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NORTH WOODS UNIT 4 BLK 16 LT 3
North Woods Unit IV Lot 3 Block 16 #051-064-15 Municipality of Anchorage Page —1—of .3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ) L') q d®(Sc PID Number: 0_-;t-064-15 Name. Gc�carcC� �li rv1PC Wastewater System: tfK New ❑ Upgrade Addreaa:.. ABSORPTION FIELD Phone: No. of Bedrooms: ❑ Dee Trench p .Shallow Trench ❑Bed ❑Mound ❑Other LEGAL DESCRIPTION Soil Bating: /q1 / Total Depth from original grade: 3 va l GPD/S. Ft. Lot: Block: Suhdi//vision: /� fn Depth to pipe bottom from originalgrade: Gravel depth beneath pipe*; 0 o ':-t / Ft. (Js Ft. Township: Range: Section: Fill added above original grade: Ft. Gravel engtth0V,`4 5elV'6 5t WELL: D New D Upgrade Gravel width: Ft. Number of lines Distance c: lines I ✓ Fl. Classifica//t�ion (Priv�ate{{ A,B,CI: IrtL t/./ Total Dept Cased To: Ft. Total absorption area: '^7'y % / / 1 SO. FL Pi e material: S� OJV.S�` �VIO Driller. ate Drilled: Static Water Level: Installer: Date installed: Ft. Vield: mp Set at: Casing Height Above Ground: TANK PM Ft. Ft. SEPARATION DISTANCES Kseptic El Holding DS.T.E.P. To From scone Tank Absorption Field Lin Station Holding Tank Public/Private Sewer Lines Manufacturer: emi� G{�!41,6 Capacity in gallons: (i/''I j�/j�k-L_ f - V, f „`— > i Material: ' J Number of Compartments: W C) �1� I Surfac-¢- ((`•�- LIFT STATION Ite ro\� I Size in gallons: Manu ji t "Pump on"level al: "Pn off' leve Nigh water alarm at (;✓ //til Pump Make el Electrical Inspections performed by: Remarks: BENCH MARK Location and Description: , Assumed Elevation: too Fitt EIj .IN'jE : ,Tsky ? ,gt.^ 585ENGINEERING 17034 Eagle River Loop Road, No. 20_4 Inspections 4 d ,,,,j. In— performed by: Eagle River, Ainska 99577 Dates: 1st 2nd JtOBLRT C. COWAN e �Q �PGa ti. enol i�-�a�`1C7 CE-8B.0i f; Huan Services approval Department of Heat ft hand Reviewed and approved by: /i l szl'7Date: L-2 -Cr t —t ` 72-013 me, 9/911 MOA 25 PERMIT No. SW990130 PAGE 2 OF 3 DEPARTMENT pHEALTH Anchorage SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 *Anchorage, Alaska 99519-6650 • Telephone 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 3, BLOCK 16, NORTH WOODS #4 P.I.D. NO. 051-064-15 RS (PLOW SPLITTER) 0 coz -#) \�G /!ITHj/t � _V' _b oeu 6 OBL2 tOOO GALLON POLYETHYLENE SEPTIC TANK EXZSDRpC 3 N��SE S H E L T EF"%:0 I N G SPQ-LIUUCE LOOP SCALE: t" = 40' / ,a� ' A Q r'z . T,9 ROBERT C. COWAN s �Q ��. CE -8801 ;?�\R i . L PERMIT NO. SW9901 30 PAGE 3 OF 3 Municipatit of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 3 BLOCK 16 NORTH WOODS #4 P.I.D. NO. 051-064-15 CO1 CO2 MTI C0 3r c�FINALl GRADE I C� 4p MT2 CO2 == 80.5' C04 = 79.7' WIN MTI = 76.1 FINAL GRADE ST1 2" INSULATION C01 = 78.4' CO3 = 78.3' MT3 = 76.0" MT2 = 75.5' 89.2' SR LATION 84.5'—Z NEW 1000 GAL. POLY. TANK 1 84.2 �Fd WATER FOUND @ 71.3 rri 14 1 64.3' B.O.H. CO2 = 77.2 C04 = 77.4 MT4 = 75.3' HEALTHAUTHORITY APPROVALS SEWERawAiEH MNNEXTENSIONS SEWER&wATER INSPECTION ENGINEERINGSIUDIES ANDNEPORIS WELL INSPECTION b FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WASTEWATER USPOSALSYSTEM DESIGN January 7, 2000 rla Municipality of Anchorage Department of Health & Human Services PO Box 196650 Anchorage, AK 99519 1 Attn: Dan Roth 1'V'I" Reference: Lot 3, Block 16, Northwoods Unit IV Dear Mr. Roth, ROBERT C. COWAN, P.E. CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 4 M This letter will certify that the test hole locations relative to the trenches shown on the On -Site Wastewater Disposal System Inspection Report are correct. The discrepancy between the test hole locations on the as built and the original design document is the result of the locations on the design documents being in error. During construction the trenches were placed near the test holes as they existed in the field. If you require additional information, please contact us at 694-2979 r'. 17034 NORTH EAGLE RIVER LOOP -SUITE 204 • EAGLE RIVER, ALASKA 99577 5& HEALTHAUTHORITY APPROVALS SEWER & WATER MAINEXTENSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELLINSPECTION & FLOW TEST SITE PLANS ROADDESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSAL SYSTEM DESIGN Date: 7-;C7-_ ROBERT C. COWAN, P.E. ROBERTA. SHAFER, P.E. CIVIL ENGINEERS (907)694.2979 FAX(907)694-1211 RECEIVED JUL 28 1999 of ut DEPARTMENTtOF HEALTH oAND eHUMAN SERVICES Dep UHe lth & HUMa,, 1Ora0e 825 L Street man SerVlces P.O. Box 196650 'Anchorage, Alaska 99519-6650 REFERENCE: L0� 6, Not, ::a The septic inspections for the referenced property were performed on � -30% R -� and 6" -3Q --q1 . Prior to submitting the On-site Wastewater Disposal System and/or Well Inspection Report we are waiting for the A5--h,,j;jt Sti1,Ve_c1 to be completed. 1 If we may be of further service please contact us. Sincerely, Robert C. Cowan, P.E. 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On -Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Permit Number: SW990130 Legal Description: NORTH WOODS UNIT IV BLK 16 LT 3 Design Engineer: 0003 S & S Engineering Owner Name: George Wilmoth Owner Address: 3111 C Street, Suite 3555 Anchorage , AK 99503 - 1Pn'1 C Date Issued: Jun 09, 1999 Expiration Date: Jun 08, 2000 Parcel ID: 051-064-15 Site Address: Lot Size: 31201 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: ❑✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy All construction must be in accordance with: 1. The attached approved design. ❑ Private Well ❑ Water Storage 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 (907) 343-4744 ( 24 hours). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: 1;Yv12 Date: Date: 6 — / ' / S& HEALTH AUTHORITY APPROVALS SEWER&WATER MN EXTENSIONS SEWERBWATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELLINSPECTION & FLOW TEST SITEPLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSALSVSTEM DESIGN ROBERT C. COWAN, P.E. CIVIL ENGINEERS (907)694-2979 FAX (907) 694-1211 April 26, 1999 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 3, Block 16, North Woods Subdivison 44 Request you issue a permit to install a septic system to serve the4three bedroom dwelling on the referenced property. One test hole was excavated and percolation test was performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation 8/28/96 water was not found. After seven days of ground water monitoring water was encountered at 10'-9". We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent properties. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/jhm Enclosure 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 1 " = 50' SITE PLAN 77777- C -3 LCH'Z 9� �+�ev •� t/• O y O cn O O rJ i CJ cnG)o O U) - tU Cf) � x O m Q :c N \SEi ACK I W -3 -' "' \\�� by m O \ LTJ m Ln N C14 o \e rs3 m O 1 \ C) r. o -., m O O m m O \\ Z I D < C) m mp; 000� mm a o d o Cm oyD,A., O \ ZZN� o \ y A Z y M ! al VAF ay m' n osow o 14100x mm2 Amp xo, 9 'CAA 9'� C 1V. / •'•. Z \� ; , = A� .l ~oNd ,jib'/^i•^•,••; „"'.•'�` V �l \ z o ata �,? z�'✓ �2fl aebz.L..' -. �x 0 fro t� 0 C 32 � xX azo z W C U -wC !n E0 2:O 1 " = 50' r-2 5'- SITE I PLAN 0 � 2 po W y C7 gym" 00 C M r �t� y m O OO m C � y d "ate �z¢ � � H �o r 0 N 0 a m b oLrT�mo x Z m s 0-0ti p � O lV —mm zr oMm� 01 N W -i '•• -ri i m m -{ m r D � I � m � O v� p U) ZS' I SEiBACN I o ' mz Z (� IOII O � N m m r o �+ I � I C� X00 D Z a ti 0 0 HI 0 O>M O a mmo y 0 �mI . r O A m SITE I PLAN 0 � 2 po W y C7 gym" 00 C M r �t� y m O OO m C � y d "ate �z¢ � � H �o r 0 N 0 a m b oLrT�mo Z m s 0-0ti p � O lV —mm zr oMm� 01 N W -i '•• -ri i m m -{ m r D < /� � m � O v� p X30 o ' mz Z (� IOII O � N m m r o V m m y C� X00 0-00V Z a ti 0 0 HI 0 O>M O a mmo y 0 �mI . O A m _yD D "M A � 00� O O co m mm m N n�< m VIZ O mom D �mn 3 0 m y j m m 1 � z o b JCAZA Z m s 0-0ti p � O lV viz <✓ zr v 01 N W -i '•• -ri i m T N m m r cm o y m /� r O :o rn II � O v� p X30 ' mz Z IOII O � N m m r i y v o n b JCAZA .'O 0-0ti p � O o Fr N viz <✓ Krp m M 01 N W -i '•• 4 f n 01 m T N m m r N o y m W I r O :o rn II O d X30 ' mz Z IOII O � N m m r V m m cn o C� X00 0-00V Z a ti 0 0 -o v n 0 mmo y M A Z _yD D 00� O O co O Y--` N y v o n m JCAZA .'O 0-0ti p � O o Fr N viz <✓ Krp m M C m _ -i '•• 4 T N m N o y m W I ?y Z n O d X30 ' mz Z b O � N m m r m. m X00 Z a ti mm= wom -o v n O mmo y M A Z _yD D 00� Zo m y v o n vv�-jl+ JCAZA o Ocy -A Z KKK �I��}y i' Krp yl ii > 0 < m C -i '•• m T Afq J rtit 01, I "il� Municipality of Anchorage . { a'>> °. % t DEPARTMENT OF HEALTH & HUMAN SERVICES . ..}". , r� 825 "L" Street, Anchorage, Alaska 99502-0650 a" «... ,. ,,. SOILS LOG - PERCOLATION TEST'rp ?•^ "j'� ✓'.' I. of ROBERT C. COWAN Ffr PERFORMED FOR: u,GR�' lnJ' ���' i DATE PER FORMEO-t-•��JS,,��"`/�3 LEGAL DESCRIPTION: )"U1 1 f3i.c /6 NB2illtvJo.d-14 11 Township, Range, Section: DEPT" SLOPE SITE PLAN t(FEET)t G" V ;4•t ..., c c I I I I I i 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS G W/6 " {2. I/). If S w,Tit S c T- I24'/.i L i, .i it S iii � S/lND WAS GROUND WATER y� S ENCOUNTERED? S IF YES, AT WHATL DEPTH? 7 p E Depth to Water AfterE� c _a Monitoring? 1616 Dale: y �/ 0 Reading Date Gross Time Net Depth to Time Water Net Drop R 'i, 0 /3 ar 7 va„ L 1 8„ 5.,. 4I o 8 '/S el y av Ss/y., ty s/8 PERCOLATION RATE 6" S (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND 41 FT S & S ENGINC•ER� ING �/ `ll PERFORMED BY:oop i} CERTIFY THAT THIS TEST WAS PERFORMED IN 1/034 ACCORDANCE WI1%0gkI§VATE4AkQ69LWF17AL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) PERFORMED LEGAL DESCRIPTION:,/,9r DEPTH V/ o : , Municipality of Anchorage atx t`•� DEPARTMENT OF HEALTH & HUMAN SERVICES �•••" -"f.f. 825 " L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST Ae ROBERT C. COW AN,� Lt46YA DATE PER FORMED:,�P— i /— w %LDG.� i6 ,✓o�r/1 Township, Range, Section: //• �• S✓.�O..n ✓-+-torr/ 17 18- 19- 20- COMMENTS 81920 COMMENTS WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? . ra Depth to Water After Monitoring? 60 y S !d /� ° E Date: F,2.7 -i f• SITE PLAN Reading Date Gross Time (FEET) Depth to Water 2 �Q/a o /zGs� ✓r. S -,2 2 3 Q o 4 /O / 0 / 5 / 6 / 0 C)/ �U 0 7 % V 8 9- 10 10- 0 �SZG rY 644v�� 5� 11 , 12 ° 0� 13- 3 0/0 0/0 14- 415 15- 16 16 17 18- 19- 20- COMMENTS 81920 COMMENTS WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? . ra Depth to Water After Monitoring? 60 y S !d /� ° E Date: F,2.7 -i f• SITE PLAN Reading Date Gross Time Net Time Depth to Water Net Drop -,2 2 5 " 0 8 g s// " PERCOLATION RATE 3 2' (minutes/inch) PERC HOLE DIAMETER 6 TEST RUN BETWEEN / FT AND 15� FT S & S ENGINEERING G PERFORMED BY: / L .+•.4�— CERTIFY THAT T7TEST WAS PERFORMED IN 4 Eagle River Loop Road 204 1, y. /q ACCORDANCE WITF¢j�aJgj,Ajl�����18ifjT GUIDELINES INES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) S& HEALTHAUTHORITV APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELLINSPECTION &FLONTEST SITE PLANS ROADDESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSALSYSTEM DESIGN ROBERT C. COWAN CIVIL ENGINEEIRS (907)694-2979 ON-SITE WASTEWATER DISPOSAL SYSTEM FAX(907)694-1211 CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Lot 3, Block 16, North Woods Subdivision #4 April 26, 1999 GENERAL: 1. The scope of this project includes the installation of a 1000 gallon septic tank and leachfreld trench for the rropo,&1three bedroom house located on the referenced property. 2. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The contractor shall be responsible for obtaining any necessary underground utility locates. 4. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: 1. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 3. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. S & S Eng/neering 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 Page 2 Lot 3, Block 16, North Woods SID #4 April 26, 1999 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. 5. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. 6. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: 1. Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed -up) before gravel (sewer rock) placement. 2. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. 3. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. 4. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. 5. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. S & S Eng/nearing Pago 4 Lot 3, Block 16, North Woods SID #4 April 26, 1999 1. The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. 2. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre -construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to cavy out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTORIINSTALLER 5 & 5 Englnooring 7�1 Parcel I.D. Municipality of Anchorage On -Site Water and Wastewater Program (347) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL 051-064-15 1. GENERAL INFORMATION Expiration Date: Complete legal description North Woods #4 S/D, Block 16, Lot 3 Location (site address) 21911 Sheltering Spruce Loop, Chugiak, Alaska Current Property owner(M Thomas & August Dawn Cornish pay phone 726-7106 Mailing address Real Estate Agent Janis Tolbert, Prudential Day phone 250-13$1 2. TYPE OF DWELLING: I] Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: Individual Weil ❑ Individual Water Storage ❑ Community Class Well ❑ Public Water System 0 TYPE OF WASTEWATER DISPOSAL: Individual Il Holding Tank ❑ Community ❑ Public Sewer ❑ Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ g1-10 ` p Date of Payment I OI I I. IA L Receipt Number 0 15$� COSA# O�Clal`�1� Waiver Fee $ Date of Payment Receipt Number 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 andfor 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 onsite 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 Douglas T. Kenley, P.E. Address 9806 E. Northstar Circle, Palmer, AK 99645 Phone (907) T464073 Engineer's Printed Name Douglas T. Kenley Date S. DSD SIGNATURE System #1 Approved for. bedrooms. System #2 Approved for. bedrooms.69i$ Disapproved. , Conditional approval for bedrooms, with the.following _.A By:_ Original Certificate Date:J The lopi of. chorage 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 civifeVneer registered fn the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's -work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA btm sheet 9-1-12.Goc If more than 1 septic system is on the lot: COSA Checidist # of _ otructure served by this sysiem Certificate of On -Site Systems Approval Checki'14--t Legal Description: _ A, WELL DATA Well type Public Date completed _ Total depth ft. Date of test Static water level Well production North Woods #4 S/D, Block 16, Lot 3 If A, B, or C provide PWSID # _ Sanitary seal (YIN) Cased to ft FROM WELL LOG WATER SAMPLE RESULTS - III g.p.m. Coliform colonies/100 mL Nitrate mg/L Arsenic: _ ug/L date of sample: B. SEPTICIHOLDING TANK DATA Parcel ID: 051-064-1 Well Log (Y/N) Wires Properly Protected (YIN) Casing Might (above ground) in. AT INSPECTION g.P.m. Other bacteria colonies/100 mi- Collected L Collected by: Tank TyWMaterial Septic/Plastic Date installed 6/30/99 Tank size 1000 gal., Number of Compartments 2 Cieanouts (Y/N) Y Foundation cteanout (YIN) -Y Depression over tank (YM) N High water alarm (Y/N) N/A Date of pumping July 6 2012 Pumper Sanitary Pumpers C. AEWRPT10N FIELD DATA Date installed 6130/99 Soil rating (g.p.d./fe or ft2/bdrm) 0_6 108 5 System type Shallow Trench Length ft. Width ft. Gravel below pipe 2 ft. Total depth ft. Eff. absorption area 771 w Monitoring tube Y Depression over field N Date of adequacy test 10/11/2012 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before testt2 in. Water added 557 gal. New depth 6 in. Elapsed Time: 1200 min. Final fluid depth 124/4 in. Absorption rate >_ 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date 0. LIFT STATION Date installed 'Pump an level at _ in. Size in gallons Manhole/Access (YIN) 'Pump off' level at a r alarm level at in. Cycles tested Meets alar & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot On adjacent lots On adjacent kits Public sewer main 75' Public sewer manhoWcleanout 100' Sewer /septic service line 25' Holding tank Animal containment areas Manprelanimal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5 ft. Property tine tq+ f. Absorption field 5+ ft. Water main 10+ ft. Water service tine I0+ ft. Surface water 100+ ft. Wells on adjacent lots 200+ ft. ABSORPTION FIELD ON LOT TO: Property line 10+ 'ft. Building foundation 10+ft• Water main 10+ ft. Water Service line 10+ ft. Surface water 100+ ft. Driveway, parkingNehide storage 5+ 3't. Curtain drain None Known Wells on adjacent lots 200+ ft. F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that 1 have determined through field inspections and review of Municipal records that the above systems are in cxueforrnarme mb MOA COSA guidelines in effect on flus date. Engineer's Printed Name Douglas T. Kenley Date lblt,3 / l —;— COM brow st�s-t-ta.dac Tract A. Ramsey Subdivision _ N 89°58'04"E 145.00' Lot 3 31,201 s.f. 4'7t W w To L} T SEPTIC 3 CLEAN—OUTS Lot 2 tA {� Ig Lot 4 V SHELTERING SPRUCE LOOP Nose: j}�15 loT is ssrvVtcu 37 P. Put"- PLOT uts"- PLOT PLAN ____ ASBUILT , SCALE I ° - � GRID Nw 14[0o Project No. rz�-os 1 Lang $ Associates, inc. 907 522-6476 Phone 11500 Daryl Avenue, Anchorage, Alaska 99515 o� Registered Land Surveyors 907 522-4625 Fax �� OF AC 9 4p 1 hereby certify that I have surveyed the following described property.P� l.oT 3 F;,LocV—IU ND4,TFI SLAUwT LV UA' -r Anchorog� Recording district. Alaska, and that the Improvements situated �.: � '•. thereon aro within the roe lines and do not encroach onto theproperty�Q P p r►y *.:. ......... D adjacent thereto, that no improvements on the property lying adjacent thereto D encroach on the surveyed premises and that then aro no roadways, transmission r lr r:.........f%.. lines or other visible easements on said property except as Indicated hereon. � t KENNETH �a. LANG Dated this the Day of Tutim tm�% at Anchorage, Alaska LS -5202 k Is the responsibility of the owner to determine the existence of any"•' easements, covenants, or restrictions which do not appear on the recorded p Rss1oN'f' subdivision plot. 4.3' q .} Gt+AW� Ulu. NC.IS_ 4- I-, ,,4',;4 ,4',; 12,x' i; ot✓ q-9' 10'x 15' ANCHOR b' EASEMENT _ 15' TELECOM. 8 �o ELECT. EASEMENT A �.3 — 0cA N 90°00'00"W. 71.67' g ui N SHELTERING SPRUCE LOOP Nose: j}�15 loT is ssrvVtcu 37 P. Put"- PLOT uts"- PLOT PLAN ____ ASBUILT , SCALE I ° - � GRID Nw 14[0o Project No. rz�-os 1 Lang $ Associates, inc. 907 522-6476 Phone 11500 Daryl Avenue, Anchorage, Alaska 99515 o� Registered Land Surveyors 907 522-4625 Fax �� OF AC 9 4p 1 hereby certify that I have surveyed the following described property.P� l.oT 3 F;,LocV—IU ND4,TFI SLAUwT LV UA' -r Anchorog� Recording district. Alaska, and that the Improvements situated �.: � '•. thereon aro within the roe lines and do not encroach onto theproperty�Q P p r►y *.:. ......... D adjacent thereto, that no improvements on the property lying adjacent thereto D encroach on the surveyed premises and that then aro no roadways, transmission r lr r:.........f%.. lines or other visible easements on said property except as Indicated hereon. � t KENNETH �a. LANG Dated this the Day of Tutim tm�% at Anchorage, Alaska LS -5202 k Is the responsibility of the owner to determine the existence of any"•' easements, covenants, or restrictions which do not appear on the recorded p Rss1oN'f' subdivision plot. Municipality of Anchorage Development Services Department Building Safety Division _ On -Site Water and Wastewater Program , 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. iCCOSA# ('15C 1016 g ) Expiration Date: 6-- a 1— /1 1. GENERAL INFORMATION Complete legal description Lor 3; Block 16; Northwods SubdiNslon 04 Location (site address) 21911 Shehering Sprue Chugiak, AK 89567 Current Property owner(s) Pavick Kelley Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Jim Mosey Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class Weil ❑ Public Water System ❑� Day phone Day phone Day phone 350'6468 TYPE OF WASTEWATER DISPOSAL: Individual On-site El Individual 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 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 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 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 Finn s s s Engineering Address 15861 S. Birchwood Loop Rd. Chugiak, AK 89567 Engineer's Printed Name Robert A. Shafer 5. DSD SIGNATURE _jef'o' Approved for %3 bedrooms. Disapproved. Phone 694.2979 Conditional approval for bedrooms, with the following stipulations: Attachments: -COSjk_Checklist_ X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By Original Certificate Date: m" +oosi Municipality of Anchorage •• •°, (• Development Services Department \�Building Safety Division —� On -Site Water & Wastewater Program ' • "` 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE A' S SYSTEMS APPROVAL CHECKLIST Legal Description: � 3 : t cx 1' i I VOerjlk2na 41_ Parcel ID: OS /-150— /S A. WELL DATA Well type I lTA)SWe_ Date completed _ Total depth iG Date of test Static water level Well production WATER SAMPLE Coliform ug/L If A, B, or C provide PWSID # _ Sanitary seal (YM) Cased to ft. FROM WELL LOG Well Log (YIN) Wires properly protected (Y Casing height(pbela ground) in. ft ft. g.p.m. g.p.m. UL ties/100 mL Nitrate mg/L Other bacteria colonies/100 mL date of sample: _ Collected by: B. SEPTICIHOLDING TANK DATA Tank Type/Matedal 'Srrn� J4ST/� Tank size /050 gal. Number of Compartmr Foundation cleanout6)N) %A5 Depression over tank 09„d Date of pumping6� Pumper Snx�t CleanoutION) C. ABSORPTION FIELD DATA _ Soil rating g.p.d./ft rft2/bdrm) Q•� System type St(ffULOW Date installed 104 ( �( Length • 0 ft. Width S• O r ft. Gravel below pipe c2.0 ' ft. i Total depth 8, ft. Ef absorption area 77( ft' Monitorin lube qEn Depression over field Date of adequacy test / Result Pas ai1) / gS For, 'a bedrooms . u n Fluid depth in absorption field before test Q in. Water added��al. New depth In. 'I „ �/So t Elapsed Time:�� min. Final fluid depth `t_5 in. Absorption rate >= g•p.d • Any rejuvenation treatment (past 12 mo.) (Y& type) c If yes, give date D. LIFT STATION f J In Date installed Size in gallons 'Pump on' level at_ in. Datum Cycles tested Mantlolef/c—cess (YM) In. High water alarm level at in. Meets alarm b circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: 1 t)f3LIC �Ft7E� Septic tank/lift station on lot On adjacent lots Absorption field on lot On adjacent Public sewer main Sewer /septic service fine sewer manhoWcleanout Holding tank areas Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation s r+ Property line �I Absorption field S '/ Water main /0 t Water service line /0 f+ Surface water /Cid f Wells on adjacent lots cK00 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: I r I Property line Building foundation 104- Water main /10 4 / r Water Service line ID 4 Surface water 100 t Driveway, parking/vehide storage �0 i Curtain drain NONE- KA)Gvt>t( Wells on adjacent lots ,?00'4- F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined rou h field review of Municipal records t at t abov conformance with MOA CO i sin e Engineer's Prinnt/ted NN me ���11�e� Date -6 _ ! V COSA Fee $ "t7U Date of Payment Receipt Number G �S69D (Rev. 11105) in Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage ^� Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.org/onsite (907) 343.7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. Q S/ — Ot - !Z — / COSA #_ tai CIO / 7 a 1. GENERAL INFORMATION Expiration Date: r — 1 .2- — /V Complete legal description L00; akxk 16; Nonhwoods subdivisbin unit #4 Location (site address) 2191 Sheltering Spruce Loop Chugiak, AK Current Property owner(S) Tmcy and Michael Hegedus 952-8601 Day phone Mailing address PO Box 670875 thugiak, AK 99567 Lending agency Day phone Mailing address Real Estate A ent Kathymstead Agent Day phone 244-e020 Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 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 IZI 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 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 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(ore) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm s a s Engineering Phone = Address 15861 S. Birchwood Loop Rd. Chugiak, AK 99567 Engineer's Printed Name Robert A. sharer Date S O 9 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the foiloa Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: pa« 1rAsr .� Municipality of Anchorage Development Services Department Building Safety Division - ' On -Site Water & Wastewater Program s 4700 Elmore 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: _ _ LAI' 3� 1(� 6; A Jkuoa dS 4 q Parcel ID: Ds-/-pC A. WELL DATA Well typeIf A. B, or C provide PWSID # _ Well Log (YIN) Date completed _ Sanitary seal (Y/N) _ Wires properly protected (Y/N) Total depthft. Cased to ft. Casing height (above d) in. FROM WELL LOG AT INSP i Date of test Static water level i Well production g.p.m. 9 P.M. WATER SAM=colonies/1'0*0 Coliform ' L Nitrate mg/L Other bacteria colonies/100 mL nic: ug/L date of sample: _ Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material _ •r L G� `� Date installed Tank size OO gal. Num er of Compartments Z Cleanout &N) _ vaS Foundation' cleanoutR. ) Depression over tank (Y/6 —d High water alarm (Y& AJO Date of pumping O Pumper '5%tj0CrA -k1' (�wPMS C. ABSORPTION FIE D DATA q t- Date installed 30 1 Soil rating g.p.d./f or ft=/bdrm) 6• System type '36M -tY II Length_ �0'� �"' QMC`1 g ft. Width ft. Gravel below pipe 7-- ft. Total depth ft. Eff.f Msorp�tion areaZ�fe Monitoring tube Depression over fieldQUO Date of adequacy test Results (Pass/Fail) For 3 bedrooms Fluid depth in aI bsorption fie d before test 9 in. Water added %�Ogal. New depth in. Elapsed Time: izD min. Final fluid depth y min. Absorption rate >_� g.p.d, Any rejuvenation treatment (past 12 mo.) (YIN 8 type) f%' If yes, give date i j D. LIFT STATION Date installed /J A- Size in gallons 'Pump on" level at Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAift station on lot Absorption field on lot Public sewer main Sewer /septic service line High water alarm level at in. Meets alarm & circuit requirements? -POW-1 C- (.,OjC, �� On adjacent tots On adjacent sewer manhole/cleanout Holding tank areas Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation —1 1 Property line 40 11 Absorption field d Water main i 0(,f Water service line 1014 Surface water Wells on adjacent lots -`2-0 o f -f SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line O I� Building foundation 3 j Water main Water Service line v /f Surface water /0614 Driveway, parking/vehicle storage V / Curtain drain Wells on adjacent lots 20 O ( i F. COMMENTS Tr . _ G. CERTIFICATION l certify that I have determir review of Municipal records conformance with MOA COST Engineer's Printed Name Date COSA Fee $ y90 Date of Payment 6 & pq n Receipt Number (Rev. 11105) field inspections and rove systams are in Waiver Fee $ Date of Payment Receipt Number "V4— fdrGo er uro)'r' Wt vNT0 WT 2> Tract A. Ramsey Subdivision Lot 3 31201 sl — Lot 2 $oQ8 6 1 72 ear CH* -P uNtc F — 5.4'x1k+0- 8 N N 89e58'04'E I SHELTERING SPRUCE LOOP Wr 17 sunMWn NY ^ F'ur,"c. vycTGA- SVYTem• - CZ1J0 Pwoi� Vx 15' ANCHOR EASEMENT • 15' 7ELECOM. 8 ELECT. EASEMENT PLOT PLAN _ ASBUILT'x SCALE I'`O�'' GRID Nw144-0 Project No. d9.osl Long dAssociates, Inc 11500 Daryl Avenue Anchorage, Alaska 99515 907 522-6476 Phone Registered Land Surveyors 907; 522-4625 Fax 1 hereby certify that I have surveyed the following desortbed Pproroperty �[..• ••.�Qs1l Lr..3 15LccV KoNOSLTFI WuopS SuB., ulflt.IV_C(i►Z_b'S Alnchorogt Recording dlsfrsct, Alaska, and that the Improvements situated49 9 thereon are within the property lines and do not encroach onto the property ! ; �•• • adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission Imes or other visible easements on sold property except as Indicated hereon. 'KENNETH G. Dated this they �_ Day of 73 till ,.., X09- at Anchorage. Alaska �Lg/ 5202 it to the responsibility of the owner to determine the existence of any e� '.?1A%' easement*, covenants. or restrictions which do not appear on the recorded PO salaNM. subdlvielan plat. in 8 Lot 4 AcK' N -- F z,4ma qr'!Q>' rYsl � Nue CZ1J0 Pwoi� Vx 15' ANCHOR EASEMENT • 15' 7ELECOM. 8 ELECT. EASEMENT PLOT PLAN _ ASBUILT'x SCALE I'`O�'' GRID Nw144-0 Project No. d9.osl Long dAssociates, Inc 11500 Daryl Avenue Anchorage, Alaska 99515 907 522-6476 Phone Registered Land Surveyors 907; 522-4625 Fax 1 hereby certify that I have surveyed the following desortbed Pproroperty �[..• ••.�Qs1l Lr..3 15LccV KoNOSLTFI WuopS SuB., ulflt.IV_C(i►Z_b'S Alnchorogt Recording dlsfrsct, Alaska, and that the Improvements situated49 9 thereon are within the property lines and do not encroach onto the property ! ; �•• • adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission Imes or other visible easements on sold property except as Indicated hereon. 'KENNETH G. Dated this they �_ Day of 73 till ,.., X09- at Anchorage. Alaska �Lg/ 5202 it to the responsibility of the owner to determine the existence of any e� '.?1A%' easement*, covenants. or restrictions which do not appear on the recorded PO salaNM. subdlvielan plat. MUNICIPALITY 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 2 Parcel I.D,tt 051-064-15 HAA#�%�emD)0J 1. GENERAL INFORMATION Complete legal description Lot 3, Block 16, North Woods Unit IV Location (site address or directions) NHN'SfiP1tPr;ng SnrurP Property owner Mike Cole/MW Cole Cons tructiopayphone 240-9901 Mailing address HC01 Box 6185 K, Palmer, AK 99645 Lending agency Mailing address. Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Public water XXX Day phone Day phone 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 XXX 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) Front MOAN21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system Is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. S & S ENGINEERING b Name of Firm 77044 Eagle River I aep Road Na 204 Phone q - D--cl 7 9 Address Eagle River, Alaska 99577 Engineer's signature ��� Date / /3/00 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for - bedrooms, with the following stipulations: Additional Comments By. /✓CGw� 1 , �' l Date /-7-00 4lITIC The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given In paragraph 5 above by an Independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rm. 1/91) Beck MOA #21 RECEIVED Municipality of Anchorage JAN DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division �MUNICIPALITY OF ANCHo 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907 s43t-4.'�4J VICES DI Health Authority Approval Checklist Legal Description: �O 3 80< %6 Y0,17111 -,14,0J W Parcel I.D.: 0's A. WELL DATA I(7-03L(L W11 -Tri!% Well type If A, B, or C, attach ADEC letter. ADEC water system number Log present (YIN) Date completed Total depth Sanitary seal (Y/N) Date of test _ Static water level Well production WATER SAMPLE RES Coliform Date, ofof sample: m le: P Cased to FROM WELL LOG Nitrate Casing height (ajbede ground) Wires property protected (YIN) ATINSPECTION Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed 3o/9 c Tank size 460 Number of Compartments Cleanouts ©N) Foundation cleanoutON) Ye 5 Depression (Yo Date of Pumping N14 "'v r'w Pumper C. ABSORPTION FIELD DATA /V 0 High water alarm (Y l-) /v O Date installed (9/ 3o/ cl 11 Soil ratingg.p.d./f 2 or ft2/bdrm) 0, System type Sf/A ��o `� ti4Ei°`r/ 4-� Length 1 a re're)L Width S4" Gravel thickness below pipe Total depth S ' Effective absorption area '7 l ) %2 Monitoring Tube present (LYNN) Y65 Depression over field (YA9) /`/ ° Date of adequacy test NIP - Results (Pass/Fail) For 13 bedrooms Fluid depth in absorption field before test (in.); mmedraTe-ly after_ gal. water added (in.): Fluid depth (ins) Minutpa-laterAbsorption rate = g.p. Peroxide 72-026 (Rev. 3/96)* 2 months) (YIN) If yes, give date D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* "Pump on" *Datum Size in gallons Cycle?. .tted— E. SEPARATION DISTANCES .. ('Jfy�,L l.vFl-Tr�i2 SEPARATION DISTANCES FROM WELL ON LOT TO: "Pump off" level at* Septic/holding tank on lot On adjacent lot Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer / ptic--service line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation -7 Property line U "F Absorption field Water main/service line /U f Surface water/drainage 00 Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: v ) v .r a0o rf Property line 10 Building foundation 3 i Water main/service line _ Surface water /()0 r Driveway, parking/vehicle storage area r Curtain drain N O N i- lG N 0 Ls N Wells on adjacent lots o 0 F. ENGINEER'S CERTIFICATION -� I certify that / have determined thru field inspections and review of Municipal recordgg1 i1h6`a66C in conformance w'th O y guidel' es in effect on this date. a / Signature j0 i 110 r'� Engineer's Name /J E R i ^ 'I P RO'URT C. COWAN ,f? Date I �3�0� "1t�1;' 'M +fir HAA Fee $ 3 [7-b ° 0 Waiver Fee $ Date of Payment b 110,3 / ( 0-0J) Date of Payment Receipt Number 5 bgReceipt Number 72-026 (Rev. 3/96)* are