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PARKSIDE BLK 2 LT 5
Parksl'*de Block 2 Lot 5 #050-591-07 Municipality of Anchorage ""' •• ee Development Services Department Building Safety Division • ' On-Sfte Water and Wastewater Program, 4700 Bragaw Sl. P.O. Box 196650 Anchorage. AK 99519-8050 Pagel of 2 www.cl.anchorage.sk.us (907)349-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM ANDIOR WELL INSPECTION REPORT Permit Number. SW070181 PID Number. 050-591-07 7 Wastewater System: ❑ New ® Upgrade Adtr TLE DRIVE, EAGLE RMR ABSORPTION FIELD a trap Ti«wt ® ll W Tr«rm a Ow a mtww a an« pl p hl a Sod Ft"V Told Deem soot W" aaa LEGAL DESCRIPTION EXISTING GPD/Fe Ft. ebra La srcawrm Depa. W pW twepm epnt «,paW pas G," depot b r pyo 2 5 PARKSIDE SUBDIVISK)N Ft. FI 7~" Rove swim Fa was aoo•a W" Vas Grml l«ism 14N 11W 6 Ft. Ft. Weil: New Upgrade 1t 011me DW«,p.e...« rte. Ft. FI c4aamatm (Pmau. A a. CI I Twit Depen. Card to T" aoaarpo mm P" Mm" ASTM 3034 EXISTING PRIVATE Ft Fr Dnar Data DrdW SWCWN Law kwww TWEED Due kw a SI1I2007 FI YWo Puny S«at Us" tw• Ano•a Ga"' TANK GPM FL F! SEPARATION DISTANCES ® Septic 0 Holding O S.T.E.P. ❑ Other. To Septic Absorption Lift Holding udraarivate wiww PREMIER PLASTIC n 1300 cr Fran Tank Field Station Tank Sewer une slat«W FM+riCar b Canpwnaa+e well +100' — — — '25 PLASTIC 2 +100' — — — LIFT STATION suf,im WM« Lot LM +5' — — — ate NO LIFT cr « 'Pump oriM « 'PUTWr « Highw««*,mal F«ndalm +5' — — — m m in Cr�� — PUT LWa a Mo EMw,r/ mepapa«w WM aY Cu1a+, Dram +50 — " SEPTIC TANK REPLACEMENT ONLY. CLEANOUTS INSTALLED Reffwft BENCH MARK LxWm.rm a•aauan NEAR TANK, AND FLOOR DRAINS INSIDE THE HOUSE, ALLOW TOP OF FOUNDATION AT HOUSE CORNER THE LINE BETWEEN THE TANK AND HOUSE TO BE SNAKED. mow«, 100 Ft INSTALATION OFAT D DND TI LEANO ' Eng{Iy1�I 81712007 •A�-41 Inspections performed by: ERES Dates: 1" P�/E�•~�'F" 1 w 2nd: Development Services Department Approval Conditional Approval Date: CHRISTOPHER R WOOD YA ••• CE:10387 L �••y�'1A t.J •1.• i ••Gr Date: 1 Iv oe • e f 'Yte Reviewed and approved by: F� Permit No. SW070181 Page 2 of 2 Municipality of Anchorage DEVELOPMENT SERVICES DEPARTMENT ON—SITE WATER & WASTEWATER PROGRAM 4700 SOUTH BRAGAW STREET P.O. BOX 196650, ANCHORAGE, AK 99519-6650 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: PARKSIDE#1 LOT 5 BLOCK 2 I I I I SWING TIES I I C 5'641.Y I I I I I I I I I I TANK MONITOR I I I I ABANDONED VEYMOA REQUIREMENTS DRAINFlELD LOT 5 050-591-07 NWeE \ WELL h"*I • •' • — MONITOR TUBE ELEVATIONS (NOT TO SCALE)p F N DATION T OUSE CORNER ENGINEER'S SEAL ASSUMED ELEVATION • loo' eo000�O0n� SCALE 1'-50' INSULAT31 %3.3', 93.2 ,.y ...................... •. CHRISTOPHER R. MOOD CE -10387 • ,� 0 0�„�OFESSK�� MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water Q Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ONSITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Permit Number: SW070181 Legal Description: PARKSIDE BLK 2 LT 5 Design Engineer: 0848 EAGLE RIVER ENGINEERING SEI Owner Name: MARGARET GARCIA Owner Address: 23551 GLACIER VIEW DRIVE EAGLE RIVER. AK 99577-9538 Date Issued: Jul 30, 2007 Expiration Date: Jul 29, 2008 Parcel ID: 050-591-07 Site Address: 023551 GLACIER VIEW DR Lot Size: 141584 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specked in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3, The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by catling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. - (EMERGENCY TANK REPLACEMENT) - SEPTIC TANK INSTALLATION MAYBE LOCATED NO LESS THAN FIVE FEET FROM ANY PROPERTY LINE OR BUILDING FOUNDATION; TEN FEET FROM ANY WATER SERVICE LINE; ONE HUNDRED FEET FROM ANY SURFACE WATER; AND ONE HUNDRED FEET FROM ANY PRIVATE WELL; AND THE SEPARATION DISTANCES REQUIRED BY 18AAC72 FROM WATER SUPPLY WELLS. Received By. Issued By Date: 7/3 d Date: 0 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 ON-SITE SEPTICIWELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcell.D. 0,5-p- Property 33D Mailing address fz -;LF i_.Vv p n 54 %lit', (rte , IX Zip Codd7ocrll-LN3� Site address 13 55 / Cr,&c c eA I li ew Dr_ Zip Code Legal description (Sub'd, Block & Lot) BCCA %Si de )s a- 1-5 Legal description (Township, Section & Range) TI N tJ t210 SES 14 Lot Size 141 Sq. Ft. THIS APPLICATION IS FOR (®all that apply): Absorption Field ❑ Septic Tank Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms 3 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 Famil welling and is in accordance with applicable Municipal Codes. 74 (Signature of property owner or authorized agent) Permit/Rush Fees: OU6b Waiver Fees: Date of Payment: 7/Z 717 Date of Payment: Receipt Number: R 79 qC1 Receipt Number: (Rev. 11/05) Eagle River Engineering ,Services C6rietophcr R. Wood, P.I;. 10421 VFW Road Suite 201 (907) 694-5195 tel Eagle River, AK 99577 (907) 694-3297 fax July 27, 2007 Dan Roth Manager, On -Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Parkside#1 lot 5 block 2 Septic Tank Replacement Permit request Dear Mr. Roth: The septic tank on the lot identified above has been determined to need replacement during a recent well septic adequacy test. The proposed septic tank replacement will have very limited impact on adjacent properties for the following reasons: The surrounding lots are all large, allowing sufficient room for well and septic sites. 2. Immediate neighboring septic systems are all +30' distance, and wells +100'. 3. This permit is for replacement of the septic tank only. 4. Drainage will not be affected and is not a major consideration in our design. The existing primary septic tank is corroded, and needs to be replaced immediately. A new 1250 gallon septic tank will be installed. Drainage will not be affected, and is not a consideration in our design. Existing leachfield appears to be functioning adequately. This work will not affect the reserve area on adjacent lots. If you have any questions please call our office at 694-5195. Sincerely, EAGLE RIV R ENGINEERING SERVICES e� *4 )) Christopher R. Wood, P.E. Principal X2003\07 -PA RKS I D E. DOC 8 vi n 3 O P O n N 89'57'00*W No NO SEPTIC �t 380.00 NO WEL NO SEPTIC++JO' 1 LOT S APPROXIMATE LOCATION OF COT TO .clow ACCESSsr"LL NEW OU AAOIL,QEANOMT ---_ IW °TAMX Tu WjtlljoZA� Novy .. •, MO SEP C,+.TTI' \\ �— I \ I \ APPROXIMATE LOCAnON / EXISTWOlEAO1i16D •ELL ' I I NO WEtL SEPTIC +](10 LOT 4 _ _ 330 Og- HEIDE DRIVE L4 Ln 0 N ® — TEST HOLE — — — EASEMENT 1. NO KNOWN SURFACE ATER +100'. • — MONITOR TUBE — PROPOSED LEACH FIELD 2. NO KNOWN CURTAIN D NS e — SEWER CLEAN OUT �� _ EXISTING LEACH FIELD 3. NO SEPTICS WITHIN 30' UNLESS NOTED + — WELL ©_ DRNEWAY 4. NO WELLS WITHIN 200' LESS NOTED WELL/SEPTIC SITE PLAN 4"' QEF' •'951/ � cl) • ?y�j, — LOT LEGAL: PARKSIDE 1 LOT 5 BLOCK 2 OWNER: MARGRET GARCIA CONTRACTOR: UNKNOWNor 0 i 1 .CER 1 HER R. ao CE -10387 �1�9 JOB 07-082 DATE:? 25 2007 SCALE 1 "=60' EACLE RIVER ENGINEERING SERVICES 10421 VFW RD. SUITE#201 A EACLE -5195 (907) 9RIVER, FAX. •577 (907) 694-3297 Eagle River Engineering ,Services Christopher R. Wood, P.P. 10421 VFW Rd. Suite 201 (907) 694-5195 tel Eagle River, AK 99577 (907) 694-3297 fax SPECIFICATIONS FOR SEPTIC TANK REPLACEMENT ONLY LEGAL: Parksideffl lot 5 block 2 July 27, 2007 A. GENERAL 1. The septic tank replacement plan is for a3 bedroom single family residence. 2. The drawing and or site plan shall be apart of this specification. 3. All materials and workmanship shall meet the Anchorage Department of health and State Department of Environmental Conservation requirements. 4. All soil tests are advisory to the design and arc to be verified or modified in the field by the engineer. 5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage, Department of Environmental Conservation requirements. 6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi -family wells. 7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. B. SEPTIC TANK 1. The sewer piping from the house shall be 4" PVC 3034 laid at 2% grade and insulated with 2" of burial foam if shallower than 3 ft., with 2 ft. minimum. 2. Septic Tank shall be a minimum of 1,250 gallon tank of MOA approved construction, insulated, or place with 4' of soil cover, min. 3. Install opposing 4"double cleanouts between septic tank and leachfield. 4. Connect tank effluent line into leachfield. No 90 -degree bends shall be used. Double 45 degree elbows shall be used in lieu of 90 degree elbows. 5. A foundation cleanout shall be installed. Twenty-four (24) hours notice required for all Inspections. Q\Documents and Settings\Carl\Dcsktop\2007wpdocs\07-parksidc tankonly- spec.doc MUNICIPALITY OF ANCHORAGE ; ® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION e ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME` �� ,(��/� -a.7"� Mq NEW El UPGRADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION '" "/�hJ/ g LIZ NO. OF BE �ROOMS ` U 1 DISTANCE T0: ell 1 ,. /'1jlJ�-(' �C�v. Absorptio rea 'E� / ej Dwellin ,i--Yl�-.�,�L�.. PERMIT NO. f� C 0 l�C� F z Manufacturer Mate ri No. of compartments `n Liq. capacity in Ilqp s IF HOMEMADE: Inside length_ Width Liquid depth -_ 6 X DISTANCE g:- Well Dwelling PERMIT NO. = Z F Manufacturer --" Material Liq id-capac' Ty in gallons W y DISTANCE TO: Well Foundation Nearest lot line PERMIT NO. J Z w No. of lines Length of each line Total length of lines Trench width r r Distance between lines Rcc f p Top of tile to finish grade t Material beneath the ,'3 inches Total effective bso�tipn area r�J C w Length Width Depth PERMIT NO. C7 Q I- w Type of crib Crib iam ter Crib depth - Total effective absorpti areaCL Lu DIS'(A/NCE TO:Well ild ng foundation NoBrestlot line J J C n Depth Driller Distance to lot line PERMIT NO. , DISTANCE T0: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS ��-�3`l SOIL TEST RATING C' INSTAL L§ R r { REMARKS - e. APPROVEDIDATE LEGAL �}�y J�✓ �vt,(� 11% L C 'eU �L�� l . .2 72-013 (RE6. 3178) U DEPHRTMENT OF HEHLTH HND EMVIRONMENTHL PRQTECTION 825 'L' STREET/ HNCHORf"IGE. HK99581 ICU %A^^. Ir������� PERMI( 810965 ) HPPLICHNT H8MHNN CONSTRUCTION POBOX 6�7/ EHGL� RIYER LGCHTION PH�K �IDE S/D TYPE OF SOIL HBSORPTION SYSTEM IS� DRFIT NFIELD 4]568 SQUHRE FEET MHXIMUM NUMBER OF BEDROOMS z ] SQIL RHTING (SQ FT/BR)� 280 THE REQUIRED �IZ OIL HBSORPTI�N S�STEM IS� �����Al� THE LENGTHDIMENSION I� THE LENGTH (IN FEET) OF T�E TRENCH OR DRHINFIELD TL E DEPTH OF H TRENCH OR PIT IS THE DISTHNCE BETWEEN THE OF THE GROUND HND THE BOTTOM OF THE EXCHVHTION (IN FEET) HN� N�L�S 8S S�T FORTH BY THE MUNlCI�ALITY OF HN�HORRGE ��� ������ �� �� I. 2�I WILL INSTHLL THE SYSTEM IN HCCORDHNCE THE GRHVEL DEPTH rr_PTH OF GRHVEL BETWEEN THE OUTFHLL PIPE HND THE BOTTOM OF THE EXCHVHTION (IN FEET)� ] BEDROOMS �EH: U 'I" F�� ������ ����� ����� ����� ����� PERMIT HPPLICHNT THE RESPONSIBILITY TO INFORM THIS DEPHRTM�NT DURING THE INSTHLLHTION INSPECTIONS 8F HNY WELLS HDJHCENT T8 THIS PROPERTY HND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE ���J F;;� I-,:� BHCKFILLIHG OF HNY SYSTEM WITHOUT FINHL INSPECTION HND HPPRO\lFjI BY THIS DEPHRTMENT WILL BE SUBJECT TO P�OSECUTION. MINIMUM DISTHNCE BETWEEN H WELL HND HNY ON_SITE SEWHGE DS PL SYSTEM IS 100 FE_`ET FOR H PRIYHTE WELL OR 150 TO 200 FEET FR0M H PUBLIC NELL [)EPENDING UPFlN THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM H PRIVATE WELL TO Al PRIVATE SEWER LINE IS 25 PEE-1- TO EETTO R COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY HPPLYSPECIFICHTIONS HON DIHGRHMS HRE HVHILHBLE' TO INSURE PROPER INSTHLLHTION �� �������� 1��� I CERTIFY THHT 1� I HM FHMILIHR WITH THE REQUIREMENTS FOR ON-SITE SYWER.E.,; HN� N�L�S 8S S�T FORTH BY THE MUNlCI�ALITY OF HN�HORRGE 2�I WILL INSTHLL THE SYSTEM IN HCCORDHNCE NITH THE CODES ]� I UNDERSTHND THHT THE ON�SITE SEWER SYSTE� MHY REQUIRE �NLH�GEMENT IF TH� RESIDENCE IS REMODELED TO INCLUDE MQRE THHN ] BEDROOMS ���� SIGNED� _~_--_ ~ ^� ISSUED BY DHTE_-��.� _M , Russell Oyster 694-2774 O & E ENGAEERING & DEVELO'b,MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 SOIL LOG Earl Ellis 686-2280 Performed for: Name: ��°�y f/ z—Tel. No. Mailing Address: Legal Description: Z_ D� Depth (feet) 0 Soil Characteristics "Z_ .S/4_7— To/0 Vie/ 3 5 6 P� �7 9 10 12 13 14 15 16 �,��-r/� � i <�,�k 3 .E •rte P OT PLAN o :5C4LE PERC.TEST .3111- "ZIVST 90 st�rsi/, /70tlel�i ,01E OF 44 A®e� eV Ground Water Encountered: Yes No If yes, what depth -V I Proposed Installation: Seepage Pit_ Drain Field Performed by: 44 4TH l .0.. �8 se:9a e ea°e eeas°e ee ae eias e �o�e.� •ee-ea•aa�.n...vaa�'ii �/ T •- Earl P. Ellis u Date: ?RO6 D`!I lil' II" { . l:Illi;li I:!' ;:'i 't i BUILDING SKETCH • Ilii fir tell .! {}�" + {{il I!F j+ .IT I . , rjl!r, ,i:; ::II iII It!j ;:a li;l j!li uii ilii i i { i:: i. iji I'i it ji ,r~i iil iii .it' irr jn, II. .,it a { IIlii• rii} 'r�'1'.:ii'j�l: iirh! ;iii � i ! ! III :! ii i. i:l, I' II t,• 'i'ir:iliil, ,i .;ll ;I. ;Iii ., :I jtf � n!' 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Ij?jil -IrI.' -I Fiimilijl!i.,ii l'!i:�.!;�:ii t;lF.:�::' ri•'r'.:it. •TIl:ti-i'i.';,c i -i;�i!:.�tIt`,i:i:i::ii-'�♦!.;jII}}:;;' 6��j?;:.�; I�i-I.::;� :': {'-:-:jiiI^.::�.:�: %'«T�_._tif. «lijyi Tr,.�}�I`:: ";',' ,;,{IYi}tj:'::,:!!wi ::tit?•:i' {{}jlht+":ii'ir..I.�-it;t'�'i....'J�,.�1•;., ' ,:•,:l"1j.^i.:r:, 111jffi ii:;..ir^i' ini'iitIl:,i i'iI fi tiiiji r!iiIr;ri i ., i!sI;'i ' yal.l .:: ". :::.I. .{.... n :: - V�1'c - �� i• y V" nurt..n r / St l{.1LCT rrllorOGRAP {s P fRRrNtCC Lq•vE VII��M� J S 1- Q J Q ONO . Y �q O� Y w w w w w w w w w w w w OF At CHORAGE 2, M�NICIQAUTY pFAT s " --TION E O O O O O O o O o O O O F F F+ EF E-F E-H f-H E-H F E-H F F 3 w 3 w w z a z CA '• i m w a C a U ; ? i Y g E• F 3 A a 00 a a O a o a 0 a 0 a 0 a 0 a a a a oaft O o V Q¢ W dF04z w w w w w W w w w w w w a A n A C7 �C J J D QU W CC a y X m W LL LL w w w w w w w w w w w w 0 0 0 0 0 0 0 0 0 0 0 0 • F F F F H F F F F F F F F F F F F F F EH F FF F F w w w w u. w "4 w w w w w Y O O N J z i w I d d Q a w i i i i i i i i i C4 `. 1 W ua rF.. H z Ow Ow � O rA v, w u o 0 o O O o 0 0 0 0 o O z —toa w o w w w w w w w w w w w w a S 3 A w d F. z d ~ ^ u^ F~ `n^ 6::u F~ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 'L' STREET/ ANCHORAGE, HK. 99501 264-4720 1�-A 1= I~L_ F:" E_ P-� r-1 I-V PERMIT NO. ( 021112 ) APPLICANT DUNC8N R MCLEOD 13 MONTE RD 694~9494 LOCATION LEGAL L5B2 PHRKSIDE LOT SIZE 999999 SQUARE FEET MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. ��F;PM I -F �X F> I R_" I—E :E; C-- F= 0::: KE M E3 E= PC =5- -1 ���:a" I CERTIFY THAT 1: I HM FAMILIAR WITH 'THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE 2: I WILL INSTALL THE SYSTEM IM ACCORDANCE WITH THE CODES. SIGNED:-- � HPPLIC8NT DUy�CHN H MC -4 ^/ � ISSUED BY- ������_v, _�..~DHTE�������f�~L���~^� V4.0 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.orglonsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. b5r7 •rJq�-D COSA# /Al)(0 Expiration Date: A % - d 1. GENERAL INFORMATION Complete legal description Q,,(ZKs�E t S gLIG 2 Location (site address) 23 S$ LA�i t2 �cNl DR - Current Property owner(s) A-4tz 4..4i2LT 4,42 6✓ -4 Day phone Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 66q eycacx2t�z:'u Si Bnfz('m T -A 790oy Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System Day phone Day phone The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite 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. TYPE OF WASTEWATER DISPOSAL: 1 j1' Individual On-site [ir ❑ Individual Holding tank ❑ ❑ Community On-site ❑ ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite 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 0.4416 iii if 2 e"t,_ S()G 5 Phone Address pn 90X 773,164/ 2:✓,,2 */C 5.9577 Engineer's Printed Name C8r&,W10FP_ Q_ Wcxvp Date 212 6/0 $ 5. DSD SIGNATURE wA.V. CF l' 0?ivRRR D Approved for 3 bedrooms. Disapproved. K Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory GFX. .`'sp • ON-SITE • •may= W11TER 1,,o WASTEWATER Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: v Original Certificate Date: a-2-7-0,9 (Rev. I LOs) Municipality of Anchorage • ^tel Development Services Department Building Safety Division 'Orf -Site Water &Wxstmt@rProgrbm' r. - 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.orglonsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: PLI/L% dcc%c S 8 Parcel ID:Q 55-0 - S5'-07 A. WELL DATA Well typee.7� DalecompletedS Total depth is 5--f If A. B, or C provide PWSID # _ Sanitary seal ON) 40- Cased to �_ft. UU FROM WELL LOG Date of test 8� Static water level t e O ft. Well production 3 9 -P.M. WATER SAMPLE RESULTS: Coliform 2•-colonies/100 mL Arsenic: A mgll B. SEPTICIHOLDING TANK DATA Well Log O/N)f fie_ Wires properly protected &N) Ve-1- Casing height (above ground) UOa — n. AT INSPECTION -7./A7�0- 1(4 ft. *3, g.p.m. Nitrate 0 L44I mg/L • Other bacteria 0 coloniesr100 mL Date of sample: 2 0 10-,f Collected by. rµeZ5, GJcLb Tank Type/Material Sr �n&� Date installed 2' '1 X00-7 Tank size _I, loo gal. Number of Compartments Cleanouts0N) _�� Foundation cleanout ON Depression Depression over lank (Y& JO_ High water alarm (Y(q) _rJo— Date of pumping-/neW rQClrg 5+- Pumper C. ABSORPTION FIELD DATA Date installed _10191_ Soil rating (g-p-djft or feibdrm) a XO System type i�n p Pti�w �Ytn�E� LengthI. 3 ft. Width 5 ft. Gravel below pipe ft. Total depth 5 ft. Eff. absorption area "-' ft2 Monitoring tube.!#_,L- Depression over field JUL Date of adequacy test `I -1 Results �Fail)�, �, For 3 bedrooms Fluid depth in absorption field before test _a_ in. Water added--IDAal. New depth= in. Elapsed Time:W�Dmin. Final fluid depth in. Absorption rate >= ►ISO g.p.d. Any rejuvenation treatment (past 12 mo.) (YO& type) _ y „dsi,1 If yes, give date D. LIFT STATION Pate installed ---- Size in gallons - - -.- •---. _._ Minh_ole/Access Y 'Pump on' level at _ in. `Pum off P High water alarm level at in. D Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM.WELL ON LOT TO: Septic tankAift station on lot _ +I Q -O Absorption field on lot + I bol Public sewer main +• 1 oo t Sewer /septic service line f ;XS ' Animal containment areas r 10 n' On adjacent lots _ +- 10 0 On adjacent lots -r I n0 ' Public sewer manhole/cleanout + I nh Holding tank -f Manure/animal excrete storage areas -t I m' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation +-,S I Property line + S 1 Absorption field +G1 Water main -f-10 I Water service line +-W) Surface water -r I()<) ' r Wells on adjacent lots -1 IOb SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line +10 I Building foundation +101 Water main + 1 o •-- rrr . Water Service line + 1 n' Surface water 4-1001 Driveway, parking/vehicle storage RO Curtain drain +50 Wells on adjacent lots +- 100' F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Jnr, S I06Q.k" - Ute? Date_ COSA Fee $ Date of Payment c' � � QcS Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number IDMR R WOOD CE:10387 •� n �� _a\cam � b� \I ASBUILT-NO CORNERS SET THIS DATE. CC 0 7 0�= � o �. G� SEWARD & ASSOCIATES LAND SURVEYING I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE: ���4♦ 1"=50' pF q ` FOLLOWING DESCRIBED PROPERTY: .0:%, (� ♦' Parkside Subd.,Lot 5,Blk. 2 DATE: r Q S AND THAT NO ENCROACHMENTS EXIST EXCEPT AS 5-6-91 A'• INDICATED. IT IS THE RESPONSIBILITY OF THE ; C^ q . in'S� ♦� OWNER TO DETERMINE THE EXISTENCE OF ANY GRID: i"""l "•"... ..."'•� EASEMENTS, COVENANTS, OR RESTRICTIONS SW 60 0.sc/��'.�4� WHICH DO NOT APPEAR ON THE RECORDED SUBDI- �j �•. o .�. M•r4 Swnd .:k VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD F& /� •. l5�e 918 �•+ ANY DATA HEREON BE USED FOR CONSTRUCTION 20-31 OFFENCE LINES, OR FOR ESTABLISHING BOUND- DRAWN: '�t�0rslrK�• ARY LINES. `�o �.+►� DMS SCS RcLM 1080524001 Client Dame Eagle River Engineering Services Project Name/H Parkside Client Sample ID Parkside Matrix Drinking Water PWSID 0 All Dateslfimes are Alaska Standard Time Printed Date/time 02/15/2008 12:49 Collected Date/time 02/07/2008 7:30 Received Date?ime 02/07/2008 17:10 Technical Director Stephen C. Ede Allowable Prep Analysis Peruncter Results PQL Units Method Container ID Limits Date Date Init Private Individual Analysis Sulfate 37.6 0.100 mg(L EPA 300.0 C (<250) 02/12/08 02/12/08 1DS Zinc 835 5.00 ug/L EP200.8 D (<5000) 02/13/08 02/14/08 Mll Total Dissolved Solids 260 10.0 mg(L SN120 2540C E (<500) 02/11/08 JDII Nickel 2.87 2.00 ug/L EP200.8 D (<I00) 02/13/08 02/14/08 MI Conductivity 474 1.00 umhos/cm SM202510B E 02/08/08 JDII pll 7.28 0.100 plI units SN1204500.11 D E (6.5-8.5) 02/08/08 JDII Alkalinity 211 10.0 mg/L SM202320B E 02/12/08 JDII Total Coliform 0 coU100mL SM209222B A (<I) 02/08/08 DLC SGS Ref.# 1080524001 Client Name Eagle River Engineering Services Project Name/H Parkside Client Sample ID Parkside Matrix Drinking Water PWSID 0 Sample Remarks: All Dates/rimes are Alaska Standard Time Printed Date/time 02/15/2008 12:49 Collected Dote/Time 01.'0712008 7:30 Received Date rime 02/07/2008 17:10 Technical Director Stephen C. Ede Allowable Prep Analysis Parameter Results PQL Units Method Container ID Limits Date Date Init Colony Count 0 coVI00mL SM209222B A 02/08/08 DLC Fecal Coliform 0 coV100mL SM209222B A 02/08/08 DLC Metals Department Hardness as CaCO3 225 5.00 mg/L SN120 2340D D 02/13/08 02/14/08 Mil Waters Department Total Nitrate/Nitrite-N 0.281 0.100 mg/L SN120450ONO3-F D 02/12/08 LCP Private Individual Analysis Aluminum ND 20.0 ug/L EP200.8 D 02/13/08 02/14;08 M11 Antimony ND 1.00 ug/L EP200.8 D (<6) 02/13/08 02/14/08 MH Arsenic ND 5.00 ug/L EP200.8 D (<10) 02/13/08 02/14/08 Mil Darium 25.5 3.00 ug(L EP200.8 D (<2000) 02/13/08 02/1408 hlll Cadmium 0.571 0.500 ug/L EP200.8 D (<5) 02/13/08 02/14/08 hilt Calcium 66000 500 ug/L EP200.8 D 02/13/08 02/14/08 Ntil Chromium ND 2.00 ug/L EP200.8 D I< 100) 02/13%08 02/14/08 Nfli Copper 48.3 1.00 ug/L EP200.8 D (<1300) 02/13%08 02/14'08 VIII Iron 456 • 250 ug/L EP200.8 D 1<300) 02/13/08 02/14:08 Mil Lead 3.33 0.200 ug/L EP200.8 D (<15) 02/13!08 02/14A8 Nil Magnesium 14600 50.0 ug/L EP200.8 D 02/13%08 02/14.08 Ntll Manganese 27.1 1.00 ug,1. EP200.8 D (<50) 02/1308 02/14;08 hill Chloride 0.960 0.100 mg/l. EPA 300.0 C (<250) 02/12,'08 02/12%08 JDS Fluoride ND 0.100 mg'L EPA 300.0 C 1<2) 02/1208 02/12,08 IDS Selenium ND 5.00 ug'L EP200.8 D 4<50) 0211308 02/14.08 hill Sodium 6270 500 ug/L EP200.8 D (<250000) 0211308 02/14,'08 Nil Silver ND 1.00 ug(L EP200.8 D I< 100) 02/13.08 02114.08 Nfll Thallium ND 1.00 ug/L EP200.8 D (<2) 02/13,08 02/14,08 Nil 1. t,\GI\Gfl/'aV 11\1 Va uv�+l avl - Complete legal description Parkside #1, Lot -5 Block 2 T14N 1W Sec 15 Location (site address or directions) NHIV Parkside Circle 2 Property owner -C 14 � riMarr�aret Garcia Day phone 694-2117 Mailing address 1535 Myrtle Drive, Eagle River, AK 99577 Lending agencyNorthland Mortgage Day phone 694-7872 Mailing address 11421 Old Glenn Hwy., Eagle River, AK 99577 Agent N/A Day phone Address Unless otherwise requested, HAA will be held for pickup 2. NUMBER OF BEDROOMS: 3 J 3. TYPE OF WATER SUPPLY: Individual well x Community well Lzn vow Nose (Lsn 'ABU) M -EL '�aoM s, oouibuo leuoissepid ay; ul suoissiwo ao saoaaa ao; apsuodsaa IOU si ebeeogouy ;o Alledioiunw ayl 'panssi si aleoilpiao a aao;aq elep az/,pue ao suoiloadsui lonpuoo ;ou op SHHQ;o s9aAoIdw3 'sluawe iinbaa 91e1s pue Ieaapa; uie}eao �4si;es of aapjo ul suoilnIpsui 6uipual aiay; pule sawoy;o siasegoind of /saunoo a se siyl saop SHHd ayl'e�seIy;o GWIS ay; ul paaalsi6aa aaaui6ua leuoissa;oad luepuedepui ue A(] anoge 9 gdea6eaed ui uanl6 suoileluesaidaa aql uodn Aluo paseq sa;eoi;iPaC) Ienojddy Al!aoylny glleaH sonssi (SHHd) saolnaaS uewnH pue y;IeaH ;o luawuedaa o5eaoyouy;o A;ljedioiunyy ayl Z. also :suoilelndlls bulnnollo; eqj gllnn swooapaq ��p1SS3jpyd ��- s 44 eU j sluawwoO 1eu0illppv ao; lenoidde leuoillpuoo 'panoaddvsla swooapaq ao; panoiddy 3l nIVNJIS SHHd 9 aanleubis s�99ulbu3._.____ LLS66 zanZa aT e MULL XOg -0°d ssaappy auoud walk ;o awsN wlloadsul slid bo alep aql uo lool;a ul suoileInbei pus `saoueulpao sapoo alelS pus IedloiunW Ile gjinn eouelldwoo ul si walsAs lesodslp ialumaisern ao/pua Alddns aaleM olls-uo ayl'uolloodsul pus uoile6llsanui AW wog; pus sail; a6eaogouy;o /`liIedloiunw aUl woaj pauiejgo uoilewao;ui eql uo paseq leul l;iaanaaq}jn; ! -ulaaaq paleoipul ainlonile jo adAl pus swooapaq;o aagwnu aul aoj alenbaps pus leuopoun; `a;es si walsAs lesodslp aaleMalseM ao/pus Alddns aa}eM alis-uo aUl lsgj smogs uolleolldde Jsnoiddy AllaoglnV ullsaH slgl;o u0lle6ils9nu1 ALU leyl A;loan ! `Molaq uMous.alep uoilspllen ayl to se pus olaaay paxi;;e leas Aw !q palpliao eV Ha3NION3 AS NOLLOUSNI dO LN3W31`d1S °9 Municipality of Anchorage y Department of Health & Human ServicesF�vr.�� HEALTH AUTHORITY APPROVAL CHECKLIST r Legal Description: /,.,r S .�/lam "'Parcel I.D. lle A. WELL DATA ce,� Well type If A, B, or C, attach ADEC letter. ADEC water system number ^//,# Log present(Y/N) —1 Total depth / gs- Sanitary seal (Y/N) Date of test Static water level Well flow Pump level Date completed Driller T1, Casedto3' Casingheight =� Wires properly protected (Y/N) . —y - FROM WELL LOG 8- /S-- Fl -.)- 1401 /Oa1 3 Gym rot z,Jicc! SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 35 Absorption field on lot /06 ' Public sewer main °t-,/`4 Public sewer service line /V AT INSPECTION Bila-5�9 / 9.p -m. S g.p.m. . ; On adjacent lots On adjacent lots 7'/°a I- Public sewer manhole/cleanout "' Petroleum tank �oNe 4pPa.t WATER SAMPLE RESULTS: Coliform Nitrate uN�lz fc�a/cr.0 Other bacteria 46 Date of sample: Collected by: s B. SEPTIC/HOLDING TANK DATA Date installed �/`�� Tank size a:: . Compartments Cleanouts (Y/N) y Foundation cleanout (Y/N) N Depression (Y/N) N High water alarm (Y/N) i ✓v � Alarm tested (Y/N) A,/ Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot l 5" On adjacent lots Foundation Jo Topropertyline Absorptionfield y3�ce•,�t Water main/service line_ Surface water/drainage //% 72-026 (Rev. 72-026(Rev. 3/91)Front MOA 21 - - CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level _ "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) _ "Pump off' level at SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA Cycles tested I Surface water _ Date installed Soil rating -2l'4' System type S'w�dce �, 4. ?e,;Il Length 1-13 Width 67 Gravel thickness 3 le Total depth S� Total absorption area 0 Cleanouts present (Y/N) A) Depression over field (`f/N) Date of adequacy test 5 7"/5i Results (pass/fail) /_fgss for 3 bedrooms Peroxide treatment (Past 12 months) (/N If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /06 ' -- On adjacent lots timed Property line L ti,r 1.7' .0 6[.'Yi.ri� fi.L6 E1�wT` To building foundation fi& ' To existing or abandoned system on lot On adjacent lots - Cutbank Water main/service line 7' io ' Surface water /V/.J -_ Driveway, parking/vehicle storage area J'ie-- ' Curtain drain nNd.Ye E. ENGINEER'S CERTIFY ATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection � '� HAA Fee $ —� 2 _Z— Date of Payment__ Receipt Number J_ 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ — Date of Payment Receipt Number Signature Engineer's Name L ti,r Date � '� HAA Fee $ —� 2 _Z— Date of Payment__ Receipt Number J_ 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ — Date of Payment Receipt Number MAY 01 '91 ie -:06 NTL-ANCH(i T 907 274-9645 r NORTHERN TESTING LABORATORIES, INC. FAIRBANKS, ALASKA 99701 (907) 456.311a - FAX 456-3125 3330 INDUSTRIAL WAY ANCHORAGE, ALASKA !19503 (907)277-8,378 • FAX 274-W6 2506 FAIRBANKS STREET Eagle River Engineering Po. Box 773294 Eagle River AK 99577 Attn! Louis Butera Our Lab 0: A109643 Location/Project: Parkside Your Sample 1D: Lot 51 Blk. 2 Sample Matrix: Water comments! Method Parameter Units -------------- - 7 --- EPA 300.0 Nitrate -N Reported By; William E. Buchan Anchorage operations Manager Report Date: 05/01/91 Date Arrived: 04/26/91 Date Sampled! 04/26/91 Time Sampled! 1600 collected By: LB Flag Definitions U = Below Detection Limit DL Stated in Result B = Below Regulatory Min. H = Above Regulatory Max. E = Below Detection Limit Estimated Value Date Result Plag Analyzed ------------------------ 1.0 U 04/29/91 Eagle River Engineering Services 11940 Business Blvd, Suite #205 P.O. Box 773294 694-5195 Eagle River, Ak. 99577 Fax 694-3297 Legal: a Date: Owner. Type of test: Test ❑ Septic Test Only 1 Well & Septic Test ❑ Other: ❑ Well Flow Meter Monitor Well Tank GPM PSI Remarks Time Reading Level Level Level ///2s _ ��e q�/ S6.ar„ s.o r✓/�' SAY;" /;ys Qoa� S3 /u zi x:23 //o 4ZA0 ss sb 56 e/+ Ode 5uc r MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AU'T'HORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section, tcwnship, range) L,,S- 13 0- /2 4G, 4,41 0I -a - Location (address or directions) (b) Applicants Name Applicants Address 67 C_ Tb (c) Applicant is (check one) Lending Institution ; Ow-ner/bdt+ r Buyer ; Other f:::j (explain); (d) Lending Institution c�/'O"i<lec Telephone Address (e) Peal Estate Co. & Agent Address Telephone 2. Type of Residence Single -Family Multi -Family Other (describe Number of Bedrooms L5 3. Water Su-22iz Individual ill Community Public rc J-7 -7 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Is the X11 adequate for the number of bedrooms specified in this HAA {Y ) 4. Sewage Disaosal Onsite Public Community Holding Tank // Is the wastewater disposal system adequate for the number of bedroaus((Y) [Page 1 of 21 2-15-84 5. Engineering Firm Providing Inspections, 'rests, Data and Information I certify that I e f feet on tFie da Sigrad Name oL F Address(''evgntt Signed by Date 6,DHEP Approval ve checked, verified, or conforffed to all IMOA HAA Ouicblines in Date r`1 Telephone _ (ENGINEER SEAL) Approved for > bedrooms Approved. Disapproved Terms of Conditional Approval 2FOIL '¢sb gB t � • s ei` '� fW A..g id57 : r4 y<9I •� y�� fe3� C�fFS i'•s •a s0 ea6'•• P�' 6$ tl0<.173:�q J�CvS1�� .20 By <-d_JI Date �— t r Conditional Tne Municipality of Anchorage Departrrent of Health and Environmental Protection dc --s not guarantee the continued satisfactory performance of the water supply ar:d/or the wastewater disposal system. This approval indicates that, as of the validation date shown above, based on the data and information furnished by an engineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func- tional for the number of bedrooms and type of structure indicated. (MEP SEAL) 7. Mail the HAA to the following address° KB2/d5/s (rage 2 of 21 2--15-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 A. WELL DATA Well Classification If A, B, or C. D.E.C. Approved(Y/N) .%- Well Log Present (Y� Date Completed Yields '- Total Depth �' Cased to -4-< Depth of Grouting Static Water Level '79 /SCJ /Up k? Pump Set At Casing Height Above Ground �� Sanitary Seal on Cast Y gElectrical Wiring in Conduit (YDepression Around Wellhead Separation Distances from Well: To Septic/ -Tank on Lot C) On Adjoining Lots To Nearest Edge of Absorption Field on Lot /C� 'ice -i ; On Adjoining Lots ff To Nearest Public Sewer Line ` v�`I To Nearest Public Sewer ,/ `� Cleanout/Manhole `u� To Nearest Sewer Service Line on Lot A / � Water Sample Collected By •� \ Zv���/1�6�/' ; Date 6// lb? 4,e Water Sample Test Results 5�12-7- Comments Comments B. SEPTIC/H TANK DATA Date Installed e / 9 1 Size No. of Compartments / Standpipe (Y ,Air -tight Caps (Y) Foundation Cleanout Depression over Tank Date Last Pumped %' Pumping/Maintenance Contract on File ( for Holding Tank High -Water Alarm (Y -A Temporary Holding Tank Permit (Y %1 Separation Distances from Septic Tank: /' To Water -Supply Db ll To Property Line To Water -"%'Service Line74 Course Comment To Building Foundation To Disposal Field. To Stream, Pond, Lake, or Major Drainage [Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA MUNI°"^ALITY OF ANCHORAGE 'T. OF HEALTH & ENVIRUNMENTAL PROTECTION UAV `<? 'I Soils Rating in Absorption Strata TypREfC�ygLzIDsi.gn Date Installed ���/7 Length of Field / L7 Width of Fields r� Depth of Field a Gravel Bed Thickness Square Feet of Absorptionea ` Standpipes Present (Y Depression over Field (TA)) _ Date of Last Adequacy Test Results of Last Adequacy Test -7-1 zp 7-ZJ Separation Distance from Absorption Field: To Water -Supply 411 jc? To Property Line To Building Foundation 70 .t To Existing or Abandoned System on Lot AJ _� / On Adjoining Lots G� ice' '0 e C -1 - To Water M/Service Line ,� O f To Cutbank(if present) z To Stream/Pond/Lake/or Major Drainage Course /'3 To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Dimensions Size in Gallons f Manhole/Access (Y/N) "Pump On" Level at "Pump Off" Level at — High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes(Y/N) Comments * * Che ck Permi I certify t at I on the da of Bedroom Rating Against HAA Request ** e checked, verified, or conformed to all MOA HAA Guidelines in effect i.nsfection. Signed � `�� Date 1�16 A % Compa MOA No. KB1/d5/s [Page 2 of 21 2-15-84 i %Y Lti 6LI C.3�6YI '�'j Lt 41L " V DATE RECE ED /ice INSPECTION APPOINTMENTS STREET LOCATI O _ aTIME TIME TIME / �I JJ ,,Ylw4 DATE DATE DATE ATTACH WELL LOG. A well log is required for all wells drilled INSPECTOR INSPECTOR INSPECTOR depth (attach log if available.) MUNICIPALITY OF ANCHORAGE fj',UNI;VIPA10TY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION" 825 L Street - Anchorage. Alaska 99501 ENVI•' -- �• .� • ENVIRONMENTAL SANITATION DIVISION a e' > OKc Telephone 264.4720 ®® //�� 11 APPROVAL OF INDIVIDUAL WATER AND SEWE&klGI6TI1V§P.- REQUEST FOR DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for DI RECTIONS: processing. - 1. PR/Q PITY OWNER 7 of /PHONE Ull�y MAILING ADDRESS PROPERZY RESIDENT (it differeTn/trom above) PHONE 2. BUYER MAILING A /%, 3. LENDING INSTITUTION MAILING ADDRE S �tl�u1/, M1 4. REALTOR/AGE - GL✓G 2M l� Gf� PHONE f c(l/4 MAI LINGADDR 5. LEGA ESCRIPTIOfjI /ice STREET LOCATI O _ 6. TYPE F RESIDENCE NUMBER OFBEDROOMS El One ❑ Four ❑ Other _ / Lam/ SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY Three ❑ Six 7. WATER SUPPLY flu CZ_ INDIVIDUAL (�D �r �� �i ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY nl-- since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY (5"" depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM 9/ d/7 INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE UST ACCOMPANYPCH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) �� o (1� - ' x���.�i�'? THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS ❑ SINGLE FAMILY ❑ ONE ❑ THREE ❑ FIVE ❑ MULTIPLE FAMILY ❑ TWO ❑ FOUR ❑ SIX ❑ OTHER 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection VerifiedINSTALLER PERMIT NUMBER DATE INSTALLED ❑Septic Tank or ❑ Holding Tank Size:- IOC-10 If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS L; APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BYjL 72-010 (Rev. 6/79)