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ROCKHILL BLK 4 LT 2
Rockhill Block 4 Lot 2 #015-063-14 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 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201437 Work Type: SepticTank Upgrade Tax Code Number: 01506314000 Site Legal Address: ROCKHILL BLK 4 LT 2 G:2438 Site Mailing Address: 9901 LONE TREE DR, Anchorage Owner: HICKOK BRADLEY T Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft: Total Bedrooms: �0 (i Department 10/15/2020 10/15/2021 49726 ❑ 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 Received By: Date: Issued By: Date: 10 15 O�2 b 0 JIMUH]UP AM -MI OF ZZ'�HCHORAN�GF_ Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section ��► Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 015-063-14 Property owner(s) BRAD HICKOK Mailing address 9901 LONE TREE DR, ANCH AK Site address SAME Legal description (Sub'd., Block & Lot) ROCKHILL BLK 4 LT 2 Legal description (Township, Range & Section) Lot Size 49726 Sq. Ft. Number of Bedrooms 4 Day phone APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank ElUpgrade 0 Duplex (D) ❑ Holding Tank ❑ Renewal ElMultiple Dwellings ❑ Privy Elf� �I (SF and/or D) Private Well ❑ F , Water Storage ❑ Al 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: � a 7 V 16 -1 1) Waiver Fees: Date of Payment: 10L I (o 20 2 e Date of Payment: Receipt Number: 0 i63"03 Receipt Number: Permit No. Q 5Pa0'r' `i 3-1 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Oct 14, 2020 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New septic tank permit Legal: ROCKHILL BLK 4 LT 2 To Whom it may concern: This is a request for a septic tank permit on the above referenced lot. This tank replacement will not impact any of the neighbors or encroach on any wells, septic or open water issues. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201437, Rebecca Carroll, 10/15/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201437, Rebecca Carroll, 10/15/20 Municipality of Anchorage Page of 2 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: SW 97D/-2-9 PID Number: D/S D!!3 /el Name: Wastewater System: ❑ New Xupgrade T J/Q.vL �>v ✓'e s l 11 Address: a Lo>✓ r ABSORPTION FIELD Phone: No. of Bedrooms: , / y Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: / Z Total Depth from original grade: /?•1a7.-' �7 GPD/Sq. Ft. Lot: Block:'(J Subd}}'v� tsion: Depth to pipe bottom from original grade: Gravel depth beneath pipe 54Z 1�OGK I 7 - 9.7,4 Ft. Ft. Township: Range: Section: Fill added above original grade: _. Gravel length: Q 5.3.8 Ft. Ft. WELL: ' ❑New ❑Upgrade ravel width:. Number of lines: Distance betwanlines: Ft. Ft. Classification (Private, A,B,C): Total Depth:Cased Total absorption area: Pipe material: F 810 Ft. Ft. 5&0 S0, Ft. D 5024 Driller: Date Drilled: atic Water Level: Installer: Date installed: Ft. A4t Keg h P-5 e7ti� 7�1 Yield: Pump Set at: asing Height Above Ground: TANK GPM t. Ft. 0 SEPARATION DISTANCES KSeptic ❑ Holding ❑ S:T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: I/ Capacity in gallons: %� / 2_5D From Tank Field Station Tank Sewer Lines A,� Q,.h WeIN — — Material: STEEL Number of Compartments: 7 G— /ODf-r' IODt4- — Surface Water IDD+ IDO 4- — — — LIFT STATION Lot t t Size in gallons: Manufacturer Line /D + -! - - -- "Pump on" level at: "Pump off' level at: High water alarm at: Foundation _.__ Curtain`y _ t+ Pump Make 6 el Electrical Inspection erformed by: Drain J ]Location Remarks:*JJohle 17cw BENCH MARK and Description: r^ 0 Assumed Elevation: %VC/• ENGINEER'S SEAL OF 4t 1st 7 t o . �a ea Inspections performed by: Dates: 2nd .., yeOO , ���%F,ao c 7116 Department of Health and Human Services appro al ,•�' ��`�® by: /� �� Date: 7 3p 9 �q pROFESSiON�s Reviewed and approved SCALE; NTS '�kiii�k ................ X� p4 PREPARED FOR1 KND ENGINEERING � f I A* 20441 PTARMIGAN BLVD - J7.V,V. EAGLE RIVER, AK, 99577 ,o DAN & TERESA SIEKKINEN I � / 9901 LONE TREE DRIVE (1307)696-6111/FcLx (907)696-8111 FESSIO� -AV ANCHORAGE, ALASKA 99516 DATE, 7/22/97 DRAWING # AS -BUILT SYSTEM DETAILS/SITE PLAN Permit SW970129 ROCKHILL SUBDIVISION, BLOCK 4, LOT 2 PID#015 063 14 LOT 2 SEPTIC M C)". ti C[] B CO MT co A—D=29,5 0 TH #97-1 B—D=29.0 A—E=76,8 E CO T CD B—E=74.9 LOT 3 SCALE i 1' = 50, ........................... ........ ........... ..... ........................... ........... ............ ........ .......... ........ 10' DRAINAGE I .......... .... ESMT, .... ....... . ........ ... .............. ............ T W 71'z z. NUNITOR TUBE w fln 9941 ORIGINAL/FINISHED GRADE 1002 n n n FILTER FABRIC, VARIES EXIST, T . SEPTIC T TANK SEWER ROCK �8679 OF At4'�V,% A'W 53.8' /rrV' r *;49Tx #A 8020 BUH - 11 SCALE; NTS '�kiii�k ................ X� p4 PREPARED FOR1 KND ENGINEERING � f I A* 20441 PTARMIGAN BLVD - J7.V,V. EAGLE RIVER, AK, 99577 ,o DAN & TERESA SIEKKINEN I � / 9901 LONE TREE DRIVE (1307)696-6111/FcLx (907)696-8111 FESSIO� -AV ANCHORAGE, ALASKA 99516 DATE, 7/22/97 DRAWING # 6 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:SW970129 DESIGN ENGINEER:KND ENGINEERING OWNER NAME:SIEKKINEN DANIEL G & THERESA OWNER ADDRESS:9901 LONE TREE DR ANCHORAGE, AK. 99516 PARCEL ID:01506314 LEGAL DESCRIPTION: ROCKHILL BLK 4 LT 2 LOT SIZE: 49726 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 6/12/97 EXPIRATION DATE: 6/12/98 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY: I l (DIY kv0 ' r Uv V% J "` DATE: ,-A.7 DATE: O6//Z qom\ 1C:)', sU Pam XND ENGINEERING 20441 PTARMIGAN BLVD. EAGLE RIVER, AK 99577-8736 11/FAX (907)696-8111 June 3, 1997 Municipality of Anchorage Dept. of Health & Human Services On -Site Services Section P. O. Box 196650 Anchorage, Alaska 99519-6650 Subject: Rockhill S/D, B4, L2 - Septic Upgrade Permit Gentlemen: Following a request from the owner, on May 21, 1997 we dug a testhole for the proposed upgrade. The well and septic were previously tested by another engineer. The well passed but the septic system failed. The results of this percolation test are attached. The lot is served by an individual well. The proposed upgrade system will be placed east of the existing system. As indicated on the site plan there is sufficient grade to maintain a gravity system. The 1250 gallon tank will be inspected and its integrity verified. If it is necessary to replace the tank we have provided a proposed design on the site plan. As indicated by the site plan drainage arrows, natural drainage is away from this site and will be maintained after construction. There is no surface water within 100' of the proposed installation. There are no known curtain drains within 50' of the proposed installation. No wells exist within 100' of the proposed installation and the community well is over 200' away from the proposed site. This upgrade should have no adverse effect on development of adjacent lots. If you have any questions, please contact me at 696-6111/FAX 696-8111. Respectfully submitted, 1KHD Engineering MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION JUN 05 1997 Kenneth M. Duffus, E. attachments: On -Site Well and Sewer Application RECEIVED Wastewater Absorption System Details/Site Plan Soils Log/Percolation Test WASTEWATER DISP❑SAL SYSTEM/SITE PLAN R❑CKHILL SUBDIVISI❑N, BLOCK 4, LOT 2 LOT 11 moo,, LOT 10 i SEPTIC 2 AY DIVERTER __ __ I I ...... IV LOT 25 NO SEPTIC SYSTEMS WITHIN 200' OF PROPOSED WELL, EXCEPT AS NOTED. NO PRIVATE OR PUBLIC WELLS WITHIN 200' OF PROPOSED SYSTEM EXCEPT AS NOTED. OF AL4 1 *;49Tx'* DU' CE -7116 w� �Ad'OFESSIOTSAl'' LOT 27 LOT 26 DESIGN CRITERIA SYSTEM LOT 3 1. 4 BEDROOMS X 150 GAL./DAY/BEDROOM = 600 GPD 2. SOILS RATING: 4.4 MIN/INCH = APPL. RATE 1.2 GPD/SF 3. 600 GPD/1.2 GPD/SF = 500 SF 4, 500 SF /<2' x 6') = 41.67'L 5, MIN, DESIGN SIZE = 1 TRENCH - 42' LONG x 2' WIDE x 6' DEEP 6. DEPTH OF GRAVEL BELOW PIPE IS 6'. 7. TOTAL DEPTH OF SYSTEM IS 12.0' FROM ORIGINAL GRADE, NOTES: 1. TIE INTO TRENCH AT END. 2. INSTALL 1250 GALLON SEPTIC TANK. INSULATE TANK IF <4' COVER, 3. INSULATE TRENCH WITH 2" HD BURIAL FOAM IF <3' COVER, 4. CONTRACTOR WILL ENSURE MAXIMUM 27 SLOPE INTO SEPTIC TANK, 5. CONTRACTOR TO ABANDON EXISTING TANK IN PLACE. D FOR: DAN & TERESA SIEKKINEN 9901 LONE TREE DRIVE ANCHORAGE, ALASKA 99516 KND ENGINEERING 20441 PTARMIGAN BLVD EAGLE RIVER, AK, 99577 (907)696-6111/Fax (907)696-8111 E, 5/30/97 IDRAWING # = 100' .%g._—_ _'Ylk I Air Municipality of Anchorage * :4-15 E, ? ; st •som0' ,00" 600.0 00 x u+a ,s,® a( DEPARTMENT OF HEALTH & HUMAN SERVICES +a�� T 825 " L" Street, Anchorage, Alaska 99502-0650 .,,. Kenn.:,; r777.0 SOILS LOG — PERCOLATION TEST i •�e C2711 ��j ® •e e• C mo PERFORMED FOR: 5�t� /` 1���Pr% DATE PERFORMED: ®O�w SSION LEGAL DESCRIPTION: /I/%/��I'(� L -(9T Township, Range. Section.'��` DEPTH SLOPE SITE PLAN (FEET) 2 Co�s� ScL-ho/ 4 5 6 Fin e' aaz nG7 S� 9n P/ CC 46 �� ��"t' WGROUNDWATER ENCOUNTERED? ba- IF YES, AT WHAT C�hLI es q t�'. DEPTH? Depth to Water Afte—r7-��� 13 5� Monitoring? T Date: 14 15 16 17 r✓G I 1Pu16,L0 18 m liJ i r■■■■■■■■■ 20� PERCOLATION RATE � � (mmutesnnch( PERC HOLE DIAMETER `TEST RUN BETWEEN f�f%% FT AND _�_.. FT COMMENTS 9V0/ L°G7 gtJn''dD1�"" 70� fif':y Alleq ----- PERFORMED BY/� _LS=1Fa'17 ..5 CEHIIFY THAI THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STAT AND MUNICGUIDELINES IN EFFECT ON THIS DATE DAIE _ �� • ., , iii ��� 20� PERCOLATION RATE � � (mmutesnnch( PERC HOLE DIAMETER `TEST RUN BETWEEN f�f%% FT AND _�_.. FT COMMENTS 9V0/ L°G7 gtJn''dD1�"" 70� fif':y Alleq ----- PERFORMED BY/� _LS=1Fa'17 ..5 CEHIIFY THAI THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STAT AND MUNICGUIDELINES IN EFFECT ON THIS DATE DAIE _ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 oe* ENVIRONMENTAL ENGINEERING DIVISION ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME �-� / PHO E NEW ❑ UPGRADE MAILING ADDRESS�ZSI LEGAL DESCRIPTION eft// % !✓ I DGS LOCATION NO. OF BEDROOMS Ux DISTANCE T0: Well Q Absorptionarea • Dwelling PERMIT NO.�y h �' w2 ~ Manufacturer Material _L No. of compartments Z� N Liq. capacity in allons 10 IF HOMEMADE: Inside length Width Liquid depth 0 � Z DISTANCE TO: Well Dwelling PERMIT NO. o z Q x �_ Manufacturer Material Liquid capacity in gallons D w x DISTANCE TO: Well•p / d Foundatio 0 Nearest lot line/ _.,.4/ PERMIT NO. J LLz 2 w 1'—oC No. of lines Length of each ne Total length a lin (3 Trench width Gj inches Distance between lines - F. 0 Top of rile to finish grade Material beneath tile� inches Total effective absgrpt� n ire • !� w Length Width Depth PERMIT NO. C7 a F w ° Type of crib Crib diameter Crib depth Total effective absorption area w N DISTANCE TO: Well Building foundation Nearest lot line J Class o/I Depth Driller Distance to lot line PERMIT NO. Lu DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER L PIPE MATERIALS , �,8_r_ c0 3 d .SOIL TEST RATING INSTALLER REMARKS 4 IF ev �I A R VED DATE LEGAL BOX 1369s STAR ImOL'TE A ANCHORAcmv ALASKA 00502 344-7`714 SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF 60 X:eet, DRILLED AT THE RATE OF 921.00 PER FOOT. PROPERTY OWNER Eta khn X &14el to 694-2275 1. A. X. LOCATION OF WELL SITE i_.t 2 Bt • � /� � n sub. (LSAa0/I/&2 // DRILLER Bel n Le. C.Laar4 of rampant e)&i i i iag It)a4.k4. WELL LOG: 0----22' 7time gAave L. 20% c ay.. 22---46' (AaveL with. 40150 46---60' Wet4iity. f,ne cyaavet 4how.i a C.Lean water beaA.&q 9Aavet at 60 feet. G7atenyte.Ld ahaara 2.0 9M with. 25 -Peet. of- Oa tet 4tan d in a 4a cavj-i as of- bot toa. 1/2 Ramie Su &aelz.,,3tb Le %wren ahau i d be .inwta Ued 10 feet- ag bot tam. Coot of- i)n i i l ixLa : 1621.00 nen f-aat X 60 Let: §1260.00 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF THANK YOU VERY MUCH. 161260.00 BERNIE CLAUS OF RAMPART PRILLING WORKS DATE Rp4,U 16th, 1981 --- ---_� DEPARTMENT IZ E' HEALTH AND EP•dV I R NMENTHI.... ,rw3TECT I ON I 825 STREET, ANCHORAGE, AK. 9' 1 ri,- cc ho� I -Fl= l=°l=-l;:rI 17' �o j APPLICANT .rAK CONSTRUCTION 2511 C:HILk::AT COURT LOCATION LEGAL LOT 2 BLOCK 4 ROCKHILL S/D LOT SIZE TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH 45000 SQUARE FEET 110:30 MAXIMUM NUMBER OF BEDROOMS •= 4 SOIL RATING (SQ FT/BR?= 125 LY)I/l�s THE REQUIRED SIZE OF THE SOIL ABSORPTIi.'N SYSTEM IS: &,.^M F.:- ll=" 6 tl—'p � ✓.�'n I 6.��.. r`R 4.9 9 0—tl ^ R.3 e"'»_ n S'a°g e""_ I 4..-o G. F" T_ ...._ � 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 P•40 SET 14IDTH FOR TRENCHES. THE GRAVEL DEPTH 15 THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL F'IF'E AND THE BOTTOM OF THE EXCAVATION (IN FEET'. PERMIT APDL I C:AN• HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE P•d1_1MBER OF RESIDENCES THAT THE WELL WILL SERVE. `IF 14 CA :R > I r4 F::> F= r—' I Cl r -«I F.-' FEE� F f. -,e L-1 I F F= Cn _...�...._.. — BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTIi_IN AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION, MI • I I ! S-TAP�IC:E F:ETIJEEP•d A !.JELL AND ANY ON—SITE SEWAGE DISPOSAL SYSTEM IS lkiie F ET FOR A v _ OR' 9_ C� TO 2E�k� FEET FROMH_-F'UBLIC: WELL DEPENDING UPON THE TYPE OF PUBLIC: WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE I'S 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. 14ELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE b1ELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. 'SPECIFIC:ATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER: INSTALLATION. I CERTIFY THAT 1: I AM FAMILIAR: WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELL'S. AS 'MET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES, . I UNDERSTAND THAT THE ON—SITE 'SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS: REMODELED TO INCLUDE DE MORE THAN 4 BEDROOMS. I �raEc.:____._.__________________________ � s' I b� � APPLICANT ,.TAF;— .TAF; CONSTRUCTION ISSUED E:`r'------------------------------- DATE_, 2.-I1.. ----- V4.0 ICIPALITY OF WW i artm"t of Health and Environmental Protection 825 L Street, Anchorage, Alt. 99501 264_#720 WELL ANEVOR Off -SITE Se&R PEMI T - a App t to -JAY 64"1 maiti.al gees: L) mat ion ; �r _ dna Nu r a x Legal Description: (;4 46rl �c'_.�. ��_1.f Lot Size: Type of Sail kAbsorption System_ Is; Trench, 2r $: Holding to e Maximum number of Bedrooms: soil Ra�i�tg4scl.ftJbr) � � � w; The Required Size of the Stall Absorption System is; DEPTH t LENGTf-�... =��,�_ GRAYEL DEPTH -5 WI'IITH n - The length dimensloA is the langth(Ln feet) of the trench or dratafxeld. depth of a trentab or pit is the distance betwaan the surface of the gerund ,, the bottom of the excavation f in feet). 'There is no set width for t Sir `tie gravel depth " the miniAum depth of gravel been the outfall Pipe ai iA the bottom of that excavation ( is feet)* Reau t m sEpu c (Hou f w) rANK SIZE GALLOM .. Permit aippLioant has the responsibility to inform thin department during the, installation inspections of any wells adjacent to this property and then l Of residences that the well WL11 serve. ` * TWO I N$F EM ONS ARE REQU I Ra ckfii.ling of any system without f IXn al inspection and approval by this depaV 14 _11, subject to prosecution. Minimum distance be a well and any ran -site sewage disposal system is 100 for a private ll car 150 to 200 feet from i public Well depending uta the �3 of public well. Hi retia m distance from a private well to a private suer is ZS feet and to a comunity sewer line is 75 feet. well logs are required' and mast be returned to this department Within 30 clays of the well completlo,1i ,other requirements may apply. SpeaLfiCations and construction diagrams are available to insure proper 9asta Uastion- 4 ** .DEMI T EXPIRES D'cE a 31, 1 4 3 1 l certify that - (1) 1 am familiar With the reru re ntn for sin. -site sewers and wells a2I set forth by the Runic:' litg of Anchorage. (2) L will install the system in accordance with codes. ( 3) i understand that the tan -site sewer system may require enl.argeaen - a' t res' t is 7�ed toL Lie i+t re tha'rts. S ign�i s f Issued by. - Date aDates I A SWI 024(1/01) 25- „. UNICIPALITY 'OF ANCHORAGE/-' Department' Health and Environments: ?rotection 825 L Street, -Anchorage., AK. 99501 264-4720 # # "HANDWRITTEN PERMIT WELL ,AND/OR .ON-S:I'T.E..S:EWER �FERMIT Applicant: c� Mailing Address: 2,5 Location: AfU�A. Phone Number: �a Legal Description: C1 -OA4_A-k , Lot_. Size: Type of Soil Absorption System Is: Trench: Drainfield.* Seepage Bed:Holding Tank: Maximum Number of Bedrooms: ._Soil Rating(sq.ft/br) The Required Size .of the.Soil Absorption 'System 2s: DEPTH I LENGTH_ �7, GRAVEL DEPTH WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a_trench -or pit .is the distance between the surface of the ground and the.bottom of the excavation(in_feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and ;the bottom of the excavation(in feet). * * REQUIRED SEPT.IC(HOLDING) TANK SIZE _ GALLONS # Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. # # TWO(2) INSPECTIONS ARE REQUIRED # # # 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 fora_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 tothis department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure, proper installation. # # # PERMIT EXPIRES DECEMBER 31, 1 9.0 .1 # # # I certify that: j (1)__I 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 codes. (3) _I understand that the on-site sewer system may requireenlargement if the residence is. remodeled to include more that`i-bed.rooms. Signed: Issued by: `t Applicant Date: �La SWP/024 (1/sl) �” l _ � rn- sj la IVr !✓ l T �IW Or 4 w MUNICIPALITY OF ANCHORAGE ac DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Q 825 L. Street, Anchorage, Alaska 99501 2844720 \ SOILS LOG — PERCOLATION TEST y V�„'A'�m o•aeees°eo®m4""! 4Vr �� �C%� cul�C 71 DATE PERFORME:9•' PERFORMED FOR: C Z 13,1— 3 Aw LEGAL DESCRIPTION: SLOPE L 61 P�{N DEPTH DEPTH .(FEET) 0gC,,,q SIC' c. 0 ir 2 �j 18 • �t®® s a•o �ammmooe•••raffff�o •e N0.1732 -E June 22,196$ v 7 3- 19 ° e!°s rr 4- a5fL) % PERCOLATION RATE (minutes/inch) COMMENTS 7 TEST RUN BETWEEN FT AND .1�..�. FT C l l�� L yL� S /HCl 5 f LT PERFORMED BY: ���� UA-) `7 CERTIFIED BY: 5 s S� 5AA)DV C7 R14 iz5. S (LT 7 9- 10 10- 4 /per / _ 11 WAS ROUNDI�VATE14 (,/D S LO ENCOUNTERED? 12 IF YES, AT WHAT P E 13 DEPTH? 14 Reading Date Gross Time Net Time Depth to Water.' T �IW Or 16- y V�„'A'�m o•aeees°eo®m4""! 4Vr Aw e17- e �® i c. 0 18 • �t®® s a•o �ammmooe•••raffff�o •e N0.1732 -E June 22,196$ 19 ° e!°s rr 20- % PERCOLATION RATE (minutes/inch) COMMENTS 7 TEST RUN BETWEEN FT AND .1�..�. FT C l l�� L yL� S /HCl PERFORMED BY: ���� UA-) `7 CERTIFIED BY: • '� Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval Parcel I.D. 015-063-14 1. GENERAL INFORMATION Complete legal description Rockhill, Block 4, Lot 2 Location (site address) 9901 Lone Tree Dr. Expiration Date: 1.1-16- .1_/6e A '7' Current Property owner(s) Darren & Sherry Tiemstra Day phone Mailing address 9901 Lone Tree Dr. Real Estate Agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Fx] Individual F Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver/Variance request for:. Received by: /"vr Date: 9 COSA to be released to the a eer, unless otherwise requested by the engineer. COSA Fee Date of Payment Receipt Number COSA # 13 / (o Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone 6. DSD SIGNATURE _ZSSystem #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved Date 9/15/2014 Conditional approval for bedrooms, with the following stipulations: By: p� Original Certificate Date: 9 `0 Thenicip 'y orage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet f Municipality of Anchorage p Community Development Department Development Services Division SA ETY On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 131607 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 4, Lot 2 of Rockhill subdivision. This inspection revealed a nitrate concentration of 7.77 milligrams per liter (mg/L) was reported for the property's well water sample. 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. 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. Parcel I.D. 015-063-14 Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 . = e ,`r Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Complete legal description Rockhill, Block 4, Lot 2 Location (site address) 9901 Lone Tree Dr. Expiration Date: Current Property owner(s) Darren & Sherry TlemStra Day phone Mailing address 9901 Lone Tree Dr. Real Estate Agent 2. TYPE OF DWELLING: Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well El Individual El Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Received by: `f ` /f Vii'` Date: � c r (. < „ .t COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Hilo— Waiver Fee $ Date of Payment �� I� g �!� ( Date of Payment Receipt Number Receipt Number COSA #_ OSO-+ Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Alk. 99510 Engineer's Printed Name Steven R Pannone 6. DSD/SIGNATURE V System #1 Approved for �/_ bedrooms System #2 Approved for bedrooms Disapproved Date 11/5/13% Conditional approval for bedrooms, with the following stipulations: Original Certificate Date: QJ / 1 J of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory V Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet r c If more than 1 septic system is on the lot: COSA Checklist # of 1 Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: Rockhill, Block 4, Lot 2 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 4116/81 Sanitary seal (Y/N) Y Total depth 60 ft. Cased to 60 ft. FROM WELL LOG Date of test 4/16/81 Static water level 35 ft. Well production 20 g.p.m. Parcel ID: 015-063-14 Well Log (YIN) Y Wires properly protected (Y/N) Y Casing height (above ground) 24 in. AT INSPECTION 11/4/13 32 4.1+ WATER SAMPLE RESULTS: Coliform /v colonies/100 mL Nitrate F, g / mg/L Arsenic ug/L Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tank size 1,250 gal. Number of Compartments 2 10 ;.- Date installed 7117/97 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping leo l 3 Pumper (--/oc, k- lot","✓� /mow C. ABSORPTION FIELD DATA Date installed 7/17/97 Length 53.8 ft. Soil rating (g.p.d./ftz or ft2/bdrm) Width 2 Total depth 12.3 ft. Eff. absorption area 560 ft2 Monitoring tube _ Depression over field Date of adequacy test 11 /4/13 Results (Pass/Fail) Pass For 4 bedrooms 1.2 GPD/BR System type Deep Trench ft. Gravel below pipe 5.2 ft. Y N Fluid depth in absorption field before test 45 in. Elapsed Time: 1440 min. Final fluid depth 45 Water added 614 gal. New depth 62 in. _ in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date D. LIFT STATION Date installed "Pump on" level at in. Datum E. SEPARATION DISTANCES WELL ON LOT TO: Size in gallons "Pump off" level at Cycles tested Septic tank/lift station on lot 100+ Absorption field on lot 100+ Public sewer main 75+ Sewer /septic service line 25+ Animal containment areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (Y/N) in. High water alarm level Meets alarm & circuit requirements? On adjacent lots 100+ On adjacent lots 100+ Public sewer manhole/cleanout 100+ Holding tank 100+ Manure/animal excrete storage areas 100+ Building foundation 5+ Property line 5+ Water main 10+ Water service line 10+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water Service line 10+ Surface water 100+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that / 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 Steven R. Pannone Date 11/5/13 COSA brown sheet -1 0-10-1 2.doc Absorption field 5+ Surfacewater 100+ Water main 10+ Driveway, parking/vehicle storage 110+ in. SU Q'm o.r N89' 53' 24'W 05.14' ! ! UNDER NO CIRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BCUNOARY DF FENCE LINES. :HE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL LIABILITY ONLY FOR THE COST OF THE SURVEY. I USTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE ..:r SURVEY SURVEY TYPE SYMBOLS =JJNOABON AS -BUILT •GAL STRUCTURE AS -BUILT DISmc ..a ° SET REBAR 4 DRAINAGE O ASPHALT --,Or PLAN . AS -BUILT ... LOT SURVEY . Ta OGRAPHY O FOUND REBAR 9 8 9. WOOD FENCE aJO- - CONCRETE w5 -BUILT ... NO CORNERS SET RE RnFICATION AS -BUILT ... NO CORNERS SET ED ASSUMED ELEV. T -fir --X METAL FENCE ® WOOD DECK ;T PLANS & LOT SURVEYS NOTE: i THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO �s ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE STRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS. SIDEWALKS, DRIVEWAYS, EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. :CH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS NOTED. VEY CERTIFICAT10N , _OTHERWISE Prepared by m_AN ,.•.�E OF 14 4b Robert E. Johns, Jr. & Assoc. _ e°... na ., +nm I +......... ' ��` Professional Land Surveyors - e w .. .1 m °r me mI mmva AV : 1700 Brink D,,,, m- o. a.° Rk ma m tM , x mr �e awnle.. All ea.maw.c n°.a wv� AV t � :• .. ANCHORAGE. ALASKA 9950- I •• , 1 Re:. Lot SF Ree. Plot File No. AnoN AS -BUILT Y• „ .,� — 60 I EM1 M Y., hw y 41i a .0 1 w A.-eme r I .. .: IM v a ,a,, a. m. M ...... ! •••ERT-� .I Checked b 1 Date Surveyed: 12/22/11 -�" — Graw.by RE I J a °1N L'' FM K na �nm� tuMna P 21 °: P ••. -- — G: 1d. 2438 0°te Drawn: 12/22/11 W.O. 11442 :TRUCTURE AS -BURT � s fk '•.,• ` Le9ol Description: - LOT 2BLOCK 4 r AAv. �, nkw' curry mm i ' mmfa m -00, mNwnry IM .1 ..d s„ • ; y°� °°'•o� ° om.-c�'"roo°Ic�mwus�A i omme +1 (es I' t� °a sioml �,�a■I■ ROCKH I LL i Municipality of Anchorage Community Development Department p Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # OSC131607 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 4, Lot 2 of Rockhill subdivision. This inspection revealed a nitrate concentration of 8.81 milligrams per liter (mg/L) was reported for the property's well water sample. 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. 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. Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING y Parcel I.D. 015-063-14 COSA # t -s C /j/0 Q Expiration Date: !�4 1. GENERAL INFORMATION Complete legal description Rockhill. Block 4. Lot z Location (site address) aooi Lone Tree Drive Current Property owner(s) •Mathew, Alexander. & Evan Carson Day phone Mailing address Lending agency Mailing address Real Estate Agent _9212 S. Shannon Dr, Tempe AZ 85284 Day phone Day phone Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUWER OF BEDROOMS: � 3., TYPE OF WATER'IaUPPLY: TYPE OF WASTEWATER DISPOSAL: IndividualWell ® Individual On-site lndividdIal Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Pannone Engineering Services, LLC Phone 272-8218 Address P.O. Box ioozv, Anchorage, AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. Date l Fa6G� Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test; and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water�.W OF levels that may fluctuate during the year, and the water usage of the family being served by the system. .�P .•••'" •w,j These conditions are outside the control of the evaluator of this system. All systems eventually fail and Z C_?�N� satisfactory test results do not guarantee future performance of the system, nor do they guarantee that `,is 49TH there are no hidden defects or encroachments. PES can therefore not provide any warranty for future • • •••• •••••• ••••-� r performance nor give any estimate of how long the system will continue to meet the operational „,.... ,,,,,„ r requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed -�� c Steven • R. Pannonei above. Any reliance upon or use of this report by any other person or party is not authorized nor will it 1�Ij No. CE 8149 s`j� confer any legal right whatsoever. Q `••«,,,.•••• 5. DSD SIGNATURE ��O.sl'.•� Approved for � bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other By: I Original Certificate Date: (Rev. 11105) Municipality of Anchorage o A a¢ • � Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Rockhill, Block 4, Lot 2 Parcel ID: oic-o63-24 F11R'PI441111173Cal Well type Private Date completed 26 82 Total depth 6o ft. Date of test Static water level Well production If A, B, or C provide PWSID # Sanitary seal (Y/N) Y_ Cased to 6o ft. FROM WELL LOG ah612082 WATER SAMPLE RESULTS: ft. 20 g.p.m. Coliform -Vt& colonies/100 mL Nitrate 37- mg/L Well Log (Y/N) Wires properly protected (Y/N) Y Casing height (above ground) 28 in. AT INSPECTION 22/22/2022 ft. 9 - p.m - Arsenic: Vill) ug/I Date of sample: tCollected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/ Steel Date installed 7/27/2907 Tank size 3.2So gal. Number of Compartments z Foundation cleanout (YIN) Y Depression over tank (Y/N) N Cleanouts (Y/N) Y High water alarm (YIN) N Date of pumping11511-2— Pumper Ad- h�W6 6 90 cES C. ABSORPTION FIELD DATA Date installed 71ili997 Soil rating (g.p.d./fe or ftz/bdrm) 2.2 System type Deep Trench Length cz.8 ft. Width ft. Gravel below pipe ;.2 ft. Total depth 22.8 ft. Eff. absorption area 56o ft' Monitoring tube Y Depression over field N Date of adequacy test 22/22/2022 Results (Pass/Fail) Pass For 4 bedrooms Fluid depth in absorption field before test 24 in. Water added600 gal. New depth48 in. Elapsed Time: 23.0 min. Final fluid depth 24 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at Datum Size in gallons in. "Pump off' level at_ in. Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot ioo+ Absorption field on lot 3.00+ Public sewer main 75+ Sewer /septic service line 25+ Animal containment areas So+ ManholelAccess (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots ioo+ On adjacent lots ioo+ Public sewer manhole/cleanout 3.00+ Holding tank ioo+ Manure/animal excrete storage areas ioo+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line io+ Absorption field 5+ Water main io+ Water service line 25+ Surface water zoo+ Wells on adjacent lots ioo+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line io+ Building foundation io+ Water main 7c+ Water Service line io+ Surface water Curtain drain 50+ Wells on adjacent lots ioo+ F. COMMENTS G. ENGINEER'S CERTIFICATION l 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 Steven R. Pannone, P.E. Date l Z d /,-? L, COSA Fee $ GI O 4 Date of Payment � I C1 I Z Driveway, parkinglvehicle storage zo+ Waiver Fee $ Date of Payment Receipt Number C i4C Ll G Receipt Number (Rev. 11/05) Liu ren R. Ponn, No. CE 8149 0 in. Municipality of Anchorage Development Services Department Building Safety Division E Onsite Water and Wastewater Program , „ , T 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. C7 /S - 0 63 - / `I COSA # DI 0 5'4tn Expiration Date: I Z2. - .2 -5-- D 7 1. GENERAL INFORMATION Complete legal description l -.o f 2 610 cle y, Rock h,l/ _511) Location (site address) 9901 L•o^c Twee Detre Current Property owners)Jev-�y t /+�++Te 6:!rlLe*7 ti+'- Day phone '273 -S1,79 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 990/ L•ooy 7 --lee DAvei A-^e1,L>= A -k 94-7-&7 Day phone Don Wo(� 6cc ll c,- Gyr N rui, r Day phone e6s-- 6.S rt-) fly I W t3Cstron f3 /mor -0So3� �%+� /Fxc 99-74>3 Unless otherwise requested, COSA will be held by DSD for pickup. Pl Kine ec t/ JD O. ! cro rF @ 6GS''6St0 wAM Car.4 ',.t Yme/ For p,clvup 2. NUMBER OF BEDROOMS: � 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well El Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Individual On-site El Individual Holding Tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given In paragraph 4 by an independent professional civil engineer registered In the State of Alaska. Certificates of Onsite Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues COSAs upon request to homeowners. Certificates of 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 engineers 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 Onsite 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. NameofFirm Elalloa Tcrhnica/ S'rrv.ea- Phone 3Hr-�3ss Address )'IS' -?a ScL+o 1�'a Cyon fTd,.Ancharago rc X195 id Engineer's Printed Name Thio dart T=. Moo ii Date 9 / 19 107 5. DSD SIGNATURE Approved for bedrooms. Disapproved. G Aa 49TH f. -Ab •� X)ORE F. MOORE CE 4599 Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other // I BY Lit „aL, (. Original Certificate Date:_ �. 0 7 (Rev. t los) Municipality of Anchorage `• Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: 6,6, t 2. 6/ac 4 N Rc-cI- Alr/ SAO Parcel ID: Q rs -063 A. WELL DATA Well type Pp f Datecompleted AtI10,161 If A, B. or C provide PWSID # = Well Log (YIN) Sanitary seal (YIN) 'r' Total depth 60 ft. Cased to 6G it. FROM WELL LOG Date of test H 116' t 61 Static water level 3s- ft. Well production 'L WATER SAMPLE RESULTS: VR Wires properly protected (Y/N) Y Casing height (above ground) 18 in. AT INSPECTION 9 /t-/ z 00 7 7 Y, ft. g.p.m. 9•5, t g.p.m. Coliform _—Q—colonies/100 mL Nitrate K,77 mg/L Arsenic: ! _Z ppb date of sample: 99 /5707 B. SEPTICIHOLDING TANK DATA TankType/Material Stp+4c lSf�e/ Tank size 12-S O gal. Number of Compartments —7— Other bacteria O colonies/100 mL Collected by: 1`42F44 Tic/, Stec - Date installed 6 / / Y / 8 / Cleanouts (Y/N) Y Foundation cleanout (Y/N) _r Depression over tank (Y/N) _N High water alarm (Y/N) N• A. Date of pumping 9/1r/2019:17 Pumper Alaem14^aw C. ABSORPTION FIELD DATA Date installed 7//'7/ 9 7 Soil rating (g.p.d./ft2 or ftp/bdrm)1 i 9Ad T System type -77 i Length _!r3- 8 ft. Width 2 ft. Gravel below pipe S. 2- ft. Total depth 13 ft. Eff. absorption area S6O ft2 Monitoring tube Y Depression over field ri Date of adequacy test 9 /s"/ C`7 Results (Pass/Fail) Pav For 'Y bedrooms Fluid depth In absorption field before test `h in. Water added gal. New depth40 8 in. Elapsed Time: Iq min. Final fluid depth 5VO. Y in. Absorption rate >= 6GO g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) Nae,, lcn c c. If yes, give date P. A. D. LIFT STATION V. R• Date installed Size in gallons 'Pump on' level at _ in. 'Pump off" level at _ in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 1 c o ' Absorption field on lot 110' Public sewer main V. A, Sewer /septic service line �> ZS•• Manhole/Access (Y/N) High water alarm level at Meets alarm ti circuit requirements? On adjacent lots > e Or, On adjacent lots > t cle' Public sewer manhole/cleanout N• A. Holding tank N• A. Animal containment areas N.A. ( even �'Y) Manure/animal excrete storage areas P. A. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation IS Property line SS Absorption field So Water main N - 14. Water service line > to' Surface water > too ' Wells on adjacent lots > car' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 6S' Building foundation ?,r Water main "-A Water Service line > to' Surface water > Icr, Driveway, parking/vehicle storage > Sb• Curtain drain None Spe^ Wells on adjacent lots 7 I� F. COMMENTS G. ENGINEER'S CERTIFICATION C'".'j;'•• ^�:.;'••.� (_ I certify that I have determined through field inspections and + ••••"•'• '•""""'f' review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name-T-Ad%v vim, -r >_ • r ruo . c • , Date S�pF-et- h ems- 19- Zoo COSA Fee $ 'y 30 = Waiver Fee $ Date of Payment 9 / 19 / 0 7 Receipt Number o o) (P 4 (Rev. 11/05) Date of Payment Receipt Number in. Municipality of Anchorage aj (v y i�a Development Services Department Building Safety Division - a• ar♦ On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsitc (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval If 070376 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 4, Lot 2 of Rockhill subdivision. This inspection revealed a nitrate concentration of 6.77 milligrams per liter (mg/L) was reported for the property's well water sample. 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. 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. SCS ReEN 1074567001 Client Name Flattop Technical Srv. Project Mo el# Lot 2 Dlk 4 Rockhill S/D Client Sample ID Lot 2 Dlk 4 Rockhill SO Matrix Drinking Water P1\SID 0 Sample Remarks: Parameter Results POI. metals by ICP/MS Arsenic ND 5.00 Waters Department Total Nitmic/Nitritc-N 6.77 0.100 Microbiology Laboratory Total Coliform 0 All Dates/Times are Alaska Standard Time Printed Datefr)me 09/172007 14:50 Collected Date/Time 09/052007 12:20 Recthed Date/Time 09/052007 13:30 Technical Director Stephen C. Fade Allo%ablc Prep Analysis Units Mehod ConteincrlD Limits Date Date Ing u8/L EP200.8 C (<10) 09/11/07 09/14'07 TK mg/L SN1204500NO3-F D (<10) 09/11/07 JDS coU100ml. S\120922211 A (<I) 09/05/07 SDI' iREE CAROL DOUTHIT with RE/MAX PROPERTIES LAND k CONSTRUCTION SURVEYC 440 WEST BENSON BLVD. N 102 ANCHORAGE, ALASKA 99503 WORK ORDER NUMBER: oA R; — JULY 23. 1997 97—L -343A a� e„ Mo "ORK OR��E S 89'53'24" E 10' x 50' DRAINAGE ESMT. ;�:`49Tt1 `l�V ••;y G d- o. ennelh L,�Dreyer; O� LS -8202 +� 0" ............ .• SaoG o 0 ��n�!essionot o 0 EXCLUSION NOTES: II is the owneri responsibility to delermine 5/8 -RD w/CAp(F) 5/8' RD O the existence of any easements, covenonts, or restrictions do not appear on the recorded subdivision pal. NOTE: 325 AIAON (b MONUMENT Under no cucamslances should any data hereon be used for HUD L TACK 0 rjwhich COnflrucllon or I" estobtishin; properly lines. FENCE- % % SURVEY CER1trICATION: LANTECH has conducted a physical survey of this property as shown on this OYCRUANG- W00D DECKS-----��---' ® drawing and that the improvements sduoled there CONCRETE- on are within the properly fines and no ancroach- marts exist other than noted ASPHALI- GRANT- E-7 SEpnG slANovur[s— (S�' DESCRIPTION: AS—BUILT OF: LEGAL wAII WCLL- S -ENGINEERS 7) 562-5291 LOT 2, BLOCK 4, %)561-6626 ROCKHILL SUBDIVISION BOaI/pAL[. 387/13 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES 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 c� Parcel I.D. # �/� �Co 3 – HAA # (E) 1. GENERAL INFORMATION Complete legal description Lo% Z -a ( k q 20 e -k. k it Location (site address or directions) 99D I L o v) e 12t° e� Property owner 1&-, � Teresa S I' -e, K k ) n e- v-) Day phone Mailing address 23 C ( Lo r) e- _12e e 7y' Lending agency Day phone Mailing address Agent ca -'r D ( Day phone ZS%- D l/�2 Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 211 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 KND Engineering Phone Lv 26e --jbl d 20441 Ptarmigan Blvd. Address Pack River AK 90677 AMA Engineer's signature 6. DHHS SIGNATURE Approved for Disapproved. M _ / bedrooms. Conditional approval for Additional Comments Date l` i bedrooms, with the following stipulations: 4UTIC Date '_7h ` 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 courtesyto 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-M (Rev. 1/91) Back MOA #21 MUNICIPALITY OF ANCHORAGE ENVIRONMENfALSERVICF.S DIVISION Municipality of Anchorage JUL 24 1997 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services DivisionF Ct QVE D 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907 $S 44 D /' // Health'7/Authority Approval Checklist Legal Description: Woca A// elk ` /_0 ' 2 Parcel I.D.: A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed Total depth J Cased to (0 0 s{_ 1_&_ __9/ Casing height (above ground) t7" Sanitary seal (Y/N) Y Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION 'k 5o P_ Date of test W / � Y el 6, /& ""f % Static water level Well production WATER SAMPLE RESULTS: Coliform r Nitrate 9 4 Other bacteria g.p.m. Date of sample: zLz 3 `7 Collected by: ine`4 B. SEPTIC/HOLDING TANK DATA / r / Date installed 7L Tank size �ZS() Number of Compartments z Cleanouts (Y/N)_) Foundation cleanout (Y/N) Y Depression (Y/N) I_ High water alarm (Y/N) Date of Pumping '7'-24-97 Pumper C. ABSORPTION FIELD DATA A &m e� %,-4C Date installed 7 Soil rating (g.p.d./ft2 or ft2/bdrm)Z System type D -r✓en c_i_ Length 53.8 Width Z. Gravel thickness below pipe 5. Z Total depth i.z! — 6, Effective absorption area 6-604' Monitoring Tube present (Y/N)_�_ Depression over field (Y/N) Date of adequacy test it/e uJ Results (Pass/Fai Fluid depth in absorption field before test (in.); Fluid depth (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) _ 72-026 (Rev. 3/96)" For after_ gal. waterja6ded (in.): Absorption rate = ,/ g.p.d. If yes, give D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: "Pump off" level at* Septic/holding tank on lot /00 + On adjacent lots /On / Absorption field on lot /00 �-t- On adjacent lots Inn Public sewer main /DD -f' Public sewer manhole/cleanout /Do 4 - Sewer /septic service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation + Property line /D -/' Absorption field /O t Water main/service line ZS F Surface water/drainage /OD -P Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /D r Building foundation In �+ Water main/service line ZS + Surface water / D D f Driveway, parking/vehicle storage area Z$ 4 Curtain drain /L)/)1+ rJona Knocyvi Wells on adjacent lots F. ENGINEER'S CERTIFICATION l certify that I have determined thru field inspections and review of Municipal in conformance with MOA HAA guidelines in effect on this date. 14 Signature JV7 Co Engineer's Name DatePOAm�^ HAA Fee $ 315,D / LSD Date of PaymentCl Receipt Number ✓ 2 c>0 l 25 7 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number Kc:: _... systems are T.SPURKLAND P.E. WEST 15TH. AVENUE SUITE 203 ANCHORAGE, ALASKA 99502-3904 (907)279-3916 Fax (907)-276-6013 RESIDENTIAL WELL INSPECTION LEGAL: Lot 2, Block 4 Rockhill LOCATION: 9901 Lone Tree Drive OWNER: Siekkinen, Dan S / Teresa TYPE OF WELL: Private, Single Family WELL LOG AVAILABLE: Yes INSTALLATION REQUIREMENTS MET: Yes WAIVERS GRANTED: None Required WELL YIELD FROM WELL LOG: 20 Gallons per Minute WELL YIELD FROM TEST: 7 Gallons per Minute DATE OF INSPECTION: May 16, 1997 TEST PROCEDURE: Well was pumped at a constant rate while the drawdown was monitored with an acoustic probe. At the beginning of the test water level was found at 34 feet below top of casing. At a pumping rate of 7 gallons per minute the water level did not change. A total of 640 gallons was pumped. TEST FOR E.COLI AND TOTAL NITROGEN: Water was tested for E.Coli and total nitrogen on May 16, 1997 E.Coli 0. Other Bacteria N(one) D(etected) Total Nitrate -N 2.9 mg/1. Max. allowable Total Nitrate -N 10 mg/1. 10 Colonies of Bacteria Allowed TEST RESULTS: This well meets the requirements of the Municipality of Anchorage. THIS WELL WILL PRODUCE MORE THAN 3 GALLONS PER MINUTE FOR MORE THAN FOUR HOURS The Municipal requirement for well flow is 150 gallons of water per bedroom per day. This well exceeds this requirement. The assessment of the condition of the well applies only to the conditions as of the day tested. The flow rate may change due to subsurface conditions that may not be observed from the surface, and changes in the land use and other factors that may impact the aquifer feeding the well. JUL-28-1997 0:31 CUE ESI ANCHORAGE CTB! Environmental Services Inc. CTBE Rd.# 976009001 Met None Sian Oswalt & Asawlaies "40 Neme/A' L2 Ak6 RocAM 9901 Lane Tne Client Sample ID L2 RM kocl"119901 LOate Tte Marriz Drlakiu8 Water Ordered By PWSlD 9075615301 P.02/03 Ciledt PO# printed Date/Tim 0711.8/97 17.15 Collected MWillme 07/29/97 07:51 Rcceived Date/Tlme 07%13/97 W-15 Todminl Director: Stephen C. Ede Rdsmad By 4tlorabis Prep Amlysia Pareaear Results POL units Method Limits Ona Dete Inic Mitrate•M 3.23 9.100 me/L OMI! 4500-Ma3f 10 max 07/25/97 JRJ Taal Coliform 0 cel/loft @Mie 92220 07/23/97 TMY MUNICIPALITY OF ANCHORAGE > • Department of Health & Human Services t ` DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # C/)A —66 1—z"I HAA # �A 1�9 - 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) A l.' Location (address or directions) qqr I l-©'( I - (b) Property owner Mailing Address Telephone: (home) Y b - Business (c) Lending Institution Re_,r,(i L.jviL L+ 2�jc ea -4_ Telephone 2 - Mailing Address (d) Real Estate Coml Address a�Z 3Ci (`e ( S Telephone � (e) -Mail the HAA to the following address: (or check here�if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single -Family 3. WATER SUPPLY Number of bedrooms Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site Public El_ Community ❑ Holding Tank 11Note: I community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. �o�a/�eki �pvrklet Telephone o2% 391 Name of Firm U l A P °l Address o2O Date v :> v f t. Engineer's Seal .a V ' t 6. DHHS APPROVAL / Approved for ti/ bedrooms by dv ' Date ll Approved Disapproved Conditional Terms of Conditional Approval CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections oranalyze 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. 7/88) Back Page 2 of 2 K� ICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 A. WELL DATA Legal Description: -1 C- I �"i is N0Jam' V'm Well Classification 1`; P_:F / If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Date Completed 411 Jb L Yield W!�P MJ Total Depths Cased to _ 0 Depth of Grouting N O/Y Static Water Level 3 Pump Set At Casing Height Above Ground /4?; °f Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) ry SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot 1004- On Adjoining Lots 1 Cx-� + To Nearest Edge of Absorption Field on Lot )' ; On Adjoining Lots 1 L7f) To Nearest Public Sewer Line N/A To Nearest Public Sewer Cleanout/Manhole N /A To Nearest Sewer Service Line on Lot N/A Water Sample Collected by i ; Date Water Sample Test Results Cil/ 3 NO, Comments B. SEPTIC/HOLDING TANK DATA Date Installed gl9t Size 11ta c' No. of Compartments Standpipes (Y/N) I Air -tight Caps (Y/N) Y Foundationre pout (Y/N) Depression over Tank (Y/N) Date Last Pumped RTq9 Pumping/Maintenance Contact on File (Y/N) NIA ; for N/A Holding Tank High -Water Alarm (Y/N) N/A Temporary Holding Tank Permit (Y/N) NZA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well I To Building Foundation To Property Line Ivy To Water Main/Service Line IN To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/69) Front To Disposal Field by Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata `� Type of System Design I �C' � N CIt Date Installed q�£3 Length of Field I r Width of Field S6 Depth of Field Gravel Bed Thickness Square Feet of Absortion Area ���f Statndpipes Present (Y/N) � � Depression over Field (Y/N) _ Date of Last Adequacy Test I c_'c�3 Results of Last Adequacy Test 4 4'3 r-v> f� ,r i�C,, a lrY/ . SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ) opo -- To Property Line To Building Foundation 3 To Existing or Abandoned System on Lot A//A. ; On Adjoining Lots To Water Main/Service Line To Cutback (if present) NSA To Stream, Pond, Lake, or Major Drainage Course NIA To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATIONONZV : Date Installed Dimensions Size in Gallons 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 "Check Permitted Bedroom Rating Against HAA Request" I certify that I have checked, verified, or conformed to all MOA and HAA gwidefines•in effect on the date of this inspection. Signed Company l i��rf1P yr �" 1 Date j �Agz� s' � Engineer's Seal MOA No. r'>. a- Receipt No. 0 �/ z dr Receipt No. Date of Payment Waiver Fee: $ Amount: $ Date of Payment 72-028 (Rev. 7/88) Back Page 2 of 2 5. LEGAL DESCRIPTION DATE RECEIVED INSPECTION APPOINTMENTS TIME NUMBER OF,BEDROOMS TIME TIME I FV SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY n` q 7. WATER SUPPLY e4_ �� I_ i �. �. 03L a DATE since June 1975. For wells drilled prior to that date, give well DATE DATE 8. SEWAGE DISPOSAL SYSTEM �S INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY INSPECTOR INSPECTOR INSPECTOR i RAGE DEPT. OF Nfr^-,Llai �ti MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL -OTECTION DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 • ENVIRONMENTAL SANITATION DIVISION RECEIVED Telephone 264.4720 R E C E I V E 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.PROPERTY OWNER PHONE Q MAILING ADDRESS PROPERTY RESIDENT (If di a ent from above) PHONE 2. BUYER PHONE p MAI LI NGADDRESS �f 3. LENDING INSTITUTION PHONE f� MAILING ADDRESS 4kajaZAL 4. REALTOR/AGENT PHONE MAILING ADDRESS r 5. LEGAL DESCRIPTION STREET LOCATION 4 e Zo,? t" 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS ❑ One Four ❑ Other I FV SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY 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 �S 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) �/�� THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ElFIVE EDOTHER EDTWO aL--<OUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: 4.) S-7� If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS .., APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY ISO D1VloED L �vNo POR. 4CC. f 4; I -I , R. 34W.,o s. At. .78 ,)6 -77 Adjoining Pegs No. 0 Adjoining Tax Book No. O Mr, Assessors Paesl Ift O Assessor's Block No. Q