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Home My WebLink AboutKNIK HEIGHTS BLK B LT 4Knik Heights Lot 4 Block B #017-033-04 6 -Z!5' Municipality of Anchorage Page t of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: t>W 93 07.z-5- PID Number: O �-7 0 33a 4 Name: ?,Cl, l 1'. Zu \C. e, lo... Wastewater System: El Now CW Upgrade Address: MIS40 1Z\45 wear( RA -N14C oOW15,e ABSORPTION FIELD -e Phone: 3hS-34z No. of Bedrooms: q R Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: Total Depth from orig inal grade hire GPD/S .Ft. VgRICS %01 +.� %\ Lot: Block: Subdivision: `"Ilt Depth to pipe bottom from original grade: "t Gravel depth beneath pipe KNlK IAP- k (s Wr S ✓AR.I WS a u yL Ft. 7 Ft. Township: Range: Section: Fill added above original grade: Gravel length: t Z N w U b 4'. (' Ft. 7d ' Ft. WELL: El New D Upgrad G rave l depth: tut it+ Number of lines: Z Distance between lines: 1 I7 ! Ft. Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Ayrw& 3034 PVC. Ft. Ft. I 0 -6 0 SD. FL A irr S)ta Driller: Date Drilled: Static Water Level: Installer: CAcMLS r-XCAV/Tf,v V Dale installed: «Icy -43 Ft. Yield: ump Set at: Casing Height Above Ground: TANK GPM Ft. Ft. SEPARATION DISTANCES ❑ Septic ❑ Hol din ST E. P. To septic Absorption Lift Holding Public/Private Manufacturer: Capacity Capacity in gallons: From Tank Field Station Tank Sewer Lines WellN 7�' 1iz.' tgl I.t,q Gam' Material: Number of Compartments: Surface Water f LIFT STATION Lot I Z Size in gallons: Manufacturer: Line 1 6. , Foundation �I 251 rim "Pump on" level at: level at: High water alarm at: Curtain " zC0 FZc9� bZ.00 Pump Ma del Electrical Inspections performed by: Drain BENCH MARK Remarks: CxtsY, cote c arra y Tf c Location and Description: 0 od c� E 6(. Ceti'Sw cul /y C 41 �I [ I UK VCA.INK t Assumed Elevation: iC�l910U 1 to If rA Inspections performed by: Coy% �� "^SI�Q' ates: 1st $'x`^`53 C.1Ati`p,1 €'9BII 2nd B-te-4320 -ti -S 1:110 f t = , ° 3rc1 j Department of Health/�jr d Hur/� hervices�app royal aIMA �.1 ISLE; ,"% Reviewed and approved by: ...ti . i 72-013 (1/91) MOA 25 Permit No. SW `�3�O2z5 Page 2, of Z. Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: LT --A V6..K % Kt-AIt< kiK FATS Ml FIµISN GAAOF / �o0.1�hv4� GOP Ole), OCn 9•'Pf Q,F. P1oR SSw,rN R.oc V_ 83,0[0 _ y - $ 0' �# b P'b'06 1Ps- 72-013 A (2/91) MOA 25 E') PID No.: 01?63304 F6,9z= ciOi F, w,su GRAoc? !Mc CCV,g�_d OW -1 GINA4- GMUE rT y G0, �F+,ir4 - L4 9EV� Gp- r,�o c IL 9Lto IVI Li. Oepi. I1� 90,016 ION �u o G o ab$ �> LK\ p. 11J d r �o D' \_X0i0 u Y 4`•Pr� .O �tla�% C,0• 'L /L 14%t_zKl STING 1ZSo c�a t, Co1.7C, 5@PTIc t�tu1G , ,V4 i• 4 0 t� o` z CIO,F;G. )Nv= 92,7c �iGc15C, Ca NL TNt� lc W M►f% $EAL t4{,p 1 f 3 i~.Y. Yr fast yi `'- _, b_ h•jS/. i#j`°rY'h pk.. �}i13� ��a �Srlial .w P$.Yct 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 (UPGRADE) PERMIT PERMIT NUMBER:SW930225 DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC OWNER NAME:JOKELA RALPH B & JOANNE OWNER ADDRESS:12540 RIDGEWOOD RD ANCHORAGE, AIC 99516 PARCEL ID:01703304 LEGAL DESCRIPTION: KNIK HEIGHTS BLK B LT 4 LOT SIZE: 43500 (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: DATE ISSUED: 7/19/93 EXPIRATION DATE: 7/19/94 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY: DATE: DATE: SITE P"Mi—REPLACEMENT WASTEWATER .ABSORPTION SYSTEM 5LJ)r\L iVVLo(VFo I F\oL 66 i Yi L'�M1IS`j ,lV �bvG \ �r \� Fi FJ Coot ii' (L ]v�TALtr\}Sox,) I WILL I i- t LL WC?9aY I I I "oLe-61 jeVr`C. s, T— L.c>r NA"', i L.)a551 KAol I ?V(z �n Roum svrfw—y-s� 41,pSo pg ; tTVR! LNIRL0 1�4K pesUlzPro� �yst� Z45c) SITE PLAN DETAILS vv 4�tf PROPOSED REPLACEMENT WASTEWATER ABSORPTION SYSTE. LOT D, BLOCK B KNIK HEIGHTS SUBDIVISION PREPARED FOR: MR. RALPH JOKELA 12540 RIDGEWOOD RD ANCHORAGE, AK, 99.516 .r ti 7. t�3a.g y"•..,v 100 V SCALE: = ' DRAWN 8Y CAI_ CONSTRUCTING ENGINEERS 342000 6 9601 BUDDY WERNER DR 694--9098 eN2tlpl 't4 = ANCHORAGE,, AK, 99516 7-1-93 DRAWING 9 93-51-07-1 ABSORPTION SYSTEM DESIGN DETAILS—STANDARD TRENCH 1� A C.0 8 cy, [L Y P 1 is 2 J Q 0 j �Lmwn'rL Ro`K Z' SCOPE OF PROJECT: New proposed absorption field is designed for a four (4) bedroom system. Lot is served by private well as shown on Site Plan. ADSORPTION AREA CALCULATIONS: Minimum Required: 4 Bedrooms x 150gpd/bedroom = 600 gpd capacity Soils rating, proposed addition, 0.6 gpd/sf Minimum sizing: 600 gpd . 0.6 gpd/sf 1C00 sf absorption area Due to depth of useable soil, Use trench design: 1000 sf (2)(71) = 72' trench length IMPACT ON ADJACENT LOTS: There are no private wells within 100' of this proposed absorption system. This proposed absorption system has minimal impact to adjacent lots as the all lots except the lot to the SVI are developed, and the SW lot is not prevented from placing a well and septic on it by this replacement system. DESIGN DETAILS PROPOSED REPLACEMENnO WASTEWATER ABSORPTION U ]LOT 4 BLOCK B KNIK HEIGHTS SUBDIVISION PREPARED FOR: MR. RALPH JOKELA 12540 RIDGEWOOD RD ANCHORAGE, AK, 99!516 NOT TO SCALE DRAWN BY CAL CONSTRUCTING ENGINEERS 346-2000 9601 BUDDY WERNEI1 DR 694•-9098 ANCHORAGE, A.K. 99516 7-1-93 DRAWING # 93-S2-07--1 1CIE 1 II 1 of 1CIE 1 II PERFORMED FOR: Municipality of Anchorage DEPARTMEN I OF HEALTH & HUMAN SERVIC ES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG _d PEF3CC}l.AYION TEST % I F�:01 nFc!`r.]1PTinni� L"7� i>��F� 7 - 5111- a A- 9 at , 10 - u� 11 ✓� f,I,. 5J�✓t�' 13 14 15 16 17 18 19 /L c-, 6f) ice. DEPTH / Net Depth to ne 'iter z — 10, (FEET) O Q„ -1 ✓q' rev y„ Ing tU" 41 1= tri` 2 3 14 SL ✓1 6: 4 —_ 5 y-� L 6- I, 7 - 5111- a A- 9 at , 10 - u� 11 ✓� f,I,. 5J�✓t�' 13 14 15 16 17 18 19 /L c-, 6f) ice. H -e Gross RTL Net Depth to ne 'iter z — 10, Net ©Uror� -- rev y„ Ing tU" 41 1= tri` a go. �naev ai.+adV 4Y�� _DATE PER FORMES"" Township, Range, lection: ti(ci 9 SZ—�x 7—!Zpj 7Z;h�1 ---- SLOPE ------ SITE PLAN - -- yA WAS GROUND WA1 ENCOUNTERED? I ER x b IF YES, AT WHAT LL'' - DEPTH? -- p E Ilepllt t0 Water Aller C - - n tlonitming7 _ -N� Dale:--- Reading Date - — — Gross RTL Net Depth to ne 'iter z — 10, Net ©Uror� -- rev y„ Ing tU" 41 1= tri` 14 zo PERCOLATION RATE _ ?'S ._ trmnutea,m0j PERC HOLE DIAMETER _ TEST RUN BETWEEN __ /FT AVD _FT COIaMENTS 7 / '� 4 ✓r PERFORMED BY: —� CERT IFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4785) GAAB-HD I GR. ER ANCHORAGE AREA BOROL DkPARTMENT OF ENVIRONMENTAL QUALITY 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279.8686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME / C� -/ �'`' _-_ _MAILINGADDRESS ��/��%� ��172G f/ PHONE -� LOCATIONS L SEPTIC TANK: EGAL DESCRIPTION NUMBER OF DISTANCE FROM WELL_ MATERIAL ��%1�%C'A�/.-? COMPARTME LIQUID CAPACITY GALLONS. INSIDE LENGTH INSIDE WIDTH SEEPAGE SYSTEM: SEEPAGE PIT: LIQUID DEPTH NUMBER OF PITS ____OUTSIDE DIAMETER OR WIDTH Z_j _ LENGTH DEPTH C� r � LINING MATERIALLC)�O/1dXO DISTANCE FROM WELL_ y — ,//BUILDING FOUNDATION��K. NEAREST LOT LINE � TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ]�6 SQ. FT. 'J TILE DRAIN FIELD: DISTANCE FROM WELL— NUMBER ELL NUMBER OF LINES DISTANCE BETWEEN LINES ABSORPTION ARE .__ SQ. FT. LENGTH OF EACH LINE NEAREST LOT LINE TRENCH WIDTH TOTAL LENGTH OF LINES IN,40TALEFFECTIVE DEPTH: TOP OF TILE TO FINISH GRADE_ DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE WELL: �� DISTANCE FROM WATER -- TYPE /./Zi114-7D DEPTH , BUILDING FOUNDATION.._ _SAMPLE /0&0&V NEAREST NEAREST SEPTIC 7(,l SEEPAGE " OTHER LOT LINE /c S SEWER LINE , TANK �! J , SYSTEM �d, CESSPOOL — , SOURCES_ DISTANCES; 'ov-6 `. /_U C DIAGRAM OF SYSTEM Ca/ �i N �� f�v�'_ 1A yes ------ = b/ L ?j XC lIZ DATE _/� 171 A P P R / G A R GREATER ANCHORAGE AREA BOROUGH //� (( , DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. �_LL tA 3500 TUDOR ROAD POUCH 6-650 ANCHORAGE, ALASKA 99502 TELEPHONE 279-8686 SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT NAME OF APPLICANT -��C �/J G�/� �'�-✓/� MAILING ADDRESS �!%'��ry� '5 �S Zx-� PHONE INSTALLATION LOCATION 1z' LEGAL LEGAL DESCRIPTION -CST 6E ."4zx ✓'% �C ��K ��/f �y'�,' INSTALLATION OF: SEPTIC TANK 4 - SEEPAGE PIT L' DRAIN FIELD , OTHER TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH TO BE INSTALLED BY `-W'e- zy;/- SOIL TEST RESULTS �G��✓�i�G NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST i COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION. �r✓_s�� - G'2' ��'%✓.�Jjri� ro%c - G'r.�.�/l�".�7� �,�..,iHrl SEPTIC TANK SIZE G�C TYPE L<LY�C'JJ�SEEPAGE AREA SIZE ��-�/�r TYPE / � /�//�/l �/ O/c' t�/ cif" G✓ �1 MINIMUM DISTANCES, REQUIREMENTS DIAGRAM OF SYSTEM FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT -�~ i DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL e/ SEPTIC TANK 25 SEEPAGE PIT aDRAIN FIELD TO NEAREST LOT LINE. WELL TO SEPTIC TANK �- G SEEPAGE PIT DRAIN FIELD ALSO CONSIDER AREA WELLS. 0 WATER MAIN TO SEPTIC TANK G SEEPAGE PIT �n , DRAIN FIELD SEPTIC TANK, •� / SEEPAGE PIT / DRAIN FIELD -+ TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. 'iI' '- HEALTH HEALTH AUTHORITY OR LICENSED DESIGNER I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. / DATE ��// / APPLICANT'S SIGNATURE ! V/��✓y`�� GAAB-HD-2 GR.EATEli kNCHORAGE AREA )ROUGH Case No. HEALTH DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 279.2511 SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT - '' .. -/// � G� (y�1it��i O N E NO NAME OF APPLICANT k;4 C / �a&? ' --MAILING ADDRESSA-r ,3 3 RESIDENCE ADDRESS v LOCATION OF INSTALLAT ION LEGAL DESCRIPTION APPLICATION TO INSTALL: SEPTIC TANK SEEPAGE PIT �- , DRAIN FIELD , OTHER TO SERVE THE FOLLOWING FA_CILITY11.54 yl S�f�ci �' — FINANCED THROUGH V4 TO BE INSTALLED BY l ;C PERCOLATION TEST RESULTS -�� ANTICIPATED DATE OF COMPLETION./Lc BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT�,y� THIS IS TO SERVE AS '/ /j`' �`1 I C < �S PERMIT 1'0 INSTALL A AS DESCRIBED BELOW. SIZE OF qNIT TO BE SERVED_Cf✓hi SEPTIC TANK SIZE_,—LeTYPE SEEPAGE AREA -TYPE DIAGRAM OF SYSTEM h/e A DISTANCES: r 76) HEALTH AUTHORITY OR LICENSED DESIGNER I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and t at the above described system is in accordance with said DATE �'�� / / APPLICANTS SIGNATURE 0' I CREATIER AIdCIIMP\pl', A' 3 5^1 V CAS-: t! rte" Perfcr'„:ed For Raglph 13. Jolcela _ Date Per• or,;esl /• /Z'- 7/ B� Kni1C Heigh fCri(I Reports c?: ,q:.ti�l: �r -Y y4e.;.a,...,.-.......,,y..,-..,,.w.,........<.....„+....•.�,......e..,a.,... Test Depth Feet_ Soil Chan, er ;.st.ic.s Location Sketch ��VERBURDEN ORGAI\I C,ETC tt . ,� _... 3 1 F! .� Sill: Gravelly sand Silty Sandy Gravel. Silty gravel. Was Ground rater 'En count ere :? ;�/ `” � °_ 4 1z las, .;t l;eprly Reading prate aMI c ��`< r.E .. `Ve e - Lieuthc HZn \eA` Dro- c� r` r x,ercoiaticr. ��f Yit "rem-7— Test P renciTpY,li Ed Niy , ,�, •� a��,..m.�.,...,.,.._-.._....,..,»_....,w...n......,....__:..�...._wa�...,.........,. Data Certified -Y, F Date 1. 7_ j' i 3 4 i' i 5 6 s 8 n I CREATIER AIdCIIMP\pl', A' 3 5^1 V CAS-: t! rte" Perfcr'„:ed For Raglph 13. Jolcela _ Date Per• or,;esl /• /Z'- 7/ B� Kni1C Heigh fCri(I Reports c?: ,q:.ti�l: �r -Y y4e.;.a,...,.-.......,,y..,-..,,.w.,........<.....„+....•.�,......e..,a.,... Test Depth Feet_ Soil Chan, er ;.st.ic.s Location Sketch ��VERBURDEN ORGAI\I C,ETC tt . ,� _... 3 1 F! .� Sill: Gravelly sand Silty Sandy Gravel. Silty gravel. Was Ground rater 'En count ere :? ;�/ `” � °_ 4 1z las, .;t l;eprly Reading prate aMI c ��`< r.E .. `Ve e - Lieuthc HZn \eA` Dro- c� r` r x,ercoiaticr. ��f Yit "rem-7— Test P renciTpY,li Ed Niy , ,�, •� a��,..m.�.,...,.,.._-.._....,..,»_....,w...n......,....__:..�...._wa�...,.........,. Data Certified -Y, F Date a �> �4 o a cl \ c;\ •c {J Eb F F� EH N E+ F+ F E. F FK Fi ��) w F H ,: d i (�w w 0 O a u 0 0 r. 7 a 0 0 0 0 0 0 0 0 0 0 0 0 J 4. W w w w w w w w w w w in z w w w w 0 MUNICIPALITY OF ANCH®RAOI: c j WDEPT; O EAr 2 � n 'd �EN1�20Ni'?1EN L Py TE I® W x W O O o O O O O O O O V� v k' 0 o APR! U luHr, W �w2 H � o o w � O r A a � RECEIVED' 40/ ��c.rcJH �/rr%irrcw, ® Municipality of Anchorage °p On -Site Water and Wastewater Program <' (907) 343-7904 f E Certificate of On -Site Systems Approval Parcel I.D. 017-033-04 Expiration Date: 02 - I 1. GENERAL INFORMATION Complete legal description Knik Heights, Block B, Lot 4 Location (site address) 12540 Ridgewood Road Anchorage, AK 99516 Current Property owner(s) Tom & Jacque Shelley Day phone Mailing address 12540 Ridgewood Road Anchorage, AK 99516 Real Estate Agent Chris Swires Day phone 338-8292 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: Three 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual Il Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: �/ n Received by: r4�--� E (a n /� . "Q , Date: / l —lip —A� COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ SZ - d d Waiver Fee $ Date of Payment Al Date of Payment Receipt Number io0/(0 Receipt Number COSA # 0.51(01ST yS _ Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Engineering Address P:O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. 6. DSD SIGNATURE System #1 Approved for "L bedrooms System #2 Approved for Disapproved Conditional approval for bedrooms Phone 522-7773 Date 11/14/2016 bedrooms, with the followii ca MICHAEL E. ANDERSON No. CE -4381 , BY _: (` Original Certificate Date: I60" The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet ( - c If more than 1 septic system is on the lot: COSA Checklist # _of _ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Knik Heights, Block B, Lot 4 A. WELL DATA - No Well on Lot. Well type Private If A, B, or C provide PWSID # Date completed 7/12/71 Total depth 178 ft. Date of test Static water level Well production Sanitary seal (Y/N) Y Cased to 178 ft. FROM WELL LOG 7/12/1971 WATER SAMPLE RESULTS 130 ft 15 g.p.m. Parcel ID: 017-033-04 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) >12 in. AT INSPECTION 11/10/16 127.2 ft. 6.2 g.p.m. Coliform 0 colonies/100 mL Nitrate 2.56 mg/L Arsenic ND ug/L Date of sample: 10/31/16 Collected by: Anderson Engineering _. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Concrete Tank size 1,250 gal. Number of Compartments 1 Cleanouts (Y/N) Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) Date of pumping 9/15/16 Pumper One Stop Pumping Date installed 7/13/1971 Y IN C. ABSORPTION FIELD DATA Overflow Dual Date installed 8/17/93 Soil rating (g.p.d./ft2 or ft2/bdrm) .6 GPD/SF System type Deep Trench Length 30/44 ft.. Width 2 ft. Gravel below pipe 7 ft. Total depth 11 5 ft. Eff. absorption area 1,036 ft2 Monitoring tube Y Depression over field N Date of adequacy test 11 /10/16 Results (Pass/Fail) Pass For 4 bedrooms Fluid depth in absorption field before test 48/84 in. Water added 615 gal. New depth 58/84 in. Elapsed Time: 1,440 min. Final fluid depth 48/84 in. Absorption rate >= 600 g p d Any rejuvenation treatment (past 12 mo.) (Y/N & type) W If yes, give date 'This is an overflow absorption trench system. The upper trench is surcharged. The lower trench w< tested and absorbed all of the water. D. LIFT STATION Date installed "Pump on" level at Datum Size in gallons _ in. "Pump off" level at Cycles tested Manhole/Access (Y/N) in. High water alarm level at Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: "Well installed prior to 1973. Septic tank/lift station on lot >5 On adjacent lots >100 Absorption field on lot >100' On adjacent lots >100' Public sewer main >75' Public sewer manhole/cleanout >100' Sewer /septic service line >25' Holding tank >75 Animal containment areas >50' Manure/animal excrete storage areas >100' SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Water main >1 0 Water service line >10 Wells on adjacent lots >100' ABSORPTION FIELD ON LOT TO: Property line >10' Building foundation >10' Water Service line >10'Surface water >100 Curtain drain >50' Wells on adjacent lots >100' Absorption field >5' Surface water >100' Water main >10' Driveway, parking/vehicle storage > 1 �, F. COMMENTS Absorption system consists of an upper trench 44' long and a lower trench 30' long. The upper trench is surcharged. All flow is to the lower trench. G. ENGINEER'S CERTIFICATION / certify that / have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Michael E. Anderson, P.E. Date 11/14/2016 COSA brown sheet 10-10-12.doc in. C=�Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.ek.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 017-033-04 HAA# _ rj Q3j0 1. GENERAL INFORMATION Expiration Date: / O — ") O — O ✓7 Complete legal description KNIK HEIGHTS SUBDMSON: LOT 4, BLOCK B. Location (site address or directions) 12540 RIDGEWOOD ROAD • ANCHORAGE. AK 99516 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address JONATHAN & ANN WHITE Day phone 337-7072 12540 RIDGEWOOD ROAD • ANCHORAGE. AK 99516 Day phone BONNIE MEHNER W/ PRUDENTIAL JW Day phone 223-0005 3801 CENTERPOINT DRNE f200 * ANCHORAGE. AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site 0 Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below,/ verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Finn GARNESS ENGINEERING GROUP, Ltd. Phone Address 3701 E. TUDOR ROAD. SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS. P.E. Engineer's Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines 8 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 alt wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the }rear, and the waterusage of the family being served by the system. These conditions are outside the control ofthe evaluatorof 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. GEG, Ltd. can therefore not prov de .any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE ✓ Approved for 3 bedrooms - Disapproved. 337-6179 Date (j Zo 0g- P�. Q...A�gs��o I Neylk._Garness. o CE -79 :i •' FFG 0011° .c/2• � cS4v Conditional approval for bedrooms, with the following stipulations: l�l�ttV�1 Y OF Ff"'rY/i,��i G`QP ..... cyo ..�� ON-SITE WATEC�ANB • m= WASTEWATER HAA Checklist V Maintenance Agreements Septic System Advisory Well Flow Advisory Supplemental Engineer's Report Other By: a2/4' fN. Original Certificate Date: ay — 0.6— (R. 17)01) Municipality of Anchorage 'Cl �• • Development Services Department Building Safety Division On -Site Water 3 Wastewater Program 4700 South Bragaw St. P.O. Box 1966W Anchorage, AK 995196650 www.ci.anchorage.ekus (907) 3437904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: KINK HEIGHTS SUBDIVISION* LOT 4, BLOCK B. Parcel ID: 017-033-04 A. WELL DATA Well type PWATE If A, B, or C provide PWSID# N/A Date completed 7/12/1971 Sanitary seal (YIN) YES Total depth 178 ft. Cased to 178 ft. FROM WELL LOG Date of test 7/12/1971 Static water level 130 ft. Well production 15 — g–p.m–Wai WATER SAMPLE RESULTS: Coliform 'tk colonies/100 ml. Arsenic: N/A mg./L. Nitrate flamgJL. l Log (Y/N) YES Wires property protected (YIN) YES Casing height (above ground) 12+ in. AT INSPECTION 6/17/2005 128 ft. 6.49 g.p.m. Other bacteria IS colonies/100 mi. Date of sample: 6/17/2005 Collected by: GEG. LtD. B. SEPTICIHOLDING TANK DATA ' IN THE CRAWL SPACE Tank Type/Material CONCRETE Data installed 7/31/1971 Tank size 1250 gal. Number of Compartments 1 Cleanouts (YIN) YES Foundation cleanout (YIN) *YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 6/17/2005 Pumper McDONALD'S PUMPING C. ABSORPTION FIELD DATA Date installed 8/17/1993 Soil rating OE> ft%drm) 0_6 System type DUAL DEEP TRENCHES Length 74 ft. Width 2 R. Gravel below pipe 7 ft. Total depth 11.8 R. Eff. absorption area 1036 ft' Monitoring tube YES Depression over field NO Date of adequacy test 6/16/2005 Results (Pass/Fail) PASS For4 bedrooms Fluid depth in absorption field before test 30.5 in. Water added 630 gal. New depth51•75 in. Elapsed Time: 040 min. Final fluid depth50.75/49.75 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN 8 type) NONE KNOWN If yes, give date – — 'mss �� t;.ow�- ��.►� �+ . vpfs�L ii D. LIFT STATION Date installed Size in gallons 'Pump on" level at _in. E. SEPARATION DISTANCES High water alarm level at in. Cycles tested Meets alar 8 circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot '50'+ Absorption field on lot 100'+ Public sewer main N/A Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent kits 100'+ Public sewer manhole/cleanout N/A Holding tank 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 10'+ Water main N/A Water service line 250+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 25'+ Surface water 100'+ Driveway, parking/vehicle storage 50+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS e ci G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and *'.• ! �* review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. A. ass. Engineer's Printed Na a JEFFREY A GARNESS Date Zo V e sd�DrotossW°d HAA Fee $ 4?� Date of Payment -7 7"0c, Receipt Number d 7ixaf� (Rev. 12101) Waiver Fee $ Date of Payment Receipt Number 07/07/2005 14:56 FAX 9077621858 Mehner & Associates 1 002 07/06/2005 11:55 9072767204 POEERT E JOR& JP. PAGE 02 06-27-05 03:26P11 FROM -CUE ESI, SGS ENV SERVICES J SGS Rctp 1053554001 Client Name (iurness Engineering Group, Ltd. Pmjcct Name/# L14 Bk a Knik IIts Client Sample 11) LI 4 Bk t5 Knik lits tsiatrta Drinking Water 9075615301 T-194 P.02/04 F-771 All Datm7imm are Alaska Standard Time Printed Date/Time 06272005 12:50 CoticctedDatc/fime 06/172005 11:45 Received Date/rime 06/172005 14:24 Technical Director Stephen C. Ede Sample Remaiks' 300.0 - Rcsult represents total nitrate plus nitrite. Allowable Prep Analysis Wrancter Results POL Units Method Container 1D Limits Date Date Init waters Department Ndrate-N 0.536 0.100 Microbiology Laboratory Total Coliform 0 mg/L EPA 300.0 B (-10) 06/20105 1B) col/100int. Sk1209222B A (—t) 06/17/05 TLF MUNIUW LLII i ur lu•� -� DEPARTMENT OF HEALTH & HUMAN SERVICES Divleion of Environmental SOMew / On -Site Ser Aws Sedton P.O, sox 198850 Anchorage, Alaska 9951386W (907)343.4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMIL// 1 IN7 L/Y DWELLING Parcel I.D. # 017-033-04 HAA # M I ' 1. GENERAL INFORMATION Location (site address ordirections) 17940 amrcwnnn ORn1F Lending agency Mailing address Day phone Agent Day phone Address Uniess otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 4 NOTE: tf community weft system, provide written confirmation from State ADEC attest - Ing to Me legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xx Holding Tank Community on-site Public sewer NOTE: If community wastewatersystem, provide written confirmation from State ADEC Ing to the legality and status of system. 72-M (Rev. 1191) Finn MOA 021 QompuW Venn M or and 11 u the 5. STATEWNT OF INSPECTION BY ENGINEER DB PalaW 7Utl.UU ar, As cartifled by my seal affixed hereto and as of the validation date shown below, l verify that my Investigation of this Health Authority Approval application shows that the on -Etta water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. l 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 westewater nld disposal system Is in compliance with ell Muand State codes, ordinances, and regulations in effect on the date of this inspection. 'd Name of Firm Phone- (907) 337.6179 Engineer's Signature — uate1s1 In conducting this eva/uatlon, AMC, I tlef1med de athorough, conadentlous englneering artalysls ofthe systemNaccordancewlt/tADECand DSOuWnes,&Reguradons.Thoreportedresultsdescribedthe pertarrrtertce of the system under Ute coed rmered at the tlme of urs teat, and separetlon distances meaeutad to randiyWandflable featursa. The operational i fe of all wells and septic system: - on Ute local soils condition, groundwater levels that may fluctuate during the year, and the usage of the famiy being served by the system. These aondBrons are outside the control of the evaluator of Ute 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, Inc. can therefore not provide any warranty for future ewilmato of how long the system wdp con dnue to meet Ute operetlonal requirements of the ADEC or MOA DHHS. The content of this report is for the sole benefit of the owner listed above. Any rallance upon or use of this report by any other person or party 16 not authorized, nor will it confer any legal right wfiatscevar. S. DHHS SIGNATURE .(L Approved for 1 bedrooms By: Disapproved Conditional approval for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Departmentof Health and Human Services (DHHS) Issues Health Authority Approval Cart)ficates based only upon the representations given In paragraph 6 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 anslyzo data before a certificate Is Issued. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineers work n -M (Rev. Vml) aa& MOA crit Camputar Verelan MunicipalltyofAnchorage �lp FANCHORAGE DEPARTMENT OF HEALTH & HUIUI ;&Vl# vICEs DNlSI Environmental Services Division 825 IL" Street, Rm 502 Anchorage, Maim 99501 (907) 343-4744 Health Authority Approval Cheddist Legal Description:, KNIK HEIGHTS S/D: LOT 4, BLOCK 8 Parcel l.D.: 017-033-04 ' A. WELL DATA Well Type PRIVATE KA, 8, or C, attach ADEC latter. ADEC water system number N/A Log present (YiN) Y Dais completed . 7/6/71 Total depth 178' ' • • Cased to .40'+ Casing height (above ground) 12"+ , Sanitary sae] (YIN) YES W res property protected (YIN) YES. : FROM WELL LOO Date or teat 7/8/71 ' r Staticwaterlevel Well production 1_5 _ 9.P.m. r WATER SAMPLE RESULTS: r O 581 AT INSPECTION 8/18/2000 - 128' 5.7+ g.p.m: Data of sample: " 8/18/2000 • Pollected by: A.W.W.C., INC. B.SEPTICM0LDINOTANK DATA ik Ias40E Rouse ' Datelneteiled 7/30/71 Tanksiza' 1250 Number ofCompartments -,X_Cleanouts(YIN)M Foundation cleanout (YM) YES' Depression (YM) NO High water alenn (Y/N) N/A Date of Pumping, 8/17/2000 Pumper A+ HOME SERVICES CCto"" F"rt C. ABSORPTION FIELD DATA `i}��D^''xµ • VPQ61 ' Date Installed 8/17/93 'Sol[ rating (g.p.dfi2 or ft2/bdrm) 0.6 System type DEEP TRENCH Larrgtir 74' 1Mdth 2' Gravel thickness below pipe 7' Total depth 11.5' Effective absorption Brea 1036 SO FT Monitoring Tube present (YIN) YES Depression over told (YIN) NO Date of adequacy test 8/18/2000 Resutis (PaselFaii) PASS For". 4 Bedrooms Fluid depth In absorption field before test (In.): 8 Immedlately after 1000 gal. water added pn.r 45.5' Fluid depth 38 (Ins) Minutes later: 195 Absorption rate 600+ CPD Per odde treatment (past 12 months) (YIN) NONE KNOWN If yes, give date ----- 72-W6 (rw.3sar CWVAK V44W D. LIFT STATION .• Data Installed Size ManholelAccesa High water alar E. SEPARATION DISTANCES level at*_,Pump off' level ar 'Datum SEPARATION DISTANCES FROM WELL ON LOTTO: Septic/holding tank on lot 501+ On adjacent Iota 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Public sewer manholeldeanout N/A Sewedaeptic service line 25'+ Llft station N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5'+ Property Ilne 5'+ Absorption field 5'+ Water main/servloe line 101+ Surface water/dralnege '100'+ Wells on adjeoent lots 100'+ SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ 13uilding foundalion 10'+ Watermein/eervice line 10'+ Surface water 100'+ Driveway, partdnglvehlde storage area 10'+ Curtain drain F. ENGINEER'S 1 cantly that 1, of Munldpal n With MOA HA Signature Engineer's U specibna and revfsw is are In conformance date. FIAA Fee $ ) Date of Payment 8 AS- / O -Z) Receipt Number d �° / G 3 ?Z= Sw. yam). CamW W Version Wella on e Waiver Fee $ Data of Payment Receipt Number 08-28-00 08:41 FROIF•CTE ENVIROMNTAL 8811301 T-101 P.02/C3 F -20I �- CT&E Environmental Services IAC. Cur Rofy 1004182001 AIC Weer & Wastewaler COr IT`iims Inc• COeosrOlr rrtnted Dstafllme 06242000 18:35 C11901 Name TrajectNamrts KnikH4iRhtsL4BkB ColbcudDatelllme 08/182000 15:40 Received DateMme 08/182000 15:40 Chest Sampla ID Matrix ICaik Heights M Bk D ' 1)riaking Water lubnInIDlreeto t pptoc Ed ' Ordered By Released PWSID 0 Sample RenwLs' Atoubi'le Rep AaJycs fall Raalu POL Uelu Me�tod Leanta Dep O+re waters Dayart:meat N1tnae-14 0.590 0.500 mWL. EPA300.0 uicrobiologyLoborstozy TondColiform 0 caVl00mL SM190222B 10 max 00/31/00 ' SCL 00/10/00 1DT MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # b 170 3 3 0—y- 1. GENERAL INFORMATION HAA # Complete legal description LOT -"'r 240 -5 -k -,ICN I K I f (_ 1G� FT5 SU(?)p I V ISi6n/ Location (site address or directions) IzS!Eo glbGEW000 2-68-D hr 3c' -o (L 6 GC AK :1957) (o ) Property owner 4L-014 4 I_0AN N F_ TQk r=LA Day phone Mailingaddress 1254Co 'RIDGr—WOOD R.iJ Auc�m-AAF_- ,A�-_ q,ci51� Lending agency1", ) h,/ Cc) n -p Day phone Z77-0700 Mailing address�L>Q�'�T� Agent /_Vr)i-, Za pp *—t— / e r -e Day phone Z-77—oiov Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: fl (NUIZ) 3. TYPE OF WATER SUPPLY: Individual well C 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: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) From MOA H21 -�joM j, aauibua leuolsseload ayl ul suolssiwo jo saoaaa aol aiglsuodsaa lou sl a6eaoyouy to Ai1ledlolunIN ay,). panesi sl aleolllliao a ajolaq elep azAleue jo suolloodsui lonpuoo lou op SHHQ to saaAoldw3 •sluawailnbei alels pue leaapal ulelaao Alsiles olaapio ui suoilnl!lsui bulpual alayl pue sewoy to sjaseyoind of Asel.inoo a se slyl saop SHHa ayl'eWely to @IBIS ayl ul paaalsl6aa a99ul6ua leuolssaloid luopuadepul ue Aq anoge g ydnibmed ul u9n16 suolleluesaidaa ayl uodn Aluo paseq sale0!3!laao lenoaddy AllaoylnV UIIeaH sonssi (SHHCI) saunas uewnHi pue ylleaH ;o luawliedaa a6eaoyouy to AllledlolunW ayl NUIlI1VJ ' C 0 aleG suollelndlls 6uimollol ayl ql!M 'swooapaq Wrp,,I 6A51 r Oita( ;e l ry VP;4l1M♦ i a' & 4 •Fi 4 Y tit 0 r"lp 6.)A [+�� 00+e�7ii�WMa�`\�� Ml sluawwoo leuolllppy aol lenoidde lauolllpuoO •panoiddes14 swooapaq T aol. panoaddy 3un.LVNDIS SHHa '9 ale4 r �,`/U ainleubis s�aaul6u3 ssaapPV �S°S - s% Ooo2-9yic auoyd 3-� , a ui �,f�.» fs�aJ wal3 to aweN -uolloodsul slyl to alep ayl uo ball@ ul suo!lelnbei pue 'saoueulpao 'sapoo alelS pue ledlolunW lie yl!m aouelldwoo ul sl welsAs lesodslp aalemalsum ao/pue Alddns .ialeM alls-uo ayl 'uolloadsul pue u011e61lsanul Aw woal pue Sall; a6ejoyouy to Alliedlolunw ayl woal paulelgo uollewaolul all uo paseq leyl Al!aanaaylanl I •ulaaay paleolpul ainlonals to ads l pue swooapaq to aagwnu ayl aol alenbape pue leuollounl'ales sl walsAs lesodslp aalennalsem jo/pue Alddns aalem alis-uo aUl leul smogs uollpolldde lenoaddy AluoglnV LIIIeaH S!yl to uo!le61lsanul Aw leyl Aj!aan I 'molaq umoys alep uollep!len ayl to se pue olaaay paxllle leas Aw Aq pollpiao sy a33NI!DN3 AI3 NO11O3dSNl dO LN3W31V1S 'S Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: J�, d,' -/<a G % �/ Parcel I.D. oi70 3345/ A. Well Data Well type If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) y Date completed 7-/2 - 71 Driller _14-11Z- Total UGTotal depth /78 Cased to 176 Casing height /Z Sanitary seal (Y/N) %� Wires properly protected (Y/N) y Date of test Static water level Well flow Pump levell FROM WELL LOG 7-12-71 /`30 /.5 - SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot %o Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform D Date of sample: 9- Iy 73 B. SEPTIC/HOLDING TANK DATA Date installed 7-3o-71 Cleanouts(Y/N) i7 High water alarm (Y/N) _ R AT INSPECTION c X) 5 7 .p.m. g.p.m`,170 Y rlr% c , On adjacent lots On adjacent lots ublic sewer manhole/cleanout 4106, Petroleum tank �` 5� Nitrate '0,5-,9 Collected by Other bacteria D _Tank size iZ 50 Compartments / Foundation cleanout (Y/N) / i�"ts( NE epression (Y/N) Alarm tested (Y/N) Date of pumping ?- / 9 - iZ Pumper c5Exy/c_E-s % P-/7-93 SEPARATION DISTANCES FROM SEPTIC/H6L-BIiaJG TANK TO: Well(s) on lot 70 On adjacent lots --1106) To property line Z6 Absorption field 3 Surface water/drainage _H /,0b Foundation Water main/service line -1561 72-026(3r93)•Front CONTINUED ON BACK PAGE aagwnN 1d19oalj -e- 2� �agwnN idlaoal� luawAed to algia L ILIMA861to Glen $ Gad JGn1eM(7J) $ Gad VVH Oleo aweN sdaau161-13 ainieu618 roo uog0adsur sry!1�r aJ p ayJ uo Joal{a•ursougapm6 VVp pup ypW pe 01 pew)o/uoo jo 'payuan 'pa40aU0 enpU I Jp4J /1!Ueo ! N oS 4 - ease 85UJOIS 0101yan/6u1i{jed 'AnM8nu(] N011VOIJUH30 S1133NIEM '3 ooi 0 01-f- uleap uplino jolem ooepns gull eolmos/ulew Jejum �ueglno oS slot lueoelpe u0 l iol uo walsAs pauopuege ao 6upslxa of gull Aliadoid ) O o / 4 �6 rnS aleP an16 'sob it Tsai Joliv aol (N/).) P19!1 rano uolssaida(] 1 UIdaP lelol adAl walsAS ,L aalem aoelinS le (N/A) S Z uollepunol 6ulpllnq of slol luaoeipe u0 Z 1 1 fol uo IIaM :Ol 0131d NOIlda0S9d WOH-d 30Md1S10 NOIl` HVd3S L� n/i! s' i oN }-1 -2 <v? Y1 i n,1ry WA) (syiuow Z 1. ised) luawleeil OP!xoaad (llel/ssed) sllnsad isal aaolaq plan uolidiosge ul lan91 J91EM isal Amnbape to ale(] (N/A) luasaid inouealo 0) 0) eaae uolidiosge leiol ssaui olUi lanea0 17 UIpIM , h b � , p E Ul6ua"1 P011elsul ale(] VJ.VCl 101"131d N0IIdH0Sl3V'a slol ivaoelpe u0 mei uo IIOM Ol NOIld1S 1=111A01443ONd1SI0 N011b'ddd3S (N/A) sapoo 18ou10919 y0W SIOGN Is lOrAai.,uo dwnd„ lana) waele aalem U6iH (N/A) IuaA suolle6 ul azlS ""'Sul 9180 NOLMLS ldl Constructing Engineers 9601 Buddy Werner Dr Anchorage AK 99516 Attn: - Our Lab #: Location/Project: Your Sample ID: Sample Matrix: Comments: Method Parameter EPA 353.3 Nitrate -N F128389 L4BB Knik Water paw (IL Reported By: Patricia A. ody Senior Chemist Report Date: 09/21/93 Date Arrived: 09/16/93 Date Sampled: 09/14/93 Time Sampled: 1830 Collected By: - MDL = Method Detection Limit * Flag Definitions B = Below Regulatory Min. H = Above Regulatory Max. Date Date Units Results * MDL Prepared Analyzed ------------------------------------------------------------ mg/l 0.58 0.05 09/20/93 3330 INDUST RIAL AVENUE 2505 FAIRBANKS S"I. FAIRBANKS, ALASKA 99701 ANCHORAGE, ALASKA 99503 907-456-3116 907-277-8378 Constructing Engineers 9601 Buddy Werner Dr Anchorage AK 99516 Attn: - Our Lab #: Location/Project: Your Sample ID: Sample Matrix: Comments: Method Parameter EPA 353.3 Nitrate -N F128389 L4BB Knik Water paw (IL Reported By: Patricia A. ody Senior Chemist Report Date: 09/21/93 Date Arrived: 09/16/93 Date Sampled: 09/14/93 Time Sampled: 1830 Collected By: - MDL = Method Detection Limit * Flag Definitions B = Below Regulatory Min. H = Above Regulatory Max. Date Date Units Results * MDL Prepared Analyzed ------------------------------------------------------------ mg/l 0.58 0.05 09/20/93 .iiia:ATFi�'=il,'(°I'ICRAGii .AI?P/1 L3r')lin!III! D,3p_ aytl'oni, of Un7?ronmentri.l 35 jdor "uad, An<,heirage, Alaska 9g % ?7q_86% D.li;e !),e r e i v 0 0, _..._._..� OU T1.rr,e of Tnsnection ®_ "ate of Tnsrmction FOR TND*rIIITDIJP.T, I_;'I ' 4'NA'f il'. ?'AC7'.TTIFi F. O;,, f '7 1. Aoproval Requested 3l✓: (AMA -4 Address: Phone . 2. ?'rooert;y Owner - Phone: 3 ff _ 3. Legal Description: e A5l%��4�°� ._ 4. Location:�P�1 f j 5. Tvpc of Faci l.a.ty to hr Tv s,.,,,(:ped — =��d � � �✓1✓i��'>�) . Number of Redrooros: 6. Well Data: A. / Tyne�_��/��.-------._....�_-�.- '3. r)c�n+.).,._.___�_..�_ C. Construction—,�/_f D, �l�_..- ! �3arterSal Analysis 7. Sewage Disoosal Svstem- A. Tnstalled �C�/�� 3. Installer C. Septic Tank: l.. 2. Manufacturer e Co t D. Seepage Pit. 1. Sire Material Disposal Fleld: 'Ibt;.tl T:-I!gth of 1:1nes 8. Distances: A. Well To: Serotic Tank � (✓ Absorntion Areae Sewer Lines iJoare,t'. Lot l.i.r:e Qt}ler Coraa:nination T3. houndation fo Se;7tir_. T:ar;k Absorption Area C. Absorption A "ea to Mearest Lot; Trine; iioquest for Anoroval of '.v dpj-,)) :InwQr � llv(:0:f?r F%lf:ll7,f;7.E' Page Two / 9. Comments: �__•_.._j27_i_r_ Anorov?d A T, i, v aVa Ir), for 0nf. ,?aY 1':!'o:1 [)(!a: (? Greater Anchorafr F! AY('7 ' oro'Inh Y eerOr- t 1.'f`r' 'f:hut', is )'1 c infoY!Tiat,Ion (on{clnn1C�11r, r2Cf!I(,' t r c)t)4.rC!V<?) f0 t)e a true and accurate on o` '.'so"vi'ic'Ater lOr:ai%e(9 at: