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SOUTHPARK #1 BLK 2 LT 12
Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191148 PID Number: 020-491-26 Dwelling: I21 Single Family (SF) El with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name JOHN BALL ABSORPTION FIELD Site Address El Deep Trench El Wide Trench ❑ Bed ❑ Mound 4541 SOUTH PARK BLUFF DR ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 5 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot Ft. Ft. Southpark #1 2 12 Fill added above original grade Gravel length Township Range Section Ft. Ft. Gravel width Beds: Number of Lines Distance between lines SEPARATION DISTANCES Ft. Ft. To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist.between trenches Tank Field Lift Station Tank Line From Ft2 Ft. Well 200'+ TANK I21 Septic ❑ S.T.E.P. l=1 Holding I=1 Other Manufacturer Capacity Surface Water 200'+ Infiltrator 1580 p.Qv DD Gal. Material Number of compartments Lot Line 5'+ NA Plastic 2 Foundation 10'+ LIFT STATION Manufacturer Capacity Gal. Remarks Alarm location Electrical installed by PIPE MATERIAL House to tank Tank to drainfield Installer A+ Home Services Drainfield CO/MT InspectorArcTerra Consulting BENCH MARK (Assumed elevation) /00 ft Inspection �� 5/22/19 2nd 5/24/19 Location and description dates: 3b 41h Deo ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp �� EL)r t,1 Conditional Approval: Date =+c9P9 ''�M "�, ♦♦j♦ • i * 49 Ili \ * 0 • •1 111 A ��r�11� i M. j�+ KENNETH M. 5 �% Septic System / ♦i s cE �1 � Approves �_ IA..._ �� Date 6) -q--/f ♦♦f k, 4, Note: this approval does not include well permit requirements. -44. ��� lb. (Rev 05/02/18) AS-3UILT SYSTEM DETAILS/SITE PLAN Perrlit:USP191148 S❑UTHPARK #1 BLOCK 2 LOT 12 PID# 020-491-26 D C /4 .A 1 41 r 411"� ea 1 f al:. CQ a HOUSE a Co . ) SCALE: 1' = 20' A-C=33.2 B-C=49.1 A-D=33.9 B-D=49.2 A-E=35.6 99.3699,0. B-E=46.0 �, A-F=38.5 i B-F=46.9 o ii _ i 1if A- =40.0 B-G=38,9 ,T k! III ;o,, I1U A-H=41.5 =o 153Q GAL B-H=31.0 Jto A-I 42.0 0 N SEPTIC B-I=37.6 a, TANK 93,79 93.4• SCALE: NTS �FN\ SCALD NTS Air �� 1 PREPARED FOR: �CTERi�I rcS `.1 �� JOHN RALL °� ��/AOIlk , / 1 4541 SOUTHPARK BLUFF DR, s * 49 TH /� * ANCHORAGE, AK mini / .. . ''t (907)-980-2589 A �� \` t, KENNETH 1•-� S / FIELD BOOKS COMPUTED: > 'r"M.' .",11 x ` �tt2 CE-71 : vrti / BOUNDARY:N/A DRAVM: KSD I1�� tti���-"1' !� STAKING: N/A CHECKED: KMD �a '1^� 1''E'$$• ,.e' ASBUILT: DATE: 5/24/190111"" Air ~~i^,9C• \ X60 \ ` DWG. FILE: GRID: 3236 (F c- lub` o�1 \`\-11111:11... _ ACRD FILE: JD8 No.: '4'''P ()A'S S UL7'I N G ,g73e l9 FILE 19017 AK.99577' Z:\WELL do SEPTIC — Filed By Legol\Southpark\Add #1 Blk 2 Lot 12\19-017 Southpark #1 B2_L12.dwg MUNICIPALITY OF ANCHORAGE oent On-Site Water&Wastewater Program PO Box 196650 4700 Elmore Road Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax (907)343-7997 '', r <okr http://www.muni.orgionsite • _� Department 4 NNOIN P.0. On-Site Wastewater Disposal System Permit Permit Number: OSP191148 Effective Date: 5/2/2019 Work Type: SepticTank Upgrade Expiration Date: 5/1/2020 Tax Code Number: 02049126000 Site Legal Address: SOUTHPARK#1 BLK 2 LT 12 G:3236 Site Mailing Address: 4541 SOUTHPARK BLUFF DR, Anchorage Owner: RALL JOHN R Lot Size in Sq Ft: 27591 Design Engineer: ARC TERRA CONSULTING INC Total Bedrooms: 5 This permit is for the construction of: ❑ Disposal Field 2 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: A 711-, Date: Issued By: Date: 5©1 MUNICIPALITY OF ANCHORAGE Development Services Department / 4.4-t' Phone: 907-343-7904 On-Site Water &Wastewater Section Fax: - 43-7997 . \v361 6 ?, 104 11410iPh ON-SITE SEPTIC/WELL PERMIT APPLICATION a APR 020-491-26 II w Parcel I.D. << ,h John Rall a68L9 Property owner(s) Day phone Mailing address 4541 Southpark Bluff Dr, Anchorage AK 99516 Site address 4541 Southpark Bluff Dr Legal description (Sub'd., Block & Lot) Southpark #1 Blk 2 Lot 12 Legal description (Township, Range & Section) - Lot Size 27591 Sq. Ft. Number of Bedrooms 5 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) I (w/wo ADU) Septic Tank ® Upgrade Duplex (D) n Holding Tank ❑ Renewal ❑ Multiple Dwellings U Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. Ze44) 4. (Signature of"pfoperty o y.r authorized agent) Permit/Rush Fees: 022.c Waiver Fees: Date of Payment: q/aq//9 Date of Payment: Receipt Number: 23(110- Receipt Number: Permit No. 05Piq l ilLI Waiver No. G:1Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc • RCTERvc3Rq ^ 67891 CONSULTING, INC 0 R 20441 Ptarmigan Blvd,Eagle River,AK 99577 a ��R 2 ,�. Office(907)696-6111,Fax(907)868-3793 s 6 2019 et CI `` April 26,2019 o! 6 8 L 9 5.rk Municipality of Anchorage Development Services Department On-Site Water&Wastewater Program P.O. Box 196650 Anchorage,AK 99519-6650 Subject: Septic Tank Upgrade Permit- Southpak#1 B 2,L 12 The owner has requested we proceed forward to obtain a septic permit to upgrade the aged septic tank on the subject lot. The proposed upgrade will serve the existing 5-bedroom house. The adjacent lots are served by public water. There is no surface water within 100' of the proposed tank. We do not expect there to be any adverse effect on adjacent lots by the development of this tank. If you have any questions, please contact me at 696-6111/FAX 868-3793. Respectfully submitted, ArcTerra Consulting, Inc. rar Kenneth • . % • fus, P.E. Attachments: On-Site Sewer Application Wastewater Absorption System Details/Site Plan 20441 PTARMIGAN BLVD • EAGLE RIVER,AK 99577-8736 • PH(907)868-3791 • FAX(907)868-3793 WASTEWATER DISPOSAL SYSTEM DETAILS SOUTHPARK SUBD #1 LOT 12 BLK 2 1 l \ \ rtuN� S/a' rc� . . �,c3' Cf�(f mt.(...) r �� . t•-':::, V\-w-Nio, ..t. - ':?,)- - ----. girli - . 0,- %, c,1\ • :, • �a, \ 7 ›. 4\‘ , \' • , e. • \ : ) . m • 0;''' .'\ .0 • 4. DECOMIAISSION EXITING &T., ;��V' INSTALL NEW WO-GAL - . • •_ N • , r • •/ SEPTIC TANK 10' FROM . G 41 .. . - / FOUNDATION W/DBL #' ' 't' ,11 c , I. POST-TANK cos /► �D . �F'tlC. • GW:I.�.)oQYs ..) • `�. 4 ,Q / • Aiz LOT• !x co .Q ;•• o/ "4 0. a •• • o zi of 0-•f is . •••••••,,, • .. flg�. 3' l Uy.. } I �t71Lil� V tr • ' I ... i , , . , ... Z... . .. .. ....... .. .... ..... .............................. .. ... . .. .. .....................• • • DESIGN: Scale: 1'= 40' 1. INSTALL 1500 GAL S.T. & INSULATE TANK IF <4' COVER. N PAGE 1 OF 1 2. MAINTAIN 10'+ FROM FOUNDATION, WATERLINE, & LOT LINE. MAINTAIN 5'+ FROM EXISTING FIELD & INSTALL 2 POST-TANK m CLEAN❑UTS. =;, -4.6,7110k3. CONTRACTOR WILL ENSURE ALL SEPARATI❑NS TO ADJACENT OF �\ WELLS, SEPTICS EASEMENTS, PROPERTY LINES, ETC... t / (S� �� 1 PREPARED FOR: CTE D (g /<s\ JOHN RALL hRRk ,. '. . 1 4541 SOUTHPARK BLUFF DRIVE /� (411:12)/* 4 •.TH /\ * ANCHORAGE, AK 99516 co _W �: / FIELD BOOKS caMPUTm:CE-7118 BOUNDARY: DRAWN: z '` 1 }sv/ N/A KMD L1.: ti STAKMIf. _ CHECKED: KMD % j •�n"c , I ASBUILT: DATE •i•'ti•+••••Y 1\ LANG 04/26/19 1 e \ bFEssio�� DWG.FOE GRID' 3236 9c(FC lac��� `�� ACRD FOE FILE JOB"°•: 19017 �iVFR,S 99577,036 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES , Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES ~ddress ~ TANK FIELD WELL LOt BJock Subdivl ion ' [: I Township. Range. Section ~ ASlBUILT DIAGRAM {Show Location ol well, s,ptic s~s[em, p~operW l[~[l loun~atlon. TANKS TYPE OF SYSTEM ~TRENCH ~BE~ ~ W. DRAIN ~OTHER WELLS ~ ¢0~ ~ PRIVATE ~ OT~v)~ ~ : ' ~ : : Scale= [,, ~',~ 72 013 (3/85) DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE WESTERN DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 October 19, 1990 STEVE COWPER, GOVERNOR 563-6775 FOR: Corwin & Associates Attn: Bruce Corwin PWSiD: 9213475 According to the records on file in this office, the Sout~ Park Subdivision Lot 3, Block ~1 Water System is in compliance with.the State of Alaska Drinking Water Regulations. Sincerely, VERA E. CRAIG Environmental Specialist VEC:pf MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-~720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT DISTANCES '"a"'~-Fccm~''- ~,,~ 'to SEPTIC ADSODP'r~ON WELL Ad,~,es~ FDO~ ~'-"--_. TANK FIELD L~GAL DESCRIPTION TANKS ~ ' t TYPE OF SYSTEM N ~ TRENCH ~BED ~ W. DRAIN D OTHER %~ · WELLS . ~. ~ g PRIVATE ~ OT~v) ~ ~ ,nstaUe, ~~ ;ate Installed:~ FT FT REMARKS: := ~ g~Z 72-013 (3~85) ~LDT. PLAN ~ AS BUILT SCALE ' K~N~{. G; I~%NG; L.S.. 1731 GEORGE B. ELL C~RCLE, ANCHOF~E, ALASKA ~95~.5' (907) 34~-6476 - I HEREBY OERTI~ THAT i }{AVE SURVEYED THE FOL~JOWING DESCRIBED- AM~Ho~z~ "T~]~ORDING DISTRICT, ALASKA, AND T~,}~T THE ~TUATED THEREON ARE W~THIN THE PROPERTY LINES ~ DO NOT ENCROACH ONTO T~ PROPERTY ~tDJACENT THERETO, THAT NO IMPROVF/4ENTS ON THE PRO~PERTY LYING ADJACENT THERETO ENCROACH ON TI~ SURV=YED PREMISES AND TIIAT TIIERE ARE NO ROADWAYS, TRANS- MISSION LINES OR OTHER VISIBLE EASEMENTS ON SAID PROPERTY EXCEPT AS INDICATED DATED THIS Th'E' ~.~~ DAY OF. ~'~9~ , 19~O_, AT ANCHORAGE, ALASKA · ;.::' / ' 7/9 } E[]'ii::J :~. ii e!~:.H" [)e ~ J j] }: C; ]: !::' A ]... ]: 'F Y 0 F:' A N C H 0 R P, b,', E I q ....... , U,'.,~ner. Nm.e;. TURNER E;[3NSTRUE;TJ:ON t]!~4~'~.):.!~'~ Adc:h'~!!~ii: I:::' 0 BC)X :]!:489 .PAI...Mi~!:R ~.. AK [}a y I:::'h c:~r'l ,~. :~ I:::'a [' c ~! 1 :1: d ~ ()20-C~5 :t ..'..65 l...crL l...r-')ga .! :: Subd :i. v i s i ~::)r'~: SOU'I"HI:;:'ARI'::: ~.~ 1 L.cd'. ~ :!.~?. 131 (::~!:: !.:: ~: Sect ion: :]; '!'c')~nsh :i.p: :t. :i.N Rarlge:: :3W L,'.::~'t. Si.z(:? 2'759i (sop ~"L,, (:~r' acPes) Max BedPc)c:~m~: 'Ibis F:'ePmi'L: 4 ]"oral Capac:Lty: 4 SEF'!I[:; '~ ..... M:i.n : :1 ' ~ ' .... ., L,.,I.,pa~ Lm~..r~ ....... D~i]th to top ;..::.r...L.~ [.l:)q ..... be:, ' "-, '" ....... I'o Munic:i. pa].ity &~,J]cl !.-h,.um?:~n Se~.vJc::~.)s u-g:i, tl'iir~ 3() days c:)~' I w:} ~..!. :ins'La1]. 'Lhe s',./s'L~:))m in ac:copdance v,Hi.'Lh a].I MOA (:::(~des and d:[stances fr'{::~m arY)/ exi~f,:Lng we11~, (.,~as'Lev~a'Le[' disposa! system or' public a]~(::) uncie::)i's'Land Lhat 'l:.he capac:i'('.'y (:h~ 'Lhc,' 'L(::)tal ~ilys'Lem :i.s 4 b(~]dr'cl(:)ms arid a!iy CWI ].a['g,:.~ment ~,~d. ]. ]. r'~:.Hq~,~:i, Pe:, ari add'i.t i(::)rla]. TURNER CONSTRUCTION CO., INC. P. O. BOX 3489 PALMER, AK 99645 (907) 745-8334 or 561-5882 February 26, 1990 Municipality of Anchorage L Street Anchorage, AK TO WHOM IT MAY CONCERN: I hereby authorize Alice A. Smith to sign for and pick up any on-site sewer and well permits for Turner Construction Rex L. Turne~ent MUNICIPALITY OF ANC~ORA.~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION 1990 RECEIVED Tom Fink, Mayor January Municipality Anchorage Department of Health and Human Services 825 "L' Street P.O. Box 196650 Anchorage, Alaska 99519-6650 8, 1990 Bounty Development 16420 St. James Place Anchorage, Alaska 99516 Subject: Lot 12 Block 2 Southpark S/D #1 Permit #890246, PID #020-051-65 The subject permit, issued by this office for a single family well and/or on-site wastewater system has expired as of December 31, 1989. Permits are issued on a calendar year basis by authority of the Municipal Code of Regulations. A new permit must be obtained from this office for an well and/or on-site wastewater system not. installed by the expiration date. If you have drilled the well, a well log needs to be sent to this office for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site wastewater system, the original as-built inspection report (three-part form) must be sent to this office for review, approval and documentation. When applying for a new permit, the fees are: $90.00 for an on-site wastewater permit; $50.00 for a well Permit; $140.00 for a combined on-site wastewater and well permit. If you have any questions, please call this office at 343-4744. Sincerely, John Smith, P.E. Program Manager On-site Services JW/ljm:200 enc: Copy of Permit ~Kids Are Our Future M L J Iq !; C .]: P A L. ]: "£' Y O F ~ gepar:'Lmen',~, o{ H~,alt. h & Human B 5L .q]"Y Dc.~, :~..C.)F I I!. x 16420 S'T,. ,.)'AMEE~ F'L.ACE ):)ay F:'hone: Lot I..(6~.(:..ja].: L:~ubdivision: ',,,80UTHPARK ~1 Lot: 12 Sect ion,'.. :5 'fo~,,~nsh J.p: i :I.N Range: L.o'L S:i.::~e 27591 (sq.. ft,, of ac:pcs) Max Bedpc, oms: 'T'his P,,:~i-mit.: 5 To~.ai C, apacit¥: ac.a::~ty~ 1~'5]" ~jallons,, E!:ach sept:Lc: NOI" :I: I:':'",/ ~)I"IHS OF:' 1, I,~F I..C I 1 .]hl,..I 343-4744 OR ._~ k.:,- .-o~;:1.1. ...~(~,,.,I,,L) I IL.L.~I ~4 X,,,,A~/,4I AND CDVERED ]:N SAME O*.,~Y OR HEmqTED DLJR]:N[~ ' ~ INSTAL. I,.A]- I ON. CERT :t; FY 'I"HA'T :: 1. :[ am Familiar. with the r'equ:ii*emerd:.s ~'cn' on'-'-s:L'Le sewer's and w~!].s as set ¢c)r'th by the Munic:Lpa!ity of Anchcn'.a(je (MOA) and the State of Alaska. 2,, I w:i. 11 in~s'La].l the system in acc:oi"danc(:.:.~ with all MOA codes and r, egulat:Lonss ai"id J.!-t c: ol~lp ]. i ~tfl ¢: 6) v.~:i.(.h the dG:'~:i, gl'] CPJ. tC'~Pi/=t f;;,[' this :}~;,, I w:i.!1 acH"~ec(~.~ to ai! I'~J[)A and State o{ A].aska pecluii'emer'r~.s .fen" the se?. back cJistct~ric:~.~.)s ~r'o;~] any exis1'..:i, ng we!l, ~*.as'[.e~z~ater' disposal, system c)r' public s(~:,v.;er'a~:H:: !~ys'Lsm (:;)n '~:,JlJ. s (::iff any a~::J.:ja(:::el'l~:., c:)p r~ear'by ].at,, 4. I t..u'tch~;,r, st.and t.l'h'~t. 't:.l~is p~p~nit :i.s v~tii;J ~o1" a maximum o¢ (Ckm"tep) BOUNT? NOTE: All Dimensions ~d Locations Must Be Field Verified Prior To Construction S5~5R SYSISM'kOOATION PkAN All Dimensions ~d Locations Must Be Field Verified Prior To Construction .SEWER SYSISM'LOGAT[ON PlAN Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST l,o 4.3 LEGAL DESCRIPTION: ~'~'7"/z' /?~/~/~' ~- ~ Township, Range, Section: 4 5 6 7 8 9 10 11 13- 14- 16- 17- 18- 19- 20- SLOPE WAS GROUND WATER AA/~ ENCOUNTEREO? SITE PLAN s L IF YES. AT WHAT 0 DEPTH? P E PERCOLATION RATE -- (minute~Jinchl PERC HOLE DIAMETER __ COMMENTS TEST RUN BETWEEN FT AND FT ACCORDANCE WITH ALL STATE_ AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: p, 2 RECEIVED G ' • Municipality of Anchorage On -Site Water and. Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 020-491-26 Expiration Date: `J - 2Z - 2-1 1. GENERAL INFORMATION Complete legal description SOUTHPARK #1 BLK 2 LOT 12 Location (site address) 4541 Southoark Bluff Dr. Anchorage __ Current Property owner(s) John_Rall Day phone Mailing address 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: 5 TYPE OF WASTEWATER DISPOSAL: 4. TYPE OF WATER SUPPLY: Individual Individual Well ❑ Holding Tank ❑ Individual Water Storage ❑ Community ❑ Community Class _ Well ❑ . Public Sewer ❑ Public Water System WaiverNariance request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $_56-0 Waiver Fee $ Date of Payment Jr .� Date of Payment Receipt Number _0 7 Ca Receipt Number COSA # 6.SC Z I Z �t 8 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 ARCTERRA CONSULTING: INC. Phone 696-6111 Address 20441PTARMIGAN_ BLVD_, EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 5/27/21 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future ��\ \ occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. Ie 1 �� 6. DSD SIGNATURE System #1 Approved for �r bedrooms -.04 System #2 Approved for bedrooms- Disapproved. \tea Conditional approval for bedrooms, with the following stipulations: 2 \N�R,( OF i O i ESVV R ANp R -z �E Q F C' \` 1,J ,F� 19 Original Certificate Date: 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 blue sheet -10-10-12 doc Legal Description: Southpark #1 Blk 2 Lot 12 Parcel ID: 020-491-26 If more than 1 septic system on lot: COSA Checklist # of *ft<ELL DATA ❑ Well o � ed with Onsite (or attached) Date drilled Total depth ft Cased to ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Comments * Public Water B. TANK DATA Age of tank(s) 5/24/19 years Tank type/material Plastic/Septic Measured operating fluid level in septic tank 49" Standpipes/foundation cleanout per record drawing Date of pumping 5/24/21 D. ABSORPTION FIELD DATA Which system tested (date installed) 6/5/90 OR ALL standpipes present per record drawing Total measured depth from grade 4.8 ft (max) Measured depth to pipe invert from grade 3.25 ft (min) ❑ N/A — pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Structure served by this system 1 Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) ug/L ❑ Arsenic less than MRL (ND) Collected Date of Sample IFT STATION ❑ Requl aintenance completed Age of lift station years Lift station material Comments: Adequacy test date 5122/21 Results Q Pass For 5 bedrooms Fluid depth prior to test 0 in Water added 750 gal New depth 0 in Elapsed time 5 min Code -required soil cover over field Final fluid depth 0 in System presoaked Absorption rate 750+gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) Gallons introduced 2000 gallons If yes, enter date Comments/Deficiencies: ** Leach field tested for 5bdrm as Dermitted COSA Checklist yellow sheet E. SEPARATION DISTANCES Frr . ate Well on Lot to: (Please enter distances if less than required or if community well) ® Yes Septic Tank/Lift Sta Lot `> 100' ft Surface Water > 100' Community Sewer Manhole/Cleanout > 100' Property Line > 5' es if No ft ❑ Yes if No Neighboring Tank > 100' El Yes if No _ ft Private Sewer/Septic Line > 25' ❑Yes if No Absorption Field on Lot > 100' ❑ Yes if No ft Ta�>100' ❑Yes if No Neighboring Absorption Fields > 100' ® Yes if No. Water Service Line > 10' Animal Co_ ❑ Yes if No ❑ Yes if No ft Manure/Animal Excreta Storage > Community Sewer Main > 75' ❑ Yes if No ft ❑ Yes if From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: ft Community Wells > 200' Absorption Field > 5' ® Yes if No ft Private Wells > 100' Yes if No. Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No. 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' 0 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' Water Service Line > 10' ® Yes if No ft Community Wells > 200' Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION / certify that l have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet ft ft ft ft ft ft ft ft ® Yes if No ft ® Yes if No ft 4, 09 >> ts� • rV s nc',. 8t, l ; •� Municipality of Anchor�ge �,;�� On-Site Water and Wastewater Progra . •�jj' (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS AP '` : T A, c3 -') Parcel I.D. 020-491-26 Expiration Date: -�{- aCZ° 1. GENERAL INFORMATION Complete legal description SOUTHPARK #1 BLK 2 LOT 12 Location (site address) 4541 Southpark Bluff Dr, Anchorage Current Property owner(s) John Rall Day phone Mailing address _ 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: 5 TYPE OF WASTEWATER DISPOSAL: 4. TYPE OF WATER SUPPLY: Individual Individual Well ❑ Holding Tank Individual Water Storage ❑ Community U Community Class Well ❑ Public Sewer Public Water System WaiverNariance request for: Distance: Received by: Date: COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ 55b Waiver Fee $ Date of Payment ______ Date of Payment Receipt Number 0-u66H _ Receipt Number COSA# __� l Q!/Qc/ _ 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 ARCTERRA CONSULTING,INC. Phone 696-6111 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 5/24/2019 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface. changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore. ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseenOr A j\\ encroachments,deficiencies or discrepancies exist, �r �� (�'rll 6. DSD SIGNATURE 1‘ �v System #1 Approved for `3 bedrooms. hEr;"e'�iis• °`�: System #2 Approved for bedrooms. ,'� Disapproved. Conditional approval for bedrooms, with the following stipulations: `olll((((((a,,vry �/ IA/ ON-SITE dWASTFIA/-.ATER PROGFAM e1 - ^AG )))»»))))"' t'-t--- Original Certificate Date: 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 blue sheet 10-10-12 doc COSA Checklist Legal Description: Southpark #1 Blk 2 Lot 12 Parcel ID: 020-491-26 If more than 1 septic system on lot: COSA Checklist# of Structure served by this system 1 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? ❑ Yes I. No Cased to ft ❑ Coliform bacteria is Negative ❑ Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND) ❑Wires are properly protected Arsenic ug/L ❑ 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 * Public Water B. TANK DATA C. LIFT STATION Age of tank(s) 0 years ❑ Required maintenance completed Tank type/material Infiltrator Age of lift station years Measured operating fluid level in septic tank Lift station material III Standpipes/foundation cleanout per record drawing Comments: Date of pumping D. ABSORPTION FIELD DATA Which system tested (date installed)6/5/90 Adequacy test date 4/17/19 • ALL standpipes present per record drawing Results Q Pass For 5 bedrooms Total measured depth from grade 4.8 ft(max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade 3.25 ft(min) Water added 750 gal El N/A—pressurized field New depth 0 in II Monitor tubes go to bottom of effective. If not, state Elapsed time 130 min depth into effective El Code-required soil cover over field Final fluid depth 0 in C1 System presoaked Absorption rate 750+gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies:** Leach field tested for 5bdrm as permitted 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' 0 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' 0 Yes if No ft Surface Water> 100' 0 Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0 Yes if No ft Private Wells > 100' 0 Yes if No ft Water Main > 10' 0 Yes if No ft Community Wells > 200' 0 Yes if No ft Water Service Line > 10' 0 Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' 0 Yes if No ft Water Service Line > 10' 0 Yes if No ft Community Wells > 200' 0 Yes if No ft Surface Water> 100' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION t. +�•.'OF �k ... I certify that I have determined through field inspections and review � r - .i. of Municipal records that the above systems are in conformance with 49 i _ '", MOA COSA guidelines in effect on this date. r KENN�",��1/S 4,i I.I1 CE 7t /*„• 'i V COSA Checklist yellow sheet / I 10' UTILITY EASEMENT Lot 3 ic 20' T&E EASEMENT Z\ Lot 1 \1 goo N sR�\ ..,.. O `� ,A,,,� / \ s'- \ Lot 4 �O cp, RETAINING N 'S \ O a / WALL N .00, '- SEPTIC \/ MANHOLE ► �A -- /SEPTIC PIPES "�� II •a / o3 (f) I o-' cRN y `�o C IS Lot 12 R.oa tl :°-:� 'ap. g 27,591 s.f. , c ____..--rt----\ 0 -i) La I N ats) \73 73:11 , 112.2'x10.2' SHED ' x Lot 7 I In \ in"' \ \ Z I .4g'1 Pti 229.11 \ I S �6 HOUSE DETAIL Scale: 1" = 20' Lot 11 / \\ >7 10' UTILITY EASEMENTS \ Y 4.0.x14.0' `= CANT �,, / \�\ 75.o 022/ Lot 8\ 6.0'x16.0'BALCONYb N y1 �u r4.0 2. 8' 2 STORY RESIDENCE o 0 w/ WALKOUT BSMT. s o 8.2• lir 20.0• 4.p• 4.0'x 1 1.0' CANT o 5.0 h 4.8' PORCH NOTE: THIS LOT IS SERVED BY A N COMMUNITY WATER SYSTEM. X83 w 1•s 't + s. N PLOT PLAN AS BUILT X SCALE 1" = 50' GRID SW 3236 Project No. 19-142/R2 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates , inc . (907) 522-6476 Phone o�opOQpx (907) 522-4625 Fax ,oQ O F q e ooI Professional Land Surveyors kenOlangsurvey.com o ,9 0 JonothanOlangsurvey.com o'� S Q I herebycertif that I have surveyed the followingdescribedproperty: OG�P +� ��� LOT 12, BLOCK 2, SOUTHPARKYSUBDIVISION - DDITION No. 1 (PLAT No. 81-338) 0* q gTH /� • *pOA 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 D no improvements on the property lying adjacent thereto encroach on the surveyed KENNETH4 : kp premises and that there are no roadways, transmission lines or other visible c, p easements on said property except as indicated hereon. QQ '�, 't ZZ[01 ...W kI4C ",:* ..i_S-520?.•' ySo0 Dated this the -= Day of , , at Anchorage, Alaska A aoo k 4b ° SSIONN►- o It is the responsibility of the owner to determine the existence of any easements, ‘PES At- covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963 Ecklund, Timothy J From: Dea Arc <dea@arcterra.net> Sent: Monday,June 3, 2019 8:29 PM To: Ecklund,Timothy J Subject: Fwd: Septic system at 4541 Southpark Bluff Dr, Anch, AK Sent Dea's phone Begin forwarded message: From: John Rall <ralljrl2@gmail.com> Date: June 3, 2019 at 7:32:56 PM AKDT To: Dea Duffus <dea@arcterra.net>, Bob Baer<bbaer@gci.net> Subject: Septic system at 4541 Southpark Bluff Dr, Anch,AK Bob and Dea, I understand there was a question asked about the septic system at 4541 Southpark Bluff Dr, Anchorage, AK 99516. We lived in the house for 29 years and never had any problems with it. The system never froze up and we never had any problems with either the tank or the leach bed. I hope this will answer your question. John Rall E Virus-free. www.avast.com • 1 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.# ~ £'~ -~-/:~. HAA# ~r~(~- 1. GENERAL INFORMATION Complete legal description LOt 12; Rl~k 2: ,qo~]thpark Subdivision Addition Location (site address or directions) 4541 Southpark Bluff Drive, Anchorage, Alaska Property owner Mailing address Lending agency Mailing address Agent Address John Rall Day phone 4541 Southpark Bluff Drive, Anchorage, Alaska Day phone 345-8269 99516 Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: xxx If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site 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 MOAII21 5. sTATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Phone Date DHHS SIGNATURE Approved for ~:'~ (,~) Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer reoistered 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. DEPT. OF ENVIRONMENTAL. CONSERVATION / / ANCHORAGE DISTRICT OFFICE 800 E. DIMOND BLVD., SUITE 3-470 ANCHORAGE, ALASKA 99515 WA~LTER J. HICKEL, GOVERNOR (907) 349-7755 January 26,1993 Mr. Jim Williams S & S Engineering SUBJECT: South Park terrace Subdivision Class "A" Public Water System, PWSID 213475 Dear Mr. Williams: I have completed a review of this office's files concerning the monitoring status of the above-referenced Class "A" Public Water System and found the following: The last satisfactory Total Coliform Bacteria Sample results was submitted to this Department on January 12, 1993. This does meet the provisions of 18 AAC 80.200(a), of the State Drinking Water Regulations. The last inorganic Chemical Contaminants Sample results were submitted to this Department on November 4, 1992. This d_p_oes meet the provisions of 18 AAC 80.200(a), of the State Drinking Water Regulations. The last Radioactive Contaminants Sample results were submitted to the Department on December 10, 1992. This does meet the provisions of 18 AAC 80.200(a), State Drinking Water Regulations. The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC) were submitted to this Department on November 6, 1991. This does meet the provisions of 18 AAC 80.200(a), State Drinking Water Regulations. Issuance of this letter does not imply that the above-referenced Class "A" Public Water System is in compliance with other prowsions of the State Drinking Regulations. If you have any questions on the above information, please do not hesitate to contact this . office at 349-7755. Sincerely, Michael Lu Environmental Eng. Asst. II prn ed recycled b y (~,D. on pape~ Legal Description: /..oT /~ ~/. ?_ .5'o~T~/~//~/(" 5'//~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Parcel I.D. ~Z~-~'-~-/-~'~-~ A. WELL DATA Well type A Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. Date completed Cased to FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main /Us/.J~- Sewer service line ADEC water system number Driller Casing height Wires properly protected (Y/N) AT INSPECTION g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: ~'£~' Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~ / ~ / ~0 Cleanouts(~N) ~/ High water alarm (Y~) ./LJ Tank size /~00 Compartments Foundation cleanout ~N) y Depression (Y/~ Alarm tested (Y/N) Date of pumping (/~/Z ~/¢Z~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /k~b,/J~'- /,~E-J'E~Onadjacentlots To property line '~'~ Absorption field Surface water/drainage /('.~o/~- /¢/~E;U/'-~o u n d ,_ ;on Water main/servir ~. line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE ~.IFT STATION AJa-''J~ ,fc'f'~ ¢- D~e Man ufactu rer Size in gallon¢'~'~- Manhole/Access (Y/N~~ Vent (Y/N) " ump off" level at High water alarm level ~ ~ ~.._.._Cycles tested Meets MOA electrical cedes (Y/~)-~ SEPAR~NCE FROM LIFT STATION TO: .~JFo'-n lot On adjacent lots D. ABSORPTION FIELD DATA Date installed ~ /.-~ /~O Length 4'~r Width Total absorption area [[ Z~o¢ Depression over field (Y/(~ Results~/fail) /¢22~J-¢,r Peroxide treatment (past 12 months) (Y/N) Soil rating /.~7) z~C/"~/cjao/,,1 System type Gravel thickness ~ ,r Total depth Cleanouts present (~'N) Date of adequacy test '~'/~/~-"7' for ~" Crt"/~"¢,) bedrooms ,.x~O,,*.JE ,/~'/VOg/.-/ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water /0C* Curtain drain E. ENGINEER'S CERTIFICATION On adjacentlots 7~OO ~'~ Propertyline To existing or abandoned system on lot Cutbank ~ /~/+/~ Water main/service line Driveway, parking/vehicle storage area ~lo~s ~ ~E~C~F/~ ~ I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date $ & S ENGINEERING 17034 Eagle Riv6r Loop Road No. 204 72-026 fRev. 3/911 Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) Legal Description (include 10t, block, subdivision, section.,~/O.~wnship, range) Location (address or directions) (b) Property owner Mailing Address (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address Telephone Telephone: (home) '~ Telephone (e) Mail the HAA to the following address: (or check here/'~if hold for pick up.) List contact person and day phone number below: -- Business 2. TYPE OF RESIDENCE 5 Single-Family/~' Number of bedrooms 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-site'~ Public [] Community [] Holding Tank [] Note:/ -If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 : 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th is Health Authority A~proval 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 regu. Jations in effect on the date of this inspection. Name of Firm _~_~.-U/[.L ~/-~r~'.,''/ /~. Telephone ~ ~ ~-~ Date ~ Engineer's Seal 6. DHHS APPROVAL Approved for ~- bedrooms by Approved ,../~ Disapproved Terms of Conditional Approval .Conditional Date The Municipality of Anchorage Department of H'ealth 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 DH HS do not conduct inspections or analyze data before a certificate is issued. The M u nicipality of Anchorage is not responsible for errors or' omissions in the professional engineer's work. 72K)25 (Rev. 7/88) 8ack Page 2 of 2 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 ParcelI.D.# CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) / Location (address or directions) Gb . / (b) Property owner Mailing Address Telephone: (home) '"k~z~/A~ Business (c) Lending Institution */~-'///~ Mailing Address (d) Real Estate Company and Agent Address Telephone Telephone (e) Mail the HAA to the following address: (or check here~if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family, y~ Number of bedrooms '~ 3. WATER SUPPLY Individual Well [] Community2~ Public [] Note: If community well system,/-must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site'S' Public [] Community [] Holding Tank [] Note:/'If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the [egailty 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. Telephone ~¢- 7~ - ,¢¢,~__~ / / Engineer's Seal 6. DHHS APPROVAL Approved for ~ Approved ~.//~ __ bedrooms by ~_d~//,~ te Disapproved Conditional Terms of Conditional Approval 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 · ,,-k~xG%~ A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: /' / '/- - 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: Date complete[ Depth of Grouting QB, C, D.E.C. Approved (Y/N) Yield Pump Set At ~ Sanitary Sea~Y/N) To Septic/Holding Tank on Lot ./' ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot/'//' ; On Adjoining Lots To Ne~e~te~rUeblitCs~ew~;rs~on Lot __/ T~ Nea,est F~blic Sewer Cleanout/Manhole SEPTIC/HOLDING TANK DATA Date Installed ~Size /~0 NO. of Compartments Standpipes (Y/N) Y Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) Depression over Tank (Y/N) ~ Date Last Pumped Pumping/Maintenance Contact on File (Y/N) "~.J,/'~ ;for Holding Tank High-Water Alarm (Y/N) ~ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: TO Water-Supply Well ~ ~0/~ ~ TO Building Foundation ~ / To Property Line 7~'~ ! To Water Main/Service Line 7~'~ / To Stream, Pond, Lake or Major Drainage Course Comments To Disposal Field 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field ~ / Square Feet of Absortion Area //~'~ Statndpipes Present (Y/N) Depression over Field (Y/N) ~ Date of Last Adequacy Test Results of Last Adequacy Test /( ~'~_ --(',-/,..// r.~¢'~¢'J= ~ SEPARATION DISTANCE FROM ABSORPTION FIELD: Length of Field '~'~;;~ / Depth of Field ~.'~ /'~/~ Gravel Bed Thickness ~' // To Water-Supply Well ~ 2--~20 './/~E¢¢~'~ f'~:['/ To Property Line ,~ To Building Foundation /,.~ '/ To Existing or Abandoned System on Lot /~//Z2r- ;On Adjoining Lots To Water Main/Service Line "~ / 7/-- To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course ,,/u/"2// To Driveway. Parking Area, or Vehicle Storage Area 7,~ / Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions ~ '/~ Vent (Y/N) _ / /_(L_ Pumping Cycles during Adequacy Test. cM: emt Sm eMnOt sA E~Y/N) **Check Perm~te'~ Bedroom¢ing Against HAA Request** I certify that ~/t'~rry9 checked,.//ve~ed, or conformed to all MOA and HA~ inspection./////// ¢/ /I~/ ~ ~ MOA NO. ¢ ~ on the date of this Engineer's Seal Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Bsck Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2