HomeMy WebLinkAboutT13N R1E SEC 10 N2NW4SW4NW4 PTNTI3N RI
10
N2NW4$W4NW4 PTN
t050- 561
-06
Municipality of Anchorage
Development Services Department ~.~=~ ~
Building Safety Division ?!!~,
On-Site Water & Wastewater Program, 4700 South Bragaw St.
~T~
~.O. Box ~96650 Aochomge, A~ 995~9-6650 ~ ~
~.d.~ocbom~e.ak.~s (907) 343-7904 ~o~e 1 of
Oo-Site Wastewate~ Oisposal System and/or Well Inspection Repo~
,.¢~ ~c/ ~.; 5-~ ~;3 ~.~ ~/~ ~ ~ ~c --~ ~: / - c e
Name:
KELLY HEITSTUMAN Wastewater System: ~ New ~ Upgrade
Address:
32717 EAGLE RIVER ROAD * E.R. AK 99577 ABSORPTION FIELD
Phone: No. of Bedrooms:
(907) 727-8478 5 B Deep Trench B Shallow Trench D Bed BMound BOther*
LEGALDESCRIPTION so,, Rating: 1.2 GPD/Sq. Ft. Total Depth f .... figinoll 2.0grod': MAX
Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe:
- - - SEE DWG. rt. 5.72Ft.
Township: Range: Section: ' RII added above odginel grede: Gravel length:
T13N R1E 10; N2, NW4, SW4, NW4 SEE DWG. Ft. 55
Grovel width: Number of lines: Distance between lines:
WELL: B New ~ Upgrade 2.5 Ft. 1 -- Ft.
.ClosslficeUon (Pdwte, A,B,C): Total ~~osed TO:(BED~K) Total absorption urea: Pipe materiel:
//rt. ~. 629 s~. rt. D 3034/
F-810
~e Ddlled: Stetlc Water ~vel: Installer: Dote installed:
Drille~ ~~ Ft. GEG, Ltd. 9/5/2005
~eld: Casing Height Above Ground:
~,. ~,. TANK
EPARATION DISTANCES = Septic O Holding O S.T.E.P. O Other*
Septic Absorption Lift Holding Public/Pdwte Menufecturer: Cepeclty in gallons:
Tank Field Station Tank s..,~ u,., ANCHORAGE TANK 1500
Materiel: Number of compe~ments:
WeN 100'+ 100'+ - - 25'+ STEEL 2
su,,o~ W~e~~00'+ ~00'+ - - - LIFT STATION
Lot Line 5'+ 10'+ _ _ _ Size in gallons:II~Monufocturer: ~
Foundation 5'+ 10'+ _ _ _ "Pump on" level at: "~at: High water olo~ et:
Cu~ain Drain ' NONE KNOWN . P~p ~~Elect~cal Inspections pedo~,d by:
I I
Remarks: OLD SEPTIC TANK DECOMMISSIONED BENCH MARK
BACKDOOR THRESHOLD
~ .... d Elevation: 100.00 Ft.
Inspect,ohs pe~orme0 by: GIG, ~td. Datos: ~st 9/s/200 ~"}~}. ~.~. ~':'3
2nd ~/s/2005~.~ ' i
3rd v&¢ /.~rFe~rness.'
V~l. fi.~f CE-7953 .." &~
Development 8e~iees Depa~ment ~pproval
(Rev. 12/01) .~ /F/
AS-BUILT DRAWING
A B C
FCO 30.4 17.4 ~0.4
C01 47.3 32.3 58.0
C02 66.2 40.0 64.0
DOLl 57.3 41.6 65.3
D91.2 58.3 42.3 66.3
C03 68.8 45.7 68.~
MT1 69.6 45.3 69.2
MT2 109.3 66.1 81.9
C04 IOg.O 66.3 81.9
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T13N, RI~ SECTION 10;
N2,N2.N2.NW4.SW4oNW4,
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;iiAPPROxiUAT~
DRN['WAY LOCATION /
/!
TI'~N, RI[., S£C'~ON 10;
S2,S2oN2,NW4,SW4,NW4, &
N2,N2,S2,NW4oSW4,NW4,
GARNESS ENGINEERING GROUP, Ltd.
CONSULTANTS & OENERAL CONTRACTORS
KELLY HEITSTUMAN [ 907-727-8478 [ 2 OF 3
!gC, N. D~CRII~ION: [DRAWN BY:
T15N, R1E, SEC. 10; N2, NW4, SW4, NW4 ~TF.: B'Ir'M'
IYP£ OF WORK:
AS-BUILT FOR NEW SEPTIC SYSTEM
(Rev 01~5)
AS-BUILT DRAWING
TOP OF TANK AT
INLET - 94.58" /~TOP OF TANK AT
~__ /OUTLET - 94.,~8
NEW 1500 GALLON
INVERT OF BUNG SEPTIC TANK INVERT OF BUNG AT
AT INLET -. 93.79 J OUTLET - 93.63
99.54
(AVG)
OF
c RELATIVE ELEVATION OF BOTTOM OF
TEST HOLE -, 81.49 (NO H20)
GARNESS ENGINEERING GROUP, Ltd.
CONSULTANTS & ~-EN~R~,I. CONTRAC?ORS ' j~l ..t.~.:.'...~l
KELLY HEITSTUIdAN J 727-8478 . 3 OF 3
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Aug 31, 2005
Expiration Date: Aug 31, 2006
Permit Number: SW050328
Legal Description: T13N R1E SEC 10 N2NW4SW4NW4 PTN
Design Engineer: 0855 Gamess Engineering Group, LTD
Owner Name: KELLY HEITSTUMAN
Owner Address: 32717 EAGLE RIVER ROAD
EAGLE RIVER, AK 99577-
Parcel ID: 050-561-06
Site Address: 032717 EAGLE RIVER RD
Lot Size: 118919 SQ. FT.
Total Bedrooms: 5 Permit Bedrooms: 5
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well
[] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and dosed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:. ~[ i~"~
Issued By~~''
Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O, Box 196650 Anchorage, AK 99519-6650
www.ci.anchorag e.ak.us
(907) 343-7904
Parcel I.D,
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Permit Number
Property owner(s)
Mailing address (1)
Mailing address (2)
KELLY HFITSTUMAN
32717 EACLE RIVER ROAD * EAGLE RNI[R. AK.
Legal description (Lot, Block & Sub'd.)
Legal description (Section, Township & Range)
Lot S, e ll; ,
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Day phone 727-8478
Zip Code 99577
T13N, R1W. SECTION 10: N2. NW4. SW4. NW4.
Number of Bedrooms
[] Well Only []
['-] Water Storage
[]
Jacuzzi
Water Softening Unit
I certify that the above information is correct. I further certify that this application is being made fora
Single Family Dwelling and is in accordance with applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd.
Permit Fees: ~ ~
Date of Payment: ~5~"~,,0~"~''''
Receipt Number: (")7~ ) (:~C~ .-~
Waiver Fees;
Date of Payment:
Receipt Number:
GARNESS ENGINEERING GROUP, Ltd.
CONSULTANTS & GENERAL CONTRACTORS
August 24, 2005
Municipality of Anchorage
Development Service Deparlment
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650,
Anchorage, Ak 99519.6650
(907) 343-7904
Ref: Proposed Septic System Upgrade for TI3N, RI E, Section 10; N2, NW4, SW4, NW4,
To whom it may concern:
The existing 5 bedroom house is served by a private well and septic system. The drainfield is currently in the
state of failure and needs to be upgraded. We are proposing that a new 1500 gallon septic tank and a deep
trench type drainfield be installed. One test hole was excavated on the property. The drainfield will be
designed around the 30 foot radius of this test hole. Comments regarding the design are summarized as
follows:
1. SOILS: See the attached logs which shows the soil classifications, groundwater monitoring, and the
percolation test results. Based upon our visual assessment, there appears to be enough silt in the insitu soils so
that a sand filter is not required.
2. DRAINFIELD DESIGN: See attached design drawing for drainfield specifications.
3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed septic system.
4. TOPOGRAPHY: As can be seen on the attached design drawing the average topography in the area of
the proposed drainfield is relatively flat. In short there are no slope concerns.
We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If
you have any questions, please contact us at 337-6179. Thank you for your assistance.
NOTE: ,4ttached is a site plan drawing, a design drawing, one soil log, which are all part of the design pactage for
this septic system. (Contact G.E.G. Ltd. for 7 page construction specification letter.)
3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507
Ph: (907) 337.66179 * Fax: (907) 338-3246 * Website: gamessengineerlng.eom
LLHt~ THAT p[RTNNS TO ~ DEIGN.
XUUBER OF B~ROOu~'$ I~ OBTAIN A COPY OF 1~£ Lt.z~r..~
~N.~0NS PER ~AY (GPO): 750 CONTACT GEG. BY PROC[ED~NG FOR~ARD
~COLATiON RA'1Z/S: <1 UIN./I~ICH ~ 1HIS INSTALLATION. 11.lE ENGINEER,
PROPOSED APPLICATION RA~.: 1~ ~ DRILLER. CONTRACTOR AND
PROPERZY CRVNER AGRrlr 11a. AT 'THEY
~L~X]~Uu DD~H:12 ~ " ~-,~
W~D~I:2.S t~( T13N. Rlr S[CTION 1~
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'~ NO SO~11C
\ ~ '"'"" /,--~' I couP~Y / i
~0~
T15N. Rl~ ~ON 10;
GARNESS ENGINEERINGGROUP,~td.t ~,[~:'.: ~S ml~ "~)
~ ~ I~,o< ~u~ I ~;~ ~= ~'~ "':": ........ :'"'~
KE~Y HEITSTUUAN I 907-727-8478 I 2 OF 3
N 0~.
T,,,. ,1~. ~c. ,o; ,~. ,w~. ~w~. ,w~ ,.*.~
~S~FOR PROPOSED SEPTIC SYSTEM UPGRADE ~/25/200~~~
OUT
OUT
'1
GRADE
FILTER
GARNESS ENGINEERING GROUP, Ltd. [~
CONSULTANT~ & GENE~L CON~CTORS ~ ~'
KE~Y HEITSTUUAN ~ 907-727-8478 5 OF 5 ~v~
T15N, RIE, SEC. 10; N2, NW4, SW4, NW4 ~ R.A.~ ~
DETAIL FOR PROPOSED DRAINFIELD UPGRADE ~ 8/25/2005
· ~., .... ,.~
GA.~ESS E~GI~EERI~G GROUP, ~td. ' Ld~~
CONSULTANTS & GENE~L ~O~ORS
I~OtL LO~ - PERCO~TIO~ ~[STI ~..~ .. ,.~ ..... ~ ........... .,~
4-- ~,'~ GC OL ~ .. ~ ',
r-~". ,0 ,, SW NH .", I
~"~ · · SP CH I
~JB JJ SH OH I
6- ~:~)~l ~ II~'~, U 1l SC ~
7-- '~'~1 ~ mm DEPTH TO DATE
~,', GROUNDWATER
8-- ~"~ D~ 7/25/2005' HNI
; mmm O~ 8/18/2005'
~IDII
= IBII
10--~ ~' ' ~'
:~J~JJ CLOCK NET TIHE WATER LEVEL NET DROP
11 --.~m umm~"~ DATE RE.lNG TIME (MI~TES) READING (INCHES)
= IBII
12_ ~"~ 8~18/2005 1 00:00 - 6- -
oo=o
J5 -- .~1U II ] 00:05 -- 6- --
. oo=.o
~ 4 -~J~JJ~'~ s oo= ~ o - s' -
~.~ 7 00:15 - 6' -
16 ~ ~,,~ 8 00:20 5 O' 6'
. ~ 9 00:20 - 6- -
17 ~ ~'" 10 00:25 5 O' 6'
~1 ~ &m 11 00:25 - 6.
1B ~~'~: 12 00:50 5 O' 6'
PERCOLATION RATE *<1 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES)
19 --/
TEST R~ BETWEEN 6.5 FT. ~D 7 FT.
20 ~ A FOUR HO~ PRESO~ WAS PERFORHED: ~ YES ~ NO
SOILS LOGGED BY: JODY UAUS PERC~ATION TEST PERFORHED BY: JODY
COHHENTS: '~ INS~ SOII~ WILL A~ AS A S~D
PERFORUED BY GEG. Ltd. I, JEFFk~ A C~N~S. C~ ~T ~lS W~ ~ER~ORUED IN ACCORD~CE
W~ ~ ~ATE ~D UUNIClP~ GUlDEUNES IN [FF[~ ON ~lS DATE: ~/~/~
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
NAME PHONE
LEGALDESORIPTION . 5~ ~'~ 2'~ '-'
LOCATION NO, OF BEDROOMS
~ DISTANCE TO: Iwell ~3~ IAbs°rpti°n area Dwelling PERMIT NO. ~ ~
~ Z Manufacturer ~. Matf~ No.
~ Liq. ca?~t~,~aH o ns ,F HOME.DE: Inside le.gth Width Liquid depth
. ~ Well Dwelling PERMIT NO.
O Z ~ Manufacturer Material Liquid capaciW in gallons
D Well Foundation Nearest lot line PERMIT NO.
-- No. of ,ines / Length of e,~ne, Total length of lines/~ Trench w]Othx~ ' inches'"~ Distance between~?~
~ ~ ~ Top of tile to finish grade Material beneath tike Total effective absorption area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ ;lass Depth Driller Distance to lot line PERMIT NO,
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
72-013 (Rev. 3/78)
PERMIT NO.
DEPARTMENT oF HEALTH AND ENVIRONMENTAL PKwTECTION
825 'L' STREET, ANCHORAGE, AK. 9950t
264-4720
CnF~--SITE '~,E~IER F"EF:rq IT
APPLICANT
LOCATION
LEGAL
HRMRNN CONST P.O. BOX 617 EAGLE RIVER
MILE l~ EAGLE ROAD
Ti~N RIE S-10 HINGST LEANDER LOT SIZE
699 2776
87120 SQUARE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MRXIMUM NUMBER OF BEDROOMS
SOIl_ RATING (SQ FT/BR)= ~00
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
E-)EF'TH= :12 LEi",IG T I't= ;-~-'-2 6RR\;EL B, EPTI4= 7
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIEL. D.
THE DEPTH OF A TRENCH OR PIT IS THE DISTRNCE 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).
RED SEPTIC TRNk; SIZE=
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMEWT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY 8ND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
TI-In] ( 2. ) I r~$PECl' I 0~'~$ 8RE ~:EK!LI I RED
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION 8ND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWRGE DtSPOSBL SYSTEM IS
±00 FEET FOR A PRIVATE WELL~ OR
150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
RES DECEt'IE:ER 3_-1.... :t"_.~ 7 ;=TM
I
i:
FORTH BY THE MUNICIPALITY OF ANCHORRGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
]:: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT
i~:ESIDENCE ~ RE~J~)ELED TO JNt::LUDE MORE THFIN }BEDROOM$.
/ /
CERTIFY THAT
I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
IF THE
Vi:. 2
? ,',CO ST UCTIO TEST '
"One Test is worth a Thousand Opinions"
2204 Cleveland Anchorage, Alaska 99503 277-0231
Perfo~ned for Hamann Const. Date Performed. 7/9/79
Legal Description: Lot -Block Subdivision
This Form reports: SOILS TEST YES PERCOLATION TEST
T13N R1E Sec.10 portion of NWl/4 SW1/4 NWl/4 Hingst Leander M.
Depth
Feet
Soil Characteristics
16'
M~6wn Sandy Gravel
( GP ) ( l~0sq, ft.
Was Ground Water Encountered No
If YES, What depth?
~eading Date Gross TJnue Net TLme Depth to H20 Net Drainage
Percolation Rate _~4inute
Proposed Installation: SEEPAGE PIT DP~AIN FIELD
Depth of Inlet Depth to Bottom of Pit or Trench
Date : ~ /~,/-;~
Pest ~d by.~ Data Certified By: ~onst. Test_
~/,vi · I
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
~.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. o5o-56:[-o6
COSA # (2:~50,,,, \\\
Expiration Date: //-- 3-///
GENERAL INFORMATION
Complete legal description T~3N RzE SEC ~o N2NW4SW4NW4 PTN
Location (site address) 3273-7 Eagle River Road, Eagle River, AK 99577
Current Property owner(s) James & Michelle Spratt
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
2.'--:~ NUMBER OFBEDROOMS:
3. TYPE oF, WATER suPPLY:
Individual-Well
Individual Water Storage
Community Class __
Public Water System
Day phone 382-4433
32717 Eagle River Road, Eagle River, AK 99577
Day phone
Sally Carmen ~ Century 2z
sallyc@c2zak.com
Unle.,ssotherwise requested, COSA will be held by DSD for pickup.
Day phone 227-0506
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site [~
[] Individual Holding Tank E~]
[] Community On-site r-]
[] Public Sewer r'-I
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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 (am) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further vedfy that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Engineering Services, LLC Phone 272-82J.8
Address P.O. Box :1.oo217, Anchorage, AK 995~o
Engineer's Printed Name Steven R. Pannone, P.E. Date 8/2/20:1.1
Engineers comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & 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. PES can therefore not provide any warranty for future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed
above. Any reliance upon or use of this report by any other person or party is not authorized nor will it
confer any legal right whatsoever.
5. DSD SIGNATURE
~ Approved for ~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: 8- .~ -//
Mun ipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O.. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Ta~NR[E SEC ao N2NW~.SW~NW~ PTN
WELL DATA
Well type _P
Date completed x/ala975
Total depth ',~.',5+ ft.
IfA, B, or C provide PWSID #
Sanitary seal (Y/N) Y
Cased to 2n2.a_n+ ft.
FROM WELL LOG
Date, of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform .,,Ne9 colonies/100 m,L
Arsenic: .ND ug/I
SEPTIC/HOLDING TANK DATA
g.p.m.
Nitrate =..zr6 mg/L
Date of sample:
Tank Type/Material Anchora~_e Tank Steel
Tank size 3.500' gal.
Foundation cleanout (Y/N) Y_.
Date of pumping ,.la, aero
ABSORPTION FIELD DATA
Date installed
Length 55
Total depth =,~.~ ft.
Number of Compartments ~_
Depression over tank (Y/N) _N
Pumper JR's SeDtic Pumping
Soil rating (g.p.d./~ or ~/bdrm)
ft. Width 2.5
Eft. absorption area .6,29
Date of adequacy test ?lzSl~,oaa Results (Pass/Fail) __
Fluid depth in absorption f'~ld before test .o..oo in.
Elapsed Time: o.oo min. Final fluid depth Dry in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Parcel ID: o5o-56i-o6
Well Log (Y/N) N
Wires properly protected (Y/N) Y
Casing height (above ground) 2~+
AT INSPECTION
~-/21/2o~_o
a2q ff.
6.0+ g.p.m.
Collected by: DRM
Date installed nlnlaoon_
Cleanouts (Y/N) Y
High water alarm (Y/N) N/A
Monitoring tube Y
System type Deep Trench
Gravel below pipe F.?2
DePression over t'Rid N
in.
Pass For 5 bedrooms
Water added76o gal. New deptho.oo in.
Absorption rate >= 750+ g.p.d.
No If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at~
Datum
Size in gallons
in. "Pump off" level at~ in.
Cycles tested
E. SEPARATION DISTANCES
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot lOO+ On adjacent lots lOO.
Absorption field on lot 100+ On adjacent lots lOO+
Public sewer main N/A Public sewer manhole/cleanout N/A
Sewer/septic service line, 25+ Holding tank lOO+
Animal containment areas 50+ Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+
Water main NIA
Wells on adjacent lots
1OO+
ProPerty line 20+
Water service line
25+
Absorption field 5+
Surface water lOO+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line, lO
Water Service line, ,25+
Curtai~ drain:,'. N~ne Known
'COMMENTS
Building fOundation lO+
Surface water loo+
Wells on adjacent lots loo+
Water main NIA
Driveway, parking/vehicle storage lO+
* H6use .l~as been Vacant and tank has not filled since last pumping.
G. ENGINEER'SCERTIFICATION
I Certify that '1 have 'determined through field inspections and ~/
review of Mun(cipal. records tha. t th.e ab. ove systems, are in ~,....L
conformance wJth MOA COSA guidelines/n effect on this date. ~ ~
Engineer's Printed Name: Steven R. Pannone, P E ~
Date. , 81212~'~ '~ ~1,;~~~/~% --
COSA Fee $ {Ji~t{~ ° O'~{~'' ~/~'~ Waiver Fee $
Date of Payment ~~[.].L Date of Payment
Receipt Number OO:~3 ~m q Receipt Number
(Rev. 11/05)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. o5o-56z-o6
1. GENERAL INFORMATION
COSA# O.~C / O/O CO
Expiration Date: ~-
Complete legal description Tz3N RzE SEC ~o N2NW4SW4NW4 pTN
Location (site address) 327z7 Eagle River Road, Eagle River, AK 99577
Current Property owner(s)
Mailing address
Lending agency
Mailing address
James & Michelle Spratt Day phone 382-4633
327~7 Eagle River Road, Eagle River, AK 99577
Day phone
Real Estate Agent Sally Carmen @ Century 2z
Mailing Address sallyc@c2zak.com
Unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 5
Day phone ;~27-o5o6
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site
[] Individual Holding Tank BI
[] Community On-site
[] Public Sewer BI
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or Water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Engineering Services, LLC Phone 272-8228
Address P.O. Box ~oo2z7, Anchorage, AK 995~o
Engineer's Printed Name Steven R. Pannone, P.E. Date 4/6/2oz~
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & 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. PES can therefore not provide any warranty for future ~,,,.,~,.~,~~ ......... ~,,.,~
performance nor give any estimate of how long the system will continue to meet the operational ~ ........
requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed
above. Any rehance upon or use of this report by any other person or party is not author,zed nor wall ~t
confer any legal right whatsoever.
~ Approved for ~.~ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
WATER AND
STEWATER
PROGRAM ·
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(Rev. 11/
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water~ & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:. T2=IN R2E SEC ao N2NWztSWzd~lW~. PTN
A. WELL DATA
Parcel ID: o~o-~6z-o6
Well type p
Date com~oleted 3.1[la97F
Total depth ~.)2.2~+ ft.
Date of test
If A, B, or C provide PWSID # ~
Sanitary seal (Y/N) Y
Cased to x]2.aN+ ft.
FROM WELL LOG
Well Log (Y/N) N
Wires properly protected (Y/N) Y
Casing height (above ground) =/s*
.AT INSPECTION
~21~2020
in.
Static water level
Well production
WATER SAMPLE RESULTS:
g.p.m.
=29 ft.
6.0+ g.p.m.
COliform Neg colonies/100 mL
Arsenic: Less than s.oo ug/I
B. SEPTIC/HOLDING TANK DATA
Nitrate a.6o mg/L
Date of sample: n/2912oaa
Tank Type/Material Anchora-ae Tank Steel
Tank size a~oo gal.
Foundation cleanout (Y/N) Y
Date of pumping '*h.912o~.o
C. ABSORPTION FIELD DATA
Number of Compartments _2.
Depression over tank (Y/N) N
Pumper JR's Septic Pumping
Collected by: Pannone Engineering
Date installed ql~_1200n
Cleanouts (Y/N) Y
High water alarm (Y/N) NIA
Date installed qlnl200~_ Soil rating (g.p.d./~ or ~/bdrrn) ',.2 System type Deep Trench
Length 55 ft. Width =.5 I ft. Gravel below pipe ~.7= ft.
UI nit ri _ _
Total depth !3.~r ft. Eft. absorption area 629 ft2 ~ 0 ng tube Y Depression over field N
Date of adequacy test ~.1~,',1',o3.o Results (Pass/Fail) P~ss For 5 bedrooms
Fluid depth in absorption field before test 0.oo in. Water added?FF gal. New deptho.oo in.
Elapsed Time: o.oomin. Final fluid depth Dry in. Absorption rate >= 750+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No ; If yes, give date
LIFT STATION
Date installed
"Pump on" level at~
Datum
in.
E. SEPARATION DISTANCES
Size in gallons
"Pump off' level at~
Cycles tested
in.
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift.station on lot ~.oo+
Absorption field on lot ~oo+
Public sewer main NIA
Sewer/septic service line
Animal containment areas
On adjacent lots ~.oo+
On adjacent lots ~.oo+
Public sewer manhole/cleanout NIA
I-k)lding tank ~.oo+
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Absorption field S+
Surface water ~.oo+
Building foundation S+ Property line ~.o+
Water main NIA Water service line
Wells on adjacent lots ~.oo+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~.o Building foundation ~.o+
Surface water ~oo+
Wells on adjacent lots ~.oo+
Water Service line 2S+
Curtain drain . None Known
F. COMMENTS
Water main NIA
Driveway, parking/vehicle storage Ao+
review of Municipal reCOrds that the above systems are
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone, P.E.
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF 0NSITE SYSTEHS ,b, PPROVAL
FOR ,6, SINGLE FAMILY DWELLING
Pa~ m.O50'* ~, I-
GENERAL INFORMATION
Expiration Date: /o~--'..~ _~'"-. ~ ~)
Complete legal description.
Location (site address or directions)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
T13N, R1E, SEC 10; N21 NW4, SW4, NW4, F'7"/%//
32717 EAGLE RIVER ROAD * E.R. AK 99577
KELLY HEITSTUMAN
c/o ACENT
Day phone (907) 727-8487
Day phone
AUDREY MASON w/ REMAX Day phone 694-4200
16600 CENT£RRELD DRNE * EAGLE RIVER, AK 99577
Unless otherwise requested. HAA will be held by DSD for pickup.
2. NUMBEROF BEDROOMS: 5
3. TYPE OF WATER SUPPLY:
Individual Well [~
Individual Water Storage
Community Class Well ~___
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ~r~
Individual Holding tank
Community On-site ~
Public Sewer
The Municipalityof Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given In paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work.
4. 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, functlonaf 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 installafion.
Name of Firm CARNESS ENGINEERING GROUP. Ltd.
Address 5701 E. TUDOR ROAD. SUITE 101 "ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS. P.E.
Phone
337-6179
Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. atlempted to provide a thorough,
co~3scientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results dosc~bed 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 end
septic systems depend on the local s~ils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions ere outside the control of the evaluator of the system. Satisfactory test
results da not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
~/' Approved for ~ bedrooms.
Disapproved.
Conditional approval for .__
Attachments:
CO~A~Ch_e. cklist
bedrooms, with the fllowing stipulations:
Arsenic Advisory
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
Original Cerlificate Date:
Municipality of Anchorage
Development Se lces Department
Building Safety DIv~ton
On-Site Water a Wastewater Program
47OO Bragaw 81met
P.O. Box 196650
veane.muni.arg/analte
(907) 343-7g04
CERTIFICATE OF ONSITE SYSTEHS APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
T13,, R1E, SEC 10; N2, NW4, SW4., NW4, /°T/~arcellD: 0~"O "~/"~ I- C~)~_~
*SEE AI'I'ACHED Lt. lie. R FROM ARROW PUMP AND WELL SERVICE.
Date of test
Static water level
Well pmduc~on
WATER SAMPLE RESULTS:
C.~iform 0 colonies/100 mi.
Amenic: NO mgJL.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Materlal SEPTIC / STEEL
Tank size 1500 gat. Number of Compadments
Foundation cleanout (Y/N) YES
Date of pumping 9/20/2006
C. ABSORPTION FIELD DATA
Date installed 9/~,/2oo~
LentFh 55
2
Depression over tank (Y/N) NO
Pumper
Soil rating ~ It~odrm) 1.2
Width 2.5 .ft.
Total del~th .12 ff. Eft. absoq~tton ama 629 ft~ Monitoring tube YES
Date of adequacy test NEW Results (Pass/Fall) PASS
Fluid depth in edsorptk~ field before test - in. Water added - gal.
Elapsed Time: - min. Final fluid depth - in. ~ rate >=.
Any rejuvenation Imatment (past 12 mo.) (Y/N & type) NONE KNOWN
Nitrate 1.15 mg./I.. Otherbecteria 0 oolonies/100ml.
Date of sample: 8/22/2006 Collected by: GEG, LtD.
Date installed 9/5/2005
Cleanouts (Y/N) YES
High water alarm (Y/N) N/A
JR'S PUMPING
System type DEEP TRENCH
Gravel below pipe 5.72 ft.
Dapression over field NO
For 5 bedrooms
New depth - in.
gp.d.
750+
If yes, give date
Well type I~rVAI~ If A, B, or C provide PWSID~ N/A Wall Log (Y/N) NO
Date completed ~ 1975 Sanite~ seal (Y/N) YES Wires properly protected (y/N) YES
ToteJ depth * 132.25ft. Cased to * 132.25ft. Casing height (above ground). 12+ .in.
FROM WELL LOG AT INSPECTION
,0/28/2005
· 136 ft.
..~Y g.p.m. 8.2 g.p.m.
UFT STATION
Date installed. $iz~ in gailon~ ~ __
-Pump o~h water alarm I. evel at __._~.- in.
~ Cycles tested Meets alarm & circuit requirements?.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAIft station on lot 100'+
Absorption field on lot 100'+
Public sewer main N/^
Sewer/septic service line 25'+
Animal containment areas 50'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/deanout
Holding tank N/A
Manure/animal excrete storage areas
100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Pmpen'y line 5'+
Water main N/A Water sewice line 10'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation. 10'+
Water sewice line 10'+ Surface water 100'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
Absorption field 5'+
Surface water 100'+
Water main N/A
Ddveway, perking/vehicle storage 10'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined thtotigh field inspections and
review of Municipal records that the above systems ere in
conformance w~th MOA COSA guidelines in effect on this
date.
Engineer's Pdnted Name JEFFREY A. GARNESS
Date Ci[z' /°&
Oata of P ,.ent
Receipt Number
(Rev. 12/ol)
Waiver Fee $
Data of Payment
Receipt Number
Sent By: Re/max o? EagZe Rlver, [nc.; 907-694-1708; Sep-14-06 11:42; Page 2/2
ASBUILT SEWARD ~SOCIAV~ LA~TD SU~i'y~NO 6'//~-(~0
I HEREBY CERTIFY .THAT I HAVE SURVEYED TH~ ~ ~'~ .
OULOWm P o. RTY, J
~D ~AT NO EN~MENf~'~XlSf J >'~
~ ~ D~INE TH[ ~ISTEN~ OF ANY J ~ID
E~T8, COVENANTS, OR RESTRI~ONS ~/~
WHI~ DO NOT ~R ~ THE RE~ ~BDI' '
VISION P~T. U~ NO CIRCUMSTANCES S~ ~ FB= /~-~
~ DATA H~N BE US~ ~ CONS~U~ION
~ ~NCE LIN~ OR ~R EST~LISHING ~ND' DRA
Gamess Engineering Group, LLC.
3701 E. Tudor Suite 101
Anchorage, AK 99507
Reference: 32717 Eagle River Road
Attention: JeffGarness, P.E.
Dear Jeff,
Please be advised that I conducted a water well inspection at the above-mentioned
address for Kelly and Mary Heitstuman. I found the overall depth of the well to be
132.25' in overall depth. The well is cased the entire depth and there are no perforations
within 50'0fthe surface. It should also be noted that I installed a new sanitary well seal
and pl.aced the well wires in conduit. If you have any questions please feel free to call
me.
Sincerel
Brian Willie
Aarow Pump and Well Service
P.O. Box 110496
^nchorage, AK 99511
Parcel I.D. #
1.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
['}/.-~0- ~in ~ - ("~lt/ HAA# ~
GENERAL INFORMATION
Complete legal description G~ ~ ~7~ ~ · ~ Y~-; S 7~, ~.Y~
Location (sito address or directions) ~¢2~ ~ ~0
Property owner
Mai ing address
Lending agency
Day phone
Mailing address
Agent Day phone
Address
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.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA ~21
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JoJ le^oJdde leUO!l!puoo
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=~I:In.LVNglS SHHa
"9
'iS ,~,Fuoa
sseJppv
uJJ!-I Jo aLUeN
'uo!~oedsu! sl4~ bo elep eq~, uo loatje u! suo!JelnDaJ pue 'seoueu!pJo
'sepoo alelS pub led!o!unV~ lie q~!M eoue!ldLuo0 U! S! Luels,~s I~sodslp JeleMelSBM Jo/pue/,Iddns
JeleM ells-uo eql 'uo!loadsu! pue uo!le~)~seAu! ,~LU LUOJJ pue sel!J eSeJoqouv bo/[l!led!o!untN eql
LUO~I peu!elqo uo!l~uuJoJu! aq~ uo peseq leq1,~jpe^ ~eqlJn; I 'u!eJeq peleo!pu! eJnlonJls Jo ed,~l pue
SLUOOJpeq JO JequJnu aqJ Jo~ elenbepe pu~ leUO!loun~ 'ales s! uJels/~s I~sOds!p ~eleMe~SeM Jo/pue
Xlddns Je~eM el!s-uo eq1 leq~, SMOqS uo!Jeo!ldde leAoJddv ,~l!Joq~,nv qlleeH s!qj jo UO!I~8!1seAu!
,~UU leq~ ,~J!JeA I 'MOlaq UMOqS elep UO!lep!leA eq~ bo se pue m, eJeq pexgje leas XuJ ,~q pe!j!IJeo By
EI'=I:INI!DN:1 AEt NOIJ. O:IdSNI dO J.N:IIN=I.LVJ.$ '~
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
· ' '/ $,~._ ,~',~?J~'¢,~ ~y~ ~:v~ Parcel I.D.
Legal Descnptlon:~~-~/~ ~)]~ ~ .
A. Well Data
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~.~
Absorption field on lot
Public sewer main
Sewer service line
If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~'-/~:~/~,~ Driller
Cased to ~ 4- Casing height
OO~ I~ l~J
Wires properly protected (Y/N)
AT INSPECTION
g.p.m, g.p.m?.~
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~
Date of sample:
Nitrate ,/', ~ ~ Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~//Z~
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size ~ ooC'~ Compartments
Foundation cleanout (Y/N) ~ Depression (Y/N)
· '~J?,~ Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (3/93)* Front
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed /%,///4/_
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed 7/~ ~/;¢~
Length. ~'
Total absorption area
Date of adequacy test
Soil rating (GPD/Ft2)
Width ~ ~ Gravel thickness
~d::~ ~f- Cleanout present (Y/N)
~,//¢/¢'_5 Results (pass/fail)
System type '7~
Total depth
Depression over field (Y/N)
for ~ Bedrooms
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
After test
· if yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Sudace water
Curtain drain
E. ENGINEER'S CERTIFICATION
On adjacent lots /O~P .~/~- Properly line ¢ ~"
To existing or abandoned system on lot
Cutbank~ ~..~" Water main/service line
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in e~ff~c~4~t~he date of this inspection.
Engineer's Name
Date
HM Fee $ ,~
Date of Payment ~ ~- ~ Date of Payment
Receipt Number ~ ~¢~/~/ Receipt Number
72-026 (3/93)* Back
'. ? ~ I .,~ lt¢) I,"X'~.'tg-.//'~Y- I ?, ~ r ,- l , . C f///I[.,i ~
· ~ r~. ,: '~ ~ il 1c:~~ J~ MUNICIPALITY OF ANCFIORAO~
. I' ;;' MUNICIPALITY~o/A~J~[~RAGE DEPT OF ; ']TH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~I~O~M[N]'AL P~:O~ECT~ON
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION '-'~'~ ~' ~ ':~
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. Incomplete requests w not be processed Please allow ten 10 days for processing.
PROPERTY OWNER PHONE
Lyla R./Leander Hingst 694-2896
IAI LING ADDRESS
Star Route A Box 1451 Eagle River, Alaska 99577
PROPERTY RESIDENT {If different from above) PHONE
BUYER PHONE
MAI El NG ADDR ESS
3. LENDING INSTITUTION
National Bank of Alaska % Ruth La Bar
MAILING ADDRESS
Pouch 7-025 99510
4. REALTOR/AGENT
J.A. Modular
MAILING ADDRESS
3400 Mountain View D~ive 99504
5. LEGAL DESCRIPTION / ,
T13N R1E Section 10/ S½ N½ N½ NW¼ SW¼ NW~ N½ S½ N½ NW¼ SW¼ NW¼
STREETLOCATION / " : '
Mile 2 Barclay Road, see attached map.
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [] Four
>[~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMI,LY ~ Three [] Six
[] Other
7. WATER SUPPLY
~X INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY · since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
· [~× INDIVI DUAL/ON-SITE**
[] PUBLIC UTI LITY
**If individual/on-site, give installation date 1979
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. :
TH, S SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR I NSPECTO R
DIRECTIONS:
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[~ MULTIPLE FAMILY [] TWO [] FOUR [] SiX
~ERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
E~PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic,Tank or [] Holding Tank
Size: I(.~) If Tank is homemade SOILSRATI~G
give dimensions: ~/~'~
TYPE OF TANK MANUFACTURE~, , ¢,._~
/ ~--,..-,.~-
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELLTO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absoretion Area to nearest Lot Line
5. COMMENTS
I~]~/APPROVEDFOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
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o
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~-~MUNICIPALITY OF ANCHORAG'/-x
Department of Health and Environmental Protection
825 L Street, Anchorage, Alaska 99501
264-4720
~quest for Approval of Individual
Property Owner: .
/
Mailing Address:.~,?h. ~ ....
Name of Buyer:
Mailing Address:
Lending Institution:
Mailing Address:
Sewer and Water Facilities
Phone:
Realtor/Agent: ~/ /4'
Legal Description: 7131~
/ 0
Street ocation:
Single Family Residence: ('~ Number of Bedrooms:
Phone:
Multiple Family Residence: ( ) Number of Bedrooms:
Water Supply: * Individual Well (u~
If Community System, name of system
Public/Co~]]unity System
Sewage Disposal System: *~n-site System (~) Public System
~7
If On-site System, date Of installation: ? ~ /~ ~ /
*NOTE: A well log is required on ALL wells drilled since 6/75.
** If on-site sewer system is over two(2) years old, an adequacy
test is required by this department.
A fee of $25.00 must accompany each request before processing
can be initiated.
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