HomeMy WebLinkAboutSOUTHFORK NORTH BLK 2 LT 1South Fork North
Lot 1
Block 2
#078-141-11
ivi V11 I I LQ1 I fr.. 111 YM wm B Lela I *I r, to,
On -Site Water and Wastewater Section - (907) 343-7904 Page of
ON -SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP231270 PID Number: 078-141-11
Dwelling: M Single Family (SF) F] with ADU El Duplex (D) El Two Single Family Project: n New M Upgrade
Name
MARK A FALLER ABSORPTION FIELD - EXISTING
Site Address n Deep Trench n Wide Trench n Bed n Mound
2225 SOUTH RIVER LANE, EAGLE RIVER El Other
Phone Number of Bedrooms Soil Rating ITotal depth from original grade
1 3 GPD/SF Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot Ft. Ft.
SOUTHFORK NORTH 2 1 Fill added above original grade Gravel length
Township Range Section Ft. Ft.
Gravel width Beds: Number of Lines Distance between lines
SEPARATION DISTANCE'S Ft, Ft.
To
Septic Absorption Holding i Sewer
Total absorption area Number of trenches Dist. between trenches
1
From Tank Field Lift Station
Tank I Line Ft2 Ft.
0F1 Other
Well 25'+ TANK 0 Septic El S.T.E.P. f -1Holding
101+
Manufacturer Capacity
Surface Water 1 100+ GREER 1000 Gal.
Material Number of compartments
Lot Line
10'+ HDPE 2
NA
Foundation 1 10'+ LIFT STATION
Manufacturer Capacity
Remarks Tank insulated. Gal.
Alarm location Electrical installed by
PIPEMATERIAL House to tank 3034 Tank to 3034
Installer JRS drainfield
Drainfield CO/MT 3034
Inspector FWCS BENCH MARK (Assumed elevation) 100 ft
Inspection 15' 10/18/23 Location and description
dates: 211 10/18/23
3 rd 4 th ITOP OF MH
ON -SITE WATER AND WASTEWATER SECTION APPROVAL
OF A
Conditional Approval: Date
7H
. .........
- --------------
Septic Systemn
Approved - Curtis HuffinaneAr,
CE 128991 -4* .4*'
-Aw,
Date 10/20/23
Note: this approval does not include well permit requirements. PROFESSO'_�
(Rev 05102/18)
PID:078-141-11 PERMIT:OSP231270
FIRST WATER CONSULTING
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
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP231270
Work Type: SepticTank Upgrade
Tax Code Number: 07814111000
Site Legal Address: SOUTHFORK NORTH BLK 2 LT 1 G:0959
Site Mailing Address: 2225 SOUTH RIVER LN, Eagle River
Owner: FALLER MARK A
Design Engineer: FIRST WATER CONSULTING
This permit is for the construction of:
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
9/11/2023
9/10/2024
62099
❑ Disposal Field ✓❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ 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
—I ys __
'T.r io (IJC Date:
Issued By: Gil/ Date:
3
MUNICIPALITY OF ANCHORAGE
Development Services Department .0 Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 078-141-11
Property owner(s) MARK FALLER
Mailing address 816 N 4TH AVENUE KNOXVILLE,
TN 37917
Day phone
Site address 2225 SOUTH RIVER LANE EAGLE RIVER, AK 99577
Legal description (Sub'd., Block & Lot) SOUTHFORK NORTH BLOCK 2 LOT 1
Legal description (Township, Range & Section)
Lot Size 62,099 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) IN
(w/wo ADU)
Septic Tank
IN
Upgrade
(D) El
Holding Tank
❑
RenewalDuplex
❑
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION
INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: _ Z
Date of Payment: , / -Zo 7-3
Receipt Number:
Permit No.
Waiver Fees:.
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / firstwaterAK@gmail.com
!
!!
August 23, 2023
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: SOUTHFORK NORTH BLOCK 2, LOT 1
The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic
tank on the above referenced lot. We propose to install a 1000-gallon HDPE tank per the
attached design to serve the existing 3-bedroom residence. We would recommend a 1500-gallon
HDPE tank be installed for future consideration or flexibility. No groundwater was noted in the
MOA on-site file, but if groundwater is encountered during installation an epoxy coated steel
septic tank may be required. The lot and area are served by private water. The design will not
impact any of the neighboring properties. Please contact us if you have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231270, Deb Wockenfuss, 09/11/23
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231270, Deb Wockenfuss, 09/11/23
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MUNICIPALITY OF ANCHORAGE
•
`f 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 ..t...‘
P— -( �� f.) NAS ,
PHONE
�a�iLi-2977
EW
❑ UPGRADE
S
MAILING ADDFIS
.0 s g C.ji &I (H r-.C.IL-11Q L�
LEGAL DESCRIPTION S
ii_c--/- 1 13.1...4Z Sou 7-1-1 Fz>�e -no, �5
LOCATION
HSL—n 7)rz.
NO. OF BEDROOMS
3
3
SEPTIC
TANK
DISTANCE TO:
Well !/
N/�
Absorption are�f
�t�
Dwelli g
��
PERMIT
p`iL43/1,
,�,LL
1
Manufacturer
C'j �C C�(L
Meteri
I �'L 1.--
No. of compartments7
1
Liq. capacity in gallons
IF HOMEMADE:
Inside length
-
Width
Liquid depth
•®___
1 f�10
O Y
J0z
2 � F
DISTANCE TO:
Well /X/
Dwelling
PERMIT NO.
Manufacturer
A
Material
Liquid capacity in gallons
TI LE
BTh 14CICI E)
TRENCH
DISTANCE TO:
Well /
Foundation - %
4/Q
Nearest lot
/5 /
PERMIT NO
� /
No. of lines /
Length of each ny /
Total lengih,gf II ngs
(!cS r
Trench vmi4lth
c5 inches
Distance between line,./
A
N
Top of tile to finish grade
/
Material beneath tile
k% ± inches
Total effective a /rptio�
"s
area n3
4_ 9
SEEPAGE
PIT
Length
Width
/Dept
e/
PERMIT NO.
Type of crib
Crib diameter
/ d)pth
Total effective absorption
area
DISTANCE TO:
Well
uil ing foundation
Nearest lot line
W
1
Class
MA
Depth
— 6x I S
Driller
Distance to lot line
PERMIT NO.
DISTANCE TO:
uilding foundation
l)\/6
ewer line
Septic tank
Absorption area(s)
OTHER
At
PIPE MATERIALS -
- IV
M'c.,
1
SOIL TEST RATING/ #a
INSTALLER
REMARKS
3
ae."
.iso.,
•o'110bj4,14.,
&q98
..~OF
~' •.H...•• %
a...4.
.P
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it • .....'..- (L'
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it o' •. Na, 1457 / v2/
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APPROVED','
y/
AL
/A,,,,
6/f
72-013 (Rev. 3/78)
, ��y 75(11`Y
fiUN 1 1 1 FHL 1 TY UF HNUHUKFILit.
DEPARTMENT OF -HEALTH -AND ENVIRONMENTAL PROTECTION
825 LJREET,- ANCHORAGE, AK 995(
264-4720- •
1.1111°--D I 1- F° R.' pi PERMIT NO: 840301
DATE ISSUED: 05/07/84
APPLICANT :
ADDRESS:
CONTACT PHON
LEGAL DESCR IP :
LOT' SIZE:
MFiX BEDROOMS
DEAN CONST: -- •
xszza -ENGINEERING- -
EAGLE RIVER, - AK - 99577
894-2979
SUBDIVISION: SOUTH FORK LOT:" 1
SECTION: 9- TOWNSHIP: - 13N RANGE: IN
62009' (SQ. -FT. OR' ACRES)
3
LISTED BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING
SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE.
DEPTH TO PIPE BOTTOM <FT. 4. a-
GRFiVEL- DEPTH (FT. ) • • • 3.0
TOTAL -DEPTH (FT: ) • • 7. 0
GRAVEL W1E:qt..' • 2. 5
GRAVEL LENGTH FT. )- - 63:0
GRAVEL `NOLUME (CU. YDS. 20:4
I' TANK - (GALS) • • 1.. 000. **
k,SOIL -RATING (SQ. FT. /BR) ' • 125
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
EE
4. 0
0. 5
BLOCK : 2
YOUR SEPTIC
F:f PI I IN
4.0
7.0
4. 5 7. 0
17.0 5.0
34.0 44.0
21. 4 28. 5
1.. 000. 0 ** 1. 000. 0 **
125 125
PERTIFY: THAT':
I AI FAMILIAR WITH ;THE -REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
-FORTH BY THE ,MUNICIPALITY OF ANCHORAGE (MOA::' AND THE STATE OF ALASKA.
2.--:-1A4ILL INSTALL THE YSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS,
AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. .
WILL ADHERE TO- ALL MOA AND STATE- OF ALASKA REQUIREMENTS FOR THE SET:: BACK
DISTANCES FROM ANY -EXISTING WELL. WASTEWATER DISPOSAL SYSTEM OR PUBLIC
SEWERAGE SYSTEM ON THIS OR- ANY ADJACENT OR NEARBY LOT.
--I UNDERSTAND- THAT -THIS PERMIT IS VALID FOR A MAXIMUM- OF 3 BEDROOMS AND
ANY ENLARGEMENT- WILL REQUIRE RN ADDITIONAL PERMIT.
A-LIFT''STATION IS INSThLLEE:. IN AN AREA COVERED BY MOR BUILDING CODES.
THEN --X-1)- AN ELECTRICAL PERMIT AND- -INSPECTION MUST BE OBTAINED; (2) AS -BU I LTS
LW I LL-- NOT BE APPROVED -WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL --WORK 'MUST BE :DONE BY A LICENSED ELECTRICIAN.
FS1GNEt:1, 7,,DATE
•
APPLICANT: -DEAN
I ISSUED: BY
k- k .•
DATE :
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
0 SOILS LOG
0 PERCOLATION
TEST
PERFORMED FOR: f BEd Al 0-e),4 DATE PERFORMED: "ze.{^ a -
,� `— 9 l D'j
LEGAL DESCRIPTION: _L O`i / �Le� e t?!1 /vD�rD e G 'e5r 'T -J 4 d .M
SLOPE SITE PLAN
1
DEPTH
(F T)
pi'�dre-
2-
3-
4-
5-
13-
14-
15-
A,AA/ �I4e)e-Z._ til h—i
L--04.4 � S /6 ,A1c.4c=5
i J 61 . - 6.4_07) 1/4045 .d
r
Anf to 000000®d����
Iyo
17 - gi fa497 4 �
�G C1'J °9®89dN 00+• 2 G 0000) 0
gs�<aa,La
P t
#,"
Russell I. Oyster ce
No. 4286E °° e
<a
1 pRGFES;0 ®+
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND/
FT
COMMENTS LO%- A; K- ben -764 N / 4— ie
r NO L rt: ,
16-
18-
19-
20 -
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
S
L
0
P
E
Reading
-Date
Gross
Time
Net
Time
Depth to
Water
Net _.
- Drop
er
v
I
PERFORMED BY:
72.008 (6/79)
CERTIFIED BY:
41 Z DATE: -
LOCATION OF WELL
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological & Geophysicol Surveys
Drilling Permit No.
(Please complete either lo, Ib or lc.) A.D.L. No.
Tel:.
An ch
Subdivision
Lot
Block
Ib: 1/4qtrs.
—ofof—of —
Section No.
Township NO
S O
Range E ❑
WO
Meridian
Tell DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS
Well # 2
/or / 434 Z
Street Address and Area of Welt Location -54)60W » ir-v." ,C Alcf7
3. OWNER OF WELL Mr. Carl Disotell
Address:
Eagle River, Ak.
2. WELL LOG
Feet Below -
Surface
M otertul Type Top
Bottom
4. WELL DEPTH: (final)
44 ft.
5. DATE OF COMPLETION
6 — 15 -_$4
Gravel, silt, soil 0
Gravel, ilt, and, water 40
40
49
6, 0 Coble tool Xriiiolary 0 Driven Dug
Auger O Jetted ® Bored p Other:
7. USEDomestic J Public Supply O Industry
O Irrigation ❑ Recharge
❑ To,t Well Other:
0 Commerical
8. CASING: O ThroadedXX® Welded
diem. h In. 1044 fl. Depth Weight 17 lbs./ ft.
diem.
In. to ft. Depth Stickup ft.
MUOICIPPIOF At`1GHO�`�-
M�NI
DEPT. OF HE LIVAG710K
ERIIRONMENTn
RECF I\J ED
9. FINISH OF WELL:
Typo: Diameter:
Slot/Mesh Slee: Length:
Set between ft. and ft.
Backfilling Gravel pack
10. STATIC WATER LEVEL: 20 tt
0 Above or P}relow land surface
Equipment used:
Date
II . PUMPING LEVEL below land surface and YIELD
ft. after hrs. pumping
ft. after
g. P. m.
hrs. pumping g.p.m.
12.GROUTING Well Groulod: O Yes 0 No
Materiel: O Neat Cement O Other:
1
13. PUMP: (if available) HP
Length of Drop Pipe fl. capacity
O Subm. ❑ Jet D Contrlfical
Other
g.p.m.
16. WATER WELL CONTRACTORS CERTIFICATION:
14. REMARKS:
Production of 5 GPM
15. Water Temperature
This ' aw was drilled
ullrri` lin Icllon and this report Is true to the bestofmy knowledge and belief;
g g AA 5385
Address:
Registered Business Name Contract License Number
P.O. Box 770504 Eagle River, Ak. 99577
Signed
Authorized Representative
Date:
une 15. 1984
Form 02- WWR (11/81) Copy Distribution: WHITE State DGGS, PINK -Driller, CANARY -Customer
N
0
N
r
e
z
0
o
Munnenpaility
or
Anchorage
POb' H 6-650
ANCHORAGE, ALASKA 99502-0650
(907) 264-4111
TONY KNOWLES.
MAYOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Permit #: 840164
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot j Block 2 South Fork North Subdivision
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1984.
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent
to this Department for documentation of the installation
and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, the original as -built inspection report
and the yellow copy must be sent to this office for review
and approval, and for documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
Keith E. Bandt, Supe visor
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SWP/057
| �
101 --��»K �
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` � �� �� �X�K�� � n���= K���� " «��-�~��� xo�~ ~, r-
��-, � _
PERMIT`NO:-
DATE ISSUED:
��UX�I����""r "-Tr" CR F-7 ���������
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE: HK 99501
264-4720
��_�I��F ������ ���.11-
040164 840164
04/11/84
APPLICANT: CARL DISOTELL
ADDRESS: SR 9385
EAGLE RIVER/ HK 99�77
CONTACT PHONE: 694-5797
LEGAL DESCRIP: SUBDIVISION: SOUTH FORK/ NORTH
SECTION: 3/4 TOWNSHIPH 13N
LOT SIZE: ^62010 (SQ�FT� OR ACRES)
MAX BEDROOMS: ]
LOT: 1
RANGE: 1W
BLOCK: 2
LISTED AR OW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC
SYSTEMt CHOOSE THE,OPTION THAT BEST FITS YOUR SITE
- -~~ ~- -.- -_
'- F--;7. EE RA C.:11-4! ED EE E� RA. I> F����r�
DEPTH TO PIPE BOTTOM (FT� ) 4.0 4.0 4�0
GRAVEL DEPTH (FT. ) 7.0 0.5 3. 5
TOTAL DEPTH (FT. ) 11�0 4%5 7.5
GRAVEL WIDTH (FT. ) 2.5 24.0 5.0
GRAVEL LENGTH (FT. ) 59.0 460 89.0 **
GRAVEL VOLUME (0.1 YDS. ) 40:9 40.8 65.9
TANK SIZE (GALS) 1/000. 0 ** 1.000. 0 ** 1/000. 0 **
SOIL RATING (SQ.FT. /BR) • 275 242
275
** GRAVEL LENGTH } 75 F'[ REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH)
** TANK MUSTHHVE AT LEAST TWO COMPARTMENTS
� CERTIFY THAT:
' 1. I HM FAMILIAR WITH THE REQUIREMENTS FOR Oft -SITE SEWERS AND WB -LS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE (MOH) AND THE STATE OF ALASKA.
2� I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS:
AND IN COMPLIANCE WITH THE DESIGNCRITERIH OF THIS PERMIT�
3. I WILL ADHERE TQ HLL•MOH AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK
DISTANCES FROM ANY EXISTING WELL/ WASTEWATER DISPOSAL SYSTEM OR PUBLIC
SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT�
4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR H MAXIMUM OF ] BEDROOMS AND
ANY ENLARGEMENT WILL REQUIRE AN HDD�TIONHL PERMIT. •
/
IF H LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOH BUILDING CODES/
THEN (i) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED/ (2) HS~BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT/ AND (]) THE .m
ELECTRICAL WORK `k��T 0W LICENSED ELECTRICIAN.
��
� � _^ 61)/7.�A-
SI6NED DATE: )/-4444A1
HPPLICHN
:ISSUED By
ISOTELL
DATE:
M
/" SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL MthEr 'IO jILT GETESTOLATION
825 L. Street, Anchorage, Alaska 99501 264NWIRONMENTAL PROTECTION
SOILS LOG — PERCOLATION TEST APR 1 ,
DAIREEFHAVEDt/i`1/8�
PERFORMED FOR:
LEGAL DESCRIPTION: Sou HH�r,-I 1\10,-th BZ L
10
12
13
14
15
tic",
Sa..4J grey I
N `�h i0I.U1S
ndwit and
16 _ 4i• •44%4h
17141,
49 • •• Sq.
18
Poy C. Reid, Jr. ; �i%
19 • No. 22511 • er
20 • / ''(4 6.
6'1 0FESS1� 1.
COMMENTS So'
MOA 51- 5.z:3 0 2'-A
SLOPE
SITE PLAN
WAS GROUND WATER S
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MUNICIPALITY OF ANCHORAGE
0
Development Services Department i Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 078-141-11
Certificate of On Site Systems Approval Zy/ z-o
�I
Expiration Date:
Legal description SOUTHFORK NORTH BLK 2 LT 1
Site address 2225 SOUTH RIVER LN Eagle River AK
Current property owner(s) FALLER
X The On -site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
i.[ VE- X P O/A-Tr--S
0
Original Certificate Date: 10/30/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approvdjune 2022
MUNICIPALITY OF
Development Services Department_
On -Site Water & Wastewater Section
ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 078-141-11
Complete legal description SOUTHFORK NORTH BLOCK 2 LOT 1
Location (site address) 2225 SOUTH RIVER LANE EAGLE RIVER, AK 99577
Current property owner(s) MARK A FALLER Day phone.
2. ON -SITE SYSTEMS SIZED FOR 3 BEDROOMS
3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ® Plastic ❑ Concrete ❑ Fiberglass
Age _NEW - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ® Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
istance:
By applying for this entitlement, this property is subject to inspection by municipal On -site staff
to verify the accuracy of the information provided.
COSA Fee $ t, 5� Waiver Fee $
Date of Payment ��,Z ��� Date of Payment
COSA # 05C 2 e�' I Waiver #
COSA Application 2022.doc
•
Legal Description: SOUTHFORK NORTH BLOCK 2 LOT 1 Parcel ID: 078-141-11
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA
® Well log is filed with Onsite (or attached) Well production at time of test 4.5+ gpm
Date drilled 6/15/84 Total depth 44 ft Water storage tank volume NA gallons
Cased to 44 ft Well disinfected for coliform test? ❑ Yes ® No
® Sanitary seal is functioning correctly ® Coliform bacteria is Negative
® Wires are properly protected Nitrate 0.548 mg/L ❑ Nitrate less than MRL (ND)
Casing height (above ground) 24+ in. Arsenic ug/L ® Arsenic less than MRL (ND)
Date of flow test for COSA 7/24123 FW-CS
Static water level at beginning of test 37 ft. Collected by Date 7/24/2023
Comments New conduit & sanitary seal installed by Sullivan.
B. TANK DATA
Measured operating fluid level in septic tank NA
Date of pumping NEW TANK
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 6/9/1984
® ALL standpipes present per record drawing
Total measured depth from grade 6 ft (max)
Measured depth to pipe invert from grade 3 ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
® Monitor tubes (MT) go to bottom of effective. (ED)
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 7/24/2023
Results M Pass
Fluid depth prior to test 10 in
Water added 450 gal
New fluid depth 31 in
Elapsed time 45 min
Final fluid depth 10 in
Absorption rate 450 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 36 in (MOA T ED)
Effective depth used 10 in (Final Fluid Depth)
Effective depth (ED) remaining 26 in
Comments/Deficiencies:_Approximate total measured depths from existing grade. Per sump observations ED appears to
be approximately 3' below sump invert.
COSA Checklist copy.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100'
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No ft
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No ft
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® 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' ® Yes
if No
ft
® Yes
if No ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
® Yes if No ft
Surface Water > 100' ® Yes if No ft
Tank to Property Line > 5'
® Yes if No ft
Wells on Adjacent Lots:
Field to Property Line > 10'
® Yes if No ft
Private Wells > 100' ® Yes if No ft
Water Main > 10'
® Yes if No ft
Community Wells > 200' ® Yes if No ft
Water Service Line > 10' ® Yes if No ft
F. ENGINEER'S COMMENTS
If tank or field is under driveway comment below
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on -site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer's Printed Name CURTIS HUFFMAN PE Date 10120123
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 �,[ ` •;� j
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 TM '
these various and dynamic characteristics and are outside the control of the evaluator of the .... .... .........
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory^
for current or future occupants or guarantee that no unseen encroachments, deficiencies or , . , • , , • • , , . „ • • , , , ,
discrepancies exist can be given by First Water Consulting & Curtis Huffman
-
��c°c,•. CE 128991, Imie,�°'
�>F�• 10/20/23 - \
�1��F0PR0FES51J0\'
COSA Checklist copy.docx
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILLY DWELLING
Parcel I D # 078-141-11
HAA# , f90C,o'1/4/27/
}
1. GENERAL INFORMATION
Complete legal description SOUTH FORK NORTH SUBDIVISION• LOT 1, BLOCK 2
Location (site address or directions) 2225 SOUTH RIVER LANE. EAGLE RIVER. AK 99577
Property owner LINDA PETTYJOHN Day phone (907) 694-8401
Mailing address 2225 SOUTH RIVER LANE, EAGLE RIVER, AK 99577
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well xxx
Community well
Public water
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 XXX
Holding Tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
ing to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21 Computer Version
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1,100.00 at,
or prior to, closing for the engineering services provided.
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. // ll�ifll
Name of Firm ALASKA WATER : WAS ER CONSULTANTS, CONSULTANTS, INC. Phone (907) 337-6179
&/
Address 6901 DEBARRXtOAra S Vt 2A g HORAGE, ALASKA 99504
In conducting this evaluation, AWWC, I .: e .ted to provide a thorough, conscientious engineering dnalysis of the
system in accordance with ADEC and O • D S Guidelines & Regulations. The reported results described the
performance of the system under the conditions encountered at the time of the test, and separation distances
measured to readily identifiable features. The operational life of all wells and septic systems depend
on the local soils condition, ground water levels that may fluctuate during the year, and the water
usage of the family being served by the system. These conditions are outside the control of o �O F 4 �4
the evaluator of the system. Satisfactory test results do not guarantee future performance � ..% Q
of the system, nor do they guarantee that there are no hidden defects or encroachments. op 1 � ..-1--
AWWC, Inc. can therefore not provide any warranty for future estimate of how long the
system will continue to meet the operational requirements of the ADEC or MOA DHHS
The content of this report is for the sole benefit of the owner listed above. Any
reliance upon or use of this report by any other person or party is not authorized, A... C 0
nor will it confer any legal right whatsoever. V .J� fr- y A. Nerness.f �0
6. DHHS SIGNATURE °(j sr '•. ,! 7953 •• ey
t! Approved for bedrooms 4P •Pr.•••••••i EcAo
4 d ofessio o
��O000��a
Engineer's Signature
Date 9
OA
Disapproved
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By:
�O
Date 7-/3-00
The Municipality of Anchorage Department of Health and Human Services (DFIHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of
homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of
DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21 Computer Version
RECEIVED
Municipality of Anchorage
SEP 1 1 2000
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 "L" Street, Rm 502 Anchorage, Alaska 99501 (907) 3148MIZIPALITY OF ANCH
ENVIRONMENTAL SERVICES
Health Authority Approval Checklist
Legal Description: SOUTH FORK NORTH S/D; LOT 1, BLOCK 2 Parcel I.D.: 078-141-11
A. WELL DATA
Well Type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number N/A
Log present (Y/N) YES Date completed 6/15/84
Total depth 44' Cased to 44.5' Casing height (above ground) 2'+
Sanitary seal (YIN) YES Wires properly protected (Y/N) YES
FROM WELL LOG AT INSPECTION
Date of test 6/15/84 9/5/2000
Static water level 20' 39'
Well production 5.0 g.p.m. 4.8 g.p.m.
WATER SAMPLE RESULTS:
Coliform
0 Nitrate ' 5 Other bacteria 0
Date of sample: 9/6/2000 Collected by: A.W.W.C., INC.
B. SEPTIC/HOLDING TANK DATA
Date installed 8/9/84 Tank size 1000 Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression (Y/N) NO High water alarm (Y/N) N/A
Date of Pumping 9/5/2000 Pumper DENALI
C. ABSORPTION FIELD DATA (45.5" FROM INVER TO BOTTOM OF SUMP)
Date installed 6/9/84 Soil rating (g.p.d./ft2 or ft2/bdrm) 125 System type TRENCH
Length 63' Width 2.5' Gravel thickness below pipe 3' Total depth 6' +/—
Effective absorption area 378 Monitoring Tube present (Y/N) YES Depression over field (Y/N) NO
Date of adequacy test 9/5/2000 Results (Pass/Fail) PASS For 3 Bedrooms
Fluid depth in absorption field before test (in.); 32.5 Immediately after 575 gal water added (in )• 48.5
Fluid depth
40.5 (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)` Computer Version
40 Absorption rate =
450+ GPD
NONE KNOWN If yes, give date
D. LIFT STATION
Date installed Size in
Manhole/Access (Y/N)
High water alarm level . * *Datum
ested
on" level at* "Pump off' level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot 100'+ On adjacent lots 100'+ -
Public sewer main
Sewer/septic service line 25'+ Lift station
100'+ On adjacent lots 100'+
N/A
Public sewer manhole/cleanout
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+ Property line 51+
Water main/service Zine 101+
Surface water/drainage 100'+
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+
Surface water 100'+
Curtain drain
Building foundation 10'+
NONE KNOWN
N/A
N/A
Absorption field 5'+
Wells on adjacent lots 150'+
Water main/service line 10'+
Driveway, parking/vehicle storage area 5'+
F. ENGINEER'S CERTIF
I certify that 1
of Municipal
with MOA
Signature —wk./t ISA
Engineer's Name JEFFREY A. GARNESS
Date cr/S/oo
field inspections and review
systems are in conformance
on this date.
Wells on adjacent lots
100'+
a00000pp
�F 4
7f 4 s
0�
00`9 e.fre
4, f
01)
VA
vA
A. .• ess:
. –7.95.3
. c°O
,. EcAd
d Prof esstoroe o
6
HAA Fee $ 300 -co
Date of Payment //- oo
Receipt Number
4z‘,/ a? )
72-026 (Rev. 3/80)* Computer Version
Waiver Fee $—
Date of Payment _
Receipt Number
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 I.D. # 078-1 41 -1 1
1. GENERAL INFORMATION
HAA# A °ICAt J �,
Ir
Complete legal description Lot I; Block 2; South Fork North Subdivision
Location (site address or directions) corner of Hiland and South River Lane
Eagle River, AK
Property owner Walter & Nancy Palkovich Day phone
Mailing address C/0 Prudential Vista 16635 Centerfield Dr. Eagle River, AK
Lending agency Day phone
Mailing address
Agent Eva Loken/Prudential Vista Day phone 689-6476
Address
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
XX
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
Holding tank
Community on-site
Public sewer
XX
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front 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 tha Ydater f-+ is inspection.
Name of Firm
Address
Engineer's signature
AEasira Wever- &
Wastewater Consultants, Inc."_
Shall be PAID $ 700
or prior to, closing for the
Engineering Services Provided.
6. DHHS SIGNATURE
✓% Approved for l H' EE bedrooms.
Disapproved.
Conditional approval for
By.
A. Garnet. ; W
1.3-7753
sem_
bedrooms, with the following stipulations:
Additional Comments
Date 9 - 9
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 151) Back MOAx21
RECEIVED
Municipality of Anchorage SEP 08 1999
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division MUNICIPALIIYQFANCHO , L
825 L Street, Room 502 • Anchorage, Alaska 99501 • (91eflintalivicESDIVIsION
Health Authority Approval Checklist
Legal Description: SOUTH FORK NORTH S/D; LOT 1, BK 2 Parcel I.D.: 078-141-11
A. WELL DATA
Well type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number N/A
Log present (Y/N) YES Date completed 6/15/84
Total depth 44' Cased to 44.5' Casing height (above ground) 2'+
Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
FROM WELL LOG AT INSPECTION
Date of test 6/15/84 9/4/98
Static water level 20' 40'
Well production 5.0 g.p.m. 4.9 g.p.m.
WATER SAMPLE RESULTS:
Coliform ' Nitrate 1.05 M9 4— Other bacteria 0
Date of sample: 8/30/99 Collected by: A.W.W.C., INC.
B. SEPTIC/HOLDING TANK DATA
Date installed 6/9/84 Tank size 1000 Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression (YIN) NO High water alarm (Y/N) NO
Date of Pumping 8/26/99 Pumper JR PUMPING
C. ABSORPTION FIELD DATA
*NOTE: WATER WAS AT TOP OF DISTRIBUTION UNE THROUGH MAJORFY
OF TEST. WATER DID NOT APPEAR IN CLEANOUT AT THE BEGINNING OF
TRENCH AT ANY POINT.
Date installed 6/9/84 Soil rating (g.p.d./ft2 or ft2/bdrm
125 System type TRENCH
Length 63' Width 2.5' Gravel thickness below pipe 3' Total depth 6'+/—
Effective absorption area 378 SQ FT Monitoring Tube present (Y/N) YES Depression over field (Y/N) NO
Date of adequacy test 9/4/98 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test (in.); 6 1/4" Immediately after 682 gal. water added (in.): *42 3/4"
Fluid depth 12 3/4" (ins) Minutes later: 165 Absorption rate = 450+ q.p.d.
Peroxide treatment (past 12 months) (Y/N) NONE KNOWN If yes, give date —
72-026 (Rev. 3196)*
D. LIFT STATION
Date installed Size in
Manhole/Access (Y/N) - o on" level at* "Pump off" level at*
High water alarm level . * *Datum
ested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot 100'+ On adjacent lots
Absorption field on lot 100'+ On adjacent lots
1001+
Public sewer main N/A Public sewer manhole/cleanout N/A
25'+ N/A
Sewer /septic service line Lift station
100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation 5'+ Property line 5'+ Absorption field 5'+
Water main/service line 10'+ Surface water/drainage 1001+ Wells on adjacent lots 1501+
SEPARATION: DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 101+ Water main/service line 101+
Surface water
Curtain drain
100'+
NONE KNOWN
Driveway, parking/vehicle storage area
F. ENGINEER'S CERTIFICATION
5'+
Wells on adjacent lots 1001+
I certify that I ave •e mi,r�7 field inspections and review of Municipal re
in conforma ce w i ' , • elines in effect on this date. p
Signature
Engineer's Name// / JEFFREY A. GARNESS
Date /'/'d/j
s are
Q . . CE` 953 0
O C.Crofession°o�
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
5027 02
q9-99
Waiver Fee $
Date of Payment
Receipt Number
ALASKA WATER & WASTEWATER
7320 EAST CHESTER HEIGHTS CIRCLE • ANCHORAGE ALASKA 99504 • PHONE 337-6179 FAX 338-3248
WELL FLOW TEST DATA
LEGAL DESCRIPTION: Len &•off Zs Sou-r1fot%L i4or rN
STREET ADDRESS:I4' -'O Com, 6' l arr* e1 ,� LArc (AO
CLIENT' &AL7F
f': Mo JAuJt't f%i.KoUICH
F.H.A. — FOUR HOUR FLOW TEST:
YES /
NUMBER OF BEDROOMS
TEST DATE START AHAB
WELL DEPTH (PER WELL LOG):
CASING DEPTH (PER WELL LOG):
CASING HEIGHT (ABOVE GROUND):
DEPRESSION AROUND WELL: YES /S ll
SANITARY SEAL: +�/ NO CJ pJ s fl Be j1'eP`A`t10&gpgice0i
TEST DATE END
Zi�Y l
z4"4
C 4
�F A .S4p
12P49m '90
o
;Jeffrey A. Gamest e
VO: CE -7953 •`O
0
Opp ��
"� �dprera fart..
WIRES IN CONDUIT: s/ NO
WATER SAMPLES TAKEN: YES / NO
TIME
METER READING
10:08
I 50 15
io:25
IS103
1.6:45
I52,03
11 toS
'no;
IJ :ZS
15gs 1
wits-
ISSoo
12tZS
icy) I
5%Pfe O
-tree--^
FLOWRATE
(G.P.M.)
0
5.81
O'
S• 01
6.o'
S•OI
IF YES, DATE:
WATER LEVEL
(BELOW TOP OF CASING)
STATIC = tio'
2•'
M2'
42'
itz'-‘4-3`
431
WELL PRODUCTION MEASURED o «.9 GPA Fog- 131 mnnIOrks
COMMENTS. 5'1s-reen WILL P2opuce 6ao+ CAu ,J -A- Oast.
DRAWDOWN
0
•-2'
0" / z' TOTAL
1/11
1' / 3' retia.
MUNICIPALITY OF ANCHORAGE Q1 1 ) 4
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL CCLIL1
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date 7:../�//6
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner(.Y. w
(c)
(d) Real Estate Company and Agent f2 .. .h-'
Address .10 - /// 6,
Telephone eGy
Mailing Address
Lending Institution Telephone
Mailing Address
Telephone: Home Business
/c/71 t d -G✓
(e) Mail the HAA to the following address: or: Check here, if hold for pick up.
List contact person and day phone number below.
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Easalp Rtvrr, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family f r�
Number of Bedrooms 3
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 0
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 2
72-025 (Rev 8/861 Front
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 regulations in effect on
the date of this inspection.
Name of Firm Telephone 6�C/`��Z
17034 Eagle River Loop ;,;,�
Eagle River, Alaska 99577
Address
Date
6. DHHS APPROVAL
Approved for
Approved
bedrooms by
Disapproved
i 4D A. ah,:4'
No. 1447-;
Date ✓ tiiedi'!' C�j /7p Il
Conditional
Terms of Conditional Approval
4t'
CAUTION
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.
Page 2 of 2
72-025 (Rev 5/86) Back
MUNICIPALITY OF ANID,!?ALITY OF ANCHORAGE (MOA)
ENVIRONMENTAL SERVIddg6ly,T iI3%UTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
A. WELL DATA
Well Classification
5 988
RECEIVED
Well Log PresentQf.N)
Total Depth 4
Static Water Level
01
Legal Description. \---'0"1-
OL--)
- (of IL mor.�C<<-- s N
k r1 too/ -1.... If A, B, C, D.E.C. Approved (Y/N)
Date Completed c 1� Yield
Cased to 11-4 Depth of Grouting
Casing Height Above Ground
12tt+
Electrical Wiring in Conduit l)
Separation Distances from Well:
To Septic/fir/fel-int Tank on Lot
LA. 1 ►'r 1
Pump Set At
4i
Sanitary Seal on CasingC(l)
Depression Around Wellhead (Y�
To Nearest Edge of Absorption Field qn lot
To Nearest Public Sewer Line t-t//A` To Nearest Public Sewer
Cleanout/Manhole t /A
(----t-V-4\t...\(:; Date 1Z -2-a--87
Cib
1
; On Adjoining Lots \ .r;.1>
; On Adjoining Lots
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
/6*, y �. U3 ��. - —( -
Comments
6.7 P�`1
B. SEPTIC/HOLDING TANK DATA
Date Installed Lc, ^e - 84 Size 1 COO No. of Compartments
StandpipesaN) Air -tight Caps
go
-Z--
N)
N) Foundation CleanoutelN)
Depression over Tank (Y/451:2 / Date Last Pumped
Pumping/Maintenance Contract on File (Y/N), ` ; for
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Heidi-Fig Tank:
1
c::, c:3
To Water -Supply Well
To Property Line
To Water Main/Service Line
Course ` cO t
Comments �Z �%�1�>1� 1vt�Plr+
c 1�
To Building Foundation
To Disposal Field
ol
To Stream, Pond, Lake, or Major Drainage
— U2'L
Page 1 of 2
72-026 (Rev. 8(861 Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 125 rl1� Type of System Design
Date Installed
Length of Field
Width of Field 'S Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area 2',18 Standpipes PresentYOJ)
Depression over Field (Y/? Date of Last Adequacy Test 11 --
Results
l Results of Last Adequacy Test • 7()—.
Separation Distance from Absorption Field:
I
To Water -Supply Well 1 7t7 To Property Line
To Building Foundation
Lot
To Existing or Abandoned System on
; On Adjoining Lots �7,� r'4
To Water Main/Service Line l `E' To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course �n
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
ailed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at ent (Y/N)
Tested for Pumping Cycles . Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signeds g, S EAIGINEEIRING to /c�
oa " "o. 2� l
Compa} p34 Eagle River Lip d ���0
Esgl_Kiver-i Alaska MOA No.
Receipt No. ` O c) /- G70 a c
Date of Payment /
Amount: $ / 7 0
Page 2 of 2
72-026 (Rev 8/86) Back
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
LABORATORIES
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
FEDERAL TAX ID # 92-0040440
ANALYSIS REPORT BY SAMPLE
Client P0# : VERBAL Req #:
Client Smpl ID: LT 1 BLK 2 S FORK NORTH 12-28-87
Sample Rec'd : DEC 29 87
Ordered By : S & S
Send
Reports To: S & S ENGINEERING
R SCHAEFER
17034 EAGLE RIVER LOOP RD., #204
EAGLE RIVER, AK. 99577
Special HOLD FOR PICK UP
Instruct:
Chemlab Ref #: 8718 Lab Smpl ID: 3 Matrix: Water
Parameter Tested Result/Units
Work Order No. : 4520
Client Account : SNSENGP
Date Report Printed: DEC 31 87 9 13:18
Released By : 2�
Reports Address #2
Allowable
Method Limits
NITRATE -N
0.16 mg/1 10
Sample ROUTINE SAMPLE
Remarks: ANALYSIS COMPLETED: 12-31-87 G�
LABORATORY SUPERVISOR: STEPHEN C. EDE
1 Tests Performed
ND= None Detected
NA= Not Analyzed
* See Special Instructions Above
** See Sample Remarks Above
LT=Less Than, GT=Greater Than
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343
5633 B Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
❑ PUBLIC WATER SYSTEM I.D.#
PRIVATE WATER SYSTEM
Name
S & S ENGINEERING
Mallin
1717r Eagle River Loop Road No. 204
-Eagle river, Alaska 99577
Phone No.
City
SAMPLE DATE:
Mo.
2 -
State
Day Year
SAMPLE TYPE:
Routine
❑ Check Sample (for routine sample
with lab ref. no. )
❑ Special Purpose
Zip Code
❑ Treated Water
❑ Untreated Water
SAMPLE Time Collected
NO. LOCATION Collected By
1 11..... -Ii.,-( \ 12--4---. 2 1 V2-:412
2 r2%'3-1-‘• E (4A5r2-,fli
3
4
5
�vtdr�le
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
(k Satisfactory
❑ Unsatisfactory
❑ Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received
Analytical Method: Membrane Filter
No. of colonies/100 ml.
Lab Ref. No.
IS)"7/r 4(
Result*
b
Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Membrane Filter: Direct Count
d Coilformll00m1
Verification: LTB BGB
Final Membrane Filter ". Its
Reported By
TNTC = Too Numberous To Count
OB = Other Bacteria
0 Coilform/100m1
Date !.2/30 07
Time: i S a m
A .0 p.m.
loll_3o%7
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH DEPT. OF HEALTH &
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTt9ENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
!JUL
1. General Information
(a) Legal Descriptip� nclude ott, block, subdivision, section, kowns p, range)
s _56 /C7 tr� 10)
Application Date
Location (address or directions)
(b) Applicants NameQ'L
Applicants Address :5-
C 7
Telephone — Home Business
(c) Applicant is (check one) Lending Institution
Buyer (; Other (explain);
(d) Lending Institution
Address
(e) Real Estate Co. & Agent
Address
Telephone
,
Owner/builder/
Telephone
/JD
(f) Mail the HAA to the following address:
2. Type of Residence
Single—Family � Multi—Family Other (describe)
Number of Bedrooms
3. Water Supply -
Individual Well Lyj 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 F --t Community fJ Holding Tank L_J
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 2]
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
f .SRO 136;1
Address �"'y ret11» ' SIVal, ALASKA ' 35l . �.oOB%v��
k
Date m0 • s"°' ' ,70' Ito
to 5fa 1�
..
a. e
aebxrt A. Might • ,
147-€ •. �+0d
.•f �c
A`,..
6. DHEP Approval
bedrooms
Approved for
Approved
Disapproved
Conditional
Telephone
Terms of Conditional Approval
CAUTION
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 DHEP 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 2]
7-19-84
J ICIPALIIY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) `JUI 261984
CHECKLIST - FEBRUARY 1984
A. WELL DATA
Well Classification S, %.
RECEIVED
Legal Description: Lor / %S -L K Z
cov7W ic A/02rii
If A, B, or C, D.E.C. Approved(Y/N)-
Well Log Present Y ) Date Completed 6?- /5 -- e
Total Depth
Static Water Level
Cased to
Casing Height Above Ground 31 e4
Yield,
9'' Depth of Grouting
Pump Set At jJ
Sanitary Seal on Casing N)
Electrical Wiring in Conduitdagi/N) Depression Around A'bllhead
Separation Distances from Wall:
(Y6)
/ y
To Septics Tank -on Lot /, / ; On Adjoining Lots CD /1—
To Nearest Edge of 41btorption Fie . fict //S ; On Adjoining Lots /0 0 /I -
To Nearest Public Sewer, L' a '
Cleanout/Manhole To Nearest
t.
Water Sample Collected By & 1. HAGiN PR g
Water Sample Test Rest i4LER V R A f.
7;?
Comments 42- j
err
To Nearest Public
Sewer Service Line
; Date
2,0
Sewer
on Lot cert
/ , 9-C Esc
-17/6-- V/& 7
1 L1C_16
B. SEPTIC/HOW= TANK IATA
Date Installed 6 ' r i Size /coo
No. of Compartments
StandpipesKi N) Air -tight Caps(t/N) Foundation CleanoutCON)
Depression over Tank
OOP Date Last P .-d
; for
Pumping/Maintenance Contract on File (Y
Holding Tank High -Water Alarm (Y/N)
Separation Distances from Septic/Holding
/
To Water -Supply Wb11 / -Z.)
r
To Property Line /d
To Water Main/Service Line
Course
Comments
Temporary Holding Tank Permit (Y/N) A/�
Tank:
To Building Foundation
it
To Disposal Field /Q /
To gam, nd, Lake, or Major Drainage
[Page 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorpt'on ftrate
q
Date Installed
Width of Field
(o
X854
/ Z< 5//_. Type of System Design i� CA{
,i
30
Square Feet of Absorption Area
Length of Field
Depth of Field
,7
Gravel Bed Thickness
,376- Standpipes Present g/N)
Depression over Field (Y/f Date
17O/,
Results of Last Adequacy Test
of Last Adequacy Test ,</C(,J
Separation Distance from Absorption Field:
To Water -Supply Well //.S To Property Line
To BuildingF undation zip /-7!--- To Existing or Abandoned System cn
Lot � C '' oining Lots 3D //
To Water Main/Service Line /F� To Cutbank(if present) /1%/
To Stream/Pond/take/or Major Drainage Course 61D
To Driveway, Parking Area, or Vehicle Storage Area /')
Comments
D. LIFT STATION
Date Installed Dimensions
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Comments
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
cles during Adequacy
Test. Meets MDA
** **
Check Permitted Bedroom Rating Against HAA Request
I certify that I have checked, verified,
on the date of this inspection.
or conformed
Signed s * ivietWt= Atitlt4 Date
SRB 19t3X
Company y ';) P rt1Vrn, ALA I<A 0,51:7' MOA
KB1/d5/s
(Page 2 of 2]
to all MOA HAA Gut ws in effect
2-15-84