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ROCKHILL BLK 1 LT 4
Rockhill Block 1 Lot 4 #015-362-04 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231245 PID Number: 015-362-04 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name JASPER WETHINGTON ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ound Site Address 6200 ROCKHILL CIRCLE *ANCHORAGE, AK ❑ Other Phone Number of Bedrooms Soil Rating Total depth original grade 907-230-4801 4 GPD/SF Ft_ LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot ROCKH ILL; BLOCK 1, LOT 4 Ft. Ft. Fill added above original gr Gravel length Township Range Section Ft. Ft. Gravel width Beds: Number of Lines Distance between lines SEPARATION DISTANCES Ft. Ft. To Septic Absorption Lift Station Holding Sewer Total orption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well 100'+ 25'+ TANK N Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer TANK Capacity 1250 Gal. Surface water 100'+GREER �,4 Material Number of compartments Lot Line 5'+ NA HDPE 2 Foundation 10'+ LIFT STATION Manufacturer Capacity Remarks PER CONTRACTOR - OLD TANK DECOMMISSIONED PER UPC Gal. Electrical installed by Alarm location Installer PIPE MATERIAL House to tank D3034 Tank to drainfield D3034 A.C.E.S. Drainfield D3034/EXISTING CO/MT D3034 Inspector GEG BENCH MARK (Assumed elevation) 97.54 ft Inspection 'Is` 9/6/2023 2nd Location and description aro- 4'"_ TOP OF MH ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp 0_0060 pp�4 Q� Conditional Approval: Date o ��• I P' 0 o�". yip 49 fd ....�.. }.. ................. D 0 ey� G rness. Approved Septic System Aents// 7requir �p"�' !u9 �3''��oNot his approval does not include well permit © ��O'Orp000�o�o #necc PERMIT NUMBER: RECORD D RA Y V I N G PARCEL NUMBER: OSP231245 015-366 2-04 \ A B \ M ill28.1 60.1 32.4 63.7 33.1 64.5 34.3 65.1 PIPE LOCATION ARE SHOWN PER .DWG FILE PROVIDED BY PLS (.PDF ATTACHED). SWING TIES WERE DERIVED IN AUTOCAD NEW 1250 GALLON GREER ROCKHILL; BLOCK 1,LOT 3 DBL GENERAL LOCATION OF NORTH END OF FIELD. PER CONTRACTOR, PERFORATIONS IN THE DISTRIBUTION PIPE DID NOT START WITHIN 6 FEET OF THE SEPTIC TANK. — EXISTING \`A 10' TELE. Afd% \ -. ELEC+ESM'T. \ HOUSE / n / ase / e e T / / / / / / N ROCKHILL; ROCKHILL; SCALE: BLOCK 1, LOT 9 BLOCK 1, LOT 8 1"=40' ENGINEERING - SALES �CONSULTING 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507' PHONE (907) 337-6179' FAX (907)338-3246-WEBSITE:—.g—.5 nginee,..g...m PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JASPER WETHINGTON 907-230-4801 2 OF 3 LEGAL DESCRIPTION: DRAWN BY: ROCKHILL; BLOCK 1, LOT 4 D.J.G. TYPE OF WORK: DATE: SEPTIC TANK RECORD DRAWINGS 9/18/2023 SOF ...............��♦ �49 4 J rA. Garress„ i #AECC884 PERMIT NUMBER: RECORD DRAWING PARCEL015-362-04 ER. �O�P231245 TOP OF TANK AT INTLET = 91.99 INVERT OF BUNG AT INLET = 91.32 TOP OF MANHOLE = 97.54 FINAL GRADE = 97.15-97.25 NEW 1250 GALLON H.D.P.E. SEPTIC TANK TOP OF TANK AT OUTLET = 91.98 INVERT OF BUNG AT OUTLET = 91.07 ENGINEERING � SALES =' CONSULTING _ �.__�_ .,' . xr� ,.y 3701 E. TUDOR ROAD SUITE 101 'ANCHORAGE, AK 99507 `PHONE (907)337-6179 - FAX (907) 33&3246' WEBSITE: �.gam ssengineernne mm PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JASPER WETHINGTON 907-230-4801 3 OF 3 LEGAL DESCRIPTION: DRAWN BY: ROC KHILL; BLOCK 1, LOT 4 D.J.G. TYPE OF WORK: DATE: SEPTIC TANK PROFILE 9/11/2023 S 89°59'22"E 150.00' •MH • ROCKHILL CIRCLE 10' � � 2 -i O D 61 2" •wE[[ �- H�uSE SINGLE FAMILY DECK SHED �: 49 TTH o S/�r,�i lTaG� SHANE A. HOLT .' G LS -6914 AS -BUILT SURVEY 1" =40' NO CORNERS SET THIS DATE OF THE FOLLOWING DESCRIBED PROPERTY 10T4 &OCKIROCKHIL LSUB. ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE THEINFORMATIONHEREON ISFOR THEUSEOFLENDINGIN5T/TUTIONSSPECIF/CALL YTOSHOWANY VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN CONFLICTSBE7WEENEXISTINGSTRUCTURESAND PLATTED LOTLINESAND/OR EASEMENTS, AND IS THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS NOTTO BE USED FOR POSITIONINGADDITIONAL STRUCTURES, IMPROVEMENTS, ORFENCELINES. EXIST OTHER THAN NOTED. EASEMENTS OFRECORD. OTHER THAN THOSEAPPEARING ON THERECORDPLAT, ARENOTSHOWN HEREON ( UNLESS INDICATED) DATED AT ANCHORAGE, ALASKA THIS 15 TFf DAY OF NOTEFENCELINESTHATMAYAPPEARONTHISDR W/NGARENOTTOSEUSEDTODETERMNE SEPTEMBER , 2023 PROPERTYLINES OR POSITIONADDITIONAL IMPROVEMENTS ANYPAVINGSHOWNHEREONMAYBEAPPROXIMATEDUETOEXCESSIVESNOWAND/ORICE. HOLTLAND SURVEYING 9309 GRO✓ER DRIVE 9GE,AK 99507 9359233-4 223.8615 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 hftp://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP231245 Work Type: SepticTank Upgrade Tax Code Number: 01536204000 Site Legal Address: ROCKHILL BLK 1 LT 4 G:2438 Site Mailing Address: 6200 ROCKHILL CIR, Anchorage Owner: WETHINGTON JASPER W Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: Effective Date Expiration Date: Dent S __o Q v Department Lot Size in Sq Ft: Total Bedrooms: 8/17/2023 8/16/2024 52448 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing t Special Provisions: • Cleanouts at each end of the trench are to be repaired or replaced as needed. LA e Issued By: Date: Date: 4 MUMCIPALITYOFANCHORILAWE Development Services Department's Phone: 907-343-7904 On-Site Water � : Wastewater Section — ' Fax: 907-343-7997 ON-SITE SEPTICIWELL PERMIT APPLICATION Parcel I.D. 015-362-04 Property owner(s) JASPER & MICHELLE WETHINGTON Mailing address 6200 ROCKHILL CIRCLE *ANCHORAGE, AK Site address 6200 ROCKHILL CIRCLE *ANCHORAGE, AK Day phone 907-230-4801 Legal description (Sub'd., Block & Lot) ROCKHILL; BLOCK 1, LOT 4 Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) Q (`N/wo ADU) Septic Tank ❑ Upgrade (D) ❑ Holding Tank ❑ RenewalDuplex ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: -225 Date of Payment: ^gAg� 3 Receipt Number: 0373.*3Ce Permit No. C.Y p z 3) 9 5 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231245, Deb Wockenfuss, 08/17/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231245, Deb Wockenfuss, 08/17/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231245, Deb Wockenfuss, 08/17/23 ti 3Q2 tia'N y N N Z w W� Z N y m� w ug a Jz p w H z g P N � o LL H O ? 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W LL° 3 0 aO o z � 'so Z w w w ,9 o < BR is 5~ J Z Ur N w F OU W Y Z- W ZW 8 �,0000vp0� 6 ° z�Z Z A=P oT�p ZO o p a, o G— O w ~ 0 V w o VO ~—. y m0O z � Om o �••'••• 0�40n N~ _ u EL <~ u.0 O0. ZEOZw qqq p_o w Q D 4 p n Q— O}} W W Q Novi w �d Zma jQv)Z V,U- _ -zu w0 W<W O yW} Zov NQI_Zp P wW1 o Z Waw w00p0j =mow O W ZZ zoUw w wo ��m �Oa[00 t . o w vow ugFW 05;W(LLZ �011i�z wzw mmMwU)� 44�vR: \s�o °Z-- w <c�a Z=oL) 0 P, 44 e9Qcs WNL W Fon �guw.W ow��m� 40000d�`�' r�N s °zo z¢�do z ar=Fo�aiF • • Municipality of Anchorage Page of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: 6W X1101 I I PID Number: 01,53 G 2Uy Name: •-r '_ 12-Met Wastewater System: ❑ New Al Upgrade Address:ABSORPTION '711 FIELD Phone: �1 • 9 ,.. '-/S73 L of se rooms: No. L� �Q Deep Trench ❑Shallow Trench ❑Bed ❑Mound ❑Other LEGAL DESCRIPTION Soil Rating: ��^^�� ``ii ` Depth from original grade: q• � r�7 V J GPD/Sq. Ft. .2sTotal Block: I Subdivision: Lot:/ n I''EX V t''1 a 11 Depth to pipe bottom from original grade: . )_.S Ft. Gravel depth beneath pipe 6 c> �-t Ft. Township: Range: Section: Fill added above original grade: Gravel length: �^ Ft. O O Ft. WELL: VIA ❑ New ❑ Upgrade Gravel depth: 6 7 C Number ofiines: Distanbetween lines: Ft !710 /e71 Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: /'� i ® L Ft. Ft. W1 / SQ. Ft. r V Driller: Date Drilled: Static Water Level: Installer: G rc e 5ys4eot,r Date installed: 00/1,3/11 Ft. ,,;� Yield: Pump Set at: Casing Height Above Ground: I� TAN K GPM Ft. Ft. SEPARATION DISTANCES Arseptic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer:. ! {�("� ` Capacity in gallons: (2,/- From Tank Field Station Tank Sewer Lines irek- e ,5 1 • Well I ®j t 1')() 1 �j� j NIA Material: ( Number of Compartments: ' 7JJ e N1A LIFT STATION ji/ 1,14 Water Lot! �tU¢ + ' /� Size in gallons: Manufacturer: Line 1)/ Foundation '20' "Pump on" level at: "Pump off' level at: High water alarm at: Curtain i st VIA Pump Make & Model Electrical Inspections performed by: Drain Iv//� Remarks: BENCH MARK Location and Description: e-A P-I(l')'Iu,n� OF p Assumed Elevation: .^9sr�� Inspections performed by: Dates: lst1)�� .. ....e... 2ndO '•.�No. 1051-E .� FGIST�' Department of He nd u n ervi approval e�'cz ® SS••••••••Aw Reviewed and approved by: ate: 72-013 (1/91) MOA 25 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.D. Box 19665 Anchorage, Alsaka 99516-6650 Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well inspection Report Leoal description: LDt 14 Ulu( -k I POCRI" )I 506, PID No.: 0153620'-1 EXIST 4-BDRM I 2 NEW /<"Ix"Al C.O. i 1� J_l'egD. / EXIST. FEILD 30'R _v \ \ z EXI T. MONITORING I WELL AND PERC. TE; LOCATION � I I SCALE: 1"=20' l NEW DEEP TRENCH�11 \ABSORPTION FEILD ......> 2nd. PERC. I \ \ TEST LOC. F 1;1 1 \ 1 \\ i NEW C.D. SWING LINES I DECK 'I B 26.5' 25' O j D 42' 36.5' F G 92' EXIST. TANK 1250 GAL. TANK AACRUSH ND INSTALL NEW NEW M ITORING WELL ` 1 GENERALIZE�j CONTOURS HE_1 110 \ z EXI T. MONITORING I WELL AND PERC. TE; LOCATION � I I SCALE: 1"=20' l NEW DEEP TRENCH�11 \ABSORPTION FEILD ......> 2nd. PERC. I \ \ TEST LOC. F 1;1 1 \ 1 \\ i NEW C.D. L4 CD0.U_ O O N C I I W cCO N OT W _ W w aro �1 a. 2 a� D Permit No. Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: LO T q , 61k lCocKI)/LL s 0660. PID No.: OD th G In o G - -O' '*7 T C Ho o u> -� > C ?. D ''.. 3 �Z -n O (F L'i c uX I. o < S c °_A 1 N 'I o A Z � e r — r �_. SEAL �itiR$ Stir r z� G D L tafeaa° a°s®°x° i@eR". ♦a tea«i 1w4eneccea tYs. B. Tr��blcr+d s u� FESS TRYCK RECEIVED NWAN Depth to Net Water Drop �)A) HAYES m SEP 12 1991 ENQWE Wins VY= e LANDSMWE ARCHUIECTS Municipality of Anchorage SOILS LOG — p8RC6UWFW"qESVrvices PERFORMED FOR: �HN 11W410n1 DATE PERFORMED. L rd. 16 L" I LEGAL DESCRIPTION: I<U(1: /FE T 1 2- 3- 4- 34 VARI 5 UN(f:0'Z 11% 5 kDrA SANDI4 15L of/! 1Vrn 51cx 6 1 7 -1F-4r ?o 8 s s►txy yQ,ovr� ,o tt 66. op HOLE 12 13 14 15. 16 17 18 19 Township, Range, Section: WAS GROUND WATER NOENCOUNTERED? IF YES. AT WHAT DEPTH? Dep111 to Water Ma 111witaing? N.A gale: SITE PLAN Reading Date Gross Time Net Time Depth to Net Water Drop �)A) 6 IN. 0/11 — — 5 1716 !N. 2 2 m IN. 10 6 1'74 jo. 20 to 1D/y 1 1l1. 30 to 00 VfAM 6'/ e+. 3o to `/a5 rFL 4o lO[O,to 60 !o 1 1 111l16, 20 -{ 12 t UPERCOLATION RATE � (m�nutesinch) PERC HOLE DIAMETER TEST RUN BETWEEN /O FT AND -7 FT COMMENTS 143 XR-C POrOAME0 TO YMIU 0AIJINAL ?(;sr sUBmWI-rW y FaMlT A#PPUCAMM. -rW -(6510'ROCCWA-5 ft.50AKIFO rok 3+ 140Q5^ -(W FWZ WA -5 601'I'1 Lee PeZ 9PA (4414UAL P. 41 PERFORMED BY: f►1�Ey 11�`�EyE� CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 8 I2 q 1 me41iN 5.33 5.82. 6.15 S." 6.15 5.9! 5.93 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 '•L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW910219 DESIGN ENGINEER:TRYCK, NYMAN & HAYES OWNER NAME:LEDERMAN SEMA E OWNER ADDRESS:6200 ROCK HILL CIR ANCHORAGE, ALASKA 99516 PARCEL ID:01536204 LEGAL DESCRIPTION: ROCKHILL BLK 1 LT 4 LOT SIZE: 52448 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 DATE ISSUED: 7/31/91 EXPIRATION DATE: 7/31/92 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: AN ADDITIONAL PERC TEST SHALL BE PERFORMED AT THE TIME OF CONSTRUCTION TO VERIFY THE ORIGINAL TEST OF 6 MINUTES/INCH. THIS TEST SHALL BE RUN PURSUANT TO THE E.P.A. DESIGN GUIDE MANUALPAGE Al, ./I 1 DATE: -T131 3j qt RECEIVED 1 ISSUED BY DATE: 7`J /` / / TRl'CK LAYMAN &HAYCS ENGINEERS/SURVEYORS/LANDSCAPE ARCHITECTS TRANSPORATION and COMMUNITY PLANNING July 22, 1991 Mr. Dan Roth Municipality of Anchorage 8th and L Street Anchorage, AK 99501 Dear Mr.. Roth 5044.0 RE: Lot 4, Block 1, Rockhill Subdv Attached is a permit application for upgrading septic system on the above referenced lot. A narrative description of probable impacts to adjacent property is discussed below: Wells - We anticipate no impact to the wells on the lot or on adjacent lots. All wells adjacent to the new septic system are located greater than 100 feet from the new system. No groundwater was encountered and the wells all have sanitary seals in place. Wastewater Systems - The proposed deep trench absorption system will replace the existing system. Testing of the existing system indicated it no longer accepted the amount of water it was designed to. In addition, a fourth bedroom has been added to the residence. The new septic system (including the installation of a 1250 gallon tank) will eliminate potential impacts to adjacent property by replacing a failing undersizedifield with a new adequately sized field. Reserve Space - Although no formal evaluation of reserve was completed, the lot is a relatively large one and can accept future fields. Drainage - The onsite well casing and septic tank had or will have positive drainage away from the improvement. The absorption field will be constructed along a contour interval and the cross -slope drainage slopes .range from 5 - 15 %. No natural or manmade ditched, swales or standing water was found on the lot. The absorption system site had good positive drainage and not drainage impacts to adjacent property are expected. TRYCK LAYMAN &HAVES ENGINEERS/SURVEYORS/LANDSCAPE ARCHITECTS TRANSPORATION and COMMUNITY PLANNING Please review the attached information and issue an approval to construct the new system. Yours Very Truly TVN7CK NYMAN HAYES,INC. Carey S Mey P.E. .JOHN HANSON �e® F s®oz.s PERFORMED FOR: GATE PERFORMED: LDT4t 13LOGK I LEGAL DESCRIPTION: POC14LL,. SUBDIVISION Township, Range, Section: rl.rN-=-_. .. ,, :z. -, SLOPE SITE PLAN r ©IZF�ANIC� C. SOILS LOG — PERCOLATION TEST'm�, �yF�ggN, q amm a to ��, �J+,^e® i'74 -VA'. Care . Msye 353 nm w ^ w® .JOHN HANSON �e® F s®oz.s PERFORMED FOR: GATE PERFORMED: LDT4t 13LOGK I LEGAL DESCRIPTION: POC14LL,. SUBDIVISION Township, Range, Section: rl.rN-=-_. .. ,, :z. -, SLOPE SITE PLAN 10 WAS GROUND WATER No ENCOUNTERED? IF YES, AT WHAT 12 DEPTH? 13 14 t bele to Weer Aute► 7 23 9t meadminp? Oett 16- 17- 18- 6 17 Bor; of Wog 19 r ©IZF�ANIC� 2 \P�R*5 UNIUI ILY FI0m 4 5 6 ' T -r 7 5 t o, ►�1i:aL ��-- 9 10 WAS GROUND WATER No ENCOUNTERED? IF YES, AT WHAT 12 DEPTH? 13 14 t bele to Weer Aute► 7 23 9t meadminp? Oett 16- 17- 18- 6 17 Bor; of Wog 19 10 PERCOLATION RATE 60 (mmutesinch( PERC MOLE DIAMETER 0� yTEST RUN BETWEEN k, FT AND % : FT COMMENTS RE -GO -AV -Q) `9Q� 2, HRf PERFORMED BY: CAR'S'( mflup, Iy MN CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 7 .. MONO o, ►�1i:aL ��-- 10 PERCOLATION RATE 60 (mmutesinch( PERC MOLE DIAMETER 0� yTEST RUN BETWEEN k, FT AND % : FT COMMENTS RE -GO -AV -Q) `9Q� 2, HRf PERFORMED BY: CAR'S'( mflup, Iy MN CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 7 .. Permit No. Page of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report 72-013 A (2/91) MOA 25 Permit No. Page Z of 17, Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: PID No.: tST � ve ll n NEW OP010, J `` ''`` �.�„C 4�,L�� RIM • WN ll0��p elf �v Ate / Y I4 r ✓ 4 � S � n g jtgeN C. Q. ENGINEER'S SEAL «° Aw 9g��� 4.0,..4 Hw.•.e Y•. 3 a 5. Mey w 6353 �✓ Y • .8 ROFESSARA IO�®� 72-013 A (2/91) MOA 25 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME )) r .,� on . � l '—+'Y `C PHONE _q 3S44( NEW ❑ UPGRADE MAI LING ADD ES Pb 6ov/ e� LEGAL DESCRIPTION ( LOCATION /�� l,� 0 a NO. OF. BEDROOMS � Y DISTANCE TO: Well ---- a Absorption area Dwelling / / T PERMIT NO. r pei Q wZQ f Manufacturer �� Material'S+�� No. of compartment N Liq. capacity in gallons p IF HOMEMADE: Inside length _,�_ Width --- Liquid depth --- Jaz DISTANCE TO: Well Dwelling PERMIT NO. = Z Manufactur Material-Liquid capacity in gallons-- J W x DISTANCE TO : Well (Of7 Foundation �D Nearest lot line L !O PERMIT NO. %�0 O W a v Z w No, of lines n Length of each lain g `'f" � Total length of IJ�'�qes g T Trench width 36 inches Distance betweep I' mess, % i CRLi xH p Top of tile to finish grade Material beneath tile �T— ineHes Total effective-orXtti® area '� W c� Length Width Depth PE RMIT NO, Q F w 1 Type of crib Crib diameter Crib depth Total effective absorption area W DISTANCE TO: Well Building foundation Nearest lot line J J Clas Depth Driller Distance to lot line PERMIT NO. W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER S' PIPE MATERIALS 5 c 1 C-0,^ pU3 I 2f SOI L TEST RAT[ NG 0 57 am iswT Itok INSTALLER REMARKS f UlX tG d tnR 70 v c a 5 r, v ..APPROVED DATE LEGAL lD Nitro N i tp vt=iL_ i Ty oF= nNct-j-)Fz-F4oF= DEPARTMENT i_ HEALTH AND ENVIRONMENTAL t,,"OTECTION 4 825 `L` STREET, ANCHORAGE, AK 99501 264-4720 0r-4— I TE !Ff=L-Jl=F;Z F='F="i ,'Fl �I -Ir PERMIT NO. < 80013.0 APPLICANT GOENTZEL BLDG INC334-5422. PO BX 10038 S. STATION LOCATION ABBOTT RD. 1 LEGAL LT.4 ROCKHILLS S/D.- LOT SIZE 54000 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SQ FT/BR)=(J--50 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH 15 THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). F.! FE Q U I r -e FE rs �=� F=F:" -r I ::. -r f=i r4 f< !F. Ic1:1 la la 13 F:i L_ I (:) t�4!E; PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. --- -F-W C-1 < f2 > FSI F�E_7 F--Z_EEQUlFRE='r_-m ..—.—...— BACKFILLING --BACKFILLING 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 A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F:l'l=F;-:lMl-r F=XF::*lFzZF=!S LWE�EN' OFEFR -1 so:B go I CERTIFY THAT 1: 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: 1 UNDERSTAND THAT THE ON-SITE SEWER SYSTEM,MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. SIGNED: "Laii ------------------ APPLICANT GOENTZEL�/BL,DG INC. ISSUED BY_ -_ V4. 0 (CAcc 12 CU TIDAWTAMIT :umil ip( 'M0maz BOX 1300, sTAm HourrE A ANCHORAGEP ALASKA 00502 SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF 89 Toot.. DRILLED AT THE RATE OF 519,00 PER FOOT. PROPERTY OWNER fll&. Q i is n _ tU5& 344-9422 LOCATION OF WELL SITE Lt ti B.Lk I SU,G DRILLER Been.& Ciau4 oZ Rainpa,�VA t3Jt.f.� 00hk4. WELL LOG: 0-----1T Sand with 15% cta4 bila deet. 17 ---- 461 Tine gtave.t. 10"'/o c tat, mate tc 1. 46----82' Stt t4 uret at4 w th. 15016 gAave o good cowue gravel. at 82 f- L, 4howiag, a Gia-teA p�toduc "a o� 8 �Pln wZ& wateA necove,�4 40 .deet Aorn 4u24ace. Su,&ae&44&te pure ( 1/2 Ko&4e ) jhoul d tre to 4ta.U_ed f We deet og lrot torn. C04t o� t3&ZUiW919.00 X 82 Teet: 91558.00 Wet Seat: 922.50 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF 91580.50 THANK YOU VERY MUCH. BERNIE CLAUS OF RAMPART DR�LLING WORKS DATE 25th, 1980 ............_ ..... ....... ..- ...... --... ........... ...... �wccrrcrn nw� Deer n�.r errn��w�rc DEPARTMENT Ofe HEALTH AND ENVIRONMENTAL PROTECTION 825 `L� STREET, ANCHORAGE, AK 99501 264-4720 L4F=IL_ L F• FE FZ M I -r PERMIT NO. A-00:193. APPLICANT BUILDERS BOX 10238, ANCH. AK 344-4422 LOCATION ROCK CIRCLE LEGAL LOT4 BLK I ROCKHILL SUB= LOT SIZE 54000 SQUARE FEET MINIMUM DISTANCE BETWEEN A WELL AND ANY ON—SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A 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::"F=F;;?Ml-r MXF:"IrRMS133 0,F=C_MME�F=F;l' :3:::L-- ::L:so;9c_;v I CERTIFY THAT 1: 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. SIGNED APPLICANT BUILDERS ISSUED BY V4. 0 I PR TP"T OF HEO. TH Fri efMAWIENTOL PROTECTION tom, 99501 a 264-4720 dz .qppL1cHHt,q Wti-DepsSOX 102ZM, AMR AX 4Z I—ctuqL LOT 4 t ROCKMLL LOT SIS 640M SQLkW FMT, 14INrtVM DISTSME 8MMEN A WELL AW AW DTA Sy'Sm IS i0g FEET Fes?8 PRXYRTE WELL OR J TO 2>FEET FROM R PUBLIC €moi.. DEPEMING 41MIt'?UM OrlS'f`AWX- rF;�3ti A PRIVATE WELL TO A PRIVRTE SEWER LINE ,I'S 2 F IA 0) J I TV'SE3" ER LIM is n reef`. 3e, OR« r c.*5�7p� aAa � �q��ys:�� mEo i t�I l } T Tw T €tfI ` €i '3 TIOM OrWR QUA Ta l' if APPLY `��KCIFIE�'ATIONS R # STRUG � � t�� ARE c I sRTt:FY THRT I; f 1 FAMILIAP WITH THE 9EQUIRE1104TS FOR CM SITE SEkWkg FM i LS R SEs' 2: 1 WILL IWrALL rHe SYSMM' IN i- kA:... i4l"i rW C M PPPLICAUT 8, IL V4. Iia#. £ ' UH C FA� TV OF HCH0R%\ G'_ ry; �iiQ Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015-362-04-000 Expiration Date: 12/25/2023 Legal description ROCKH ILL BLK 1 LT 4 Site address 6200 ROCKHILL CIR Anchorage AK 99507 Current property owner(s) WETHINGTON JASPER W X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: During the adequacy test for the drain field it was discovered that 86% of the effective depth was used up leaving only 14%, or 10 inches of the original 72 inches of effective depth remaining to treat wastewater. Original Certificate Date: 9/25/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an - independent- professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory X Tank Age Advisory Arsenic Advisory Other COSA Approval June 2022 UNICIPALM`OF ANCHORRAGE Development Services Department ` Phone: 907-343-7904 On -Site Water & Wastewater Section Fax. 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 015-362-04 Complete legal description ROCKHILL; BLOCK 1, LOT 4 Location (site address) 6200 Rockhill Circle Anchorage Current property owner(s) Jasper & Michelle Wethington Day phone 230-4801 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: 0 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: 0 Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel A9 Plastic ❑ Concrete ❑ Fiberglass Age "yf�" - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed 0 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 $ Esc% Waiver Fee $ Date of Payment 2-0 11 Date of Payment COSA # V S C 3/ 3 io 3 Waiver # COSA Application June 2022 COSA Checklist Legal Description: ROCKHILL; BLOCK 1, LOT 4 Parcel ID: 015-362-04 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _ A. WELL DATA N Well log is filed with Onsite (or attached) Date drilled 5/25/80 Total depth 82 ft Cased to 82 ft 0 Sanitary seal is functioning correctly n Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 7/26/23 Static water level at beginning of test 37.8 ft. Comments B. TANK DATA Measured operating fluid level in septic tank NEW Date of pumping NEW ❑ Required maintenance completed, if AWWTS Comments: - D. ABSORPTION FIELD DATA Which system tested (date installed) 8/13/91 X ALL standpipes present per record drawing Total measured depth from grade 11.75 ft (max) Measured depth to pipe invert from grade 4.25 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. On Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not us r more than 30 days prior to date of test Gallons introduced allons date Any rejuvena ' reatment (past 12 months) s, enter date Comments/Deficiencies: *OVER 90% FULL COSA Checklist June 2022 Well production at time of test 5.7+ gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes © No FE -1 Coliform bacteria is Negative Nitrate 7.35 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑Q Arsenic less than MRL (ND) Collected by GEG, Ltd. Date 7/26/23 C. LIFT STATION ❑ Required maintenance completed Age of lift station ye Lift station mater' Adequacy test date 7/20/23 Results Q Pass Fluid depth prior to test _ Water added 607 gal New fluid depth *68 in .m Elapsed time 120 min Final fluid depth 62 in Absorption rate 600+ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 72 in Effective depth used 62 in Effective depth remaining *10 in 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' DYes if No ft E Yes if No ft Neighboring Tank > 100' Q Yes if No ft Private Sewer/Septic Line > 25' Yes if No ft Absorption Field on Lot > 100' E Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' Q Yes if No Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' [j] Yes if No ft Q Yes if No ❑ N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank an bsorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' � Yes if No ft Surface Water > 100' Q Yes if Tank to Properly Line > 5' [Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' ■ Yes�f No ft Private Wells > 100' � Yes if ft ft ft ft ft 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 Gamess Engineering Group, LTD. (GEG) Phone 907-337-6179 Engineer's Printed Name Jeffrey A. Gamess Date In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry oQ600; practices. The reported results describe the condition of the system/s on the date/s of the evaluation. y Separation distances were measured to readily identifiable features. Hidden defects or encroachments may No _ exist that were not identified during the evaluation. The operational life of all wells and septic systems depend o S () upon a variety of variables, including (but not limited to) soil conditions, groundwater levels (that may fluctuate p /��( during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing).Z These can vary, and are outside the control of GEG. Satisfactory test results do not . • • >1 Tthe system/s. conditions future performance of the system/s; therefore, GEG makes no warranty (express or implied) regardin 0 guarantee the future performance of the well or septic system. GEG makes no representation whether an alternative well the in the of the current systems fail to perform No _ Water Main > 10' 0 Yes adequate) in the future. The content of this report is for the sole benefit of the person/party that retained GEG y po P P to perform the evaluation. Reliance upon the information provided in this report by any other person or party No ft Community Wells > 200 n Yes If No _ Water Service Line > 10' f' Yes ' No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS ��►SC� � )zS/Z 3 ft ft ft ft ft 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 Gamess Engineering Group, LTD. (GEG) Phone 907-337-6179 Engineer's Printed Name Jeffrey A. Gamess Date In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry oQ600; practices. The reported results describe the condition of the system/s on the date/s of the evaluation. y Separation distances were measured to readily identifiable features. Hidden defects or encroachments may F exist that were not identified during the evaluation. The operational life of all wells and septic systems depend o S () upon a variety of variables, including (but not limited to) soil conditions, groundwater levels (that may fluctuate p /��( during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing).Z These can vary, and are outside the control of GEG. Satisfactory test results do not . • • >1 Tthe system/s. conditions future performance of the system/s; therefore, GEG makes no warranty (express or implied) regardin 0 guarantee the future performance of the well or septic system. GEG makes no representation whether an alternative well the in the of the current systems fail to perform .... . $ eff A. Garn s: or septic system can be installed on property event either , Q adequate) in the future. The content of this report is for the sole benefit of the person/party that retained GEG y po P P to perform the evaluation. Reliance upon the information provided in this report by any other person or party — Q ° CE -79 (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. 0 aP'ofeSS-'-"o COSA Checklist June 2022 LICENSEE #AECC884 ��D�OOO�a 911412,3 l'llitrate Advisory Certificate of On -Site Systems Approval # OSC231363 Subdivision: Rockhill, Block: 1, Lot: 4 A water sample revealed a nitrate concentration of 7.35 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. Mailing Address P O Box 196650 igaz "gm *Anchorage, Alaska 99519 666 i *www muni org From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Ma�Ung Address P O Box 196650 *Anchorage, Alaska 99519 6660 *www murn org r Municipality of Anchorage Development Services Department Building Safety Division , Onsite Water 8 Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage. AK 99519-6650 I Caf n GSS www.ci.anchorage.ek.us 0 V (907) 343-7904 RPnevJ-�� CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 01536204 HAA# n y n2 57) 1. GENERAL INFORMATION Expiration Date: R —7 — 0-.E Complete legal description - ROCKHILL S/D: LOT 4. _BLOCK 1 Location (site address or directions) 6200 ROCKHILL CIRCLE Current Property owner(s) MICHAEL & SUSAN PRICE Day phone 229-3802 Mailing address P.O BOX 243583 • ANCHORAGE, AK 99524 Lending agency Day phone Mailing address Real Estate Agent CLAIR RAMSEY w/ DYNAMIC PROPERTIES Day phone 261-7554 Mailing address 3111 'C` STREET • ANCHORAGE, AK. 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 samples. (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 Health Authority 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 riles and from my investigation and inspection, the onsite 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD. SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines 8 Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwaterlevels that may fluctuate during the year, and the water usage ofthe family being served by the system. These conditions are outside the control of the evaluatorofthe system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will It confer any legal right whatsoever. 5. DSD SIGNATURE —�z Approved for L7L bedrooms. Disapproved. Phone 337-6179 Date '/'. ' S Conditional approval for - bedrooms, with the following stipulations: -- •• nnr gtfE�, WATER AND PROGRAM' Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other B, Al 132::L Original Certificate Date: tn•..17.OU Municipality of Anchorage Development Services Department Building Safely Division ' OnSite Water d Wastewater Program : , •' 4700 South Bragaw St. P.O. Box 1WB50 Anchorage, AK 995196650 www.d.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ROCKHILL SID: LOT 4 BLOCK 1 Parcel ID: 015-362-04 A. WELL DATA Well type PRVATE 'SYSTEM TESTED LESS THAN TWO YEARS AGO. If A. S. or C provide PWSIDlf N/A Date completed 1980 Sanitary seal (YM) YES Total depth 82 ft. Cased to 82 ft. FROM WELL LOG Date of test 5/25/1980 Static water level 40 R. Well production 8 g.p.m. WATER SAMPLE RESULTS: Coliform _is,_ colonies/100 ml. Arsenic: N/A mgA. S. SEPTIC/HOLDING TANK DATA Nitrate y_:11 mgiL. Well Log (YIN) YES Wires property protected (YM) YES Casing height (above ground) 20 in. AT INSPECTION *5/7/2004 42 R. 5.8 — 9 -pin - Other badede 2coionies/100 ml. Date of sample: 5/9/2005 Co9eded by. GEG. Ltd. Tank Type/Material STEEL Date installed 8/12/1991 Tank size 1250 gal. Number of Compartments 2 Cleanouts (YM) YES Foundation dean0ut (YM) YES Depression over tank (Y/N) NO High water alarm (YM) N/A Date of pumping 5/10/2005 Pumper McDONALDS PUMPING C. ABSORPTION FIELD DATA �MTi MT Date Installed 8/12/1991 Sop rating llj.p.d ft%drn) 0_8 System type DEEP TRENCH Length 60 ft. Width 2.5 ft. Gravel below pipe 6 ft. Total depth 1 t a ft. Eft. absorption area 0*720 ft' Monitoring Um YES Depression over field NO Date of adequacy test 2==2a Results (Pass/Fal) PASS For 4 bedrooms Fluid depth In absorption fteld before test '3n in. Water added 1300 gal. New depth J1/art. Elapsed Tine: 166 min. Final fluid deplhn141n. Absorption rate as 600+ g.p.d. Any re)uvenmtkm treatment (past 12 mo.) (YM &type) NONE KNOWN H yes. Give date _ "SYSTEM SLIGHTLY UNDERSIZED. ***SYSTEM TESTED LESS THAN TWO YEARS AGO. 0. LIFT STATION Date installed "Pump on• level at _in. Stze in gallons High water alarm level at in. n e T Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAlft station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line 25'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 1000+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 101+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field Inspections and * �........ +, . review of Municipal records that the above systems are in conformance with MOA HAA guldetines in effect on this date. . • • , . y mess.* Engineers Printed Name JEFFREY A. GARNESS Date SIO �J S '�eP�orss+ls^d �c HAA Fee $ Waiver Fee S Date of Payment Date of Payment Receipt Number Receipt Number (Rw. 1201) 05-31-05 02:38PU FROWCUE ESI, SCS ENV SERVICES -SQ%- 9075615301 T-879 P. 02/07 F-180 SCS Rel.N 1052464001 All Dates/Times are Alaska Standard Time Client Name Garness Engineering Group, Ltd. Printed Date/Time 05/312005 10:38 Project Name/# Rockhill S/D: Lot 4. Bk 1 Collected Date/time 05/092005 12:51 Client Sample ID Rockhill S/D; Lot 4, Bk I Received Date/I•ime 05/092005 14:15 Mauls Drinking Water Technical Director Stephen C. Ede Sample Remarks: 2540C - Sample analyzed out of hold time. EP 300.0 - Aaaly2ed outside of hold time for NOx. Allowable Prep Analysis Parameter Results PQL Units Method Container Limits Date We kit Metals Department Hardness as CaCO3 170 5.00 mg/L SM20 2340D D 05/10/05 05/12/05 SCL Private Individual Analvais Aluminum 70.0 20.0 ug/L EP200.8 D 05/10/05 05/12/05 TIC Antimony 1.00 U 1.00 ug/L EP200.8 D (<-6) 05/10/05 05/12/05 TK Arsenic 5.00 U 5.D0 ug/L EP200.8 D (<-50) 05/10/05 05/12/05 TK Barium 8.43 3.00 ug/L EP200.8 D (<-2000) 05/10/05 05/12/05 TK Cadmium 0.500 U 0.500 ug/L EP200.8 D (<-5) 05/10/05 05/12/05 TK Calcium 51600 500 ug/L EP200.8 D 05/10/05 05/12/05 TK Chromium .3.03 LIM ug1L EP200.8 D (<-Ica) 05/10/05 05/12/05 TK Copper 11.3 11.00 ug/L EP200.8 D (<-1300) 05/10/05 05/12/05 TK hon 250 U 250 ug/L EP200.8 D (<-300) 05/10/05 05/12/05 TK Lead 0.944 0.200 ug/L EP200.8 D (<-15) 05/10/05 05/12/05 TK Magnesium 9860 50.0 ug/L EP200.8 D 05/10/05 05/12/05 TK Manganese 4.76 1.00 ug/L EP200.8 D (<-50) 05/10/05 05/12/05 TK Chloride 13.4 0.100 mg/L EPA 300.0 D (<-250) 05/09/05 JIB Phosphorus 200 U 200 ug/L EP200.8 D 05/10/05 05/12/05 TK Fluoride OADOU 0.100 mg/L E•PA3DO.0 D (<-2) . 05/09/05 110 Potassium 1250 500 ug/L EP200.8 D 05/10/05 05/12/05 TK Nitratc-N 4.12 O.IOD mg/L EPA 300.0 D (<+-10) 05/09/U5 JIB Selenium 5.000 5.00 ug/L E1`200.8 D (<-50) 05/10/05 05/12/05 TK Nitrite -N 0.100 U 0.100 mg/L EPA 300.0 D (<-1) 05/09/05 110 Sodium 4470 500 ug/L EP200.8 D (<-250000) 05/10/05 05/12/05 TK Silicon 4700 200 ug/L EP200.8 D 05/10/05 05/12/05 TK Silver 1.00 U 1.00 ug/L EP200.8 D (<-100) 05/10/05 05/12/05 TK Thallium 1.00 U 1.00 ug(L EP200.8 D (a2) 05/10/05 05/12/05 TR 05-31-05 02:39PM FROWCUE ESI, SGS ENV SERVICES 9075615301 T -8T9 P.03/07 F-180 SCS RrLN 1052464001 All Datrs/1'imes are Alaska Standard Time C1lmt Name Garnets Engineering Group, Ltd. Printed Dat Mme 05/312005 10:38 Project Name/# Rockhill SID; Lot 4. Bk 1 Collected Date rime 05/092005 12:51 Client Sample 1D Rockbill SID; Lot 4, Bk 1 Received DatelTime 05/092005 14:15 Matris Drinking Water Technical Director Stephen C. Ede Allowable Prep Analysis Parameter Results POL Units Method Container ID limits Date Date tail Private Individual Jlnalvain Sulfate Zinc Total Dissolved Solids Nickel HCO3 Alkalinity CO3 Alkalinity Oil Alkalinity Conductivity pit Alkalinity Total Coliform 14.4 0.100 mg/L EPA 300.0 0250) 0525/05 JJB 96.7 5.00 ug/L EP200.8 D (<-5000) 05/10/05 05/12/05 TIC 234 10.0 mg/L SM20254DC C (<-500) 05/17105 KP 2.00 U 2.00 up/L EP200.8 D (<=100) 05/10/05 05/12/05 TIC 148 10.0 mg/L SM20 2320B C 05/12/05 PLW 10.0 U 10.0 mg/L SM20 23208 C _ 05/12/05 PLW 10.0 U 10.0 mg/L SM20 2320E C 05/12105 PLW 360 1.00 umhos/cm SM20 251013 C . 05109/05 KAL 7.40 0.100 pit units EPA 150.1 C (6.5.8.5) 05/09/05 KAL 148 10.0 mg/L SM20 23200 C 05/12/05 PLW 2OB. NoCali CDVIDOtnL SM20 9222B A (<-1) 05/09/05 TLF 05-31-05 02:39PU FRO(}-CTiE ESI, SCS ENV SERVICES 9075615301 SGS/GYBE ENVIRONMENTAL SERVICES -SG$- Drinking Water Analysis Report for Total Coliform Bacteria READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE MUST BE COMPLETED BY WATER SUPPLIER p PUBLIC WATER SYSTEM Of ❑ PRIVATE WATER YSTEM ❑RnWp n- Sand lnwb ❑ Send Res. SAMPLE COLLECTION: r.nm M nr SAMPLE TYPE: Tmnspon.d to Leb By: ❑ Same as conector Other TO BE COMPLETED BY LABORATORY Sample Receiving: Date: Time: l Li Temp: Delivery Method: L Received By: Camiena: T-879 P.04/07 F-180 200 W. POTTER DRIVE ANCHORAGE, ALASKA 99518 Tel: 907-562-2343 Fax: 907 -WI -5301 9.'Routlne ❑ Repeat Sample (refer to lab no. ❑ Special Purpose Q Sww hwn ❑ Treated Water ❑ Untreated Water [Iewnpeo.er30ho said; ❑ RUSH SAMPLE Razu" Inal M wrellaOw G] as „n„ ,LPhone N w RRl_ 1a- te LOcasona Fax 0: •................................................... o o..................u.......................... o .... • ................. •............... Serd Barter(oloalcal Water Analysis Recordp�� MM04At10 (PIA) RESULTS: ANC FBK ,NN Analyeb Bean• /7 TOW Coaam: 0etefr'me t 71r --E Colic Swd to CNent Ans"cal Method: nAembrane Filter D MMO-MUG (PIA) Reported By: Sqn n MEMBRANE FILTER RESULTS: Phoned [], Faxed ❑ Died DR CdaniWloOmL OiWrmr VerTnuon:Spoke.nm• EC• ❑ UnSatlStaCtOry DatOMMO: Ste' // °-r Form i FW- 0053 12n= Municipality of Anchorage • ''� Development Services Department = . Building Safety Division S. .,. On -Site Water & Wastewater Program e. . 4700 South Bragaw St. ` D P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us - Ll 0 Ll (907) 343-7904 Parcel I.D. CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 01536204 1. GENERAL INFORMATION HAA# Oq Q V� 0 Expiration Date: 1 Complete legal description ROCKHILL S/D: LOT 4. BLOCK 1 Location (site address or directions) 6200 ROCKHILL CIRCLE Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address . MICHAEL & SUSAN PRICE Day phone 229-3802 P.O BOX 243583 * ANCHORAGE, AK 99524 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Day phone Day phone TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in.the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 samples. (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, 1 verify that my investigation, based on procedures outlined in the Health Authority 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that 1 ore are 'Pj6'encroachments.GEG;-L7d-Can-thereforewot provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer.any legal right whatsoever. 5. DSD SIGNATURE Phone 337-6179 Date rr o4- L/ Approved for T bedrooms. Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: Note: The well for this property meets existing State and Municipal Codes. There are nitrates present. It is suggested that periodic testing be performed to -insure the wells continued suitability. Current nitrate concentration is 5.17 mg/1. EPA maximum concentration is 10.0 mg/l. More information on nitrates is available from the On -Site Services Program, at 343-7904. Attachments: / HAA Checklisty Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other _ By: Original Certificate Date: 6— (Rev. (Rev. 12101) n Mlunic i alit of Anchorage c f 9 Development Services Department Building Safety Division ; ' On -Site Water & Wastewater Program 4700 South Bragaw St. s P.O. Box 196650 Anchorage, AK 99519-6650 I www.ci.anchorage.ak.us (907)343-7904 II , HEALTH AUTHORITY APPROVAL CHECKLIST ROCKHILL' S D• LOT 4 BLOCK 1 Parcel ID: 015-362-04Le al Description: A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed ry;seal leted 1980 Sanita YES Wires properly protected (Y/N) YES ( Y/N ) Total depth 82 ft. Cased to_ 82 ft. Casing height (above ground) � 20 in. �r AT:INSPEC FROM WELL LOG i ri TION Date of test 5/25/1980' 5/7/2004 Static water level 40 ft 42-1! ft . : Well production 8 g.p.m. 5.131g.p.m. WATER;SAMPLE RESULTS: 1 i Coliform colonies/100 ml. Nitrate, 5,17 mg /L: Other bacteriacolonies/100 ml. Arsenic N A mg:%L. Date of sample: 5/7/2004 Collected by: GEG, Ltd. B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL' Date installed 8/12/1991 YES Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of .pumping per 4/27/2004 Pum DENALI EXCAVATION' &� PUMPING SERVICE C. ABSORPTION FIELD DATA *MT1 /MT1 2-11jF Date installed 8/12/1991 Soil rating p:d./ rft2/bdrm) 0.8Syste type DEEP TRENCH Length E 60 ft. ; Width 2.5 ft. Gravel below pipe 6 ft. Total depth 11 •7 ft. Eff. absorption are�a�20 ft2 ; Monitoring tube YES Depression over field NO i Date of adequacy test 5/7/2004 k :; Results (Pass/Fail) ---PASS; For 4 bedrooms . 31/44. Fluid depth in absorption field before test 3/7 in. Water added 1300 gal ' ; New depth in. ,,� 21/24iF �_ 600+ g,p Elapsed Time: 166 min. ; Final fluid depth n. Absor tion `rate, d.' NONE KNOWN . I i! Any rejuvenation treatment (past 12 mo.) (YIN & type) ; If yes, give date — G Sv l U N O FJZ S 1Z E.fl I� D. LIFT STATION Date installed "Pump on" level at in. Size in gallons "Pu Datum' Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ jr Manhole/Ac High water alarm level at I in. - i Meets alarm & circuit requirements? i' On adjacent lots ••100'+ On adjacent lots 100'+ I Public sewer main N/A Public sewer manhole/cleanout N/A - Sewer /septic service line 25'+ Holding tank N/A 'SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building'foundation 5'+ Property line 5'+ Absorption field ' '' S'+ Water main N/A - Water service line 10'+ Surface water 1001+ Wells on adjacent lots 100'+ j. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ___;,_.10'+ Building foundation 101+ Water main N/A i Water service line. 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain'drain NONE KNOWN Wells on adjacent lots 100'+ :f j. F. COMMENTS G. -ENGINEER'S CERTIFICATION o OF Ice ..;. rtify� that !have determined through field inspections and p ,�� • 4- '� DO 'review of Municipal records that the above systems are in �" " ' ' conformance with MOA HAA guidelines in effect on this date. r e y rues Engineer's Printed Name JEFFREY A. GARNESS CE 95 !o'`�°�p� Date 'I" 5���LO4- Q0�44ap �no;�o rofe9 0�oa OOD�DOO i �HAA Fee $ Waiver Fee $ 1J. Date of, Payment Date of Payment rl Receipt Number `"�' Receipt Number Rev. 12/01) I i' 5-11-04; 4:19PM; ;907 5615301 # 2/. 3 GS Ref.# 1042368001 :tient Name Garness Engineering Group, Ltd. 'roject Name/# Rock Hill L4, B1 .lient Sample ID • Rock Hill L4, B 1 iatrix Drinking Water All Dates/Times are Alaska Standard Time Printed Date/Time 05/11/2004 12:51 Collected Date/Time 05/07/2004 12:20 Received Date/Timb 05/07/2004 13:35 Technical Directk::1zs tephe .Ede Releas y ample Remarks: EP300 -Nitrate recovers outside control limits for MS due to possible matrix interference. arameter Results PQL Units Method Container ID Allowable Prep Analysis Limits Date Date aters Department Nitrate -N 5.17 0.100 acrobi.ology Laboratory Total Coliform 0 mg/L EPA 300.0 B (C=10) 05/07/04 JMP co]/100tnL SM18 9222B A (<=1) 05/07/04 DKC 5-11-04; 4:19PM; SGS/CT&E ENVIRONMENTAL SERVICES -S-G$ Drinking Water Analysis Report for Total Coliform Bacteria' READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMME MUST BE COMPLETED BY WATER SUPPLIER ❑ PUBLIC WATER SYSTEM W# PRFVATE WATER SYSTEM ' : ❑ Send Results ❑ Send Invoice' n w.rr syswn, �hi r,�narAumfrry Nn �7,07M V/u z/V. �,�/ � / i �,. Fa Nuro.r . 70 � � -rud�- �Ib cofsuft AIL 1S� ❑ Send Results ;907 5615301 #. 3/ 3 200 W. POTTER DRNE ANCHORAGE, ALASKA 99518 Tel: 907-562-2343 • Fax: 907-569-5301 Lab Ref Na. 1042368 m q Send invoke SAMPLE C OLLECTIOP9 SAMPLE TYPE: ' • hv.M nth,•..M.+<a..rl.{I.r.rM�bb..ls�rp. wMWw Dat.: ®�� ❑ Routine E3 Treated Water AM a.! R o M Repeat Sample 0 Untreated Water..' Tune; «+a• Location: (refer to lab no. : • •1 ❑ Special Purpose Collector. _, rS✓/'J.!' ' Prh1.W New Transported to Lab By:V---ame as collector Other. , nm. .n,. 'O BE COMPLETED BY LABORATORY Sample Receiving: Dater []Sample over 30 hots old; ❑ RUSH SAMPLE Results may be unreliable Time: "3 Temp: im • Hour W8Kw Phone # �I'ri,�"v Q Delivery Method: i For Remote Location. Fax P. ' Received By - ' Prk+ od Nam• Comments: r ............... ......................... ........ ••.............. ......•.......... •....•....:..•...•........... •....... ....... ..•....:..... • BacterlologiC21 Water Analysis Record: Sent to ADEC: MMO-MUG (P/AI RESULTS: ANC FBK JUN ., Analysis Began: • cSI"1 c5JD TotalCoiiorm: DatrlTlme: —'cam Analyst E. Col: Analytical Method: Membrane Filter MMO-MUG (P/A) teported By; . s.w,awre MEMBRANE FILTER RESULTS: Drcrd Count (� Colorks/100ml- Verification: Sent to C6w* Phoned ❑ Faxed 0 DatelT'me;_ ��rr Spoke with: T.mC.r...' LTB: ` BGB• • 0 Satisfactory s.rwcawrn { EC: ❑ Unsatisfactory • TNTC � T thamrous to Date/Time: ��(D�d� l��� 06.on»rBacs"k Form 9 FW- 0053 12/17/03 ROCKHILL CIRCLE TME woom"TKW mm" TS 1011 TKC USE Or UN"o Rf500lDO" SKCItJLLT TO SNOW AMY C011RICTS 8"WN � — `�4 ".Ffl DOSRW STRUCN m AMD RARER LOT UNLS OR RASMMS ANO M MOT TO K USED FOR POSMT Q A0o1T10MK STWXTURES oR rU1CNNEi WDADM Or W=D. OTMER THAN TNOX "" ON TME RECORDED RAT. ARL NOT BMW MUMOW MOTE- AMY TE*CrUWM SNOMM ARL UMUO AMRO=ATMY AND ARC NOT TO K VSW TO DETIYUK UMES �!t a WCAlm STMxTuvs. \ ANY PAYRID SMO.N NAY K APMMWATE DUE TO SHOW CON0ITWNT. NOTE Z PROPERTY CORNERS FOUND DO NOT PIT Tri THE SUBDIVISION BOUNDARY IN COMPARISONTO COED COMPUUTEDTPOSITIIONSOIN RELATION T 0 THE SUBDIVISION BOUNDARY WERE USED FOR THIS SURVEY. rS_// �r Dy OF A Alco : 49TH `':v0 a, or aD O p SHANE a HOLT: � b OQr LS -6914 Z s �'�rOf'esslan� �o t 11� �1 �O r' \p6 AS -BUILT SURVEY SCA1_.. s 40' I HEREBY CERTIFY THAT 1 HAVE PCRFORMGD A MORTGAGEES INSPECTION OF THE FOLLOWING DESCRIBED PROPERTY. LOT 4, BLOCK 1. ROCKHILL SUS. THIS __28TH__ MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES�i� Division of Environmental Services — On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel l.D.# 015362oy HAA# W�1S\Q- kQ 1. GENERAL INFORMATION Complete legal description L- q j .61 K .1 0 oc, l i 11 ) _JS v 6 d I',/ 's; 1o0 - Location (site address or directions) ^7LIno(Awr AK Property owner J -y 1°t h H4Lvt Son Day phone 27e- `-S73 Mailing address I I 1d St An c.ltor,A-ce AK q lSo f Lending agency Day phone Mailing address Agent Poio,n 4er Day phone I Address 3230 G Sfree_f Aplc4c�u /'ser Ah G93 So Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: if community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further 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 `Tr N rnA4 es Z) c• Phone 24'1-0S4-/,3 Address �'l l I I.U(rs + 8 /4VC-1 AV) c, t7oi-a�) e � AI -C qq 50 1 — 3`l 17 - Engineer's signature 6. DHHS SIGNATURE 0 Approved for bedrooms. Disapproved. Conditional approval for Additional Comments Date S^,-131 bedrooms, with the following stipulations: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA#21 Municipality of Anchorage W o Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A s a, W u m Legal Description: r! y 0 81K Rk),kA "'11 6"&- Parcel I.D. 015.3 6 2-O`J O w r. A. WELL DATA N 1A n; W rn Well type Icr"'✓" c If A, B, or C, attach ADEC letter. ADEC water system number z Log present (Y/N) Date completed S /fie /60 Driller. Total depth 624 Cased to t + Casing height 3,� rr Sanitary seal (Y/N) d Wires properly protected (Y/N) Date of test Static water level FROM WELL LOG O S 12 d5 Ig o /i0 Well flow g f g.p.m. Pump level -7 V SEPARATION DISTANCES FROM WELL TO: AT INSPECTION MONIGIPAI, 4 1 T:IVtRC�N1 4 1 .1 G -4- g. m. No -r 0cr&Vmq Septic/holding tank on lot 105 trt ; On adjacent lots l UOT.f `+' Absorption field on lot % 20 P ; On adjacent lots ()O -4- A Public sewer main X62` Public sewer manhole/cleanout 1 Sewer service line Petroleum tank "orle :fin Ar 26�, WATER SAMPLE RESULTS: Coliform / / ��/ Nitrate 3 s m� �� Other bacteria peoe 1 Date of sample: yht I Collected by: B. SEPTIC/HOLDING TANK DATA Date installed —0S M /9 i Tank size 1.2So "r Compartments 2 Cleanouts (Y/N) __yf=5 Foundation cleanout (Y/N) J es Depression (Y/N) ,v High water alarm (Y/N),; Alarm tested (Y/N) Date of pumping" Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Wells) on lot 0-1� F+ On adjacent lots jOo + Foundation _ To property line 70 ft Absorption field 10, Water main/service line Surface water/drainage -PO')CI Areal .2 0 Ft 100 -Pt- f 72-026 (Rev. 7/91) Front - CONTINUED ON BACK PAGE C. LIFT STATION /,A Date installed Size in gallons Vent(Y/N) Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off' level at Cycles tested Surface water _ 6P' Ne �_e f)ata installari U� /l3 M l Rnil rntinn U .iaF} Cvctcm f%/nn!J I� ✓1 C• 1 �.f+ Length (a O + Width i�� Gravel thicknes's C 2-5 Total depth � ` 216 P+ Total absorption area T-1; b P'� i Cleanouts present (Y/N) VeS AjCA Depression over field (Y/N) 1 �� Date of adequacy test ew �� ` J Results (pass/fail) Nf for /A bedrooms Peroxide treatment (past 12 months) (Y/N) IV % If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I to F -i- On adjacent lots jU� } f Property line b0>+ To building foundation ft�.3Y r To existing or abandoned system on lot 12 Ff On adjacent lots _ 10 f Cutbank N / Water main/service line % Uy F-4 Surface water Vaic n Aref. Driveway, parking/vehicle storage area 6 b F+ Curtain drain E. ENGINEER'S CERTIFICATION 1 certify that 1 4hhec11, Signature Engineer's 4 Date HAA Fee $ Date of Payment Receipt Number !2/t verified, or conformed to all MOA and HAA guidelines in effect � U T Waiver Fee: $ Date of Payment Receipt Number ®%�pte of this inspection. OFA4 Q� " t A �,� NORTHERN TESTING LABORATORIES, INC. 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378 • FAX 274-9645 600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-4793115 • FAX 479-0547 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY CLIENT ❑ PUBLIC WATER SYSTEM I.D. # PRIVATE WATER SYSTEM NAME Mailing !!llJJee�p(('"'GG AQ,t�ge City State Zip Code SAMPLE DATE: (& � Phone 215-0 5�3 Mo. Day Year Purchase Order No. SAMPLE TYPE: Routine ❑ Treated Water ❑ Special Purpose ❑ Untreated Water ❑ Check Sample (for original contaminated sample with lab reference no. 1 Sample Time No. Location Collected Collected by Laboratory Hof.. No. -AM 2 3 4 Ia. 5 6 7 8 9 10 Signature of Representative FOR LABORATORY USE ONLY CASH CHARGE PREPAID THAN ITTAL I SPECIAL INSTRUCTIONS MAIL HOLD FOR PICKUP TO BE COMPLETED BY LABORATORY Received at: [�/Anch. ❑ Fbks. Date Received Time Received �" J Next Sample Due COMMENTS: SATISFACTORY O UNSATISFACTORY U RESAMPLE R OTHER BACTERIA OB TOO NUMEROUS TNTC TO COUNT Direct Verification Final CountLS Result.Comments — i-- r- * of Total Colifor Col ies per 00 mis. Re to y� L9 Date I I NORTHERN TESTING LABORATORIES, INC. 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 • FAX 456-3125 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 • FAX 274-9645 Tryck Nyman Hayes Inc. 911 W. 8th Avenue Anchorage AK 99501 Attn: Carey Meyer Our Lab #: A113295 Location/Project: - Your Sample ID: Lot 4, Block 1 Rockhill Sample Matrix: Water Comments: Method Parameter Units EPA 300.0 Nitrate -N /i�ymcm I Reported y• Wilfiam E. Bdhhan Anchorage Operations Manager mg/l Report Date: 08/21/91 Date Arrived: 08/16/91 Date Sampled: 08/16/91 Time Sampled: - Collected By: - 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 Flag Analyzed 3.5 08/19/91 MUNICIPALITY. OF ANCHUHAUt, DEPARTMENTS 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' Application Date F GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) td -r 4 BLOCK ! TZoCK Nil/ Svgp Sec /4 T /ZAJ Z 31,x/ Location (address or directions) IoZoo ROCK Hit/ C//2CLoe (b) Applicant Name 3 -ohm HA-Q-C—Pt Telephone: Home Business Z A -'1s 73 Applicant Address 00 ROCK �4111 IR41 E (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder 9; Buyer ❑ ; Other ❑ (explain); 115", F j e..&XA L Telephone (d) Lending Institution� Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: p/t-AsE G'RLL oWNE2 2.TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms .3 '3.' WATER SUPPLY Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite 9 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 (11/84) Dino i �.f 7 5.'l. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ry i 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 OU141)17-AGAl6:tJ(--M- IO%J6 Telephone gO7"Z74,- X-�7© Address /o/ �-' r1ax-- o -ch L.h al g A -ii c4 -j om G c$ Date _4 ar or*: 00TH Engineer's Seal IN 60a40 4ois°p.aeoa• oo°N ou R 2'. Michael E. Anderson `. 4301-E .G° 0K0 OFESS\IJ 6. DHEP APPROVA (3 Approved for bedrooms Date / Approved Disappr Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 0--- O of O MUNICIPALITY OF ANCHORAGg DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION] MUNICIPALITY OF ANCHORAGE (MOA) �� HEALTH AUTHORITY APPROVAL (HAA) < V q� Q l.�W, CHECKLIST - FEBRUARY 1984 ((� (' 264-4720 BRE C E I�/D, Y. f Legal Description: LOT 4 SZOCAC / EOCK 11124 5UB,Dl1//S10Al A. WELL DATA Well Classification Pty IuArE If A, B, C, D.E.C. Approved (Y/N) NA Well Log Present (Y/N) Date Completed �5 �8Ian Yieldf �f'� Total Depth ez' Cased to 40' t Depth of Grouting A+F_ / Static Water Level '40 . Pump Set At JVOT DET rmwraD 15G' F Casing Height Above Ground 38.E Sanitary Seal on Casing (Y/N) ,y Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Depression Around Wellhead (Y/N) ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot 1307 ; On Adjoining Lots 100' To Nearest Public Sewer Line 4 To Nearest Public Sewer Cleanout/Manhole 4- To Nearest Sewer Service Line on Lot to / ri Water Sample Collected by G)UA>,e A / Mc FA1?i5Eu ; Date 61301 Water Sample Test Results SATIS FACTOTtU Comments WELL 15 oU eT a ADE QJATf< B. SEPTIC/HOLDING TANK DATA Date Installed Size bdbo G. No. of Compartments ?. Standpipes (Y/N) —_ Air -tight Caps (Y/N) Foundation Cleanout (Y/N) �✓ Depression over Tank (Y/N) Ii Date Last Pumped /986 Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) K 4 Separation Distances from Septic/Holding Tank: To Water -Supply Well )19, To Property Line 9 8 To Water Main/Service Line //'o ; for /986 Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field Course AIONG !N AitEA Comments ; epTtr_ SYSTEM 1S AX)AQ0AT'r-_ Page 1 of 2 To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 150 Type of System Design Tk'ENCH Date Installed 1980 Length of Field 45 Width of Field Depth of Field Gravel Bed Thickness S Square Feet of Absorption Area Q 50 Standpipes Present (Y/N) Depression over Field (Y/N) N Date of Last Adequacy Test a/8ee Results of Last Adequacy Test PASSE C-, Separation Distance from Absorption Field: To Water -Supply Well 130� To Property Line 4B To Building Foundation sz 1 To Existing or Abandoned System on Lot NOM F ;On Adjoining Lots /000 -/- To To Water Main/Service Line To Cutbank (if present) NoT PRESENT To Stream/Pond/Lake/or Major Drainage Course NOME /hl AREA To Driveway, Parking Area, or Vehicle Storage Area /DOS Comments 5Y 5rE'An 15 A DED tAATF= D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) — Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify thyyattI�I havechecked, verified, or conformed to all M A �npd HAA guidelines in effect on the date of this inspection. Signed ii f4.C6t OF fn -Rate a Company QvAIII A4 C1"V 6X , MOA No. Receipt No. -�A 7 4 0 ! w�(F`oF /7—/��IU ~ \v ..oaso. Date of Payment r%sy.�P�.•° °'•. oaS Amount: $ 0 J * r®�T� )`; 1�° Engineer's Seal Page 2 of 2 72-026 (11/84) •� �uFFSS1u"� - APPLI"T FILLS OUT UPPER HAV'`' -ONLY Time Property Owner Ronald Ray Phone Meiling Address n/a (Seller has moved out of state) Zip Code Buyer Merrill Lynch Relocation Management Address P. 0. Box C 91000 Bellevue WA - Zip Code 98009 Lending Institution n/a Phone Address Zip Code Realty Co. & AgentPhone 279-7611 Address Dynamic Realty, 501 W. Norther Lights, Anchorage Zip Code 99503 Legal Description Lot 4, Block 1, Rockhill S/D Street Location nhn Rockhill Circle (Take- Abbott Rd. to Main TRee turn right, right on Rockhill) Type of Residence X�Single Family 3 Multiple Family No. of Bedrooms,— ❑ Other Water Supply // � .{/�� Individual -. (®.� (��3 .- L ;L. n)-)! 1�. ATTACH WELL LOG. A well log is required for all wells drilled since. June. 1975. Community For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility - Sewer Disposal r) USI �� 7980 [X)Individual •n Year Individual Installed: _ ❑ Public Utility - When Connected to Public Utility: ❑ Holding Tank - NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEST BEFORE PROCESSING CAN BE INITIATED. Time Time - Time Time t Date Date Date Date )D-�-��� Inspector Inspector - Inspector Inspector P Y a4 Field Notes: { MUNICIPALITY OF ANCHORA OL DFPT 0. R. ENVIRu;11,'-:f;;P._.:.-.v.L—TION l' T 2 1982 RECEIVED ( }) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED � ( ) CONDITIONAL APPROVAL' DATE BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received �" t Q !j "" Well to Tank Septic Tank Size Ronald Ray c/o Petie Strang Dynamic Realty r 501 W. Northern Lights Anchorage, AV, 99503 November 1, 1982 Subject:, Lot 4 Block I Rochhill S/D Approval for the individual isewer and water, facilities cannot be granted until the following items have been completed: 0 The ton of the well casing should be sealed so that it is water "tight. The water analysis report needs to be submitted to this office from the Chem Lab, 5633 B Street, for our review. A7 The septic tank pumped with a receipt submitted to this department. Please notify this Department for a reinspection when the noted discrepancies have been corrected. If there are any further questions, please call this office at 264-4720. Sincerely, Robert C. Pratt Associate Environmental Specialist RP214/p/EH a DATER CEIVED INSPECTION APPOINTMENTS STREET LOCATION TIME,' eOC/C/.i/cc C/A�Z'+ TIME TI E NUMBER OF,BEDROOMS ❑ One E] Four E:1 Other SINGLE FAMILY DATE w�C y DATE DA INSPECTOR Y/( /✓ C ,S{UPPLY K'l INDIVIDUAL* INSPECTOR INSPECTOR *Ile since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY ff 8. SEWAGE DISPOSAL SYSTEM MUNICIPALITY OF ANCHORAGE DEPT. OF I-II-ALTH & / YEAR ON-SITE SYSTEM WAS INSTALLED. p^IVB DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECI%)QRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 • NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. J U L 3 1 1900 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTYOWNER ��>.�r�rnS PHONE e �ae1E,-72cc MA;ING ADDRESS \fox io23C6 o,- Ar..cr/ PROPERTY RESIDENT (If different from above) PHONE �? .( t B t `a G -+ id ra c t- t A 2. BUYER PHONE MAILING ADDRESS 12- d- c iC i-( i G 3. LENDING INSTITUTION PHONE MAILING ADDRESS GA(5 61 Ste- / c . AA 4. REALTOR/AGENT PHONE MAILING ADDRESS -1 L `-cs 1 l 1r iC G 5. LEGAL DESCRIPTION 1-0-7- `( S c 1C P0 c K H i C � STREET LOCATION eOC/C/.i/cc C/A�Z'+ 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS ❑ One E] Four E:1 Other SINGLE FAMILY Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER ,S{UPPLY K'l INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM X INDIVIDUAL/ON-SITE** / YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) cF'-It� I a'O THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ TWO ❑ THREE ❑ FIVE ❑ OTHER ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLICUTILITY Connection Verified PERMIT NUMBER DATE INSTALLED �U INSTALLER ❑Septic Tank or ❑ Holding Tank Size: IOOU If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL _ 1,���. 4. DISTANCES WELLTO: -Septic/Holding Tank (6� Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS CD, --APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED Z/2 DATE BY /^/