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SAMPSON ESTATES BLK 4 LT 8
Sampson Estates Biock 4 Lot 8 #051-811-13 • Municipality of Anchorage Page 1 of 3 • DEPARTMENT OF HEALTH AND HUMAN SERVICES ' ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/orWell Inspection Report ' Permit Number. sW000056 PID Number 051-811-13 • Name: MM&M Contracting::: . Wastewater System: (Z1'New. 0 Upgrade Address: . P.O. Box - 670.495 Chugiak, AK' 99567 ABSORPTION FIELD . • Phone: 688 =12 3 6Three No. of Bedrooms: (3) .. ) 3 Deep Trench 0 Shallow Trench 0 Bed 0 Mound 0 Other LEGAL DESCRIPTION Soil Rating: •• 6' , • . ' GPD/Sq. Ft. Total Depth from original grade: • • 1 1 Lot: Block: Subdivision: • 8 • . - :. 4 ... Sampson . Estates Depth to pipe bottom from original grade: : 4 • • ...• ''FL Gravel depth beneath pipe Fc. Township: • Range: Section: Fill added above original grade: .•0 • Ft. Gravel length: . 5 8 • Ft. WELL:"... IN New.''.. • Upgrade .. Gravel width:' 3 Ft Number of lines: 1 Distance between fines _ FL Classification. (Private. A,B.C): • . . ' Private ... . Total Depth: . .:'120- - Ft_ Cased To: • • 1.20 Ft. Total absorption e : 1/2', .. '' •. so: Fc. Pipe material: ASTM D3034 "•P.VC..•.'. .. Driller: .:.: • " . . : .. .. • ' • . .Sullivan Water '•.• Date Drilled: -. :4'/12/00 Static Water level' 98 .'-.. Ft. Installer. • ' .• ° ' : MM&M:Contractinq Date installed: .' •• • 5/1 0 • —" 8/16/00 Yield:' . ::. '.. • 20. GPM Pump Set at. .: FL Casing Height Above Ground: >2' Fi• : • . ; TANK. • :.:• • ' ":"SEPARATION DISTANCES.' • '" . j:Septic : ": o Holding :.: 0 S.T.E.P. • :.: • ' To From ." • Septic . Tank. Abaorpt on Field ' • Litt : • .• Station Holding Tank Publ'KJPrivate Sewert`ines Manufacturer.'...^ Anchorage•' Tank. • • Capacity in gallon : ••••1,000' • • welt' >1.001 >10'01 •N/A . N/A.1: • >25' Material:• Steel : Number of Compartments: • . . Two • .. . • surface•LIFT. .water >100'. >100' .. N/A': N/A •-NJA STATION'-., N/A..: ' . - • . Line >5 r. >1 0' • • N/A N/A N/A: Size in gallons: : . ...' Manufacturer. . . Foundation • : >5': .' >10'.� 'N/A N/A-..: N/A' • `Pump on' level at•:... "Pump off" level at ,' High vrater alarm at • . •-'• curtain •`None' 'Drain Noted `.ori .Lot " Pump Make &Model . Electrical Inspections performed by: .., Remarks:- .:2". Insulation . Over Tank. :. . ....:..BENCH MARK • : , Location'and Description: B• . ack .Deck • • • •.•. ..:• Assumed Elevation:' ... •• • 1 0:0 .. Ft 10tt��RR • .4-4. +"' performed by: ' - MEA • . Dates; l sty / 10/00 '•• ° ` r - F r • '40 ../ .:Inspections 2nri 5/1210n A ..• � .-. .ry.�. .�.�(..r.j. 3rd '8/16/00 :• Department of Health and Human Services. approval - Reviewed and approved by: . /-Date- .9- 7 ,.p 0 ,CCC! .,Aw ..w• • q �.�: .. "• . -boa'' -. pi 4..•� i�" �� ,, Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 - Anchorage, AK 99519-6650 - 343-4744 On -Site Wastewater Disposal System or Well Inspection Report Permit Number SW000056 Page 2 of 3 PID No. 051-811-13 33' Section Line Easement Alternate Site TH3 C5• 1 c1 TH1 S2 ., Well PLAN :AS -BUILT "SCALE 1" =30'. GABRIEI CIRCLE A B .. C' S1 . _ 8.3 32.0 S2 .. 14.4 37.9 C4 .• . 45.8. . 60.2 C5 . 24.3. 41.0 M1 ;: 46.2. 60.3. ., C6'' 98.4 , 86.8 Well PLAN :AS -BUILT "SCALE 1" =30'. GABRIEI CIRCLE Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 - Anchorage, AK 99519-6650 - 343-4744 On -Site Wastewater Disposal System or Well Inspection Report Page 3 of 3 Permit Number SW000056 PID No. 051-811-13 in 9 9.2 c`�n m U 2" Insul. 1,000 G 94.5 Sep. Tan• 10' 94.3 6.7 1 97.6 93.76 Geotextile Fabric 504;41? 44.44114194 Drain Field Rock ----A, CEAL,,ef kt • F �a4• +a . .. • .• .-.• •�•� :$ f .. 5 ':^ .t.»jti..'� �'' PROFILE AS BUILT 0 ti 4 42,01 27' 93.72. 86.6 80.0± 1"=10'. Municipality of Anchorage Department of Health & Human Services 825 L Street, Anchorage, AK 99502-0650 SOILS LOG - PERCOLATION TEST Performed For. 1vIM&M Contracting Legal Description: Lot 8. Block 4. Sampson Estates Subdivision SLOPE Date Performed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 21 OG/OL GM TESTHOLE NO. 3 SM Was Groundwater Encountered? If Yet, What Depth? Silty Depth to Water Sand With After Monitoring Gravel Date: Bottom of Hole No S L 0 P E SITE PLAN ,�: �€ 444,1`% • # r� ,catea�.i6 V.. ti rr �• s° 0. 8/16/00 4�tV",' ' See Site Plan 1% Reading Date Gross Time Net Time Depth To Water Net Drop Perc. Rate: 20 Min./Inch Test Run Between: N/A Comments: Soil Materials Same As Testhole Nos. 1 and 2 Perc. Hole Diameter: N/A Performed By: Mike Anderson, I, Michael E. Anderson Certify That This Test Was Performed In Accordance With All State and Municipal Guidelines In Effect On This Date: 4/7/00 • 0�1 : COUNTRY REALTY OWNER OF LAND PHONE NO. : 9076881238 Aug. 28 2000 08:49AM P1 . Griffith 4Jrfl1huj flag by DOC Co. dba • SULLIvAN WATER .WELLS P.O. BOX 670272, CHUG[AK, ALASKA 99567 • TELEPHONE 688-2759 C b 'Irre4e--ra-vto ADDRESS , ox. --745 4 '77 t 4-,4/K LEGAL DESCRIPTION , (`4P4/7.1 -1).J ,c= S ' L2�k. 4 20 PERMIT NUMBER Oooc s.4 Date of Issue Q - /�- pa• TAX INDENTIFICATION NUMBER nom 1 - ej / - / 3 Is well located at approved permit location? ❑ No • Method of Drilling:it rotary ❑ cable tool Depth of well: / 0 Casing Type Srr=Fc.- Wall Thickness. ,,?S 0 inches Diameter k.// inches, depth / 2v feet Liner Type: "ia�)� Casing Stickup Above Ground: o� feet Static Water Level (from ground level): 09'!t' • feet Pumping level: feet after •hrs. pumping • gpm Recover Rate: 0 qpm • . Method of Testing: /,e Well Intake Opening Type: • (©•Open End ❑ Open Hole ❑ Screened; Start feet Stopped feet ❑ Perforations Start �fegttisiopped • feet Grout Type: /3.c.3.) TJ'4:Td Volume )J61_L3 S Depth: from Q feet. to 1 • feet Pump Intake Depth: feet Pump Size hp Brand Name BORE HOLE DATA DEPTH From To 0 .2 4 .4J // ai a 9t 0 00. z, Well Disinfected Upon Completion? b -(es 0 . No Method of Disinfection: C //L v/Z'- Jt.STh 41:fel - C .11r,.J 4. J. -Tic BJP • d vE e. • /.7-iRd z-^/ ,r/c. r 5 G. SA.40 .6..<4../z.. --t SA -:;gyp .11-'44147F, RECEIVED S p 0 6 2000 triicspahry. ut Anchorage Dept Health & Hump Soryiutn Driller's Name _ /_�.P,�,c� 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 Envirr-sr,?w l° --- Received Time Aus•28. 8:28Ah1 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On -Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 51/0/co /02;011t:- 1/4570-16-e) a: 3t:- 570 -lam @ ?at, - 6//40/617)(08,3 at,- 8//4o/617)L08,3 ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT Initial Permit Number: SW000056 Legal Description: SAMPSON ESTATES BLK 4 LT 8 Design Engineer: 0014 Anderson Engineering Owner Name: MM & M Contracting Owner Address: PO Box 670495 Chugiak , AK 99567 - Date Issued: Apr 12, 2000 Expiration Date: Apr 12, 2001 Parcel ID: 051-811-13 Site Address: 022655 GABRIEL CIR Lot Size: 40317 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: n Disposal Field a Septic Tank 0 Holding Tank ❑ Privy a Private Well 0 Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 (24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: -i' it. Lac,./ Issued By: atiA4-/ Date: 44— l - c n Date: 4 - 13 -oo April 8 X2000. 'Municipality, of Anchorage Department of Health.and Human Services 825 "L" Street Anchorage, AK 99502-0650 Subject: Lot 8, Block 4, Sampson Estates Subdivision Septic System Design and Permit Application Impacts to` A•djacent'PropertieS'•• Dear Onsite Services Engineer The, owner of Lot 8, Block 4, .Sampson Estates Subdivision intends to construct a three • bedroom home on the lot.' We are hereby requesting a permit be issued to construct a new well •and septic system to ,serve the house proposed for the lot. The attached Site: Plan and backup documentation shows theIocation and configuration of the new septic': system :and the location of the well.. • The 100' protective radius. for the well and neighboring _wells is also shown on the Site Plan . 'Two testholes were recently placed on the. lot to verify conditions and determine design parameters. ,'Silty gravel was found from 1' below the surface, to 5' below the surface. Silty sand With some gravel was .then encountered to the ; bottom of the : testhole. ' 'A, percolation rate of•12minutes per inch was attained in the upper layer. and 20 minutes per inch in the lower, layer. No groundwater was encountered in either hole and none• was noted during the monitoring periods. We have therefore designed a deep trench absorption system based on the slower percolation rate. The distributiori piping will be placed at 4' belowthe ground surface and 7' of drainfiield rock will be -placed in the trench. Thetotal depth of thetrench will be 11' below the•original ground surface.'; The ,. length of the trench will be 55': The lotsurface siopes.from north to south at rates varying from ;1 % to 2% with a slight grade:from: west to east.- The.: trench will .be placed perpendicular to the slope as required by the: Municipalc: Orinance. The existing drainage pattern on the lot will be • maintained through final development If the, system: is constructed, in accordance, with our design the following statements appy:- _ 1::: The system, if constructed as designed,.will have no adverse impact on the wells in the area -or those to be constructed in the, future. • • 2 'The. system, if constructed as'designed, will have no adverse, impact on 'existing septic systems in the area or those to be constructed in the future Lot 4, Block 8, Sampson Estates April -8, 2000.- . Page: Two: The system, if constructed as designed, will have no adverse impact on reserved space, either surface or subsurface, on any lots located in the area. The system, if. constructed; as designed, will have no adverse impa•ct on drainage • ,=patterns in the area. The' current drainage pattern will be maintained THIS PROJECT EAST WEST 1319.50 .(79-245) 79-195 1320.00 CL0(N) 212.78 Usf 11650 0 0 0 0 1 0 O N n O O h / / /• / / • ♦/ 10 to. Ewe &12 ws.0, / / / / \ N8r25.13..t 211- 1•••••••••• 1 0 3 3 'te,1zA ' Lin 4.4 00 �. F 2 AREA MAP 10 SCALE 9" 900' t'tt•S;•• • oor \,o \ 9 • • O v. 10' Etoc & Tdatowun E�.d. O 0 Cs N88'044 2-w 175 nn 1.1.0 1 .33' Section Line Easement Lot 8, Block 4 Sampson Estates Lot 9 SCALE 1" =30' Alternate Site 1,000 Gallon . Septic Tank 11 TH1 X ,3' de X 7' Eftecti - '-pth Absorpt on 55' Lon ► - . :'TH2; • Three VO Bedroom Ho 00 Proposed Well ® Gabrie: Well. Circle LOT 8, BLOCK 4, SAMPSON ESTATES SUBDIVISION DESIGN FACTORS: Three Bedroom Home Perc. Rate: 16 - 30 Min./Inch Application Rate: .6 GPD/SF SYSTEM REQUIREMENTS: Deep Trench System 1,000 Gallon Septic Tank 7' Drainfield Rock 3 Bedrooms X 150 GPD / .6 GPD/SF = 750 SF of Absorption Area 750 SF/14 SF/ LF of Trench = 53.6 LF Trench Length Therefore: Construct a Deep Absorption Trench System With One Lateral 5 5 ' in Length with 7' of Drainfield Rock Beneath the Distribution Pipe. Distribution Pipe in Trench Placed at 4' Below the Original Ground Surface. Total Depth to be 12' From Original Ground Surface. Mound Over Trench to Provide a Minimum of 3' of Cover. 3.5' .5 7.0' r 1+1 • 4 V • * If • • e. fin •A.. sem. �•�.�n •i ••/• T •��,,C • • 'ti • r \N'tl..N14o E: t Natural Backfill *04f 43 3:0'• Co. igitt Geotextile Fabric 4" PVC Holes Down Drainfield Rock, TYPICAL DEEP. TRENCH SECTION (NO SCALE) Grade Area Over Trench to Drain Away. Provide 3' Cover Over Trench and 4' Over Tank or Insulate. Maintain 10' Separation From Lot Line. Maintain 10' Separation From Water Service Line. Maintain 100' Separation From All Wells Municipality of Anchorage Department of Health & Human Services 825 L Street, Anchorage, AK 99502-0650 SOILS LOG - PERCOLATION TEST Performed For. MM&M Contracting Legal Description: Lot 8. Block 4. Sampson Estates Subdivision SLOPE Date Performed: 1 2 3 4 5 7 8 9 10 11 12 13 14 15 16 17 18 21 Perc. Zone OG/OL GM TESTHOLE NO.1 SM Was Groundwater Encountered? If Yet, What Depth? No Silty Depth to Water Sand With After Monitoring None Gravel Date: Bottom of Hole 4/6/00 S L 0 E % ' 3/29/Qf1- ; SITE PLAN See Site Plan Reading Date Gross Time Net Time Depth To Water Net Drop 1 29 -Mar 2:15 2.5" 2 2:45 30 5" 2.5" 3 2:46 2" 4 3:16 30 4.5" 2.5" 5 3:17 2.5" 6 3:47 30 5" 2.5" Perc. Rate: 12 Min./Inch Perc. Hole Diameter: 6" Test Run Between 5.5 Ft. and 6.5 Ft. Comments: Percolation Cavity Presoaked Prior to Testing. Performed By: S&S Engineering, I, Michael E. Anderson Certify That This Test Was Performed In Accordance With All State and Municipal Guidelines In Effect On This Date: 417/00 Municipality of Anchorage Department of Health & Human Services 825 L Street, Anchorage, AK 99502-0650 SOILS LOG - PERCOLATION TEST Performed For: MM&M Contracting Legal Description: Lot 8. Block 4. Sampson Estates Subdivision SLOPE Date Performed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 21 Perc. Zone OG/OL GM TESTHOLE NO2 SM Was Groundwater Encountered? No If Yet, What Depth? Silty Depth to Water Sand With After Monitoring None Gravel Date: Bottom of Hole 4/6/00 S L 0 P E SITE PLAN 3/29/00 _47,c):44:11.r:NL;L:4:fil"4,1 k` ."oe �. * '• 7i. f1,e # L 'Mari; : r1 .. ".'f."R''' . "t See Site Plan Reading Date Gross Time Net Time Depth To Water Net Drop 1 29 -Mar 2:20 2.5" 2 2:50 30 4" 1.5" 3 2:51 2" 4 3:21 30 3.5" 1.5" 5 3:22 2.5" 6 3:52 30 4" 1.5" Perc. Rate: 20 Min./Inch Perc. Hole Diameter. 6" Test Run Between 4.5 Ft. and 5.5 Ft. Comments: Percolation Cavity Presoaked Prior to Testing. Performed By Tim Kimbrough. I, Michael E. Anderson Certify That This Test Was Performed In Accordance With All State and Municipal Guidelines In Effect On This Date: 4/7/00 ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: LOT 8, BLOCK 4, SAMPSON ESTATES SUBDIVISION GENERAL: 1. The scope of this project includes the procurement and placement of a new 1,000 gallon septic tank. It also includes the construction of one new 55' long x 3' wide x 7' effective depth absorption trench at the location shown on the attached Site Plan. The total depth from original ground of the trenches will be 12' below ground. Mounding over the trench may be required to provide a minimum of 3' of protective cover. A minimum of 100' separation must be maintained from the existing well on the lot to all components of the new septic system and the reserve system. 2. Construction shall be in accordance with the approved site plan, design drawings, Municipal Permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The Contractor shall be responsible for obtaining all underground utility locates and for the layout of the septic system and verification of the location of all lot lines. .4. Unless specifically agreed otherwise, the contractor shall be responsible for final grading areas subsequently depressed from soil settling. Property owner shall be responsible for revegetation of affected areas unless specifically agreed otherwise. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Department of Health and Human Services for system installations. Owners installing their own systems must receive prior approval from D.H.H.S. before beginning system installation. SEPTIC TANK INSTALLATION 1. The new 1,000 gallon septic tank must be procured from an approved source and installed at the location shown on the plans. 2. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 3. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 4. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial insulation. Lot 8, Block 4, Sampson Estates Subdivision April 8, 2000 Page2of3 6. A foundation cleanout shall be installed one to four feet from the building foundation. Two cleanouts are required between the tank and the drainfield. 7. Final grading over the tank shall be such that a positive slope exists away from the septic tank. DRAINFIELD CONSTRUCTION: 1. The drainfield shall be constructed to the dimensions shown on the design. The bottom of the trench shall be within 2" of level. 2. Distribution piping must be placed level with perforations down atop a level bed of drainfield rock. Rock should then be placed over the pipe to provide a minimum of 2" of cover. 3. A silt barrier or geotextile fabric must be placed between the drainfield rock and the natural soil backfill. 4. Monitor tubes must be 4" in diameter and installed at the locations shown on the design. The portion below ground must be perforated. 5. Contractor shall verify the septic tank and drainfield are a minimum 100' away from any private water wells in the area, 150' from a Class "C" Well or 200' from any community well. 6. Direct bury insulation must be placed over the distribution system if Tess than 3' of backfill depth is available. Finish grade over the trench must be mounded to prevent settlement or depressions. 7. Grade area surrounding the absorption trenches to drain away. 8. A minimum 2' of accepting soil is required below the drainfield rock for a 5' wide trench. Contractor shall verify this condition prior to placement of the rock. All pockets of unacceptable materials must be removed and replaced. MATERIAL SPECIFICATIONS: 1. Septic tanks must be constructed by a municipally approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662 or A.B.S. (perforated and solid). 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Co. Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). • Lot 8, Block 4, Sampson Estates Subdivision April 8, 2000 Page 3 of 3 5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed between the final drain rock layer and the native soil layer. 6. All drain rock shall be .5" to 2.5" in diameter with Tess than 3% passing the #200 sieve. INSPECTIONS: Municipal Ordinance requires a minimum of two inspections. These inspections must be conducted under the supervision of a professional engineer registered in the State of Alaska. The first inspection must be conducted after the excavation of trenches, beds or pits and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled. The second inspection must be conducted after the placement of the geotextile fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No backfill should be in place at the time of inspection. Contractor shall provide a copy of all field survey layout and construction notes for use in preparing the certified as -built of the completed system. Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APP WSPikti % -tea-I L APR 14 2.014 Parcel I.D. 051-811-13 Expiration Da 1. GENERAL INFORMATION Complete legal description Sampson Estates Block 4 Lot 8 Location (site address) 22655 Gabriel Circle, Peters Creek, AK Current Property owner(s) Roberts Mailing address same Day phone 350-2082 Real Estate Agent Tony Roberts 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class C Well Public Water System Received by:- _ COSA to be released to the engineer, unless otherwise requested by the engineer. 3 Day phone 350-2082 TYPE OF WASTEWATER DISPOSAL: Individual ❑ Holding Tank ❑ Community ❑ Public Sewer n COSA Fee $ 524 Date of Payment Elilifh�t Receipt Number 0/53 3 COSA # JSCIL///. Date: Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm NorthRim Engineering Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 4/14/2014 6. DSD SIGNATURE By: System #1 Approved for 1 bedrooms. System #2 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: iU�\UU\t1111 rrr ,-ett'" 01,yC170`ter yON-SITE m WATEK AND ' WASToz^ t)e PROGRAM �-2-). <i�,r�SEEN ��, J)IO Original Certificate Date: 171 -c2 cZ' The Municipality of Anchorage Devlopment Services Division (DSD) Issues Certificates 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 COSA blue sheet 9-1-12.doc X Nitrate Advisory Arsenic Advisory Other If 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: Su,..v So., Es fc s ea L F Parcel ID: G Si- 8//- A. WELL DATA Well type / �J If A, B, or C provide PWSID # Date completed y//2/2000 Sanitary seal (Y/N) y Total depth /ZO ft. Cased to /20 ft. FROM WELL LOG Date of test 474Z/2 coo Static water level 7 t ft. ft. Well production 06 g.p.m. WATER SAMPLE RESULTS: Coliform (` colonies/100 mL Nitrate 7 mg/L Arsenic 0.24 ug/L Date of sample: /ny Collected by: sal B. SEPTIC/HOLDING TANK DATA Tank Type/Material 5a alto/ f e.� r Date installed ste4c/2 D o v Tank size /6 d6 . gal. Number of Compartments Z . Cleanouts (Y/N) Foundation cleanout (Y/N) �/ Depression over tank (Y/N) // High water alarm (Y/N)'43/41 Date of pumping .172 J Pumper !fjf/jr! Well Log (Y/N) %/ Wires properly protected (YIN) Casing height (above ground) /0111 in. AT INSPECTION g.p.m. C. ABSORPTION FIELD DATA Date installed / 2000 Soil rating (g.p.d./ft2 or ft2/bdrm) 6- 6 System type T,�,,, Length .S, ft. Width 3 ft. Gravel below pipe 7 ft. Total depth // ft. Eff. absorption area eat ft2 Monitoring tube Y Depression over field tet/ Date of adequacy test y707 Results (Pass/Fail) _ ." For bedrooms Fluid depth in absorption field before test 27 in. Water added Cf 50 gal. New depth 3 % in. Elapsed Time: 76 min. Final fluid depth 3 1! in. Absorption rate >= y SQ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) vet/ k - If yes, give date D. LIFT STATION N4 Date installed Size in gallons "Pump on" level at in. "Pump off' level at Datum Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main /or,'r A14 Sewer /septic service line Animal containment areas 25174- 0 5'f0 ' SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (YIN) in. High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots /G G "7' On adjacent lots /00 '* Public sewer manhole/cleanout /v* Holding tank A/4 Manure/animal excrete storage areas Building foundation 5''`- Property line / a '`, Water main 0U/9- Water service line / O Wells on adjacent lots / d o `r ABSORPTION FIELD ON LOT TO: Property line /0 ''~ Building foundation /D Water main 41/1 25 f- Surface water rt Absorption field Surface water /oc�`r S fi /oGfir— Water Service line Curtain drain VA/fr, F. COMMENTS 100'�F Driveway, parking/vehicle storage Wells on adjacent lots ZOO 't la's" G. ENGINEER'S CERTIFICATION I certify that t have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effectann this date. Engineer's PrintedteName S 7E.A/6 fE4C Date ' /ri/ y COSA brown sheet_10-10-12.doc Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel 1.D. 1-13051-94 1. GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address coSA# nq 0061 Expiration Date: G -02.171 -09 SAMPSON ESTATES; BLOCK 4, LOT 8 22655 GABRIEL CIRCLE *PETERS CREEK, AK DAVE & CHRISTINE CADOGAN Day phone 688-4003 22655 GABRIEL CIRCLE *PETERS CREEK, AK Day phone ALISON LANE W/ PRUDENTIAL Day phone 563-5500 3801 CENTERPOINT DR. 1200 *ANCHORAGE, AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well a Individual On-site II Individual Water Storage 0 Individual Holding tank 0 Community Class Well 0 Community On-site 0 Public Water System 0 Public Sewer 0 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered In the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP. Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LID. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines B 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, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the syste These conditions are outside the control of the evaluator of the system. Satisfactory tes results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how brig the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will It confer any legal right whatsoever. Phone 337-6179 Date 3 �/ 9/o 9 o/.Qity. 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for y A.ess. p CE -7953 `F�p ••3/fcilo90?c 1 o PrA4db �,/ r �Y r S.F. • ON-SITE .•'s ��� WATERAND ; c^= Zia WASTEWATER : PROGRAM bedrooms, with the fllowing stipulations: -0�`!4 ..... •:g i Mill11111 Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other (Rev.11/05) Original Certificate Date: 3 -•2- '/ - 049 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: _ SAMPSON ESTATES, BLOCK 4, LOT 8 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Parcel ID:(') S / - S / / / 3 Date completed 4/12/2000 Sanitary seal (YIN) YES Wires properly protected (Y/N) YES Total depth 120 ft Cased to 120 ft Casing height (above ground) 18+ in. FROM WELL LOG AT INSPECTION Date of test 4/12/2000 3/10/09 Static water level 98 ft. 96 ft Well production 20 g.p.m. 5.87 g,p,m, WATER SAMPLE RESULTS: Coliform colonies/100 ml. NitrateR'3 (mg./L. Other bacteria 0 colonies/100 ml. Arsenic: Nd ug./L.Date of sample: 2/10/09 Collected by: GEG Ltd. B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 5/10-8/16/2000 Tank size 1000 gal Number of Compartments E Cleanouts (YIN) YES Foundation cleanout (YIN) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 10/30/08 Pumper SANITARY PUMPERS C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE Date installed 5/10-8/16/z000 Soil rating (g.p.d./ft'o 58 ft. Length System type TRENCH Width 3 ft. Gravel below pipe 7 ft Total depth ' '10 8 ft. Eff. absorption area 6122 ft' Monitoring tube YES Depression over field NO Date of adequacy test 3/10/09 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth In absorption field before test 31 'in. Water added 470 gal. New depth 31 in Elapsed Time' E min. Final fluid depth 31 In Absorption rate >_ ' 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE KNOWN If yes, give date - D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. "Pump off' leve High water alarm level at in. Datu i Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots Absorption field on lot 100'+ On adjacent lots 100'+ 100'+ Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line 25'+ Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line101+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. 7 A. Engineer's Printed Name JEFFREY A. GARNESS Q E-795 9 ,�� // � • •3/1 Q�0 \ F,e Date 3 9 /O 9 O��d pro res siodoAO000 .; 5s L__ "lC1 O — Date of Payment 31 ).0 04:\ Receipt Number 0 3 3 5 1 (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number SG$ SCS Ret# Client Name Project Name/t/ Client Sample ID Matrix PWS1D 1091015001 Gamcss Engineering Group, Ltd. Sampson Estates 134 L8 Sampson Estates 134 L8 Drinking Water 0 Printed Date/Time Collected Date/time Retched Date/Time Technical Director 03/192009 13:00 03/112009 8:10 03/112009 13:35 Stephen C. Ede Sample Remarks: 4500NO3 - Total Nitrate/Nitrite - The sample MS is outside of QC criteria (biased low). The LCS is within QC limits. parameter Results PQL Units Method Allowable Prep Analysis Container ID Limas Date Date Ink Metals by /CP/MS Arsenic Waters Department Total Nilmtc/Nitritc-N Microbiology Laboratory Colony Count Total Coliform Fecal Coliform ND 5.00 ug/L EP200.8 C (<10) 03/16/09 03/18/09 NRB 3.36 0.100 mg/L SM20 4500NO3-F 13 (<10) 0 0 0 co1/100mL SM20 92228 co1/100mL SM20 92228 co1/100mL SM20 922213 A A A 03/16/09 JDZ 03/11/09 DLC 03/11/09 DLC 03/11/09 DLC Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 SouthBragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-811-13 1. •GENERAL INFORMATION Complete legal description Lot 8, Block 4, Sampson Estates Subdivision HAA # D`'t O1° Expiration Date: S — Q. % - O Location (site address or directions) 22655 Gabriel Circle Current Property owner(s) Jeff and Melissa Miller Day phone 688-6402 Mailing address 22655 Gabriel Circle Chudiak, AK 99567 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: Three (3) 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: ® Individual On-site El O Individual Holding tank ❑ ❑ Community On-site ❑ ❑ Public Sewer 0 The Municipality of Anchorage Development Services Department (DSD) Issues 'Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well arid may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 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 Anderson Engineering. Phone .522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. Date 5/19/2004 co'=• 4 ; MICHAEL E. ANDERSON1 , 1 5. DSD SIGNATURE 1••f 81 Nd. CE -43•:' ti= ��♦ �•.... _� Approved for 3 bedrooms. ♦♦♦ s��.•� • Disapproved. Conditional approval for . bedrooms, with the following stipulations: t(((((((aq, Additional Comments . ON-SITE `�: WATER AND WASTEWATER PROGRAM • •• Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory ' Other / w. P� By: Original Certificate Date: SI �% - 1i�' (Rev. 12100) • Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 I. LegalDescription: II A:'WELL'DATA Well type Private Date completed 411212000 Total depth 120 ft. HEALTH AUTHORITY APPROVAL CHECKLIST Lot 8, Block 4, Sampson Estates Subdivision Parcel ID: 051.811-13 11 Well Log''(Y/N) Y If A, B, or C provide PWSID # Sanitary seal (Y/N) Y Cased to 120 ft. Date of test Staticwater level Well p Ioduction -WATER SAMPLE RESULTS: I. Coliform 0 colonies/100 ml. Date of sample: 517/2004 FROM WELL LOG 411212000 98 ft. 20 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel' Tank size _1.000 gal. L1I Foundation cleanout (Y/N) Y Date' ofpumping 511712004' C. ABSORPTION FIELD DATA I I Date installed 5/1112000 IH11" Length 581 ft.` Total depth 11.8 ft. Date of adequacy test 517/2004: 1I Fluid depth in absorption field before test 116 in Elapsed Time: 167 min. Final fluid depth 27 in: Wires properly protected (Y/N) Y Casing height (above ground) 18 in. AT INSPECTION 11 5/7/2004 ; 111 98.5 1 ft. g.p.m. Nitrate 1.62 mg./I. Collected by: TLK . Number of Compartments 2 Depression over tank (Y/N) N 5.5 EI Other bacteria 1I g.p.m. colonies/100 ml. Pumper JRs Pumping Date installed;5110/2000 Cleanouts (Y/N) Y High water alarm (Y/N) N Soil rating (g.p:d./ft2 or ft2/bdrm) .6 GPD/SF System type Deep Trench 3 ft. Gravel below pipe 7 j, Eff. absorption area 812 ft' Monitoring tube Y Depression over field N Results (Pass/Fail) Pass Width Water added486 gala I Absorption rate>= 450 Anyrejuvenation treatment (past 12 mo. Y/N & ;, (P ) ( type) ` N If yes, give date I ft. For 3 bedrooms New depth30 in. g.p.d. D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off level at - in. High water alarm level at Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot >100' On adjacent Tots >100' Absorption field on lot >100' On adjacent Tots >100' in. Public sewer main NIA Public sewer manhole/cleanout NIA Sewer /septic service line >25' Holding tank NIA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Water main NIA Absorption field >5' Water service line >10' Surface water >100' Wells on adjacent Tots >100' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line >10' Building foundation >10' Water main >10' Water Service line >10' Surface water >100' Curtain drain None Noted Wells on adjacent Tots >100' F. COMMENTS Driveway, parking/vehicle storage >25' G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Michael E. Anderson, P.E. Date 5(1912004 ,,: IVA MICHAEL E. ANDERSON'S �r • No. CE -4381 e •f tl �:���•o 9• HAA Fee $ 430 Date of Payment S' 24— D 3 Receipt Number S�Z Zy (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number 04/06404 09:50 FAX 907 273 8440 03!15/ 02-•' Fia 10:04 FAX 6898499 PRUDENTIAL VISTA REAL ES VISTA REAL ESTATE >rtc P N0. - 91378881238 FROM : Cp,}t.(1 RY REFLTY • a J04 2000 05:00PM P2 • GLI U U L • am S �G \ . • is ;b \4. SEWARD .& ASSOCIATES LAND SURV ING 69 4 —0 82 c• ...:R..e'ea.,-rrX,e67-G7-4g)77,1,.SYrz, &S8UILT t NEP.ESY CERTIFY WHAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY: .s'/ ,o.fe)/1/Et1.�, lcT4 .e.C! S! ' AND MAT NO ENCROACHMENTS PUS. t XCL TI' AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY . EASEMENTS; CCIVENAN S, OR RESTRICTIONS t WHICH Do NOT APPEAR ON THE RSCORDS) SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SKO D ANY DITA HERVN BE USED FOR A8L15H NG TION ND - O ENC LINES, OR FCR ARY LINES. DRAWN: +eaQQA ° &,...c..ofA �!� ,s_.-.:6:4-.‘,4'4 olearit 3.. ore•,. mc,t so.,.� �• s t44LS-v91B �,:•a rw � �j r 5-11-04; 3:47PM; SGS SGS Ref.# Client Name Project Name/# Client Sample ID Matrix 1042367001 Anderson Engineering B4, L8 Sampson Est Hose Bibb Drinking Water ;907 5615301 # 2/ 3 All Dates/Times are Alaska Standard Time Printed Date/Time 05/11,2004 12:51 Collected Date/Time 05/07/2004 10:05 Received Date/Time 05/07/2004 13:20 Technical Director j Stegh C. Ede' Released Sample Remarks: Parameter Results PQL Units Method Container ID Allowable Prep Analysis • Limits Date Date Init Waters Department Nitrate -N Microbiology Laboratory 1.62 0.100 EPA 300.0 B (<=10) 05/08/04 IMP ' Total Coliform 0 col/I00mL_SM18 9222B A (<=1) 05/07/04 DKC :s;Inset ;sal G) -n 0 O 3 0 T1 rd o CC m cD- 0 ETa m c a) C) E-)-• , c A- (nc Dv 73 m•• C) 3 c c v 3 O cn .J ❑ ■❑ -< CD CD cD (1) N CO ❑ ❑■ Z Z Z O 0 0 ■ ❑❑ D » ..- cn .P NIVNinN-►Oin.ACJN co C _1 • 3 a)cn Recov - co �� co ccoo o co co i n N R. O co 3 (D •�NJ b o b cn Y (n co co in co co O Static cn 1.NA, cn End Recovery 1 Start Well Recovery J Start SAS Recovery 1 Comments :s;Inset ;sal G) -n 0 O 3 0 T1 rd o CC m cD- 0 ETa m c a) C) E-)-• , c A- (nc Dv 73 m•• C) 3 c c v 3 O cn .J ❑ ■❑ -< CD CD cD (1) N CO ❑ ❑■ Z Z Z O 0 0 ■ ❑❑ D » :ONf10b9 3AO2V ONISVO El < o ` vCD 3 o 0 - ci) co 5 /(IuO Mold IIOM /qu0 henbapy ogda9 oo 0 :01H3 avO1)1113d SW0Ot1438 W X_ cn O� .A Cn 0 m a) 10 # 103 0 cn 00 0 0) co 0 () C▪ n 3 sews uos INSPECTOR: T.L. Kimbrough 0 m # 103f02id 0 A 0▪ 0 .P NIVNinN-►Oin.ACJN co co co N c0 co - co �� co co co co co O co 3 (D cn 0) 6 Ain c 6 •): cn 1.NA, cn cn `1' (0 N -n (D co w w0 ''' 54 52 tcoo v • -03 CD 323 486 54 106 160 214 a < 0 czt coCD o CO UD 0 00 co CO D CO COO a) (0 oo0ocn"m COO r cn < n : m 6 = 00 00 C) CD O -&(n 000n0D g -i 4).t. c0 c0 in in .p 4).41..A4,3 c0 c0 CO c0 Cn 6 01 0 con 0 0Cn < c 4 :r co a 1 4t. 03 b in w--`-�0D o b o v1 ..--; Cn nD Cn 1 W co 0 0 cJ1N-'•00cl in in in in b € -1 v m(Da: a A b in Ca -,-,0D O O O 01 a) n D v ;n oo) 0O �oo�rnrn0 CnCn66bo-0 r -12 -I EE Es 0 0000 D --, 0,0 055> = th v , 00 0000on ^rr0 < c O 00 0000- -_,cn 0= 5:" 0 0 00000 --r170 0 'fD cacn I 89422 88426 88589 88157 88209 88263 88317 88103 Meter Reading End Well Flow Test IMissed Reading Missed Reading End SAS Test Missed Reading Start Test I Comments :ONf10b9 3AO2V ONISVO El < o ` vCD 3 o 0 - ci) co 5 /(IuO Mold IIOM /qu0 henbapy ogda9 oo 0 :01H3 avO1)1113d SW0Ot1438 W X_ cn O� .A Cn 0 m a) 10 # 103 0 cn 00 0 0) co 0 () C▪ n 3 sews uos INSPECTOR: T.L. Kimbrough 0 m # 103f02id 0 A 0▪ 0 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us ' (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-811-13 1. GENERAL INFORMATION HAA# l-/' D a- D o () '7 Expiration Date: 6 - y `� Complete legal description f "SAMPSON ESTATES SUBDIVISION; LOT .8,BLOCK 4 • Location (site address or directions) 22655 GABRIEL DRIVE * CHUGIAK, AK 99567 Current Property owner(s) JIM & DARE EMBRY Day phone Mailing address Lending agency Day phone c/o LES BAILEY w/ PRUDENTIAL VISTA Mailing address Real Estate Agent Mailing address LES BAILEY w/ PRUDENTIAL VISTA Day phone 689-6464 16635 CENTERFIELD DRIVE * EAGLE RIVER, AK 99577 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System RI 3 TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Note: Alaska Water and Wastewater Consultants, Inca shall be paid $ 1,285.00 at, or prior to closing for the engineering services provided. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone 337-6179 Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, AWWC, inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AWWC, Inc. can therefore not provide • any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Date 4•// /0 Z Conditional approval for bedrooms, with the fllowing stipulations: vA A. Gayness. —7953 opt •ev QOro f e s sio°oo DO000 Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other (Rev. 12/01) , to((((((((t/fffr A44, f� • CN -S1 TE ;'G: WATER AND ; m•: EVtATER PROGRAM a k• • •• • • • - •I JJJJ��,�i,M„N5 Original Certificate Date: ` I ' 0 .2.. Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH. AUTHORITY APPROVAL CHECKLIST SAMPSON ESTATES SUBDIVISION; LOT 8, BLOCK 4 Parcel ID: 051-811-13 Legal Description: . A.. WELL DATA' Well type,; PRIVATE . Date completed 4/12/2000 Total depth 120 11;1; If A, B, or C provide PWSID# N/A Sanitary seal (Y/N) YES Cased to 120 ft. ft.' FROM :WELL LOG Date' of test • 4/12/2000' I i. Stat c water level 198 ft Wel 'production 20 g.p.m. i,.;I WATER SAMPLE RESULTS: Coliform' 0 colonies/100 mi. Nitrate 1.45 mg./L.' Date of sample:, 2/25/2002 I Arsenic.' N/A mg./L. . B. SEPTIC/HOLDING TANK DATA - Tank Type/Material • Tank size 1000 gal. •Number of Compartments Well Log (Y/N) YES 11 Wires properly protected (Y/N) Casing height tabove ground) AT INSPECTION 2/25/2002 99 STEEL 5.6+i' g.p.m. YES 18+ Other bacteria 0 colonies/100 mi. Collected by: AWWC, INC. Date installed ' 5/10 8/16/2000 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES - Depression over tank (Y/N) NO Date of pumping • 2/26/2002 Pumper 1�'.r ABSORPTION FIELD DATA Date installed 5/10-8/16/20010 Soil rating Length1 58 ft. Width 3 1 Total depth 11.8 ft. Eff. absorption area Date of adequacy test 2/25/2002 Fluid depth in absorption field before test 23 in. Elapsed Time: 5 min. Final fluid depth 28 in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) • ii High water alarm (Y/N) N/A JR'S ` PUMPING System type Gravel below pipe 7 ft. Depression over field NO DEEP TRENCH 812 ft2 Monitoring tube YES Results (Pass/Fail) PASS AbsorptionFrate >= NONE KNOWN For 3 bedrooms New depth 30 in. 450 .g.p.d. If yes, give date — D. LIFT STATION Date installed Size in gallons Manhole/Ac "Pump on" level at in "Pump off" - in. High water alarm level at in. Datu Cycles tested Meets alarm & circuit requirements? E SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A On adjacent Tots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Sewer /septic service line 25'+ ' Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ ' ` Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent Tots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main ,Water service line 10'+ Surface water 100'+ Driveway, parking/vehiclestorage 101+ ,Curtain drain NONE KNOWN F. COMMENTS Wells on adjacent Tots 100'+ G. ENGINEER'S CERTIFICATION 1 certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Na Date 311 fl'L JEFFREY A. GARNESS .. r °A D A. Garness: —7953 .... 4 / .' Dov 4‘\'‘OO°ro fesslo12o o AA Fee$ 375, o 0 Date of Payment Receipt Number (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number FEB -28-02 04:26PM FROM-CT&E ENVIRONMENTAL SRV 9075615301 T-701 P.02/03 F-317 CT&E Environmental Services Inc. CT&E 1021007001 Client Name AK Water & Wastewater Consultants Inc. Project Name/t/ Sampson Est Lot 8 Blk 4 Client Sample ID Sampson Est Lot 8 Blk 4 Matrix Drinking Water Ordered By PWSID 0 Sample Remarks: Client PO# Printed Date/Time Collected Date/Time Received Date/Time Technical Director Released 13 02/28/2002 8:28 02/25/2002 17:30 02/26/2002 11:55 Stephen C. Ede Allowable Prep Analysis Parameter Results PQL Units Method Limits Date Date bit Waters Department Nitrate -N 1.45 0.200 mg/L EPA 300.0 (<10) 02/26/02 JDT Microbiology Laboratory Total Coliform 0 co1/100mL SMI8 9222B (<1) 02/26/02 SBH 02/27/2002 10:10 FAX • FROM COUNTRY REALTY •`V ASBUILT PHONE NO. : 9076881238 „r,/ 9e, `'pi` �Do"�'r Z/Z,;; f ? SE�'T/o/YZW6- IZ/I 002 Oct. 04 2000 05:00PM P2 \4k it tl 11 • pric I HEP.EBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY: AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. IT 1S THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS. COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RETARDED SUBDI- VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OF FENCE LINES, OR FOR ESTABLISHING BOUND- ARY LINES. r 0TH D� 1 •• • F ,o• .r• .▪ ot.. • b'\ • e /S idd .v'.� SEWARD •& SCALE: x""30 DATE: sem/ i'' Co, R' 6p ASSOCIATES LAND. SURVEYING 6 9 4- 0 6 2 GRID: ,f/a'/,r4(0 moNIEM DRAWN: „0C2,e®,m tt A OF A„��� yrs 'r zy-x- .rft-c ..<.�-•+•e�- f Ove+. husk So.v „ kit f .'. •LS -t9) 1a' 4,71,e••r Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On -Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-811-13 HAA# / 19(~ Y:1 `7` Expiration Date: 1. GENERAL INFORMATION Complete legal description Lot 8, Block 4, Sampson Estates Location (site address or directions) 22655 Gabriel Circle Current Property owner(s) MM&M Contracting Day phone 688-1 236 P.O. Box 670495 Chugiak, AK 99567 Mailing address Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: Three (3) 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site El Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results Tess than 30 days old. Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 !Rev. 01'001' 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 Health Authority Approval Guidelines for the Health Authority Approval application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Anderson Engineering Name of Firm Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P:E. 6. DHHS SIGNATURE Approved for 2 bedrooms. Disapproved. Conditional approval for Date 8/29/00 ----l' , .1. :7.,,:::::::071,4::::,:::,,,,c,z-\,:-...',., 4.ri'.ter.;+irrt:ry �ax ENGINEER'S J.,. i ,•.0.it• 1r...• ty ,' r � bedrooms, with the followingstipUla'tions. Additional Comments Attachments: . HAA Checklist Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: ifi7 et.). Expiration Date: % r.' 7- G 75-025 (Rev. 01100)' Original Certificate Date:. 9 - 7 0 0 Reissue Date: ;Legal Description; -Municipality of Anchorage Department of Health and Human ServicesR E :C Division of Environmental Services On -Site Services Section 825 "L" Street Room 5021 P.O. Box 196650 Anchorage, AK '99519=6650 www.ci.anchorage.ak.us (907) 343-4744 ! I Ilk EIV SEP 0 5 2000 1 MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION HEALTH AUTHORITY APPROVAL. CHECKLIST,1! i:Lot 8 Block' 4, ;Sampson Estates A. WELL DATA 11 WeII type Private Date completed 4'/1 2 / 0 OSanitary seal v Total depth 1,1H120 1,. 11 � i l+ Date of test I;', ij; Static ater,level ft Well production WATER1111 : SAMPLE RESULTS: I,1, Coliform 0 colonies/100 ml Date of isample: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Date insta led 5/10/00 ' Tank size 1 .' 0 Cleanouts IY Foundation cleanout Y; I s - Date of pumping !New' Construction illy. C. 'ABSORPTION FIELD DATA,: .:`. j III , ri 'Date installed 8/16/00 If A, B, or C provide PWSID # ft Cased to 120 ft FROM WELL LOG 4/12/.,00 98 20 g.p.m 8/31 /00;; Steel 11111, Length 581, ft ' Total depth 1 1 1 'ft Date of adequacy test !N/A. Results (Pass/Fail) 1 For I1 I in. + i,. Fluid depth ;in absorption field before test in !Water added P i gal Ili ;Elapsed Time • min Final fluid depth in Absorption rate >= g.p.d. ' 1 I Iii 1l1, I Any rejuvenation, treatment (past 12 mo.) (YIN & type) I If yes, give date 1111i 72-026 (Rev. 01100) I Nitrate 1.54 mg/I -' Collected by: MEA Parcel LD.: 051-811-13 -Well;Log 'Yes Wiires properly protected v Casing he'ghtl (above ground) >24 in. AT INSPECTION 1:. ft g.p.m IF1 Other bacterial �.I10 colonies/100 ml tl 00 gal Number of Compartments 2 . Depression over tank N High water alarm N NAI tli! Pumper ;Soil rating (g:p d./ft2 or ft2/bdrm) 6 System type Width 3 ft Gravel below pipe • 7 1ft1111 Effective absorption area812 ft2, Monitoring tube 111:11 I Depression over field .N • Deep Trench bedrooms New depth D. LIFT STATION - N/A Date installed • Size in gallons Manhole/Access "Pump on" level at in "Pump off" level at in High water alarm level at in Datum -. � - Cycles tested Meets alarm & circuit requirements E. SEPARATION DISTANCES SEPARATION DISTANCESFROM WELL ON LOT TO: Septic tank/lift station on lot >100 'On adjacent lots >100 ' Absor tion field on lot On adjacent lots p > 10 0 >100' Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line >25 Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation > 5 Property line >5 Absorption field > Water main N/A Water service line >10 ' Surface water >100 ' Drainage >100 ' Welis on adjacent lots >100 ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line >10 ' Building foundation >1° Water main N/A Water Service line >10 1 Surface water >100 ' Driveway, parking/vehicle storage >25 Curtain drain None Noted Wells on adjacent lots >100 ' F. COMMENTS G. ENGINEER'S CERTIFICATION certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Michael E. Anderson, P. E• Date 8/29/00 0�5e �. EERY ?it eis • trotterl HAA Fee $ 3 ' c). Da Date of Payment 77; l'V Receipt Number C/c715.71- 72-026 (Rev. 01/00)' Waiver Fee $ Date of Payment Receipt Number 09-06-00 09:42 CT&E Ref # Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID FROIt-CTE ENVIRONIENTAL CT&E Environmental Services Inc. 1005252001. Anderson Engineering Sampson Est Lot 8 Blk 4 Sampson Est Lot 8 131k 4 Drinking Water 0 56153-01 T-736 P.02/03 F-023 Client PO# Printed Date/Time Collected Date/Time Received Date/Time Technical Director :. Released By 09/05/2000 16:34 08/31/2000 20:00 09/01/2000 15:30 Stephen C. Ede Sample Remarks: Parameter • WatersDepartment Nitrate -N • • Results • PQL . Units Method Allowable Prep . Analysis .. Limits Date Date Init • 09/01/00 • . SCL Microbiology Laboratory Total Coliform • 0 • col/100mL SM1S 9222E JDT