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SKY RANCH ESTATES #1 BLK 5 LT 14
Sky Ranch Estates #1 l. ot 14 Block 5 #015-301-24 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. fiuu So77 II 0M,1 el y not /deeded aInHq -AC, r,+MJ) I /tea��. -rrejr inyt�ll�d dze��r 4a,) loere l' I Municipality of Anchorage NOV 2 1-2023 On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP221399 PID Number: 015-301-24 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name Katy Malone ABSORPTION FIELD 9 Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 11900 Steeple Chase Cir. ❑ Other. Phone Number of Bedrooms Soil Rating Total depth from original grade 3 0.45 GPD/SF 9.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 1.0 Ft. Gravel depth beneath pipe 8.0 Ft. Subdivision Block Lot Sky Ranch Estates #1 5 14 Fill added above original grade 4.6 Ft. Gravel length 63.0 Ft. Township Range Section Gravel width 5.0 Ft Beds: Number of Lines NA Distance between lines NA Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 1,008 Ft2 1 n/a Ft. Well 108.2 100'+ NA NA 25'+ TANK X Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1,000 Gal. Surface Water 100+ 100'+ NA NA Material Number of compartments Lot Line 3.8 8.5 NA NA NA Plastic 2 Foundation 12.7 10.0 NA NA LIFT STATION Manufacturer Capacity Remarks Tank to neighboring well is 94' Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Isabella Exc. Drainfield 3034 CO/MT 3034 Inspector PES BENCH MARK (Assumed elevation) 100.0 ft Inspdection 15` 7/10/23 7/11/23 Location and description 2 n 3'd 7/12/23 4119/12/23 Top of adjacent deck ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional `' Approval: Date Q'` • •• *;•49MH .... .. .. ....... "$even annome Septic Syste � �en �. CE 8149 `•.•231110 Approved .�i or Date Cd 26Z �• Note: this appro I does not include well permit requirements. 0M,1 el y not /deeded aInHq -AC, r,+MJ) I /tea��. -rrejr inyt�ll�d dze��r 4a,) loere l' I � AGO0O-- 2>co 70 I y £ K, o" 'i c- mx ml 10 m fTl I mpopercC Z`LZ p-1 >pNDzz�o=D y £ --i om0 Wmnz (n M Mr- o z� g z m mn z F -m O to Cj D r n cm �rnc�(1�DUlmD�Z�0 Owcn-<7OmOX_ Z�z r �' r Dpm Comr 0 D n�� �m (n rr r X m .L7 m D .AJ o90, O{�m .Ll 70(- G)� fJDI DNO mo—� M* _ .. Z m o N W .. _ c� 0 N n O N D n m CO 00 N N N N -� O = m U n N N -P N W N 0 -<;;o U) (n D N -1I -;1- ct �I -P O W GW W N (A W w w -p- PO / p .P i O -u-1 m0 W -P Cn D IF �rnc�(1�DUlmD�Z�0 Owcn-<7OmOX_ Z�z r �' r Dpm Comr 0 D n�� �m (n rr r X m .L7 m D .AJ o90, O{�m .Ll 70(- G)� fJDI DNO mo—� M* _ .. Z m o -, Z7 Z .. _ c� 0 m o rnm o0 w0 D Do m Ul (.n o w m � 00 �0�'�0.1 r- MCD om cn I D -Ti Z (f) C -0 m O = m U n v z m TI Co onz 0 -<;;o U) (n m o m _ _ _ Fq-/ I o / m / o�l�x, o o f I o (1, o^.l r �n N i 00 0 3\ 0cLn \ ., / Zl m rp a/ nrn \ I n m F,�zz I gc)D co \ \ "' � rrl N O \ w_ w m \ 1 I / 1 I ^I1I� •�� I n /'' \ I • \ / N �I / / I / I / D cn�m�o \ \ �� I aoomvxem�n 1 m mm mv�aoz \ \\ C7 r0zwz o-imm / U m oto v vnm—v / n mr� O o2>, o I 'o \ r �' r z r Nom>o o90, O{�m mCN • ��� / cn� m o.n.� • o �x m =vow I ao / Zl— m D `D v-ioo �mm � z i z --i xnvz�n onz 00 ' o o=Z m mmXmoy mo <0 0Zm Z / zMo i -u-1 m0 1 D IF AF NOTES: PANNONE ENG SVC LLC (C.1. 1088) RECORD DRAWING P.O. BOX 1807 PALER, AK 99645 PHONE 907 745-8200 FAX 907 745-8201 DRAWN ACP/DRM SKY RANCH ESTATES #1 B5 L14 CHECKED SRP KATY MALONE 11900 STEEPLECHASE CIRCLE SITE PLAN ANCHORAGE, AK 99516 1 REVISIONS DATE 11/10/2023 1"=50' P.I.D. NO 015-301-24 2 OF 3 0 y v D m D mZ m r v .o O 'n F m a Z N v , cn M PES TH-1 0 o ZTEST HOLE (1981) I i -D 0 c o��c I I AI I' - r r p M in �o 2m L)D ;o ;u-0 tn y X 0 ;;u z 0 M 0 o� x D o -{ z "' 0 c� Z D M M I 0 M 0 M z �o 0 -rG G1 Z m m z 0 SII w PES TH-1 I TEST HOLE (1981) I FOUNDATION CLEAN OUT rICLEAN OUT SER w CLEAN OUT w O DOUBLE CLEAN OUT CLEAN OUT MONITOR TUBE MONITOR TUBE CLEAN OUT NOTES: PANNO14E ENG SVC LLC (C.1. 1088) P.O. BOX 1807 PALMIER, AK 99645 PHONE (907) 745-8200 FAX (907 745-8201 QF �p' ..... �►:46Iti:1k •• ••• ••$levan an* a CE 8149�g 2/1/24, ........ REVISIONS DATE 2/1/2024 RECORD DRAWING M SKY RANCH ESTATES #1 B5 L14 KATY M ALON E 11900 STEEPLECHASE CIRCLE ANCHORAGE, AK 99516 SCALE 1:8 M ACP/DRM � I SRP D� z .0 PERMIT N0. OSPxxxxxx SHEET 2OF3 M 0 0 Tl C z � m m Z G7 = M o p co 0 u � �� 9 p �� N a FIF o, I+� D �o m z a m a w z a� 0 o H D r `� I D Z r0 rr r0 Dm 0o r o r x_ A mz Do p Z Z Z I z 2 m D 0 � r � D O M li J p W J N I 4' I w PES TH-1 I TEST HOLE (1981) I FOUNDATION CLEAN OUT rICLEAN OUT SER w CLEAN OUT w O DOUBLE CLEAN OUT CLEAN OUT MONITOR TUBE MONITOR TUBE CLEAN OUT NOTES: PANNO14E ENG SVC LLC (C.1. 1088) P.O. BOX 1807 PALMIER, AK 99645 PHONE (907) 745-8200 FAX (907 745-8201 QF �p' ..... �►:46Iti:1k •• ••• ••$levan an* a CE 8149�g 2/1/24, ........ REVISIONS DATE 2/1/2024 RECORD DRAWING SKY RANCH ESTATES #1 B5 L14 KATY M ALON E 11900 STEEPLECHASE CIRCLE ANCHORAGE, AK 99516 SCALE 1:8 DRAWN ACP/DRM P.I.D. NO 01 z. I _24 CHECKED SRP SECTION .0 PERMIT N0. OSPxxxxxx SHEET 2OF3 DEVELOPMENT SERVICES DEPARTMENT On -Site Water and Wastewater Section www.muni.org/onsite PERMIT # OSP221399 PID 015-301-24 SUBD Sky Ranch Estates #1 CHANGE ORDER 907-343-7904 Fax: 343-7997 TRACT BLOCK 5 LOT 14 CONTACT PERSON Steve / Kim PHONE 745-8200 PLEASE GIVE A DESCRIPTION OF THE CHANGE We request a change order for the total depth of the system on the subject lot. The system was installed as a remove and replace of an existing system at the same depth and elevation as the original system, but at a depth of 9.0' from original grade instead of 9.0' from existing grade, a difference of approximately 1.0. All surrounding test holes and the test hole on this lot justify this depth. CUSTOMER SIGNATURE Date: ■ On -Site Reviewer: Comments Issued (date) Review Time (hours) I- 5 ei APPROVED (date) TOTAL HOURS HOURLY RATE $145 TOTAL TO BE PAID DATE PAID RECEIPT # 240.pp. - IS.pERj 0 SPR . ..... 0 DRNE S69 15' ROW '446 7S, 100, Rapp.00, Lo t jtj� 0 %3 r) co Cq F7771 e N 0 00 Asphalt Drive%ay Demo'd During Survey 0 r_7_7 Shed 7 A25.58' 8220.00' 0 X S 85-55,08- w 189.00' 50' ROW Lot 13 Or k'401 2. 0 15 30 49th'N /Starere y Hurst On S_ � Sur eymg US SURVEY FEET NOTES �'k fESSiONaI -All dimensions shown are grid bearings and ground distances, record boundaries are per Plat No. 71-166 -49th Star has conducted a physical survey of the property and all details shown on this Asbuilt Survey are correct. Under no circumstances should any data hereon be used for establishment of property lines. -It is the owners responsibility to determine the existence of any easements, covenants, or restrictions; no title research performed. AS BUILT SURVEY LEGEND 49th Star Surveying I-LC PO Box 738 Lot 14, Block 5, (D Septic Tank Lid Girdwood, AK 99587-0738 Sky Ranch Estates, Unit No. 1, 0 Clean Out (907)891-6111 Anchorage, AK JerernyP49th5tar5urveying.com O Well W.O. 2249 — IDATE: 7/23/23 SCALE: 1"=30' 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: OSP221399 Work Type: Septic Upgrade Tax Code Number: 01530124000 Site Legal Address: SKY RANCH ESTATES #1 BLK 5 LT 14 G:2737 Site Mailing Address: 11900 STEEPLECHASE CIR, Anchorage Owner: MALONE SCOTT A & KATY E Design Engineer: PANNONE ENGINEERING SERVICES This permit is for the construction of: Effective Date: Expiration Date cnr Sof � ' n I"1 r r 1 llCl)ill'CIl7@17C Lot Size in Sq Ft: Total Bedrooms: 1/20/2023 1/20/2024 18202 Q 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 Special Provisions: • Per the design, a 10 mil poly shall be installed on the face of the wall and extending 3' below the surface of the driveway. Bkoeived:8y: - Se-,LkeA 4o Date: Issued By: /� 612 Date: Z72 3 t»cnt S' Municipality of Anchorage Uep;irtment P.O. Box 196650 • 4700 Elmore Road Anchorage, Alaska 99519-6650 • (907) 343-7904 ® Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Division On -Site Water and Wastewater Program * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV231002 COSA#: Permit#:OSP221399 PID#: 015-301-24 Legal Description: SKY RANCH ESTATES #1 BLK 5 LT 14 Engineer: Pannone Engineering Services Multiple waivers have been requested for this upgrade justifications. The approved waivers are: • Tank to well separation, 92' • Field to property line separation, 7' • Tank to property line separation, 1' • Field to field separation, 18' • Field to excessive slope, 6' See the engineer's waiver request for This waiver approval applies to the proposed septic system only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. ............................................... ■ ............................. ■ 1 Waiver is Granted: X Waiver is not Granted: Date: r' 20 Approved by: X,441 Name of Reviewer .............................. ■ ............................. ■ ............... **** VARIANCE/WAIVER REVIEW **** MUNICIPALITY OF ANCHORAGE :._ Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 015-301-24 Property owner(s) Katy Malone Day phone Mailing address Site address 11900 Steep Chase Anchorage AK 99516 Legal description (Sub'd., Block & Lot) Sky Ranch Estates #1 L14 B5 Legal descriptio ownship, Range & Section) Lot Size ; Sq. Ft. Number of Bedrooms APPLICATION IS FOR: (® all that apply) Absorption Field X❑ Septic Tank ❑X Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ APPLICATION IS AN: Initial ❑ Upgrade X❑ Renewal ❑ 3 TYPE OF DWELLING: Single Family (SF) X❑ (w/wo ADU) Duplex (D) ❑ Multiple Dwellings ❑ (SF and/or D) THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/ ush Fees: Waiver Fees: _ e of Payment: 9)a(bb-;k rrC Date of Payment: Receipt Number: d�3lD VI Receipt Number: Permit No. OS'Pa a 1 _6qo� Waiver No. Permit App_-'-:- Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221399, Deb Wockenfuss, 01/20/23 Page 2 of 2 S. Waivers: Please see attached waiver request. 6. Drawing Markings: The Drawings are marked "For MOA Review 0nky.When written notification that the revievvi»conop|eteandnofurthercononoentsavereceivedfnonoK4uAOn-SheDepar1mentthenotewiUbevernoved and "For Construction" drawings will beissued. The proposed installation will not affect the future development of this or the surrounding lots. If you have any questions or concerns, please contact me at 745-8200. Steven R.Pannone, P£ Owner/Civil Engineer Mailing: P,O8ox18D7,Palmer, /\Kq9645 Te|�phone,(9O7` 745-8200 FAX:/9D7)745-82O1 Pannone Engineering Services LLC Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve@panengak.com Mailing: P.O. Box 1807 Palmer, AK 99645 Telephone: (907) 745-8200 FAX: (907) 745-8201 January 17, 2023 Municipality of Anchorage Development Services Department On-Site Water & Wastewater Program 4700 Elmore Road P. O. Box 196650 Anchorage, Alaska 99519 Subject: Sky Ranch Estates #1 B5 L14 11900 Steeple Chase Circle Waiver Requests Drain field to Lot Line Due to area constraints on the lot the proposed drain field upgrade encroaches on the south property line. The distance required by AMC 15.65 is 10.0’. we are requesting a waiver to 7.2’ from the proposed drain field to the south property line on the subject lot. Granting this waiver will not pose a threat to public health on this or surrounding lots. Septic Tank to Lot Line Due to area constraints on the lot the proposed septic tank upgrade encroaches on the south property line. The distance required by AMC 15.65 is 5.0’. we are requesting a waiver to 1.5’ from the proposed septic tank to the south property line on the subject lot. Granting this waiver will not pose a threat to public health on this or surrounding lots. Drain Field to Drain Field Due to area constraints on the lot the proposed drain field upgrade encroaches on the Sky Ranch Estates #1 B5 L13 drain field. Per the 1994 record drawing and inspection report for Lot 13 the effective depth of the drain field ranges from 13 to 11 feet. This requires a separation distance of 26 ft. We are requesting a waiver to 18’ from the proposed drain field to the drain field on Sky Ranch Estates #1 B5 L13. Granting this waiver will not pose a threat to public health on this or surrounding lots. Drain Field to Slope Exceeding 25% Due to area constraints on the lot the proposed drain field is less than 25 feet upgradient from a slope exceeding 25%. As shown in the attached slope section percolating effluent will daylight through the wall. The existing drain field is in failure with effluent at the invert of the drain field. There is no evidence of effluent daylighting through the retaining wall. This indicates an infiltration rate greater than 46% as shown on the attached section. To prevent the possibility of effluent daylighting through the wall 10 mil poly shall be installed in the face of the wall and extending 3 ft below the surface of the driveway. We are requesting a waiver to a distance of 6.0’ from the edge of the drain field to the retaining wall. Granting this waiver will not pose a threat to public health on this or surrounding lots. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221399, Deb Wockenfuss, 01/20/23 Page 2 of 2 Mailing: P.O. Box 1807 Palmer, AK 99645 Telephone: (907) 745-8200 FAX: (907) 745-8200 Septic Tank to Well Due to area constraints on the lot the proposed septic tank upgrade encroaches on the Sky Ranch Estates #1 B5 L13 well. We are requesting a waiver for the proposed septic tank to the existing well on Sky Ranch Estates #1 B5 L13 to a distance of 92 ft. The well on Sky Ranch Estates #1 B5 L13 is a private well and was drilled in 1977. The data is summarized as follows: LOT # WELL DEPTH STATIC WATER LEVEL YIELD Date Collected H2O Test Date Soil Characteristics Well Log Data Nitrate Level Lot 13 224’-3” 184’ 2.6 gpm 11/15/1994 3/1/2000 Y Y 0.1 Per the MOA Nitrate Values App there are no surrounding wells with a nitrate level higher than the allowable limit, the nitrate value for the subject well is 0.1 mg/L as shown in the table above (This value was obtained from the MOA Nitrate App). The ground water in this area typically flows from the east to west. The soil cross-sections are similar across the area and a homogenous cross-section was used to calculate the DEC criteria for all components. As outlined under 18 AAC 80.020 and 18 AAC 72.021(a), I have calculated the following points: Lot 14 to Lot 13 Well: Distance from sewer system bottom to groundwater 7.50 Soil sorption 5.61 Soil permeability 2.70 Water table gradient 2.00 Horizontal separation 2.68 Total Points 20.49 “The sum of the above values could equate to the following conditions: 16-24 Almost sure to be free from any form of contamination from household sewage.” In my opinion, this waiver request meets the above criteria for approval and does not constitute risk to health. I hope the above information will assist you in determining that the waiver should be granted. If you have any questions or concerns, please contact me at 907 745-8200. Sincerely, Steven R. Pannone, P.E. F.ASCE Owner/Civil Engineer PANNONE ENG SVC, LLC (C.I. 1088) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221399, Deb Wockenfuss, 01/20/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221399, Deb Wockenfuss, 01/20/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221399, Deb Wockenfuss, 01/20/23 A.? '62 } `-D — `— _�.. SPP UCS y 1I1 s L 10 15' - ROV}!— E Lto) it JL r� rt 2-S tory r 3 House '-� A25.s8' shed N-� Iz 2tl.oa tQ 1 S 85"55"fl8° � 1 s9.tlt3' / . ROW Lot 13 f OF41� Tri _� /,r t -- rw U 1.5 30 s.,`. ... 12clr `a r , lremy A. Fiurs%a l LSA 1796 US SURVrY NI rI T NOTES pAOF�SSIONA��� -All dimensions shown are grid bearings and ground distances, record boundaries are per Plat No. 71-166 -49th Star has conducted a physical sw-vey of the property and all details shown on this Asbuilt Survey are correct. Under no circumstances should any data hereon be used for establishment of property lines. -It is the owners responsibility to determine the existence of any easements, covenants, or restrictions; no title research performed. AS BUILT SURVEY LEGEND 49d-1 , Surveying, - PO� � € e y' PO Box 738 Lot 14, Block 5, 0 Clean Out Girdwood, AK 99587-0738 Sky Ranch Estates, Unit No. 1., (947)891-6111 Anchorage, o well Jeremy@49thStarSurveying.com W.O. 2249 i DATE: 23125/22 __SCALE: _ 1.." 30 MUNICIPALITY OF ANCHORAGE ~-~-~ DEPAR'rMENT OF HEAl. TH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telepl~one 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT ~HO~ ~ ~EW ~~~ ~j~C~U NO. ' V ] We I ~)sorption are~ Dwelllng~ DISTANCETO' - ~ , ~ . / PERMIT Liq, capac)t~rX~ns IF HOMEMADE: Inside len~h ~ Width__ Liquid~,p,~ mSTANCeZ~ ~.- ~,~ ..... PE~MIT"NO .... " ~et~ - //~ . .... -M~ Liquid ~p3e~'in gallons DISTANCE TO: ~' OTHER .4'~ 72-013 (Rm 3178) Formation from to /G , oQ Driller DELTA DRILLING COMPANY SRA 13OX 394 B ANCHORAGE, ALASKA 99507 .E:,EPRRTMENT (iii::: 825 "' L'" F"ERHIT NO. ':] 8:]_0500 > FIPF'L I CFINT CFIRL..ESON COI'.,IS T LOCRT I ON . NHi'.,I I.qH I S':F'ER I i'.,IG SPRUCE LEC~iFIL. L:]~4 5:5 Sky Ranch Estates TYF'E OF SOZL RSSOF::F'TION SYSTEi',I IS: MF~XIFIUM NUM[3ER OF DE[)ROOHS .... ]: F:'O B'?.I Subdivision TF:ENCH :.=.,OIL RFIT I NG LOT SIZE ::L820D SQUFtI:;:'.E FEET ('SQ F"r/BR) = 1"[.lEi: REQIJIRED L:;IZE OF 'I'HE SOIL. FIBSORPTION SY?-;.,TEM IS: THE' I_ENG'I'T'I DIMEI",ISIOI",I IL=, THE LEI'qG'FH ,::IN FEET.':, OF THE TRENCH OR DRFIINFIEL.D. THE [:,EPTI..I OF R TRENCH OR PIT I2; THE DI'=:,TFINCE BETHEEN THE '.'SURFRCE ElF "['HE GROUN[:, FIND THE BOTTOM OF THE EXCFI',,,'FITION (IN I=EET>. 'T'HERE I.S NO SET NIDTH FOF.'. TRENCHEL:.,. THE GRR',,,'EL. DEF'TH I:E; 'FILE I',1INIMUH DEPTH OF: GRFi',,¢EL. BETHEEN THE: OUTFFILL. PIF'E FIHD THE BOTTOM OF THE E',:.::CFI',,,'FITION <IN FEET). F'ERM:['I" FIF'PI_ I CRNT HFIS THE RESPONS I B Il.. I T¥ TO Z NF'ORM INSTFILLFITION ZNSF'EC]'IONS OF' RNY I.,4ELL.S RD.]'FICENT TO i'4UI',IBER OF: REE;I[:,EI'.~CES ]'HI:-]T 'THE 1.4ELL N ILL SERVE. THIS [:,EF'RRTMEI'.,IT [:,LIRII'.,IG THE THIS PROPER'FY FIND THE BFtC:KF'ILL. IF,IG OF RNY SYS'TEM HITHOUT FII'.4FIL INSF'ECTZON laND RPPF;tO',,,'RL. BY THIS DEF'FIRTMIEI"~T I.,.IZLL BE SUSJIECT TO PROSECUTION. HINIMUM [:,IS'FRNCE BETI.,.IEEN FI HEL. L RhlE:, FINY ON-SITE L:.;EHFIGE IDISPOSRL SYSTEM IS 100 FEET FOR FI PRIVFITE I,~EL.L. OR 150 TO 200 FEET FROM Fl PUE~LIC HEL. L. DEF'ENI)iNG UF:'ON THE T"r'PE OF PUBI_IC NEL..L. I'"IINZMUM DISTFtNCE FROH R F'F;:I',,,'RTEE HELl_ TO R F'RIVFITE SEHER LINE IS 25 F'E:ET FIND 'T'O FI COHMI_INZ'I"'¢ SENER LINE IS 75 FEET. HELL LOGS RRE REQUIRED RND MUST DE RETUI~'.NED TO THE DEF'FII~:THENT 1.4I]'HIN ]~O DFIYS OF THE HEL. L COMPLETIOI'4. O]"HER RE6:!LIIREMENTS 1"1F¢¢ flPF'LY. SPECIFICRTIOI'4S RND CONSTF;'.UCT]:ON [:,IFIGRFIHS FIRE FI',,,'FIII...FIE:[...E TO INSURE PROPER INSTF~LLFITION. I CERTIFY 'I'HFI"f' ::1.: I FIM FFIMIL.):FIR HI'FH THE F:.'EQLIIRE]','IENTS FOF~'.]"FI DY THE i',IUNICIF'RI...iTY OF: FINCFIORRCiE. 2: I I,.III...L IN'.S'f'FILL. "I'HE 'SYSTIEH II'.,I FICCORDFINCE 14ITH THE C:O[:,ES. 2:: I UN[:,ERSTSN[:, THFI"F TFIE ON-SiTE S[:T.I,.IER SYSTEM MFtY REL=.!UIRE FNLRF,'C~EMEN]' RE'Si[:'ENCE: I2!; REHO[:'ELED TO INCLUDE MORE TH[IN 2; BEDROOMS. F:IF'PL Z CFINT CFIRL..E S';ON C(] N':'~;T F'OR ON-SITE SEP.IEF::L'5 FIND I,]EI...LS RS SET ! F 'FHE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [;;~"~' SOl LS LOG PERCOLATION TEST 2 3 6 7 8 PERFORMED FOR: ~.~ Q~.~Oy~ LEOAL DESCRiPTiON: ~O-t' I~./ ~'~ ~.~-,',-'~,-.- SLOPE 11 13- WASGROUNDWATER ENCOUNTERED? IF YES, AT WHAT DEPTH? DATE PERFORMED: ~'--~.C~'-~I SITE PLAN 14- 16- 17- 18- 19- 20- COMMENTS PERFORMED BY: Gross Net Depth to Net Reading Date Time Time Water Drop -~ ~ lO ,'1.5~ i0 ~, ~'/.~ ,O~- · ¢~ 1~ I~G IO ~, ,IS~ PERCOLATION RATE ~ ,~'"~ (minutes/inch) TEST RUN BETWEEN ~*' FT AND ~-~ FT 72-008 (6/79) MUNICIPALITY OF ANCHORAGE o� Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 015-301-24 Certificate of On -Site Systems Approval Expiration Date: 1 /15/25 Legal description SKY RANCH ESTATES #1 BLK 5 LT 14 Site address 11900 STEEPLECHASE CIR Current property owner(s) MALONE SCOTT A & KATY E X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: By: , Original Certificate Date: 2/6/24 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 �MUMCO_ fkUY OF G771�p�'?�� VEPH Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 015-301-24 Complete legal description Sky Ranch Estates #1 Block 5 Lot 14 Location (site address) 11900 Steeple Chase Circle Current property owner(s) Katy Malone Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: 0 Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: [M Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel Wd Plastic ❑ Concrete ❑ Fiberglass Age c1 - 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 $ 6 0 Date of Payment zzz Ay COSA# US C_Zy l 0 Waiver Fee $ Date of Payment Waiver # COSA Application_June 2022 COSA Checklist_June 2022 COSA Checklist Legal Description: Parcel ID: If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist_June 2022 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F.ENGINEER’S COMMENTS G.CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Phone Engineer’s Printed Name Date MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Envlmnmental Services On-Site Services Section P.O, Box 196650 Anchorage,/Maska 99519-6650 (907) 343-4744 CERTIFICATE-' OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING Parcel I.D. # 015-301-24 HAA # J'~)i'('") 000 1. Gl=NEPAL INFOItMATION Complete legal descdption._.~SK¥ RANCH [SI, #11 [_OT 14. BLOCK Location (site address or directions)__1190o STEEPLE CHASE CIRCLE ANCHORAGE AK Property owner BRAD AND KAT HASLE-Fr Dayphone__(.907) 000-oooo Mailing address 119oo STEEPLE CHASE CIRCLE. ANCHORAGE AK. 99516 Lending agency Day phone Mailing address Agent CAROL BUTLER - REMAX PROPERTIES Address ~TF~EET NAME Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 5 3. TYPE OF WATEP. SUPPLY= Individual well xx Community well Public water NOTE!: If community well system, provide wdtten confirmation from State ADEC attest- lng to the legality and status of system. 4, TYPE OF WASTEWATER OISPOSAL: Individual on-site Holding Tank Community on-site Public sewer XX Day phone_(907) 257-0116/244--1800 NOTE: If community wastewater system, provide written confirmation from State ADEC lng to the legality and status of system. 72-025 (Rev. 1/91} Front MOA #21 Computer Version 5. STATEMENT OF INSPECTION BY ENGINEER Engineer, s signature As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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. ! further verity that based on the Information obtained from the Municipality of Anchorage files and from my Investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal a~¢State codes, ordinances, and regulations in effect on the date of this inspection. ~/ Name of Firm ALASKA WA~'E'"~ w~TE'~,~I~ CONSULTANTS, INC. Phone (907)337-6179 DEBARR E/CAD. Address 6g01 ~U~,/~2~ ,~/~:H(~RAGE. ALASKA 99504 , ,' Date g * ALASKA WATER & WASTEWATER CONSULTANTS,' INC. SHALL BE PAID $2025.00 AT, OR PRIOR TO, CLOSING FOR THE ENGINEERING SERVICES PROVIDED. 6. DHHS SIGNATURE ~(~ Approved for 3 bedrooms Disapproved Conditional approval for bedrooms, with the following stipulatiOns: Additional Comments Date z~ -2,~4'''- O0 The Munidpality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA fY21 Computer Version ,4t:CEIVED MAR 14 2(}00 Municipality of Anchorage ~ DEPARTMENT OF: HEALTH & HUMAN SERVIC~NIc~p^uT¥ oF ^N~ Environmental Services Division 'm~'~'qMENTAL SERV~L,~ 825 "L" Street, Rm 502 Anchorage. Alaska 99501 (907) 343-4744 ~) Health Authority Approval Checklist Legal Description: SKY RANCH FST. #1; LOT 1,~, BLOCK 5 Parcel I.D,: 015-301-24 A. WELLDATA .~' t.o~ g,~- o~ ~-~. Well Type ~RIVATE _ If A, B, or C, a~ach ADEC leffer, ADEC water system number N/A Log present (Y/N) YES Data completed 11/19/81 Total depth _ 201' _Cased to__ 201' _Casing height (above ground) Sanitary seal ~/N) YES Wires propedy protected (Y/N) YES Date of test FROM WELL LOG AT INSPECTION _ 11/19/81 2/22/2000 Static water level 23' 183' 5.52 Well production 1 o g.p.m. g.p.m. WATER SAMPLE RESU~S: Coliform '~ Nitrate Date of sample: 2/22/2000 Collected by: Other bacteria. A,W.W,C. INC. B. SEPTIC/HOLDING TANK DATA Date installed 7/6/81 _Tenksize_ 1000 Number of Compartments__2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES DepFession (Y/N) NO High water alarm (Y/N) N/A Date of Pumping_ 2/22/2000 Pumper NORTHLAND PUMPING C, ABSORPTION FIELD DATA Z~/G~- Date Installed 7/6/.~-1~.9 _Soll rating (g.p.d./l~. or ft2/bdrm) 262 ft2 bdrm System type TRENCH Length 61' Width _ 3' Gravel thickness below pipe 8' _Total depth lO.8' Effective absorption area 976 SQ FT _ Monitoring Tube present (Y/N) YES Depression over field (Y/N) NO Date of adequacy test. 2/22/2000 Results (Pass/Fail) PASS For Fluid depth in absorption fiekl before test (in.); ~ 27" Immediately after 745 Fluid depth_ 32.25 _(ins) Minutes later: 321 Absorption rate = Peroxide treatment (Past 12 months) (Y/N) NONE KNOWN If yes, give date 72-026 (Rev, 3/98)* Computer Vemlon 3 Bedroorns gal. water added (in.): 42.5 450+ D. LIFT STATION Date installed Size Manhole/Access (Y/N) ~ level at* "Pump off' level at* High wa~ *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line 100'+ On adjacent lots 1 OO% 100'+ On adjacent lots 100'+ N/A Public sewer manhole/cleanout N/A 25'+ Lift station N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5'+ Property line 5'+ Water main/service line 10% Surface water/drainage 100'+ SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Surface water 100'+ NONE KNOWN Curtain drain lru field inspections and review ,eve systems are in conformance 'ect on this date, JEFFREY A, GARNESS Absorption field 5'+ Wells on adjacent lots.* . ' '95' WAIVER REQUESTED .Water main/service line 10% Driveway, parking/vehicle storage area 10% Wells on adjacent lots 100'+ V0/?~o~ "/~ ~ E-7953 .." ~ HAA Fee $ D Date of Payment ~)////~r'~ Receipt Number '~ ~'~' C~-~ g ~' '7 ,) 72-028 (Rev, 3/g6)* Computer Version Waiver Fee $ /-~ Date of Payment -~//'z~,/0"~ Receipt Number '-~'~.d¢ ~'1~z R¢ck Mystrom. [vlayor Mtmic tpality of Anchorage Department of Health and Human Services 825 'rE" Street PO Box 196650 Anchorage. Alaska 99519-6650 April 25, 2000 Jeffrey Gamess Alaska Water & Wastewater Consultants, Inc. 6901 Debarr Road, Suite 2-B Anchorage, AIr`- 99504 Subject: Waiver Request for Sky Ranch Estates #1, Lot 14, Block 5 Waiver Request #WR000011 Parcel ID #015-301-24 HA000094 DeaL' Mr. Gamess: Your request for a waiver of the required 100 feet horizontal separation from the on-site wastewater disposal system to private well has been approved. The approved separation distance is 95.0 feet. The waiver granted is from the septic tank on the subject property to the well located on Sky Ranch Estates #1, Lot 13, Block 5. This waiver approval applies to the existing on-site wastewater disposal system to private well separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. Sincerely, Civil Engineer On-Site Water Quality Program I = .v · ' 2,,c-" =o ~=.8+ 2 7.5 2.7 2.$ ALASI WATER & WASTEWATER ~: ..... ' :, :..' ~ ::: _::r CONSUI-TANTS, INC. March 6, 2000 Municipality of Anchorage, DHHS Onsite Services Section P.O. Box 196650 Anchorage, AK 99519-6650 REFERENCE: L 14; Bk 5, Sky Ranch Estates #1. Request waiver of separation distance between septic tank, and well located on L 13 Bk 5 Sky Ranch Estates # 1. Dear Mr. Roth: In the process of performing an inspection for the purpose of obtaining a Health Authority Approval, we noted that the septic tank on the subject property is approximately 95 feet fi'om the private well on Lot 13, Bk 5, Sky Ranch Estates. Attaehed is a drawing, which is based upon our field measurements. The facts are summar~ed as follows: The well was drilled in 1977 and the septic system was installed in 1981. Consequently, the well is grandfathered. The house and septic tank on Lot 14 were constructed on a pad cut into the hill. It is physically impossible for the tank to overflow and run towards the well on Lot 13. In fact, the daylight basement in the house would have to flood completely in order to overflow the tank. Regardless, if the tank did overflow, the effluent would run towards the northwest along the natural slope contours. In short, the only path of contamination would have to be subsurface. Attached is the well log for Lot 13, Bk 5. It is 224 feet deep, with a static water level of 184 feet. The geological profile is as follows: 20-60 feet is sand, gravel, and clay; 73-9l feet is hardpan, 101-176 feet is "sandpan", and 181-.196 feet is a gravel/clay nfix. These geologieaI layers should provide adequate filtration so as to protect the aquifer. 6901 Debarr Road, Suite 2-B * Anchorage, Alaska 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * awws~alaska.net Recent water samples from Lot 13, Bk 5, Sky Ranch h~dicated no bacteria, and nitrate levels of ,, .~'mq/g.. Based upon this data it is clear that the water quality has not been ~dversely ~mpacted by this encroaclunent. Based upon the aforementioned facts, it appears that there is virtually no risk in granting the subject waiver (95 feet from tat~k to well). If you have any questions, please contact me at 337-6179. ~Ttl~mk you for your consideration of this nmtter. Presi, ~ /~e~ss~.E., M.S. 6901 Debarr Road, Suite 2-B * Anchorage, Alaska 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * awws~alaska.net LOT 4, BLOCK 4, / I / ........ -- ..................... ~'"~-~--.~. ~. SkY RANCH EST. #1 ,% LOT 6, BLOCK 4, ....... / ~ '---~_~ SKY RANCH EST. #1 ALAS~ WATER ~) WASTEWATER CONS~T~TS, ~C. 6901 DEBARR ROAD, SUITE 2B. ANCHO~GE, ~. 99504 SKY RANCH ESTATES SUBDIVISION ~1; LOT 14, BLOCK 5 ....................... SITE Pr. AN FOR WAIVER REQUEST 0AROL BUTLER 257-011 B~AD AN~ KAT HASLETT ~/o (g07) ~ATE:3/6/2000 BY: PAGE: J.L.M. 1 = 50' 1 OF 1 f MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~/""¢-~0['~¢ HAA# 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 14; Block 5; sky Ranch Estates #I Location (address or directions) 11900 Steeple Chase Circle (b) Property owner Joan ~homas,)/5 L~,~..,..~ Telephone: (home) Business Mailing Address 11900 Steeple Chase Circle. Anchorage. Ak. 995~6 (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address C Street & 52nd Telephone 562-I 222 Heritage Real Estates ATTN: Helen Henderson Anchorage, Ak. 99503 (e) Mail the HAA to the following address: (or check here []~.if hold for pick up,) List contact person and day phone number below: S & S ENGINEERING 17034 Eaqle River Loop Ro~d Ne. 294 Ea~Je River, Alaska 99577 2. TYPE OF RESIDENCE Number of bedrooms'--~ Single-Family ~X 3, WATER SUPPLY Individual Well~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attestin9 to th legality and status. 4. SEWAGE DISPOSAL On-siteY~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025(Re¥ 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. '1 further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Date S & $ ENGIN~.ERING 176~34J~!~_ ~h~r Lo~cJ~_O~Ld No, 204 Eagle River~ Alaska 99577 Telephone ¢- 6. DHI-IS APPROVAL Approved for ~ bedrooms by Approved ,~.. Disapproved Terms of Conditional Approval Date '-(/I ?~/~. 0 Conditional The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only u pon 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. ..r~s MUNICIPALITY OF ANCHORAGE (MOA} ~,¢'~'"~ll~,/-~ Health Authority Approval (HAA) .,~,,©~ ~.~.~'~ob~'° CHECKLIST - FEBRUARY 1984 ~'4~ A. WELL DATA Well Classification [ ~'~[;:;'\ 'J~ ¢::~'D'';~'I.~ If A, B, C, D,E.C. Approved (Y/N) /,4/~ Well Log Present ((¢;/N) ¥ Date Completed ll-t~I - E~I Yield Total Depth'~¢~ Casedto '~ Depth of Grouting '----" Static Water Level ~ ~--~ Pump Set At L~ ~ Casing Height Above Ground 1 "~ U"IF Sanitary Seal on Casingd~) Electrical Wiring in ConduiH~/N) ~/ Depression Around Wellhead (Y/¢~' SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot t, ~(¢¢- ; On Adjoining Lots To Nearest Edge of Absorption Field .on, Lot [ c;~'~t'f- ; On Adjoining Lots To Nearest Public Sewer Line ~/~C:~ To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ,~..~__~ I,.~ Water Sample Collected by ~ ¢~' ~ '~::'~"~--~ ¢-. Water Sample Test Results _~-~'~\ ~'~ ~ Comments B. SEPTIC/HOLDiNG TANK DATA Date Installed _"7--~--P~[ Size Standpipes~N) Depression over Tank (Y~ PumPing/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: \ ~ No. of Compartments Air-tight Capsd¢CFN) ~ Foundation Cleanout2~N) f.~ / Date Last Pumped __~,~' "~'~--'¢) ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Water-Supply Well \ ~tj¢ To Property Line ~ ~ t ~_ To Water Main/Service Line TO Stream, Pond, Lake or Major Drainage Course Comments ~'~c.~ ,~.~ ~,~ I 72026(Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata "~-~:~ "¢'/'¢¢~ Type of System Design"'"~--~ Date Installed '~ ~ [P - ~ ~ Length of Field Width of Field ""¢~' Depth of Field Gravel Bed Thickness '~-~' Square Feet of Absortion Area '¢~"~ (42 '~ Statndpipes Present(~/N) Depression over Field (Y/d~P~ I`4 Date of Last Adequacy Test Results of Last Adequacy Test ~'1'~ ¢' ~ r SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot t~/~ To Water Main/Service Line To Property Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Existing or Abandoned System on ; On Adjoining Lots "~ c:~ ¢m To Cutback (if present) D. LIFT STATION ~.aztee~ "Pump On" Leve~_ High Water Alarm Level at ~ Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) ~ Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** ~ I certify thst I have checked, verified, or conformed to all MOA and HAA guidelines in effe~-t,,l~ ..~ of this _ ~ ~ /d./ Receipt No. Date of Payment ¢7 --~' -- ~' O Amount: $ //.~ ~.2(_~ 72-026 (Rev. 7/88) Back Waiver Fee: $ Date of Payment Page 2 of 2 APPLI( 'NT FILLS OUT UPPER HAI ONLY Property Owner ,7~/-? ,,? ~// /~ )//4: ,~/ ~-.= MaUi.9 Addre Address Lending Institution ,/:~)/'~2 ::~ / ,.] ~ ~ / .-/~. ~ /~. ~ ~, Z._~ /.~ )-xt. I, /(,,~ ~ ~ ,. :,' - Phone Phone Water Supply ~.lndividual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. E] Community For wells drilled prior lo that date, give well depth (attach log if available). [~ Public Utility Sewer Disposal Individual Year Individual Installed:_ Public Utility When Connected to Public Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE iNITIATED. Time Time Time Date Date Date Inspector Inspector Inspector Field Notes: Time Inspector NIC:IPALIIY DJ: ANCi~DRAG[: ENVIRONMEN [AL PRO [ECRON (~'~ ) APPROVED BEDROOMS ( ) DISAPPROVED ( ) CONDITION,~ APPROVAL.' 'CONDITIONS OF APPROVAL Soils Rating Date Sewer Installed ?/ Well To Absorption Area Well to Tank WeLl Log Received Septic Tank Size 72.023 (31~2) ~ate ~ Time Date "~ In'specter ~ Inspector Comments ~(L ,~.0 ~. Date Sewer Inst~le'~d~j-;z~:~----- Soils Rating fe~'mqt'Tq~. Well To Absorption Area Well to Tank Inspector Holding Tank Size Well Log Received Property Owner Mailing Address Address Lending Institution APPLICANT FILLS OUT LOWER HALF ONLY LL)-- Realty Co, & Agent Address ~) / ~ Typo,~sidence I] SinCe Family ~k. ~ Multiple PamHy No, of Bedrooms ~ ~ Other Phone Phone Water~pply Individual Cornmunlt~ Public Utility Sewagg~isposat Id' Individual ATTACH WELL LOG. A welt Icg Is required for all wells drilled since June 1975. For wells drilled prlo. t to that date, give well depth (attach Icg if available.) Year Individual In tailed: ~ [] Public Utility F3 Holding Tank When Connected to Public IJtillty:' NOTE: THE INSPECTION FEE MUST ACCOMPANy EACH REQUEST BEFORE PROCFSSING CAN BE INITIATED.