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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
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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
— — — — —
— — — — — — — — — — — — —
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Lot 3 a)El
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Lot 2
0
CD
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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
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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
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ou
Easement
I S78'03_0(0)1_1'C___
Lot 4 1 123.00
Im
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A 9th
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00
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Lot 1
00 'T_-,.,�izabeth L Wola'tka W
oaf
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8036 - LS • af
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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
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