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GREAT LAND ESTATES #3 BLK 4 LT 12
Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3 ON -SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211099 PID Number, 05113327000 Dwelling: ff Single Family (SF) El with ADU 0 Duplex (D) El Two Single Family Project: E] New W, Upgrade Name JODEN TRUST ABSORPTION FIELD R Deep Trench R Wide Trench F1 Bed R Mound Site Address 19712 CHUGACH PARK DR [I Other Phone Number of Bedrooms Soil Ra6rig Total depth from original grade 227-2362 14 GPD/SFI Fl LEGAL DESCPJPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Fi Subdivision Block Lot Great Land Est #3 B4 L 12 Fill added above original grade Ft. Gravel length Fl Township Range Section Gravel vAdth Beds: Number of Lines Ft. Distance between lines Fi SEPARATION DISTANCES TO Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist between trenches From Tank Field Tank Line Ft' R welt 1001+ na na 1251 + TANK X, septic 0 S.T.E.P. El Holding [I Other Manufacturer Capacity GREER-deep 1500 Ga Surface Water 100'+ na na Material Number of compartments Pistc 2 NA Lot Line 10*+ na na Foundat !on lot+! 77 na na LIFT STATION Manufacturer Capacity Remarks Ga Alarm location Electrical installed by PIPEMATERIAL 1--touse to tank D3034 d Tankto D3034 rainfield Installer Dean Drainfield COIMTD3034 Inspector NorthRim Eng. BENCH MARK (Assumed elevation) 100 ft Inspection im 4f2l/21 4/22/21 tion and description dates, 2r'13 th Lr� rch r 4 ON -SITE WATER AND WASTEWATER SECTION APPROVAL IP OF Conditional Approval: Date Septic System Steve Eng Approved CE-6256 ';F 4W Date �Pjr Note: 5/ 1-3 2�r this approval does not include well permit requirements, N OR THRIM ENGINEERING SteveEng. com PO Box 770724 igle River. Alaska 99577 4 jr,", . * �GREAT LAND ESTATES #3 PRI. BUICK 4 LEIT 12 WASTEWATER 1' = 6 0' S ;S� b U (Y) N L 4- F- i o 06 �W =� ( zj �£ �3 tn Cl- v L� Q7� L ~ ` � ^. W N O z n, a L GC p Ul € U un 4 V W 0 0 `� � U In ` � 1 ~ OJ Lij ad, u �, n r � P� in rn ON Ln.. o o O u L a o_ o 3 p L o d N C > a, w a, W W LJ z ul< o a, L W LLJ j U al d > o O M > O > E_ F--I F--1 Q i {— r/ C J u L O_F- n W do F- E OW o C) o L �t O d > p aj .�-� t�a►�wMMy w..., > a, o W : ,. - (1J s =s Qy :' g d 04 -P d @J n co o'�oO1, o oZ N U o O t� > � p� n ~z W ue � 0 3 O� LEGEND: AS —BUILT CERTIFICATE: / �� I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND LICENSED TO 2" ALUMINUM CAP ON 5\8" REBAR FOUND PRACTICE LAND SURVEYING IN THE STATE OF ALASKA,THAT THIS s 5\8" REBAR FOUND w DRAWING REPRESENTS A SURVEY MADE BY ME,THAT THE MONUMENTS SHOWN HEREON ACTUALLY EXIST AS DESCRIBED,AND THAT NO (REC) RECORD INFORMATION FROM PLAT 73-184 Lu ENCROACHMENTS EXIST EXCEPT AS INDICATED. 1O'X25' (MEAS) MEASURED DATA,-- w w ANCHOR � EASEMENT SEWER LINE, - Of 9/3/2025 10406 BURIED PAER coo Y DATE 71�n % ,,,��,, REGISTRATION NO. Q ��� Y w p o i� Q "Lin 0coyyw I 0QC)w i REGISTERED LAND SURVEYOR LOT 10 COw< irk c=) JOHN P. O'CONNOR Q s�32ss �c CD CD F = ''``N",1 ------------- 1 �40�� .. Q .. LOT 13 U3 3ROWocoyvial �*: 49 4b o v �� .. JOHN P. O'CONNOR "' �W ��v w p, , n� . LS-10406 _�j AW w / F DATE 9/3/2025 J� voi BLOCK 4 CO�z't ��Fo' ... a�� LOT12 I <v ��v�0 ,.AROFESSIONA 2.72 ACRES °� 3? Z <c* lq LOT 2 CURVE DATA N�� '� i ��� N� 24, �� �� ;' ° EXCLUSION NOTE: Cl: RADIUS=170 �p� 8' ��NA Y ,� DELTA=42'30'12" V IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE LENGTH=126.11' THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR CHORD LENGTH=123.24 I v� RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED CHORD BEARING=S21'11'16"W ^ o� I �° O SUBDIVISION PLAT.UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OR BOUNDARY LOCATION. AS —BUILT SURVEY OF LOT 12 BLK 4 GREAT LAND ESTATES UNIT No. 3 RECORDED IN THE ANCHORAGE RECORDING I DISTRICT: PLAT # 73-184 `p�iC"���, SOUTHWEST ALASKA SURVEYING ��P 2800 N. PARK DR. ��� LOT 1 WASILLA,AK 99654 -- 302.76' REC p`ry' PHONE OFFICE 907-373-1607 CELL 907-631-2503 S87106 30 E P��� LOT 11 / 0 SCALE: 1 "=60' Certified Drilling Log, O Doc CO dba BILL S. COLE ULLIVANO WATER WELLS 0 P.O. Box 670269, Chugiak, AK 99567 688-2759 OWNER OF LAND: 10 Oxentenko ADDRESS: 19712 Chugach Park Dr. Bore Hole Data Depth From To LEGAL DESCRIPTION Great Landestates #3 BLK 4 LT 12 DATE: 5/1/2023 0 2 Casing Stickup PERMIT NUMBER: OSP231076 DATE OF ISSUE: 4/24/23 TAX IDENTIFICATION NUMBER 05113327000 is well located at approved permit location: ®Yes ❑No Method of Drilling: ®air rotary cable tool Depth of Well: 140' Casing Type: Steel Wall thickness .250 inches Diameter: 6 inches, depth 140 feet Liner type Static Water Level: 79 feet Recovery Rate 4 ® gpm gph Method of Testing Air Well Intake Opening Type: ® open end open hole Screened Start feet Stopped ® Perforations Start 90 feet Stopped 98 Grout Type: Bentonite Volume: 50lbs. Depth: from 2 feet, to 42 feet Well Disinfected Upon Completion: ®yes ❑ no Method of Disinfection: Chlorine 50 PPM Comments: 2 4 Overburden 4 15 Sand & Gravel 15 18 Sand 18 28 Sand and Gravel 28 30 Sand 30 98 Sand and Gravel 98 140 Bedrock Drillers Name: Cole Sullivan ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. Matsu Borough: Department of Environmental Conservation. C 1PA"ITY OF ANCIIHORAGE Pl��IIUW-," vvv%n, R Legal Address: I Subdivision L71'e-ed- I T _R Section Lot On -site Water & Wastewater Section certified contractor performing the well decommissioning: N7 -7 Signature: Co pan - Well decommissioning date S LZ "j, 2 Method of decommissioning: AMC 15.55.06OL1 a. F❑-1 b. n C.P�_ 1 Location: Use the space below to provide a drawing of the property showing the following items: • North arrow • Decommissioned well location • Location of other water wells on the property • Two separate swing -tie distances for each well shown on the drawing ote: The swing -tie distances shall be measured from either permanent structures or the property corners. C�/ Site Water and Wastewater\FormskCRenf Forms)Well R i A I a Tll LLIVA VVJ3 101 VV— Avi 'N PUL," LOg -s zs, i a,-n re 4 c L Pik '71 FAI Pump inStlal!at7W 'Da.11--e: mip lnzak,, De,),4 -op oF \Avei� e E5 P'LlMr, N`Odel: PumSize: p Ditiess Adapt��,,- Burila�� De,'pt-sh� fee Disin-fected Upon Conn, "on cHna Stu-,, 1:1PP"Aii ,-omments: pitless B I clek Ifivan IlValier �, ens (—r')Xe,-,l -f Oq kv AtteniLtion- The ,,, r�s t -,-Fjj r -:�— ', ha providie a jc�urnp M rip, a, 11 _1, i) WATER OLLAUTY TESTING EST ING Colifbrm C, C01/100ML Mtrates L n]l- M91L Arsenic n 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 Water System Permit Permit Number: OSP231076 Work Type: Well Upgrade Tax Code Number: 05113327000 Site Legal Address: GREAT LANDESTATES #3 BLK 4 LT 12 G:1260 Site Mailing Address: 19712 CHUGACH PARK DR, Chugiak Owner: JODEN TRUST Design Engineer: This permit is for the construction of: Effective Date Expiration Date Lot Size in Sq Ft Total Bedrooms: it 0 I DeI)aI-tIII ell t 4/24/2023 4/24/2023 4/23/2024 118483 ❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy Q 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: 4 Permit OSP211099 was issued to replace your septic tank. When a new survey is completed to capture the location of the new drilled water well, please provide this survey to North Rim Engineering so they can submit their final inspection report and record drawings. Recognize that the septic pipes visible above grade on lot 13 do not represent the full extent of the septic field. The underground septic bed is sized 15'x 34' and is approximately centered on the visible septic pipes. The new well is to be 1 00'from the edge of the field, not necessarily just from the closest septic pipe on lot 13. To close this water well permit please submit: • Well Log • Pump Install Log • Water sample results; nitrate, bacteria, arsenic • Well Decommissioning Log or justification that the existing well remains connected to the house water plumbing. • new as built survey Received By: Date: r� Issued By: Date: Z ?'0 a- MUNICIPALITY OF ANCHORAGE 4 Development Services Department \ '}�`° .`aT / Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 05113327000 Property owner(s) JoDenTrust (Jo Oxentenko Albert Ball) Day phone 907-227-2362 Mailing address PO Box 671527 Chugiak AK 99567 Site address 19712 Chugach Park Dr Chugiak AK 99567 Legal description (Sub'd., Block & Lot) Great Land Estates #3, Block 4, Lot 12 Legal description (Township, Range & Section) Lot Size 118,483 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: (® all that apply) Absorption Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ED Water Storage ❑ APPLICATION IS AN: Initial Upgrade Renewal ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: TYPE OF DWELLING: Single Family (SF) 0 (w/wo ADU) Duplex (D) ❑ Multiple Dwellings ❑ (SF and/or D) Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Si (ature of property owner or authorized agent) Permit/Rush Fees: Waiver Fees: Date of Payment: Receipt Number: Permit No. (2'5p2'3IO%,6 Date of Payment: Receipt Number: Waiver No. G:Oevelopmenl ServiceslSuilding SaretylOn Site Water and WastewalefformslCllent FormsTermit Application.doc DenJo Trust (Jo Oxentenko & Albert Ball) Lot 12, Block 4, Great Land Estates ##3 19712 Chugach Park Dr Well Permit April 21, 2023 Attached: On -Site Septic/Well Permit Application On -Site Water and Wastewater Fees form Copy of survey dated 4/17/23 showing the location of new well and other Our new well will be drilled approx 10 feet from our existing well toward our property line. The location of the new well will be: • Aprox 10 feet north from our current well • Aprox 107 feet from our northern Neighbor's (Lot 13) septic system • Aprox 118 feet from our septic system (lot 12) • Neighbor across the street's (Lot 2, Block 7) septic system is well over 100 feet away. Using the recorded engineers survey, 100' radius of the septic doesn't completely cross Chugach Park Dr. This would make it impossible to be within 100' of our well. • All other neighbors are too far away. There are no other hazardous waste or potential pollutants (petroleum hydrocarbon storage tanks, animal containment areas or manure/animal excreta storage area) located within 150 feet from our new well site. Once the new well has been drilled, we will provide the city with a completed as -built survey to satisfy both our septic permit from 2 years ago and our new well permit. Regards, o Oxentenko 907-227-2362 alaskanjo@hotmail.com r- 0 O X76 REC so w o oozQ2 C f1 _ 111x mm NV Zoe Z N v ;u d �l=N n v � •N �000,1111 r ? p m rn "r -a) m n I4 06 D N R _ m n — Hamoli� —g N F ask/p c AO r Z FFnCF 2 Ck�RY CFckO�pSFO Y / o�� ���" \ \ m z A O N R r� X c \ ��o 0 D Z D SFp 0 0 G 90 S}S �c \z z w tiw as. `� 2�°s �� o co 0. ?.je�/� 39a' �o fF��ti co� \S� 1 > \ W �� c .p. 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LZS=ONl2JV38 02JOHO VZ'CZ L=HlON3-1 0210HO L L'9Z L=HlON3-1 „Z L,OC.Z'b=Vl-130 OL L=Sn10M21 : L0 SMOV ZL'Z Z U0l $1>I0018 vivo 37855 0 L 10-1 �I r\ 101 ��ap I o� iaa� 1 2� N w I �=mo co ��_ / ��NO) a / 100 O N " / \ 213N0d 03RJn8 < \ / 3N13 2J3M3S 1N3W3SV3 2i0ZX,Ol yl VIVO 03HnSV3W (SV3W) Mi Vet-U-1Vld W02JA NOLLVW2103N1 02100321 (0321) mONnOd ZI 21V83N „8\9 O �I ONnOd 2JV8321 „8\9 NO dV0 WnNIWn-iv „Z \ �aN303-1 \ 0 L 10-1 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: OSP211099 Work Type: SepticTank Upgrade Tax Code Number: 05113327000 Site Legal Address: GREAT LAND ESTATES #3 BLK 4 LT 12 G:1260 Site Mailing Address: 19712 CHUGACH PARK DR, Chugiak Owner: JODEN TRUST Design Engineer: NORTH RIM ENGINEERING This permit is for the construction of: Effective Date Expiration Date ,.S' Q DeI)artment Lot Size in Sq Ft: Total Bedrooms: 4/15/2021 4/15/2022 118483 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage CI 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: 1. Locate the the field prior to construction to confirm that the 5' separation between the tank and field will be met. 2. FYI: The septic system on Lot 13 may be within the well radius. Received By: Date Issued By: Date MUNICIPALITY OF ANCHORAGE Development Services Department �� Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-133-27 Property owner(s) JODEN TRUST Day phone 227-2362 Mailing address 19712 Chugach Park Dr Site address same Legal description (Sub'd., Block & Lot) Great Land Est #3 B4 L12 Legal description (Township, Range & Section) Lot Size 118,483 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank 0 Upgrade 0 Duplex (D) El Holding Tank ElRenewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A 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 rized agent) Permit/Rush Fees: Z25 Waiver Fees: Date of Payment: M717-1 Date of Payment: Receipt Number: D( 6n�; .D Receipt Number: Permit No. 05,0 Z I I C) q Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc SteveEng.com Steve Eng, PE, PH 907-694-7028 SteveEngPE@gmail.com Date: 4/5/21 Number of Pages: To: MOA On-Site Services Subject: Great Land Estates #3 Block 4 Lot 12 Septic Tank Failure The subject septic tank has failed- a new tank will replace the old one. The existing seepage trench appears to be working OK. Please issue a permit so the tank can be replaced. Please review as soon as possible. This is a large lot with no nearby neighbor conflicts. If there is need for additional information or clarification please give me a call. Thanks-Steve Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211099, Deb Wockenfuss, 04/15/21 Great Land Estates #3 Block 4 Lot 12 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: The current septic tank has failed- the seepage trench still functions. This lot is small with nearby wells drawn on plan sheet. No adverse impacts are expected from tank replacement. The easements are depicted on the lot. The slope is indicated in the area of the septic system. No conflicts to neighbor properties. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. New 2- compartment, 1250 gallon septic tank. Watertight couplings on inlet & outlet. 5 minimum between the tank and trench. 5 to property lines & 10 to house. 4 of cover or insulation is required for tank; an equivalent of 1 insulation for 1 foot soil cover. Tank & solid pipe must be set on well compacted, stable soil. No large rocks for tank bedding. Plastic/fiberglass tanks require special bedding per MOA- sand or pea gravel. 4 diameter cleanouts with airtight caps are required 1 to 4 from foundation wall, prior to any 90 degree bend in 4 inch line, in 2 nd tank compartment, and two adjacent opposing cleanouts between the tank and the absorption field, not more than 10 from the tank positioned to provide cleanout access towards the tank and towards the absorption field. Manhole Riser required in 1 st tank compartment. All cleanouts must extend to at least ground level. In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron. Insulation must be placed over any pipe installed under driveways or parking areas. Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, Sewer Service Line is minimum 2% slope. Septic Tank to be pumped every two years or when required. Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211099, Deb Wockenfuss, 04/15/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211099, Deb Wockenfuss, 04/15/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211099, Deb Wockenfuss, 04/15/21 ~,,~, MUNICIPALITY OF ANCHORAGE ~_~-,~/r- DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ~~ ~i ~ , ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME / PHONE I ~EW LEGAL DESCRIPTIQN / LOCATION / NO. O~ ~EDROOMS ]el Absorption area Dwellin9 Z PERMIT NO. ~ ~ ~nU~C~UF~F ~F~ NO, o~ comp~Ftments i~ I~ HOE~AD~: ~ ~ ~ll D~l~n~ P~IT NO. DISTANC~ TO: ~ ~ ~ ~nu~ctuF~F ~F~I L~qu~d c~P~C~W ~n g~llons ~Zm DISTANC,~ TO:~l~~~--~ ~ound~don~ ~ N~s~lo~ Hn~6 ~ P~H~IT~~NO. ~ Z ~~ No. of lines / Lengt~f,-~c? line Total length ~°f lines, Trench width.~ inches Distance,~between lines ~ ~ ~ Top of tile to finish grade ~ Material beneath tile Total effective absorption area Length Width Depth PERMit NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMit NO, Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: PleAT ER IA LS~ INSTALLER RE~ARKS A~ ~ DATE LEGAL 72-0~3 (Rev. 3/78} PERMIT N0. ~Y~I~! L~'' H~HLIH Hr~ ~¥~U~PI~IHL 825 "~/STREET, MNCHORMGE, MK. ~.~ ' R64-47~0 I.~ELL ~-~[:~ ~]~-~--SITE '~ElqE~ F'E~-I IT ( 8006~6 ) MPPL I C:RNT LOCRT I ON LEGRL WILEY DENSON BUF ....b~_, EMGLE RIVER LOT 12 BLK 4 GREMTLMND ESTMTEq · LOT SIZE ±]c0~_~8171 SQUMRE FEET TYPE OF '-q~]IL RBSORF'T!ON _r_TEM IS: TRENCH MMXIMIIM NUMBER OF BE[.,RLIUH.=, = 4 =&ilL RRTtNG ,::S.C..! FT,/BR.)=,_,'="=._, THE F,'EF.~ IRED ..,I~_E GF THE '-]FIIL HB_-.LF, FTI_N _,~_-,TEM __: [:,EF"T H = 1'1, L E~'-.~GT H=,-,"-:-'Pi, ._ g-~ I~.' F~ '-..' E L [:,E F' TH== 7 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF M TRENCH OR PIT IS THE DISTMNCE BETWEEN THE SURFMCE OF THE GROUND RND THE BOTTOM OF THE EXCMVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES, THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRMVEL BETWEEN THE OUTFMLL PIPE RND THE BOTTOM OF THE EXCMVMTION (IN FEET). F.'. E l;., UR ][ F:E[).=SEF'T 1' C: T R ~'-,~1-::.' S. I ZE= :.1_ 2 5 F'-l_ _ F'ERMIT HFFLI_.HNT HMS THE RE",FON.=,IE, ILIT'r TO INFORM THI=, EEPMRTMENT DI_IRING THE INSTRLLMTION INSPECTIONS OF MNY WELLS MDJRCENT TO THIS PROPERTY MND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. T I-,I C~ (: :-':: ]" Z I ['4$PEC:T I Clf-~S RF:E REL--]-.LI Z RE[) '- "-- _ _ _ - ' ' FI ' BY BRCKFILLING OF MNY -&_,TEM WITHOUT FINML IN~PEr:TIr]N MND HFFR_%,RL , THIS [:,EPRRTMENT WILL BE SUBJEC:T TO PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL MND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS 100 FEET FOR R PRIVRTE WELL OR ±50 TO 200 FEET FROM M PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTMNCE FROM M PRIVRTE WELt_ TO M PRIVRTE SEWER LINE IS 25 FEET MND TO M COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS RRE REQUIRED MND MUST BE RETURNED TO THE DEPMRTMENT WITHIN ~0 DMYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MRY MPPLY. SPECIFICMTIONS RND CONSTRUCTION DIMGRMMS RRE RVRILMBLE TO INSURE PROPER INSTMLLRTION. I CERTIFY THRT 1: I MM FRMILtMR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY THE MUNICIPMLITY OF MNCHORBGE. ~: I WILL INSTMLL THE SYSTEM IN MCCORDMNCE WITH THE CODES. ~: I UNDERSTMND THMT THE ON-SITE SEWER SYSTEM M~Y REQUIRE ENLMRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THMN 4 BEDROOMS. SIGNED: RPPLICRNT i ~=.UE£. WILEY DENSON .................. [:.HTE~ ...... V4. 0 0 & E ENG-nqEERING & DEVELOF~AENT CO. Box 99, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 I~ussell Oyster 694-2774 Performed for: Name: /i/~/' ~ Mailing Address: Legal Description: SOIL LOG Depth (feet) 0 Soil Characteristics Earl Ellis 688-2280 Tel. No ~c~--2~ 10__ 11__ 12__ 13__ PLOT PLAN PERC. TEST 14__ 15__ 16__ Ground Water Encountered: Yes Proposed Installation: Seepage Pit Comments: Performed by: No / If yes, what depth Drain Field. ~ CHUGIAK, ALASKA 688-3199 .� W1L(�q S PDRILLING CO'. It*t WE SERVE ALL ALASKA POST OFFICE BOX 42 - CHUGIAK, ALASKA 99567 KODIAK, ALASKA 486-4826 OWNEROF LAND....................................................................................... DEPTH OF WELL....................................................................................... ADDRESS...........:......................................................................................... STATIC LEVEL OF WATER FT. ................................................................ WELL- SITE............................................................................................... DRAW DOWN FT........................................................................................ DATE- STARTED...................................................................................... GALS. PER HR........................................................................................... DATE- ENDED........................................................................................... KIND OF CASING...................................................................................... KIND OF FORMATION: FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ....................... FT.................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ........................ FT................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ........................ FT................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ........................ FT................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ........................ FT................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ........................ FT................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ........................ FT................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ........................ FT................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ........................ FT................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ........................ FT................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ....................... FT.................................. FROM...................... FT. TO ...................... FT.................................... FROM ....................... FT. TO ........................ FT................................. MISCL. INFORMATION: DRILLER'S NAME................................................................................................................... MUNICIPALITY OF ANCHORAGE Development Services Department„, Phone: (907)343-7904 On -Site Water & Wastewater Section Fax: (907)343-7997 Certificate of On -Site Systems Approval OSC25'1505 Parcel ID 051 -133-27 Expiration Date: 10/20/2026 Legal description GREAT LANDESTATES #3 BLK 4 LT 12 Site address 19712 CHUGACH PARK DR Current property owner(s) JODEN TRUST X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or conditions: No comments W Original Certificate Date: 11/6/2025 This rtificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject s em(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, evelopment Service 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 submittal. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory X Tank Age Advisory Arsenic Advisory Other 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units F� Holding Tank ❑ Community Septic or Public Sewer 6. SEPTIC TANK: ❑ Steel M Plastic ❑ Concrete ❑ Fiberglass Age 4 _ See advisory if steel or fiberglass older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Distance: Expedited review requested: ❑ 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 $ Waiver Fee $ Date of Payment Date of Payment COSA # Waiver # COSA Appltcafior_Apr2025.doc COSA Checklist_May2025 .docx COSA Checklist Legal Description: GREATLAND ESTATES #3 BLOCK 4 LOT 12 Parcel ID: 051-133-27 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 5/1/2023 Total depth 140 ft Cased to 140 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 36 in. Date of flow test for COSA 10/21/25 Static water level at beginning of test 80 ft. Well production at time of test 4+ gpm Water storage tank volume None gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 6.55 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date 10/20/25 Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank 67” Date of pumping 10/20/25 Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. DISPOSAL FIELD DATA Which system tested (date installed) 11/5/1980 ALL standpipes present per record drawing Total measured depth from grade 12.8 ft (max) Measured depth to pipe invert from grade 7.5 ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes (MT) go to bottom of effective. (ED) If not, state depth into effective 3' Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced 2000 gallons 10/20/25 date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date 10/21/25 Results Pass Fluid depth prior to test 5 in Water added 600 gal New fluid depth 36 in (UP TO LATERAL) Elapsed time 1440 min Final fluid depth 4 in Absorption rate 600 gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) 72 in (MOA 6’ ED) Effective depth used 40 in (Final Fluid Depth + Missing ED) Effective depth remaining 32 in Comments/Deficiencies: Total measured depths from existing grade. ED per measurements, visual observations, MOA records & appears approximate. After testing, JRs subsequently cleaned & jetted septic field. COSA Checklist_May2025 .docx E. SEPARATION DISTANCES From Well on Lot to: (Please enter distances if less than required) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Disposal Field on Lot > 100’ Yes if No ft Neighboring Disposal Fields > 100’ Yes if No ft Sewer Line/Main > 100’ Yes if No ft Sewer Manhole/Cleanout > 100’ Yes if No ft Sewer Service/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 Disposal Field(s) on Lot to: (Please enter distances if less than required) Tank to Foundation > 10’ Yes if No ft Field to Foundation > 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/Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: 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 FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 11/06/2025 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 11/06/25 MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT A , 907-343-7904 On -Site wafer and wastewater Section Fax; 343-7997 www.muni.org/onsite Nitrate Advisory Certificate of On -Site Systems Approval # OSC251505 Subdivision: Great Land Estates #3 , Block: 4, Lot: 12 A water sample revealed a nitrate concentration of 6.55 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Since nitrates are known to slowly increase, we recommend you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. Nitrate Fact Sheet From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 05-'l -13.~ -27 HAA# 1. GENERAL INFORMATION Complete'legal description Location (site address or directions) ~ ~l -/I ~ c.-b/u d-~r/' p,~.-t,~ L)i~ Property owner Mailing address Lending agency Mailing address ,~:o ~ C- $ ~/¥ ~'/ Day phone P 0 L~CX 67~1~° £H~C~ ¢~' ¢r ,..r-- 6 7 Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water 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. I/¢JlJ Front MOA#21 o 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 verifythat based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature $ & S ENGINEERING ;7¢¢34 Eagle ~iver Loop Road No. 204 Eagle River, Alaska 99577 Phone ~/*~¥_ ~.c/ 7~ Date ////? /¢¢~' DHHS SIGNATURE ~ Approved for ¢ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date / 2_ - ~/ - ¢(~ 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. 1/91 ) ~aCk MOA ~1 Municipality of Anchorage DEP^R MENT OF HE^' H & HUM^N SERVi E IV E D Environmental Se~ices Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (90~43-~8 ...... Municipality of Anc~ra~e Health Authority Approval ~necK~t, Health & Human ~erwces Legal Description: Lo T- I ~- /3 v~ c~ N' A, WELL DATA WellWpe ~ ~ IfA, B, crC, a~ach ADEC leEer. ADE© water system number Log present~/N) '~ ~ J'" Date completed Total depth c~ 0 Cased to Sanitary seal i~'/N) ¥ ~ ~ Casing height (above ground) Wires properly protected {~/N) Date of test FROM WELL LOG I, / AT INSPECTION Static water level Well production g.p.m. g.p.m. WATER SAMPLE RESULTS:. Coliform o Nitrate Date of sample: l~/l(,/ qy 4- B, SEPTIC/HOLDING TANK DATA Date installed I~ ! J" ! ~'o Tanksize Collected by: Other bacteria (P s & S ENGINEERING 17034 Eagle I~lve~. I ~,%,- ~o"_~ ~!e. 204 Eagle River, AJasl(a ~577 Number of Compartments '~ Cteanouts ~/N). ¥ ~-~ Foundation cleanout ~'N) Date of Pumping z~ / c~ ¥' 5 Depression (Y/~ ~'~ © High water alarm (Y/I~ ~, o Pumper ~ ~ J C. ABSORPTION FIELD DATA Date installed h t/ 5'-/' ~' 0 / Length ~ '7 Width Effective absorption area ~/ Date of adequacy test ~ Fluid depth in absorption field before test (in.); D~ y Immediately after ~- ~ ~ gal. water added (in.): Fluid depth 3. ~/ (ins) Minutes later: ~ -.~ Absorption rate = ' ~ 00 + g.p.d. -~ ~ ~- ~.(~.~.~.,3I~/ /(,Iq Y ~',,,~ ~.,'~ J b~.y . Peroxide treatment (past 12 months) (Y/N)/- ~.,,~. ~ ,~ ~ ~, ~, If yes, give date '- Soil rating (g.p.d./fF or~.-.-.~ ~' ~- System type 7~ Gravel thickness below pipe ~' / Total depth / Monitoring Tube present(~/N) Y~'J Depression over field (Y/~. Results ail) For bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested SEPARATION DISTANCES Size in gallons "Pump on" level at* _ ~ level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public Sewer rnanhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~- ~ Property line ~ ¢ Absorption field Water main/service line / 0 ,p- Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Propertyline /o -y- Building foundation /'0 Surface water / oO ~L Curtain drain W o ,,~ ,~ I¢ ~ e ~,v ~ 6 Wells On adjacent lots Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots / 0 o F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records in conformance with MOA HAA guidelines in effect on this date. Signature Q//~Z /~]'~'--~.--.~ Engineer's Name /~ ~ ~ ~/, z- C. ~o ~,,t~ Date z/ //.-/ /~/ ~' Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number ~ IVIUNICIPALITY OF ANCHORAGE L~../ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONIVIENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date August 6, ~-986 GENERAl. INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 12, Block 4 Greatland Estates T15N 'R1W Sec, Location (address or directions) ChuEach Park Dr o 10 (b) Applicant Name Inez LeBlanc Telephone: Home 688-3979 Business Applicant Address PoO. Box 6713~-4 Chugiak, Alaska 99567 (c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain); (d) Lending Institution Home Saving8 & Loan Assn. Telephone Address lOO1 E, Benson AnchoraCe; AK 99508 (e) Real Estate Company and Agent N/A Address 276-1451 Telephone (f) Mail the HAA to the following address: P-ick~p by er~inee:¢ TYPE OF RESIDENCE Single-Family [] Multi-Family [] Number of Bedrooms 4 Other WATER SUPPLY Individual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite [] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11,84) Page 1 of 2 ENGINEERING FIRM PROVIDI~:~'INSPECTIONS, TESTS, FILE SEARCH, D~'I~, AND INFORIVtATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage flies 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 EA6f. E ~iVE~ERING SERVICES Telephone Address EAGLE RIVEfl. AK 99577 Date~ ~ ~k~ P. 0. BOX 773294 DHEP APPROVAL Approved for /~/X/-~ ~- bedrooms by Approved ~/~ Disapproved Terms of Conditional Approval Conditior~al. Date CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 ( 11/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MO~j HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: IfA, B, C, D.E.C. Approved (Y/N) ?~/~ Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Well Classification Well Log Present (Y/N) ,~/ Date Completed //-..2 ?-,..co Yield Total Depth ¢~' / Cased to ~'O /' Depth of Grouting /~'/'~ Static Water Level P~ ",~/~'-" ~./~ ¢'~' ~:~.r.~..'.r Pump Set At ¢' ~ ~ Casing Height Above Ground 37 i. Sanitary Seal on Casing (Y/N) Y Depression Around Wellhead (Y/N) To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results ; On Adjoining Lots ~/-~¢ ' ; On Adjoining Lots ¢/~'~ To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~- ; Date ~ --47 Comments B. SEPTIC/HOLDING TANK DATA Date Installed ///~' // Standpipes (Y/N) /~' Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well /~Z / To Property Line / To Water Main/Service Line ~'/~ ' Course Size /,¢¢ ,~-a ?o/, No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field ¢' To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line ;"'7o" To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field / &~ / Gravel Bed Thickness '""- Standpipes Present (Y/N) Date of Last Adequacy Test 7'o Property Line To Existing or Abandoned System on ; On Adjoining Lots "'--~ ~ / To Cutbank (if present) ~/~ LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Date MOA No. Company ~,~- ~/'¢; £~--, Receipt No. /-[ 0¢:.~/ Date of Payment Amount: $ Page 2 of 2 Eagle River Engineering Se~ices P. O. aox 7732~4 Eagle River, AK Sg577 694-5195 72-026 (11/84) j,-.-- !.~ , ~ '~._~ 'b,.~rE RECEIVED .... ~ INSPECTION APPOINTMENTS /~~ ~. TIME TIME NJ ~ TI~E DATE DATEiNsPE INSPECTOR C I NSP ECTOR MUNICIPALITY OF ANCHORAGE MUNICIPALIW OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF HEALTH 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL P~.OTECTION ENVI RONMENTA L SANITATION DIVISION Telephone 264-4720 DIRECTIONS: Complete all parts on page 1, Incomplete requests wilJ not be processed. Please allow ten (10) days for processing. 1, P~P~yOWNER , ~ ~ ~ / ~ PHONE MAILING AD.ESS ~ ' ~) ~ ~ PROPE~T~ID~NT (If different from above) PHONE 2. BU~E.'-'--~ ~/~.~ .~ ~ ' ~ - PHONE ~A~U~G~ESS 3. LENDIN~NSTIT~T~ - MAi LI NG(~ E~~ ' ~ ~' ~' ~//~ PHONE. / 5 LEGAL DESCRIPTION / / .~...~ ~ .,,~-'"/~_ .'~ .,2 -, STREET LOCAT~ '/ ~ ~, '" ///" /~ z 6. TYPEOF RESIbENCE ~ ' - ' NUMBER OF ..~,- ~ ~'- ~ One ~ Four ~ Other ~NGLE FAMILY ~ Two ~ Five ~ MULTIPLE FAMILY ~ Three ~ Six 7. WATER SUP~L-'Y ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISP~S¢[~- SYSTEM [~'/I N DIVI DUAL/ON-SITE** [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date. give well depth (attach log if available.) /J?/'~'~-~YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72 010 (Rev. 6/79) ~ / THIS SIDE FOR OFFICIAL USE ONLY 1, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] TFIREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBL,C UT L,TY Connection Verified __ INSTALLER [:~]Septic Tank or [] Holding Tank Si ze: _ / ,.,~- .~0 If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION ,~REA MATERIAL 4. DIST~S S~ptic/~oldiafl Tank Absor0tion Area kine ~earost Lot kine Absorption Aroa to n~arest ~ot [. COMMfi~TS ~ CO~DITIO~Ak A~PBOVAk (letter must accompan~ certificate) ~ DISAPPBOV~ DATE BY ,,'