HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 4 LT 14
MUNICIPALITY OF ANCHORAGE
Development Services Department `rc
p p Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-011-27-000
Expiration Date: 2/5/2025
Legal description ZODIAK MANOR ALASKA BLK 4 LT 14
Site address 8521 SOLAR DR Anchorage AK 99507
Current property owner(s) HULING THOMAS & AMBER JOINTREVOCABLE TRUST
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
Original Certificate Date: 2/22/2024
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
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. 015-011-27
Complete legal description Zodiak Manor Alaska Block 4 Lot 14
Location (Site address) 8521 Solar Drive, Anchorage, AK 99507
Current property owner(s) Thomas & Amber Joint Revocable Trust Day phone
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
3. TYPE OF WATER SUPPLY: 0 Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank X Community Septic or Public Sewer
Age N/A - See advisory if steel older than 20 years
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 $ 2 O Waiver Fee $
Date of Payment 2/ 7-D Z-0 Z`1 Date of Payment
COSA # d S C- 2 r'�) 3 t' Waiver #
COSA Application—June 2022
6/4/75 112
112
4.38
* Met code at installation
N/A N/A
N/A
>
Benjamin Schiller, P.E.
(907) 522-7773
.tNiGn iicLL UK: LLLAZi WU VU NUT FILL IN-
N
Drilling
Drilling Co. M Ci
mss-• .M— —/0 S vi
Driller"
F'
Area Z��f,
Well Owner `
14. Use of Well
%0OFS" DwMry On 41V4 W 47 .�
Location {address of.: Township, Range. $ Section (if known); distance from road:
kc Hen, vi
42
Size of CasingDepth of Holeleet. Casedto %
feet.
Static grater level feet (above) (below) land surface. Finish of well
(check one) Open end (AI: Screen ( ): Perforated ( ).
Describe screen or perforations:`
Well pumping test ai allons per til (am) for hours with
feet of drawdown from static level.
Remarks G . S, elev. 266' , Z
t4ELL LOG
Depth in feet from Give details of formations penetrated, size of material,
ground surface color, and hardness'
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Munici ali of Anchora
p tY ' JUL 1 1 2017
On-Site Water and Wastewater Program • A,, P•
(907) 343-7904 FQ S A F E T Y
Certificate of On-Site Systems Approval s s L 9
Parcel I.D. 015-011-27 Expiration Date: I ^t
1. GENERAL INFORMATION: HLAsKA
ii
Complete legal description ZODIAK MANOR: LOT 14, BLOCK 4
Location (site address) 8521 Solar Drive*Anchorage 99507
Current Property owner(s) Dwight Cork Day phone 382-3795
Mailing address 5...m e
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual ❑
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer
WaiverNariance request for: Distance:
Received by: Date: ' //8/i
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 5a�(. — Waiver Fee $
Date of Payment 41 01 Date of Payment
Receipt Number U`t7 (0 Receipt Number
COSA# 0n0-7? I A7`'- Waiver#
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,
lig
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: Gayness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101-Anchorage, Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date:
4QQoo�p��
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system OF A,
in accordance with the guidelines and regulations established by the Municipality of Anchorage and 457,K\c„: • ••• •.-stIn
industry practices. The reported results describe the condition of the system/s on the date/s of the Q
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or � Q TH ��l�n
encroachments may exist that were not identified during the evaluation. The operational life of all wells Q * U
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, Q VAn
groundwater levels (that may fluctuate during the year), quality of construction (materials and I D
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary,and / .... .. Q
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the Q ,J: srmess.:
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of On E `79 3
the well or septic system. GEG makes no representation whether an alternative well or septic system VQ', . •�ceO
can be installed on the property in the event either of the current systems fail to perform adequately in V:e +t.`'� ./7 c/ ,
the future. The content of this report is for the sole benefit of the person/party that retained GEG to �QaP�otessio�°oma
perform the evaluation. Reliance upon the information provided in this report by any other person or
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
7( System #1 Approved for 3 bedrooms ••
System #2 Approved for bedrooms •\.;•0. Or HIVChU
Disapproved 01\I-S1-CE '
Conditional approval for bedrooms, with the followingtipt]l f�cs•
AND
wAS;EVNATE-R U
ftf r
� 1
By: w• Original Certificate Date: 7-1 Y'(•
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 Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA bice sheet 10.10.12.doc
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
ALASKA
fkr
Legal Description: ZODIAK MANOR OT 14, BLOCK 4 Parcel ID: 015-011-27
A. WELL DATA 'PER MOA DOCUMENT DATED 6/16/75
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (YIN) NO
Date completed 1975' Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth *112 ft. Cased to CNK ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 6/16/17
O
Static water level N.- ft. 84.1 ft.
• "
Well production g.p.m. 6.4+ g.p.m.
WATER SAMPLE� RESULTS:
Coliform �3colonies/100 ml. Nitrate "3 510 51'
` mg./L. Collected by: GEG, Ltd.
Arsenic: 13 ug./L. Date of sample: 6/16/17
B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER
Tank Type/Material Date installed
Tank size gal. Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N) Depression over tank (Y/N) High water alarm i
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2or ft`/bdr • System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorptio . ea ft` Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absor. '.n field before test in. Water added gal. New depth in.
Elapsed T • e: min. Final fluid depth in. Absorption rate >= g.p.d.
y rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION 141
Date installed_ Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off" level at '• wa er alarm level at in.
11- •• Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots 100'+
Absorption field on lot NIA On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 1o0'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIE 1 : I LOT TO:
Property line B • -' • oundation Water main
Water service lin- Surface water _ Driveway, parking/vehicle storage
. .in drain Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION 4• P•..••• • ' s 40j
I certify that I have determined through field inspections and '• 49"• .... it
of Municipal records that the above systems are insi
si
conformance with MOA COSA guidelines in effect on this
1:11
•••• 3` ;
date. IAV J f . A. ..rness : C
Engineer's Printed Name JEFFREY A. GARNESS f•1 CE-795
♦. • ".. 2410/. `
Date 1-/i41/1- .4 f/'°RIDFESSICI*'4.
LICENSE 4••Iiitmws%4�
*AECC884
(Rev.10/12/12)
1 8
0) ISI
Lot15 I E
ado IN1
30 1 N89°55'00"E 160.00 w Lot 18
Io � I - —
0 Nr
+�.___.---Wood fenc
O
Lu Lot 14 26.0 I o
NCt l '-b
ti
12.0
Cl 1Q • — — —•... Porch o deck3 N 8.0
O 48.2 24.0 v , aa * O
0 1 Story Frame House r O
Q Asphalt N Greenhous Ln
-
0 p `.. -----�..__' 1 50.0 Sh I O
U) I Z x hain link fence I z
_� o Lot 19
x x x1 x#
(r-i 30 N89 55 00 E 160.00
1
Lot 13
REVISED 7-7-17, ADDED WELL W
```���`� AS-BUILT NO CORNERS SET THIS DATE
�� OF• •A 'L di , I hereby certify that I have performed a Mortgagee's inspection
of the following described property: LOT 14, BLOCK 4,
....4,:s„....:..
P•• • • • •`'1- �# ZODIAK MANOR ALASKA SUBDIVISION
U,• 49th �1_ •• 9 /
r*• /\ •* / Anchorage Recording District,Alaska,and that the
'• w improvements situated thereon are within the property lines
•... and do not overlap or encroach on the property lying
/ 'M° '.Brett A. Wilmot .,o I adjacent thereto,that no improvements on the property lying
/ . I, r adjacent thereto encroach on the premises in question and
„_ ` .�•• 112392- LS • - _ that there are no roadways,transmission lines or other
SCALE: 1"= 30' F1'••• •• 5� y
/, FO • •• • • . • ao visible easements on said property except as indicated
t ;OFF'ss. . J hereon.
Dated at Anchorage,Alaska
EASEMENTS OF RECORD,OTHER THAN 1 ����� this 28th day of JUNE _,2017..
THOSE SHOWN ON THE RECORDED FRED WALATKA&ASSOCIATES
PLAT ARE NOT SHOWN HEREON. Engineers and Surveyors
SSS, FB 17-8, pg 7 BE (907-248-1666)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D.
CERTIFICATE OF HEALTH AU'THORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
0//- ;~-F HAA# \'~
1. GENERAL INFORMATION
Complete legal description
Lo~ 14; Block 4; Zoc~ak Manor Subdivision~
Location (site address or directions)
8521 ~ Drive
Property owner H.U.D. 111-039582-703 Day phone
Mailing address _605_~¢&&..~ 4th Av~.nu~, Aneho~ag¢-~ A/z, 99503
Lending agency Day phone
Mailing address
AgentSandy H~'e~stad ASSOCIATED BROKERS Day phone 563-3333
Address 640 W~St 36th Av~nu& S~t~ 0n~, Anchorage, Alaska 99503
Unless otherwise requested, HAA will be held for pickup.
NUIVIBER OF BEDROOMS: 3 ~/
'TYPE OF WATER SUPPLY:
individual well XX
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
XX
Public sewer
NOTE: If community wastewater system, provide written confirmation h'~m State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Fronl MOA ~21
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 of this Health Authority Approval application 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.
Name of Firm
Address
Engineer's signature
DHHS SIGNATURE
~ Approved for
7034 Eagle Ri,vet Loop Road
bedrooms.
Phone
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Service~ (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to 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 Municipalify of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA
Municipality of Anchorage ~i~
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ,/,,e~_~/oc,k/4i Z~-,ocJ, 6~ Nt.~,,aor Paroel I.D.
A. WELL DATA
Well type,S;Nc? ~'~a;l¥ If A, B, or C, attach ADEC letter.
Log present (Y/N) ~J. Date completed
Totaldepth ( hL___Casedto [ I '~
ADEC water system number
I~ .~' Driller
Casing height
Sanitary seal (Y/N) ~
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
A'r INSPECTION
[ O-.,~. ?)~I~JCIPALITY OF ANCHORAGE
NVt O I NT^ S ,WCES gmSlON
OCT 3 0 1991
~"~. ~g.p.m.
RECEIVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots _ I CO .(-
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Date of sample: --I C) - ~,~ ~J
'~EPTIC/HOLDING TANK DATA
[)ate installed
Cleanouts (Y/N)
Tank size
Foundation cleanout (Y/N)
Nitrate _,~¢F~ '~.¢r t"-~,miC ~, ~_Fther bacteria
Collected by:_ ~+ ~ ~-~t~)e¢~/~r~
Compartments
Depression (Y/N)
High water alarm (Y/N) Alarm tested (Y/N)
.~/..Dat~ of pumping Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK
Well(s) on lot On adjacent lots Foundation
To property line Absorption field Water main/service line
.,~u rface water/drainage --
72-026 (Rev. 7,91)From ~'~-'~r'Z..-~;:~ix~¢'~ "'~'~"~ ~'~¢-~;:~, CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed%~
Size in gallons
Vent (Y/N) "~ "Pump on" level at
High water alarm level
Meets MOA electrical codes ~Y/~
SEPARATION DISTANCEIFFTOM LIFT"~ATION TO:
Well on lot Onadj~ent lots
D. ABSORPTION FIELD DATA
Date installed
Soil rating~
Len¢ Width Gravel thickness
Total Iion area
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Depression
~ld (Y/N)
Surface water
Results (pass/fail)
System type
Total depth
Peroxide treatment
3nths) (Y/N)
SEPARATION DISTAN,
Cleanouts present (Y/N)
Well on Jot
To building foundation
On adjacent lots (
Surface water
Curtain drain
Date of adequacy test
for
ABSORPTION FIELD TO:
If yes, give date
bedrooms
n adjacent rots Property line
__ To existing or abandoned system on lot
Water main/service line
Driv parking/vehicle storage area
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.
$ & S ENGINE£EING
Signature ; ;'C,3,; E-~jI,, "' "- 204
Engineer's Nam~:~(¢le .~iver, Alaslca 9~
HAA Fee $
Date of Payment /O'
Receipt Number
72 026 (Rev. 3/91) Bsck MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
NOV- 8-~1 FRI 11:01 aNNU FIELD gERVIOE$ FaX NO, §0?662642? P, 01
F
MUNI~IPA,L~ 'rY ,oF ANCHORAO6
SEWER
84 05242
SCHEDUL~.D COMPLETION DATE
WATER & WAST/=WA~E t UTJL TY . · ~SINGLE,FAMILY
3000 ARCTIC'BO,ULEVARD .~ ': -': .... . ,. ·
PHONE.,2~7-76~2 ',"'"),". · '~..; ~; · ". r., ~.. ~. MULTI,OWELL... . . .NO
~,-~4 "'.~:'..,X ~.'~'~.'..~.."":. '~..~' ' ' ".~: .'.,' ''~ ..... ' - . . NO, A~TS ....
LO~ ' .',' ' · ' 'BLocK _ .m INDUSTRIAL
CONNECTION 81ZE
INSPECTION
PERMIT
REIMBUR.~IBLE
NUMBER
~-~ T RA ~ TO R: ~.-~~"~'
(LIb~ns~'& Bond ;'eq~lrcd -. '. "' "~
ON PROPERTY ONLY "'
MAIN TAP~"~O PRO'PERTY LINE ONLY
(MOA or.~.tate ROW Permit Requited) ,
MA N TAP & ON PROPERTY CONNECT
{MOA or State ROW Permit ~¢~u[red)
· ....
DEPOSITS
ASSESSMENTS
F~ Pai(~ prev'ious!y ' '"
~' M~in',~xter~ioh" agrec, meni
~ S~bdivlsion ~greement . .
E} E~n~d connect agreeme]~L ..: '
~Pefld~ng%A~OU~NTS
~ CK~' '
I~SPECTEO ~Y:
DATE:
, Ir ~A~Vo~ MR~L~YDWTI~FEHCTOH~I3MIT IO N J'"; A N D A E G U I' A TIO N $ 0 NT~/.~ 1'~!{ ~ B
,'i_" .;..,,r ,, .,,, '.. ' [~_' ~E.MI~ URE' ' '
' i~?~T ]'N A CONSPICUOUS '~A~'E AT T~%'B SITE'
L AWWU CUSTOMER S~RVJCE
SEWER INsPEcTION REPORT
Z
Z
.7¸'
/ GREA
£ER ANCHORAGE AREA BO uUGH
Department of Environmental Quality
3330 C Stree[
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
MAILING ADDRESS ~ /~/a ~, PNONE '~ ~//~/'',~ O ~ L
LOCATION ~%~ ~'*~
LEGAL DESCRIPTION ~ ~' ' ·
SEPTIC TANK:
DISTANCE
EROM WELL lO0
INSIDE LENGTH
_ MANUFACI'URER ~.~(~
INSIDE WIDTN
SEEPAGE 'P~::: ( ,,C~'-~..~,~
NUMBER OF PITS____, DIAMETER __
NUMBER OF
COMPARTMENTS
LIQUID DEPTH
OR WIDTH ' , LENGTH DEPTH
LIQUID CAPACITY
GALLONS.
LINING MATERIAL
BUILDING FOUNDATION___,
CRIB SIZE: DIAMETER
NEAREST LOT LINE____
DEPTH _ DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL. AREA)
SQ. FT.
ADDITIONAL ABSORPTION
WELL:
TYPE ~-~ ~ ____ CONS FRUCTION
BUILDING NEAREST
EOUNDATION -, LOT LINE
CESSPOOL
OTHER SOURCES__
APPROVED ............ DISAPPROVED__
DEPTH
NEAREST SEPTIC
SEWER LINE ..... , lANK __,
REMARKS
DISTANCE FROM:
SEEPAGE
SYSTEM
DISTANCES:
INSTALLED BY: ,
P PE MATER AL.~-,"q~.
LOT SI-OPE: ...........
REMARKS:
DIAGRAM OF SYSTEM
,T~ co'T CI Ae
DATE _~Fff) ~'~_ APPROVED
G.A.A.B.
~/-a'~ ,GREA,-R ANCHORAGE AREA
SEWAGE DISPOSAL SYS'rEM -- APPLICATION AND PI"RMIT
NAME OF APPLICANT
INSTALLATION LOCATION --
LEGAL DESCRIPTION --
PHONE
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY 'tO Be SERVED
FINANCED THROUGH
SOIL TEST RESULTS
COMPLETION DATE ANTICIPATED
DRAIN FIELD ., OTHER __
NOTE: THIS PERMIT IS NOT VALID WITHOUT ~OIL TE~T
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK SIZE TYPE SEEPAGE AREA SIZE TYPE
MINIMUM DISTANCES, REQUIREMENTS
DRAIN FIELD·
CAST IRON INTO AND OUT OF SEPTIC TANK AND NTO CRIB CROSSING GAP OF
EXCAVATION 5 Feet INTO JNDISTURBED SOIL
4 iNCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE Pit
FITTED WITH AIRTIGHT REMOVABLE CAPS.
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 2B-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
DATE
APPLICANT'S SIGNATURE
4-,15--75
Organic ~,laterial (PT)
Sandy Silt (ML)
,0.¢
----0.5'
Silty Sand w/ Some
Gravel (SM)
Sandy Silt (ML)
10.5'
Silty Sand w/ Some
Gravel (SM)
16.0'
Sandy Silt w/ Some
Gravel (~4L)
No Water Table
-~20.0' T.D.
R
Log Represents
Lot 13 Block 4
Zodiak Manor Subdivision
Engineering ~ Geologicel Consu[tanfs If~c,
Sebring Builders
Log of Test Hole
Anchorage, Alaska
DATE 4--15--'7 5 Ts ~._~ ..... [ ....... [ ....
CALE ]"--31 OWN BY B~[ CHKD e¥ pj PROJ. NO. 562014 I~[v~ NO. A-01
MUNICIPALITY OF ANCHORAGE
DEF~ARTMENT 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 /'/>Z /~,
GENERAL INFORMATION
(a) LegaJ Description (include lot, blocJq subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~L~I,J
I<- [ ~J' .,~¢f L4)_ Telephone:Home ~'~5//¢ "-~'~ (,.'-. G '~~ Business
ApplicantAddress ~5'Z/ ~,~ ~)~tqt~ ~(~A~I~ ~L~ ~t~5'IU~ ~'~
(C) Applicant is (check one): '.ending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain);
(d) Lending Institution. C,,G'-/~i'fZx25'~ /~//f2,v&C~/') ~"~;';~ Telephone
Address
/
(e}Real Estate Company and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
/'2
o, n6
TYPE OF RESIDENCE
Single-Family j~i(' Multi-Family []
Number of Bedrooms
Other
WATER SUPPLY
Individual Well Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAl.
Onsite [] Public¢ Community [~] Holding Tarfl( [~
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting te the legality and status.
Page 1 of 2 72-025 (11~84)
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
Authority Approval 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.
Name of Firm ~)lJ~t~
Telephone '~... 7~, - .~ '7 YO
Engineer's Seal
DHEP APPROVAL
Approved for ~ bedrooms by , /
Approved ~__: Disapproved.
Terms of Conditional,Approval
Conditional
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 [)HEP 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
WELL DATA
Well Classification -
Well Log Present (Y/N) _
Total Depth _// ~ ! Cased to
Static Water Level ¢"~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
If A, B, C, D,E.C. Approved (Y/N)
Date Completed .(J~J~ Iz"~lo~h'~ Yield
Dept.h'of Grouting - -~-
Pump Set At ___-
Sanitary Seal on Casin~ (Y/N)
Depression Around Wellhead (Y/N)
Separation Distances from Well: /N~//~ '
To Septic/Holding Tank on Lot , ; On Adjo n ng Lots
To Nearest Edge of Absorptioa Field on Lot _ ; On Adjoining Lots
To Nearast Public Sewer Line /~)/ "f" '_ To Nearest Public Sewer
Cleanout/Manimle .... ~'~O'~ '¢"" To Nearest Sewer Service Line !on Lot
Water Sample Collected by _~Jg
Water Sample Test Results _ .-~/~;'I'".tSF/~ e,~"O/?.,~ -
Comments
!
B. SEPTIC/HOLDING TANK DATA
Date installed
Standpipes (Y/N) _ __ Air-tight Caps (Y/N) --
Depression over Tank (Y/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
To Property Line
To Water Main/Service Line _
Size No. of Compartments
Foundation Cleanout (Y/N) --
Date Last Pumped
;ifor
Temporary Holding Tiank Permit (Y/N)
__ To Building Foundatioh
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Coursa
Comments
Page 1 of 2
C. ABSORPTION FIELD DATA ,/~
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line __
To Existing or Abandoned System on
; On Adjoining Lois
To Cutbank (if present)
D. LIFT STATION
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 thaU ha~/e check.e.d, verified, or conformed to all M OA,/~..nd HAA guidelines in effect on the date of this nspection
Signed ~,//,0.4.~ ~:~ ~¢1~¢~ Date /~l~,
Company ~t/~f¢~ ~(~, MOA No.
ReceiptNo. /O O/ O O~ ........
Date of Payment /~/~1/~ ~:~:'::¢ :~:
Amount: $ _ ~
Page 2 of 2
72-026 (11/84}
Engineer's Seal
825 L Street* Anchorage, Alaska 99E01 AP R 1 9 I9;"9
ENVIRONMENTAL ENGINEERING DIVISION CEIVED
Telapho~m 264-4720 R E
REQU EST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILrrlES
DIRECTIONS: Complete au parts on page 1. Incomplete requests will net be ~rocessed. Please allow ton (10) days for orocessing,
t. OWNER
MAILING ADDRESS
PROPERTY RESIDENT (if different from abovel
2, BU
MAILING ADDRESS
). LE~DING INfiTITUT?~I
~IAIL NG ADDRESS
4, REALTOR/AGENT
PHONE
PHONE
PHONE
PHONE
MAILING ADDRESS
E, LEGAL
STREET LOCATION
TYPE OF RESIDENCE NUMBER DF BEDROOMS
[] One [] Four
~ SINGLE FAMILY
[] Two [] Five
[3 MULTIPLE FAMILY I]~"~ Three E~ Six
WATER SUPPLY
[] Other
NDIVIDUAL*
[] COMMUNI'rY
~UBLIC UTILITY
8. SEWAGE DISPOSAl. SYSTEM
~ N DIVI DUAL/ON-SITE*'
[~ PUBLIC UTILITY
+ ATTACH WELL LOG. A well log is reauu'ed for all wells drilled
s'nce June 1975. For wells drilled erior to tl3at date, gwe well
depth (attach log if available.)
**1 f individual/on-site, give 'nstallation date
If system is over two [2) years old an adec Jacv test is required
bv this Department,
NOTE: THE INSPFCTION FEE MUST ACCO[V, PANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR I NSP ECTOR
DIRECTIONS:
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY --
DATE DRILLED
[] PUBLIC UTI LITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDI VI DUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tan~: or E3 Holding Tank
Size: /~OO If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
'~, DISTANCES Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
~APPROVEDFOR .'~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
r~ DISAPPROVED
DATE i BY (Title)
LEGAL DESCRIPTION
72-010 (Rev, 3/78)
Pa,qe,2 of two pages - Ret, at for Approval of Individual ,~ .~r & Water Facilities
Legal Description .~ ~ /L/ ~//~, Z/ ~,~//~c //~/~/F~ ~/~2 , .
Comments
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
Date
EQ-034 (1/74)
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
1. Approval requested by:
Mailing Address: __~Lth_2~ E
2. Property Owner:
Mailing Address: ___B~x 'I~C SRA=
3. Legal Description: __l_ot l_4~__B]~ck
4. Location: ~S~_l~_llr_~_v.e~
5. Type of facility to be inspected _Single Eamil~
6. Well Data:
A. Type ~i]_l_ed
C. Construction __Approved
7. Sewage Disposal System:
A. Installed
C. Septic Tank: 1. Size
D. Seepage Pit: 1. Absorption Area
E. Dispesal Field: Total length of lines
8. Distances: Borough Approved
A.Well to: Septic tank
Nearest lot line
B.Foundation to septic tank
C.Absorption area to nearest lot line
Date Received _ June 16_~__1.975
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Phone: 2.17-567'1
Phone: 344-3065
_Z od i a c _ M a n oJ:_,SJJ bd i v_i~S.iO ri _
No. of bedrooms
B. Depth ll2'
D. Bacterial Analysis
Borough Approved June 16,1975
B. Installer
2. Manufacturer
2. Material
, Absorption area
Other contamination
, Absorption area
OK
, Sewer Lines ,
EQ-O3q (1/74) Page 1 of two pages
Type of
3330
'GREATER ANCHORAGE ARk/, BOROUGII
Oepartnlent of Environmental Quality
"C" St., Anchorage, Alaska 99503 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACiLITiES
Mailirlg Address:
Name of Realtor or
Nailing Address
Inspection: CJ~RO VA FHA CONV
?roper~y Owner: ~_ ~C
Mailing Address: ~ , ·
7. Type of Facility to be inspected:
8. Water Supply
Type of Supply: Public Utility
If Individual, number of dwellings
if individual~ depth of well
9. Sewage Disposal. Systeir,
l'ype of S~steln: Public Utility
If individual, date of installation'
/nd= =~
~viuual ~
presently served----L ....
Individual (on-site)
