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HomeMy WebLinkAboutSTONY BROOK BLK 2 LT 2Onsite File Stony Brook Block 2 Lot 2 #015-511-18 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP221291 PID Number: 015-511-18 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name GREG FISCHER ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ound Site Address 6861 MACBETH ANCHORAGE, AK El Other Phone Number of Bedrooms Soil Rating original grade 907-227-2644 4 J`rotaldepth GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft, Gravel depth beneath pipe Ft. Subdivision Block Loi STONY BROOK; BLOCK 2, LOT 2 Fill added above original gr a Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic I Absorption Lift Station I Holding Sewer To�talorption area Number of trenches Dist. between trenches FromTank Field Tank LineFt2 Ft. Well 100,+ TANK 9 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER TANK Capacity 1500 Gal. Surface Water 100'+ I Material Number of compartments Li + I NA HDPE 2 Foundation *10'+I LIFT STATION Manufacturer Capacity Remarks OLD TANK DECOMMISSIONED PER UPC Gal. PER CONTRACTOR *5'+ TO SECOND FLOOR DECK SUPPORT Alarm location Electrical installed by Installer PIPE MATERIAL House to tank D3034 Tankto D3034 A+ HOME SERVICES Drainfield D3034/EXISTING CO/MTD3034 Inspector GEG AND MOA BENCH MARK (Assumed elevation) 97.46 ft Inspdection 15i 9/14/2022 - Location and description 2nd TOP OF MH 3rd - 41h _ ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Qo600p�� _ Date o . �� Op �... �...� ....................o f� �, %�` eY A'`S' ess. Septic System �� Approvei, 1..._. Date p0 CE �9 3 p O Note: this approval does not include well permit requirements.�p P�DfeSsiDf\ \ #AECC884 krvcv uotvu /o/ PERMIT OSP221291 RECORD DRAWING TOP OF MANHOLE = 97.46 FINAL GRADE = 96.54-97.29 TOP OF TANK AT INTLET = 91.86 --\ 11 11 ( I 7- TOP OF TANK AT OUTLET = 91.86 INVERT OF BUNG AT INLET = 91.1 NEW 1500 GALLON H.D.P.E. SEPTIC TANK INVERT OF BUNG AT OUTLET = 91.01 olr Tp ENGINEERING =SALES -CONSULTING 3701 E. TUDOR ROAD, SUITE 101 -ANCHORAGE, AK 99507 -PHONE (907) 337.6179' FAX (907)338-3246 ' WEBSITE: vrcnv.9amess gig ,ring.com PREPARED FOR: PHONE NUMBER: PAGE NUMBER: GREG FISCHER 907-227-2644 3 OF 3 LEGAL DESCRIPTION: DRAWN BY: STONY BROOK; BLOCK 2, LOT 2 D.J.G. TYPE OF WORK: DATE: �,_ SEPTIC TANK PROFILE 10/5/2022 PARCEL ID NUMBER: 015-511-18 s�'wssw-%4 ®0 Aw _ °o 1 •. �......t.... �i ...t... i :: ra 0 �^ 1j Je reyA Gar`ess•• :•10.7 o 00 c��� •. If C -795 AV LICENSE ®� ®iS®®�®®®® #AECC884 / PERMIT NUMBER: PARCEL ID NUMBER: OSP221291 DRAWINGRECORD 015-511-18 A B 6BL1 16.1 37.0 CONTRACTOR DID NOT HAVE LATERAL LINE LOCATED BY A PROFESSIONAL PRIOR TO DBL2 16.8 37.2 INSTALLATION. HOWEVER, THE DRAINFIELD WAS EXPOSED TO THE NORTH DURING THE MH1 18.3 38.1 INSTALLATION (CONFIRMING THE 5' SEPARATION DISTANCE), BUT NOT THE WEST. IN SHORT, THE ST1 22.4 41.0 SEPARATION FROM TANK TO FIELD ON THE WEST SIDE IS UNKNOWN. IS ASSUMED TO BE 5'+ BASED DBL3 23.4 41.6 UPON THE DRAINFIELD CLEANOUT LOCATIONS, MOA RECORD DRAWING AND TRENCH LENGTHS. DBL4 1 24.1 1 42.2 -91 NOTE: PIPE LOCATIONS ARE SHOWN PER GEG SHOTS STONY BROOK BLK 2 LT 3 TAKEN WITH LEICA DISTO S910 LASER DISTANCE METER. SWING -TIES TO VACANT HOUSE CORNERS WERE GENERATED IN AUTOCAD. APPROXIMATE LOCATION OF EXISTING NEW 1500 GALLON HDPE GREER TANK B EXISTING 4 BEDROOM HOUSE STONY BROOK / n, BLK 2 LT 1 DRIVEWAY a SCALE: / •y..•_..r 1"=30' t 10:111t *JOLKITAVA 11 �___ --•_- _.v. �.. ...�..u_ . _.�_, ��_�.. ,,..._s_.. � __..._.��. �.. , °�,_ �__._. ,..�..,. _ �,_... �.._ ,..w 4t ��•' ��� �®gyp •: _ T .......... ,9 _ ........ :............::.....0 E�tIGINEERING SAkES CONSUL��P`�rG r ` `4 a s 3701 E. TUDOR ROAD, SUIT 101 -ANCHORAGE. ALASKA• HONE(907)337-61 9'V% SITE: wwngamessengineen.ngmm z w•o•. • ••.n..ti......... •..�.... '...•... PREPARED FOR: PHONE NUMBER: PAGE NUMBER: ®� •' J-ffrey A. &Arness GREG FISCHER 907-227-2644 2 OF 3 C -79 2i PROJECTILEGALDESCRIPTION: ® t() j7 2�;�\p DRAWN BY: ®® �`�P ••• .�• <` 14 STONY BROOK; BLOCK 2, LOT 2 D.J.G. ®® FD.ppp"'��j',,•••••• l TYPE OF WORK: DATE: SE a®11VFESS, �®®® SEPTIC SYSTEM DESIGN UPGRADE 10/20/2022 LICENSE 84 °�®® South Lakewood Hills Subd. Lot 5 Lot 6 1 N89 -56-30"W 1 186.00 10' UtilitV Easement — — — — — — — — — — — — — — — — — — F - 0 LO Lot 3 a)El a) U) M W Lot 2 0 CD Z W Lot 7 8172T Lot 3 . _�_\ t�_, I Septic vent (typ)—, 00 Septic vent Lot 4 12 AN U*J CO 0"10. I % I CP o ;P 3.00 deck OF 44 4 0- 1-p Storage S, 2.0 OH w0o, 49th o. Ci• 0 °a PsQr 00 P_4 00 ..... Lot 1 -ID, Ret. wall 4 rh lizabeth L 0 5 r 0 1, Wolatka 8036 - LS • (9CIP . ;�7 ACT AW PZP Well "OFESS104*L N N, 0 RECERTIFIED 9-22-22 Chain link fence AS -BUILT NO CORNERS SET THIS DATE I hereby certify that I have performed a Mortgagee's inspection in accordance with ASPLSStandards of the following described property: LOT 2, BLOCK 2, STONY BROOK SUBDIVISION Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on the 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 this 13th day of December , 1996. EASEMENTS OF RECORD, OTHER THAN FRED WALATKA & ASSOCIATES, L.L.C. Recert 7-06-22 THOSE SHOWN ON THE RECORDED Engineers and Surveyors FB 22-1, pg 45-47 PLAT ARE NOT SHOWN HEREON 907-248-1666 BE BEP UNLESS OTHERWISE NOTED. This drawing is a representation of conditions found at the time the mortgage location survey was performed. This document does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained on this drawing shall not be used to establish any fence. structure or other improvements. This drawing shall only be used for a single property transaction. Use of this drawing by the original client or by others at a later date without the consent of Elizabeth L. Walatka is a violation of Federal Copyright law. Unless gross negligence is discovered, the liability extent of the preparer is limited to the amount of fees collected for services in preparation of this product. MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http:JAvww.munLorg1onsite Permit Number: OSP221291 Work Type: SepticTank Upgrade Tax Code Number: 01551118000 Site Legal Address: STONY BROOK BLK 2 LT 2 G:2639 Site Mailing Address: 6861 MACBETH DR, Anchorage Owner: FISCHER GREG & Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: Effective Date: Expiration Date: ,joen t Qn Department Lot Size in Sq Ft: Total Bedrooms: 8/4/2022 8/4/2023 70408 El Disposal Field 0 Septic Tank El Holding Tank El Privy 11 Private Well 0 Water Storage All construction shall be in accordance with: 1. The attached approved design. Z All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (1 8AAC72) and Drinking Water Regulations (1 8AAC80) 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 B Issued By: Date: )'GOOL Date: iadoz� MUIN110PAUTY .0, bliz ANCHORAGE Development Services Department ��` � ` � `�� Phone. 907-343-7904 On -Site Water & Wastewater Section Fax. 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 015-511-18 Property owner(s) GREG FISCHER Mailing address Site address 6861 MACBETH *ANCHORAGE, AK Day phone 907-227-2644 Legal description (Sub'd., Block & Lot) STONY BROOK; BLOCK 2, LOT 2 Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Date of Payment: Absorption Field ❑ Initial ft Single Family (SF) ❑ Septic Tank [] Upgrade Q (w/wo AD U) Holding Tank El Renewal Renewal ❑ (D) ❑ Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 4,2 2 5 Waiver Fees: Date of Payment: _ 7 I a5 2 0 � �2 Date of Payment: Receipt Number: 033 666 Receipt Number: Permit No. OSP ) 0 91 Waiver No. GADevelopment Services\Building Safety\On Site Water and WastewaterTormsUient FormsTermit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221291, Rebecca Carroll, 08/04/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221291, Rebecca Carroll, 08/04/22 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221291, Rebecca Carroll, 08/04/22 South Lakewood Hills Subd. Lot 5 Lot 6 1 Lot 3 .1 -0 0 co CD 0 0 0 ou Easement I S78'03_0(0)1_1'C___ Lot 4 1 123.00 Im F AM 06), AW A 9th 4 go I *'* 00 '000 00 Lot 1 00 'T_-,.,�izabeth L Wola'tka W oaf 00 8036 - LS • af AM zo, Aral RECERTIFIED 7-06-22PA; 7 /1 - 2--ov— 2__ AS -BUILT NO CORNERS SET THIS DATE I hereby certify that I have performed a Mortgagee's inspection in accordance with ASPLS Standards of the following described property: LOT 2, BLOCK 2, STONY BROOK SUBDIVISION Anchorage Recording Precinct, Alaska, and that the improvements situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements on the 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 this — 13th -day of December 1996. FRED WALATKA & ASSOCIATES, L.L.C. 907-248-1666 Engineers and Surveyors Lot 7 Lot 3 F."Irm. SCALE: 1 60' Septic vent (typ) 0"\ 2.0 OH 15" Co deck "ro Storage 2.0 OH '0 Q 1Z; Ret. wall Well Chain link fence-\/ EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE RECORDED F8 22-1, pg 45-47 PLAT ARE NOT SHOWN HEREON BE BEP UNLESS OTHERWISE NOTED, This drawing is a representation of conditions found at the time the mortgage location survey was performed. This document does not constitute a boundary survey and Is subject to any inaccuracies that a subsequent boundary survey may disclose. The Information contained on this drawing shall not be used to establish any fence. structure or other improvements. This drawing shall only be used for a single property transaction. Use of this drawing by the original client or by others at a later date without the consent of Elizabeth L. Walatka is a violation of Federal Copyright law. Unless gross negligence Is discovered, the liability extent of the preparer is limited to the amount of fees collected for services in preparation of this product.  MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT , PHONE ~NEIN L. zT o4oll/ [~]UPGRADE ~AILING ADDRESS DESCRIPTION LOCAtiON I -- ( ~ V Ne. OF BEDR~S DISTANCE TO: IWell /m'~ IAb'°~nt'°' ~r~" Dwel]ing P~~( ~n  Manufacturer ' Mater%~x No. of compart~ts "'"'~r~'~ ,F HOME,DE: Inside length .... Width Liquid depth ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O ~ Manufacturer Material Liquid capacity in gallons O Well Foundation Nearest lot line ~ DISTANCE TO: 1~+ -' PE~[ ~r~ ~_~m~ ~ No. of lines / Length of ea~ Total length of li~s. Trench wldth~ches~ Distance between lines ~ Top of tile to finish grade ~, Material beneath tile qZinches Total effective ~Tn~, Length Width ' Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area m Well Building foundation Nearest lot ~ine ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE M ERIALS , INSTARLE ~ L REMARKS i ~ 72-013 (Rev. 3/78) o,t., -. / '" /. -7-- ~ .'T.~ L~-~ Time' Depth IViaterial$ and Remarks Length Length · 633 EAST 81ST AVENUE ANCHORAGE, ALASKA 99502 SUBSURFACE EXPLORATION Shift Report of Operations /- Name ~. ,,.. .... Static Level~,~{:; GPM-YIELD fi'- ~ ' i ~, .:; I: b ~:~,', , ,', , ~'."" 7'6; >,-~ ~--~ i / '7' ~ :-;':. /:/~ ~ r.. 2. f'" ,1~ o- ,/~; / .¢--,, ': ?,,., / : DRILLER' ' ~ ~ INSPECTOR MUNICIPALITY OF ~NCHORAGE Department ~ Health and Envlronmental~otection 825 ~ Street, Anchorage, AK. >3~50t 264-4720 * * * HANDWRITTEN PERMIT * * * Permit ~ 8Do~~ , , - , ~ ON-SSTE SEWER PERMIT Location: Legal-Description: ~'T~ Type of Soil Absorption System Is: Trench: Drainfield: Maximum Number of Bedrooms: sr o u Lot si e: / Seepage Bed: __ Holding Tank: soil Rating(sq.ft/br) /~-- The Required Size of the Soil Absorption System Is:' ~7~ ' ' ' LENGTH 7g GRAVEL DEPTH .~.Y:z~- WIDTH DEPTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(MErL-'D-rI~3) TANK SIZE = __L_~O GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 3L 1 9 8 3 * * * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the ~sidence is remodeled to include more that ~bedro/o~s. Signe~: ~ Issued by: ,, A~plicant Date: SWP/024 (1/81) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL/~t~OTECTION Street, Anchorage, Alaska 99501 2~-~720 825 SOILS LOG - PERCOLATION'TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 5 6 7 9 10 11 12 13- 14- 15- 16- 17- 18- 19- 20 COMMENTS SLOPE SITE PLAN P E IF YES, AT WHAT DEPTH? "~ Gross Net Depth to Net Reading Date Time Time Water Drop ¢tt~0 5.'5'2 , '-/'7 / ~?,/D-Z¢ ~ ;~? /of~n , ~o ' 17 ~ ,'~o /o ~ ,5~ ' i/ ~z~ ~ ,' ~ ' d't PERCOLATION RATE TEST R~N"ET~EEN 4;'~. FT A.D ~ ~T PERFORMED BY: 72-008 (6/79) · ~/_ Yh~f~f2m 5t 1 ti? Development Services Department , On -Site Water & Wastewater Section Certificate of On -Site Systems Approval Parcel I.D. 015-511-18 Legal description STONY BROOK BILK 2 LT 2 Site address 6861 MACBETH DR Expiration Date: Current property owner(s) FISCHER GREG &IMM TERESA A Phone: 907-343-7904 Fax: 907-343-7997 6/29/2024 X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: By: Original Certificate Date: 6/28/2024 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other iel r� to �-o, � oCh'© i W ct i'Llec O:ff ol" � COSA Approval—June 2022 MUNICIPALITY OF ANCHORAGE Development Services Department- Phone:907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 015-511-18 Complete legal description Stony Brook 62 L2 Location (site address) 6861 Macbeth Drive *Anchorage Current property owner(s) Greg Fischer 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS Day phone 907-227-2644 3. TYPE OF WATER SUPPLY: 0 Private Well Fj Private Well serving 2 dwelling units F-1 Private Well serving 3+ dwelling units El Community Well or Public El Water Storage 4. TYPE OF WASTEWATER DISPOSAL: A] Private Septic Fl Private Septic serving 2 dwelling units F] Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: F] Steel X Plastic El Concrete El Fiberglass Age 2 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: [] AWWTS F-1 Bed [3 Deep Trench Iff Wide Trench R Seepage Pit Waiver request for: Expedited review requested:, Distance: � By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ SSV 3,30 Waiver Fee $ Date ofPayment -&-5-Zq C/z 7 A V y L2� _ Date of Payment COSA #. y5., -7,q[-2-19 Waiver # 0 .� V a q ) 0 2-f, COSA Applicatb%June 2022 � o , Legal Description: Stony Brook B2 L2 Parcel ID: 015-511-18 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _ A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 11/17/1983 Total depth 210 ft Cased to unk ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 6/22/22 Static water level at beginning of test 193.8 ft. Comments B. TANK DATA Measured operating fluid level in septic tank Date of pumping 6/26/24 ❑ Required maintenance completed, if AWWTS Comments: plastic & less thatn 2 years old D. ABSORPTION FIELD DATA Which system tested (date installed) 9/19/1983 ❑ ALL standpipes present per record drawing Total measured depth from grade *11.3ft (max) Measured depth to pipe invert from grade **8.2 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ' ❑ Presoaked required if V (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Well production at time of test 5.3+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes FOR No FN Coliform bacteria is Negative Nitrate 1.72 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L * Arsenic less than MRL (ND) Collected by Garness Engineering Group Date 6/13/24 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 6/22/22 Results 0 Pass Fluid depth prior to test 0 in Water added 882 gal New fluid depth ****9 in Elapsed time 145 min Final fluid depth 1 in Absorption rate 600+ gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 42 in Effective depth used 22.5 in Effective depth remaining 19.5 in 1 14 Comments/Deficiencies: ` In new MT (on North/south leg of trench) installed to depth of 46.5' hw invert after adequacy test was performed ** At C05 *** Old MT/Sump used for test (extends 20.5" below invert) **** 2" in MT after first 158 gallons COSA Checklist June 2022 G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Gayness Engineering Group LTD. (GEG) Phone 907-337-6179 Engineer's Printed Naive Jeffrey A. Garness Date In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry oo6poOp" practices. The reported results describe the condition of the system/s on the date/s of the evaluation. o F Separation distances were measured to readily identifiable features. Hidden defects or encroachments may �Q exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including (but not limited to) soil' conditions, groundwater levels (that may fluctuate p during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing / DO the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not ......... . . . guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding O the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the currents stems fail to perform Gare Y P f y A. Garness: adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG dC 9, : CE -7953 p� to perform the evaluation. Reliance upon the information provided in this report by any other person or party Q (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. �Q P e COSH Checklist June 2022 LICENSE % ofess%°oma #AECC884 E. SEPARATION DISTANCES' From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) 1 Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100' Fol Yes if No ft Q Yes if No ft Neighboring Tank > 100' Q Yes if No ft Private Sewer/Septic Line > 25' [0] Yes if No ft Absorption Field on Lot > 100' E Yes if No ft Holding Tank > 100' QYes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' QYes if No ft � Mm Yes if No ft •� ' Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' EYes if No ft w- -•------Q.. es if No ft �.�--3�.-,�_._--�:_-�--�_.u.i-� e,ra� ��a -"may z.:•�-�,�� z �, ❑ N/A- Served by Comm ity Well (not on lot) or Public Water t-" From Septic/Holding Tank and AbsorptioCield(s) n Lot to: (Please enter distances if less than required)Building Foundations> 10' ❑ Yes iff Surface Water > 100' Q Yes if No ft , Tank to Property Line > 5' Fm_1 Yes if No ft Wells on Adjacent Lots: m Field to Property Line > 10' 0° Yes if No ft Private Wells > 100' 112-1 Yes if No ft 1 Water Main > 10'0 Yes if No ft Community Wells > 200' FE -1 Yes if No m r ft Water Service Line > 10' Yes if No ft If tank or field is under driveway comment below r F. ENGINEER'S COMMENTS *Estimated from end of drainfield to building foundation - Drainfield runs under deck (approximately 15" from monitoring tube to deck post). } Tank is 5'+ from support from 2nd story deck. Both Mts were dry on 6/27/24. Drainfield is believed to be lower in elevation than footing, so no separation distance concerns G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Gayness Engineering Group LTD. (GEG) Phone 907-337-6179 Engineer's Printed Naive Jeffrey A. Garness Date In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry oo6poOp" practices. The reported results describe the condition of the system/s on the date/s of the evaluation. o F Separation distances were measured to readily identifiable features. Hidden defects or encroachments may �Q exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including (but not limited to) soil' conditions, groundwater levels (that may fluctuate p during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing / DO the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not ......... . . . guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding O the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the currents stems fail to perform Gare Y P f y A. Garness: adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG dC 9, : CE -7953 p� to perform the evaluation. Reliance upon the information provided in this report by any other person or party Q (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. �Q P e COSH Checklist June 2022 LICENSE % ofess%°oma #AECC884 Mun'c'pal'ty of Anchorage I3 pntmnt , P.O. Box 196650 0 4700 Elmore Road Anchoraqe, Alaska 99519-6650 0 (907) 343-7904 0 Fax (907) 343-7997 http://www.muni.org/Onsite Development iC Division On -Site Nater and Wastewater Program * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV241026 COSA#:OSC241219 Permit#: PID#: 015-511-18 Legal Description: STONY BROOK BLK 2 LT 2 Engineer: Garness Engineering Group 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 6.0 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. Waiver is Granted: X Waiver is not Granted: Date: _�ct� 2� Approved by: L4�&Z��L., Name of Reviewer .E` **** VARIAN C EiWAIVE R REVIEW **** 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. # ~,\Z)~ ~\\ _ \f~/ HAA # ~-~ 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent ~c~¢ Address ~111 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: individual on-site ~ Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72q325 (Rev. 1191) Front MOA #2! STATEMI-'NT 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 applicstion 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. NameofFirm F /~'f/'~£ 7"~ch.,~ ~c,[ _~r'w'¢a./ Phone Address )y~O ~cAo ~/~ ~c ~or~.. ~ Engineer's signature ¢~ ~ ~ Date DHHS SIGNATURE Approved for ¢ Disapproved. Conditional approval for bedrooms. bedrooms with the following stipulations: Additional Comments Date 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 D H 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 omissions in the professional engineer's work. 72~Y25 (Rev. 1191) Back MOA ~21 Legal Description: A. WELL DATA Health Authority Approval Checklist ~'/.¢,n,y /~t-~c,/,~.~/_.~ ParcelI.D.: Bo Co Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES ....Environmental Services Division · 825 L Street, Room 502 · Anchorage, Alaska 99501e (907) 34'3UN~ila~LIT¥ OF ANCHOV./~ ENVIRONMENTAL ~ERVICES OCT 2 5 199G R ¢EIVED Well type Log pmscut Total depth Sanitary seal IfA, B, or C, attach ADEC letter. ADEC water system number Date completed t I / t ? I ,~ ~ Cased to '~ t O' Casing height (above ground) Wires properly protected (Y/N) Date of test Static water level I 7 eg ' Well production ~' WATER SAMPLE RESULTS: Coliform dY Col /too ~,~ FROM WELL LOG AT INSPECTION I~.' g.p.m. ~,~ + · g.p.m. Nitrate Otherbacteria plon~ reffo f /','~ Dateofsumple: lO I/Fl)o~ Collectedby: t~'la/-A:? 7-ec,~ _C~'c SEPTIC/ItOLDING TANK DATA Date installed ~/8.~ Tank size ~ Ntunber of Compartments Foundation cleanout (Y/N) 'f Depression (Y/N) N High water alarm (Y/N) bt. ,4. Date of Pmnping IFJ/'ZY/go/ Pumper _Z-_c',~,~ar ABSORPTION FIELD DATA Date installed 9 / ~-3 Length ~0' Width Effective absorption area 7¥/ ~' Date of adequacy test Iv It Ifil 9ff' Results (Pass/Fall) fiat'.., For "/ bedrooms Fluid depth in absorption field before test 0n.); 3~ Immediatelyafier?e3 gal. wateradded (in.): Fluid depth :~K t/z (ins.) Minutes later: I ~ K Absorption rate: ~ ,b~'~O g.p.d. Peroxide treatment (past l2 months),(Y/Ixr) Ale,ne ~no~.,~, Ifyes, givedate b/,~. Soilrating (g.p.d./ll2orR2/bdrm) I~~- ot Systemtype 0-' ~,,o'e -/TeaC4 Gravel thickness below pipe ¥ ~* Total depth / :~ ,,V / Monitoring Tube present(Y/N) 'r' Depression over field (Y/N) /a D. LIFr STATION /~, A. Date ins~ailed Manhole/Access (Y/N) High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line Size in gallons "Pump on" level at* "Pump off' level at* On adjacent lots ~> loc, ' On adjacent lots '~. loc,, ' Public sewer manhole/cleanout Lift station N.A. IV. A. SEPARATION DISTANCES FROM SEPTIC, HOLDING TANK ON LOT TO: Building foundation t t' Property line Y,5" Absorption field I I. ~- ' Water main/service line' '~ to' Surface water/drainage ~ t oo' Wells on adjacent lots > too ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ~ la' Surfacewater > la'O~ Curtain drain_Non e see~, Wells on afljacent lots ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records that the abobe s~stems dre __ Proper~Line ES' Water main/service line Driveway, parking/vehicle storage area ~. tOO' in conformance with MOA HA~ guidelines in effect on this date. Engineer's Nmne "7'"h,r~d~,r'e /~. t-fc, o'~¢ '~ Engineer, Ln.g ,S~/Iere. ' Date Ir-2/Z-~196 HAAFee $ ~F--~ ~ Date of Payment _/T) /~k~ Receipt Number_ ~X~'O (/Q'~ f'5'~w) Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number CT&E ESI DNCHORDGE ~ ~073451~55 N0.965 CT&E Environmental Services Inc. Laboratory Division ~' ~~'~ Laboratory Analysis Report CT&E Ref.# Client Name Project Namd# Client Sample ID Matrix Oedeced By PWSID 965600001 Flattop Teclmical Sro. L2 1t2 Stony Brooks S/D L2 B2 Stony Brooks S/D Drinking Water Sanlp]c Reolarks: Client PO# Printed Date/Thne 10/21/96 20:29 Collected Dnte/Time 10/16/96 14:30 Recelved Date/Time 10/16/96 15:05 Technical Director: Stephen C, Ede Released B~ ~~ At to~ab[o Prop Ana[ysi~ 200 W Potter Drive. Anchoraue. AK 99518-1606 -- Tel: {907) 562-2343 Fax: {907) 561-5301 3180 Pager Road, Fairbanks, AK 99709-5471 -- Tel: (907) 474-8656 Fax: {907) 474-9685 ENV[RONt~ENTAL FACIL{TIES IN ALASKA. CAL{FORNIA, FLORIDA, iLLINOIS, I~IARYLAND, MICHIGAN. MISSOURI, NEW JERSEY, OHtO, WE~T VIRGINIA 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. # ~¢'3~~ ~,~\- \0~ GENERAL INFORMATION Complete legal description Location (site address or directions) /o86/ Y//l¢ SETH Property owner H~S~ALL Mailing address l~ox ~ltH'~ Lending agency Mailing address Day phone 272. Day phone ,¢¢ Day phone Address Unless otherwise requested, HAA will be held for pickupo 2. NUMBER OF BEDROOMS: /¢ 3. TYPE OF WATER SUPPLY: Individual well v/'' Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site ":" ' ' Hoi~ingtank Community on-site Public sewer ' NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72q)25 (Rev. 1/91) Front MOA#21 sluewwoo leUOB!ppv :suo!l~lndBs I~iU!MOIIOJ eq3 qliM 'SLUOOJpaq JOJ lsAoJdde I'aUO!~.!puoo · peAoJddeBlC] . I~=I=INIgN=1 AG NOI/O=IdSNI dO J.N::IIN=IJ.y.LS '~ Municipality of Anchorage ~i~ Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT 2, BLK 2~ STaN¥ ~Rool< Parcel I.D. A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. Date completed Cased to .2 Jo ADEC water system number 11//7/~3 Driller Casing height Wires properly protected (Y/N) FROM WELL LOG Date of test I~/t?/~ S Static water level 7~, ' Well flow ~ g.p.m. Pump level AT INSPECTIO~JNiCiPAUTY OF ANCHORAGE I OJ c~5' J '2. ENVIRONMENTAL SERVICES DIVISION R t IVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 128 ~ro C.c. Absorption field on lot >/~ Public sewer main Sewer service line ; On adjacent lots O/oo / ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: t ~/,5-/~ z Nitrate ~/7 ~'~,,~' //-~ Other bacteria Collected by: FZ. Ar T'rOP B. SEPTIC/HOLDING TANK DATA Date installed <~ /~ Cleanouts (Y/N) ~ High water alarm (Y/N) Date of pumping ! ~' / ~'o ,/~ ~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Tank size 125o GAL. Compartments 2. Foundation cleanout (Y/N) Y' Depression (Y/N) N.,~. Alarm tested (Y/N) Iv,/I · Well(s) on lot I;78~ F~ C.O. Onadjacentlots Topropertyline frS" Absorption field Surface water/drainage :~/'oo ~ Foundation iii ?~ P'"~"~' Water main/serviceFine 72o 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) __ __ High water alarm level "Pump on" level at Manufacturer __ Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA Date installed cf[~ Length $O Width ~5- ' Total absorption area '-7 Depressior~ over fi~id' (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot :> To building foundation On adjacent Iots~ 3o Surface water Surface water Curtain drain Soil rating 182 ~'//SDR't4 Gravelthickness .3.5¢ Cleanouts present (Y/N) Date of adequacy test for z~ NoNE K~Ow'N If yes, give date System type Total depth Y On adjacent lots '~¢'oo/ Propertyline ;2~'/ F~6~ To existing or abandoned system on lot N ,/I, Cutbank N,,~. Watermain/serviceline ~$o/ Driveway, parking/vehicle storage area ~ ~ bedrooms (',0 I E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature "~.-,/~-~-¢~-~'~- ~. Engineer's Name '~"~/dc* ~,,~' Date ~ c~ ~ ~, /~ HAA Fee $ Date of Payment Reoeipt N u mber c~X~/._,~'~/ Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev, 3/91 ) Back MOA 21 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99516 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANAL¥OIS RESULTS ~or INVOICE 4{ 59213 Chemlab Ref.~ 92.5477 Sample # 5 ~atrix: WA~ER Client Sample ID PWSID Collected Received Preserved with 2/2 BTONT BROOR NORTH HOSE EIB UA OCT 5 92 @ 13:15 h~s. OCT 5 92 @ 16:25 hzs. Client Name :TLATTOP TECHNICAL SRV Client Acct :ELATTOT BPO# : PO# :HONE RECEIVED Eeq! : Ordered By :TED MOORE Analysis Completed : OCT 7 92 Send Reports to: 1)FLATTOP TECHNICAL SRV 2) Parameter Results Units Method Allowable Limits NITRATE-N 0.47 mE/1 EPA 353.2/300.0 10 Sample ROUTINE SAMPLE COLLECTED BY: CI~IS. 1 Tests Pez£o~med ' See Special In{tructions Above UA=Onavatlable NA- Not Analyzed LT-Less Than, GT-Oreatez Than ~'~ SGS Member of the SGS Group (Soci~t~ G~n~rale de Surveillance) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRCNMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1 o General Information (a) Application Date Legal Description (include lot, block, subdivision, section, township, range) Lot 2 Block ~ Ston~ Brook Subdivision Location (add~ess or directions) Mac Beth Drive (b) Applicants Na~ Michelle, Inc. Telephone 349-2623 (c) (d) Applicants Adcbzess Applicant is (check one) I~nding Institution Buyer~; Other~__~(explain); Lending Institution Address Post Office BOx 11-1235 Anchor~$e, 99511 Te le phone (e) l~al Estate Co. & Agent Address Telephone 2o ~ype of l~sidence Single-Family ~ Number of Bedrooms 3o Water Sup lp~i Individual Well [~ Multi-Family four Other' (describe) Cc~nunity ~ Public Note: If community well system, must hav~ w~itten confirmation f~cm the State Department of Environmmntal Conservation attesting to the legality and status. Is the well adequate for the number of bedrocks specified in this HAA (Y/N) 4o Sewage Disposal Onsite ~ Public ~ Community ~-~ Holding Tar~{ ~--~ Is the wastewate~ disposal system adequate for the number of kedrocms (Y/N) [Pa~e 1 of 2] 2-15-84 5o .Engineering Firm P~_ovidin~ Inspections, Tests, Data and Information I oe~tify that I have checked, verified, or conformed to all FDA HAA Guidelines in effect on the date of this inspection. Signed Date Name of Firm Telephone Address Signed by Date ( ENGINEER SEAL) This Department has received written confirmation from the engineer(A.E.C.S) regarding the conduit on the well casing. This has been completed and this property is now fully approved. 6.DHEP Approval Approved for four b~droc~ Approved ~-~[ Disapproved E~ Te~ms of Conditional Approval Conditional Date July 17,191 ~ne Municipality of Anchorage Department of Health and Envirorm~ntal Protection dces not ~uarantee the continued satisfactory performance of the water supply and/c~ the wastewate~ disposal system° This approval indicates that, as of the validation date shown above, based on the data and information furnished by an engineer registered in the State of Alaska, the w~te= supply and wastewater disposal system is safe and func- tional for the nu~er of bedrcoms and type of structume indicated. ~ (D HEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] 2-15-84 . '.' MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPAR~fMENT OF HEALTH AND flNrv~RONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL C~IFICATE 1. Ger~ral Information Application Date L~//~/~ (a) Legal Dasc~iption (include lot, block, subdivision, Location (address or directions) (b) Applicants Nar~ Applicants Add~ess (c) Applicant is (check one) Lending Institution Buyer ~--~; Other ~_~ (explain); (d) Lending Institution section, township, range) Telephone 9 6-I / Te le ~hone Address (e) I~al Estate Co. & AGent Address Telephone 2. _Ty~e of N~sidence Single-Family Numbe~ of Bedrooms 3. Water Individual Wall Multi-Family ~-~ O'b~er Public y-~ descrike) Note: If cc~?unity ~11 system, must have w~itten confirmation f~cm the State Dapa~t~snt of Environmental Conservation attesting to the legality and status. Is the ~11 adequate for the number of bed~ccms specified in this HAA ~/N) 4. _Sewage Disposal Onsite ~ Public ~ Co~unity ~ Holding TarZ ~ Is the wastewater disposal system adequate fc~ the numbe~ of b~dro~s ) [PaGe 1 of 2] 2-15-84 5. E~gineering Firm Providing_Inspections, Tests, Data and Information I o~rtify that I have checked, verified, c~ ccnfo~n~d to all MDA HAA ~utdslines in effect on the date of this inspection. Date ~/g~ Telephone ~g-~/~ ~-D ~d) S i~ned by (ENGINEER SEAL) 6. DHEP Approval Approved for Approved ~--~ L/ ~edrooms Disapproved ~ Conditional ~ ' '/ The Municipality of Anchorage Depa~ta~nt of Health and Envircnn~ntal Protection dces not guarantee the continued satisfactory performance of the water supply a~d/o~ the wast~water disposal system. This approval indicates that, as of the validation date sh~n above, based on the data and information furnished by an engineer registered in the State of Alaska, the w~ter supply and wastewater disposal system is safe and func- tional fo~ the number of bedrocks and type of structure indicated. (DHEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] 2-15-84 ~UNJcI~ALITY OF ANCHORAGE MUNICIPALITY OF kNCHORAGE (MOA) DEPT, Or HEALTH& ENVlRONi~Nt~L R HEALTH AUTHORITY APPROVAL '(HAA) ,.. · CHECKLIST - FEBRUARY 1984 .: N AR 2:0 ' WELL DATA .;. .. Well ClasSification ("~)O~g_._ If A, B, c~ C, D. EoC. Approved(Y/N) Present/ /N) Date C plet d //- l?- 3 Yie.,ld . Well Total D~pth~Jf3 t Cased to ~O~ Depth of Grouting Static Water Level ~ ' Pump Set At Casing Height Above Ground /,~/ Sanitary Seal on Casing ~/N) Electrical Wiring in Conduit ~'~' Depression Around Wellhead (Y~ Separation Distances frcm Well: To Septic/Holding Tank on Lot ~/~c~ ; On Adjoining Lots ~od/ To Nearest Edge of Absorption Field on Lot ~/~PO/ ; On Adjoining Lots ~/oo To Nearest Public Sewer Line ~J~/~ TO Nearest Public Sewer Cleancut/Manhole ~ &~ To Nearest Sewer Service Line on Lot Water San~ple Collected By ~/~ ; Date ~/f-~ Water Sample Test Results ~ ~/~%~ B. SEPTIC/HOLDING TANK DATA Date Installed c~/~,~ Size /~f-~ NO. of Compartments 2_ Standpipes ~'~/N) Air-tight Caps ~/N) Foundation Cleanout ~N) . Depression over Tank (Y~ Date Last Pumped Pumping/Maintenanc~ Contract on File (Y/N) ~/~-; for Holding Tank High-Wate~ Alarm (Y/N) iL3/z~ Temporary Holding Tank Permit (Y/N) Separation Distances f~om Septic/~o~Li;~g Tank: ! To Building Foundation // To Disposal Field //,3- / To Stream, Pond, Lake, c~ Maj°r Drainage To Water-Supply Well To Property Line To Water Main/Service Line Course Conlnents [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/~2 Width of Field 0 Square Feat of Absorption A~ea Depression over Field 3~ Results of Last Adequacy Test Length of Field ~3)C>' Depth of Field '~ / Gravel Bed Thickness 3,5- / Standpipes ~esent ~) ~te of ~st A~qua~ ~st ~/~ To ~ater-Supply Well To Building Foundation Lot ~g/~ Separation Distance from Absorption Field: ~/~c~ To Property Line /~ To Existing or Abandoned System ca / ; On Adjoining Lots To Wate~ Main/Service Line Ag~_ ', To Cutbank(_~sent To Stream/Pond/Lake/o~ Majo~ D~ainage C~se To D~iveway, Parking A~ea, or Vehicle Storage A~ea Ds LIFT STATION /xJl~,~' Date Installed Size in Gallons "Pump On" Level' at High Water Ala~mLevel at Tested fo~ A///~ Electrical Codes(Y/N) Dimensions Manhole/Access _(.Y_~ ). "Pump Off" Level at ..... ___ Vent. (Y~) ~inu Cycles ~ing Adequa~ ~st. Meets MDA .Cor~0ents ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, 'verified, or conformed to all MOA HAA on the date of this ins,~ection. Signed ~-~__~.~.~--~.~ < ~ ~ / Date KB1/dL/s [Page 2 of 2] 2-15-84