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Home My WebLink AboutDALE BRIGGS BLK 2 LT 5Dale Briggs Block 2 Lot 5 #050 -182 -OS Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP181392 PID Number: 050 182 05 Dwelling: ❑■ Single Family(SF) ❑ with ADU El Duplex (D) ❑ Two Single Family Project: El New ❑1 Upgrade Name Dan Abts ABSORPTION FIELD Site Address 17340 Monte ❑ Deep Trench ❑Wide Trench ❑ Bed El Mound ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot Ft. Ft. Dale Briggs 2 5 Fill added above original grade Gravel length Township Range Section Ft. Ft. Gravel width Beds:Number of Lines Distance between lines SEPARATION DISTANCES Ft. Ft. ToSeptic 'Absorption Holding Sewer Total absorption area Number of trenches Dist.between trenches From Tank 1 Field Lift Station Tank Line Ft2 Ft. Well .+ 100 +100 — - +25 TANK l Septic ❑S.T.E.P. 0 Holding 0 Other Manufacturer Capacity Surface Water +100 +100Anchorage- - 1250 Gal. Material Number of compartments Lot Line +10 +10 . - - NA Steel 2 Foundation +10 1 +10 — — LIFT STATION Manufacturer Capacity Remarks Tank Replacement Only Gal. Old tank disposed of per code Alarm location Electrical installed by PIPE MATERIAL House to tank 30034Tank to 3034 Installer drainfield Guaranteed Services Drainfield 3034 CO/MT 3034 Inspector CHARLES BALZARINI BENCH MARK (Assumed elevation) 100 ft Inspection 1" 11/21/182nd Location and description dates: yd zit" bottom of siding ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date i�P,� OF AL_94..° Ade_*.49. :-.�� * /, ../. ...... i / Septic System ' CHARLES G BALZARII j Approv �v-- Date ,� -1 D -� Q ��`�� • CE-13854 ••.•��./ 1 ��F'PF•. .•�k�.r Note: this approval does not include well permit requirements. lll\PROFESSION`S (Rev 05/02/18) 2/17/19 DALE BRIGGS B2 L5 *, SO H 70n *' STM *0/ \ . . /‘ . . ". . .7 --. . F<< q� YCHARLES G BALZARIN j 2S I 11 F CE-13854 ••`� DRIVEWAY •c/fIF•. 2/ si1.4 •••'�r N / �i,��PROFESS\,* . / \ >> • NEW 1250 GAL TANK. _ SWING TIES f A 3 \C 23.7 31.4 0 31.6 349 / \ E 33.7 36.1 / / \ F 35.1 37.2 / DECK A f.".vri 4 BR HOME FCC B NEW AFTER / TANK CLEANOUTS DECK t------------ 100' WELL AJ RADfUSiii EXISTING ~ DRAIN FIELD TO REMAIN LEGEND o CLEANOUT MEADOW BROOK SUBDIVISION — NO WELL OR SEPTIC No MONITOR TUBE TEST HOLE PLAN — SCALE: 1" = 30' +100.0' DECK FOUNDATION 99.6\ 4.2' COVER 94 8_7 1250 GAL TANK \-94.5 SCHEMATIC ELEVATION - SCALE: NTS LEGAL DESCRIPTION: DALE BRIGGS BLOCK 2 LOT 5 C&M ENGINEERING SERVICES OWNER: DAN ABTS DATE:02/15/19 REV: IDRAWN: CB REF: 907-854-5558 SEPTIC RECORD DRAWING // 2(-1 , H"P""ry MUNICIPALITY OF ANCHORAGE BJ ; _ OA til\t 11 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 I)t t,irtni, ni ryChONP6E On-Site Wastewater Disposal System Permit Permit Number: OSP181392 Effective Date: 10/30/2018 Work Type: SepticTank Upgrade Expiration Date: 10/30/2019 Tax Code Number: 05018205000 Site Legal Address: DALE BRIGGS BLK 2 LT 5 G:0152 Site Mailing Address: 17340 MONTE RD, Eagle River Owner: MUNSON OLIVIA A Lot Size in Sq Ft: 45000 Design Engineer: C & M Engineering Total Bedrooms: 4 This permit is for the construction of: ❑ Disposal Field Q Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By Date: b f I v Issued By: )t,C_P Date: lOilf a O/67 EPL-AWS MUNICIPALITY OF ANCHORAGE • Development Services Department -iarPhone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/VVELL PERMIT APPLICATION Parcel I.D. 050-182-05 Property owner(s) Olivia Munson Day phone Mailing address 17340 Monte Site address 17340 Monte Legal description (Sub'd., Block & Lot) Dale Briggs Block 2 Lot 5 Legal description (Township, Range & Section) Lot Size 45000 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (IE all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑ (w/wo ADU) Septic Tank ❑ Upgrade 111Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy [ (SF and/or D) Private Well [[ Water Storage LJ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: none Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. Charles Balzarini, C&M Engineering (Signature of property owner or authorized agent) Permit/Rush Fees: 02/.5 Waiver Fees: Date of Payment: Iblaa f l B Date of Payment: Receipt Number: QatIaM Receipt Number: Permit No. 3, p ?/34Q Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 10/10/2018 RE: Proposed Septic System Modification for Dale Briggs Block 2 Lot 5 Dear Reviewer, The above referenced property is currently served by an older 4 bedroom septic system. The 1250 gallon tank has failed and is in need of immediate replacement. We are proposing that the existing tank be replaced with a new 1250 gallon (minimum) tank constructed and installed in accordance with MOA requirements. A polyethylene tank is recommended. As shown on the plan, the tank will be greater than 10’ from the house foundation. The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover. The repair shall be performed by a moa certified installer in accordance with MOA requirements. The engineer will inspect the tank before backfilling. Repair of the proposed system will not negatively impact adjacent lots. Though the tank will be positioned tight between the 100’ radius of the onsite well and a neighboring well. Site limitations require that the new tank encroach within 5’ of approximately 2’ of existing drain field sidewall. This could impact approximately 16 square feet of absorption area. Per the inspection report, the system has 544 square feet of absorption area and with the 125 square foot per bedroom rated soils, only 500 square feet of absorption area was required. Therefore, any impacts by the tank proximity to the drain field will not significantly impact the system’s capacity. We do not believe a waiver fee is required for this minor encroachment. Upon completion of the installation, a record drawing will be submitted showing the location of the new tank, leachfield, well, and other applicable features. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE (10/28/18) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181392, Rebecca Carroll, 10/30/18 LEGEND o CLEANOUT • MONITOR TUBE ® TEST HOLE .0.5%\ SLOPE INDICATOR DALE BRIGGS B2 L4 MONTE ROAD DALE BRIGGS B2 L5 DRIVEWAY w TH •• CHARLES G BALZARIM ��F�,,•• CE -13854 .•��`�� PROFESSlO�P� DALE BRIGGS B2 L6 WELL NOT LOCATED, BUT VERIFIED NOT WITHIN 100' OF PROPOSED TANK. REPLACE EXISTING FCO IF NECESSARY ,- I Li "2 LF OF DRAINFIELD SIDEWALL ISNEW AFTER WITHIN 5' OF TANK / TANK CLEANOUTS DECK 1008) g.LL RADIUS EXISTING DRAINFIELD TO REMAIN MEADOW BROOK SUBDIVISION - NO WELL OR SEPTIC SEPARATION DISTANCE NOTES: THE PROPOSED SEPTIC TANK IS GREATER THAN: 100'FROM ANY PRIVATE WELLS 200'FROM ANY PUBLIC WELLS \ 100' FROM ANY SURFACE WATER 10' TO ANY PROPERTY LINE OR FOUNDATION SCALE: 1" = 40' ZZ LEGAL DESCRIPTION: DALE BRIGGS B2 LOT 5 C&M ENGINEERING SERVICES OWNER: DAN ABTS DATE: 10/27/1 REV: DRAWN: CB REF: 907-854-5558 SITE PLAN REPLACE EXIST TANK FLAG EXACT 1250 GAL TANK. 100' WELL DEMOLISH OLD TANK PER MOA RADII PRIOR REQUIREMENTS TO COMENCING WORK 5.0 DECK 4 BR HOME w TH •• CHARLES G BALZARIM ��F�,,•• CE -13854 .•��`�� PROFESSlO�P� DALE BRIGGS B2 L6 WELL NOT LOCATED, BUT VERIFIED NOT WITHIN 100' OF PROPOSED TANK. REPLACE EXISTING FCO IF NECESSARY ,- I Li "2 LF OF DRAINFIELD SIDEWALL ISNEW AFTER WITHIN 5' OF TANK / TANK CLEANOUTS DECK 1008) g.LL RADIUS EXISTING DRAINFIELD TO REMAIN MEADOW BROOK SUBDIVISION - NO WELL OR SEPTIC SEPARATION DISTANCE NOTES: THE PROPOSED SEPTIC TANK IS GREATER THAN: 100'FROM ANY PRIVATE WELLS 200'FROM ANY PUBLIC WELLS \ 100' FROM ANY SURFACE WATER 10' TO ANY PROPERTY LINE OR FOUNDATION SCALE: 1" = 40' ZZ LEGAL DESCRIPTION: DALE BRIGGS B2 LOT 5 C&M ENGINEERING SERVICES OWNER: DAN ABTS DATE: 10/27/1 REV: DRAWN: CB REF: 907-854-5558 SITE PLAN M p.V 7t+ ROwp ZZle SB9'J9'Oa' E /Sn.uu m3 wane Fsaru � —� AbrFA,F.9,11 jRn<uy �..,,•„„ S 8Y59'oe'E /$p -pp a e "wylar,.< du[ F, A84�u T NO 1`gRNEg9 SETT1M3 MTE r.+e.� ...J I«, It'e'tMDerpa lapt Ilwem� —G— �J/_4J'TTpp^//,.�./"fY� ArMore9e RacnMirq Rrxind, AWE. eM Met the j . ...L.... ... fS.. Jo np or° . AluaW mel9onNMNn ma plcprly Yne6 alq aV attme li m N PraMr1Y IYmO aGecer,l maTftlM.nVD-BIIknRMP2p0r1y1Nlp 9(f.dtrtlMreb '.� :• \o. 919E e k ara oapr m IIfM RmiYi i.. P Yaotron aM Inst mN ve ro °t\+..,'°`... .--': �.`''f rPwnge. nenerrvsaon Imes ormna.v¢¢y eaaprenlcm sea NW at aA+Pe&P w.aIjaW EFEMEM90REORTHH%Df—ka yPeyrsonH. ARCNOSESON HREccaOO ID p PFlIEOW IXA A ASSOOIATES IFT FRE NOT $MOWN HEREQN. TKo qF (3�2a&1663 enoteen era Sorwyv9 \ MUNICIPALITY OF ANCHORAGE 1 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION \ 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE C9NEW J \ f C ) -9�/ % ❑ UPGRADE M%ING ADDRESS VC). 80y 61-7 LEGAL DESCRIPTION Selaael LOCATION�' t NO. OF EDROOMS Jo Well Absorption r a PERMIT O. DISTANCE TO: �li� O i ' �700e V6 .Y �Z nufacturat Mat(ri I No. (compartments wl- F Li( capacity in gallons IF HOMEMADE: Inside length Width Liquid depth d Y DISTANCE TO: Well Dwelling PERMIT NO. JV2 _ H Manufacturer Material Liquid capacity in gallons O DISTANCE TO: Well ountlat Nearest lot a PEHMIT 0., m= c ILL Z No. of li es Lenf o a ch line Total tang h f Ines Trench widtty Distance tween lines FZw1.2 L •tile inches F- Top of til to linith gratle Material beneath Total active ab rption area O e Inches '/j Length Width Depth PERMIT NO W t7 41— Type of crib Crib diameter Crib depth Total eflettive absorption area W G DISTANCE TO: Well j9 Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERM T J d DISTANCE T0: Building foundation Sewer line Septic tank Absorption areas) OTHER PIP MATERIALS SOIL TEST RATING INSTALLER �t i // 7 A `lJ C1Gt) REMARKS 12 ,MC CP 75 � `7n t v a � v r� t. APP V U� DATE LEGAL 72-013 (�. 3/78) U "�' f•1ur-.i I r- I F L 11-•r• re F= Hr-JC=I-t Fll7iE= Lo13-70 • DEPARTMENT OF HEALTH AND ENVIRONMENTAL PRUTFCTION /I e 'L' STREET, ANCHORAGE, AK. 49501 W 264-4720 1•IEELL FIr-•IC> I=Ir-4— = I TE-..C-L•JE-__F." I='F=F=:t•1 7�T PE:FPIIT NO. ! 780852) IFLu�•�-ILI APPLICANT HAMANN CONST,L� (�P. O. BO; E17 EAGLE RIVER = ''<:7 44---. LOCATION DALE BRIGGS SUEDln(?J�Ea., LEGAL. L5 B2 DALE BRIGG'S LOT SIZE 43550 SQUARE FEET TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH 106:MUM NUMBER OF BEDROOMS = 4 SOIL RATING (SO FTIBR)- 12'5 THE PEOUIRED 51� � THE SOIL AE:SORFTIQ j -':S:' N IS: L; t _ 6 =-' -I- F -I -- L E t -J r, T t-1—YYYY� 1fs1fs'' r� F! n E t_ T_'• E_ = F=, 1- t-41 �3 THE LENGTH DIMENSION IS THE LENGT � (IN FEET) OF THE TRENCH OF: DR'AIh!FIELC>. THE DEPTH OF A TRENCH OR: FIT IS THE DISTANCE BETWEEN TPF SURFACE OF THE GPOUND AND THE BOTTOM OF THE EXCAVATION CIN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH 1S THE MINIFUJM DEPTH OF GRAVEL BETWEEN THE OUTFALL F'IF'E AND THE EOTTOM OF THE EXCAVATION (IN FEET). F-' F = C'! l_I I E__ F= C'• C-. F! L_ L_ Co r-.1'= PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPAETt1ENT DURING THE INSTALLATION INSPECTIONS OF ANY (JELLS ADJACENT TO THIS PROPFR:TY AND THE NUt1BER OP RESIDENCES THAT THE WELL WILL SERVE. ---- 1-1•1u < �, ] I tJ-.PECT 11_IrJ = FI F. E= F:F i-!l_t I F:EC• --- RnChFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APF'ROVRL BY THIS DEPARTMENT WILL. BE SUBJECT TO PROSECUTION. HINIMUM DISTANCE BETWEEN A WELL AND ANY ON --SITE SEWAGE DISPOSAL _`_TEM IS aw FEET FOR A PRIVATE WELL; OR 100 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. TIL LOGS HPE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS C,_ THE WELL COMPLETION. 10HEP R.EQUIR:EMENTS MAY APPLY. _PECIFICATIONS AND COJ'=TR.UOTION DIAGRAMS ARE fVPJLAPLE TO INSURE PROPER INSTALLATION. F'-, L F=:1-1 I T E ; f"' I E= E _• Cs F--= Co E h1 Es EE F' 0 1-. I CERTIFY THAT :!:.I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWER FOPFH BY THE MUNICIPALITY OF ANCHORAGE. ._ I WILL INSTALL THE SYSTEM IPJ ACCORDANCE WITH THE CODES. 2. I UNDERSTAND THAT THE ON-SITE SEWER: SYSTEM MAY REOUIRE rESIDENC:E IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. IGNED IS LIED i i 1 J vONST BY v " AND (JELLS AS SET ENLARGEMENT IF THE eonsE:ucEion 'J�: = -�-QU On, tort iivrtl o tk^v.n"E :c7cn :�\ • 2204 Cleveland F,nchoraoe, Alaska 99503• a _ _Rate Perforr.gd Performed For Ilk W' n " C2pa(G r• u Leval Description: Lot J_R1ocl: 2. Sub divis�nnPercolation T s This Form Renorts Soils Lon C tenth Feet Sgil 2 4— Q 12- 14—. 16, 18— v, 8— L,'as [round Water Encountered? 010 if res, At what Depth? Readinq I Date .l Gross Time liet Time Depth to H2O Net Dronj Fercolatinn Rate _Ilinute Drain Field — Frnrosed Installation: Seenaoe Pit Depth T om Of Pit 0 Trench De^th of inlet raly� —PDQ- b&Zar'on•6- Data Certified E'y: �. N Test Performed 8y — Date- •�FlNK l'1 -so 6�ce✓ )JOT sEf t1 SOP 7MU OPLY. 0� Td T P,^ ri � I g� 0 r% Pi- ire 514 ri I lz c N 0 LQ W LLJ z ce I I I Z w z LL] ww 0 X, 0 w 0 0 LQ LLJ z ce I I I Z w w LL] LLA 0 LQ LLJ z ce I I I Z w w LL] 0 �tVL/Wz 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 Parcel I.D. 050 182 05 1. GENERAL INFORMATION Expiration Date: Complete legal description Dale Briggs Block 2 Lot 5 Location (site address) 17340 Monte Current property owner(s) Dan AbtS Mailing address Real estate agent 2. TYPE OF DWELLING: Fx-1 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic El Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ '15,56 Waiver Fee $ _ Date of Payment_ 31g11q Date of Payment Receipt Number Receipt Number COSA # Waiver # Distance: 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 C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 2/20/2019 of ALNgs�l t 6. DSD SIGNATURE A System #1 Approved for bedrooms �� CHARLES G BALZARINI System #2 Approved for bedrooms t♦��; . CE•13854w�� Disapproved ��,lkF�PROFESS1ONP��.� Conditional approval for bedrooms, with the following stipulations: VVI 61 F(M.,V -k-e�Ce� � `�S� WICVe Q oy-4OW>�d 17_-I2_-I.S7 -f- t,!fl( e)onft�P )2 -I2 --z o , T1-e� Tel"i-_ll, Ltikkkk " J� I-NUUNAM 6;• o 11)?)1}1111 " (� 10'2C�" Original Certificate Date: The Municipality of Anchorage Development 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. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Z= WATFR Amn WASTEWATER z J� I-NUUNAM 6;• o 11)?)1}1111 " (� 10'2C�" Original Certificate Date: The Municipality of Anchorage Development 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. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: Dale Briggs Block2 Lot 5 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Parcel ID: 050 182 05 Structure served by this system 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Well production at time of test +5 gpm Date drilled 9/11/76 Water storage tank volume na gallons Total depth 153 ft Well disinfected for coliform test? ❑ Yes ❑ No Cased to +40 ft ❑ Coliform bacteria is Negative ❑ Sanitary seal is functioning correctly Nitrate 0.250 mg/L ❑ Nitrate less than MRL (ND) ❑ Wires are properly protected Arsenic ug/L ❑ Arsenic less than MRL (ND) Casing height (above ground) +12 in. Collected by C&M Engineering Date of flow test for COSA 12'20!18 Date of Sample 10/15/20 Static water level at beginning of test 96 ft. Comments reported production rate limited by plumbing and testing apparatus, actual rate may be higher. B. TANK DATA Age of tank(s) <1 years Tank type/material steel ❑ Standpipes/foundation cleanout per record drawing Date of pumping na new tank D. ABSORPTION FIELD DATA shallow trench Which system tested (date installed) 9/78 IN ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of drainfield. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced na gallons Comments/Deficiencies: COSA Checklist yellow sheet C. LIFT STATION ❑ Required maintenance completed Age of lift station na years Lift station material na Comments: na Adequacy test date 12/12/18 Results Q✓ Pass For 4 bedrooms Fluid depth prior to test 30 in Water added 600 gal New depth 32 in Elapsed time '1440 min Final fluid depth 30 in Absorption rate 600 gpd Any rejuvenation treatment (past 12 months) If yes, enter date na na E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' 0 Yes if No Community Sewer Manhole/Cleanout > 100' ❑✓ Yes if No ft Q Yes if No ft Neighboring Tank > 100' QYes if No ft Private Sewer/Septic Line > 25' OYes if No ft Absorption Field on Lot > 100' ✓O Yes if No ft Holding Tank > 100' Q✓ Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' 0 Yes if No ft ✓0 Yes if No ft ft Community Wells > 200' QYes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' Yes if No ft ✓Q Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' Q✓ Yes if No ft Property Line > 5' Q✓ Yes if No ft Driveway/Parking > 0' 0✓ Yes if No, comment Absorption Field > 5' Yes if No ft Wells on Adjacent Lots: Water Main > 10' Q✓ Yes if No ft Private Wells > 100' F, -/]Yes if No ft Water Service Line > 10' 7 Yes if No ft Community Wells > 200' QYes if No ft From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Q Yes if No ft Driveway/Parking > 0' FV Yes if No, comment Property Line > 10' 0✓ Yes if No ft Wells on Adjacent Lots: Water Main > 10' ✓0 Yes if No ft Private Wells > 100' 0 Yes if No ft Water Service Line > 10'✓0 Yes if No ft Community Wells > 200' Q✓ Yes if No ft Surface Water > 100' Q✓ Yes if No ft F. ENGINEER'S COMMENTS new tank installed in 2018, all standpipes verified. RE -INSPECTED 10-15-20. NO CHANGES IN CONDITION FROM PREVIOUS TEST G. ENGINEER'S CERTIFICATION +'® OF A/,,: '��••.....40, ! certify that I have determined through field inspections and review '®CO 'd P of Municipal records that the above systems are in conformance with '� TH '9 ) MOA COSA guidelines in effect on this date. 2/15/2019 d ... .. ..... ...... . CHARLES G BALZARKI ��sTF . CE-13854AIW • ,��`�� pROFESS1Q* COSA Checklist yellow sheet 0lx®®Iln 0a�' EPIAALS MUNICIPALITY OF ANCHORAGE Development Services Department 4 Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On-Site Systems Approval Parcel I.D. 050 182 05 Expiration Date: —�� 1. GENERAL INFORMATION Complete legal description Dale Briggs Block 2 Lot 5 Location (site address) 17340 Monte Current property owner(s) Dan Abts Day phone Mailing address Real estate agent Day phone 2. TYPE OF DWELLING: Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well LI Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ 55U Waiver Fee $ Date of Payment 3/q<<9 Date of Payment Receipt Number Q4W13 13 Receipt Number COSA# Oso 1gt6(iO 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 C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 2/20/2019 AC II go °'•• 04 6. DSD SIGNATURE . System #1 Approved for qt bedrooms ��' "�'�''`j``• `• • CHARLES G BALZARINI System #2 Approved for bedrooms �9��•.• •CE-13854 ..•�`� Disapproved ilk °PROFEss0-- Conditional approval for bedrooms, with the following stipulations: ,kokt(trct((4,, OF,q (f ON-Slit WATFR AND SCr WASTEWATER z^ PRUGRAM O if))/)))))lt)11111 , Original Certificate Date: 57-1 0 -1 The Municipality of Anchorage Development 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 X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: Dale Briggs Block2 Lot 5 Parcel ID: 050 182 05 If more than 1 septic system on lot: COSA Checklist# 1 of 1 Structure served by this system 1 A. WELL DATA 0 Well log is filed with Onsite (or attached) Well production at time of test +5 gpm Date drilled 9!11176 Water storage tank volume na gallons Total depth 153 ft Well disinfected for coliform test? ❑ Yes 0 No Cased to +40 ft Coliform bacteria is Negative • Sanitary seal is functioning correctly Nitrate 0.876 mg/L ❑ Nitrate less than MRL (ND) ■❑Wires are properly protected Arsenic ug/L ❑■ Arsenic less than MRL(ND) Casing height(above ground) +12 in. Collected by C&M Engineering Date of flow test for COSA 12/20/8 Date of Sample Z-(Z-J9 Static water level at beginning of test 96 ft. Comments reported production rate limited by plumbing and testing apparatus, actual rate may be higher. B. TANK DATA C. LIFT STATION Age of tank(s) <1 years ❑ Required maintenance completed Tank type/material steel Age of lift station na years • Standpipes/foundation cleanout per record drawing Lift station material na Date of pumping na new tank Comments: na D. ABSORPTION FIELD DATA shallow trench Which system tested (date installed) 9/78 Adequacy test date 12/12/18 •ALL standpipes present per record drawing Results E Pass For 4 bedrooms Total measured depth from grade 12 ft(max) Fluid depth prior to test 30 in Measured depth to pipe invert from grade 4 ft(min) Water added 600 gal ❑ N/A—pressurized field New depth 32 in ElMonitor tubes go to bottom of drainfield. If not, state Elapsed time <1440 min depth into effective ❑■ Code-required soil cover over field Final fluid depth 30 in El System presoaked Absorption rate 600 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) na date of test) Gallons introduced na gallons If yes, enter date na Comments/Deficiencies: COSA Checklist yellow sheet • E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot> 100' Community Sewer Manhole/Cleanout> 100' ❑✓ Yes if No ft El Yes if No ft Neighboring Tank > 100' ✓0 Yes if No ft Private Sewer/Septic Line >25' 0 Yes if No ft Absorption Field on Lot> 100' E Yes if No ft Holding Tank> 100' 2 Yes if No ft Neighboring Absorption Fields > 100' Animal Containment> 50' ✓❑Yes if No ft ❑✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' E Yes if No ft ✓❑Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑✓ Yes if No ft Surface Water> 100' E✓ Yes if No ft Property Line > 5' ✓❑Yes if No ft Driveway/Parking > 0' E✓ Yes if No, comment Absorption Field > 5' ✓❑Yes if No ft Wells on Adjacent Lots: Water Main > 10' E Yes if No ft Private Wells > 100' ✓❑Yes if No ft Water Service Line > 10' ✓0 Yes if No ft Community Wells >200' E Yes if No ft From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ✓❑ Yes if No ft Driveway/Parking > 0' p Yes if No, comment Property Line > 10' ✓❑Yes if No ft Wells on Adjacent Lots: Water Main > 10' ✓Q Yes if No ft Private Wells > 100' ✓❑Yes if No ft Water Service Line > 10' ✓❑Yes if No ft Community Wells >200' E Yes if No ft Surface Water> 100' ✓❑ Yes if No ft F. ENGINEER'S COMMENTS new tank installed in 2018, all standpipes verified. G. ENGINEER'S CERTIFICATION ,r1 i �of�gs11� I certify that I have determined through field inspections and review ,' Y • .9,+ of Municipal records that the above systems are in conformance with *: 49 Thi .*$4 MOA COSA guidelines in effect on this date. 2/15/2019 / ..././7,...... / /CHARLES G BALZARINI r�, /F',•.f. CE-13854 ••`,rte , e)." .... •'• i 1. COSA Checklist yellow sheet illle�-`F`=`-•- • MONTE ROAD 8221E o 0 Cr) co S89°59'00"E 150.00 — -1-"_..., — — r r -..r.,---Plastic fence ti 5'i Wire fence Lot 4- LOT 5 Lot 6 0 0 O /� WeII on property line o O o / I i Ofti M CO } I N a LU zi-; O W 11�Easement for well protection �� o 0o for Lot 4, Block 2. 0 SCALE: 1"= 40' o ( Book 423, page 975 ) 00 o Z ,„‘,‘,V\\,t` o z �� F • A.; r) 0., TIP* ',r M1unl,cipality ofrAnchorage 'I , ;iF.;nDepartment of;Health andiHuman';Servrces 7 T �r 41V., �6t,v }"• ' .',.,,Division of Enviionmental,Servlces I • )0,', 'On'Site Services Sectiory 825'L' Street 1' Rooni 5023 it , -r •-' RO . Box �196650'Ahch6rag6, AK 99519=6650 t„ 9r• �i: ', . ir';.;, i t.r, d' , * ) 4�>:,l :,www.cl:arichorage.ak:us; sr',(907,)$43-47441'rJcilrl.i,;ticl^7451.; .'. iD"iJS1 brcS',eCJa ti'+vrjdirq� °C�f i }CERTIFICATE OF',HEALTH AiJTHORITY?APPROVAL r i i ih f'' FOR A'SINGLE'FAMILY DWELLING'? r e, . � I .^/, f, y.,l..; :,• 3_ - - 1 e �,t r 'o , ''?k r+s1 �' i,t ParcelLD. 'O D-`%R•z=O S ' ' yHAA# ['7 [ -6,60" 'l.Expiration Date 1.';.!GENERAL INFORMATION r _:Completelegaldes npUon Lot 5 'Block '2t DalefBrIil QSu 's bdivision Location(siteaddressordirections)'; 17340 PlonieiRoad Current Proproperty.owner(s) James `HansenDay phone Y694 -9748 Pr Mailing address 17340`ltonte'Road,:EaQle River `+AK 99577 ,r r , i<,r).. �Y. fr :.:( i .)I "1. - ,i.4CtJ, l � .,;.i tf U.n�r..., i d e';•.d,y r. r..: _ Lending agency' 1=/ ;Day phone •'' Mailing addess Real Estate Agent ? Day phone Mailing Address Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: - 2. NUMBER OF BEDROOMS: -4. " 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ®" Individual On-site 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 AuthorityApproval 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 t_. 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 lesslhan 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. . 72025 (Rev. 01/00)• 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 ;66ied,on procedures outlined in the Health'Auttiority Approval Guidelines for the Health Authority Approval `i. application show that the on-site water.supply and i':•; - /or wastewater disposal system is safe, functional and adequate 'for the. humber 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 on1.-site'watersupply.and/or wastewater disposal system is in compliance with all applicable Municipal . ordinances; and regulations in effect at the time of installation. s & gia 17034 Eiy1t Rlvdr Loop Road No. 204 Name of Firm -iA Eigta'Riv`ei; Aliiki 99577 1 f 1 'Phone' :G `f Y9 `l Address Engineer's Printed Name 'Robert Cowan Date r r,. S P, RoeCE 6801 COWAN 6.... DHHS SIGNATURE ;,+. • ` . JG Approved for �- bedrooms t i Z�� o ESst -.-.....,_..t.._ -�.t ..,.,... ...---._�:... _._ .. :.-.•......._.._... '�"�t. Disapproved Conditional approval fort bedrooms; with the following stipulations Attachments: HAA Checklist Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory. Other Original Certificate Date: _ 1- 3-0/ Expiration Date: T' 3 - D D Reissue Date: 72-025 (Rev. 01/00)' Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On -Site Services Section 825 V Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-4744 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LOT 5 FL.oGJ- 2,; �l} LF �2 / e f s Vt� Parcel I.D.: oro -1 B Z A. WELL DATA Well type✓49L_ Date completed 9 /1 M Total depth 153' It Date of test Static water level If A, B, or C provide PWSID # Sanitary seal �5 Cased to it FROM WELL LOG ,7/// ;-6 3.7' ft Well Log Wires properly protecteds Casing height (above ground) in. AT INSPECTION Well production /O 9 -p.m S. Q g.p.m WATER SAMPLE RESULTS: Coliform D colonies/100 ml Nitrate a . 1Y mg/I Other bacteria o colonies/100 ml Date of sample: J A-41 7/0✓ Collected by: 5 8 5 ENGINEERING B. SEPTIC/HOLDING TANK DATA 17034 Eag!a River Loop Road No. 204 Eagle River, Alaska 99577 Tank Type/Material t5t T . STF'%e�L Date installed Tank size 7Q5Z gal Number of Compartments Cleanouts YkLFounclation cleanout t Depression over tank _NQ High water alarm 47 A Date of pumping 12 # In I &V Pumper _'T/7's C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d.lft2 or ft2/bdrm) /ZS System type Z4&ryG H Length 3� ft Width L_ ft Gravel below pipe _�ft Total depth 19, ft Effective absorption area C44 h2 ;Monitoring tube IIAS Depression over field 6 Date of adequacy test LV131t71 Results (Pass/Fail) Iq SS For 01jille, bedrooms Fluid depth in absorption field before test 3 �� " in Water added Z gal. New depth 3O in. Elapsed Time: :30 min Final fluid depth 4 -7' in Absorption rate >=4 eo g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Al6Vi )�IA/OwN If yes, give date — 72 026 (nev. 01/00)' D. LIFT STATION Date installed ize in gallons Manhole/Access "Pump on" level at P` in "Pump off" level at in High water alarm level at in Datum Cycles tested Meets alarm & circuit requirements. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 0: On adjacent lots Absorption field on tot /00 �A On adjacent lots ! o U ' + r i Public sewer main / 00 Public sewer manhole/cleanout /00 1 Sewer /septic service line 2 S f Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Building foundation /0 Property line 7 14 Absorption field 5 Water main n/ IA- Water service line //7 -r' Surface water / o o ',I - Drainage 1a Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 19 4- Building foundation / O 1- Water main ,V /R Water Service line O '+ Surface water /00 '1 Driveway, parking/vehicle storage /0 �*- Curtain drain aN Wells on adjacent lots 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 HAA guidelines in effect on this date. Engineer's Printed Name 0 /i E T_ C _ eJ e✓9� Date f -a-If d/00 HAA Fee $ 3 00, e a� Date of Payment Receipt Number 72.026 (Rev. 01/00)' Waiver Fee $ Date of Payment Receipt Number' .... ;rt, S4 AM 11 !f�yS ROCERT C. COWAN 1 CE -8801 ;.- M MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel LD. # 195n-nf; HAA# "USSIhLInSS 1. GENERAL INFORMATION Complete legal description Lot 5; Stock 2; Date 132i.gg4 Subdiv.i.6lon; Location (site address or directions) t T 3a0 Affinto Riad Property owner Jama S Noma Jan6en Day phone Mailing address 17340 Monte Road Eaqte Riven AP.aska 99577 Lending agency FTRCT NATTONAI RANK of ARCHo2AGE_ Day phone Mailing add Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 y 3. TYPE OF WATER SUPPLY: Individual well XX Community well Public water 694-9748 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: XX 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. 72-0250".1191) Fro Q MoA121 S. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm < Ek jNggRtNG Phone Address 17034 Eagle River Loop Road No. 204 ay 5 77 Engineers signature Date 7-25"2 6. DHHS SIGNATURE Approved for x'c'u _ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 13y: Date 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 thei r lendi ng 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 engineers work. 72.M (Fav 191) Back MOA a21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description;Wt' `7 t5L V- 1, P'0<t.E parcel I.D. 0 SC —/9%, -ate A. WELL DATA Well type \t If A, B, or C, attach ADEC letter. ADEC water system number '� 1 Log presentCY)N)y Date completed 9 - i t 41b Driller Sohl Total depth 1 S3 Cased to 1 S',- Casing height 17 Sanitary seal 69N) Wires properly protecteddDYN) WATER SAMPLE RESULTS: Lev. AA Coliform O I1O000 Nitrate Z •Z Other bacteria Date of sample: '1iZ--01Z S & S ENGINEERING Collected by:Loot, R&W NO 15nd &awe.Eagle River, Alaska 99577 B. SEPTIC/HOLDING TANK DATA Date Installed `�1 Tank size I Z�b Compartments Z Cleanouts PN) _ Foundation cleanout (0N) 4 Depression (Y/ High water alarm (Y& Alarm tested (Y/N) A)t& Date of pumping ? Z Z —qy Pumper _6A -,J11 -AA u SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s)onlot 1001 Onadjacentlots 100 Foundation S �k 1k Topropertyline 10 Absorption field 0 Water main/service line t o Surface water/drainage 1 L) C>, 72026 (Rev. 751) Front CONTINUED ON BACK PAGE FROM WELL LOG AT INSPECTION Date of test Static water level Well flow 1C0. f> t fT7 g.p.m. lD .17 g.pr-1 r- z Pump level J1y JtiL rn -- ^' v m o C `� m ` SEPARATION DISTANCES FROM WELL TO: T ti z ti Septic/holding tank on lot t ; On adjacent lots lob Absorption field on lot ; On adjacent lots t o D `d 1 a' "tl� Public sewer main Public sewer manhole/cleanout Sewer service line a- Petroleum tank �� t WATER SAMPLE RESULTS: Lev. AA Coliform O I1O000 Nitrate Z •Z Other bacteria Date of sample: '1iZ--01Z S & S ENGINEERING Collected by:Loot, R&W NO 15nd &awe.Eagle River, Alaska 99577 B. SEPTIC/HOLDING TANK DATA Date Installed `�1 Tank size I Z�b Compartments Z Cleanouts PN) _ Foundation cleanout (0N) 4 Depression (Y/ High water alarm (Y& Alarm tested (Y/N) A)t& Date of pumping ? Z Z —qy Pumper _6A -,J11 -AA u SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s)onlot 1001 Onadjacentlots 100 Foundation S �k 1k Topropertyline 10 Absorption field 0 Water main/service line t o Surface water/drainage 1 L) C>, 72026 (Rev. 751) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size In gallons Vent(Y/N) High water alarm level Meets MOA electrical ( on lot Manufacturer Manhole/Access (Y/N) "Pump on" levet at ISTANCE FROM LIFT STATION TO: On adjacent lots ip off" level at Cycles tested Surface water D. ABSORPTION FIELD DATA . I- /Y. -7 Date Installed CA-) S Soil rating ly< 4// a, System type T��ASLa Length ,Z7`f 1 Width znkl Gravel thickness S t Total depth 17-1 i Total absorption area 5 Cleanouts present (ilN) Depression over field (Y& Date of adequacy test�- Resuits&,SS)fail) pl�._ for F2>0 1t- (R-) bedrooms Peroxide treatment (past 12 months) (YO fi (GAJo\AAJ If yes, give date% - SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot } On adjacent lots �k Propertyline 101ffA- To building foundation - to %.),- To existing or abandoned system on lot 1) !4 On adjacent lots 30Cutbank �A 0, Watermain/service line lb Surface water 0O t+ Driveway, parking/vehicle storage area S� 1 Curtain drain A8 .a Vsc7a u...,J E. ENGINEER'S CERTIFICATION,,- ,.., ry I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this Inspection. S 8 S ENGINEERING di Signature 17034 Eagle Itl 01-11, Eagle River, Alaska 99577 a o, so* Engineer's Name ij Date %-%29- oil!y HAA Fee $ Date of Payment Receipt Number _ 2 �- 72-026 (A". 1/91) Back MOA 21 Waiver Fee: $ — Date of Payment Receipt Number L Jr -4 '% it LR J. CHAFER No. 8215 rMUNICIFAMY Or h v MUNICIPALITY OF ANCHORAGE DEPT. OP HEALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTWYIQINIMENTAL PrzOTECTION STREET LOCATION _ 825 L Stroat • Anchorage, Alaska 89501co • —L JU1 1 6 1979 c" I NUMO R UP BEDROOMS 1 M ENVIRONMENTAL ENGINEERING DIVISION ❑ One fy, Four ❑ Other \ ❑ Two "❑ Five Telephone 2644720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all pans on page i.lncomplets rapuats will not be proeased. Please allow tan 1101 days for processing, 1. PHOPERTYOWNER - ' ATTACH WELL LOG. A well lop is required for all wells drilled PHONE _ L—A a�REUTEL ❑ PUBLIC UTILITY NONE M,a1LING ADDRESS .. _ _ / QO P_0. BOX 25 PIONTE RDS EAGLE, IVER.ALASKA 99577 7 PROPERTY RESIDENT Uf ddierent from above) -, _PHONE If system is over two (2) years old an adenuacy test is required 2. BUYER Eby this Department. PHONE JAMES & NEOMA JANSEN 694-9748 MAILING ADDRESS' S.R. BOX 191 C. EAGLE RIVER ALASKA 99577 3. LENUING INSTI FUTION PHONE ALASKA MUTUAL SAVINGS BANK 694-9571 MAILING ADDRESS - - BOX 1068,EAGLE RIVER ALASKA 99577 A. REALTOR/AGENT PHONE NONE MAILIUG ADDRESS , 5. LEGAL DESCRIPTION - -. LOT 5, BLOCK 2, DALE BRIGGS SUBD., EAGLE RTVER, ALASKA STREET LOCATION _ MIN MONTE RD. (MAP INCLUDED 8. TYPE OF RESIDENCE NUMO R UP BEDROOMS ❑ One fy, Four ❑ Other CXJ SINGLE FAMILY ❑ Two "❑ Five ❑ MULTIPLE FAMILY ": ❑ Three ❑ Six 7. WATER SUPPLY , I- CX) INDIVIDUAL* 150' ' ATTACH WELL LOG. A well lop is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach lop if available.) [ , 8. SEWAGE IDISPOSAL SYSTEM - - - 1500ghliflndividual/on-site, Installationdate_a4;_. 21 INDIVIDUAL/ON-SITE" give If system is over two (2) years old an adenuacy test is required ❑ PUBLIC UTILITY o Eby this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. NOudIa3S3a lV03l . 03AOaddVS10 ❑ (9)eo!1111ao Auedwoaae lsnw iallal) IVAOaddV IVNOI110N00 ❑ SWOOa030 HOA03AOaddV---IZ S1N3WW03 '9 awl iol isaicau of ea,V uontliosgV awl 101 MI&ON awl Aa aS ea,y uugajosgy 4ue.1 BwploHlonda$ :Ol 113M11 S33NVISIO '4 V38V NOl1dHOSOV lV1Ol H3UnlOVlnwn NNV1d03dA1 DNIiVH Sl los :SUOisuau0p aAIB spewauloy $l Nuel 11 az!$ Nuel BuipIOH❑ lO Nue,j Ol1daS❑ 8311V1SNl payuaA U01130uuo3 Alnun3nand❑ 311S-NO,"IvnolAIONI0 W31SAS IVSOdSIO 30VM3S 'S a31lv1sN131g0 83ewnN 11WL,3d 03AI333M 001 Pa!}ua/1 uoHPauuo3 Alnun 3nand ❑ A11Nnwwo3 ❑ IvnOIAIONI ❑ AlddnS 1131VM 2 0311180 31VO 113M dO Hld30 83eWnN 11W83d XIS ❑ anod ❑ OAU ❑ a3H10 ! ❑ 3AU ❑ 33aH1 ❑ 3NO ❑ AIIVJVd 31dulnW ❑ AIIWVd 310NIS ❑ 33N30IS3a d0 3dA1 I SWOO8039 d0 UNIVAnN Ii :SN01103810 80133dSN1 11O1D3dSNl 80133dSNl 31VO 31VO 31Vn 3W11 3W11 3W11 S1N3W1NIOddV NO1133dSNl 03A133311 31VO,1 AINO 3Sn Ivl31dd0 aOd 3015 SIHI MUNICIPALITY OF ANCHORAGE MUNICIPn.UTY C- ANCHOP.AGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. ;'. -'U': £, 825LStreet -Anchorage, Alaska 99501 I..;.-CTION 1` ENVIRONMENTAL ENGINEERING DIVISION t FHy 1 1. 1079 Telephone 264-4720 CC �� REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE�Y-FS42 IMED t DIRECTIONS: Complete elt parts on page 1. Incomplete requests will not be processed. Please allow ten 110) ays for processing. 1. PROPERTY OWNER r �In�a "'c4 PHONE t 7 r•r\ 0 r 10 F -335 MAILING ADDRESS T r inO n —/ / PHONE PROPERTY RESIDENT tit ddlerent from.abo el / \ Siren � nn.. C 2. 13UYER 7. WATER SUPPLY PHONE _ It' P1c_ ? ' ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY MAILING ADDRESS 1\i 3. LIENDIP&4k4STITUTIN '�� PHONE t � MAI LI ADORE n q. REA TOR/AGE T 1 \ ` PHONE MAILING ORES$ \ ,t \" " \� 7 V 5. LEGAL DESCRI TION d STREET LOCATION /� / 6 w//D 6. TYPE OF RESIDENCE NUM Be, H OF 6EORQ�OMS SINGLE FAMILY ❑ One 110 Four ❑ Other ❑ Two Five ❑ MULTIPLE FAMILY ❑ Three Six 7. WATER SUPPLY V6 INDIVIDUAL' ' ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM � INDIVIDUAL/ON-SITE" installationd;lte If system is over two (2) years old an adequacy test is required If ❑ PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 7201013/781 il/D7' i��ApY THIS SIDE FOR OFFICIAL USE ONLY — INSPECTION APPOINTMENTS DATE RECEIVED , TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE '97 SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO -91 FOUR ❑ SIX 2. WATER SUPPLY INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL GATE DRILLED LOG RECEIVED 3.SEWAGE DISPOSAL SYSTEM '❑INDIVIDUAL/ON-SITE ❑PUBLIC UTILITY_ Connection Verified PERMITNUMBER DATEINSTALLED ILI_ INSTALLER SOILS RATING QSeptic Tank or ❑Holding Tank Size:�C) If Tank is homemade give dimensions: TYPEOFT NK MANUFACTURER TOTALABSORPTION AREA C L MATERIAL 4. DISTANCES WELLTO: Sepuc/Holding lank I Absorption Area I Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS ❑ 'APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY Title LEGAL DESCRIPTION