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T12N R4W SEC 4 NW4SE4 PTN
TI N R4W 4 KIW4 $ #011-051-24 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division ~// - 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON=SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Na,.e DISTANCES A~,~FflO~ TANK FIELD WELL Phone(s) Perm,,~, ¢/7/"°' No~-°l Bedrooms ..... WELL TANKS N ~/'SEPTIC ~ HOLDING TYPE OF SYSTEM ......... ~ ' FT ¢ ' FT WELLS ~RIVATE ~ OTHER (Identify) _~_ Inspection& PeHormed by: ~uniclpal and State Duidehnes m erie dal: ~:~ 72 013 (3/85) (!l,'.::'[!i I. SL~'~...u?t,, Anthem a(.:?:, Alaska 9950 :I. :343....q7>'.0 C)hl...,~i~! l'l{:i: !~I~:WI!!:I:R & SEI:::'TIC t'AN!< & Wiii:l.l... I:::'li]::~l'.'l:[T ANC]IOF,'.A(..)I:, AK ':?"~'t.'~ :I :L [])ay P h or'l*::~ ~ (::: ap a!::: :i [ y :~ :l ~, 500 !) a :1. :1. (::)r'l !!~. [Eac l'l !i~(:.![:1 'L :i (::: :r)~.:.)l::) ~'. I'l 'L ~::! '(' op c) ~ s(:.~:,p t :i. c: '[ al'l k ( s ) -::: 4.0 Wl~il..[..,: Log mLd.~i'L be !!iu.~;lffl'l.I.'.'l.[.!d 'l'.c)I"h..ulic:ipa].i'Ly of Anch()i"agi:'~ Del:)av'Lmi'-)r'lt i::)t I. lealth l::'l::i:l:( E:lq(.i[NliEEt:d}3 :r)I!:SIGN :I:NST'AI.t. 2 3q" TI::~I!!:NCHS W:[TI'I 6' 01:r Gl:RAVEl. B BE:I .()W F:' I:I::"1 :. MA :I:NI (] I N :1(.) ' BE t'l.~Jl~:l:~:lXl 'I'I?ENCI'IS,. NOT I I:::Y D['IItS I:::'R :I:OR TO THiS F:'ERI"I:tT ]:S :[SSU!~:D I:::C)I::,'. A S:[Iq()I..E F'AI"IZI...Y RI~:S:[DEN(:;I:~: (]NI.Y AND [ C!!]:([ II:::Y THAI ~ J.,. I ~'d~l fam:i].:i, ar' w:i.'Ll'l '(.I'd.~) i'(.~(::tu:i.l'c)mc.!tl'~.!i~ ~'(::!1'" Olq...!ii:i.'l.¢~ !?i(~!~CH"!B ,";~l'ii::l ~(::,:l:t.!i~ F(::)v'Lh by ~:.1'~:¢ I~h..u~:ic::ipal:i. ty ~::)~' Ar~c:hcmag~:;) (MOA) and the Sra.'L(.:.: I::)~' Al,~.sl.~:a,, ;~:'.:, I ,,~:i.J] :i.t'r'~[~'[.al]. 'Lb(:::. s',,s'l'(.~m in a(:::l::~:)t'~:l~'.tl~(:::()~) ~,j:[-l:.h F~]]. MO(:~ cc)des and aA,-~(:l in (:::om!:)] Jar')c(:.~~ ~,.~J'l:.h 'Lh(a cl~s~:.:i.(lil cPJ'~](~[':[~:~ c){ th:i.s i::) r:.? P l~ 'i t ,, 3., !: ~:i. :! L adl'1cu'e:, t(::~ aJ :1. MC)A and S'l. atiq ~::)~ ~.l:t.~.~ska r'c~quit'(~m~:.?rrLs .For'. 'Lb(.:) ~(~'~'. ba(:::l.:: ,"J:[~[,'~'.6~l'lC::(2?~ ~l'.(:)m ,'~u'iy ~.~xis'L:i.i']g ~(~)].].~, i4~:~:.e~a~'..(~?[' d:iSl::)osal system (:)r' public ,'::tl'~ ~..' ~::,l'~ .I ~,:~ ~". (]~,iTm:,j:i~ ;,,~ :~ I J [' e):,i,:~u :t p ~) a;I ,zt(::! (::) :~. '[:. :1 C:)FI a ,t, I:) ~H'~ m :L L ,, ...... . f ......... NOTES: Proposed well lecotlon wlll be In excess of 100 feet from other uupti~ b-y~tenl~ looutud un udjucunt lots 1-t, 2 1. 2 and 1. Propoeetl septlc system location wlll bi; In excess of 100 feet from other wells located on adjacent lots 14, 21. 2 and 1. Campbell Polnl, 0 184,00' EasL Kitlisa ,' Road F, eundse~ Pa¥ing.~a~:c~L~-,-: Drainage ~ ,) Chain Li,nk Fenoe~ ¥ood I ~ ,HUb & Taok~HT ,'.'~te.'.'..':Spain.'. E~gt:;:':;:':'b~r~t~n bu~v~.'.'.'.'.'.T~pe'.: ~ x ~pike or PK-~P 15AU688' -- 1 "~30' Lot NA Bledk NA,,, !.._ 0 Iron Roper-IR 212~ PARCEL 2 " ~RD ' ' 'rANIANA HILLS e ~ Aluminum Cap-AC BS 12N 4W 4 SM ~~ I hereby oerttfy ~hat the property desoribed h~reon has ~.....~ ..;:....~ mg d]reofion, and that ~he ~mprovement~ situ.ted thereon ar. ~ffMn ~he propertg ~ ~ ... ~.~ .. ~ ~ lines and do no~ overlap or enoroaoh on the proper~y ly~ng adjaoent thereto unless .ffW.:"~' ~. %~. --~ o~her~ise ~hown. That no improvements on ~he property ly~ng adjaoen~ ~hereto ~,~,,~..~....~;~..,, ~ enoroaoh on {he premises tn question and that there are'no roadways, transmission ~~/~.., ltne~ or other ea~ernents on said property exoept as sho~n. R"'~;~, ..... ~'". ~'~"~;~'"".;~ -. , It ts ~he responsibility of ~he o~ner or butlder~ prior ~.o°n~truott?n~ ~o verify ~, ~.% [S-3425 .~ proposed building grade relative to finish grade and uflhtg oonneoflons, and to · ~?.~. ,...~ ~ determine the existenoe of any easements, oovenants or restriotions ~hioh do not ~,' ...... .",~ ~ appear on the reoorded subdivision plat. ~%~ Listed distances & direottons prevail over ~oallng. Reproduotion may oause distortion · :,:,:,:eK.j~.~i~r:,:'.:,:,:.:.' .... PAC 1 - 27- ] X Post Offfoe Box 112207 Anohorage, Alaska 99511 (907) lFbrm i-27X Plot Plan/Ash.fit ORIGINAL GRADE 2 4 6 9 11- 12- 14- 16- ENO 18- TEST IIOL£ 20- -organico ~,-~ ,-,L°"-"' '*" ': '"' iltg ' '" · fine a aend ...., ..., ..... light brovn :" ; ' "*';';'" '; ', , ,",',',',' , '", ' · s ~rl rll finn hilt 2 above plpe ...... dark bravn.'., ,. .. j .. .. ,, ,, .... ; ,..;. . ',. ,, , , ;,, ..~' , ;~¥ ', . · ";", ...... "" ;.'.',,,., "'.. ' 6' FE. ET DEEP ..:.,,.'.:,,; , · ,: . :...:'.:V SE~[R ROCK .,. ' ' ." "'. '." BELOW DRAIN '. ' " "" ''" :5 .... ;:.¥:. TYPICAL HINIMUH 4 tnoh perforated drain pipe - holes down Clean gravel septto rook 1/2 inch to 1 t/2 tnoh diameter Undisturbed earth Engineered Filter Fabrto NOTE8 4' m4n~murn Dover over drain pipe Filter febrto requtred above pipe prior to book flll Trenoh must be level smeared trenoh ~alls and bottolw must be reeked Bottom of trenoh mtnlmum & feet above bedrook and 4 feet minimum above ~/ater table PARCEL 2 TANAINA HILLS SUBDIVISION SECTION 4 TI2N R4W SFi SETPIC DETAIL- 1 Lateral Line-Deep Trenoh-Geptin System-Profile Vier COMPARTMENI' ~EPTIC TANK Clean-out Tgpioam~! ~ 77' 6 FEET GRAVEL DEPTH 2 FLEET YYPICAL MINIMUM NOTEU Clean-out Reautred prfer to 90 dearee bends ~aterpreof l'loohanioal clamp required et inlet and outlet Trenoh installed love1 Trenoh Installed aeroos slope Smeared trenoh ~alls and bottom must be raked gtpUo tank must be Insulated ~tth 2" htgh densltu butte1 tgpe stgrofoam or equivalent Insulation (~he~e required) 2" high den~ttg durra1 tgpe polgstrene or equal ever fines and trenoh ~hen earth baokfi11 ts less than 4'. Over ang fines In,tailed under a drtve~ag and/er parktng~ regardless of depth. 6etbaeks: 30' ~tntmum ffo~ ~renoh to ang other dratnfleld--lOO'mtntmum ffo~ tank and trenoh to rlver, lake or strea~ for Individual sgs~e~s ~ells~ 1~0' for Class C ~ells and ~00 Feet for Class A or g ~ells 10 Clean-out for~ !' to 4' ffo~ ~oundaUon eotto~ of trench ~tnt~um 6 feet above bedrook and 4 feet ~tnt~um above ~ater table lip ~HORT FORMUL&8 Number of Bedrooms X 8off RaUngs ,. Total Area Required ~ X 18~ .~ 92~ Square Feet Length = Total Rrea Required = 925 (Depth of Oravel X 2) (6' X 2') 77' Required 77'~ Destgned PARCEL 2 TANAINA HILLS SUBDIVISION SECTION 4 TI2N R4W 5M SEPTIC DETAIL - ! Lateral Ltne Deep Trenoh ggstem-Plan Vier Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Township, Range, Section: ?'7.~,'v' /Z.~'.~..~:/2'/, .~ ~%2/2,-~'4 SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? /,/t c, r¢,, y z, £ IF YES. AT WHAT ._~ DEPTH? Oeplh lo Water Alter Monitoring? "~ Dote', .... Gross Net Depth to Net Reading Date Time Time Water Drop ~.~ ,, ~., ~m t~ /~ ~ ~" · 7b .... ~ .4.' 55/ /~ ~ ~" , PERCOLATION RATE /.~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND ~ FT "/~"r' "~'/~'~" 2' CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE: 72-008 (Rev. 4/85) NOTES: Proposed well location will be In excess of 1 O0 feet from other uaPtlc ~ystoms located on adjacent lots 1't, 21, 2 and 1. Proposee septlc'~stem locatlon w111 be In excess of 1 OO foot T~om other wello located~dlaoont lots 14, 21. 2 and 1. ',,~, Campbell PolnL ~ Road ' Lot ¸:50' 184,00' ~.. 56,00' Easl %, Kltllsa Found Set Pavtng,m~:~c~ Draltnage ~ Chain Link Fenoe4~-~4-~ ¥ood Fenne ~ · Q Hub & Took-HT , . · ,~.~t-;,. ., .; ..:Sp~le,'.' L~at,.~t{~, ~u~.'.'.','.',Tope' ~ x Spike or PK-SP 15AU688 1"=~0' Lot N.A Bleak , NA ~ ~ Iron Pipe-,IP '.'.6~d'.'.'. ;:~o~:. · 0 , Iron Repar-IR ' "~1~' ' ' __ PARCEL ~ ~ ~ , Bras~ Cap-BC ,~e~d ..... b~; :~' ~Q' TANIANA HILLS I~mneMp rangn lie e ~ IAlumtnumCapsAC~~ RD 12N 4W ~ SM ..~%~,.,,..... ~ e mU direotton~ and that the improvements situated thereon are ~lthin the propertg :~ .. . - ., ~- e lines and do not overlap or encroach on the propertg 1gins ad}aoent thereto unless .~.. o~herwise ~hown, That no improvements on the propert9 lgtng ad~aoent thereto ~49~ ~ ~ ~ ROber~D SchiUing :?~ I~ iS th~ r~sponsibili~9 of ~he o~neP or butlder ~ Prto~ ~o oons~ruoflon~ to verif9 .. ~ - ' .~ proposed building ~rade relative to finish grade and ufllit9 oonneoflons, and to ~ ~ '% ,, ~ ~ determine the exfstenoe of an~ easements, oovenants or restrtoUons ~hf? do not {~%~,.. ...... ~...~ ....... .~ ~ . ~ appear on ~he reoorded subdivision plat. .~ Listed dlstanoes & dtreotlons prevail over soaltng. Reproduotion mag oause dtstortt .,.,,,., nr, o~ee~ ~m~r.,, ~ .,, ,,,., .,, 1-27-1X Fgrm 1-27X Plot III I I I I IIII I I I I TO COMPANTMENT ~EPTIC TANK Cleon-out 6 FEET GRAVEL DEPTH 2 FEET TYPICAL MINIMUM 2 F££T TYPICAL HIRIHUH _.2__ MINIMUM All olean-outs must Dome to ground level ..... Treneh tn~alled level Trenoh Installed aoroos slope Smeared trenoh ~a11~ and bo~om mu~t b~ raked 8etbaoks: S0' n11n~mum ~orn ~enoh to any other d~atnfleld--t 00'minimum ~or~ tank and tr~noh to rtver~ lake o~ ~ream 10 Clean-out form 1' to 4' ~om foundation Bottom of trenoh ~tnt~u~ 6 feet above bedrook and 4 feet mtnJ~um above ~ater table gHORT FORHULA~ I Ilflll ......... ll~lllllil ...................................................... ~- "_- ...................... ~ '_~ .................................. Number of Bedrooms ~ Soft Ratings e Total Area Required X 1~ = ~2~ Square Feat Length (Depth of Gravel g :2) (6' X 2') ~ ??' ~equtred ?O' De~tgned PARCEL 2 TANAINA HILLS SUBDIVISION ~ECTION 4 T12N R4V/§H 1-6~B1-4-1A X ~EPTIC DETAIL - I Lateral Line Deep Trenoh ~3gstem-Ptan Vier WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological & Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either la, lb or lc.) A.D.L. No. I-~--":]..IBorough Subdivision Lot Block [-'~'1 V4qtrs. secflon No. Township N[~ Range E[--] Meridian !c. DISTANCE AN~ DIRECTION FROM ROAD INTERSECTIONS $, OWNER OF WELL: / S~reef Address and Area of Well Loc~fion 2. WELL LOG Feet Below Surfuce 4. WELL DEPTH: (final) 5. DATE OF COMPLETION Material Type Top Bottom t'72;"~ ft. '~ -- ':z.Q ,~' ": :;"' /;~ .~ ~ D Auger ~*tted ~ Bored ~ Other: ":':~:~* ..... ~ /i'~'~ "/' '~/ , ~ Public Supply ~ Industry ;~ ,:/~ ,~ :'. e / ~5' :~ ~ Irrigation ~ Recharge ~ Commericol ~:,.~ .~ .... ,. ,: .-~ ,,.; ,,,,~. c ,,': ,-,' ~ ~:,,t i:~ 8. CASING: t r h'~, ~* ~'.~ ,~..... ~ /' ~~, ~r~'7 diam. L/~,~ in. o /',~ft. Depth Weight /~'~7 lbs./ft. ~-~ 9. FINISH OF WELL: ...... :~":_ ...... :/ .~'~...~...- ~ ~,~ ~., ~ Diameter: / ' '~-~'~ ~-~' ~ ~h' /";;' r ~ ~/ Length: ...... w ,~ -- Backfilling Gravel pack ..... ' ...... '~, I0. STATIC WATER LEVEL:, / ~ --~" ft. ~/~"~, ~, ~ :,:, ,,, '~'. ~ Date ,/~'~'T~//, ~ Above or ~elow ~and surface ~ .~,.-"~'"'" II. PUMPING LEVEL below load surface and YIELD '~ ................ 1~2? ,. ,,,~ / ~. ,u~,i,~.<~:' ~.,.~. ~ ~F HEA~T~ ~ __ ft. after --hfs' pumping g.p.m. Material: ~ Neat Cement ~ Other: Length of Drop Pipe ft. copocity g.p.m. 14. REMARKS: 16. WATER WELL CONTRACTOR'S CERTIFICATION: 15. Water Temperature ~o ~ F ~ C This well wes drilled und~r~my j~rl,s'~iction end this report is true to fha best of my knowledge end belief; /.~eglsfe~d ~usi~ess N~me ./ Contract License Number A u t hor'l zed ?~epresentotive . Form Og-WWR (11/81) Copy Distribution; WHITE-State DGGS, PlNK:Driller~ CANARY-Customer Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street CERTIFICATE FOR A P.O. BoX 196650 Anchorage, AK 99519-6650 . ~ (907) 343-7904 . OF ON-SITE SYSTEHS AP SINGLE FAHILY DWELLING Parcel I.D. 011-051-24 1. GENERAL INFORMATION Expiration Date: Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address T12N~ R4W~ SEC 4 NW4~ SE4 6821 KITLISA DRIVE *ANCHORAGE~ AK WASHINGTON MUTUAL Day phone PO BOX 1169 MILWAUKEE, WI 55224 Day phone RAY DAHL W/ REMAX Day phone 110 W. 58TH SUITE 100 *ANCHORAGE, AK 99577 unless otherwise requested, COSA will be held by DSD for pickup. C/O AGENT 244-7611 2. NUMBER OF BEDROOMS: 5 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well · Individual On-site [] 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 On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an indePendent professional civil engineer registered in the State of Alaska. Certificates of On-Site 'Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water 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. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the vafidation date shown below.. I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, sho~4~ that +.he 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 furt,Eer verify that based on the informetion 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 GARNESS ENGINEERING GROUP, Ltd. Phone 357-6179 Address 5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 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 & Regulations. The rePorted results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater 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 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 provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. DSD SIGNATURE \._./~ Approved for . ~'- Disapproved. Conditional approval for bedrooms. .... -. ~: ON-SITE ~; WATER AND ~ ~ ~STEWAT~ ~. ~, PROGRAM bedrooms, with the following stipulations~ ~ '. Attachments: COSA Checkiist Septic System Advisory Well Flow Advisory Nitrate Advisory, (Rev. 11/0~ ~ ' Arsenic Advisow Maintenance Agreements Supplemental Engineer's Report Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: T12N, R4W, SEC 4 NW4SE4 Parcel ID: 011-051-24 WELL DATA Well type PRIVATE Date completed 8/20/88 Total depth '158 ft. *WELL If A, B, or C provide PWSID# N/A Sanitary seal (Y/N)YES Cased to '158 ,ff. INFO PER 2000 HAA Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. Date of test FROM WELL LOG *8/20/88 AT INSPECTION 2/21/11 Static water level * 105 ,ft. 87 ft. Well production *5.00 g.p.m. 5.00 g.p.m. WATER SAMPLE RESULTS: Coliform (~ colonies/100 mi. Nitrate /~ ~_ mg./L. Arsenic:~J~ ug./L. Date of sample: 2/21/11 Other bacteria (~) colonies/100 mi. Collected by: GE(:;, Ltd. B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Tank Type/Material Tank size__ gal. Number of Compartments Foundation cleanout (Y/N) D~~~~- Pumper. C, ABSORPTION FIELD DATA Date installed High water alarm (Y/N) Date installed Soil rating (g.p.d./ft2or ft2/bdrm)__ System type Length .ft. Width .ft. Gravel ~.~ Total depth ft. Eft. absorption area ft= Monitoring tube_,..~epression over field Date of adequacy test ~ ~ Results (P~s/Pait)'''''~ For~bedrooms Fluid depth in absorption field be~~in. Water added __gal. New depth in. Elapsed Time: ~ Final fluid depth__ in. Absorption rate>=____ _g.p.d. An ' enation treatment (past 12 mo.) (YIN & type) 'NONE ........ KNOWN If yes, give date - D. LIFT STATION Date installed "Pump on" level at Size in gallOns Manhole/Access in. "Pump off,, level_.a~. High water alarm level at .in. ~ ~ Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lotN/A Absorption field on lot N/A Public sewer main ~¥?~ Meets alarm & circuit requirements? On adjacent lots 100'+ On adjaCent lots 100'+ Public Sewer manhole/cleanout Sewer/septic service line 25'+ Holding tank Animal containment areaS 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Building foundation Property line Absorption field Water main Water service line. Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPT~T TO:- Pv~;rtsYe lirv~e ~ -- ~nerdati°n: ' D ~Wi~teewrar~ipna~ Cu~_~3ip~tl~~ Wells on adjacent lots. F. COM G. ~ENGINEER'S CERTIFICATION ! certify that I 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 N{ame JEFFREY A. GARNESS' Date ~ j l / l li COSA Fee ~; Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number EASEMENTS OF RECORD. OTHER THAN THOSE SHOWN ON 'THE F(ECORDED PLAT. ARE NOT SHOWN HEREON. 1:2.4. m m mm mmmmm 100' WELL ~DIUS / I I ,<, KITLI SA DR . -. .. ?~. T12N, R4W, SEC 4, NW4, SE 4 PNB ~PE OF WORK: DATE: ~ ~rofess~O~~ SEPARATION DISTANCES 2/22/11 I)EPT. OF ENVIRONMENTAL CONSERVATION / / I)I¥ISION OF' ENVIRONMENTAL IIEALTH DRINKING WATER AND WASTEWATER PROGRAM 1075 CtIECK STREET P.¢). BOX 871064 WASII,I,A. ALASKA 99687-1064 htlp:llwww, slate, ak.usldecldeh AUG 0 I Zoo0 AWWU ENGINEERING Telephone: (907) 376-5038 Fax: (907) 376-2382 July 21. 2000 Mr. Bill Johnson, P.E. CRW Engineering Group 3900 Arctic Blvd.. Suite 203 Anchorage, Alaska 99503 Kine-aid Park Access Road Upgrade (CRW No. 9418B):, Separation l)ist;mcc Waivcr Request and Plan Review for MOA Sanitan' Sewer Extensions Dear Mr, Johnson: On July 19, 2000, this office received your submittal of additional infommtion for the referenced project, in response to the Department's letter of July 14, 2000. I have reviewed the submittal, including the satisfactoD' water quality analyses for the private well on parcel 2, and have the lbllowing comments: The plans show an g-inch sanita~' sewer and associated cleanout will be installed 56 feet front a private well located on parcel 2. within section 4, TI2N, R4W, S.M. (measured from center line of tt~c well to center line of thc sewer). You have requested a separation distm~cc waiver to the private well be granted tk)r thc sanitz~q,' sewer. 'Ibis request is to waive the l)cpmmcnt's minimum separation dist;mce requirement of 100 feet between a private well and sewer dcanoul, and 75 ['cet between a private well and community sewer line. 1 have evaluated fiw information that is available, including soil and groundwater conditions, geology, the recent satisfactory water bacteria and nitrate analyses for this well, and determined that the potential for contamination due to the lesser separation distances, is not significant. Thcrctbre. a waiver for thc proposed separation distrmce of 54 feet (estimated edge of well to edge of sewer) is granted in accordance with provisions of the State's Wastcwater Disposal Regulations. I g AAC 72. This waiver includes both the sewer cleanout and community sewer line where it is within well's protective radii. Proposed is thc installation of approximately 117 lineal feet of g-inch class 50 ductile iron pipe within the Lowell Court right-of-way and approximately 83 lineal feet of 8-inch class 50 ductile iron pipe x~/thin the Tanaina Drive right-of-way. The plans show a water line crossing will be completed as part of this project. The crossing will need to conform to the rcquiremcms of the State's Wastewater Disposal Regulations 18 AAC 72.020(g)(2). Mr. Bill Johnson, P.E. Page 2 July 21, 2000 Finding other details of the plans satisfactory, approval to construct is for tl'lese sanitary, sewers for the concerns of the Department, subject to the following conditions: 1 )tlmt the sanitary sewer installations be done under the direction of a registered engineer and that unqualified record drawings, documenting the installations and having the engineer's professional seal and original signature, be submitted lk~r Department review and approval, 2) Ibat specific record information be provided to verify the sanitary sewers have been installed in accordance with the M unicipality of Anchorage Standards SpeCifications, and 3~ that specific record information be provided to vcrit~' thc water line crossing conforms to the requirements of 18 AAC 72.020(g)(2). Thc DcpartmetWs conditional approval to construct is constituted by the enclosed certificate. Please remffmbc~ t"~hat once the inslallation of the sanitary sewers have ~een completed, an approval to operate certificate will need to be obtained from the Department. This will require that the enclosed Certification of Construction form be completed and submitted along ~'ith the requested record information for Department review and approval. This approval does not gnmt or imply an}' additional authorization or approval that may be required by other federal, state, or local entities. If you have an}' questions, please do not hesitate to contact Sincerely. Enclosures: AS \\'illiam Tyrcll. PAL. AWWU w:'encl. 12:28 FAX 9072697650 FRANK H. MURKOWSKI, GOVERNOR DEPT. OF ENVIRONMENTAL CONSERVATION DIVISION OF ENVIRONMENTAL I-IEALTI1 DI~NKING WATER AND WASTEWATER PROGRAM 555 CORDOVA ANCHORAGE, AK 99501 ?hone: (907)269-7519 Fax: (907) 269-7650 ' http:llwww.smTe.ak.uslded Bill Johnson, P.E. CRW Engineering Group 3900 Arctid Blvd., Suite 203 Anchorage. Alaska 99503 June 24, 2003 Kincaid Park Acccss Road'U~rade, (C RW Number 9418 B) Separation Distance Waiver Request, ADEC Project ~ 754 Dear Mr. Johnson: The Department has reviewed thc record drawings and supporting documentation submitted for the Kincaid Park Access Road Upgrade. In reviewing thc file and the recold drawings. It appea~s fl~at the request for a waiver submined on July ~ 7, 2000 had not been completed by the Department, v.e apologize for this oversight. A review of the site conditions, the ~ve[I log, and th,: request to waive thc required separation distance bet-ween the wastev.'ater collection line and the private ~ater system source well from 100 feet to 56 feet is protective of public health and is appro¥cd, based upon the submitted information. This approval is contingent upon your receipt of any other state, federal or local authorizations which are required for your pro. leek You are required ro obtain all off,er accesseD' authorizations before proceeding ~'ith your project. You are advised that ifthls development will require placing fill in wetlands or working iu a stream, river or lake, permits from the U.S- Army Corps of Engineers and the Alaska Department of Fish and Game may be required. A Coastal Projects Questionnaire will help you identi~ other p~rmits and approvals flint may be required tot your project. Any person who disagrees with this decision may request an adjudicatory hearing in accordance with 1 $ AAC 15_ t 95- l g AAC 15.340 or an informal reviex~ by the Division Director in accordance with lC A_AC ! 5.185. Informal review' requests must be d~:livered to the Division Director, 555 Cordo;'a St.. Anchorage, Alaska 99501, within 15 days of the permit decision. Adjudicatory. hearings requests must be delivered to the Commissioner of the Department of Environmental Conservation. 410 Wiloughby Avenue. Suite 303, ~uneau, Alaska 99801, withi, 30 days of the permit decision. Ifa hearing is not ~equested within 30 days, the right to appeal is waived. Respectfi~[ly, William R. Rieth, P.E. Environmental Engineer i~TUSA Drive Mumclpahty o.f Anchorage Development Servtces Department Building Safety Division On-Site Water and Wastewater Program " ° 4700 Bragaw Street P.O. Box 196650 Anchorage. AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING 1. (~ENERAL INFORMATION C~rnpl~ie legal descril~tion Location (site address) G~,2t I~;~/,~,r~.- Current Property owner(s) D~.~,;3 Mailing address (o~ 2.] J('~ ~5.A., COSA# Expiration Date: Da~, phone Lending agency Dayphone Mailing address Real Estate Agent Day phone Mailing Address Un/ess otherwise requested, COSA will be held by DSD foc pickup. 2. NUMBER OF BEDROOMS: .~ 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL.' Individual On-site Indiwdual Holding Tank [-] Community On-site [] Public Sewer The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given In paragraph 4 by an independent professional civil engineer registered In the State of Naska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage Is not responsible for errors or omissions In the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify Ihat 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. Phone Date Address 'Z~ ~. I~~k ~,. 2o~: A~o¢,~ A~ Engineers Printed Name L~r~ ~u~[[ ~ bedrooms. 5. DSD SIGNATURE Approved or Disapproved. Conditional approval for ;" .... bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report · Other- By:. F Odginal Cedificate Date: ~' -/--//.- 0 ~ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 9g$1g-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: TIZN' A. WELL DATA Date completed Total depth ~10~ ft. Date of test Static water level Well production Parce,,O: IfA, B, or C provide PWSID # ---' Sanitary seal (Y/N) ~ Cased to "/qO ft. FROM WELL LOG ~1~.~, ft. I,{l~x~,3 gp.m. Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION fL gp.m. ri % in. WATER SAMPLE RESULTS: Coliform {~ colonies/100 mL Nitrate ,~V~) mg/L Arsenic: ND ppb date of sample: B. SEPTIC/HOLDING TANK DATA Other bacteria Collected by: .~ colonies/100 mL Tank size , gal., Number of Compa~ments~._.____..~,~) Foun~) High water alarm (Y/N) Date ' ' Pumper C, ABSORPTION FIELD DATA Date in~talled Soil rating (g.p.d./ft2 or ft2/bdrm) __ System type Length. ff.. :~' Width ff. Gravel below pip~_~ Total depth ft. Eft. absorption area ft~ Monito~ over field __ Date of adequacy test ~ FOr bedrooms Fluid depth in absorpt,~ Water added_, gal . New depth in. D. LIFT STATION Date installed 'Pump on" level at __ in. Size in gallons Manhole/Access (Y/N) ~ 'Pump off' level at ~ level at in, Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main ~5 ~+ Sewer/septic service line Animal containment areas On adjacent lots lO0 On adjacent lots ' J~3' ~- Public sewer manhole/cleanout EX) ~+- Holding tank ,,'v'/A Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line __ Absorption field Water main Water service lin u ce water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water Service line Surface water ~ Wells on adjacent lots Water main F. COMMENTS 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 COSA guidelines in effect on this dale. Engineer's Printed Name L3n'5 ....~,l:~' Date Waiver Fee $ Date of Payment Receipt Number EASEMENTS OF RECORD. OTHER THAN THOSE SHOWN ON THE RECORDED PLAT. ARE NOT SHOWN HEREON. "ASBUIL'!4' : NO corners Bet I hMM)y c~nify tMt I hive ,,u~eye~ im~o~ementl ~ituateo IAoroofl are me properly yng idiacefll IAorelo, ~t,no Improvomen~ on properly lying i~8com e ncmr~o~ I~e I~emisos in quesum aha ~M ~Aere ore ne rc~awoys, V~ns~iss~m lines c~ omer vlJbe emmenu on siicl i~openy excel. ~ .l~c~lecl hetean. 0 · THE .INFORMATION HEREON 18 'FOR THE ~ C~c *LENDING INST1TU~ON~ SPE~FIGN. LY.TO ~ ~ CONFUCTS B.~EN ~S~ ' ~D P~D LOT U~S ~ ~SE~ ~ ~ ~T ~ ~ ~D F~ P~TIO~ 8~8 ~ F~S. Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 011-051-24 1. GENERAL INFORMATION Complete legal description Expiration Date: T12N, R4W, Section 4, Parcel 2 Location (site address or directions 6821 Kitlisa , Anchorage Current Property owner(s) Rick Gonzales Day phone Culmie Cookery 727-7626 Mailing address Lending agency Day phone Mailing address Corkery Real Estate Agent Coldwell Banker Fortune/Connie Dayphone 727-7626 Mailing Address 2525 C Street, Ste. 100, Anchorage, AK 99503 Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: d* //,t/'~ ,, ' NUMBER OF BEDROOMS: 5 TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] Individual Holding Tank [] Community On-site Public Water System [] Public Sewer [] The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. 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 sample results less than 30 days old. Certificates are valid for one year for properties served by Class Aor B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 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 Health Authority Approval Guidelines for the Health Authority Approval application show 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 verity 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. S & S ENGINEERING NameofFirm 17'; - ' :.Looo~oadNo, 204 Phone Address Eagie {{iver, AlasJ(a 99577 Date Engineer's Printed Name DHHS SIGNATURE ~ Approved for .~ bedrooms, Disapproved. Conditional approval for ~ ... · ENGINEER~'v ,. , ~ ~.'~'.~ -~ ............ ,,.,..- ~¢ bedrooms, with the following stipulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: Original Certificate Date: Reissue Date: Municipality of Anchorage ¢,ECEIVED Department of Health and Human Services Division of Environmental Services JUN 1 On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 MUNI(-IPALI|'y OF ANCHORAGE www. ci.anchorage.ak.us "~I~r'~qMENTAL SEI~VICES OlVir', (907) 343-4744 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: I°,4£ Parcel I.D.: __ If A, B, or C provide PWSID Cf __ Sanitary seal 'Y~'-~' i5'¢Y ft A. WELL DATA Well type/o,~ j v4 F( Date completed Total depth ! 5' ;¢ fi Cased to FROM WELL LOG Date of test Static water level / 0 Well production .% o WATER SAMPLE RESULTS: Coliform O colonies/100 mi Date of sample: B. SEPTIC/HOLDING TANK DATA Tank Type/Material ft g.p.m Nitrate O. ~' mg/I Collected by: - Well Log Wires properly protected Y¢-~' Casing height (above ground) / /:r .i~. AT INSPECTION ~//,~/o o / o .s'- ft w ~/~ '7 ~- g.p.m Qther bacteria O colonies/100 mi S & $ ENGINEERING 1:"~~ '.; ,~ :: ~ !v~,!- Loop Road No. 204 Eagle [~,iver, Alaska 99577 Date installed °1/~/'¢ Y Tank size Cleanouts ¥&~' Foundation cleanout Date of pumping ~ (~/"~/'~ ,~ c. AaSORPT ON F ELD DATA Date installed ~/I/~ Soilrating (g.p.d./ft2or~)~0 Length Width % ft Gravel below pipe gal Number of Compartments Depression over tank ,~ o High water alarm __ Pumper ) S4,4-c ~' j¢O System type 7, ,4 4.,¢ c¥¢ ~ J ft / ~$ Total depthI~/ ¢ft Effective absorption area ~' ft2 Monitoring tube'YCJ' Depression over field /''' o Date of adequacy test (,//,¢//oo Results~Fail) /o~$~ For '&- bedrooms Fluid depth in absorption field before test P't7 in Water added ;P 3z/,~- gal. New depth, z/ ~ ~ in. Elapsed Time: ;)- O min Final fluid depth '/'/4, in Absorption rate >= '7~-o g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) j,u 0,¢ r'~_ ~/'J'~'¢"~ If yes, give date - 72-026 (Rev. 01/00)~ D. LIFT STATION Date installed "Pump on" level at .__ Datum SEPARATION DISTANCES Size in gallons __ Manhole/Access __ in "Pump off" level at ~ater alarm level at __ in ~._.-.---C-~ycl~ Meets alarm & circuit requirements SEPARATION DISTANCES FROM WELL ON LOT TO: [ Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots / ob --/- On adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~_ o ' 4- Properly line ~ -f' Water main /v/4 Water service line / o ~- Drainage /v/,~ Wells on adjacent lots / o~) -/ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ) o 4- Building foundation Water Service line I o '¢ Surface water / ¢o Curtain drain¢'~'''4- ~,v~,~,¢ Wells on adjacent lots Absorption field Surface water Water main )d/g Driveway, parking/vehicle storage F. COMMENTS 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. Engineer'sPrintedName ~O13g?,;~-' C. ~.uw,,).~ Date (-¢ / / '~/'~ HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 01/00)* 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 0 II- 0~'/ ~ ~z./ HAA# 1. GENERAL INFORMATION Complete legal description Location (site address or directions) ,Property owner Mailing address Lending agency Mailing address Day phone Day phone Agent Address ~)-(~ Oo ¢ o,~.a~v4 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Day phone NOTE: Individual well ~ Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. X TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank : Community on-site Public sewer NOTE: ff community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. /2-025(Rev. 1/91) Front 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 Address Engineer's signature s & S ENGINEERING 17034 -~-3!e P!w_- L~_-,~ R~=-2 Eagle River~ Alaska 99577 Phone. (~-~"¢/ '7~ Date ) /,~- /9 '7 DHHS SIGNATURE _ ~' ~ ~f'-,, Approved for '~--[1~_._(,.,~/) bedrooms. __ Disapproved. __ Conditional approval for bedrooms, with the following stipulations: Additional Comments By: -- 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. Th~ 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 professional engineer's work. MUNICIPALITY OF ANCHo~GE [NVI,~ONMENTAL ~R¥1CF.$ DIVISION Municipality of Anchorage dAN DEPARTMENT OF HEALTH & HUMAN SERVICES RE(~ Environmental Services Division -' 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description:'1'/3./v l~l~ ~ ¢¥',cr,¢,,~ '/' P,4,~c,~_ ~ Parcel I.D.: © t/ /D ~'i ¢ 3, z¢ A. WELL DATA Well type [ "/v~,~ 7' ~. Log present (~,)N) ¥ ~ ~' Total depth ) g' '~' Sanitary seal ~N) ¥' ~ ~ If A, B, or C, attach ADEC letter. ADEC water system number Date completed -~'//,~ u / t¢~,/' Cased to I ~' ,~' Casing height (above ground) FROM WELL LOG / Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform Date of sample: ! S, tS_ E_ P~T_J~C~HOLDING TANK DATA Date installed Ci /! Wires properly protected (~)N) ¥ e' ~ AT INSPECTION Nitrate g.p.m. C~) . t Other bacteria Collected by: '-~' ~' ") -£/v ' Tanksize./''~-c*C' Number of Compartments ~ Cleanouts~-~N) Foundation cleanoutf(~ClN) ¥/J ../' Depression DateofPumping 1~/1~/~)7 Pumper /t C. ABSORPTION FIELD DATA Date installed o) / / / ~' ~' Soil rating (g.p.d./fF or'ft~b~_di;~m~ ~' (2 System type ~' ,~ g ,v-c Length '7 f¢ Width ;~' Gravel thickness below p pe ¢¢ Total depth'¢ / ~/ Effective absorption area (~J ~ (~ Uon?ring Tube .p.~es~nt (?~N) y ~ ~'' Depression over field (Y/'~) ,~/O , Date of adequacy test ///'1 { (/ 7 Results (Pass/Fail) /o g ~. j For .~;'- bedrooms Fluid depth in absorption field before test (in.); I ' s'" Immediately after'7$'~ gal. water added (in.): Fluid depth %/ "~'~ i,$' '? 6'-0 '¢ II (ins) Minutes later: Absorption rate = g.p.d. Peroxide treatment (past 12 months) (Y/N)/v o,-, ¢~- ~': '~r~ ~ If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles t~.,sted~'--~ Size in gallons oncQ~vePat*J-* "Pump off" level at* "Pump ~~Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: S~pt~holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM~_E2_TI~HOLDING TANK ON LOTTO: Foundation ;~) O Property line -~- ¢'- Absorption field Water main/service line /cO tq_. ~ I O Surface water/drainage .' o o .4- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line / o -F Building foundation 3 0 ~ Water main/service line Surface water ~ © o ~t. Driveway, parking/vehicle storage area Curtain drain N o,-, ~- ~<,., o ~ ,./ Wells on adjacent lots loc -) F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal in conformance wit~ ~0,¢ HAA guicJelines in effect on this date, Signature Engineer's Name Date I // 9 7 are HAA Fee $ ~('I7) , ¢;~ Date of Payment 0 ///'~--/¢.,~ ReceiptNumber ~5-~,¢.. ('~Z/t[.,ffC¢'' .) Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* '/t~l~ CT&E Environmental Services Inc. CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWS1D 970159001 S & S Engineering TI2N R4W Section 4 Parcel 2 Drinking Water Drinking Water Client PO# Printed Date/Time 01/14/97 11:08 Collected Date/Time 01/08/97 17:00 Received Date/Time 01/09/97 08:30 Technical Director: Stephen C. Ede Re edBy Sample Remarks: Smnple collected by: Bob C. Nitrate-N Total Coliform Results 0.100 U 0 Atiouabte Prep Analysis PQL Units Hethed Limits Date Date Init 0.100 mg/L SM18 4500-NO3F 10 max 01/10/97 JBL 0 col/100mL SM18 9222B 01/09/97 TAV MUNICIPALITY OF ANCHORAGE Department o! Health & Human Services D V SION OF ENVIRONMENTAL SERVICES 343-4?44 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parce,,.D. HAA 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner Telephone: (home) Z'-/-C-ZTg~Business. Mailing Address (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent Address _ . , Telephone (e) Mail the HAA to the following address: (or check here ~,if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENt.CE Single-Family ~ Number of bedrooms IF 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the. State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DI/CrPOSAL On-site L~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TFSTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Engineer's Seal 6. DHHS APPROVAl,. · Approved for ~ bedrooms by Approved ~' -_--Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. MUNICIPALITY OF ANCHORAGE (MOA) ,H_ealth Authority Approval (HAA) ,~'~! CHE'CI~,~- IST - FEBRUARY 1984 ,,L ' 343 4744 Legal Description: ~/Z~ R E (" l V A. WELL DATA Well Classification /~/~. / Well Log Present (Y/N) ,¢ Date Completed ,¢-Z,~- Total Depth ,4 ,¢ Cased to /-¢'~¢ Depth of Grouting _ Static Water Level /~.5-' Pump Set At __. 5'-/ (/T..,t.,,z.4/.~4 tt-~ If A, B, C. D,E.C. Approved (Y/N) Yield ~ ~,~'? Casing Height Above Ground ,Z ' Electrical Wiring in Conduit (Y/N) _ ,V' SEPARATION DISTANCFS FROM WELL: To Septic/Holding Tank on Lot /~.z/' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line /~' '" To Nearest Sewer Service Line on Lot Water Sample Collected by __ Sanitary Seal on Casing (Y/N) __ Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots /'~¢ To Nearest Public Sewer Cleanout/Manhole ~ ,,¢~',~'~¢¢)~'~/~' ; Date Water' Sample Test Results Comments B. SEPTIC/HOLDING 'TANK DATA Date Installed _ q~J~ ~ Size ~(~ &A~. No. of Compartments Standpipes (Y/N) )/ Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) . Foundation Cleanout (Y/N) )/ Date Last Pumped /V,~- 4~' ; for ~,.~-,~ Temporary Holding Tank Permit (Y/N) x1¢'/-'//4 _ SEPARATION DISTANCES FROM SEPTIC/FIOLDING TANK: To Water-Supply Well _ // To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments ,.~E't:~Trr~ ~-/¢~/~/ /S To Building Foundation To Disposal Field // 72 028 (Rev ?lo0) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation '?//~ Lot ,,t/,~ ,t~: ~,,J To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course . To Driveway, Parking Area, or Vehicle Storage Area Z ~ ' Comments ..d.,¢.5~'/07-/o,,~ $~,?S/--~-/v~ ~'~/~J tS Type of System Design Length of Field Z. ~ Depth of Field /~ ~ Gravel Bed Thickness ¢/ ' Statndpipes Present (Y/N) ,V' Date of Last Adequacy Test To Property Line '¢'/' To Existing or Abandoned System on ; On Adjoining Lots /~ '/' To Cutback (if present) ,,t,'~,4/'~¢/.~,~..~'.~-,4,,~- Date I n stall'~F-~ Dimensions Size in Gallons % Manhole/Access (Y/N) "Pump On" Level ~ "Pump Off" Level at at High Water Alarm Level at ~ Vent (Y/N) _ Tested for ~'~"~-~~mping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA gu~ inspection. Signed ~'~'~- ¢~/(../3. t ~'., Company ~/~/v,,'J ~t.~'o ,J Date _ / ~//V/* ~ MOA No. Receipt No. Date of Payment Amount: $ 72-028 (Rev 7/88) Bsck Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 on the date of this ~gineer's Seal ANDERSON ENGINEERING P. O. BOX 240773 Anchorage Alaska 99524 907 33%8367 12-11-89 Municipality of Anchorage 825 L Street Anchorage, Alaska 99501 Re: T12N R4W S4 SM Parcel 2 (6801 Campbell Point Rd.) To Whom It May Concern: Although the on-site water & sewer systems for this property were installed around Sept. 1, 1988 the home has been vacant due to a change in builders during construction. Initial occupancy is scheduled for approximately January 15, 1990. If you have any questions please contact me. Yours Truly, L. Wayne McFadden llio.,~b) o 353.2 i.O SUBD ION T12N~4W SEC 4 . BLOC~OT~4SE4 ~N ' : .'. ~ ' h MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING ~//~L"~' / -~--.¢-Z'~'~-- ~-'5 HAA # {'~(~¢. J (%L~\ ~'.'.~.(./~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner -/c¢~;,-?~/-~ z_,¢, ,SZ;/~)/,~,,-? .~'.~:>;.--Telephone: (home)--?¢,'¢"~,, Mailing Address ¢g/c~ ~.k' //~_p~¢-'. ~ //,¢¢~',¢~/2//E,;,T /-/'./~'~_ (c) Lending Institution /~'/~r?.._.~. ,¢/¢'X'¢_. Telephone .-~¢ Mailing Address ./~ { /~g-.cw 5'g~¢./ /.~ ~'- (d) Real Estate Company and Agent /[/'D/c'Z~ ~ ~-¢',,~'~'~¢ - ~.;~'-"-"-"-"-~'4-,,1,¢/;--, Address Telephone (e) Mail the HAA to the following address: (or check here ,Z;Y~f hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-FamilyEY'~"~ Number of bedrooms 3. WATER SUPPLY Individual Well ~ ...... Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 ~ ,to ~ e[~ed 'HJOt~ e. Jeeu!!Sue leUO!SSetoJd eql u! sue!ss!rue Jo SJOJJ8 JOl elq!suodseJ leu s! eSeJoqou¥,to ,tl!led!o!unR eql 'penes! s! eleo!,tBJeo e eJoleq elep ezXleUe Jo suoBoedsu! 1onpuoo leu op 9HHQ ,to seeXoldUJ3 's~ueuueJ!nbaJ ale,s pue leJepe,t u!e~eo/i,tsBes o~, Jap Jo u! suoHn~!lsu! §u!puel J!aql pue seu~oq ~o sJeseqoJnd el ,~selJnoa e se s!tB seep SHHQ eql 'e~lSel¥ ,to elel9 eq~ u! peJe~s!beJ Jeeul§ue leUO!SSetoJd ~uepuedepu! ue Xq e^oqe ii tlde~Be~ed u! ue^!6 suogelueseJdeJ eql uodn ~lUO peseq pe~eo!~!Jee le^oJdd¥ Xl!Joqlnv q~leaH sense! (SHHG) seal^mS uemnH pue q~leeH ~o luetu~Jedec] eSeJoqouv,to,~llled!o!unR eq.L leAoJddv leUOB!puoo ,to suuJel lees s,Jeeu!lSu3 MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: ? ;'~--/',' A. WELL DATA Well Classification Well Log Present (Y/N) Y' Date Completed ,;¢% ,~'_D Total Depth/~'~ Cased to /~' Depth of Grouting Static Water Level /D ~' Pump Set At Casing Height Above Ground Electrical Wiring in Conduit (Y/N) MUNICIPALITY OF ANCHORAGE ENVIRONMEN'IAI. SERVICES DIVISION i' 2 8 1988 SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ,//'¢', 4 To Nearest Edge of Absorption Field on Lot /-.'¢/ ¢*' If A, B. C, D.E.C. Approved (Y/N) Yield To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by ~ Water Sample Test Results Comments Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) /// ; On Adjoining Lots ; On Adjoining Lots --/' To Nearest Public Sewer Cleanout/Manhole ; Date B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) /~D,o ~,-,'~,,'No. of Compartments Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Date Last Pumped -'~"~.~ ; for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well /./~/', To Property Line Z¢/" ' To Water Main/Service Line /J/~,4¢ To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation To Disposal Field // 72-026 JRev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field ,~ ' Square Feet of Absortion Area /,~-~/ Depression over Field (Y/N) '~/ Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments /.~,.¢,u.~_ ~,?,/~t Type of System Design Length of Field ~,¢'~' Depth of Field /,~0 ' Gravel Bed Thickness ~' ~ Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line '~// ' To Existing or Abandoned System on ; On Adjoining Lots ,~-X~:~$~ ,'~-/,~g'? ' To Cutback (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed 2~'~/~.,~5/.~ Company ~ ~¢//~J~ Date ~~ MOA No. ~ ~"/K~ Receipt No. Date of Payment Amount: 72-026 (Rev. 7/88} Back ~ ~ ROberfD. Sch~Jling Receipt No. ~ ~0PFg~A~~ Waiver Fee: $ Date of Payment Page 2 of 2 Engineer's Seal P0 BOX 112207 ANCHOI~AGE, ALASKA 99~1 I 5epiereber 18, l Pay 5UB,JEC.'T: On-site {~ewage Disposal System T12N RSW Seotlon 4 Seward MeMdlan Parcel 2 Permit -~880171 blunloipallty of Anti, crags Departmen( of Health and Human Services Environmental Health Division 825 L &treet Anti, crags, Alaska 99502 ATTH: Dan Bowles Dear Please find attached the requh'ed docurnentatlor~ for the Subject project for appr'oval of operation, As woo can see the orienal horizontal location of the septic s~wstem has been changed, This ohan(le was done to allow kmdser~ping to not be disturbed, This design change will not affect the protective radius requirements re4ulred by your department and the systen~ ts In compliance with current re(lulations, $I~ould ti~ere be furtl~er Information necessary please contact me or RoOst D Goodman at 349-5552, Sincerely, ?(ober't D ;",,cl'dlllno, PE