HomeMy WebLinkAboutLAKE O THE HILLS EAST BLK 3 LT 4 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page ( of 7......., ON-SITE WASTEWATER INSPECTION REPORT Permit Number: )•1>ti [ at l b';• 7.- PID Number:(,9 IS". 3,-;1—( ' Dwelling: [.Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New [,Upgrade Name ABSORPTION FIELDAV-v%� n A titI/ . r et CAI Site Address ❑ Deep Trench ❑Wide Trench ❑ Bed ❑ Mound ❑ Other Phone Number of Bedrooms Soil Rating Total depth from or. . al grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade avel depth beneath pipe Subdivision Block Lot Ft. Ft. (..*(1-t. Q t• .vC I-7 (I c "3 K Fill added above original grad Gravel length Township Range Section Ft. Ft. Gravel width Beds: Number of Lines Distance between lines SEPARATION DISTANCES Ft. Ft. ToSeptic Absorption Lift Station Holding Sewer Total ab rption area Number of trenches Dist.between trenches From Tank Field Tank Line Ft2 Ft. Well otf�/ TANK ,Septic ❑ S.T.E.P. EI Holding I=1 Other �r , Manufacturer capacity Surface Water ' S !^ v e r 2 S 0 Gal. �d �` Material Number of compartments Lot Line /014_ NA Pf°I.74 I Vjs/ _ Z LIFT STATION Foundation to Manufacturer Capa Remarks 4. (42 v."ws nig- I Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank Tank to I r Installer � 3K drainfield 34 �./ii In t An k.e f`� Pr e e Drainfield 3,0)K CO/MT Inspector M h,, A jr,d co 4,0 rte• BENCH MARK (Assumed elevation) /0 Z, ( ft Inspection 151 Location and description dates: 2i0 3id 4th P7 0 VA 4 l Q ON-SITE WATER AND WASTEWATER SECTION APPROVAL .,-grrgnee7s7`St �� Os- 'v� c is Conditional Approval: Date .�c� •' ,- •'•77 `;. :11*0 '49T .• ,. MICHAEL N. ANDERSCN.M�� Septic S �p� ��f• ' C c91o911,11T •••�� -.,...,- i4,*... Approved VA �' Date J a l rD pR , �s\-- Note: this approval does not include well permit requirements. �A\0``••• (Rev 05/02/18) Permit No. OSP191037 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: LAK 0 THE HILL EAST BLK 3, LOT 4 PID No.: 015-333-18 MARK A B CO1 48 44 TC01 49 45 j TCO2 55 49 CO2 58 52 CO3 59 52 NT 48 48 \\ NEW 1250 TANK P 1 1 I BENCH CO2,.13 BENCH, GARAGE SLA: TCO2 -- MT1 • TC01 \--- / / \ : Allk A DRIVELWA lill1I IIIII ` •rrririii / / rrrrrrr/ �- 0 / / j / / / !LOT SERVICED BY COMM. WATER / V V / / / 1 lel • 11 1 / 'AL .I 1"=50' co, iicoi CO2 CO3 0,111Malill 1 m, TCO2 . .�E OF q� *•. MI III i ivl ''49TH '••0 or+snc cacw MK • f/hVi 0 .• .MICHAEL N. ANDERSON: 8 ��-05, N o. E 9f 669 r>4 ;;EPTIC SECTION ... ECTION1 . N.T.S. •44,'��t lAi  MUNICIPALITY OF ANCHORAGE 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 IJ~SPECTION REPORT F') ~ ¢' %' ~¢' ' //(; PHONE ~(~EW NAME MA~¢ ADDRESS LEGAL DESCRIPTION LOCATION ~ NO. OF BEDROOMS Wel,~l~ Absorp4o;bre~ Dwelling 24, PERMIT NO. DISTANCE TO: ~ Manufacturer Materia~ ~_~C No. of c~partments ~< , ~S~ Inside 1on~ Width Liquid depth I 2 ~5~O IF HOMEMADE: ~ ~ DISTANCE TO: V/ell Dwelling ,,' PERMIT NO. O ~ ~ ~anufacturer Material Liquid capaciW in gallo~s ~-- Well ~ Tronc~wgth /O'X/ Distance~een lines ~ DISTANCE TO: ff/~ Foundatio;oI Nearest lot line PEB~T ~O. No. of lines ~ Length of each line Total length of, lines Z-~, ~ ~S'' inches e~ ~o r~ti o. ~ Top of tile to finish grad, ~,O/ ~il~ ~¢~L ~ '~inches Length Width Depth PERMIT NO. ' ~ ~ Type of crib C rib diam Crib depth , Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class E epth Driller Distance to lot line PERMIT NO. ~ BuiMi n Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS ~" ~ ~b~7o~ j 2 -~ "~V~ ~ '~ ~" ~ ~'~ '"'~ ~ ~,~ JOHN E. SW),NSON o ,~ ~ i APPR~VBD % 1834-[ ~ ~' . DA LEGAL 72-013 (Rev. Permit ~ Applicant: Department< '{~i%~-~J~ ~v'~6~ /~rotection ., 825 ~/ Street, Anchorage, AK. ~9501 264-4720 * * * HANDWRITTEN PERMIT * * * ~ ~©~3~ ~W~5_~ ON-SITE SEWER PERMIT Mailing Address :~/~-~/~- '~/ Location: ~ ~ ~ ~ m ~ ~//~ ~ Phone Number: Legal Description: ~ ~3~ ~/~-~o3 Type of Soil Absorption System Is: Trench: Drainfield: Seepage Bed: Lot Size: Holding Tank: Maximum Number of Bedrooms: .~ Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is: LENGTH /~ '~" GRAVEL DEPTH ,~' · WIDTH ,?29 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 = /~doO 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 1 9 8 3 * * * 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 codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to inslude more tha~.3 bedroo~ SWP/024(1/81) 'S &S ENGINEERS, INC TI25 Old Seword Hwy. Anchoroge, Alosko ~09N~UTY OF ANCHO~A~/ ; 349_6561 / DEPT. OF HEALTIfl & FNVIRONMENTAL P~O~ECTION SOILS LOG - PERCOLATION TE~u~ ~ 8 ~3 SLOPE SITE PLAN 1 2 3 4 5 6 7 8 11 ~ JOI/N E. -1834-E PgOFE~SIO~, 15- 16- 17 18 19- 20- SOILS LOG WASGROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? 'x/ ,~. 5 / PERCOLATION TEST L / .-,.,/ · P 71 /'I / /" / Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE __ VI'.</_J~ ] (minutes/inch) TEST RUN BETWEEN ~"~"'~' . FT AND ~ FT ^ ~~/~ k.~ 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 GENERAL INFORMATION (a) Legal Description (include Ici, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~V~ N~V~V/~ Telephone'. Home ~ Business Applicant Address 7~DI ~ OP ~ ~; AN~,; ~. ~q~/~ (c) Applicant is (check on~): Lending Institution ~; Owner/builder~; Buyer ~; Other ~ (explain); (d) Lending Institution ~t~ PJ~J~'/~' ~qOJ'~ ~-,O, Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family~ Multi-Family [] Number of Bedrooms _~ Other WATER SUPPLY Individual Well [] Community'~ Public 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 SEWAGE DISPOSAL Onsite,~ 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 (11/84) EN'GINEERING FIRM PRO~/IDINr~,~ISPECTIONS, TESTS, FILE SEARCH, DA~,~¢.ND 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 thet 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 ~/~' -~' ~' '~' ; /W~, Telephone ~7~ -~ Address ~/~ ~" ~~ ~') ~' ~~ Date ~~ Engineer's S ¢_a,!. Approved for ~ bedrooms by-~~ ~'~ ate Terms of Conditional Approval 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 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (M~)~D HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 WELL DATA Well Classification Well Log Present (Y/N) -- Total Depth -- Cased to Static Water Level "'" Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot ifA, B, C, D.E.C. Approved (Y/N) ~/~,~ Date Completed ~ Yield Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) """ ; On Adjoining Lots > ,.~9~) ' To Nearest Edge of Absorption Field on Lot )'.~Od)' ; 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 ~O~,~.;, ~/ Ot.U,N~--~ ; Date ~' ~1'O~ ~'~:::~ Water Sample Test Results _~.~'"r~~_~y~ Comments &~),_~.~, ~'~f-' ~~ _~,f~J~llJl.~lO~l I::~L~~~ , SEPTIC/HOLDING TANK DATA Standpipes (Y/N) Y~-'.~ Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /~/,~ Separation Distances from Septic/Holding Tank: To Water-Supply Well ~ ~'~)~ # To Property Line '~/~..~ To Water Main/Service Line Course ~/~' Date installed ~"~)--~B Size /,~.~"O~¢~., No. of Compartments ~ Foundation Cleanout (Y/N) Y~-'~ Date Last Pumped ,M2'/-//~:~ ' ~ · for Temporary Holding Tank Permit (Y/N) _ , To Building Foundation ¢'~ / To Disposal Field "~ / To Stream, Pond. Lake, or Major Drainage Page I of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~ '"'~ / ~-'-'-~ Width of Field Type of System Design Length of Field Depth of Field ~o.~' · Gravel Bed Thickness '~8 ~ Standpipes Present (Y/N) To Existing or Abandoned System on Square Feet of Absorption Area Depression over Field (Y/N) /k~O Date .of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ~',r~,~)O" To Property Line To Building Foundation _,,~, · Lot ~&~//l~ ; On Adjoining Lots To Water Main/Service Line *~/~ ! To Cutbank (i~ present) To Stream/Pond/Lake/or Major Drainage Course ,/~:~;) / To Driveway, Parking Area. or Vehicle Storage Area ,~',~ / 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 Tested for Electrical Codes (Y/N) Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that J, havecheckect, vedC, ied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed /)t~],~ E ~ Date '/7/'"_~_,5~--O Company ~//.~).Z,N) J,t~J~, MOA No. Receipt No. ';L~c~/,~ ~ ,~,3 ~ Date of Payment LI ~ Amount: $ .. ~'n~ 6~__._ Engineer's Seal Page 2 of 2 72-026 (11/84) Project Title ~7~/Jt~ l~lOyi~C~l~ Page Title W.O.# c~-~' Date q--J '~"~ By DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA g9501 Telephone: (907) Address: 274-2_533 PWS I.D.# ~/3~20~ To Whom it May Concern: According to records on file in this office the Water Regulations Water System is in compliance with the State Drinking Sincerely, A~UNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONIvtEN~AL P,ROTECTIoN RECEIVED Anchorage Fairbanks ~.PT'rl F~i~ ToP p~ __~rnp ¢~AN ouT' INTO MUNICIPALIT~ OF ANCHORAGE DIVISION OF ENVIROnmeNTAL HEALTH DEPARTMENT OF HEALTH AND [i~B;IRONMENTAL PROTECTION APPLICATION FOR HEALI~H ALrfHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal D~scription (include lot~ blcck~ subdivision, section~ township, range) Lot 4 Block 3 Lake O' The Hills East Subdivision Location (add~ess or directions) (b) Applicants Name Bowen Quality Construction Co. Te lepho~ Applicants Address 3605 Arctic Boulevard #1571 Anchorage 99502 (c) Applic~a_nt~is (check one)Lending Institution ~; O,~am~r/builder~; Buyer ~-~ ; Other ~ (explain); (d) l~nding'Institution Alaska Mutual Bank Telephone Address (e) Real Estate Co. & Agent Address Telephone 2. ~ of t~sidence Single-Family ~ Number of Bedrooms 3. Water Su_p~ Multi-Family three Othe~ (describe) Individual Well ~ Cormunity ~ Public ~ Note: If community ~11 system, must ha~ w~itten conf~rn~tion frcm the State Department of Environr~ntal Conservation attesting to the legality and status° Is the well adequate fo= the number of bedrooms specified in this HAA (Y/N) Is the wastewater disposal system adequate for the number of bedrocms (Y/N) [Page 1 of 2] 2-15-84 5. Engineerinq Firm P~ovidinJL~n_spections, Tests~ Data and Information Icer, tify that I have checked, verified, c~ ~onformmd to all MOA NAA Guidelines in effect on the date of this inspection° Signed Date Naxe of Firm Telephone Address S ignsd by Date This Department has received confirmation from the engineer(S & S Engineers) that the final grading has been completed and this property now meets with Municipal ordinances and guidelines. ( ENGINEER SEAL) 6. DHEP Approval / Approved for three bedrocks By /0~-.c~ Approved ~ Disapproved ~ Terms of Conditional Approval Conditional ~--~ Date 6-21-84 The Municipality of Anchorage Depa~twent of H~alth and Enviromrental P~otection does not guarantee tb~ contir~ed satisfacto~ performanc~ of the ~ter supply and/or the wastewater disposal system. This approval indicates that~ as of the validation date shown above, based on th~ data and infc~mation furnished ~z sn engineer registered in the State of Alaska, the water supply and wastewate~· disposal system is safe and func- tio~ml for the numbe~ of bedrocr~s and typs of structure indicated~ (a~EP SEAL) Mail the HAA to the follcwing add~ess: KB2/d5/s [Page 2 of 2] 2-15-84 MUNICIPALITY OF ANCHORAGE DMSION OF ENVIRONMENTAL HF~tLI~H DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HF~AL.TH AUTHO~ APPROVAL CERTIFICATE 1. General Information Application Date 4-30-83 (a) Legal Des~iption (include lot, block, subdivision, section, tcwnship, range) Location (add~ess or directions) (b) Applicants Name Bowen Quality Construction Co. Telephone 562-3208 Applicants Address (c) Applicant is (check one) Lending Institution Buyer~--~ ; Other~-~ (explain); (d) Lending Institution Alaska Mutual Bank Adc~ess Minn-Benson 3605 Arctic Blvd. #1571 Anchorager AK 99502 ~ ; Owner/builder ~ ; Telephone 338-7890 (e) Real Estate Co. & Agent None Address Telephor~ 2. ~]fpe of Residence Single-Family~ Number of Bedrooms 3. Water Su~ o Multi-F~nilyF-q 3 Other (describe) Individual Well ~ Co~,~nity ~ Public ~ Note: If co~]mnity %~11 system, must have w~itten confirmation frcr~ the State Department of Environmental Conservation attesting to the legality and status. Is the well adequate for the number of bedrcc~s specified in this HAA (Y/N) ~ ~sposal (Jnsite ~ Public ~ Corar~nity ~'-~' Holding Tank ~--~ Is the wastewater disposal system adequate for the number of kedrooms (Y/N) y~ [Page 1 of 2] 2-15-84 5. E~ngineerincI Firm Providing Inspections, 1%sts, Data and Information I certify that I have checked, verified, or ccnforr~d to all MOA HAA Guidelines in effect on the date of this inspection° Date Te le~ 6. DHEP Approval Approved for -~ bedrocms E~ ~ Date Approved ~ Disapproved ~ Conditional. ~erms of Conditional Approval Cy~L~¢~.~,,i~~ The Municipality of Anchorage Department of Health and Environmantal Protection dces not g]arantee the continued satisfactory performance of the water supply and/or the wastewater disposal system. This approval indicates that, as of the validation date shown above, based on the data and inform~ntion furnished by an engineer registered in the State of Alaska, the water supply and wastewater disPOsal system is safe and func- tional fo= the number of bedroa~$ and t~R~e of structure indicated. (DHEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/~//~4 Width of Field '~ ~ Square Feet of Absorption A~ea ~-~) Depression over Field (Y/N) k;O~ ~ate of ~st A~a~ ~st Results of ~st A~a~ ~st Sep~ation Distan~ ~ ~s~ption Field: To ~te~-Supply ~11 ~/~ To ~o~rty Li~ [O,~ / To Buildin~ Foundation ~/ To Existing Lot ~/~ ; ~ ~joining ~ts To Wate~ Main/~vi~ Line 7~' To ~t~(if pre~nt) To St~e~ond~ke/~ Majo~ ~aina~ ~ To ~i~way, Pa~king ~ea, ~ Vehicle St~a~ ~ea ~/~ Type of System Design ~e/ngth of Field ~_G + 89 -- (b Dept~h of Field ~ ~' ! Gravel Bed Thickness z~ ~ Standpipes P~esent (Y/N) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Din~ns ions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Tested for Electrical Codes(Y/N) Pumping Cycles du~ing Adequacy Test. M~ets MOA Cc~m~ents ** Check Pe=mitted Bedroom Rating Against HAA Request I certify that I have checked, verified, on the date of this inspect_lion. Company K l/dL/s [Page 2 of 2] i,ines in effect Date //~/A~ ~ ~/ MOa No. ~D-~/-L~3~ 2-15-84 ae Well Classification ~i/L5,~ Well Log P~esent (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances f~c~ Well: To Septic/Holding Tank on Lot MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: MUNICIPALITY OF ANCHOI~,GI~ DEPT. OF HEALTH & ENVIRONMENTAL PRO~fECTIO~ 8 1984 A, B, C, proved(Y/N) ,,Date Completed ~ Yield Depth of Grouting. Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~;~_00' ; On Adjoining Lots ! To Nearest Public Sewer Line ~> ~Z. OCO To Nearest Public Sewer Cleanout/Nanhole To Nearest Sewer Service Line on Lot Water Sample Collected By /~,,6~/~L$~7-~/~],~]/~A)~ Date ;~/2.1/~z/) ~/~./~ Wate~ Sa~L~le Test Results //OO/Z¢,4~,,'Ci ,~ (~4aT~e,,~lOZ-o~,~.a.:- I~f~,?t/ B. SEPTIC/HOLDING TANK DATA Date Installed ~--~3[~.~ Size 12.,5-0 E-,.,4L$ No. of Cc~va~tments ~_ Standpipes (Y/N) ~ Air-tight Caps (Y/N)~g.5 Foundation Cleanout (Y/N)~.~ Depression over Tank (Y/N) ~O Date Last Pumped ~/~ /d~J ~q~/--6w~ r --~ Pumping/Maintenanoe Contract on File (Y/N)A//~ ; for /U~-~J ~gt/S7~A4 Holding Tank High-Water AlaFm (Y/N) /~//~ Temporary Holding Tank Permit (Y/N) /~./~4 Separation Distances f~cm. Septic/Holding Tank: To Water-Supply Well ~/~ TO Property Line "~k~.-~.~! ~0'5' TO ~ter MaiM~vi~ Li~ >.~[O / _/DO ' '+ To Building Foundation To Disposal Field ~F,Oz To Stream, Pond, Lake, c~ Major D~ainage [Page 1 of 2] 2-15-84 MUNICIPALITY OF ANCHORAGE (-.----- Development Services Department L_�� Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On-Site Systems Approval Parcel I.D. 015-333-18 Expiration Date: o2-1, b 2,02,6 1. GENERAL INFORMATION Complete legal description LAKE 0 THE HILLS EAST BLK 3 LT 4 Location (site address) 7001 LAKE 0' THE HILLS C I R, ANCH AK Current property owner(s) DONNA TRACY Day phone Mailing address SAME Real estate.agent Day phone 2. TYPE OF DWELLING: Single Family (w/wo ADU) ❑ Duplex _ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF.WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well 0 Community Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: OA— Date: 17/( COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee S 550. 00 Waiver Fee $ Date of Payment °2[(21 [ O I l Date of Payment Receipt Number 2 34105 Receipt Number COSA# OSCICI I.056 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 2'27-19 01— ,e1 r Y-..• '6 p`n'` 6. DSD SIGNATURE e v'.e..e .:......'eee epee!. ;. ‘>< System#1 Approved for 3 bedrooms +� o ratcfiAEc'ra.`Ac ,y r F� } System#2 Approved for bedrooms 6ia '•. CE-9 p`� ,6F'<�`: i'° !t 4:64 •.2/117 T se `mss„ Disapproved 1 fg� Ott ��' Conditional approval for bedrooms, with the following stipulation . j ON-SITE `yc WATER AND o WASTEWATFR g 1.1 PROGRAM G; C JSERv\GFS By: C4j . Original Certificate Date: 3 '"'-L --19 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval(COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other ' COSA Checklist blue sheet COSA Checklist Legal Description: LAKE 0 THE HILLS EAST BLK 3 LT 4 Parcel ID: 015-333-18 If more than 1 septic system on lot: COSA Checklist# of Structure served by this system A. WELL DATA ❑Well log is filed with Onsite (or attached) Well production at time of test gpm Date drilled Water storage tank volume gallons Total depth ft Well disinfected for coliform test? 0 Yes 0 No Cased to ft 0 Coliform bacteria is Negative 0 Sanitary seal is functioning correctly Nitrate mg/L 0 Nitrate less than MRL (ND) ❑Wires are properly protected Arsenic ug/L 0 Arsenic less than MRL(ND) Casing height(above ground) in. Collected by Date of flow test for COSA Date of Sample Static water level at beginning of test ft. Comments COMM. WATER B. TANK DATA C. LIFT STATION Age of tank(s) 2019 years 0 Required maintenance completed Tank type/material PLAsT'c t` Age YP (/�eeAge of lift station years Measured operating fluid level in septic tank NEW Lift station material Standpipes/foundation cleanout per record drawing Comments: Date of pumping NEW D. ABSORPTION FIELD DATA Which system tested (date installed) 8-31-83 Adequacy test date 2'15-19 ❑� ALL standpipes present per record drawing Results ❑✓ Pass For bedrooms Total measured depth from grade 8.5 ft(max) Fluid depth prior to test 8 in Measured depth to pipe invert from grade 4.5 ft(min) Water added 500+ gal ❑ N/A—pressurized field New depth 16 in ❑■ Monitor tubes go to bottom of effective. If not, state 1440 depth into effective Elapsed time min 0 Code-required soil cover over field Final fluid depth 8 in 0 System presoaked Absorption rate 500+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) UN date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: 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' Community Sewer Manhole/Cleanout> 100' ❑Yes if No ft ❑Yes if No ft Neighboring Tank > 100' ❑Yes if No ft Private Sewer/Septic Line> 25' ❑Yes if No ft Absorption Field on Lot> 100' ❑Yes if No ft Holding Tank> 100' ['Yes if No ft Neighboring Absorption Fields> 100' Animal Containment> 50' ❑Yes if No ft ❑Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑Yes if No ft ❑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' 0 Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑✓ Yes if No ft Private Wells> 100' ✓❑ Yes if No ft Water Main > 10' p 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' ✓❑ Yes if No ft Private Wells> 100' I✓ Yes if No ft Water Service Line> 10' ✓❑Yes if No ft Community Wells> 200' ❑✓ Yes if No ft Surface Water> 100' ✓❑ Yes if No ft F. ENGINEER'S COMMENTS ...."1-0,.. OF AC NkA G. ENGINEER'S CERTIFICATION i y,`:..• •.'1.:rpt/ I certify that I have determined through field inspections and review r* /0 of Municipal records that the above systems are in conformance with �i 4 9 T N MOA COSA guidelines in effect on this date. 4; E ' -a�$ / /..... 1 COSA Checklist yellow sheet '�'eaAb-~. TRACT B i I 3500 IgE � - N 61.4 Ni '� U 0 o cn amuw . / 25' LAKE MAINTENANCE EASEMENT m LOT 5 • LOT 4 s 29,774 s.f. v+(9. A,., A0. F CV. m z SEPTIC PIPES O 0 0 / — — Z � - rn v '` / / -. 73 1.7'x1.7' CANT 11 / N\ w CHAINLINK FENCE / N 22.8' �a rn x w Q C r .� 20.8 �, y . to cr. 0 9.1 ��:: . . #: ., % L1S < 2 STORY a o i + '�HE N sj w RESIDENCE 23.2' • 37:9 . .: . O o o'siiii ItpKE CIRCLE — Z )1 54.6' % �1 ?p ,PORCH W/ `(i �� - - 9 CANT ABOV� n� • o cn 2. ' I* 12.8'x 14.5' DECK x x /����O14 ,o ill. \ _ �- ' l -.- — ' w/ 8.6'x 11.0' SHED BELOW • 10.0'x20.7' DECK / WOODEN WALKWAY w/ 8.1'x21.5' DECK BELOW/ 1�n�5 , " ei bl 43 LOT 3 10' ELECTRICAL EASEMENTS NOTE: LOT IS SERVEDBY A COMMUNITY WATER SYSTEM. PLOT PLAN AS BUILT x SCALE 1" = 40' GRID — SW 2639_ Project No. 19-055/R1 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates , inc . (907) 522-6476 Phone oaooOppO Professional Land Surveyors keno(907) 522-4625 Fax O F A C���� kenOlan surve cam jonathanOlangsurvey.com ��P ' '."76Art I hereby certify that I have surveyed the following described property: QOM LOT 4, BLOCK 3, LAKE 0' THE HILLS SUBDIVISION (PLAT No. 82-8) *?: 49TH �� .-9*4� Anchorage Recording District. Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the roe I t adjacent thereto encroach on the surveyed D P properly rtY Y1xB j Y (po . KENNET G. �Q premises and that there are no roadways, transmission lines or other visible Q 2% .' easements on said property except as indicated hereon. Q4 '• Z"LS-52� • J p Dated this the i2�`? Dayof F=IeftM, D(�-+� i�11 w 4 • �'••.•••• .. �' OO at Anchorage, Alaska Qp4pROFESSIONPt.`paw It is the responsibility of the owner to determine the existence of any easements. �4ppoo•'�' covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963