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KASILOF HILLS BLK 2 LT 6
Kosilof Hill lock 2 Lot 6 · 015-161 -24 MUN,O,,AL,T¥ O': ANO,ORAGE ,'//I '~, DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION (~ ENVIRONMENTAL ENGINEERING DIVISION 825 LStreet-Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELl_ INSPECTION REPORT NAME IPHONE I ~W ~AI LING ADDRESS LEGAL DESCRIPTION LOCATION ~O, OF BEDROOMS ~,ST,~C~TO:~ )0 ~J ¢ ~ ~ ~anufacturer Material ~0, of CO[~psFtn]oR~S ~ ~ Li(. capa~ty in gallons Inside length Width Liquid depth % 2~ IF HOMEMADE: Well Dwelling PERMIT NO, ~ ~ DISTANCE TO: O Z ~ Manufacturer Material Liquid capacity in gallons ~ Well Foundation ' ~earest lot line PERMIT NO. ~ 5 D~ST*~C~ TO: ~/ O O · -ZW ~ ~-2_I ~ inches I- ~ ~ Top of toe to finish grade Materiai beneath tile ¢ Total effective absorption area Length Width Depth PERMIT NO. ¢ DISTANCE TO: ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER ............ PIPE MATERIALS SOIL TEST RATING t%% -- - INSTALLER REMARKS l_ k x( [:,EPFIRTMEI',!T r"~¢:' HERt_.TH FIND EN',,,' I F;.':Oi'.,ff'tEt.,Ff'FIL r:'"':'OTECT I ON ',~i', ::.:: 5 "' F:'E[;~:MtT NEI. ,:: S:1. E~;2¢:.~: ) FIPP[.. 7 Ci::II",FI" M. [:'. MC PHERSEIN L..OCWF I (:)hi "["T'F'E OF SO I I... I::IE:SORPT I ON :5'T?'.';TEM I '.5: P'IFIXIM[.IM I'.,ILIME:ER OF BE[:,ROOMS.; = 4 THE REC4LIIRED SIZE OF THE :'~;OIL. F1DL:;C~F.:PTIOi",I S'T'STEM IS: THE LEI'.,IGTH [:,IMEN:E;ION 1'S THE I..ENGTH (IN FEET) OF THE TRENCH OR [:,RRINFIE:LE:,. THE DEPTH OF R TRENE:H OR PZT IS THE ['.,ISTRtqC:E BE't"I.,.!EEN THE; L:;LtRF:FICE OF THE GR. OUi'.4E:, I=Ii'4[:, THE E:OTTOM OF' THE E::.:',C:R',,,'F1TIOI'.~ ,:: IN FEET). THERE I:E; NO SET ~,.!~E:,TPI FOR TRE:NCHES. THE GRFI',/EI... [:,EF'TH IS THE MINIMUM DEPTFI OF GRR',,,'EL E:ETI.,.IEEi'.,I THE OUTFRL. L. PIF'E FIND 'THE DOT'FOM I]IF THE EXCFt',,,'FITION ,:: IN FEET). F'ERM I T F:IF'PL I c:ai'.,rr k. IF:i:.E, THE RIESPOI'.,tS I E: I L I I"T' TO I NFOI:;.'ff"I TH I ?.~; E.',EPFIRTMENT [)1.1[:;: I I'.,tl.] THE :1: Iq~ZT'FIL.LF:IT I ON i N"=';F'EE:T I 01'.,!~; OF FII'.,t'T' Iq[LES FIDJFtE:EI'.,IT TO TH I S PROPERT'T' FINE:, TIdE I",IUME',ER O1::: F.':ES:[[':'EI"4CES TFIFIT THE. I.,.IE;LL. I,.!IL.[. SER","E. 8RCI<F ILL. I IqG OF:' Ri'-,I'T' S"r'STEM 141 THOUT F'I NRL I NSF'EC:T I ON F'IN[:, FIPF'RO',,,'AL E:'T' 'TH I S DEPFIRTMENT 14ILL. BE SLIBJECT TO F'I:~:OSEC:U]'ION. I',I.T.i'.,IIM[.IM DI'Zr'RI'.IE:E E:ETI,.IEEi'.4 FI 14ELL. FINE:.', Fii'.4'¢ OIq--SI]"E SEI4RGE [:,t'.SF:'OSFiL S'T'STEM ;.tEH;3 FEET FOR FI PR I ',,,'RTE HELL OR ~50 TO ;2E~O FEET FROM FI PUE~LIC NELL [:,EPEN[:,ZNG I. JPOt",I TI'-I[F ]"¥PE OF F'IJE',LIL-: I.,.IE[..L. MIiqIMLIM E:'I.S'f'F'INCE F:ROM FI PRIVFI'FE:. I.,.IEL. I_ TO FI PRI',,,'FITE SEI4ER LINE :[:']; ;;::"5 FEET Ri",l[:' TO FI COi'"IMUNIT"/ SEI4ER LINE IS '?5 FEET. .t,.IEt...l_. L. OGS FIRE RE6!I..IIF;rED FIND MUST DE RE'FUF.:I",IE[:' TO THE [:'EPFIR]'MEI"4T I,.IITH!N 3:0 [:'FI'CS OF THE 14ELL COMPL. ETI. OI",I. OTHER F.:EOU I F.:[::'MENTS MFt'T' FIF:'PL'¢. SPEC I F I F:RT IONS FINE:' COI",ISTRLtCT Z ON E:'I RGt;~!IaMS RRIE RVFI :[ LFtBLE TO I IqSIJRE PF..'OPEF.". Z t"4!'.']TFILLFIT I ON. Z C:EI:;.':T I I:::"T' 'I"HFIT '1: I FIM FRMILIFIR 14ITH THE REQUIREI',IEI'.,ITS FOR E~i'.~-.-SITE SEt.,.IERS Fff.,t[:, HELLS RS SET FORTH B'.¢ THE MUIqZCIF'RL. IT'T' OF RNCFIORFIGE. ;;:i:: I t,.tILL. Ii'.,tSTFiLL TFIE S"r'STEM IN FICCOR[:,FINCE( 1.4ITH THE CO[:,ES. }'.::: I UNDERSTRN[:, THFI'f' THE Oi'.,I-SITE SE!-,.IER S'T'STEM MR"/ RFC!Ii IRE EI'.,IL.I:::IIq?.GEMEI",IT IF THE RES I [.',EI'.,IE:E I S REMO[:,ELEI} TEl I NC[,.UDE MORE TPIFIN 4 BEf.':,ROOM'.:;;. '.:~; I E~iI'.,IEE:,: RPF'L I C:FINT r"l. [:,. MC; PhtEI:;..:SON I S::i;I..IED D'¢_ ....................................................................... [:,FITE ........................................ V,':I.. 0 Department MUNICIPALITY OF ANCHORAGE = Health and Environmenta2 'rotection 825 ~ Street, Anchorage, AK. 99501 264-4720 j~ --~ * * * HANDWRITTEN PERMIT * * * L~/~/~, ~ I.~ WELL AND/OR ON-SITE SEWER PERMIT Applicant: _.~ ~ ff~~ Mailing Address: ~/ Location: ~L~>..~L/~ ~ ~"~ Phone Number: c~ ~< Legal Description: /- ~/~ ~ ~L~O?~ ?~ Lot Size: Type of Soil Absorption System Is: Trench: £/ Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: ~. Soil Rating(sq.ft/br) DEPTH The Required Size of the Soil Absorption System Is: "~/ LENGTH c//~_~ 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 minimuza depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(~) 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 for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this 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 8 1 * * * I certify that: (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 require enlargement if the residence is remodeled to include more that ~.bedrooms. ~ Signed: /</,~,~':////~,~,.~ ~,~----' ]issued by: '~ ~~,'~/~ Date:_ SWP/024(1/81) SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 90501 264-4720 SOILS LOG - PERCOLATION TEST 1 5 1 2 13 15 16 17 18 19 20 COMMENTS PERFORMED [] PERCOLATION TEST SLOPE SITE PLAN WAS GROUND WATER S ENCOUNTERED? ',~/~'- L O P E IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop ~COLATION RATE (minutes/inch) RUN BETWEEN FT AND -- FT CERTIFIED BY: 72-008 (6/79) 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 Parcel I.D. 015-161-24 1. GENERAL INFORMATION Complete legal description COSA # O ExPiration Date: KASILOF HILLS BLOCK 2, LOT 6 Location (site address) 10900 GLAZANOF DRIVE, ANCHORAGE, AK 99507 Current Property owner(s) TONY & SHEILA HILLEGEIST Day phone Mailing address 10900 GLAZANOF DRIVE, ANCHORAGE, AK 99507 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address = Unless otherwise requested, COSA will be held by DSD for pickup. NUMBER OF BEDROOMS: TYPE OF wATER suPPLY,:~ Individual Well ' ' ::), [] Individual Water Storage [] Community 'ClasS· Well [] Public Water.System . [] 4 TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding Tank Community On-site Public Sewer The Municipality of Anchorage Development Services Department (DSD) issues Certificates of 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 tiles and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3792 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deticiencies or discrepancies exist. bedrooms. DSD SIGNATURE ~x' Approved for q DisapProved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: -//- // 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: KASILOF HILLS BLOCK 2, LOT 6 Parcel ID: 015-161-24 A. WELL DATA Well type PRIVATE IfA, B, or C provide PWSID # Date completed 4/20/1981 Sanitary seal (Y/N) Y Total depth 285 ft. 34 f. Date of test Cased to FROM WELL LOG Static water level 29 ft. g.p.m. Well production 4.0 WATER SAMPLE RESULTS' 5;,// Coliform NEG colonies/100mL Nitrate 5.41 Arsenic: ND .mg/I Date of sample: 1.0/27/2010 B. SEPTIC/HOLDING TANK DATA Well Log (Y/N) X Wires properly protected (Y/N) Y Casing height (above ground) 24 in. AT INSPECTION 10/27/2010 33 ft. 3,7 g.p.m. mg/L Collected by: AtcTe. rta Tank Type/Material Septic/Steel Date installed 5/1-981 Tank size 1250 gal. Number of Compartments _2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) __N High water alarm (Y/N) N Date of pumping 1_0/27/10 Pumper McDonalds C. ABSORPTION FIELD DATA Date installed 5/1981 S0il rating (g.p.d./ft2 or ft2/bdrm) _12,5 System type Trench Length 5__~2 ff. Width 3 ff. Gravel below pipe 6__ft. Total depth ..10.1 ff. (Measured 10/27/10) Eft. absorption area 624 ft2 Monitoring tube Y Depression over field N Date of adequacy test '10/27/10 Results (Pass/Fail) .Pass For 4 bedrooms ' Fluid depth in absorption field before test 60 in. Water added 750 gal. New depth 71 in. Elapsed Time: .137,5 min. Final fluid depth 60 in. Absorption rate >= .600 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N__lf yes, give date --- D= LIFT STA'flON Date installed "Pump on" level at ~ Datum in. E. SEPARATION DISTANCES SiZe in gallons "Pump off" level at ~ Cycles tested in. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station .on lot 1_00'+ Absorption field on lot 1_00'+ Public sewer main 75'+ Sewer/septic service line 2.5'+ Animal containment areas 50'+ 100'+ Manhole/Access (Y/N) High water alarm level at in. Meets alarm & circuit requirements? I certify that I have datelined thmu h field ins ~ions and ' ::'~' '~~=': review of Municipal reco~s ~at the above systems are in confo~n~ with MOA COSA guidelines in effe~ on this date. ~:~~ Engineer s P~nted Name KE~ETH M. D~US :,~~: Date 1/20/2~1 ~ ~- t~t / , '::~~~:~~:" COSA Fee $490.00 Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Absorption field 5'+ Surface water 1_00'+ Water main 1_0'+ Driveway, parking/vehicle storage 1_0'+ Wells on adjacent lots lO0'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: BUilding foundation 5% Property line 5'+ Water main 1_0'+ Water service line 1_0'+ Wells on adjacent lots 1_00'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 1_0'+ Building foundation 10'+ Water Service line 1_0'+ Surface water 1_00'+ Curtain drain 50'+ (None Known) COMMENTS On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank 1-00'+ Manure/animal excrete storage areas SGS Ref.# 1113619001 Client Name ArcTerra Engineering and Surveying Printed Date/Time 08/08/2011 16:23 Project Name/# KasilofHills B2 L6 Collected Date/Time 08/04/2011 12:00 Client Sample ID KasilofHills B2 L6 Received Date/Time 08/04/2011 12:34 Matrix Drinking Water Technical Director Stephen C. Ede Sample Remarks: Allowable Prep Analysis parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 08/04/11 08/05/11 NRB Waters Department Total Nitrate/Nitrite-N 5.11 0.100 mg/L SM20 4500NO3-F B (<10) 08/04/11 AYC Microbiology Laboratory E. Coli Negative 1 100mL SM20 9223B A 08/04/11 DLC Total Coliform Negative 1 100mL SM20 9223B A 08/04/11 DLC ARc TERRA CONSULTING~ INC 212 E. 51st Ave, Anchorage, AK. 99503 Office (907) 868-3791, Fax (907) 868-3793 August 10, 2011 Municipality of Anchorage Development Services Department On-Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: OSCl11015- Kasilof Hills Block 2, Lot 6 Attached are the results of new water sampling completed on August 4, 2011 for the referenced property. Please re-issue the COSA which expired on 4/26/11,. If you have any questions, please contact me at 868-3791/FAX 868-3793. Respectfully submitted, ArcTerra Consulting, Inc. Kenneth M. Duffus,~. Attachments: SGS Laboratory Analysis Report Updated COSA Checklist 20441 PTARMIGAN BLVD · EAGLE RIVER, AK 99577-8736 ° PH (907) 868-3791 ° FAX (907) 868-3793 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 DVVELLING Parcel I.D. 015-161-24 1. GENERAL INFORMATION Complete legal description COSA# (~'~--.. il Expiration Date: J'~ - ~ ~ - /// KASILOF HILLS BLOCK 2, LOT 6 Location (site address) 10900 GLAZANOF DRIVE, ANCHORAGE, AK 99507 Current Property owner(s) TONY & SHEILA HILLEGEIST Day phone Mailing address 10900 GLAZANOF DRIVE, ANCHORAGE, AK 99507 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. NUMBEROF BEDROOMS: 4 3. TYPE, OF WATER sUPPLY: 16diVidual Well [] Individual Water Storage [] Community Class Well [] Public Water SyStem TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding Tank Community On-site Public Sewer The Municipality of Anchorage Development Services Department (DSD) issues Ce~i_~a_tes_oLOn-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 vedfy 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. DSD SIGNATURE ~ Approved for ~ Disapproved. Conditional approval for Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3792 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 01/20/2011 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the COndition of the well and septic applies only to the cOnditions as of the day tested. The flow and absorption rates may change due to subSurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being sewed by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future . ~.~-"C.~:';.. occupants or canArcTerra guarantee that no unseen ..'-".:. ~--' i~~.,!i-.:~ encroachments, deficiencies or discrepancies exist. bedrooms. '" ':~'~ ~~:.:;:~ ': bedrooms, with the following stipulations: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory X~' ..... ON-,SITE WATER AND : STEWAT : : Arsenic Advisow "~' ~ ~' ' Maintenance Ag~oements Supplomontal fincnoor's Ropo~ Othor Original Certificate Date: 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: I(AS]"LOF I-II'LLS BLO~ 2, LOT 6 WELL DATA Well type PRIV'AT]~ IfA, B, or C provide PWSID # Date completed 4/20/1981_ Sanitary seal (Y/N) Y__ Total depth 285 lt. Cased to 34 lt. __ mg/L FROM WELL LOG Date of test 4/21/1981 Static water level 29 lt. Well production 4.0 g.p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/100mL Nitrate Arsenic: ND .mg/I Date of sample: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed Parcel ID: 015-161-24 Well Log (Y/N) _Y Wires properlY protected (Y/N) Y Casing height (above ground) 24 in. AT INSPECTION 10/27/2010 33 ff. 3.7 g.p.m. Collected by:. ArcTerra Tank size 1250 gal. Number of Compartments _2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) __N High water alarm (Y/N) N Date of pumping :10/27/:10 Pumper McDona]ds C. ABSORPTION FIELD DATA Date installed 5/:1981 S0il rating (g.p.d./ff2 or ft2/bdrm) :125 System type Tzeach Length 5:2 ft. Width --3 ft. Gravel below pipe 6__6_ft. Total depth 10.:1 ft. (Measured 10/27/10) Eft. absorption area 624 ft2 Monitoring tube Y Depression over field N Date of adequacy test *:t0/27/10 Results (Pass/Fail) :Pass For 4 bedrooms Fluid depth in absorption field before test 60 in. Water added ~80 gal. New depth ~1 in. Elapsed Time: 1375 min. Final fluid depth 60 in. Absorption rate >= 600 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N_?yes, give date -_:- UFT STATION Date installed 'Pump on' level at Datum in. E. SEPARATION DISTANCES Size in gallons "Pump off' level at Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/li~ station on lot 100'+ Absorption field on lot 100'+ Public sewer main 75'+ Sewer/septic service line 25,+ Animal containment areas 50'+ in. Manhole/Access (Y/N) High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank I00'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5% Property line $'+ Water main 10'+ Water service line Wells on adjacent lots 100'+ Water Service line 10'+ Surface water 100'+ Curtain drain 50'+ (None Knowa) F. COMMENTS 10'+ Absorption field $'+ Surface water 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Driveway, parking/Vehicle storage. 10'+ Wells on adjacent lots 100'+ Field is operating in the top 16% of the effective depth~the top 1: G. ENGINEER'S CERTIFICATION .~~ I celfify that, have determined through field i.s~io.s a.d rev~w of Mun~i~l re~ ~at ~e above systems are in ~n~an~ w~ MOA COSA gui~l~s in effe~ on ~is date. Engineers P~nted Name KE~E~ M. D~S Date ~/20/2~1 COSA Fee $490.00 Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage 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 Nitrate Advisory Certificate of On-Site Systems Approval # 111015 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 2, Lot 6 of Kasilof Hills subdivision. This inspection revealed a nitrate concentration of 5.41 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. SGS Ref.# 1105804001 Client Name ArcTerra Engineering and Surveying Printed Date/Time 11/05/2010 8:15 Project Name/# KasilofHills B2, L6 Collected Date/Time 10/27/2010 16:30 Client Sample ID Kasilof Hills B2, L6 Received Date/Time 10/28/2010 9:10 Matrix Drinking Water Technical Director Stevhen C. Ede Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 10/29/10 11/01/10 KDC Waters Department Total Nitrate/Nitrite-N 5.41 0.100 mg/L SM20 4500NO3-F B (<I0) 10/29/10 AYC Microbiology Laboratory E. Coli Negative I 100mL SM20 9223B A 10/28/10 DLC Total Coliform Negative 1 100mL SM20 9223B A 10/28/10 DLC 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 Parcel I.D, # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1, GENERAL INFORMATION Complete legal description Kasiloff Hills, Lot 6, Block 2 Location (site address or directions) 10900 Glazonof Drive, Anchorage Property owner HUD Day phone 271-4342 Mailing address 222 w. 8th Ave. (Box N-64), Anchorage, AK 99513 Lending agency N/A Mailing address Day phone Agent Sandy Hjelmsted/Associated Brokers Day phone 563-3333 Address 640 w. 36th Avenue, Suite 1, Anchorage, AK 99503-5807 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well x Community well Public water NOTE: · If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATF. R DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: X 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 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/orwastewaterdisposalsystem 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. NameofFirm Eagle River Engineering Services Phone 694-5195 Address P.O. Box 773294, Eagle River, AK 99577 Engineer's signature Date DHHS SIGNATURE ~/// ~ Approved for .. Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date 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. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /~45/l.0~7~ ~~lC&S, LOT' ~ ~ ZCl./d ~ Parcel I.D. A. WELL DATA Well type Log present (Y/N) ?f./5 Total depth ~ ~.,K Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Cased to ~' -¢.d Date completed ¢///~' ¢/o¢ / Driller '--~'¢/ ~ Casing height Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level k/,'V~'/L/~/~'-/'/ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /¢7~¢ Absorption field on lot //~' Public sewer main A////) I;Zu-btie'sewer service line ~¢ ~ g.p.m. AT INSPECTION ¢' /'-~ g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~:~ Nitrate Date of sample: c'~//~2 ¢/~ ~-- Collected by: Other bacteria B. SEPTIC/H4~L-DtNG TANK DATA Date installed 05/~"/ / Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size /~ -~¢ Cornpartments ~-- Foundation cleanout (Y/N) ~/~S Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /¢ ~ ' To property line ~ 2- Surface water/drainage On adjacent lots Absorption field / Foundation Water main/service line ¢ /0 / 72-026 (Rev, 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer /~'" Size in gallons Manhole/N) Vent (Y/N) "Pump on" level at ~ "Pump off" level at H gh water alarm level ~ Meets MOA electrical codes..(.Y~' ~//~ Cycles tested SEPARATION AS'T~NCE FROM LIFT STATION TO: W~_~D~j On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length ~ ~ Total absorption area Depression over field (Y/N) Results (pass/fail) Width /40 Peroxide treatment (past 12 months) (Y/N) Soil rating /~-5 ¢/z¢/¢ System type Gravel thickness ~ ' Total depth Cleanouts present (Y/N) Date of adequacy test ¢~/~1/ %~//¢E ~¢~ T for ~ bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot // To building foundation On adjacent lots Surface water Curtain drain /-/0/'/~, On adjacent lots ¢¢/~ (~ / Property line /¢ / To existing or abandoned system on lot Cutbank /d//¢ Water main/service line / ¢ /~/ Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Engineer's Name Date HAAFee$ /TD Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number Louis Butera, P.E. Registered Civil Engineer February 12, 1992 Robbie Robinson Municipality of Anchorage Dept. of Health & Human Services 825 L Street Anchorage, AK 999502 Re: Kasilof Hills, Lot 6, Block 2 Dear Mr. Robinson: We researched the concerns you expressed in your telephone call of February 10, 1992, and our results are as follows: Notes from the MOA inspector at installation show that the absorption field is 5' from the lot line. There is an asbuilt by Kenneth G. Land, L.S., which is enclosed, that shows the separation distance to end monitor as 10'; all data sheets subsequent to the inspector's notes state the distance as 10'. I wonld tend to rely on the accuracy of the registered survey versus original inspection report. The total depth was noted on our data sheet using measurements obtained by probing the existing monitor tube depth. We have no way of knowing if this monitor tube was installed correctly, modified at a subsequent date, partially filled with rocks, or if earth cover was removed from the field location. Therefore, our depth of field may not be the actual depth of the field. The original engineer who approved the installation obviously felt the system was installed in the correct layer, and our adequacy test shows the system is absorbing adequately. If you would like, I can change the data sheet to reflect the permit depth of field of 14' and so note that on the report. Identical data was presented with our application for Health Authority Approval of July 16, 1991 which was approved July 29, 1991. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. P.O. Box 773294 · Eagle River. Alaska 99577 · Telephone (907) 694-5195 · F~ (907) 694-3297 PLOT PLAN ,, AS BUILT _ X GRID SCALE I H~r~b? certify that I have surwycd the/ollowin~( d~scrib~d property: 'i :' ~tqc HO~--~,(-~ R~cordin~ Di~trict~ Ala~ka~ and that t~ tmpr~v~mlnt~ ~ituat~d thereon witAin tht p~rty lln~s and t~ not ~ncroach onto tk~ prop~ty adjQc~nt th~ret% that no improvements on the property lying udjucent thereto ~ncroach on th~ surveyed pr~mis¢.s ~nd ' that thert ar~ no roadways, transmission lin~s or other vis/bh ~os~m~nts on said property lx~pt ~s indt~t~d hereon. D ' '[ ~ It is tht rt~ponsibilit7 of th~ owner to d~t~rmine th~ ~xist~nc~ el an~ easements, or r~strictio~ which do not appear on th~ r~cordtd subdividon plat. JOB 1731 George Bell Circle AnchoracJ% Alaska 9961.5 (90?) 345-6476 ....... · ~-EB 07 '92 08:03 HORTHERH TESTIHG, F~HCHORRGE ~agl P.o. 8agl~ Attn Our Loca Your Samp Co~ Meth~ EPA Hicrc P. River Enginaering Box 773294 River AK 99577 Louia Butera ab #~ ion/Project= Sample ID: e Matrix~ NORTHERN TESTING LABORATORIES, INC:. 3330 INDUSTP, IAL AVENUE .~AIREANK~, ALASKA ~g701 2505 FAIRBANKS STREET ANCHORAGe, ALASKA 9~§03 4~6-3HB. FA~ 4~6-312~ 277-83'/8 '. FAX 274-9645 Repot[ Date: 02/07/92 Date Arrive~t 0~/31/92; Date sampled: 01/29/92 Tim~ Sampled~ 0900 Al16115 Kasiloff Hills Water MDL = Method Detection, Limit Flag De~initions B = BelOw Regulatory Mkn. H ~ Above Regulatory M~x. cstima~e~ Value Uni~ Reeu~ ~].ag MDL .Ana~y~ed ~d Parameter · 00 0 Nitrate-N mg/1 <MD~ 0.5 biology Supervisor 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 ' Parcel I.D, # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Kasilof~ Hills, Lot 6 Block 2 /10900 Glazonof Drive, Amchorage Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone 2~1-4342 222 W. 8th Avenue (Box N-64), Anchorage, AK 99513 N/A Day phone Sandy Hjel~ted/Assoclated Brokers Day phone 563-3333 640 w. 36th Avenue, Suite 1, Anchorage, A~ 99503-580? Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well X Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 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 MOACf21 'NJOM s,Jeeu!Sue I~uo!ssejoJd eq~ u! suo.ss!uJo Jo sJoJJe Joj elq!suodseJ Jou s! eBBJoqouv Jo /q!l~d!o.unv~ eq/ 'penss! s! el~o!i!lUeO ~ eJoieq ~1~p ez/,iBu~ Jo suo!~oedsu! ~,onpuoo lou op SHHa jo seeXolduJ~ 's~.ueLueJ!nbeJ e1~ls pu~ I~Jepej uJB~eo/u,s!j~s olJapJo u! suon, nl.1su. 8u.puel J!eq~, pu~ SaLUOq JO sJes~qoJnd o~, Xse~Jnoo e s~ sJql seop BI-iNa eq/'~lS~lV ~o e~,~l~ eql u~ peJels~BeJ Jeeu~Sue IBUO~SSe~oJd luepuedepu! u~ Xq e^oq~ g qd~JB~Jed u! ua^!6 suo!l~,ueseJdej eq~ uodn Xluo pesBq sel~o!J!~eO I~^oJddv /qpoqmv q~l~eH senss! (SHHCi) seo!AJeS UBLUnH pU~ qil~eN ~o JueLu~J~dec] el~Joqou¥ Jo/qll~d.o!un~ eq.L s;uewwoo leUOp,!pp¥ :suo!~elnd.~s 8U!MOllOb eq; q~!M 'SLUooJpeq Job le^oJdde leUOp,!puoo ~ 'SLUOOJpeq 'pe^oJddesjQ Jo, peAoJddv ~ ~ll:lnJ.~'Ngl$ SHHa ~~ eJn;eu6!s s2eeuil~u3 '9 LLS66 )t~ '~eA.-[;~ @I.6g.,gr '~'6~ELL xo8 'O'cI sseJpp¥ S6 LS-ff69 euoqd sa~p~_~eS 6uT~eeUTbU2 .teATbi et~6e2 LUjL-I bo eLueN 'uo!;oedsu! siq~ to e;ep eq; uo ;oebte u! suop, eln§ej pue 'seoueu!pJo 'sepoo eIelS pue led!o!unlAl lie q~,!M eoueildLuoo u! s! me;sAs leSods~p ~e;eMe;SeM ~o/pue Alddns ~eieM e;!s-uo eq; 'uo!loedsu! pue uoileB!;se^u! ALU LUOJ¢ pue Selib eBeJoqouv LUo~b peulelqo uop, eLUJo~u! eql uo peseq hell; Ab!Je^ ~equnb I 'uleJeq peleo!pu! e~nlonJ;s ¢o edam, pue sLUooJpeq jo ~eqLUnu eli; JOb elenbepe pue leuo!lounb 'ebes s! LUelsAs lesods!p JeleMe;seM Jo/pue Alddns Je;eM el!s-uo eq; leql SMOqS uo!;eO!ldde le^oJddv Alpoq;nv q;leeH siq), bo uo!;eB.;se^u! ALU ;eLi; AbpeA I 'MOleq UMOqs mep uo!lep!le^ eq; ¢o se pue oleJeq IJ::I::INI~DN:~ A8 NOIJ. O:IdSNI -I0 /N~I61::IJ.V'.L$ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST If A, B, or C, attach ADEC letter. ADEC water system number ,4,,/'.,~ Date completed ~'/~,/~/ Driller /¢~¢',~.-~ ,-~'¢,'¢-~.. / Casedto ?'-/ Casing height ~r /~ Wires properly protected (Y/N) ,?' Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG AT INSPECTION "2'~ / ~ g.p.m. -t-/, ¢. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ,,"¢ ,¢- / Absorption field on lot //¢'- / Public sewer main ~v/,,~ ,'r~ub~ sewer service line ¢sr'~ ' ,g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout /'//"/ Petroleum tank ,'"'"-'~ WATER SAMPLE RESULTS: Coliform Date of sample: B, SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) ,,v High water alarm (Y/N) Date of pumping Nitrate Collected by: Other bacteria _,,,~' Tank size /.~..r-o ~" Compartments Foundation cleanout (Y/N) .,v- Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /~s' To property line Surface water/drainage On adjacent lots /-,'¢ / Absorption field /5'" Foundation /Y ' Water main/service line v-,,,~-' 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length Width 2'" Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (/~) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot //5- / To building foundation On adjacent lots Surface water Curtain drain /""~¢ Soil rating /""~-¢~'~,'~ System type 2'-r~,¢4 Gravel thickness __~" Total depth Cleanouts present (Y/N) ,~ Date of adequacy test ~J~JN~' for bedrooms If yes, give date On adjacent lots '¢'"""'¢ / Property line ~'5- / To existing or abandoned system on lot Cutbank '~,/-'~ Water main/service line. Driveway, parking/vehicle storage area ~'¢,* E. ENGINEER'S CERTIFICATION Signature ~~' Engineer's Name .Z.,....:,- /'~.~ ~ ..-,,, Date. ~.///' ~/~,' I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on .thedate of this inspection· ~ '; ,'%, .. :'", ...... ' · ', %. HAA Fee $ j/'7(/~, ~0 Waiver Fee: $ Date of Payment ¢' //~"- ¢/ Date of Payment Receipt Number ..~_..~..?~-'~ ~' ('' ~¢~'~ ') Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANALYSIS REPORT BY SAMPLE for ~ORKo[der! 35974 Date Report Printed: JUL 10 91 ~ 09:04 Client Sample ID:~SILOFF HILLS 6/2 PWSID :UA Collected JUL 8 91 ~ 16:00 hrs. Received JUL 8 9i @ 16:45 b_rs. Preserved with :AS REQUIRED Client Name :EAGLE RIVER ENGINEERING Client Acct :EAGLERP BPO { PO ! NONE RECEIVED Req ! Ordered By :LOU BOIERA Analyste Completed :JUL 9 91 Laboratory Supe~Lso~EPHEN C. EDE Roleaeed By : ~~x'~.~ Send Reports to: 1)EAGLE RIVER ENGINEERING Chemlab Bef l: 913243 Lab Smpl ID: I Matrix: ~ATER Allowable Parameter To*ted Result Units Method Li~ita NITRATE-N 2.6 ~/1 EPA 353.2 10 ROUTINE SABLE COLLECTED BY: 1 Teats Performed ' See Special Instructions Above DA-Unavailable ND- None Detected "See Sample Remarka Above NA- Not Analyzed LT-Leae Ihan, Gl-Greater Ihan Member of the SGS Group (Soci~t~ G6n6rale de Surveilla.ce) A Eagle ltiver l~ngineering Services 11940 Business Blvd, Suite #205 'P.O, Box 773294 Eagle River, Ak, 99577 694--5195 Fox 694-3297 Owner: //~/0 ,//'2 .r / /-'/:-- Date: Type of test: U Well Flow Test El Septic '[esl Only ~ Well & Septic }est O] Other', Meter Monitor Well Time Reading Level Level Level GPM PSI Remarks o°5-76 MUNICIPALITY OF ANCHORAGE" DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 (a) Legal Description (include lot, block, subdivision, section, townshipf range) (¢) Location (address or directions) Applicant Name }~ ~--~ / Applicant Address t c~c~ t'gr~ J~C~Telephone: Home ' '~df~,, ~ Business . . · J Applicant is (check one): Lending Institution []; Owner/builder/~; Buyer []; Other [] (explain); (d) Lendinglnstitution ~:~t'~'¢"'¢ ~ I~~ Telephone Address (e) Real Estate Company and Agent .~c_~ . ' AdOress Telephone (f) Mail the HAA to the following address: S & S ENGINEERING 5R B 196X F-AGI-E-EIrVER~ Al( 99577 2. TYPE OF RESIDENCE Single-Family ~' Multi-Family [] Number of Bedrooms 3.: WATER SUPPLY : . Individual Well,~ Community [] Other Pul~lic [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 41 SEWAGE DISPOSAL ,:, 'Onsite¢ PublicF1 Community[] Holding:Tank["]. ~ i :i : ; "i :;i i Note: If community Well system, must have written confirmation from the State Department of Enviror~mental Conservation attesting to the legality and status. ... ~ 72-025 (11/84) Page 1 of 2 5. ENGINEERING FIRMPROVIDIN ,NSPECTIONS, TESTS, FILE SEARCH, DA..ANDINFORMATION ' ~'.!~ As certified by my seal affixed hereto and as of the validation date shown below, I verify that myipvestigation 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. [ 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 Telephone ,JUL '7 1986, the date of this inspection· Name of Firm S & $ ENGINEEEIN6 SE B 196X Address --'EAGEER1VI~R, AK 99577 ' Date DHEP APPROVAL Approved for Approved bedrooms by ~ Disapproved Conditional Terms of Conditional Approval Date CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations g~ven in paragraph 5 above ey an ndependent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the · 72-g25 (11/84) ' '" ' WELL DATA Well Classification Well Log Presentd~/N) Total Depth ~'Z~'5'-' Static Water Level MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: L~-~,.t- Cased to Casing Height Above Ground Electrical Wiring in Conduit(Ci~/N) Separation Distances from Well: To Septic/H~Idln§; Tank on Lot If A, B, C, D.E.C. Approved (Y/N) Date Completed ~'"~¢¢' - ~¢ ~ Yield ~_.-- Depth of Grouting Pump Set At Sanitary Seal on Casing~L'~N) Depression Around Wellhead (Y/~[~ ; On Adjoining Lots To Nearest Edge of Absorption. Field one3/_;t I~o ~ ~ ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cieanout/Manhole ~/~' To Nearest Sewer Service Line on Lot Water Sample Collected by ~ ~ ~ '~__.¢0~=~ i,,JClE4...-f,,,J/4 ; Date '~-~ ~'~ Water Sample Test Results %/t~'/~r,.,¢,cd~.!;~-.~ Comments X~J¢~..~..- k/, ~ ~-1...~ ~ %tJ,.-~v,Jd~ o,~.~ (_~f-~'..~ ~ B. SEPTIC/Hg-I.D,,'NG TANK DATA ~'-/Z.-'6 ,/ Size ('7....~'-'~ No. of Compartments Foundation Cleanout(~N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) Date Installed Standpipes C/N) Air-tight Caps(~N) Depression over Tank Pumping/Maintenance Contract on File (Y/~.~ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Pt~idh:? Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course To Building Foundation ~ ~ ~ To Disposal Field ~' ~}' ! To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field .Square Feet of Absorption Area f.~'Z~ Depression over Field (y,~ Results 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 Type of System Design Length of Field Depth of Field _ Gravel bed Thickness Standpipes PresentdC~/N) Date of Last Adequacy Test ! To Property Line / To Existing or Abandoned System on ; On Adjoining Lots To/Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions /~ ~anhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) 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 M CA and HAA guidelines in effect on the date of this inspection. SignedS gt S ENGINEERING Date JUL 7 1986 SRB 196X c°mp~'GLE RIVER, AK 99577 Receipt No. %of Date of Payment Amount: $ MOA No. c~-5- ~:2~O-->¢ Page 2 of 2 72*026 (11/84) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONYLEN]~L HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR ttEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot:, block, subdivision, section, township, range) (b) Location (address or directions) Applicants Name~ Id' d~" ~'/°/~6'~Zz2Tele ~hone ~"~ ._~:-../~.ZS~_ .... ~ - Home Business (c) Applicants Address ~.~_~_~/>'t~ :~,z/-,,~ gAf/Lpg: --" .;./d'zz ,'~K~':~/ 5"' ~ Applicant is (check one) Lending Institution [J~Z[ ; ~ner/bui!der ~'~ · (e) Real Estate Co, & Agent Address (f) Telephone Mail the HAA to the following address: ~L~~'' z'z- K'?--~': :__~-~:.~_~__~:x%~:<.~.,~Z ~.-7 2..T~yy~e of Residence Single-Family ._~: Number of Bedrooms Indiv:[dual Well Multi-Family Other (describe) Note: If community well system, ~nust have written confirmation from the State Department of Environmental Conservatio~ attesting to the legality and status° 4..S_e wa ~_e__D._i s~ o__sL~ 1- Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legnlity and status. [Page 1 of 2] 5. E~ineering Firm Providing In_. sj~.ctionsz Tests, File Searcrh_,_Jjata 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 structnre indicated herein. I fnrther 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 ~stewater disposal system is in cempliance with ali. Municipal and State codes, ordinances, and regula-~ tions in effect: on the date of this inspection. Name of Firm (ENGINEER DIIEP ~.A~j)r ov al Approved for '7~.~.~.~ ~i~ ~_uz_ bedrooms Approved ..~-'" Disapproved Terms of Conditional Approval CAUTION THE ~FO'NI(,IPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENV].RO~;~ENFALV ' ' PROTECTION (DHEP) ISSUES HF~ALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGILAPIt 5 ABOVE BY AN INDEPENDENT PROF[",S,~O~q~ ENGINEER REGISTERED IN TttE STATE OF ALASKA. THE DHEP DOES Tills AS A COURTESY TO PURCIIASERS OF IlOMES A>ID THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAl, AND STATE REQUIRf?- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. TIlE MUNICIPALITY OF ANCI1ORAGE IS NOT RESPONSIBLE !fOR ERRORS OR OMISSIONS IN TIlE PROFESSIONAL ENGINEER'S WORK° (DHEP SEAL) RR4/ej/D1.8 [Page 2 of 2] 7-19~84 ae WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Well Classification fA/DA/,~ Well Log P~esent (Y/N) Total Depth ~_~.~ ' Cased to Static Water Level ~ ' Casing Height Above Ground 2-~-c~ Electrical Wiring in Conduit (Y/N) Separation Distances f~om Well: To Septic/Holding Tank on Lot NoI.I.9~ J.O~]d 1VIN-]~NO~IAN5 ,~ HLqWH JO 'ida(] Legal Description iiOV~..~:qV~,~© If A, B, ~ C, D.E.C. Approved(Y/N) ~ Date Co~leted A~,~ ~o.,~ Yield Z~f ~pth of Grouting~ .~/~ Pu~ ~t At ~ ~ Sanit~y ~al on Casing (Y~) ~ession ~ound ~llhead ~Y~) -; On Adjoining Lots ~ I To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line ./~ /~-\ To Nearest Public Sewer Cleanout/Manhole Water Sample Collected By Water Sample Test Results To Nearest Sewer Service Lir~ on Lot ;Date Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~- I Z -- ~5! Size /g~-O ~-~- No. of Co,~a~tments Standpipes (Y/N) '~_ f; Air-tight Caps (Y/N) \/~'~ Foundation Cleanout (Y/N) Depression over Tank (Y/N) ~%)0 Date Last Pumped /k~//% / Pumping/Maintenance Contract on File (Y/N)~J//4 ; for_ Holding Tank High-Wate~ Alarm !Y/N) ~J//~ Temporary Holding Tank Permit .(Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply We 11 I (~ i To Property Line To Water Main/Service Line Course ~/a.' /' To Building Fc~]ndation 2_~! To Disposal Field i~ ! To Stream, Pond, Lake, or Major Drainage Receipt ~ Date Paid: Amount: %~ ~:~, [Page 1 of 2] 2-15-84 C. ABsoRPTIoN FIELD DATA Soils Rating in Absorption Strata Date Installed ~-~/2'-~/ Width of Field ~ /n/£,~-s / Square Feet of Absorption Area ~4 Depression over Field (Y/N) ~O Results of last Adequacy Test /Jz/~ /./~-- Type of System Design Length of Field _ ~_ / Depth of Field /4- / Gravel Bed Thickness ~ Standpipes Present (Y/N) Date of Last Adequacy Test Separation Distance from Absorption Field: TO ~t~ter-Supply Well . ..I Z ~.~ To Property Line To Building Foundation ~; To Existing or Abandoned System cn Lot ~J/~. ; On Adjoining Lots??__~/ To Water Main/Service Line ~/~ To Cutbank(if present) To Stream/Pond/Lake/or Major Drainage C.ourse To Driveway, Parking Area, or Vehicle Storage Area > ~--~ / Comments LIFT ST TIO ,43©7- Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Cor[¢~m nts Check Permitted Bedroom Rating Against HAA Request I certify that I have checked, verified, or conformed to on the date of this i~i~. Signed ~~-/~~ Date Co, any ~5~ ~ ~ ~J /~ MOA No. KB1/dS/s nes in effect [Page 2 of 2]