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HomeMy WebLinkAboutKIMPTON LT 5Onsite File Kimpton Lot 5 #051-072-68 (RtlV VD/VL/ l of Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201446 PID Number: 051-072-68 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name ANDREW STANLEY KMAK ABSORPTION FIELD - EXISTING ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 21624 OBERG ROAD, CHUGIAK ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot KIMPTON 5 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area z Number of trenches Dist. between trenches From Tank Field Tank Line Ft Ft. Well 100'+ -- 25'+ TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal. Surface Water 100'+ -- Material HDPE Number of compartments 2 Lot Line 10'+ __ NA Foundation 10'+ __ LIFT STATION Manufacturer Capacity Gal. Remarks Tank insulated. Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Installer JRS Drainfield CO/MT 3034. Inspector FWC BENCH MARK (Assumed elevation) 100 ft Inspdection 1s` 11/20/20 11/21/20 Location and description god 3'd 4th BOTTOM OF SIDING ON-SITE WATER AND WASTEWATER SECTION APPROVAL ---\>>l A �� Conditional Approval: Date ' •:tp • Curtis Septic System Approv es , Huffman . %, �'Fc • , Date l ' 30 -Zo CE 128991 . i�TF • . 11/21/20;Q-�n lk;- OPROFESSIO0�•��'�' Note: this approval does not include well permit requirements. (RtlV VD/VL/ l of PID: 051-072-68 PERMIT: OSP201446 35.4' `r i• WELL N N .3' 0 28.0' PAVED oi SH D D/W Y W X U (/) LxJ o z o o 1CD � o XO Q w 00 i— O LOT 5 o m w CO O co ry STAKED WELL RADIUS A 6 W PRIOR TO CONST. FCO cv z m o O ry INSTALLED NEW 1000 -GAL HDPE C 0 MH cC) LIJ ® SEPTIC TANK p • CO m WITH DCO. Co E DCO N II N CO O EXISTING FlELD _ SCALEt 1' = 30Q ® 11r) m A -C=33.9' B -C=20,6' A -D=37,0' B -D=25.3' A -E=39.7' B -E=29.3' SEPTIC SECTION SCALEt NTS KIMPTON LOT 5 PREPARED FOR: ANDREW KMAK 21624 OBERG ROAD CHUGIAK, AK 99567 FIRST WATER CONSULTING 13030 SUES WAY ANCHORAGE, AK 99516 907-350-9566 firstwaterAK@gmail.com SUPPORT®SERVICE q • DATE: 11/23/20 SURVEY: JLS DRAWN: FWCS SCALE: 1" = 30' Jdm� OF ALS * 9 TH * rtis Huffman wx CE 128991 11 /23/202(�ics N Dnsslovlp AV MUNICIPALITY OF ANCHORAGE 01? -Site W r $ WaMewaker Program PO eon 196e 4700 Elmore Rod 1 uichpr , Akski %519-X60 Phone: X907) 343-79U Palls: X907] 34.3-7N7 WNF*W.MUMLOCgkriei6e On -SIM l-act(ewater Dicporal Syotcm Permit Permit Number, O P201446 Work Type: SepticTank Upgradie Tax ode N4lmber: 05107268000 S Lagar Addm8u; KIMPTON LT 5 G:1468 Sita Mailing Address: 21624 08ERG ISD, Chugiak Cwnar: KMAK ANDREW $TArgLEY Desiol n Eng linear: FIRST WATER CONSU LTI NG Th is permit Is for the ocingtmc! don ef: Effective Cater Expiration Date Lot Size in Sq Ft Total B[adroarns W212020 1 U23i2021 52§50 Q Disoosal Field 0 SWIG tank 0 Holding Tank ❑ P6YY D Private Well ❑ 1N01I151r r$gO All nstruell shall be in accon Lance with: 1. The attached approved design, 2. AEI requirerne n tt,specrFed In Anchorage NMunWal code- Chaptare 15. 55 and 15, 65 and the State of Alaalk& W3!5tew@ter CispoSel Regul.800175 (78AAC72) end Drinki-ng Vfater Regulabons (IaMC60) 3. The wastewater code requlraa insP@4*0n!s -durN the installation. The en9i"er :9I1e If notify tlwe DeV8FQpM0Fjt Services Departrrient per AMC 15.65. Provide nutM0300n May calling (907) 343-7904 {24J7�. 4. Fnam October 15 to April 15, s subsurface soil absOr' bn qstem unider oonstructbn d u ring freezi r; g wea th er shall be either_ a, Opened Ond Clawed On the swrre day. ar b. CoVered. sea led, and heated to provem freezing SpecMvl P rOV1111icna: W&ll located in T&E Easement requires letleta of non -objection prior to eqy future COSA approval. ReceNed Sy; -1 I slued By.. 1 Qf22i10 Data: Date- 10 3 13030 Sues Way, Anchorage, AK 99516 907-350 -9566 / firstwaterAK@gmail.com October 20, 2020 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: KIMPTON LOT 5 The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic tank on the above referenced lot. We propose to install a 1000-gallon HDPE tank per the attached design to serve the existing 3-bedroom residence. The lot and area are served by private water, with exception of the lots to the east, which are served by public water. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201446, Rebecca Carroll, 10/23/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201446, Rebecca Carroll, 10/23/20 NON -OBJECTION TO EASEMENT ENCROACHMENT DOCUMENT this document Matanuska Telephone Association, Inc. (MTA) declares that it has no ection to the encroachment of the well within the 10' utility easement located at Lot 5 of npton Subdivision, filed as Plat No. 82-472 in the Anchorage Recording District. ;ase be advised that MTA through the issuance of this document does not forfeit any of its hts to the use of the area cited. In the exercise of these rights MTA will, if needed, upgrade, Lintain, repair, and/or replace buried or aerial telecommunications facilities within the ;ement. Any repairs that may be required to the encroachment as a result of utility istruction will be borne by the property owner of record. This document does not authorize placement of any additional encroachments within the easement area. Property owners are iuired to obtain utility locates before doing any kind of work in the utility easements and will liable for any damages caused by their construction work in the easements. document is in no wav an agreement to vnnate arw --r +i,- „t;l; for Matanuska Telephone Association, Inc. this 9th day of November, 2020 by, Jessica Burnett, Real Estate & Properties Supervisor Matanuska Telephone, Association, Inc. P.O. Box 3550 1 Palmer, Alaska 99645 1 mtasolations.com 1907.761.2510 MUNIL,;IHPd-I I Y UI- ~rqL.,i"lUId~L~l:2 ~ DL ~.RTMENT OF HEALTH AND HUMAN SEE..~;ES ~- Environmental Health Division D ¢ / ~) ''~ ~2. ~:2 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES ", SEPTIC ^ddress ' TANK FIELD WELL ~.o. ~ ~-~-/~s.~.~. /w~-.~-~ , ~,o~ ~~ No o, ~oo~s WELL I ~ / LEGAL DESCRIPTION I Subdiws~on Township, Range, Section AS-BUILT DIAGRAM (Show Iocahon of welt, septic system, property hnes, foundahon, TANKS ~EPTIC ~ ~/~ ~ ~ HOLDING ~anufacturer Capacity ~n gallons . ~ Material NO. of Compadments TYPE OF SYSTEM ~ TRENCH ~ED ~ W. DRAIN ~ OTHER t~ ,/V,~ ~top~pe~got m ,l°taldePthfr°m°rigmalOrade~ ~ ~ ~ ~ ~ t~ Gravd length Gravel w~dth ] Tota~ a~sorptlo~ area I Distance ~et .... Imeg Number of hnes ~ Sod rating ~i G~. ~ 6o,~S~ WELLS//-/~-&~ - i/-/~-~ ,9[r"~'~}~1- ~1~ Il ~IVATE ~./.*/.G~ OTHER,Identify) ~gJ ~ CI--~S~If;C~tlO~'(A.B.C' ]oral Depth J Cased ,o L ~ ~ I FT FT instaJle~ Date Instalted: · , Scale: N ~ EN GI~ E~SEAL ' S & S ENGINEB~ .~n~ ~.le River L~p Road No. 2~ I .... ~ ~r~ ~ask~ ~5~ ~dify ~t Ibis inspection was pedormed according lo all · ,./.~-/~ ~udcipal and~.es i. eflSCt e. Ibis date: . ~ ~ Health Department Approval: Date; ', 72-013 (3/85) i !',rt ¢~( Yi Pt"iilii~II!E; LlEt!.i,~.~i... OIESC;I::;; ;( I::'T 111CIN: L.CI i" t:~i I< I MI='TC!ig Sii!i:C 4 lfi¢.:~X,,tqUMBIET;: O1= ;E~EDROOI'4S: 13 ~SOli.... i::;:¢.~i'ilkiG: ,!;47 S(;;~ I:::'"I"/Bi::;: SCi i I...'I'E%T DE:I:::"I H ',', i O F'r fi. liE; iS ¢.:]i'~l L!F'iSFI~:.~iOi-E ElF t( Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST SEAL) PERFORMED FOR: DATE LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 Township, Range, Section: SLOPE SITE PLAN 10 11 12 13 14- 15 16 17 18 19- 20- WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT DEPTH? p E Depth lo Water After _ ~ Monitoring? ~ Date: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE L/C;> (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN / FT AND ~ FT COMMENTS L~'''~ .'~O/t-.--s c;:,~ ~'~V~"/~--,- A~. ~~ ~ ~1 ~ ~S/~ .............. ~gle River, Alaska ~577 ~ ~ ~/~' /-- ~ 72-008 (Rev. 4/85) MUNICIPALITY OF ANCHORAGE ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT qAME fA/F; PHONE b6~o- Z.Z(~? [] UPGRADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS Well I I Absorption area / , Dwelling DISTANCE TO: ] /(~ ~ I ~"~ Material Manufacturer JLi? ~p3it~n gallonsI IF HOMEMADE: Inside ,:gth _ DISTANCE TO: IWell Manufacturer / I~ Material ~ We . Foundation ; Nearest lot line DISTANCE TO: I No. Of lines I Length of each li~eY/~ Total length of lines Trench width ' I /~ . . Top of tile to finish grade Material beneath tile Length ~ f Width ~ r Dept~ ) / Tv~e of crib Crib diameter Crib depth Well / ~ Buildin~n~n DISTANCE TO: / / O '~ ~/ '~ IClass ~ Depth Driller Distance to lot line DISTANCE TO Building foundation Sewer ne Septic tank inches inches PERMIT NO. No, of compartments Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO, Distance between lines Total effective absorption area Total effective absorption area Nearest lot line PERMIT NO. PERMIT NO. Absorpt on area(s) OTHER PIPE MATERIALS P//'C SOILTEST RATING INSTAELER REMARKS E / /,v ' F__c 5 OWNER OF LAND ADDRESS ~'~ O LEGAL DESCRIPTION DATE- Started .) PERMIT NUMBER SULL AN WATER WELLS P. ofBO~27~-~C, HUGIAK, ALASKA 99567 · TELEPHONE 688-2759 , ~ ~7~0 ,~,d DEPTH OF WELL ~. ~ ~ ~ t ,'~ /C STATIC LEVEL OF WATER I ~ t ~a ~ ~c3 ,.,3 ,)-,d/$ ~ DRAW DOWN FT. Ended '~,/)//f'.~ GA~. PER HR KIND OF C~g~NG KIND OF FORMATION: From O Ft. to .~-. Ft. d) o t.j'~? ~y oa~. ,,;,;c.:- ,,,,d From--Ft. to--Ft. From "~ Ft. to i~ :. Ft '~"~"~,~ t~,~;~?~ Fromm. Ft. to Ft From Ft. to Ft. cZ c ,-~ ~ ~,'t t ~.'E ~ From Ft. to Ft. From t ~ Ft. to ~O Ft ,'~'¢~'~'~'~/'~ From~Ft. to Ft ¢ zT, .: · From ~Ft. to Ft. " ,~ c ..... From~ Ft. to Ft From /.~:~{~ Ft. to / (~ g Ft. '~t ;~ r-', ~ J".*~/Y c From Ft. to Ft. From Ft. to Ft. ,~'~ A;',,; .., ~3 ~- ...,..~ */~,'f.<~ From Ft. to Ft. From /L,?Ft. to ~cyo Ft, ~'q/~. 7' From Ft. to Ft. From .)o O Ft. to ,~.3 ~Ft. C' 4 -qf ,~g t5 ,'.:'W :/~d From Ft. to.~Ft. From.~Ft. to Ft.. From Ft. to.~Ft From Ft. to Ft From Ft. to Ft From ~ Ft. to Ft. From Ft. to Ft From Ft. to Ft ' ' Trom Ft. to .Ft.. From Ft. to Ft. From ~Ft. to Ft. From Ft. to.~.Ft. From Ft. to__Ft. From Ft. to Ft From Ft. to Ft. MISCL. INFORMATION: PERMIT NO. DEF'RF.'.TMENT r: HERLTH RND EN',,,'IRqNMENTRL.. 'F.'-TEFTInN 825 "L" STREET., RNCHORRGE., BK. 9L'~50:1. 264-472¢i ~-IELL R~-~[:, C~~~--'--; I TE '----;-.EI~-.~EF-: F'E~-:~--~ I T ,:; 82:E~"t7---': ) RPPLICRNT LOCRTION LEGRL EXCRVRT t NG ENG I NERR=, L 5 KIMPTON S?D PO BOX R-~5 CHUGIRK 99567 '68B-2289 LOT SIZE 999999 SQURRE FEET TYPE OF SOIL RBSORPTION SYSTEM IS: DRRINFIELD NRXIMUM NUMBER OF BEDROOMS = -'-': SOIL RRTING (SQ FT,."BR)= 226 THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS: [:,EF'TH= 5 [_ E~-~,.ST H = :E: ~_'--~ GF-:R%.'EL [:, E F' T ~4:= "~--: THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF ]'HE EXCRMRTION (IN FEET). THE T~:E~4E:H ~4I[:.TH IS 5. E~k]O FEET. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). F-:E g--:.~ LI lC F-:E[:, _'SEF'T lC C: T R~'-.l~::' 5 ;[ ZE = ± 0 r.-":'-I ~_--~ ISRLL PERMIT RF'PLICBNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT [:,LIRING THE INSTRLLRTION INSPECTIONS OF RNY WELLS RDJRCENT 'TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERYE. 'T~,~(~ (2) I ~_-'~.PE£:TIC~-~_'~ F~:E F:Eg~L~I ~:E~ BRCKFILLiNG OF RNY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISF'OSRL SYSTEM IS f00 FEET FOR R PRIVRTE WELL OR i50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DiRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. i CERTIF'¢ THRT i: IRM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE 2: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. 2:: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE RESIDENCE I'-7 REMODELED TO INCLUDE MORE THRN ]: BEDROOMS. RF'F'L I CRNT E',:-:;CR',,,'RT ! NG ENG I NEF.:F.:S i '_=,'SLIE[:, BY. .......... [: RTE_~..~:,. 5~ ...... ' ',,,'4. E'; P©%~-4bl 6 650 ANCHORS(i_:. (907) 2(,i .'ii <Permit ~: 82]_007 ~~January , 1983 TO: Permit Applicant Subject: T15N R1W Section 4 S¼ SE¼ NE¼ SE¼(Proposed Lot 5 Kimpton) A permit issued by this depar~nent for an individual well and/or on-site sewer system has expired as of December 31, 1982. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal Ordinance. If you have drilled the well, a well log needs to be sent to this department for documentation of the installation date and to close the permit. If a private engineer inspected the installation of the on-site sewer system, please have them send us the as-builts for our files and documentation. If there are any further questions, please call this office at 264-4720. Sincerel~ Robert C. Pratt, R.S. Acting Program Manager Sewer and Water Program RCP/ljw enc: Copy of Permit SWP/057 F'ERMI T N0. r-ll_l~-~ IC:i .... RLIT"T" C~F R~-4Ck~J~:R,SE DEPRRTMENT 0F HERLTH RND ENVIRONMENTRL PROTECTION 825 'L~ STREET, RNCHORRGE, RK. 99501 264-4728 ~.IELL fl[-4E~ ,]f-~--SITE SEP~EF: PEF:F1 IT ( 821007 ) RPF'L I CRNT LOCRT I ON LEGRL E,%'C:RVRTING ENGINEERS PO BU,'-', - ='.~ ..... -" H-'..._ CHUGIRK 9_'9.567 T1 RtW S4 SE4 N S LOT SIZE 999999 SQURRE FEET TYPE OF SOIL HE,_,UF..FTIUN _-,~=.TEM IS: DRRINFIELD " II II ' ' = MR,:".IM_M N_MBEF.. OF BEDROOMS _3.': SOIL RHTIN~~._-,t..! FT/BR)= .-'.-'b ,-q THE REQUIRED SIZE OF THE =.LIL RBSORPTION SYSTEM IS: ~-.EPTH= 5 LEf-JGTH= :-3 £'~ ,3RR"-/EL ~-" EF~ TH= THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRYRTION (IN FEET). THE TE:Ef-~CH I-,~IDTH IS 5. ~2~l~E~ FEET. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). ~:E _f;--!LI I ~:ED ~.EF'T I C: TRf-~[::: '_:. I ZE= _-LC-,E'~C-, PERMIT RPF'LICRNT HRS THE RE=.FON_-,I.-,ILIT~ TO INFORM THIS DEF'RRTMENT DURINI'~ THE INSTRLLRTION INSPECTIONS OF RNY WELLS RDJRCENT TO THIS PROF'ERTY RND THE NUMBER OF RE_,IDENL. E=, THRT THE WELL WILL SER. VE. T~,] :: 2 ) I ~-~SF'EC:T I C,~-~'--=- RF-:E F-.'E@L~ I ~:E[) BRCKFILLING OF RNY _.,=,TEll WITHOUT FINRL IN=.FEUTIUN RND RF'PRO',,.'RL BY THIS DEPRRTMENT WILL BE =,UE,..EuT TO PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS t00 FEET FOR R PRIVRTE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. I CERTIFY THRT t: I RM FRMILIRR WITH 'THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE. 2: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. ~: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE F.'.ESI[:,ENCE IS REMODELED TO INCLUE:,E MORE... THRN 3. BEDROOMS. ~':~ / I =,~UED E~. ~ ..... [: HTE__~~_-~ .~ 2-4 11] !2~ I L.~/MUNICIPALITY OF ANCHORAGE ~'~' ;' ~'"'~ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SO!LS LOG- PERCOLATION TEST SLOPE /, ~, . /AS GROUND WATER IF YES, AT WHAT / /c~ /...~ DEPTH? PERCOLATION TEST SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop /z, ~- ? /~ - s " //,v~'? /o ,, i~ ,, ~ ,, MUNICIPALITY Development Services Department _'7 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I. D. 051-072-68 1. GENERAL INFORMATION Complete legal description KIMPTON LOT 5 Expiration Date: Location (site address) 21624 OBERG ROAD, CHUGIAK, AK 99567 Current property owner(s) ANDREW KMAK Mailing address Real estate agent 20610 JAYHAWK DRIVE, CHUGIAK, AK 99567 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 2 - 29- zoZl Day phone Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 9 12,50 G01)fl0 Waiver Fee $ Date of Payment 11 111 1 � 0� D Date of Payment Receipt Number 617 % 0 .3 Receipt Number COSA # 05G 2016 y 5 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. I acknowledge that On-Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 11/19/2020 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. 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 in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to r these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory �ig�Q: • • . !f,9 �) for current or future occupants or guarantee that no unseen encroachments, deficiencies or _ discrepancies exist can be given by First Water Consulting &FW[ S *� TH •* �r 6. DSD SIGNATUREbedrooms Curtis Huffman System #1 Approved for rr� ��61 . CE128991 •'��`���/ � 1/19 �itFRF�P System #2 Approved for bedrooms \\\ OFESSIOESS0 Disapproved Conditional approval for bedrooms, with the following stipulations: PNW NENT Sj1111��1 Original Certificate Date: 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 X Nitrate Advisory C Septic System Advisory Arsenic Advisory Well Flow Advisory Other Legal Description: KIMPTON LOT 5 Parcel ID: 051-072-68 If more than 1 septic system on lot: COSA Checklist # _of A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 4/21/1983 Total depth 221 ft Cased to 221 ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA 10/6/2020 Static water level at beginning of test 140 ft. Comments B. TANK DATA Age of tank(s) NEW 0 years Tank type/material SEPTIC / HDPE Measured operating fluid level in septic tank NEW ® Standpipes/foundation cleanout per record drawing Date of pumping NA - NEW D. ABSORPTION FIELD DATA Which system tested (date installed) 11/14/1987 ® ALL standpipes present per record drawing Total measured depth from grade *3_5 ft (max) Measured depth to pipe invert from grade *2_6 ft (min) ❑ N/A — pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective Structure served by this system _ Well production at time of test 4+ gpm Water storage tank volume_ gallons Well disinfected for coliform test? ❑ Yes ® No ® Coliform bacteria is Negative Nitrate 5.72 mg/L ElNitrate less than MRL (ND) Arsenic ug/L ® Arsenic less than MRL (ND) Collected by_ FWH Date of Sample 10/29/2020 C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: Adequacy test date 10/6/2020 Results Z Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 600 gal New depth 0 in Elapsed time <1 min ® Code -required soil cover over field w/ INSULATION Final fluid depth 0 in ❑ System presoaked Absorption rate 450 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) If yes, enter date Gallons introduced gallons FWf;SComm ents/Deficiencies:.*Elevations /measurements taken at testing show an approximate ED of 1' �;..> E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ® Yes if No ft Community Sewer Manhole/Cleanout > 100' ® Yes if No ft ® Yes if No Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' Surface Water > 100' ® Yes Animal Containment > 50' ® Yes if No ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ft ft ft ft ft ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No _ Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No _ Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No _ ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S 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. -49 Mi Curtis Huffman d���'Fc•,• CE 128991 S �'pROFESSIO AL® .� ft M www.muni.org/onsite Nitrate Advisory Certificate of On -Site Systems Approval # OSC 201645 Subdivision: Kimpton Lot 5 A water sample revealed a nitrate concentration of 5.72 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. 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. z Ma�Ung Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www mum org From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening, or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Madmg Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org N89`56'50"E 211.86' AS -BUILT OF: KIMPTON SUBDIVISION LOT 5 PLAT 82-472 SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance should any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. NOV 23, 2020 1 1"=40' 20-075-2 Ui BY: CaiECKm Byl =6 NUMBER: BOOI(/f+A( JLS NW1458 200246 = FND ALUMINUM MONUMENT OO = FND 5/8" REBAR 49TH .... ..:.*. i•.JOHN L. SCHULLER. �° s� LS -10408 2 r o . ®,� fessiono� v�p,LD LAND I IP" Ul . f0 1831 Talkeetna Street Anchorage, Alaska 99508 (907) 227-1455 office (907) 274-4992 fax (N89°53'47"E 211.78' R) X----Xr---x — 35.4' N WELL O N 72.3' 0 cv SHED PAVED d 28.0' �• 6 D/W 100 Y t(J X x L w O O W Z to Y Y m Lno Q G o X= Iw ^ � O I 00 28.0'Q . 00 NCO �� I z d- M N —� p C -0N d SEPTIC a MH I m OJ rr, N VENT (tm) ®a N O N � 0_ J LLJ M O O r� 0 Q O n M o O O Z L I 00 O Z a0 O LOT 5 m Q I to Li Q W Ig O r- I 30' X X—A N89°56'04"W 191.89' (191.72' R) 0 — GLACIER ROAD ANCHORAGE RECORDING DISTRICT, ALASKA AS -BUILT OF: KIMPTON SUBDIVISION LOT 5 PLAT 82-472 SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a physical survey of this property as shown on this drawing and that the improvements situated hereon are within the property lines and no enchroachments exist other than noted. Under no circumstance should any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. NOV 23, 2020 1 1"=40' 20-075-2 Ui BY: CaiECKm Byl =6 NUMBER: BOOI(/f+A( JLS NW1458 200246 = FND ALUMINUM MONUMENT OO = FND 5/8" REBAR 49TH .... ..:.*. i•.JOHN L. SCHULLER. �° s� LS -10408 2 r o . ®,� fessiono� v�p,LD LAND I IP" Ul . f0 1831 Talkeetna Street Anchorage, Alaska 99508 (907) 227-1455 office (907) 274-4992 fax MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Location (address or directions) (b) Property owner ~::~¢¢¢--~¢--~-/~-~'--~,/'" Telephone: (home) Mailing Addres~ ~.~ (c) Lending Institution' Business Mailing Address (d) (e) Real Estate Company and Agent - f? .. Telephone Mail the HAA to the following address:'(or check here~'if hold for pick List contact person and day phone number below: S & S ENGINEERING 17034 Eagle River. Loo~ Road No..204 ' Eagle River, Alaska ~577 2. TYPE OF RESIDENCE Single-FamilyJ~ Number of bedrooms ,~ 3. WATER SUPPLY Individual Well/[;~ Community [] Public [] Note:~lf community well system,, must have written confirmation from the State Dep~rtment of Environmental con~e'r~atioh attesting t~) th i~gali'ty and Status: ' ' ~ ':'" ' "' 4. SEWAGE DISPOSAL Omsite~,, Public [] Community [] Holding Tank [] .; Note: If community well sYStem, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72.025 {Rev. 7/88) Page I of 2 'XJOM s.Jeeu!Sue leUO!Sse,toJd eq~ suo!ss!uJo JO s Jo J JO suop, oedsu! ),onpuoo ~ou op SHHQ jo seeAOld~U3 's~ueuaeJ!nbeJ e),B~,s pub IBJepe,t uim, Jeo A,tsRBs o~ JepJo u! suoRn),p, su! 6u!pual J!eq~ pub seuuoq Jeeulbu@ IBUO!SSojoJd ~,uepuedepu! uB Aq e^oqe le^oJdd¥/~l!Joq~nv q~IBeH senss! (SHHQ) seo!AJe9 uewnH pub q~,lBeH ,to ~,ueua~,JBdoQ eSBJoqou¥ ,to/9,!led!o!u nlAI eqJ. IB^oJddv [Buo!l!puoo jo su. JJS/ IBUOBipuoo pe^oJddBs!a / /X~ pe^oJddv ~-- Jo,t pe^oJddV 'lYAOldddY SHHa '9 " ~¢~,~51~I~NICIPALITY OF ANCHORAGE (MOA) ~,r,~"~O Health Authority Approval (.AA) ,~'tt~'~ ~,/ CHECKLIST- FEBRUARY 1984 ~O~ ~ ~' ~ Legal DescriptiOn: ~ ~ Well Classification ~ ~l~i ~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present ~) ~ Date Completed ~-~ ~ Yield Total Depth ~ Case~d~'~ ~ Depth of Grouting ' Static Water Level Casing Height Above Ground \~_ Electrical wee'lng in Conduit~N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ' To Nearest Edge of Absorption Field, o~ Lot To Nearest Public SeWer Line ¢//~ To Nearest SeWer Service Line on LOt Pump Set At Sanitary Seal on Casing([~N) Depression Around Wellhead (Y/~[~j~ ; On AdjOining Lots \. ~,~;;~ ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole \ 0o/~ Water Sample.Collected by ~ ~ ~-~ ~.~d~ x r-S¢::~,--~ ; Date Test ,esu, Comments ~¢~ ~ ~~ ~-~%-~ To Water-Supply Well B. SEPTIC/HOLDING TANK DATA Date Installed (~'°~ Size Standpipes~;~N) ~ Air-tight Caps ~N) Depression over Tank (Y/~ Pumping/Maintenance Contact on File (y/N~,~ Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: No. of Compartments '~- ¥ Foundation CleanoutCC~/N) , ~ Date Last Pumped ;for ~~//~. Temporary Holding Tank Permit (Y/N) To Property Line To water Main/Service Line \ ~ )'~- To Building Foundation To Disposal Field To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area ~. ~ ~::¢¥' ~' Depression over Field (Y/~ ~ Results of Last Adequacy Test ~--~ ~ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot \ c;~ ~ To Water Main/Service Line '~'~'~ ~'¢¢--' Type of System Design Length of Field ~"¢¢~ Depth of Field "U,,-~ Gravel Bed Thickness ~:::~, ¢' Statndpipes P resent 4;2i~q~1) Date of Last Adequacy Test -/ To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line \ ¢r~ To Existing or Abandoned System on ; On Adjoining Lots '"~'=~' '~ To Cutback (if present) Comments D. LIFT STATION ~,~ Date~nstalled ,,S, ize ih-~ons __ __ Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) P___~_umping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Company 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Date MOA NO. (~'~' ~ ?--"- ~::~.-.~ Date of Payment . ~' '//-- d~ Amount: $ / ,'~ O~ ~ O 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. /~,. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order ~ 11871 Date Report Printed: FEB 24 89 ~ 16:11 Client Sample ID:LL, RI~PTON PWSID :UA Collected FEB 22 89 @ hrs. Received FEB 23 89 ~ 12:00 hrs. Preserved with :AS REQUIRED Client Name : S & S ENGR Client Acct: SNSENGP P.O.~ NONE REC'D Req ~ O~dered By : RJS Analysis Completed :FEB 24 89 Send Reports to: Laboratory SuperviooL :STEPHEN C. EDE 1)S & S ENGR ~eleased By :.~ ~'. ~ 2) Special Instruct: Chemlab Ref ~: 4350 Lab Smpl ID: 1 Matrix: WATER Allowable Parameter Tested Result/Units Method Limits NITRATE-N ND(O,10) mg/1 EPA 353.2 Sample ROUTINE SAMPLE. Remarks: SAMPLE COLLECTED BY RJS. 1 Tests Performed ' See Special Instructions Above UA=Unavailable ND= None Detected '~ See Sample Remarks Above NA: Not Analyzed LT=Less Than, GT=Greatez Than MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITT. AL) (a) Legal Description (include lot, block, subdivision, section, township, ran-ge) Location (address or directions) (b) Property Owner ,~A/'C, , ~, ~,k~-r~.- Telephone: Home L~¢E,- z.~ MZ, Business Mailing Address (c) Lending Institution /~-~'~'~'~ ' ~'~ /c-~,~. ¢_.-,~T~i- Telephone Mailing Address (d) Real Estate Company and Agent Address ~ O. I~o,~. ~ -/ t_~ -~-~ ,~-- ~$ ~-~"-/- Telephone /_ ,~,./ - (e) Mail the HAA to the followina address: or: Check here ~ hold for pick up. List contact person and day phone number below. f, & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle ~iver, 2. TYPE OF RESIDENCE Single-Family ~ Number of Bedrooms 3. WATER SUPPLY Individual Well II'Community Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [[]'"'//Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 72-o25 IRev 8/86~ Front 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. Name of Firm S Address 17034 Eagle River Loop Road No. 204 Eagle River~ Alaska 99577 Date Telephone 6. DHHS APPROVAL /" ," Al~proved for. ~bedrooms by f/~/~,~,,'~:~ ....-,~p'~'o~" ~ .... Di~aPP~°~ed .......... c0~d iiio hal Terms of Conditional Approval ._~. .~ -."~x..i~.r~ ~\~,\' ..' CAUTION ' ' ' : The Municipality of Anchorage Department of Health and Human Services (DHHS issues Health Authority Approval 'Certificates based °nly upon'the rep~eSentati0h:s given i~ paragraph 5 above 'by'an independent professional enginee~ 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. Page 2 of 2 72-025 fRev 8/86) Back LtTY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE (MOA) iv~dN~CIPA ' ENviRONMENTAL sERVICES DIVISICIttEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 NoV l o B'87 RECEIVED WELL DATA Well Classification ~, 264-4744 Legal Description: /__~'T ~- /~.t,'~l~7'~,,'J ~4Fjt'). If A. B, C, D.E.C. Approved (Y/N) Well Log Present,N) Total Depth 2'. Z.-! ~ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit ~i)/N) Separation Distances from Well: To Septic/Holding Tank on Lot Date Completed Cased to 2_..~.... I ~ c¢'- ~.( ~(~ Yield Depth of Grouting Pump Set At Sanitary Seal on Casing ~i~TN) Depression Around Wellhead (~/~ /?...L~I ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /~ 5-! ; On Adjoining Lots ~'O~ /C- To Nearest Public Sewer Line ~J/~ To'Nearest Public Sewer Cleanout/Manhole ~/A To Nearest Sewer Service Line on Lot ~ ~ %4- Water Sample Collected by .% 4-- ~ ~.'-.,-_[ C~ ~_~_...~D_~/..z~ ; Date Water Sample Test Results ~ 4,,'~'-~r--4c.f')-~y' ~c--...¢~_ ,~¢~"~4"~"~ Comments t,4) ~'-c. L ~"~..-Z~¢ J~' '~--~ ,~5 B. SEPTIC/HOLDING TANK DATA Date Installed .~'~ Stand pipes'"~'N) Depression over Tank (Y/(~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well / ~'r¢~ To Property Line To Water Main/Service Line Course /oo Size ! ~o:, No. of Compartments Air-tight Caps ('~N) Foundation Cleanout (--(~N) Date Last Pumped ~ /¢~ -f5^ -,.¢~) ; for ------- Temporary Holding Tank Permit (Y/N) ~J'/'f:~ To Building Foundation 2_. ~' ~ To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026 (Rev 8/861 Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed // Width of Field To Water-Supply Well To Building Foundation Lot Square Feet of Absorption Area /5'¢~ Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: /~ ' Length of Field L/'~'f Depth of Field -~ .~ Gravel Bed Thickness Lo. ~' Standpipes Present (~N) Date of Last Adequacy Test To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments d¢~ ~ Type of System Design To Property Line __ To Existing or Abandoned System on ; On Adjoining Lots ~O/4' To Cutbank (if present) D. LIFT STATION 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 Adequa(~y Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request I certify~t k&a.~lE~'~l~ll~l~verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection· · 17034 Eagle River Loop Road No 2E4. - //, --'/~ -- Signed ........ ' L)ate z~/.// Ea~le River, Alaska ~¥~zl / / Company MOA No, Date of Payment /////¢/~'-., ~ Amount: $ //'('~ ~'J Page 2 of 2 72-026 fRev 8r861 Back CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA99518 TELEPHONE(907) 562-2343 ~.-~¢.~ FEDERAL TAX ID # 92-0040440 MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION NOV ~ 8, 1987 RECEIVED APPLIC FILLS:OUT UPPER HAL UNLY Mailing Address ,~-~ ) ~ _ Buyer ~.)1~¢c' Zip Code ~ ~-~ Gx Phone . ~ p Phone Type of Resi~nce ~ Single Family ~ Multiplo Family Ro. o[ Bedroo~ ~ ~ '~ater Supply '' ' ~ Individual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. to that date give well ~pth (attach log if available): For drilled prior Community B Public Utility Sewer Disposai : Year individual installed: lC~ ?~ 5 ~ ~ Individual ~ wBen Connected to Public Utility: ~ Public Utility "~ ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST ~EFORE ~OCESSING CAN BE INITIATED. Time Time Time Time ~4/~ Date Date Date ¢/?//2 Date Inspector Inspector Inspector Inspector FieldN°tes: //~'O ._~ ~ ~ [~ 0 ~7 ~ ~I (~) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED DATE Soils Rating Date ~wer installed Well To Absorption Area Well Log Received Well to Tank Septic T~k Size