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Home My WebLink AboutSAMPSON ESTATES BLK 1 LT 10mpson Estates Block Lot 10 #051-822-28 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON -SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231376 PID Number: 051-822-28 Dwelling: ❑■ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New M Upgrade Name Andy Rembert A RPTION FIELD ❑ De Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 22318 Sampson Drive Other Phone (907) 301-6461 Number of Bedrooms Three (3) Soil Rating Total depth from original grade ,sF Ft. LEGAL DESCRIPTION Depth to pipe invert from original g e F Gravel depth beneath pipe . 441 Ft. Subdivision Block Lot Sampson Estates 1 10 Fill added above original grade Ft. Gr length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Dista between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between t r hes From Tank Field Tank Line Ft2 Well >100' N/A N/A N/A >25 TANK❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1,000 Gal. Surface Water >100' N/A N/A N/A Material Plastic Number of compartments 2 Lot Line >5' N/A N/A N/A NA Foundation > 10' N/A N/A N/A TATION Manufacturer Capacity Remarks 2" Foam insulation over tank. Gal. Alarm location Elec tailed by Installer PIPE MATERIAL House to tank D3034 Tank to D3034 drainfield J R's Septic Drainfield D3034 CO/MT D3034 Inspector M. Jakubisin BENCH MARK (Assumed elevation) 100 ft Inspection 15' 11/8/23 2 �d Location and description 3b Bottom of Siding @ NE Corner 4m ON -SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp OF l� Conditional Approval: Date /*:49TH 7 �/ �•• BenJars�chiller �� Septic System Approved Date 7i 1 y -202� F� •. CE 12592 �� '/P�c ,11/13/23C�� ills PROFESSION Note: this approval does not include well permit requirements. �� cv VV/VL/ 1 Vi SAMPSON ESTATES, BLOCK 1 LOT 10 PERMIT # OSP231376 PID # 051-822-28 G _ \ ®LOCK 2 LOT 6 ASPHALT PAVEMENT ® / BM \ \ A SV 1n� CO , E N G I N E E R I N G r. . . Benja i Schiller i�'�� • CE 2592 011113123 AM `�i ®��Ia�PROFESSIONP�'�� 15, i / i LOT 10 EXISTING 65' LONG ABSORPTION TRENCH TO REMAIN IN SERVICE NEW 1,000 GAL SEPTIC TANK w/ NEW CLEANOUT AT CONNECTION 0 50 100 ON kE OM FEET 111=50' A B CO 17.1 20.8 MH 21.0 23.8 SV 24.9 27.3 2C0 30.7 32.6 I I I l ti LEGEND CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEAT` MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT SAMPSON ESTATES, BLOCK 1 LOT 10 PERMIT # OSP231376 ENGINEERING � '.V PROFILE AS -BUILT (NO SCALE) .� �. .......... ' • • • Benja in Schiller oF� •, CE 12592 �`� s -srF a3 .•�V�,i �it®®D l'ROf ESSiONP�.o'®' fgg to cr W 00 a L :r 0 CrIc 5L 0 ps M: fm ILZ 0 w A SIP *a o 00 0 02 ats 'Cor CL 2 :1 a !tcL:Llt < 120 3( 0 00 ol z "I p COL 03 0 -0 CLQ .% 0 or 00 oow:zm.zz Z:p to 00 3 cc at la- 0 CL=O COM 0 40 CL 0 00 V CL 0 00 =0 On r 0 ;5-wr .0 CL 3 12 0 00 > 0 C*, 0 a jr 03 ca > 70-M &-jr-t" I AM 0 e--�o U) M rn OD M o ci MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP231376 Work Type: SepticTank Upgrade Tax Code Number: 05182228000 Site Legal Address: SAMPSON ESTATES BLK 1 LT 10 G:1560 Site Mailing Address: 22318 SAMPSON DR, Chugiak Owner: REMBERT ANDRE E & SUSAN E Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date Expiration Date: r• t r1 h Department Lot Size in Sq Ft: Total Bedrooms: 11 /3/2023 11 /2/2024 57438 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: S 5 v1', � 0 (L --c r- Issued By: Date: Date: t ( 3 Z 2. z .3 _ 3 MUNICIPALITY OF ANCHORAGE Community Development Department r Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON -SITE SEWER/WELL PERMIT APPLICATION t Parcel I.D. 051-822-28 Property owner(s) Andy Rembert Mailing address PO Box 770067, Eagle River, AK 99577 Site address 22318 Sampson Drive, Chugiak, AK 99567 Day phone (907) 301-6461 Legal description (Sub'd., Block & Lot) Sampson Estates, Block 1 Lot 10 Legal description (Township, Range & Section) Lot Size 57438 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑X Septic Tank ❑X Upgrade ❑X (w/wo ADU) Holding Tank ❑ Renewal ❑ Duplex (D) El Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: � b 0Waiver Fees: Date of Payment: 1 i Z Zo 23 Date of Payment: Receipt Number: � 3�'i Receipt Number: Permit No. 0 S A 3 (� Waiver No. Permit App_:-: ,�.,:c November 2, 2023 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Sampson Estates B1 L10 – 22318 Sampson Dr Septic tank replacement Dear On-Site Services Engineer: The owner of the above lot has chosen to replace their septic tank, which is past the life expectancy for a steel tank. We are submitting at permit to replace it with a new 1000-gallon tank. Please refer to the attached plan for the tank location, which shows the location of the existing home and septic trench. The new tank will be 100’ from wells on this lot and adjacent lots, 5’ from the existing trench, and 10’ from the house foundation. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231376, Curtis Townsend, 11/03/23 Benjamin Schiller CE 12592REGISTEREDPROFESSION A L E N GINEER 1"=50' CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND SAMPSON ESTATES, BLOCK 1 LOT 10 FEET 0 50 100 S A M P S O N D R I V E 3-BDRM HOME SEPTIC PLAN 11/1/23 GOLI A T H D R . EXISTING 65' LONG ABSORPTION TRENCH TO REMAIN IN SERVICE DECOMMISSION EXISTING 1,000-GAL STEEL SEPTIC TANK NEW 1,000 GAL SEPTIC TANK Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231376, Curtis Townsend, 11/03/23 Municipality of Anchorage Page 1 _of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 e Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: SW990132 PIDNumber:--051-822-28 Name: MM&M Contracting Wastewater System: [] New [] Upgrade Address: P.O. Box 670495 Chugiak, AK 99567 ABSORPTION FIFLD I No. of Bedrooms: Phone: 688-1236 Three }(~ Deep Trench D Shallow Trench E3Bed I~Mound BOther LEGAL. DESCRIPTION S°ilRating: .45 GPD/Sq. Ft. T°talDepthfr~%Ofiginalgrade: Sub~l[v~io~: Depth to pipe botto~r~m original grade: Gravel depth beneath pipe Lot: 1 0 Block: 1 Sampson P3states Ft. Ft WELL: ~ New [] Upgrade Gravelwidlh: 3 ' Numbero~lines: Ft -- Fk Classification (Private, A,B,C): Total Depth: Cased TO: Total absorption area: Pipe material: Private 202 Ft. 201 Ft. 1 ,040 SO. Ft ASTM D3034 PVC )rifler: DateDdlled: StaticWaterLevel: Instalter: Dateinst lied: Sullivan Water Wells 6/17/9'. 174 F,. MM&M Contracti:~g 6~17-21/99 -- 1 5 GPM Ft. 2 Ft. SEPARATION DISTANCES ~s.ptio u Holding g S.T.E.P. T0 Septic Absorption Lilt Holding Public/Private Manufacturer: Capscityin gagons: From Tnnk Field Slation Tank SewerLines A~chorage Tank 1 ¢ 000 Material: Number of Compartments: We~ >100' >100' H/A ~/A H/A Steel T~o Water Lot > 5 ' > 10 ' N/A N/A N/A Sizein gallons: J Manufacturen Line Curtain No~e JoEed )n Lot Pump Make & Model JElectri~ltnspectionspedormedby: Drain Remarks: 2" Insulation Placed Over BENCH MARl( Location and Description: Tank. Garage Slab 100.0 ~t, Inspections pedormed by: Depadment of Health and Human Se~ices approval 72~13 {Rev, 9/91) MOA 25 Municipality of Anchorage Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P,O. Box 196650 Anchorage, AK 99519-6650 343-4744 On-Site Wastewater Disposal System or Well Inspection Report Permit Number SW990132 PID No. 051-822-28 ,Well Wel Three S2 S1 17. .7 S2 22.4~ 25.2 C4 34.21 23.6 C5 73.5~ 79.6 M1 73.~1 '79.5 PLAN AS-BUILT SCALE 1" = 50' Municipality of Anchorage Page 3 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, AK 99519-6650 343-4744 On-Site Wastewater Disposal System or Well Inspection Report Permit Number SW990132 PID No. 051-822-28 96.7 n asu2 ,000 Gal. Tank 95.85 / 99.2 Geotextile Fabric Drainfield Rock 65' 87 5 ~_,80.0 PROFILE AS-BUILT HORIZONTAL SCALE 1" = 10' NO VERTICAL SCALE by SULL ¥AN WELLS P.O. BOX 670272, CHUOIAK, AEAOKA 9B~87 ~, TELEPHONE 688-27B9 OWNSR L~(3AL DESCRIPTION PERMIT NUMBER ~q 0 1 ~0'~ ' Date of Is'sue '~ - q- ~ o~, __ TAX INDENTIFiCATION NUMI3ER ~::)"~1 '~ ~'~ ~ .Method o~ Drilling: "~a~ ~ cable · ' Depth of well: ~ ~ ' '"'Canine Type ~T~'. WalIThickness X ~ ~' inches L'ner TyAe: ~ ... Oas~ng Stick~p Above Ground: ~' feet. -- Static Water Level (from ground evel): .I ~ ~.~ feet . P~mp~ng evel .......... ]~ee~ mfle~_ t~r~. pumping ._gpm Reoov~r Rate: '/~ gpm Mmhod of Testing: ~ I ~ . We.~ ~nt~ke Opening Type; ~n End O Open Hole ~ ·Screened Stud feet Stopped ........... feet ~ Perorations 8ta~_.~eet 8topped. feet ~ :' - ~O~, ' PepJh: from ~) feet, to '/: feet Pump intake Depth( feat Pump Size ........ hp . Brand Name Well Disinfected Upon Completion? ~s' ~ No Metho'd of Disinfectlm~: ~k'~ ~ ~ BORE HOt~E DATA · DEPTH ,,ch 0 g_199'q Dept. Health & Human Serwces · · ATTENTION: It is the responsibility of the property owner to aubmit a copy of the weli log io the proper aulhorlty.'MunioipaiKy of Anchorege: Depadment of HeaRh & Human Services and/or Department of Environmental Conservation. MatSu Borough: Received Time Au~,,3l, 2:42PM : · ANDERSON ENGINEERING P.O. BOX 240773. ' ANCHORAGE, AK 99524 522-7773 522.6779 [FAX) DATE: TO: FROM: SUBJECT: MEMORANDUM September 30, 1999 Donna Meats ~.~ Mike Anderson, P.E. Lot 10, Block 1, Sampson Estates Septic System As-Built Slope Separation Distance RECEIVED SE? 30 19!)9 Mtmlcipallty of Anchorage Oept. Health & I-k~man Services On Wednesday, September 29, 1999, I inspected the slope immediately northeast of the absorption trench on Lot 10, Block 1, Sampson Estates Subdivision. I took several measurements on the slope and have plotted the ground elevations on the attached drawing. The edge of the slope is also shown oil another drawing submitted for your review. The edge of the slope is more than 35' from the finished grade of the trench for all but the last 15'. The pipe invert at the end of the trench is approximately 3' higher than the slope elevation 35' away. The 4:1 slope from the pipe invert extended toward the slope will not penetrate the slope for nearly 50'. It would therefore appear to meet the intent of the Municipal Ordinance. It is true the horizontal distance from finished grade at the northeast end of the trench is not a minimum of 35' from the edge of the slope. The horizontal distance from the invert of the pipe at this end is approximately 30' from the slope. At 35' from the invert the slope elevation is 3' lower as mentioned above. 'The 4:1 slope extended from the invert, however, is nearly 6' lower than the slope surface at 35'. The chances of effluent surfacing on the slope is very small. The slope is well vegetated. If effluent flows from the absorption trench at a 4:1 slope it can not escape from the slope unless it has traveled at least 50' which is more than sufficient length to provide proper treatment. ! / f ! / / ! / P.O. On-Site Wastewater Disposal System or Well mit Number SW990132 Municipality of Anchorage Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION Box 196650 Anchorage, AK 99519-6650 343-4744 Report Well We] Three Inspection PID No, 051-822-28 ~2 S1 19. 23.1 S2 25. 27,.3 C4 34.2~ 23.6 C5 73.5] 79.6 M1 73.41 79.5 PLAN AS-BUILT SCALE 1" = 50' ANDEP, SON ENGINEERING p.O, BOX 240773 ANCHORAGE, AK 99524 522,7'/'73 522,6779 (FAX) MEMORANDUM DATE: TO: FROM: SUBJECT: September 29, 1999 Jeff Poet Mike Anderson, P.E. ~ Lot 10, Block 1, Sampson Estates Septic System As-Built The septic tank on Lot 10, Block 1, Sampson Estates Subdivision was moved forward yesterday afternoon to assure 100' separation from the well on the lot to the west. Last night I measured the distance from the well to the first tank cleanout at nearly 102'. This would indicate the tank is at least 100' from the well. 'The swing ties from the house verify the tank has been moved nearly 2' forward. I have modified the as-built to reflect the new swing ties an am submitting it with this memo. Please let me know if additional information is required. On-Site Wastewater Disposal it Number SW990132 ~ell Wel Three Municipality of Anchorage Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMI-'NTAL SERVICES DIVISION Box '196650 Anchorage, AK 99519-6650 343-4744 System or Well Inspection Report S2 PID No. 051-822-28 A S1 19 S2 25 C4 34 C5 73 M1 73 B 23.1 27~3 23.6 79.6 79.5 PI. AN AS-BUILT SCALE 1" = 50' MUNICIPALITY OF ANCNORAGE Department of Health and Haman Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 995~9-6650 (907) 343-4744 Date Issued: Jun 09, 1999 E-'xpiration Date: Jun 08, 2000 ON-SITE WASTEWATER DISPOSAL SYSTEM /WATER SUPPLY PERMIT Initial Permit Number: SW990132 Legal Description: SAMPSON ESTATES BLK 1 LT 16 Design Engineer: 0014 Anderson Engineering Owner Name: M M & M Contracting Owner Address: PO Box 670495 Chugiak, AK 99567- Parcel ID: 051-822-28 Site Address: Lot Size: 57438 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [~ Disposal Field [] SepticTank [] Holding'Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 'i 8AACS0 ). 3. The engineer must notify DHHS at least 2 Ilours 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. 5. The following special provisions. The top of tl~e absorption field must remain a minimum of 35' from the top of the slope break. Issued By: / / ANDERSON ENGINI-'ERING 1 P,O, BOX 240773 / ~NCHORAGE, A~ 99524 5227773 522 6779 (FAX) I May 22, 1999 Municipality of Anchorage Department of Health and Human Services 825 "L" Street Anchorage, AK 99502-0650 Subject: Lot 10, Block 1, Sampson Fstates Subdivision Septic System Design Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The owner of Lot 10, Block 1, Sampson Estates Subdivision intends to build a three bedroom home on the lot. We are therefore applying for a permit to construct a well and septic system to serve the house. The placement of the well on Lot 9 immediately to the west of this lot severely restricts the area available for the septic system. In addition a steep bluff near tile midpoint of the lot running from east to west also makes placement difficult. The Site Plan shows the location of both the adjacent well and the bluff along with the area available for the construction of the new system. Also included is a cross section of the new absorption trench in relation to the slope. The top of the trench is nearly 35' from the slope. ']'he bottom of the trench is more than 50' from the edge of the slope. We would like to move the trench to within 25' of the slope at the top and 45' at the bottom to provide more room for the system and alternate site. We therefore request a waiver to the minimum setback of 50' to a 25% slope. The material encountered in the testholes is silty gravel with some sand from 2' to 4'. From 4' and lower the material is almost totally silty gravel with a percolation rate near 60 minutes per inch. It is doubtful effluent can pass through this material fast enough to daylight on the surface of the slope. The surface of the slope is now heavily vegetated with many very mature trees. 'The surface is very stable and flattening of the slope would require removal of the trees and damage to a very pristine environment. We are proposing to place a 65' long x 3' wide by 8' effective depth absorption trench to dispose of the septic effluent. The distribution pipe will be placed at 2' below the ground surface. Total depth of the trench will be 10'. No groundwater was encountered during the placement of the testhole, but was noted during the ensuing monitoring period at 14' below the surface. Since this is the high water period of the year we are confident groundwater will not conflict with the new system. The ground surface on the lot slopes to the southeast in the area of the new absorption trench. The trench will be constructed parallel to the slope and 25' from the top edge of the bluff if acceptable. Again the bottom of the trench will be 45' from the edge of the slope. No conflicts exist with other lots in the area where septic systems have been or will be constructed or wells are currently in place. Lot 10, Block 1, Sampson Estates Subdivision May 22, 1999 Page Two If the system is constructed in accordance with our design the following statements apply: The system, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on reserved space, either surface or subsurface, on any lots located in the area. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, Michael E. Anderson, P.E. Attachments / Pr( Exi SITE PLAN SCALE 1" = 50' ANDERSON ENGINEERING P.O. Box 240773 ANCHORAGE, AK 99524 (907) 563-7155 (907) 337.8855 JOB SHEET NO. OF CALCULATED BY DATE CHECKED BY_ OATE SCALE LOT 10, BLOCK 1, DESIGN FACTORS: Three Bedroom Home Parc. Rate: 54 to 57 Min./Inch Application Rate: .45 GPD/SF SAMPSON ESTATES SYSTFM REQUIREMENTS: Deep Trench System 1,000 Gal. Septic Tank 8' Drainfield Rock 3 Bedrooms X 150 GPD / .45 GPD/SF = 1,000 SF of Absorption Area 1,000 SF/16 SF/ LF of Trench = 62.5 LF Trench Length Therefore: Construct a Deep Absorption Trench System With One Lateral 65' in Length with 8' of Drainfield Flock Beneath the Lateral. Distributien Pipe in Trench Placed at 2' Below the Original Ground Surface. Total Depth to he 10' from Original Ground. Natural 1'-6" Backfill __Geotextile Fabric 6" 4" Perforated PVC (Slots Down) Drainfield Rock NOTE: TYPICAL DEEP TRENCN SECTION (NO SCALE) Grade Area Over Trench to Drain Away. Minimum 4' From Groundwater. Maintain 10' Separation From Lot Line. Municipality o! Anchorage DSPARTMEN'T OF HEALTH & HUMAN SERVICES 825 "L" Street Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST p~RFORMED FOR:__ MM&M Sampson Estates 5 6 7 8 9 10 11 12 13 14- 15. 16 17 18 19- 20 DAT5 PSRFO 'Township, Range, Section: SLOPE SITE PLAN II COMMSNTS p~'~RFORMED BY: . A. HRTR] R I ~-~---~. --~n d e r s o n t. Y=-S. AT W"AT ' Se ~l~n ~0 DSPTH? Jit~ II ".' - " I Z :qo $o ¥ 'g//." I/ Y,~" I . p~_RCO~'r,ON R^'r=... Z-7 ._ (m,.,~,,n~) P-=RC ~OLE m^M~t-R - ,5._.___"__ ' d Parc,. Cavity presoaKe prior to testing. Municipality o{ Anchorage DEPARTMENT OF HEALTH & HUMAN SELRVICES 825 "L" Street Anchorage, Alas~. ~2502-O650 SOILS LOG -- PERCOLATION TEST pERFORMED FOR:._ MM&M CoBtrmc~i mo LEGAL DE$CRIPTION:_~Ot 10: R1 m~k ] · ~ Sampson Estates 7 8 9- 10 11 13 14 15 16 17- 18 19 20 COMM~_NTS DATE ToWnship, Range, Sectiom SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? S Perc. Cavity j PERCOLATION RAT:- ~'%'/ (rmnt,,t~mch) PERC mOL5 DIAMET~-R -- ~ '~ TE$% RUN BETWE-=N ' ~- FT AND __ ~ ,-F~' presoaked prior to testing. pC_RFORMED IN ON-SITE WASTEWA'rER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: LO']' 10, BLOCK 1, SAMPSON ESTATES SUBDIVISION GENERAL: The scope of this project includes the procurement and placement of a new 1,000 gallon septic tank. It also includes the construction of a new 65' long x 3' wide x 8' effective depth absorption trench at the location shown on the attached Site Plan. The total depth of the trench will be 10' below existing ground. Mounding over the trench may be required to provide a minimum of 3' of protective cover. Construction shall be in accordance with the approved site plan, design drawings, Municipal Permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The Contractor shall be responsible for obtaining all underground utility locates and for the layout of the septic system and verification of the location of all lot lines. Unless specifically agreed otherwise, the contractor shall be responsible for final grading areas subsequently depressed from soil settling. Property owner shall be responsible for revegetation of affected areas unless specifically agreed otherwise. Contractors installing wastewater disposal systems must be certified by the Municipal Department of Health and Human Services for system installations. Owners installing their own systems must receive prior approval from D.H.H.S. before beginning system installation. SEPTIC TANK INSTALLATION 1. The 1,000 gallon septic tank must be procured from an approved source and installed at the location shown on the plans. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 3. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 4. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial insulation. A foundation cleanout shall be installed one to four feet from the building foundation. Two cleanouts are required between the tank and the drainfield. Lot 10, Block 1, Sampson Estates May 22, 1999 Page 2 of 3 7. Final grading over the tank shall be such that a positive slope exists away from the septic tank. DRAINFIELD CONSTRUCTION: 1. Tile drainfield shall be constructed to the dimensions shown on the design. The bottom of the trench shall be within 2" of level. Distribution piping must be placed level with perforations down atop a level bed of drainfield rock. Rock should then be placed over the pipe to provide a minimum of 2" of cover. 3. A silt barrier or geotextile fabric must be placed between the drainfield rock and the natural soil backfill. 4. Monitor tubes must be 4" in diameter and installed at the locations shown on the design. The portion below ground must be perforated. Contractor shall verify the septic tank and drainfield are a minimum 100' away from any private water wells in the area, 150' from a Class "C" Well or 200' from any community well. Direct bury insulation must be placed over the distribution system if less than 3' of backfill depth is available. Finish grade over the trench must be mounded to prevent settlement or depressions. 7. Grade area surrounding the absorption trenches to drain away. A minimum 2' of accepting soil is required below the drainfield rock for a 5' wide trench. Contractor shall verify this condition prior to placement of the rock. All pockets of unacceptable materials must be removed and replaced. MATERIAL SPECIFICATIONS: 1. Septic tanks must be constructed by a Municipally approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Cast h'on (perforated and solid), ASTM D3034 or P.V.C. (perforated and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662 or A.B.S. (perforated and solid). 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Co. Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). Lot 10, Block 1, Sampson Estates May 22, 1999 Page 3 of 3 5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed between the final drain rock layer and the native soil layer. 6. All drain rock shall be .5" to 2.5" in diameter with less than 2% passing the #200 sieve. INSPECTIONS: A minimum of two inspections are required by Municipal Ordinance. These inspections must be conducted under the supervision of a professional engineer registered in the State of Alaska. The first inspection must be conducted after the excavation of trenches, beds or pits and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled. The second inspection must be conducted after the placement of the geotextile fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No backfill should be in place at the time of inspection. Contractor shall provide a copy of all field survey layout and construction notes for use in preparing the certified as-built of the completed system. Certificate mfOO_Site Systems Approval Parcel I.D. 051-822-28 Expiration Date: Legal description SAMPSON ESTATES BLK 1 LT 14 Site address 22318 SAMPSON DR Chugiak AK X The On -site oystem(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Original Certificate Date: 10/25/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subje system(s) is/are in substantial compliance with municipal code. The Municipality Anchorage, Development Services Department (DSD) issues COSAs based upo representations provided by an independent professional engineer. The Municipality Anchorage is not responsible for errors or omissions in the professional engineer's work. COGA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory X Arsenic Advisory Other COSA Appmvaij* 2022 MUNICIPALITY OF ANCHORAGE #. Development Services Department.zq Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 051-822-28 Complete legal description Sampson Estates Block 1 Lot 10 Location (site address) 22318 Sampson Drive, Chugiak, AK 99567 Current property owner(s) Andre & Susan Rembert Day phone (907) 301-6461 2. .ON -SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: X Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: X Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ■❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 24 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑■ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On -site staff to verify the accuracy of the information provided. COSA Fee $ 5570 Waiver Fee $ Date of Payment T/%2-3 Date of Payment T-- COSA # D S Waiver # COSA Application —June 2022 Septic Tank Advisory Certificate of On -Site Systems Approval # OSC231413 Subdivision: Sampson Estates Block:1, Lot: 10 The septic tank for this property is 24 years old. The average life of an asphalt coated steel septic tank is 20 years. Typical replacement costs are $10,000 or more, not including engineering, surveying or MOA permitting fees. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. T Mailing Address P O Box ww 96650 *Anchorage, Alaska 99519 6650 * wmuni org �. Sampson Estates Block 1 Lot 10 051-822-28 6.0 6/17/99 202 N/A 202 18 10/16/23 Forge Engineering 160.5 9/27/23 50" 9/18/23 JR's 6/21/99 11.0 2.9 N/A N/A N/A 10/16/23 64 1330 88 1440 74 >450 96 74 22 Benjamin Schiller, P.E.10/18/23 (907) 522-7773 Municipality of Anchorage Development Services 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 Parcel I.D. 051-822-28 1. GENERAL INFORMATION Complete legal description COSA# 05C Expiration Date: SAMPSON ESTATES BLOCK 1 LOT 10 II-q ,11 Location (site address) 22318 Sampson Dr, Chugiak, AK 99567 Current Property owner(s) Paul & lana Syring Mailing address Lending agency Mailing address Real Estate Agent Matt Dimmick Team Mailing Address Day phone 22318 Sampson Dr, Chugiak, AK 99567 Day phone Day phone Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3..TYpEOF WA. TER ~UPPLY: Individual ,Wel.I [] .IndividUal Wate~ Storage [] Community Class __ Well [] Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site 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 Firm ARCTERRA CONSULTING, INC. Phone 868-3792 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 08/04/2011 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may notbe observed from the surface, changes inland use, local soil characteristics, groundwater levels that maY fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. DSD S~,~NATURE V Approved for Disapproved. Conditional approval for bedrooms, with the following stipulations: ~: ~ATFRAND : mC -- . WASTEWATER . - Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other 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 Well Log (Y/N)'~ Parcel ID: 051-822-28 Wires properly protected (Y/N) _Y Casing height (above ground) 18 in. AT INSPECTION 7/22/2011 175 ft. 5.3+ g.p.m. Collected by: ArcTerra Legal Description: SAMPSON ESTATES BLOCK 1 LOT 10 A. INELL DATA Well type P~~ ifA,. B, or C provide PWSID # Date completed6//999 Sanitary seal (Y/N) Y Total depth 202 ff. Cased to 201 ft. FROM WELL LOG Date of test 6/17/99 Static water level 174 ft. Well production 15 g.p.m. WATER SAMPLE RESULTS: Coliform Neg colonies/100mL Nitrate 1.8 mg/L Arsenic: ND mg/I Date of sample: 7/~../2011 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septie~Steel Date installed 6/1999 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 7/22/11 Pumper JRs Pumpin.q C. ABSORPTION FIELD DATA · Date installed 6/1999 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.45. System type Trench Length 65 ft. Width 3 ft. Gravel below pipe 8__ft. Total depth 1_.~.0 ft. Eft. absorption area i040 ft2 Monitoring tube Y Depression over field __N Date of adequacy test 7/'22/2011 Fluid depth in absorption field before test __ Elapsed Time: 735 min. Final fluid depth *55 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N__lf yes, give date -- Results (Pass/Fail) Pa§s For 3__ bedrooms 47 in. Water added 480. gal. New depth *57 in. D. LIFT STATION - N/A. Date installed "Pump on" level at Datum in. Size in gallons "Pump off" level at Cycles tested in. E. SEPARATION DISTANCES Manhole/Access (Y/N) High water alarm level at in. Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main Sewer/septic service line 25'+ Animal containment areas 50'+ On adjacent lots 100'+ On adjacent lots 10~'+ Public sewer manhole/cleanout N/A Holding tank 100'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation $'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 160'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water Service line 10'+ Surface water 100'+ Curtain drain 50'+ (None Kaown) COMMENTS Water main 10'+ Driveway, parking/vehicle storage Wells on adjacent lots 100'+ 10'+ I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance w/th MOA COSA guidelines in effect on this date. Engineer's Printed Name KENNETH M. DUFFUS Date *Trench appears to be operatin,q in upper 50% of total depth. Absorbed 100 ,qallons to reach operatin,q level and remained steady for remainder of test. No wa~ur was observed in lateral line at any time ENGINEER'S CERTIFICATION j~.~~ ~ Ik.ll~ Waiver Fee $ Date of Payment Receipt Number COSA Fee $490.00 Date of Payment Receipt Number (Rev. 11/05) 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.munl.org/onsile (907) 343-79O4 CERTIFICATE OF ON-SITE SYSTEHS /~,PPROVAL FOR ,b, SINGLE FAhllLY DWELLING Parcel LD. 1. GENERAL INFORMATION COSA# ) OqCO Expiration Date: Completelegaldescription SAMPSON ESTATES; BLOCK 1~ LOT 10 Location (site address) _22318 SAMPSON DRIVE * CHUGIAK: AK * 99567 Current Property owner(s) Mailing address Lending agency Mailing address SHANE ANDERSON Day phone 22318 SAMPSON DRIVE * CHUC~AK~ AK * 99567 Day phone Real Estate Agent Mailing address BROOKE STILTNER W/ REMAX Day phone 694-4801 16600 CENTERFIELD DR * EAGLE RIVER~ AK * 99577 Unless othen~ise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: _ 3 3, TYPE OF WATER SUPPLY: Individual Well [~ Individual Water Storage Community Class, Well ~ Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site 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 1o 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. (Cert ficates 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 f the validation date shown below, I verify that my As certified by my ~e~affixed hereto an..d a,s.o .......... of On Site S~'stems Approval Guidelines for this application, investigation, based cedures outhneo ~n the ~.,enlnu~ ' .*' ater su I and/or wastewater disposal system is (are) safe. functional and adequate shows that tho o~.. ~dit .~wa_ t~~ _P~P,'.Y.__ ~, ..,,,,.lure Indicated hereto. I further venfy that based., on the.. .~._,. . for the nu.?Der of Deorooms anu [yPu v, ° ........ ' information obtained from the Municipality of Anchorage files and from my ~nvesbgatlon eno ~nspecu, on, 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 °f installati°n' Nameof Firm GARNESS ENGINEERING GROUP. Ltd. Address 3701 E. TUDOR ROAD. SUITE 101 * ANCHORAGE. AK 99507 Engineer's printed Name JEFFREY A. GARNESS. P.E. Phone~ 337-6179 Date Engineer's Comments: In conducting this evalua§on, GEG, LtD. attempted to provfde a thoreugh, 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 end septic systems depend on the local soils condition, groundwater levels that may fluctuate dudng the year, and the water usage of the family being sen/ed 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 prevido 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 tistod above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal tfght whatsoever. 5. DSD SIGNATURE .~Approved for ~ bedrooms. Disapproved. Conditional approval for ON SffE WATERAND m.'.- :. WASTEWATER .' · bedrooms, with the fllowing stipulation,~ ~.~'.. Attachments: COSA Checklist Septic System Adviso~ Well Flow Advisory Nitrate Advisory (Rev 11fO5] Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other O, g na, Ce , ate Date: //- I - m 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 SYSTEHS ,PPROVAL CHECKLIST Legal Description: A. WELL DATA SAMPSON ESTATES; BLOCK 1~ LOT 10 Parce 9. Well type .PR~VA?¢ IfA, B, Or C provide PWS D# ,,N/A Date completed 6/17/1999 Sanitary seal (Y/N) YES Total depth. 202 fl. Cased to 201 fl. Date of test Static water level FROM WELL LOG 6/17/1999 174 Well production 15 WATER SAMPLE RESULTS: Coliform., (~) colonies/100 mi. Arsenic: .~0 ug./L. SEPTIC/HOLDING TANK DATA g.p.m. Well Log (Y/N) YES Wires properly protected (Y/N)., YES Casing height (above ground). 18+ AT INSPECTION 10/31/2008 167 ft. 4.64 g.p.m. N trate~, · (,, I mg./L. Date of sample: 11/3/2008 Other bacteria O C°lonies/100 mi. Collected by:, CE(; Ltd. Tank Type/Material ,, SEPTIC/STEEL Tank size, 11000 gal. Number of Compartments. 2 Foundation cleanout (Y/N) ,YES Depression ove~ tank (Y/N).NO Date of pumping ,, 10/1/2008 Pumper, ABSORPTION FIELD DATA ~BELOW EXISTING GRADF'] Date installed .s/IT-21,/1999 Soil rating O! ft21bdrm) 0.45 Length 65 ft. Width : 3 ff. Total depth '11 ft. Eft. absorption area,1040 ft2 Monitoring tube,YES Date of adequacy test. 10/31/2008 Resuits (Pass/Fail) ,, PASS Fluid depth in absorption field before test _,27 in, : Water added .650 'gal. Date installed 6/17-21/1999 Cleanouts (Y/N) .., YES High water alarm (Y/N) N/A JR'S PUMPIN(; Elapsed Tme: .,100 min. Final fluid depth.,36 in. Any rejuvenation treatment (past 12 mo.) (YIN & type) . System type, DEEP TRENCH Gravel below pipe 8 ft. Depression over field NO For 3 bedrooms New depth., 43 in. Absorption rate >= 450+ g.p.d. NONE KNOWN If yes, give date in. ~ ~~s alarm& circuit req,' E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO; 100'+ Septic tank/lift station on lot 100'+ Absorption field on lot Public sewer main N/A N/A Sewer/septic service line 25'+ 100'+ Animal containment areas 50'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation. 5'+ Property line 5'+ Absorption field. 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wefts on adjacent lots "102.17 , SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: property line 10'+ . Building foundation 10'+ Water main 10'+ .. Water service line 10'+ Curtain drain NONE KNOWN On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout Holding tank N/A Manure/animal excrete storage areas N,/A Surface water 100'+ ,Driveway, parking/vehicle storage Wells on adjacent Iots~ 100.'/5 F. COMMENTS *MEASURED FROM CENTER OF CLEANOUT TO CENTER OF WELL USING TOPCON TOTAL STATION. 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 date. Engineer's Printed Name JEFFREY A. GARNESS Date COSA Fee $ ~ 30 Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPRO /AL FOR A SINGLE FAMILY DWELLING Parcel I.D. (~'-/-~.,2~ -~' HAA # O~'~)~ ,, ," · Expiration Date: 1. GENE~L INFORMATION .C~mplet~}eg~l d~script~on ~/~ ~/a~ ~ l/ 5~a~ ~ ~ /~' "Locatidn'(~Jte addresS'or directions) ~/~ ~ ~-, ~/z~¢,~ · ~,.utcenf. P?opertyt owner(s) · 'Mailing address Lending' agehcy Day phone Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. ~. /ff'. .~, ,~ ~o e~.t~',~' ~ t,',, ~ ~C. e.~.~ 2. NUMBER OF BEDROOMS: ~;? , 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] [] Individual Holding tank [] [] Community On-site .~ [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. •SD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water 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 vaIidation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipalily 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. Engineer's Printed Name ~t~< 9~~ ~ ~n J~ 5. DSD SIGNATURE [/'"' Approved for _"~ Disapproved. Conditional approval for Phone Date bedrooms, bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Origina, Certificate Date: Logal DescriptiOn: A. WELL DATA Well type F~'/:, Date completed Total depth ~ o.~ _ft. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 w~w.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST ' Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform &) colonies/100 mi. Arsenic: #/~ rog.Il. SEPTIC/HOLDING TANK DATA If A, B, or C provide PWSID # Sanitary seal (Y/N) Cesedto ~'/ ff. FROM WELL LOG ft. . g.p.m. Nitrate ,~,4~'" mg./I. Date of sample: Tank Type/Material Well Log (Y/N) ~ ¢5 Wires properly prote~, ted (Y/N) ~'~ 5' Casing height (above ground) ~/~ AT INSPECTION I ~£ ft. g.p.m, in. Other bacteria ~ , coloniesll00 mi. Collected by: £r~'-~ /'~'¢'~/~' Tank size / ¢'~° gal Number of Compartments Foundation cleanout (Y/N) ~f ~',~ Depression over tank (Y/N) 4'~ Date of pumping .'~//0/4) 5' Pumper FI LD Length ~ 5 ~. W~h Total depth/f.~ ~. Eft. absorpt~n area/~ Date of ed~uacy test f~ R~ul~ (pes~Fail) Fluid depth in abso~on field ~fore test ~ in. Water edd~ Y~ gal. Ela~ Time: ~ ~. Final flu~ depth ~, in. Any rejuvenati~ trea~ent (past 12 mo.) (YIN & ~) Date installed ~,,'/~//¢ ~ Cleanouts (Y/N) ~'~ High water alarm (Y/N) System type Gravel below pipe ~ ft. Depression over field ,~'~ For .~ bedrooms New depth ~¥.~'. in. Absorption rate >= "/~'d g.p.d. If yes, give date '---' D, LIFT STATION Date installed 'Pump on' level at __ E. in. SEPARATION DISTANCES Size in gallons 'Pump off" level at Cycles tested Manhole/Access (Y/N) · ' ra rmlevel~t ' Meets alarm & circuit requirements? in. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot /~,, ~ ~4'.~', Public sewer main Sewer/septic service line On adjacent lots /'~'~ On adjacent lots /~,~ ~ ,~. Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation /~ ~ ,~'~ Property line 7z//~'- Water main Wells on adjacent lots /z,~, ?' r~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line $ ? ~'/' Water Service line Curtain drain Absorption field '7 /'~. Surface water /~ ~, v-/~ Building foundation .,E~ ~ f~' Water main Surface water /z?~ ~ .~. Driveway. perking/vehicle slorage ,.5- ~'7~ Wells on adjacent lots /~ .'~ ~. F. C~,OMMENTS rev~w of Municipal records ~at the above systems EngineersPrinledName ~,,~. ~ HAA Fee $ ~/L Date of Payment Receipt Number ~ (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number Lot i 0, Block 1, Sampson Estates Subdivision Attachment to F, Comments: This system was tested on 7/3/04 by another engineering firm. The owner is requesting re-issuance ora tlealth Authority Certificate. Visual inspection was made on 9,2/05, at which time the septic tank water was at 48" and the level in the monitoring tube was 30". No water was found in any ofthe piping clean-outs. Water was run into the foundation clean-out to verify that water was getting out to the monitoring tube at the end of the leach field. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. ~:P~'/- T'2 A - .2 'zv 1. HAA # Expiration Date: GENERAL iNFORMATION Complete lega descrlpbon ~_W'~.~-.~..~..o.~ ~-~.r-.~.~.~_~ ..~/..~ .~./ Location {site address or directions) ~,~.,,~ ~ .~' ~.~,~,~,,~ /~.~, ~/~/~./,~,~ Current Prooerty owner(s) Mailing address Lending agency Mailing address Day phone Day phone Real Estate Agent Mailing Address Day phone Un/ess othe/~v/se requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: .~, 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: ,,~ Individual On-site [~ [] Individual Holding tank [] Community On-site [] [] Public Sewer [] The MuniCiPality of Anchorage Development services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. CertifiCates of Health AUthority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wasteWater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water 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 Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with ali applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Address /~/ Engineer's Printed Name 5. DSD SIGNATURE ~ Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: -~ ~ ~ ~- O /7/ {Rev. 01/02) rage Parcel ID Sal Wires casi] Date of san Date il lied :)artments ~2 Cleanouts([~N) tank (Y~J~ ~ High water a arm (Y~ Pumper. ' ft. bedrooms New ~3epth?O',.~ tn lic sewer main Cycles tested tn le/Access (Y/N~ High water alarm ,evel at Meets alarm & circu t requirements? Absorption field Surface water Wells on Building foundation ~.~'~/ Water main Dr veway, park~ng/ve}~c e storage Wells on adjacent lots ~'/,¢',¢ ~t the above systems are in in e this date. waiver Fee $ Date of Payment Receipt Number 880~ 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 r)WEL. LING 051 -822-28 HAA# ~,~.O~(,'~ L~.~" GENERAL INFORMATION Complete legal description Lot'10r Block Location (site address or directions) Property owner Mailing address MM&M Contracting Dayp~0ne 688-1236 P.O. Box 670495 Chugiak, AK 9956'1 Lending agency .Mailing address Agent Address ~' Day phone Day phone Unless otherwise requested, HAA wi~! be held~ for pickup. NUMBER OF I~iEDROOMs: Three (3) TYPE OF WATER SUPPLY: Individual well zXX Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status'of system. TYPE OF WASTEWATER DISPOSAL: Individ~ual on-site Holding tank Community on-site Public sewer NOTE: XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~)25(Rev, 1/91) Front MOAt¢21 o STATEMENT OF INSPECTION BY ENGINEER As certified by my ~eal affixed hereto and as of the validation date shown below, I verify that my investigation of thi~ Health Authority Approval application shows that the on-site water supply and/or wastewate? 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 Anderson Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineeds signature Date 9/28/99 DHHS SIGNATURE Y Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with thee 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. The DH HS does this as a courtesy to pumhasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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 DEPARTMENT OF HEALTH & HUMAN SERVICE~ Environmental Services Division 82!5 L Street, Room 502 · Anchorage, Alaska 99501 · (907) ~"~[4~4 uthorit ...... - .... Municipal ty ct Anchorage Health A y Ap~.~va ~rlecKIIStDept, Hearth & Huma ~ Serv cee Legal Description: Lot A. WELL DATA Well type Private Log present (Y/N) Total depth Sanitary seal (Y/N) 10~ Block I t Sampson Est. ParcelI,D,: 051-822-28 IfA, B, or C, attach ADEC letter. ADEC water system number Y Date completed 6 / 1 7 / 99 202 ' Cased to 201 ' Casing height (above ground) Y W res proper y protected (Y/N) /~]' INSPECI'ION FROM WELLLOG 6/17/99 174' 15 g,p,m. _ Nitrate 2.95 mg/L Other bacteria 0 COllected by: A. Harala Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 Date of sample: 9 / 8 / 99 B, SEPTIC/HOLDING TANK DATA Date installed 6 / 1 7 / 99 Foundation cleanout (Y/N) Date of Pumping New C. ABSORPTION FIELD DATA Tank size Y Y 1,000 Number of Compartments 2 Cleanouts (Y/N). Y Depression (Y/N) N High water alarm (Y/N). N Pumper Construction Date installed 6/1 9-21/99 Soil rating (g.p.d./ft~ or fF/bdrm) _. 45 Length 65 ' Width 3 ' Gravel thickness below pipe Effective abserption area 1,040 SF Monitoring Tube present (Y/N) Y Date of adequacy test_New Const. Results (Pass/Fail) Pass Immediately after. Absorption rate = If yes, give date __ g.p.m, Fluid depth in absorption field before test (in.); Fluid depth _ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* N . System type Deep Trench Total depth 1 0 ' Depression over fiald (WN) N__ For Three bedrooms gal. water added (in.):. .g.p.d. N/A D. LIFT STATION None on Lot Date installed Manhole/Access (Y/N) High water alarm level at* *Datum Cycles tested E, SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot > 1 0 0 ' Absorption field on lot > 1 0 0 ' Public sewer main N/A Sewer/septic service line > 2 5 ' Size in gallons "Pump on" level at* "Pump off" level at* On adjacent lots > 1 f} r) ' On adjacent lots > 1 0 0 1 Public sewer manhole/cleanout Lift station N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation > 5, ' Property line ~ 5 ~ Absorption field Water main/service line > 1 0 ' Surface water/drainage > 1 0 0 ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line. > 1 0 ' Building foundation > 1 0 ' Surface water > 1 0 0 ' N/A Curtain drain None Noted on Lot F, ENGINEER'S CERTIFICATION I certify that I have determined ~ >5' Wells on adjacent lots > 1 0 0 ' Water main/service line Driveway, parking/vehicle storage area > >100' systems are Wells on adjacent lots · in conformance with MOA HAA guidelines in effect on this~date. Signature Engineer's Name Michael E, Anderson¢ P.E. Date 9/28/99 HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number