HomeMy WebLinkAboutHERITAGE PARK BLK 2 LT 11Onsite File
Heritage Park
Block 2
Lot 11
#050-211-69
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201297 PID Number: 050-211-69
Dwelling: ❑■ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ NewU ■ ❑ pgrade
Name
REDMOND ABSORPTION FIELD
Site Address
10526 TRADITION AVE, EAGLE RIVER AK Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Phone El Other Number of Bedrooms Soil Rating Total depth from original grade
3 9 GPD/SF 7.5
FtIF'" LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pip
Subdivision Block Lot 1.0 Ft. 6.5
HERITAGE PARK BLK 2 LT 11 .
Fill added above original grade Gravel length
Township Range Section
2.6'+ Ft. 41 Ft.
Gravel width Beds: Number of Lines Distance between lines
SEPARATION DISTANCES 2.0 Ft. Ft.
Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between trenches
Tank Field Lift Station 533 F12 1
From Tank Line
Ft.
Well 501,} TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer ICapacity
Surface Water 100'+1001 -}• GREER 1000
Gal.
Material Number of compartments
Lot Line 10'+ 10'+ NA PLASTIC 2
Foundation *10'+ 10'+ LIFT STATION
Manufacturer Capacity
Remarks * COMM. WATER SERVICE Gal.
Alarm location Electrical installed by
PIPE MATERIAL House to tank 3034 Tank to 3034
Installer drainfield
MIKE N ANDERSON, P.E. Drainfield 3034 co/MT3034
Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 104,1 ft
Inspection
dates: 7/22121 2�d 7/23/21 ption
Location and description
3rd 4'h TOP OF TANK MH
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engine(s Stamp
Conditional Approval: Date
piOW
,
49r�i
. ............
• MICHAEL N. AADPRSCN �
Septic System r � •
Approved �-- 10
LjE�DateS"rz?6ZZ 11 �'•.• CE 9�4� q�, _.
Note: this approval does not include well permit requirements.
(Rev 05/02/18)
Permit No. OSP201297 Page 2 of 2
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: HERITAGE PARK BLK 2, LOT 11 PID No.: 050-211-69
MARK
A
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SEYnG SECTION DRY JULY 2021 /�®(fie ®'
Sods Log - Percolation Test �oFr
Performed For:/� �''®'1►�'
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Legal Description: �t'� t a �t.. 2.. L -VI t j Township, Range, Section: 71 —"-z'2
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Municipality of Anchorage
•
Development Services Department
On -Site Water Wastewater
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and Section
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P.O. Box 196650 Anchorage, AK 99519-6650
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Sods Log - Percolation Test �oFr
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Legal Description: �t'� t a �t.. 2.. L -VI t j Township, Range, Section: 71 —"-z'2
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Date
Gross Time
ENCOUNTERED?
Depth to Water
Net Drop
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IF YES. AT WHAT DEPTH?
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Depth to Water After
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Date:.?><'7''t'�
Site Plan
Reading
Date
Gross Time
Net Time
Depth to Water
Net Drop
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COMMENTS (i llL-ea d nT
PERFORMED BY: /ted /1(A , I CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 3;J a- -
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MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
'. PO Sox 196650 4700 E'more Road
Anchorage, Alaska 99519-6650 Phore: (907) 343-7904 Fax (907) 343-7997
http://wvrv,.muni. orglonsile
On -Site Wastewater Disposal System Permit
Permit Number: OSP201297
Work Type: Septic Upgrade
Tax Code Number: 05021169000
Site Legal Address: HERITAGE PARK BLK 2 LT 11 G:0055
Site Mailing Address: 10526 TRADITION AVE, Eagle River
Owner: REDMOND MICHAEL REVOCABLE
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING
This permit is for the construction of:
Effective Date:
Expiration Date
Lot Size in Sq Ft:
Total Bedrooms:
Cpuell r S
N/%
Ucparnncnt
7126/2021
7/26/2022
20216
2 Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions: Prior to construction of the absorption field, a test hole is required in location shown on the
site plan. Test hole shall verify minimum separations to impermeables and seasonal high groundwater, as well
as confirm percolation rate. Construction may proceed at your own risk prior to 7 -day groundwater monitoring. If
results require a design change, construction shall stop pending Onsite review and approval of a change order.
Please submit results with the inspection report (or charge order, if required).
Received By: !�✓�
Issued By: /
Date: 7 Z/
Date
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 050-211-69
Property owner(s) MICHAEL REDMOND Day phone
Mailing address 10526 TRADITION AVENUE, EAGLE RIVER AK
Site address SAME
Legal description (Sub'd., Block & Lot) HERITAGE PARK BLK 2 LT 11
Legal description (Township, Range & Section)
Lot Size 20,216 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
Fx_1
Initial ❑
Single Family (SF)
El
(w/wo ADU)
Septic Tank
0
Upgrade Q
Duplex (D)
❑
Holding Tank
❑
Renewal ❑
Multiple Dwellings
❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES
A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees:-Ag4G,25 Co UID Waiver Fees:
tio-Date of Payment: Zj -_ S Date of Payment:
Receipt Number: i%S� (� Receipt Number:
Permit No. Q_5P 012q_ Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
June 27, 2021
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: New septic permit
Legal: HERITAGE PARK BLK 2 LT 11
To Whom it may concern:
This is a request for a new septic permit on the above referenced lot. We are
proposing a new system including the tank. A new test hole will be done prior to
the installation with 7 day water monitoring also. The test hole data in the MOA
file shows excellent soils and no water. All of the lots are serviced by community
water. No cut-banks for steep slopes over 25 percent existing within 50 feet of the
proposed site. The old system will be decommissioned per the MOA codes.
This new system will not impact any of the neighboring properties. The slope
across the site is 12 percent, see the site plan.
Sincerely
Michael N. Anderson, P.E.
4661 Natrona
Anch, Ak 99516
Ph 727-8864
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201297, Rebecca Carroll, 07/26/21
SEPTIC FIELD SECTION
DESIGN CRITERIA:
6.0' EFFECTIVE
3 BDRM X 150 = 450 GPD
SOILS = 450/0.8 = 562 GPD
562 GA/12 = 46.8 use 47'
2.0' WIDE
47' LONG
(1) TRENCH
7.0' DEEP 1.5'2.0'
-7.0
-1.0
MOUND OVER
FILTER FABRIC
SEWER ROCK
3,3(
GRADE
1"=200'
PROPERTY LINE
PROPOSED
DRAINAGE FIELD
EXISTING
HOUSE
-CITATION ROAD-
SCALE:
DJRDRAWN:
DATE:
HERITAGE PARK, BLOCK 2, LOT 11
Anchorage, Alaska
MICHAEL REDMOND
6/3/2021-TRADITI
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-
& INSULATION
AREA SERVICED BY COMM. WATER
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201297, Rebecca Carroll, 07/26/21
1"=50'
PROPERTY LINE
EXISTING
HOUSE
PROPOSED
ABSORPTION FIELD
HERITAGE PARK
BLOCK 2, LOT 11
SCALE:
DJRDRAWN:
DATE:
HERITAGE PARK, BLOCK 2, LOT 11
Anchorage, Alaska
MICHAEL REDMOND
6/3/2021
-IVY H
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DITI
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SHED
DRIVEWAY
HERITAGE PARK
BLOCK 2, LOT 10
HERITAGE PARK
BLOCK 2, LOT 12
HERITAGE PARK
BLOCK 1, LOT 17
HERITAGE PARK
BLOCK 1, LOT 18
HERITAGE PARK
BLOCK 1, LOT 10
NOTE:
AREA SERVED BY
COMMUNITY WATER.
NO WELLS WITHIN 200'.
CO
DCO
DCO
TCO
CO MT
WATER
LINE
EXISTING TANK AND
FIELD TO BE
DECOMMISSIONED
PER UPC
12% SLOPENEW TEST HOLE
REQUIRED PRIOR
TO EXCAVATION
10' UTILITY
EASEMENT
NEW 1000 GALLON
PLASTIC TANK W/
20" RISER
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201297, Rebecca Carroll, 07/26/21
OF q jq�;4p
CO.'4g TH
S "�< fil o
n r SHANE A. HOLT
dpi LS -6914 o�O THESURVEYDATA AND MEASUREMENTS HEREONAREPREPARED FOR THE
�" ao
OWNER OFRECORDAS OF THE DATE OF THIS SURVEY.
ANY USE OF THIS DRAW/NG BY THIRD PART/ES /S PROHIBITED UNLESS
of e s s o nab
OOO����p WRITTEN PERM/SS/ON /S PROV/DED.
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPEOFI CALLY TO SHOW ANY
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES.
EASEMENTS OF RECORD OR OTHER RIGHTS OF WAY, OR ANY ENTITY NOT ON THE RECORD PLAT
ARE NOT SHOWN HEREON, UNLESS NOTED.
NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
ANY PAVING SHOWN HEREON MAYBE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE.
AS-BU/LT SURVEY I" =301
NO CORNERS SET THIS DATE
K1 HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
LOT 11, BLOCK2, HERITAGE PARKSUB
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EXIST OTHER THAN NOTED.
DATED AT ANCHORAGE,ALASKA THIS 20TH DAY OF
JUL Y 2020
HOLT LAND SURVEYING
9309 GROVER DRIVE
3909, FB205-2 ANCHORAGE, AR 99507
MUNICIPALITY OF ANCHORAGE
DEPARTIV1ENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
[] UPGRADE
MAiLiNGADDRE~SS Y~"" j~
4, Sc L .r
LEGAL DESCRIPTION
-tt D2
LOCATION
Well
DISTANCE TO: I
Manufacturer
Liq. capacity in gallons I ........ .~n~ Inside length
Manufacturer
NO. of lines / Length of ea~..line; Total I 'Zn of¢lines,
Top of tile to finish grade z Materi neath tile
3
Type of crib Crib diameter Cried
DISTANCE TO: /
[Cl~s Depth Driller
DISTANCE TO:
Building
DwellingI~ !'/~
Material .~ ~.~_
Width ~
NO. OFB~)OMS
No~"~f compartments
~_
Liquid depth,_..___.-
PERMIT NO.
Material Liquid capacity in gallons
Distanceb t6~ e ines
Total effective absorp~n area
PERMIT
Total effective absorption area
Trench width
:.~O inches
Nearest lot line
PERMIT NO,
Absorpt on area(s)
Distance to lot Hne
OTHER
PIPE MATERIALS
so~ TEST .AT~NG
NSTALLER
REMARKS
72-01~ (~ev. 3/78) f
DATE LEG,
PERMIT NO.
APPLICANT
LOCATION
LEGAL
825 '"L STREET, ANCHORAGE.. 264-4?20
i'-i~"'.~'S I TE SEL-JER F'ERr4 I T
( 82077]: )
KYLE J SCRLIS
Lii B2 HERITAGE PARK
LOT SIZE 999999 SQURRE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS
SOIL RATING
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
[~EF"T: |-=, :B LEI'-JGTH= 42 GRR'-.-"E L [:,EPTH= 5
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE'BOTTOM OF THE EXCAVATION (IN FEET).
F;:FL--41J l' RE[:, SEPT l' C TRI'-.iI--% --,=;. l' ZE= :l.¢-J F_.-~,--:-i 6RLLCiI'-I$
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF RNY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THRT THE WELL WILL SERVE.
TL4E, (2> I ~-JSPECTIO~-JS ARE REG!IJI F:ED
BRCKFILLING OF RNY SYSTEM WITHOUT FINRL INSPECTION AND RPPROVRL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWRGE DISPOSAL SYSTEM IS
i00 FEET FOR R PRIVATE WELL OR t50 TO 200-FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM R PRIVATE WELL TO A PRIVRTE SEWER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY RPPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
RVRILRBLE TO INSURE PROPER INSTALLATION.
PFRr'I I T E::--::F' I F-:ES DEL--:Er-IBER _.~.t.. t-~82
I CERTIFY THAT
i: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
SIGNED:
RF'PLICRNT K~ SCRLIS
V4. 0
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 :264-4720
SOILS LOG- PERCOLATION TEST
X SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
10
12
~3
14
17
18
19
20
SLOPE SITE PLAN
COMMENTS
WAS GROUND WATER RI
ENCOUNTERED? ~ SI-
O
p-
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
TEST RUN BETWEEN
72-,0q8 (6/79)
PERCOLATION RATE ~.] / ^ (minutes/inch)
,,., ,4
.,//.:.///
CERTIFIED
MUNICIPALITY OF ANCHORAGE
Development Services Department U Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 050-211-69
Certificate of On -Site Systems Approval
Expiration Date:
7-2-3 -2__��z(
1. GENERAL INFORMATION
Complete legal description HERITAGE PARK BLK 2 LT 11
Location (site address) 10526 TRADITION AVE, EAGLE RIVER AK
Current property owner(s) REDMOND Day phone
Mailing address SAME
Real estate agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
0
Public Sewer
❑
Waiver request for:
Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 2.`60 Waiver Fee $
Date of Payment A 2 Date of Payment
Receipt Number 0_'�2D 16 56 Receipt Number
COSA # 0 S G Z. Z. 1 1 1 9 Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864
Address 4661 NATRONA AVE ANCH AK
Engineer's Printed Name MIKE N ANDERSON, P.E. Date 3126122
F i HO,�r,-
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Original Certificate Date: Z� Z
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Id A• • ' ^ u
+^
6. DSD SIGNATURE
r °49THf�J
,.,;, ,;.......,';
System #1 Approved for 3
bedrooms d.... .. ..........
System #2 -Approved for -
^ MICHAEL N. A,,:DLnq�Ciq •r �
...
bedrooms _C 9A69 _
Disapproved
Conditional approval for
bedrooms, with the following stipulAiyy.���.
F i HO,�r,-
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.� . .
Original Certificate Date: Z� Z
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: HERITAGE PARK BLK 2 LT 11
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Comments COMM. WATER SYSTEM, CLASS A WELL
B. TANK DATA
Age of tank(s) new years
Tank type/material "°°"° "
Measured operating fluid level in septic tank new
❑ Standpipes/foundation cleanout per record drawing
Date of pumping new
D. ABSORPTION FIELD DATA
Which system tested (date installed) new
❑ ALL standpipes present per record drawing
Total measured depth from grade 10.1 ft (max)
Measured depth to pipe invert from grade 3.6 ft (min)
❑ NIA — 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 0 gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
Parcel ID: 050-211-69
Structure served by this system
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by
Date of Sample _
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date new
Results E Pass For 3 bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Hosorptlon 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)
Yes
Septic Tank/Lift Station on Lot > 100'
ft
Surface Water > 100'
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
❑ Yes
if No ft
Neighboring Tank > 100' ❑ Yes
if No
ft
Private Sewer/Septic Line > 25' ❑ Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No
ft
Holding Tank > 100' ❑ Yes
if No ft
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' ❑ Yes
if No ft
❑ Yes
if No
ft
Yes
if No
Community Sewer Main > 75' ❑
if No
ft
Manure/Animal Excreta Storage > 100'Yes
❑ Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
RV
Yes
if No
ft
Surface Water > 100'
Yes if No ft
Property Line > 5'
®
Yes
if No
ft
Wells on Adjacent Lots:
Q
Absorption Field > 5'
Q
Yes
if No
ft
Private Wells > 100'
M Yes if No ft
Water Main > 10'.,✓Q
ft
Yes
if No
ft
Community Wells > 200'
[/1 Yes if No ft
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'
Q
Yes
if No
ft
Private Wells > 100'Cj✓ Yes if No ft
Water Service Line > 10'
F71
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
COSA Checklist yellow sheet
4 9 T
yf` MICHAEL N. ANBERSC;J ; '1W
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Lot 11; Block 2; Heritage Park Subdivision
Lpcation (site address or directions) 10526 Tradition, Eagle River, Alaska
Property owner
Mailing address
Tom and Nancy Schmitt
Day phone
Lending agency
Mailing address
NORTHLAND MORTGAGE
Day phone
Agent Carolyn McPhee - RE/MAX OF EAGLE RIVER Day phone 694-4200
Address 16600 Centerfield Drive, Suite 201, Eagle River, Alaska 99577
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 k~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water xxx
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:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewatersystem, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA 1~21
~ I A I t'MI-N I UI" IN~SPI=(.;TIf,.,IN
As certified by my-seal 'Affixed
_ hereto, and as of the validation date shown below, I verify that my
invest g,a! ..o.n of th s Heaiih Authority.~pproval application shows that the on-site water supply
and/or wastewater dis~o~'~.l sy~tem'i:SCafe, functional and adequate for the number of bedrooms
.!..:..~ _ and typeofstructure, . indicated herein:[. ,furtherverifythatbased on the information obtained from
' - the Mun'icipality_of.'~-nchorage files:an.d from my investigation and inspection, the on-site water
supply and/or Was(ewa~ disPoSal §~'§tem is in compliance with all Municipal and State codes,
ordinances, and _~egul_atio.ns in:effect.¢b~ ~n the date of this inspection.
Name ofFi~m'':~-:~=:' : ~ii:~
'S'& S ENGINEERING
Address .... ~17034 Eagle Rib, er L-o~o~¢ Roa~ No. 204
Eagle River, Alaska
Engineer's signature :~ i
D/S SIGNATURE
r .
. Approved for
Phone
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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 th is 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. T. he Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. ~/gl) Back MOA ~1
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A, WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Parcel I.D.
FROM WELL LOG
If A, B, or C, attach ADEC letter. ADEC water system number ,-/'
Date completed Driller
Cased to Casing height ~,--'"'~
Wires properly protected (Y/N)
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM
Septic/holding tank on lot
Absorption field on lot
Public sewer main
SeWer s 'ervi~
WATER./~'M PL ,E RESULTS:
Co/~r_m ~_ Nitrate
Bate of sample:
; On adjacent lots
; On adjacent tots
Public sewer manhole/cleanout
Petroleum tank
Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~,o
Cleanouts (~/N) y
High Water alarm (YIn)
Date of pumping
Tank size t c~_~o Compartments "/---
Foundation cleanout d~ y .2~ Depression (¥~
Alarm tested (Y/~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To prOperty line
Surface water/drainage
72-~26 (Rev. 7/91) Front
On adjacent lots
AbsorPtion field
Foundation
Water main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Manufacturer
Manhole/Access (Y/N)
"Pump on" level at ~-~ ul~d~mp off" level at
~~yol~s tested
Meets MOA electrical codes (Y/N~¢-~'~
SEPA~M LIFT STATION TO:
Wetl~o n lot
On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed \ O- \0-~"~ Soil rating I '~¢'04¢/¢¢.- System type
Length /Jr '/~ Width '~2'o'~
Gravel thickness ~' Total depth
Total absorption area ,¢f"L.o ~
Cleanouts present O/N)
Depression over field (Y~) ~ Date of adequacy test ~,c>-
Results ~fail) ¢*A~ for "-~¢,t'L¢_..4~
Peroxide treatment (past 12 months) (Y~ /Jo,JR- ~/.,J~,J If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water \
Curtain drain
On adjacent lots ¢[,~ Property line
~0~ To existing or abandoned system on lot
Cutbank CJ ~,' Water main/service line ~.~=:,'~
Driveway, parking/vehicle storage area '~ O ~ '~'
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
Date
$ & S ENGINEERING
17034 Ea_~le River Loop
Eagle River, Alaska 9~577
HAA Fee $ // ~/~1' ~>/~/.'"-~
Date of Payment
Receipt Number
72-026 (Rev. 3/91 ) Sack MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
APPLI( NT FILLS OUT UPPER HAl,..:ONLY
Phone
Property Owner .i~\l[(~ ,~ _~,~,.~ ~'L~,~ ./~'
Lending Institution ~< r~,~ ~ ~ Q ~ /~ Phone
Address ~ ~ O~ ~ ~_q ~ Zip Code
~ ~' ' ~_~ ~:) ~ l~ ~m Phone
Address Zip Code
Legal Description /_0-~ ii BLI4 ~ H~r,4~be
Type of Resi~nce
~ Single Family
~ Multiple Family No. of Bedroo~
~ Other
Water Supply
g Individual A~ACH WELL LOG. A wal log is ~equired for all wells drilled since June lg75.
~ Community For wells drilled prior to that date, give well depth (atlach log if available).
g Public Utility
Sewer Disposal
~'lndividual Year Individual Installed:
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector :. Inspector Inspector r(~
Field Notes: MUNICIPALITY OF ANCHORAGE
DFPT 0
ENVIR'Oi ,~M ,_-t
[;CT 2 :L !98;~
( ._~) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
8oils Rating Date ,Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
72.023 (318~)