HomeMy WebLinkAboutMEADOW BROOK BLK 3 LT 8A
MUNICIPALITY OF ANCHORAGE
Development Services Department ? Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050-191-12
Legal description MEADOW BROOK BK 3 LOT 8A
Site address 18138 Sanctuary Eagle River
Current property owner(s) Jesse and Krista Morrell
Expiration Date:l Z 31 20Q_3
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for
Comments or advisories:
0
bedrooms, with the following stipulations:
Original Certificate Date: j 2 -�-/ 223
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval_June 2022
MUNMPAUTY O
i` ®
Development Services Department
On -Site Water & Wastewater Section
Phone: 907-343-7904
Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 050-192-12
Complete legal description MEADOW BROOK BLOCK 3, LOT 8A
Location (site address) 18138 SANCTUARY DRIVE, EAGLE RIVER, AK 99577
Current property owner(s) JESSE & KRISTA MORRELL Day phone
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ® Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ! Steel ® Plastic ❑ Concrete ❑ Fiberglass
Age 47 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ® Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $
* 5-5-6
Date of Payment 1 %A /An
COSA # 83c 23 ibO -7
67111 (41 1
Waiver Fee $
Date of Payment
Waiver #
COSA Applicalion.doc
COSA Checklist.docx
COSA Checklist
Legal Description: MEADOW BROOK BLOCK 3, LOT 8A Parcel ID: 050-192-12
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA - PUBLIC &/OR CLASS “A” WATER – SEE ATTACHED AWWU CONNECT CARD / AERIAL
Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank 44”
Date of pumping 01/16/2023
Required maintenance completed, if AWWTS
Comments: 1ST COMPARTMENT / SUNSET TANK
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 6/18/1976
ALL standpipes present per record drawing
Total measured depth from grade 9.3 ft (max)
Measured depth to pipe invert from grade 5.3 ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective 5.8 OF 6’ IR ED
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 1/16/2023
Results Pass
Fluid depth prior to test 41 in
Water added 610 gal
New fluid depth 47 in
Elapsed time 1400 min
Final fluid depth 41 in
Absorption rate 450 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 72 in (6’ED)
Effective depth used 43.4 in (0.2’ MISSING + FLUID)
Effective depth remaining 28.6 in
Comments/Deficiencies: Measurements and elevations taken of septic system. See attached letter.
COSA Checklist.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) - NA
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No *5 ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
*Per code at time of construction and GAAB approved inspection report. Also per attached AWWU docs,
water service line appears to be 10’+ to septic. See attached letter.
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 1/20/2023
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
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
1/20/23
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / firstwaterAK@gmail.com
January 26, 2023
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC SYSTEM – MEADOW BROOK BLOCK 3, LOT 8A
The owner has requested that we obtain a COSA on the above referenced lot. The owner purchased this
property within the past year or so that was “bank-owned”. It appears that the previous occupants had
rented this property for several decades and the previous owner was foreclosed on. The previous renters
and the current residing owner have had no known issues with the septic system.
Upon pumping and site investigation, it appears that there may be some sort of absorption fix or un-
documentation. Given the direction of the unknown cleanout towards the valve and double cleanout and
the proximity of this unknown cleanout to the existing apparent original cleanout of the documented
GAAB field, which are based on visual observations and measurements – this appears to be a fix of some
sort and that the entire field should be considered as one absorption field. Based on the elevations
measured, small area and close proximity of the existing septic, we would recommend approval of this
G.A.A.B. (MOA) septic system and add a COSA caveat that any modifications or upgrades to the
existing septic system would need MOA permit approval.
Existing elevations of the apparent original field showed 5.8’ effective depth and the bottom of this 6”
monitoring tube was approximately 0.8’ below the steel driven MT and 8.09’ below the invert of the
unknown field cleanout per the attached rough sketch of this site. Alaska Quality Pumping (AQP)
pumped the plastic Sunset septic tank that had only one cleanout visible with a fluid depth of 44” and the
levels seemed to be operating normally. A camera was used on 1/25/23 by AQP and the tank material was
reverified as plastic. The lot and area are served by public water per the attached AWWU documents.
The existing septic appears it will not impact any of the neighboring properties. Please contact us if you
have any questions.
Sincerely,
Curtis Huffman, P.E.
SKETCH -From the house: i FCO, 1 ST CO, DIV, DCO, Steel MT, *CO (unknown), CO & 6" MT on the opposite E side.
It appears and is suspected that the original field has been repaired or fixed with the DIV valve & unknown *CO & in
close intertwined proximity to or a part of the documented 1976 GAA13 field. They 16" MT had the shallowest elevations
and per the COSA & letter we would recommend Issuance of the COSA. Fi�sri�Jale�
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GREA, R ANCHORAGE AREA BORC
Department of Environmental Quality
3330 C Street
Anchorage, Alaska ggs03
8H
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL_~YSTEM
SEPTIC TANK:
FROM WELL k/~'C'"'c"Pv!'4~ MANUFACTURER _ l-t TERIAL
),
INSIDE LENGTH ~;; INSIDE WIDTH__ __ LIQUID DEPTH
NUMBER OF '~.
COMPARTMENTS
_ ?
LIQUID CAPACITY_/ ¢'':~¢' ¢~AL. LONS.
TILE [)RAIN FIELD:
DISTANCE FROM WELL
NDMBER OF LINES
ABSO RP'FION AREA
DEPTH:
('~¢ FOUNDATION __
J DIST/:C4CE BETWEEN LINES
.,~
1 DEPTH OF FILTER
TOP OF TILE TO FINISH GRADE '/~' MATERIAL BENEATH TILE
NEAREST LOT LINE
TRENCH WIDTH
TOTAL LENGTH
OF LINES __
IN. TOTAL EFFECTIVE
IN. ABOVE TILE _IN.
WELL: ~
TYPE ¢.~?-¢t-1..4.'q, /~ C~ON)ST RUCTION
DEPTH
DISTANCE FROM:
BUILDING NEAREST NEAREST SEPTIC
FOUNDATION. , LOT LINE ---- SEWER LINE--, TANK
SEEPAGE
SYSTEM
CESSPOOL _
OTHER SOURCES
APPROVED DISAPPROVED __REMARKS
DISTANCES:
SEWER LINE DEPTH:
LOT SLOPE:
REMARKS:
DIAGRAM OF 'EM
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lh~s form re9or~s: 3o~ls
Depth
Feet
6-
7-
8-
9-
ll -
12-
13-
14-
Was ground water encountered? A/O .... If yes, at what depth?
Reading Date
~-e~l-a-~-o-~ r ate
Gross Time Net Time Dep].h to W,.a.tm[..
minute.
Net Drop
,Proposed installat--C~-n-;- Seepage Pit . Drain Field
Depth of Inlet . Depth ,to bottom of pit or trenci~ __
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MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
R [ C [ t ~'; ~'~FC'I'IFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. ~ ~) ~ - - ' ~ ?~' '~ ~ X~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Meadow Brook, Lot 8A, Block 3, T14N, R2W, Sec.12
Location (address or directions
18138 Sanctuary Drive, Eagle River, AK
(b) Property owner Veterans
Mailing Address 235 E.
(c) Lending Institution
Mailing Address
Administratio~elephone: (home)
8th Ave. Anchoraqe, AK
Telephone
Business 271-2222
(d) Real EstateCompanyandAgent Bob Martin/Coldwell Banker
Address4105 Tudor Centre Drive. Anchorage. AK 99508
Telephone 561-2488
(e) Mail the HAA to the following address: (or check here Fi, if hold for pick up.)
List contact person and day phone number below:
p~ck-up by Engineer
2. TYPE OF RESIDENCE
Single-Family [] Number of bedrooms 3
3. WATER SUPPLY
Individual Well []
Community [] Public ~]
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4, SEWAGE DISPOSAL
On-site:E] 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-o25 (Rev. 7/aB) Page 1 of 2
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NOI.L'VINI:IO:INI ~3N~' ¥.L~Q 'NOU¥:~$ ~]'11.-I 'S.L$~£ '$NOI.LO~idSNI 9N1~31^O1:1cl INI:II:I ~SNII:I:B3NIeN3 '9
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (NAA)
,CHECKLIST- FEBRUARY 1984
ANCHO~,AG~ 343-4744
sE~w~_.~s o~v~oh~ Legal Description: ~
Well Classification
Well Log Present (Y/N)
.Date Completed
Total Depth Cased to
Depth of Grouting
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
If A, B, C, D.E.C. Approved (Y/N) '4¢//4
Yield
Pump Set At
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
· Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ,/¢'?~ Size
Standpipes (Y/N)
Depression over 'Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
/'~'~.5' No. of Compartments
Air-tight Caps (Y/N) ,"P" Foundation Cleanout (Y/N) ,Y
Date Last Pumped ,~//,E'?
"~//"'¢ ;for
/l//,¢ Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well ~/?,4
To Property Line /-"/'¢ /
To Water Main/Service Line
To Building Foundation
To Disposal Field
To Stream, Pond, Lake or Major Drainage Course
S/
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/N)
Results of Last Adequacy Test
Type of System Design
Length of Field ~2-/
Depth of Field /b'
Gravel Bed Thickness ~ /
Statndpipes Present (Y/N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well i,,~/,~
To Building Foundation
Lot
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line ¢- ?
To Existing or Abandoned System on
; On Adjoining Lots ~-'~¢ ·
To Cutback (if present)
Y-lo /
D. LIFT STATION ,/u///,ccj~
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping 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 guid~i4~e§'~ri'~'ff~e,t,;~o~n the date of this
. . ~-.-",,. ~F ,.<~ ~' ' ~
Signed Eagle Riv0r Engineering Services ~]%' ~,~ ¢',--,~ ~; ',,':¢~ "~,¢ (A
Company P.o. Box 773294 ~ ~- ~*¢0',;_?; ~'~':. ~ ~ ¢~
Eagle Rivo,, AK 99577 ~~d'd~neer's Seal
Date
Receipt No. O¢.~'- A /// ? ~/ ~ 77/~ Receipt No
Date of Payment ~? ' / 2 -- 06~./~ Waiver Fee: $
Amount: $ ./~-~¢~ , d2~) Date of Payment
72-026 (Rev 7/88)Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF ImALTH AND ENVIRONbmNTAL PROTECTION
APPLICATION FOR ImALTH AUTHORITY APPROV~ CE~TI~ICATE ~/~ z~/
General Infatuation Application Date ~f/~/~z
........
(a) Legal Description (include lot, block, ~ubdtvistdm, se tion,~t~v~ship, range)
Location (ad~ress, or directions) / '+~/ Og~ ~'.;f: f~
,~Ci? ~, .t- , ,, 1~_ .~ ,%' r~ ~ ,~~ ,~'- '~' ~.
(b) Applicants Name Telephone-' Ilome Business
Applicants Address
(c) Applicant is (check one)Lending institution I]~l[ ; O~.rner/builder ~q~
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the I~k to the following address:
e
Other (describe)
Iudividual Well Iii[ Community Ii----] Public~'
Note: If community well system, must have written co~i~ation from the State
Department of Enviro~mmntal Conservation attesting to the legality and status.
S ewe_g? e D__i_s_pos a 1
Ons i t e'~.~_]~ . .
Public F-------~ Community [---~ Holding Tank ~]
Note: If cormaunity well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
Engineering. Firm Providing Inspections_z_. __~'_zz~Tests File Search, Data and Information
As certified by my seal affixed hereto and as of the validat:ion date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewa~'er 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 ~kll Municipal and State codes, ordinances, and regula-
tion:~ in effect on the date of this inspection.
Name of Firm
Address
Date
Telephone
(ENGINEER SEAL)
DIIEP A royal
Approved Eot .... , bedrooms i37 '~: ~ ,.~ ,~ ,.
Approved Di sa p pr oved Cond i t i o rt~'~l
T~'~'lrl:i oil Cond (.t:l. onal Al~proval
CAUT I ON
THE MUNICIPALITY OF ANCIIORAdE DEPARTMENT OF HEALTH AND ENVIRONbIENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH fi ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN TIlE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOHES
THEIR LENDING INSTITUTIONS IN ORDER TO S~TISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR fuNALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF fuNCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/DI8
[Page 2 of 2]
7-19-84
ae
Be
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
MIJNICIPAI.IiY OF ANCI1QRAG~
D!}FI'. OF Iii!Al !It A
CHECKLIST - FEBRUARY 1984
Legal De,s c rip ~;~.on
Well Classification
Well Log t~esent (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Eiect~ical wiring in Conduit (Y/N)
Separation Distances f~om Well:
To Septic/Holding Tank on Lot ~C~O
St:F 2 iti::'
Da~e Completed Yield
Pump Set At
Depth of Groutinq
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot'~(> ../t_ ; On Adjoining Lots
To Nearest.Public Sewer Line To Nearest Public Sewer
Cleancut/Manhole To Nearest Sewer Service Line on Lot
Wate~ Sample Collected By ; Date
Water Sample Test Results
Cozm~nts t~"?/~ ~z~/;&/~ ~/~/'~/~ ,-
/
SEPTIC/HOLDING TANK DATA
Date Install.~,d ~y / '~ Size
No. of Compartments ,.~_~--
Standpipe~/~ Air-tight Caps ~.~ _Fou~ iO~ -~C le anou~ ~')
Depression over Tank (~ Date Last P. ,u~oed~.j / ' ~/Z~X~ t'//)'~
Pumping/Maintenance Contract on 'File (Y/N)~J/~: ; fo~Xr~' ........
Holding Tank High-Wate~ Alarm (Y/N)/~///~ Temporary Holding Tank Permit (Y/N)
Separation Distances f~om Septic/Holding Tank:
To Water-Supply Well ~ ~Ll)O 't TO Building Foundation ~'
TO Property Line
To Water Main/Service Line
Course
Comments
To Disposal Field ~ (
.:~/~ TO Stream, Pond, Lake, or Major Drainage
Receipt ~
Date Paid:
Amo un t:
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /~/'7~
Width of Field .~
~J L/L~ Type ,Df System Design
Length of Field ~ '2 ~
__ ~p~ of Field ~'~2 ~
Gravel Bed Thickness ~ '?
Depression ovez, Field (4¢~ " Date of Last Adequacy Te~t/~,~////~/~
Results of Last Adequacy Test --2/~3 ~/_% ..~.~ r'~O.? ~ ~
Separation Distan~ from ~sorption Field:
To Water-Supply ~11 ~O0 .~ To ~o~rty Line /d .~
To Building Foundation ~d3 f To Existing or ~andc~d System
Lot /3 /~ ; ~ Adjoining ~ts ~ ~ -~[~
To Water Main/~rvi~ Line 3;0 / To Cutba~(if pre~nt) /'/~/~--
To ~iveway, Parking ~ea, or Vehicle Area
Cor~rsnts
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Ala~mLevel at
Tested for
Electrical Codes(Y/N)
Dimansions
Manhole/%ccess (Y/N)
/'Pumo Off" Level at
,P/
Ven (Y/N___!
l~mping ,Cycl%~ ~ing Adequacy Test.
,V~e ts MOA
Con~nents
** Check Permitted Bedrocm Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA HAA C~Jidelines in effect
on the date of this iDmpection.
Date ' ,.- /
/
[Page 2 of 2]
2-15-84
£ J 11..z. L45.
MUNIOIPALITY OF ANCHORAGE D~PT, OF lEAl.TH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROi'~NMENTAL pRoTECTION
ENVIRONMENTAL ENGINEERING DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
:~IR£CTIONS: Complete all parts on page 1, Incomplete requests will not ba processed, Please ~llow ten (10} days for processing,
-% PROPERTY OWNE~ ~ PHONE
~AH_ING%DDR
PROPERTY RESIDENT(Ifdiffe~nt fromabo } I PHONE
PHONE
'2, BUYER '
~AILING ADD~ES8
3. L~DING INSTITUTION I 27c--PHONE
MAILING ADDRESS
4, REALTOR/AGENT
MAILING ADDRESS
PHONE
5. LEGAL DESCRIPTION
STREET LOCATION
6. 'TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One [] Four
BI Two [] Five
~[ Three [] Six
[] Other~
7, WATER SUPPLY E] INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
S. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE**
~ PUBLIC UTILITY
**If individual/on-site, give installation date ,/~'~ ,,
If system is over two (2) years old an adequacy test is required
by this Department,
NOTE: THE iNSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR I NSP ECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2, WATER SUPPLY PERMIT NUMBER
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or []Holding Tank
Size: / O(J) O If Tank is homemade SOILS RATING '
give dimensions:
TYPE OF TANK MANUFACTURER
Absorption Area to nearest Lot Line
5, COMMENTS
¢_ - ROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION
72-010 IRev. 3/7R)
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 '~C" Street, Anchorage, Alaska 99503 274-4561
Date Received September 22, 1976
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Conv·
1. Approval requested by:
Mailing Address: 319 west 5th Avenue
2. Property Owner: Robert D. Cousineau/James E.
Mailing Address:
4.
5.
6.
Security Pacific Mortgage
Legal Description: Lot 8A Block 3 Meadowbrook
Phone: 272-9501
DavisPhone: 276-7777
Location: NHN Sanctuar~
Type of facility to be inspected
Well Data:
A. Type
C. Construction
Single Family
~ndividual
7. Sewage Disposal System:
No. of bedrooms
B. Depth
D. Bacterial Analysis
A. Installed
C. Septic Tank:
D. Seepage Pit:
1. Size
1. Absorption Area
E. Disposal Field: Total length of lines
Distances:
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
C. Absorption area to nearest lot line __
On-site system
1976 B. Installer
2. Manufacturer
2. Material
, Absorption area
, Other contamination
, Absorption area
, Sewer Lines
EQ-034 (1/74) Page 1 of two pages
Page 2 of two pages - Re st for Approval of Individual ~ er & Water Facilities
Legal Description
Lot 8A Block 3 Meadowbrook Subdivision
Comments
Disapproved Date
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED Date
EQ-034 (1/7~)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2510 East Tudor Road, Anchorage, Alaska 99504 276-2221
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
SEP 2
RECEIVED
1. Type of Inspection: CMRO.
2. Property Owner: Robert D. Cousine¢tu
Mailing Address:
3. Name of Buyer: ¢.hn~l R~ C.. ~4n~i nsf-nh
Mailing Address: Elmendorf AFB
VA FHA CONV x×
and James E, Davis
Day Phone: 276 7777
Day Phone: none
4. Name of Lending Institution: Security Pacific Mortggw Corp
Mailing Address: 319 West 5th Ave Anchorage
5. Name of Realtor or Agent: Executive Realty
Mailing Address: 2810 C. St,
6. Legal Description: Lot 8A Block 3 ,t;ea_dowbrook S/D
Phone: 272 9501
Phone:276 7777
Location: NHN Sanctuary Drive Easle River Alaska
7. Type of Facility to be Inspected:
8. Water Supply
Type of Supply:
sfr
No. Bdrms. 2
Public Utility
Individual
If Individual, number of dwellings presently served
If Individual, depth of well unknown
Sewage Disposal System
Type of System: Public Utility
If Individual, date of installation 1976
Individual (on-site) xx
72 003(3/'76)