrooms System #2 Approved for Disapproved Conditional approval for Date 11/20/18 ' bedrooms, with the following CE -13854 A AW AW _ (Y W By: Original Certificate Date: The Municipality ofAnchorage Development Services Division (DSNissues Certificates ofOn-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, CO8AChecNist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other Ifmore than 1septic system is onthe lot: COSA Checklist# 1 of 1 Structure served by this system 1 Legal Description: Sleepy Hollow #2 Block 1 Lot 13 Parcel ID: A. WELL DATA Well type If A, B.orCprovide PVVS/D#Ta Date completed - Sanitary sea[ (YYN)-__ Total depth -ft. Cased to -ft. FROM WELL LOG Date of test Static water level - 01 Well production - g -p -m- VVATERSAMPLERESULTS: Well Log (YYN)- Wires properly protected (Y/N)- Coongheight(aboveground)-n. AT INSPECTION ft. Coliform nd colonies/1OO mL Nitrate 5.04 nlg/L Arsenic _[ug/L Date ofsample: Collected by: C&M Engineering Tank | Date installed 9/1/13 Tank size ?lX}l}gal. Number ofCompartments 2 C|eanouts(YYM) yes Foundation cleanout (Y?N)\|eS_ Depression over tank (Y/N) |VJHigh water alarm (YYN) no Date ofpumping PumperAlaska Quality Septic Date installed Soil rating or*z«~drn7 typetrench Length 2 ft. Width 3 ft. Gravel below pipe 8 ft Total depth _T{ft. Ef[absorption area 448 ft2 Monitoring tube yes Depression over field 7x}__ Date ofadequacy test Results (Pann/Fei|)pass For bedrooms Fluid depth in absorption field before test 0 in. Water added gal. New depth 0 in. Elapsed Time: min. Final fluid depth 0 in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12mo.)(Y7N&type) none known |fyes, give date Da______ D. LIFT STATION Deba installed -- "Pump ^Pumpmflevelsd-- Datum -- WELL ON LOT TO: Size in gallons -- in. "Pump off"level at -- Cycles tested -- Septic tank/lift station onlot +100 Absorption field on lot +100 Public sewer main Sewer /septic service line. f100 Manhole/Access (YYN)-- in. High watealarm leveled — in. __ Meets alarm &circuit requirements? -- On adjacent lots Onadjacent lots f 100 Public sewer manho|e/ceanout +100 Holdingtank +100 Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK DNLOT TO: Building foundation Property line Absorption field Watermain +10 Water service line + 10 Surface water +100 Wells on adjacent lots +100 Property line Building foundation VVabarmain Water Service !inef 10 Surface water Driveway, pading/vohidexkoroge Curtain drain +50 Wells on adjacent lots +100 * Property Served bv a communitV well located at Sleepy Hollow#2 B1 Ll 5. +^ MT penetrates approx. 6' into effective. E. ENGINEER'S CERTIFICATION / certify that / have determined through field inspections and review ofMunicipal records that the above systems are in con/bnnenoa with &Y[\4 CC)SA guidelines /neffect on this date, Engineer's Printed Name Charles Balzarini Date 11/30/18 COSAcanary s���-15.doc MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 907-343-7904 3 On -Site Water and Wastewater Section rax. 34-7997 www.muni.org/onsite Nitrate Advisory Certificate of On -Site Systems Approval # OSC181627 A water sample revealed a nitrate concentration of 5.04 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. 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 ofnitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. |tmay also result from the breakdown oforganic matter buried inthe soil. TOXICITY: Nit/ate is generally not toxic to adults o/ children over the age of two or three years, but is associated with o potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nit/ate converts to nitrite, which can pass through the intestinal vvaU into the blood stream. There it combines with the hennog|obinand 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 toits solubility inwater and negative ionic charge, filtration and other common home water treatment systems such as softening o/ 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 spectro photometer 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. Olt • Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcell.D. 051-511-05 1. GENERAL INFORMATION Expiration Date: 2 - / J / Complete legal description SLEEPY HOLLOW #2 BLOCK 1 LOT 13 Location (site address) 18854 MOUNTIAN ROAD CHUGIAK AK 99567 Current Property owner(s) Silverberg/Burger Alaska Com. Prop. Trust Day phone Mailing address Real Estate Agent 2. TYPE OF DWELLING: PO BOX 6598, ITHACA NY 14851 ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class C Well Public Water System ❑ WaiverNariance request for: Day phone TYPE OF WASTEWATER DISPOSAL: Individual Holding Tank ❑ Community ❑ Public Sewer ❑ Received by , t X, Date: COSA to be released to the engineer, unless 8;hfi' wise requested by the engineer. COSA Fee $ /7' q 0 Date of Payment - 3 - % j Receipt Number (' zr��' d 6 COSA # / '3 tt L/ 6 ,zr Waiver Fee $ Date of Payment Receipt Number Waiver # 6. 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 9/30113 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 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 Ar OF' AL \ encroachments, deficiencies or discrepancies exist. 'i ,j TH 6. DSD SIGNATURE l� KENNETH U. DIFRI.S / System #1 Approved for bedrooms. `+ '- 7 1e / System #2 Approved for bedrooms. \ F mrls;ro* ` �► Disapproved. Conditional approval for bedrooms, with the following stipulations: By: A Original Certificate Date: The nicip ity w le Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the repres talions 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 10-10-12.Eoc 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: SLEEPY HOLLOW #2 BLOCK 1, LOT 13 Parcel ID: 051-511.05 A. WELL DAT CxS Well type Puhlij-- If A. B, or C provide PWSID # 213522 Well Log (Y/N) Date completed Sanitary seal (Y/N) Wires properly protected (Y/N) Total depth ft. Cased to ft. Casing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test Static water level Well production WATER SAMPLE RESULTS: ft. Coliform NE& colonies/100 mL Nitrate 3.2.2 mg/L Arsenic: ND ug/L Date of sample: 10-10-17, B. SEPTICIHOLDING TANK DATA Tank Type/Material SEPTIC / STEEL Tank size 1000 gal. Number of Compartments 2 Foundation cleanout (Y/N) Y Depression over tank (Y/N) N Date of pumping NA -NEW TANK Pumper C. ABSORPTION FIELD DATA ft. Collected by: ARCTERRA Date installed Cleanouts (Y/N) Y High water alarm (Y/N) N Date installed 812411983 Soil rating (g.p.d./ft2 orfe/bdrm) 140 System type DEEP TRENCH Length 28 ft. Width 3 ft. Gravel below pipe 8 ft. Total depth 10* ft. (Measured 8/26113) Eff. absorption area 448 ft2 Monitoring tube Y Depression over field N Date of adequacy test 812 712 01 3 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 600 gal. New depth 0 in. Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 450+ 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 E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot _ Absorption field on lot Public sewer main Size in gallons "Pump off' level at _ in. Cycles tested Sewer /septic service line Animal containment areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ 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 Manure/animal excrete storage areas Absorption field 54 Water main 104 Water service line 101+ Surface water 1004 Wells on adjacent lots 1004 ABSORPTION FIELD ON LOT TO: Property line 104 Building foundation 10'+ Water main 10'+ Water Service line 101+ Surface water 1004 Driveway, parking/vehicle storage 5'+/- Curtain drain 50'+(NONEKNOWN) Wells on adjacent lots 1004 F. COMMENTS in. *See attached Sullivan Water Wells letter. Recently installed MT extends approximately 6' below the lateral into the 8' effective depth. Vacant system presoaked prior to test -no water present in MT throughout presoak or test. Property connected tom water system and disconnected from private well on adiacent property. Cmja55, G. ENGINEER'S CERTIFICATION 1 certify that 1 have determined through field inspections and review of determined through field inspections and review of Municipal records that inspections and review of Municipal records that the above systems are in Municipal records that the above systems are in conformance with MOA above systems are in conformance with MOA COSA guidelines in effect on conformance with MOA COSA guidelines in effect on this date. COSA guidelines in effect on this date. on this date. Engineer's Printed Name KENNETH M. DUFFUS Date 9130113 COSA brown sheet 10-10-12.doc 41%,N OF _AL4 X11 / �� * 4 q TI I* �* P� K€NNDUI / 7u6 Al `O ��FEB9SO4Nt' ?=26.88, Z N W W Z V W 11. ? N W � � J W CA g Cn N W rn � Ln r D (7) — D M C) �J O RECORDING DISTRICT, ASBUILT OF: SLEEPY HOLLOW SUBDIVISION, NO.2 LOT 13 BLOCK I PLAT 73-86 GRAVEL D/W .0 SURVEY CERTIFICATE: 1, John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance shoulc any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. 13-034 JLS I NW1060 1 1301 SEPTIC VENT (typ) LOT 13 BILK 1 W 0 0 234.73' REC & MEA) Z W W N N O O N N rn OO = FND 5/8" REBAR �4t�� OF AL' /.:4 Th...... L. SCHULLER.-3S-10408 AO.OPt ti�DD��� LAN xt 6 r 1831 Talkeetn. Street Anchorage, Alaska 99508 (907) 227-1455 office (907) 274-4992 fax MUNICIPALITY OF ANCHORAGE Department of Health & Human Services h} • DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # oS/ 0r HAA # L�PIM C] \ C: 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) G /3 G3/SGEE�Y//o//_o4uS•uan>vo•z(1/,ypz�SEG/ST/SyZ?ZW�) Location (address or directions) '4�" w( /it/ iPO ; C. 4Ue /L k Pe7el?S C/{ . (b) Property owner iPi4YiYJOA/O C�af6eR Telephone : (home)6_5-040- 3SflusinessS6Z-332 2 Mailing Address %' d e4X 46 ;72-3'4 9 ,4/e 99S /o (c) Lending Institution L/. 1, Telephone Mailing Address (d) Real Estate Company and Agent — Address Telephone — (e) Mail the HAA to the following address: (or check here elf hold for pick up.) List contact person and day phone number below: RAY l3vit G E /2 S �, Z ~ 353 a.[ I.1AXXY /Ff{TEs 7el.9 2. TYPE OF RESIDENCE Single -Family e Number of bedrooms — 3. WATER SUPPLY Individual Well e Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site 1?� Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rm 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION - 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 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 A -S. C Telephone 3419 S7Srf Address G74-'0 f4/2CT/e S�C//f -<,O AID A�/���O�fIGC Date Tv�v� -9, / 98.9 SCE OF A" q9� Engineer's Seal 6. DHHS APPROVAL Approved for -- —bedrooms by ' Date Tz! f Approved _2r� Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 notconduct inspections oranalyze data before a certificate is issued. The Municipalityof Anchorage is not responsible forerrors oromissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES Divl,MQN MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) SUN 91989 CHECKLIST -FEBRUARY 1984 t 343-4744 RECEIVED Legal Description: Ge -9 T /,3 61- OCA- / S'1_6EpY Nc��� ow �vG�O• No, A. WELL DATA Well Classification If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) __ Date Completed :o zw_e 2 Yield 7_ Total Depth le'�5) Cased to /Bp 1 Depth of Grouting V Static Water Level Pump Set At -Z" _'� Casing Height Above Ground z Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Y SEPARATION DISTANCES FROM WELL: Depression Around Wellhead (Y/N) IV x To Septic/Holding Tank on Lot //S > ; On Adjoining Lots 16 � /-/' To Nearest Edge of Absorption Field on Lot 12:2 --;On Adjoining Lots /77 r To Nearest Public Sewer Line 411 - To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot /�� 7 Water Sample Collected by 4.S ; Date 6 />/e 2 L_�' Water Sample Test Results Comments /3y cyELG. VX11-1—ClIe, SC,- &c C4.4„ GpC7 G.qT g tLocx / /S TNC OA/! I,' .OEVG401OG/2 L.g% 6f,117'1-11 IV A /q0'/e OF GVE'LG. S E PTI C/44G691 NG -TANK/ K..,,DATA Date Installed���SizeLdaa No. of Compartments /—SC (F6 ON Standpipes (Y/N) y Air -tight Caps (Y/N)/-rc/,n 0,v Foundation Cleanout (Y/N) —� Depression over Tank (Y/N) eV Date Last Pumped /-9a i Pumping/Maintenance Contact on File (Y/N) ;for Holding Tank High -Water Alarm (Y/N) IP�IA Temporary Holding Tank Permit (Y/N) "I/ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well -'V-S_' To Building Foundation To Property Line 6 `+1 r To Disposal Field To WaterM,4p/Service Line �S r To Stream, Pond, Lake or Major Drainage Course ALZA - gvE/L /vo 1 Comments A4 e'.O. StPARtIT/D f/ g' TAAk pC,orll 1,1g1cArC A /Z_CC)q. TAA//< ////r/O1 0A16 \ TA,V/< 6_o ', j'j ,-'o sG uOC' �' i F/4Z_ElJ TAn/Ar 1-,E- 7- STe9/r/LJ Fq/< 72026 (Bev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata s0S�,5�C Type of System Design T2BticL/ Date Installed BIZAlB3 Length of Field �1 Width of Field i/ Depth of Field "2 / Gravel Bed Thickness Square Feet of Absortion Area Statndpipes Present (Y/N) y otiE Depression over Field (Y/N) /V Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD To Water -Supply Well / Z Z / To Property Line BO /?f To Building Foundation 29 / To Existing or Abandoned System on Lot /V144 ; On Adjoining Lots 3a4� -"'- To "`To Water Main/Service Line 36 ` To Cutback (if present) S To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area S `� Comments ul-47-c2 1A104/eE01.117° ?1/C/O/a? TO725.5 - lOoir.ro,�.vT SX.Vr"At7) . rySTEJ' S -/Z O -Z-1161-9 -TNOvc EO 4vsi % E2 A a r<" of Sr•I/9 A0. Pot /Bh rs. rs/aootayd/2A/SE/417/✓Lr STAT/C FGOcv GEY iL. D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y **Check Permitted Bedroom Rating Against HAA Request** "Pump Off vel at (Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA gqiddptW,iNaffect inspection. R :rUfa 44 fit@ Signed tel// a.* Company :.�Ttl r f3 fr Date „ J„1,� MOA No. Receipt No. d //` gip/ Date of Payment Amount: $ John D. MCCl, Op sf°.• CE -4706 RqFESSI� Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 on the date of this Engineer's Seal °\CIIEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 S STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 5622343 innoa..*o r+ics FEDERAL TAX ID 0 920040440 ANALYSIS REPORT BY SAMPLE for Work Order t 13903 Date Report Printed: JUN 9 89 0 14:37 Client Sample ID:1,13, B1 SLEEPY HOLLOW S/D 12 PWSID :UA Collected @ Ins. Received JUN 8 89 0 12:00 his. Preserved with :AS REQUIRED Analysis Completed :JUN 9 89 Laboratory Supervisor PH C. E Released By ............/.............. Special CALL UPON COMPLETION. FOR RAY BURGER. Instruct: Chemlab Ref f: 5627 Parameter Tested ------------------- NITRATE-N Sample ROUTINE SAMPLE. Remarks: Lab Smpl ID: 1 Client Name BATES HARRY Client Acct BATEHC P.O.1 NONE REC D Req f Ordered By Send Reports to: 1)BATES HARRY 2) Matrix: WATER Allowable Result/Units Method Limits ------------------------------------------------------------------- 3.7 mg/1 EPA 353.2 10 ..............................,...................................................................... 1 Tests Performed See Special Instructions Above UA -Unavailable ND- None Detected See Sample Remarks Above NA- Not Analyzed LT -Less Than, GT -Greater Than H 0 N 0 3 p N NN N � z W H N CA 1 �• H • O t / w= i4 It • f a,� 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 264-4720 1. GENERAL INFORMATION Application Da 1` � (a) Legal Description (include lot, block, subdivision, section, township, range) Loz 13 RL_ V_ ) SLcEpy LJOLin) Scl6'n Location (address or directions) (b) Applicant Name c Home Applicant Address 1U4Q W -4-,u 7(, 1_if2t�d27— cry (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer ❑ (d) Lending Institution Address (e) Real Estate Company and Agent Address Telephone Telephone Business 561-66111 Other (explain); 141L (f) Mail the HAA to the following address: LTJ DEe.V ZI NOVAF'�2apc,er�/ iV1 ��Kf��til��T 107-0 (,1J_ 17 A tQ Pare. -r !2 D 2. TYPE OF RESIDENCE Single -Family, Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well ❑ Communityx 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 Cl 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 pve4 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA,.. AND INFORMATION ri 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 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 Address �7i0O Date �Z Telephone DHEP APPROVAL Approved for12 2 bedrooms by i Approved A Disapproved Conditional _ Terms of Conditional Approval dhep CAUTION Engineer's Seal 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 72-025 (11/84) MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION MUNICIPALITY OF ANCHORAGE (MOA) TH f )(".0 1 7 1987 HEALCHECKLIST - FEBRUARY 1TY 84HAA) 264-4744 RECEIVED Legal Description: I„(� f �-� 0L- s �_v Ff o �w A. WELL DATA Well Classification p / nm \/ �1_� 1L�� I�A B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) — Date Completed Yield — Total Depth Cased to — — Depth of Grouting Static Water Level Pump Set At _ Casing Height Above Ground Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot — :'zZoo ` — ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot _tea` ; On Adjoining Lots — To Nearest Public Sewer Line To Nearest Public Sewer Clea noLlt/Manhole -� To Nearest Sewer Service Line on Lot I� Water Sample Collected by �122P-/ C ^mss Date a Water Sample Test Results 713' Y rg C' /6 e 1� _ Comments �p�L__ttu_/__/o�sJ B. SEPTIC/MOLDING TANK DATA Date Installed 10_/1-/ —_ Size �5 No. of Compartments _ Standpipes (Y/N)— Air -tight Caps (Y/N) �T' Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped �A °cr, % o a ' .7 Pumping/Maintenance Contract on File (Y/N) �� � ;for �Z14 Holding Tank High -Water Alarm (Y/N) JSL A_Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: 1 To Water -Supply Well ?� To Building Foundation To Property Line To Disposal Field To Water Main/Service Line Course Comments Page 1 of 2 72-0261Rev 61661 Front To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design 7�f`lC 4 - Date Installed jab Igo Length of Field Width of Field .S6 Depth of Field —( L Gravel Bed Thickness Square Feet of Absorption Area 495' rt 44- Standpipes Present (Y/N) Y/ Depression over Field (Y/N) — Date of Last Adequacy Test Results of Last Adequacy Test SH TL S FgC70C4 Separation Distance from Absorption Field: To Water -Supply Well 7ZG0� )+ To Building Foundation . — Lot � /� To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course y To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Inst a d Size in Gallons "Pump On" Level at High Water Alarm Lev( Tested for Electrical Codes (Y/N) Comments To Property Line To Existing or Abandoned System on On Adjoining Lots _ .Iov -f- To To Cutbank (if present) I -C J# Dimensions Manhole/Access (Y/N) — 'Pump Off' Level at " Check Per f ed Bedro m Rating Against HAA Request " Icertifythatl eck n ied, or conformed to a I I MOA and HAAguidelinesin effect on the date of this inspection. Signed Date ZVA47 Compan MOA No. 5T8�'d«o Receipt No. — - D l — 70 O C� Date of Payment00 Amount: $ Dom— Engineer's Seal Page 2 of 2 Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA 72-026 (Re, 81861 Back r MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALT14 CERTIFICATE OF INSPECTION FOR HEAL.I H AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 204-4720 lD•'l`i'�� Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, mngo) r /2 L__J�C)G-/-_C.'lU Location (address or directions) (b) Applicant Name�jPD((JC9C__ Telephone: Home�1�2`_%._'_GZ .� 1 _. Business Applicant Address��-�'--�----- --- - N"'), _ (c) Applicant is (check one): Lending Institution ❑ , Owner✓buildertf'3`; Buyer IJ ; Other L.1 (explain); (d) Len din Institution _ .__-t->v7_/ti) 1:�.�"�'_T/''G=_ . g � -- Telephone -----------..—._.--_-- Address __(_._ r' I l--'.«' ui yS' —_-- (e) Real Estate Company and Agent Address .__-.-- Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family 0 Multi -Family ❑ Other Number of Bedrooms _—_ 5___.— 3. WATER SUPPLY Individual Well ❑ Community 0 PublicFd Note: It cornmunitywell system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite 0-- Public ❑ Community D Holding Tank C] Note: If community well system, must have written confirmation from the Slate Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 11 1r W50n-84i G, ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION Q As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this F lean}, 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 all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Date DHEP APPROVAL Approved for f1COF e- bedrooms by Approved . _—.__; \__..— Disapproved Conditional _ Terms of Conditional Approval CAUTION , Robo9 ^"w �44.,�'/ioFEsstoN «' Date The Muncipality of Anchorage Department of Health and Environmental Protection fDHEP) issues Health Authority Approval certiticatos based solely upon the representations given in paragraph 5 above by an independent professional engineer regMered 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 viork. Page 2 of 2 A. WELL DATA Well Classification Well Log Present (Y/N) MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1964 JUL 31985 264-4720 Legal Description: r-3_ LI -N 1D If A, B, C, D.E.C. Approved(ON) Date Completed Yield _ Total Depth - Cased to — Dep of Grouting Static Water Level ++ Pump Set At — Casing Height Above Ground —__ `Sanitary Seal on Casing (Y/N) — Electrical Wiring in Conduit (Y/N) _ Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/H&drsg Tank on Lot —_ZC'I- —_ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot?� �� Wil`-._ ; On Adjoining Lots To Nearest Public Sewer Line Cleanout/Manhole _ Water Sample Collected by — To Nearest Public Sewer To Nearest Sewer Service Line on Lot Date Water Sample Test Results — I Comments ��L.-LG f1Y2G-L <<'_1i.7 B. SEPTIC/14-TANK DATA X3:3 Date Installed Size No. of Compartments — Standpipes(O/N) _ Air -tight Caps((PN) — Foundation Cleanout ON) Depression over Tank (Y Vo Date Last Pumped /'J Pumping/Maintenance Contract on File (Y/N) /i�fi _ ; for Holding Tank High -Water Alarm (Y/N) _JJ _ Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/4494frrg Tank: I � To Water -Supply Well ��� "(' To Building Foundation To Property Line _ Lp �-1- To Disposal Field — S I, To Water-Main/Service Course _ ki Comments Page 1 of 2 72-026(11/84) To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 14,041lr"((, Type of System Design Date Installed Length of Field 2� VM3i=@ Munro Depth of Field Gravel Bed Thickness `1 Square Feet of Absorption Area '4+e 91�,, Standpipes Present(MN) Depression over Field Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well To Building Foundations t t - Lot N/N To Water MatrrfService Line r7, I --h To Stream/Pond/Lake/or Major Drainage Course _ To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments A N Date of Last Adequacy Test /Jr�,Lc% To Property Line \r� t -i' T�Existing or Abandoned System on On Adjoining Lots �J�A �To Cutbank (if present) . Dimensions nhole/Access (Y/N) "Pump Off" Level at Vent(Y/N) ** Check Permitted Bedroom Rating Against HAA Request ** Pumping Cycles during Adequacy Test, Meets MOA I certify that I have checked, verified, or conformed to all M A a d HAA guidelines in effect on the date of this inspection. Signed S' ENGlNURUNC Date"13 196X 2 85� n�wtD��q Comipahyl. 7)VERr ALA$KA 100 MOA No. Receipt No. �Jy \\�� do Date of Payment ��� 165 • .ao e � " •�• • E Amount:$ L6 oD A qe[5.' l.p.•• Page 2 of 2 72-026 (11/84)