HomeMy WebLinkAboutELMORE #2 BLK 8 LT 1Elmore #2 Lot 1 Block 8 #018-172-34 12-013 (Rev. 9/91) MOA 2S Municipality of Anchorage Page Of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: YJV96i& E PIDNumber: L/P/ZZ34 Name. RobertX Wastewater System: New ❑ Y Upgrade Address: : 414C, ABSORPTION FIELD Phone:/ _ 2 5 No. of Betlrooma: ❑ Deep Trench xshallowTrench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: 2.O GPD/S.Ft. ny Lot: Block: Mqclivision: ' Depth to pipe bottom from original grade: Gravel depth beneath pipe //1%G W2- - 0, Ft. 01.15 Ft. Township: _ Range: Section: Fill added above original grade: Gravel length: — 2• Ft. // 45 Ft. WELL: E:X1sc ❑ New ElUpgrade Gravel width: Numberoflines: Distance between lines: w... Classification (Private, A,B,C): Total Depth: Cased To: tl 7' Ft. Total absorption area: — Ft. Ft. Pipe material: Ft. Ft. SQ. Ft. ,q 3034 Driller: Date Drilled: Static Water Level: Installer Date installed:_ Z4. �� 4 Yield: Pump Set at: Casing Height Above Ground: GPM Ft. Ft. TANK SEPARATION DISTANCES ❑ Septic ❑ Holding WS.T.E.P.B<CCyLC To From Septic Tank I Absorption Field Lift Station Holding Tank Public/Private Sewer Lines Manufacturer: Capacity in gallons: J� We1NJo ; I r Y J �I r Material: Number of Compartments: Surface Water N t ,L A I • ' LIFT STATION Lot Line 2 Size in gallons: Manufacturer: VE bDbL Foundation 19 Mig 2-5 "Pump on" level at: j "Pump off' level at: High water alarm at: -3tq et P'=set sc •" Curtain Drain / r Pump Make B Model Electrical lrspections perfor etlb f •e Remarks: - `ecove-)- 42" BENCH MARK d� - y Location and Description: lid /c c/ S' ,r C- Assumed Elevation: �r 4 Ft ENGINEER'S SEAL OF qju' tit l Inspections performed by: Dates: 1sLI d A7 2nd 22 Department of Health and Human Services approval E 7a�a ' Reviewed and approved by: Date: 2'20-97 12-013 (Rev. 9/91) MOA 2S Permit No. _SW96017Z Page 2. of .3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: Lo -F1 68 E(mare _%6, �r2 PID No.: 05 1 8 1 723 4 NEW SYSTEM SLIGHTLY ....... VER Fq�Er PLACE. �•' ` 42 x 47 ( HOUSE 1 FCO ........... OF 30 -FT BLOCK 8 V TH 1 AleR 1 in 30 ft 72-013 A (1W) - 3 sfty n Q Permjt No. S141-960/72 Page 3 of 3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 9951-9-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Legal Description: Loi /�. 81h 8 amore 02 PID No.: rJJ8172.34 oI ool o� .9 ?��I 74 S ; m T a.7 N ._........... _ D. m v+- ..... ,. 8 ft e..e.. .......... C 0 ... ham'. ----i 03 vx _O 00 P d W ,, co 40 I I t o cv nt ..... _...... ,.a......................... .......t i._.._............_............4..._...........l..l.......... «: _I I b O " tl 1 m: ar ci v C s LO I I F yS ¢C fn C 0 o..-- ... _LOL EdTF U 0 jokel ejgeeWJedwj I I 01 U1W 11 9:i I I E °II r o m 01 u!w 11 tlir, , « G N £ II 8 �0a f W.00 d ill: n a— Z 9_ O J Y m4 N > W 9 e ' S G I' O Q it LLIN N F o W E��r 3 0 Y j ay.oT '� CL *0' CL ESSt(i@ 72.013 A (1193)' T- -1-1 E i L. 2 E L E L F- 1. T R I: V 9 1 INSPECTION REpopr MUNICIPALITY OF ANCHORAGE, BUILDING SAFETY DIVISION 3500 EAST TUDOR ROAD �NSPE'.:11CN: YUIC£ 56J-3484 INSPECTION: rAX sol !7. �. 1- 8z.,5 ?Lr O; 34J-8211 nes xti_ i i' —.y PERMiTR f t BLOCI(,SUBOIWSiON �1yyJ,� 1P5'sctn�er+ bnr G (.)MML-r: i 5 pr OiagCTION9; ,641)M 5157" ryPE OF +NSPeCTK vca /61`40 NONCOMPLIANCE OBSERVED I I CORRECMNB ESSENTIAL AS EXPLAINED BELOWIj WILL E•£XAMINt AT NEXT INSPECTION I I DO Nor CONCEAL UNTIL REINSPECTED COMMEN r9: tFnR INSPECTOR USE ONLYI a INSPECIOn �/k <� HATE: 11612 1 WHEN CORRECTIONS ARE MADE PLEASE CALL FOR REINSPECTION 00 NOT REMOVE THIS NOTICE i FEB -05-1997 10:08 SPENRRD PRWN SHOP LOCATION OF WELL Iof.....gunshots Jrkor to. ID ai Is. 907 562 9982 P.02 WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of GeOlogicol a Geophysical Survey$ .Orllllpd Permit No. 'A.D.L. No lo. D1p.ouOk subdlviligo Lei RICCb [ib. I/aatra� SDC!{Dn Noy Township R13 Raaea E[) Meridian rre;K4 r /FI8/'C !. 1—oe_at_:It— sd W❑ Ice DIST NCL AND DIRECTION FROM ROAD INTERSECTIONS a. OWNER OF WELL: Yrti r f .,1 i rF1 $-i'ow Address; { k0 ) draw: Te f -1v N c e Strut address old Area of Well Loaatlen P, N k Y. WELL LOG Feet Below Surface p, WELL D PTH: (flus) 5, DATE OF C))O/�M�PLETION 10 — Z Material Type Tup settom W"4 G. Cable tool []Rotary []Driven Duo ,e J t ❑ Adder []Jelled ❑ Sharon Q otear: r y ; 1,-p T. Use; I Domestic [] Public Supply ❑ Industry ❑ Irrigation ❑ Realtors. 0 CammeAdc.4 O Teat Well ❑ Other: {ey✓w� �!! $'rbY' y C, f �' { o S 'Q J V8 S. CASINO; [] Threaded 0 Welded ft. Depth Weight �tbs./ft. diem, —4L-- 10- to� dlam.—I.. lam_ ft. Depth Stlahup— It. S. FINISH OF WELL: Type: � DlemotU'I ilot/Maah 94a: e'�t fans/h: Sot bdween ft, and ft. Seallf 111"ll gravel pack T 19. STATIC WATER LEVC�U/�_�I1. O Abero or Below load winds I_ pets Equipment used: ' 11. PM VV" blow,Ippnd luffage ped YII fler G.• nye, purnpino e.p.m. _ It.. Tl ulfer _hro. p.mpdg _9 -P -m- I E.Cftou"Nri WIII Graafodl OY.s t2s Me Ofher: Material: ❑ Neat Cemenl Q AR 14 1997 13. PUMPt (H evellable) he t Lenste of Drop Pipe ft. capacity I Dept. Heat [] Subm, O .hat ❑ Cenlrlflael ❑ other Is. REMARKS: IS. WATER WELL CONTRACTOR'S CERTIFICATION: IS. Wall, Temperature ❑ F C y. This wot�I .s1` drilled underrlod.dte Ian And this repast is true to the Dell at my h I.dpe one 1,01.8 e p, 17ri 11'11 A4 —�1 x' 7e eyl.tered sulMes Ne Dnlmcl Ic6ns. um Dar Addreu: Signed: DotDote: auhAor ae representative.. f .. � . ruJels •' enc. nr.t.Iemisw:' wwx-Fs..u�nana .tuC-$slave (•.ANARY•CaefOmee C1DCLf-LL MUNICIPALITY O{{��F ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW960172 DESIGN ENGINEER:SKLH CONSULTANTS OWNER NAME:GRAY ROBERT L OWNER ADDRESS:P.O. BOX112323 ANCHORAGE, AK 99511 PARCEL ID:01817234 LEGAL DESCRIPTION: ELMORE #2 BLK 8 LT 1 LOT SIZE: 41255 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: PAGE 1 OF 1 C%ISL� CLC' 1sd 1 a DATE ISSUED: 7/08/96 EXPIRATION DATE: 7/08/97 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED ISSUED BY DATE • ! DATE: SKLH Consultants 1700 Vashon Circle Anchorage, AK 99515 Mr. Dan Roth, P.E. Dept. of Health & Human Services Municipality of Anchorage 825 L. Street Anchorage, AK I July 1996 RECEIVED JUL 1 1996 Municipality of Anchorage Dept. Health & Human Services Re: Lot 1, Block 8, Elmore Subdivision #2 Revised Biocycle Treatment System Design, Revision 1 dated 7-1-96 Dear Mr. Cross: Attached is a revised system design for the proposed on-site disposal system to serve the above referenced property. The changes area a result of the 6-25-96 meeting between myself, Mr. Bob Gray, the property owner, and Mr. Cross of your office. The revisions consist of the following: D� a. The depth of the system was raised to provide 4 -ft of separation from groundwater. h J b. The gravel depth below the perforated pipe was reduced from 1.5 feet to six inches ^/ The existing root mat and silts shown on the soil log of TH-1 will be removed to the UAL underlying sandy gravel beginning at 12 inches below ground surface and backfillede/ with coarse sand. '/,/0 c. The application rate was increased fro ffi two attdlsf9fabsorption area to three""M/sf Svsl of absorption area. (The increased application rate is still less than the maximum 7L allowable of four gpd/sf for the receiving soil layer.) Raising the system requires fill to be mounded over the absorption field for frost protection. The proposed design includes two inches of insulation with two feet of fine grained soils to provide an equivalent cover of four feet. Once construction is complete, the cover will / z be seeded for protection against erosion and for aesthetics.�y, r� j"r'a �'(� If you should have any questions, please call. Sincerely, 'Ste n C. Hendee, P.E. P m Fw o . e SKLH Consultants 1700 Vashon Circle Anchorage, AK 99515 SEPTIC SYSTEM DESIGN Proposed system for LOT 1, BLOCK 8, ELMORE SUB. #2 Test hole excavated 8-27-93. No impervious soil layers were found. Groundwater encountered at 7.8 below ground level (bgl) on the date of excavation. The seasonal high groundwater was measured on 6-2-96 at 4.8 feet bgl. Proposed system will be Biocycle Treatment System with a 5 -ft shallow trench. Percolation test: 7 minutes per inch Application rate: 2.0 gpd/sf (allowed 4.0 gpd/sf) Daily design flow: 450 gpd (150 gallons/day/bedroom x 3 bedrooms) Required Area: 176 sf (450 gpd / 2 gpd/sf = 225 sf. Adjust for 18 inches of septic rock below pipe. 225 x 0.78 = 176 sf Trench length: 35 ft (176 sf / 5 ft) Elevations: Top of MT at TH-1:100.0 ft (temporary bench mark at this rime) Seasonal high water:93.4 ft Field bottom: 95.9 ft Top of septic rock: 97.9ft (depth of rock 2 feet) Finish grnd surface: 99.2 (equivalent 3 ft cover with 2 -in insulation) The installation of this septic system does not adversely impact the development of adjacent lots for on-site water and wastewater systems and is not within the protective radius of any existing private or public water wells installed as of this date. The property is generally flat with a slight slope of approximately 1 percent towards the southwest. Installation of the proposed system will have virtually no impact on the existing drainage patters. There is ample room for both the primary system and a replacement system on this lot. _ t 0 Lu CL 0 J w 7 n z EXIST. WELL RIVERTON AVE. j LOT 1 EXIST. WELL 100 FT t 1 t �l r r � LOT 12 EXIST. WELL E. 145 AVE. ALL EXISTING PRIVATE WELLS WITHIN 100 FEET SHOWN. ALL EXISTING PUBLIC WELLS WITHIN 200 FEET SHOWN. THE PRO- POSED SYSTEM IS NOT WITHIN THE PROTECTIVE RADIUS OF OF ANY KNOWN PRIVATE OR PUBLIC WELL. 16 op °�'f�ssio,,#` LOT 2 (UNDEVELOPED) (UNDEVELOPED) LOT 11 SKLH CONSULTANTS LOCATION MAP EXIST. WELLS & SEWERS LOT 1, BLOCK 8, ELMORE SUB. #2 X 0w LOT 12 EXIST. WELL E. 145 AVE. ALL EXISTING PRIVATE WELLS WITHIN 100 FEET SHOWN. ALL EXISTING PUBLIC WELLS WITHIN 200 FEET SHOWN. THE PRO- POSED SYSTEM IS NOT WITHIN THE PROTECTIVE RADIUS OF OF ANY KNOWN PRIVATE OR PUBLIC WELL. 16 op °�'f�ssio,,#` LOT 2 (UNDEVELOPED) (UNDEVELOPED) LOT 11 SKLH CONSULTANTS LOCATION MAP EXIST. WELLS & SEWERS LOT 1, BLOCK 8, ELMORE SUB. #2 k W J W al N a Z z o J ;W > ui ¢w o Qa z 7 wr N <O zm F O <a a F OQ Owz }w s Ire 4 Lo -i r I N< {+ Z w OD V \ .Y U O J \ ICD N O Z C/3 m grwn ° �+ o 4 xaOwQ N Ono Na=0 V1I F Owz }w `s' m Lo -i r I N< N C/3 m Z �+ 4 Y O_ v m Owz }w `s' m r Q N< {+ Z w . a < ` �� w w W O Q 11-O o> N J a -J 3 <.a y C CL O N Ld O ,WZw -j i I. W� W Lj .4c U 4U ,• OL NOgo LL O -- ~ w rn rJ = U) M N 0) rw co x LLI Y Li Z Lu U wQ77d DU rd Q r O \ (n 0 -- F� ------- w W / i X M.9 J I N 03 S IILL F m to g LU � e Ove l td -04 W 9Z '464 MOO-LO-OON J 3OV-18 N013i w W 3 W Owz }w `s' m Q z Z wam# and=o O� . a < ` �� w o> x w ZO +v2 ozw� min w d ,WZw i I. w W 4U ,• OL NOgo LL O -- ~ w CO LLI e\ wQ77d DU rd Q r O \ � 2 4 -- F� ------- w / i X M.9 J I N S IILL F m to LU -j W Ove l td -04 w w 9Z '464 MOO-LO-OON 3OV-18 N013i S ft -a m O m Y Ec T »o z Q J Q W A CCmO W m17 � mm3 p�LL _oom am Y a m Y 2 0 a 00 Y Y h � 4. r0 N f m d P-17 ft 1 112 ft c 0 m c m IL fq CU N 0 03 V5rn LU ME o c 0I— o w cn w a0 CO Y w U3 t— O 0) ' � aels� e�gsewaedwa 0 03 ulw 31 9 a 40 y'90 'AGI-3•JeJsM m m 0 > > O m C EN 0c w t m3 0; -ulw 31 E "b e Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR:f7'oe %43( GRs`Y DATE PE LEGAL DESCRIPTION:Liif IOMOCIf 441;DYc D,EPT.E7YH Ir-e (DiP J'U3LI 4:t! -)Ajb R007 1 O IyltiT _�Z o 2�a, Z $ 8-93 2U / 4.S" 3 '3s bCfUK l �iC�Ii1� G1iAi`1 4 o. -' : -�; �; VeA CZ CJt= Z5 /L7-, 5 fl ' -" r%pTl�f,!(,jr'.s , IgIGr2EFt."./LIG r CvB3EG% rf, l}GPilf 6 7'7, 8' $�?-7 I �3 8 10 11 12 13 14 15 16 17 18 19 20 Township, Ran SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT J _' DEPTH? Section: Depth to Water After r Monitoring? Date: 9-/3-93 SITE PLAN Reading Date Gross Time Net Time (ytin) Depth iC a Water Net Drop O 8-28- o Z $ 8-93 2U / 4.S" ,S• JPERCOLATION RATE ZJ (minutes/inch) PERC HOLE DIAMETER h TEST RUN BETWEEN XIS' FT ANDC-"0 FT COMMENTS PRE".=OAkE"/7 oW.'V1VIGHT &C -7Q )""`Y2 11,U-7,444a),Q p w 4),c 1,, Cft1�p7F.iJl?" CQ/019,014 MCA, �+ / J PERFORMED BY: VS�sket / L'. I J. �7P/Y(Sj .P CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: eq "ZV =/.3 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: AQ{7C:JC,` Giwq DATE PEI LEGAL DESCRIPTION: LOT / LIiJG',jl (S E1020 oEM49 r rT TOUER.&-/A-Aaj.glav R-oor 2p pi Time (Mo! 3 f%. S g 'Cr D2Y 7J fn,:)J.sT 4ul7;L/ 4- �.... �. Dc P, // Da/15�a rn ^'A-- 10 Depth to Water After ' 5- 11 6 12 13 14 15 16 17 18 19 20 Township, Range, Section: SLOPE / :PIS WAS GROUND WATER ENCOUNTERED? Time (Mo! i c: S g 'Cr /6,5 DEPTH? %Q �.... �. E ^'A-- 10 Depth to Water After ' q q Monitoring? 9.-9 Date: -J-? d A 2—J—? 11 12 13 14 15 16 17 18 19 20 Township, Range, Section: SLOPE / :PIS WAS GROUND WATER ENCOUNTERED? Time (Mo! i Net Drop S IF YES, AT WHAT / L O /6,5 DEPTH? %Q ''rr ^] IR_7 Ly. E _ Depth to Water After q q Monitoring? 9.-9 Date: -J-? d A 2—J—? SITE PLAN JPERCOLATION RATE J21D (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN 16- FT AND FT COMMENTS 1/AKO /?/A/ i:2 4 HQf 915- TN %/MlTE©B 652M ILIL/ES PERFORMED BY: '_5 - HP-/zlec P n I ---_-' �knr �cl� offCERTIFY THAT THISTESTWAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Ci ZC7 ✓3 72-008 (Rev. 4/85) Time (Mo! Depth to Water Net Drop 0 /6,5 0 !/4 MGNet JPERCOLATION RATE J21D (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN 16- FT AND FT COMMENTS 1/AKO /?/A/ i:2 4 HQf 915- TN %/MlTE©B 652M ILIL/ES PERFORMED BY: '_5 - HP-/zlec P n I ---_-' �knr �cl� offCERTIFY THAT THISTESTWAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Ci ZC7 ✓3 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG - PERCOLATION TEST � PERFORMED FOR: /i//p (7 013 i?7- R;a� DATE F LEGAL DESCRIPTION: ZaT [ LShCl< R rfnllYT A% TOWnshID. Ranne. Sectin, XFEEETi- 2 r� � N 3 'V N. 4 V 5 m 7 8 g 10 11 12 OR6HAJ/cs, R6a7 /1747- F/.PST 6�( l�l17GK/ v;DFT py7J5� /'CUA -GK_Y CLi�Y. V_7--rZY /�7or51" 4'alnp oEf�i N, W�1 Tc%t7 SEEPri✓G rvrz:, "OLE Ar c`3 , I 1 11' 13 14' 15 16 17 18 19 20 SLUPE WAS GROUND WATER //�� ENCOUNTERED? 7_<.S IF YES, AT WHAT DEPTH? Qj Depth to Water After 9?�9 Monitoring? O Date: 11 1i PLAN PERCOLATION RATE /✓A (minutee/inch) PERC HOLE DIAMETER TEST RUN BETWEEN — FT AND' FT COMMENTS 4'Y0 /'frYLULL{7/.;JIJ I'G `%' Pc�,,50/2,911'Dj py /rlls. � :PrJIJ ira<?T"s�r'F/ i7-. rci�r i Alae Tn j)T'/E' D!<O a f/L SS'ST /Y7 PERFORMED BY:fYf 1)r'ja -r cS CERTIFY THAT THIS `TEST 7 WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) Municipality of Anchorage Department of Health and Human Services — 825 "L" Street Rick Mystrom, P.O. Box 196650 Anchorage, Alaska 99519-6650 Mayor Dear Homeowner/Prospective Buyer: The on-site wastewater disposal you are interested in purchasing is an "alternative" wastewater disposal system. This system, known as a "Biocycle Aerated Wastewater Treatment System", is undergoing testing within the Municipality of Anchorage under the Alternative System section of the Wastewater Disposal Regulations (AMC 15.65). There are certain risks involved with the ownership of one of these systems: This system has been shown to be effective in other areas. The system is currently undergoing a two year testing period in Anchorage under the guidance of the Department of Health and Human Services (DHHS) and the State of Alaska Department of Environmental Conservation (ADEC) to determine its effectiveness in a subarctic environment. Testing results on systems installed in 1994 have been very encouraging. Copies of initial test results are available from the DHHS. 2. The Biocycle system has not been tested and approved by the National Sanitation Foundation (NSF). Currently, Anchorage Municipal Code for Wastewater Disposal Regulations requires proprietary equipment to have NSF approval. This approval or changes to the Wastewater Disposal Regulations through Municipal Assembly action will be necessary prior to this system being approved as a standard system. If this system fails to meet the requirements set for it to become a standard, code approved wastewater disposal system, it may have to be removed and replaced by either a holding tank or (if possible) other wastewater disposal system that meets Municipality of Anchorage requirements. The cost of any conversions required to meet code requirements will be the responsibility of the homeowner at the time of conversion. 1 (we) certify that I (we) have read the above statements and am (are) aware of the risks outlined. (Purchaser Name) (Purchaser Name) (Purchaser Signature (Purchaser Signature) Notarize Here SJ6SceS6ta An -i -o St,Joen.l ae;p6eG; 1 -AE -HTS Ion -i aAY O� JJntt Ici9�. t�OeTR2Y r�JBts L Fp2 HE S7 -ATE OF AL,aSI<A. Hy C_0K4" -rSSMON EXIPZe6S Hq>e Z2, lata -(' . N • '� ; Municipality of Anchor eNOV 0 2 2015 % On -Site Water and Wastewater Progra (907)343-7904 - Certificate of On -Site Systems Approval' Parcel I.D. 018-172-34 Expiration Date: 2-11.-1,6 1. GENERAL INFORMATION Complete legal description ELMORE #2; BLOCK 8, LOT 1 Location (site address) 14401 TETON PLACE -ANCHORAGE, AK 99516 Current Property owner(s) WILLIAM VACENDAK Day phone 444-8388 Mailing address Real Estate Agent 14401 TETON PLACE *ANCHORAGE, AK 99516 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well © Individual Individual Water Storage ❑ Holding Tank ❑ Community Class _ Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: TANK AND DRAINFIELD TO SURFACE WATER Distance: 70' & 60' Received by� �Date: 1n COSAto be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ '22,� Date of Payment j i�,ltl�r( ht Receipt Number C/fg D"�SL COSA # osc[ J 1(0Di i Waiver Fee $ �' Sri Date of Payment ! // W /,5- Receipt Number MOW& /waiver# (95V16'jt4q 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Garness Engineering Group Ltd. (GEG) Phone _(907) 337-6179 Address 3701 E. Tudor Road, Suite 101 Anchorage AK 99507-1259 Engineer's Printed Name Jeffrey A. Garness Date !t) fru%MS In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend on a variety of variables including, but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the - event either of the current systems fail. The content of this report is for the sole benefit of the person/party who retained GEG. Reliance upon the information provided in this report by any other person orparty, including but not limited to subsequent property purchasers, is not authorized. In short, GEG disavows any legal duty to anyone other than the person/party who paid for this report. 6. DSD SIGNATURE r/ System #1 Approved for 3 bedrooms 0 The Municipality of System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms, with the following Original Certificate j2Y OEgNcyo ON-SITE WATER AND rr WASTEWATER o- is.PROGRAM �; �e r•Q\ ' Services Division (DSD) issues Certifcates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist (� Septic System Advisory Well Flow Advisory COSAbluesheet 9-1-12.doc Nitrate Advisory Arsenic Advisory Other H more than 1 septic system Is on the lot: COSA Checklist # _of_ Structure served by this system _ Certificate of On -Site Systems Approval Checklist Legal Description: ELMORE #2; BLOCK 8, LOT 1 Parcel ID: 018-172-34 A. WELL DATA * me Well type PRIVATE If A, B, or C provide PWSID# N A Date completed 1 /10/72 Sanitary seal (Y/N) YES Total depth 114 ft. Date of test Static water level Well production Cased to 114 ft. FROM WELL LOG WATER SAMPLE RESULTS: 1/10/72 80 ft. Coliform 0 colonies/100 ml. Nitrate 0.81 mg./L. Arsenic: NO ug./L. Date of sample: 10 /6 /15 B. SEPTIC/HOLDING TANK DATA Tank Type/Material BIOCYCLE/FIBERGLASS Tank size 1500 gal. Number of Compartments 4 Well Log (YIN) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 10/2/15 ft. 3.5+ g.p.m. Collected by: GEG. Ltd. Date installed 9/26/96 Cleanouts (YM) YES Foundation cleanout (YM) YES Depression over tank (Y/N) NO High water alarm (YIN) YES Date of pumping AS NEEDED Pumper SEE MAINTNENCE REPORT C. ABSORPTION FIELD DATA BELOW EXISTNG GRADE TO BOTTOM OF SOUTH MT Date installed 9/26/96 Soil rating (g.p.d./feo /bd 2_0 System type SHALLOW TRENCH Length 45 ft. Width 5 ft. Gravel below pipe 0.5 ft. Total depth *2.8 ft. Eff. absorption area 225 ft' Monitoring tube YES Depression over field NO Date of adequacy test 10/2/15 Results (Pass/Fall) PASS For 3 bedrooms Fluid depth in absorption Feld before test o in. Water added 457 gal. New depth 5 in. Elapsed Time: 120 min. Final fluid depth 1 in. Absorption rate >= 450+ g,p,d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give data MT ON NORTH END OF TRENCH ONLY EXTENDS 1" INTO THE EFFECTIVE. MT ON SOUTH END OF TRENCH EXTENDS 6" INTO THE EFFECTIVE. D. LIFT STATION BIOCYCLE *PER BIOCYCLE ALASKA*PER CARCEL ELECTRIC IN 1996 Date installed 9/26/96 Size in gallons 1500 Manhole/Access (Y/N) YES "Pump on" level at *27 in. "Pump off' level at*23 in. High water alarm level at *31 in. Datum BOTTOM OF TANK Cycles tested N/A Meets alar & circuit requirements? **YES E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main Sewer /septic service line 25'+ Animal containment areas 50'+ Public sewer manhole/cleanout 100'+ Holding tank Afti Manuretanimal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 1 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water *70'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10+' Water service line 10'+ Surface water *65' Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *SEE ATTACHED WAIVER REQUEST G. ENGINEER'S CERTIFICATION I certify that I have determined through feld 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 It h ZIS (Rev. 11105) October 28, 2015 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Ref: Waiver Request from Septic Tank & Drainfield to surface water. Elmore #2; Block 8, Lot 1 To whom it may concern: We request that your department issue a 60 -foot waiver from the existing drainfield on Lot 1 to surface waters located to the southeast (see attached drawing). Additionally, we are requesting that your department issue a 70' waiver from the existing septic tank on lot 1 to the previously mentioned surface water to the southeast. Justification for requesting this wavier are as follows: • The subject lot has a MOA approved CAT II system (Biocycle). The effluent quality is much higher than that of a standard drainfield. Furthermore it has an alarm system to notify the owner of a high level condition. • The area between the drainfield and the surface water is vegetated (lawn). • The drainfield is located in a highly visable area. If effluent were to overflow, it would be easily recognizable by the homeowner, or the Biocycle maintenance provider. • There is a maintenance agreement between the home owner and the AWT service provider. The system is inspected a minimum of twice per year. We are unaware of any adverse impacts this waiver would have on adjacent wells or septic systems. P.E., M.S. 3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259 Phone: (907) 337-6179 * Fax: (907) 3383246 * Website: www.gamessengineering.com A GARNESS ENGINEERING GROUP, Ltd CIVIL & ENVIRONMENTAL ENGINEERS October 28, 2015 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Ref: Waiver Request from Septic Tank & Drainfield to surface water. Elmore #2; Block 8, Lot 1 To whom it may concern: We request that your department issue a 60 -foot waiver from the existing drainfield on Lot 1 to surface waters located to the southeast (see attached drawing). Additionally, we are requesting that your department issue a 70' waiver from the existing septic tank on lot 1 to the previously mentioned surface water to the southeast. Justification for requesting this wavier are as follows: • The subject lot has a MOA approved CAT II system (Biocycle). The effluent quality is much higher than that of a standard drainfield. Furthermore it has an alarm system to notify the owner of a high level condition. • The area between the drainfield and the surface water is vegetated (lawn). • The drainfield is located in a highly visable area. If effluent were to overflow, it would be easily recognizable by the homeowner, or the Biocycle maintenance provider. • There is a maintenance agreement between the home owner and the AWT service provider. The system is inspected a minimum of twice per year. We are unaware of any adverse impacts this waiver would have on adjacent wells or septic systems. P.E., M.S. 3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259 Phone: (907) 337-6179 * Fax: (907) 3383246 * Website: www.gamessengineering.com ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT BETWEEN MUNICIPALITY OF ANCHORAGE AND J UJ i a 6ay I'e nd Thor- W 00013e 1t THIS MAINTENANCE AND REPAIR AGREEMENT made and entered into as of this %± Day of hLVMLer of 20_L6-, by and between J Ll 461 bay t e S herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY." In consideration of the mutual covenants contained herein, the parties to this Maintenance and Repair Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. Municipality grants permission to Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as located at (legal description). j51mor, al#Z Gc5 L 1 I�fi0l Te-7twl Pl 4K fgg1 , 2. Definitions. Alteration. Any change to the design or function of an AW WTS that includes the installation or removal of any parts, components or pieces not included in the original construction permit and design. Certificate of On -Site Systems Approval (COSA). An approval by the Municipality of existing water and wastewater disposal systems given at the time of property sale and title transfer in accordance with Anchorage Municipal Code (hereinafter, "AMC') 15.65. These approvals certify that the systems are adequate for the homes that they support and meet the codes that were in place at the time of system construction. Damage. Any man-made or natural change in a system that would inhibit the system from performing as designed. Maintenance and Repair. The scheduled and as needed replacement of existing parts, components and pieces of an AWWTS that were included in the original design which would allow the AWWTS to continue to perform as designed. ? Permit. An On -Site Wastewater Disposal Permit as required by AMC 15.65 to construct and operate an AWWTS. 3. Term. The term of this Maintenance and Repair Agreement shall begin on the date of approval by the Municipality to operate the installed system or issuance of a COSA, and shall continue while the AWWTS is in use or is operational or until the property is sold or title is transferred by the owner and a new COSA is issued to the new owner or transferee of the property. 4. Alterations, Installation and Removal of Additional Equipment. Prior to performing any alterations to an AWWTS, the owner agrees to obtain an On-site Wastewater Disposal Permit from the Municipality in accordance with AMC 15.65. 5. Maintenance and Repairs. A. Throughout the term of this Maintenance and Repair Agreement, the Owner shall maintain their AWWTS in a satisfactory condition capable of producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. The owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the municipality and the manufacturer of the AWWTS for the entire term of the AWWTS. In addition, it shall be the responsibility of the Owner during the term of this Maintenance and Repair Agreement, and any renewals thereof, at the owner's sole expense, to pay for any and all: (1) repair(s), (2) maintenance, (3) adjustment(s), (4) replacement costs, and (5) inspection costs. B. Owner agrees to comply with all applicable ordinance, laws, regulations, rules and orders for the AWWTS. C. Upon request by the Municipality, the owner agrees to provide the Municipality a written schedule of routine maintenance and repairs which have been performed on the system. When a record of maintenance is documented and maintained by the system vendor, the owner agrees to allow the Municipality access to this information. D. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60 for improper discharge. E. Owner agrees that only maintenance and repair personnel approved by the Municipality will inspect and make any necessary maintenance, repairs or permitted alterations to the system. F. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS upon 24 hours written notice. G. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. H. Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the Owner's AWWTS. 1. Owner agrees to provide and maintain a telephone connection to the AWWTS as required by the AWWTS approval. 6. Nonwaiver. The failure of either parry at any time to enforce a provision of this Maintenance and Repair Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Maintenance and Repair Agreement or any part hereof, or the right of such party thereafter to enforce each and every provision hereof. 7. Amendment. A. This Maintenance and Repair Agreement shall only be amended, modified or changed by a writing, executed by authorized representatives of the parties, with the same formality that this Maintenance and Repair Agreement was executed with, and such writing shall be attached to this Maintenance and Repair Agreement as an amendment. B. For the purposes of any amendment modification or change to the terms and conditions of this agreement, the only authorized representatives of the parties are: / a. Owner: �UILIra IJdVIpe, b. Municipality: Director, Community Development or desienated authority C. Any attempt to amend, modify, or change this contract by either an unauthorized representative or unauthorized means shall be void. 8. Jurisdiction: Choice of Law. Any civil action arising from this Maintenance and Repair Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Maintenance and Repair Agreement. 9. Severability. Any provisions of this Maintenance and Repair Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Maintenance and Repair Agreement. OWNER: By: (signature) Date: t,.. (print name) STATE OF ALASKA THIRD JUDICIAL DISTRICT The foregoing instrument was 2C G , byJRmMI&-_j�)� IARUBLIC FOR My Commi ion expires: MUNICIPALITY: ss. '1 -d before me thisQrddayof 13D -J, By: (signature) name) Date: Title: C. Any attempt to amend, modify, or change this contract by either an unauthorized representative or unauthorized means shall be void. 8. Jurisdiction: Choice of Law. Any civil action arising from this Maintenance and Repair Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Maintenance and Repair Agreement. 9. Severability. Any provisions of this Maintenance and Repair Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Maintenance and Repair Agreement. OWNER: BY: (signature) Date: Io 3n l5— (print name) STATE OF ALASKA THIRD JUDICIAL DISTRICT The forego 20Y, , by My MUNICIPALITY: ss. ed before me this day of By: (signature) name) Date: Title: XARY ,p PUSoo iiyeof i -A� Z ' �4 �DA EkOIfB�' h MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING Parcel I.D. # 018-172-34 HAA # 1. GENERAL INFORMATION Complete legal description FI MORE SUBDIVISION 42: LOT 1. BLOCK 8 Location (site address or directions) 14401 TETON PLACE ANCHORAGE AK 99511 Property owner BOB AND ROSEANNE GRAY Day phone (907) 345-1287 Mailing address 14401 TETON PLACE ANCHORAGE. AK 99511 Lending agency Mailing address Day phone Agent CLAIR RAMSEY w/ DYNAMIC PROPERTIES Day phone (907) 261-7600 Address 3111 "C" STREET ANCHORAGE AK 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 XXX NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xxx Holding Tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC ing to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 Computer version Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1,000.00 at, or prior to, closing for the engineering services provided. 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Muni�!pal and State codes, ordinances, and regulations in effect on the date of this inspection. ,moi Name of Firm Engineer's Phone (907) 337-6179 in conducting this evaluation, AWWC, 1 c. httbihpted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC andPOA DUHS Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, ground water levels that may fluctuate during the year, and the water o�00 usage of the family being served by the system. These conditions are outside the control of opo F the evaluator of the system. Satisfactory test results do not guarantee future performance o of the system, nor do they guarantee that there are no hidden defects or encroachments. ' AWWC, inc. can therefore not provide any warranty for future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DHHS. * , , , , The content of this report is for the sole benefit of the owner listed above. Any 1 t reliance upon or use of this report by any other person or parry is not authorized, nor will it confer any legal right whatsoever. a •.J fff A. Gan 6. DHHS SIGNATURE E-79 Z Approved for 3 bedrooms Disapproved Conditional approval for Additional Comments 0 U/ bedrooms, with the following stipulations: Date a _-Z 3--0 0 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1191) Back MOA #21 Computer Version kECEIVEL) Municipality of Anchorage AUG 22 2 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division MUNICIPALnY of A 825 "L" Street, Rm 502 Anchorage, Alaska 99501 (907) 343-4744NMENTAL 3ERvt Health Authority Approval Checklist Legal Description: ELMORE SUBDIVISION #2; LOT 1, BLOCK 8 Parcel I.D.: D18-172-34 A. WELL DATA Well Type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number N/A Log present (Y/N) YES Date completed 1/10/72 Total depth 114' Cased to 114' Casing height (above ground) 32" Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES FROM WELL LOG Date of test 1/5/72 Static water level 80' Well production 5 g.p.m. WATER SAMPLE RESULTS: AT INSPECTION 8/17/2000 46' 5.1 g.p.m. Coliform O Nitrate 0.57 mg/L Other bacteria 0 Date of sample: 8/17/2000 Collected by: A.W.W.C., INC. B. SEPTICIHOLDING TANK DATA *BIOCYCLE Date installed 9/26/96 Tank size *1500 Number of Compartments 4 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression (Y/N) NO High water alarm (Y/N) N/A Date of Pumping 8/17/2D00 Pumper A+ HOME SERVICES C. ABSORPTION FIELD DATA [NORTH/SOUTH] Date installed 9/26/96 Soil rating .p.d./ rft2/bdrm) *2.D System type JEM TRENCH Length 45' Width 5' Gravel thickness below pipe 6" Total depth 3.4' Effective absorption area 225 SO FT Monitoring Tube present (YIN) YES Depression over field (YIN) NO Date of adequacy test 8/17/2000 Results (Pass/Fail) PASS For 3 Bedrooms Fluid depth in absorption field before test (in.); 0/0 Immediately after 540 gal. water added (in.):2.75" 3.0" Fluid depth O/O (ins) Minutes later: 628 Absorption rate = 450+ Peroxide treatment (past 12 months) (Y/N) NONE KNOWN If yes, give date ----- 72-026 (Rev. 3196)' computer Version D. LIFT STATION *PER BIOCYCLE ALASKA Date installed 9/26/96 (1310CYCLE) Size in gallons 1500 Manhole/Access (Y/N) YES "Pump on" level at* *30.5" "Pump off' level at* *19.5" High water alarm level at* Cycles tested 45" *Datum BOTTOM OF TANK E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main Public sewer manhole/cleanout N/A Sewer/septic service line zo + Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: 100'+ Foundation 5'+ Property line 5'+ Absorption field 5'+ Water main/service line 10'+ Surface water/drainage 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main/service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage area 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. ENGINEER'S I certify that 11 of Municipal ryry with MOA H4 Engineer's Id inspections and review stems are in conformance this date. HAA Fee $ v Y -D` ery Date of Payment / Receipt Number 72-026 (Rev. 3196r Computer Version Waiver Fee Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # LZ6172:34 HAA# \f�� �(C i 1. GENERAL INFORMATION Complete legal description Oct R/CCk 6 -CL,- 2. 3. 4. Location (site address or directions) 144e/ %r' 'm A)jk"%)o Loc_ Property owner Day phone .562 -5 23-� Mailing address r C, ,LSCA /IG -5G5 /-11)C HK 1 Lending agency Nci,' CO2S'/ )!X1 in?l Day phone Mailing add Agent Address — Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water 3 Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site _�— Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. IM) Front MOA 021 S. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate forthe 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 conaa/&wt S Phone 344"7r9& Address Engineer's signature 6. DHHS SIGNATURE rr Approved forE 13 bedrooms. Disapproved. Conditional approval for Additional Comments Date 17fil) ,97 bedrooms, with the following stipulations: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto 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 N21 ENVIRONMENTAL SERVICES DIVISION FEB P�-r~'7 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES E C. E I V E Environmental Services Division LA 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: LC f 13M 2 Parcel I.D.: C%/�f72�4 A. WELL DATA Well type PVT If A, B, or C, attach ADEC letter. ADEC water system number Nf/ Log present (Y/N) Y Date completed / —/ c 72 - Total depth 114 Cased to 114 Casing height (above ground) Sanitary seal (Y/N) Date of test Static water level Well production WATER SAMPLE RESULTS: FROM WELL LOG -5-72- Wires properly protected (Y/N) AT INSPECTION 1 -le ..97 Coliform Nitrate C , 3�-I m -T Other bacteria Date of sample: 2B , /Cw6L0/Y '.97 - Collected by: 9— p.m- B. SEPTIC/HOLDING TANK DATA 9(, srt Date installed _9'2i� • � Tank size/C t Number of Compartments 4 Cleanouts (Y/N) N/ Foundation cleanout (Y/N) Y Depression (Y/N) / High water alarm (Y/N) Date of Pumping /V/, Pumper /v/% /VELA' /,hiZ7//ahi '71. C. ABSORPTION FIELD DATA96 Date installed 3 26 ' 9-ir- Soil rating q .p.d./ft or ft2/bdrm) 2 System type Length 4J Width 5 ' Gravel thickness below pipe _Total depth Effective absorption area 22.5 Monitoring Tube present (Y/N) Y Depression over field (Y/N) _ i Date of adequacy test A//A Results (Pass/Fail) /VFX' For bedrooms Fluid depth in absorption field before test (in.); IVI-) Immediately after= gal. water added (in.): Fluid depth / W (ins) Minutes later: AO Absorption rate = /VA g.p.d. Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)' If yes, give date _ /v'A D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at` _ Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at` 'Datum "Pump off" level at' SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot On adjacent lots %%CoS: 0Ver 256 Absorption field on lot / // On adjacent lots 296' 246 Public sewer main AIMO Public sewer manhole/cleanout 1\107-le- Sewer \107'1P. Sewer/septic service line Lift station NA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 19 Property line 27 Absorption field Water main/service line ,50Surface water/drainage AIAWe, Wells on adjacent lots 26C SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / / Building foundation 38 Water main/service line 75 Surface water 1i 6)z kb1) i lj'i M n /G+C Driveway, parking/vehicle storage area Curtain drain More E6and da /hil') &5 Wells on adjacent lots 241 F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal in conformance w'th MOA HAALguidefines in effect on this date. Signature Engineer's Na e 5 L'G17 Date 29 ,Tjzzuarta `.5'7 HAA Fee $ 36-z' ` Waiver Fee $ Date of Payment/2yl % l Date of Payment Receipt Number 3% ��� 1 Receipt Number 72-026 (Rev. 3/96)' r°t the abbvesyst rns are Ce ,q Ara e 7 '•x�«zw �T "