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HomeMy WebLinkAboutSOUTHFORK BLK 1 LT 2Southfork Block Lo1- 2 #078-0! !-04  Municipality of Anchorage ..,,.,. Development Services Department On-Site Water & Wastewater Program, 4700 Sou~ Bragaw SL P.O. Box 196650 Anchorage, AK 99519-8850 www.d.artchorage.ak.us (g07) 3437904 Page 1 of On-Site Waetewater Disposal System and/or Well Inspection Report Permit Number:. SW010347 PID Number:. 078-011-04 ~ame:lNGRID GAVALYA Wastewater System: [] New · Upgrade MILE 7.,3 HIGLAND ROAD * EAGLE RIVER, AK 99577 ABSORPTION FIELD No. of Bedmeml: Ph°ne:(907) 696--7440 .3 o Oe*p Tr. nch· Sha~ow Tr. nch D Bed D Uound DOther LEGAL DESCRIPTION 1.2 ~/~ ~ 5.5-6.5 2 1 SOUTH FORK 3.`36-4.36 ,L 2.14 - - - 0.59-;3.0 n 60 WELL: n New n Upgrade 5 rL 1 - ~. ,L rL 428 so.n D `3054/ F-810 ~L CALKINS CONSTRUCTION 9/14/2001 SEPARATION DISTANCES .septia o,~,,., OS.T.~,. To Septic A~.orpflon Lift Holdlng ~c~ I~. c...~.~ In ;:': Held $~on Tank CREER 100<3 we, 10o'+ lOO'+ - - 25'+ STEEL 2 s,,o:, wo~,, lOO'+ lOO'+ - - - LIFT STATION Foundation 5'+ 10'+ -- Curtain Drain ,. N~NF KNOW Remarks: -EXI$~NG $EPT]O TANK WAS .~,NDONED BENCH MARK PER UPC. TOP OF DECK NEAR POINT "B" 100.00 3rd 9/14/2001 ~ "' Department of Health and Human Services approval ~13~...;_.:.U....:..'_,"~.~ R~vlewed and approved by~.~.~J~- Date: c7-2~OJ ~.~ N~..* AS-- BUILT DRAWING SWO10547 078-011-04 fiNAL OP~Or i 99.06-99.89 TOP OF T~K A~ = ~P OF T~K AT IN~- g4~1~ I ~ 0~- 94.31 I~ OF BUNG SE~C TANK ~ or BUNG AT AT IN~ - 93.87 j ~ - 93.47 ~S~ WATER & WASTEWATER ~ INGRED GAUALYA (907) 696-7440 2 .~ ~.,~: ~0~. '.,~ '::~ ~ ~-~ SOUTH FORK SUBDIVISION; LOT 2. BLOCK 1, PROFILE AS-BUILT DRAWING OF SEPTIC SYSTEM UPGRADE AS BUILT DRAWING ~' ea~ur~ ~UUB~: ~ 078-011-04 SW010547 A B C ST1 51.62 22.91 - $T2 57.17 ~28.10 - ~NO D~Nn~ ~ BE DBL1 59.67 30.62 - ~ ~ a R~ S~ D8~ 61.02 31.99 -- ~ , FD 163.27 -- ~ C01 ' -- . ~ MT1 -- " ~ A % , ~. // / ~ 51.51 ~ 73.20 94.10 71.96 94.06 107.68 145.25 105.97 143.83 A B C ST1 51.62 22.91 - ST2 57.17 ,28.10 - DBL1 59.67 30.62 - DBL2 61.02 31.99 - FD 65.27 51.51 - C01 - 73.20 94.10 MT1 - 71.96 94.06 C02 - 107.68 145.25 MT2 -- 105.97 143.83 ~ [XIS"~NG [ ii ~ /11111 INGRID OAVALYA (907) 696-7440 2 OF 5 ).~J f,~y,. ~,s~. , ~ ,~,,.~: ~:.....,... .~ SOUTH FORK SUBDIVISION; LOT 2, BLOCK 1, ~......" AS-BUILT DRAWING OF S~PTIC SYSTE~ UPGRADE MUNICIPALITY OF ANCHORAGE Development Sen~ces Department On-Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343.7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Aug 29, 2001 Expiration Date: Aug 29, 2002 Permit Number: SW010347 Legal Description: SOUTHFORK BLK 1 LT 2 Design Engineer: 0041 AKWater & Wastewater Consultant Owner Name: Ingrid Gavalya Owner Address: PO BOX 244383 ANCHORAGE, AK 99524~4383 Parcel ID: 078-011-04 Site Address: Lot Size: 149672 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [.~ Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must be in accordance with: 1. The attached approved design. 2. Ail requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Municipality of Anchorage Development Sewices Depadment Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw SL p.o. Box lg~L.~0 Anchorage, AK ggs'lg-~L50 w~v.cLanchomge.ak.us Parcel I.D. ON-SITE SEWER/WELL PERHIT APPLICATION FOR A SINGLE FAHILY DWELLING 078-011-04 Permit Number ~J O lO '~' Z~'T Property owner(s) Mailing address (1) Mailing address (2) INGRID GAVALYA BOX 244383 * ANCHOEAGE. AK Dayphone 696-7440 ~pCode 99524 LegaldescripUon (LoL Block&Sub'd.) LOT 2. BLOCK 1: SOUTH.,,FORK SUBDMSION Legal descripUon (SecUon. Township & Range) Lot Size ' / ~-/q (p '7 ~ Acms/Sq.FL Number of Bedrooms THIS APPUCATION IS FOR: Sewer Only [~] Sewer and Well Sewer Upgrade · Well Only Water Storage THIS PROPERTY CONTAINS: Hot Tub Swtmmlng Pool Therapy Pool ~]~ Water Softening Unit I certify that the above Information Is cormcL I further certify that this application Is being made for a Single Family Dwelling and is In accordance with applicable Municipal codes. ALASKA WATER & WASTEWATER CONSULTANTS~ INC. permit Fees: ~ ~O Receipt Number. Waiver Fees: Date of Payment: Receipt Number. ALASIG WATER & WASTEWATER CONSULTANTS, INC. August 14, 2001 Municipality of Anchorage Development Services Department On-Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, Ak 99519-6650 Reft Proposed Septic System Upgrade for Lot 2, Block 1, South Fork Subdivision To whom it may concern: The existing 3 bedroom house is served by a private well and septic system. The drainfield is in a state of failure and needs to be upgraded. A test hole was excavated in the area of the proposed septic system. The septic system will be designed around the 30 foot radius of this test hole. We are proposing that a 1000 gallon septic tank and a five foot wide drainfield be installed. Comments regarding the design are summarized as follows: 1. SOILS: See the attached logs which shows the soil classifications, groundwater monitoring; and the percolation test results. It is our opinion that an application rate of 1.2 gallons/day/fi' should be used. 2. TRENCH DESIGN: a. Percolation Rate: 3.3 minutes/inch b. Allowable Application Rate: 1.2 gallons/day/ft2 c. NumberofBedrooms: 3 d. Design Flow: 450 gallons per day e. Minimum Absorption Area: 375 ft2 f. Total Depth: 6 feet (max.) g. Effective Depth: 2 feet h. Width: 5 feet i. Reduction Factor: 0.70 j. Minimum Length: 60 feet long k Effective absorption area = 429 ft2 3. SIJRFACE WATERS: There are no surface waters within 100 feet of the proposed upgrade. 6901 Debarr Road, Suite 2B * Anchorage, AK 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com 4. TOPOGRAPIIY: There is a 15 to 20 percent slope running approximately northeast to southwest; in short, there are no slope concerns. We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assistance. Pres ]amess, P.E., M.S. NOTE: Attached is a site plan drawing, a design drawing, and a 7 page construction specification letter which are all part of the design package for this septic system. 6901 Debarr Road, Suite 2B * Anchorage, AK 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwe.com n"' n I~1 I~ , \\ \ ~ ~ I ? i xk \ %......~**~,/ ,; // ',k x, ~S~ WATER & W~TE~TER mNGRID 8AUALYA 696-~440 1 OF 2 SOUTH FORK SUBDIVISION; LOT 2, BLOgK 1, ~[ OF WOR~ SITE P~N FOR SEPTIC SYSTEM UPGRADE NOTE: THE CONTRACTOR SHALL HAV~ THE 100' WELL RADIUS SHOWN FLAGGED BY A REGISTERED LAND ;URVEYOR PRIOR TO CONSTRUCTION. ARMPROPOSO NEW DRAINF'IELD. CAVATE A TRENCH THAT IS ( DEEP IAa, XlUUM BY ~ Dr BY ~0 FELrr LONG. ADD 2 i OF Ct. RAN. WASHED SEWER DRAJNROCK. IN~TAJ..L ~n TO SLOPE CONTOURS, ~EXIST1NG DRNNF1ELD TO BE /., J USED AS A RESERVI: $1TE ~.~'~.~ ~,X \ \~, I I / c.~. ,~ EX~n~¢ sE~c ?~( TO BE/ HOUSE \ '~ / ~ou.~o_. TO_p?.n~ -lo'* \ ~ / ~"~.~ ............. ·..... ALASKA WATER & WASTEWATER ~ , PREPARED FOR: PHONE NUMBER: PAGE NUMBER: ~ ..4~:.:.,~,. ,,~..p.~.% ........ ;:...-~ INORED GAVALYA 696-7440 2 OF 2 SOUTH FORK SUBDIVISION; LOT 2. BLOCK 1 ~._".....M. ....... '~ DESIGN OF PROPOSEO SEPTIC SYSTEM UPORADE ~'~%~,~.~:~:~ ALASKA WATER & WASTEWATER ~/4'~1~ ~ ~L"..7.~, , CONSULTANTS, INC. ~ D~CRI~ON: So~ FORK SUBDMSION; L~ 2, BLOCK 1 PERFORMED FOR: INGRID ~V~YA DA~: 8/4/2~1 ~['~ ITEST HOLE ~1I ~ GW ~ ORG GM CL GC OL % . sw ' " s.S" C.o. 7~Oi}l,ll c~/sa DEPTH TO DATE ~ IUI,JTJI-/ ~oE GRO~DWATER 8 ~ ~ I ~ltl I BOU~ERS D~ 8/4/2001 9 ~[~ COBB~ O~ 8/6/2001 10 11 DATE RE. lNG CLOCK NET TINE WATER LEVEL NET DROP TINE (HINGES) RE. lNG (INCHES) 8/6/2001 1 1:30 - 6- - 12 2 1:40 10 2 ~/2' 3 1/2' 13 3 1:40 - 6' - 4 1:50 10 2 3/4' 3 1/4' ~4 5 1:50 - 6' - 6 2:00 10 2 3/4' 3 1/4' 15 7 2:00 - 6- - 8 2:10 10 16 9 2:10 - 6' - 17 10 2:20 10 11 2:20 - 6' - 18 12 2:30 10 19 PERC~TION ~TE 3.3 (HIN./INCH) PERC. H~E DIA. 6' (INCHES) TEST R~ BET~EN 5.5 ~. 2 COHHENTS: pSE-SO~EO P~C HOLE FOR 4+ HOURS. PERCO~ON PERFORMED ~ ~ WATER & W~A~R I. JE~R~ ~ ~NESS. CE~ T~T THIS W~ PE~ORMED IN ACCORD~CE W~ ~ ~A~ ~D MUNIClP~ GUIDEUNES IN E~CT ON ~IS DA~: MUNICWALITY OF Development Services Department -' On -Site Water & Wastewater Section } Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 078-011-04 Expiration Date: ^2-3'' 2 1. GENERAL INFORMATION Complete legal description SOUTHFORK BLOCK 1, LOT 2 Location (site address) 1717 HILAND DRIVE, EAGLE RIVER, AK 99577 Current property owner(s) ROBERT & BRIDGET MCMULLEN Mailing address Real estate agent Day phone 1717 HILAND DRIVE, EAGLE RIVER, AK 99577 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 550 Date of Payment Receipt Number COSA# OSG21117S Date: Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. 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 4/15/2021 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 rs�11 these various and dynamic characteristics and are outside the control of the evaluator of the s well and septic system. Therefore, any estimate of how long a system will function satisfactory g�Q:' . • for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & FWN ' * . 911-I .......* 6. DSD SIGNATURE �Curtis Huffman System #1 Approved for bedrooms cCE128991 slF�•..41151�9••4P l F9PROFEESSOSSI��P� System #2 Approved for bedrooms ttO\\ Disapproved Conditional approval for bedrooms, with the following stipulation n nil C�i-rr � WATER AND �rn/AST�_V*ATER Z.= GerN O i, 0, J� By: v�/—�X Original Certificate Date: q-2-- 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: SOUTHFORK BLOCK 1 LOT 2 Parcel ID: 078-011-04 If more than 1 septic system on lot: COSA Checklist # _of _ Structure served by this system _ A. WELL DATA ® Well log is filed with Onsite (or attached) Water storage tank volume NA gallons Date drilled 4/21/1984 Well disinfected for coliform test? ❑ Yes ® No Total depth 80 ft ® Coliform bacteria is Negative Cased to 80 ft Nitrate 0.2 mg/L ❑ Nitrate less than MRL (ND) ® Sanitary seal is functioning correctly Arsenic 5.0 ug/L ❑ Arsenic less than MRL (ND) ® Wires are properly protected Casing height (above ground) 12+ in. Collected by Date of flow test for COSA 4/14/2021 Static water level at beginning of test 59 ft. Date of Sample 4/12/2021 Well production at time of test 0.33 gpm Comments DUE TO SHALLOW WELL & LOWER PRODUCTION MAY CONSIDER WATER STORAGE SYSTEM FOR PEAK / CONTINUOUS USE — SEE ATTACHED MOA ADVISORY. WATER PRODUCTION COULD VARY SEASONALLY. B. TANK DATA Age of tank(s) 19 years Tank type/material SEPTIC / STEEL Measured operating fluid level in septic tank 51" ® Standpipes/foundation cleanout per record drawing Date of pumping 4/19/2021 D. ABSORPTION FIELD DATA Which system tested (date installed) 9/14/2001 ® ALL standpipes present per record drawing Total measured depth from grade 7_5 ft (max) Measured depth to pipe invert from grade 5.3 ft (min) ❑ N/A — pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: Adequacy test date 4/14/2021 Results f g Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 600 gal New depth 0 in Elapsed time <1 min ® Code -required soil cover over field Final fluid depth 0 in ® System presoaked Absorption rate 450+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N date of test) Gallons introduced *600 gallons If yes, enter date Comments/Deficiencies: *Presoak deemed adequate since no water showed in the monitoring tubes during the presoak or test, the property became vacant just 30 days ago per realtor & similar 2018 adequacy test results. F�' 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 ft Wells on Adjacent Lots: Community Sewer Manhole/Cleanout > 100' ® Yes if No 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 ft Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' Surface Water > 100' ® Yes Animal Containment > 50' ® Yes if No ® Yes if No ft 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) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ft ft ft ft ft ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: 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) 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 1 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. .... ..........� �� • Curtis Huffman �� ��c •. CE 128991 �� �'�>F•. ,4/22/21. •��� ,,� iM ft Municipality of Anchorage A 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 'Nater Well Advisory Certificate of On -Site Systems Approval (COSA) # OSC211178 During a recent COSA on-site inspection and test of the potable water supply well on Block 1, Lot 2 of Southfork subdivision, the well's productivity was determined to be .33 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3 -bedroom residence is .31 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. 0 O Z T F- u< 0 Z z 0 � 00 U W x .0- < 0v W I- 0 ::)0 0 Vi Z F- > O C:) ko CD < > '.0 C:) LLJ JouZ M o Lf) (Ij < z < V) UJ u F- 00 w W Z V9K �],M SO OOS Z < 2 < LU u < 0 LU LL Q< F 0 p Q a z n !O<Z 0?:u y 1 0 uirn LL I- ;- LL o [L- z j� U -i 0 < < Y LD C) F- 0 Lr) z zpz z 0 T < w Cl- -1 C) 00< m x < Yzw - 2� 2 0 LLj -r LU U<M � 0 U z L9 0 z 0 0 L.Li U ff� = LU Z ou z u < 0 Z < z Z cr) Ln T 0 2 :E �u N CP ix- 00 u Lu U�-§ m -j �z < w 0 00 !Z n- U CO II m z LL U ..o. z o' I-- § Z 0 0 Zo z �< >! 0� 2 -i u I "t < ,I 0�z 3: z 0 Uw tx x < < z 0 W -j Z < < o o o1w r o- Lli L.) w0 Z vi w -F Z W < o Z F- 1: z< <wz C) �Zw; Co Lu T- -1 0 z OT _, w ( -zq 'cr-) Ho�< z z a- u V) u z < 0 C,� C� > 0. do F- >, - z Lo, 0 w < < u LI) C) CD w< 4 Ln 0 C� U) 0 fu Z -F blo * LU V) Ln C6 U) E y, rl_ w< < t m 00 -j c) a) -- k.0 Lf) OP z Q) CJ rl (y) 00 Lr) cl) r,4 W C: W Qct 0 0 c U lD O C: u i 0 o U Z3 j_- w > N Ln < Ln 0- d < 'o -JU z ZI: 5O w 50 9=1- 10" Z w 'jo, -rc 5 U) LL _j 0 z < O c) W D Z; ,vc V(3v Oao c)) > z V) 0 0 F °� H ��4 d�l V) e, C/) e w 0 Y���d pd �DOO - X LLI 10 1 -j Municipality of Anchorage • On-Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 078-011-04 Expiration Date: 7 _/c( 1. GENERAL INFORMATION Complete legal description Southfork Block 1 Lot 2 Location (site address) 1717 Hiland Rd Current Property owner(s) McMullen Day phone 694-4994 Mailing address Same Real Estate Agent Janan Day phone 694-4994 I 2. TYPE OF DWELLING: N E►' -14 ® Single Family (w/wo ADU) lD c i Z0a ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class C Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Received by: Date: //?'/.7 COSA to be released to the engineer,unless therwise requested by the engineer. COSA Fee $ S24. 00 Date: Date of Payment I)--11 I/IC) Date of Payment Receipt Number 01BciOD Receipt Number COSA# O I gI X33 Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm NorthRim Engineering Phone 694-7028 Address PO Box 770724, Eagle River Engineer's Printed Name Steve Eng Date 12/112018 - • r?. 6. DSD SIGNATURE System #1 Approved for 3 bedrooms. System #2 Approved for • bedrooms. Disapproved. • Conditional approval for bedrooms, with the following stipulations: ;,;. :5-`, °N�SITC WATER AND r. WAST WATER <— PROGRARR <<- � 1 BY� ( US-- Original Certificate Date: I-7-I 9" The Municipality of Anchorage Devlopment Services Division(DSD)Issues Certificates of On-Site Systems Approval(COSA)based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet 9-1.12.doc . 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: SCO T/-f Fat ly (5/ L-2 Parcel ID: O780//Oq A. WELL DATA Well type P If A, B, or C provide PWSID# Well Log (YIN) y Date completed 1/Z//ory Sanitary seal (Y/N) y Wires properly protected (Y/N) >f Total depth SPO ft. Cased to FQ ft. / Casing height(above ground) /2 in. FROM WELL LOG AT INSPECTION Date of test. Lf/2///Sy /2�/a7/8 Static water level 2 5 ft. 55 ft. Well production / g.p.m. , 2 g.p.m. WATER SAMPLE RESULTS: Coliform IN e colonies/100 mL Nitrate $ mg/L )22444ie Arsenic A.I P ug/L Date of sample: )2- (0-(Se Collected byA:l t'U eta • B. SEPTIC/HOLDING TANK DATA Tank Type/Material S �7Tic.�..TrE EL Date installed 7/0l Tank size/DGO gal. Number of Compartments 2 Cleanouts(Y/N) Foundation cleanout(Y/N) k Depression over tank(Y/N) ^/ High water alarm (YIN) .4/ Date of pumping Pumper�'Y Pum er 4 ig.,( C. ABSORPTION FIELD DATA Date installed 9//S/,?/ Soil rating (g_p.d./ft2 or ft2/bdrm) 1. 2 System type T,fe"c._ Length ‘C) ft. Width S ft. Gravel below pipe 2. / ft. Total depth S ft. Eff. absorption area 42&ft2 Monitoring tube y Depression over field ,v / P Date of adequacy test / 2/10/fl Results (Pass/Fail) For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added .06+ gal. New depth ? in. Elapsed Time: 2o min. Final fluid depth 6 in. Absorption rate >= LI-CQ * g.p.d. Any rejuvenation treatment(past 12 mo.) (Y/N &type) UA/K— If yes, give date D. LIFT STATION A A 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 /06) 14-- On adjacent lots Absorption field on lot /, a /4- On adjacent lots /GO `7 Public sewer main /Oa Public sewer manhole/cleanout /40 ->L Sewer/septic service line 2.S(� Holding tank /DO %" Animal containment areas St7 r-F Manure/animal excrete storage areas /00 174 SEPTIC/HOLDING TANK ON LOT TO: Building foundation /d r* Property line /o ('� Absorption field /d < r Water main /0 f Water service line / 1 'F Surface water /QC, -1— e Wells on adjacent lots /Oa 'f' ABSORPTION FIELD ON LOT TO: Property line /O /'� Building foundation /a 'f" Water main /0 /4" Water Service line /0 'f Surface water /OD `'1" Driveway, parking/vehicle storage /O (� r Curtain drain 1/i//r Wells on adjacent lots /00 F. COMMENTS G. ENGINEER'S CERTIFICATION ."41114.x., t:yr tit I certify that I have determined through field inspections and '® ( ith review of Municipal records that the above systems are in r Y , p a de conformance with MOA COSA guidelines in effect on this date. I-; r,�r ;� * Engineer's Printed Name Sre%lE d6 Date /Z��//f / •> u� wO iNllift • • COSA yellow sheet_2-6-15.doc 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 Parcel I.D. 078-011-04 ' ..FORM T ON ~: Oomplete legal desCd~tion Southfork, BIk 1, lot 2 Location (site address)' 1717 Hiland Road C~urrent Property owner(s) Dave Watts "Mailing'address P.O. Box 772191, Eagle River, AK 99577 Lending agency cos^# Expiration Date: Day phone 696-2902 Day phone Mailing address Real' Estate. Agen,t Careen Muir Keller Williams Realty Day phone 865-6545 Mailing Address Unless otherwise requb"sted, COSA will be_held by DSD for pickup. 2. NUMBER OF BEDROOMS: ..- 3 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 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 suppl~, 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 ~)p~plication, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional an?ill,equate for the number of bedrooms and type of structure indicated herein. I further verify that based on the' if~f~'i~t~n obtained fr,o.m the Municipality of Anchorage files and from my nvestigat on and nspect on, the on-sit~¢~t~, supply a. nd~br..wastewater disposal system is(are)in compliance with all applicable Municipal and State c°~e~i:':~,' ordinances, and regulations in effect at the time of installation. '~' Name of Firm Pannone Engineering Services, LLC Address P.o. Box 100217, Anchorage, AK 99510 Engineer's Printed Name Phone 272-8218 Date ~.,/~/~'~P DSD SIGNATURE ~J/ Approved for . Disapproved. Conditional approval for bedrooms. bedrooms, with the followir~'~.~tiPulations: Attachments: COSA' Checklist X ..S. ePU c .Sys..t~,m .~dvisory Well Flow Advisory Nitrate Advisory By: (Rev. 11105) Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: Municipality of Anchorage Development. Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Southfork, BIk 1, Lot 2 Parcel ID: 078-011-04 WELL DATA Well type Private Date Completed Total depth Date oftest' ~ static water Ieee! If A, B, or C provide PWSID # ~ Sanitary seal (Y/N) Y Cased to 80 ft. FROM WELL LOG 4~21/1984 C:~ABSORPTION FIELD DATA: 25 ·(est.) ft. Well production 4 9pm (est.) g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 0.224 Arsenic: · ND ug/L. date of sample: e/~9/2o~o ,SEPTIC/HOLDING TANK DATA Tank Type/Material Steel Tank size- ,~,ogo ~ .gal.,, ~ mg/L Number of Compartments 2 Depression over tank (Y/N) N Pumper JR's Pumping 0.7 "~ate~install~ed 9/14/200~1 ;? :i soil rating (g.p.d./~ or ft2/bdrm) 1.2 ~lpd/SF Le~gthi:,,,60 ..... .. ,.;~ft?F Width 5 ff. Total del:fth,~· ,,.Ct ....... Eft. absorption area Date of adequacy test 8/1!9/2010 428 ft2 Monitoring tube Y Results (Pass/Fail) Pass in. Water added 450 gal. Fluid depth in absorption field before test 0 Elapsed Time: 0 min. Final fluid depth 0 in. Well Log (Y/N) Y Wires properly protected (Y/N)Y Casing height (above ground) ~8 AT INSPECTION 8/19/2010 57 ft. g.p.m. Collected by: Pannone Engineering Any rejuvenation treatment (past 12 mo.) (Y/N & type) N in. Date installed 9/14/2001 Cleanouts (Y/N) Y High water alarm (Y/N) N System type Shallow Trench Gravel below pipe 2.14 Depression over field N For 3 New depth 0 Absorption rate >= 450+ . If yes, give date bedrooms in. g.p.d. D. LIFT STATION Date installed "Pump on" level at Datum Size in gallons in. "Pump off" level at ~ in. Cycles tested E. SEPARATION DISTANCES Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? in. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100+ Absorption field on lot _ 100+ Public ..sewer main N/A Sewer iseptic serviceline 25+ /~mimal containment areas 50+ SEPARATION.DISTANCEs FROM SEPTIC/HOLDING TANK ON LOT TO: Building fo'~dation '~10¥' - Property line 10+ ~sorption field Water main N/A~, , ?. ::, Water service line 25+ Surface water 100+ On adjacent lots On adjacent lots 100+ Public sewer manhole/cleanout N/^ Holding tank N/^ Manure/animal excrete storage areas 100+ 5+ 100+ Wells on adjacent lots 100+ .-. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line f0+ Building foundation 10+ Water main N/^ ."water. Semice line 25¥ Surface water 100+ Driveway, parking/vehicle storage 10+ C~rt~i~i,.. drain NOn~ Known Wells on adjacent lots 100+ t ~'i~ that t have determined through field inspections and review'of'Municipal remus that the above systems are in ~~. ~nformance wtth MOA COSA guidelines in e~ on this date. Date of Payment ~ - / - / ~ Date of Payment Re~ipt Number O ~ / ~ / ~ Receipt Number (Rev. 4/10) LOT 1 35' P.V.C. Pipe O© LOT 2 5 Cleanouts 42.3 EXISTING HOUSE 42.3 Well m CHUGACH STATE PARK Legend: Septic Standpipe Water Well Fence --X--X NOTE: THIS DRAWING SHALL NOT BE MODIFIED FOR USE AS A PLOT PLAN WITHOUT THE EXPRESSED WRITTEN CONSENT OF LANTECH. & CONSTRUCTION SURVEYORS--PLANNERS--ENGINEERS 4.40 West Benson Boulevard, Suite 200 Phone: 562-5291 Alaska 99503 Fox: 561-6626 Dote: August 25, 2010 Drown Bp PL. Od,.. 2010L189 C~,~od S:~ JMZ LOT 3 o~,~ e~. Careen Muir/Keller Williams '"°°' AS-BU ILT Lot 2, Block 1, Southfork Subdivision Plat: 82--121 sool~: 1"--50' etd: SW1059, SW1060 Reft 2001L485 SURVEY CERTIFICATION: LANTECH has conducted a physical survey of the property as shown on this drawing and certifies that the improvements situated thereon are within the property lines and no encroochrnents other than noted. EXCLUSIONARY NOTE: it is the owners' responsibility to determine the existence of any easements, covenants, restrictions or right-of-way takings which do not appear on the recorded subdivision plot. Under circumstances should any data hereon be used for const for establishing property lines, or for plot-plan purposes. 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) # 101189 During a recent COSA on-site inspection and test of the potable water supply well on Block 1, Lot 2 of Southfork subdivision, the well's productivity was determined to be 0.7 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3-bedroom residence is 0.31 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. ...................... SG,S SGS Ref.# 1104279001 Client Name Pannone Eng. Srv. Printed Date/Time 08/24/2010 11:08 Project Name/# Southfork S/D BI,L2 Collected Date/Time 08/19/2010 12:15 Client Sample ID Southfork S/D B1,L2 Received Date/Time 08/19/2010 15:15 Matrix Drinking Water Technical Director Stephen C. Ede Sample Remarks: Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C ((10) 08/20/10 08/23/10 KDC Waters Department TotalNitrate/Nitrite-N 0.224 0.100 mg/L SM204500NO3-F B (<10) 08/19/10 AYC Microbiolog~ Laboratory E. Coli Total Coliform Negative I 100mL SM20 9223B A 08/19/10 SDP Negative I 100mL SM20 9223B A 08/19/10 SDP Parcel I.D. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 8outh Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak..us · (907) 343-7904 t CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAHILY DWELLING 078-011--04 HAA# hlb GENERAL INFORMATION Expiration Date: I ~ ' '~' .¢'" O I CompletelegaldescriptJon SOUTH FORK SUBDR/1SION; LOT 2, BLOCK 1, Location (stte addrass or directions) 7.3 HIGHLAND ROAD * EAGLE RIVER~ AK 99577 Currant Property owner(s) Mailing address Lending agency INGRID GAVALYA Day phone 351-5078 7.3 HIGHLAND ROAD * ANCHORAGE, AK 99577 Day phone Mailing address Real Estate Agent Mailing address JANET GORTEN w/ PRUDENTIAL JACK WHITE Day phone, 230-5049 3201 'C' STREET SUITE 200 * ANCHORA(;E, AK 99503 Unless othen~fse requested, HAA will be held by DSD for plckup. 2. NUMBEROF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Indivldual On-site Individual Holding tank Community On-slto Public Sewer The Municipality of Anchorage Development Sendces Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an Independent professional civil engineer registered In the State of Alaska. Certificates of Health Authority Approval ara required for the transfer of title (except between spouses) for properties served by a single family on-sita wastewater disposal and/or water supply system. DSD also Issues ~ upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties sewed by a pdvate or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a pedod of up to one year with valid water samples.) CedJticates are valid for one year for properties sewed 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 engineeCs work. Note: Alaska Water and Wastewater Consultants, Inc. shall be pald $ ~ OCT ~aa~ to closing for the engineering services provided. or pdor I 4. STATEMENT OF INSPECTION BY ENGINEER As cea§ed by my seal affixed hereto a~d as of the validaEon date shown below, I vedfy that my Invesb'gaEon, based on procedures outlined In the Heal~h Authodty Approval Guidelines for this applicaEon, shows that the on-sire water supply and/or wastewater disposal system is(are) safe, funcb'onal and adequate for the number of bedrcoms and type of structure Indicated herein. I fud, her verify that based on the Informab'on obtained f/om the Municipalih/ of Anchorage files end from my Invesiigab'on and lnspec~on, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulaEons in effect at the §me of lnsiallation. NameofFIrm ALASKA WATER &: WASTEWATER CONSULTANTS. INC. Address 6901 DEBARR ROAD. S(JITE 2B * ANCHORAOE. AK 99504 Engineer's Printed Name JEI-i-~EY A. OARNESS. P.E. Engineer's Comments: In conducEng this evaluation, AWWC, In~ attempted to provide e thorough, conscientious engineering analysis of the system in accordance wlfh ADEC end MOA DSD Guidelines & Regulations, The repoded msutt$ described the performance of the system under the cond~'ons encountered at the time of the test end eepecaC~n distances measured to readily Idon§fiable fea~res, The eperalionol life of all v/elis end septic systems depend on the Iocal soils condi~'on, groundwaler levels that may fluctuate dudng the year, and the watar usage of the famlTy belng servad by the system. These conditions am outside the conb=l of the evaluator of the system. Sa#$facfory tost results do net guarantee futura performance of the system, nor do they guarantee that them are no hidden defecfs or encroachments. AW1/VC, Inc. can therefore not provide any wan'anb/ or fufum estimate of hey/long the system wTl continue to meet the operational requirements of the ADEC or MOA DSD. The content of this rope~t Is for the sole bener[t of the owner listed above. Any reliance upon or use of thls rupert by any other per~'on or party is net authorized, nor wfll it confer any legal #ght whatsoever. 5. DSD SIGNATURE L"/ ^pproved for _C] Disapproved. Conditional approval for __ Phone 337-6179 ..... ON-SrTE bedims, wi~ ~e fllo~ng s~pula~ons: ~ ~ WATER AND Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manltenance Agreements Supplemental Engineer's Reort Other Original Certificate Data: ~'- ;;2,,~'- O I Municipality of Anchorage Development Services Department (~,-Slte Water & Wa~ Program 4700 ~outh Ollgaw ~t. P.O. B~x 196650 Anchamge, AK gg51g-8850 Ce HEALTH AUTHORITY APPROVAL CHECKLIST SOUTH FORK SUBDIVLSION; LOT 2t BLOCK It PamellD: 078~-011-04 ¥~cl.L DATA Welltype Date completed 4/21/84. Totaldeplh 80 IL ifA, B, ore IXOVlde PWSID# N/A Dasedto 80 lt. FROM WELL LOG 4./21/ 4. 55 4 2 Depression over tank (Y/N) NO Pumper Date of test Slal]o water level It. Wel~ produc~on .g.p.m. WAI-cR 8AMPLE RESULTS: Co~3ml ~ colones/lO0 n~. Date of sample: ~ 8EPTIG/NOLDINO TANK DATA Tank Type/Material STEEL Tankslze 1000 gal. Number of Compartmente Foued~on cleanout (Y/N) YES Date of pumping NEW ABSORFilON REM3 DATA Date ~s~ed, Ckmnouts (Y/N) YEs High water alarm (Y/N) System type TRENCH Gravel below pipe 2.14 IL Depression ovor ~eld NO For 3 bedrooms New dept~ Ir~ AbeorpUon rate >- g.p.d. ff yes, give date Ruld depth In absot131ion field before test in. Elapsed Time: min. Final fluid depth .any rejuvenation treatment Coast 12 mo.) (Y/N & t3tpe) Wen Log (Y/N) , w~es pmpe~ pmmcted (Y/N) Cas~g belght (above ground) AT INSPECTION 7/31/01 57 IL 0.71 g.p.m. YES YES 12+ AWWC~ INC. , Length 60 IL Width 5 fl. Total dep~ e7.1-7.7 IL F.~. IIb~l~on ~ 428 It~ Monltudng tube YES Date of adequacy test NEW Results(Pass/Fall) PASS Water added gal. D. UFT 8TATIOH ate ;ni;~led Size In gallons ~ Pump on' level at in. 'Pum n. High water alarm level et In. ~ Cycles tested Meets alarm & circuit requlmmente? SEPARATION DISTANCES SEPARATION DISTANCES FROM WF[I ON LOT TO: Septic tenMilt staUon on lot100'+ .N3sofpl/on field on lot. 100'+ Public sewer main N/A Sewer/Mt)tlc sen~ce Ilne 25'+ Cuttein drain NONE KNOWN F. COMMENTS On adjacent lots 100'+ On adjacent lots 100'+ Public sewer n'mnhole/cteanout Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line Water main N/A Water ~erdce ilne Wells on adjacent Inte lOO'+ SEPARATION DISTANCE FROM ABSORP'rlON FIELD ON LOTTO: Prope~y line lO'+ Building foundation lO'+ Water ~endce Ilne 10'+ Surface water 10o'+ We~ on adjacent lots 100"+ 5'+ Absorpl]on field. 5'+ 10"+ Surface water 100'+ Water rosin N/A Driveway, pa~ng/Vehlcle storage 25'+ O. ENGINEER'8 CERTIFICATION I certify that I have determined thn~47h field InRoec6~na and renew of Mun/c/pa/records ~hat I:he above systems am In conformance wfth MOA HAA guidelines in effect on this date. Englnesfl Pdnted Nan)e JEFFREY A. GARNESS Date ~ Waiver Fee $ Oats of Payment Receipt Number Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anehorage.ak.us (9O7) 343-7904 Water Well Advisory, Health Authority Approval # 010507 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block 1, Lot 2 of South Fork subdivision, the well's productivity was determined to be 0.71 gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a 3-bedroom residence is 0.31 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 la~vns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. I~~O " MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 N-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME ~ PHONE ! ~NEW ~, DISTANCE TO: JWel'/o~ ' Abs°rpti°narea7 , Dwelling ~ Z Manufacture~ [ ~ ~ r~¢~~ ~,~ ~ ~~r~ '~)ME~D ~: Inside length Width Liquid depth D~STANC~T~: ~e~ Dwelling PERMIT NO. 0 ~ ~ Manu[acturer Material ~iquid caoacitg in ~allons ~ Foundation ~earost lot line P~MIT ~0. DISTANCE TO: Well / / No. oflines Length of ea~ine/A~ Total length of lines Trench width Distance between lines ~ -- Top of tile to finish grade [ Material beneath tile Total effective absorption area Q inches .~ ~ . Width ~0 ~ ~ ~ )PE~I Type of crib Crib diameter Crib depth ~ Total effe~iv~sorpt~ea DISTANCE ,O: Well//8 / ~ Building ~n~io~ Nearest Eot ,in~o Clas~ ~ Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank. Absorption area(s) OTHER PIPE MATERIALS ~ SOIL TEST RATING/ ~ ,~ / REMARKS I 72-013 (Rev. 3/78) DEF'I::IRTMENT OP'" HEALTH AND EN',,,'I RONE1ENTRL PRCITECTICIN ,:,,=:.._, L STREET., AN'":HOF.:F'IGE., AK 9950::L 264-4720 PERMIT NO: DATE ISSUED,: APPLICANT ADDRESS: CONTFtC:T F,~IUt,IE . LEGAL [:,E:SE:R I F': L. OT SIZE: MAX B E:E:,F..'.O 0 MS: R&S CONST. 5 S&S ENGINE:ERING EAGLE RIVER, AK 99577 694-29?9 SUBDIVISION: SOUTHS FORK SECTION: S~,..":~L Fl TOHNSHIP :t. 0. 4A CSL.]. ¢'7'. GR FtCRES) LOT: 2: BLOCK RFIi'.,IGE: :I.H LISTED E:ELOH ARE THE IDF'"I-IOf.,IS AVRIL. FIE:LE TO '.r'OU tN [,E'-nISNII'.,tG 'T'EIUR .=,EFTI... .... ,,,- . ""- ' ' ":; '-ITE. :'rcTEII. C:HOOSE THE OF'TIOf',t THFtT E,E.z,"f FIT.: 'T'OUR :, DEPTH TO F'IF'E BOTTOM <FT. ) GRF1VEL DEPTH (FT.) TOTAl_ DEPTH "..'FT. ) GRAVEL P.IIDTH (FT.) GRAVE'L LENGTH ,::FT'. ) GRAVEL VOLUHE (CLI. "r'DS. ) TFINK E;IZE (GALS) SOIL RATING <SL.]. FT. ,..'AR) 4. R 5.0 4.0 2. Pi 0. 5 ::L. 5 2. 5 t7~-"7 b-'"'~ 5. 0 ±24. 0 :+::+: .-~:4. *0 /" '12-:4. 0 ~:7. ;2 21.'4 12. 4 ±., 000. 0 :~'.:+: i., 000, 0 :+::+: ±, 000. 0 :+::+: :+::+: GRFI'v'EI_ LEf.,IGTH :::. 75 FT. F..EI.,~.LIRE=, MLILTIPLE F..LIN.:., ,::NCIT EXC:EEDING -"'= FT. EFIC:H) :+::+: TFINI'::: HUST HFIVE FIT LEAST TI.,~CI COMPIRRTMEN'FS I CERTIF"¢ THAT: ±. I Afl FAMILIAR WITH THE REQUIREMENT:5 FOR ON-SITE SEWERS FIND HELLS RS SET FORTH B"r' THE MLINiCIPlaL. I"f'"r' OF ANCHORFIGE (flOR;:, FIND THE STATE OF FtLFISKA. 2. I HILL INSTALL. ]"HE S'¢STEM IN FICCORDANCE HITH ALL MOFI CODES AND REGULFtTIONS, AND IN COMPL. IFINC':E HITH THE DESIGN CRITERIA OF"' THIS PERMIT. ~:. I HILL ADHERE TO F:tLL MOA AND STATE OF ALASKFt REQUIREMENT'-:; FOR THE SET BACK DI'STANCES FROM AN"r' EXISTING HELL, 1.4RSTEHFITER DISPOSAL S%'STEM OR PUBLIC SEHERAGE S'¢"STEH ON THIS OR AN"r' ADJACENT OR NEFIRB"¢ LOT. 4. I UNDERSTAND THAT THIS PERMIT IS VFILID FOR A MAXIMUM OF 2-: BE[:'ROOMS AND AN"r' ENLARGEMENT HILL REQUIRE AN ADDITIONAL PERMIT. IF A L. IF:'T STATION IS INSTALI_Ei} IN AN AREA COVERED B'T' MOA BUILDING CODES, THEN ,:.'l) tan ELECYRICAL PERMIT AN[:, INSF'ECTION MUST BE OBTAINED.~ (2) AS-AUILTS' WILL NOT BE APPROVED WITHOUT FIN ELECTRICAL INSPECTION REPORT; AND (]:) THE EL. ECTRICAL P.IORK ML.IST BE DONE B'T' R LICENSED ELECTR. ICIFIN. 8 9 10 11 12 13- 14- .15 - 16- 17 18 19- 20- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVl RONIVIENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST C/~° ~- 7~o T'tS~J [] SOILS LOG COMMENTS PERFORMED BY: 72-008 (6/79) WAS GROUND WATER //~0 ~ ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? PERCOLATION TEST PERCOLATION RATE ZO (minutes/inch) Gross Net Depth to Net Reading Date Time Time Water Drop / 3--z~ z? .... Z'~ ~ ,. 3r ,o,, ~, 1~ ~-rr ALASKA i rlUlRonmJ nTAL C0rlTROL SI RUICI $, IFIL -(Jnclin¢¢rin(I $ ~nuironmcnlaJ Studies MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION Soils Report for South Fork Subdivision This subdivision is located on Highland Drive along the South Fork of Eagle River and approximately 10 miles fro the Glenn Highway. It ~onsists of 35 acres, with 14 lots and 2 tracts of land consisting of over 40 acres. Land Forms JUL 2 3 1981 RECEIVED This subdivision straddles the South Fork of Eagle River and encompasses cleared land and native forest. The land slopes toward the river and toward the northwest. It is a glacial U shaped valley with a water fall at the mouth indicating it to be a hanging valley. The slopes o~ the eastern portion are relatively constant until the land drops to the river flood plain. The river valley flood plain had numerous wet areas caused by surfacing of the river underflow. Test boles were not made in this area because of this phenomenon. Vegetation The easternmost portion of the subdivision is at or near the timberline. The spruce trees are sparce, 35-40 ft in height and strongly tapered. Birch is nearly nonexistant thoughout the subdivision. Alder, willows, and grasses are most prevalent on the eastern side of the river. A strip of spruce forest borders the eastern edge of the river. Soils The soils were tested using a John Deere crawler tractor with backhoe. The maximum obtainable depth was 13-14 feet. A wheeled backhoe was tried but could not operate in the terrain. The heavy boulders and cobbles made it impossible to drill with the Minuteman drill. In disturbed areas the soils tend to be cobble pavement with silty sandy gravels to the depth studied. Beneath undisturbed areas, the soils tended to consist of organic soils to one foot and silty sandy gravels with cobbles and boulders to the test depth. Bedrock was encountered in test holes 3 and 5 at a depth of 11 and 7 feet respectively. It should be noted that this 7 foot bedrock depth would easily accept a mound type sewer system and with more testing a deeper bedrock depth might be obtained. Soils in boles 1 and 3 on the eastern side of the river rated at 280 square foot per bedrock. Test holes 2 and 4 were rated at 95 square foot per bedroom. This shows 1220 LUcst 25tl~ Auenu¢ · Anchorecj¢, Alaska 99503 "' (907) 276-1351 that the soils above the ridge, though consistently classified as silty gravels, can have drastically different percolation properties. Test hole 5 was not tested as the bedrock was too close to the ground surface. The land on the west side of the river was tracted due to inconclusive data on the soils. Cc~clusion All of the lots on the east side of the river appear to be potentially acceptable for on-site sewer systems. River bordering lots, 3 and 4 in particular, may present construction problems due to steep slopes, accessability, and the required 100 ft minimum distance of the sewer site from the river. PERFORMED FOR: MUNICIPALITY OF ANCHORAGE ' . DEPARTMENT OF HEALTH AND ENVIRONMENTAL pROTECTION ,IZ] PERCOLATION / TEST ...,$/, ~., 825 L. Street, Anchorage, Alaska 99501 264-4720 / D rge s.s-.e_ , EppX.~'-~ 1( ott :%' DATE PERFORMED: O"~-- /Zf'_~ I' SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20- WAS GROUND WATER S ENCOUNTERED? /~(~ OL P E IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water ~'.~ Drop 3 3 :o~ ~0 ~'q('~ O. 0% COMMENTS PERCOLATION RATE TEST RUN BETWEEN r~,~ S,3-/~ 9.3-' CERT~F~EDBY: L. 7~,¥ PERFORMED BY: f-) 72-008 (6/79) (minutes/inch) (J"~'~' FT . MUNICIPALITY OF ANCHORAGE OEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -- PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 DATE PERFORIVIED: SLOPE SITE PLAN N 3 8 9 10 1t 12 13 14 15 16 17 18 19 2O Gross · Net Depth to Net Read ng Date Time Time Water Drop :2 '. '--% / PERCOLATION RATE __ TEST RUN BETWEEN · '¢7 '-~ FT AND (minutes/inch) '~ FT PERFORMED BY: CERTIFIED BY: DATE: 72-008 (6/79) MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~'~'"~ ~ - (~\ / - ~')L~ HAA# 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) f,ot 2 B]oc.k 1: Southfork Suhdv. T15N R1W Sec. 8 Location (address or directions) Mile 7.2 Hiland Rd, Eagle (b) Property owner HUD Mailing Address River, Ak Telephone: (home) Business 27].-4342 Associated Brokers (c) Lending Institution Mailing Address 640 W. 36th Ave, Anchorage, (d) Real Estate Company and Agent N/A Address Telephone 5¢,3-3'~ 33 Ak 99513 Telephone (e) Mail the HAA to the following address: (or check here r-I, if hold for pick up.) List contact person and day phone number below: Pickup by Enqineer 2. TYPE OF RESIDENCE Single-Family:~ 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 th legality and status. 4, SEWAGE DISPOSAL On-site [] 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. 72-025 (Rev. 7/88) 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 regulations in effect on the date of this inspection. NameofFirm Eagle River Engineering SvcsTelephone 694-5195 AddressP.O. Box 773294, Eaqle River, Ak 99577 Ehgineer's Seail' · ,., 6. DHHS APPROVAL Approved for '-?' bedrooms by Approved ,~<,_ Disapproved Term~ of Conditional Approval Conditional Date The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated 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 DHHSdo not conduct inspections or analyze data before a certificate is issued. TheMunicipalityofAnchorageis not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev, 7/88) Back Page 2 of 2 NOIglAIO S~DIA~g I¥~N~WNO~IAN~ BO~dOHDN¥ ~0 ALI1V41DINQ~ A. WELL DATA Well ClaSSification Well Log Present (Y/N) ¢~/ Date Completed z./,/~,/$ Total Depth ,~ / Cased to 5'9 / DePth of Grouting Static Water Leve! ~' 2 ~ Pump Set At Casing Height Above Ground .~ dj Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line /v To Nearest Sewer Service Line on Lot ya_~- ~ Water Sample Collected by E~,~' Water Sample Test Results ~2~.. ~ Comments ,,1 ~"~ ~I~JNICIPALITY OF ANCHORAGE (MOA) ~U ~,~.~ '1 (] Health Authority Approval (HAA) ~.~__~// CHECKLIST - FEBRUARY 1984 066 T 100 343-4744 Legal Description: ~ If A, B, C, D.E.C. Approved (Y/N) /, ;~ ~:~-, Yield Sanitary Seal on Casing (Y/N) ~ ~ Depression Around Wellhead (Y/N) ~ ~ ; On Adjoining Lots /~ '?/o~ ~ ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole B. SEPTIC/HOLDING TA~. DATA Date Installed StandPipes (Y/N) ,J/ -~ Air-tight CapS (Y/N) Depression over Tank (Y/N) /~ ' ~ Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) No. of Compartments ~' '-~ FoundatiOn Cleanout (Y/N) Date Last Pumped ; for '~/"~ Temporary Holding Tank Permit (Y/.N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line ~ To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course To Building Foundation To Disposal Field Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata /"~ g- '~ Date Installed /~',p-~/ I Width of Field ~ / Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field '~ '~ / Depth of Field Gravel Bed Thickness ~;'~'o Statndpipes Present (Y/N) /~/ -- Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well /'~'> To Property Line To Building Foundation ~ / To Existing or Abandoned System on Lot "~'/'~ ; On Adjoining Lots ~--'~ To Water Main/Service Line ~-z~ ' To Cutback (if present) .~, To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION ,¢~///~t.~ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off'.' Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA gmdehnes m~.effect on,'the date of this inspection. Signed ~~ Eagle River Engine0rlng Servicee Company ~. O. . ......... Date /~'//~'/~' '~ ~a~le River, AK 99577 MOANo. ~-~ Receipt NO. Date of Payment Amount: $ 72-026 (Rew 7~88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 A Eagle River Engineering Services 11940 Business Blvd, Suite //205 P.O. Box 773294 Eagle River, Ak. 99577 694-5195 Fax,694-3297 Date: I©/~ Type of test: [] Well Flow Test [] Septic Test Only IZt Well & Septic '[est [] Other: Meter Monitor Well Tank Time Readinc Level Level Level /,Zr O0 l"Z: o~ :3.?. oS: OPM PSI Remarks MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name'"~O~ b,~,~,~,~,~,~,~,~,~,~ (.,.H'oL.o Telephone: Home ~¢:f~'~-U~-'~(-~ Business Zr-~r~- (c) Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~; Other ~ (explain); (d) Lendinglnstitution ~~,~/~~ Telephone ~4 ~'- ~~ Address ~ ~- ~ ~'/'~ /~ /~' ?~ (e) Real Estate Company and Agent Address ~ ~ T.e. lephone (f) "-Mail the HAA to the following address: S & S ENGINEERING SRB 196X EAGLE RIVER, AK99577 ;,' TYPE OF RESIDENCE Single-FamilyJ~ Multi-Family [] Number of Bedrooms '~ Other 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 attestin9 to the legality and status. Page 1 of 2 72.025 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 dispos~s~, s~e~m~l~i_i~l~:~l~li~a~c_e with all Municipal and State codes, ordinances, and regulations in effect on the date of this insCfe~iCrfr. Name of Firm SR B ]96X Telephone Address EAGLE RIVER, AK 99577 .M, Ay Date DHEP APPROVAl. Approved for Approved bedrooms by Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection tDHEP) issues Health Authority Approval certificates based solely upon the representations 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 requirements. 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. Page 2 of 2 MUNICIPALITY OF A, .~tOt~AGF- DEPT. OF HEALTH & 'MUNICIPALITY OF ANCHORAGE (MOA) WELL DATA I=NVIRONMENTAL PROTECTI~LTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 ~Y 0~ 264-4720 RECEIVED Legal Description: Well Classification Well Log Present~'J~ Total Depth ~' Cased to Static Water Level Casing Height Above GrounC Electrical Wiring in Conduit Separa~tion Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E.C. Approved (Y/N) Date Completed Depth of Grouting Pump Set At Sanitary Seal on Casing~- Depression Around Wellhead (,~' . On AC joining Lots To Nearest Edge of Absorption Field on Lot ///~ · : On Adjoining Lots To Nearest Public Sewer Line /"/~c To Nearest Public Sewer Cleanout/Manhole --'-' To Nearest Sewer Service Line on Lot Water Sam pie Collected by ~ ~ ~'~'G. ~j'-~,~-..~/~l/~/~ ; Date Water Sam pie Test Results .-~',"~-/~; Comments B, SEPTIC/HOLDING TANK DATA / / Date Installed ,.~--/~-~/~.c/4 Size Standpipes ¢~ Air-tight Caps Depression over Tank Pumping/Maintenance Contract on File [Y/N) Holding Tank High-Water Alar,.rlq (Y/N) ------- Separation Distances from Septic/Holding Tank: To Water-Supply Well' /<~):~' To Property Line /~) ? 'Y'- To Water A4aicdService Line Course Comments ~- ,,~'~D/_, 0 ~c~f' No. of Compartments Z Foundation Cleanout<~J~)'. ,Date Last Pumped ~ /"//~'-/'/~ /'~/t-- ;for ~ Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field //,, / To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026~11/84) C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ,5'"-~ Width of Field Square Feet of Absorption Area Depression over Field ~ Results of Last Adequacy Test Separation Distance from Absorption Field: TO Water-Supply Well ///~ / To Building Foundation ~ Lot '/'~'/A.~ Type of System Design Length of Field Depth of Field Gravel Bed Thickness ~----°C'~(~ "~ Standpipes Present(~R~t) Date of Last Adequacy Test To Water Mare/Service Line: .~:~ I ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line /'~ / ¢ To Existing or Abandoned System on ; On Adjoining Lots ::~c.~ ~ + To Cutbank (if pres.ent) /'¢/-~ Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify~h~ ~l~l~l~L/~l~l~d, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~._'~ = ! ?_~.~, Date Compar~A_~LI¢ _B!V___~ _A__K 99~;77 MOA No. Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF ~ALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Da~e ~/~/~ (a) Legal Description (include lot, block, subdivision, section, t~n/~ip, range) I--o7- 1 (b) Location (a~dress or directions) 7, I Applicants Name -~ L~/~Sz/~3C~-3 Telephone - Home Business Applicants Address ~ ~O~ ~,~Z~' ~i~, ~ (c) Applicant~is (check one) Lending Institution ~--] ; Owner/builder ~; Buyer ~--~ ; Other~_J (explain); (d) Lending Institution ~/ p/~--/~ Telephone Address (e) Real Estate Co. & Agent Address <f> Telephone Mail the HAA to the following address: 2. ~ype of Residence Single-Family,P~. Number of Bedrooms 3. Water Suppl~' Individual Welt.[~, Multi'Family ~--~ Other (describe) Community~-~ Publlc~ 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 2] e Engineering Firm Providin~ 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 Approved for 3 bedrooms By Approved .~-~ Disapproved __ Conditional 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 MUNICIPALITY OF ANCHORA/]E (MOA) HEALTH AU~HO~TY APPROVAL (BAA) CHECKLIST - FEBRUARY 1984 '~,I~UNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION !'AU6 1984 RECEIVED Well Classification ~ ~"~'~ ' Well Log P~esent~/N) Total Depth ~O / Cased to ~tatic Water Level Ca§lng Height Above Ground Electrical Wiring in Conduit ~N) Separation Distanaes f~cm Well: 'To Septic/~.~cl~ing Tank on Lot TO Nearest Edge of Absorption Field on Lot If A, B, c~ C, D.E..C. Approved(Y/N) - ' Date Completed ~_/~//~¢ Yield Depth of G~outing. Sanit~y ~al on ~si~ ~) ~essi~ ~o~d ~l~ead (Y~ ; On Adjoining Lots / ; O~ Adjoini.~g Lots To Nearest Public Se~ne ~-~/~ To Nearest Public Sewer Cleancut/Manhole ~ To Nearest Water S~u~ple Collected ~JJ ~.~ ~l~l~ Water Sample Test Res~aJ~ ~ VE,, ALASKA SEPTIC/J~ TANK DATA Date Installed ~/~/67 ¢ Size /~ No. of Cu~a~tr~nts Standpipes(~/N) Air-tight Caps ~/N) Foundation Cleanout ~/N) Depression ove~ Tank (Y~ Date Last P~ged Pumping/Maintenance Contract on File (y/~)'~/t; for Holding Tank High-Water Ala~m (Y/N)~')/~ Temporary Holding Tank Permit (Y/N) Separation Distances f~am Septic/F~ Tank: To Wate=-Supply Well //Z~ / To Building Foundation /~ / To P~opert¥ Line To Water Main/Servig~ Course /3//% Tc Disposal Field ~ '/ To Stream, Pond, Lake, c~ Major D~ainage Comments [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Abso~ptio,n S.t~ata / ~5- ~//~ Type of System ~sign Date i~talled ~/~/~ ~n~ of Field ~ ~ ; 'Width of Field ~' ~p~ of Field ~ / Square Feet of Absorption A~ea ' isolts, ofTest Gravel Bed Thickness ~ # u~/m~ ~ &~O ~ standpipes P~esent ~N) ., /Date of Last Adsquacy Test ,<)~z~ Sepa~a~tion D~n~e from Ab.s=pt}on Field: To ~ildfw F~tion ~ ~ To Existing or ~ndo~d Sys~m ~ Lot ..... ~. ~-.-~ -, ~ ~ ~ ~joining ~ts ~ /~ To "Bfiveway'~ .Parking A~ea, c~ Vehicle Stc~age A~ea . C~,.~=nts D. LIFT STATION Date Installed Size in Gallons "Pump O~" Level at High Water Alarm Level at Tested for Electrical Codes (.Y/N) C~,~nts Dimensions Manhole/accesS (Y/N) "Pump Off" Level at Pump~du~' ] Vent (Y/N) lng Adequacy Test. Msets ~DA ** Check Permitted Bed~ocm Rating A~ainst HAA l~quest ** I certify that I have checked, verified, c~ confc~m~d to all MOA HAA Guidelines in effect on the date of this inspection. Signed KB1/d5/s [Page 2 of 2] 1~7.~ · 2-15-84