HomeMy WebLinkAboutSILVER CREST BLK 2 LT 17MUNICIPALITY OF ANCHORAGE
Development Services Department A Phone: (907)343-7904
On -Site Water & Wastewater Section Fax: (907)343-7997
Certificate of On -Site Systems Approval
OSC251285
Parcel ID 015 -062-48 Expiration Date:
Legal description SILVER CREST BLK 2 LT 17
site address 7100 CANDACE CIR
Current property owner(s) ROUNDS PETER G & LAURIE J
X The On-site system(s) is/are approved for 4 bedrooms
W
6/23/2026
Conditional approval for bedrooms, with the following stipulations:
Comments or conditions:
No comments
Original Certificate Date:
7/21/2025
This Cert" "cate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
systeropiment
) is/are in substantial compliance with municipal code. The Municipality of Anchorage,
Deve Service 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 submittal.
ATTACHMENTS:
COSA Checklist X
Absorption Field Advisory
Tank Age Advisory
Other
Well Flow Advisory
Nitrate Advisory X
Arsenic Advisory
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. 015-062-48
Complete legal description SILVER CREST BLOCK 2 LOT 17
Location (site address) 7100 CANDACE CIRCLE ANCHORAGE, ALASKA 99516
Current property owner(s) ROUNDS PETER & LAURIE
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: FE Private Well serving # 1 dwelling units
❑ Other Non-public well as regulated by MOA ❑ Water Storage
❑ Community Well or Public
4. TYPE OF WASTEWATER DISPOSAL: ❑Q Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel X Plastic ❑ Concrete ❑ Fiberglass
Age 4 _ See advisory if steel or fiberglass older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed RN Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $_ SSU
Date of Payment 7/15-%
COSA# 05(ZY/2ff
Waiver Fee $
Date of Payment
Waiver #
COSA Application_Apr2025.doc
COSA Checklist_May2025 .docx
COSA Checklist
Legal Description: SILVER CREST B2 L17 Parcel ID: 015-062-48
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 8/16/1978 Total depth 82 ft
Cased to 80.7 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 35 in.
Date of flow test for COSA 6/23/25
Static water level at beginning of test 63 ft.
Well production at time of test 4.5+ gpm
Water storage tank volume None gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 6.95 mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by Date 6/23/25
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank 58"
Date of pumping 6/23/25
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. DISPOSAL FIELD DATA
Which system tested (date installed) 8/23/1978
ALL standpipes present per record drawing
Total measured depth from grade 11.6 ft (max)
Measured depth to pipe invert from grade 4.4 ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes (MT) go to bottom of effective. (ED)
If not, state depth into effective 7.2 ft
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 6/23/25
Results Pass
Fluid depth prior to test 58 in
Water added 600 gal
New fluid depth 76 in
Elapsed time 1440 min
Final fluid depth 58 in
Absorption rate 600 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 96 in (MOA 8’ ED)
Effective depth used 68 in (Final Fluid Depth + Missing ED)
Effective depth remaining 28 in
Comments/Deficiencies: Tested the in use 1978 trench, owner has been alternating between fields every 3 years. Approximate total
measured depths from existing grade. ED per elevation measured shots, visual observations, MOA records & appears there is 7.2’ of
measurable effective depth (ED).
COSA Checklist_May2025 .docx
E. SEPARATION DISTANCES
From Well on Lot to: (Please enter distances if less than required)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Disposal Field on Lot > 100’ Yes if No ft
Neighboring Disposal Fields > 100’
Yes if No ft
Sewer Line/Main > 100’ Yes if No ft
Sewer Manhole/Cleanout > 100’
Yes if No ft
Sewer Service/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Disposal Field(s) on Lot to: (Please enter distances if less than required)
Tank to Foundation > 10’ Yes if No ft
Field to Foundation > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main/Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 07/17/2025
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
07/17/25
MUNICIPALITY
DEVELOPMENT SERVICES E}E' RTM NT � '°'� 907-343-7904
On-Site water and wastewater Section f Fax: 343-7997
www.muni.org/onsite
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC251285
Subdivision: Silver Crest, Block: 2, Lot: 17
A water sample revealed a nitrate concentration of 6.95 milligrams per liter (mg/Q.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for
important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
Silver Crest
Lot 17
Block 2
#015-062-48
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: ________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211327 PID Number: 015-062-48
Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New X Upgrade
Name
PETER ROUNDS
ABSORPTION FIELD
El Deep Trench ❑ Wide Trench ❑Bed ound
Site Address
7100 CANDACE CIRCLE *ANCHORAGE, AK
❑ Other
Phone
Number of Bedrooms
Soil Rating
original grade
907-230-9770
4
]Total
depth
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
SILVER CREST; BLOCK 2, LOT 17
Fill added above original gr
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total orption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ftz
Ft.
Well
1001+
TANK K Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER TANK
Capacity
1250 Gal.
Surface Water
100'+
Material
Number of compartments
Lot Line
51+
NA
HDPE
2
Foundation
101+
LIFT STATION
Manufacturer
Capacity
Remarks OLD TANK DECOMMISSIONED PER UPC
Gal.
PER CONTRACTOR
Alarm location
Electrical installed by
Installer
PIPE MATERIAL House to tank D3034 drainfield Tank to
D3034
ANDERSON CONTRACTING
Drainfield D3034/EXISTING co/MT D3034
Inspector GEG AND MOA
BENCH MARK (Assumed elevation) 100.00 ft
Inspect151 8/31/21 -
Location and description
2nd
3'd _ 4th _
GARAGE SLAB
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's tamp
060
°ooh
Conditional Approval: Date
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Approved PD (L 9- CA P' CL Date 10 % �ZZ
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Note: this approval does not include well permit requirements.
'A rofesslo' ''
ilAECC884
kI\GV VJ/VL/IVi
PERMIT NUMBER:
OS0211327 RECORD DRAWING
TOP OF MANHOLE = 101.86
FINAL GRADE = 101.68-101.75
MH1
TOP OF TANK AT INTLET = 97.71 --\ 11 19 1 1 /- TOP OF TANK AT OUTLET = 97.66
INVERT OF BUNG AT INLET = 97.00
NEW 1250 GALLON
H.D.P.E. SEPTIC TANK
PARCEL ID NUMBER:
015-062-48
INVERT OF BUNG AT OUTLET = 96.80
(ff"ARNEk"l-30S YEN(311NEFF'RING"
(ff_lR0UP,,Lwtd
ENGINEERING -SALES -CONSULTING,
#
3701 E. TUDOR ROAD, SUITE 101 'ANCHORAGE, AX99507' PHONE (907) 337-6179* FAY (907)33S.3246'V1ESSITE —vngidng—
PREPARED FOR:
PHONE NUMBER:
LICENSE44iIIIIIIIIIII,
#AECC884
PAGE NUMBER:
PETER ROUNDS
907-230-9770
3 OF 3
LEGAL DESCRIPTION:
DRAWN BY:
SILVER CREST; BLOCK 2, LOT 17
D.J.G.
TYPE OF WORK:
DATE:
ASEPTIC TANK PROFILE
10/4/2021
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#
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LICENSE44iIIIIIIIIIII,
#AECC884
PERMIT NUMBER: RECORD DRAWING PARCEL ID NUMBER:
OSP211327 015-062-48
DBL1
\
29.8
32_2
DBL2
30.7
32.0
MH
32.3
33.6
STI
36.6
36.1
DBL3
38.3
37.2
DBL4
39.4
38.0
FD
39.8
38.2
FS
41.6
40.3
C01
44.6
46.8
CO2
84.0
91.9
MT1
83.2
91.4
CO3
44.7
40.7
C04
1 85.4
80.4
MT2
86.1
81.5
1 '
/
Gx' G? /
00' � / i PNS PG r
Gi
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\
----NEW 1250 GALLON HDPE GREER . • '
/ TANK WITH DOUBLE CLEANOUTS
CO2 T7 BEFORE AND AFTER TANK
7
1985 TRENCH _" N�'�
\ M 2
C
\ 1978 DRAINFIELD
100' WELL RArm 1c
/
EXISTING 4
BEDROOM HOU
r
O
n `1985 TRENCH
v�
APPROXIMATE 100'
WELL RADIUS
\ ` N
'ROUP, Ltd
Y --= ENGINEERING <, SALES) CONSULTING
3701E TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 • PHONE (907)337-6179- FAX (907) 736-3240 • WEBSITE:
www 9amersengn enng.com
PREPARED FOR:
PHONE NUMBER:
PAGE NUMBER:
PETER ROUNDS
907-230-9770
2 OF 3
LEGAL DESCRIPTION:
DRAWN BY:
SILVER CREST; BLOCK 2, LOT 17
D.J.G.
TYPE OF WORK:
DATE:
SEPTIC TANK RECORD DRAWINGS
10/11/2021
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MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP211327
Work Type: SepticTank Upgrade
Tax Code Number: 01506248000
Site Legal Address: SILVER CREST BLK 2 LT 17 G:2439
Site Mailing Address: 7100 CANDACE CIR, Anchorage
Owner: ROUNDS PETER G & LAURIE J
Design Engineer: GARNESS ENGINEERING GROUP LTD
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date
111cnC ,
c ..
n �
V.
t_�GI)ill'tIII ell t
Lot Size in Sq Ft
Total Bedrooms:
8/9/2021
8/9/2022
43002
❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April, 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
w mo
Date.
Date:
.012
t
a2 I
4
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a.�il i � � �_� :A �S '� -� � � • �} �--� �` � h�s � �.�. ij � �`� �'�v�~�/3 n�. `�3 C' �
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_ •x: _ ._ - - - ' -, _ _ �. re air ,
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section \'---�
F ax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 015-062-48
Property owner(s) PETER ROUNDS
Mailing address 7100 CANDACE CIRCLE *ANCHORAGE, AK
Site address 7100 CANDACE CIRCLE *ANCHORAGE, AK
Day phone 907-230-9770
Legal description (Sub'd., Block & Lot) SILVER CREST; BLOCK 2, LOT 17
Legal description (Township, Range & Section)
Lot Size Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) 0
Septic Tank
Upgrade Z
(w/wo AD U)
Holding Tank
❑
Renewal ElDuplex
(D) ❑
Privy
❑
Multiple Dwellings ❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER, REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
J r F ( .> S �' W � Ill L owl 1
(Signature of property owner or authbfized agent;
Permit/Rush Fees: 0 2.2 5 Waiver Fees:
Date of Payment: _ _ 8�� zo2 Date of Payment:
Receipt Number: D 3 1106 Receipt Number:
Permit No. 0-5P2-11-32-7 Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211327, Rebecca Carroll, 08/09/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211327, Rebecca Carroll, 08/09/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211327, Rebecca Carroll, 08/09/21
i--~ MLINICIPALITY OF ANCHORAGE
~--~% DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
) ENVIRONMENTAL ENGINEERING DIVISION
82.5 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME .... PHONE ~ [] NE~/
MAILING ADDR~
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS~
'~ Well Absorption area Dwelling PERMIT NO.
DISTANCE TO:
~<~ = ~u~c~ur~,- ~ X' "S +"'~ '~ ''~/~L ~,.ri~, .o. o,~o~r,m..,~
~ ~ Liq. capacity in gallons IF HOMEMADE: inside length Width LiquM depth
¢ -
~ ~ DISTANCE TO: Weft Dwelling P~RMIT NO,
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ DISTANCE TO: Well ~ ~ ¢ F~undation ~(> / Nearestlotlin~ / ~ERMITNO. ~{ ~..~ //~
~ ~ Trench width Distance between lines
~ ~ ~ N°' of lines ~ Length~ °f~)'each~oline. Total length ~°f lines~. ~ *t- ~/~inches
H ~ ~ Top of tile to finish grade ~ateria) beneath tile Total effective absorption area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
m i Well Building foundation Nearest lot line
~ DISTANCE TO:
~ NO. '
~ Class Depth Driller Distance to lot line PER
~ Building foundation Sewer line Septic tank Absorptions, area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOl L TEST RATING
~PP~O~E'D DATE LEGAL
~ -~6, ~'3 ~',')ve,~ c,"~"/ Z<,Y
,~1
72-013 (Rev, 3/78)
I 'IAI:RI::~'.Y W
'7 :t. 0 0 C} A t'"! I:) C} C [iil
~':'. ~{]:, iii!; '"" ~:;~' iL
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR: ~ Cr-c¢~"'I ~
LEGAL DESCRIPTION: ,_~,' ['4¢,'~¢¢j"~ /~ i0'/:- ~- Lot-
DATE PERFORMED:
SLQPE
SITE PLAN
1
.... 2. mL ~.,'~ F
5
6
7
8
11
12
13
t4-
15-
16
17
18
19
20
COMMENTS
PERFORMED BY:
72-008 (6/79)
WAS GROUND WATER S
ENCOUNTERED? AD L
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
q"~q i°~q ~'.¥ "'
~ o "--H' ' .5" 6
~ ~ o3q 'T 5' -
lo 't ~ ,)' b" -
i°5~
(minutes/inch)
~ H'm'-
TEST RUN BETWEEN FT AND FT
CERTIFIED BY: DATE:
-/ /
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION: '~'
Ob o~e.,*i'u £o~'~
SLOPE
DATE PERFORMED:
?If P
SITE PLAN
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
S
h° L
O
P
E
IF YES, AT WHAT
DEPTH?
,¢ ' ,rL'~ .A,-.
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE 1(~'
(minutes/inc~) ~'
TEST RUN BETWEEN ~ FT AND z/. S. FT
72-008 (6/79)
S~vercrest Block 2 Lot 17
This is a revised soil log, requested by John Kennedy. The ori~
ginal soil log, done by me, shows OL from 0 to 1.5, then ML
from 1.5 to 4, then GM from 4 to 14. The GM perked out. I
differentiated the ML from the GM because in the test hole, the
stuff did look tighter towards the top.
However, when Ed Sanderson proceeded to install the system, he
noticed that the pipe leaving the tank was 2 feet below ground
level. He reasoned that, instead of making a 10 foot deep
trench with 6 foot of rock, he could make a 10 foot deep one
with 8 foot of rock, thereby shortening the length of the
trench and leaving more room for replacement systems.
NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF NEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Stre0t- Anchorage/Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Robert Mi lby_.
MAI LING ADDRESS
3408
Woodland Park Dr.
LEGAL DESCRIPTION
Lot 17, Block
TPRONE
272-2805
~"N EW
UPGRADE
LOCATION
2 Silvercrest Subdivision
NO. OF BEDROOMS
4
PERMIT NO.
780433
Dwelling
20' 21
Material
Steel
Well ! 1 Absorption area
DISTANCE TO /~. ~
I/
/
Manufacturer
Greer
ILiq, capacity in gallons ,WellIF HOMEMADE: Inside length
[ DISTANCE TO: L~ Dwelling
' J Well /
DISTANCE TO: I /'~ jFoundation ~14
No. of lines Lengtb of each line [Totallengtho lines
Top of tile to finish grade Material beneath tile
Lengtb Width Depth
~f crib Crib diameter
_ ~' ~ETO: Cribdepth
Well Building foundation
Class Depth Driller
DISTANCE TO: Building foundation Sewer line
No. of compartments
2
Widtl~ Liquid depth
PERMIT NO.
Material
Nearest lot line
20
Trench width
3 ~inches
Gravel 96nchas
Liquid capacitv in gallons
PERMIT NO.
780433
Distance between lines
Total effective abs~.qtion area
704 SQ. F'
PERMIT NO.
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO.
Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
Cast Iron/Plastic Leach
SOIL TEST RATING
165
INSTALLER
H & M Excavating
REMARKS
APPROVED
Lot 17~ Block 2,
Silvercrest Subdivision
72-013 (Rev, 3/78)
'M-W DRILLING, INC.
DRILLING LOG
Well Owner ]R0bct:t li[].bv Use of Well
Location (address of: rI'ownship, Range, Section, if known; or distance main road
I,oI: 17 Block 2 o.Llvarcrast oubdivisiort, A!wt ora3~
Size of casing.
Static water level .
Screen ( );
.Depth of Hole
, ft. (~b~,~,~)
Perforated (
Describe screen or perforation
Well pumping test at :i gallons per
of drawdown from static level.
Date of completion l~ / 1 (, ,/7 8
32 feet Cased to ~q0.7 feet
(below) land surface. Finish of well (check one)
).
t'~/A
(minute) for J hours with 'I "~
Wr. LL LOG
Depth in feet f~om..
ground surface Give details of formations penetrated, size of material, color and hardness
open end ( .]C7 );
_TO .Lltg S t'.ickup
2 TO 5 Organic~,~
5 TO. ].2 _Silty sand & graw.~l
12 TO__23 Silty gravel
23 TO. 65 r;.tl, ty sand: gravalSly
65 TO 75 :xi]. ty gravel
75 TO 79 tku:d p,:m: gravelly
79 TO__~.~ 2 Uct t ~t: gravel
TO
TO
TO
.TO
TO
TO
TO
',' ¥ i]l,[ (< 973
3--CONTRACTOR
DEPFIRTMENT, L ~EALTH AND EN,/IRONMEHI'Ft~'" 825 'L" .STREET., FINCHORRGE., Al<.
~-~[:, ~3P-~ ~-:~ ;[ -17[ :5~ ~:&...I E [~ P' EE F;:~ ~,"~
~qELL.
APPLICANT ROBERT MIl. BY ~408 WOODLAND PRRI< DR.
LOCATION CANDICE CIRCLE
x,Y_,I E.M
TYPE OF SOIL ~B_.ORBTION [RPINFIELD
MflXIMUM NUMBER OF BEDROOMS ~ 4 SOIL RFITING (SO F'T/BR): 165
THE REQUIREb SIZE OF TFIE SOIL. FtBSORPTION SYSTEM IS:
TFIE LENf3TH DIMENC:;.I:ON IS THE I_ENG'FH (iN FEET) OF THE TRENCH OR E:,RFIINF'IEL.D.
'['fiE r;oEPTH OF Ft TRENCH OR PIT IS THiE: DISTANC:E BETWEEN THE S, LIRFFtCE OF TFIE
GROLINE:, RN[:, THE BOTTOM OF THE EXCI:qVFITIOI'.,I (IN FEET).
T 8-1E 'T' P-. E Y-~ C l-I [.-It Il: Is-...-r ~dt X ."F:~ ]g. NT.z~ ~:~ ~.?.:-~ F::' E: E; T
'/HE GRAVEL. DEPTH IS THE MINIMLIM DEPTH OF' GiRFIVEL E:ETWEEN THL:: OIJTFFIL. L P:r.F'E:
FIND THE[ BOTTOM OF THE E',:<CFtVFITION (IN FEET).
F'ERMIT APPLICANT HAS THE RESPONS;IBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF FINY WELLS FIDJRCENT TO THIS PROPERT9 AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
BFICI(FILI_ING OF ANY SVSTEM HITHOUT FINFIL INSPIEC:TION FllqD APPROVFIL 13V THIS
DEPFIRTMENT HILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN FI HELL AND ANY ON-SITE SEWAGE DISPOSAl.. SYSTEM IS
±00 FEET FOR A PRIVATE HELL.; OR
t50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE T'¢PE OF PUBLIC. HEL. L.
WELl_ LOGS 8RE REOUIRED AND MUST BE RETURNED TO ]'HE DEPARTMENT WITHIN ]:0 DAYS
OF THE WELL COMPLETION.
OTHER REC,!UIREMENTS MR9 APPLY. SPECIFICATIONS AND CONS'f'RUCTION D!FIGRFtMS fqRE
RVAILABLE TO INSIJRE PROPER INSTALLFITION.
I CERTIFY ]'HAT
1: I tim FAMILIFtR HITH TFtE REQUIREMENTS FOR ON-SITE SEWERS FIND HELLS RS SET
FORTH BM THE MUNICIPBLITM OF 8NC'.HORBGE.
2: I WILL INSTFIL. L THE SYSTEM iN ~CCORDBNC:E WITH THE CODES.
3: :[ UNDERSTAND THFIT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENL. BRGEMENT IF' THE
RESIDENCE IS REMODELED TO INCLUDE MORE THFII'.~ ,4 BEDROOMS.
FIF'PLIE:AI",IT ROBF'RT MIbE:Y ~/~/
m ,ii I I
4040 "B" STREET,
LA . i~.. TLAB ANCHORAGE, ALASKA 90503
,,, PHONE: 007-279-2581
Project ~'
.o~e No, l?t ~ f~ Woter Level Whi,e
Locotion ~t~/' £~)v.¢v- ~ Water Level After Drilling
Test Hole
Drilling J,'F'¢--t_~ ~ /
Field Log
W.O. No._~
Logged
Frost~ Drill~ Weather
Standard
Penetration
BLOWS/6"
Frost /~/tO ~,% Drill f-.~,//' Weather
.Test Ho~,¢
Field Log
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE ~,1~-~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILLY DWELLING
015-062-48
GENERAL INFORMATION
Complete legal description
SILVER CREST SUBDIVISION: LOT 17. BLOCK
Location (site address or directions) 7100 CANDANCE CIRCLE ANCHORAGE. AK 99516
Property owner
Mailing address
Lending agency
Mailing address
JEANETrE & TOM WELLMAN Day phone 7 -
7100 CANDANCE CIRCLE ANCHORAGE. AK 99516
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OFWATER SUPPLY:
Individual well xxx
Community well
Public water
NOTE:
If community weft system, provide written confirmation from State ADEC attest-
ing to the legafity and stafus of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding Tank
Community on-site
Public sewer
NOTE:
XXX
If community wastewater system, provide written confirmation from State ADEC
lng to the legality and status of system.
72-025 (Rev. 1/91) Front MOA 1Y21 Computer Version
Note:Alaska, Water. and Wastewater Consultants, Inc,. shaft be paid $400.00 at,
or prior to, ctosing for the engineering services provioea.
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 anc; type of
structure indicated herein. I further vedfy that based on the information obtained from the Municipality of
Anchorage flies and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is in compliance with all Munic;Ip,~l/~nd State codes, ordinances, and regulations in effE.ct
on the date of this inspection.
Name of Firm ALASKA WA-T'ER &¢ AS'/'~ECVATER CONSULTANTS, iNC. Phone f907't 337-6179
/ t /i / t//.,~,. . --
Address 6901 DEBARR/ROAD,IS,~JV E 2Er A4~,~.,.ORAGE, ALASKA 99504 , / _
EngineeOs Signature (.._~/./~,~/~ ~/'
In conducting this evaluation, AWWC, ,n.~. ¢o~q )ted to pJrovido a thorough, conscientious ong/neorinlg a/,alysis of the
system in accordance with ADEC and MOWDH rS Guidelines & Regulations. The reported results described 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 soils 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 eva/uator of the system. Satisfactory test results do not guarantee future performance
of the system, nor do they guarantee that there are no hidden defects or encroachments.
AWWC, /nc. can therefore not provide any warranty for future estimate of how long the
system wi//continue to meet the operational requirements of the ADEC or MOA DHHS.
The content of this report is for the sole benefit of the owner listed above. Any
reliance upon or usa of this report by any other person or party is not authorized,
nor wi//it confer any legal right whatsoever.
6, DHHS SIGNATURE
~ Approved for LC' bedrooms
Disapproved
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The 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 Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
72K)25 (Rev. 1/91) Back MOA ¢k21 Computer Version
Legal Description:
A. WELL DATA
Well Type PRIVATE
Log present (Y/N)
Total depth 82'
Sanitary seal (Y/N)
RECEIVED
Municipality of Anchorage ~
DEPARTMENT OF HEALTH & HUMAN SERVICE~cT,,
0
2000
Environmental Services Division
825 "L" Street, Rm 502 Anchorage, Alaska 99§01 (907) ~43-4744
MUNICIPALITY OF ANCHORAI]E
ENVIRONMENTAL SEEVICES DIVISION
Health AuthOrity Approval Checklist
SILVER CREST S/D; LOT 17~ BLOCK 2, ParCel I.D.:
015-062-48-000
If A, B, or C, attach ADEC letter. ADEC water system number
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform 0
Date of sample: 10/5/2000
B. SEPTIC/HOLDING TANK DATA
Date installed 8/23/78 Tank size
YES Date completed
Cased to 80.7'
YES
FROM WELL LOG 8/16/78
NOT GIVEN
8/16/78
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
6/27/2000
N/A
24"+
YES
68'
5 g.p.m. 4.7 g.p.m.
Nitrate 4.39 mg/L Other bacteria 0
Collected by:
A.W.W.C., INC.
1250 Number of Compartments 2 Cleanouts (y/N). YES
N/A
Foundation cleanout (Y/N) YES Depression (Y/N) NO High water alarm (Y/N)
Date of Pumping 6/27/2000 Pumper OLD McDONALD'S
C. ABSORPTION FIELD DATA
Date installed 4/26/85
Length 67' Width
Effective absorption area 992 SQ.FT.
Date of adequacy test 6/27/00
Fluid depth in absorption field before test (in.);
Fluid depth 39" (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72026 (Rev. 3196)* Computer Vemlon
,Zilc'ZI"T¢2.~CJ,,.[ ~(,:,~¢._j'~ t.~¢,~ q"~-~t~'~' *MEASURED IN FIELD.
Soil rating (g.p.d.~2 or(~) 220 System type TRENCHES
2'-4' Gravel thickness below pipe 8' Total depth *8.9'- 10.8'
Monitoring Tube present (Y/N) YES. Depression over field (Y/N) NO
Results (Pass/Fail) PASSED For__ 4 Bedrooms
0" Immediately after 1029 gal. water added (in.): 43.5"
261 Absorption rate = 600+
N/A If yes, give date -
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons
"Pump on" ~ff' level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
100'+
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
100%
On adjacent lots
On adjacent lots
1 CIO'+
100'+
N/A Public sewer manhole/cleanout.
25'+ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+ Property line 5'+
Water main/service line 10'+ Surface water/drainage 100%
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation
Surface water 100%
Curtain drain NONE KNOWN
of Municipal ref~ord~ tt~i~ ~he ~/oove /stems are in conformance
Signature ~"-~//'F ~f- ~'~--"~
Engineer's Name ~ ' ~ JEFFREY A. GARNESS
Date /0/~/00
__ Absorption field __
__ __Wells on adjacent lots.
N/A
N/A
5'+
100'-F
10'+ .Water main/service line 10'+
Driveway, parking/vehicle storage area. 10'+ __
Wells on adjacent lots 100%
HAA Fee $ ~:~'
Date of Payment
72-026 (Rev, 3/96)* Oomputer
Waiver Fee $
Date of Payment
Receipt Number
10-05-00 12:18 FROU-CTE ENVIROHUENTAL 5615301 T-OFO P.OI/02 F-826
CT&E Environmental Services Inc.
Laboratory Division
200 W. Petter Drive
Anchorage, AK 99518
Tel: (907) 562-2343
Fax: (907) 561-5301
CT&E Ref. #:
Client Name:
Project Name:
Client Sample ID:
Matrix:
PWSID
1005997001
AK Water & Wastewater Cons.
n/a
Silver Crest Lot 17 B 2
Drinkiag Water
Client PO#:
Printed Date/Time:
Collected Date/Time:
Received Date/Time:
Technical Director:
n/a
10/05/00 12:00
10/03/00 08:15
10/03/00 10:50
Stephen Ede
n/a Released By:
Sample Remarks:
Allowable Prep Analysis
Parameter Results PQL Units Method Limits Date Date Init
Total Coliform (MF) 0 col/100 mi SM9222B 10/03/00 KAP
Nitrate 4,39 0.5 mg/L EPA 300 10,0 10103100 SCL
~ MI~ICIPALITY OF ANCHORAGE
; D~VISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Info~nnation_ ~.~X~ >~\ Application Date ____~
Location (ad~,dress or diy~) L ~ ~ ~ _ .
(b) Applicants Name [~%~-~ ~ Telephone - Home Business
Applicants Address ~ ~>z~ C.~Om~ ~J~V-- ~ ~_ _
(c) Applicant ~is (check onp) Lending Institution ~-_~ ; ~ner/builder ~
Buyer ~--~ ; Other ~ (explain);
(d) Lending Institution ~7~ Telephone
Address
(e) Real Estate Co. & Agent
Address
(f)
Telephone
Mail the HAA to the following address:
2. Tyrol Residence
Single-Family~
Number of Bedrooms
3o Water
Multi~-Family~--~
Other (describe)
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.
4. Sewage Disposal
Onsite ~ Public ~ Community ~ Holding Tank ~
Note: If community well system, must have ~,~itten confirmation from the State
Department or'Environmental Conservation attesting to the legality and status.
[Page I of 2]
5. Engineering Firm Providiqg Inspections, Tests~.~ile Search~ D__ata and Information
DHEP Ap_p~roval
Approved for~_~f~___bedrooms
Approved~'%/
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 vrith all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm ~ ~ ~~$~-.~ Telephone ~]4~ ~-~
Conditional
Disapproved
Terms of Conditional Approval
CAUTION
T}~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESE~-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY ~N 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 REQUIRE-
MENTSo EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. TIlE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/Di8
[Page 2 of 2]
7-19-84
Well Classification
Well Log P~esent (Y/N)
Total Depth ~ Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit ,{Y/N)
Separation Distances from Well:
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
Legal D_escrip_ ti ,on: ~O~tT
If A, B, c~ C, D.E.C. Approved(Y/N)
Date Completed
Pump Set At
To Septic/Holding Tank on. Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
MuN[CIPALI'~Y OF ANCHORAGE
DF. PT. OF HEAL]'H &
ENVIRONMENIAL pp, O'fEclION
Depth of Grouting ~/k
Sanitary Seal on Casing (Y/N)~
Depression Around Wellhead (Y/N) ~
; On Adjoining Lots I~P'
; On Adjoining Lots
To Nearest Public Sewe~
Cleanout/Manhole ~/~k To Nearest Sewer Service Line on LOt ~'~
Water Sample Collected By ~(~[-~ ; Date 5J'TJ~/~
Wate~ Sample Test Results ~z~,.~'~,~-~
Co. manta
B. SEPTIC/HOLDING TANK DATA
Date Installed ~D lz J 1~ si~e 12 o NO. of Compartments ~
Standpi~s (Y~) ~ Air-tight Caps (Y~) ~ Foundation Cleanout (Y~) ~
~ession o~= Ta~ (YIN) ~ ~te ~st P~d ~/~
P~ing~intenan~ ~n~a~ on File (y~)~/k ; for ~/~
Holding Tank High-Wate~ Ala~ (Y~) ~/~ Ternary Holdi~ Tank ~rmit (Y~)~/~
Sep~ation Distan~ ~ ~ptic/Holding Tank:
To Water-Supply Well
To Property Line ~D'{~
To Water Main/Servi~ Line
Cour se ~) / }k
Comments
To Building Foundation 'Z.II- "
To Disposal Field I(~
TO Stream, Pond, Lake, o~ Majo~ Drainage
[Page 1 of 2]
2-15-84
Ce
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~I~l~
Width of Field
Square Feet of Absorption A~ea
Length of Field (eq
Depth of Field [o
Gravel Bed Thickness ~
Standpipes P~esent (Y/N)
Type of System Designq-~
Depression over Field (Y/N) ~ Date of Last Adequacy Test
Results of Last Adequacy Test ~/~
Separation Distance from Absc~ption Field:
To Water-Supply Well [~2~' To P~operty Line
To Building Foundation ~ To Existing or Abandoned System cn
Lot ~ ; On Adjoining Lots 5~D ' ~
To Wate~ Main/Service Line ~Lo' ~- To Cutbank(if present)
To St~eam{Pond/Lake/c~ Major D~ainage Course
To D~iveway, Pa~king A~ea, c~ Vehicle Stc~age A~ea
De
Date Installed
Size in Gallons
"Pum~ On" Level at
High Wate~ Alarm Level at
Tested fo~
Ele ct~ical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing. Adequacy Test.
Meets MOA
Cfa~nts
** Check Per~mitted Bedroom Rating A~ainst HAA Request
I certify that, I~have checked, ve~'ified, (:~ c~nfok-nmd to all MOA ~ Guidelines in, effect
on the date~of ~3~isinspection. " ' ' ,~ ' ~"-" '"'""~ ~
,~/
/_
(
Si__ed - __ __ __. ~.~.? ,~ , '--, ~' .
C~any
2-~5-84
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS; Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) davs for processing,
PHONE
PROPERTY RESIDENT (If different from above) / ' PHONE
2, BUYER PHONE
MAILING ADDRESS J
~. LENDING INSTITUTION~.'~
MAILING ADDRESS
4. REALTOR/AGENT
-MAILING ADDRESS
5, LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One j[~ Four [] Other
[] Two E~] Five
[] Three ~] Six
7, WATER SUPPLY
I
NDIVIDUAL-
COMMUNITY
[] PUBLIC UTILITY
ATTACH WELL LOG, A well log ~s reeuired for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available,)
8, SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
*~ If individual/on-site, give ins[allation date_
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.
72-010(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TiME TiME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
I. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2. WATER SUPPLY PERMIT NUMBER
[] INDIVIDUAL DEPTH OF WELL
[] coMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVI DUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY ~_ -~
Connection Verified
iNSTALLER
[]Septic Tank or []HoldingTank ~ ,~ J~
Size: /~,-~'~ If Tank is homemade SOILS RATING
give dimensions: / ~
TYPE OF TANK MANUFAC~U/RER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Se ,c H ~ ~
pt' / olding T~nk Absorption Area ISewer Line I Nearest Lot Line
WELL
TO:
I
I
Absorption Area to nearest Lot Line
5, COMMENTS
I~/'APPROV ED FOR ~' BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED ~
DATE BY {Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
BL OCK RET. WALL
.r"
./' o . r
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALL Y TO SHO WAN
CONFLICTS BETWEEN EXISTING STRUCTURES'AND PLA 7TED LOT LINES ANDZOR EASEMENTS' AND IS
NOT TO BE USED FOR POS`ITIONINGADDITIONAL STRUCTURES IMPROVEMENTS OR FENCELINES.
EASEMENTS OFRECORD OTHER THAN THOSEAPPEARING ON THE"RECORD PLAT, ARENOT SHOWN
HEREON ( UNLESS INDICA TED)
NOTE:' FENCE'LINES THAT MA YAPPEAR ON THIS DRA MNG ARE NOT TO BE USED TO DETERMNE
PROPERTYLINE'S OR POSITIONADDITZONAL IMPROVEMENTS.
ANYPA DING SHO WN HEREON MA YBEAPPROXIMA TE DUE TO EXCESSIVE SNO WAND/OR ICE
AS UIL. T SURVEY I " = 40'
NO CORNERS SET THIS DATE
I HEREB Y CERTIFY THA T l HA VE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
10 T 17 8L 06<2 SIL VER CREST SUB.
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THA T THE
VISIBLE IMPROVEt1riENTS .Sl TUA TED THEREON ARE W1 THIN
THE PROPERTY L INES AND NO VISISL E ENCROACHMENTS
EXIST OTHER THAN NOTED
DA TED A T ANCHORAGEALASKA THIS 28 TH DA Y OF
SEPTEMBER , 2022
15619 227--37
HOZ T �LAND SURVEYING
9309 GRO VER DRIVE
ANCHORf9GEAK 99507
.223-86 15 3759GCI. NET