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Home My WebLink AboutLIST LT 1 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211174 PID Number: 067-301-40 Dwelling: N Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ■0 Upgrade Name JOHN PETRAITIS A ORPTION FIELD ❑ De Trench El Wide Trench El Bed ound Site Address 30319 LIST CIRCLE, EAGLE RIVER, AK 99577 Other Phone Number of Bedrooms Soil RatingTotal depth fr original grade 406-5170 4 /SF Ft. LEGAL DESCRIPTION Depth to pipe invert from origins EXISTING avel depth beneath pipe Ft. Subdivision Block Lot LIST - 1 Fill added above original gr JG!!length Ft. Ft. Township Range Section - - - Gravel width Ft. Beds: Number of Lines Dist a between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total orption area Number of trenches Dist. between chis From Tank Field Tank Line Ft2 Well 100'+ EXIST. - - 25'+ TANK [9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity GREER TANK 1250 Gal. Surface Water 100'+ EXIST. - - Material Number of compartments Lot Line 5'+ EXIST. — - NA HDPE PLASTIC 2 Foundation 10'+ EXIST. - - LIFT STATION Man r Capacity Gal. Remarks Alarm location installed by PIPE MATERIAL House to tank D3034Tank to D3034 drainfield Installer DEAN CONSTRUCTION Drainfield EXIST. CO/MTD3034 Inspector GEG CONSULTANT, ERIK WIDGER BENCHMARK (Assumed elevation) 99.75 ft Inspection v, 6/10/2021 Location and description ection 2 d TOP OF MANHOLE LID 3rd 41h ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp oo600p0�4 Conditional Approval: Date .... G Septic SystemJif Hess.' 1/CE Date C7-2 Ap Z 9G3 79cQ� e O��fPr•-.,:��f;��?,,t.••�oo Note: this approval does not include well permit requirements.Pr aAecce4ea0�00�0\0 trcev uotuzna/ q_� PERMIT NUMBER: OSP211174 WELLW yOUSFOM �I NOTE: OLD SEPTIC TANK WAS EC@MhTt9•SteNE6=iE8it:EJbtJr ' �. •. PER THE CONTRACTOR. DRIVEWAY te' _ , DBL1 39.6 54.0 DBL2 40.6 54.8 MH 42.9 56.5 ST1 47.7 60.4 DBL3 48,7 61.2 DBL4 49.4 61.7 C01 86.2 94.4 MT1 85.1 93.4 CO2 72.0 86.3 MT2 67.3 80.5 PARCEL ID NUMBER: 067-301-40 FA W m¢ o 0 NOTE: PIPE LOCATIONS ARE / I z m SHOWN PER GEG SHOTS / TAKEN WITH LEICA DISTO ' / rr' S910 LASER DISTANCE �R METER. SWING -TIES TO / V HOUSE CORNERS WERE I 0 GENERATED IN AUTOCAD. / INSTALLED DOUBLE CLEANOUT AFTER TANK (DBL3 & DBL4)— LIST CIRCLE JSTALLED DOUBLE CLEANOUT BEFORE TANK (DBL1 & DBI -2) NEW GREER PLASTIC 1250 -GALLON SEPTIC TANKS F Cpl TO U / \ M EDGE 0 HIVE 99t FEET FRO 96 F00- W J .v SORED I+ REaUESTING EGEOFWELL \ I_ 0 o° 5 Oz w� a o O J =Y � U Z ASSUMED LOCATION OF I �\ I o f EXISTING TRENCHES BASED \ \ — ,41� UPON 1986 INSPECTION REPORT IN MOA RECORDS (9 ' ------------- -------------� mmmmmp-p4l7Wr-l-7Mq-� ENGINEERING SALES,CONSULTING _ _..-..,_ _.,,.: .:<�.� ANCHORAGE, ALASKA - PHONE (907) 3375179' WEBSITE: www.gamossangineaMg.00m PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOHN PETRAITIS 406-5170 2 OF 3 PROJECT/LEGAL DESCRIPTION: DRAWN BY: LIST; LOT 1 J.L.M. TYPE OF WORK: DATE: RECORD DRAWING OF SEPTIC TANK UPGRADE 7/13/2021 1'=4U' 1 Air } ;w� ..........y r l��It...................., v ............. i i - f ......... 0 �n J rey A. Garness ®��J,' CE -7953 LICENSE �g��®S4 ®0 4AECC884 OSP211174 RECORD DRAWV 1t I N G 067-301-40 NUMBER: PERMIT NUMBER: PARCEL ID f 1 TOP OF MANHOLE NESS ENW"31NEERING GROUP, Ltd ENGINEERING SALES CONSULTING _. ,.. .. _ _....., ANCHORAGE. ALASKA' PHONE (907) 337-8179' WEBSITE: wwagamessongineenng.wm PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOHN PETRAITIS 406-5170 3 OF 3 PROJECT/LEGAL DESCRIPTION: DRAWN BY: LIST; LOT 1 J.L.M. TYPE OF WORK: DATE: RECORD DRAWING OF SEPTIC TANK UPGRADE 7/13/2021 ANK = 92.50 VERT OF BUNG OUTLET = 91.67 yyy® Aw ........ 9: ; ,..1....... ........... �..L.. 1.'. .1:.....;. .® ® � : f ey A. Garness : Lv v ��0� ✓ CE -7953 4 4�R�ESS, LICENSE ICEN E �tally®�®� MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http:llwww.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP211174 Work Type: SepticTank Upgrade Tax Code Number: 06730104000 Site Legal Address: LIST LT 1 G:0702 Site Mailing Address: 30319 LIST CIR, Eagle River Owner: PETRAITIS JOHN & Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 6/1/2021 6/1/2022 64700 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: Locatethe beginning of the field to confirm that the 5' separation between the tankand field will be met. Received By: L t--" Date: Issued By: 4 r A/ Date: 151 UNICPALITY OF ANCHORAGE Development Services Department ' Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 067-301-04 Property owner(s) JOHN PETRAITIS Mailing address 30319 LIST CIRICLE *EAGLE RIVER, AK Site address Day phone 907-406-5170 Legal description (Sub'd., Block & Lot) LIST; LOT 1 Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (Zx all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) x❑ Septic Tank Z Upgrade Fx I (w/wo ADU) (D) ❑ Holding Tank ❑ RenewalDuplex ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: N/A Distance: - I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: # g"� Waiver Fees: Date of Payment: .5 Z6 Z�z Date of Payment: Receipt Number: 0 Receipt Number: Permit No. 0 S jz2 ") % y Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Applicalion.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211174, Deb Wockenfuss, 06/01/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211174, Deb Wockenfuss, 06/01/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211174, Deb Wockenfuss, 06/01/21 ~=-., MUNICIPALITY OF ANCHORAGE D' ~RTMENT OF HEALTH AND HUMAN SEt Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~m~ DISTANCES ~t~ ~. ~ ~ SEPTIC ABSORPTION ~ .... TANK FIELD WELL LEGAL DESCRIPTION AS-BUILT DIAGRAM (Show Iocahon of well, septic system, property hnes, foundahon, Ma~ulacturer Capacity ~n gallons Depth to p~pe bottom from Total depth from original gradeF~ ~ Number o,, .... Soil rahng~ S~ P,pe materia, ~ ~ ~ PRIVATE ~OTHER (Identify) ,~ Dale Inslalled: Inspectio~ed bY: I Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: ~ Township, Range, Section: SLOPE 1 2 3 4 5 6 7 8 9, 10- 11 12 13 14 15 16 17 18 19 2O SITE PLAN WAS GROUND WATER ENCOUNTERED? A) O S IF YES, AT WHAT ~ DEPTH? p E Moniloring? Dale: Gross Met Depth to Net Reading te Time Time Water Drop PERCOLATION RATE (-~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ¢ FTAND 2 FT COMMENTS,~¢.,~ ~.,~,,~-.~,,,¢~.~2~.~ ,~,,~0,~/¢I¢ ~ ~ ~ ~ ~ r e~ ~/~ PERFORMED BY: ~ & ~ BN61NEERIN8 ~ ~CERTIFY THAT THIS TEST WAS PERFORMED IN ~7034Ea leRi~erL RoadNo 2 ~¢ ~ ' , ACCORDANCE W~H,L~.~_M~AL GUlP'EL ~CT ON THIS DATE. DATE: . '~ ~ ~agleKWer~ ~la~aT~ai/ ¢~CT ON THIS DATE. Db , . ~ · MUNICIPALITY OF ANCHORAGE i O DEPARTMENT Of HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENI'AL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL DESCRIPTION NO. OF BEDROOMS LOCATION ~ ,. ~ . DISTANCE TO: Well ~/O~ ' Absorptionare~ , Dwe,ling ¢ ~ , PERMITNO~ Mater~F~ No, of 'cQmpar tments ~ ~ Liq. capacit~ v- ~O IF HOMEMADE: ~ * :~ ]n~allons Inside length Width Liquid depth Well ~ ~ ~ ~ ~ DISTANC~O';1 ~ ~ ....... ~ Dwelling PERMIT NO, '~¢ Material ....... LiqUid eapac~y in gallons · O. of lin*~ Length of each I~o Total length of lin~ _ Trench width. , Dist ween lines ~'~ Top of tile to finish gra~ Material beneath tile ~ i~.Total~fecti,~e~¢r ~th Depth PERMIT NO. ~ Length ~ ~ Type of cr /¢' Crib depth//_..-¢-- -- 'N~ _/~- m / .Buir~ng foundation %. .~eare¢¢[0t line - .... ¢ DISTANCE TO: Clas~ ~ ~ .~ Depth Driller Distance to lot line PERMIT NO. ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE MATERIALS SOIL TEST RATING INSTAELER REMARKS / ~ APPR~ ~ DATE LEGAL THE LENGTH D!!I'iEN~E;!ON ~E; 'THE LENGTH ,:;IN FEET) Of:' THE TRENCH OR [:,F:F!INF!ELD. "rile DEF'TH OF Fl 'TF:ENCI-~ OR F'ZT !:5 THE DZ:STi:~NE:E E;ETF!EEN THE :E;Lli:~:FRCE OF THE GROUND FiND THE E:OTTOH OF THE E',:.,iCRVRTIOI'.,! ,:: Z N F'EET). THERE iS NO SET !.,.iiE:q"H F'OR TRENCHES. THE GRRVEL DEPTH ZS THE h'iZNZHt.!H DEPTI4 OF GRRVEL. E=E'1"!4EEN THE OUTFRI...L PiPE RND THE BOTTOH OF THE E';-::CF~VRTiE~N (ZN FEET::,. Z PEF~:i',!'r ~ F:!PPLt h,f.,, l'-'IF!:i~; THE F:'rE':.~P.Z.'.:~FIE:'rL.'_rT? TO ,1'. ,, .,.,1~,i', 'THIg; ........ Zi'.JSTF-tI.~_..::FF;~231'.4 tZixi'E;PE:'CT.~FiI'.,i'::; OF' Fii"~."¢ 4Eij~'~ RD..)'FiCEiNT TLq TH, IS F'Fi:ELr.:'IE[;~'.Th.' FIi'.,II) THE .h,IUHBFF:F: OF .... E:ESiL3E.NCE:':'i; "r'~l'"'T-.h. '""'""~ mi: 1,~[:'t~ .............. l.,.!:[~ SEF~:'v'E. ......... ,r - ............................................. ! E:.ERT 11: F'? 'Ti-IRT ::L: t RH F:'RHIL!R,~R !.4:[TF! THE REii:!UiREHENTS FOR ON-SiTE :SEi4ERS RN[:, k!E!....L.S RS SE'T F'O~'.TH Bh-' THE HUh!iE:IPF:IL I T'?' OF FIt'4CHOFtF!GE.' ;2: I Ft!LL !NtE;TI:!LL THE S'~.'STEH iN !~E:E:OF~:DRNCE k!ITH THE E:O[::,ES. 3:: I LiNDER:SI'I¢~I'4[)THFIT THE ON-'SITE SE!.,,iEF: Sh"STEH HFi'.¢ FtE:6tRJI'RE EI'4L..FIF[:GEHENT IF THE F~F'F'L. I E:RNT HFIFFI" I i',,1~ L l ST / ~ O & E ENG,NEERING & DEVELOrMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 SOIL LOG Performed for: Name: Mailing Address: ~"/'~' /'~' Legal Description: ~-¢)'T~ / Earl Ellis 688-2280 Tel. No. ~'-37/-~ Depth (feet) 0 Soil Characteristics 11__ 12__ 13__ 14 15__ 16__ Ground Water Encountered: Yes Propose.d Installation: Seepage Pit / No ~ If yes, what depth Drain Field Comments: PLOT PLAN PERC. TEST Performed by: Z ,,? R[ls;ell Oyster 694-2774 Performed for: Legal Description: Depth (feet) 0 3__ 4__ 5 6__ 7__ 8__ 9__ 16 O & E ENGINEERING & DEVELOr'MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Earl EIII~ SOIL LOG 688-2280 Mailing Address: ~'-~- /f-~f~-~'~-~'""~ ~.~"-~ ~_.~e ~.~ fU~z~/ ~/~_. 9'~-77 Soil Characteristics Ground Water Encountered: Yes__ Proposed Installation: Seepage Pit Comments: ~f~43~ /_._,AJ/~ No /~' If yes, what depth Drain Field ~ PLOT PLAN PERC. TEST Performed by: ~ ~ :~ Municipality of Anchorage ° r On -Site Water and Wastewater Program (907) 343-7904 Certificate of On -Site Systems Approval Parcel I.D. 067-301-04 1. GENERAL INFORMATION: Complete legal description LIST; LOT 1 Location (site address) 30319 List Circle *Eagle River Current Property owner(s) John Petraitis Mailing address Real Estate Agent 2. TYPE OF DWELLING: © Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Expiration Date: 1a -Z2 -21 Day phone 406-5170 Day phone 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well --. =`V` .G > tzr-��s t �' v Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Well + �r p_�+Lu Distance: t Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ - 0 Date of Payment %5A Receipt Number. 056ti2rs COSA# 05C_21 1395 Waiver Fee $ Date of Payment Receipt Number Waiver ## OSv 211 o 5 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm: Garness Engineering Group Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road Suite 101- Anchorage, Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: _4 1 In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life.of all wells and septic systems depend upon a variety of variables, including but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. 6. DSD SIGNATURE System #1 Approved for _Y__ bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, #AECC884 OF ((( C�, r44,i i Q �E with the followi7stiptl � Sv,t G�p�ER CO O S� J NkA �r1` -. Original Certificate Date: 7r 2 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist _ Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other 94 Leo=1 Description: LIST; LOT 1 Parcel !D: 067-301-04 If more than 'I septic system on lot: COSA Checklist #f of Structure served by this system FORMERLY CLASS "C" WELL A. VVEELL DATA ❑ Well log is filed with Onsite (or attached) Well production at time of test 8.3+ gpm Date drilled '6/4/76 Water storage tank volume N/A gallons Total depth *122 ft Well disinfected for coliform test? ❑ Yes C No * Cased to 122 it ;-Coliform bacteria is Negative [,l Sanitary seal is functioning correctly Nitrate �_ mg/L ❑ Nitrate less than 1'0RL (ND) C Wires are properly protected Arsenic ug/L ❑�senic less than MRL (ND) Casing height (above ground) 18+ in. Collected by GEG, LTD. Date of flows test for COSA 7/1/21 Date of Sample 7/1/21 Static water level at beginning of test 87.8 ft. Comments *INFO TAKEN FROM 1988 COSA - NO t!>,/ELL LOG IN MOA OR DNR RECORDS B. T:Ai,!K DATA !E1 LIFT STATION' Age of tank(s) NEW years Required maintenance completee` Tank type/materia! e of lir station vF' sMteasured operating fluid level in septic tank NEW station matedStandpipes/foundation cleanout per record drawing mment Date of pumping NEW 1988 & 1982 D. ADSORPT!0:\1 FIELD DATA Which system tested (date installed) "66a"62 Adequacy test date 5/15/21 ALL standpipes present per record drawling Results ❑Pass For 4 bedrooms Total measured depth from grade ""& lose ft (max) Fluid depth prior to test DRY in Mieasured depth to pipe invert from grade *7.08 ft (min) Water added 691 gal ❑ N/A — pressurized field 8 New depth in ❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 30 min depth into effective *G9& so P ® Code -required soil cover over field Final fluid depth DRY in ❑ System presoaked Absorption rate 600+ god (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NO date of test) Gallons introduced N/A gallons If yes, enter date N/A Corriments/Deficiencies: TESTED 1982 TRENCH ONLY - 1988 TRENCH MT WAS DRY 5/15/21 COSA Checklist yellow sheet E SEPARAT;GrDiSTAi'.CES From Private VVeli on Lot to: (Please enter distances if less than required or if community well Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100' ❑✓ Yes it' No ft d Yes if No ft Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' M Yes if No ft ,Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100' Z Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ✓❑ Yes if No ft F,-/� Yes if No ft M@rlLlre/Animal Excreta Storage > '100' Community Sewer Main ? 75' ❑✓ Yes if No _ ft ✓❑ Yes if No ft From Septic/f so'sding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑✓ Yes if No ft Surface Water > 100' El Yes if No ft c� t� rI Property Line = 5' ✓ `les ❑ if NoLots.- `t Wells on Adjacent Lots: Absorption Field > 5' Absorption ❑✓ Yes if No ft Private Wells > 100' ✓❑ Yes if No Water Main > 10' 0 Yes if No ft Community Wells > 200'✓❑ Yes if No ft` ,Nater Service Line > 10' ❑✓ Yes if No ft If septic tank is under driveway comment below �y (7 From 4.bsor ption Field on Lot to: (Please enter distances if less than required) Bi.tilding Foundation > 10'Yes if No ft If absorption field is under drive vay comment below Property Line - 10' ❑✓ Yes if No ft Wells on Adjacent Lots: Water itiain > 10' 0 Yes if No ft Private Wells _- 100' ❑ Yes if l"lo x99 ft Water Service Line > 10' ❑✓ Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Surface Water > 100' ✓❑ Yes if No ft DC6—j ULS I C�l ei `f -D- :. ENGINFEER'S COMMENTS *TO WELL ON NORTH SLOPE; BLOCK 2, LOT 1 B. THERE IS NO FOUNDATION CLEAN OUT, BUT THERE ARE DOUBLE CLEAN OUTS PRIOR TO TANK. v^^. E'NGIII,EER'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. COSA Checklist yellow sheet A ;..:... ;.. ....... ..... _J r rev �A` Garn ss, CE� i�) oceo #AECC884 Loi 2 PrN O O O cn N 0] J i Loi Q--2 130.0' N 89'56'33"E 230.00' -� 15' T&E EASEMENT-` WELL 76.8' RETAINING WALL— Loi `l 64,700 S.F. FENCE R`cS'DCc S. I l 1.8' PROW CANT rn / h, S 89-55'1 5"W 210.55' cn C LIST CIRCLE 81.7' - —ROOFTOP DECK WOOD SHED —SEPTIC— PIPES i MANHOLE—' t 1 1 0 NOTE: AGREEMENT TO PROVIDE ACCESS TO WELL RECORDED IN DOC. No. 1988-026253-0 PLOT PLAN AS BUILT _X_ SCALE _1=__ 50' _ GRID SE 0702 Project No Z1-38�R1 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang Associates, !nCo (907) 522-6476 Phone qo�0 (907) 522-4625 Fax ao`�"oopQ Professional Land Surveyors ken0langsurvey.com O g.� � jonothan0longsurvey.com I hereby certify that I have surveyed the following described property: LOT 1, LIST SUBDIVISION (PLAT No. 83-530) p 49TH Anchorage Recording District, Alaska, and that the improvements situated thereon are""/"/"" within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed �'�� :' • KENN M GGA LANG premises and that there are no roadways, transmission lines or other visible c� easements on sold property except as Indicated hereon. ,.t. -•�- J.LS-5202. Dated this the Day of -- U ; _-----__ r'' at Anchorage, Alaska 4p oR apo 404O_FSSIONA�-�� It Is the responsibility of the owner to determine the existence of any easements, 4p4OQ� covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 Ca �a ity of Anchorage P.O. Box 196650 0 4700 Elmore Road Anchorage, Alaska 99519-6650 0 (907) 343-7904 0 Fax (907) 343-7997 http://www.muni.org/Onsite eel end Services Degartment On -Site Water and Wastewater Section ****'wV'rARIAN`kCT/WAIVER REVIEW X x x X Waiver#: OSV211052 COSA#:OSC211395 Permit#: PID#: 067-301-04 Legal Description: List Lot 1 Engineer: Garness Engineering Group Applicant: John Petraitis Your request for a waiver of the required 100 feet horizontal separation from the absorption field to the private well on North Slope Block 2 Lot 1 B has been approved. The approved separation -- distance is 99.0 feet. See engineer's waiver request for justifications. If separation is determined to be less than 99.0 feet, the property owner of North Slope B2 LIB will need to request and pay for a revised waiver, since the well was drilled after the absorption field was installed. This waiver approval applies to the existing absorption field only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. a0aaaaeaavavaiamaaaevaaaaataeaaaaaaaaavaaaaameaavvaeaaseaaamaavaaaavmaavamaaem1 Waiver is Granted: X Waiver is not Granted: Date: 1 0�. t oC.a1 � Approved by: Name of Reviewer vveeveveamvsevmeeevmmvavvevavvvaeavmvsevaavvemmmvavemvveeaemaavvveemmmvaeevvevt July 27, 2021 Municipality of Anchorage Development Services On -Site Water & Wastewater Program ��z/� fireyrt4ss 4700 Elmore Road CE -7953 •��'' Anchorage, Alaska 99507 Phone: (907) 343-7904 Ref: Waiver Request for List SID; Lot 1 — Drainfield to Neighboring Well To whom it may concern: During a recent site visit for the purpose of obtaining a COSA, we found that the separation from the end of the drainfield on the subject property encroaches upon a neighboring well located on North Slope SID; Block 2, Lot 1 B. We measured 99+/- feet from the edge of the cleanout to the edge of he well. To be conservative, we - are requesting --a 96 -foot- separation distance waiver- for this encroachment. The drainfield associated with this encroachment was installed in 1988 and the well on the neighboring property was installed in 1994. In short, the encroachment was created by the neighboring property owner; therefore, the owner of the subject property should not be responsible for any waiver fees. The following is justification for this waiver: ® Attached is the neighboring well log. As can be seen on this log, there is confining gray clay soil from 65 to 94 feet and there is a silt & clay layer from 94 to 147 feet. These confining layers should protect the aquifer. ® The grade for existing drainfield is lower in elevation than the grade at the neighboring well. If any wastewater where to daylight from the drainfield, it would not flow towards the well. Kogru Place is between the drainfield and this well. Based upon these justifications, there is minimal risk with granting this waiver. If you have any questions, plea,�e,6,ontact us at 337-6179. Thank you for your assistance. Sin rnessA P. E., M.S. 3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259 Phone: (907) 337-6179 * Website: www.gamessengineering.com MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ['~.~--~ ~ ?~"~\ - (~ HAA # 1. GENERAL INFORMATION Complete legal description Lot 1; LZ~t Subdivision Location (site address or directions) 2305 Eagle River Road Property owner Mailing address Lending agency Mailing address Kevin & Patricia Rattue 2305 Ea_qle River Road Day phone Eagle River, Alaska 99577 Day phone Agent Virginia Kohfield RE/MAX OF EAGLE RIVER Day phone Address 16600 C6nterfield Drive Eaqle River, Alaska 99577 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: NOTE: 694-4200 Individual well Community well XX Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer XX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. NOTE: 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, ~ verify that my Authority Approval application shoWS that the on-site water supply investigation of this Health . · and adequate for the number of bedrooms · _ s osal system is safe, funct~o.nal._~. ~.oo,~a nn e information obtained from ~l/~/p~%~rd~ ~c~tcatedherem i furthervemYm~'~ ....... th water i the Municipality of Anchorage flies and from my investigation and inspection, the on-site supP[Y 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. Phone S & S ENGINEERING Name of Firm ~ver Loop Road No, 204 Address ~ Date ~-~'~ ~''' ~ ~' Engineer's signature DHHS SIGNATURE _~ /~ Approved for --// Disapproved. ' Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Sepiices (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engtneer re,cj ste!ed ~n the State o4 Alaska The DHHS does this as a courtesy to purchasers of homes and their lending instituttons ~n 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. Legal Description: Municipality of Anchorage DePartment of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A, WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number Log present(Y/N) Date completed Driller Total depth Cased to Casing height Sanitary seal (Y/N) Wires properly protected (Y/N) Date of test FROM WELL LOG Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot g.p.m. AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer main Sewer service line WATER SAMPLE RESULTS: Date of sample: Nitrate B. SEPTIC/HOLDING TANK DATA Public sewer manhole/c,leanout Petroleum tank /. Collected by: Other bacteria 17034 Eagle River Lo~p Road No. 204 Eagle River, Alaska 99577 Date installed "~ -- l L~ >~?--- Tank size ~7_~'o Compartments Cleanouts ~'~N) ~/ Foundation cleanout ~I~3'N) y Depression High water alarm (Y~ ~J Alarm tested (Y/N) 'J//~ Date of pumping ~,- ~ o - ~ 2- Pumper ~",~, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot J ~'0 ' On adjacent lots To propertyline /~ ¢ ¢- AbSorption field Surface water/drainage /~o / ¢' Foundation '/--/-5" / ~ ' wate~ main/service line /~/ ¢' 72-026 (Rev. 7/91) Front ' CONTINUED oN BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOAeI~ Manufacturer Manhole/Access (Y/N) .~---~-'-~- "Pump on" level at / -~m;~"Pump off" level at ..----'~'~ Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed ~ ~ ¢~" ~ ~" ~ Length ~ ~ Width Total absorption area --<'"'~- Depression over field (Y~J~ ~--! Results ~fail) Peroxide treatment (past 12 months) (V,~) Soil rating 17-.¢ ~'/~ System type ~'¢-¢~J'4-/'~/ Gravel thickness ~ ~ Total depth /2. ~ /' /d ~ Cleanouts present ~_.~/N) \/ Date of adequacy test ~ ~ ,7. Z_ ~'~ / for (/'¢~') ~"~ u/r._ bedrooms /Z/J ~ ~U,,../ If yes, give date ~/~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot l ~ '7~ ~ To building foundation On adjacent lots ,~ Surface water ID~ Curtain drain On adjacent lots 'J'/.~' Property line lot J¢ ~ To existing or abandoned system on lot ~'//~, 3utbank ~/~ Water main/service line ~o 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. Signature Engineer's Name Date ,~ 8~ S ENGINEERING 17034 Eagle Rive~' Loop E~.gle River, Alaska 9957~' HAA Fee $ / ~[~, ¢J7~ Date of Payment ,~ Receipt Number Waiver Fee: $ Date of Payment Receipt Number DEPT. OF ENVIRONMENTAL CONSERVATION WALTER J. HIOKEL, GOVERNOR ANCHORAGE DISTRICT OFFICE 800 E. DIMOND BLVD., SUITE 3-470 ANCHORAGE, ALASKA 99515 July 1, 1992 349-7755 Mr. Raymond Shafer S & S Engineering 17034 Eagle River Loop Road, Suite 204 Eagle River, AK 99577 SUBJECT: PWSID #217097, well serving Williams Subdivision Dear Mr. Shafer: A review of the available records on file in this office indicates that the William Subdivision Class 'C' Public Water System, serving Lots 1, 2, and 3 is in compliance with the provisions of 18 AAC 80.060, State of Alaska Drinking Water Regulations. If the Department can be of further assistance, do not hesitate to call us. Sincerely, Michael Lu Project Engineer ML/pf 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 HAA # 1. GENERAL INFORMATION . Complete legal description Lot I~ List Subdivision: Location (site address or directions) NHN List Circle Property owner Mailing address Emerson Molt Day phone Lending agency Mailing address Day phone Agent Sharon Minsch Re/Max of Eagle River Address 16600 eenterfi~ld Dr. #201 Ea,qle River~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 Day phone 6.94-4200 - Ak. 99577 i:, : TYPE OF WATER SUPPLY: NOTE: Individual well Community well ~ Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site , Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA~21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S & S ENGINEERING 17034 Eagte River Loop Road No. 204 Address t:ngl,~ ~ivr... ~,l,-,,~b~ 09577 Engineer's signature Phone Date / / DHHS SIGNATURE ~,/~ Approved for ,~/--Z,~"/Z//.~ bedrooms. Disapproved. conditional approval for bedrooms, with the following stipulations: Additional Comments 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-O25 (Rev. 1/91) Back MOA 1¢21 -i ~ ~_.c,-¢ Municipality of Anchorage ~1~ " Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHEC.,K. LIS~'~E~3n.-~ Le al Description: '\ ~--~-,'¢ Parcel I.D. A. WELL DATA Well type ~-' If A, B, or C, attach ADEC letter. ADEC water system~umber Log present (Y/N) Total depth Sanitary seal (Y/N) Date completed Driller Cased to Casing height Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well flow Pump level g.p.m. g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot t, ~'C> ' / Absorption field on lot Public sewer mai~ Public sewer service line WATER SAMPLE RESULTS: Coliform ~ c"~"/~:~o ~ Nitrate Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed '~ ~ I U, Cleanouts ~'N) High water alarm (Y,~ Date of pumping ,~- 2-'~ ~"! ; On adjacent lots ; On adjacent lots. Public sewer manhole/cleanout Petroleum tank Collected by: Tank size ~'~ ~ Foundation cleanout ~/N) Other bacteria ',¢ Depression (Y~ Alarm tested (Y/N) $ & $ ENgiNEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Compartments Well(s) on lot t~-c> ' To propertyline \ O ' 4--- Surface water/drainage SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: On adjacent lots Absorption field Foundation Water main/service line 72-0~6 (Rev. 3/91) Front MOA21 , CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Manufacturer Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at High water alarm level Meets' MOA electrical codes (Y/~ SEPA~NCE FROM LIFT STATION TO: W.e-H~,n lot On adjacent lots Surface water D. ABSO'RPTION FIELD DATA Date installed "~ -\L~-' Length ~ ~ ' Width Total absorption area Depression over field (Y/~P Results .(~[~fail) ~;;;~/~---.~---~ Peroxide treatment (past 12 months) (Y~) · cf'cOl '~'9'5 Soil rating \"~,~ ¢--" Gravel thickness /-~ Cleanouts present ~N) Date of adequacy test for (~ ¢~ ~ ~O~ ~ If yes, give date System type Total depth bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot \ L¢Z--~ On adjacent lots ~'~//~ To building foundation ~ On acl.iacent lots "2.2L~ ~ ~ Surface water ~ ~ ~ ~' ~ Curtain drain ~J I,~ Property line To existing or abandoned system on lot Cutbank ~ ],~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICA'rlON I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect Inspection. ~ ~, ~ ~n~in¢-r'~ Name ~/'~..¢t : ........ HAA Fee $ / Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number 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 SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) E-:m- Location (address or directions) (b) Property Owner L---Ir~lp~"~ ~:::~,o:"TW" Telephone:Home tC2~Z~'-'"~.~ Business (c) Lending Institution '.5 T.e. lephone Mailing Address' · (d) Real Estate C0mpar~y ~nd Agent Address '~0. ~ ~ Telephone '~:~,~,~ (e) Mail the HAA to the followinq address: or: Check here,~, if hold for pick'up. List contact person and day phone number below. S & S ENGINEERING 17034 Eagle River Loop Roa~ EalTle River, Alaska 99577 TYPE OF RESIDENCE Single-Family,~ Number of Bedrooms WATER SUPPLY Individual Well [] CommunityJ~-- Public [] ~...--"'~ ~, Note: If community well system, must have written confirmation from the State Department of Environ mental 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 Environ mental Conservation attesting to the legality and status. Page 1 of 2 72-025 fRev 8/861 Front '~Jo~ sdeeu!Sue IBuo!ssejoJd @q~ u! SUO!SS!LUO nO SJO.lJe JOJ elq!suods@~ ~ou s! ebeJoqou¥ jo A~!led!o!unv~ eql 'p@nss! si elB:)!biPe3 B eJojeq B~Bp ez/,iBue Jo suo!~oedsu! 13npuo3 ~ou op SHHQ jo saeAoldLU=] 's~ueLuaJ!nbeJ e~e~s pub le~epeJ u!Bpeo /,Jsi~es o~ JepJo u! suoi~n~!lsu! 5u!puel J!eq~ pub secuoq bo sJesBqo~nd o], AseMno3 B sa s!q~ seop SHHQ eqj. 'e)lSel¥ bo eIBIS eq~ u! pe~e~s!beJ ~aau!bue leUO!SSebo~d ~u@puedepu! uB Aq e^oqB ~ qde~l]B~ed u! ue^!6 suoilB~uasa~da~ eqi uodn ,~luo pesBq sa~eo!j!peo le^o~ddv A~poq~n¥ q~leeH senss! (SHHQ) seo!^JeS ueuJnH pue q~leeH bo ~UeLUpedeQ e6BJoqouv jo Al!led!o!unv~ eq.L NOIJ. n¥o leUO!l!puoo @uoqdele£ WELL DATA APR 1 9 988 MUNICIPALITY OF ANCHORAGE (MOA) ' MUNICmAq~, ..... I~£ALTH AUTHORITY APPROVAL (HAA) DEPF. OF MEALFM & ~t~F/'ECKLIST ' FEBRUARY 1984 ENVIRONMENTAL PROTEC-~ION 264-4744 Legal Description: .RECEIVED Well Classificatio, n Well Log Present(~N) Total Depth \'7~-'~ ~ Static Water Level Casing Height Above Ground Electrical Wiring in Conduit~N) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E.C. ApproveddCi~TN) Date Completed ~;>~z~. ~ '~ (,¢ Yield Cased to \'"'~?'"? Depth of Grouting ---'-- ~t ~ Pump Set At ~_)~6.~ ~_.~q 4-- Sanitary Seal on Casing (~/N) 7' Depression Around Wellhead (Y/~ ;On Adjoining Lots To Nearest Edge of Absorption Field on 17ct \ ~ ; On Adjoining Lots To Nearest Public Sewer Line ? ~/,~:~ To Nearest Public Sewer Cleanout/Manhole ~-4/j~. To Nearest Sewer Service Line on Lot "-~-~ Comments B. SEPTIC/HOLDRNG_TANK DATA To Water-Supply Well To Property Line To Water Main/Service Line Course Date Installed ~, ~' ~-~__~Z- Size Standpipes (~N) "~ Air-tight Capsd~) Depression over Tank (Y/~ '~-~ Pumping/Maintenance Contract on File (Y/N) / / ~Holding Tank High-Water Alarm (Y/N) ~' Separation Distances from Septic/Held~g..Tank: No. of Compartments "/ Foundation Cleanout (~N) ~' ,Date Last Pumped ; for ~/,& Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1..Of 2 -; :. · 72-026 fRev 8/86) Fronl C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~'~¢~;>'/-~ ~ Width of Field ~-~ ~ Square Feet of Absorption Area Depression over Field (Y/~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot r~/,~ To Water Main/Service Line Type of System Design Length of Field Depth of Field Gravel Bed Thickness ~'~'~'~:¢"~'~;d%z"%~ Standpipes Present.N) Date of Last Adequacy Test To Property Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Existin!~ or Abandoned System on ; On Adjoining Lots "~(;:/'+' ] To Cutbank (if present) Comments D. LIFT STATION Size in Gallo ns~-----. ,,pu m p On,, Level at-~'"~---.._~ ~ High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) ~ .~mping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request I certify that I have checked, verified, or conformed to all M/~A a.n.~;AA guidelines in effect on the date of this inspection. Sign~,d& S E,..~.G~,N.ER!_kl¢- Date ////~///0Od6¢/ Com~[~:~ 4 Eagle River Loop Road No. 21~O,,A No. Eagle River~ Alaska 99,577 Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 fRev 8/861 Back 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 March 9, 1988 Application Date GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Properly Owner /~h;t'£z I~'xt Telephone: Home Mailing Address (c) Lending Institution Telephone Mailing Address ' Business. (d) Real Estat8 Company and Agent T~C~FT ~F4LTy/~e~e 05.¢~5~ Address 'P.~3. Rnx 774~7; Eag~a. Rx'u¢.r; A.F~,~.a. 9qF;77 Telephone ~94~73~8 (e) Mail the HAA to the fotlowina address: or: Check hereJ~ if hold for pick up. List contact person and day phone number below. S & S ENGINEERING/B94-2979 17034 Ea~l~ Riv6r Loop Road, Suit~ 204 Eagl6 River, Alaska 99577 ordzr~d by Pet~ TYPE OF RESIDENCE Single-Family,[~ Number of Bedrooms WATER SUPPLY Individual Well [] Community,~ Public[] (Class C) 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 confirmatior~ from the State Department of Environ mental Conservation attesting to the legality and status. Page I of 2 72-025 fRev 8/861 Front '~Jo~ s. Jeauibue leUO!SSejoJd eq~ u! suo!ss!uJo JO s Jo Jla ,Iot elq!suodseJ lou s! ebeJoqau¥ jo/q!ledia!unR eq/'penss! s! a~ea!l!pea e eJojeq eiep eZ/~leUe Jo suoiiaedsu! ~onpuoa ~ou ap SHHQ jo sea/~oldW3 's~uaLue~!nbeJ ale,s pue leJape~ u!e~Ja3 ,~js!~es o~ Jap Jo u! suognl!~,su! 5u!pual J!eqi pue sauJoq Jo sJaseqaJnd oh/~sepnoa e se s!q~ seop SHH(] eqj. 'e~tselV jo e~e1S eq~ u! peJe~s!beJ Jaeu!bue leUO!SSeloJd ~uepuedepu! ue /~q e^oqe S qdeJDeJed u! ua^ih suop, e~uaseJdeJ eqi uodn /[lUa peseq se~eay!pea eAoJddv ,~lpoq~n¥ q~leeH senss! ($HHQ) seo!^Jes ueuJnH pue q~leaH jo ~uewpedeQ ebeJoqauv jo/q!led!own~ aq/ NOIJ. nYO 'S WELL DII~C~ ~D Well Classification Well Log Present'[;)'N) Total Depth \ '7.~'/.~ Static Water Level Cased to. MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 Legal Description: ~'~"~ Casing Height Above Ground Electrical Wiring in Conduit((2~'N) "/ Separation Distances from Well: / To Septic/Holding Tank on Lot \~C;~ If A, B, C, D.E.C. Approved ,~N) ~' Date Completed ~:, ~'¢c ~"~ (~¢, Yield ~ "L.-~- Depth of Grouting Pump Set At I'~. --k Sanitary Seal on Casing ~;~:N) Depression Around Wellhead To Nearest Edge of Absorption Field on Lot ,/.. To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot Comments B. SEPTIC/HOLDING TANK DATA To Property Line To Water Main/Service Line Course No. of Compartments Foundation Cleanout ~N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) Date Installed Stand pipes~.~i~'N) y Air-tight Caps~N) Depression over Tank (Y/(~) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/l{~ Tank: To Water-Supply Well \~C> To Building Foundation ,¢:3¢~ ]¢: To Disposal Field ~ I To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026 fRev 8t86~ Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/4[~P Results of Last Adequacy ,Test Separation Distance from Absorption Field: To Water-Supply Well \ t~ To Building Foundation I,.¢p¢.~ Lot ca/A' Type of System Design '~':b / Length of Field / Depth of Field Gravel Bed Thickness To Water Main/Service Line Standpipes Present ((~¢N) Date of Last Adequacy Test To Property Line ~-P ~' To Existing or Abandoned System on ; On Adjoining Lots ~ t'Jr- To Cutbank (if present) t'~/~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments I.4- ~"'~teq~st ailed Size in ~ "Pump On" Level at ~ High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) ring Adequacy Test. Meets MOA ** 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 $ & $ I~NGINEERING Date C ..... ,~7034 Eagle Eider Loop Eoa~ No. 204 ~agle River, ~,~ ...... MOA NO. Receipt No. ~ ~ 3 ~ Date of Payment ~,~/~' ~ Amount: $ ./ Page 2 of 2 72 026 fRev 8/861 Back En ' , ~.