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HomeMy WebLinkAboutLIST LT 3List Lot 3 #067-301 -02 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program. 4700 S. Bragaw St. P:. Box 196650 ww.d.anchorage aAnchorage, ws (907) 343- 0 N-SITE 43-ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PID Number. ___0(022L - 6011 (r `tom Page f of 3 Permit Number: StA OYOSt•l Nam.:.BRy4a It 3a,(S "telt "°aefsoz/S LIST G2CL; . e.e. NYn'be a B.droon.: LEGAL DESCRIPTION Block: Lot 3 s.eo LM: (sr 5/6 Townsmup Flange: Secoom: Well: EjC(JVNC e❑ Upgrade Gasyecabm (Private. A B. /Total Cased m: FI. FL Dreier Sabc to Leal: R Ytxd. I PerryCasing Above Ground: GPMLI FL SEPARATION DISTAr To Septc Absorption Uft From Tank Field Station p'f' -r AI/1 we. /00 / 0o' Fr N/4 Sonia Wale /Q0'0- /00 Latae 0ea. (0'r K/9 Foundatron /p't /6(I- NA - Cain Drain Vilt4 eJ/4 VAM CES Holding Tank RR �/4 a/1 ,t//4 N/4 Wastewater System: 0 New 2 Upgrade 'optttlprivate Sewer LNe Remrka* sod (, AU.onf s Fr, c ABSORPTION FIELD 0 Caner nein TrsShalom' 0 Shalom Trench Mound O Bed 0 e /� Tout Depth from on4lul Vine: 5 7.FI. 2S'r Sae Rating: rcrIN GPOIVI' Depet lo V W bottom fan coral grade. SF1. H added above cannel grade: FI Gaal WW1: TOW .ofaP•at ea: rztAric 40peo A-FTF'- r)<(Sr4 12 50 t »c Loi T4, f K. BULL Rag yric-vi 'cowrie -'Ed r b o2(come. S FI. 7SO Fr Gravel depth beneath ppe: Gravel Length: zit FI 7i F1. Numdet 0 Ines: I [sande between Ines: Ft.+ „,. WarW.Pift. so3ct Data retake,:/WC2Fia "1 TANK �7Septic ❑ Holding ❑ S.T.E.P. 0 Other. k.nuIxiasapaaty. (ctteet4 re rrnv . Sea Gr. Nurrner 01 Carpxlmomu. / LIFT STATION Sze.71Aanufaclurei. •P T Pump de' was at. I Wgn.9'e PunyFjaanry • perlatrod by mane BENCH MARK LWbat and 0e10pb1ev �tJ�+� Fxrsn�e C. o �n/n- AbdomenE..abon. /00 F1. B rrwi aJ //.crit r VAIk Inspections performed by: /ilb2TIft(° Metered: 6•- Dates: 1' /ora7/04f 2^°/3/42 7/0cf Development Services Department Approval 3 Reviewed and approved by: t> Date: 9- 0 n �'� - ' ten II0OI E 122e1 (IAN 12 Ord5?1... F"A�r� �l • r* 149114 •;t �t 0000 ice . Sista W En+7 4. de • PE 6256 V `✓ 1 s .n Z14 PROFE5=t`3'' .ri `W EMENTS A 2.5 161 4.5 163.5 0 93.5 2 83.5 83.5 79.7 Septic Tank Test Hole Cleanout Drainage Easement o Surface Water or Swale 1' = 40' 4 1 _,_.,t1 LIST S/D ENGINEERING .. . LOT 3 I PLAN NORTHRIM c;•-• �� •. LAYOUT 17237 Boor Pow Circle Eagle R/w. Alaska 99577 AS -BUILT DIMENSIONS 11/8/04 f2'of 3 SNDIIVA3-13 rr 0 0 r-4 N 1 W N g CI w 0 h h 0 3 (0 N N h S O ID 11 4-4 IT 11 O.U1:AW IVr m VI 13 fl D N h f O .+ e+ Z O�y� z bCuO S Z m ri0 �Vl�w O4 3 n(0N z n 300n.S+X3^Z rn n to N n,C.+0M <C3 r 3 0 c Q 3 m3a 3 < < '0Zy3 H0 ='!0 CN N3 Sip <<J n m N N '+N • ;C UI n o.+ 3 <3> coh 3 c 0 IV �hC O 3 in r -omn * 3 r T N W 3 n On S O_ < Q - f0 r m 0 n S C hC 3 03 3 n O C h 0 a 3 n S O Z C IO D x m C 0 3 II m fV r N m ., N - I Z cl D Z I`ll rl< -<O C ZN - -I mm < - 4 h N Dp_ Irl In W f'1 Z O corn Iii, r -z£ A Zr ri x r y Z < Z rn za r • +,06 = 13 ap0u3 ln414 • C -4 O -4 owa zr mr v C .TI Z m< zD n r t1 3 N (11 S o 0 0 • 0 (0 3 -I h C O .P I'1 o C h 1- 0 N x 0 3 4+ 0 Z -1 C 0 3 3 n S O z 00 ID -1 C 3 uollo9 DOS MaN i m x O C 3 Q 0 4+ 0 n '0 0 3 r c+ N 3 O h N — m X N f'1 h < • (D eC+ : O 3 3 0 11 c co 5.'4. ID No 0 3 i0 0 3 0 c h N l ,g16 = uol}vna 1 I I youaJl MaN 01 13 v n 0 O < N 3 Z (0 n N f#47 • c O h C O h 3 N 11 '.0 0" t MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Permit Number: SW040459 Legal Description: LIST LT 3 Design Engineer: 0838 North Rim Engineering Owner Name: BRIAN & DORIS NIVER Owner Address: 30215 LIST CIRCLE EAGLE RIVER , AK 99577-9717 Date Issued: Oct 27, 2004 Expiration Date: Oct 27, 2005 Parcel ID: 067-301-02 Site Address: 030215 LIST CIR Lot Size: 62341 SO. FT. Total Bedrooms: 6 Permit Bedrooms: 6 This permit Is for the construction of: E Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must 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 engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By(-5—nr. Issued By. 9i urn 1 a Q� Date. /G/2 77c c( Date: /6/a )/6 t{ Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. i�-I ^�'2,C11 - np? Permit Number SW Property owner(s) 8/2 y4N se- boR / S nf/vER Day phone 675/- 4/4LL Mailing address (1) 30215 LIST CeRcc.p , 6'Le 2r c/a. ,4J. Mailing address (2) Zip Code 9 ?S7 7 Legal description (Lot, Block & Sub'd.) L / s r s/b , L..or3 Legal description (Section, Township & Range) Lot Size 'err' Acres/8crft Number of Bedrooms 6 ba, 34 t ev 4. THIS APPLICATION IS FOR: Sewer Only Well Only Sewer and Well ❑ Water Storage Sewer Upgrade 0 THIS PROPERTY CONTAINS: Hot Tub 0 Swimming Pool ❑ Therapy Pool ❑ Jacuzzi Water Softening Unit 0 0 certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property odor authorized agent) Permit Fees: T n n f /7 r Art S) Waiver Fees: Date of Payment: /0-.2G-0(-/ /, Date of Payment: ¥Receipt Number: 6 0 0 ° Receipt Number: (Rev. 12/00) NorthRim Engineering 17237 Bear Paw Circle Eagle River, AK 99577 907.694.7028 October 26, 2004 MOA On -Site Water & Wastewater Program 4700 Bragaw St Anchorage, AK 99519 RE: List S/D, Lot 3, Eagle River, AK The existing septic system on the referenced property requires an upgrade due to the addition of another bedroom. The house now has a total of 5 bedrooms. The new septic system will be sized for 6 bedrooms. The existing septic tank will be checked for structural integrity; if necessary it will be replaced by a new tank. A 500 gallon tank will be added after the existing tank. The old absorption bed will be connected via a Bull Run valve- this will allow future use if the bed rejuvenates over time. The replacement absorption trench required placement within an existing MEA power line easement. A letter of non -objection was obtained from MEA (attached). We are requesting a rush approval. Please review the replacement septic system design for the existing 6 bedroom single family home. I have included design plans & specs, design guidelines, & soil tests. If there is need for additional information or clarification please give me a call. Sincerely, Design Enclosures HIM E, ,INEERING List S/D, Lot 3 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Siang: This is an existing single family, 5 bedroom home. A new bedroom was added after the last septic system upgrade in 1994. The new septic system will be sized for 6 bedrooms. The existing septic tank was installed new 10 years ago; thc tank Kill be exposed & inspected for structural integrity- it will be replaced if necessary. If the tank requires replacement, a new septic tank will be installed & the old tank properly abandoned. A new 500 gallon scptic tank will be installed after the 1250 gallon tank. This lot is about 1.5 acre in size and no adverse impacts are expected from installing a new absorption trench, adjacent to the old leach line. The neighboring subdivision lots are similar in size. No water wells are near the proposed absorption trench site. The lots to the east (Lots 1 & 2) are developed with no conflicts to the existing wells, scptic systems, easements, or property lines. To the south & west lies Chugach State Park land. A soil test discovered uniform soil with a favorable percolation rate (2 min./inch). An application rate of 1.2 GPD/FT' was used for sizing the absorption trench. Groundwater was monitored for over a week and not encountered. The existing septic systcm will be connected via a Bull Run valve. This will allow the existing absorption bed to rejuvenate with time for possible future use. If the septic tank has to be replaced, the existing septic tank will be pumped, crushed, and filled with sand/gravel or removed and properly disposed of. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. • New 500 gallon septic tank in series after the existing 1250 gallon tank; Existing Tank to be inspected for structural integrity, watertight couplings on inlet & outlet. • 5 foot minimum between the tank and bed. 10 foot to property lines. • 3 feet of cover or insulation is required for trench; an equivalent of 1" insulation for each foot soil cover. The finish grade must be mounded to promote drainage over the bed. • Tank & solid pipe must be set on well compacted, stable soil, Perforated pipe to be installed level with perforations down • 4 inch diameter cleanouts with airtight caps are required 1 to 4 feet from foundation wall, prior to any 90 degree bend in 4 inch line, in each tank compartment, and two adjacent opposing cicanouts between thc tank and the absorption field, not more than 10 feet from the tank positioned to provide cleanout access towards the tank and towards the absorption field. • All cleanouts must extend to at least ground level • Trench to be placed level, minimum of 4 feet to groundwater, 6 feet to bedrock from drain -rock • Drain rock to be '4 inch to 2 '4 inch screened. Drain rock to be distributed uniformly throughout the trench. • Silt barrier (filter fabric) to be installed above the drain rock • Smeared trench sides must be raked or scarified before drain rock placement • Insulation must be placed over any pipe installed under driveways or parking areas • Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, • Sewer Service Line is minimum 2% slope • Septic Tank to be pumped every two years or when required • Insulation board shall bc extruded direct burial polystyrene (Dow Styrofoam HI or equal) Test Hole Telecommunications Easement Private Water Well 0 R100 1 i 0 W I Existing 1250 Gallo Septic Tank Clean -Outs ew 500 Gallon Tank Existing Line Cleanouts ew 'Bull Run' Valve Power ne Monitor Tube & Cl ae nout— Drainage Easement No Surface Water or Swale 1' = 40' NORTHRIM ENGINEERING 17237 Bear Paw Circle EGO* R/w, Alaska 29577 y.;1'......''.. "'49 y !" y�/.' '� a -w .. 10.".."'. ' LIST S/D - PLAN LAYOUT LIT 3 NEW TANK & LINE balec 10/26/04 rrof 4 o LI 0 in M (0 N O ).004 1 P. M Cr; 10 tO0 N89.55'15' E u u 0 0 U ti b e rn A ".BO t W C 0 0 00'OS 00'Sf; 0' M 01 co L_—LL 00'S[t =cc Z.CLE OON 9140 ' M,65,0:.0CN >1-1nd a}o}S tate Park H CO ED >- Q J AREA SYSTEMS Opposing Cleanouts N 3 O C 0 O, To New_ Trench U Ol C N 0 G. a O a -75C 5. N f�� N 3 O C d O, U 0C oI- a, U C O 0 0 C 3 O La_ cn X New 500 Gall nchorage Ta • CU > O U 0 0 0w R O W Y W C y• 1 0a O ON Q • • Monitor Tube W > _ J U Q Z > Z Q3 J w J Z = W OF H Z . W J.N. Q >z> F- nnN.Q W > J z 09 W d' 3z -J wow Z U Leach Line Eff VU u a, Cu C C CI0 Q 0 3 N O U N a W Z O >. Q Y 0 N F' J d+1X 0 W F-• NIX aN C >' +: •O E Xy 4.a,t 0 w in 0 °+"Q- 1- f<()>in�a,£u CU nZ+ N d 6 a, 0 0 a _> > C aC�N } t d--�300oa te- d�> w0 CU N N: 0.1 L CU+�U -P vi yam. 3>t4. 1--C Z ED O 1Cr -- Z s 6P30 N yN ° 3 0 1Z7 a� O 0 C Otis d Z 8... Q,��"v�3via� X W ELEVATIONS #1877:44,t P14-4 z I4�: a 3 W 0°, o �? i? • Iy N 0 O L75 :IS A U L aa, p, N N� N c-0++ a, o, L N� o0 N d N U1 W 3l }r— N s a�03 ,, Q 0) N U U S N C 0 aiC ► L 3� 3 Zet £ c u N F -MF -U7 W A r: Nf")st N N a 3 0 C o, U c d a alter Fabric fMinimum 6' to Bedrock, 4' to Groundwater NEW TRENCH • Y/ THRIM M NEERING Performed For: Bryan & Doris Niver Legal Description: List S/D, Lot 3 SOILS LOG — PERCOLATI❑N TEST Date Performed: 10/13/04 1 - 2 - 4 - 5 - 6 - 7 - 8- 9 - 10 - 11 - 12 - 13 - 14 15 - 16 - 17 - 18 19 20 - DEPTH (FEET) 777/7/2 M1 • •Q• Organic T.H.\ /�� S-ilri a Groundwater? No GW Depth Sandy Gravel Water Depth Itorino.None Date: 10/20/04 # Date Gross Tine Net Tine Depth Net Drop 1 10/13 0 -- 8' -- 2 10/13 2 2 nin, 7' 1' 3 10/13 35 -- 8.5' -- 4 10/13 37 2 nin 7.5' 1' 5 10/13 70 -- 8.5' -- 6 10/13 72 2 nin 7.5' 1' 21 Percolation Rate _2.0 nin./Inch Perc Hole Diameter Test Run Between 3' and 4' Comments: Writer rnn nut in under 1 rilnute� Performed By jjorthRim Fng. L-5-- .. CERTIFY THAT THIS TEST WAS Performed In Accordance with All to/Municipal Guidelines In Effect ON THIS DATE. DATE: 10/20/04 „49•• NOR THRIM ��".••• ENGINEERING 17237 Boor Pow CIrcl p•. Eagle R/w, Alaska 99577 Sa-an. • ,. 47 T. H. 1 TESTHOLE LIG .• "'''• GEOTECHNICAL os« - pc 10/20/04 11 of 2 • Y/ THRIM Q INEERING Performed For: Bryan & Doris Niver Legal Description: List S/D, Lot 3 SOILS LOG - PERCOLATION TEST Date Performed: 10/13/04 1 - 2 - 3 - 4 - 5 6 - 7 - 8 - 9 - 10 - 11 - 12 - 13 - 14 - 15 - 16 - 17 - 18 - 19 - 20 - 21 DEPTH (FEET) .44/7/27 • .O 'L Organic GW Sandy Gravel T,H. 2 Groundwater? No Depth -- Water Depth: None After Monitoring. -- Date: -- # Date Gross Tine Net Time Depth Net Drop 1 10/13 0 -- 9' -- 2 10/13 2 2 min 8' 1' 3 10/13 32 -- 8' -- 4 10/13 34 2 min. 7' 1' 5 10/13 70 -- 8' -- 6 10/13 72 2 min, 7' 1' Percolation Rate 2.0 min./inch Perc Hole Test Run Between 4' and 5' Comments: Wntpr rnn nut in undera inutc� Performed Byj'lorthRim Fng I- CERTIFY THAT THIS TEST WAS Performed in Accordance with All S to/Municipal Guidelines in Effect ON THIS DATE. DATE: 10/20/04 Diameter 6 �..f.IZ NORTHRIM h:iP N ''49m '' T. H. 2 bon TESTHILE LOG ENGINEERING 17237 Bear Pow Circle Eagle Mar. Alaska 99577 i •. a �°'.'"'''''. - GEITECHNICAL 20f 2 10/20/04 ENCROACHMENT NON -OBJECTION AND AGREEMENT THIS AGREEMENT, made and entered into this 2S day of t -Eh tjc!2004 by and between MATANUSKA ELECTRIC ASSOCIATION, INC., an Alaskan non-profit member owned electric cooperative of Palmer, Alaska, hereinafter called `First Party*, and Bryan & Doris Niver of Eagle River, Alaska, hereinafter called `Second Party', WITNESSETH THAT: A septic system leach field constructed across the platted 30' powerline easement within Lot 3, UST SUBDIVISION, according to Plat #83-530, Anchorage Recording District T14N, RIE, SEC. 32, Third Judicial District, State of Alaska NOW, THEREFORE, for and in consideration of their mutual agreements and other good and valuable consideration, the receipt of which is hereby acknowledged, First Party, for itself, its successors and assigns, waives its objections to Second Party's encroachment on the said easement for the purpose mentioned, subject to the following conditions: 1. Second Party will hold First Party harmless from liability for any injury or damage to any person or property which may result from such encroachment. 2. The said encroachment will be without prejudice to First Party's full enjoyment of any and all rights it may have in and to such easement. 3. Any facilities or property of First Party which are damaged or destroyed as a result of such encroachment will be repaired or replaced. The cost of repair or replacement will be paid entirely by Second Party. 4. Second Party will comply with all applicable safety codes and regulations. 5. Any expenses which First Party may incur in the relocation or modification of its facilities to accommodate the said encroachment will be paid entirely by Second Party. 6. If second party desires to add second story or modify existing structures, MEA must be notified in advance. By its execution of this Agreement, Second Party agrees, for itself, its successors and assigns, that its encroachment upon the named easement as hereinabove mentioned will be subject to the foregoing conditions. IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by their duly authorized representatives and agents as of the day and year first above mentioned. MATANUSKA ELECTRIC ASSOCIATION, INC. (First Party) BY: Wayne D. Carmony General Manager or his Representative Page 2 BRYAN J. NIVER & DORIS M. NIVER BY: B an . Niver (Second Part BY: Doris M. Niver STATE OF ALASKA • rgvg ACKNOWLEDGEMENT : SS. THIRD JUDICIAL DISTRICT : The foregoing agreement was acknowledged before me this J5 day of n" IObef 20nh- by DORIS M. NIVER "COPE "',� ZeittV14P1� =G: """••., ' Nota���YYY��� ublic for the State of Alaska e50: ON y N 9h My commission expires: ic% 0 7 ' p 3:>- % 4;\ % ��omm S;;on.;,Q•• ACKNOWLEDGEMENT STATE OF ALASKA : SS. THIRD JUDICIAL DISTRICT : Jho gping agreement was acknowledged before me his criI _ GV� t 'a r!YJ('��t.''....4QI� "'sty BRYAN J. WIVE WIVE 10 s fee fi `•,, 4`' efrqrt Ot. `tf. I Notary Public for the State of Alaska II. oc1/27tntssiofits....-- My commission expires: % S da of MEA ACKNOWLEDGEMENT STATE OF ALASKA : SS. THIRD JUDICIAL DISTRICT : c NOTARY The foregoing agreement was acknowledged before me this �d �lf pusuc Or to&r 20 fil by WAYNE D. CARMONY . •••.??' ,QF &t.1^% -147 otary Public fo the State of Alaska My commission expires: Municipality of Anchorage/Page of P DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: 511) g14o33P PID Number 496:1 3° /oZ Name: Smritc-y STANuLo,u/s . Wastewater System: • New Upgrade Address: P etAL 772ye/ ��fF,gw�Ak59s72 ABSORPTION FIELD Phone:G / V93.3—No.'of Bedroom: Lf Deep Trench ❑Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION • Soil Rating: GPD/So. Ft. Total Depth fromoriginalgrade: Lot: Block: Subdivviiaion: 3 '— ,4 / ST Jif6 Depth to pipe bottom from original grade: S Ft. Gravel depth beneath pipe .S- Ft. Township: „„ I� 1---/4A1 Range: // /c. / Section: 3 `- Fill added above original grade: Fi Ft. Gravel length: S Ft. /l� WELL: • New OX iXEU-A l e Gravel width: Ft. Number of lines: I Distance between lines: -- Ft. Classification (Private, A,B,C): PB, t;0')-8 Total Depth: 3 3c, Ft. Cased To: 33c, Total absorption area: (530Ft. O SQ. Ft. Pipe material: / J''C 303p4/ 4' 6 FSO Driller: Sr,�,v7173 Date Drilled: /O/t,//3 Static Water Level: 57' Ft. Installer: Cre-C)0AJST i Date installed: ?/,/`% Yield: I CQ GPM Pump Set at: Casing H ight Above Ground: u'C Ft. /A'" Ft. TANK SEPARATION DISTANCES }Septic 0 Holding ❑ S.T.E.P. To From Septic Tank Absorption Field Lift Station Holding Tank Public/Private Sewer Lines Manufacturer CJ4 7hv•y,t Capacity in gallons: i ZSR Welt' 1zZ 139 MIA- '1'- z.5.--t- Material: 5rL---0z. Number of Compartments: 2 Waters 1Q0 toot` p9V AO t00.1.," LIFT STATION it/, LotN/H Line 3©t• 3o4- AJA- A1/4 /II Size in gallons: Manufacturer. Foundation /6g 36, AO NA A0J "Pump on" level at: 1 "Pump off' level at: ( High water alarm at: Curtain Drain 44-AA A'// //4/y` A///- N h Pump Make & Model Elec rical Inspections performed by: Remarks: apc-,,� g qi/ - Asn ie o BENCH MARK (2- C23901144 4-9-NL, c/ A o / non/+t- I,QC-wVc/7L 8L-A,4 Location and Description: , iv rr?i- S' CR/vsL - BOSF- - ,vv".- ...514.616e -ocx-'_ Assumed Elevation: Oho ENGINEER'S SEAL 4 -fess .. , mcaAooue.2ndsno, sgs ,g 6' - 6}ffl ft D ryi !ns. I b. e . : azo y' 1Cso `p1 ��� inspections performed by: `-D` R•�3-z--' Aa Dates 1sttq�� Q 9'// Department of Health and Hum. Services appy al Reviewed and approved by:,, /',•4' / Z8` ,Date• Permit No. W 9'4 O3?G Page 2_ of Z Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: (-.01- µm• PID No.: 4 5 `FeArrie. co /'CO St 4 z. Go 8o 3 S- c.o 1 z. 3 77 y 4 7 5- 9'f 7r /?38 82.4. / ENGINEERS SEAL gNft oirt OF 44. Owld.R : tkaYlefi :320 f / 9 PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST j") -r71 --A-.1 rt11.4,1-4/Nei 3 LEGAL DESCRIPTION: c lAT J LIST )t& ,L 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 DEPTH (F E E T) o?-MAw '- S if 5,d-ry a1FvL'�-t_ wic.:0GG/eS c -c P COMMENTS Lf G NEER'S SEAL) ott OF tom. 220 •5 a .0. ,: DATE PER FOt'i.(�9,`� 4 „` 44,E'e..FE5Rus I'> Township, Range, Section: ><. 3Z-1 T/ .74e7'r, SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? s L 0 P E Depth to Water After Monitoring? Date: 11/4 N Reading Date Gross Time Net Time Depth to Water Net Drop y/,o/99 1�: ,tC r ztts -23s to G^ 11 " S" Z x;34 - LNG so %- 103/4i '/ Xi 3 vv)- Zs, - eo Co to W 9% Lt. Z'SFr- 3.fer , o C,- w/x- ✓_ 3/0-3i9 /0 6.-/D11.. ¢` Cv 3'2v -3.3c IC) (v -/o -6. /.01 7 3:3i -3:V/ io G -io/ `/7%t. PERCOLATION RATE Z/3_ (minutes/inch) PERC HOLE DIAMETER 4.fi TEST RUN BETWEEN ' 4i FT AND 4 FT if CIL-.7 "ro 0Lna So.c-S lac-z!O/'T =avitt R. Dayton P.E 2:1210 Donalar St. PERFORMED BY:.. ..igiak, Alaska 99567 u pc„t/,tn /l62 ys�v�- I l , ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) • ERTIFY THAT TH(S.TEST WAS PERFORMED IN • DATE: PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW940330 DESIGN ENGINEER:DAVID R. DAYTON, P.E. OWNER NAME:STANULONIS STANLEY F & OWNER ADDRESS:P.O. BOX 772484 EAGLE RIVER, ALASKA 99577 PARCEL ID:06730102 LEGAL DESCRIPTION: LIST LT LOT SIZE: 623411 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 9/01/94 EXPIRATION DATE: 9/01/95 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 (24 HOURS) . 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ENGINEER SHALL PERFORM A SOILS AND PERCOLATION TEST AT THE / TIME OF CONSTRUCTION TO A MINIMUM DEPTH OF 16 FEET IN THE / VICINITY OF THE ABS,QRPON FIELD. RECEIVED BY: ISSUED BY: DATE: DATE : % / - y¢ D. R. DAYTON, P.E., R.L.S. 20210 Donalar Chugiak, Alaska 99567 (907) 696-2417 August 18, 1994 Dept of Health & Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Re: Lot 3, List Subd septic system up -grade Attn: Mr. Jim Cross Dear Mr. Cross, The home on the subject lot has been found to be a 4 BR house with a 1,000 gallon septic tank. The seepage trench is oversized but lacks 6'- in length for a 4 BR system. We propose to install a 1250 gallon tank upstream from the existing tank. The distance from the existing tank and the existing trench would be used for the trench extension. Since the trench performed so well when tested (970 gallons with full recovery in 31 hrs) we request waiving a test hole, perc test and 7 day water monitoring. We will verify the soils during construction and field modify the design if necessary. The system addition will have no affect on neighboring wells or septic systems. There will be no measurable impact on reserved areas or on drainage. Time is of the essence and your prompt attention will be greatly appreciated. Sincerely, David R. Dayton /4-7, 2.9 ZO' A�•�v.sh� C'y+Sd mFNT 0 0 V C1 ST c2. tzr yin fe PI 2105 d. It �L4% LoT �J Ltsr S., S ,a,,c. 'SY 571 H lat"Cale-A0 David R. paytan !.E. 20210 Danalar St.: Q. -. Chugiak, Alaska 99567 • S��r-tc Sys Uf'Cy4"0a - 4x512 SYS6y+ti. cwt_. oR.4C.,N4. Srs7 4.. Jc . Si= �2 vA Uie_Asr) n7G, TPswcb4 4140 S ►t ArP0 a-rion-1At, A -2C4 Co O a Lo • A,oa,rio�, ie5 \&-ga�`/ �OJL GO bit �9vL,7'7q� S'CfY& ve-� bele f')Pts A r 1 KJ S"ih4-4..nr1-i0ni 4 bUon i lj 1 t I bx) a O /xt-o, o C. 0, U t 0 oz Z-Y-Ctiic., kJ 4S-rr5-Ct. /lbw i Z 4 C. O, Oal '-J P57' I I'IC David R. Dayton P.E. 20210 Donalar St.. r Chugiak, Alaaka 99567 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 NAME !' ! kJ Sf PHONE b94!_39/,s-- ITAEW ❑ UPGRADE MAILING ADDR S / �, I/ ��pr^ S( i� _T Iq- _ C 7 /J % _ LEGAL DESCRIPTION - S T. C. u.);11 A -H., S l 0,at 3 L st 51,0, LOCATION NO. OF BEDROOMS 3 SEPTIC TANK DISTANCE TO: Well {�/JceS`EA FMaterial Absorption area 6 Dwelling 8a. PERMIT NO. /� 8 62690, Manufacturer 'P92- _5%'c_ L No. of compartments 2 Liq. capacity in gallons /06c3 IF HOMEMADE: Inside length - Width Liquid depth --- O -la Z = Z F DISTANCE T0: Well Dwelling PERMIT NO. Manufacturer Material Liquid capacity in gallons TI LE DRAINFIELD TRENCH DISTANCE TO: W II p�paci Foundation a w 96 Nearest lot line .tir0 ( PERMIT NOh 6)20 Y ip No. of lines ( Length of each line / 7� Total length of lines (41 Trench width 34 inches Distance between lines -� Top of tile to finish grade,Material "'.-,2 /2 beneath tile Se i inches Total effective absorptionarea 'V</- at SEEPAGE PIT Length Width Depth PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area DISTANCE TO: Well Building foundation Nearest lot line JClp w d Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIA,LS b 3634 ) � !V SOIL TEST RATING laS'0 clty.,›),2ADIN INSTALLER REMARKS .SY I`pf 5411 nCF cid & (`IV\ Se, -,1,,.e C (el I b -4' S� APPROVED � �y///�/get DATE LEGAL ..,..../.1)o7(/l[i7 /A✓1(t. a - _ . 9/(` r -Z OWNER OF LAND ADDRESS LEGAL DESCRIPTION ei t i t%$: i}, 1 `': r = � ♦DRAW Db } [)'.TF • StartedI')' ma' nded ,> l GAt&FER / ., PERMIT NUMBER , KII�ID OF C KIND OF FORMATION: rrom 7 Ft to :rem Ft to ;: ron7 -� ..��' Ft. to rrom Ft to rrom �' Ft t f] . =?. From , Ft to ' rom i J L Ft to From / '70). . Ft. to From /i Ft to.t From Ft. to :., From From `! Ft to ya r"7 Froin ?' `3 Ft' to From Ft. to From ! • Ft. to `_ From Ft. to From Ft' to ;f '- ISCL. INFORMATION RILLLER'S NAME >` 'JF7 peric:EMF:F11:3EE -g3 DEPARTMENT HEALTH AND ENV I RONMENTAL r ROTECT I ON ri 825 'L ' STREET, ANCHORAGE, AK 99501 264-4720 14LLFi r4 Cs r-4 EE L4 a- ri "T. (LW PERMIT NO. ( 820946 ) Ma\ ,g -an -Q APPLICANT MARTY LIST LOCATION LEGAL T. C WILLIAMS(LOT 3 LIST S.'D) SR L453 EAGLE RIVER 99577 694-3915 LOT SIZE 7C71:1:77. fowARE FEET TYPE OF SOIL ABSORPTION SYSTEM 15: TRENCH MAXIMUM NUMBER OF BEDROOMS - 3 -SOIL RATING (SQ FT/BR)= 125 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: C:NEEP'IFF-1== 1....Jar-41.73-171-1== .477 C3F,7:FTVEIL.._ CREEF=M-1== 4 THE LENGTH DIMENSION IS THE LENGTH IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH O A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE: BOTTOM OF THE EXCAVATION <IN -FEET). THERE IS NO SET WIDTH TRENCHES. THE GRAVEL DEPTH 15 THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). miaNK E1-== PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. 71,40 <;-a> INECTION:E; --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL E:E SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST E:E RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATIOR 11-E.N82 I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE coma 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEE:ROOMS. SIGNED: APPLICANT MARTY LIST 10106166 IT) P os -Y) V4.0 10-= ISSUED BY21L.2\11_0-i-A1 DATE g.:114 -.2a. „MUNICIPALITY OF ANCHORAGE,, Department f Health and Environmenta Protection] 825 1, Street, Anchorage, AK. 99501 - 264-4720 * * * HANDWRITTEN PERMIT * * WELL AND/OR ON-SITE SEWER PERMIT Mailing Address: Permit # CC`'IL-l(o Applicant: Location: Phone Number: profro(:: 1 i Legal Description: 1r ���`; is , l x ( ) Lot Size: _ 1Y Type of Soil Absorption System Is: Trench: x Drainfield: Seepage Bed; Holding Tank: Maximum Number of Bedrooms: 1 Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is: DEPTH g .LENGTH L/ i GRAVEL DEPTH </ WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = / ” )GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * # * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * I certify that: PEtMIT EXPIRES DECEMBER 31, 1 9 3 2 (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence 4 s remodeled to include more that 3 bedrooms. Signed: Applicant SWP/024(1/81) Issued by: 0,, Date: ///c//b,--- n Cb, Russell Oyster 694-2774 O & E ENC; VEERING & DEVELOr MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 SOIL LOG Performed for: Name* /" 4 :4/2T/ Ai C).S "/ S y S� /gax / S35, t# ,�i1 rL, 7'7 Mailing Address' Earl Ellis 688-2280 Tel. No ‘.41- 39« Legal Description: Lor 3 i Li S v " Depth (feet) Soil Characteristics 0 1 NZ_— /�T � op (F-.' 2 3 4 UP ec9.9-as . 34-x405-' 41241 JL, 5 Co8c_l�r/�S 6 7 .211 'r9 .!1 . 1 -. /maxis f r7' 7 -. 8 9 10 ,//1 mAia v& 11 12 84, r �� O c f r- 13 14 15 16 PLOT PLAN G PERC. TEST of Co ,Q1.: 4% V Ground Water Encountered.: Yes No If yes, what depth ..i'49.<.:. .:...0 0 el fVs Earl P. Ellis 0I S'.� NO. 1745-E .® Comments' l' •, �•• �C�® tiil '- OFESSIOP®4+" Proposed Installation: Seepage Pit— Drain Field v0►'r Performed by: Date. N1 Lk) 1 k� ' 1 LI PA_,QE_ ��z_� ;0 - _o in,Acm 1C c b[,i 1 - LiztS �u_1tmr1Aa 1 _0 `AtLS1 L.h �L � e`\ -\"\e Cz1�C:Ll� 1 cio Lo k \I,� Ln 06 (L) LTS2J.„)..(4VtLil tta, -L,Aro-r s/).-` 0 4 Russell Oyster 694-2774 O & E ENC;.,NEERING & DEVELO, iVIENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 SOIL LOG Performed for: Name• `%/ / IVO -S Z/ 7 // Mailing Address. a. go X /iS 3 � � � �� ��tiEz.„ ,/i• 77 Earl Ellis 688-2280 Tel. Noe 4 37AS- Legal Description: /C., Depth (feet) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 / L,s; 5 ,t// -S Soil Characteristics M /L J i 54 Ar S' 62.i/E- L 6 "95 ZGiCa54 PO/,8,e_)\ P 6,4,e,s- 5,9410 /115 ED . 4-/tfs, 3,41 too <57efte, ,07-70A4 0 f 6,1? L0C 4-7-R9 MUNICIPALITY OF ANCHORAGE F L T(P4AN.TH �•. ENVIE .:-'." E 7 1982 C 44N ED Ground Water Encountered: Yes No If yes, what depth Proposed Installation: Seepage Pit- Drain Field Comments. ��ti OF A� `11� go JB° e6. ••\''99 .. ®I �.. ,0000**Jj�g/j00 0000eaee4r•e ISe Earl P. Ellis : �✓ �� � o. NO. 1745-E s Z4,® Performed by: Date. 5 UMCWA TY 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. 067-301-02 1. GENERAL INFORMATION Complete legal description LIST LOT 3 Location (site address) 30215 LIST CIRCLE, EAGLE Current property owner(s) STACEY TALOTTA Mailing address Real estate agent Expiration Date: V C.t 1 , 9, () 'r� 1 AK 99577 30215 LIST CIRCLE, EAGLE RIVER, AK 99577 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 6 Day phone Day phone 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 $ Waiver Fee $ Date of Payment I `� ao �z 1 Date of Payment Receipt Numbers 10-2, Receipt Number COSA # 0.SG 2 1 1-33S 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 6/15/2021 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 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 & FWrS 6. DSD SIGNATURE System #1 Approved for System #2 Approved for Disapproved Conditional approval for to bedrooms bedrooms 49 ..na .....::��� Curtis Huffman X29* CE 128991 pROF S N bedrooms, with the following stipulations: OF A11leyo ����i r '(''`SER o (55 9/) '�AIT Sti-W' By: PU Lcl ` o, au�,Q Original Certificate Date: 0 � 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 Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Other �� ('j,c�nttSorH X COSA Checklist Legal Description: LIST LOT 3 Parcel ID: 067-301-02 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 10/1983 Total depth 330 ft Cased to 254 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 6/7/2021 Static water level at beginning of test 50 ft. Well production at time of test 4.6+ 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 of Sample 6/7/2021 Comments __________________________________________________________________________________ B. TANK DATA Age of tank(s) 27 & 17 years Tank type/material SEPTIC / STEEL Measured operating fluid level in septic tank 49” & 48” Standpipes/foundation cleanout per record drawing Date of pumping 5/24/2021 C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: SEE ATTACHED MOA TANK ADVISORY D. ABSORPTION FIELD DATA Which system tested (date installed) 10/28/2004 ALL standpipes present per record drawing Total measured depth from grade 9 ft (max) Measured depth to pipe invert from grade 4.6 ft (min) N/A – pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective 4.4’ INTO THE 5’ED Code-required soil cover over field System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Adequacy test date 6/7/2021 Results Pass For 6 bedrooms Fluid depth prior to test 0 in Water added 940 gal New depth 0 in Elapsed time <1min Final fluid depth 0 in Absorption rate 900+ gpd Any rejuvenation treatment (past 12 months) N If yes, enter date Comments/Deficiencies: 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 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 From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Property Line > 5’ Yes if No ft Absorption Field > 5’ 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 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 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 If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No F. ENGINEER’S COMMENTS G. ENGINEER’S CERTIFICATION I 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. 6/25/21 MUNICIPALITY OF ANCHORAGE    DEVELOPMENT SERVICES DEPARTMENT    907‐343‐7904  On‐Site Water and Wastewater Section                                                                                           Fax: 343‐7997  www.muni.org/onsite         Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org      Septic Tank Advisory   Certificate of On‐Site Systems Approval # OSC211338   Subdivision:  List  Lot: 3  The 1,250 gallon septic tank for this property is 27 years old.  The average life for a  steel septic tank is 20 years. Typical replacement costs range from  $7,000  to  $11,000.   This advisory must be attached to all copies of the subject Certificate of On‐Site  Systems Approval.               This is an example of what the metal of a 30 year old steel tank MAY look like.    Received Date/Time 06/08/2021 10:36 06/07/2021 17:05Collected Date/Time 1213079001 Matrix SGS Ref.# Client Sample ID List LT 3 Client Name Project Name/# Printed Date/Time 06/29/2021 8:30First Water Consulting Services (FWCS) Technical Director Stephen C. Ede List Lt 3 Drinking Water Sample Remarks: Parameter Results LOQ Units Method Allowable Limits Prep Date Analysis Date InitContainer ID Metals by ICP/MS DSD06/25/21SM21 2340Bmg/LHardness as CaCO3 06/17/21ND5.00 Waters Department (Provisional Cert for Nitrate-N) EWW06/09/21SM21 4500NO3-Fmg/LTotal Nitrate/Nitrite-N ND 0.200 (<10)C Microbiology Laboratory A.L06/08/21SM21 9223B100mLE. Coli Negative 1 A A.L06/08/21SM21 9223B100mLTotal Coliform Negative 1 A Private Individual Analysis DSD06/25/21EP200.8ug/LAluminum 06/17/21ND20.0 DSD06/25/21EP200.8ug/LAntimony 06/17/21ND1.00 (<6) DSD06/25/21EP200.8ug/LArsenic 06/17/21ND5.00 (<10) DSD06/25/21EP200.8ug/LBarium 06/17/21ND3.00 (<2000) DSD06/25/21EP200.8ug/LCadmium 06/17/21ND0.500 (<5) DSD06/25/21EP200.8ug/LCalcium 06/17/21ND500 DSD06/25/21EP200.8ug/LChromium 06/17/21ND5.00 (<100) DSD06/25/21EP200.8ug/LCopper 06/17/213.15 1.00 (<1000) DSD06/25/21EP200.8ug/LIron 06/17/21ND250(<300) DSD06/25/21EP200.8ug/LLead 06/17/21ND0.200 (<15) DSD06/25/21EP200.8ug/LMagnesium 06/17/21ND50.0 DSD06/25/21EP200.8ug/LManganese 06/17/21ND1.00 (<50) DSD06/25/21EP200.8ug/LNickel 06/17/21ND2.00 (<100) DSD06/25/21EP200.8ug/LPotassium 06/17/21ND500 DSD06/25/21EP200.8ug/LSelenium 06/17/21ND5.00 (<50) Page 2 of 8 Received Date/Time 06/08/2021 10:36 06/07/2021 17:05Collected Date/Time 1213079001 Matrix SGS Ref.# Client Sample ID List LT 3 Client Name Project Name/# Printed Date/Time 06/29/2021 8:30First Water Consulting Services (FWCS) Technical Director Stephen C. Ede List Lt 3 Drinking Water Parameter Results LOQ Units Method Allowable Limits Prep Date Analysis Date InitContainer ID Private Individual Analysis DSD06/25/21EP200.8ug/LSilver 06/17/21ND1.00 (<100) DSD06/25/21EP200.8ug/LSodium 06/17/2196700500 DSD06/25/21EP200.8ug/LThallium 06/17/21ND1.00 (<2) DSD06/25/21EP200.8ug/LZinc 06/17/21ND10.0 (<5000) Page 3 of 8 Received Date/Time 06/16/2021 10:47 06/15/2021 13:30Collected Date/Time 1213079002 Matrix SGS Ref.# Client Sample ID SPIGOT Client Name Project Name/# Printed Date/Time 06/29/2021 8:30First Water Consulting Services (FWCS) Technical Director Stephen C. Ede List Lt 3 Drinking Water Sample Remarks: Parameter Results LOQ Units Method Allowable Limits Prep Date Analysis Date InitContainer ID NRZ06/22/21SM21 2540Cmg/LTotal Dissolved Solids 231 10.0 (<500) A Private Individual Analysis A.A06/25/21EPA 300.0mg/LChloride 06/25/211.64 0.200 (<250) A SEM06/21/21SM21 2510Bumhos/cmConductivity3935.00 A A.A06/25/21EPA 300.0mg/LFluoride 06/25/210.379 0.200 (<2) A A.A06/25/21EPA 300.0mg/LSulfate 06/25/212.05 0.200 (<250) A SEM06/21/21SM21 2320Bmg/LAlkalinity20410.0 A SEM06/21/21SM21 2320Bmg/LCO3 Alkalinity ND 10.0 A SEM06/21/21SM21 2320Bmg/LHCO3 Alkalinity 199 10.0 A SEM06/21/21SM21 2320Bmg/LOH Alkalinity ND 10.0 A SEM06/21/21SM21 4500-H BpH unitspH8.4 0.100 (6.5-8.5) A Page 4 of 8 Parcel I.D. Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Braaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Ole - 30 /-0)- HAA # d 5(J3Sr/1 Expiration Date: _ / / - q — el 1. GENERAL{INFORMATION Complete legal description L f Location (site address or directions) Current P roperty'owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 02/5- t,.r f- Orr e - Day phone w 3c c Day phone 1‘Y Day phone Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank 0 Community On-site ❑ Public Sewer 0 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water uest to homeowners. valisupply I or s90 daysDSD also issues frorn the date of issue for props upon erties served by a private ertificates or Class Cf welHealth and may be reissued lare with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation, based on procedures outlined in the Health Authority 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. /G� /tfOr' hi 5n �j Phone 6 / 702 Name of Firm p V /� Address / 7o137 R PL ()`�-1. 1/) /US Engineer's Printed Name S'1�2vC� �✓� q Date OF A( 1 lit ,+. < • S 1 •,•_. Ike •P .31" • Stettin W. Eng At, 5. DSD SIGNATURE 1 s•. of a.... .....c}:$540 t% Approved for % bedrooms. t�1�F�PgoFEsit0.`"�`• Disapproved."•' Conditional approval for bedrooms, with the following stipulations: Additional Comments ��G.• ON-SITE WATER AND WASTEWATER YKVulv+m /f PitIENT t )1)11 Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other (Roy 01/07) Original Certificate Date: 8 - 9 - O 5 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: F J.c f SAC) , / 1. A. WELL DATA Well type P Date completed /0.3 Total depth 730 ft. Cased to 2 FROM WELL LOG io/dt3 If A, 8, or C provide PWSID # Parcel ID: 0/07- 301- 0,Z Well Log (Y/N) Y Sanitary seal (Y/N) 7/ Wires properly protected (Y/N) y . �r Casing height (above ground) /l in. ui Date of test Static water level S-3 Well production WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate ¢ .S' mg Arsenic: mg /I. Date of sample: or B. SEPTIC/HOLDING TANKDATA Tank Type/Material 4nchn (J r24 kiS e,2r Date installed /o/ze/'o ft. 20 g.p.m. AT INSPECTION 7// 4los 4//' ft. tS g.p.m. Other bacteria tt''( colonies/100//mi. Collected by: Alo.-1‘ �j1! �sn �c .+q /SC * Tank size Soo gal. Number of Compartments 2 Cleanouts (Y/N) y Foundation cleanout (Y/N) Y Depression over tank (YIN) !'i D. LIFT STATION Date installed Size in gallons "Pump on" level at in. "Pump off" level at Datum Cycles tested l E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT T0: Septic tank/lift station on lot /06" t Absorption field on lot /0011- Public 00rtPublic sewer main /f/4 i Sewer /septic service line /JO r f Manhole/ACcess (YIN) in. High water alarm level at in. Meets alarm & circuit req irements? On adjacent lots /00 44- On t On adjacent lots /0 0 rr Public sewer manhole/cleanout X4/4 Holding tank /<</e4 • SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: / Building foundation SO r Property line 304- Absorption field s Water main N�� Water service line SQ t Surface water /0 a <7‘ Wells on adjacent lots /C$Q tt SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 30 t Building foundation 50 rt Water main At /4 t(AI'Qu4.) Water Service line `sd r * r1`/'Surface water /44 Driveway, parking/vehicle storage �_ iv Wells on adjacent lots /00 i* OLD r,�eng- Curtain drain NOT .n4401- A flay,✓ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Date HAA Fee $ 4/340 'IV Date of Payment 3/05— Receipt /OS Receipt Number 7 �d Tim (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number -ve9're 'yj E XYZ Zy r,. •>Q 7 • . , • 7 Zo 'O.Ar4J4'Cr et -'"-'/T. NCTE:NO BUILDING SETBACK VIOLATION PER APPROVED VARIANCE CASE 094-186. ifeerir=%C/«'1�v"74 '/ r ,ovetr,gt a'' 9%4- 12/14/94 Added setback case number. ASBUILT-NO CORNERS SET THIS DATE. I HEREBY CERTIFY •THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY: 2 rr rab'e tory AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SHOUID ANY DATA HEREON BE USED FOR CONSTRUCTION OF FENCE LINES, OR FOR ESTABLISHING BOUND- ARY LINES. SEWARD & ASSOCIATES LAND SURVEYING 694-0 SCALE: sic DATE: x/617 GRID: FB: ,sc • ZS' DRAWN: ops �P• l �1 95'f- t • co x Duo.* Mrk Seward i 4/ ._ LS -6918 w Mat -Su T•st Lab 9077463012 07/27/05 31602am P. 002 Mat -Su Test Lab of Alaska Water Quality Testing Email: rnat4ngaatlabtltrnrterahaa.Com Mile 3.2 Palmer -Waste Hwy. Midtcwn Community Butinasa Pant Phone: (907) 745 3096 Client: North Rim Engineering 17237 Bear Pew Circle Eagle River. Ak. 99577 Attn.: Client ID: Lot 3 Uet PWSID# Source: M.S.T.L.S: 51543 Sample Maltz: Comments: P.O. Box 2749 Palmer. Ak 99645 Fax: (907) 7453010 Date Arnved: 7/19/05 Report Date. 726R5 Sample Date: 7119/05 Sample Time 1500 Cotlecled Ey: SE Method Parameter Units Rusutta MDL Csta Preoared Dale Analyzed MCL 11 SM 4500-NO3-E Nitrate -11 mg/L <MDL 0.50 7/26/05 7/26/05 10.0 I SM 4500-1403-E Nitrite -N rmUl <MOL 0.05 7/26/05 7/26/05 10 Total Nitrate/Nitrite mg/L <MOL 0.50 726/05 726/05 10.0 Legend. MRL s MetPod Report Level Ma= Max. CoitammaIt Level R = Present 1 Mslhod Btaak E = Estunated Value H =Above MCL 0 - Lost to DiLt'on Reearted By Jon Paul Campbell Lab Manager MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska Parcel I D # 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 04,7- 3v HAA# 1. GENERAL INFORMATION Complete legal description tor -3 Li 6r- scc&D Location (site address or directions) ENo o>2 Lisr G',ecas o rL(L )4.<9A R"- / Property ownerSrnn)1z.--y F S77t-iJu 4-0N l s Mailing address Po. 697ZYY9 Cti1-hcc2 k_ 99577 Lending agency Day phone Day phone 95/-5/93,5 Mailing address G.rrrw1-0916 e-buf. x_ Agent Address Day phone 6 ‘.7--4)3 - Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- - ing to the legality and status of system. ',TYPE OF WASTEWATER DISPOSAL Individual on-site Holding tank Community on-site • I z. <: Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system., , - ,rt 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. 'David R. Dayton P.E. Name of Firm 20210 Donalar St. Chugiak, Alaska 99567 Address Phone 6,6 1,-,2.7// 7 Engineer's signature ,9, 6. DHHS SIGNATURE Approved for bedrooms. By: Disapproved. Date 407/ • t7.1" „4.0. attytim.tt Empt 7 A tvttt, tiittv 4 4 ":,P± •REP .1;11,11,k1r 1:13";r0 ill). 2201(3 ••\s,.6 " Conditional approval for bedrooms, with the following stipulations: Additional Comments 1 Date CAUTION 'The Munidibality 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 profeisienal engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Beck MOA 021 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Zar 3 /..4 5w6 2 Parcel I.D. p - 3O ">aL A. Well Data Well type I '1,,lrr, If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed /o/Z,/9; Driller 5u44. „--0-•..1 Total depth 330 Cased to 3 3 Casing height >ek "i Sanitary seal (Y/N) y Wires properly protected (Y/N) y FROM WELL LOG AT INSPECTION ,,c Date of test t01ulk3 //, 199N e0 S n Static water level S -v Well flow er m N Q g.p.m. Co g-pm— vo y Pump levell , rn -> in v c SEPARATION DISTANCES FROM WELL TO: o R, Z Septic/holding tank on lot Absorption field on lot Public sewer main 13� ; On adjacent lots ; On adjacent lots /OCA /00 - °LIM, Public sewer manhole/cleanout A/✓f Sewer service line L Tr Petroleum tank �✓,N is -� WATER SAMPLE RESULTS: Coliform 0 Nitrate O , /0 Other bacteria 0 Date of sample: VO, Collected by: EV -4,01,77.1.., .' B. SEPTIC/HOLDING TANK DATA ,tL f R -s04_ Date installed ]///9l� Tank size / L S Compartments `2— Cleanouts (Y/N) Y Foundation cleanout (Y/N) y Depression (Y/N) High water alarm (Y/N)/)i- Alarm tested.(Y/N) A�/;_ Date of pumping ,AJ j% div r Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 1.Z 2- On adjacent lots f 00 t- Foundation 6 i To property line 3 0 + Absorption field 7 Water main/service line Z 5 Surface water/drainage 72-026 (3/93)' Front z• , t— CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" Level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA '7?ii- -veer) (1,106an, n� Y/9V 4, ,.Titi..21), Date installed (' P -16.1,.)..' 7%k z Soil rating (GPD/Ft2) IL si/ 'a System type rr,-.�/r 4 X 4: 3 -45" -4 9, Length f Width .•5 Gravel thickness 5 ' Total depth i� 9 Total absorption area Vyo Cleanout present (Y/N) _y Depression over field (Y/N)'1 Date of adequacy test A -,/,r l /, 9'/ Results (pass/fail) Pro 5 for ek - Bedrooms Water level in absorption field before test c, ,, After test (2 '' Peroxide treatment (past 12 months) (Y/N) /17 If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /39 On adjacent lots /So r- Property line 3o4 -- To building foundation To existing or abandoned system on lot A/c)tia On adjacent lots /U o'- Cutbank //oti w Water main/service line - Surface water /00 rDriveway, parking/vehicle storage area Io Curtain drain /�lor✓ 'MOtW� E. ENGINEERS CERTIFICATION I certify that t have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature David R. Dayton P.E. 20210 Donalar St. Chugiak, Alaska 99567 Engineer's Name Date .} d� HAA Fee $ 30 0 Waiver Fee $ Date of Payment 946 9 V Date of Payment Receipt Number oZ �i 3 (W) Receipt Number SINCE 1908 CT&E Ref.# Client Sample ID Matrix ClientName Ordered By Project Name Project# PWSID Commercial Testing & Engineering Co. Environmental Laboratory Services�z��o�®�® ® 000zv000 o�o�o��� 00000 94.4607-1 LOT 3 LIST SUB WATER DAVID DAYTON, P.E. DAVID DAYTON UA LABORATORY ANALYSIS REPORT Sample Remarks: ROUTINE SAMPLE COLLECTED BY: P. DREWETT. Parameter QC Results Qual Units WORK Order Printed Date Collected Date Received Date 82070 09/13/94 09/09/94 09/09/94 @ 08:59 @ 10:30 @ 11:15 Technical Director STEPHEN C. EDE Released By: Allowable Ext. Method Limits Date c hrs. hrs. hrs. Anal Date Init ----------------- ----- ------------------------------------------ Nihate-N 0.10 U mg/L —EPA 353.2/300.0 10 09/12/94 CMR * See Special Instructions Above * * See Sample Remarks Above U = Undetected, Reported value is the practical quantification limit. D = Secondary dilution. UA=Unavailable NA =Not Analyzed LT= Less Than GT= Greater Than 5633 B Street, Anchorage, AK 99518-1600 — Tel: (907) 562-2343 Fax: (907) 561-5301 FNVIRnNMFNTAI FACII ITIFR IN Al ACICA (-Tit nRAnn FI fRIfA a I INols_ MARYLAND. NEW JERSEY. OHIO, UTAH, WEST VIRGINIA MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Datedn5 (a) Legal Description (include lot, block, subdivision, section, township, %a7 3i ;sT u D• Location (address or directions) �S'P fox 3C, _i Ewcr�E ✓c`/C� RK 99 77 range) (b) Applicants Name/i 4ie, T; n/tt to , /.,/,,,;7- Telephone - Home Business Applicants Address _d � LY: LC C� : r/c� .g/c, l ! 7 7 (c) Applicant is (check one) Lending Institution Buyer ; Other fJ (explain); (d) Lending Institution A"s P��>> ac f2loAITc;446C Telephone 6,i'5:1-72.&) Address (e) Real Estate Co. & Agent F 7741_ t % 4--)! e, Y)f-'5 Address , / 4/-/• Owner/builder (f) Telephone Mail the HAA to the following address: L`R ` Ta t Gts ; l 7 9�, (2_1<"i. 2. Type of Residence Single -Family Number of Bedrooms 3. Water Suppl1 Individual Well �7 Multi -Family Other (describe) Community Public ri Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal OnsiterEl Public Community I r Holding Tank El Note: If community well. system., Tust have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 21 5. 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 regula- tions in effect on the date of this inspection. Name of Firm Telephone Olo 103X Address i°x„1;( 'SIV: -F;. Alt7 Date /4 6. DHEP Approval (ENGINEER SEAL) Approved for( ; iZ;La_ bedrooms By/ L-/ Disapproved • Approved /,---- Terms of Conditional Approval 7 " S '$ Conditional CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 A. WELL DATA Well Classification Well Log Present Total Depth 3 Cased Static Water Level c MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 lfd MUNICIPALITY OF ANCHORAGE' DEPT. ENVIRONMENTALET Afei & i eCTIO,N SEP 2 7 1984, RECEIVED Legal Description: / 3 // S S%,c, If A, B, or C, D.E.C. Approved(Y/N) Date Completed A�2�g3 Yield 2E7/144to .7,j Of Depth of Grouting / Pump Set At el G r Casing Height Above Ground Electrical.Wiring in Conduit 1 - (Y/N) Sanitary Seal on Casing (. /N) Depression Around Wellhead (Y6 Separation Distances from Well: To Septic/Tank on Lot /0 0 74 ; On Adjoining Lots /Co 94 To Nearest Edge of Absorption Field on Lot /00 / ; On Adjoining Lots_/00 To Nearest Public Sewer Line To Nearest Public Sewer Cleancut/Manhole H/ To Nearest Sewer Service Line on Lot C f - Water Sample Collected By ; Date Water Sample Test Results} 7/ $ k,= }4:_77yr ..( Comments B. SEPTIC/HReTNIG"TANK DATA Date Install- • 4//4 Size eVa, No. of Compartments Standpipes Air -tight Caps /N) Foundation Cleanout (Y/N) Depression over Tank (Y Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ''/3 for /770 - Holding Tank High -Water Alarm (Y/N)111A-- Temporary Holding Tank Permit (Y/M) A0 z ft/ Lc --c) Separation Distances To Water -Supply Wall To Property Line To Water T+ i 4Service Line t Course from Septic le -r) oi.ding Tank: To Building Foundation /07 - To Disposal Field 6 To Stream, Pond, Lake, or Major Drainage Continents [Page 1 of 2] Receipt # 0071-706 Date Paid: ,-! Amount: cS v d 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 72c Type of System Design/e4 Date Installed ;1/407Z Length of Field Width of Field 3 6 1 Depth of Field Square Feet of Absorption Area Depression over Field (Y, Results of Last Adequacy Test Gravel Bed Thickness Standpipes Present Li) Date of Last Adequacy Test 4-4964,/./.46-. A/ &(l✓ E'j r 7% z_ej ie-, 77z Separation Distance from Absorption Field: ToWater-Supply Well SPU L To Property Line /0 / To Building Foundation /7.0 1 To Existing or Abandoned System on Lot N ! ; On Adjoining Lots /6-1 lam" To Cutbank(if present) /i /11 - To Water /Service Line Oe To Stream/Pond/Lake/or Major To Driveway, Counts Drainage Course fJ l Parking Area, or Vehicle Storage Area 20 D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Comments Dirensions Manhole/Access (Y/N) Off" Level at 4— Vent (Y/N) Pumping Cycles during Adequacy lest. Meets MOA ** ** Check Permitted Bedroom Rating Against HAA request I certify that I have checked, verified, cr conformed to all MOA HAA Guidelines in effect on the date of this inspection. Signed Company KB1/d5/s e sF3etioX 1,4 -ALE RIVER, ALASKA ' da?7 P 1, 4'944979 (Page 2 of 2] 2-15-84