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HomeMy WebLinkAboutSKYWAY PARK ESTATES BLK 6 LT 17B MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site !plater System Permit Permit Number: OSP211003 Work Type: Well Upgrade Tax Code Number: 01915119000 Site Legal Address: SKYWAY PARK ESTATES BLK 6 LT 17B G:2729 Site Mailing Address: 12330 SKYWAY DR, Anchorage. Owner: COLVER RYAN BLAKE & LORNA RAE Design Engineer: This permit is for the construction of: Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: Department 1/15/2021 1/15/2022 26400 ❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy Q Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: To close this permit please submit: 1. Well Log 2. Pump Install Log 3. Water sample results 4. Well Decommissioning Log Received By:Date: 1/26/21 _ Issued By: (/(/ Dater_ EI MUNICPALITY OF ANCHORAGE Development Services Department _ Phone: 907-343-7904 On-Site Water & Wastewater Section - Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 019 151 19 000 1 8 Property owner(s) COLVER RYAN BLAKE & LORNA RAE Day phone 907-382-3754 Mailing address 12330 Skyway Drive Anchorage AK 99515 Site address 12330 SKYWAY DR Legal description (Sub's., Block & Lot) SKYWAY PARK ESTATES BLK 6 LT 17B Legal description (Township, Range & Section) Lot Size 26000 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 Septic Tank ElUpgrade (w/wo ADU) Holding Tank ElRenewal Duplex (D) ❑ Privy El Multiple Multiple Dwellings ❑ and/or D) Private Well F-1 Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. �2__ (Signature of property owner or authorized agent) Permit/Rush FeeWaiver Fees: Date of Payment: T�rZ j Date of Payment: Receipt Number: 01 �,G D Receipt Number: Permit No. Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 1 � � I O Well 20' UTIIJiY nASEMENT I I Lot 1 A I / 30.0 r` —EASE- 4-05..12' jWOODEN FENCE 12._/x 16.2' SHED / w/ RAI.IF ` — // 25,60 aJS o \ /NOaDEt`i FENCELU / Aar M Of WELL—ti — — — — I ASPHALi. ' / 144,1 7A e 1 5'x6.2' DRIVE'NAY - / \ \ CANT \ \ p $' 29.1 ' � z \ �' ����• � 2so• ��// / til Pleu�rvrell location 2.6'x16.0' BALMY \ 21.0' IJ O O Well Private sewer line WEST 34.12 o / / — — / SNORE DRIVE PLOT PLAN AS BUILT X_ SCALE _ 1 " = 50' GRID SW 2729 Project No 20-447R1 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone --- (907) 522-4625 Fax Notes: Professional Land Surveyors ken*langsurvey.com 1) Existing well will be Jonathan®langsurvey.com decomissioned. I hereby certify that I have surveyed the following described property: 2) New well location will LOT 17B, BLOCK 6, SKYWAY PARK ESTATES (PLAT No. 64-120) meet all required Anchorage Recording District, Alaska, and that the Improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that separations. no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the ' l ' 1 Day of _- _ ='' at Anchorage, Alaska. Ryan Colver 1/8/2021 t 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 plot. h~--'-i~' DRILLING (907} 345-0593 WATER WELL RECORD STATE OF ALASRA DEPARTMENT OF NATURAL RESOURES Division of Geologicol ~ Geophysical Surveys PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW960324 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:KOSMICKI STANLEY & JEANNE M OWNER ADDRESS:8355 ELEUSIS DR. ANCHORAGE, AK 99502 DATE ISSUED:10/01/96 EXPIRATION DATE:10/01/97 PARCEL ID:01915119 LEGAL DESCRIPTION: SKYWAY PARK ESTATES ELK 6 LT 17B LOT SIZE: 26400 (SQ. FT.) NUMBER OF BEDROOMS: 0 THIS PERMIT: 0 THIS PERMIT IS FOR THE CONSTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: DATE: DATE: / / $0°- LOT .~ - '" M.n~ctI~ll .ty o~ Anchorage I~UILDING SAFETY DIVISION LOT SURVEY CERTIFICATION ~o,~ '/"=40' ~'~' E7E9 LEGEND ~ ~'o~s ol' Aluminum copped m0num~nf/recovered 0 tto~ pipe and/or rebar recovered. O 2 x2 hub 6 tack recovered · 5/8"x~" tabor set this survey ~ .1~7 ~. /~7~ ~Ub'l.  pr~red ~y: &L SUTTON · Registered ~ [90T)~79-6~ 619 ~ 61~hth Arm. ~e ~ka Tom Fink, Mayor N unicipality Anchorage Department of Health and Human Services 825 %" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 April 6, 1992 La Lay Woo Quan % Kosmicki 221 Mariner Drive Anchorage, Alaska 99515 Subject: Lot 17B Block 6 Skyway Park Estates Subdivision Permit ~SW910046~ PID ~019-151-19 The subject permit, issued April 4, 1991 by this office for a single family well and/or on-site wastewater system, has expired as of April 4, 1992. A new permit must be obtained from this office for a well and/or on-site wastewater system NOT installed by the expiration date. If you have drilled the well, this office for documentation close the permit. a well log must be sent to of the installation and to If a licensed Professional Engineer has inspected the installation of the on-site wastewater system, the original as-built inspection report must be sent to this office for review, approval and documentation. All inspection reports must be submitted within 30 days of construction completion. When applying for a new permit, the fees are: $200.00 for an on-site wastewater permit; $75.00 for a well permit and $275.00 for a combined on-site wastewater and well permit. If you have any questions, ~lease ~ "P~ogram M~ar~ager ~ On-site Services call this office at 343-4744. enc: Copy of Permit PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW910046 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:QUAN LA LAY WOO OWNER ADDRESS:C/O KOSMICKI, 221 MARINER DRIVE ANCHORAGE, ALASKA 99515 DATE ISSUED: 4/04/91 EXPIRATION DATE: 4/04/92 PARCEL ID:01915119 LEGAL DESCRIPTION: SKYWAY PK EST BLK 6 LT 17B LOT SIZE: 26400 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS RECEIVED BY: ~//~-~ ISSUED BY: ~-~'~'~-~ DATE: ~/-3~ DATE: z-~. ~/~ ~/ 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. 019.151-19 Expiration Date: 11-3 — z©? -6 1. GENERAL INFORMATION Complete legal description SKYWAY PARK ESTATES BLOCK 6, LOT 17B Location (site address) 12330 SKYWAY DRIVE, ANCHORAGE, AK 99515 Current property owner(s) STEPHEN HOWARD Mailing address Real estate agent Day phone _12330 SKYWAY DRIVE, ANCHORAGE, AK 99515 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: Private Well Private Septic Water Storage ❑ Community Well ❑ Public Water System ❑ Day phone TYPE OF WASTEWATER DISPOSAL: Private Septic ❑ Holding Tank ❑ Community ❑ Public Sewer Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $/ 1 D Cod I D- a Date of Payment Receipt Number 7�3Z COSA# 0SL�201351 Waiver Fee $ Date of Payment Receipt Number Waiver # 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 7/17/2020 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & FWGS . 6. DSD SIGNATURE System #1 Approved for _�,_ bedrooms System #2 Approved for bedrooms Disapproved *: ,9TH * r�r ...�." Ir • '. Curtis Huffman j •CE 128991 7,/17 202%\���%r ll`F�PROFESSOkNP Conditional approval for bedrooms, with the following stipullltift{�aff" Original Certificate Date: -Zoos) 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 Legal Description: SKYWAY PARK ESTATES B6 L17B Parcel ID: 019-151-19 If more than 1 septic system on lot: COSA Checklist # _of A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 11/23/1996 Total depth 122ft Cased to 122 ft ® Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA 7/16/2020 Static water level at beginning of test 92 ft. Well production at time of test 0.95 gpm Comments B. TANK DATA — NA PUBLIC SEWER Age of tank(s) _ years Tank type/material Measured operating fluid level in septic tank ® Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA — NA PUBLIC SEWER Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade _ft (max) Measured depth to pipe invert from grade _ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective Structure served by this system _ Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ® No ® Coliform bacteria is Negative Nitrate mg/L ® Nitrate less than MRL (ND) Arsenic 36.1 ug/L ❑ Arsenic less than MRL (ND) S W Collected by F E Date of Sample 7/16/2020 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date Results ❑ Pass For bedrooms Fluid depth prior to test in Water added gal New depth _ in Elapsed time min ❑ Code -required soil cover over field Final fluid depth in ❑ System presoaked Absorption rate gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) If yes, enter date Gallons introduced gallons Comments/Deficiencies: FW�S 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' ® Yes if No Community Sewer Manhole/Cleanout > 100' ❑ Yes if No NA ft ® Yes if No Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' ❑ Yes if No NA ft Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ® Yes if No ® Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) NA PUBLIC SEWER Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No _ Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: ® Yes Absorption Field > 5' ® Yes if No ft Private Wells > 100' ® Yes if No Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No _ Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) NA PUBLIC SEWER Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No —ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ®Yes if No —ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION Aw �. I certify that I have determined through field inspections and review ®,AW��,: •' • • . • •��� Of Municipal records that the above systems are in conformance �i • •:� 1 with MOA COSA guidelines in effect on this date. : • 7H '. • Curtis Huffman �r� �F� •. CE 128991As .• i�`4�® %.-P oFESS ON���-,®�• ft ft ft ft ft ft ft ft Municipality of Anchorage ® Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 Water Well Advisory Certificate of On -Site Systems Approval (COSA) # 201351 During a recent COSA on-site inspection and test of the potable water supply well on Block 6, Lot 17B of Skyway Park Estates subdivision, the well's productivity was determined to be .95 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 4 -bedroom residence is .41 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. www.muni.org/onsite Arsenic Advisory Certificate of On -Site Systems Approval # OSC201351 Subdivision: Skyway Park Estates, Block 6, Lot 17B A water sample revealed an arsenic concentration of 36.1 micrograms per liter (ug/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 ug/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. information on arsenic is available from the On -Site Water and Wastewater Program website (www.muni.org/onsite) or at 343-7904. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. OFANCHORAGE lot DATE OF APPLICATION 10/01/96 ER UTILrrY BLVD, SCHEDULED COMPLETION DATE 12/31/96 664-2M MX 6 LT 17B SINGLE FAMILY SKMAY PARK ESTATES M UTI -DWELLING No. APTS COMMERCIAL 191-511.9 GFJD 2729 AS -BUILT 1006WMESS C) to ==CKI ST"LEy & 3RAMM M PHONE AXMWRAGX,AX 99523-0442 R_ ASSESSMENTS f Main Line Extension r E*fing Service Only City Tap F] Have Been Levied F To Be Levied At Qnry 50' or Longer : p - To Property Line Only comments ftT &:On Property. cC- Oftnned OwneRfiR - Main Top Only Staff 1130 SIZE 4 ISSUED SAP INSPECTION FEE $ 104.00 PAID F] CASH PERMIT FEE $ 35.00 Q CHECK# -7a $ INSP (�Q L E DEPOSIT $ 0.00 TOTAL$ 139.00 DATE' ACMSS E. PHONE POST IN A CONSPICUOUS PLACE AT THE JOB SITE AWWU INSPECTOR DATE SCHEDULED / / TIME INSPECTOR SUBDIVISION SKYWAY PARK ESTATES BLK/LT/TRACT BLK 6 LT 17B INDICATE NORTH S f ��L f off' oo y I ✓Es r P o ryl kjo Q � a e a t CA rR SIZE MAIN: PE DEPT AT MAIN: ;2 �.. AT PROP. LINE: iI CONNECT LOCATION: M U COMMENTS At ECT INSPECTED A ��o DATE: Municipality Of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorag e.ak.us (907) 343-7904 CERTIFICATE Of HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 019-151.19 1. GENERAL INFORMATION Complete legal description HAA# Expiration Date: Lot 17B, Block 6~ Skyway Park Estates Subdivision Location (site address or directions) 12330 Skyway Drive Current Property owner(s) Robert F_ and Klm L McDaniel Day phone 522-3110 Mailing address Lending agency i2330 Skyway Ddve Anchora,qe~ AK 99515 Day phone Mailing address Real Estate Agent Day phone Mailing Address Un/ess othen/vise requested, I-/AA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: Four (4) e TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Public Water System Well TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding tank [] Community On-site [] Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the Slate of Alaska. Certificates of Health Authority Approval are required for the transfer of ti0e (except between spouses) for properties served by a singte family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample resuJts less than 30 days otd. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage flies and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Enqineerin.q Address P.O. Box 240773 Anchoraqe, AK 99524 Engineer's Printed Name Michael E. Anderson. P.E. 5. DSD SIGNATURE L'/'''/ Approved for ~ Disapproved. Conditional approval for bedrooms. Phone 522-7773 Date 6119102 bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: & '" .-~ 0 ' O..TZ_ Municipality of Anchorage Development Services Department Build~ng Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (9o7) 343-79o4 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Descflption: Lot 17B, Block 6, Skyway Park Estates Subdivlsllon A. WELL DATA Well b13e P~vate Date completed 1!tZ3/1996 Total depm 122 fi. Date of test Static water level Well production WATER S/UetPLE RESULTS: Coliform 0 colonies/19o nd. Data of sample: 6/13/2002 e. SEPTICtHOLDING TANK DATA Parcel ID: 019-151-49 If A, B, or C pruvide PWSID # Sanitary seal (WN) ! Casedto 122 ft. FROM WELL LOG 11/23/1996 86 ft. 10 g.p.m. wel~ Log ~/N) Y w~es propedy pmtactad (Y/N) Y Casing height (above ground) >24 AT INSPECTION 63 ft. 7,25 g.p.m. Nib'ate ~2 mg.a. in. Tank Type/Material Tank size gal. Foundation cleanout (Y/N) Date of pumping. C. ABSORPTION FIELD DATA Munidpal Sewer System Number of Compartments Depression over tank (Y/N) Pumper Otherbacte~'ia 0 colonies/19oml. Date installed Total depth lt. Date of adequacy test Ruid dep~ in absoq3tion field before test in. Elapsed Time: min. Final fluid depth Any rejuvenation ~reatmant (past 12 mo.) (Y/N & type) Soil rating (g.p.d,/fF or ~/bdrm) ft. Width ft. Eft. abscxption area It2 Monitoring tube __ Results (Pass/Fait) Water added in. Date installed C~eanouts (y/N) High water alarm (Y/N) System type Gravel below pipe Depression over field fto Absorption rate >= If yes, give date New depth in. g.p.d. D. UFT STATION Date inst~lad 'Pump on' level at in. Datum E. SEPARATION DISTANCES Property line Water Sewice line Curtain drain F. COMMEI~rs Size in gallons "Pump off" level at in. Cycles tested Mant~e/Accese (Y/N) High water alarm level at Meets almm & circuit requirements? On adjacent lots >100' On adjacent lots >100' Public sewer manhele/cloanout >100' Holding tank Absorption field Surface water SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanldlift station on lot N/A Absorption field on lot N/A Public sewer main >75' Sewer Iseptic service line SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Prope~ line Water main Water service line Walls on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foondMJon Surface water Wells on adjacent lots Water main Driveway, partcing~ide ~orage in. 'Waiver Fee $ Receipt Number HAA Fee $ Date of Payment Receipt Number (Rev. 12/oo) G. ENGINEER'S CERTIFICATION ~w o Mu~l ~s ~t ~ a~ ~ms am =ngm~r s Pnn~ Name M~chael Date ~2