HomeMy WebLinkAboutHERITAGE PARK BLK 2 LT 204 OCD •• Q. 1 k - (DO
Municipality of Anchorage
On-Site Water and Wastewater Program - (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number:OSP181143 PID Number: l��®.� (00
Dwelling: ® Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ® Upgrade
Name:
ANDREW & KELLY ADRIAN
ABSORPTION FIELD - EXISTING
® Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
19436 LAURA LEE CIR., EAGLE RIVER, AK
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
4
1.2 GPD/SF
9 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3 Ft.
Gravel depth beneath pipe
6 Ft.
Subdivision Block Lot
HERITAGE PARK 2 20
Fill added above original grade
Varies 0.66 — 0.92 Ft.
Gravel length
42 Ft.
Township Range Section
Gravel width
3 Ft.
Beds: Number of Lines
1
Distance between lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Tk
Field
Tank
Line
504 Ft2
--
-- Ft.
Well
200'+
200'+
NA
NA
25'+
TANK ® Septic I S.T.E.P. ❑ Holding ❑ Other
Manufacturer
ANCHORAGE TANK
Capacity
1 1250 Gal.
Surface Water
100'+
100'+
NA
NA
Material
STEEL
Number of compartments
2
Lot Line
5'+
10'+
NA
NA
NA
Foundation
10'+
10'+
NA
NA
LIFT STATION
Manufacturer
Capacity
Gal.
Curtain Drain
NA
*50'+
NA
NA
Remarks Existing septic tank decommissioned
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
per code. Deep burial tank installed.
*Unknown.
Pump make and model Electrical Inspections performed by
PIPE MATERIAL House to tank 3034 Tank to 3034
Installer Northern Excavation
drainfield
Drainfield 3034 CO/MT 3034
Inspector FWCS / Mike N. Anderson
BENCHMARK (Assumed elevation) 100 ft
Inspdectio I5` 6/23/18 6/23/18
Location and description
: 2nd
3'd 6/23/18 4'h
Door Sill
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
Conditional Approval: Date
ice. o
ar ° A 0 T i i
a
�°e ooe o ° e 000 ou oo Do .f�
$I —C, MICHAEL N. A1DER CiJ
V y a D ° tl.y9
j:.1i
CE - c f 5
Approved Date
a<<1°1?n
r; a ILIIi�.9
� A a t
�
inspection Neport_a-i-iz.aoc
IPermit No. O.SP1811.43. .
Page: 2.... of ....2
Municipatity 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 BLOCK 2, LOT 20 PID No.: 050-211-60
X10' u nLI1Y
EASEMEN
0
L=90.53' R�5
8.2'12.2' SHED QR'' rye':•
7.1'x7.7SHED N;y 243' FCk Lot 20
f\ 7 Q
\\\/"/� ^• 25,499 s.f.
S CFC s Lot
68 E CO
X43 B MT
WOODEN FENCE Co2 STORY1.5' F O
`dry RESIDENCE X
EXIST. FIELD
Z� 1s
le8 BM DECK TH#1 \ j
moo. po '6'j
8.0' x 20.8' DECK p CO CO
a'
2.5' x 4.8' CANT 27 S C
2.0' x 4.8 CANT
A CO O COs MT
WOODEN FENCE Co CO G
CID
V: NEW 1250—GAL S.T.
r
N 81'24'0 DNERTER BOX CHAIN
A -C=26.8' 2r 101,12'
B—C=32.4' Lot 27 N 89'55'53"W 10
A -D=32.5'
B -D=37.5' Lot 26
A -E=91.7' Lot 25
B -E=63.5'
A -F=90.1'
B -F=63.2'
A -G=97.6'
B -G=86.8' SCALE: 1" = 30'
FCO FCO COI CO2 CO3 MT MT C04
TC 02 J F A
99.81 99.75 92.00 FINAL GRADE 9226 91.34 ORIG. '�i• O• .��� 1
rl GRD. / 1 J
INSULATION 0,0
ORG
FILTER FABRIC 1'0 1. •`l
*: 4.9 TH * �
93.23 1,250 GALLON \23 116 g,3q gg,34 GM/SM / /
STEEL TANK SEWER ROCK
DEEP BURIAL
MICHAEL N. ANDERSON.
82.34 �, �'r No. E 9489
SEPTIC SEC TIONBOH 1 ftPE A SS10 INN, .w -
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w .-
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MUNICIPALITY OF ANCHORAGEQc`u{
On-Site Water&Wastewater Program r
• •,f PO Box 196650 4700 Elmore Road _
06
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.org/onsite ^•
ill lig
9kCMOR0"
On-Site Wastewater Disposal System Permit
Permit Number: OSP181143 Effective Date: 6/18/2018
Work Type: Septic Upgrade Expiration Date: 6/18/2019
Tax Code Number: 05021160000
Site Legal Address: HERITAGE PARK BLK 2 LT 20 G:0055
Site Mailing Address: 19436 LAURA LEE CIR, Eagle River
Owner: ADRIAN ANDREW P & KELLY M Lot Size in Sq Ft: 25499
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
Disposal Field El Septic Tank ❑ Holding Tank 0 Privy 0 Private Well 0 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
Received By: Date: p /o
firr
�.90etz� Date:
6 /g /
Issued By: � Al R
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division — Fax: 907-343-7997
On-Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 050-211-60
Property owner(s) ANDREW & KELLY ADRIAN Day phone 208-590-9847
Mailing address
19436 LAURA LEE CIR.. EAGLE RIVER, AK 99577
Site address 19436 LAURA LEE CIR., EAGLE RIVER. AK 99577
Legal description (Sub'd., Block & Lot) HERITAGE PARK B2, L20
Legal description (Township, Range & Section)
Lot Size 25,499 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field Initial ❑ Single Family (SF) X
(w/wo ADU)
Septic Tank Upgrade Duplex (D) U
Holding Tank ❑ Renewal ❑ Multiple Dwellings
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signatuf• • operty owner or authorized agent)
Permit/Rush Fees: 569 Waiver Fees:
Date of Payment: 1a1ltiI f g Date of Payment:
Receipt Number: a.Z113 Receipt Number:
Permit No. OSP121143 Waiver No.
Permit App_9-1-12.doc
Michael N. Anderson, P.E.
Civil/Structural Engineering and Construction
4661 Natrona Ave. Anchorage, Alaska 99516
Phone 345-3377
Fax 345-1391
June 14, 2018
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 BLOCK 2, LOT 20
To whom it may concern:
This is a request for a septic permit on the above referenced lot the old system has failed. A test hole was
excavated and found clean sandy gravel with a trace of silt for the entire depth. The perc rate was found to
be 2 minutes therefore a simple deep trench was designed with an effective depth of 6 feet. No water was
measured in the test hole during or after the excavation. The tank will also be replaced at the same time
and a diverter to the original field installed. The slope at the proposed trench is location is 12-17%, but
then flat with no cut banks within 100 feet.
The lot and area is served by public water and this system will not impact any of the neighboring
properties due to the lot layout.
Please call me if you have any questions.
Sincerely,/A„
Michael N. Anderson, P.E.
4661 Natrona
Anch, Ak 99516
Ph 727-8864
DESIGN CRITERIA! OUND OVER
RS RADE
4 BDRM X 150 = 600 GPD
SOILS = 600/1.2 = 500 GPD &IFABRICLTER
INSULATION
500 GGPD / (2 X 6') ED = 42' .0 y 0 PIPE
(1) TRENCH SEWER ROCK
9.0' MAX DEPTH FROM ORIGINAL GRADE
6.0' EFFECTIVE -9'0
2.0' WIDE 4 0
42' LONG ' f"'
SEPTIC FIELD SECTI❑N
Iop.,sx G, teLE
fLOTS SERVED BY ;I, ....„...„.....------------,
it
PUBLIC WATER
Y
€ \ KE
APPY BOROX.XLO&C.
WATER UNE 10' Mitt
EASEMENT
v LIDO,53 R.6°.cA
• '
Q7 .� STAKE PL
Lot 1Y 10
4,.
q - Lot 21
DEC%ammo
18 'iqT.W�6' , ''e
.oam. 4—BR RESIDENCE * cM rug Mgt•s •
\
rte®sun
Lot ZQ �/
MICE ?b,40D v. se ane'n®( 4 `` \ •'I
as.u' �,, ,. ' ,e. oo �1 na „ii, ., rw
NEP 36'54 woo I
wow powN Ef- --II. , 1 >I w o"ooei snv¢
"CPC"
Hca N ED 66'6311 109.00'
Lot ?a Lot 27
Lot 20
Lot 25
STAKE PROPER Y LINE, ESMTS,...
PRIOR TO CONS RUCTION.
------- ------- -------
Se f is De in Preparers ...46:46.-lik‘
ANDREW ADRIAN �., OF.AL. cs
,j.
�,
HERITAGE PARK BLOCK 2, LOT 20 G`� �I— �
Eagle River, Alaska / * 4 ,9�TH� i� * /
Michael N. Anderson, P.E. DATE: 6/14/2018 ` N. ANDERSON'
No. CE 8488 4 /
4601 Natrone Avr DRAWN: BMW N . . v
' A.
Anchorage, Alaska JJ51 i:, \
(907)727 8864/FAX: (907)345 i S91 SCALE: 1" = 50' � �I�i
}\ \ VVI-\I GMLI INC _ ` IU UTILITY
EASEMENT
• • STAKE PROPERTY LINE, ESMTS,.. PRIOI
••• TO CONSTRUCTION.
\ 440,
. •
/ 40, ,50 00
PC'J<<;`. 46 L=90. 53' R--
43 // FLAT
d 6.8' x 9.9' WOODEN DECK
,,4v40,4 -�WOODEN WALKWAY s Lot 2
DECOM. EXISTING CO,
7g3 411111*
TANK & INSTALL
NEW 1250-GAL
1.5' S.T. OUTSIDE OF \FLAT DECK W/ COS & M �Vi.
RESIDENCE . DIVERTER & 5' FROM
EXIST. FIELD. ,2SED FIELDDECKCO ' TH
27.s,
CO Co . `-..41f FLATFLAT
25% 'CO
s,,..,,, DIVERTER 20'
iJZ-C%
ZO
d' EXIST. FIELD
N 8 24 02' NO CUT BANKS OR SLOPES
w 01. 12' >25% W/IN 100' DOWN SLOPE
OF PROPOSED FIELD. N 89'55'53"W 100.0
Lot 26
Lot 25
Septic Design Prepared for +....wq4k\
ANDREW ADRIAN A*rAir <S, OF ��'
HERITAGE PARK BLOCK 2, LOT 20 oe 62 . ��c •`p
Eagle River, Alaska / * 49TH /N * /
441/4A
Michael N. Anderson, P.E. DATE: 6/14/2018 N. ANDERSON
/, CE 8489 '`w j
1.601 Natrone Ave. DRAWN: BMW \ NO.
\nchorage, Alaska 99516 �,
907)727 8864/FAX: (907)345 1391 SCALE: 1" = 20' � ssia=
Municipality of Anchorage "'ENG 1gMR� AE.raR..'
/ Development Services Department P, t;•• •.-y';';
•
On-Site Water and Wastewater Section ®* e�9T
t. ,-
, `t r 4700 Elmore St. ; �
i P.O. Box 196650 Anchorage,AK 99519-6650
'��� _ WWW.munl.or /onsite ' �/ • •' •r
(907)343-7904 ,•.o. MICIiF.cL N. ANDERSON :�'i �`/
v
If s•• CE-9469 �•.. �.
.1f . C� _s
Soils Log - Percolation Test tb ri ,.••• • , � �
Performed For: A r'TEN T12�k) 4 Da/4IV Date Performed: J/4, �4/7°/`��'
Legal Description: e 1 r`} . ARK RS Z, L20 Township. Range, Section: t
Slope Site Plan
V Sr l
Depth
(Feet)
1- an-6/0 L
3-
4-
5-
6_ cPlop, rritov
7- of S!c'T
8 Sit"
WAS GROUND WATER
9- ENCOUNTERED? N d
S
10- IF YES,AT WHAT DEPTH? — L
Depth to Water After o
DP
11- Monitoring? Pill/ E
12- Date. 4P/I//t
13-
14- Reading Date Gross Time Net Time Depth to Water Net Drop
15-.�--_ i0 hf (e/-7110 /0 AN) 6v r, ,5 „
16 6 rr s
17 r.
4„ it 5
18- (eu •
c
19-
20-
PERCOLATION RATE . (minutes/inch) PERC HOLE DIAMETER (o
TEST RUN BETWEEN 5. FT AND 4, FT
COMMENTS p/2e-s04/450 P4/tiyt, 77) 7L-ST
,ol-u ,£eJAING-r rb VA: Ipt, 71
PERFORMED BY: /k/(/\LA( I CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: &//7/t
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
--t: ± ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME { ,.
J`7
`HjONE
T V ���
NEW
❑ UPGRADE
MAILING ADDRESS Q�
LE AL DE RI' 1oAi
6 i /
LOCATION
NO. Q BED�R�OOMS 9
�`
SEPTIC
TANK
Wel�l���%�_���
DISTANCE TO:ie(Y�/"�yT
Absorption eLea
Dwelling / �'
C✓
P IIT NO.
Manufacturer
Mated
No. of compartments
Liq. cap tviigallons
/f:2
IF HOMEMADE:
Inside length
Width
Liqu th
ODz
0 z Q
2 I–
DISTANCE TO:
Well -
swelling -
PERMIT NO.
Manufact -
Ma -rial
Liquid capacity in efis
TILE
DRAINFIELD
TRENCH
DISTANCE TO:
Welle r)
fly Jyj9���
Foundation6-/,L•yf `
rl
Neares201ir2e
Cl
PERM 79.7
`�
No. of lines,
LengtjLgf/eych line
Total �thtbf linesr-�
Tren, wJdth
inches
Distance omen lines
�(/
Top of tile to finish grade,,
C7l
Material beneath tile
7c2.._ inches
Total ec absorption area
SEEPAGE
PIT
Length
Width
Depth
PERMIT NO.
Type of crib
Crib diameter
Crib depth
Total effective absorption area
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
w
Class
Depth
Driller
Distance to lot line
PERMIT NO.
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIA firctjt 46.124.,. ..
"111111•-•s
cifilq"
SOILTES-fG/�ATIIJNC
N\4...
laTALLER
r
REMARKS /
atltt[i
a/
tilitttht►oiitctik)cl
ty
r-4.--
r`
Sr.
APPROVED
..4.,,�
/
a
DATE LEGAL
i /� — ! /'— 7
72-013 (Re. --3,783'
Permit #
Department, , Health and EnvironmentaJ 'rotection
5 y Street, Anchorage, AK. -A501
264-4720
* * HANDWRITTEN PERMIT * * *
ON-SITE SEWER PERMIT
Applicant: i�J¢ �iZGSoi� Mailing Address:
Location :! - y12 12. 2 /t iT r, Pik Phone Number: 3g4LL y % SS
Legal Description: G-ZIU!
Lot Size:
Type of Soil Absorption System Is:
Trench: 1/ Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: // Soil Rating(sq.ft/br)
/l The Required Size of the Soil Absorption System Is:
DEPTH w LENGTH /� / GRAVEL DEPTH 7. WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /26Y)4 GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* # * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * PERMIT EXPIRES DECEMBER 31, 1 9 3 7
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with co.es.
(3) I understand that the on-site sewer sysmay -quire enlargement if
there idence is remodeled to include mo - 3 bedrooms.
SWP/024(1/81)
Issued b
Date:
(1�
t
p.30_32-cp
W -A -A-±-0
(Le-kua.41 0-( /c
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8 .���a-" "��,n �� ��v��.�' r, E=
DEPARTMENT & 'HEHLTH AND ENVIRONMENTAL /,~�TECTION
825 'L' STREET/ ANCHORAGE: AK. 99501
264-4720
^ , 1.7.§ ����� �������m 7-
PERMIT NO. ( 83.0286 )
APPLICANT DEYCON ENT. INC:. 5411 OLD SEWHRD HWY. 561-1082
LOCATION
LEGAL LOT 20 BLK 2 HERTIGGE PARK SUB LOT SIZE 999999 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS 3
SOIL RATING (SQ FT/BR)=
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
85
���1-1-1= A_CH L_P4C-MA= 3212
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHEa
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
����� ������= ���� ����O��
�
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE
—~_ -11,4CH �%..2> ItqS7.F"a(D-FILDP-41-17.
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PR0SECUTIONL
MINIMUM DISTANCE BETWEEN H WELL HND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION!.
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
]: I UNDER 'THND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
SIGNRESIDENCE S REMODELED 1 CLUDE MORE THAN 3 BEDROOM&
0
/
PPLIC~JT` D
CON ENT. IN1
ISSUED B.
( �l�.��/ / /� ;
PERFORMED FOR:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST f�
DATE PERFORMED: — 12 _ 83
e vcor\
LEGAL DESCRIPTION:
2
3
4
5
6
7
8
9
10
12
13
14
15
16
17
18
19
20
DEPTH
(FEET)
COMMENTS
),n+ ZO "Elk 2_
over 6u. -deo
GM
Gw
•...•>... .•:a.•.
(� • A0Y0 A. nnpwrvri[.v
895-E
•2!),
tei!'Ct!�irf'j t�
SOILS LOG
❑ PERCOLATION
TEST
HcrlIrk Yr
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
5 10' 15' Z0r
�o
S
L
0
P
E
ITE PLAN
O
z
4-5
O
61
8
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
0 02
+i
/
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN
FT AND
FT
PERFORMED BY:
72-008 (6/79)
CERTIFIED BY: - % --_"' 9 DATE: — /S��
20'
(5'
(0'
S,
O
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 050-211-60
Expiration Date: G % o2 - / &O
1. GENERAL INFORMATION
Complete legal description Heritage Park, Block 2, Lot 20
Location (site address) 19436 Laura Lee Cir.
Current Property owner(s) Kathi Olmstead Day phone
19436 Laura Lee Cir.
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
O Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
WaiverNariance request for:
4
TYPE OF WASTEWATER DISPOSAL:
❑ Individual
❑ Holding Tank ❑
❑ Community ❑
[j Public Sewer ❑
Distance:
Received by: ,<./
COSA to be released to the engineer, unless otherwise requested by the engineer.
f
Date
COSA Fee $ 624
Date of Payment
Receipt Number
COSA#
ceReit 1
040101 Ot
oSGl4/2t2
Waiver Fee $
Date of Payment
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 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 Pannone Engineering Services LLC
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
6. DSD SIGNATURE
VIP System #1 Approved for
System #2 Approved for
Disapproved
Conditional approval for
By:
Phone (907) 272-8218
Date 6/5/2014
bedrooms
bedrooms • S}even I & noriri :
ll� fig. CE -8149
bedrooms, with the following stipulations:
ott(tirtl;
ti' y OF �'(t7
'O
J� phi-SITE6:
141?� WATER AND
,Trn 7%
"o WASl0..z.-
:. opnr;RANI co_
�%i7T SER�\c'�`
)-5,»l;,n,),)..->
Original Certificate Date: 6, / a ` %*/
The orage 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 blue sheet t :{ c
If more than 1 septic system is on the lot:
COSA Checklist # 1 of 1
Structure served by this system 1
Certificate of On -Site Systems Approval Checklist
Legal Description: Heritage Park, B2, L20
A. WELL DATA
Parcel ID: 050-211-60
Well type
Public If A, B, or C provide PWSID # AWWU Well Log (Y/N)
Date completed
Total depth ft.
Date of test
Static water level
Well production
WATER SAMPLE R . TS:
Sanitary seal (Y/N) Wires properly protec
Cased to
FROM WELL LOG
Coliform
ft.
g.p.m.
colonies/100 mL Nitrate mg/L
enic ug/L Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Tank size 1,250 gal. Number of Compartments 2
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
Date of pumping 56-7 An i t/ Pumper P„.
C. ABSORPTION FIELD DATA
Date installed 1/18/1984
Casing he
IN)
above ground) in.
NSPECTION
ft.
g.p.m.
Collected by:
Date installed 1/18/1984
Cleanouts (Y/N)
High water alarm (Y/N) N
Soil rating (g.p.d./ft2orft2/bdrm) 85 SF/BR
System type Deep Trench
Length 31 ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth 9.3 ft. Eff. absorption area 340 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 6/5/2014 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 31 in. Water added 627 gal. New depth 38 in.
Elapsed Time: 215 min. Final fluid depth 31 in. Absorption rate >= 600+ g.p.d.
No
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at in. "P
Cycles tested
Da
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic servic
containment areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+
Water main 10+
Wells on adjacent lots i"" ' a"(7)
Man
/N)
in. High water alarm level at
Property line 5+
Meets alarm & circuit requirements?
On adjacent lots
On ad'
in.
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
Water servige line
40
ABSORPTION FIELD ON LOT TO:
Property line 10+
Water Service line 10+
Curtain drain 50+
F. COMMENTS
Absorption field 5+
10+ Surface water 100+
Building foundation 10+ Water main 10+
Surface water 100+
Driveway, parking/vehicle storage 10+
Wells on adjacent lots 1410+2 OO atua
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone
Date 6/5/2014
COSA brown sheet 10-10-12.doc
r�-crc°f.'1r:11•AV 9
A • • t1everi. ' annone : •
tt% CE -8149 .�
e- ste I
„ty,
- hoc er iit `Si; .1 Fre,j.,
In, L L.fok,
, , 4
AS DOHA
r-
I hereby toady that Race rawitixtret the a:Achy-eta itiegiteigA
proptsrty cat. rd c:
Anchorage Recording Precinct, Alaska, and that the in:pyritic
merits thated thcrear, are within the property linus. and dc
net overlap ex- encroash cin the property lying adjacent there-
to, that no impreventente pcsgeitY tienla tighwent thereto
eheroach Ot1 the pi en tbc.• in question and ghat there an ttO
roadways, triVISITthSiOn Nino oh other vikbkt ceteinceeti
said property eiccept as indicated hereon.
[Haug ;a Beek Ittetcr, Alaska
, sit
thie trecytt„,day 52A ” ir
11-0BAST
U. JOHNSON ;Its- --
SCALE, Registeted Land SlittOyte WitglUc;
Box Faith Hittei, Alaska
Phone kit)?) 814,5545
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
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 # C.)60_a 1I -zoo
HAA# 9c1c)�Thr
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 20, Block 2, Heritage Park
Location (address or directions)
19436 Laura Lee
(b) Property owner Geehan /u?L�C» iJ Telephone : (home) Business
Mailing Address 19436 Laura Lee, Eagle River, Ak. 99577
(c) Lending Institution Homequity Telephone
Mailing Address
(d) Real Estate Company and Agent Jack White Co.— Lynda Banner
Address
10928 Eagle River Rd., Eagle River, Ak. 99577
Telephone 694-5500
(e) Mail the HAA to the following address: (or check hereif hold for pick up.)
List contact person and day phone number below:
& 5 ENGINEERING
i 7034 Eaylt River Loop Road No.204
aagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family a Number of bedrooms 4
3. WATER SUPPLY
Individual Well 0 Community 0 Public a
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-site Cl Public 0 Community 0 Holding Tank 0
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 Telephone
S & S ENGINEERING
Address 17034 Eagle River Loop Road No. 2Q4
Eagle River, Alaska 99577
Date
c5-772./9
6. DHHS APPROVAL
Approved for bedrooms by 0.42;1/ Date --/‘'--/‘'- R7
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 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. 7/88) Back
Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
Y OF ANCrtKLIST - FEBRUARY 1984
ENVIR�" TALSERVICESDIVISI0 343-4744
AY 1 1938
A. WELL DATA RECEIVED
Well Classification ' ` If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Date Completed Yield
Total Depth Cased to Depth of Grouting
Static Water Level Pump Set At
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot j- 2Q -t ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot--11Pol-k•
Legal Description' 2c 8V4-, .
; On Adjoining Lots
To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by ; Date
Water Sample Test Results
Comments 1-1 • 0.
B. SEPTIC/HOLDING TANK DATA
Date Installed 1-1e,-eei. Size \?amu No. of Compartments Z'
Standpipes 07N) Y Air -tight Capsc 'N) Y Foundation CleanoutCVN)
Depression over Tank (waygate Last Pumped ^1Z"-C3�
Pumping/Maintenance Contact on File (Y/N)
tip ; for
Holding Tank High -Water Alarm (Y/N) t/A Temporary Holding Tank Permit (Y/N) b
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course 1 �-: t�
Comments n�-7‘4‘--1e1r-14(,
To Building Foundation
To Disposal Field \ 4
72-026 (Rev. 7/88) Front
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata g2 Type of System Design
Date Installed `- 1 -- Length of Field
Width of Field Depth of Field
7' Gravel Bed Thickness to
Square Feet of Absortion Areas Statndpipes Present "N) `/
Depression over Field (Y/0 tJ Date of Last Adequacy Test --- —I 1 -el
Results of Last Adequacy Test ,,e=i---)Sf-ba't Li V 'fall,
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well 2ice'4- To Property Line `,c:)t-t-
To Building Foundation 2 r To Existing or Abandoned System on
Lot Lb ; On Adjoining Lots ----)21:7, t
To Water Main/Service Line L1� j -I' To Cutback (if present)
l
To Stream, Pond, Lake, or Major Drainage Course \ k
To Driveway, Parking Area, or Vehicle Storage Area 3o -1--
Comments
''7l(
10
D. LIFT STATION
Date Installed Dimensions
Si
lions Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for umping Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines
inspection.
Signed
S & S ENGINEERING
17034 Eagle River Loop R..ad Na. 204
Company laska 99577
Date L.) 2 ' 1
MOA No ( 8-7- o
Receipt No. cD� ,„;.2 // 1> 6Jc/2-
Date of Payment .5"-72
Amount. $ / 74.
72-026 (Rev. 7/88) Back
Receipt No
Waiver Fee• $
Date of Payment
in effect 4-44,,timlite of this
.04 419,Q
O MI
�y®,H Y ••
n :CIV
•� $
i�
69 /V*. i.r:l
i111 A. Pieria:
k'iia46.. .0° h���'c
Page 2 of 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1, GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
0
(f)
Location (addrgss or directions)
Applicant Narne a(2 --
Applicant Address ._—_. -
�OL-sZ.��✓
Telephone: Home kgr. /7'V1 Business 6 9y--- /.:9-0 b
Applicant is (check one): Lending Institution 0y; Owner/builder 0 ; Buyer 0 Other
(explain);
Lending Institution
Address
Telephone
Real Estate Company and Agent
Address
Telephone
Mail the HAA to the following address:
r.,•
C>
2. TYPE OF RESIDENCE
Single -Family Multi -Family 0 Other
Number of Bedrooms
3. WATER SUPPLY
Individual Well 0 Community ® Public 1f
Note: If community well systern, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite
Public 0 Community 0 Fielding Tank
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2
72-025 (11,84)
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 Heaith
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
Address
Date
6. DHEP APPROVAL
Approved for 64:' bedrooms by€C Date
Approved-- Disapproved ____ Condition
Terms of Conditional Approval
SPE; cr''
Telephone
' r OF Aiotr
eao n.,�o�a d'/
koJ .09
go ao
str
a a
aE `_
e,
(} i`.•e✓� ab •.
Jn
1%V/ A. "i' (�'':
.`a No. 14,57.E
�
%d
0
oq
e•ceaa
�C}•�a.T����an
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
A. WELL DATA
Well Classification
A
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
1AUG 61gbz
Legal Descri tp ion ' " E E V ED
If A, B, C, D.E.C. ApprovecyN)
Well Log Present (Y/N) Date Completed Yield
Total Depth Cased to Depth of Grouting
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Hofthrrg Tank on Lot ' 1 `'1
Pump Set At.
anitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
To Nearest Edge of Absorption Field on Lot ,Z.vL,i
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Line To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot
Water Sample Collected by ; Date
Water Sample Test Results
Comments W‘ •
W, a 17. "t -V"'1
B. SEPTIC/Ido4rD-we TANK DATA
Date Installed \'t s_ 6(' Size 17.--c'->—c'
Standpipese/N) Air -tight Caps
cal)
No. of Compartments Z
Foundation Cleanout/N)
Depression over Tank (4 1.3-- Date Last Pumped '"-1 -
Pumping/Maintenance Contract on File (Y/N) 1 ; for
Holding Tank High Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) `r - /a
Separation Distances from Septic/Ide+dlrr -Tank:
To Water -Supply Well
To Property Line c" 1 ,1_
To Water Main/Service Line
h
Course
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
n
es-ir>v Type of System Design `�t AA.°4-
Width of Field _.
Length of Field
Depth of Field
Gravel Bed Thickness
tL�
a �
Square Feet of Absorption Area '.64+Standpipes PresentON)
Depression over Field (Y/0 Date of Last Adequacy Test 0e4-,
Results of Last Adequacy Test /44
Separation Distance from Absorption Field:
To Water -Supply Well To Property Line l I
To Building Foundation 2-4 To Existing or Abandoned System on
s
Lot 1 A ; On Adjoining Lots
To Water Main/Service Line I c' t A-- To Cutbank (if present) � h
To Stream/Pond/Lake/or Major Drainage Course f A
To Driveway, Parking Area, or Vehicle Storage Area '' '
Comments
D. LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for
Electrical Codes (Y/N)
Comments
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed 8 aNGIWELSfirl mitRlNC Date k/31,6S
. '-UVEA, ALASKA :5577 ids 00_3Company " '' MOA No.
PH, L44-29/9
Receipt No T Pr) to u J
Date of Payment
Amount. $
Page 2 of 2
72-026 (11/84)
a' (o -2'S
q 57-
Irk\ [1CD NUR) 1.01\ K-41
ENVIRONMENTAL CONSERVATION /
DEPT. OF EN /
ANCHORAGE/WESTERN DISTRICT OFFICE /
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
DATE:
7/21/9.s-
PWS
/Z4ISS
PWS I.D.a 2V 2 2
BILL SWEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
To Whom it May Concern: j'' /
According to records on file in this office the ,47 U, /a%. ,�- p9 fe trees/
Su/,,dfiviJio/I Water System is in compliance with the State Drinking
Water Regulations
Sincerely,
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
Application Date ,5-7,/,/ R56
1. General Information
(a) Legal Description (include lot` ,block, subdivision, section, township, range)
Location (address or directions)
Ci'e-
(b) Applicants Nave /e/i'l CCo' /J o•CJ -Beal 010, 8(Jiilephone3V
Applicants Address 4IL. 3J D i E /Cc/ 6y hilt'/? ?J v:
(c) Applicant is (check one) Lending Institution ; Owner/builder ;
Buyer n ; Other l (explain);
(d) Lending Institution
Address 7
''ne Sereibil7 .121 Telephone
. sue,/ /ley- G cy.1,�./
(e) Real Estate Co. & Agent
C' --y ® ✓� e s �r0� �Gf(��c �l
Address �� .<J /�
Telephone
2. Type of Residence
Single -Family lx ! Multi -Family' i Other (describe)
Number of Bedrooms `¢"
3. Water Supply
Individual infill I f Community L Public] CzSS( 4
Note: If community cell system, must have written confirmation from the State
Department of.Environnental Conservation attesting to the legality and status.
Is the well adequate for the number of bedrooms specified in this HAA
4. Sewage Disposal
Onsite
Public'
Community [ Holding Tank ET
Is the wastewater disposal system adequate for the number of bedrooms /)
[Page 1 of 2)
2-15-84
5. Engineering Firm Providing Inspections, Tests, Data and Information
I certify tha ave checke•, verified, or conformed to all MDA HAA Guidelines in
effect on t is nspection.
Signed
Name of Firm
Address
Telephone
Signed by
Date
t- SAE 19GX
G94.,277
6.DHEP Approval
Approved for
Approved
(ENGINEER SEAL)
bedrooms
Disapproved
Conditional
Ter s of Conditional Approval
The Municipality of Anchorage Department of Health and Environmental Protection dc
not guarantee the continued satisfactory performance of the water supply and/or th
wastewater disposal system. This approval indicates that, as of the validation da
shun above, based on the data and information furnished by an engineer registerec
the State of Alaska, the water supply and wastewater disposal system is safe and f
tional for the number of bedrooms and type of structure indicated.
(DHEP SEAL)
7. Mail the HAA to the following address:
KB2/d5/s
[Page 2 of 2)
2-15-84
A. WELL DATA
L, Z0 i3 lie/ l ret -re -
HEALTH
` -ref
MUNICIPALITY OF ANCHORAGE (MOA)MUNICIPAL.ITY OF ANCHORAGE
HEALTH AUTHORITY APPROVAL ( HAA) DEPT. OF IiEZCH1 &
ENVIRONMENTAL. PROTECTION
CHECKLIST - FEBRUARY 1984
11 AY 81984
RECE E�
Well Classification If A, B, cr C, D.E.C. Approve
Well Log Present (Y/N) Date Completed
Total Depth Cased to
Static Water Level Pump Set At
Depth of Grouting
Yield
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on
Depression Around Wellhead (Y,41)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Line To Nearest Public Sewer
Cleanout/Manhole
Water Sample Collected By
Water Sample Test Results
Comments
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK/DATA
Date Install- a /i Q `7 Size 4 LS Non of Ccrnpartir nts
Standpipes � Air -tight Cap Foundation Cleanou
Depression .ver Tank (r -„ = es Date Las Pumped /def
Pumping/Maintenance Contract on File ( '- ; for Ar/44
Holding Tank High -Water Alarm Temporary Holding Tank Permit -(Y t2/4
Separation Distances from Septic/Ho ding Tank: / 7
To Water -Supply We 11 'f” C.44-55.4 To Building Foundation
% 0 * To Disposal Field /I"(
To Property Line _/ L�
To Water44-:4 8e i Line 5y- 7L To Stream, Pond, Lake, or Major Drainage
Course !/t/,^fi �^ f
Comments 1907 /S /L;--o41,n 71:,46 f76)1/1/
res-s/o>j f u e7 774,1v4( 4.iiLc, 8r te_iL 6-&2 lvi-74//A)
7--//,F /JEY7" 30
,) f', P/IJi)L /2,09//,-/o- /
/.A -S A/07 -
[Page 1 of 21 aEElkJ �c.---6Cm- ille,
c� �et� te6,� n ,,,, CQ..0-4 Z�.. mo,q
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed //is
Width of Field
Square Feet of AbsorptionIdea
Depression over Field (V
34'o
Results of Last Adequacy Test
Type of System Design
3/�
Length of Field
Depth of Field
/o r
Gravel Bed Thickness
Standpipes Present
Date of Last Acbquacy Test
//
Separation Distance from Absorption Field:
To Water -Supply Well CC.. q S S/49
T �
To Building Foundation E
Lot 1^� /p- ; on Adjoining Lots 3o
To Water.i/Service Line (27.)
To Property Line /0 /
To Existing or Abandoned System cn
To Cutbank if present)
To Stream/Pond/Lake/or Major Drainage Course
0/A
To Driveway, Parking Area, or Vehicle Storage Area
Continents
n./
7 �tJ
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Electrical Codes(Y/N)
Comments
ming Cycles during ,Adequacy Test.
Meets MOA
** 'Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified,
on the date of this inspection.
Signed
Co an 8F111 198r, ,, MOA No.
mp Y ; �) v p Al A., VA r �r
9911-9.77':)
KB1/d5/s
or conformed to all MOA HAA Guidelines in effect
Date ,s71d" `ff
[Page 2 of 2]
2-15-84
SIMIE DIF CAISE8A
DEPT. OF ENVIRONMENTAL CONSERVATION
SOUTHCENTRAL REGIONAL OFFICE
437 "E" STREET, SUITE 200
ANCHORAGE, ALASKA 99501
To Whom It May Concern:
DATE: S � - S 1 7
PWS T.D. # a (7 o
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
According to records on -file in this office the (/—/��f2
a'ae if P1w d7 Water System is in compliance with' he State Drinking
WatelRegulations.
Sincerely,
f�
