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HomeMy WebLinkAboutHERITAGE PARK BLK 2 LT 3Heritage Park Block 2 Lot 3 #050-211-77 Municipality of Anchorage Page of 3 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: PID Number. _(CL-2, Name: Wastewater System: 0 New ❑ Upgrade LEGACY Hor7E5 Address: ABSORPTION FIELD 5L4(0l NEI+/ Si7YNA Clk. 4NCR0,<,4&9, AK Phone: No. of Bedrooms: p Deep Trench X]Shallow Trench ❑ Bed ❑ Mound ❑ Other 333— 019TI 3 LEGAL DESCRIPTION Soil Rating: Total Dep3 from original grade: I,a GPD/S Ft Lot: Block: Subdivision: Depth to pipe bottom from original grade: I Gravel depth beneath pipe n 3 opt He e i TAVB ox a ? Ft. Ft. Township: Range: Section: Fill added above original grade: Gravel length: L4 Al a.r Ft. 79' Ft. W El New El U rade P9 Gravel width: 5 Number of lines: 1 Distance between lines: Al. A. Ft. Ft. Classification (Private, C): Total D Cased To: Total absorption area: Pipe material: Ft. Ft. -37 5 SQ. Ft. P V c Driller: to Drilled: Static Water Level: Installer: Date installed: Ft. L,E-&ACY HonES TANvAl2Y Ieici3 Yield: Pump Set at: Casing He bove Ground: - TANK GPM Ft. SEPARATION DISTANCES N Septic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines AIVCHORAUiF TANK I a5U Material: Number of Compartments: Well STEE[ a Surface LIFT STATION Water Lo 72-5' > aOr Size in gallons: - Manu rer: °e "Pump on" level at: "P Y' leve High water alarm at: Foundation I D� � Curtain Pump Make el Electrical Inspections performed by: Drain BENCH MARK Remarks: Location and Description: Assumed Elevation: Pt o�, ..- o o 00o U �p f,>W •° a 9rC ��Y® p� /� 0 1 � d u' L1A / L9 11511A ✓ I� V s° e B 900,0�0°O d 001" }oWosn Inspections performed by: Dates: 1st 1_4,n "!/.� �/S 3ui96 ©Sao ? 2nd e9 o9ao90 09 RARLE V. AUSMM 6 E t. `yoa CE 1393 Department of Health a umann ices approval 447))4 99®090a04 1� /J Reviewed and approved by: Date: 72-013 (Rev. 9/91) MOA 25 Permit No. Page a of 3 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: �oT3� LK� NER/TAl F PKj s�, i/vas eiw PID No.: 72-013 A (1193)' Permit No. Page 3 of 3 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: L� AL K a IHE2 !TA('E PK / S �i 7 /4 Al . 2 / w PID No.: 72-013A(1193)' Co = CLEANOUT M W = M. NIT R S T = .;.......... ................................ S4FPr/c TAN/< ....... ..................... ........................ ............................... ...... ................................. .............. ......................... ...... ................ ........................ ........................................... Cod 5�y54� God (-oti MW Goa :i —tb a GkouNr� s —14 z o n— z Gavv/vo it.} I � 14- '14.5 15 EcE✓. 1.7 .............................. 3 I..t.........I.O...................................................................... q....5................_................... ...........................�.ca.................................... 5 Y5TE /•� 2rov8RT OATOMr io' AT L3Jrror� OF C-02 ru fir. 3�+ IN 49YH - �oo o©eat-BAO@$gP 4 7/// SG A L E: EARLE V. AUSMAN e CE..)M ag /1 ' �'4i' `•• ep • mss �S' 006,46.66 ow 72-013A(1193)' I 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 PERMIT PAGE 1 OF 1 PERMIT NUMBER:SW930002 DATE ISSUED: 1/11/93 DESIGN ENGINEER:POLARCONSULT EXPIRATION DATE: 1/11/94 OWNER NAME:DESIGNS IN WOOD LTD OWNER ADDRESS:10648 TRADITION AVE ANCHORAGE, ALASKA 99516 PARCEL ID:05021177 LEGAL DESCRIPTION: HERITAGE PARK SLK 2 LT 3 LOT SIZE: 27661 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM 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 DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS 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 PROV RECEIVED BY: ISSUED BY: DATE :/ /Z /" r DATE: / - // ` /J polarconsult alaska, inc. ENGINEERS • SURVEYORS • ENERGY CONSULTANTS December 30, 1992 DHHS, Environmental Services, On-site Services P.O. Box 196650 Anchorage, Alaska 99519 Attn: Permit Review Officer Re: Design and Construction Approval for On-site Sewer System at Lot 3, Block 2, Heritage Park S/D. Dear Sir or Madam: Please accept the following design for review and permitting. As shown on the soil logs, groundwater has been monitored to a depth of 8'. It has been verified that no impermiable layers exist within 10 feet of the surface. The proposed system does not affect the current use of the adjacent properties and will have minimum future impact. If you have any questions, please give me a call. Si ely, David Ausman, CE Attachments: On-site Sewer/Well Permit Application Site Plan, Sheet 1 of 4 System Design Calculations, Section, Sheet 2 of 4 Percolation Test, Sheet 3 of 4 Percolation Test, Sheet 4 of 4 $200 Check for Permit Fee 1503 WEST 33RD AVENUE • SUITE 310 • ANCHORAGE, ALASKA 99503 PHONE (907) 258-2420 • TELEFAX (907) 258-2419 polarconsult alaska, Inc. 1503 West 33rd Avenue • Suite 310 ANCHORAGE, ALASKA 99503 (907) 258-2420 Fax (907) 258-2419 JOB HGFZr7A6 /-,E� PA2< f�,j E) /LOT -S� hSLK L SHEETNO. / OF T CALCULATED BY 'hA. DATE 1 Z 1 I CHECKED BY DATE SCALE P90OUCT204.1(sfr&SWS)205-1(Paddea)®9 In. Groton. We 01471. TO Of0eePNONE TOIL FREE I-8*2255W polarconsult alaska, Inc. 1503 West 33rd Avenue • Suite 310 ANCHORAGE, ALASKA 99503 (907) 258-2420 Fax (907) 258-2419 II PRODUCT 204 ]1Siogle SWLS1 M 1(Pad dod1 J�?Inc. Grob Mm, 01471. To Order PHONE TOLL FREE I A00 -22M JOB 46 /-� m t K// -.f f X SHEETNO. ` }-ten 4 OF CALCULATED BY � DATE Z C/ CHECKED BY DATE M a �1 V 2 n�su�iir�nvo 3 a ._. ........ � OF A4 .._... ... _... o ..... . Q Qg 4 TI �� -. $�sa ��o>>aea//aj1j[//;o//oo ooe�1TT��O//��©DO((//OP}��O�o✓� - ....... s° EARLE V. AtISAAM �_ _ ..... ..... Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG - PERCOLATION TEST PERFORMED FOR: SF. P. GOi4STTZ1I nj Q DATE PERFORM 'aseo. 4w LEGAL DESCRIPTION: 43yZ t_Le� P.0 Township, Range, Section: T1JJ SLOPE SITE PLAN O ° Ho SE _ 2 D 3 c) :e 4- '._c 5 ' 0 6 C 7• V V 9 L 10 END 11 of 12 Tia j- 13 13 14 15 16 17 18 19 6-w /)1w _t II WAS GROUND WATER /JO ENCOUNTERED? S IF YES, AT WHAT L C DEPTH? P E Depth to Water After / Monitoring? Non/ Date: ■■■■■,m -1 --mm .■■■mem■■ mom..■.■■ ■■■■■...■. 20 11 PERCOLATION RATE � (minutev(inchl PERC HOLE DIAMETER �L'— �J TEST RUN BETWEEN 2 FT AND 3 FT )MMENTS H4264 4264 /Tey ZleaA ` A-"-7CALFTO F -r PERFORMED BY:--T-')AV I t� I DA,I CERTIFY THAT THIS TEST WAS PERFORMED IN ATE:7ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:- 72-008 2-008 (Rev. 4/851 I rim _jm�Mmml - • • -moi 20 11 PERCOLATION RATE � (minutev(inchl PERC HOLE DIAMETER �L'— �J TEST RUN BETWEEN 2 FT AND 3 FT )MMENTS H4264 4264 /Tey ZleaA ` A-"-7CALFTO F -r PERFORMED BY:--T-')AV I t� I DA,I CERTIFY THAT THIS TEST WAS PERFORMED IN ATE:7ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:- 72-008 2-008 (Rev. 4/851 I Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST O 49th U % AVOW CE as" . PERFORMED FOR: Tr P 0Qs-r;ZUI,TI0V.) DATE PERFORMED LEGAL DESCRIPTION: LO% - e101 -X Z Township, Range, Section: -r l t J I R Iyjf a. DEPTH Q y��Q/%%il� P�iK• SLOPE SITE PLAN ' 1 O S� 1-410�S 3=: 3 4 5 9 6 7 8 ,p 9 10 d FN17 11 or— r" -r" z 12 13 14 15 16 17 18 19 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? & .) Depth to Water After ` Monitoring? Date: /A S L O P E Reading Date Gross Time Net Time Depth to Net Water Drop 7 7-2 AL /4: 30 0 0 47 'V//to q: 20:� o - 5 — ;z/; 30 / /3 / H: 2Z: 30 :z 2"00 ; 90 i 20 PERCOLATION RATE 5'-3 (mmutesnnch) PEAL HOLE DIAMETER TEST RUN BETWEEN FT AND SFT „OMMENTS ����i7 �� LQC; �G/9GC 7'0 PERFORMED BY: -7bAV I h AUS M L41)i I nom., CERTIFYTHATTHIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE D ZQ 9Z 72-008 (Rev. 4/85) Municipality of Anchorage On -Site Water &Wastewater Program (907) 343-7904 1 RUSHI r RUSH! CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 050-211-77 1. GENERAL INFORMATION Expiration Date: C" _ % 1), ! S. Complete legal description HERITAGE PARK; BLOCK 2 LOT 3 Location (site address) 10648 TRADITION AVENUE * EAGLE RIVER, AK * 99577 Current Property owner(s) Mailing address Real Estate Agent SAM HUTCHINSON Day phone 717-5676 10648 TRADITION AVENUE * EAGLE RIVER, AK * 99577 2. TYPE OF DWELLING: E Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: Day phone TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual On-site 0 Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System 0 Public Sewer ❑ Received by — Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ (s LM -0) Date of Payment &02%,je---,, Receipt Number Qa,63% COSA # (08C1313yg Waiver Fee $ Date of Paymem Receipt Number 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 cin -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. 1 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. 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, groundwaterlevels 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 other person or party is not authorized, nor will it confer any legal right whatsoever. 6. DSD SIGNATURE V System #1 Approved for �7 bedrooms. System #2 Approved for bedrooms. Disapproved. Phone 337-6179 Date 11 6 ? o OF q �V4D4 *9r- Conditional approval for bedrooms, with the following stipulations: G armass o t0FAA(25' gON-SITE WATER AND WASTEWATER l PROGRAM IVI svJ� Original Certificate Date: 4!� — / a - / 3 The Municipality or Anchorage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatations 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. ATTCHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory (Rev. 11105) Nitrate Advisory Arsenic Advisory Other If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Ilefitm Pa, lc' boc, z L.L 3 parcellD: f�SD-zll-�i A. WELL DATA Well type Date completed Total depth ft. Date of test PUBLIC WATER If A, B, or C provide PWSID# _ Well Log (YIN) Sanitary seal (Y/N)— Cased to ft. FROM WELL LOG Static water level Well production WATER SAMPLE RESUL Coliform m ug./L. B. SEPTIC/HOLDING TANK DATA Nitrate mg./L. Date of sample: Wires properly protected (YIN) Casing height (aboround) in. "P56TION ft. g.p.m. Collected by: Tank Type/Material SEPTIC/STEEL Date installed 1/1993 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (YIN) N/A Date of pumping % /J Pumper JR'S PUMPING C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE Date installed 1/1993 Soil rating (g.p.d./ftor /bdrm 1.2 Length 75 Width System type SHALLOW TRENCH Gravel below pipe 0.5 ft. Total depth *4.79 ft. Eff. absorption area 375 ft' Monitoring tube YES Depression over field NO Date of adequacy test 6/12/13 Results (Pass/Fail) PASS For bedrooms Fluid depth in absorption field before test 0 in. Water added 530 gal. New depth 0 in. Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 450+ P g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE If yes, give date - D. LIFT STATION Date installed Size in gallons Manhole/Access "Pump on" level at in. "Pumpoff E. SEPARATION DISTANCES water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on Public sewer main Sewer /septic service line areas On adjacent On adjacent lots manhole/cleanout Holding tank Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 51+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+PRIVATE/200'+PUBLIC SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Properly line 10'+ Building foundation 10'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent Iotsl00'+PRIVATE/200'+PUBLIC F. COMMENTS G. ENGINEER'S CERTIFICATION I cerfify that I have determined through field inspections and review of Municipal records that the above systems are in " conformance with MOA COSA guidelines in eSect on this date. EngineeesPrinte N me JEFFREY A. GARNESS �004� Date d��,a 0.11/051 Municipality Of Anchorage T. I(" ''�'j Development Services Department F Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-211-77 COSA# of) C- 1. GENERAL INFORMATION Expiration Date: 7�%- Complete legal description HERITAGE PARK S/D; BLOCK 2, LOT 3 Location (site address) 10648 TRADITION AVENUE * EAGLE RIVER, AK * 99577 Current Property owner(s) RANDY & DEBI WRIGHT Day phone 854-8749 Mailing address 10648 TRADITION AVENUE * EAGLE RIVER, AK * 99577 Lending agency Day phone Mailing address Real Estate Agent BARBARA CRITTENDEN W/ PRUDENTIAL VISTA Day phone 242-2227 Mai16gaddress . „p 16635 CENTERFIELD DRIVE * EAGLE RIVER, AK * 99577 Unless, otherwis ..: requested, COSA will be held by DSD for pickup. 2. NUMBER OF .BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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. STATErOENT 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 Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and;%r 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 r t .-r it t,"ie Municipality t f /1 fila d m i,-Wectirr tion ainspection, ti1e infGriifatiGn obtained nOfif ufc ro�uniCipali�yGf r�i7Ci�Tvragc u��,S aiiv f ori, ,uy,.,..,�..ya�,.,,, and on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR. ROAD, SUiTE 101 * ANCHORAGE, AK 99507 6 1a /11 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 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 other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Allah men s: COS' Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory ArSeniC Advisory Maintenance Agreements Supplemental Engineer's Report Other By: G - Original Certificate Date: (Rev. 11/05) WASTEWATER PROGRAM ; t� )))))))))) Municipality of Anchorage F • V ar • Development Services Department Building Safety Division On -Site Water & Wastewater Program s T 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: HERITAGE PARK S/D; BLOCK 2, LOT 3 Parcel ID: 050-211-77 A. WELL DATA PUBLIC WATER Well type If A, B, or C provide PWSID# Well Log (Y/N) Date completed Total depth ft. Date of test Static water level Well production WATER SAMPLE RE� Sanitary seal (Y/N) Cased to FROM WELL LOG Wires properly protected (Y/N' ft. Casing height (ab ground) AT I CTION ft. t!atw "Coliform Monies/100 ml. Nitrate mg./L. Argenic: ug./L. Date of sample: B. SEPTIC/HOLDING TANK DATA Collected by: 9 -p.m in. Tank Type/Material SEPTIC/STEEL Date installed 1/1993 Tank size 1250 gal Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 6/7/2011 Pumper JR'S PUMPING C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE Date installed 1/1993 Soil rating g.p.d./ or W/bdrm) 1.2 System type SHALLOW TRENCH Length 75 ft. Width 5 ft. Gravel below pipe 0.5 ft. Total depth *4.6 ft. Eff. absorption area 375 ft2 Monitoring tube YES Depression over field NO Date of adequacy test 6/25/2011 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth 0 in. Elapsed Time: — min. Final fluid depth 0 in. Absorption rate >= 450+ g,p.d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. "Pump off' level High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot On adjacent Absorption field on lot On adjacent Public sewer main service line PUBLIC SEWER Public sewer manhole/cleanout Holding tank Animal containment areas Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 200'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 200'+ F. COMMENTS oa�p00 G. ENGINEER'S CERTIFICATION ®`'� OF oS I certify that I have determined through field inspections and 49 �O review of Municipal records that the above systems are in .. ' .. ' ' ' ' ' ' ' • ' ' . • • . ' '0 conformance with MOA COSA guidelines in effect on this date. 0 Gar ess Engineer's Printed Name JEFFREY A. GARNESS Q m �p e E Date of essio��oL7 COSA Fee $ 4q U Waiver Fee $ Date of Payment (0 —df --I I Date of Payment Receipt Number Oq � qq 1 Receipt Number (Rev. 11/05) m 0 O a y p L U c Q iz. �� o vv� o Uv E u� O O >1roc \ ~ _ — v3oU dNU 8i o8ic vol m O t0j� Z � u VON T O Z i.D _ m - m 'U d O N O O O ¢QOOOUD U' gO.Eo.w��v�F»3�za ` O` O. UI L Z p F .UU_Mz.__0w?>UwaHzzUNNa 000 d log �' 6Z86Z OZ81,Z (� r-, UM Es 01 Lll6L • '{k ow CO . oy 9 ZQ Q •\ Z � � aW JN 00 o F � n LLI � r a d! r �`QQZ S Li O .L9p ( F! f Cf) _ o O on A! f O I- `u i1 7 I i tl i I m I o \q:r n Ia8 t2 o i IaZI w tl +yam 0�1 02 • 86L1Z 7 B k OV9 2 LL a # $$$ o Z � 8 n m zIi,5, ow4vi5 �o p� g 8 momz>3� W :I 8 � n � g y C 3S� y gg k' �ocaioOOEoe i' S£ 4 4 8 8 _ • ©^^���^®®C'C' LL i z Ir Z I- Municipality of Anchorage • Development Services Department Building Safety Division �— On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519519fi650 /U� www.muni.org/onsite (907)343-7904 r CERTIFICATE OF ON-SITE SYSTEMS APPROVAL V p� FOR A SINGLE FAMILY DWELLING 1� Parcell.D. (250-Z11-77 COSA# Dq 6036 1. GENERAL INFORMATION Expiration Date: C) Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address HERITAGE PARK, LOT 3, BLOCK 2 10648 TRADITION AVE • EAGLE RIVER, AK 99577 VICTORIA McCONNELL Day phone C/O AGENT 10648 TRADITION AVE ' EAGLE RIVER, AK 99577 Day phone JOHN O'HARA w/REMAX PROPERTIES Day phone 257-0183 110 W. 38TH SUITE 100 • ANCHORAGE. AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System N Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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. D. LIFT STATION Date Installed Size in gallons Manhole/Access (YIN "Pump on" level at in. 'Pump off" leve High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on tot Absorption field on lot Public sewer main Sewer /septic PUBLIC WATER On adjacent Public sewer manhole/cleanout Holding tank areas Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service tine 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that / have determined through field inspections and ; 9 %� e review of Municipal records that the above systems are in """" ' " V ""' "" conformance with MOA COSA guidelines in effect on this date. J. A ess.: Engineer's Printed Name JEFFREY A. GARNESS QQ A. 53 e, Date QDre. l�.ho8' 0 i COSA Fee $ c� O Waiver Fee $ Date of Payment It 7 /0 Date of Payment Receipt Number 60 i5 Zq Receipt Number (Rev. 11/05) 8I-)9 HERITAGE PARK SUBDIVISION LOT 3; 68 sOCK 2 % 1 1 � o ` 1 i IrwaN � t - �IfOIrYMf ' Yi+ \ 1 I \ LOT 7 tv VM. 9sur. !1 SO I r AS—BUIL MNIrn111tW.1MrrwMYN MN..N M.I.Y YM M MSN..µ WtU. W MNnY wn Mrs.. NN. wn Y IwlnNrnul rl IN Mw n MMw.N IN rnr.Wr Y=Nr rryr M. Mn Nw N N.••• MrMM. rin r INY MM MIn1.IN rn.. I.YI rY-NN NWNw rMrwr.w.n Wnr w.l Nn M N N Y 1 n 1 n n 1 r YN Y.1 MM.NnN IMWI.. Iw.MINw. r u LIO/rr rrosrW •wr.w r�MKr. rrW r•r• e r wm r m.[a wr NN Nn. tfill 0 08/01/2008 10:53 9073449821 JRS SEPTIC t� t� apt JRs Pumping PO Box 773415 Eagle River, AK 99577 (907)694.6454 Biltina Information Vicki McConnell Job Description: 10008 10648 TradnIon Avenue P.O. Number. Eagle River, AK 99577 Terms: Net 30 (907) 694.0676 Satesrep: Dawn -Dawn Map Book: Job Site information erose streets: yyarAdmiral Rd Vicki 10648 Tradition Avenue Eagle River, AK 99577 (907) 694-0676 277-7964 Job Commentr. PAGE 01 Service Agreement Number: 026470 Order Date: 09 -Jul -2008 Service Date: 22-Ju0008 12:00 Technician: Mike Tax %: 0 Job Type: Repeat Map Grid: 100- - 1000g ry old DOG = Gate will be unlocked = Please don't dog OUT ed 6 pumped tak = all good Additional Location Comments Diagram: S: 1Dia0rams12359m bm0 Blue -gray house will firs on garage /fence/ dogs/ must be home because of dogs 3bdmt septic In back, comer of deck by a little tree T1 E� 161 Service Type Qty Price Each Tax? Septic Service 15K 1 $0.00 No Gallons Planned: 1000 Gal. Actual: Hose Length: Double Tank: 0 Pump System: EZ Battles Inlet: 0 Baffles Outlet: 0 Extension Actual $0.00 NonTaxable Totat Taxable Total Tax Total Grand Total Estimated Charges: Actual Charges: Customer agrees to the terms and conditions shown. THIS IS A BINDING AGREEMENT. Signature and Title of Customer Representative Accepted by JRs Pumping Date Date Aecepted For your added convenience we accept; American Express. Dleover, Nae and Master Card payments over the phone. After 30 Days account will be turned over to COLLECTIONS. 330.00 For NSF Checks Returned. Parcel I.D. # MUNICIPALITY OF ANCHORAGE ° DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 050-211-77 HAA # 1. GENERAL INFORMATION Complete legal description Lot 3; Block 2; Heritage Park Location (site address or directions) 10648 Tradition Eagle River, AK Property owner Robert Holloway Day phone 696-5636 Mailing address 10648 Tradition Eagle River, AK 99577 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 % 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 xxx Holding tank 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) 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. S & S ENGINEERING (, q q - )-2 % `I Name of Firm 17034 Eagle River Loop Road No 204 Phone Eagle River, Alaska 99577 Address Engineer's signature 6. DHHS SIGNATURE _>_ Approved for �sf� = bedrooms. Disapproved. Conditional approval for Additional Comments UJITW Date >S� ROBERT C. COWAN ! •ti CE -8801 f� bedrooms, with the following stipulations: 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+h,I Environmental Services Division !1 "r)W.4FWTA1 — 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 MAR 06 1998 Health Authority Approval Checklist /� l Legal Description: ZeT3 &6CK Z l/ K/T�G� ikk � Parcel I.D.: OS -0 II A. WELL DATA I�jA Well type P W3 L-, C_ wAr2.2 If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well production WATER SAMPLI Date completed Cased to FROM WELL LOG LTS: Nitrate of sample: B. SEPTIC/HOLDING TANK DATA Casing height Wires properly protected (Y/N) J/AT INSPECTION Collected by: Other bacteria Date installed TAt A 13 Tank size J250 Number of Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) q_ Depression (Y/N) tj High water alarm (Y/N)!q,4 Date of Pumping ?- / S Pumper JA S C. ABSORPTION FIELD DATA Date installed ZrA4 G 3 Soil rating((g.p.d./W r ft2/bdrm) /' �-System type .451M f (�iG� T/�Fi✓�/� Length %S/ Width `S / Gravel thickness below pipe /Total depth 5 .Z L Effective absorption area 37S- 7Siii Monitoring Tube present (Y/N)4— Depression over field (Y/N) /J Date of adequacy test Results (Pass/Fail) PXSS For 13 bedrooms Fluid depth in absorption field before test (in.); Immediately aftergal. water added (in.): _ Q Fluid depth W14 (ins) Minutes later: Absorption rate = bfS-o f g.p.d. Peroxide treatment (past 12 months) (Y/N) r' ` ' 4- `{'v0 "'ti 72-026 (Rev. 3/96)* If yes, give date D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles E. SEPARATION DISTANCES Size in gallons "Pump on" ei-� *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer "Pump off" level at* 1/4 _ On adia tfs__� On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: i Foundation s Property line 3Qf f Absorption field Water main/service line %D�� Surface water/drainage QA Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line 30� Building foundation LO Water main/service line Surface water i4- /� Driveway, parking/vehicle storage area �� Curtain drain K j�i2 Wells on adjacent lots �- a, 0U F. ENGINEER'S CERTIFICATION l certify that 1 have determined thru field inspections and review of Municipal in conformance wit M -A HAA guidelines in effect on this date. Signature Engineer's Name /� �Ja� e/� �� w 4", Date HAA Fee $ 3� o, o ci Date of Payment \ Receipt Number l t 3Sr Z U) 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number y� 4 ROBERT C. COWAN N aPit � CE -8801 are p € F Gi MUIb NICIPALPTYOFANCHQRAGE 41. q > ( • , ;:DEPARTMENT QF HEALTH,8i:HUMAN $ERVICrES ;. �. I` D(y)cion of, Environrr►ental Services 1 1r ;.Ii st i �. I t � Or, Site Services Section t P;O �Boi�"196650�g,�Anchorage,;Alaska ;99519-6650,° r z S r 7 1 4•'k 7 �!e ij[ i J -c i +` y;tsgg,'1 d ra'pp �Sa- 1 .#ti' 1111 343-47h4' Qj �..ci1c -yal+h' a. h + ..` d 7` •'c._ 41.iYrtTlA F}td1 / QrATA QF IiEA ,TH`All,THQRI fYA,I s,fk" APP.�OYA A'SINC�I�E �rAMII ( PWE4LING , t �'S3'j °¢ rrr 4�+eWF,1`�' `iy:t <sr i,}}n'. -.�° f' f:�r��'st<I+I, s•� i t=nn�.ii,cr'{rt 1,i i 4 a r �3 ?'i77a if 1ar> f} lax Jry f , +f HAA u W KJl 1��1��'l � ' 050x211^77 ,fix I{f, � � i�'r: ,x ` ' � I parcel I Dr � )p e l"5 r 7><) `r }�1 �+Et�FPn �� `*+✓��PY^�'Y'i�I ��r fir..i�reXr'�¢t� 1 GENERAL.',INFQ�RMATIpt�}N�f Wi „1 - y , . c js�.,? r". h u z y c F �u ,•.. s�.,q. c, ��TE fiiP J< € t c i Corpplete`Iegal dest{riPtion -y x � !L r ! iEi�- kar {s Herita a park r:Lot, 3, Blk,?2 r r 9. - + t i !✓� t ),i q,x r , 1 ! r ItLocation (site address or'directions) ` j. .p U 1064$r'_Tradit ion) Eagle giver ; 1 I' 'J5 r ` 696:8541 ,.John &udp, Merchentz Property ownersDay phone y± address),'35,10648 `Tradition Ea le River Ak 99577 Mailing i «r Lending agency's�M,na' C)iTV�ll „I ' Pay phone Shy—�1 R1 rItifQ.fs_ .✓ah 41F�,: I o ,i i,� 460,West01* or,x"Anchorage', AK 99509';'-', Mailing' Addre$s Tsl�S LY Y alt rYf ` ✓� _r�1, �4 1p i t 4 562-2378 i P,7 i 4 Coldwell Banker Mark1iShe ; Day phone Agent ITT, 1R Y { ♦. g /.. r I , t € { }xit , zt t' t,',1 h4 t r,v b5ii�}.ykfiF..d>`yr?°]%2�X�s 9N.a°bkrf}IF§}'i i It3 ''s `IFtJI ' f�i t` ' .Address 4�4n 'j r srt}p t` ii it Ir f5 1 - 1 r z ! PI i d 4 k. N if s' Yj, zv e )114141r 3fv` S l5ws;'i4�iL. ' "f Unless otherw►se re ueate0 ,HA NWIiI a eld for plc[4up , qFr� a q t, r l `1ir ° C 2 NUMEER,OF 13EDROO S• 7: 3 ?�j ;rl,� z f} 'st ofr Ir ixIXIA o lt�.vl tpr,�r- 3 TYPE QF:WATER SUPPLY; 1dam dpi-fli,�rtrrr,it�i+as gg � d!y + �: N r g t��r:� s `[At firg,,, t,v fikr4id t ri i7. i evFl» 4i Indlvidual�Well dipp t. r C } _',k I $ , I - Z _ - r - Community,Well-;i* lI tisi�.r�rl !tl ,+ !y J0- lg rJ t OF 11 It 1 € it ) it X 1 Public water ® cr � ,. NOTE. If community well 4yst0M, provide written confirmation from Slate ATJEC attest- ing to the legality and status of aysteri► 4. TYPE OF WASTEWATER DISPOSAL: It f r Rndiv(dua an sib X `1��,,y, Ir#.rii ;7; .ny3�p,5��,. hr+a{ n� �N s { 7^. q r ; r , Holding tank' i rally �U._�t f i pJ,}, z tt �3 J , u yCommuni#Y d#td4 ,_i i 1 1 -"'✓r 1 �� ' .$Car1;,. seW�r,��-(p F 1 +' d S 1 ' i s,} is , '-• �)5 lqi 9 j, �.}�# NOTE, if communrty,wasteu ate system, prpVi. a written confirmat►on Iron► State ADEC Y,ev dnk{ attest►nto the3'lega{itya�d status"of system 9' �ty� 5'],£f; dal € r t - r, pgi�x��di of#Ii, 31Yt�3y+ ,dP✓`.pI ��4� , ! IPI 'i s e+ r _ 72-025 (ROV. 1/91) Front r IS, r i 1 1 r f r a'ry 9L iC£yI y✓41 nV< if a,l �! r t} r . .fq FJr1 r{ �;Glr r4}i 171 I f 5 STATEMENT'OIFINSPECTION. BY412 INEfrt r ;f`1'{{{{IyIyIy' „E� Yl 1"T, a9� r(a� tl Fl 11� IIId 7 c� 1 1 t Y r Ir ° - .-s :�. a 79• rLll; k s f���fff 17 � 1 'ter ) 11 , I{.a., i I__! As certified b my seal at�ffxe'd hereto an d s the a daE oh date shown below, I verify that my.,,,.. in' stigatloh.;bf this Health Authority`ApproV'alFappllo'atfbn`)shAtSws that the`on site water supply ' ylj dt >;,I rF I 'ilia .9 .ifs! (."y I :r and/or wastewater diI.sposal system�i.#,safe, funetidnal . ladequate for the number of bedrooms and type of structure indicated herelri'.] further Verify that used on the )nformatron obtained from . the Municipality of Anchorage files and from, my tinvestption and inspection, the on-site water supply and/or ;wastewater4disposal system.is, in compliance 6rith all Municipal and State codes, ordinances, and regulation* �n effect;on the:date of this inspection 4 1 yr ar v{I jl II '3 :gar Eag12 River En ineerin ''Se+��ices ft` ' '- I i phone And tit 45` ` Name of Firm 3 5 Address { Engineer's signatureDate wR! 5S" IT .4 r. 'r I r I•fr Sx`FI s`N r'. pi :; it!� y 4fI• A I (lr •!°°� $ as CQ'e..:L. ,.4 at ti ,f - - I'` .. ,.-,t Str•:...I 1'I, J�%, �d4t I_.., !IIIc 1s(" � r �� 9 � � sn • lbulrA.'Oulera � ttJ/ o+ �•.� CE 6736 •: �� 1 f I , j.1 -: rr i1 � ,i rS e` V1 � J r 4`��a ' ,f{N.:i:4 a�••✓.t,V' �/ s r r,, Ij}IS it aY Jis ra t IJy 1�11�y1a� (a?t{rl�+iii I�ei �. i I � ROF�SS��� .M 6.r DHHS SIGNATURE;] ;,� x,ri) , I�� atn A��`e.�e"►°O'" I. l l 11 X 1:1 [ 1 1 t S1d`a,yr.0 1 Appr6Ued for lei t✓ It,� ''rd l-;.bedrodmst�ii�{57p�'IN4l';7 lil(E�'Y<r ,iihS IJafll ;y E s,rk.� I;r',11 ';:li 111 AY "� tri y II il�. t Mi rr k,r-' Irl it Ir I�Y333t1"4" rl..,: Disapprovedit` It " 4fl f �Ir Mil���i `rait,l rlrl�bSi.1 {r �r{I< inl.rthl .a1Y}e�kXt4 hlY#,l hilri'�IIIYIA { - , CondI lonal approval fo�1�lH l� x'�'`i{ 1Y'r k I ►V 1bedPrlS�tt s MIth`Yth� lf611bwMg l st1pu1atIOhs: %���i "� Aj_i 0�I�I�t4��'�j i I'Ef I�rN is r9! f d S ria I r 1 r: I� I r e '.. i f N,. h 1 t7. f r 1 ! t t r r r ryl 7lj d (`! I'S s Jf t -r,,I r Ii r y l a { r .r 7 II 'Additional liOmment3 Ja Yf ig4rl °'rf�l 1 3+1nr�4i 3 l s li ; r n:. 1t II 4 li yYtatillr-Yn7 n� tIj'(I I:.q is i I.rt� I 1 II 41 _I I�r ,1 - t„�f ill rr N}}r111G� r (55 rr I' .'S "Al I' 1 5 r^Ir h l t 2�•it) rfr .(24t j 7t :stiY °.i '.t/. t .: x. i S$dx4�'�'�wfl',�4r,l1k5gsy 4,'Hi(drt By! ,\_ Date V ITT• {l 1 3 1p t�"iu 11t ... r , rr r-II�'(LE1l, ,t klg7r X77 .1-r y Sl i17f.f \� 'L ✓� ✓ I r ri r ]n,r 1 n /1'151rY`a" �! r(rpt r�„r rrn ( I x 1'r� rl li,> 4 f+ i,w1l ill".�r? 1'� sk rld•:''.I y.."i`i,� ili7 �rlr'1 -r :,Qi1. lr. {.,. h, r. CAUTION !! n/1 JL5 , - f 1 1 (f 451r�'h1 7M1 UY 4l" 1 I :1 is The niipallty ot'Ahchorage bepartmeht df Health, and Htlman Ser�/�Ces (bHIS) Issues Health Authority I W - ♦ ) ;.:1'1 1/1 - i�r f x 9 r r �pproval`:Certiflcate based only upon thefrepresentations giVAli,ittfiperagrapFit5 above by an;indepAndent 'profession`�l a)rregistered in the Stateof Alaskai"r a bHH rldea thfs'asacourtesytopurchasers ofhomes 1 t p„ r and-thpir-lencIQ l'hstltuti6ns in order to satisfy,certain federal and State r fementaI Employees of bHHS do not conduct,,inspectl8lnst or aha! ie date before;Fa 6ertlficate118 isstbetf Th'e,°Municlpallty of Anchorage is not I , responsible forlerrdrs or omlasj6ns In the ptgfassional',etigiffn�yeea'v[/r�tryt)��,'4'G �sslt t {„r r rt•' t ,! 4F[ f 11S rl� r 7 C /4 TQi 11V'if/E t t b - I'' •' rrl- 6111 l.i tklat [1 h1.� YS [1 (}Yr i+Ai ltr rtr lLi 11.1i k, 72-026 (Ray. 1/81) Back MOA M21 pl �, It!`r. G')a,vi ;Ira xt X)if,l Sl 1 f`; tLRgYIr nl r!e''��s ��ay 'olr r yl ' - f r i r rf 1 r+l ILL Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: %ilk!T4676 A4u�1 Parcel I.D. a50 _- �7_1/ '-71% Lo -7 3 /3 mac* Z__ A. Well Data Well type 4/8L- I If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed Driller Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump levell Cased to FROM WELL LOG SEPARATION DISTANCES FROM WELL TO' Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line WATER SA LE RESULTS: Colifo Nitrate _ ate of sample: B. SEPTIC/MG TANK DATA Date installed -rfi!/ y3 Tank size Casing height _Wires properly protected (Y/N) AT INSPECTI0 g.p.m. ; On adjacent lots _; On adjacent lots sewer manhole/cleanout Petroleum tank Collected by: RECEIVED g-PIUN 2 21995 —Niunic+palny of Anchorage Dept. Health & Human Services Other bacteria Y� �5p Compartments Cleanouts (Y/N) Y c,�;s Foundation cleanout (Y/N) YES Depression (Y/N) /Y o High water alarm (Y/N) ��N Alarm tested (Y/N) Date of pumping _DT[ ys Pumper SEPARATION DISTANCES FROM SEPTIC/HSG TANK TO: Well(s) on lot NA On adjacent lots 0 + Foundation f S 7 To property line t3() / Absorption field �S � Water main/service line Surface water/drainage /"1R 72-026(3/93)• Front CONTINUED ON BACK PAGE C. LIFT STATION lVllq Date installed Size in gallons Vent (Y/N) High water alarm level . "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DIS ANCA FROM LIFT STATION TO: On adjacent lots D. ABSORPTION FIELD DATA rer Manhole/Access (Y "Pump off" Level at Cycles tested Date installed JAN 93 Soil rating (GPD/Ft2) Length Width S Gravel thickness Z Surface water System type 5Hl41-Lo3 J j22fl\l l/f Total depth 2 / /2 7 Total absorption area 6 7 Cleanout present (Y/N) Y6� Depression over field (Y/N) &/o Date of adequacy test GCaJ2v.195 Results (pass/fail) PIS for 2 Bedrooms h Water level in absorption field before test U After test 0 Peroxide treatment (past 12 months) (Y/N) /Y /A If yes, give date r��q SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot fi/ -1 On adjacent lots r Property line % 3o 7 To building foundation /0 To existing or abandoned system on lot AI/4 _ On adjacent lots Cutbank N1,4 Water main/service line Surface water Driveway, parking/vehicle storage area t io Curtain drain E. ENGINEER'S CERTIFICATION r/ o� I certify that t have checked, verified, or conformed to all MOA and NAA guidelines in effect on th;dte,of t4is inspection. /� S 000009 p.a ei� aV C °p Signature e9iea ec F /, Engineer's Name %V I S ��(,JLEaA I G Pte:. eaa4:_F �5. C a Louis A 2ulera 4� /_ {j �^ �!`°aa CL -6736 e Date �Li ss' �G �j 'ao°a{, <° Y <% V1 �w or� arae; ��,�',c� HAA Fee $ Date of Payment`— Receipt Number ,%�Z 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE - • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska. 99519-6650 .343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D.# 050-211-77 HAA# HA990388 1. GENERAL INFORMATION Complete legal description Lot 3 Block 2 Heritage Park Subdivision Location (site address or directions) Property owner, Legacy Homes Day phone 333-0888 Mailing address 5461 New Smyna Circle, Anchorage, Alaska Lending agency Day phone Mailing address Agent Day phone _ -._ Address .: .Unless otherwise requested, HAA will be held for pickup. three (3) 2. `;_. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: =_ Individual well Community well -water Public • ° . NOTE: if community well system, provide written confirmation from=State ALYECt attest Ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: f Individual on-site xxxxxx ";,`<<, � E. Holding tank 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) Front MOA#21 - 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Polarconsutl Phone 258-2420 Address 1503 West 33 Avenue Suite 310 Anchorage, Alaska 99503 Engineer's signature Date This is a re -type of the original copy of the Health Authority that was issued on July 16, 1993. The origi3r i t the bank that requested the original Healththori m re there are any questions, please call us at 343-4744. 6. DHHS SIGNATURE xxxx Approved for Three (3) bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: \ Additional Comments . l -:'BY: Date July 16, 1993 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-M (Rev. 1/91) Back MOA #21 MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services M , DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # (1 �C7 - \ \ - —1 ' 1 HAA # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) LoT 3� &k 2 , S -:� T/gN-0 91 Vy Location (address or directions) L ): W1 C�" (b) Property owner LFc-�C-Y L�ar�ES Telephone: (home) ` Business �33-OS g Mailing Address Sy to ! NEw 6 (4 yH,4 C�,e . Aloe- / . (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address Telephone Telephone (e) Mail the HAA to the following address: (or check here ❑, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single -Family Number of bedrooms 3 3. WATER SUPPLY Individual Well ❑ Community ❑ Public' Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-siteX Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 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 regulations in effect on the date of this inspection. Name of Firm P t,142 Telephone 25-f - Z q 2 o Address 1,15-05 �3 2d. AA/C,4044 -f^ Date 5�y� U rt j� Engineer's Seal EARLE V. AUSMAN o t . CE - 1393 a••' �4��'�cfr�s4ciia= ®,w 6. DHHS APPROVAL Approved for f—bedrooms by 4Date Approved Disapproved Conditional Terms of Conditional Approval CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 notconduct 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. 7/88) Back Page 2 of 2 Legal Description: A. WELL DATA Well type Log presen /N) _ Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST ,BZW 11E2rrAUe Pk- Parcel I.D. El If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing height Wires properly protected (Y/N) WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Public sewer service line WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Nitrate AT INSPECTION On adja6ent lots _ On adjacent lots Public sewer manhole/cleanout Petroleum tank — Collected by: Other bacteria Date installed /U.3 Tank size X250 Q24 Z Compartments �/Z Cleanouts (Y/N) / Foundation cleanout (Y/N)y Depression (Y/N) High water alarm (Y/N) // N14 Alarm tested (Y/N) N//4 Date of pumping SLA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot/vAq • On adjacent lots �vA Foundation To property line �' 2G_ Absorption field 2 Water main/service line Z j Surface water/drainage A -11 A 72-026 (Rev. 3/91) Front MOA 21 - CONTINUED ON BACK PAGE en � � n rTl M b Jr_ ® Mo Mz rri w v_C ® <_ G O 72-026 (Rev. 3/91) Front MOA 21 - CONTINUED ON BACK PAGE C. LIFT STATION Da ' stalled Size in gallons Vent (Y/N) on" level at High water alarm level Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surf ater _ Date installed --74"V, 4Y q3 Soil rating S An"ll �M System type SNa(_Lo v T,eg-Ne R Length, �S r g Width S Gravel thickness 3 7-2- S -h-r(-- Z 12 '�arr� s Total depth Total absorption area Cleanouts present (Y/N) Depression over field (Y/N) Date of adequacy test /V/"q Results (pass/fail) /VIA for Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot '/ To building foundation On adjacent lots > :�S— D i If yes, give date On adjacent lots ZY Property line ;>' 2-0 / To existing or abandoned system on lot &A Cutbank—A4ZA Water main/service line > 6-C) Surface water /��Z q, Driveway, parking/vehicle storage area j 0 / Curtain drain �ZA E. ENGINEER'S CERTIFICATION bedrooms I certify that I have checked, verified, or confo ed to all MOA and HAA guidelines in effect on 0h�date of this inspection. Signature /i U ,aaooaoe,o Engineer0's Name � !7 3 �{ ' � o006NT Date /(� 6, 1 EARIE V. AUSMAN CE -1393 HAA Fee $ / %b ceZ Date of Payment l?—/ Z —?3 Receipt Number z�4n_�p r 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number