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Home My WebLink AboutSOUTHPARK #2 BLK 3 LT 16i ~ DEP.a ~IENT OF HEALTH AND HUMAN SERVI( · Environmental Health Division (~) " 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT N~ne ~--1-~/V't E'$ ~)o ~U~ DISTANCES ~ SEPTIC ABSORPTION A~ TANK FIELD WELL Phone(s) Permit NO. No of 8~d~oo~ WELL Township, Range, Section ~II~, ¢~ ~1 y~¢, 3 AS-BUlLT.lAGRAM(Showlocat,onolwell. sepficsystem, propertyl,nes, lounda,,o., . d~weway, water bodies, etc.) TANKS N ~ SEPTIC U HOLDING ~ Capacmty in gallons Material NO of Compa~ments TYPE OF SYSTEM ~ FT _ 3 FT S FT 0 FT WELLS ~ PRIVATE ~ OTHER fldentifv) Classdicahon (A,B,C) 7otal Depth FT Cased toFT REMARKS: ~ ~ U ~ t~ ~ ~ V ~ ~ ' Inspections Pedormed by: m ~/~6~ ~ ~¢ ~50 ~ cedily Ihat this inspection was pedormed according Io all ~ ~A~[ch~[ E, Ander~n · Mu~icipalandgtal,,uidelinesineflectonlhisdate. ~~ ~ ~¢ 72 013 (3/85) F%Fd'I ]; ',r NJ)= DATE :¢SSUED;: ........ ..,,_~ ....,:,: !,, ~ ...... Al ,, (.,, ,.,.~ .il., - .';¢.¢i ', ,; , 4q :I. I,.,~ .~. 1,1' .~. ~::....b C i F;tCt .E: ~-..i::. :~l.dr:; L,!s.LI-',; F~I U::lf)]'U t :~] 3i'll= ,,~L)U FrlF ¢-iRi'.. SUEd) i._ 0 T ' ' "' "" ' ......... ~::~ ¢'' ~::' :' ¢'":::' .~. ,~, :.~ ,. :,~,i, ........ ( ............... ACRES) *.,~-.~/ u,. [, I i,,:,. vO,~\k DEPT. OF HEALTH & EN'VlRONME~NTAL 'PROTECTION ',. . ,SI=~ER SYSTi~M LOOATIONPLAN~:~I~ FOK 5blBD. i '~00.+ FF.' A~/AY NORTH ~.~'P,A ...... : DEPT· OF HEALTH & . Municipality O, Anchora,~vi,ONM~NTAL · -, DEPARTMENT OF H~LTH & HUMAN SERVICES ~ SOILS L~G -- PERCOLATION TEST .~ ,,.~o.~o.: ~o~ 5~ -~'~ RECEIVED'. L;GALDESCRIPTION: ~~k ~(~°wnship'Range'Secti°n:Tl[~l}~X~ ... ~/~, ~i~. .4 5 6 7 14- '17 - 20- I~'0 ~Pfi°]~x WAS GROUND WATER ENCOUNTERED? IF YES. AT WHAT DEPTH? Depih la Waler Alter., Monitoring? NO \ ',N Gross Net Depth to Reading Date Time Time Water ~..Drdp J , PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER I TEST RUN BETWEEN FTAI~D FT ' ,,,, ~ ~ , ~ .~ ~d Iq' W.~lb4 r~',~ '~+ 72~8 (R~, 4/~) ~ ' MUNICIPALITY OF Development Services Department On -Site Water & Wastewater Section Parcel I.D. 020-502-14 c ANCHORAG Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Complete legal description SOUTHPARK #2 BLOCK 3, LOT 16 Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: 7– / � —2-0 2-0 Location (site address) 15610 JENSEN CIRCLE, ANCHORAGE, AK 99516 Current property owner(s) GUY & ANNETTE BALLY Day phone Mailing address Real estate agent 15610 JENSEN CIRCLE, ANCHORAGE, AK 99516 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 5 4. TYPE OF WATER SUPPLY: Private Well ❑ Water Storage ❑ Community Well ❑ Public Water System Public Sewer Waiver request for: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Day phone TYPE OF WASTEWATER DISPOSAL: Private Septic Holding Tank ❑ Community ❑ Public Sewer ❑ Date: COSA Fee $ Waiver Fee $ Date of Payment g 2l �� Date of Payment Receipt Number �� Receipt Number COSA # 052, Iq 13 R Waiver # Distance: 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm ANDERSON CONSTRUCTION & ENGINEERING Phone 345-3377 Address 4661 NATRONA AVENUE, ANCHORAGE, AK 99516 Engineer's Printed Name _MICHAEL N. ANDERSON, PE Date 08/02/2019 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. 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 in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. 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, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by FWf.S and Anderson Construction & Engineering 6. DSD SIGNATURE System #1 Approved for 5 bedrooms System #2 Approved for bedrooms Disapproved �►-,* `%'\ OF AL\ AIF /. * :'49 THW.6vp oe,(40 *, 00,01. 1111CHAEL N. ANDER30N: No. CE 9489 j •'•.8/2/19 .••'•/ Conditional approval for bedrooms, with the following stipulations: va,�A I C� M1'4 u By: 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 Checklist blue sheet Legal Description: SOUTHPARK #2 BLOCK 3 LOT 16 Parcel ID: 020-502-14 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA -PUBLIC ❑ Well log is filed 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 B. TANK DATA — 6/5/2009 1500 -Gal Age of tank(s) 10 years Tank type/material SEPTIC / STEEL Measured operating fluid level in septic tank 49" ® Standpipes/foundation cleanout per record drawing Date of pumping 7/16/2019 Structure served by this system 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 F1Nitrate less than MRL (ND) Arsenic _ ug/L ❑ Arsenic less than MRL (ND) Collected by Date of Sample C. LIFT STATION - NA ❑ Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA — 30' & 25'L x 2.5'W x 6-7'ED — @ 1.2 GPD/SF = 780 SF Which system tested (date installed) 6/5/2009 ® ALL standpipes present per record drawing Total measured depth from grade 13.4 —14.8 ft (max) Measured depth to pipe invert from grade 7.4 — 7.8 ft (min) ❑ N/A — pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective ® Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced _gallons Comments/Deficiencies COSA Checklist.docx Adequacy test date 7/16/2019 Results M Pass For 5 bedrooms Fluid depth prior to test 4 / .26 in Water added 750 gal New depth 10139 in Elapsed time 1320 min Final fluid depth 3 / 24 in Absorption rate 750 gpd Any rejuvenation treatment (past 12 months) N If yes, enter date FWE E. SEPARATION DISTANCES Frr rivate Well on Lot to: (Please enter distances if less than required or if community well) ® Yes Septic Tank/Lift S a • on Lot > 100' ft Community Sewer Manhole/Clean _ 00' Yes if No ft Yes if No ft Neighboring Tank > 100' ® Yes if ft Privat er/Septic Line > 25' ® Yes if No ft Absorption Field on Lot > 100' ® Yes if No Iding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > IAnimal Community Wells > 200' ® Yes if No ft Contai t > 50' ® Yes if No ft ® Yes if No ft Manure/Animal Excreta St�O0'Com y Sewer Main > 75' ® Yes if No ft ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Wells on Adjacent Lots: Property Line > 5' ® Yes if No ft Private Wells > 100' ® Yes if No ft Absorption Field > 5' ® Yes if No ft Community Wells > 200' ® Yes if No ft Water Main > 10' ® Yes if No ft If septic tank is under driveway comment below Water Service Line > 10' ®Yes if No ft Surface Water > 100' ® Yes if No ft 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' ❑ Yes if No *1' ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS *2009 Waiver OF AL 1k 4 G. ENGINEER'S CERTIFICATION l certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance 49TH j with MOA COSA guidelines in effect on this date. :MICHAEL N. ANDERSON.' No. CE 9469 COSA Checklist.docx ''••.8/.311.9•' � nsslvo, AV ASBUILT I,,.---- SMARA & ASSOCIATES LAND SURVEYING 694-0829 f HEREBY CERTIFY -THAT I HAVE SURVEYED THE 'SCALES FOLLOWING DESCRIBED PROPERTY- _ OF A� tib moor r s✓3'xc! �' %� GDT/d G'.!!3 DATE; cjs AND THAT NO ENCROACHMENTS EXIST EXCEPT AS se i f f .s G; 4 INDICATED. IT IS THE RESPONSIBILITY OF THErHy x OWNER TO DETERMINE THE E.'as'PENCE OF ANY GRID= p `°""°° ..• EASEMENTS, COVENANTS., OR REfiTRICTIONs WHICH DD NOT APPEAR ON THE RECORDED SUBDI- 0 D—. murk S.—d :. VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD I`B' �y ¢Q� . Lys�-�s ANY DATA HEREON BE USED FOR CONurRUCTION OF FENCE LINES, OR FOR ESTABLISHING BOUND-'�q ARY LINES. rDhiWN- 16W-5r, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot 16: Block 3; Southpark #2 15610 Jensen Circle Location (site address or directions) ~ ._ Anchorage, AK Property owner H6{~ard Mayspn C/O 1st Inspection 5~2-~d~reen Bay Road Mailing address Lending agency .: :' Mailing address ~' Day phone Network Highwood, Illinois 60040 Day phone 345-6004 Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2, NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community wel ×x~ Public water NOTE: U community well system, provide written confirmation from State ADEC atte's~- TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: ing to the legality ano status of system. Xxx If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~25 (Rev. 1/91) Fronl MOA 5. STATEMENT OF INSPECTION BY ENGINEER, Address Engineer's signature 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 w~stewater 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 Eagle River, Alaska 99577 DHHS SIGNATURE ~ Approved for __ Disapproved. bedrooms. " .' '- Conditional approval for bedrooms, with the following stipulations; Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to pu rchassrs 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. MUNICIPALITY OF ANCHOP, AGE ~NVIJ~ONMENTALj~ ~/? J' I"% I I'~ i'~SERVICES DIVE~ION~ Municipality of Anchorage MAR DEPARTMENT OF HEALTH & HUMAN SERVICES 20 1997 Environmental Services Division 825 L Street, Room 502. Anchorage. Alaska 99501. Health Authority Approval Checklist Legal Description:t~T' /(' r]~,~c .,~ ~o~'7-/~,'/,'~ ~ '~ Parcel I.D.: 0 A. WELL DATA Well type Co,~m ~, ,~-7 Log present (Y/N) Total depth Sanitary seal (WN) Date of test Static water level Well production B.~HOLDING TANK DATA c: If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to__ Casing heig~ gr.~d) _ _ __ Wire~rotected (Y/N) FROM WELL LOG ' ~ AT INSPECTION g.p.m. Nitrate Other bacteria ' g.p.m. Collected by: Date installed '~' ~ ~ 7 Tank size ) o~"c, c~.~_Number of Compartments Foundationcleanout~'q) ¥~J- Depression(Y~ .~o High water alarm (YA~ ...... ) '1~ "' 0 Date~efPUmp~ng ~,:,.~ ~, Pumper Eo/'D ABs'ORPTtON FIELD DATA% Date inst~lled ' ~:,'~';7 ''. Soil rating (g.p.d./fF or~ L~ngth ~c ~- Width~ ~ Gravel thickness below pipe ~ Total dePth EffeCt~ive' ' absorption area ~ ~ OFr Monitoring Tube present ~1) ¥~$ Depression over field (Y~ N O Date of'ad0qUacy test 3/1~/~ '7 Results~Fail) /~,t-~J For L/ bedroome Fluid depth in absorption field before test (in.); Fluid depth ~t O (ins) Minutes later: / ~ Absorption rate = (~ 0 0 ~- .g.p.d. Peroxide treatment (past 12 months) (Y/N) /,,0~ ~:~o~J If yes, give date -- 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Size in gallons ._-- ............ ~ Manhole/Access (Y/N) "Pu~t¢''-'-''''~ "Pump off" level at* High water ala~~ *Datum . Cycl~e,sJeetCd E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: I~holding tank on lot Absorption field on lot __ On adjacent lots ~~bPub ic sewer manhole/cleanout Public sewer main line Lift station SEPARATION DISTANCF:S FROM~ROLDING TANK ON LOTTO: Foundation S" '¢~ Property line ~- 'Y-- Absorption field Water main/service line /~ + Surface water/drainage/o 0 -~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line J 0 -/'" Building foundation / 0 'h- Water main/service line Surface water / o O '-P- Driveway, parking/vehicle storage area Curtain drain rv o ,v & 14 ~ o ~,,, ~ Wells on adjacent lots ¢3, (] O '/- F. ENGINEER'S CERTIFICATION I certify that l have determined thru field inspections and review of Municipal records th, ~t.~~are in conformance with MOA HAA, guidelines in effect on this date Engineer's Name [~_&6~%_ ~. 60~g~ ~, _¢ ~...~,.~ Date ~/go/ fi7 HAA Fee $ Date of Payment '~/~/J /¢ ~ Receipt Number ,_.~//~¢ ,~ ( ~/-~ ~/~' L/ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* 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.# /'~(~)~ {~'~'- ,~c~ NAA# 1. GENERAL INFORMATION Complete legal description Lot 16, Block 3,' Southpark Add. ~f2 Location (site address or directions) 15610 glensen Circle o~f of Old Seward and Rabbit Creek. Property owner James Mailing address 15610 ~Tensen Circle. Anchoraae. AK Lending agency National'B~nk Day phone 265-8580 Day phone 267~5700 Mailing address Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: 4 N. Individual well Community well X Public water If community well system, provide written confirmation from State ADEC attest- ing tO the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: X If community wastewater system, provide written confirmation from. State ADEC attesting to the legality and status of system. 'I STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown belo~i I Verify that my investigation of this Health Authority Approval application shows that the on-site ~/ater supply and/or westewater 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 flies 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 Environmental V~-Lnac;ement;, ItCh. Phone 562-2,580 Address 907 E. [~r~l:f~RCC¢., StYe 21, ~/~/z'tchora~;e, A~ 99518 , ~ 2/4/94 Engineer s signatt ,_~..~ Date DHHS SIGNATURE .~. Approved for bedrooms. Disapproved. Conditional approval, for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates ba.';ed only upon the representations given in paragraph 5 above by an independent p rofessional engineer registered in the State of Alaska. The DH HS 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 ()missions in the professional engineer's work. 72~)25(Rov. t/91) Back MOA~f21 Municipality of Anchorage /~ Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:Lot 16, Block 3, Southpark Addle2 Parce D ~'~q~l~[~E~(~-.~(~ A. Well Data Well type Co~±t7 Well If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date completed Cased to g.p.m. FROM WELL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 1000 '£t. -l- Absorption field on lot 1000 £t. + Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform Nitrate Date of sample: B, SEPTIC/HOLDING TANK DATA Date installed 8/87 Cleanouts (Y/N). ¥ High water alarm (Y/N) N Driller Casing height Wires properly protected (Y/N) AT INSPECTION MUNICIPALIIY OF ANCHO~L~ [NVIKuNMENTAL SERVICI~S DIVISION ~'"E~ 0 4 1994 g.p.m. RECEIVED ; On adjacent lots 1000 ft, + ; On adjacent lots 1000 ft. + Public sewer manhole/cleanout Petroleum tank None Collected by: Tank size Foundation cleanout (Y/N) Date of pumping Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: On adjacent lots Absorption field Nc~e observed Well(s) on lot To property line 25' Sudace water/drainage Other bacteria 1250 gallons Compartments 2 ¥ ,Depression (Y/N) Alarm tested (Y/N) N Isaacs Pumpin~ Service 7.5' N Foundation 12.5 ' Water main/service line 160' 72-026 (3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level __ Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed 8/87 Length 55 3 Total absorption area __ Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) On adjacent lots Width 660 sq. ft, CIeanout present (Y/N) 2-4-94 Results (pass/fail) 58" from G.L. Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Soil rating (GPD/FF) 152 sq. ft. Gravel thickness 6 Y Pass N Sudace water System type T~ench ~q~e Total depth 10.5' Depression over field (Y/N) N for 4 Bedrooms Aftertest 55" from G.L. If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Weilonlot N/A To building foundation 20' Onadjacent lots 100 £I:. Surface water None observed Curtain drain None obse:czed E, ENGINEER'S CERTIFICATION I certify that I have checked, verified, or co~formed to all MOA and HAA guidelines in // On adjacent lots N/A Property line 25 ' To existing or abandoned system on lot N/A Cutbank None Water main/service line 167,5' Driveway, parking/vehicle storage area 42.5 ' HAA Fee $ Date of Payment Receipt Number 72-026 f3/~3~' Sack Waiver Fee $ Date of Payment Receipt Number this inspection. MUNICIPALITY OF ANCHORAGE ON-SITE WASTEWA TER DISPOSAL SYSTEM FIELD AUDIT Legal Description ~ O~- Site Address ] ~ ~ / 0 DoCument Type /L~, /~ , ICL/< ~ ~ o ~ T/4 Engineer/Firm .51/~ ?..~ o, IV Excavator Inspection Findings /c /~ / Z F I'~./ E F ~ L ~ E ~ ~ ~ /~ CpFLa¢~T,, ,. Initials THE 1463-5-92 0~-i7-1g~4 iS:J4 ~-0~58~1561 ENVIROMENTAL MANAGEMENT INC. P.0~/0~ TOT P~, P,01 TIME ~TiM~ D[PTH ~ O Z O ~ 0 ~G ~G ~G/~D ~¢ ,. W .... TOTF~- P.01 MUNiCiPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION ,xlOV 0 1987 RECEIVED WELL DATA Well Classification MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: /--~'J % If A, B, C, D.E.C. Approved (Y/N) %~ '-~C)~ Depth of Grouting J~ ~ ,~JCt Pump Set At '~ J~* (~1 Sanitary Seal on Casing (Y/N) '~ y Depression Around Wellhead (Y/N) ~1~ Well Log Prese~.nt (Y/N) I' Date Completed Total Depth ~ Case~ to Static Water Level . ~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot ~"'~f~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ql~ ; On Adjoining Lots To Nearest Public Sewer Line ~/~1~ To Nearest Public Sewer Cleanout/Manhole~'~1_-- ~ I [/ . I.~l~"~t~To Nearest Sewer Service Line on. Lot~ '~,~ '~"~'/I~' Water sample Collected by '..,.~ ,~ ,I~."~ ; Date Water Sample Test Results Comments ~;)/LO~Of~2.'~/ /,.¢ .~;'¢~.V~"'~ ~)/ 4 ~4~,q~ ~ I~/ B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) y Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding :Tank High-Water Alarm (Y/N) Size ./Z.~"~ ~/- No, of Compartments Z. y Foundation Cleanout (Y/N) y Date Last Pumped ~ ; for Temporary Holding Tank Permit (Y/N) /~/~ Separation Distances from Septic/Holding Tank: To water-Supply Well To Property Line ,~' To Water Main/Service Line Course Comments ~'~--'~ 7'} To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026{I 1/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ,~/~ Width of Field ~ Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To water-supply Well /~/A ~ ., TyR,.e of System Design Length of Field ..~ Depth of Field Gravel Bed Thickness ' ~" / ~"/-- 2. Standpipes Present (Y/N) Date of Last Adequacy Test /'g~"'~ To Property Line Y To Building Foundation Lot / To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ; On Adjoining Lots To Existing or Abandoned System on To Cutbank (if present) ! I00 ~- D. LIFT STATION Date Installed ~['~/ ~ Size in Gallons "Pump On" Level at ~ High Water Alarm Level at Tested for · Electrical Codes (Y/N) Comments Dimensions Manhole/Access {Y/N) '-'"'- "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** Signedl certify t~~checked,~_ verified,~ateOr conformed to all Company f~t~).PJ¢ ~L~-'~J/-,&(.. MOA No. ReceiptNo. ~' ~O/-- OOC) ~ Dateof Payment // -- '/--~ 7 Amount: $ ~ ~ ~ Page 2 of 2 72-026 (11/84} MOA, and~HAA guidelines in effect on the date of this inspection. //1¢/8 7 Engineer's Seal " STEVE COWPER, GOVERNOR DEPT. OF ENVIRONMENTAL CONSERVATION// i' ANCHORAGE/WESTERN DISTRICT OFFICE / 3601 "C" STREET, SUITE 1334 ANCHORAGE, ALASKA 99503 563-6775 DATE: 11-04-87 PWSID ~: 213475 To Whom It May Concern: ~ccording to the records on ?ile tn this o??ice, TERRACE S/D ADD. ~2 Water System is in State o? Alaska Drinking Water Regulations. the compliance with the :.Ronald S, Klein '" Environmental Field O??icer