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KRAMP BLK 3 LT 3
Kramp Block 3 Lot 3 #016-171-12 �0 P .1 H 4 ! 1. 43 4: v �4. . 1: 1 " r� �T- i:, �- 4 !1 � �� - � 11 i—DoE DEPRRTMENT L HEHLTH HND SRI IR0NMEITHL /. QTEcT[ON 825 'L' STREET, HPqCHORHGE, HK, 99501 2�4-4720 K 10 Q vl 1~1 PERMIT NO ( 8202]2 ) HPPLlCHNT ROUND�HOUSE BUILDERS IN SRH 8OX 15612 745��375 LOCHTION NORTH RHVEN LEGRL L3 B] KR�MP S/D LOT SIZE 12000 SQUHRE FEET W K 141 Val 1 T 15: X Fl� :1 lot K op; 0 & TO up: 1-1 ES., :1111��� I CERTIFY THHT 1 I HM FHMILIHR WITH THE REQUIREMENTS FOR OINSITE SENERS RND WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORRGE 2� I WILL INSTHLL THE SYSTEM IN RCCA) RDHNCE WITH THE CODES ~ ..... ..... ..... �.... .... ..... ... �..... ..... ... .... �.... ..... ~�..... ..... HPPLICHNT ROUND~HOUSE BUILDERS INC ISSUED BY .... .... _... ... __ V40 An R -N F z z 1 :, i it r 3 tw-13 TI y(IMPT fs W PRO pov r t' 105 510---p 4:_,7 Sol? 1 F wJ1413110:00 don. YjaY giryl Y, MIS ONS, {!If"} Qj-;f 3, �&NKF! HMO 09,05 AS 510, a fit I I i a: :q- Vf 'Pli. VINATT it -MMM Uj ;ICV.CUOCSIIII:I- sit m vs 4" s s c,.._: PA 0 d J1 0 jy /IV/S VJS yr )L)- I Al 6 1)' z PU tAUNICIPALITY OF At,,CHORAGE .O e-, r7 �CEIVED 0 QpGE aUi •- Municipality of Anchorage 6 , ;-:°.".*:`�• `° On-Site Water and Wastewater Program ...._:-. (907) 343-7904 .;:1: 1':31-11,e'6.--7:'.::: j�' ;l a' ° v��Yj Certificate of On-Site Systems Approva a JUS 20/s c Parcel I.D. 016-171-12 Expiration Date: /',,, 1a __Ai,4:' 6 8 L 9 1. GENERAL INFORMATION: Complete legal description KRAMP; BLOCK 3, LOT 3 Location (site address) 11830 Northern Raven Drive *Anchorage 99516 Current Property owner(s) Lisa Fraser Day phone 529-5275 Mailing address Real Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual ❑ Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community El Public Water System ❑ Public Sewer ❑ WaiverNariance request for Distance: Received by: ./r 10r Date: 1/ COSA to be releas-• to the en. -er, unless otherwise requested by the engineer. COSA Fee $ FJ 710 Waiver Fee $ Date of Payment l'f tceltt Date of Payment Receipt Number 021t5OG Receipt Number COSA# 14 (411 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: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101-Anchorage,Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: .7/16// ,Q000000 In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system ' OF 4 4. %'N in accordance with the guidelines and regulations established by the Municipality of Anchorage and ,:&=, -c....,,.••••.•• •.'-''./ SAN industry practices. The reported results describe the condition of the system/s on the date/s of the ' evaluation. Separation distances were measured to readily identifiable features. Hidden defects or A. • I 0 encroachments may exist that were not identified during the evaluation. The operational life of all wells i/* 4- i T 1 •,��.�O and septic systems depend upon a variety of variables, including but not limited to, soil conditions, •• • Q groundwater levels (that may fluctuate during the year), quality of construction (materials and Q workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and d. are outside the control of GEG. Satisfactory test results do not guarantee future performance of the / •f' - A. G. ness.: 0 system/s; therefore, GEG makes no warranty (express or implied)regarding the future performance of .4)0 • •c ._-. .. ��0� the well or septic system. GEG makes no representation whether an alternative well or septic system s .• ' •c*,:::, can be installed on the property in the event either of the current systems fail to perform adequately in 44 rare • "i..Ik. .!•�" ��°� the future. The content of this report is for the sole benefit of the person/party that retained GEG to 01\v,0'profess or\0o'Q perform the evaluation. Reliance upon the information provided in this report by any other person or �OppQo party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. #AECC884 6. DSD SIGNATURE System #1 Approved for bedrooms \`\�,� h I System #2 Approved for bedrooms ON-SITE -›, Disapproved WATER AND 11-' .::) W STEWATER Conditional approval for bedrooms, with the followincnstipl� � AM �c ...r,r-..- ,,1`r • By: l \- (7-7(7-7 ' / NOriginal Certificate Date:1 1q —1,X The Municipality 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 Nitrate Ad171s6q:; ;, Septic System Advisory Arsenic Adyis.oy, - •, r. Well Flow Advisory Other ' ' r�'... ' �' COSA blue sheet 10-10-12.doc If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: KRAMP; BLOCK 3, LOT 3 Parcel ID: 016-171-12 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 6/82 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 114 ft. Cased to 114 ft. Casing height(above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 6/82 7/10/18 Static water level 40 ft. 50.7 ft. Well production 10 g.p.m. 3.5+ g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 ml. Nitrate t`ID mg./L. Collected by: GEG, Ltd. Arsenic: 14. ® ug./L. Date of sample: 7/10/18 B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Tank Type/Material Date installed Tank size gal. Number of Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression over tank (Y/N) High water alarm Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft2or ft2/bdr • System type Length ft. Width ft. Gravel below pipe ft. Total depth ft. Eff. absorptio - ea ft2 Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in abso • .on field before test in. Water added gal. New depth in. Elapsed e: min. Final fluid depth in. Absorption rate >= g.p.d. y rejuvenation treatment(past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at .• wa er alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/'4 On adjacent lots 100'+ Absorption field on lot N/A On adjacent lots 100'+ Public sewer main *75' Public sewer manhole/cleanout *100'+ Sewer/septic service line **UNKNOWN Holding tank 75'+ Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption field Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIE ! a 1 LOT TO: Property line B " _* • foundation Water main Water service lin- Surface water Driveway, parking/vehicle storage -in drain Wells on adjacent lots F. COMMENTS *PER AWWU RECORDS (SFF ATTATCHED DRAWINGS) . PHYSICALLY CONFIRMED SEPERATION TO NE AWWU MANHOLE. NW AWWU MANHOLE WAS NOT FOUND. **NO REQUIRED SEPERATION DISTANCE IN 1982 G. ENGINEER'S CERTIFICATION ..,!. , -......Y..1-. .,'9S♦ ♦♦ • 4442-- % * /certify that I have determined through field inspections and • * 4'Thi 1\ •-. ♦• review of Municipal records that the above systems are in • ' • conformance with MOA COSA guidelines in effect on this •••• • • • date. ♦s % _ • ey A. Garness JEFFREY A. GARNESS ♦ e b.,.*.•7L •••** :i Engineer's Printed N me ♦ /4-11113 .407 _ Date �/(:,/ ♦♦♦ PROF.. ...` P:.. LICENSE ,0llIIvi"S` *� #AECC884 (Rev. 10/12/12) CO MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT • 41,-1- 1 1 907-343-7904 On-Site Water and Wastewater Section Fax: 343-7997 www.muni.org/onsite Arsenic Advisory Certificate of On-Site Systems Approval # OSC181341 Subdivision: Kramp ,Block 3, Lot 3 A water sample revealed an arsenic concentration of 14.8 micrograms per liter (ug/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/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. information on arsenic is available from the On-Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On-Site Systems Approval. Mailing Address: P. 0. Box 196650*Anchorage,Alaska 99519-6650 *www.muni.org A * Ski4 VW (TM 9 • 41 4 11 1101 1 1 2 S 6 , 0 •_ 1 c! N•.• •• • •• . • • • •, • � : •- • . • • • • - ••• ,r •• • e •• ••• •• • • w00% •• • • •. 1 • • • r ___ _ __� • 1. , •• � . 4 i O r ..1.4\ 1/41 ln • I► I • . . , RET. PRIVATE I WELL c -•---- Rail ° PRIYATE W -> WLL I �/ WELL PRIVATE 4 '��•� J. WELL � I • 44. 9 R.B. TO.0 1 ' r- ' , Thf1 � ./., • i ki. . . y - • • • 1 ' - - -. _ __ .41 I., . • • 1 I 300.00LF = DIP « 501111r, # 5 "' G it:, 10 . • , N i0 PRIVAT ,'. I ire) "� ` 70 00 • • _ :�• , WELL O ' : ILw1 1 � ‘‘ ... ' WELLA ! ._ < i ,NrtENcstw'' �rJ o�(> �� Fti,„ CONNECT PERM.ITZ_ .� ( - :60 30 s v� .. ,...,OF„C\\04- DATE OF APPLICATION "-L/ '/"P�i WATER a SEWER UTILITIES SCHEDULED COMPLETION DATE-/v e'f?.. 3000 ARCTIC BOULEVARD ,INGLE FAMILY PHONE-277-7622 ❑MULTI-DWELLING No.APTS 0 COMMERCIAL LOT/TR .,.:3-ACT _� BLOCK0 INDUSTRIAL ' SUBDIVISION �'+ . -(:/ 7 GRID DRAWING No. 6"..4.8 ' BUILDING AD RESS 1 ' . -7-sf,__M . R-A (U OWNER /4?/.9--4/ 47�-eS-ze..r. v?",/PHONE ,�9-S ,>rt'2c-7 MAIL ADDRESS S/1 /9 /56--/, 3---. 9 .7 CONTRACTOR: (2-,')�,'S t seG ASSESSMENTS (License abond required) 0 Paid previously 4ON PROPERTY ONLY ❑ Main extension agreement ID ❑MAIN TAP-TO PROPERTY LINE ONLY ❑ Subdivision agreement ❑ Extended connect agreement ❑MAINTAP BON PROPERTY CONNECT ❑ Pending-AMOUNTS ' /1 PERr�IT ISSUED BY: CONNECTION SIZE -7 CHARGE y ��`-xi_ --e--t-) INSPECTION FEE t A/2- (90 ❑ CASH PERMIT FEE 0 S; Q0 0 PAID CK# ,5 REIMBURSIBLE NUMBER - DEPOSIT t INSPECTED BY J { TOTAL t 4-5,4 ') DATE: PERMITTEE �o MAIL -eA7 /_tri (PLEASE PRINT)OAR/ S'/P`"xcRtifj711�; ADDRS�t fes,-' PHONE:3 !�QO /. I HAVE R AD THE CO TIONS AN ' GULjI HE REVERSE SIDE OF THiS, PERMIT ND GEE ►• ' TH PERMITTEE SIGNATURE ,',// i/(// 1� POST IN A CONSPICUOUS PLACE AT THE JOBSITE 80-021 (4/80) INSPECTORS COPY ``T Municipality of Anchorage AL (. Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 016-111-12COSA# 03Clal32i� Expiration Date:�- 1. GENERAL INFORMATION Complete legal description Kramp Subdivision, Block 3, Lot 3 Location (site address) 11830 Northern Raven Drive, Anchorage, AK 99516 Current Property owner(s) Lisa and Geary Fraser Day phone Mailing address 11830 Northern Raven Drive, Anchorage, AK 99516 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: Four (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 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 Anderson Engineering Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. 5. DSD SIG,DIATURE =Approved for Disapproved. Conditional approval for bedrooms. Phone 522-7773 Date 8/2112012 bedrooms, with the following stipulations: Attachments COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory �C Maintenance Agreements Supplemental Engineer's Report Other By: 141, Original Certificate Date: / �— (Rev. 11M) Municipality of Anchorage • '� Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot 3, Block 3, Kramp Subdivision Parcel ID: 016-171-12 A. WELL DATA Well type Private If A. B, or C provide PWSID # _ Well Log (Y/N) Y Date completed 6/62 Sanitary seal (Y/N) Y Wires properly protected (YIN) Y Total depth 114 ft. Cased to 114 ft. Casing height (above ground) >18 in. FROM WELL LOG AT INSPECTION Date of test 6182 8/2112012 Static water level 40 ft. 35.9 ft. Well production 10 g.p.m. 4.0 g.p.m. WATER SAMPLE RESULTS: Coliform o colonies/100 mL Nitrate N/D mg/L Arsenic: 15.4 ug/I Date of sample: 5/25/2012 Collected by: MEA B. SEPTICIHOLDING TANK DATA Tank Type/Material AWwu Sewer System Date installed Tank size gal. Number of Compartments _ Cleanouts (YIN) Foundation cleanout(Y/N) _ Depression over tank (Y/N) _ High water alarm (Y/N) Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ftz or ft lbdrm) System type Length ft. Width ft. Gravel below pipe ft. Total depth ft. Eff. absorption area _ft2 Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail) For _ bedrooms Fluid depth in absorption field before test in. Water added_ gal. New depth in. Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN) "Pump on" level at _ in. "Pump off' level at _ in. High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL QN LOT TO: Septic tank/lift station on lot NIA Absorption field on lot N/A Public sewer main »5' On adjacent lots NIA On adjacent lots NIA Public sewer manhole/cleanout >100' Sewer /septic service line >25' Holding tank NIA Animal containment areas >50' Manure/animal excrete storage areas >100' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption field Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water main Water Service line Surface water Driveway, parking/vehicle storage Curtain drain Wells on adjacent lots F. COMMENTS: Lot is Served by AW WU Sewer System. G. ENGINEER'S CERTIFICATION F I certify that I have determined through field inspections and W#; 48id review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Michael E. Anderson, P.E. .� %• Cadj ♦� Date 8/2112012 � �'•' t._ Pterr COSA Fee $ qotO — -- nn Waiver Fee $ _ Date of Payment ��J I 1 a` (. Date of Payment Receipt Number 09?2 ob G Receipt Number (Rev. 11/05) Municipality of Anchorage s 11`1' FP .tf L Community Development Department 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 Arsenic Advisory Certificate of On -Site Systems Approval # 121376 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 3, Lot 3 of Kramp Subdivision. This inspection revealed an arsenic concentration of 15.4 micrograms per liter (ug/L) for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/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. Information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. LANTECH r r �„• O O W ,00,9E M ,OZ,L0.00 N X - X - X X - X- X - X - X X - NjuaW@SD3 Xa!i!1r ,OL e n W o a y W r' O n � m T� a0 0 r o X _ � �>fV W ^ J N m a � W O C N 1 o 0 CDm o N o Cf) CA ro r O \\ W D � p y M �1'l o 2 � m LANTECH r r �„• O O W ,00,9E M ,OZ,L0.00 N X - X - X X - X- X - X - X X - NjuaW@SD3 Xa!i!1r ,OL n � m 'a n � m X _ � o o ° � O \\ X p y M �1'l o 2 � CA 0 o4n p. =zo co c O J N m N I O mO to O m 3A> n c 2 o- CO mmNrZ �� nN T I Z 9'91 ��aoa-- �o vmo�ZO n g oma` m Z Mem w J m 0 m ,o �z0 s-� �rC) m o o N N N S Sg s n O Z m O m ZO m In x0m� ro° O mOZrO Z m o omoc oa• 'n mma O =rm N CD �HPo '°Sa m O vA'r m yoo'Oo qs� o 0 S X D ncim ;om 3Q c Z 70 roro m LANTECH r r �„• O O W ,00,9E M ,OZ,L0.00 N X - X - X X - X- X - X - X X - NjuaW@SD3 Xa!i!1r ,OL W O WO (133b1S SIM3�) 3ANG N3AVi l N�13Hi2JON I o � X CA co c C1 J J N N I O O 9'91 2 � x o x N CD 2W 0 S X . ,-WP,...) � !D a O - 9'6l _ o I o rt a ro m N I n N N � 3 X 3 I x x ,00'9L 3 ,oz,/ -0.00 S W O WO (133b1S SIM3�) 3ANG N3AVi l N�13Hi2JON A -�j - C MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services h 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 I.D. # n\In— \1 - 1Q GENERAL INFORMATION HAA # Complete legal description 1-a f 3—. (3 lac '1- 3 /-Cr-Qrn 2 S /b Location (site address or directions) 11 530 NorlAcrn Raur� Property owner _ perVrof U'ske/_ Day phone 3yS-3917 Mailing address 11630 Nof-05e,-n Buren A-ncLiorrtgp, A" 995 16 - 71 Lending agency 1!5�-"AC Day phone 562 - 2tel Mailing address g6_0 Gv T<do !3 p( AS c6 +- s 99503 AgentrH� Re Day phone 217 - 0i0,5 Address 26`00 x0"0'0 Sf, i��ctianagt-- Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: -3 '1 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 wafbr 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 r(a' P 7_�'cti pica ( 1frverv-1 Phone 3 yS- 17 Address 1 V3_2 o Cc46 4� /-,'cLiel a7� Engineer's signature %nom �.1 Date /6 /9 y t, 39r H 10 THEODORE F. A1OORk . CJ 6. DHHS SIGNATURE% CE - 3589 yAAAyyy •• ..... • �:v Approved for bedrooms. S� c„"� Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: Date �- 24 — �gL 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 order to satisfy certain federal and state requirements. Employeesof 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 1121 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: I.ol3, Ol 3, kraino!2 Parcel I.D. A. Well Data Well type P -, r If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Ir completed C/ 6z Driller Archtc Dr-///y7� Total depth ! 1 t!' Cased to / / W 1 Casing height 301, Sanitary seal (Y/N) Y Wires properly protected (Y/N)_ Y FROM WELL LOG AT INSPECTION e Date of test _� /® __21 / 13 /9 1 n Static water level q0 3V `y �i Well flow 10 g,p.m. Pump levels 99 ' 70' � c k Y �c SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Alt f} ( /}wwu Sewer] ; On adjacent lots > /oci ' Absorption field on lot N, A . ( A uwa.0 Sewn J-; On adjacent lots > 100/ Public sewer main 71S, r Public sewer manhole/cleanout / 07 Sewer service line > ZS' Petroleum tank None seee) WATER SAMPLE RESULTS: Coliform G cc, / /iavm -L Nitrate ._ o. / w+y / Other bacteria O cr, / /iia Date of sample: S'/ 19 / 9 H71- 6 / 1 /9'/ Collected by: Fla/ -APA Tec/, Sic B. SEPTIC/HOLDING TANK DATA Date installed N,A. Secue� Tank size Cleanouts (Y/N) _Foundation cleanout (Y/N) Compartments Depression (Y/N) High water alarm (Y/N) Alarm tested (Y/N) Date of pumping Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage 72-026 (3/93)' Front On adjacent lots Absorption field Foundation Water main/service line CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Surface water D. ABSORPTION FIELD DATA /`M-11. Sewel) Date installed Soil rating (GPD/Ft') System type Length Width Gravel thickness Total depth Total absorption area Cleanout present (Y/N) Depression over field (Y/N) Date of adequacy test Results (pass/fail) for Bedrooms Water level in absorption field before test After test Peroxide treatment (past 12 months) (Y/N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots Property line To building foundation To existing or abandoned system on lot On adjacent lots Cutbank Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on Signature � T" inspection. "k¢O nr �'JL CUo�0� �• Engineer's Name / Date 616-19y bra><,, � A� �A+�ak:x:Yti bb5�- HAA Fee $ .AGO w Waiver Fee $ Date of Payment �� �� l,�G Date of Payment Receipt Number °� 7 / :17 2ZReceipt Number �T MUNICIPALITY OF ANCHORAGE o» /7/ /2_ DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL oK —(D' ,� OF ON-SITE SEWER AND WATER FACILITY 264-4744 q �/ Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) "-r 3 R" ce 3 KkA*04 Location (address or,dirQ5.' 7Art W. A'_4?ji/�� (b) /vU Property. OwneC, � - • '���R��/3�/ / Telephone: Home Business Mailing Address /x'_30, j2�%2v/ (c) Lehdi fg Institution ; Telephone Mail ing•Address (d) Real Estate Company and Agent'r Address () z Telephone s4'3 SS 0 (e) Mail the HAA to the following address: or: Check here if hold for pick up. List contact person and day phone number below. he,r✓3 c.11Gc Flex, UF. 2.. TYPE OF RESIDENCE Single -Family Number of Bedrooms 3. WATER SUPPLY 3 Individual Well`. Community C] Public ❑ Note: If communitywell system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite ❑ Public M, Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (Rev 8/86) Front 4Oe9 l99/e naal Sao-eL Z 10 Z abed '�JOM S,JaaUIbUa 1euolssaloJd a41 u! suoiss!wo Jo sJoJJa Jol apsuodsaJ lou si a6eJo4ouy to AUledlolunW a41'panssi si aleoilp iao e aJolaq elep azAleue Jo suolloodsui lonpuoo lou op SHH(] po saaAo1dw3 'sluawaiinbai alels pue IeJapal ulepao ,(1s11eS 01 JapJO ui suollnl!lsu! buipual na4l pue sawo4 to sJase4oJnd of AsalJnoo e se s141 saop SHH(]a41 e>lse!V po alelS 941 u! paJa1s16aJ Jaauibua leuolssaloJd luapuadapul ue Aq anoge 9 gdeJ6eJed u1 uaA16 suopeluaswdw a41 uodn Aluo paseq saleo!p!laao IenoJddy AI!Ao4lny 4lleaH sanss! (SHH(]) sa01AJaS uewnH pue 4lleaH to luawlJedaa a6eJo4ouy to Al!1ediownW aU1 NOIlf1V0 leuo11!Pu0(] IenoJddy leuo!1!puo(] po swJal panOJddes!(] e1e(] � ,(q swooJpaq panoJddy Jol panoJddy 1VA0addV SHHO '9 88 /, 4 ale(] �OSdb 740 14pfoy M ?/ / ss@jppb' FSS 6 L auo4dalal S� wJ1d l0 aweN 'uolloadsui si41 po alep 941 uo 10911a u1 suopelnb@A pue'sa0ueu1pJo'sapo0 @121S pue led!oiunVq Ile 41!M eoue1ldwoo ui s! wals (s lesods!p JaleMalsem Jo/pue Alddns JaleM al!s-uo 941 'uopoadsui pue uo!leblpsanul ,(w woJl pue sal!l a6eJo4ouy to ,(1!led!o!unN 941 woal pau!elgo uollewJoluj a41 uo paseq 1e41 A1!JaA Ja4pnl I uiajaq paleo!pui aJnlonJls to ad,(1 pue swooJpaq to Jagwnu a41 Jol alenbape pue 1euo11ounl'ales si walsAs lesods!p JaleMalsem Jo/pue llddns Jal2m al!s-uo a411e41 SMo4s IenoJddy Al!Jo4lnV 4112@H s!4110 uo11e611sanul,(w 1e41 Ap!JaA I 'Molaq UMOgS alep u011ep11eA 94110 se pue olaJa4 paxyle leas Aw Aq palpliao Sy NOIlVWa03Nl (INV VIVO `HOHV3S 3l1d `S1.S31 `SN01103dSN1 ONIOIAOdd Wald ON1833NION3 V%Wcyty b7 ><-2 9 MUNICIPALITY OF ANCHORAGE (MOA) HEALT#1 AUTHORITY APPROVAL (HAA) G\eP�`,� Ds�Cv` ��✓c KLISFEBRUARY 1984 �S�\264-20 NDN\ MEN�P� Legal Description: Go!� �NJ`zpC1voi 9 p A. WELL DATA Bue 3 /eleAqP Well Classification a- If A. B, C, D.E.C. Approved (Y/N) AIJA Well Log Presen YJ) n Date Completed Yield - �• 6ph Total Depth _ //5' Cased to Depth of Grouting A)IA Static Water Level exe,S Pump Set At v411#4 Casing Height Above Ground Sanitary Seal on Casing (Y N) Electrical Wiring in Condui (YiN) Separation Distances from Well: Depression Around Wellhead (Y(@ To Septic/Holding Tank on Lot WA_ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot •'� ; On Adjoining Lots i To Nearest Public Sewer Line 711 To Nearest Public Sewer Cleanout/Manhole �� f' To Nearest Sewer Service Line on Lot — Water Sample Collected by ,ores A', cJ10A1 ; Date 4rr30 _5'r Water Sample Test Results )34L 7- -&- Afl7-9 4-rOl "tom Comments `%f pM"� /'40"J 7-ryr B. SEPTIC/HOLDING TANK DATA Date Installed (Y/N) Depression ove(Y/N) Size Air -tight Caps (Y/N) Pumping/Maintenance Contr File (Y/N) Holding Tank High -Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well To Property Line To Water Main/Service Line Course Comments Page 1 of 2 72-026(11/84) No. of Compartments A)14 0 Foundation Cleanout (Y/N) Date Last Pumped for Temporary Holding Tank Permit (Y/N) To 8064ag Foundation To Disposal Fi To Streams -R nd, Lake, or Major Drainage C. ABSORPTION FIELD DATA ils Rating in Absorption Strata Width of Fi Square Feet of Absorption Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) \ Date of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION to Installed Size in Gallo "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Line On Adjoining Lots To Existing or Abandoned System on To Cutbank (if present) Dimensions Manhole/Access (Y/N) "Pump Off” Level at Vent (Y/N) mping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** \� I certify that I have ckk verifi d, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed G^GE�. �-� Date %'%4-641r' Company ACfLS MOA No r OF &'hb Receipt No.�lc ©'s 1(�� o oo J;:`44 4 • �f, Date of Payment �l�� r•e° °„+ 0 o s ... • / r7 n Amount: $ ! /� •a°�„• oa e,e„eee••e ®` LERC. RFID, JR. s° ® 2251 f` Page 2 of 2 � � Professlo*\ 72-026 (11/84) Time Time le Cate Date Date �J Inspector Inspector Inspect((� nn 10nYOQn��S. _ Comments __ _ Conditional Approval MUNICIPALITY OF ANCHORAGE (,..: -) f; 7 119, 8r% DECEIVED 1� Date Sewer Installed Permit No. Septic Tank Size e Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property Owner ROUND-110USE BU7]DEMS, ING. Phone Mailing Address SRA 13OX1561-7.., Anchorage, AK. 99507 345-3875 Buyer Address Lending Institution Alaska Mutual Banff. Phone Address 1501. Ni. 31st , Anchorage, AK. 99503 274-2551 Realty Co. & Agent Areca Realty , Candee Schweitzer �® Phone Address Iy794 Business Park Blvd. , Bldg. F, Anch. , 99503 78-2525 Legal Description :Got 3, Block 3 Kramp Subdivisihon Street Location Northern Raven Typef Residence 9Single e Family 3 11 Multiple Family No. of Bedrooms El Other Watet�Supply (_t Individual ATTACHWELL LOG. A well log is required for all wells drilled since; June Community 1975. For wells drilled prior to that date, give well depth (attach log if Public Utility available.) Sewage Disposal :7) Individual Year Individual Installed: _ XPublic Utility When Connected to Public Utility: J Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.