HomeMy WebLinkAboutLAKEWOOD HILLS LT 15Municipality of Anchorage
On-Site Water and Wastewater Section - (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number.- OSP211191 PID Number: 015-122-06
Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade
Name
JARED TRAVIS ABSORPTION FIELD
Site Address ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
10380 HILLSIDE DR ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
5 GPD/SF Ft
LEGAL DESCRIPTION Depth to pipe invert from original gradeGravel depth beneath pipe
Subdivision Block Lot
LAKEWOOD HILLS LOT 15 Ft. Ft.
Fill added above original grade Grave( length
Township Range Section
Ft. Ft.
Gravel width Beds: Number of Lines Distance between lines
SEPARATION DISTANCES Ft. Ft.
Tol' Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between trenches
Tank Field Lift Station Tank Line
From FC
Ft.
Well 1100'+l t ( 50r+ TANK ® Septic E]S.T.E.P. [E]Holding ❑ Other
f Manufacturer Capacity
Surface Water 100'+ GREER TANK 1500 Gal.
j Material Number of compartments
Lot Line 10r+ INA PLASTIC 2
Foundation 0'-I- LIFT STATION
Manufacturer Capacity
Remarks -TANK DEMO PER UPC, Gal.
Alarm location Electrical installed by
PIPEMATERIAL House to tank Tank to
Installer 3034 dminfield 3034
MIKE N ANDERSON, P.E. Drainfield Co/MT3034
Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 100 ft
Inspdeact sn 1n 6/8/21 2�a Location and description
3ftl 41' SW CORNER OF HOUSE
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Eniners.�Stamp
Conditional Approval;Date "`�� �'• 'e -`'`
-- f' 49TH*
'
—.......... rf
f;
Septic System j M!(H �LEN9AbQ�cRSC r
Approved-C;- '0� Date 1`1 )6)21 �i���;�•.,1� jrv�zl.•�;�„�
Note: this approval does not include well permit requirements.
(Rev 05102/18)
Permit No. OSP211191 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: LAKEWOOD HILLS LT 15 PID No.: 015-122-06
MARK
A
`,
C01
16
34
TC01
18
28
TCO2
25
25
CO2
28
21
CO3
29
20
I
I
I
WELL I
NEW 1500 GA N PLASTIC TF
W/ 20" RISER /
i
✓'
�B
WELL
� BENCH, GARAGE SLAB
A BUILT
SCALE: 1'}=50'
SEPTIC SECTION
N.T.S.
MICHAEL N. ANDERSON:
No. CE 9469
OCK RET. WALL
A,
OCG 49 TH��
0
G
O�O`gN� SHANE A. HOLT qjOa
Q� LS -6914 cb�oO
%�OOssionaoao�
O�oo
/V dy 5/ U7 L L6U.(/U w-vvI" I vvlxv" i i — �w
NOTE :
NO EASEMENTS APPEAR ON
THE RECORD PLAT ON THIS LOT
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY 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, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOWN
HEREON ( UNLESS INDICATED)
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 MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE.
I INCH PIPE
2 21'W 7.58' FROM
--' COMPUTED POS/TION
_00000DO
�F
I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
LOT 15, LAKEWOOD HILLS SUB.
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 _7 TH DAY OF
_JUNE , 2021.
1928, FB 13-51, 167-3,213-71
11
HOLT LAND SURVEYING
9309 GROVER DRIVE
ANCHORAGE,AK 99507
907.223.8615
MUNICIPALITY OF ANCHORAGE
Onsite Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.orglonsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP211191
Work Type: SepticTank Upgrade
Tax Code Number: 01512206000
Site Legal Address: LAKEWOOD HILLS LT 15 G:2539
Site Mailing Address: 10380 HILLSIDE DR, Anchorage
Owner: TRAVIS JARED M &
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING
This permit is for the construction of:
❑ Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date:
n cnt
� n
I� n
Department
Lot Size in Sq Ft:
Total Bedrooms:
6/4/2021
6/4/2022
37800
❑ 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
Received By: /' Date:
Issued By: -ZA (/!/[, ��f�, Date: Z
MUNICIPALITY OF ANCHORAGE
Development Services Department - Phone: 907-343-7904
On -Site Water & Wastewater Section - Fax: 907-343-7997
ON-SITE SEPTICM/ELL PERMIT APPLICATION
Parcel I.D. 015-122-06
Property owner(s) JARED TRAVIS
Mailing address 10380 HILLSIDE DR, ANCH AK
Site address SAME
Day phone
Legal description (Sub'd., Block & Lot) LAKEWOOD HILLS LT 15
Legal description (Township, Range & Section)
Lot Size 37800 Sq. Ft. Number of Bedrooms 5
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) 0
(w/wo ADU)
Septic Tank
0
Upgrade 1.1
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: 4p225fi'A135 Waiver Fees:
Date of Payment: All I Date of Payment:
Receipt Number: 003 7C 2 Receipt Number:
Permit No. 05102 I 1 F1 t Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
May 30, 2021
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: New septic tank permit
Legal: LAKEWOOD HILLS LT 15
To Whom it may concern:
This is a request for a septic tank permit on the above referenced lot. This tank replacement will not impact
any of the neighbors or encroach on any wells, septic or open water issues.
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
OSP211191, Deb Wockenfuss, 06/04/21
1"=50'
PROPERTY LINE
PROPERTY LINE
EXISTING WELL
100' RADIUS
WELL
EXISTING
HOUSE -HILLSIDE DRIVE-REMOVE (2) STEEL TANKS,
INSTALL 1500 GALLON PLASTIC
TANK W/ 20" RISER, MAINTAIN 5'
SEPARATION FROM ALL DECK
SUPPORTS TYP.
DRIVE
W
A
Y
LAKEWOOD HILLS, LOT 15
SCALE:
DJRDRAWN:
DATE:
LAKEWOOD HILLS, LOT 15
Anchorage, Alaska
JARED TRAVIS & LESLIE CAYCO-TRAVIS
5/13/2021
LAKEWOOD HILLS, LOT 14A
LAKEWOOD HILLS, LOT 16
HILLSIDE PARK PUD
LOT 13
COMM. WATER
SERVICE
DCO
DCO
NO WELL
WITHIN 100'
WELL
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211191, Deb Wockenfuss, 06/04/21
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name' ' ~ ' '
DISTANCES
................. ' ~ TANK FIELD WELL
Phone(s)~7~_ ~7~[ Permit~~No. No. of Bedrooms~ WELL 10 f I
~ ~/ T I ~ ~ / ~ ~dnveway,~S'BUlLTwater~lA~RA~bodies, etc.)(Sh°w [ocat ..... 1 well, septic system, proCerty hnes, loundat,on,
~ SEPTIC ~ ~ HOLDING
TYPE OF SYSTEM
~TRENCH ~ BED ~ W. DRAIN ~ OTHER
Depth to p~pe bottom from Total depth from original grade~
Numberoll .... /Soil rahn9 jP,pematerial ¢,~ ,.~ r..~ ~1 /
~ I SQ FT
..... ~'~' '[)(J / Daelnstalled J m m ~ ~ /
PRIVATE OTHER fldentifv) J J m l,
Classification (A,B,CI Total Depth Cased to J J CO,
REMARKS' I / ' 7~
q v came ~ I ~ ' r
I ceflily that this inspection was peflormed according to all
Health Depadment Approval' ~ Date: _ ~ ~. -. ~, ?. ...... ~..
,r.:'ar'c:e.t. Ic:l~ 015-..:1. Z:~?.-..-06
Lc)'L L..ega].:i !iih...d:id:[v~.~-~:i. ciri~ LAI<EWOOD HILLS L, ot:
Sect J.c:,r'l~ 14 T~wr'~sl"~ip: ].2N Range:
Max Bedr'ooms: 'l'hi:s I::'cePmi'L[ :~ "l"ota]. Capacity[
...,...,,::,,:'c,"r', '~.,.,...+'" I"ANK: tq i n :i. mum 'Lc:rLa :l. si.:i.:p'L :i. c:: t an k ~:;; apac: :i. 't.y ~ ]. ,. 5f'.... } cfa.. ]. ]. tin s ,, Each
..~:,rlk mus'L haw.:~, a'L leas'L ~4~ c:~mpar'tmerrLs. Depth 'Lo top of sep'['..:~.c tank (s)
CEI.:;: 1' :I I::'Y THAT ::
I am famil:i, aP with 'l'..he r. ec:!uir'emen'l:.s fop c)n..-*,s:i.'Le s~;ei~.,ePs arid ~,;el[J.s as set
i,::)r'.tli l::ly t!'te Mun:[c::i. pa].ity c)f Al'icl'li::)P&~jE' (MOA) arid
]: ~/o:i.:l.:t. ir-~s'l:.a.i.], tl"i(:z.) ~By~i~V[.E.)fii :i.i'] aCC:OI'~d4M"iC:E' W:i'l:.h al! t~ti::)i:.:~ C:I3CIi.i. HB and r'.e~3uJ, at:i. clr'Is,
arid ir'i c::c:,mp].;iarice v4J.'[..h the design c:r'.i'Ler~:i.a c,f 'l:.l'iJ.!~i penmit..
I ~.~:i.:l.t ac:lheve 'l'.c:i al;I. MCiA ar'id State of A:i. as!.::a I'.i:~H::li..liPe)iliet"l'L~i i'!::il'~ t.h(.:-~ s(~;.rt:. I::iai;;:l.::
i::I:J.~B'~..&.iqC::~e!B l'PCdii any ¢~-~,x:i. st. ing ~x,x;.~.l.:l., i~afa'~.i:e~.9;ii'[..~)P c:lL~i~pc)sa], sy~t. em
alsc) und(~q"stand that 'Lhe c:apac::i, ty c:ll t.t-m~ 'Lo'i:.al system is 5 !:!et:Ir'ex]ms ar'icj
any en:l. ar'gemei'"~t. ~,~:i:i.]. i~equ:i. Pe ~'~r'! addJ. tJ. ciFia:[ peprn:i.'t..
iOP TEC'HNICAL SE
CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS
a-m~onoRE F. MOORE, ~'.E. -~ .~ehruar"~v~n, 1989 14530 ECHO ST.
PH: (907) 345-1355 ANCHORAGE, ALASKA 99516
M.O.A. Dep't. of Health and Human Services
P.O. Box 6-650
Anchorage, AK 99519
Dear Sirs:
By means of this letter I am requesting your issuance of a permit to upgrade
the wastewater disposal system serving the residence on Lot 15 of Lakewood Hills
S/D, from the present 3 bedrooms to 5 bedrooms, which is the size of the existing
residence. While the measured perc rate in the native GM material was 2 minutes
per inch, I have sized the upgrade on the basis of 125 square feet per bedroom.
The large lot size allows ample room for the 5000 square feet required to be
reserved for the original and replacement sites. The topography in the western
portion of the designated replacement area slopes to the west at 20-25 %.
The proposed upgrade trench will be located 15 feet from the top of a 7 foot
high HII slope on the north, and 40 feet from the top of a natural 40% slope on the
south. It is my professional opinion that the fact that the proposed trench is deep,
with sewer rock between 8 feet and 13.5 feet, will ensure that there is no
possibility of effluent daylighting, and thus the normal 50 foot separation is not
needed in this instance.
Please give me a call if you have any questions.
Sincerely,
Ted Moore, P.E.
TR'. lB
/_07' I (
THEODORE F. MOORE
· . CE-3589 ..
l~oT IZ/ L/4l~-ec/ooO ~-~ILL;
.~ IT~ Pt-AH
a sc~r'/ef'eo( (2faT',
PLAN
PIPE= .Z1~157'. J
VIEW
I GOO ~
.CE P-ri
5 EC T I0 N
SP_-.?TtC 5 )"£T£t"l [J?~f~APE
Pl..AN ~ ~cE~TION
Lot 15, Lakewood Hills
10380 Hillside Drive
Septic System Upgrade Specifications
The purpose of this upgrade is to increase the rated capacity of the
wastewater disposal system from 3 bedrooms to 5 bedrooms.
The layout of the improvements shall be as shown on the site plan and
design, except that minor deviations may be approved by the engineer.
All materials and construction practices shall be in conformance with M.O.A.
requirements.
The existing 1000 gallon septic tank which is located too close to the ,well
shall be removed and replaced with a new 1500 gallon, 2 compartment tank,
configured as shown to maintain 100+ feet from the well and 5+ feet from the
existing soil absorption trench. Simply relocating the existing tank and coupling it
to a new 500 gallon tank is acceptable, if visual inspection by the engineer reveals
that this 1983 tank is still in good condition.
The new soil absorption trench shall be 25 feet long constructed parallel to
the existing trench, with care being taken to maintain 12 feet separation from the
existing trench, and 100 feet separation from the well on lot 16. The perforated
distribution pipe shall be laid level at 8.5 feet below original grade, with approved
sewer gravel extending from 8.0 feet to 13.5 feet in depth.
The non-perforated line leading from the tank to the trenches shall be
constructed with a tee sloped to favor distribution to the original trench first. The
line between the tee a~d the perforated pipe in the original trench shall be laid
level, while there shall be a rise of 1" in the line leading to the new trench, before
it descends to the level of the perforated pipe.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION: ~,~1
1
9
10
11
12
13
14
15
16
17
5
6
7
8
19
20-
', THEODORE F. MOORE
~" C~ q~o .'
~ ~e~ '. ....... _ ~
DATE PERFORMED:
SITE PLAN
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED? J~/
¢¢.~jq~ ~ s
IF YES, AT WHAT d4. ~,C¢~1¢ Z O ~' OL
DEPTH? p
Depth to Water Alter
MonilorinD? Date:
PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN .~ FT AND ~'.~' FT
Gross Net Depth tO Net
Reading Date Time Time (~-t ~'o) Water Drop
~H~o I :0~.'~0 ~ ~
PERFORMED B,; j~'//¢4'/~., '7~C~,r/t,'Ccd' .~'¢¢z/1~_/', ~~ k/~. ~¢¢¢.~¢~ CERTiFY THAT THiS TEST WAS PERFORMED i,~/¢¢'/'
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~/~/'~ ¢/'(:~:'~
OP TECHNIC AL SERY!
CIVIL & ENVIRONMENTAL ENGINEERING * ENERGY CONSERVATION & ANALYSIS
THEODORE F. MOORE, P.E.
PH: (907) 345-1355
February 24, 1989
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
MUNICIPALITY OF ANCHORAG~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
M.O.A. Dep't of Health and Human Services
P.O. Box 6-650
Anchorage, AK 99519
FEB 2 & 1989
RECEIVED
Dear Sirs:
Enclosed, per your request, is a sieve analysis of soil from the test hole dug
February 14, 1989, on Lot 15, Lakewood Hills S/D, showing a 21% silt fraction. I
feel this is representative of the grain size distribution encountered at the 15 foot
depth. As the test hole depth increased past 14 feet, I noted that the silt fraction
was greater, which would provide a slower perc rate. I trust that this information
will resolve any remaining questions you have regarding the requested upgrade
permit.
Sincerely,
Ted Moore,
LABORATORY TEST REPORT
R&M CONSULTANTS, INC,
TESTON Field Sample R&M PROJECT NO. 950004 (951001)
CLIENT/PROJECT Flal;~;op Technical Services/Lot #15. Lakewood Hills LABNO. 1
SOURCE Lot #15, Lakewood Hills SUBMITTED ByClient FIELD NO.
SAMPLED FROM Test Hole #1 DATE SAMPLED 2-22-89 DATE REPORTED2-2b,-89
LOCATION DEPTH 15 feet DATE RECEIVED 2-23-89 ..
GRAIN SIZE DISTRIBUTION .... ':':-'; CLASSIFICATION · ·
% PASSING A5 SPEC. UNIFIED AASHO FAA
SIEVE RECEIVEC ;;~':;'~; '!~'~' ' '~ :
5" - .- : . ' %+ 10 ::?':'~'.;~' ?'[':'~g;?' :: -' ::: OPTIMUM MOISTURE
4" %+3 --:'~i;' : -:. ":;~:'~: ....
MAX. WET DENSITY
3" · % GRAVEL . ~;:.....:;:' ,:' : ,: .' ;~ '
MAX, DRY DENSITY
2" .]00 % SAND " CORR. MAX. DRY DENSITY
1 ]/2" 95 % SILT :'
% FRACTURE
l" 7~ % CLAY METHOD
3/4" ~9 FSV ' NATURAL DENSITY
1/2" 6[ LL NATURAL MOISTURE
3/8" 58 PL WEIGHT LOOSE
= 4 ~1 PI WEIGHT RODDED
~ 8 CLA55 ~
= 10 q5 TOTAL WT. TESTED J ~ J
: ]6 1,276 GMS
I
= 20 ~ REMARKS
=30 * = Assumed
: .o ~ I
.O~M ~ I I J
,00SMM ~ J J J
COARSE SPEC FINE SPEC DELETERIOUS MAT.
i
CLAY LUMPS~ ~ I
STICKS & ROOTS ~ J I
I
J l '
ABSORPTION
, FINENESS MODULUS
I SULFATE SOUNDNESS I $ I J
I FREEZE--THAW RATIO ] I
L. A. ABRASION LOSS GRADE .
DEGRADATION VALUE I I
THIN.ELONGATED_ MOISTURE -- PERCENT
COARSE SPEC FINE SPEC
Tom Fink,
Mayor
unicipality of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
February 8, 1989
Janelle Pfleiger
Remax Properties
2600 Cordova St.
Anchorage, AK. 99503
Subject: Lot 15 Lakewood Hills Subdivision
Dear Ms. Pfleiger,
This letter will confirm our earlier conversation concerning the
septic system for the subject lot. As we discussed the
Anchorage Municipal Code (AMC) does not allow for an on-site
septic system to be utilized for more bedrooms than the system
was designed for.
AMC 15.65.040.C does not apply to existing non-conforming
systems, rather this paragraph and paragraph D apply to
innovative system design. Under AMC 15.65.035.A a septic system
must have been designed and operating in compliance with the
standards in effect at the time of installation. As such the
existing septic system for Lot 15 can only be approved for a
three bedroom single family residence. It may,be possible,
however, to upgrade the septi'c system to accommodate the
existing five bedroom residence. The upgrad% would have to
comply with the standards set forth in AMC 15.65. This would
include design approval and permit issuance by this department.
I trust this will clear up any misunderstanding which may have
occurred. Should you wish further clarification please don't
hesitate to contact this office.
Sincerely!
Daniel N. Bolles
On-site Services
cc: A1 Sundquist, P.E., Manager On-site services
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LOCATION NO. OF~DSOOMS
~Wg~~ Absorptiqn are~ Dwelling I P T
DISTANCE TO:
Liq.~a~in gallons IF HOMEMADE: Inside length Width Liquid depth
~ Well Dwelling PERMIT NO.
DISTANCE
TO:
~ ~ ~ Manufacturer Material Liquid capacity in gallons
~ Well. -- . Foundatio~ Nearest lot ],ne PER~O~
- .o. of lines [ Length of ~,i~e Total length of /lines Trench width..:~ inch'- Distance ~?~n lines
~ E ~ Top of tile to finish grade ~,~ Material be;e~;th the Total e~fe~t~ye absorption area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth ~ Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
SOIL TEST RATING
INSTALLER ~ ,
R EMAR KS
APPROV~ DATE LEGAL
Date Drilledl 4~21-83
Static Water Level
162 feet
Draw Down ua feet
WEI~L LOG
Legal: Lot 15, Lakewood Hills
Gallons Per Minute 8
Total Feet of USsing 200
Tyoe Material Drilled:
0 feet to 20 sand gravel
20 to 63 cemented hardpan
63 to 156 clay
156 to 194 clay with rock
194 tO 200 grave]
200 to 202 Water gravel a~ aquifer
Hefty Drilling
S.R.A. Box 1553 H
Anchorage,Alaska
99507
PERI'~IT NO,
BPPLiCflNT PBUL B. SELLENS
LOCATION
LEGAL LOT ±5 LAKENOOD HILLS
TYPE OF SOIL ABSORPTION SYSTEM iS:
t"tAXIIdUM NUMBER OF BEDROOMS = Z
2i47 RRCADIA [:,R.
LOT S I ZE '3'9'39._c. 'B S_.3UARE FEET
TF.:ENCH ,Z_/
SOIL RFITING ,'BI_-]! FT,.-'BF.t)= ±40 '-J~--'~'~-~
THE REQUIRE[:, SIZE OF THE SOIL ABSORPTION SYSTEM IS:
[:,EF'TH= 1£~ LE~,STH= 2:5 "SE:ANgEL [:,EF'7-H= e]
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFI~CD.
7'HE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE E×CAVATION (IN FEET).
THERE iS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF' GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE E×E:AVATION (IN FEET).
PERMIT RF'PLICRNT HRS 'THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT 'THE NELL WILL SERVE.
Th-lC, .:: 2 ::. Z ~'-,P_---.F"EC: T I Eli'-.12; FtF:E F-: E L----! Li I F-:ED
BACKFILLING OF RNY _-,~=,TEH NITHOU"r FINRL INSPECTION FIND FIF'F'F-:C%'RL BY THI_:,
DEPRRTMENT WILL BE SUBJEC'F 'TO PROSECUTION.
HINIMUM DISTRNCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
±00 FEET FOR A PRIVATE NELL OR ±50 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF' PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIYATE WELL TO R PRIVATE SEWER LINE IS 25 FEET
TO A COMMUNITY SEWER LINE tS 75 FEET.
NELL LOGS RRE REQUIRED AND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 20 DAYS
OF THE NELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS BND CONSTRUCTION DIAGRAMS ARE
AVAILRBLE TO iNSURE PROPER INSTALLATION.
i CERTIFY THAT
t: i RM F'AHtLIAR NITH THE REQUIREMENTS FOR ON-SITE SENERS AND NELLS AS SET
FORTH BY THE MUNICIPALITY OF RNCHORRGE.
2: ! WILL INSTALL THE SYSTEM IN ACCORDRNCE NITH THE CODES.
2: I UNDERSTRND THRT THE ON-SITE SEWER P¢STEM MRY REQUIRE ENLRRGEMENT IF THE
RESIDENCE IS REMO[:,ELED TO INCLUDE MORE THRN 3: BEDROOMS.
StGNED: _.7~LICRNJ PflUL R: SELLENS
PERFORMED FOR:
LEGAL DESCRIPTION:
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
PERCOLATION
TEST
1
2
3
4
5
6
7
8
9
~-~10
11
12
13
14
15
16
17
18
19
2O
COMMENTS o_ /'-/'o
SLOPE SITE PLAN
WAS GROUND WATER S
ENCOUNTERED? ,~O L
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop:~/
PERC'~LATION RATE ~ ~ ~,~30 __?., ?.-~ (minutes/mch~
TEST RUN BETWEEN ~' ~- FT AND ~ OFT
PERFORMED BY: ~''~ ¢ ~/~'~1 (¢. CERTIFIED BY: DATE: ~"~¢2 ~/~'-Z .
POL/QH 6-650
ANGHORAGE, AI_ASKA 99502-0650
(907) 264-4111
? ON¥ ~'~A~OWLES,
DFPARTMEN~ OF ~IE;,! I i .' F) ENVIi~ONMENTAI PROFECTION
<Permit #: 820848
· January 31, 1983
TO: Permit Applicant
Subject: Lot 15 Lakewood Hills Subdivision
A permit issued by this department for an individual well
and/or on-site sewer system has expired as of December 31,
1982.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log needs to be sent
to this department for documentation of the installation
date and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, please have them sen4 us the as-builts
for our files and documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerel~
Robert C. Pratt, R.S.
Acting Program Manager
Sewer and Water Program
RCP/ljw
enc: Copy of Permit
SWP/057
PERMIT NO.
DEPARTMENT HEALTH 8ND ENVIRONMENTAL ]OTECTION
825 'L' STREET, ANCHORAGE~ AK. 99501
264-4720
( 820848 )
APPLICANT PAUL A SELLENS 2±74 ARCADIA DR
LOCAT I ON
LEGAL Li5 LAKE&.~OOD HILLS LOT SIZE
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
272-795~
999999 SQUARE FEET
MAXIMUM NUMBER OF BEDROOMS
SOIL RATING (SQ FT?BR)= i40
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
[:,EPTH= ±0 LEI'-~GTH= -:=;5 Ii R :-'~'~.' E l Bi-PTi-
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 EXCBV8TION (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 E~CAVATION (IN FEET).
RE¢!LI I ~:EE) SEPT I ~:: TH~-I~-C $ I ZE= 100~:~ GHI ..L~]~-~$
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.
T[~E~ (2) I [-~SF'E~]TI,][-~S F~:E E:FO.L~IRED
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION RND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
t00 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 THE DEPARTMENT WITHIN ~0 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F'EF-:t-11 T E.'=-::P I E:ES [:,,FC:FFIBEE: 3:L.. ~ 982
I CERTIFY THAT
t: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS.
MUNICIPALITY OF ANCHORAGE
1
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I .D. 015-122-06
1. GENERAL INFORMATION
Expiration Date: I 1 LI 0, ()Q 1
Complete legal description LAKEWOOD HILLS LT 15
Location (site address) 10380 HILLSIDE DR, ANCH AK
Current property owner(s)
Mailing address
Real estate agent
JARED TRAVIS
SAME
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
Day phone
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
El
Private Septic
I]
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ M
Date of Payment Co (_01 2021
Receipt Number ®I bb -o
COSA # 0 S C a 1131 9
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. 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 6-8-21
1
rte : 49TIl
6. DSD SIGNATURE
System #1 Approved for 5 bedrooms MICHAEL N. ANDERSON ;
CE - 4 64
System #2 Approved for bedrooms ( ✓�� •��
Disapproved t��q�'Ii1FFSSiGN�4��
Conditional approval for bedrooms, with the following stipulations:
i
J= ON-SITE m
I,, \!ATER p
PROGRAM
By: Original Certificate Date: rn j Y o-0 2
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: 4
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: LAKEWOOD HILLS LT 15
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 4121/83
Total depth 202 ft
Cased to 200 ft
❑� Sanitary seal is functioning correctly
Q Wires are properly protected
Casing height (above ground) 12 in.
Date of flow test for COSA 5/6/21
Static water level at beginning of test 150 ft
Comments
B. TANK DATA
Age of tank(s) NEW years
Tank type/material S"_°`"s
Measured operating fluid level in septic tank NEW
X Standpipes/foundation cleanout per record drawing
Date of pumping NEW
D. ABSORPTION FIELD DATA
Which system tested (date installed) '8/31/83
❑ ALL standpipes present per record drawing
Total measured depth from grade 12.3 ft (max)
Measured depth to pipe invert from grade 6.3 ft (min)
❑ N/A — pressurized field
Q Monitor tubes go to bottom of effective. If not, state
depth into effective
Parcel ID: 015-122-06
Structure served by this system _
Well production at time of test 5+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes No
❑ Coliform bacteria is Negative
Nitrate 7.73 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L M Arsenic less than MRL (ND)
Collected by MNA
Date of Sample 5/6/21
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _ years
Lift station material _
Comments:
Adequacy test date 5/6/21
Results ❑� Pass For 5 bedrooms
Fluid depth prior to test 5 in
Water added 750+ gal
New depth 15 in
Elapsed time 1440 min
0 Code -required soil cover over field Final fluid depth 5 in
❑ System presoaked Absorption rate 750+ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months)
date of test)
Gallons introduced 0 gallons If yes, enter date
Comments/Deficiencies: `TESTED 1983 (SOUTH TRENCH) TESTED ONLY. 1989 TRENCH FULL
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
❑✓
Yes
Community Sewer Manhole/Cleanout > 100'
❑v Yes
if No
_ ft
[Z Yes
if No _ ft
Neighboring Tank > 100' ED Yes
if No
_ ft
Private Sewer/Septic Line > 25' ED Yes
if No_ ft
Absorption Field on Lot > 100' ✓l Yes
if No_
ft
Holding Tank > 100' Yes
if No _ ft
Neighboring Absorption Fields > 100'
Yes if No _ ft
Water Main > 10'❑
Animal Containment > 50' Yes
if No ft
El Yes
if No
_ ft
Yes if No _ ft
Water Service Line > 10'
Yes
if No _
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway comment below
Community Sewer Main > 75' ❑✓ Yes
f No
_ ft
✓0 Yes
if No_ ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
❑✓
Yes
if No
_ ft
Surface Water > 100'
❑✓ Yes if No _ ft
Property Line > 5'✓❑
Yes
Yes
if No
_ ft
Wells on Adjacent Lots:
Absorption Field > 5'
❑✓
Yes
if No
_ ft
Private Wells > 100'
Yes if No _ ft
Water Main > 10'❑
_ ft
Yes
if No
_ ft
Community Wells > 200'
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'✓Q
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' Yes if No_ ft
Water Service Line > 10'
Q
Yes
if No
_ ft
Community Wells > 200' ❑✓ Yes if No _ ft
Surface Water > 100'
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l certify that / 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
h.. l
t -
49TH ...... ��
..........
A� MICHAEL N. ANURSON
CE 69
S Iz��`��
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904
On‐Site Water and Wastewater Section Fax: 343‐7997
www.muni.org/onsite
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Nitrate Advisory
Certificate of On‐Site Systems Approval # OSC211318
Subdivision: Lakewood Hills, Lot: 15
A water sample revealed a nitrate concentration of 7.73 milligrams per liter (mg/L).
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. Please see the attached “Nitrate Fact Sheet” for
important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On‐Site
Systems Approval.
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as “blue baby” disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a medi a with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several “wet chemical” methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive “screening test”, and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
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 15, Lakewood Hills
Location (site address or directions 10380 Hillside Drive
Property owner
Mailing address
Lending agency
Mailing address
Agent N/A
Ad dress
Melvin McLauqhlmn Day phone
10380 Hillside Drive, Anchorage, AK
pH~/Homequity Day phone
400 E. Las Colinas Blvd., Suite 300, Irvinq, TX
Day phone
(907) 346-8236
(214) 506-8857
75039
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
x
Public sewer
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 Criterium-Alaska Enqineers
Phone (907) 349-1003
DHHS SIGNATURE
Z Approved for/2/¢~-
99511-1790
Date
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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.
72q)25 (Bev 1191) Back MOA
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Lot 15, Lakewood Hills
If A, B, or C, attach ADEC letter.
Parcel I.D.
Legal Description:
A. WELL DATA
Well type Private
Log present (Y/N) Yes
Total depth 202
Sanitary seal (Y/N) Yes
ADEC water system number
Date completed 4/21/83 Driller Hefty Drilling
Cased to 200 Casing height 2'
Wires properly protected (Y/N) Yes
FROM WELL LOG AT INSPECTION
Date of test 4/21/83 7/24/92
Static water level 162 159
Well flow 8 g.p.m. 6.3 g.p.m.
Pump level N/A 80
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot 102
Absorption field on lot 110
Nitrate
; On adjacent lots 150 plus
; On adjacent lots 150 plus
Public sewer manhole/cleanout N/A
Petroleum tank N/A
2.8 Other bacteria 0
Collected by: Ted Johnson, P.E., Criterium-AE Eng.
Tank size 500+1000 Existing Compartments 1 &
Foundation cleanout (Y/N) Yes Depression (Y/N)
Alarm tested (Y/N) N/A
Public sewer main
Public sewer service line N/A
WATER SAMPLE RESULTS:
Coliform 0
Date of sample: 7/30/92
El. SEPTIC/HOLDING TANK DATA
Date installed 3/21/89
Cleanouts (Y/N) Yes
High water alarm (Y/N) No
Date of pumping Not available
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
On adjacent lots 100
Absorption field '10
2 Existing
No
Foundation 22
Water main/service line
Well(s) on lot ].02
To property line 40'
Surface water/drainage
72-0~6 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed N/A
Size in gallons N/A
Vent (Y/N) N/A
High water alarm level
"Pump on" level at
N/A
Man ufactu rer N/A
Manhole/Access (Y/N) N/A
N/A "Pump off" level at
Cycles tested
N/A
Meets MOA electrical codes (Y/N) N/A
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot N/A On adjacent lots
Surface water
N/A
D. ABSORPTION FIELD DATA
Date installed 3/21/89
Length 125 ~"?~.)-- ''\~ Width
Total absorption area 250
Depression over field (Y/N) No
Results (pass/fail) Pass
Peroxide treatment (past 12 months) (Y/N)
Soil rating GM
Gravel thickness
No
Trench
~, System type
~:::~"~ Total depth I~
Cleanouts present (Y/N)
Date of adequacy test
for
Yes
7/24/92
If yes, give date N/A
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 102
To building foundation 35
On adjacent lots 50 plus
Surface water N/A
Curtain drain N/A
On adjacent lots 100 Property line 35
To existing or abandoned system on lot
Cutbank 35 Water main/service line N/A
Driveway, parking/vehicle storage area 70
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.
Engineer's Name Theodore A. Johnson
Date August 4, 1992
HAA Fee $ ~IC;~ O~
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 502.2343
~I815 ~U~ [o~ I~VOICK t 56505
FAX: (907) 561.5301
Client $,apls ID ; ~LL 10380 HIbL$IDg
Collected : J~L 30 92 8 15:00 h~.
BPOt :
Par~etez Rs,ultm Units Wethod Allowable Limtm
NHgAIK-N 3,8 ~/i EPA 353,2
MUNICIPALITY OF ANCHORAGE .,~'~
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
L(~ / ~ - t ._-~ .-~ - ~--~-~' HAA# ~--~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner H¢~'¢~"/c~ _..~U1~,¢~2'~ - - Telephon[: (hom~) Business
(c) Lending Institution ~ ~do~ Telephone
Mailing Address
(d)
Real Estate Company and Agent
Address
Telephone '~ 7~"' - '~ '7"'~"/
(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. WATER SUPPLY
Individual Well t~. 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-site [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AN[) 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.
6. DHHS APPROVAL
Approved for ,~ bedrooms by
Approved ~ Disapproved
Terms of Conditional Approval
Conditional
Date
The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph S 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 DHHSdo not conduct inspections
or analyze data before a certificate is issued. The MunicipalityofAnchorageis not responsible for errors or omissions
in the professional engineer's work.
72~085 (Rev. 7/88)Back Page 2 of 2
~ MUNICIPALITY OF ANCHORAGE (MOA) ~
! eA/jb",,, ~ Health Authority Approval (HAA)
~LITYOFAN~i~iST' FEBRUARY 1984 '
EN~NTAL SERVICES DIVISION343_4744
MAR 2 ;~ 1989 Legal Description: ~.,o ~ /g'~
A. WELL DATA RECEIVED
Well Classification
Well Log Present (Y/N) Y~ Date Completed
Total Depth 'EO 8' Cased to ~¢Z:~' Depth of Grouting
Static Water Level I~f~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot IO ! ~
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
If A, B, C, D.E.C. Approved (Y/N)
Pump Set At ~ t~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
N
; On Adjoining Lots ,,~ too
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results 5'c~{-~.~-cJo~',~, -
Comments ~ ~';~'
B. SEPTIC/HOLDING TANK DATA
Date Installed 3,/~1/~ Size ~OO ~-,5"'c~ No. of Compartments
Standpipes (Y/N) 'r' Air-tight Caps (Y/N)
Depression over Tank (Y/N) ,/~
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Foundation Cleanout (Y/N) 'r'
Date Last Pumped ,q,,~.
; for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line ·
To Water Main/Service Line
To Building Foundation
To Disposal Field
SS'
To Stream, Pond, Lake or Major Drainage Course
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
1YE /I 8,S"/:~/Z:~c(~'~',Type of System Design
$/~.f/8~ Length of Field ~0' ~
Depth of Field /~'j ~,~
Gravel Bed Thickness ~ ~ ~
/
Square Feet of Absortion Area ~/8¢2 .~- ¢~¢¢ Statndpipes Present (Y/N)
Depression over Field (Y/N) /"/ Date of Last Adequacy Test
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well /1¢2 ~ To Property Line 3',-,~"
To Building Foundation ,..'~¢J A.~-§~ ~ ~/¢~//{)1 To Existing or Abandoned System on
Lot .~,.¢¢,.~.. ,/,~ r .~,_~/~;~.~..,,,/( ;~ ; On Adjoining Lots ~
To Water Main/Service Line ~. I~c' To Cutback (if present) ~,,4,
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments /4,¢,(¢'~¢~.¢? /-¢,¢~ o~ ~//¢'
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA gui effect on the date of this
inspection.
Signed ~z-'~
Company
~,~, ~ Engineer's Seal
Date ~
Receipt No. . _
Date of Payment ~ ~ ~¢ ¢ Waiver Fee: $
Amount: $ //~,'~ Date of Payment
72~026 (Rev. 7/88) Back Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
Client S~,~ple ID:LiS, LAREWOOD
Coliecte~t F'~]B 10 89 ~ 13:15 h-~,
Pze~erved. with :NOffg
ANALYSIS ~EPOBT BY SAl~3LE for ~ozk O~dez $ 11667 Dote Repo~t Printe~: F~B 13 89 ~
C].iont Acet : FLATTOT
Eeq $
Ordered By : TED MOOSE
~naivsJ.~ Completed :FEB 13 89 Send ~pozts to:
Laboratory Superviso/ :STEPHEN C, EDF, !)FLATTOP TECHNICAL SRV
/
Cberolab 5of $:: 4219 Lab Smpl ID: 1 Matrix: WA?ER
Allo~able
NITRATE-l: 1.5 ~,~/1 EPA 353,2 10
S~mple ~OOTiNE SAI~PLJ~
Te~ts P~fo~m~d ~ Se~ Special In~t~uetion~ Above UA=Unevai].abl~
None Oetecte~ *~ See Sample ~emazk~ Above
MUNICIPALITY OF ANC~ORAGE
DMSION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH ADTHORITY APPROVAL CERTIFICATE
1o General Information
Application Date
Legal Description (include lot, block, su~b~.ivisiont section, _t. ownship, range)
Location (add~ess o~ directions) .
t-t- / C ~. :'~ ~ /-3 E~' ~/:~ ~¢ ~"1 ,, ,~:. ~., F (i> ~;"},4~'L. ~ ~+' ~
/
(a)
(b) Applicants Nam~_~ .~F-:'/:/-./L't z':'P~]) ./3(%::- Telephone ._pP.-~
Applicants Add~ess '?._O / ~ /?'/C.. /~-C> eL)
(c) Applicant is (check one) Lending Institution ~--~; (~m. er/builder ~ ;
Buyer ~ ; Other ~ (e~lain);
(d) ~nding Institution
(e) ~al Estate ~. & A~nt /~_
/
AdZe s s
Telephone
2. T_~_of Pesidence
Single-Fami!y ~
Nu~aber of ~drooms
3. Water S~_~
Multi-Family
Other (describe)
Note: If community ~11 system, must haw written confirmation frcra the State
Department of Environmental Conservation attesting to the legality and status.
Is the ~11 adequate fo~, the number of bedrocms specified in this HAA (Y/N)
4. _Sewag.e.. D__isposal
\/
Is the ~stewater disposal system adequate f~r the r..umbe~ of bedrocms (Y/N)
[Page 1 of 2]
5o E~ineerinq Firm Providinj~Inspections, Tests, Data and Information
I certify that i have checked, verified, or conformad to all MDA HAA ~uidmlir~s in
effect on the date of this inspection.
Signed
Nan~ of Firm
Address
Date
(ENGINEER SEAL)
6. DHEP Approval
Approve d for
Approved'~
~ badrcc~s
Disapproved ~
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Environn~ntal P~otection dces
not guarantee the continued satisfactol~y performance of tbs water supply and/or the
wastewater disposal system° ~is approval indicates that, as of the validation date
shovm above, based on the data and information furnished by an engineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and func-
tional for the ~ of hedroc~s and type of structure indicated°
( DHEP SEAL)
7. Mail the FAA to the following address:
/c /'.--Id x_x/(_
KS2/dS/s
[Page 2 of 21
2-15-84
C o"t"' tS'
A®
MUNICIPALI~ OF ANCHO~GE
DEPT. OF H~ALTH &
~CIP~I~ OF ~C~GE (MOA)ENViRONM~NTAL PROTECTIO~
RECEIVED
Well Classification J ~//~ / ~ If A, B, c~ C, D.E.C. Approved(Y/N)
Well Log P~esent (Y/N) y Date Completed q-n/- J Yield
Total Depth ?.~O ~' t Cased to
Static Wa~er Level / ~ ?~ '
Casing Height Above Ground 3 ~)x,,
Electrical Wiring in Conduit (Y/N)
Separation Distances f~cm Wall:
To Septic/~olding Tank on Lot
Pump Set At
Y
Depth of Grouting
Sanitary Seal on Casing (~/
Depression A~ound Wallhead (Y/N)/tx
!
; On Adjoining Lots 'P /OO
To Nearest Edge of Absorption Field on Lot //~- / ; On Adjoining Lots
To Nearest Public Sewer Line /~/~ To Nearest Public Sewer
Cleanout/Manhole it~/ /4r To Nearest Sewer Service Line on Lot
Water Sample Collected By ~ ~X33' ~ ~/O/~ ; Date 3--- / 6 ~ ~>
Water San~ple Test Results ~/c~ 7'-~3"T-' /'~ ~-'~7"'"~ C-/'-'/
D /cc/x cJ3
B. SEPTIC/HOLDING TANK 5~TA
Date Installed 3--3/--~ Size /O(f) Oy NO. of Compartments
Standpipes (Y/N) ~/ Air-tight Caps (Y/N) ~ ~Foundation Cleanout (Y/N)
Depression ove~ Tank (Y/N) /~/ Date Last Pumped
Pumping/Maintenance Cont~ac~ on File (Y/N) /C/ ; for
Holding Tank High-Wate~ Alarm (Y/N)/t//~ Temporary Holding Tank Permit (Y/N)'
Separation Distances f~om Septic/Holding ~ank:
To Water-SupplyWall /d)O
To P~ope~ty Line ~ ~O ~
ToWater Main/Service Line '~-/'O '
Course /'.."/ /~
To Building Foundation /~
To Disposal Field /O /
To Stream, Pond, Lake, c~ Major D~ainage
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ -3/~ ~
Width of Field ~ ~f
Square Feet of Absorption Area
Depression over Field (Y/N)
/G/O Type of System Design
Length of Field ~/C_) /
Depth of Field /dP f
Gravel Bed Thickness ~ ~
Standpipes Present (Y/N) oy'
Date of Last Adequacy Test
Results of Last Adequacy. Test
Separation Distance from Absorption Field:
To Water-Supply Well //~- ~ To Property Line -~-/dP
To Building Foundation ~.5- / To Existing or Abandoned System on
Lot /~7 4 ; On Adjoining Lots -(-~-~P ~
To Water Main/Service Line '7~/d3 ~ To Cutbank(if present)
To Stream/Pond/Lake/or Major D~ainage Course ~/~
To D~iveway, Parking Area, or Vehicle Storage Area ~-~
Ccrarents
De
** Check Permitte~ Bed~con Rating Against HAA Request
LIFT ~
Date Installed ~ Dinm nsions
Size in Gallons ~ Manhole/Access (~Y~_~--"~' ..........
"~ ~" ~1 at ~ "~ ~vel at
High Water ~ ~vel at ~ Vent (Y~)
Tested for ~ing Cyc~g Adequa~ ~st.
Electrical Co~s (Y~)/
~ets MOA
I certify that I have checked, verified, or eonforn~d to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed
Company
Date
KB1/d5/s
[Page 2 of 2]
2-15-84