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HomeMy WebLinkAboutDEER PARK BLK 2 LT 4Deer Park Block 2 Lot 4 #051-042-29 • Municipality of Anchorage On-Site Water and Wastewater Program • (907)343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: PID Number: 051-042-29 Dwelling: ❑■ Single Family(SF) ❑ Duplex(D) ❑ Multiple(SF and/or D) Project: El New ❑■ Upgrade Name: Randolph & Marlene Wallace A- ORPTION FIELD Address El De- Trench El Shallow Trench El Bed ❑ Mound 22326 Deer Park Dr, Chugiak • Other Phone 'Number of Bedrooms Soil Rating Total depth from original grade 342-2421 3 t-D/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original •ode Gravel depth beneath pipe Subdivision Block Lot Ft. Deer Park 2 4 Fill added above original grade Gr. el length Township Range Section Ft. Ft. Gravel width Beds:Number of Lines Dist-• - between lines SEPARATION DISTANCES Ft. Ft. To Septic Absorption Li,Station Holding Sewer Total absorption area Number of trenches Dist.between : ches From Tank Field Tank Line Ft2 Well >100' TANK Septic 0 S.T.E.P. ❑ Holding 0 Other Manufacturer Capacity Surface Water >100' Unk 1300 Gal. Material Number of compartments Lot Line >5, NA Plastic 2 Foundation >5' LIFT STATION Manufacturer Capacity Curtain Drain >50' Gal. Remarks Pump on level at Pump off level at High water alarm at Septic tank replaced by previous owner; no documentation available. Data in. in. in. based on site surveys, and camera survey. Pump make and model Electrical Inspections performed by PIPE MATERIAL House to tank Tank to Installer drainfield Unk Drainfield CO/MT Inspector Brandon Jones, AK Rim Eng. BENCH MARK (Assumed elevation)100 ft Inspection : 15, 2/19/18 2nd 2/21/18 Location and description d3rd 4th Top of middle concrete piling under porch. COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL kvi"aillAti � `_•.A OF Atqs / Conditional Approval: Date :_ •co • '..-y Ie fi:*: gni •* i .._A,...,..._ j .),L,... .,::,.... -5 Mary . Shreves : "� 4 �I-.P••• CE 9351 .14Q —CIG Date 3'."'ij'10 /;ill, 111FE\S\° ``` Approv t,` " - /ip 6 Inspection Report_9-1-12.doc ts/ \-20' ACCESS EASEMENT LOT 5 WELL TYPICAL / EDGE OF PLOWED ACCESS IPP i i / ,. - `� / t F . N78•28,46.w 4 - z Ioi 4 PLASTIC 36 •85, \� PEDESTAL / / LOT 4 RISER TYPICAL "\ S'x,OE' US UTY ' IENT 42.285 S.F. ® u.G T E ..r / / / U7 //NAT. GAS �'�.\ ��- / 0 *�a , / o ;10? �� of G"TYPICAL / 0��� POST I DEac TYPICAL—! �' 1" = 80' I �1 SHED NO FND. CANT TYPICAL— 'p U�I ARCTIC ENTRY — O� / / I 4.6' 4, r - 4,1F4?°` s , / #4), / RETAINING WALL , \ It II ` Z � sA8 .02'5 0"E — DRIVEWAY C 295.37' / OFF LOT FENCE) / CZ I C1 ' - LOT 3 �' t71 I tt i BLOCK® �.i b \:t111 I (C CUUTED DATA / iqj 25 (M)-MEASURED DATA (R)-RECORD DATA PER PUT \ •0 U.G.-UNDERGROUND T&E-TELECOMMUNICAT1ON & 1't ELECTRIC j`+ I NAT.-NATURAL FWD-FOUNDATION 10' MIN. 10' MIN. BM 100' CAPPED CLEANOUT CAPPED VENTS r1 ' p 101.17' 17 \____ 96.75' i- r SOIL / SEPTIC ABSORPTION TANK SYSTEM 4" PVC AT UNIFORM SLOPE 92.75' BM=TOP OF CONCRETE PIER BELOW DECK. SEPTIC SYSTEM PROFILE Not to scale Conventional Single Family Residential `•`.••`OF At� ���/4 S H PTIC TANK R I-I: C ORD DWG . co.: • / LEGAL / •••* / DESCRIPTION *:•4 TH ,........ . . Deer Park Block 2 Lot 4 , Mary Shreves .. 4....,..7 6(12, . CE 9351 - '',I ii i 11\ESS•v�```� ALASKA RIM ENGINEERING, 3 14 18 WO:Scaled as shown 1800052 //G f l� INC. DAA \ ..........ic.iamow o \ \. 1 \ in III J U J t o �4 K DR. 'Z' I �,,s, ER pAR J w �m i � '.2ss -00 DE o, ow / D LA 4(�� / • N — X in O U } • cn / �,Z 7 „uj 0/ i / T I. )— I 6 < z re Q O/ I. ry 2e 9" • k% ' \ oo. y ,a.4.7,,,. \ • .>.-- ..) A```te 2.7' , T,11' -H \ c h. 0 rye. 0 to p 3 8``x`,3\` •\ N f0 4.6' 'v J J CO N U J Q Q U 2 Qcn v / U 1-, N 0 Y i— E- C'"J O w w Q 3 '^� OJ Y Cl) 0 0 U U) 1-` U ( Z c\1 o O Z w '� m Z Q w 0 �0. p N a_ Z (n 3 z N I- F Q Q _J coLC) NZ Q Q ZZ zN o_ too 0 F8-iO c. oO� �ho (3rQQOUQ wU _ LOU QJ O D c[wUppZ Lii Z U �CILUU HI '7J-1WCC 0<p Z3. W°11 L+1JZQtL \,2 \C-) U JII wII �II BASIS OF BEARING Z Z H\ ilfJ��vD F— Z L� ii. S00'04'58"E _ 149.94'(R) 149.91'(M) 0 —0 co 6 UNSUBDIVIDED 0 NOTES: 1. EXCEPTING FOR GROSS NEGLIGENCE, THE LIABILITY FOR THIS SURVEY SHALL NOT EXCEED THE COST OF PREPARING THIS SURVEY. 2. THIS SURVEY REPRESENTS VISIBLE IMPROVEMENTS & CONDITIONS ON THE DATE OF SURVEY. 3. THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEY & IS SUBJECT TO ANY INACCURACIES THAT A SUBSEQUENT BOUNDARY SURVEY MAY DISCLOSE. 4. THIS SURVEY PERFORMED FOR RANDOLPH & MARLENE WALLACE, IT SHOULD ONLY BE USED FOR A SINGLE PROPERTY TRANSACTION. REUSE OF THIS DRAWING FOR ANY PURPOSE NOT STATED ABOVE WITHOUT THE EXPRESS WRITTEN CONSENT OF ALASKA RIM ENGINEERING, INC. IS A VIOLATION OF FEDERAL COPYRIGHT LAW. EXCLUSION NOTE: IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES. SURVEYED BY: FARMER SURVEYING LLC. MAILING ADDRESS: 6183 N. STEEN RD. WASILLA, ALASKA 99654. OFFICE: 9131 E. FRONTAGE RD. SUITE #20, PALMER, ALASKA 99645. PHONE: (907) 355-0620 EMAIL BCFARMER®MTAONLINE.NET 18-34FSLLC UNDER CONTRACT TO: ALASKA RIM ENGINEERING INC. �����",f1�I�11 KA ALASKA RIM ENGINEERING, INC. ` �,-- ur 4i ia, AS—BUILT 9131 E. FRONTAGE RD. ��,`P•.•' J' PALMER, ALASKA 99645 ? s �1 :-9 i, wawaPalme PH: (907)745-0222 : FAX: (907)746-0222 i /49TH /\ ?* i AfRE EMAIL: akrim®alaskarim.com WEB: www.alaskarim.com WO: 1800052 i �� PAGE: 1 of 1 FB: 18-02 4.0 136,PO Robert J. Farmer •�_o am Engineers: Planners: Surveyors SCALE: 1 " = 50' FILE: 1800052AS 1`",�•. 10615—S ••;1.-.1. I HEREBY CERTIFY THAT A MORTGAGE INSPECTION WAS PERFORMED �F�•• • •, �• UNDER MY DIRECTION ON THE FOLLOWING DESCRIBED PROPERTY: ,,I//111��SsIITh�����`` ANCHORAGE RECORDING DISTRICT,DEER PARK SUBDIVISION, BLOCK 2AN ANCLOT HORAGE, ALAPLAT SKA. '1111%"°%%Z.Z7-14, SURVEYED ON THE date OF month, 2018. ©2018 MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On-Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-042-29 Property owner(s) Randolph & Marlene Wallace Day phone 342-2421 Mailing address 22326 Deer Park Dr, Chugiak, AK 99567 Site address 22326 Deer Park Dr, Chugiak Legal description (Sub'd., Block & Lot) Deer Park, Block 2, Lot 4 Legal description (Township, Range & Section) Lot Size 42,285 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) X (w/wo ADU) Septic Tank ❑X Upgrade U Duplex (D) _ Holding Tank ❑ Renewal ❑ Multiple Dwellings E Privy U (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. ' 111.6(1, �► , K /?cis r let 1/7t (Signature of pi( perty owner or authorized agent) tush Permit/Rush Fees: a l5-f 1D-01 Waiver Fees: Date of Payment: 31(Si ii ck 11211 Date of Payment: Receipt Number: oZ ca Receipt Number: Permit No. Waiver No. Permit App_ ::..c ALASKA RIM ENGINEERING,INC. ENGINEERS—PLANNERS—SURVEYORS (1111 9131 E. Frontage Road A Palmer,Alaska 99645 Telephone(907)745-0222 Fax (907) 746-0222 Online at: www.alaskarim.com March 14, 2018 Mr. Tim Ecklund Municipality of Anchorage, D.S.D., On-Site Water and Wastewater Department 4700 Elmore Road, Anchorage, AK, 99519 Re: Lot 4, Block 2, Deer Park 22326 Deer Park Drive, Chugiak Septic Tank Documentation AK Rim Engineering File No. 1800052 Dear Mr. Ecklund: This narrative addresses the septic tank on the above lot. The septic tank was installed by a previous owner and no documentation exists for the installation. MOA files have the documentation for the septic drainfield. Based on the onsite inspection and the camera survey performed on the interior of the tank: • There is a 3-bedroom single-family dwelling on the above referenced lot. The subject property is served by a private well and an onsite septic system. • The septic tank was pumped on 3/6/18, and the pumping receipt shows 1,300 gallons was pumped from the tank (see attached, Sanitary Pumpers pump invoice). • The invoice indicates the tank is level, and that a standpipe was broken below grade. We confirmed this standpipe was repaired. • The camera survey of the tank interior was conducted by MW Drains and Services, LLC. The survey showed is not steel, but was not able to determine the material, so the top of the tank was exposed and it was observed to be black plastic material. • An adequacy test performed by our firm on 02/20/18 showed the septic drainfield to be functional at this time, as per MOA standards. The septic tank also passed the adequacy test. • The lot is 42,285 sf in size. A survey as-built was conducted by our firm, showing the existing drainfield as well as the onsite well (see attached As Built Survey). • The as built survey also locates the neighboring wells. • The setback between the well and the septic tank is greater than 100 ft. • The setback from this septic tank and the wells on the surrounding properties is also greater than 100 ft (see attached, As Built drawing). Municipality of Anchorage Page 2 of 2 March 14, 2018 • Based on measurements made in the field, the ground cover was measured over the septic tank to be 2.92 ft. We documented that an additional 1.5 ft of gravel cover was installed over the tank (see attached, Septic Tank Profile Drawing). If you have any questions, please contact me at 907-745-0222 or at marys(a alaskarim.com. Sincerely, ALASKA RIM ENGINEERING, INC. `POFAtg ! /1,� p! Mary L. Shreves, P.E. ,,, „ • • Project Engineer %9�• Mary . Shreves i�,• • I ' CE 9351 ....Z.: Attachments: / f,Pe '••......•••v„\ /fill!1!19\1la10�P�`� • Survey As Built, dated 2/27/18 •� • Site Plan Drawing: Septic Tank Record Dwg • Sanitary Pumpers Receipt MUNICIPALITY OF ANCHORAGE a` f\ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION II ENVIRONMENTAL ENGINEERING DIVISION j 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 —' ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME c �7 ��+ Celi—i I PHONli �+� � �33 EW El MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDS .. DISTANCE T0: :ell /0,3 � AbsorP nn ar ;i /, Dwelling T J� PERMIT / � p 6 u Y � V P Q Manufacturerril _ / C-✓ Mat C No. of comps tments L W 1„ w L4q.Cpacity inyallons �� IF HOMEMADE: Inside length Width Liquid depth 6 02 DISTANCE TO: Well Dwelling PERMIT NO. _? Liquid capacity in gallons Manufacturer Material O= W DISTANCE TO: Well �` Founsi. o3 -I LL Nearest Inl J,t/, yU PEH t_"46 / C7 -1 n Z 2 W No. of lines Length otr IineJ Total Iwy7ttyol Imes C.. Tre Vth Distance tween lines 2 `3 ` J C: riches Ir H Topt file to lints gra a f�i: er�l bear th / / Total effecti bs rption area O Z L /✓I!/ ( ✓f inches W Length Width Uepth PERMIT NO. (7 d H Wa Type of crib Cnb tlia r er Crib depth Total effective absorption area v' DISTANCE TO: Well Building foundation Nearest lot line J J Class -1--.� Yellin Driller Distance to lot line PERMIT NO. iDISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS - e, v t 0 t SOIL TEST RATIN INSTALL REMARKS rd a -�� OF A(q��� 10 off 0 A. Shafta c• Robarl •7 W� �� 0. Z7nl "r 111:11.4 APPH DATE LEGAL S Engineering 122(013 (Rev. 3178) / t7 LJ t4 I CT 35^4 FL_ I IFN CD F= Fs r4 co cm ro Fl C3 E DEPARTMENT HEALTH AND ENVIRONMENTAL OTECTION 825 'L' STREET. ANCHORAGE, AK. 99501 264-4720 WELL_ FINE+ Qui—=ITE SEWEFZ F"EFZM I T PERMIT NO. ( 810596 ) APPLICANT MYERS CONST P0. BOX 351 694-9633 LOCATION PETERS CREEL: LEGAL I,OTjACLK 2 DEEP. PARE( SUB LOT SIZE 43560 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SQ FT/SR)= 85 THE REQUIRED SIZE OF THE SOIL ABSOP.PTION SYSTEM IS: CvEF'TH= 7'_ L LENGTH= C•EP'TH= 4 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). FZE:UlU I FZEE} E;EF='T I C TFiNK f3I ZE= 1ID013 C3nL_LQt-7S PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER. OF RESIDENCES THAT THE WELL WILL SERVE. --- T444 C ^ 7 I t.1EP'ECT I QNE F1FZE FZ au I EEF? --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER. LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER. REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAM'= ARE AVAILABLE TO INSURE PROPER INSTALLATION. F='Elz:t7I T EXP I F2ES3 E}ECEt•1BEFZ 2:11 I CERTIFY THAT 1: I AM FAMILIAR. WITH THE REQUIREMENTS FOR OM -SITE SEWERS FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER. SYSTEM MAY REQUIRE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. SI APPLI 1'4 S 1 AND WELLS AS SET ENLARGEMENT IF THE v // ISSUED EY- --------DRTE_v(���S1J_ V4. 0 • IR SOILS LOG MUNICIPALITY OF ANCHORAGE \,DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 2644720 SOILS LOG - PERCOLATION TEST PERFORMED LEGAL DESC DEP (FE! 1 / 2- 3- 4- 5- 6- 9- 10- 11 34 56910 it 12- 13- 14- is- 16- 17- is- 9 21314151617is9 20 SLOPE SM CW GM WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT ✓ DEPTH? DATE PERFORMED: C /) 0 A I SITE PLAN Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE TEST RUN BETWEEN PERFORMED BY: I CERTIFIED 72-008 (6/79) FT AND (minutes/inch) FT A_ 0 -RETURN TO: Division of Geological and eo"�hyslcal Surveys (OGGS) STATE OF ALASKA 3001 Porcupine Drive (Tel.. no: 277-6615) DEPARTMENT OF NATURAL RESOURCES Anchorage, Alaska 99501 WATER Y E L L RECORD Drll l Ing Company alma LOCATION OF WELL Please complete either Is, Ib, or Ic. U.S.G.S. Local No. Drilling Permit No. A.D.L. Mo. Ia. Borough Subdivision Lot I Block Ib. Fraction / Section No. To ship N/S Range E/Y Meridlan It. Distance and Direction from Road Intersections Street Address and Area of Well Location ). OWNER OF VELLt . n Address: i 2. WELL LOG Feet Below Surface No brio! Type lop Bottom 4. WELL DEPTH: (completed) ill ft. Surface Elew[lon en/—['—.1 Date of Complet Ion S. [:]Cable tool ❑Rote ry Driven 11Dug 13 Auger ❑Jetted ❑Bored ❑Other: y�y'. tel.\• L1 .1Y c- •.� /„ 6. USE: ❑Domestic ❑Public Supply [3 Industry C] Irrigation ❑Recharge ❑Commrclal []Test Well ❑Other: vl j <. .. ,, v.v LU1 /v 7. CASING: ❑Threaded OWelded i. In. to _ft. Depth Weight lbs/ft. In, to ft. Depth B. FINISH OF WELL: et: "1�' Type:!" ' Diameter: Slot/IMsh Size: Length: Set batren ft. and ft. Fittings: 9. STATIC WATER LEVEL: ft. ❑ Above ❑leiow land surface Type Of Measurement' 10. PUMPING LEVEL below land surface ft. after hrs. pumping 1 '' g.p.m. ft. after Mrs. pumping g.p•m. 11. WELL READ COMPLETION: ❑ In Approved Pit },❑ Pltless Adapter Inches above grade 12. GROUTING: Well Grouted: ❑ Yes ❑ No Material: ❑ No[ Cement ❑ Other: 13. PUMP: (If available) HP I / Length of Drop Pipe ft. capacity 9•p• e sproting Type:`❑Submen lbN ❑Rau ❑ Jet ❑ Other: 14. REMARKS: 15, WATER WELL CONTRACTOR'S CERTIFICATION: This well Wes drilled under my Jurisdiction and this report is true to Registered llwsinosl Name Address: the best of my knowledge and belief: ontrac[ License Numo.r Signed: ./'.�/ /_.. ���. �`'. .+ C%/' i!. ..r ,.. Data: ll '. • j. Form 02•WWR Authorized Representat•.e Copy Distribution: WHITE - State DOGS, PINK - Driller, CA14ARY - Customer • • GE .@L •-41 c Municipality of Anchorage C On-Site Water and Wastewater Program •;il l i (907)343-7904 SAF E 7 Certificate of On-Site Systems Approval Parcel I.D. 051-042-29 Expiration Date: l% —I (7 r/•S 1. GENERAL INFORMATION Complete.legal description Deer Park, Block 2, Lot 4 Location"(site address) 22326 Deer Park Dr., Chugiak Current Property owners) Randolph & Marlene Wallace Day phone 342-2421 Mailing address- • 22326 Deer Park Dr, Chugiak, AK 99567 Real Estate.Agent, , Tony Lewkowski Day phone 205-7114 2. TYPE OF DWELLING: 0 .'Single'Family (w/wo ADU) . t ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) / ` / �� 3 3. NUMBER OF BEDROOMS: o 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Q Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: • Distance: 96,6(7--------___ Received by: (,/; Date: (31 LY h(COSA to be released to the engineer, nless//otherwise requested by the engineer. \ &Ai/ I COSA Fee $ 5 st ?J)5 1a % ! 4b Waiver Fee $ " -i' 1 Date of Payment '3'15!! c_k 11241 Date of Payment 316 1 ' ,I 1(2-11 Receipt Number c(- 4o Receipt Number , .5 .- COSA# 0 5C- 13.1 fl 8'S Waiver# - V 1 i n(:),i 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 AK Rim Engineering, Inc. Phone 745-0222 Address 9131 E. Frontage Rd, Palmer, AK 99645 Engineers Printed Name Mary L. Shreves Date //z//1 6 ..,Y,‹i':••• k *•.t://".i. 6. DSD SIGNATURE �••••••r� — ft.1-.' ." ."'"---i- System#1 Approved for 3 bedrooms ; Is�'� \ Mary Shreves �<,� System #2 Approved for bedrooms ®j 00•°• CE 9351 ��v ® r '•.,• Disapproved ®®A®oOap ....s�o`®o o®• Conditional approval for bedrooms, with the following stipulairdYA010®®® c'`,��P�c moo. sg (.0 es. .)C�lil{l;�t�ll«��S-- B _ 1 ( ,1 Original Certificate Date: 3 _0l0_ /g 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 X Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet r c 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: Deer Park, Block 2, Lot 4 Parcel ID:051-042-29 A. WELL DATA Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y Date completed 7/9/81 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 70 ft. Cased to 70 ft. Casing height(above ground) 18 in. FROM WELL LOG AT INSPECTION Date of test 7/9/81 2/19/18 Static water level Unreadable ft. 42.9 ft. Well production 10 g.p.m. 8.2 g.p.m. WATER SAMPLE RESULTS: Coliform Absent colonies/100 mL Nitrate 7.17 mg/L Arsenic <MRL ug/L Date of sample: 2/19/18 Collected by: Brandon Jones B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Plastic* Date installed Unk* Tank size 1300* gal. Number of Compartments 2 Cleanouts(Y/N) Y Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 3/6/18 Pumper Sanitary Pumpers C. ABSORPTION FIELD DATA Date installed ,t184, Soil rating (g.p.d./ft2 or ft2/bdrm) 85 System type deep trench Length 32 ft. Width 3 ft. Gravel below pipe 4 ft. Total depth 7.5 ft. Eff. absorption area 256 ft2 Monitoring tube Y Depression over field N Date of adequacy test 2/20/18 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 494.7 gal. New depth 0 in. Elapsed Time: 75 ''min, Final fluid depth 0 in. Absorption rate >= 450 g p d Any rejuvenation treatment(past 12 mo.)(Y/N &type) N If yes, give date oejrl4,4;,;; ,l l f i l°% 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 in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot >100' On adjacent lots >100' >1Absorption field on lot 00� On adjacent lots 1OOH Public sewer main >75' Public sewer manhole/cleanout >100' Sewer/septic service line >25' Holding tank >100' Animal containment areas >1 00' Manure/animal excrete storage areas >100' SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Absorption field>5' Water main >1 0' Water service line >1 0' Surface water >100' Wells on adjacent lots >100' ABSORPTION FIELD ON LOT TO: Property line >10'0' Building foundation >10'0' Water main >10' Water Service line 1O' Surface water 100' Driveway, parking/vehicle storage >10' Curtain drain >50' Wells on adjacent lots >100' F. COMMENTS *Septic tank size based on septic pumper receipt. Septic tank was installed by previous owner. Camera survey of tank confirmed tank is plastic. G. ENGINEER'S CERTIFICATION ````\\A‘111Ii I certify that I have determined through field inspections and ♦�•N��G OF "/ /// review of Municipal records that the above systems are in ,�P,••' ••.;4' li conformance with MOA COSA guidelines in effect on this date. . . �: */� Engineer's Printed Name •Mary L. Shreves, P.E. 5 *.• gTH /al Date //1//1 .•♦ 9 % Mary Shreves • � ' • LJ� � = 'sj,••••• CE 9351 •• A COSA canary sheet_2-6-15.doc MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT • ,7.r3 907-343-7904 On-Site Water and Wastewater Section ` Fax: 343-7997 www.muni.org/onsite Nitrate Advisory Certificate of On-Site Systems Approval # OSC181085 Subdivision: Deer Park, Block: 2, Lot: 4 A water sample revealed a nitrate concentration of 7.17 milligrams per liter (mg/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On-Site Systems Approval. Mailing Address: P.0. Box 196650* Anchorage,Alaska 99519-6650 *www.muni.org Nitrate Fact Sheet From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen,which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. Mailing Address: P.O. Box 196650*Anchorage,Alaska 99519-6650*www.muni.org P] Parcel I.D. 051-042-29 Municipality of Anchorage =�� On -Site Water and Wastewater Program y (907) 343-7904 s x Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Expiration Date: 6 __2 " Complete legal description Deer Park, Block 2, Lot 4 Location (site address) 22326 Deer Park Dr. Current Property owner(s) Misty Wright Mailing address Real Estate Agent 22326 Deer Park Dr. 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well lX Individual Fx I Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver/Variance, Received by: COSA to be released to the unless otherwise requested by the engineer. COSA Fee $ 52-( Date of Payment 6 Iq Receipt Number 06 4114, COSA #Gl r FI U - Date: Waiver Fee $ Date of Payment Receipt Number Waiver # 6. 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 Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone 6. DSD SIGNATURE _�z System #1 Approved for >> bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for Date 10/10/13 OF ­.'S!;v*en* If. I% -a.•. CE—E bedrooms, with the following stipulations: f)aririorie: By: x �� Original Certificate Date: The Municipal ityof Ahe ®rage 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 blue sheet ' c If more than 1 septic system is on the lot: COSA Checklist # -L_of I Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: Deer Park, Block 2, Lot 4 A. WELL DATA Well type Private If A, B, or C provide PWS ID # Date completed 7/9/1981 Sanitary seal (Y/N) Y Total depth 70 ft. Cased to 70 ft. FROM WELL LOG Date of test 7/9/1981 Static water level Unreadable Well production 10 IN g.p.m. Parcel ID: 051-042-29 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) 18 in. AT INSPECTION 10/9/13 38 ft. 4.3+ g.p.m. WATER SAMPLE RESULTS: Coliformeg colonies/100 mL Nitrate 10.4 mg/L Arsenic ND ug/L Date of sample: 2/12/2014 Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 7/3/81 Tank size 1,000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Date of pumping 2/4/2014 Depression over tank (Y/N) N High water alarm (Y/N) Pumper Sanitary Pumpers Y C. ABSORPTION FIELD DATA Date installed 7/3/81 Soil rating (g.p.d./ft2 or ftz/bdrm) 85 SF/BR System type Deep Trench Length 32 ft. Width 3.3 ft. Gravel below pipe 4 ft. Total depth 7 ft. Eff. absorption area 256 ft2 Monitoring tube Y_ Depression over field N Date of adequacy test 3/21/2014 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 1 in. Water added 476 gal. New depth 2 in. Elapsed Time: 120 min. Final fluid depth 1 in. Absorption rate , 450+ g,p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date D. LIFT STATION 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 100+ Absorption field on lot 100+ Public sewer main 75+ Sewer /septic service line 25+ Animal containment areas 100+ Manhole/Access (YIN) in. High water alarm level at Meets alarm & circuit requirements? On adjacent lots 100+ On adjacent lots 100+ Public sewer manhole/cleanout 100+ Holding tank 100+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Water main 10+ Water service line 10+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 110+ Water Service line 10+ Curtain drain 50+ Surface water 100+ Wells on adjacent lots 100+ F. COMMENTS * Sample taken on 2/18/2014 ** Sample taken on 3/17/2014 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. Engineer's Printed Name Steven R. Pannone Date COSA brown sheet 10-10-12.doe 3/21/2014 Absorption field 5+ Surface water 100+ Water main 10+ Driveway, parking/vehicle storage 110+ in. Municipality of Anchorage pr� Community Development Department tl= Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # OSC 141072 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply for Block 2, Lot 4 of Deer Park subdivision. The inspection revealed a nitrate concentration of 10.4 milligrams per liter (mg/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. Due to concern that the well may be a conduit for pollution to be entering the supply aquifer, additional water quality testing is required. Please provide water quality test results from an approved laboratory in accordance with the following schedule. July 15, 2014 Total Coliform and Total Nitrate/Nitrite-N December 15, 2014 Total Coliform and Total Nitrate/Nitrite-N On-site Water & Wastewater Program Ak� �B I L L & COLE ULLIVAN WATER WELLS P.O. Box 670269, Chugiak, AK 99567 888-2759 TO• 'C driYlOY�.� L.+`l 42P.Q:�i" Uft4 P N` a q GATE OF ORDER-_--_ ORDERrgxENeY CUSTOMER'S ORDER NO (} DAY WORK (} CONTRACT (} EXTRA r 1 Boa 71'w . .-�Ao iLQ...- �- dD Trory TERMS: B PHONE0`�-� 7 1 STARTING DATE - �0'7 QTY. DESCRIPTION OF WORK PRICE AMOUNT aJ a�Cj /Jmil 4-n �3(Ljiuxc At G z i s is 1 i i C' i Q 4c Work ordered by DATECOMPLETED Signature I hereby acknowledge the satisfactory completion of the above descdbed work. r vel J 1 4 f`,,t `"RETURN TO: Division of Geological and hyslcal Surveys (DGGSL 3001 Porcupine Drive (Te ,ne: 277-6615) Anchorage, Alaska 99501 W A T E R W E L L R E C O R D Drilling Company Name -- LOCATION OF WELL Please complete either is, lb, or lc. U.S.G.S. Local tic. Drilling Permit No. A.D.L. No. STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES Ia. -. OC'1 BoroughSubdivision ]I Su T.k Lot Block lb. Fraction Section No. Township N/S Range E/W Meridian ic• Distance and Direction from Road Intersections Street Address and Area of Wall Location 3. OWNER OF WELLt-. Address: Z. WELL LOG Feet Below Surface ' Material Type Tap Bottom 6. WELL DEPTH: (completed) /f.,' ft. Surface Elevation '"''' Date of Completion ..,i. 5, ❑Cable tool QRota ry C3 Driven ❑Dug El Auger ❑Jetted E] Bored ❑Other: :�til2fa t 'i-) 7,77 $ri: ;;rave_. t}j U 6. USE: Q'Opmestic ❑Public Supply ❑industry ❑ Irrigation ❑ Recharge ❑ Commercial ❑ Test Well ❑ Other: -:. •ir k'i. „_,_, �_ ;q Fii e2' 7. CASING: ❑ Threaded ❑'Welded in. to ft. Depth Weight __lbs/ft. in.. to ft. Depth - R. FINISH OF WELL: pw Type::?,�59 lt: Diameter. ,. Slot/Mesh Sian: Length-: -- Set between ft. and ft. Fittings: 9, STATIC WATER LEVEL: ft. ❑ Above 11 Below land surface Type of Measurement: 10. PUMPING LEVEL below land surface - ft. after hrs. pumping 9 -P.M. ft. after hrs. pumping g.p.m. IL WELL HEAD COMPLETION: ❑ In Approved P.. ry Pltless Adapter inches above grade 12. GROUTING: Well Grouted: ❑ Yes ❑ No Material: ❑ Neat Cement ❑ Other: 13• PUMP: (if available) HP Length of Drop Pipe -'� ft. capacity "'- 9.p. Type: ^--Q Submersible ❑ Reciprocating ❑ Jet ❑ Other: 14. REMARKS: 15. WATER WELL CONTRACTOR'S CERTIFICATION: This well was drilled under my jurisdiction and this report Is true to jl'j uEi ._ j?S'7.nir, Registered Business Name t Address: the best of my knowledge and belief: -1; 173&5 Contract License Number g '- .a'., - "� . %-E/✓`%-.y .rr>t_r: �._. Authorized Representative' c...m ns-uw rnev.Dlctrihutlom WHITE - State DGGS. Date ' PINK - Driller. CANARY - Customer Z­� Municipality of Anchorage Development Services Department Building Safety Division _ On -Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. Uhl-o42'20t COSA# D9 07,1VExpiration Date: / () — I (e 1. GENERAL INFORMATION Complete legal description Lot 4, Block 2; Deer Park Subdivision Location (site address) 22326 Doer Park Dr. Chugiak, AK 99567 Current Property owner(s) Michael Fishback(John Fishback) Day phone 274-2600 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3- 3. TYPE OF WATER SUPPLY: Individual Well ❑✓ Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Day phone Day phone 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 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 sample results. (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 S a S Engineering Phone 694-2979 Address 15861 S. Birchwood Loop Chugiak AK 99567 Engineer's Printed Name Roberta Shafer 5. DSD SIGNATURE G__*' Approved for _2 bedrooms. Disapproved. Conditional approval for Date /d Lo % bedrooms, with the following stipulations: �o,el Ciq3�790�� I'Ci Re, c,f,l J2�—�N"51TE—'c"s WATER ANn r WASTEWATER . Attachments://i N COSA Checklist X Arsenic Advisory "J'imfmltt"� Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other By: d - �� r� Original Certificate Date: 7- in — 0.9 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program "' 4700 Elmore 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: L-01LI . � I k<?.- , (Oee f Pae -k- YA Parcel ID:Q TJ — 0142-:129 A: WELL DATA Well type ,Pr*.,Jr VL If A, B, or C provide PWSID # _ Well Log (Y/N) _ 1 Date completed -11 V1 Sanitary seal (Y/N) 'Wires property protected (YM) T Total depth�� fL Cased to 22: ft Casing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test l 6 �y `1 (0 c Static water level no0 I _ytow n ft �3 ft. Well production 10 g.p.m.: Ll 9-P m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate y2� mgll Other bacteria p colonies/100 mL ,Arsenic: «a/ : ug/L date of sample: Collected by: S¢'S LK,Y�I�elc WppNJ�O�/G=irl B.' SEPTfc/HOLDING TANK DATA Tank Type/Material Se Dii Date Installed 3 43 Tank size ocx) gal. Number of Compartments 2 Cleanouts (YIN) Foundation cleanout (YIN) 6.1 Depression over tank (Y/N) N• High water alarm (Y/N) N 1nJlJC... C(4WfS 4C I Dateofpumping "1 Is -lo% Pumper C. ABSORPTION FIELD DATA Date installed I s h i Soil rating (g.p.d./ft= r ft'/bdr 8S System type zytv 7 Length 32 ft. Width ft. Gravel below pipe_ ft. Total depth i ft. Eff. absorption area ZM ftp Monitoring tube �!_ Depression over field &L Date of adequacy test Results (Pass/Fail) >e%55 For 3 bedrooms Fluid depth in absorption field before test 8 in. Water added gal. 'New depth ! in. Elapsed Time: 110 min. Final fluid depth /l lin. Absorption rate >= 4S`0 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) 11AIJ - If yes, give date D. LIFT STATION Date Installed Size in gallons 'Pump on' level at_ In. 'Pump off" Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot /00 f Absorption field on lot too r'/ Public sewer main N Sewer /septic service line /- Animal containment areas �b rfi High water alarm level at in. Meets alar & circuit requirements? On adjacent lots /0011 On adjacent lots /UJ r1 Public sewer manhole/cleanout AJ 18 Holding tank A 1 Manurelanimal excrete storage areas 1069 SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: r Building foundation _ T / Property line S^ r r? Absorption field / r / Water main Water service line /Q 1 Surface water r Wells on adjacent lots /QQ / SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10 1-f Building foundation /0 r* Water main / O rt Water Service line /0 if Surface water 10014 Driveway, parkinglvehicle storage / Of; Curtain drain hone- k -^w 11 Wells on adjacent lots der F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined throug field inspections, and i * review of Municipal records that the bove syste ���iiie in conformance with MOA COS Engineer's Printed N me �T Date 10 D COSA Fee $ r Date of Payment Receipt Number (Rev. 1 V05) Waiver Fee $ Date of Payment Receipt Number r. m %V� A% ASSUILT-Nb CORNERS SET 'rHIS.DATE. • -SEWARD & SOC . 1ATES LkM SMVrMm 688-4566 LV Ham CERTIFY THAT I HAVE SURVEYED THE' 6C4LE' .FOLLOW= DESCRIBED PROPERTY - AND THAT NO ENOiOACHMENTS EXIST INDICATED. IT IS THE RES . SIBILI :0fAS. 49 6 OWNER TO DETERMINE THE .EXISTENCE -.OFN .. (MID, EASEMENTS, COVENANTS,- OR.RESTRI=6 S '- ;-. ............. WHICH 00 NOT APPEARON T 'R 9� A% VISION •PLAT. UNDER NO CIRCUMSTANCES S Fbr 1 1 ANY DATA HEREON BE USED FOR CONSTRUCTION 44 - Or FENCE LINE; OR FOR ESTABLISHING MIND- AllY%LiNES. DRAWNP T*d bAla TW3 Jd M4/3S ZO IET 26, OC 170 MUNICIPALITY ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 051-042-29 1. GENERAL INFORMATION HAA # Complete legal description Deer Park Lot 4, Block 2 T15N R1W Section 4 Location (site address or directions) 22326 Deer Park Drive Property owner Hans Jensen Day phone 561-7877 Mailing address HC 80 Box 5192, Chugiak, AK 99567 Lending agency N/A Day phone Mailing address Agent Sharon M.i.nsch/ReMax Day phone 694-4200 Address 16600 Center Field Dr., Eagle River, AK.{ 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site x 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. 22-0251Re 11911 Fmn1 MOA.21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Fagte River Engineering services Phone 694-5195 Address P.O. Box 773294, Eagle River, AK 99577 / Engineer's signature Date 1117 9 a 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: 1- c �—z ✓ 'z •, 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 their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. )t U25(Ao IAP Bac. MOA.21 y, Municipality of Anchorage jai Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: �^'�y �/f'� !!f'er7.�orsr Parcel l.D.—O$/�D�l2-Z9 A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number ",0/,4 Log present(Y/N) Date completed 7-6-11 Driller r" 4,g tv...(.roW Total depth % Cased to 70 1 Casing height -I t �� Ae4orr Sanitary seal (Y/N) f Wires properly protected (Y/N) Y Date of test Static water level Well flow Pump level FROM WELL LOG 7/6 /lr/ /Van Ramco. -cam`( /O g.p.m. 60 AT INSPECTION /J/a-8/9d 5.3 m o g•P•C -4, f ct y rrt ao 4.0 N SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /03 ; On adjacent lots Y ivJ� Absorption field on lot f /3 ; On adjacent lots T/°o Public sewer main N/A Public sewer manhole/cleanout .t/ /H Sewer service line 9a Petroleum tank ^✓cove ee. - WATER SAMPLE RESULTS: Coliform 79— Nitrate 1 017 1 / Other bacteria 19 Date of sample: / o�t 8 /9 Z Collected by: ENG INfL� B. SEPTIC/HOLDING TANK DATA Date installed /5 y/ Tank size /DUD 5 Compartments -Z ".vder Cleanouts (Y/N) y Foundation cleanout (Y/N) % 4� �,AMs Depression (Y/N) High water alarm (Y/N) /✓ Alarm tested (Y/N) Date of pumping 9/,:%h z Pumper JJ&Z X SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: i✓/q Well(s) on lot Jo 3 On adjacent lots Foundation To property line �9"3 Absorption field J" Watermain/service line Surface water/drainage ri°o' 72-026 (Rev. 791) Front CONTINUED ON BACK PAGE C. LIFT STATION Date Installed Size in gallons Vent(Y/N) — High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer _ Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surface water Date Installed Soil rating System type Tr�J° S Length 3�� Width `/`' ~ Gravel thickness Total depth 6.6 Total absorption area SSS Cieanouts present (Y/N) y Depression over field (Y/N) '� Date of adequacy test Results (pass/fail) PASJ for 3 bedrooms Peroxide treatment (past tz months) (Y/N) '✓ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots -- 71-/4" Property line a 8 To building foundation /S" To existing or abandoned system on lot N /A On adjacent lots Cutbank N /A Water main/service line ~io Surface water 'v Driveway, parking/vehicle storage area y i° Curtain drain E. ENGINEER'S CERTIFICATION 1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date o/ this inspection. HAAf• •��.,� air • –'=`�i3��� f ,.� Signature r e• ,. �0e� a.���!! it• r. Engineer's Name -Ge)A­; of"75&i< Date /s f 3°5.1 y Y.... � Rte. t��+, ; . . •:�� ; -f- HAA Fee $ /70 i n Date of Payment Receipt Number 7_4,L ' -Z3 7476075 72-079 (R". 7/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number Eagle River Engilleerhig Services j 1194U Business Blvd, Suite #205 r" P.U. Box 773294 694-5195 Eagle River, A. 99577 Fax 694-3297 Legal DrCe PAR - Lor N BI -r 2 Owner: Date: /o/zs/vZ Type of test: I U Well now Test t7 Septic Test Only t4 Well do Septic Test C] Other: lime Meter Monitor Well TUnk GPM PSI Reading Level Level Level ' r;o iiPHID q „ Ny •g it. 12:514 118. 4/0 //: 460 4 Z' S. Z ,r,7o /iF ,/0 43' - 17 //goo Z�� — ' !. i..^ r IgG3 /IST./,� 0'_ 43 — ?/0 — '— — 206:2i //r .74,0 /!3 V P/v 9.> G N ' L;+ .• Remarks ref f 4:4G• — it !/9. DII.2 _ / 5�e 340.3 n ENO NEU Oiu 90 4:4G• — it r`. e0_1, MUNICIPALITY OF ANCHORAGE DIVISION OF E.WIROIM14TAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information (a) tion (include Location (address or directions) (b) Applicants Name Applicants Application Date block subdivision, section, township, range) Z-% (c) Applicant is (check one) Lending Institution ; Owner/builder Buyer [--I ; Other = (explain); (d) Lending Institution Address iness (e) Real Estate Co. 6 Agent - _ _Qo L r Y, Address (f) Telephone Z Ma+± the HAA to the following address: 2. Type of Residence Single -Family Multi -Family Other (describe) Number of Bedrooms 3. Water Supply Individual Well Community Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite Public Community Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 21 J 5. Engineering Firm Providing Inspections, Tests File Search Data_and Information As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal'system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein.. 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 regula- tions in effect on the date of this inspection. Name of Firm Telephone 8 Y. f' ENt31F:�AlN� ti a LE NM X70 E.57T �,�� Q .4 , / a_ E i/k � Von A..( '.. r.Wa....-L.N FF A- Shofar 6. DHEP Approval Ii �•E'• Approved for �� bedrooms By 0 ,� Approved Disapproved v Condi Terms of Conditional Approval CAUTION Date THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DEEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 21 7-19-84 r',N1CIPiQ{1 i CF DEPT. CF fi:AC;i g MUNICIPALITY OF ANCHORAGE (MOA)•{ �ti.,.vr F cT;c.i HEALTH AUTHORITY APPROVAL (HAA) JFM J 0 M5 CHECKLIST - FEBRUARY 1984 j? A. WELL =A Le al DescriptiRhE W F�s�,/�(� ?j B Z Ji Well Classificati If A, B, or C, D.E.C. Approve Well Log Present (Y)M Date Completed Z 3 Yield61-1 If Total Depth 2 2 ' Cased to 7'6 /. S Depth of Grouting_ Static Water LevelReTaJ Cut/1'C- Pump Set At Lk VC. Casing Height Above Ground 2 err Sanitary Seal on Casing (Y Electrical Wiring in Conduit _(Y/N)7;fro✓c d Depression Around Wbllhead ( ) Separation Distances from Well: To Septic/Holding Tank on Lot /l J ; On Adjoining Lots /0-D To Nearest Edge of Absorption Field on Lot /.5-b J On Adjoining Lots S -D '1 To Nearest Public Sewer Lire -7' �✓/, To Nearest Public Sewer Clea ncut/Manhole /v / ,0 To Nearest Sewer Service Lire on Lot ZS Water Sample Collected BySrl2bi-ee/%yaefAGA:11p'_ Water Sample Test Results S c 70 Comments /-s G 11 7 /1 '5' /74 tO112 a dF's� fl 7 Ti-// ✓' O C D CELL o AJ B. SEMC/2 TANK DATA Date Instal Zia i�3 siae o _ No. of Carpartrnents z Standpipes (YAn- Air -tight Caps (Y (} Fou rdal-ion C anon ( ) Depression over Tank (Y Date Ias Pumped Pumping/Mainterance Contract on File(Y y� ; for —� Holding Tark High -Water Alarm (Y/NV Temporary Holding Tank Permit (YIN)AIM Separation Distances from SepticAleidIM Tank: r To Water re To Building Foundation ¢S To Property Lire /0 �4_ To Disposal Field r To Water Mair,/Servics Line 20 E To Steam, Pond,'Lake, or Major Drainage Course' /v J nJ E Comments I, Receipt $ Date Paid: {..b� Amount: (Page 1 of :21 2-15-84 C. ABSORPTION FIELD DATA 12 Soils Rating in Absorption Strata 9.S Type of System Design Date Installed Z -/D - g? 3 Lergth of Field 2 J Width of Field 2 0 ' Depth of Field Gravel Bed Thickness /Z Square Feet of Absorption Area .5�)O Standpipes Present Date of Last Adequacy Test Depression over Field A Results of Last Adequacy Test /�J B=} cess h'6rer 0r�S_ Separation Distance from Absorption Field: To Water -Supply Well / -7 4-- To Property Lire l0 To Building Foundation r&- To Existing or Abandoned System on Lot /V D ^J E t Cn Ad joinirg Lots 40 1 {- To Water Main/Service Lire l0 -?'-' To Cutbark(if sent) N AO ^IE To Stream/Pond/Lake/or Major Drainage Course A.l 0 w � f4 To Driveway, Parking Area, or Vehicle Storage Area '-0 Camhents /U L9 /Jr D. LIFT STATION Date Installed Dimansicns Size in Gallons Ma ole/Access (YIN) "Pump On" Level at Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping ycles during Adequacy Test. Meets MOA Electrical Codes(Y/N) Camhents '* Ched: Permitted Bedroam Rating Against HAA Request *t I certify that I have checked, verified, or eonfctirtmed to all MOA HAA Guidelines in effect on the date of this inspection. r Signed A n hp 1~valsarhY fM Date alts 195X CatQany f r_...nLE_91YEE6 A{UR u^°Tl MOA No. RB1/d5/s (Page 2 of 21 of Reb.rh A. Sha1nr Too. 1457E 2-15-64 CONSTRUCTION AND OPERATION CERTIFICATE ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION PUBLIC WATER SYSTEM APPROVAL TO CONSTRUCT Plans for the construction blit water system located Alaska, submitted in accordance with 18 AAC 80.100 by have been reviewed and are ❑ approved. ❑ conditionally approved (see attached conditions). If construction has not started within two years of the approval date, this certificate is void and new plans and specifications must be submitted for review and approval before construction. APPROVED CHANGE ORDERS Change (contract order no. or descriptive reference) Approved by Date The "APPROVAL TO OPERATE" section must be completed before any water is made available to the public. APPROVAL TO OPERATE The construction of the public water system was completed on (date). The system is hereby granted interim approval to operate for 90 days following the completion date. TITLE DATE As -built plans submitted during the interim approval period, or an inspection by the Department has confirmed the system was constructed according to the approved plans. The system is hereby granted final approval to operate. TITLE DATE [ oe &e 4 ANEW CONSTRUCTION 1-Iti u , 5. LEGAL DESCRIPTION L cRECEIV ED INSPECTION APPOINTMENTS Estates TIME TIME TIME c ". t ' QI-t��°yt-N' Cr DATE DATE 2 -�+t.a DA E INSPECTOR INSPECT INSPECTOR 7. WATER SUPPLY INDIVIDUAL' MUNICIPALITY OF ANCHORAGE V . Di P1 OF P- 4T ! & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIOWNVIRL 6MEN1.'-:. •... TcCT1014 825 L Street - Anchorage. Alaska 99501 � I� SEP 1 0 t9S1 ENVIRONMENTAL SANITATION DIVISION Telephone 2644720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE Jyex_s Conzt=cti z, I 4-2 80 MAILING ADDRESS 9._Box-3-rLLShug.iak,-At 9956 PROPERTY RESIDENT 111 different Irom shove) PHONE 2. BUYER ISM =N , Hans r., & Pamela G. Jensen 279-8980 161AI LING ADDRESS Anchorage. AK 9950d TNreet 3. LENDING INSTIT IO PHONE MAILING ADDRESS 201 14- 16t -h P-0- Box 4112090 Annhorage. AK 99509 4. REALTOR/AGENT PHONE Jim tin gue Totem Realty InC. 694-9494 MAILING ADDRESS — P.O. Rox 911. EacTle River. AK 99577 5. LEGAL DESCRIPTION Lot 4, Block 2, Deer Park Estates STREET LOCATION NIIN Deer Park Drive 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS SINGLE FAMILY ❑ One ❑ Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY LX Three ❑ Six 7. WATER SUPPLY 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.) 8. SEWAGE DISPOSAL SYSTEM ❑ INDIVIDUAL/ON-SITE" 1981 YEAR ON SYSTEM WAS INSTALLED. ❑ PUBLICUTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEST BEFORE PROCESSING CAN BE INITIATED. 101Rw. eJ791 .t. 7' a �. O1 31 �� .� t", I ". THIS SIDE FOR OFFICIAL USE ONLY " 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑_.ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER - ❑Septic Tank or ❑Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holtling Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS APPROVED FOR 3 BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) , ❑ DISAPPROVED DATE u