HomeMy WebLinkAboutBRUIN PARK BLK 1 LT 2Bruin Park
Block 1
Lot 2
#016-101-11
Municipality of Anchorage Page of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: So 9`1Wl3 PID Number: OIlo -101-I1
Name: A _Wastewater
System: ❑ New I'Upgrade
Address:
Ak 4�T5
ABSORPTION FIELD
o ro
rooms:
Phone:141No. of Bedddr
'S
❑ Deep Trench El Trench Bed Mound Other
LEGAL DESCRIPTION
Soil Rating:
1.2
Total Depth from original grade:
I
GPD/Sq. Ft.
I I
Lot:Block: 2 Subdivision:
a P4
Depth to pipe bottom from original grade:
1
Gravel depth beneath pipe
: ur,v
R
Ft.
Ft.
Township:
..►—
Range:
Section:
Fill added above original grade:
,
Gravel length:
2
^�
! -3 Ft.
- � Ft.
WELL: ❑New ❑Upgrade
�Xz+STS
Gravel width:
S
Numberoflines:
'
Distance between lines:
N co
Ft.
Ft.
Classification (Private, A,B,C): Total D
Cased To:
Total absorption area:
Pipe material:
Qft,)AT E Ft.
Ft.
3%6 SQ. Ft.
lAS7AA D Ir -RIO
Driller: Date Drilled:
Static Water Level:
Installer :+
.
Date installed:
f ff -7
Ft.
t,,
Yield:
Pump Set at:
Casing Height Above Ground:
TANK
GPM
Ft
Ft.
SEPARATION DISTANCES
(Septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufact rer: �}^
Capacity in gallons:
/�
From
Tank
Field
Station
Tank
Sewer Lines
A, W { j41�i K
(�(J�.I
We] h.�
loo ,+
Ioe+
a5 +
Material:
s-rEec.
Number of Compartments:
Surface
Water
t
lip +
'
�d� f'
t
�,
LIFT STATION
Lotto
ti,
6h
—"
Size in gallons:
Manufacturer:
Line
IQ
^
Foundation
�}
I OI
_
-�
_
"Pump on" level at: "Pu eveI at:
High water alarm at:
Curtain
Pump Ma ode!
Electrical Inspections performed by:
Drain
O
�-
NO�J kj
Remarks: E x, s c 4 X
BENCH MARK
p
PVMI-t CI?V-S1-4t,.0 �rLL✓�d W-
Location and Description:
Fi
G'4. it
�9 TO PorArr-
Assumed Elevation:
OU Ft
ENC L
O
Inspections performed by: S & s E;,,!GJALRiwG Dt s: 1 st
rt(r,
1703 Eagle River Loop Roa �
2nd S -�'i -7
•' • • ." .•• ••,•
AoROBERT C. COWAN Q
Eagl River, Alas 9957!
r^�,
Department of He h and a ervices approval
Reviewed by: Dates
and approved
72-013 (Rev. 9/91) MOA 25
PERMIT NO. SW97001 3 PAGE 2 OF 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P,❑, Box 196650 ® Anchorage, Alaska 99519-6650 (* Telephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM APUD/OR WELL INSPECTION REPORT
LEGAL LOT 2, BLOCK 1, BRUIN PARK S/D P.I.D. NO. 016-101-11
DRIVEWAY
INSTALLED CO2
FLOW (FD) RTER _ 2
DBL2 � 1 1
DBLt ST2 1 11 TH
NEW 1000 GAL. ST1 1
cot 1
SEPTIC TANK MT E- 1
11
r \ MT1 p- 03
�r^G EXISTING TRENCH\j
6T4
® I�
NEW TRENCH-/
FCO 1 24.5' 14.0'
i C01 74 0' 56 5'
ST1 ST2 FINAL GRADE
H , 91.55' H
85.5' 1000 GAL
SEPTIC 85.3'
TANK
FINAL GRADE
81.25'
NO WATER FOUND
74.75' B.O.H.
CO2 = 92.35
CO3 = 92.25'
I
h -•i
w I
WELL
I
SHED �+
b®d
SCALE 1" = 40'
UPS
CO2 = 85.15'
CO3 = 85.25' ROR�RT C. COWAN�4
"r•, •. CE - 8801
0.
ST1
75.0'
59.5'
ST2
75.5'
62.5'
DBL1
76.5'
64.5'
DBL2
76.5'
65.0'
FD
76.5'
65.5'
CO2
67.0'
61.2'
CO3
67.0'
39.5'
MT1
68.5'
41.5'
MT
121.0'
100.0'
MT1 CO2
CO3
81.25'
NO WATER FOUND
74.75' B.O.H.
CO2 = 92.35
CO3 = 92.25'
I
h -•i
w I
WELL
I
SHED �+
b®d
SCALE 1" = 40'
UPS
CO2 = 85.15'
CO3 = 85.25' ROR�RT C. COWAN�4
"r•, •. CE - 8801
0.
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17-le?0"'A�E 1 OF 1
MUNICIPALITY OF ANCHORAGE �
DEPARTMENT OF HEALTH AND HUMAN SER ICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW970013
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:WYSOCKI DANIEL R &
OWNER ADDRESS:P.O. BOX 111502
ANCHORAGE, AK 99511
PARCEL ID:01610111
LEGAL DESCRIPTION:
BRUIN PARK BLK 1 LT 2
LOT SIZE: 18500 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
DATE ISSUED: 1/31/97
EXPIRATION DATE: 1/31/98
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
DATE: 1/31/97
DATE: 0/33! tZ
S&S
Ing
January 13, 1997
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
HEALTH AUTHORITY
APPROVALS
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
SEWER&WATER Anchorage, AK. 99519
MAIN EXTENSIONS
REFERENCE: Lot 2, Block 1, Bruin Park Subdivision
SEWER&WATER Request you issue of a permit to upgrade the septic system
INSPECTION serving the three bedroom house on the referenced property.
A test hole was excavated and percolation test performed in
the area of the proposed upgrade. The approximate location
ENGINEERING STUDIES of the test hole is located on the attached site plan.
AND REPORTS
At the time of excavation no water was encountered and
after seven day ground water monitoring, the monitoring
tube was found to be dry.
WELL INSPECTION
&FLOW TEST
Attached is the proposed upgrade design.
We do not anticipate any adverse effects on neighboring
wells, septic systems or drainage patterns by the
SITE PLANS installation of the proposed septic system.
If you require additional information, please contact us.
ROAD DESIGN
Sincerely,
SOIL TEST
/f4rv,-
Robert C. Cowan, P.E.
RCC/gk
PERCOLATION
TEST Enclosure
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
s&S�
,ineekinq
January 28, 1997
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
RECEIVED
HEALTH AUTHORITY JAI `� 30 1997
APPROVALS
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services MLar��d:'taais�;� ul Arlchcirage
P.O. Box 196650 Dept. Health &Human ,Servlc;es
SEWER &WATER Anchorage, AK 99519
MAIN EXTENSIONS
REFERENCE: Lot 2; Block l; Bruin Park
10821 Forest Drive
SEWER &WATER Request you issue a Conditional Health Authority Approval on the
INSPECTION referenced property due to winter conditions.
Upon completion of an adequacy test by Flattop Technical Services the
septic system was found to be saturated. There is no eminent health
ENGINEERING STUDIES hazard and there will be no adverse effects as a result of granting
ANDREPODREPORTS g g
the conditional approval.
The septic system will be upgraded no later than 15 June, 1997.
WELL INSPECTION
&FLOW TEST If you require additional information, please contact us.
Sincerely,
SITE PLANS ty�
Robert C. Cowan, P.E.
ROAD DESIGN RCC /gk
SOIL TEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
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ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
HEALTHAUTHORITY I
REFERENCE: Lot 2, Block 1, Bruin Park Subdivision
APPROVALS
January 13, 1997
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
��N �rctiL
1. The scope of this project includes the installation of
SEWER &WATER
MAIN EXTENSIONS
a 1000 gallon septic tank and a leachfeild trench to
serve the three bedroom residence located on the
referenced property. The existing septic tank is to be
excavated, pumped, crushed, and abandoned completely.
SEWER&WATER
The existing leachfield is to be abandoned such that
INSPECTION
it may be used in the future.
2. Construction shall be in accordance with the approved
site plan and design drawings, Municipal permit with
ENGINEERING STUDIES
any special provisions or conditions, and all
ANDREPORTS
applicable State and Municipal Wastewater Disposal
Regulations.
3. The contractor shall be responsible for obtaining any
WEL CTION
necessary underground utility locates.
&FLOW TES
FLOW
4. Unless specifically agreed otherwise, the property
owner shall be responsible for final grading areas
subsequently depressed from soil settling.
SITE PLANS
5. Contractors installing wastewater disposal systems
must be certified by the Municipal Health Department
for system installations. Owners installing their own
ROAD DESIGN
systems must also receive prior approval from the
Municipal Health Department.
SOILTEST
SEPTIC TANK INSTALLATION:
1. A septic tank is to be constructed by a certified
tank manufacturer. Construction shall include
PERCseptic
TESTOLATON
two 4" cleanouts for pumping access.
2. The septic tank shall be sufficiently bedded to
prevent settling or shifting of the tank.
STRUCTURAL&
MECHANICAL
3. All standpipes on the septic tank shall extend a
INSPECTIONS
minimum of 12 inches above final grade.
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 9 EAGLE RIVER, ALASKA 99577
Page Two
Lot 2, Block 1, Bruin Park Subdivision
January 13, 1997
4. Septic tanks installed with less than 4 ft. of cover shall
be insulated.
5. A foundation cleanout shall be installed one to four feet
from the building foundation. In the line between the tank
and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic
tank). These cleanouts shall be located on undisturbed
soil not more than 10 ft. from the tank. The first
cleanout, in line, shall be to clean toward the leachfield.
The second cleanout shall be to clean toward the septic
tank.
6. Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
1. Excavate the proposed trench to the dimensions shown on the
design. The bottom of the excavation shall be within 2
inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed -up) before
gravel (sewer rock) placement.
2. Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier_ must be installed between the final gravel
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
4. Monitor tubes shall be of four (4) inch diameter,
installed approximately in the locations shown on the
design, and extend a minimum of 12 inches above final
grade. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is
equivalent to the effective depth of the gravel as noted on
the design.
Page Three
Lot 2, Block 1, Bruin Park Subdivision
January 13, 1997
5. Backfill over the final gravel layer must not be less than
twenty-four (24) inches. Insulation must be installed when
the backfill depth is less than thirty-six (36) inches.
The finish grade over the trench must be mounded to prevent
the formation of a depression after settling.
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Type of Pipe Perforated Solid
Cast
Iron
Yes
Yes
ASTM
D3034
(PVC)
Yes
Yes
ASTM
F810
(HDPE)
Yes
No
ASTM
D2662
(ABS)
Yes
Yes
Use of a type of pipe other than listed above must be
approved by the inspecting engineer.
3. Insulation shall be at least 2" thick extruded direct
burial polystyrene (Dow Chemical Company Styrofoam HI or
equal).
4. Septic tank inlets and outlets shall be fitted with
watertight couplings (Cau_lder, Fernco, or equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N,
or equal) must be installed between the final leachfield
gravel layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the #200 sieve.
7. When sand is being used as a filter material, its gradation
specifications must conform to current M.O.A. or D.E.C.
requirements, which ever applies.
Page Four
Lot 2, Block 1, Bruin Park Subdivision
January 13, 1997
INSPECTIONS:
Typically there will be a minimum of three (3) inspections
required during the installation of the wastewater disposal
system. These inspections will occur as follows:
1. The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel. A septic tank
may be set in place, but may not be backfilled before
this inspection.
2. The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
3. The final inspection is to occur upon final grading of
the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at least 24 hours prior
to the start of construction. If necessary, a pre -construction
meeting will take place on-site. The inspecting engineer will
not coordinate, direct or control in any way the contractors
activities.
The owner shall contract with the contractor to perform the work
outlined in these specifications and plans and in accordance
with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S
Engineering. S & S Engineering shall be the owner's
representative and will inspect the work as stated above to
document the contractors activities. Final acceptance of the
contractors work rests with the owner and the M.O.A.
Page Five
Lot 2, Block 1, Bruin Park Subdivision
January 13, 1997
S & S Engineering shall have no liability to the owner or to
others for acts or omissions of the contractor or any other
persons performing work on this project or the failure of the
contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer
will not be responsible for the construction means, methods,
techniques, sequence, procedures or the safety precautions
incident to this project.
CONTRACTOR/INSTALLER
d p
may/ � 0 t � r1 �° ✓,��
e Municipality of Anchorage
t DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST i
1Pg +� ROBERT C. COWAN ;^
P '
,.J /7N,4K WySOGKI E
PERFORMED FOR: j14AR0SEDATE PERFORM%b�?,T,`,����i!
LEGAL DESCRIPTION: Lor a B) -OC K 1 69',N ARK Township, Range, Section:
DEPTH SLOPE SITE PLAN
(FEET)(7 /i4ANJL
2 1, 15j3 (ado vLy C,44.0#1 N
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18
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ro"'L y+ "Oof'o WAS GROUNDWATER
ENCOUNTERED?
Si' 3HN�; 5 0-f-
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W,A VE L IF YES, AT WHAT
DEPTH? p
E
Depth to Water After
Monitoring? i7 R i Date:
f3_0.H.
S
ME
20 -{ 8
uPERCOLATION RATE < I (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN /0 FT AND I FT
COMMENTS S'4f"PLf _704"" y4'-. S I1, 11 C 14-4).%S1 .s.
ENGINEEKINv
PERFORMED ByweS4 ago eeR,,,s.."k Loop Road No. 204 I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE �PA�Lwl�TEaAND 99577
U NICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
Percent Passing by Weight
No. 4
ft 9 1 -
No. to
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No. 20 R.
z 30
No. 40 C7
H 50
No. 60
No 10004
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72-013 (Rev. 3/78)
MUNICIPALITY C' ANCI-IOP.AGE
MUNICIPALITY OF ANCHORAGE
DEPT. C);F
•
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOWI IIRONiv',E:i'v ,il_ P".11._-t; LCTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720SEP
19
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION
REPORT
NAME
P
EW
Paul Johnson
3 - 2911
UPGRADE
MAILING
ADDRESS
126 east 72nd. Ave. Anchorage, Ak. 99507
LEGAL DESCRIPTION
Lot 2, Block 1, Bruin Park Sub-Division
LOCATION 0+1VIa.11ey east to .Forest Dr., South on Forest Dr.
NO. OF BEDROOMS
to Second lot on east side.
3
DISTANCE TO:
Well
Absorption area
Dwelling
PERMIT NO.
VY
115'
10 ,
651
0
tZ
Manufacturer
Anchorgge Tank
Material
Steel
No. of compartments
WQ <
2
ti
Liq. capacity in gallons
1000
IF HOMEMADE:
Inside length
Width
Liquid depth
Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
J0Z
O z F
Manufacturer
Material
Liquid capacity in gallons
O
Well
Foundation
Nearest lot line
PERMIT NO.
-r =
w790530
DISTANCE TO:
125'
75,
311
u.
w
of lines 1
Length of each line
Total length of lines
Trench width
Distance between lines
No.
Z
24'
24+
3 6 inches
'-
crF.-
Top of tile to finish grade
+
Material beneath tile
Total effective absorption area
c
4
96 inches
384 S.F.
Length
Width
Depth
PERMIT NO.
w
C9
Q 1—
Type of crib
Crib diameter
Crib depth
Total effective absorption
area
wa
W
Well
Building foundation
Nearest lot line
DISTANCE TO:
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
Building foundation
Sewer line
Septic'jpk
Absorption area(s)
DISTANCE TO:
OTHER
PIPE MATERIALS Cast Iron P.V.C.
P.V.C.
Perforated as required
L
-
SOILTESTRATING
125 s . f ./Bedroom
-
INSTALLER
Schachle Excavating
o S
e
REMARKS
� �
I
,f
\
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-r ��k
A-,,%1e
_A
•we•MNs•••
1.
C.
4 'Rr- ! Y
/
DaAf J. Harman
s'•
NO. 1198-E
to��dpHOF
ft SSI�jr�
o 7,FEs
,17 lorl�
APPROVE DATE LEGAL
r
)avid J. Harman., P. Z. 7/13/79 Lot 2, Mock 1,
Druin Park Subd.
72-013 (Rev. 3/78)
N&
[/ FA�Pw^
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
& FEE F" -1- 1-4 === fl. L._���(3 -T+A == 12 at Cl FT Fl%-" lEE". I_ E:--ff FEE 9:":,* -T- N-1=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH OF H 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).
����l(.: �"P41<_' �E;XKElnz= flLQa0QA
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.
--- l- 1-1 C-'9 r- ;2� > :[ 14 to F" EF Cl -1- 1: F"I FR EZ FZ Em C,"! L_1 1: F -R': _--
BHCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM
�����"1 101 K I.. X "1- 10 C3 F" Ff 54 CT
hl C3 FZ Fq C3 E.-.,:'
DISPOSAL SYSTEM IS
DEPARTMENT OF HEALTH
AND ENVIRONMENTAL
PROTECTION
FOR ON-SITE SEWERS AND WELLS AS SET
825 'L' STREET,
ANCHORAGE, HK
99501
H PUBLIC WELL DEPENDING
UPON THE
264-4720
OTHER
REQUIREMENTS
��"__EE` * "r. -f, FEE
cm FEE 5A FEE F-:.' F ---*"F,--
F".". Jr -1 1-�
PERMIT
NO. ( 790530 )
PROPER INSTALLATION.
THAN ] BEDROOMS.
APPLICANT
PAUL JOHNSON
3126 E 72ND
344 2911
LOCATION
FOREST DR.
LEGAL
LOT 2 BLK 1 BRUIN PK SUB
LOT
SIZE 22500 SQUARE FEET
TYPE OF SOIL
HBSORBTION SYSTEM IS: TRENCH
MHXIMUM NUMBER
OF BEDROOMS = ]
SOIL RATING
(SQ FT/BR)= 125
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
& FEE F" -1- 1-4 === fl. L._���(3 -T+A == 12 at Cl FT Fl%-" lEE". I_ E:--ff FEE 9:":,* -T- N-1=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH OF H 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).
����l(.: �"P41<_' �E;XKElnz= flLQa0QA
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.
--- l- 1-1 C-'9 r- ;2� > :[ 14 to F" EF Cl -1- 1: F"I FR EZ FZ Em C,"! L_1 1: F -R': _--
BHCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM
DISTANCE BETWEEN H WELL AND ANY ON-SITE
SEWAGE
DISPOSAL SYSTEM IS
100 FEET
FOR H PRIVATE
WELL/ OR
FOR ON-SITE SEWERS AND WELLS AS SET
FORTH
150 TO
200 FEET FROM
H PUBLIC WELL DEPENDING
UPON THE
TYPE OF PUBLIC WELL
OTHER
REQUIREMENTS
MAY APPLY. SPECIFICATIONS
AND CONSTRUCTION
DIAGRAMS HRE
AVAILABLE
TO INSURE
PROPER INSTALLATION.
THAN ] BEDROOMS.
�FEE
K t-1 X "I"' ���1.
FT EE n3 �FEE ������
�1..�
I
CERTIFY THAT
1:
I HM 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 UNDERSTAND THAT THE
ON-SITE SEWER
SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE
IS REMODELED TO
INCLUDE MORE
THAN ] BEDROOMS.
SIGNED:___
APPLICANT PAUL JOHNSON
ISSUED B CHTE_. V-:
0 SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
Pouch 6650, Anchorage, Alaska 99502 276-2221
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: Paul Johnson DATE PERFORMED: 9/7/79
LEGAL DESCRIPTION: Lot 2, i+Block 1, Bruin Park Subbivision
DEPTH SLOPE SITE PLAN
(FEET)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Inorganic Silt
?TSCS "IVjL"
Coarse, Sandy
Gravel,
--
__
� _
�-
+__-7
4----
__
4. _
Poorly Graded
L
Ijittle or ''do
1,1ines
WAS GROUND WATER
S
S ,,
TJ �G j �� (a.]�
?
ENCOUNTERED.
1 n L
01P
C
I
IF YES, AT WHAT
E'
DEPTH?
I
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
20 PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS R.eccomend Equivalent area for 125 Ft./ Bedroom
Below 4 .foot Depth
PERFORMED BY: B • Schachle CERTIFIED BY E: 9ZZZ79
David . I1arman, P. E.
72-008 (7/76)
2833 East 72nd Avenue
DAILY DRILLING LOG
PENN JERSEY DRILLING CO.
Anchorage, Alaska 99502
ADDRESSO.-aftl4k. *_-Forewt Deg
1�f --- ----------------------- - --------------------------------
WELL-SITF4't A ...... &W-1 ......... &JUI)7 ... f.m.r.410r, ......
DATE -STARTED ....... /.(V-- ___ #*&$ --- - --- I --- ? .............................................
DATE -ENDED ... ...... A0_._ _
77
............ ........................................
hWNICIPALITY 0F ANCHORAGE
DEPT. OF i • ioN
I
AP R 10 198()
STATIC LEVEL OF WATER FT-----------------------------------------------------
DRAW DOWN FT-------------
GALS. PER 9W... - f*1
------ jr ..... AL-im ----------------------------------------- ----------
KIND OF CASINGAC ....... We.14.4-41
19
HIND OF FORMATION:
FROM... ---JO -------------- FT. TO --- 7 .................. ................ FROM__ --- 44f ----FT. TO ------- e* -7 .... FTC Vd ... " 444#;^'
FROM----7.•--------------FT. TO_19 ------------ Flunsfy ... afVO4 FROM ...... / _7 ------ FT. TO__ ---- ----------_-.FT.-- --- "d' _Af�p ed"
FROM---J-9-------------FT. TO --- V-41 ------------ FT.C-14-vt --- 44mae I FROM_ ---_------------------ FT. TO...... ----------------....FT.---------- .............................
FROM .... V. ia. - - --------- FT. TO ... 19._'j ............ F4P#y..Cjk 6r* ift FROM.------- --------FT. TO ------_-_-------_-_-- FT ............ ............ _ .............
•
FROM.0 - ------------
-_77- FT. TO ...... fif ........... FT.4&* ... 111A FROM.... ...........FT. TO--------------------- ----FT.------------........------......--------
FROM ---_9f ............FT. TO.,AU ............ FAfty --- C.11my 1186QFROM .......................... FT. TO.. -.._-------- ----FT.---- ....... ....................
FROM -10M) ----------- FT. TO ---1#24V---- .... FIL --- 01.41-4-----• - olq/ A OM. -------- ........... YT. TO-------------------- -----FT.------......---------------
FROM ----.61y .......... FT. TO .... Q -t .......... FT"f ----- TO-------- ----------------FT-_-------------
FROM ... 41.... ------.FT. TO ... A . ........... FUC/Ofl ACM"l FROM--------- ....... ----FT. TO.....------- ............FT.------------ .................
FROM---In------......FT. TO ... 49) ........... FTAIMP --- Chy..# C ....... __ ........ ----- FT. TO ............. .-----FT.------------------..... ----------
FROM ... ...................... FT. TO .......................... FTIS M --.f 19U,4Ajf.Q"f?d;ROM _-------- __ ........... FT. TO ....................... _FT ---------- _ ................
FROM...
A.D...------.FT. TOI - - - --------- FT.C4#/ .. f-IMMO/ FROM --------- _ ........... _FT. TO ....................... _FT .........................................
MISCL. INFORMATION:
DRILLER'S NAME ... Ur�V. ..."----------------
L-35
owl RJ RhA J: 10 1: 10" 10 1.. X -F, ".? ��44 CD FA CA FQ FA Ch E��
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ^~
825 'L' STREET, ANCHORAGE, HK. 99501
264-4720
1.4 ETZ R.. L.. I" FEE ITT F-1 :11-T-
PERMIT NO. ( 790572 )
HPPLICHNT PHULGJOHNSON PO BOX 797 ]44-2756
LOCATION FOREST DR
LEGHL L2 B1 BRUIN PARK S/D LOT SIZE 22500 SQUARE FEET
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELLj OR
150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL
WELL LOGS ARE REQUIRED HND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION,
OTHER REQUIREMENTS MAW' APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F"" FEE 0011-1 1: J- EE >4 F" 3: FT EE ni Ex EF CT EF tq E3 EF F& 71fL" AL so 7" E;;If
I CERTIFY THAT
1: I HM FHMILIHR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTA.. 1HE 6YSTEM IN ACCORDANCE WITH THE CODES.
SIGNED�__________
HPPLICF��P
ISSUED BY__��_ __ __DHTE______ll_��_ _�� Y3,2
J '
�;- 61991011
7'6, u.--- Municipality of Anchorage v`"
On-Site Water and Wastewater Program N c tail 11.6.
(907) 343-7904 ° Jud % a 1:s) E T.
cat
ti
Certificate of On-Site Systems Appro :2 ..`'
Parcel I.D. 016-101-11 Expiration Date: 417' 6 '1.�
1. GENERAL INFORMATION:
Complete legal description Bruin Park; Block 1, Lot 2
Location (site address) 10821 Forest Drive*Anchorage,AK
Current Property owner(s) Michael Reeves Day phone 382-5325
Mailing address
Real Estate Agent Colin Roth Day phone 865-4700
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:
Individual Well ® Individual El
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: 415 Date: 24/2_274
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 62-(o – Waiver Fee $
Date of Payment (p - 2 I - 1 B Date of Payment
Receipt Number O S�3G Receipt Number
COSA# OSC I?1 o-i?C) 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: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road,Suite 101-Anchorage,Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: L/1 let?
o000p
r
kik
In conducting this evaluation,GEG provided an engineering evaluation of the well and/or septic system oa 0 r A Q-,
in accordance with the guidelines and regulations established by the Municipality of Anchorage and ��.. ••••••y."7'
industry practices. The reported results describe the condition of the system/s on the date/s of the ' n
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or • '' .•.' V,1
encroachments may exist that were not identified during the evaluation. The operational life of all wells j* O n I %,�*V0
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, G, I
groundwater levels (that may fluctuate during the year), quality of construction (materials and
workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the , •• fr A. Carnes.; /J
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of i7/ •• c 79 ��G
the well or septic system. GEG makes no representation whether an alternative well or septic system )r i" • /f .cii
can be installed on the property in the event either of the current systems fail to perform adequately in \1��s,. •••s/.1.6. i't c,Cie
the future. The content of this report is for the sole benefit of the person/party that retained GEG to v�e�prp es slo"oa�
perform the evaluation. Reliance upon the information provided in this report by any other person or ��O4O000Q
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms
System #2 Approved for bedrooms ��\� ' OF fuY�NO
Disapproved Cie SVTE w
ON- c� •.
z
Conditional approval for bedrooms, with the followingtstiMpg :AND
WATER o'
(-) WASTE
c/ pROGRN\A
-
in tG
XBy: `-- -, ���� � .L__'. Original Certificate Date: ^Z,
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10.10-12.doc
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: Bruin Park; Block 1, Lot 2 Parcel ID: 016-101-11
A. WELL DATA
Well type Private If A, B, or C provide PWSID# N/A Well Log (Y/N) Yes
Date completed 10/10/1979 Sanitary seal (Y/N) Yes Wires properly protected (Y/N) Yes
Total depth 167 ft. Cased to Unknown ft. Casing height(above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 10/10/1979 5/16/2018
Static water level Unknown ft. 59.1 ft.
Well production 8+ g.p.m. 3.9+ g.p.m.
WATER SAMPLE RESULTS:
Coliform Neg colonies/100 ml. Nitrate ND mg./L. Collected by: GEG. Ltd.
Arsenic: <5 ug./L. Date of sample: 5/17/2018
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 5/9-14/1997
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Yes
Foundation cleanout (Y/N) Yes Depression over tank (Y/N) No High water alarm (Y/N) N/A
Date of pumping 5/30/2018 Pumper A+ Home Services
1979 Trench
C. ABSORPTION FIELD DATA *Below Existing Grade 1997 Trench
7/19/1979 125 DeepTrench
Date installed 5/9-14/1997 Soil rating .p.d./ft 2/bdr 1.2 System type Shallow Trench
24 3 8
Length 37.5 ft. Width 5 ft. Gravel below pipe 4 ft.
*13.6+ 384 **Yes
Total depth *12.4+ ft. Eff. absorption area 375 ft2 Monitoring tube***Yes Depression over field No
Date of adequacy test 5/16/2018 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 7 in. Water added 637 gal. New depth****27 in.
Elapsed Time: 120 min. Final fluid depth 22 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) None Known If yes, give date —
*Tested adequacy of East (1997) trench in use. West (1979) trench was dry upon
inspection on 5/16/2018.
**MT in 1979 trench only extends approximatley 3.6 feet below invert of distribution line.
***MT in 1997 trench extends approximately 3.0 feet below invert of distribution line.
****Approximatley 6.96" below invert of distribution line.
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at .• wa er alarm level at in.
I . - •• Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots *100'+ (w/ Caveat)
Absorption field on lot 100'+ On adjacent lots *100'+ (w/ Caveat)
Public sewer main 75 + Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation **0' Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain None Known Wells on adjacent lots 100'+
F. COMMENTS
*Could not locate standpipes on property to north (Bruin Park; Block 1, Lot 1) owners not home
at time of inspection (5/16/2018) **See attached waiver request
060 , '�
G. ENGINEER'S CERTIFICATION oc_.OF ,4i!C 4 �0
���/� i. •.- moo
I certify that I have determined through field inspections and I T �� *°O
review of Municipal records that the above systems are in �� VA
conformance with MOA COSA guidelines in effect on this d Q
date. 'U •.Je r..% A.744111. -ss.:
Engineer's Printed Name JEFFREY A. GARNESS °Q g, **I CE-�79 0 p�
• b-
Date 6,1141 13 O4�4�,Qa •�'t o o\�0�4
04 rofesskodo
a
�Ooo�o
#AECC884
(Rev. 11/05)
uanics
GARNESS ENGINEERING GROUPLtd A�'M`°T.�"",�"`5v "'
ENGINEERING SALES CONSULTING ' Dealer
June 18th, 2018
Municipality of Anchorage
Development Service Department
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Drainfield to Foundation Waiver; Bruin Park; Block 1, Lot 2
To whom it may concern:
As can be seen on the attached as-built survey, the homeowner constructed a "slab on
grade" foundation for his shop located over the south 3-4 feet of the 1997 drainfield. Per
discussions with Tim Ecklund at the MOA onsite department, a cleanout and monitoring
tube were installed midway through the drainfield near the shop foundation. We are
requesting that your department issue a variance from the required separation distance
of 10 feet from drainfield to foundation down to 0 feet. Justifications for granting this waiver
are as follows:
• The foundation is slab on grade
• The drainfield distribution pipe is approximately 9' below grade at the new cleanout
The sewer line under the shop was not camera inspected to confirm integrity. We are
unaware of any adverse impact issuing this waiver may have on adjacent wells and/or
se•tic systems.
Since -ly, f
I
e re. A. t,.: '.E., M.S.
Presirnt
3701 East Tudor Road, Suite 101 *Anchorage,Alaska 99507-1259
Phone: (907)337-6179*Fax: (907)338-3246*Website: www.garnessengineering.com
Q 7751 A
ti
`� ( Lot 1 I I
EAST 185.00 30
I30 _ Y �� -. -_.. -.— _ . _-.x.-- -/,. . x , ,( x ), ,r __ H ._ .I
- -�_ 1
'---� ISI
\NIet t fence "Is
ph "' =
30 •' o ----) \--''''
:v.No m
1
? I 0 Wood fence
�" Ret.wall 0 Z
CC 0 o Lot 2 o w
0N. F• 0 240 ° Or r
0 ♦ ICC
Lot $
Septic vent(typ)—° 26.5 -
I 'I • C� ,.a�o o� 05) 1 Z 0
,_ }—
wCC e a�� \�'�o� o 1 Z
00 I O .! 76.• 26.0 ` 0
W Z No Shop o 24� " Z <
r'
o t °aC� z ;I
41-1
Shed 26.0 Ota 46.2 ZI
deck /Chain link fence(typ) cd o r / rp I
I)
30 EAST 185.00 ---
Lot 3 30
RECERTIFIED 5-30-18 .•
AS-BUILT NO CORNERS SET THIS DATE
`�\%� I hereby certify that I have performed a Mortgagee's Inspection
Or 14of the following described property: LOT 2, BLOCK 1.
4.• e • , . .A� A I BRUIN PARK SUBDIVISION
49th ' . •S.-57 4 Anchorage Recording Precinct,Alaska,and that the
/ • I\ ••* / improvements situated thereon are within the property lines
/ .l. .• .. and doe notat encroach on the property lying
adjacent thereto,that no improvements on the property lying
adjacent thereto encroach on the premises in question and
„_ 0 •VN lizobeth L. Walotka . . / that there are no roadways,transmission tines or other
SCALE: 1"= 30' ft`'s,,'• 8036 - LS ••• i visible easements on said property except as indicated
g `1,>> • . . • ••o4°,�mg
hereon.
�o •J� —AttrDated at Anchorage,Alaska
1 �essiowL this 25th day of September, 1979
EASEMENTS OF RECORD,OTHER THAN 1 X%`N•N%
THOSE SHOWN ON THE RECORDED FRED WALATKA&ASSOCIATES,L.L.C.
/ �-
PLAT ARE NOT SHOWN HEREON FB 79-5, pg 12 (D - 1 I b BE 907-248 1666 Engineers and Surveyors
UNLESS OTHERWISE NOTED. FB 18-5, pg 9
Municipality of Anchorage ,""nr•
1 � r
P.O. Box 196650 • 4700 Elmore Road ". ,.
Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997 Dc par tmcnr
http://www.muni.orq/Onsite
Development Services Division
On-Site Water and Wastewater Program
**** VARIANCE/WAIVER REVIEW ***
Waiver#: OSC181280 COSA#: Permit#:
PID#: 016-101-11
Legal Description: Bruin Park
Engineer: Garness Engineering Group
Applicant: Michael Reyes
Your request for a waiver of the required 10 feet horizontal separation from the absorption field
to the Foundation has been approved. The approved separation distance is 0 feet.
This waiver approval applies to the existing absorption field only. Any future upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this
waiver.
❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected
adjacent property.
® Adjacent properties are not affected by this waiver.
Waiver is Granted: X Waiver is not Granted:
Date: Approved by:
Nam= • Reviewer
Rec#: N/A Amount: $0.00 Date Paid: N/A
**** VARIANCE/WAIVER REVIEW ****
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343.7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. 016-101-11
1. GENERAL INFORMATION
Complete legal description Lot 2, Block
,
-i1 2.010 (o
HAA# 050r,59
Expiration Date: /0 20/I
Bruin Park Subdivision
Location (site address or directions) 10821 Forest Drive
Current Property owners) Tom Adams
Day phone 743-0385
Mailing address 10821 Forest Dr. Anchorage Alaska 99519
Lending agency FSBO Day phone
Mailing address
Real Estate Agent None Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Q
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑�
Individual Holding tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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 Health Authority 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 Theta Environmental & Engineering Phone 242-0755
Address 660 Maney Dr. Wasilla, Alaska 99654
Engineer's Printed Name Ronald E. Godden
5. DSD SIGNATURE
✓ Approved for bedrooms.
Disapproved.
Date 07/20/06
OF AAt
gyp'•• •s�
� y•EtF3l, _
.t�:499TH-.,
...
%:RONALD E. G=EiN.-A
Conditional approval for bedrooms, with the following
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
By:
tew.oiuxr IU\
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: 1 70 LOU
% Municipality of Anchorage
'Development Services Department
Building Safety Division
--� On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 2, Block 1, Bruin Park Subdivision Parcel ID: 016-101-11
A. WELL DATA
Well type P=�• If A, B, or C provide PWSID #— Well Log (Y/N) Y
Date completed 1014 Sanitary seat (YM) Y Wires property protected (YIN) Y
Total depth 167' ft. Cased to 167' ft. Casing height (above ground) 30 in.
FROM WELL LOG
Date of test 10/10/79, On File, MOA
Static water level UNK'
1
Well production 86• g.p.m.
WATER SAMPLE RESULTS:
Coliform u colonies/100 ml. Nitrate U 10(NDr Mg./I.
Arsenic: ND mg.li. Date of sample: °01�
B. SEPTICIHOLDING TANK DATA
AT INSPECTION
09/22/05
68.66
3.48
Other bacteria 0
ft.
colonies/100 ml.
Collected by: R. Godden
Tank Type/Material Anchorage Tank, Steel* Date installed 5/9/97'
Tank size 1•000' gal.Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (YIN) Y - Depression over tank (Y/N) N - High water alarm (Y/N) N/A
Date of pumping 09/22/05 Pumper Unknown
C. ABSORPTION FIELD DATA
Date installed 5/9/97' Soil rating (g.p.d.M2 or ft=/bdrm) 1_2' System type Wide Bed'
Length 37.5' R Width 5' ft. Gravel below pipe 4' It,
Total depth 11_0 ft. EH. absorption area 375 fe Monitoring tube Y Depression over field N_
Date of adequacy test 0922/05 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test dry in. Water added 638 gal. New depth37 in.
Elapsed Time: 15 min. Final fluid depth dry in. Absorption rate >= 638 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) Unknown If yes, give date
D. LIFT STATION
Date installed N/A Size in gallons N/A Manhole/Access (YIN) N/A
'Pump on' level at N/A in. 'Pump off level at N/A in. High water alarm level at NIA in.
Datum N/A Cycles tested N/A Meets alarm & circuit requirements? NIA
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot 100-01" On adjacent lots +1100.0 ft
Absorption field on lot +100 It On adjacent lots + 100 o Ft
Public sewer main N/A Public sewer manhole/cleanout NIA
Sewer /septic service line + 25 ft Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 110 Ft Property line +10 ft Absorption field +10 ft'
Water main N/A Water service line + 25 ft' Surface water + 100 It
Welts on adjacent lots +100 ft
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line + 10 ft Building foundation +10 Ft Water main NA
Water Service line + 25 Ft- Surface water +`100 ft Driveway. parkingIvehicle storage +10 ft
Curtain drain N/A Wells on adjacent lots + 100 It
F. COMMENTS
+ From MOA Records, Installation Inspection Report, 5/9/97 This is an update from 10/06/05.
G. ENGINEER'S CERTIFICATIONxx
= OF
1 certify that I have determined through field Inspections and SCP' s�v4
review of Municipal records that the above systems are in i y
49h' I
conformance with MOA HAA guidelines in effect on this date. �� , � ' _ • i? �
Engineer's Printed Name Ronald E.Godden 00 jam c .......
Date LO �0�, /� 9s•' hALD E OODDEN;
7
HAA Fee $ ?70
Date of Payment1b, 110 405-
Receipt Number
(Rev. 12101)
Waiver Fee $ _
Date of Payment
Receipt Number,
SCS RcLN
1063672001
Client Name
Theta Env. Engineering
Project Name/M
Lt 2 Bk 1 Bruin Park
Client Sample ID
Lot 2 Bk 1 Bruin Park
Matrix
Drinking Water
M%SID
0
All Dates/Times are Alaska Standard Time
Printed Date/rime 07/17/2006 8:08
CollectedDate/lime 07/06/2006 18:25
Receieed DateMme 07/07/2006 11:45
Technical Director Stephen C. Ede
Sample Remarks:
AIIo%iblc
Prep Analysis
Parameter
Results
PQL Units
Method
Container ID Limits
Date Date
[nit
Waters Department
Nitrate -N
ND
0.100 mg/L.
EPA 353.2
B (<10)
07/07/06
ALR
Microbiology Laboratory
Total Coliform
0
col/IOOmL
SM209222B
A (<I)
07/07/06
TLF
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\ Municipality of Anchorage
1 6, ••y.
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.orglonsite
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FORA SINGLE FAMILY DWELLING6c �
Parcel I.D. 016-101-11 HAA # 055
Expiration Date:
1. GENERAL INFORMATION 1131
Complete legal description Lot 2, Block 1, Bruin Park Subdivision
Location (site address or directions) 10821 Forest Drive
Current Property owner(s) Tom Adams Day phone 743-0385
Mailing address 10821 Forest Dr. Anchorage Alaska 99519
Lending agency FSBO Day phone
Mailing address
Real Estate Agent None Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well 0
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site . ❑✓
Individual Holding tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
tide (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work.
4. 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 Health Authority 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 Theta Environmental & Engineering
Address 660 Maney Dr. Wasilla, Alaska 99654
Engineers Printed Name Ronald E. Godden
Phone 242-0755
1
Cr
5. DSD SIGNATURE r�C •,8 •�
✓ Approved for 3 bedrooms. �%X tO ESS{ONA��-
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory
Well Flow Advisory
Supplemental Engineers Report
Other
By: Original Certificate Date:_.1t7/1&S::
(R". 01NS)
Municipality of Anchorage
I • `� Development Services Department
% Building Safety Division
On Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.orglonsite
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 2, Block 1, Bruin Park Subdivision Parcel ID: 016.101-11
A. WELL DATA
Well type PMNs
Date completed 101Q
Total depth 167' ft.
Date of test
If A, B. or C provide PWSID #
Sanitary seal (YIN) Y
Cased to 167' ft.
FROM WELL LOG
10/10179. On File, MOA
Well Log (YM) Y
Wires property protected (Y/N) Y
Casing height (above ground) 30 in.
AT INSPECTION
09/22105
Static water level UNK• ft. 68.66 ft.
Well production 8.6' g.p.m. 3.48 g,p,m,
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi. Nitrate o,rallol Mg./I. Other bacteria 0 colonies/100 ml.
Arsenic: NO mg./I. Date of sample: °� Collected by: R. Godden
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Anchorage Tank, Steel.l Date installed 5/9/97
Tank size 1.000 ' gal. Number of Compartments 2 Cieanouts (YIN) Y
Foundation cleanout (YM).X n Depression over tank (YIN) N High water alar (Y/N) NIA
Date of pumping 09/22/05 Pumper Unknown 334AC.5 &y rj A/s
C. AB8ORPTION FIELD DATA'
Date installed'519/97* ' " fSoil rating (g.p.d./tt2 or ft'/bdrm)1_2' System type Wide Bed'
Length 37.5' ft. Width 5' ft. Gravel below pipe 4' ft.
Total depth 11_0 ft. Elf. absorption area 375 ftZ Monitoring tube Y Depression over field N
Date of adequacy test 09/22/05 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test dry in.' Water added 638 gal. New depth 3.7 in.
Elapsed Time: 15 min. Final fluid depth dry In. Absorption rate >= 638 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) Unknown If yes, give date
D. LIFT STATION
Date Installed N/A Size in gallons N/A
'Pump on" level at N/A in. 'Pump off level atN/A 'in.
Datum N/A Cycles tested N/A
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100.0 ft'
Absorption field on lot +100 ft*
Public sewer main N/A
Sewer /septic service line + 25 ft*
Manhole/Access (Y/N) NIA
High water alarm level at N/A
Meets alarm & circuit requirements? N/A
On adjacent lots + 100.0 ft"
On adjacent lots + 100.o Ft•
Public sewer manhole/cleanout N/A
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation + 10 FV Property line +10 ft* Absorption field +10 ft'
Water main N/A Water service line + 25 ft- Surface water + 100 ft•
Wells on adjacent lots + 100 ft
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line + 10 ft•• Building foundation +10 Ft• Water main NA
Water Service line +25 Fl- Surface water +100 ft' Driveway, parking/vehicle storage +10 ft
Curtain drain N/A Wells on adjacent lots + 100 ft*
F. COMMENTS
From MOA Records, Installation Inspection Report, 5/9197 .� • •. :•
G. ENGINEER'S CERTIFICATION j •'•�/
/ �: /
1 certify that I have determined through field inspections and � li• • � � ��
review of Municipal records that the above systems are in / O; U /
conformance with MOA HAA guidelines in effect on this date. /
Engineer's Printed Name Ronald E. Godden /���1ld,•
�,�r•
Date lM l!t �b 5�
HAA Fee $ Waiver Fee $
Date of Payment _ (� �g OS Date of Payment
Receipt Number �J�S(o s/t Receipt Number
(Rev. 12101)
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REGF.RTIFIED 1-3-9oQYjJ;7.3o-93a}1!�o-�O-oS��j!
%'%%%% AS -BUILT NO CORNERS SET THIS DATE
�.OF AL4%t
f»d Wdlatko i{T
NO. 3255-S , 60 i
OFfSSIOM �tw'-
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED F��79-5 Pvl 12 $VJ
PLAT ARE NOT SHOWN HEREON.
I hereby certify that I have performed a Mortagee's in-
spection of the following described property: --
LLL --
Anchorage Recording Precinct, Alaska, and that the improve-
ments situated thereon are within the property lines and do
not overlap or encroach on the property lying adjacent there-
to, that no improvements on property lying adjacent thereto
encroach on the premises in question and that there are no
roadways, transmission lines or other visible easements on
said property except as Indicated hereon.
Dated at Anchorage, Alaska
th:a ;i? ' day of e5F r SM ff*FR 19 -71_
FRED WALATKA & ASSOCIATES
Engineers and Surveyors
Municipality of Anchorage �, .��•
• Development Services Department
Building Safety Division
OnSlte Water 3 Wastewater Program
4700 South Bragaw St
P.O. Box 196650 Anchorage, AK 99519.6650
www.d.androrage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 016-101-11 HAA# 'Ij AD 10 4/11
1. GENERAL INFORMATION Expiration Date:
Complete legal description BRUIN PARK SUBDMSION: LOT 2. BLOCK 1.
Location (site address or directions) 10821 FOREST DRIVE ' ANCHORAGE, _AK 99516
Current Property owners) JODY CRAWFORD Day phone 522-6411
Mailing address 10821 FOREST DRIVE • ANCHORAGE AK 99516
Lending agency Day phone
Mailing address
Real Estate Agent RON SMiTH w/ INVESTMENT REAL ESTATE Day phone 441-8905
Mailing address 525 WEST 3RD AVENUE ' ANCHORAGE. AK 99501
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
N
Individual On-site
is
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
Community On-site
❑
Public Water System
O
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an Independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may
be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of
up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B
wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid at, or prior
to closing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the. validation date shown below, I verify that my
frwestigation, based on procedures outlined in the Health AuthorityApprm al Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system ls(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 MunicipalilyofAnchorage files and from myinvestigation and Inspection, the
on-site water supply and/or wastewater disposal system fs(are) In compliance with a0 applicable Municipal
and State codes, ordinances, and regulations In effect at the time of Installation.
Name of Firm ALASKA WATER k WASTEWATER CONSULTANTS, INC.
Address 6901 DEBAT R ROAD, SURE 2B • ANCHORAGE, AK 99504
Engineer's Printed Name JEFFREY A. CARNES S. P.E.
Engineer's Comments:
In conducting this ere/uaWn, AWKV, Ina attempted to protide a thorough,
consdentious eng/neertng anayA of the system In accordance wMADEC and MOA
DSD Guldeffnes d RegulaWrm The roported results described the performance of the
system under the owdttions encountered at the time of the test and separation
distances measured to maddykfentlfiable features. The operadaw Hte of ali waits and
septic aystems depend on the k WaoAs cnndltior, WmIrdwatar kwets that may
ftuduate during the year, and the water usage of the famly befog served by the system.
These condftions are outside the control of dw eWustorof the system. Sedslactorytest
results do not guarantee future peAorrnance of the system, nordo theyguarantee that
Mom are no hdden defects ar erxxoechments. AWwC, Inc. can drerelore not provide
arty warranty orfuture estimate of tmbng the system W continue to meet the
operathnat requirements of ft ADEC or MOA DSD. The content of this report is for
the sole benefit of the ownerpsted aboe. Anyrefiance upon or use of this report by any
other person or party Is not audwrized, nor *9 It confer arryW fight whatsoever.
5. DSD SIGNATURE
—� Approved for 3 bedrooms.
Disapproved.
Phone 337-6179
Date G of
Conditional approval for bedrooms, with the fllowing stipulations:
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Manitenance Agreements
Supplemental Engineer's Reort
Other
`���t��•i(Yt 0 � r��C�i���
AQP '••`�o�'-
ON-SITE • c
.Tco Arm • R':
WASTEWATER
rm
By:— a'4c�`, Original Certificate Date:_ G% –/0 - O/
Q
(R-. Irmo)
Municipality of Anchorage
Development Services Department
J`4-111�
.
oo-sPo, wa� weecawater P�opram
4700 south Sregaw SL
P.O. Boot 198850 Mehorege, AK 995198850
www.d.anehorageAkua
(907)843-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: BRUIN PARK S/D: LAT 2. BLOCK 1. Parcel ID: 016-101-11
A. WELL DATA
Well type PWAIE K A. e, or C provide PWSID9 N/A
Date completed 10/10/79 Sanitary aeal (YrtN)YES
Total depth —16-7-11; Cased to 7 67 g
FROM WELL LOG
Date of test 10/10/79
Static Water level UNKNOWN fl,
Wen production S+ 9.p -M.
WATER SAMPLE RESULTS:
Well Log (YEN) YES
Wires properly protected (YIN) `ES
Casing height (above ground) 12+ In.
AT INSPECTION
8/30/2001
63 fl
5.0+ g.pm.
Conform .0` cokxges/100 ml. Nitrate o .1 m9A- Other bacterle J— WonkW100 ml.
Date of sample: 9/4/2001 Collected by: AWWC. INC.
a. SEPi1CIHOLDING TANK DATA
Tank Typa%ateriat STEEL Date installed 5/9-14/97
Tank stze 1000 gal. Number of Compartments 2 Clearwuts (YIN) YES
Foundation dsanout (YIN) YES Depmsakm over tank (YIN) NO High water alarm (YIN) N/A
Data of pumping 8/30/2001 Pumper OLD MCDONALD'S
C. ABSORPTION FIELD DATA 'ONLY TESTED 1979 TRENCH
Date installed?-13-79/_5-9—e7SW rating (g.p dAebr ft%bdrm)125 1.2 System" TRENCH
Lente 24/37.5 fL Width 3/5 JL Gravel below plpe /4 8 /L
Total depth 1Y 12 Eff. absorption area 375 fe Monitoring tube YES Depression overfleld NQ
Data Of adequacy test 8/30/2001 Resufle (PasslFall) 'PASS For-3—bedrooms
Fluid depth In absorption field before test 0 In. Water added 1549 gal. New depth 33 In.
Elapsed Time: 340 min. Final fluid depth 0 In. Absorption rate » 450+ g.p.d.
Any rejuvenation Insatment (peat 12 mc.) (YM 6 type) NONE KNOWN K yea. CW data
D. LIFT STATION
Date Installed Sirs In gallons
'Pump on' level atn.
High water aterm level at in,
Cydes Meets alarm & dreult requiremerb?_
E. SEPARATION DISTANCES
10'+
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic taWfft station on lot
100'+
Absorption field on lot
100'+
Public sewer main
N/A
Sewer /septic service One
25'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/deanout N/A
Holding tank_ N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property One 5'+ Absorption geld 5'+
Water main N/A Water service One t o'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property One
10'+
Building foundation
10'+
Water main N/A
Water service One
10,+
Surface water
100'+
Driveway, parldng/vehlde storage 5'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certl& that I have determined truth Reallnspecilons and * ` .*
review of MuMdpal records that the above systems are /n .... ......
conBxmance wfih MOA HAA guidelines In effect on Ods date.
Engineers717,
JEFFREY A 79GARNESS Date�•^ted Pret...b�d eco
HAA Fee S ?N - `a"
Date of Payment 2/ Lo/D/
Receipt Number
Waiver Fee
Data of Payment
Receipt Number
1. GENERAL INFORMATION
Complete legal description Lot 2; Block `l "Bruin Park Subdivision
Location (site address or directions) 10821 Forest Drive
Anchorage, AK 99516
Sharon Psenak-Wvcocki 349-5019
Pnpert ��(er. ._ :'.°. _.... - _ Day phone
_Maliing' address
�.
4;- _ Y. 786-2588
�-Lend ing agency -Alaska USA Federal Credit Union Day phone
Attn: Mark Williams
'~xMailing address
A ent, Connie,�Bates/ Vista Real Estate Day phone 562-6464
9
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well
RECEIVED
xxx MAY 2 2 1997
Municipality of Anchorage
Dept. Hgalth & Human Services
Public water
NOTE: If community well system, provide written confirmation from State .4. DEC attest -
Ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XXX
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA M21
S. 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.
'7
S & S ENGINEERING y a aJ
Name of Firm Phone
17834 Eagle River Loop Road No. 204
Address
Engineer's signature Date s� �,a
REQUEST YOU ISSUE A NON CONDITIONAL HEALTH AUTHORITY APPROVAL. ALL WORK HAS BEEN
COMPLETED. —
_ - 0
AA ROBERT C. COWAN
6. DHHS SIGNATURE �.�1�. CE - 8801
Approved for 3 bedrooms. ftt'� ° _.`•.'..'�t`1...
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
BY 6 Date q
f,
CAUTION
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 orderto satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data ' before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-M (Rev. "I) Back MOA #21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: 10 a a L o "c OR v tj PA A K 5% Parcel I.D.: 0
A. WELL DATA
Well type P 1? IV# T C if A, B, or C, attach ADEC letter. ADEC water system number
Log present (YN) Y Date completed /0 I / o l -71
f
�
Total depth Cased to �0 - Casing height (above ground) I
Sanitary seal ON) Y Wires properly protected &N) �` s
FROM WELL LOG AT INSPECTION
3 . SkRvi,
Date of test to bo /" 7 1/ lg 7 caf
Static water level v /,K �'
Well production "} g.p.m. 6 4 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 Nitrate nY I Other bacteria
Date of sample: I a. / ' o /-1 fy Collected by: Y E v ra o o R
B. SEPTIC/HOLDING/TANK DATA
Date installed °$'� F q Tank size 10,14 Number of Compartments Cleanouts&N)
Foundation cleanout &N) Y s Depression (YQ �"O High water alarm (YA% oli o
Date of Pping ��� ^'�^' Pumper `
C. ABSORPTION FIELD DATA
. 5 N I}LLOW
Date installed q Soil rating g.p.d.A z or ftz/bdrm) System type r R N
Length '3 7-�' -5-Width Gravel thickness below pipe Total depth
Effective absor tion area 3 7 S` Z Monitoring Tube present 1N)Y*- r Depression over field (YIP
Date of adequacy test ^' �� �' �' ✓ Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption field before test (in.); Immediate) gal. water added (in.):
Fluid depth
��(Ins) Minu Absorption rate _ g.p.d.
Peroo' ment (past 2 months) (Y/N) If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N) _
High water alarm level at*
Size in gallons
"Pump on" level
"Pump off" level at*
*Datum
K V E D
E. SEPARATION DISTANCES MAY 2 Z 1997
Municipality of Anchorage
SEPARATION DISTANCES FROM WELL ON LOT TO: Dept. Health & Human Services
�
eptic holding tank on lot � o d ''- On adjacent lots I c c r4
Absorption field on lot ° o -t On adjacent lots /0C) o -I
Public sewer main �'� 14- Public sewer manhole/cleanout N /*
e
Sewer /septic service line C �' f Lift station Nth
SEPARATION DISTANCES FROMAEPTIC HOLDING TANK ON LOT TO:
Foundation f" Property line Absorption field
Water main/service line !a -f Surface water/drainage )a o "� Wells on adjacent lots oda
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
i
Property line 1.0 i _�_ Building foundation 10 r-1 Water main/service line
i
Surface water loo �+ Driveway, parking/vehicle storage area
Curtain drain Wells on adjacent lots /00
F. ENGINEER'S CERTIFICATION
i certify that 1 have determined thru field inspections and review of Municipal record ms are
in conformance with MOA HAA gui elines in effect on this date.
Signature '`�/�'�1 *►
Engineer's Name �a,B , �• �a�.�^� 17,A � ;.... l
/ yo Rtb�kT C, ASWAN
Date S / 2 g 7 �' CE -8801
HAA Fee $
30u, 0°
Date of Payment 1 /t, q 7
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
S&S�
1tneepung
May 21, 1997
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
HEALTH ALT
APPROVALSLSHORITY
RECEIVED
MUNICIPALITY OF ANCHORAGE
MAY 2 2 1997
SEWER&WATER
Department of Health and Human Services
Municipality of Anchorage
MAIN EXTENSIONS
P.O. Box 196650
Dept. Health & Human Services
Anchorage, AK 99519
REFERENCE: Lot 2; Block 1; Bruin Park Subdivision
SEWER & WATER
INSPECTION
A Conditional Health Authority Approval (HAA)
was issued on 1/16/97
ENGINEERING STUDIES
for the referenced property. All work required for the Conditional
AND REPORTS
HAA has been completed.
Please issue a full Health Authority Approval at
this time.
WELL INSPECTION
&FLOW TEST
If you require additional information, please contact us.
Sincerely,
SITE PLANS
Robert C. Cowan, P.E.
ROAD DESIGN
RCC/gk
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
T. 0.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # of C, - > o / - I/ HAA # 2Q
1. GENERAL INFORMATION -
Complete legal description L° T a (3 to cr 1 R RP'+Rk
Location (site address or directions) 1 0 S a 1 r-° R6 s T D R) vor_
Ac,go4A4E , 4k cl 9 Sf C�
roperty•owner :SHA Ro N P S�NA� -- W y soc K i Day phone 3 - ? q
e ' .Mailing'address t4,s r oR
Lending agency Yt 5 Tq yo LyN� Lgw���GDay phone S'6 a- t; H
x._ Mailing address '� a ! S r. , S- it f_ 30 q gN ci(o.2.4 c -C J9 k 1 So 3
Agent C o N N f a_ 1'3 4-Tf S ~- vis T A R1gf_ Es %Day phone
Address ,g�4j<
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well X
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
A rvne ne ureerewer=o n1C0ACAI
i
5. STATEMENT OF INSPECTION BY ENGINEER.
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
S& S ENGINEERING G - ,Z 9
Name of Firm17034 coviave,LoopRead Phone q 7
Address Eagle River, A ska 99577,
Engineer's signature L Date
Y &/ S DEQ✓e STeO,
Stori c SY'r f., ro 0 a y Tv•/,f l s-,
oft
t
A
Municipality of Anchorage_
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: 2 o i DL v, nl PARK Parcel I.D.: 016 - /0 r ~ I t
A. WELL DATA
Well type Pv A r If A, B, or C, attach ADEC letter. ADEC water system number
Log present &N) Y e S' Date completed ) o %o /"7c)
Total depth & -7 Cased to Casing height (aboveground)
Sanitary seal &N) Y S Wires properly protected (P/N) YE -S
FROM WELL LOG AT INSPECTION C Pc•0' -r o moo R C
�=4arTo{� TCcH. SC.�vr�aS�
Date of test I v ro -7c) I / 3 / q %
Static water level V / K G 3
Well production g g.p:m. 3, g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 Nitrate 0 Other bacteria 0
Date of sample: a` % 30 / 014 Collected by: T mo 0 2
B. SEPTIIC/HOLDING TANK DATA
Date installed 13 / '71 Tank size ° 0 0 Number of Compartments oZ Cleanouts (DN) Y11
Foundation cleanout (9/N) Y s Depression {Y/Vi ! LO High water alarm (Y/Q r"
7flNK yo g I0e.ACif 0 nv2iiv� VPG�E�y.oE
Date of Pumping Pumper
C. ABSORPTION FIELD DATA
Date installed �� 3 Soil rating (g.p.d./It2 or ft2/bdrm System type
Length a H Width 3 Gravel thickness below pipe h Total depth / a
rrZ
Effective' absorption area 3 64 Monitoring Tube present (9N) XfJ Depression over field (Yr& -v o
I ? p 0 u I�G�s4 RRA(coan� EB
°v&r�t0
Date of adequacy test i % Results (Pas ail _FA I L '' For bedrooms
Fluid depth in absorption field before test (in.); u K Immediately after y s gal water added (in.): S t a `om er t o
Fluid depth u �K (ins) Minutes later: " K Absorption rate = < Y,ro g..p d.
Do,,13-Y Ire 0 h0044 .r;_ �y r�Ec.,y—rC_'1 L T X4Vict S'
Peroxide treatment (past 12 months) (Y/N) k ^'0 w r' If yes, give date
72-026 (Rev. 3/96)"'
D. LIFT STATION
Date installed
Manhole/Access (Y/N) _
High water alarm level at*
E. SEPARATION DISTANCES
"Pump on"
*Datum
Size in gallons
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot / Q f "� On adjacent lots
Absorption field on lot 1 0 0 On adjacent lots
Public sewer main r/ /4
"Pump off" level at*
Public sewer manhole/cleanout
I
Sewer /septic service line a 4- Lift station
SEPARATION DISTANCES FROMbFEEWHOLDING TANK ON LOT TO:
W 1A
Foundation Property line S Absorption field
Water main/service line & P r Surface water/drainage / ° 0 t Wells on adjacent lots /V 0 1-71-
SEPARATION
-y`SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line 10 � Building foundation /0 /-- Water main/service line /0
r
Surface water o o
Curtain drain 0 v n' E- k' N o w n�
F. ENGINEER'S CERTIFICATION
Driveway, parking/vehicle storage area /0 4
Wells on adjacent lots > 0 0
I certify that I have determined thru field inspections and review of Municipal
in conformance wit M A� guide 'nes in effect on this date.
Signature"
Engineer's Name A66.,w-o- Ct ` e -v*,,,
Date / ( 14 /0/7
HAA Fee $ � no t Lp Waiver Fee $ _
Date of Payment ��`� /� % Date of Payment
Receipt Number 0,6 % Receipt Number
72-026 (Rev. 3/96)*
iMO.•i..� / �� y l4JF
Rl)BERT G. tbWA-N �4,Q
ox CE - 8801
are
MUNICIPALITY OF ANCHORAGE
• Department of Health & Human Services M1
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. #—('-)\ILLn1 - I I HAA # �� ��n n:.l n[n
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
L20 81, BRviN PARK 5.1
Location (address or directions)
108)LI FORREST 'OR.
(b) Property owner BRUCE XERR Telephone: (home) Business 344 - `4Ssl
Mailing Address P.D. BoX III op4 4wc� - Al< ggso
(c) Lend i ng Institution ARFc4A V NORTl♦LAMD MOM Telephone 2_7y-SISO
Mailing Address 2605 An c-hor e�-I-e Ak 99503
(d) Real Estate Company and Agent RE MA X VIOLET 14 w c E
Address 2_4,00 C0RDoVA AncApr!r%e, Ah 49.s'o3
Telephone 2 76 - 27h t
(e) Mail the HAA to the following address: (or check here V, if hold for pick up.)
List contact person and day phone number below:
TED OR CHRi
2. TYPE OF RESIDENCE
Single -Family � Number of bedrooms 3
3. WATER SUPPLY
Individual Well ' < Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-sitel�( Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm FLATTOP TECO SVC5. Telephone 34s- 13.5-S
Address 1 4 53o EC fro s7' A NCH, q9S/6
Date Tu(y 6_ r99a
Aln
• . 1 6 C > t ... . f ..
Engineer's Seal
F. ',OCRE L9
�. I/a
DHHS APPROVAL
Approved for bedrooms by ate ,7�
Approved Disapproved Conditional
Terms of Conditional Approval Z/l/ x lc
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)
CHECKhIST - FEBRUARY 1984
NICIPALITY OF ANCH. RA$143-4744
ENVIRONMENTAL SERVICES DIVISIQN
Legal Description: L 2, 81 151PV 1N PARK
J U l.. 61990
A. WELL DATA RECEIVED
Well Classification PRIV'AT'E / If A, B, C, D.E.C. Approved (Y/N) K.A.
Well Log Present (Y/N) YES Date Completed 10!/o�7q Yield >3. GPM MEAS 6/3:119/W'
Total Depth X67, Cased to - 67 I Depth of Grouting ly•A .
Static Water Level 571 Pump Set At 5 6 3 t
Casing Height Above Ground 21'! Sanitary Seal on Casing (Y/N) YES
Electrical Wiring in Conduit (Y/N) YES Depression Around Wellhead (Y/N) KO
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot 1214 ; On Adjoining Lots 23 fP
To Nearest Edge of Absorption Field on Lot 13S r ; On Adjoining Lots ? 1 Got
To Nearest Public Sewer Line 7100 t To Nearest Public Sewer Cleanout/Manhole 7 luo
To Nearest Sewer Service Line on Lot T+,
Water Sample Collected by FLATTOP 16CM • SVCS ; Date 6129 �4n
Water Sample Test Results Sex is iac kory , 0 rohfarm / foom-Q,_ N.D.I'< 0.1 m,/I) NITItATE-N
Comments DuRIN6 WC -LC FLOW TEST OF (o12g/90 1 S7EADY PvMP,A(6 AT MAx. PuMp ouTPur'
OF 3.5 GPM DREW 'THE' WATER LE✓FL DOWN To 63' ByT No FURTHER
B. SEPTIC/HOLDING TANK DATA
Date Installed 3/77 ' Size 1000 G No. of Compartments 2
Standpipes (Y/N) YES . Air -tight Caps (Y/N) YES Foundation Cleanout (Y/N) YE5
Depression over Tank (Y/N) No Date Last Pumped 7/3/90 (..tscx.a cs
Pumping/Maintenance Contact on File (Y/N) ; for _NA
Holding Tank High -Water Alarm (Y/N) N, A . Temporary Holding Tank Permit (Y/N) N -A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well 124
To Property Line qO '
To Water Main/Service Line
$S
i
To Building Foundation (P5
To Disposal Field
To Stream, Pond, Lake or Major Drainage Course 7 l DO
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absor tion Strata 125 L31131901 Type of System Design TRENCd
Date Installed 9 79 Length of Field 2 L
Width of Field 3(0 It Depth of Field
Gravel Bed Thickness 96"
Square Feet of Absortion Area 384 D Statndpipes Present (Y/N) ids l
Depression over Field (Y/N) N0 Date of Last Adequacy Test 629190
Results of Last Adequacy Test RDEQv4TC Fak 3 BDRM
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well 1-35, To Property Line 38 / PER 9171 NSP. 12EPoRt�
To Building Foundation _ 7S To Existing or Abandoned System on
Lot ___N.A
On Adjoining Lots '— 60
r
To Water Main/Service Line RS To Cutback (if present) q, A
To Stream, Pond, Lake, or Major Drainage Course /00 1
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION No Kt r
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)
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and
inspection.
Signed
Company Flakop Zkchniml Servtc'.y
Date fu l e-,, /9 90
MOA No. 9d –o!!2
Receipt No. a
Date of Payment
Amount: $ DO -
72-026 (Rev. 7/88) Back
Receipt No.
Pumping Cycles during Adequacy Test.
HAA gnud*�ti►� e`frfOect on the date of this
AW
Ldp•�,(•/•/'►•••••`••'•'••••••'••°•®Engineer's Seal
"d w► •s a••• •• ••.i •• ••
•
THtO'vCr:c F. ':"i00RE
V�`..• CE -oee
59
P�.
Waiver Fee: $
Date of Payment
Page 2 of 2
5. LEGAL DESCRIPTION
DATE RECEIVED
INSPECTION APPOINTMENTS
t (PA,��
TIME
TIME
TIME
DATE
DATE
DATE'
r
INSPECTOR INSPECTOR INSPECTO�
MUNICIPALITY OF ANCHORAGE DEPT. OF 1-'-i ;LTM &
F
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECgWWONMENTAL P 0'i ECTION
825 L Street . Anchorage; Alaska 99501
MAY 14, 1980
0*
ENVIRONMENTAL SANITATION DIVISION
DEC[!, /[D
Telephone 264.4720 RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. -
1. PROPERTYOWNER
PA �('trt Soft
PHONE
3tE,9 s:� t J
(A
❑ COMMUNITY
MAILING ADDRESS LL
1t c)l -E •76 ' A- S W+6 19 U_NZDY u -&- S
PROPERTY RESIDENT (If different from above)
PHONE
8. SEWAGE DISPOSAL SYSTEM
2. BUYER )
PHONE
PUBLIC UTILITY
MAILING ADDRESS
3. LENDING INSTITUTION PHONE
MAILING ADDRESS
4. REALTOR/AGENT
s)
PHONE
149 `teg
DDRESS
MAILING IADDRESS
'�11
`(/�� /� /
'1 6 l
5. LEGAL DESCRIPTION
116T 2_ NLOCICr (
t (PA,��
N •
STREET LOCATION
6. TYPE OF RESIDENCE
NUMBER OF�BEDROOMS
E]One ❑ Four EDOther
SINGLE FAMILY
Two ❑ Five
❑ MULTIPLE FAMILY
,i<Three ❑ Six
7. WATER SUPPLY
A INDIVIDUALS
* ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
ElPUBLIC UTILITY
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
- . INDIVIDUAL/ON-SITE**
>
197,9YEAR ON-SITE SYSTEM WAS INSTALLED.
PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
72-010 ( Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE
❑ TWO
❑ THREE ❑ FIVE ❑ OTHER
❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
QQ
3. SEWAGE DISPOSAL SYSTEM
❑ INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑ Septic Tank or ❑ Holding Tank
Size: / 00 0 If Tank is homemade
give dimensions:
SOILS RATING
C ��
TYPE OF TANK-
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
j J$'
jAbsorption Area
�S
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
W
Z' APPROVED FOR —3 BEDROOMS
❑ CONDITIONAL APPROVAL (letter mu a company certificate)
DISAPPROVED
DATE .. l
BY
72-010 ( Rev. 6/79)