HomeMy WebLinkAboutT11N R3W SEC 14 & 15 BOUND ON N. BY THE VILLAGES TR 18 AND THE S. BY TR 20All
EMN
r a
�� ra
Municipality of Anchorage
Community Development Department Page 1 of 2
On -Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181433 PID Number: 020-311-21 ❑ New 21 Upgrade
Name:
Gerald and Dana Shearer
ABSORPTION FIELD
❑ Deep Trench El Shallow Trench El Bed El Mound
Address
19850 Villages Scenic Parkway
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
GPD/SF
Fl.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Fl.
Subdivision Block Lot
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
11 N 3W 14&15
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft'
Ft.
Well
109.7
N/A
N/A
I N/A
102.1
TANK p Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Anchorage Tank
Capacity
15000al.
Surface Water
100+
N/A
N/A
N/A
Material
Number of compartments
Lot Line
95.9
i N/A
N/A
N/A
STS —
2
NA
Foundation
12.6
N/A
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
N/A
N/A
N/A
N/A
Gal.
Remarks Tank Replace Only
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
Pump make and model
Electrical Inspections performed by
Installer
PIPE MATERIAL House to tank 3034 Tank to
drainfield 3034
Beeks Contracting
Drainfield 3034 Co/MT 3034
Inspector Pannone Engineering Services
BENCH MARK (Assumed elevation) 100ft
Inspections,
dates: 12/14/18 2"d 12/17/18
Location and description
3d 4n,
Top of lowest tear on retaining wall
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
�9»2
OF A( `h
Conditional Approval: Date
,; `�tG X45+ ��
co
TH
/ tteven *Ponnorae•d
814
¢ �l �
Approve �—y Date ( —1
.g
A��
nispeamI mupurt_,-i-it.aoc
A B
T1
Ti 23 19.0
9
2=2 .7 28.0
DCO 1 31.5 31.0
4�
DRAIN FIELD (E)
NO WELLS/SEP-
WITHIN 200'
WELL (E)
ls�
fiQ
4_
3 BR
�\ �1' HOUSE (E)
T 1_�' VV_
vv
DCO
T2
REMOVED 1500g SEPTIC TANK
INSTALLED NEW 1500g SEPTIC TANK
WITH DOUBLE CLEAN OUT
NO WELLS/SEPTiCS
WITHIN
z
200'
Z;:�
on
O;zD D
Z < 0 0
z z
m
q <
0 u
. ........
97.4
1
92.8NEW 1500g 92.6
SEPTIC TANK
PROFILE
NOTES:
PAMONE ENG SVC, LLC
P.O. BOX 100217 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
OF A��kk
.4cS
' ro v
Dote
12/1 8/2018
RECORD DRAWING
Scale
T11 N, R3W, SEC 14&15, BOUND ON N. BY
THE VILLAGES TR 18 AND THE S BY TR 2(�—;�
DRAWN BY:
w .... .. �y
-o - p
S. t I P, o*'n*n ope
DRM
P.I.D. NO
UZO-311-21
PERMIT NO.
GERALD & DANA SHEARER
19850 VILLAGES SCENIC PARKWAY
ANCHORAGE, AK 99516
CE 8149
ACRO�sSO�-
OSP181433
PLAN
Sheet
I OF 1
TARPOINT�—
>
co M
0
M, T" --4
AMW
ID
JPI.
TI
>
CO
7c (y iiR
0 3 0 C ID
CZ 0 s w --0 t-) 3� iFao
z CA 0, 0. Cr (J) (j) 50' Section Line Easement
o"
P CD =r rD m 0
-4
0 0 c L
ID P,
CD rD
Z tj rA :3
2 - 50'
0 Section Line Easement
w M
0
<
M Ij T — — —
m 0- K
:z r) 0 (D
m 71: 00 CD
m
(D (D
3
rL
0 �O
o 00 :3 /U
C) "
0 -3 rD
rT
ISI
<
OorD
0- CD
-7
ca lb
0 Z 0 0 2_ SIX
Ln 0 CL
>
0
-- &
(D
>
o,
(D M
o. -a � 0 b0
0 ccb (v)
3 6- y (D
(D 0 a)
D G) (D
ID 3 �O Z m
CA
(D 8 -, - i- "--
3 :27 < �D - x
rD 0 < LE
>
0
—�AT
@ z z a
> U)
< ID
(D 0 (D (D OJ
:3 U;, -0 :3
0- "01
(D C :3 0 N 0 0 r
(D Ln
(D M
z 150,
M
150, v
0
w n
M rD M
>
=r 00 0) -0
0 Ul ,
I b ;0
0) < (D I rr, -0 Ln
DO 0 rD N
M
> 0
-n
aq (D (D
7K (D 0
LO Ln 0 rD
Ln C) 1
(D
=3
a)
Cp
Z -1Z6
�4
9.0t
CD
O
'I0
Cp
ADAWAUG
Cb
,S- 'E':Cp
p
In
Cr
Cb
gi
IDM 9AUG
MUNiCIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program '
FOBox 1S6650 4700 Elmore Road
Anchorage, Alaska 8S51S-665V Phone: (907)343-78O4 Fax: (9U7)343-7897
»up:/�vxw.munio��noi/o ~ �
On -Site Wastewater Disposal System Permit
PennKNumber DSP181433 Effective Date: 12/6/2018
Work Type: SepticTenkUpgrede Expiration Date: 12/6/2018
Tax Code Number: 02031121000
Site Legal Address: TY1NF<3VVSEC 14&15BOUND ONN.BYTHE VILLAGES TR18AND THE S.BYTR
20 G:3738
Site Mailing Address: 198G0VILLAGES SCENIC PKWY, Anchorage
Owner: SHEARER GERALD B&DANA C Lot Size inSqFt: 207348
Design Engineer: PANNONEENGINEERING SERVICES Total Bedrooms: 3
This permit is for the construction of:
[] Disposal Field 21 Septic Tank [] Holding Tank [l Privy [] Private Well E]Water Storage
All construction shall beinaccordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72)and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.85.Provide notification bycalling (Q07)343'7004(24/7)�
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall baeither:
a. Opened and Closed onthe same day, or
b. Covered, sealed, and heated to prevent freezing
Received B)
Issued By:
Date:
Dote:
. ?)"+I
MUNICIPALITY OF ANCHORA
�DIL1�4N5no
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 020-311-21
Property owner(s) Gerald & Dana Shearer Day phone
Mailing address 19850 Villages Scenic Parkway, Anchorage, AK 99516
Site address 19850 Villages Scenic Parkway
Legal description (Sub'd., Block & Lot) Bound on N. by The Villages Tr 18 and on the S. By Tr 20
Legal description (Township, Range & Section) T1IN, R3W, Sec 14 &15
Lot Size 207,346 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑ Initial ❑
Single Family (SF) ❑X
Septic Tankx❑ Upgrade x❑
(w/wo ADU)
(D) El
Holding Tank ❑ RenewalDuplex
❑
Multiple Dwellings ❑
Privy ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE / 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: 3(4q —
Date of Payment: 12.1 (o 1. L e
Receipt Number: m 23
Permit No. ('31 sPI �1(43--?,-)
Permit App_'-'-:. .:..,:c:
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP181433, Rebecca Carroll, 12/06/18
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP181433, Rebecca Carroll, 12/06/18
NAME
MAILING ADOR ESS
LEGAl_ D ESC'R~ PTION
LOCATION
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-/~ WELL. INSPECTION REPORT
· / ~ ~] UPGRADE
NO. OPBEDROOMS
Well PERMIT NO.
DISTANCE TO:
Manufacturer
-~-
WMth
DISTANCE TO:
Foundation NO,
dth
Total e~)e~ctive ab'sot
PERMIT NO.
DISTANCE TO:
Crib diameter rib depth
: Building foundation
Building foundation er line
DISTANCE TO:
OTHER
Distance to Io[ line
S0ptic tank
PERM'T NO. 21
Absorption area(s)/~)
PIPE MATERIALS
' 3o3H
SOIL TEST RACING
INSTALLER
REMARKS
APPROVED
DATE LEGAL
F:'EF'.H I T I'.,10.
E.,EF f.lllL, fl "ii::' HFFFIITFI
,::,,:-, "L." -, I F. EL. I,
':Z '"lit F:I:TF:[NG ,::_: '3 f I EF..-
THE F'.EQLI i I:;;¢E[:, S i ZE OF' THE SO :!: L. I~ E,::, ~ F .F f J ~ I,I '_:;'-r'STEM :
....... Z :5 THE 13, ~ ~;TFff.~CE E:~?',I "FHE SLIRFFICE OF THE
GF:OUN[:, RND THE EL F T ...11 OF THE
.... ~ ........ ..~
FIN[:, THE E:OTTOM OF THE E:4CFI',,,'FITZON ,:; ~1'.4 FEET>.
F'Ef;;:M I '1" I:IF'F'L ]: CFIi',!T HF:I'-::~; THE F~:E.'EZ;F'O['.4~; I E: ~ L I T"r' -I'T3 I NFORhl
II'.,ESTFILI_FIT]:L-tN lt,I::',FE_.I Z I,L::, OF FIN'./ NELL'.:~; FI[:,.:ff~CEi'.,IT TO
NUME:ER ElF' I..E_,ZL. Lhl~.~ ..... THF:IT THE HF:L.I_ !,.111_1.. ::,EF~.,E.
-I~H i S [:,EF'F:tF~:TMEI'.,IT DUB: Z h,h3 THE:
/HI_, FF~_FEF] T FIN[:' THE
,.,: .,.: .- - ' -,, F~,' ]:S
BFICI<F'ILLII',IG O1:: FII'-.I'T' L:.':'T'STEPI I,I:["I'HOIJT FII.,IFIL II,L, FE...] IOi'..I FINE:, tll li ,I-IL :, T,LI
DEI':'FIF~:THENT HIL. I.. E,E :SLI[L_TECT TO I: F .... E...UTI.
hiIN:[MLIM I)IS'I'FINCE DETI.qEEN I:::1 I, IELL FIN[) RI"J'T' ON--":".;I"f'E SEI.qRGE: DISPOL::;FII_.. Sh'S"FEM IS
::l. EIEI F'E:E'I" FOF?. F:I PP.I',,,'FITE HE:EL (:)K~ :l..SEI 'l'O ;2E,3 FEET FROM FI PLIE:I_.IC HELL [:,E:PENC, ING
UPON THE Th.'F:'I:!! OF:' F'UE~LIC HE:I...L.
MII",U:MIJH I)ISTFIhlCE F'fi'.OM f:l I::'~::~',,,'FITE HELl_ TO ]:;I PRIVI::ITE SEI.,.IEF~: L:[NE ZS 2~!; FEET FIHC,
TO FI COMf'IUNII-"? 'L:;EI, JEF: L:[NE :1:.':_:; 7'5 FE:ET
O'I-HER REQU ]: 'F..'E:MEi",ITS I'"IFI'T' RI::'F'L."¢. SPEC Z F' ~ CFI-r' ]: ON'.'.-:; i::ff.,tD CONSTF:IJE:/' ~ ON E:, I FiGN:FiI,'I':'!; FIF:E
FI',/f:I]:L.I::IBI..E: TO :[i'.,I:E;I..I~;'.['_-': PP. OF'E:R
:[ CEF..'T I Eh' THFIT
i: I Rf'l F'F!MiLIFIR H ITH THE: I;;:EQLIIF.'.'EMENT'S FOP. ON-S;]:TE SEI.4ERS RND I,.IELI_S RS SET
F;'ORTt. I E',h.' THE MLIN~CZF:'FIL:[T'T' OF' FINCHORFIGE.
2: I I,.IILJ_ II'.,ISTFfL. L "I'HE S'T':E;I"EM Z~.,I FIE:CORDFINCE I.,.IZTH THE CODES.
3:: I UNDEEFi:2;-I"FIN[::, I"FIFIT 'I'~I[E OI'.,I-.S~TE: SE:HEP. ?T%TEM I'qFI'T' F:E(;:ILIZRE
F?.E:SZDEhlCE ZS REHO[::,EI_ED TO ~I'.4CL. I_IDE PIORE THFIN ~: E:EDROOMS.
F::I [::' F:'L..} I *~ I:~iEF;~:~ L E:, 5;FIEFIF[:ER
Eh,II...FII:~:GEHEI'.~T IF:' THE:
MUNICIPALITY OF ANCHORAGE
Department ~ Health and Environmenta. ~rotection
825 ~ Street, Anchorage, AK. 99501
Applicant:
WELL
264-4720
* HANDWRITTEN PERMIT * * *
A.N~eR--eN~S4-T~E~ PERMIT
~L~Mailing Address:
Location: ~7
Legal Description: ~// ~,~a<J ~', /_~ ~ ~L~d~ /~-Lot Size:
Type of Soil Absorption System Is:
Trench: Drainfield:
Maximum Number of Bedrooms:
Seepage Bed: Holding Tank:
Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH GRAVEL DEPTH WIDTH
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 grave], between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = 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 withomt 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
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 1 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
I will install the system in accordance with codes.
I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 bedrooms.
(2)
(3)
Applicant
are
Date:
SWP/024(1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchora§e, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
.2
..~3
4
7
8
O.
10-
L/ILL. AG ~S
DATE PEREORMED: ~I U L"/
SLOPE
SITE PLAN
13
14
15
16
17
18
19
2O
2225-[~
£ 25, 1911
S
WAS GROUND WATER ~ O ~)
P
E
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Tired Water Drop
~:15 '1~ ~ ~1 ~
~'IL~ ~ ~-o ~
PERCOLATION RATE ~ .~ (minutes/inch)
, TEST RUN BET~NEEN ~ FT AND ~..:.'.'.'.'.'.'.'.~ FT ~
COMMENTS ~J~ ,,, .,I,,,~,z.~_,~, ~.,~ ~. ~ P~ ~ ~..~ sw~
I
72-008 (6/79)
U
: ~ i i i i i D~PT, O~!H~A~TFi &!
~ii~ ooooooooooooo
F'EF?.hllT Nil]. ,:i
I)EF'FIF'.THEI~.,IT F''~:: HE[FILTH FIN[:, Ei'.,I',,,'IF?.CINHEI'.,!TFIL. "-'qrCFrEC'I"ION
~:.',2:]i " 'L:;TtliEET., I:iNL-:I.~It3~'.FIG,cL, FILE. rE': .d.
~.,-~ ~[~£ IL ~. ..... F" E:~ It~'.'. ti"-1% 'T
',EL1. EI 2 7' ±
RF'F'L :[ E':F~N T
LOCF:]T :[ ON
LEGRL
GERFtL.D 'ZE;HERRER
E?'r' 'v'ILLFIGEE; F:'FIFd:I'EHFI'¥'
T±±N R2ckl SE(;: ±d. & POR.
2429 EFI:E,'I' 17"I'H FI',/ENUE 9951;¢4. 2'7::L-d. S82
15 LOT --fi;]~ZE ±EIIEIEI¢ZIE~ ~I;!L.IFIF',i:E FEET
PIlNIPII.IM I:>]:STRNCE E~ETI,JE:EN Ft F.IELL_ Ffl'.,IE'., FIN"r' ON'-Si"FE '_::;EHFIGE DISF:'OSRL .'.5"r'STEH I:5
:~.E~E) F[':-.FT FOR FI F:'E[',,"RTE NELL OF: ±SE~ TEl 2EIEI FEET F'ROId R PUBLIC I.,.IELL. DEPENDING
UF'ON THE: T'T'F'E (:iF' PUE[LIC: HEL. I .....
I"lI[',l:[FIUfd [:,ISTRNC:E FRO['I F:I F'R:[',/FITE HELL 'FO I::1 PRIVF:ITE .?.;EklER LINE:
'TO R E:OHHUNIT'¢ :SEHEF.' L]:t",IE I'--q 7'5 FEE-I-.
14ELL L. OG~; FIRE ~:EI]:!I..J[[F,;~E['.;, ~:~[',1[:, f'IU!":;T BE RETUFd:NE['.' l'O THE DEF'RF:.'Tf'IENT HITHIN }i:E~ [)l::l"r'~;
OF' THE HELL COHPL..ETIOI",I.
OTHER I;?.E6:!U:[F:EHENTE; hlR'¢ FIF'F'L'T'. '_:'SPECZFICFITION"2; FINE:, CON'.'STRL~CTIOI"4 B, IRGF~:FIH:E;
I:t',,"l"':l :[ LFIBLE TEl I N%I..I[~'.E PROPER ~ N".5'I"FII...LR'I" I I_-IN.
! CERT I F"¢ 'rF.IFfT
t: I flH FFtHILIRR NI'FH 'TIDE ¢~:EQL.IIFd:EMENTS F'CI[~: ON-.-SITE SEI.qERS RNC, HEL. LS RS SET
FORTH E',"r' THE HUN;[CIPRL..IT"r' OF RNC:HOf~:RC'iE.
2: I HILL INSTFI[..L THE S",":~;"I'EI"I ];N RCCOR[:'RNCE HITH THE
5 1GNE[:': ......................................................................................
FIF'F'L I CFd",Ff' GERF':IL[:, L:;HEFIREF'.
Parcel I.D. 020-311-21
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
Expiration Date.
Complete legal description T11 N, R3W, Sec 14&15, Bound on N by The Villages Tr18 and sbyTr2O
Location (site address) ,) 19850 Villages Scenic Parkway
_
Current Property owner(s) Gerald & Dana Shearer Day phone
Mailing address 19850 Villages Scenic Parkway, Anchorage, AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
F-1 Single Family (w/wo ADU)
171 Duplex
El Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Fx]
Individual
El
Individual Water Storage
n
Holding Tank
Fl
Community Class Well
❑
Community
El
Public Water System
❑
Public Sewer
11
Waiver/Variance relwe;rt for:
—Distance:
Received by: _
COSA to be released to
unless otherwise requested by the engineer.
Date:
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined
in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater
disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply
and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at
the time of installation.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 745-8200
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R Pannone
6. DSD SIGNATURE
'V System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Date _ Zgrz,
Conditional approval for bedrooms, with the following stipulations:
By: � - l i`�A � i � J' �z2 T, m CEJ- % [-�,r)Original Certificate Date: -be C I c I
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet f � c
Ifmore than iseptic system ksonthe lot:
COSACheck|ist#�__o�__
Stmctunaoen�dbythis oystem _1____
Legal Description: T11w.RM, Sec 1wu5,Bound n»wuvThe Villages nnoand eurTr2» Parcel ID: 020-311-21
A. WELL DATA
Well type P[k/8t8 If A, B.urCprovide PVVS|D#Well Log (YYN) `/
Date completed 7/8/1981 Sanitary seal (Y7N) `/ Wires properly protected (Y/N) Y
Total depth 340 - Cased to 20'BR*. Casing height (above ground) 24" in.
FROM WELL LOG AT INSPECTION
Date oftest 7/8/1981 12/17/2018
Static water level [1Ok
ft�
Well production 4nn Q4m-
VVATERSAMPLERESULTS:
Coliform NeO ^o|onieaUOOmL Nitrate O7Q5, mg/L
Arsenic ND ug/L Date ofsample: 12/5/2O1A
B. SEPOC/HOLD|NGTANK DATA
TankType/Ma\eho| Septic/Steel
Tank size 1500 go|. Number ofCompartments 2
Foundation cleanout (Y/N) \/ Depression over tank (Y/N) N
Date o[pumping NewPumper
C.ABSORPTION FIELD DATA
1:
ft.
3.5
9-13-m�
Collected by: PES
11��1�
Date installed '/1^
C|eanouts (Y7N)YHigh water alarm (Y/N)
N/A
Date installed 8/1981 Soil rating (g,pd./ft2orft2 /bdm) 190cf0br System type Wide Trench
Length 90 ft. Width 5.0 ft. Gravel below pipe 1. 5 �
Toa}depth f3.5 ft. Efiabsorption area 577 ft2 Monitoring tube \/ Depression over field Kj
Date ofadequacy test 12/17/2018 Reou|io(Poso/Fei|) Pass For bedrooms
Fluid depth inabsorption field before test 0 in. Water added /4SO gal. New depth 0 in.
Elapsed Time- 90 min. Final fluid depth � in. Absorption note '= 4��+ g.p.d.
Any rejuvenation treatment (past 12moj(Y/N&type) /» Kyes, give date________
D. LIFT STATION
Date installed
"Pump on" level atin.
Datum
E. SEPARATION DISTANCES
WELL ONLOT TO:
Size ingallons __
"Pump offleve|at
Cycles tested
1�g7'
Septic �n��m��nonkt._
Absorption field onlot 100'f
7�`f
Public sewer main
Sewer /septic service line 25+
__ Manhole/Access (Y/N)_
in. High water alarm level at
Meets alarm & circuit requirements?
1��'+
Ona�n��|o�____
On adjacent lots 100'f
1��'f
Public sewer
Holding tank 100'+�����
Animal containment areas 50'+ Manure/anima|excrete storage areas 100'+
SEPTIC/HOLDING TANK ONLOT TO:
Building foundation 12'6' Property line 104
Water main 25'f Water service line 25'f
Wells onadjacent lots 100'f
ABSORPTION FIELD 0MLOT TO:
Absorption field 10'+Surface water
100'f
Property line 10'f Building foundation 104- Water main 10'+
Water Service line 25'f Surface water 100'+ Dhvewey,parking/vhicle storage 10'+
Curt50'f
Curtain Wells onadjacent lots 100'f
F. COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that /have determined through field inspections and
review of Municipal nsonnds that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven P8DOOD8
Date
coSA canary sheet_2-6'15.mm
even nnone.-
in.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL NEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date ,~/' P- ~ f ¢~"
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~l~ ~ Telephone:Home ~ff~-TE~
Business
Applicant Address
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Familyl~ Multi-Family []
Number of Bedrooms_ ,,~
Other
WATER SUPPLY
Individual Well [] Community [] Public []
Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4, SEWAGE DISPOSAL
Onsite [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11,84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certifiod by my seal affixed hereto and as of the validation date shown below, I verity that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastawater disposal system is safe, functional and adequate
[or the number of bedrooms and type of structure indicated herein. ~ 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
wasteweter disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Nameof Firm ~1~¢¢¢~
Address ~ ~¢'~0
Date ~ / 8 ~ / ~
Telephone
Engineer's Seal
DHEP APPROVAL
Approved /~ Disapprov~ Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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,
Page 2 of 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAl- HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH.AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (incLude lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~E~(~ ~'~1~'~¢¢¢ Telephone: Home ~ ?¢-'~g~
Applicant Address /~ ~,'z Z,~[~ ,~['/.]/~ ~/
(c)
Business '8~','
Applicant is (check one): Lending Institution []; Owner/builder ~,; Buyer D; Other ~ (explain);
(d) Lending Institution ~.,~,Lr'£~'/¢/T,'v P"?~'"-~/~
Address .~ ,.,¢ ~'"O Z7 ,,,,,,,,~ ,c,'.,<, Z, /
(e) Real Estate Company and Agent __
Telephone
2¢:. ~/?,??
Address
Telephone
Mail the HAA to tile f~llowing address:
/'?~¢,S'~ .¢,'/~.~¢:£b~ .~c~','.,~
TYPE OF RESIDENCE
Single-Family J~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well t'~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4, SEWAGE DISPOSAL
Onsite [] Public [] Community [] Holding Tank []
Note: If community woll system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status,
72-025 (I t~84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Aulhority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for tile number of bedrooms and type of structure indicated herein. I further verify that based on tile information obtained
from tile 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
tile date of this inspection.
Name of Firm f~'lct f~of 1'~c/1,,?'~¢c~( ..~¢,'~-'~c ~ Telephone ',~
Dale
~- Engineer's Seal
%~Z& '... .." .~'
ApprovedDHEP APPRO~A~for Z~ bedrooms by O~ g~
Approved Disapproved Conditional
CAUTION
Tile Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon tile representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
Paae 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description:
DEPT, OF HEALTH &
ENVIRONMENTAL PROTECTION
MAr/2 41~8~
RECEIVED
WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth ~ ~/~ ~ Cased to
Static Water Level '?~t~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N) __
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot '"~
To Nearest Public Sewer Line ~¢
Cleanout/Manhole ~le J),
Water Sample Collected by "r-~t.~
Water Sample Test Results _ ,~
Comments B~$,~' /~r
beM~t'~ be/o~o 'Tx/'
If A, B, C, D.E.C. Approved (Y/N)
Date Completed 7 ! ~/~ I Yield
Depth of Grouting
PumpSetAt ~'~r '~'2'~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots ~,
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot N¢/~,
; Date ,~ / l"7 / c~
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) ___~ Air-tight Caps (Y/N)
Depression over Tank (Y/N) N
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well I I q¢
To Property Line ~
To Water Main/Service Line ~ tc~,~
Course ~'
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
; for N~/J ·
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments ,..S')z.=( ]-ero ha[ be,?,o m cede
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ¢ [3 !/¢/
Width of Field ~ ~
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well (d)O~ '/''
To Building Foundation _ ~ ,.,5-¢
Lot ^b
To Water Main/Service Line Nt~,
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments .¢vx /-~'m hcz/ ~rz# ¢,~ ~:,r~
t/l~"¢~ Type of System Design
Length of Field ~¢o '
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N~
Date of Last Adequacy Test
To Property Line ~ ,5'~)
To Existing or Abandoned System on
.; On Adjoining Lots ~' :~o
To Cutbank (if present)
D. LIFT STATION j~.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of {his inspection.
,¢,_4'"<25 ~
Signed ~_~,..-¢~,.z~ .'¢'~, ~ Date
Company F',/~//¢/¢ ~¢,'}¢ur~! -('~-¢' MOA No.
Receipt No, ,~'~7--/
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Engineer's Seal
