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HomeMy WebLinkAboutLITTLE BEAR BLK 2 LT 5Little Bear Block 2 Lot 5 #014-061-34 4 A vi O >4 3 H H H 3 y H H > ® O O Int z C, y O iro c� E O O O O O O O O O O O O O 'b ' o Z y H H H H H .HH H H H H H O O O O O O O O O O O O :uj :'vi :.J :\1 bco : r :11TI H H H H H H H . i , ; Y? :J u L/ :C 7 ;7 o C m oil �4 pli m P21 y A vi O >4 3 H H H 3 y H H > ® O O A vi O >4 H H H H H H y A vi O >4 H CD Vr 0 N w N N m m z G) R0Y Z C, y iro c� E H CD Vr 0 N w N N m m z G) R0Y Z �- DEPARTMENT HEALTH AND ENVIRONMENTAL -"OTECTION 2510 E. TUDOR RD. . ANCHORAGE.- Ate:. 9- -1 0i PERMIT NO. 6-:i9 ; APPLICANT ED R INNER 87.10 WELLSLEY COURT1- LOCATION 8 E74' BEAR PLACE LEGAL 1-5 B2 LITTLE BEAR SUBD LILT SIZE {r:J.l�i�l SQUARE FEET 1• MINIMUM DISTANCE BETWEEN A WELL AND AY'd't ON --SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL. OR 200 FEET FOR A PUBLIC: WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED7*0 THE DEPARTMENT WITHIN :_F.1 OF THE WELL COMPLETION. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. I CERTIFY THAT .i_: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON --SITE SEWERS AND WELLS (-i': SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. : I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. S. I APPLICANT ED RINNER ISSUED BY - 313 M T13N T12N I. 3 25' 25' I'>. `r /0,Uhlity Easement Drainage Area Boundary 30+37.59 V CO 2 •e ... g. O• 'at104 w 95�p. Ili_ , LF 20+00 Existing 015 M.H. E-1-1-1-5 IAap!S/15.0 I 35 i 4.s�.s. SS;e :: A•.5'A.S. FSA. Pi. 21+50.15=30+00 lC MH 1 J a q . r= . y.o� I` - I� I_ v �, 'r, h r' 1 10.03 4.25' 'S''6' I� � 1 O.d O • 0.5' /0' N 125.78 L.F. LLtTTLE 300.00L.F. %BEAR \�F _ _ N 0° lO 00"'W _ — �� $ � W 26+33.68 25+07.90 22+07.90 CO I MH 3 MH 2 I /o' /o• Z o' l o' /•o' � \ J IIS I_ Q3 :: I<. , I � 3.0• y5' G.oA.B ¢.o"A.0. \L VICINITY MAP SCALE: la= I Mile LO w CM R O M I 3 Drainage Area oundary.1�q N I AS -BUILT" LE to__CYN - - N - - - N_ -- --- - - - N_ 165 --------.------ --- ------ -._.-- - -------- _ - O .� _..bOr -Ex/sting-Ground - -- --------__--- --- ----- [s9.-5a A.. -g - - - - - -- ---- - - ---- - -- l6O P-roposel�hed_Grade GD /Ga.46 op -M -N -t✓<J6B- /5g. -/o /l -B. mun �oB.o4lB_-_ _ --. - - - 4 - roP-M 5i�89 _ioP-Mh�/575�J 752.-5SA.6. -- - --- __. l_ - r _ �� _- -_ - - --- _ . _.. _ - TOP MH TOP-C0_A51"6 1__r-op05e0= Fl /shed Ora de - 155 - -- - - - - - - - - _ - - - - l55 - - -- - - - Slope=---- - - J _ /5 Slope •_ oCIO ///V 45IR49- AB / .LB3' --:I_ _I _. _ -.- - _ — �� -- � I - - S/ape=-r0.4-/0 - - - - _. ---- - -- - -- _... N INV. d49 -B9- ABJ5L22 __ - - - - - _ --.---- - --- __.._.- - -� - _.._... ----_.-- -I — __ _AB _ 5/.32_- _ _ __- - _ W LNV. -/_48§9-A /-49.94 _ _ {� _ _ —TOP + to -dLO S — ____._ __ --- --I--- ---- -. __ N /NV1.Fi8-F .149.66 ,-B -.._-. _._ IS-IIUV_. -148 68=AB l_$0.04 ^E -/NV. ,.. -r 49.-72 __AS. W % _V- - _ - �_ - - W -/NV /4_9.81 - -- - - - -- -s - - - - - �/. a�l� JF • - -- ---- - -- --- - - 76 S /N_V._.. A ewer canstruci/on w // ccmp/ with -Mu cipa/ slandovds and-- - Cons rucf-rap connec ion. specccolio s /40 - - - - - -- - - - - - - - - - - -- - - l4O 2 An /ols to receive service connection - - - --- 3 - _ A C P6ve_ lenga Is_ inc lu e- -9__of D./.P CD- I 0_000 _11f.-H.�onnectio I -- -- -ar-,— //-0.-/.--to-be-class-2. I - 26+00 25+00 24+00 23+00 22+00 21 +00 20-00 _ 30+00 31 +00 5 D 5D OD s0 GRAPHICSCALE LITTLE BEAR FIELD BOOKS REV DATE DESCRIPTION BY TBM NO. LOCATION ELEV. TBM NO. LOCATION ELEV. DATA DWN CKD DATA DWN CKD By BY BY BY DESIGN 6AAB120 2.5" BC Mon. 0.3 mile E 178.03' BASE TELE Q-'���➢'��°�➢ ➢�➢C��'§•• 9TH SANITARY SEWER __ - Lake Otis Parkway 24.5' TOPO ELEC STAKING N E.68ih. Ave. PROFILE DESIGN a°D➢11 e9we"Ilaalen ��w?�y �6 o . �RALPR . ' JOICELA , , Of SAN SEWER QUANTITIES �i➢➢ ➢➢11��➢°� v SQA➢'D'eg'on •Q N195 -En ®' '/N� .Baby Bear Place. ASBUILT I STORM SEWER CITY CHECK 278-3773 ��i.�T������ 'CONTRACTOR I WATER G. A.A B. CHECK - 212 E. INTERNATIONAL AIRPORT RD. `+ttlAl. "=- DATE JUNE , 1976 GRID 2034 INSPECTOR, GAS CODED BY HOR, I -SO' \ SHEET I of CONSTRUCTION RECORD REVISIONS VERTICAL DATUM VERTICAL DATUM PLAN CHECK Anchorage, Alaska 99502 SEAL SCALEVEn, I"=5' ACCT, NO. 76-11 1 N9466 - - CIdE NO. Tina This Ubdivision Lake Campbel 68th Ave. Landing Strilp 14 6 5 3 2 � e z a m 0 yI Diamond Blvd. 8 9 10 Hw II 7 a ft Ave �w a v o` 3 3 18 ° y 17 16 15 14 a a o z O'Malley Road 19 20 21 22 23 VICINITY MAP SCALE: la= I Mile LO w CM R O M I 3 Drainage Area oundary.1�q N I AS -BUILT" LE to__CYN - - N - - - N_ -- --- - - - N_ 165 --------.------ --- ------ -._.-- - -------- _ - O .� _..bOr -Ex/sting-Ground - -- --------__--- --- ----- [s9.-5a A.. -g - - - - - -- ---- - - ---- - -- l6O P-roposel�hed_Grade GD /Ga.46 op -M -N -t✓<J6B- /5g. -/o /l -B. mun �oB.o4lB_-_ _ --. - - - 4 - roP-M 5i�89 _ioP-Mh�/575�J 752.-5SA.6. -- - --- __. l_ - r _ �� _- -_ - - --- _ . _.. _ - TOP MH TOP-C0_A51"6 1__r-op05e0= Fl /shed Ora de - 155 - -- - - - - - - - - _ - - - - l55 - - -- - - - Slope=---- - - J _ /5 Slope •_ oCIO ///V 45IR49- AB / .LB3' --:I_ _I _. _ -.- - _ — �� -- � I - - S/ape=-r0.4-/0 - - - - _. ---- - -- - -- _... N INV. d49 -B9- ABJ5L22 __ - - - - - _ --.---- - --- __.._.- - -� - _.._... ----_.-- -I — __ _AB _ 5/.32_- _ _ __- - _ W LNV. -/_48§9-A /-49.94 _ _ {� _ _ —TOP + to -dLO S — ____._ __ --- --I--- ---- -. __ N /NV1.Fi8-F .149.66 ,-B -.._-. _._ IS-IIUV_. -148 68=AB l_$0.04 ^E -/NV. ,.. -r 49.-72 __AS. W % _V- - _ - �_ - - W -/NV /4_9.81 - -- - - - -- -s - - - - - �/. a�l� JF • - -- ---- - -- --- - - 76 S /N_V._.. A ewer canstruci/on w // ccmp/ with -Mu cipa/ slandovds and-- - Cons rucf-rap connec ion. specccolio s /40 - - - - - -- - - - - - - - - - - -- - - l4O 2 An /ols to receive service connection - - - --- 3 - _ A C P6ve_ lenga Is_ inc lu e- -9__of D./.P CD- I 0_000 _11f.-H.�onnectio I -- -- -ar-,— //-0.-/.--to-be-class-2. I - 26+00 25+00 24+00 23+00 22+00 21 +00 20-00 _ 30+00 31 +00 5 D 5D OD s0 GRAPHICSCALE LITTLE BEAR FIELD BOOKS REV DATE DESCRIPTION BY TBM NO. LOCATION ELEV. TBM NO. LOCATION ELEV. DATA DWN CKD DATA DWN CKD By BY BY BY DESIGN 6AAB120 2.5" BC Mon. 0.3 mile E 178.03' BASE TELE Q-'���➢'��°�➢ ➢�➢C��'§•• 9TH SANITARY SEWER __ - Lake Otis Parkway 24.5' TOPO ELEC STAKING N E.68ih. Ave. PROFILE DESIGN a°D➢11 e9we"Ilaalen ��w?�y �6 o . �RALPR . ' JOICELA , , Of SAN SEWER QUANTITIES �i➢➢ ➢➢11��➢°� v SQA➢'D'eg'on •Q N195 -En ®' '/N� .Baby Bear Place. ASBUILT I STORM SEWER CITY CHECK 278-3773 ��i.�T������ 'CONTRACTOR I WATER G. A.A B. CHECK - 212 E. INTERNATIONAL AIRPORT RD. `+ttlAl. "=- DATE JUNE , 1976 GRID 2034 INSPECTOR, GAS CODED BY HOR, I -SO' \ SHEET I of CONSTRUCTION RECORD REVISIONS VERTICAL DATUM VERTICAL DATUM PLAN CHECK Anchorage, Alaska 99502 SEAL SCALEVEn, I"=5' ACCT, NO. 76-11 1 N9466 - - CIdE NO. MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section ��—� Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 014 061 34 1. GENERAL INFORMATION Expiration Date: 2 Complete legal description LITTLE BEAR BLOCK 2 LOT 5 Location (site address) 6700 BABY BEAR k Current property ownerMARCOTTE/NALLs) Day phone Mailing address Real estate agent Day phone 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 ' i 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septi ' ❑ Water Storage ❑ Holding Tank El Community Well ❑ Community ❑ Public Water System ❑ Public Sewer'. 171 Waiver request for: I I Distance: Received by: Date: P COSA to be released to the engineer, unless otherwise requested by the engineer. I COSA Fee $ 06 Waiver Fee $ Date of Payment 3 Lz19p0,b Date of Payment Receipt Number 670LI ® Receipt Number COSA # L15(f off) l [ ln_ Waiver # f 6. STATEMENT OF INSPECTION BY ENGINEER . i 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 C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINIDate 3/10/2020 *.��TH *rr 6. DSD SIGNATURE ! •...... _y System #1 Approved for bedrooms CHARLES G BALZARIM � System #2 Approved for bedrooms ����F��s... CE -13854 Disapproved �l PFFD p ' • • • ' NAS ���-r �l ROFESSIO .�. Conditional approval for bedrooms, with the following stipulations: t i 3 OtA ASTL- Yet ATR PRO JJ'J�i �ENr xG�,`. By: Original Certificate, Date: 3 Z The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Sy liems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory (' Well Flow Advisory Other .I t COSA Checklist blue sheet COSA Checklist Legal Description: LITTLE BEAR BLOCK 2 LOT 5 Parcel ID: 014 061 34 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 1977 Total depth 58 ft Cased to 58 ft ❑ Sanitary seal is functioning correctly © Wires are properly protected Casing height (above ground) +12 in. Date of flow test for COSA 3/6/20 Static water level at beginning of test 22 ft. Comments B. TANK DATA Age of tank(s) years Tank type/material Measured operating fluid level in septic tank ❑ Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Well production at time of test +4.2 gpm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ❑ N ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by C.Balzarini Date of Sample 3/6/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date Results ❑ Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date 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 Wells on Adjacent Lots: Community Sewer Manhole/Cleanout > 100' Yes if No ft 0 Yes if No Neighboring Tank > 100' ❑ Yes if No ft Private Sewer/Septic Line > 25' ❑ Yes if No Absorption Field on Lot > 100' 174-1 Yes if No ft Holding Tank > 100' 0 Yes if No Neighboring Absorption Fields > 100' Surface Water> 100' ❑ Yes Animal Containment > 50' 17471 Yes if No Yes if No ft WELL ONLY, PROPERTY IS ON PUBLIC SEWER. Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑ Yes if No ft Q Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' ft ft ft ft ft ❑ Yes if No ft Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No. Water Main > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No. Water Service Line > 10' ❑ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots: Water Main > 10' ❑ Yes if No ft Private Wells > 100' E] Yes if No Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No Surface Water> 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS WELL ONLY, PROPERTY IS ON PUBLIC SEWER. G. ENGINEER'S CERTIFICATION l certify that l 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. 3/15/20 COSA Checklist yellow sheet OF A/,., 49 TH •. ��� .... CHARLES G BALZAR191 CE -13854 .�- ft ft ft ft • Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 Certificate of On -Site Systems Approval Parcel I.D. 014-061-34 3 Expiration Date: 1. GENERAL INFORMATION Complete legal description Lot 5, Block 2, Little Bear Subdivision Location (site address) 6700 Baby Bear Drive, Anchorage, Alaska 99507 Current Property owner(s) Brandon Frazier Day phone (907) 441-0271 Mailing address 6700 Baby Bear Drive, Anchorage, Alaska 99507 Real Estate Agent Ed Davison @ Prudential Day phone (907) 273-7230 2. TYPE OF DWELLING: f 1 0 Single Family (w/wo ADU) t ' ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) WaiverNahance request for: Distance: Received by: € W, T1, Tyt,' Y ! Date rr - COSA to be released to �he engineer, unless otherwise requested by the engineer. COSA Fee $ 7F V R Waiver Fee $ _ Date of Payment 2,; 2 a Date of Payment Receipt Number ��l7t� / Vff�� Receipt Number COSA#' Waiver# 3 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual ❑ Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer E WaiverNahance request for: Distance: Received by: € W, T1, Tyt,' Y ! Date rr - COSA to be released to �he engineer, unless otherwise requested by the engineer. COSA Fee $ 7F V R Waiver Fee $ _ Date of Payment 2,; 2 a Date of Payment Receipt Number ��l7t� / Vff�� Receipt Number COSA#' Waiver# 6. 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 Pinard Engineering Address PO Box 871347, Wasilla, AK 99687 Engineer's Printed Name Paul E. Pinard, P.E. 6. DSD SIGNATURE _1Z System #1 Approved for 9 bedrooms System #2 Approved for bedrooms Disapproved Phone (907) 357-3647 Date Conditional approval for bedrooms, with the following By: - ~>Z✓ Original Certificate Date: :z "! The unic�al MCliorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the rep, septations given in paragraph 5 by an independent,professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other ` C SA blue sheet r i If more than 1 septic system is on the lot: COSA Checklist # of _ Structure served by this syst_em Certificate of On -Site Systems Approval Checklist Legal Description: Lot 5, Block 2, Little Bear Subdivision A. WELL DATA Parcel ID: 014-061-34 Well type Pvt If A. B, or C provide PWSID # Well Log (Y/N) Y Date completed 1/13/77 Sanitary seal (Y/N) Y Wires properly protected (YIN) Y Total depth 58 ft. Cased to 58 ft. Casing height (above ground) 12 in. FROM WELL LOG AT INSPECTION Date of test 1/13/77 7/25/13 Static water level Well production WATER SAMPLE RESULTS: 18 ft. 12 g.p.m. Coliform 0 colonies/100 mL Nitrate ND mg/L Arsenic ND ug/L Date of sample: 7/17/13 B. SEPTICIHOLDING TANK DATA Tank Tank size gal. Number o mpartmenl Foundation cleanout (Y/N) _ Depression overtank Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ftz or ftZ/bdrm) Length ft. Width _ Total depth ft. Eff. absorption area Date of adequacy test Fluid depth in absorption field before test Results in. Elapsed Time: min. Final fluid depth _ Any rejuvenation treatment (past 12 mo.) (Y/N & type) 24.3 4.0 ft. 9.p -m. Collected by: Pinard Engineering Date installed Cleanouts (Y/N) ft. Monitoring tube water alarm (Y/N) System type Gravel below pipe ft. Depression over field For bedrooms Water added \g I. New depth in. in. Absorption rate >= g.p.d. If yes, give date D. LIFT STATION Dateinst_ d "Pump on" level at Datum Size gallons in. "Pump off' leve Cycles tested _ E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot NA Absorption field on lot NA Public sewer main 50'+ Sewer /septic service line 25'+ Animal containment areas 50'+ SEPTIC/HOLDING TANK ON LOT TO: BDitdin oundation Property line Water main Water service line Wells on adjacent lots ABSORPTION FIELD ON LOT TO: Property line Building foundation Water Service line Surface water Curtain drain Wells on adjacent lots F. COMMENTS Manhole/Access (Y/N) _ High water alarm level at Meets alarm & circa r On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank NA Manure/animal excrete storage areas 100'+ G. ENGINEER'S CERTIFICATION I certify that 1 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. Engineer's Printed Name Paul E. Pinard, P.E. Date 7/25/13 COSA brown sheet 10-10-12.doc Absorption fief Surface water Water main i Driveway, parking/vehicle storage IDp p • i000000 • 9VWVV Paw e, Pinard .` 4792 in. LOCATION: Lot 5, Block 2, Little Bear Subdivision DRILLER: Penn Jersey Drilling DATE WELL COMPLETED: 1113/77 WELL DEPTH: 58' STATIC WATER LEVEL (top of casing): 24.3' PINARD ENGINEERING P.O. Box 871347 Wasilla, AK 99687 (907) 357-ENGR (3647) WELL FLOW TEST JOB NUMBER: 13-237 DATE OF TEST: 7125/13 FIELD STAFF: PJ Pinard Time Elapsed Time (Minutes) Static Water Level Flow Rate m Cumulative Gallons Pumped Remarks 3:50 PM - 24.3' 4.0 - Start Test - Meter 113240 4:05 15 32.3' 4.0 60 113300 4:20 30 33.9' 4.0 120 113360 4:35 45 34.4' 4.0 180 113420 4:50 60 34.8' 4.0 240 113480 5:05 75 35.1' 4.0 300 113540 5:20 90 35.4' 4.0 360 113600 5:35 105 35.6' 4.0 420 113660 5:50 120 35.8' 4.0 480 113720 6:05 135 35.9' 4.0 540 113780 6:20 150 36.0' 4.0 600 113840 6:35 165 36.2' 4.0 660 113900 6:50 180 36.4' - 720 Stop Test- 113960 RECOVERY 6:55 PM 5 27.9' All well protection features are adequate. Average Flow Rate: 4.0 gpm Comments: DURING THIS TEST, THIS WATER SUPPLY WELL WAS CAPABLE OF PRODUCING 4.0 GPM FOR LIMITED PERIODS. THIS TEST DOES NOT Reviewed by: Paul Pinard NOT CONSTITUTE A WARRANTY OR GUARANTEE THAT THE WATER 17/1 SUPPLY SYSTEM WILL CONTINUE TO FUNCTION AND PRODUCE AT THIS RATE. Date: 7/25/13 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water 8 Wastewater Program ' 4700 South Bragaw SL 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 Parcel I.D. 014-061-34 HAAft_ O.S' O /Z 4 1. GENERAL INFORMATION Expiration Date: _ rp — O Complete legal description LITTLE BEAR SUBDIVISION• LOT 5 BLOCK 2 Individual Water Storage ❑ Individual Holding tank Location (site address or directions) 6700 BABY BEAR DRNE • ANCHORAGE AK. 99507 Current Property owner(s) Mailing address Lending agency Mailing address MARTIN ODSATHER Day phone _229-6822 (AGENT) C/o USA HERRINGTON w/ DYNAMIC PROPERTIES Day phone Real Estate Agent LISA HERRINGTON w/ DYNAMIC PROPERTIES Day phone Mailing address 3111 "C' STREET • ANCHORAGE. AK 99503 Unless otherwise requested, HAA will be held by DSD forpickup. 2. NUMBER OF BEDROOMS: 3 229-6822 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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 supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with new water samples. (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 certiried 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 onsite 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 verity that based on the Information obtained from the Municipality ofAnchorage riles and from my investigation and inspection, the onsite 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. Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any otherperson or party Is not authorized, nor will It confer any legal right whatsoever. 5. DSD SIGNATURE _-jC Approved for -3 bedrooms. Phone 337-6179 Date 3 2 ° Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklisty Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other ON-SITE , G� SND . m WASTEWATER sir,.'•. By f7.�/�1 Wj I Original Certificate Date: �? - a Municipality of Anchorage ' Development Services Department Bugding Safety OIv*Ion On-site Water b Wastewater Program ' • °' ° 47M South Bragaw St. P.O. Box 196550 Anchorage, AK 09519.6650 www.d.anchor sge.ek. us (907) 3437904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LITTLE BEAR SUBDIVISION; LOT 5. BLOCK 2 Parcel ID: 014-061-34 A. WELL DATA WOO type ER ATE If A, B, or C provide PWSID# N/A Date completed 1/13/1977 Sanitary seal (YIN) YES Total depth 58 ft. Cased to 58 ft, FROM WELL LOG Date of test 1/13/1977 static water level 18 ft, Well production 12 g,p,m_ Well Log (YIN) YES Wires property protected (YM) YES Casing height (above ground) 12+ in, AT INSPECTION 3/22/2DO5 31 R, 5.6 g.p.m. WATER SAMPLE RESULTS: Coliform _ colOnles/100 ml. Nitrate 0Lm9A. Other bacteria _i& colonie3/100 ml. Arsenic. N/A mg JL. Date of sample: 3/22/2005 Collected by: GEG. LtD. B. SEPTICMOLDINl3TANK DATA PUBLIC SEWER Tank Typo/Material Tank sae gal. Foundation cleanout (YIN) Number of Compartments over tank (Y/N) _ Pumper Date installed (YM) High water alarm (YM) C. ABSORPTION FIELD DATA PUBLIC SEWER Date hstatled Soy rating (g•p•dlft'or ft%drtn)_ System type Length ft. Width ft. Gravel Total depth ft. ER. absorption area_ ft' Monitoring over field ft. Date of adequacy test Results s afF il_ For bedrooms Fluid depth in absorption field before in. Water added _gal. New depth _in. Elapsed Time: Final fluid depth _ in. Absorption rate >= g.p.d. treatment (past 12 mo.) (YM 3 type) If yes. give date D. LIFT STATION Date installed "Pump on" level at _in. E. SEPARATION DISTANCES Size In gallons High water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanklliR station on lot N/A Absorption field on lot N/A Public sewer main •50'+ On adjacent lots 1009+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Sewer !septic service line 25'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Building foundation Property line Absorption field Water main SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property Una Water service line F. COMMENTS Building Wells on adjacent lots *WELL DRILLED PRIOR TO 1983. G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspedions and review of Munidpal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name JEFFREY A GARNESS Data Do v HAA Fee $ LkSC2 i I 1 �"� Date of Payment - a�t" C'-2 Receipt Number Q(6171 ;41 (Rev. 1vol) rN Surface water PUBLIC SEWER Driveway, parkinglvehicle storage Waiver Fee S Date of Payment Receipt Number 3-2e-OS;12:20 ;CT and E Garness Eno GrouD ;5615301 0 2i 2 SGS/CT&E ENVIRONMENTAL SERVICES Drinking Water Analysis Report for Total Coliform Ba e� READ INSTRUCTX*S ON REVERSE awe BEFORE COLLECTING SAMM '\ MUST BE COMPLETED BY WATER SUPPLIER . p PUSLIC WATER SYSTEM 00 (vk7ATE WATER SYSTEM 0 SIM Raa1Ra Q Sand bacim . SAMPLE COLLECTION: . r�..Y+r. r iia al b.�r.Y.a•r Dow. 03 [ 5 an v� 200 W. POTTER DRIVE ANCHORAGE, ALASKA 9851 a Tel: 907562-2343 'Fax* 907561=5301 Lab Rol No. .. . 1051524 SAMPLE TYPE JyROutine TmrpoRaO m Lab Dr. Q Same as Collector Other. 13 Treated Water Repeat SampM 0 Untreated Water.. (refer to lab no. 1 LI Special Purpose O BE COMPLETED BY LABORATORY Sample Reeeivina: Date: 1 ��%�" ❑ S.mpW ever w hen ol4 ❑ RUSH SAMPLE Time: L ROW&aur beW MMW Temp.. ❑ b Nov Waher Phone r . Dellvary Melford an1oW LOCaO 17— Fax Received By: (v-05— -:0 Prnra N * / .......................................................................... ............... ...... ... ..................... Bacteriolooical Water Analysis Record• Sent b ADM MMO-BURT (PIA) RESULT& ANC FSK �/ ADayala saaant�7% -sy' TOW Coirans DJerrily� . . Amlpt Sent a CSa11C Analytical MaUnd: . MEMBRANE FILTER RESULTS: Olmd count ComiaWoomt. Phoned Q FaxedQ Downff' mbrane Filtera•vwvksw t sock. Wbk MMO-MUG (PIA) v+.o..,. LTB: ace• j� Satisfactory. ..ac... { Ee• ❑ Unsatisfactory' Reported By: %ro1.. Daternnn: �— p?-o.i— 1I:.00 am -d ~.a.�~rrr srbna -- •_ _ .Fom*FW-OM 17JIT103 I 3-28-05: 5:28PM: :907 5815301 ■ 2/ 7 CS Ref.N 1051524001 Ment Name Gamess Engineering Group, Ltd. 'roject Namem Various Meent Sample ID Bear S/D Lot 5 Bk2 Iatric n mg Water ample Remarks: All Dates/Times are Alaska Standard Time Printed Date/Time 0328/2005 16:21 Collected Date/Time 03222005 14:37 Received Date/Time 03222005 14:52 Technical Director Stephen C. Ede snmeta Results PQL Units Method Allavable Prep ContainerW limits Date Analysis Date Init rivate Individual Analysis Chloride 172 0.100 mg/L EPA 300.0 D (o-250) 03/23/05 XM Fluoride 0.100 1.1 0.100 mg/L EPA 300.0 B (o-2) 03/23/05 XM Nitrate -N 0.100U 0.100 MA EPA 300.0 B (o-10) 0323/05 XM Nitrite -N 0.100U 0.100 mg/L EPA 300.0 B (o-1) 0323105 XM Sulfate Total Dissolved Solids 129 1.00 mg/L EPA 300.0 B (<-250) 0323/05 XM 292 10.0 mg/L SM20 25400 C (r--500) 0325/05 KAL HCO3AIkalinity 102 20.0 mg/1. SM2023200 C CO3 Alkalinity 20.0 U 20.0 mg/L SM20 23208 C 0323/05 PLW Off Alkalinity 20.0 U 20.0 mg/L SM20 23208 C 0323/05 PLW Conductivity 400 1.00 . umhos/cm SM202510B C 0323/05 PLW PH 7.60 0.100 pH units EPA 150.1 C (6.5-8.5) 0325105 0322/05 KAL PLW Alkalinity 102 20.0 mg/L SM20 2320E C 0323105 PLW Total Coliform 0 c01/I00mL SN12D9222B A (r—p 0322/05 TLF - I'RELINIINARY - Ii W 82$1 % ORA/NA6E n >v !lralry E4SGWEVT o ,rn T ll� Z r O N m m mcn mxz i O0 * I `.�' -+ Z o I MOMozm t o Zm� mao nl mmo Y t. 6:1 z 9 m moo= 1 wI�^,� u�� o \ 'z N T w r 91 4 v /Z a '_.... . IA 113 m 'I, 11 t5r nim^ '+ 1:4 OR o .� �vvQ�o _ O'10,00 rW e o. 00 �ir�m3p0 ` m � n m y I v m m y m'S-0ommvmc�n ABy BEAR DF.a v'cn -niZn W m N v. cn �mga B o g to m� CL g q CA > � m a 'm ° m'� �m N N a'is o » n m' !p MUNICIPALITY OF ANCHORAGE ® DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services .1 ik On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CE TiFI `;''E O HEALTH AIJT.'-- !ITY +PFROV/AL -'OR A SINGLE FAMILY -: /ELLING#/i Parcel l.D.# ©14-Ot"t-3�� H A A # y� 7?al"n 1. GENERAL INFORMATION Complete legal description L -O I `J� t 17 LF_ BIEAe- Location (rsile addross or directions) L12 ,--,Ag Y 9�1EA Property owner_— Day phone b 13b (7:> Mailing address — Lending agency Day phone Mailing address Arent 1 c ,. s; __1# rte.; �� ��ti _ Day phone 2��'�/��� Address Unless otherwise requested, HAA will be hId for; pickup. 2. NUMBER OF BEDROOMS: RECEIVED 3. TYPE OF WATER SUPPLY: APR 28 1997 Individual well Municipality of Anchoragg Community well Dept. Health & Human Servievp Public water NOTE: If community well system, provide written confirmation from State ADEcC attest= ing to the legality and status of system. - 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank tl Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) From MOA X21 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 furtherverify 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 (o (��erit �a�V-Vao-�4_4 >= Phone Address 4-6t ho26) 3 A,, y. Q R t O i Engineer's signature 6. DHHS SIGNATURE Approved for K_��r:_bedrooms. Disapproved. Conditional approval for nal Comments Date �1a z /? bedrooms, with the following stipulations: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA N21 MUNICIPALITY Of- ANCHORAGE Municipality of Anchorage ENVIRONMENTAL SERVICES DIVtSION DEPARTMENT OF HEALTH & HUMAN SERVICES APR 2 8 1997 Environmental Services Division �/ 825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4�1 E 1( E DA Health Authority Approval Checklist Legal Description: L, Vt,�? ki ¢-O-e jj�u� Parcel I.D.: 0 1 � " 061— aJ q A. WELL DATA Well type If A, B, or C. attach ADEC letter. ADEC water system number Log present (Y/N) �� Date completed /�/ 3 / T7 Total depth ?; & Cased to Sanitary seal (Y/N) 1 FROM WELL LOG Date of test +�� 17-7 Static water level t t9i 1 Well production Ig g.p,m. WATER SAMPLE RESULTS: Casing height (above ground) 11 Wires properly protected (YIN) AT INSPECTION �y y g.p.m. Coliform N % Nitrate _� t) Other bacteria Date of sample:/ 27— /--�?7 Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Tank size Foundation cleanout Date of Pumping C. ABSORPTION FIELD DATA Date installed Length Width Effective absorption area Date of adequacy test (>ia41C � �F— U✓ 72 - Number of Compartments Cleanouts (Y/N) Depression (Y/M High water alarm (YIN) Pumper rating (g.p.d./fe or 82/bdrm) Gravel thickness below pipe Fluid depth in absorption field before test (in.); Fluid depth (ins.) Minutes later: System type Total depth g Tube present(Y" Depression over field (Y" (Pass/Fail) For bedrooms Immediately after_ gal. water added (in.): Absorption rate = g.p.d. Peroxide treatment (past 12 months) (Y" If yes, give date D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* "Pump off' level at* *Datmn SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot _ Nl/k- ; On adjacent lots Absorption field on lot ✓ ; On adjacent lots i/ Public sewer main -7071 Public sewer manhole/cleanout > /C Sewer /septic service line > /o Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation roperty line Absorption field Water main/service line Surf e water/drainage Wells on adjacent lots SEPARATION DISTANCE FROM ABSIPRPTION FIELD ON LOT TO Building foundation Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain Wells on adjacent lots Property line F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records that the, above systems are in conformance with MOA HAA guidelines in effect on this date. Signature Engineer's Name! Pvt S U r (C(c�t t d� 411gureermg..SQal Here Date HAA Fee $ 9 a Date of Payment �z/�/ 0 Z7 Z Receipt Number Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE / M . • _ DEPARTMENT OF HEALTH & HUMAN SERVICES M 1 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. # O (4-- 0 & ( _ j q HAA # 0 mac) 1 C - 1i t n 1. GENERAL INFORMATION Complete legal description Lot 5; Block 2; L.i tt-e Bean Subd�vision Location (site address or directions) 6700 Baby Bean Dki.ve Property owner H.U.D. 111-037868-703 Day phone Mailing address 605 We -6t 4th Avenue Anchofcage, Ah. 99501 Lending agency Day phone Mailing address Agent Sandy Hje n4ta.d ASSOCIATED BROKERS, INC. Day phone 563-3333 Address 640 Wut 36th Avenue Suite One Anehonage, Ak. 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 v' 3. TYPE OF WATER SUPPLY: Individual well XX Community well Public water NOTE: if community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer XX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 A 1.1 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 5 & S NISIGINGERING Phone 17034 Eagle River Loop Road No. 204 Address _.4Alaska Engineer's signature DHHS SIGNATURE \ Approved for Disapproved. zli4� (3 bedrooms. Date � S2— k A��.�a`an''.�'A.P,,9�A e e ° 0 •° 9T `moiiF u oa•eee Ja ••d �•° ;, n 15 • �? �y p ° V N�'P�� Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ��,_� a -r Lrt Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LA��- & c T /t- AeAr ,S Parcel I.D. A. WELL DATA Well type,-rNgle Fit 114lf A, B, or C, attach ADEC letter 1 Date completed - Lk - J -1Driller Ae ti� 'k r�T Total depth 8 Cased to Casing height Z Log present(Y/N) '0�4-- 0�0 1---35/ ADEC water system number Sanitary seal (Y/N) Wires properly protected (Y/N) �► Pea P6Iler FROM WELL LOG AT INSPECTION Date of test 13 - }� t7 - Z ?' ` 9 MUNICIPALITY OF ANCHORAGE Static water level IRGIsMENTALSERVICES DIVISION Well flow 9 -P.M. ot'f . 0 1991 Pump level U K V K RECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 0 1 K (Aobl+c- 6L'k0� On adjacent lots .f70 '-1 Absorption field on lot fJ � ; On adjacent lots ( 0 D -t Public sewer main f Public sewer manhole/cleanout 5 Sewer service line 2 5 + Petroleum tank !J dNe (S o' o t,-� rJ WATER SAMPLE RESULTS: Coliform ��4ti5t�lG �ndt� Nitrate-Z�*1(A1: rs4 Other bacteria �P✓ Date of sample: D-ZeL f1 Collected by: °� S Z --A)5 lJIIJ eV lNq B. SEPTIC/HOLDING TANK DATA nAI i C- se Date installed Cleanouts(Y/N) High water alarm (Y/N) Date of pumping Tank size Foundation cleanout (Y/N) SEPARATION DISTANCES FROM Well(s) on lot To property line Surface water/drainage 72-026 (Rev. 7/91) Front Compartments - - Depression (Y/N) Alarm tested (Y/N) Pumper ING TANK TO: On adiatent lots Foundation Absorption Water main/service line CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pum on" level at "Pump off' level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATIO TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date insta d Soil rating System type Length Width Gravel thickness Total depth Total absorption ar Cleanouts present (Y/N) Depression over field (Y ) Date of adequacy test Results (pass/fail) for bedrooms Peroxide treatment (past 12 months) /N) If yes, give date SEPARATION DISTANCE FROM ABS O PTION FIELD TO: Well on lot On adja nt lots Property line To building foundation existing or abandoned system on lot On adjacent lots Cutbank Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on thAate of this inspection. S S ENGINEERING N SignatureaUlt! _ *o OT oQQ River, Alaska 99577 Engineer's Name` ` C 00 Date ,ao Fi go V CC HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number \� MUNICIPALITY OF ANCHORAGE DEPARTME, OF HEALTH AND ENVIRONMENT _ PROTECTION 825 L Street, Anchorage, Alaska 99501 279-2511, ext. 224 or 225 �F Date Received: May 9, 1977 #1: Time#2: Time #3: Time Date Date Date Insp_ Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: Amfac Mortgage Company_ Mailing Address: Phone: 2, Property Owner: Sebring Builders Mailing Address: Star Route A Box 1540C 99507 Phone: 344-3069 3. Legal Description: Lot__5 Block 2 Little Bear Subdivision 4: Single Family Residence: (x) Number of Bedrooms: - Multiple Family Residence: ( ) Number of Bedrooms: 5. Well System: Individual Well (x) Community/Public Svstem ( ) Permit # Depth of Well 60' Well Log on File (�}-- Construction Bacterial Analysis 6. Sewage Disposal System Permit # Septic Tank Size Absorption Area On-site System ( ) Public Utility Installed Installer _ Manufacturer _ Soils Rate Material 7. Distances: Well to Septic Tank to Sewer Line Nearest .Lot line to Nearest Lot Line to Absorption Area Absorption Area Page Two Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 5 Block 2 Little Bear Subdivision Comments: Affadavit Attached: ;(:') Letter Attached: ( ) Approved: Date: Disapproved: Date: Department Worksheet: MUNICIPALITY OF ANCHORAGE Department of Health and Environmental p)1Idjj(�A� T(o`Yi, 825 L Street, Anchorage, Alaska 9,9gtrlFi�T i. ;, >i:i:TioN 279-2511, ext. 224, 225 �*equest for Approval of Individual Sewer and Water1`Vc'lii s 1. t O 2 3 MP 5. N Proper y wner. P Y!y! Mailing Address: l J` Phone: 14 Name of Buyer: tf ek-5 — Mailing Address: Phone: Lending Institution: Mailing Address: Realtor/Agent: Mailing Address: Legal Description: le Street Location: Single Family Residence: Multiple Family Residence: Phone: Phone: ( "�- Number of Bedrooms: '3 ( ) Number of Bedrooms: 7. Water Supply: *Individua.l Well (S-1- Public/Community System ( ) If Individual Well, well depth e�6) If Community System, name of system 8. Sewage Disposal System: On-site System ( ) Public System If On-site System, date of installation: *NOTE: A well log is required on ALL wells drilled since 6/75. 3/77