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HomeMy WebLinkAboutT12N R3W SEC 33 LT 74T12N, R3W, Section 33 Lot 74 #018 251-11 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP241364 PID Number: 018-251-11 Dwelling: ❑N Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑■ Upgrade Name David &Suzanne Todd ABSORPTION FIELD El Deep Trench ❑Wide Trench El Bed El Mound Site Address 3244E 144th Avenue ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot 74 Fill added above original grade Ft. Gravel length Ft. Township Range Section 12N 3W 33 Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ftz Ft. Well 100'+ NA NA NA 25'+ TANK ❑p Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1250 Gal. Surface Water 100'+ NA NA NA Material Number of compartments Lot Line 5'+ NA NA NA NA HDPE (Deep Burial) 2 Foundation 10'+ NA NA NA LIFT STATION Manufacturer Capacity Remarks Septic tank replacement only. Gal. Portions of drain field repaired per permit approval. Alarm location Electrical installed by PIPE MATERIAL House to tank D3034 Tank to D3034 drainfield Installer ARM Services, LLC. Drainfield Co/MT D3034 Inspector PES BENCH MARK (Assumed elevation) 101.01 ft Inspection vt 11/14/24 11/14/24 Location and description 2nd da:3rd 4th See Site Plan, South Patio Door Threshold ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp ?�qs��� Conditional Approval: Date �� �F low, .......�. . .. S���N�. Septic Syste i . CE 8149 � Approved G Date I 'f Not . this approval does not include well permit requireme ts. (Rev 05/02/18) / 1250 GAL GREER POLY TANKPROFILE PA N N O N E E N G S V C , L L C ( C . I . 1 0 8 8 ) 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 hftp://www,muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP241364 Work Type: SepticTank Upgrade Tax Code Number: 01825111000 Site Legal Address: T12N R3W SEC 33 LT 74 G:3034 Site Mailing Address: 3244 E 144TH AVE, Anchorage Owner: TODD DAVID & SUZANNE Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 10/22/2024 10/22/2025 108900 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ 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 Received By: S �` ' % Date: Issued By: �x— Date: 1 ? L, 2� 4 MUNICIPALITY OF ANCHORAGE SEMEN= Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON -SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 018-251-11 Property owner(s) David & Suzanne Todd Day phone Mailinq address Site address 3244 E 144th Avenue Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) T12N R3W SEC33 Lot 74 Lot Size — 108,900 _Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: (Z all that apply) Absorption Field F-1 Septic Tank I -XI Holding Tank El Privy ❑ Private Well ❑ Water Storage ❑ APPLICATION IS AN: TYPE OF DWELLING: Initial El Single Family (SF) RX EX-1 Duplex ADU) Upgrade Renewal El Duplex (D) D Multiple Dwellings El (SF and/or D) THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number: Permit No. CF Waiver Fees: Date of Payment: Receipt Number: Waiver No. Permit App_'-'- : - : Pannone Engineering Services LLC Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panengak.com Mailing: P.O. Box 1807 Palmer, AK 99645 Telephone: (907) 745-8200 FAX: (907) 745-8201 Municipality of Anchorage Development Services Department On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, Alaska Subject: T12N R3W Section 33 Lot 74 Septic System Upgrade Permit Request This is a design narrative for a permit to install a 1250-gallon septic tank to replace an existing 1250-gallon septic tank to be issued for this property. The existing tank is 31 years old and is likely perforated and leaking, it will be decommissioned per code. Currently the lot is developed. The proposed replacement will be connected to the existing drain field. The existing drain field was camera inspected by Arm Septic Services and found to contain a separation at approximately 15-16 feet from the head of the drain field following a bellied portion of the line that extends approximately 7-8 feet, as well as the end of the drain field lateral appearing disconnected from the vertical cleanout. These damaged portions of the drain field align with the present vehicular traffi c load. The drain field lateral will be repaired along with the instal lation & repair of all associated standpipes as indicated on the attached site plan. Rigid insulation will be installed over the existing drain field to prevent any further deterioration of the system. This lot and the surrounding lots are served by private wells. There are currently no wells within 100’ of this upgrade. 1. Upgrade Tank Design. A foundation clean out installed if needed. The tank will be located: 5’+ from any property line. 5’+ from any deck/stair support. 10’+ from building foundation. 10’+ from any water line. 100’+ from any surface water. 100’+ from any private wells. 200’+ from any public wells. The proposed installation will not affect the future development of this or the surrounding lots. If you have any questions or concerns, please contact me at (907) 745-8200. Sincerely, SRP Steven R. Pannone, PE, F. ASCE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241364, Curtis Townsend, 10/22/24 Page 2 of 2 Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 Physical: 332 East Manor Ave, Anchorage, AK 99501 Telephone: (907) 272-8218 FAX: (907) 272-8211 Owner/Civil Engineer 18 October 2024 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241364, Curtis Townsend, 10/22/24 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241364, Curtis Townsend, 10/22/24 Jun 30 11 05:00p Beau Maxim 19073391985 Mark Begich Mayor Development Services Department Building Safety Division On-Site Water & WastewQter Program 4700 Elmore Road P.O. Box 196650 Anchorug¢, AK 99507 www. muni,or'q/onsil¢ (PO7) 343-7904 Pump Installation Log Well Drilling Permit Number: SW Date of Issue: Parcel Identification Number: Legal Description T12N R3W SEC 33 LT74 Property Owner Name & Address: DEAN O'NEAL 3244 E. 144TH AVE ANCHORAGE AK 99516 : Pump Installation Date: 6rm/~ ~ Pump Intake Depth Below Top of Well Casing: ~o~ feet Pump ~¢[anufacturer's Name: GOULD$ Pump Model: 10SB054220 Pump Size 1/2 hp Pitless Adapter Burial Depth: 1o feet Pitless Adapter Manufacturer's Name: CAMBEL Pitless Adapter Installer: N/A Well Disinfected Upon Completion? [] Yes [] No Method of Disinfection: RECIRCULATED USING CHLORINE PELLETS Comments: Pump Installer Name: BEAU MAXIM Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. Municipality of Anchorage Page ~ of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519~6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Wastewater System: ~ew ~ Upgrade Address: Phone: NO of Bedrooms: ~O~ ~eepTrench ~ Shallow Trench ~ 8ed ~Mound ~Other L E G A L D E S C R I PT I O N so, Rabng: , ~ _GPD/Sq Ft. Total Depth/¢ from/ original grade: LeE 8lock: Subdivision: Deplh lo pipe boltom from original grade: Gravel depth beneath p~pe WELL: d New~ ~F/'¢ ~ Upgrade Gravel width: ~, ~ Fl Number of lines:/ Dislance belween lines:~ Ft. Classification (Privale. A.B.C): Total Depth: Cased TO: Total absorption area: Pipe materia?//¢~ GPM Pump Set at: J Oas,ng He,gh, Above Ground: TAN K SEPARATION DISTANCES ~ptic ~ Holding ~ S.T.E.P. TO Septic Absorption Lill Holding ~ublic/Pnvale Manufacturer: Capacity in gallons: ~ ~ Material:.~ / Number of Compartments: Surface Water >/~C/ ~/5~' ~ >/5~' LIFT STATION Remarks: BENCH MARK Assumed Elevation: ~NGINEEB'8 SEAL Inspections performed by: ~ ~rx/~ _ Dates: 1st Department of Health and Human Services approval '~ -~ Reviewed and approved by: c~t~q ~(~_ Date: '.,.., 72-013 (Rev 9/91) MOA 25 Permit No...'~vk/ ~05~-,~' Page ~Z of '~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report ?-/ Legal Description: ,~T~ /~.¢uJ .(~'u'-o '~ ~ PID NO.: W~'LL / Permit No. ~ ~j ~2¢~;)_~/%'j Page '~ of '~' Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 ·'Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: I PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW920385 DESIGN ENGINEER:ARCTIC SLOPE CONSULTING GROUP OWNER NAME:BROWNELL THOMAS E & NANCY J OWNER ADDRESS:7740 SOLARSET CIRCLE ANCHORAGE, ALASKA 99517 DATE ISSUED:il/13/92 EXPIRATION DATE:il/13/93 PARCEL ID:01825111 LEGAL DESCRIPTION: T12N R3W SEC 33 LT 74 LOT SIZE: 108900 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM 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 (18AACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: DATE: DATE: October 15, 1992 Mr. Dan Roth Municipality of Anchorage Dept. of Health m~d Human Services 825 L Street Anchorage, Alaska 99501 Re: Septic System Approval Lot 74 T12N R3W S33 Dear Mr. Roth: Attached is the permit application for upgrading a septic system on the above referenced lot. Below is a narrative of probable impacts to adjacent properties. Adjacent Wells - There are no existing wells within i00 feet of the proposed new septic system. Adjacent wells have sanitary seals, and the proposed absorption field does not adversely impact adjacent wells. Adjacent Wastewater System - All the surrounding lots are undeveloped except for the lot immediately to the south. An absorption bed is also in use on that lot. Reserved Space - Adequate space remains for a similarly sized trench within a 30 foot radius of the test holes on either side of the proposed system. Drainage_ - The existing grade around the proposed system slopes gently (1-3%) to the southwest. Positive drainage away from the field and existing wells will be maintained. No surface water will be directed toward the field and no existing streams are within 100 feet of the proposed field. Mr. Dan Roth October 15, 1992 Page 2 The installation of this on-site system will have no probable impacts to adjacent wells or septic systems. The proposed system's separation distance radius will include parts of adjacent lots, but will not interfere with the on-site systems on these lots. Sincerely, ~Mag~ ~~. Sr. Civil Engineer ASCG November 9, 1992 Ms. Susan Oswalt Municipality of Anchorage Dept. of Health and Human Services 825 L Street Anchorage, Alaska 99501 Re: Septic System Design Lot 74, T12N, R3W, S33 Dear Ms. Oswalt: You expressed five concerns regarding the sewer design submittal for Lot 74, T12N R3W S33. All sewers and wells within 200 ft of the system are shown on the attached design revision. No curtain drains or streams are within 200 ft of the proposed system. Also indicated on the design is an appropriately sized reserve area for a deep trench of similar design to the proposed trench. The depth and length of the proposed trench have also been revised to be consistent with the depth of testhole #1. The use of a single monitoring well is sufficient to accurately gauge the water level in the area of the proposed system, since the surface and subsurface conditions and surface elevation within the proposed system area do not vary significantly. At the client's request, the sizing of the system was based on a slower acceptance rate than indicated by the percolation test results. Very truly yours, CSM:EG:MLT: 1110-0026.041 Permk No. I of Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone:345 4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description ELM LOT 74 T12N R3W S53 PID No: R FIVE NOV 1 3 199 Ocp~ ~,.,diu~ & Human SITE MAP /"=/00' o >- E 144TH AVE D :)rage Service8 EXISTING WEL WELL @ 200~ LOT 75 VACANT AREA BM AISE CORNER OF ABAND. FOUNDATION (ELEV=IO2)t BM R SW CORNER OF ABAND. FOUNDATION BM A BM B LOT A EXISTING WELL 0 _ MOSEL~ SUBDV, OLd Permit No. Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEAL_TH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone:3d5 47¢4 On Site Wastewater Disposal System and/or Well Inspection Report Legel Descrip'.ion BLM kOT 74 TI2N RSW S53 PID No: I .~,~ ;urlOr'ag CLEANOt~ ,/.//~ ~, IUlllan Sot'Vi 4" ACCESS TUBES SEPTIC CLEANOU rs - 63' P2 __-~ ~ CLE BM B SEPTIC SYSTEM r~L~, ~VIEW DESCRIPTION BMA ISE CORNERSE OF ABAND. BM BS[SW CORNER OF ABAND. ELEV.=I02) ] NATIVE MATERIAL GROUND FILTER FABRIC SEPTIC ROCK ABSORPTION SYSTEM CROSS SECTION NOT TO SCALE ABSORPTION SYSTEivl PROFILE NOT TO SCALE NOTES I C0NTRACIOR TO VERIFY MIN. SO. FOOTAGE PRIOR TO pLACINg TOPSOIL, ...-~.~: OF 4/ h~ _,.?'..' '... ,f ~, ,':~;.." /~ '.? v '~ %,"......'~t~ ',, System Calculations for Lot 74 ASCG Calculations 30-OCT-92 Page 1 of 1 'Tank Size 4 Bedrooms = 1250 Gallons Absorption Field Sizing Using an acceptance rate of 0.8 gal/SF/day and a daily load for 4 bedrooms of 600 gal/day. Req'd Absorption Area = 600 gpd / 0.8 gpd per SF = 750 SF System Dimensions 63.0' long * an absorbing depth of 6.0' * 2 sides = 756.0 SF ASCG SOILS LOG - PERCOLATION TEST PERFORMED FOR: ACRFAGE SYSTEMS LEGAL DESCRIPTION: BLM LOT 74 TWSItP, RNG, SCTN TI2N RSW S33 DATE PERFORMED: 22 SEP 92 0-- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 11- SANDY, TEST HOLE 1 I A SE CORNER OF ADAND. FOUNDATION BM B SW CORNER OF AOAND. FOUNDATION PERC TEST SLOPE SITE PLAN [ ....... ABANDONE ., FKIVALL , ~, ~ F~ nuu~F~ WAS GROUND WATER ENCOUNTERED? N 1F YES, AT WHAT DEPTH? DEPTH TO WATER AFTER MONTrORING? DATE: ~SEP92 L% 13- 14- 15- 17- 18- 19- 2O- HOLE BOTTOM NO. GROSS NET DEPTH TO NET DATE 'rIME TIME WATER DROP B2SEP92 15:30 0 min 5' 0 0" - 15:35 5 mln 2,4" 15:40 10 min 2.3" 15 15:45 5' ~ 4" 5' 23" 5, 2 i. 5' 1 %' 1 7~' 5'-1 7" 15:52 22 min 15:57 27 mln 1,7" 16:02 3~ min 1,7" PERCOLATION RATE Z9 (MIN/INCH) PERC HOLE DIAMETER 6.0" ~TEST RUN BETWEEN 5'-0.fi' FT AND 5'-2.4' Fr COMMENTS: PERC HOLES WERE PRE-SOAKED FOR FOUR HOURS PRIOR TO TESTING PERFORMED BY: ERIC OROPP / OREG MAGEE CER:I'II~Y THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFI~ECT ON THIS DATE: 22 SEP 92 ASCG SOILS LOG - PERCOLATION TEST PERFORMED FOR: ACRF~GE SYSTEMS LEGAL DESCRIPTION: BLM LOT 74 TWSHP, RNG, SCTN TI2N R3W S33 DATE PERFORMED: 22 SEP 92 0- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10~ 11- 12- 13- 14.- 15- 16- 17- 18- 19- 20- SAND GRAVEL TEST ltOLE 2 DESCRIPTION ~L SLOPE HOLE BOTTOM & PERC TEST WAS GROUND WATER ENCOUNTERED? N IF YES, AT WHAT DEPTH? - DEPTH TO WATER AFTER MONITORING? DATE: - SITE PLAN }~?,o ,~ ~,~.~ ABANDON _..~v/~/~ HOUSE TH2&3 GROSS NET DEPTH TO NET NO, DATE TIME TIME WATER DROP I 22SEP9B 15~23 0 min 8' 0,0' 2 15:28 5 nln 8'-3,6' 5,6" 3 15:33 10 min 8'-314' 4 15:38 15 mln ~'-3,0' 3,0" 5 i5:45 a~ mln 8' a,6~ 6 ~5:50 a7 min 8' a,9~ ~,9' 7 15:55 32 min 8' ~,9~ 2,9" 8 - 9 10 - PERCOLATION RATE 1.7 (MIN/INCH) PERC HOLE DIAMETER 6.0' TEST RUN BETWEEN g-0.0' Fr AND 8'-3.6' FI' COMMENTS: PERC HOLES WERE PRE-SOAKED FOR FOUR HOURS PRIOR TO TESTING PERFORMED BY: ERIC GROPP / GREG MAGEE CERTIFY THAT TI-IlS TF3~T WAS PERFORMED 1N ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EP'I-'ECT ON TillS DATE: 22 SEP 92 ASCG SOILS LOG - PERCOLATION TEST PERFORMED FOR'. ACREAGE SYSTEMS LEGAL DESCRIPTION: BLM LOT 74 TWSHP, RNG, SCIN TL2N R3W S33 DATE PERFORMED: 22 SEP 92 1- SAND 2- 3- 4- 5- 6- 7- 8- 9- 10~ 11- TEST HOLE 3 DESCRIPTION I A SE CORNER OR ABAND. FOUNDATION BM B SW CORNER OF ASANO. FOUNDATION 8M A 8M B TH -'~-- PERC TEST SLOPE HOLE BOTTOM WAS GROUND WATER ENCOUNTERED.9 N IF YES, AT WHAT DEPTH.9 DEPTH TO WATER AFTER MONITORING? DATE: - SITE PLAN WF~ HOUSE --L[m'~FO~NDATIC 12- 13- 14- 15- 16- 17- 18- 19- 20- GROSS NET DEPTH TO NET NO. DATE TIME TIME WATER DROP 1 22SEP92 16:01 0 min 2 16:06 5 mln 2'-8,5' 2,5' 4 16:16 15 mln 2'-8,0~ 6 16~86 ~5 min 2' 8,0' 2,0~ 7 16:31 30 mln 2'-8,0" 2,0~ 9 , 10 PERCOLhTION RATE .Z5 (MlN/INCH) PERC HOLE DIAMETER 6.17 TEST RUN BETWEEN 2-6.0" Iff AND 2-83' FI COMMENTS: PERC HOLES WERE PRE-SOAKED FOR FOUR HOURS PRIOR TO TESTING PERFORMED BY: ERIC GROPP / G~ MAGEE CERJI'IFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MLrNICIPAL GUIDELINES IN EFFECT ON THIS DATE: 22 SEP 92 FIVIUNICIPALITY OF ANCHORAGE Development Services Department / Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 018-251-11-000 Expiration Date: Legal description T12N R3W SEC 33 LT 74 Site address 3244 E 144TH AVE Anchorage AK 99516 Current property owner(s) TODD DAVID & SUZANNE 9/24/2025 X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: M Original Certificate Date: 11/25/2024 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 COSA Checklist_June 2022 COSA Checklist Legal Description: Parcel ID: 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 Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist_June 2022 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/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 Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 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 > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC & MOA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail, and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore, we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Phone Engineer’s Printed Name Date r,nT 54 LOT 55 1 LOT 56 I T,, — — — — — — — — — — — — - 1 PP \ — — — - - -- - - O� / m \ BASIS OF BEARINGS: (S 89.59' E 329 67')CALC. 329.92'MEAS. — — — — — ' ORGIN 144th Ave- 33' ROW RESEERVATION FOR ROADWAY E E m & PUBLIC UTILITIES PER PATENT 031431 / / e P 62.2' ------------------ --------------------------- w - - - - - - - - - - - - - - - - - - - - - - - - - 27.9' w I m 100 WELL 321' I 60.7 RADIUS I m 15.4' :. O0 :. �� 4.8' m o 12.0' T LOT 75 LOT "74 SECTION 33 T12N R3W C7 (S 89-59'15" E' 329.67')CALC. LOT 87A N 2 STORY RECORD DATA PER BLM DEPENDENT RESURVEY RESIDENCE OF T12N, R3W, S.M., AK, ACCEPTED 2/14/1952 5� 12.1' 4.0' m FOUND 5/8" REBAR, NO CAP o SHED GRAVEL DRIVEWAY 32.2' m OVERHEAD UTILITIES o P POWER POLE n SEPTIC PIPE m 0 O WELL 0 DECK m � MH O c° T Ell m w 0 N m c D r m m C7 LOT 87B ASPLS MORTGAGE LOCATION SURVEY NOTES: NO TITLE REPORT WAS PERFORMED FOR THIS SURVEY, EASEMENTS SHOWN PER THE RECORD PLAT. THERE MAY BE ADDITIONAL EASEMENTS NOT SHOWN HEREON. THIS MORTGAGE LOCATION SURVEY HAS BEEN PREPARED IN ACCORDANCE WITH ASPLS MORTGAGE LOCATION SURVEY STANDARDS. IT IS A REPRESENTATION OF THE CONDITIONS THAT WERE FOUND AT THE TIME OF THE SURVEY. THIS SURVEY DOES NOT CONSTITUTE A BOUNDARY SURVEY AND IS SUBJECT TO ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. THE INFORMATION CONTAINED IN THIS DRAWING SHALL NOT BE USED TO ESTABLISH ANY FENCE, STRUCTURE, OR OTHER IMPROVEMENTS. UNLESS GROSS NEGLIGENCE IS DISCOVERED, THE LIABILITY EXTENT OF THE PREPARER SHALL BE LIMITED TO THE AMOUNT OF FEES COLLECTED FOR SERVICES IN PREPARATION OF THIS PRODUCT. LEGEND RECORD DATA PER BLM DEPENDENT RESURVEY ( ) LOT 73A OF T12N, R3W, S.M., AK, ACCEPTED 2/14/1952 5� FOUND 2.5" BRASS CAP O FOUND 5/8" REBAR, NO CAP GRAVEL DRIVEWAY FENCE - E E - OVERHEAD UTILITIES o P POWER POLE °° SEPTIC PIPE MH SEPTIC TANK LID O WELL DECK 0' 40' 80' LOT 73B SCALE: V= 40 FEET (11"x17") �. OF. A�gsl 49TH ••*1 J •,Ryan G. Johnson; r�+,•.No. 192159 ,•� 11/20/20�4•S AW SIONK� Aft, AS -BUILT OF: 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. 018-251-11 Complete legal description T1 2N R3W SEC33 Lot 74 Location (site address) 3244 E 144th Avenue Current property owner(s) David & Suzanne Todd 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS Day phone 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: 0 Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel 0 Plastic ❑ Concrete ❑ Fiberglass Age New - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑■ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: 0 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 $� Waiver Fee $ Date of Payment COSA # 05 . C 2 `� % 7 Date of Payment Waiver # COSA Applicalion_June 2022 Parcel I.D. # MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Sita Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING 018-251-11 1. GENERAL INFORMATION Complete legal description T12N. R3W. SEC 55: LOT 74- Location (site address or directions) 3244 E, 144TH ANCHORAGE. AK 99516 Property owner THOMAS BROWNELL Mailing address 5244 E. 144TH ANCHORAGE. AK 99516 Lending agency Mailing address Day phone Day phone (907) 345-8469 Agent _BRENDA REYNOLDS w./ RESIDENTIAL MORTAGE Day phone (907) 222-8800 Address 14-00 w. BENSON BLVD. ANCHORAGE. AK 99505 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4- TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: 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 i~21 Computer Version Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1500.00 at, 1 or prior to, closing for the engineering services provided. J 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspec~on, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal aCd State codes, ordinances, and regulations in effect on the date of this inspection.~ ,/~/~/( NameofFirm ALASKAWATER&~ ~S$EWATEECONSULTANTS, INC. Phone (907)337-6179 Address 6901 DEBARR R(D/AD, E/L~/ ~-',2/B/~N/CH~RAGE, ALASKA 99504 , /n conducting this ovaluation, AVVWC, Inc. ~, ~ tod to provido a thorough, consciontious ~/~ineo[ing analysis of tho system in accardance with ADEC and MQ~ DH, ~ Guidellnes & Regulafions. The reported results described the performance of the system under the conditions bncountered 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 theevaluatorofthesystem. Satisfactorytestresultsdonotguaranteefuturepefformanca 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 will continue to meet the operational requirements of the ADEC or MOA DHHS. 'j,~.~.~..~,/~...~ .:....~ The content of this report is for the sole benefit of the owner listed above, Any ~,..~.~.~. .. .. .(: ...... ll- i,/ ?/ ',,,,j ~ reliance upon or use of this report by any other person or party is not authorized, ~'r ~' A. ~er~es§..' · . ............ nor will it confer any legal right whatsoever. 6, DHHS SIGNATURE X Approved for ~' Disapproved Conditional approval for bedrooms · bedrooms, with the following stipulations: Additional Comments Date 7-/~ -00 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. 72-025 (Rev. 1/91) Back MOA ¢Y21 Computer Version Legal Description: A. WELL DATA Weli Type PRIVATE Log present (Y/N) Total depth Sanitary seal (Y/N) ECEiVED Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICESJUL 05 Environmental Services Division 825 "L" Street, Rm 502 Anchorage, Alaska 99501 (907) 343~cT~p^uT¥ '~/Ic'©NMENTAL SERVICES DIVIS!"" Health Authority Approval Checklist T12N, RSW, SEC ,7,3; LOT 74- ParcelI.D.: 018-251-11 [*PER PREVIOUS INSPECTION REPORT] IfA, B, or C, attach ADEC letter. ADEC water system number N/A NO Date completed · 88' . Cased to 40% YES UNKNOWN Casing height (above ground) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 Nitrate Date of sample: 6/8/2000 B. SEPTIC/HOLDING TANK DATA Date installed 9/15/95 Tank size Foundation cleanout (Y/N) Date of Pumping 6/7/2000 C. ABSORPTION FIELD DATA Wires propedy protected (Y/N) YES FROM WELL LOG ..._ ~/ g.p.m. AT INSPECTION 6/7/2000 7~-' g.p.m. 4.. 17 mq/L Other bacteria 0 Collected by: A.W.W.C., INC. 1250 Number of Compartments 2 Cleanouts (Y/N): YES YES Depression (Y/N) NO High water alarm (Y/N) N/A Pumper, McDONALD'S Date installed 9/14/93 - 9/15/9,7, Soil rating (g.p.d./ft2 or fl2,/bdrm) 0.6 System type TRENCH Length 84' Width. 3.5' Gravel thickness below pipe 6' Total depth 1 O' Effective absorpfion area 1000 SQ FT MonitodngTubepresent(Y/N) YES Depressionoverfield'(Y/N) NO Date of adequacy test 6/7/2000 Results (Paes/Fail). PASS _ For 4 Bedrooms Fluid depth in absorption field before test (in.); . 1" Immediately after 1101 gal. water added (in.): 21" Fluid depth DRY (ins) Minutes later: 960 Absorption rate = 600+ Peroxide treatment (past 12 months) (Y/N) NONE KNOWN If yes, give date 72-026 (Rev, 3196)* Computer Version D. LIFT STATION ~ Date. installed_ _ ~~ Manhole/Access (Y/N) ~lat* "Pump off'level at* Hi ghWatee,,(a~* * Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot. 100'+ Absorption field on lot 100'+ Public sewer main N/A I'WAIVER REQUESTEDI On adjacent lots 100'+ On adjacent lots *75'+ Public sewer manhole/cleanout N/A Sewer/septic service line 25'+ Liffstation N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5'+ Property line. 5'+ Absorption field 5'+ Water main/service line. 10'+ Surface water/drainage 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main/service line 10'+ Surface water Curtain drain_ F. ENGINEER'S CERTII I cer# ythetl ¥ of Municipal ~co~d~ ! Signature Date 7/~/~ 100'+ Driveway, parking/vehicle storage area NONE KNOWN / ~T'~# ru field inspections and review ;~l~/~C ) systems are in conformance efts on this date. JEFFREY A. GARNESS 10'+ Wells on adjacent lots 100'+ HAA Fee $ ~ Data of Payment "~ ~-~'~ Receipt Number (c~ 7 72-028 (Rev. 3/98)* Computer Vemlon Waiver Fee $. Date of Payment Receipt Number Rick Mystrorn, Mayor Municipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 http://www.ci.anchorage.ak.us July 18, 2000 Jeffrey Gamess Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, Suite 2-B Anchorage, AK 99504 Subject: Waiver Request for T12N, R3W, Section 33, Lot 74 Waiver Request #WR000050 Parcel ID #018-251-11 HA000288 Dear Mr. Garness: Your request for a waiver of the required 100 feet horizontal separation fi:om the private well on the subject property to the septic system on T12N, R3W, Section 33, Lot 55 S180' less Wl 10', has been approved. The approved separation distance is 75.0 feet. This waiver approval applies to the existing on-sitewastewater disposal system to private well separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely, Daniel J. Roth Civil Engineer On-Site Water Quality Program MUNICIPALITY OF ANCHORAGE Department of Health & Human Services On-Site Services Waiver Review Worksheet WR#: WR000050 PID#: 018-251-11 HA#: HA000288 Date Received: July 5, 2000 Legal Description: T12N, R3W, Section 33, Lot 74 Permit~: Engineer: Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, suite 2-B, Anchorage, AK 99504 ,~ ~Applicant: Thomas Srownell ~ Waiver Requested: 75 foot waiver from the well on the subject property to the septic system on the neighboring property (T12N, R3W, Section 33, S2 of lot 55). Criteria: 1. Geology Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: 2, Special Conditions: 3. Other: Waiver is Granted: Waiver is not Granted: List Conditions or Reasons for above: Date: By:. Rec#: 0000 Amount: 0000 Date Paid: 0000 Name of Reviewer ALASKA WATER & WASTEWATER July 3, 2000 Municipality Of Anchorage Department of Health & Human Services P.O. Box 196650 Anchorage, AK 99519-6650 Attn: Dan Roth SUBJECT: T12N; R3W; Sec 33; Lot 74; Waiver of separation distance between the subject well and the neighboring septic system located at T12N; R3W; Sec 33; S 1/2 of Lot 55. Dear Mr. Roth, The referenced property has a 4 bedroom house and is served by a private well and a private septic system. Records fi:om your department indicate the septic system was installed in September, 1993. According to the homeowner, the well was drilled in 1959, however there is no well log available. We performed adequacy tests on the well and septic on June 7, 2000 for the purposes of obtaining a Health Authority Approval. During our field investigation, we found the separation distance between the subject well and the drainfield directly across the street to be only 75 feet. We are requesting that your department waive the subject separation distance to 75 feet between the subject well and the neighbors septic system on T12N; R3W;Sec 33; S 1/2 of Lot 55. It is our opinion that the required 100 ft. separation distance fi:om the private well to the neighboring drainfield could be waived to a 75 feet without implementing any health hazard for the following reasons: 6901 Debarr Road, Suite 2-B * Anchorage, Alaska 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * website: akww¢.com Recent analysis of the water from the well serving the subject property indicated no bacteria, and nitrate levels of 4.17 mg/L. We believe the nitrate levels may be slightly elevated due to the existing horse corral located immediately next to the well (see asbullt survey). There is a road (E. 144th Avenue) between the subject well and the encroaching drainfield. The septic pipe at the end of the drainfield is next to the street (see photo attached). Elevation shots were taken (see attached site plan). It appears that if any surfacing effluent were to occur, it would mn down the road in a easterly direction, instead of crossing the road toward the well. Neighboring well logs (Lots 88A & 88B) indicate the aquifer if approximately 91 to 104 feet below the surface, and is confined by layers of silt and silty gravel. With these conditions, it is unlikely the tapped aquifer is being effected by subsurface migration of contaminates from the drain.field in the immediate vicinity. According to the current owner, (Tom Brownell), the original house was built between 1962 and 1965. It burned to the ground in 1976 and was rebuilt in 1993 right next to the original building site. According to the records we obtained from D.H.H.S., the separation distance from the subject well to the drainfield across the street did meet the 100 foot requirement in 1973. However, another drainfield was added later, causing the current encroachment (see attached drawings). After extensive research, it appears that the neighboring septic system is undocumented. The only drawings showing the neighboring leachfield are on documentation from the subject property T12N;R3W;Sec 33; Lot 74. There is sufficient documentation on the subject property to confirm that the subject well was drilled prior to the original leachfield across the street and positively before the other leg of a trench was added. When the septic system on the subject property was upgraded in 1993, the engineer noted that there were no septic systems within 100 feet of the subject well. Therefore, it is assumed that the septic system was installed after that time. Consquently, we feel that the burden of the M.O.A. waiver fee should not fall on the property owner of T12N; R3W; Sec 33; Lot 74, but should be the responsibility of the neighbor across the street, South Half of Lot 55; T12N; R3W; See 33. If you need additio,p~ ~information, please contact us at 337-6179. S' 13 . E. M.S. Pre~tddnt ( 6901 Debarr Road, Suite 2-B * Anchorage, Alaska 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * website: akwwc.com [ I ~ ~ ] T12N, R3W, SEC , T12N, R3W, SEC 33 ~P~C ~ MOS~ S/D J LOT j SNOW S/D DIXON S/D LOT 87B J T12N, RSW, SEC 35 DIXON S/D J J LOT 86A J LOT 88B1 7/5/2000 B~WN BY: AI,~ W~TER & W~TEWATER K.g.w. -~= ........ ~:~.~.~ ~- ........ -, CONSULTANTS, INC. ~.~ .... '=""~ ~ I" ~ ..... .... H~ .............. ~ .' , , · ......... ;...~ THOMAS BROWNELL (907) S45-8469 1 Of 2 T12N, RSW, SEC 53; LOT 74 ~E OF WORK: ~xx rofess~O~ SITE P~N FOR REQUESTED WELL WAIVER LOT 55 T12N, RSW, SEC 53 i~1 i [ ESTIMATED LOCATION · OF TRENCH I Illl Illllll EL~AT[ON = 103.30 ~~.._~'~ 100.37 ~o~.~o '~ ~ou~ [~,,o~1 lOO.OO, Al ~ASg %~TER & ~VASTEWATER K.D.W. = 20' ~ . ' THOMAS BROWNELL (907) 545-8469 2 OF 2 1~ I~. T12N, RSW, SEC 55; LOT 74 '~ '" ~ .'"'' ELEVATIONS FOR REQUESTED WELL WAIVER 2.50 ACRES N 89°59'59"E 529.9~ H FmCE (~x) BLM LOT 74, SEC. 33, T12N, R3W X--X I .T I (SEE D~L) ~ ~ X 60.6' N 89°59'59"E 529.95' FAST 144TH AVE. 15.0' BUILDING DETAIL SCALE: 1"=20' AS-BU IL T PROPI:RTY D~iCi~U ~OVE ~D ~T NO JE~ A ~1, ~,Ls. ff IS ~E R~PONSIBI~ .0~ ~E OWN~ TO' 4726 ~ ~CHO~E~ PHONE 2~-~ A~ ON ~E RECORD~ SUBDMSION P~T. ~. . , ~'~ U~ NO CIRCUU~C~ SHOU~ ~ DATA GRiD DATE H~EON BE US~ ~R CO~U~oN OR FOR ~34 ~/2~ ~A~USHING BOUND~ OR ~CE UNES. ~' r.S. dOB NO. 93219 ~7~ NOTE: NO CORNERS BET THi'S DATE, 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 AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Comprete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address.. Day phone Agent Address Day phone' Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: Individual well NOTE: Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site ~X. % Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Fronl MOA #21 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 ,z~/,,r z) ~--72.~0/,../ :;~-~6 / ~ ~.'"ET/.,/~/~ Phone Address '-~O, ~'/-, Z-'/0 7 7 Engineer's signature ~ ~- ~ Date DHHS SIGNATURE )~- Approv¢~ for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additiona~ 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 [n the State of Alaska. The DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the p?ofessional engineer's work. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: i~L ~v\ L~), 7'-/i T'/Z_/,J, )2~, 5 .~=~Pa,'cel I.D. A. Well Data Well type Ib~Z idA~l-E-7 Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed (/),,JiL-cJOt~J¢ Driller Cased to ~ ~ Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG AT INSPECTION v/A '-/,.t. ,_~ g.p,m. Absorption field on lot Public sewer main Sewer service line SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /~/ ~ ? ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank .-~ .'t/~-~' WATER SAMPLE RESULTS: Coliform ¢ Date of sample: Nitrate Z¢ A~,¢//_ __Other bacteria ¢ Collected by: /~ .'~ B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) /"4/ Date of pumping Tank size Foundation cleanout (Y/N) Compartments '-7 ~o Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /~ / On adjacent lots -Z~: ] ?O To property line :~ /l~/ z Absorption field '~' ~- / Surface water/drainage ~-/.~-- 43 ' Foundation -- Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) 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 ~//"/,, %/~ 3 Soil rating (GPD/Ft2) Length ~4~,_,~ I Width .)..) Gravel thickness Total absorption area /0//~ >:?7 ~ Cleanout present (Y/N) Date of adequacy test ,A/~'7..d ~sr-40~-~lOt~Results (pass/fail) Water level in absorption field before test ~ O.d Peroxide treatment (past 12 months) (Y/N) .'~ Total depth / 6) Depression over field (Y/N) /-J for ~C~'O ~J~,~- Bedrooms After test /~O/4 Lc' If yes, give date /k,~ //¢1¢ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: I Well on lot / / ~ To building foundation On adjacent lots '*~/~) / Surface water '~'/~:~'~ Curtain drain I t On adjacent lots ~' Z-DO Property line ~ /Z.'7 To existing or abandoned system on lot Cutbank 7~ Water main/service line % 7.%¢ / Driveway, parking/vehicle storage area ~//O E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effe, ct.: on. ,the, date. of this inspection. Signature Engineer's Name Date HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number Subject: Onr'si t~: Sewer and t.~ai:ur F,milities Servi Single Family i)wulting L~tI: 74, Sec. 33, l'12~i~, IL:~W~ im Augtlsl; 3l, 1973, this Uepartmen~; performed ail inspection on your sewur an<l water Facilities aC ~i,~' abovo subjecC location. 'l'h(~ scvmr sys~eln, cons'isling of a sup~ic ~.amlk and ~wo (2) seepage pi~s, appears ~o be funci;ioning satisfactorily al/d is approw~d by ~rlis Uap,w~-- lflent. '[i~u t>rivaCe wel'l is an adequal:e di:~tance away from your s{}wer sys.- tern. 'f~e neighboril~!~ sewer system, bolono'ln~ to ~he Don C. NcEwens, Lot au, Sec. 33, 'l'12ii, i(3W, S.$'i., is 'locatea arl adequate distance froli)yoklr wel I. t'nc only tiling ~na[: will h(~ hounded for ~his ~lc~parCl~lan['s approval 'is ~ sa~isfacl;ory war, er sa,il)lC and Um well casing (~xb,)nded twelve (IZ) iucnes auova uround lewq a.d the well pit fil'h;d in. We ai)~reciate, your visit to our office and reguest for future approva'l If you nave any questiOliS, please t~o not )lesil, a~e bo conCac~ us. Eniironmen~al CoaCrol Officar mld ~{nclosure: ~Jiagral~ of G(;noral Condi ti oils GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 %" Street, Anchorage, Alaska 99503 274-4561 Time of Inspection D te of ZnspecUon REQUEST FOR APPROVAL OF INDTVIDUAI, SEWER & WATER FACILITIES FOR 1. Aoproval Requested By: 2. Prooertv ~ner: .,~ Phone 3. Legs] Description: ,~ .~~.~/~, 5. Type of Facllity to be Inspected: ¢/~;~¢~~~ .... 7. Number of Bedrooms Well Data: g, Depth ,. ~/4..~W~E~__~<~-.-¢ ....... D, Bacteria] Analysis ~¥~/¢<<?-~/ Sewage Disposal Sys%om: A. Installed. /~_-.~_~c-/~_~Z~ B. Installer C. Septic 'rank: ],o Stze~./~2. Manufacturer Do Seepage Pit: 1. Size~~/2, Material. ?:'~/~.~/~2¥~'¢~/'~r~---~~'*~ , -- Disposal Field: Total Length of Linea__.~4?.___///-/~ ....... Distances: A, ~%ll. To: Septic Tank~) ~- , Absorption Aree__~ , Sewer Lines Cente inatlon / /~ _, Nearest Lot Line ~ ~ , Other '8. Pr,undatfon to Septic Tank /ff / ' Absorption Area ,~3~ ~ C. Absorption Area to Nearest Lot f, tne ,~k~ ~ . ~.ecWast for Approval of '~ndiviaual Sewer Page Two 9.Commen~s~ 5~~' f'~h~ Approva] Valid for One Year From Date Signed G~eater Anchorage Area Borough, Derartment of Environmental Quality D~AGRAM OF SYSTI~M I certify that the information contained in this request for appreval to be a true and accurate representation of the subject sewer and water facilities located at-" Signed , Oat. e