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Home My WebLink AboutCAMPBELL POINT BLK 4 LT 3AOnsite File Formerly Lots 3, 4 and 5 Municipality of Anchorage "ouwu LT On -Site Water and Wastewater Section • (907) 343-7904 Page 1 oy. ON-SITE WASTEWATER TION REPORT INSPECTION ®CT E Permit Number: OSP211202 PID Number: 011-262-34 Dwelling: 9 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New Upgrade Name RANDY VANANTWERP ABSORPTION FIELD ElDeep Trench ElWide Trench ❑Bed ound Site Address 6960 WEST DIMOND BLVD ❑ Other Phone Number of Bedrooms Soil Rating depth original grade 907-268-1316 4 GPD/SF JTotal Ft. LEGAL DESCRIPTION Depth to pipe invert from original grad Gravel Gravel depth beneath pipe Ft. Subdivision Block Lot CAMPBELL POINT; BLOCK 4, LOT 3A Fill added above original gr Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES 0 Septic Absorption Lift Station Holding Sewer Total orption area Number of trenches Dist. between trenches From Tank . Field Tank Line Ftz Ft. Well 100,+ TANK A Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER TANK Capacity 1250 Gal. Surface Water 100'+ Material Number of compartments Lot Line 51+ NA HDPE 2 Foundation 101+ LIFT STATION Manufacturer Capacity Remarks OLD TANK DECOMMISSIONED PER UPC Gal. Electrical installed by PER CONTRACTOR; SEE ATTACHED WAIVER REQUEST LETTER Alarm location PIPE MATERIAL House to tank D3034 drainfieldTank to D3034 Installer A+ HOME SERVICES Drainfield EXISTING CO/MTD3034 Inspector GEG AND MOA BENCH MARK (Assumed elevation) 96.67 ft Inspection15, 9/8/21 - Location and description nd TOP OF MH 3b _ 01 _ ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date •. s��o ooh V. ...................Q Q 'A. Septic System Approved Date 1 2 / ,Z6?2 J r Gorrss; �p 9 CE- s 0�� ... [ 014..il•' o Sa _o Note: this approval does not include well permit requirements. #nECC 84��O000',O(N krwa vaivzi 10) -* —1 aAk I v 6,t"/. b V VM veal. PERMIT NUMBER: OSP21120022 DBL1 41.0 1 17.3 DBL2 41.3 1 17.8 MH 42.6 1 19.0 ST1 45.6 1 22.1 DBL3 46.7 23.4 DBL4 .2 24.2 MT1 .2 ].2 25.3 CO2 26.3 PARCEL ID NUMBER: 011-262-34 a d a. a 4 A ¢ NEW 1250 GALLON HDPE GREER TANK WITH DOUBLE CLEANOUTS BEFORE AND AFTER TANK o EXISTING a ° ' HOUSE APPROXIMATE LOCATION OF EXISTING d• m DRAINFIELD; CLEANOUT AND MT a / INSTALLED AT WEST END OF FIELD m Tl 2N R4W SECTION 9 W2SW4SW4 RN :. ....:...... ...� �� -• ,� ENGINEERING�SALES �,CONSULTING 0 0 3701 E. TUDOR ROAD. SUITE 101 'ANCHORAGE. AK 99507 • PHONE (907) 337-6179 • FAX (907) 3313-3246 • WEBSITES—9.messengineering-m , •. .......... ....... 0 PREPARED FOR: PHONE NUMBER: PAGE NUMBER: • ey AeGarness •:' I1► RANDY VANANTWERP 907-268-1316 2 OF 3 �j J,'s� CE -795 ' _ AV LEGAL DESCRIPTION: DRAWN BY: �� •., C,f �rt• •\� CAMPBELL POINT; BLOCK 4, LOT 3A D.J.G. . ••' �'��' TYPE OF WORK: DATE: LICENSE♦/M "" E�, ��' I. -SEPTIC TANK RECORD DRAWINGS 10/1/2021 #AECC864 ��jkliiks* PERMIT NUMBER: PARCEL ID NUMBER: OSP211202 RECORD DRAWING 011-262-34 TOP OF MANHOLE = 96.67 FINAL GRADE = 96.4-96.5 MH1 ST1 IMP TOP OF TANK AT INTLET = 89.51 TOP OF TANK AT OUTLET = 89.49 INVERT OF BUNG AT INLET = 88.77 INVERT OF BUNG AT OUTLET = 88.64 NEW 1250 GALLON H.D.P.E. SEPTIC TANK t 9 ........... #� ......... p............ 0 ENGINEERING,, SALES%CONSULTING� �� .�, �� ,., 3701E TUDOR ROAD. SUITE 101' ANCHORAGE, AK 99507 ' PHONE (907) 337-6179' FAX (907) 336-3246' WEBSITE:—g—engin-ring.— , . z.. ..••• •• ....... ...... 0 PREPARED FOR: PHONE NUMBER: PAGE NUMBER: ♦ �n ffrey . arSS RANDY VANANTWERP 907-268-1316 3 OF 3 ♦jar C -77,53 '•� LEGAL DESCRIPTION: DRAWN BY: �� •'•. j (� \� CAMPBELL POINT; BLOCK 4, LOT 3A D.J.G. ♦♦♦ ...4•''P�,� " E OF WORK: DATE: LICENS TYPE♦�� "" E�,�♦♦ SEPTIC TANK PROFILE 10/1!2021 #AECC884 V El lENGINEERING G 1®1 1®G AeroCell ENGINEERING � SALES, CONSULTING _;,•.R �. x s � ,. p September 29th, 2021 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Ref: Septic Tank Upgrade at Campbell Heights; Block 4, Lot 3A To whom it may concern: During the installation of the new septic tank at the subject property, it was conveyed to GEG by the contractor that the septic tank could not be installed 5'+ to the drainfield due to the location of the private utility lines (that serve the subject property). Based upon this fact, GEG contacted the MOA onsite department and spoke with MOA onsite employee Deb Wokenfuss to discuss the proposed location of the new septic tank. It was determined at that time that a waiver would be granted down to 3' if there was no effluent and/or weeping of the drainfield into the tank hole during excavation. Per A+ Home Services there was no effluent that was "backflowing" into the tank hole during excavation and there was none noted by GEG during the top of tank inspeciton. A+ home services was able to maximize the separation distance form tank to drainfield to approximately 4.5' (physically confirmed by GEG). In short, we are requesting that your department issue a variance from tank to drainfield down to 3 feet. If you have any questions, please contact us at 337-6179. Thank you for your assistance. M.S. 3701 E. Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259 Phone: (907) 337-6179 * Website: www.garnessengineering.com a YARD LIGHT # SEWER PIPE AS�BUIL TSURVEY f " - *301 NO CORNERS SET THIS DATE I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY LOT 3- A, BLOCK 4, CAMPBELL POINT SUB. ( PLAT 82-125) ANCHORAGE RECORDING DISTRICT, ALASKA., AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN I TO SHOY ANY THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS 'rS; A NP IS EXIST OTHER THAN NOTED. 'CEL INES - DATED AT ANCHORAGE,ALASKATHIS 28TH DAY 0 F '0 r SHOUN SEPTEMBER 1 2021 I -1.----,.-- 11-1 -11 --1' — r rr.iJ Y1111W.Lfvu ^Ill- lwv/ /v UL U,3r-v /V vr-lr-nlllyr- PROPERTY LINES OR POSITION APPITIONAL IMPROVEMENTS. ANY APAUTAII.- V1461VAI MrPrIlAl MAY BE ADDPAYrNArf- Al/f- 'rA f-v1-r-rf- vr- )IYVW AIVIIIVII iLr-. Li/) I Ir A I fr L lvv Iufl T-LlvV 93e9 GROVER DRIVE ANCHORAGE,AK 99507 345-5513 15052, FB 213-34,217-48 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP211202 Work Type: SepticTank Upgrade Tax Code Number: 01126234000 Site Legal Address: CAMPBELL POINT BLK 4 LT 3A G:2322 Site Mailing Address: 6960 W DIMOND BLVD, Anchorage Owner: VANANTWERP RANDY L Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: Effective Date Expiration Date Lot Size in Sq Ft: Total Bedrooms: �l»cnt o� I r UC.I)FlI'Clllelli 6/10/2021 6/10/2022 76862 ❑ Disposal Field Q 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 Special Provisions: Locate the beginning of the field to confirmthat the 5' separation between the tank and field will be met. Received By: Issued By: Date: Date: 4 '`- 'f`�? 'ANCHORAGE i 13 gay c a 14 111 Development Services Department �' % , 4 �' Phone: 907-��, 3-790 On -Site Vllater & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 011-262-34 Property owner(s) Randy Vanantwerp Mailing address 6960 W. Dimond BLVD *Anchorage, AK Site address 6960 W. Dimond BLVD *Anchorage, AK Day phone 907-268-1316 Legal description (Sub'd., Block & Lot) Campbell Points; Block 4, Lot 3A Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank 0 Upgrade Z (D) ❑ Holding Tank ❑ Renewal E]Duplex Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: N/A 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: Q2 5 Waiver Fees: Date of Payment: I % / d D Date of Payment: Receipt Number: 6 a'11 5 (g Receipt Number: Permit No. 0-5 d �2, Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211202, Deb Wockenfuss, 06/10/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211202, Deb Wockenfuss, 06/10/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211202, Deb Wockenfuss, 06/10/21 fl~ MUNICIPALITY OF ANCHORAGE ~ 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 MAILING ~DR~SS .EGAL DESCRIPTION' 'Z~ ~ ~ ~ Top of tile to finish grade ~ / Material beneath tile ~ / ~pt~on area ~[ Well Building f~ndation Nearest lot line ~ DISTANCE TO: ~ ~ u~{~ - Absorption area(s) ~ DISTANCE TO: pipe MATERIALS INSTALLER REMARKS P, O. Box 4-1224 * 13lOC Inte~rmtional Airport Road {907) 2744611 ANCHORAGE, ALASK~ 99509 DRILLING LOG Well Owner " Use of Well D~,~,~ ~'f~ Location (address. of: Township, Range, Section, if k?~own;. . or distance. .- ...... main road Lot 3A Rln~-Ic ~ C.~.,~?;I~olI 'Pn"bnt" Size of casing ,q" _ _nepth of Hol~ 'I'~ ' feet _..Cased tn _~_qg_ O feet .... '~;:, Static water level 3S& ft. ~ha~.~ (b~.low) land surfac~. Finish of well (check one)' open'end ( x Screen ( );~ Perforated.( ~.! '~' ..... ' Describe screen or perforation ' ~'*" - - · ~ · ~;i.;-,'.~ Well pumping test' at 1 fl gallons 'p~t~ of drawdown from static leveL,.~ 3~ ' Date of completion '~"" '~" ~1 r~°.9 f., ,' ,-' ':' .'. (minute) for 1 hours with 100.~. WELL LOG ); Depth in feet from ground surface Omo 2 ' 2 mo 4 · 4TO 190 - ?I~TO ?80 2a0TO 322 ~TO 353 .TO Give details 6f formations penetrated, size of material, color and hardness Casing" ~tte~c-u~ .-,-..?~ ;: '. .,r. ''~.--' '. ''[' ' '--': ~'--.--, . Grty silty.~}nd;'~.H20 ..}e~[~..:~.ng coat,er to frs-ell · l., '. .... ~, ,,, *. ," ..... -' :"~"'-~:~."1, Crav silt- s~nd,~20 B~rf~- ...... ~': TO ____TO TO TO. TO .TO 3 -- CONTRACTOR PERMIT NO. f'lLI I'.i I lC I PFIL I T4-' OF Fll'.ICH~-~RI::IGE DEPRF, TMENT'-' C~HERLTH RND ENVIRONMENTIRL F"=~TECTION 825 "L STREET, ANCHORIRGE, 264-4?20 0 ~----'~;- I TE ~'~,EI.WE F-." PER£~I I T IRPPLI CRNT 80B GOULD LOCIRTION SRND LRKE RRER LEGRL L,x~ 8 4 CIRMPBELL POINT TYPE OF SOIL IRBSORPTION SYSTEM IS: TRENCH LOT SIZE 276-0400 SO,URRE FEET MRXIMUM NUMBER OF E:EDROOblS = 4 SOIL RRTING <SO, FT?BR>= 125 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: DEPTH= :!_4 LEt~IGTH= 42 GRR',.-'EL DEPTH= THE LENGTH DIMENSION IS THE LENGTH <IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETHEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION <IN FEET). THERE IS NO SET HIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETHEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). RE~.I_I I RED ~EPT I C TRN~( --<:;. I -~--"E= '~ 25¢4 GRL_LONS PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO iNFORM THIS DEPRRTMENT DURING THE INSTRLLRTION INSPECTIONS Of RNY HELLS IRDJRCENT TO THIS PROPERTY IRND THE NUMBER OF RESIDENCES THRT THE HELL HILL SERVE. T&-IO < 2 > I t-~_'_'_'i;,P EC T I 01'-~$ RRE REQL~ I REE, BRCKFILLING OF IRNY SYSTEM HITHOUT FIHRL INSPECTIOH RND RPF'ROVRL BY THIS DEPRRTMENT HILL BE SUBJECT TO PROSECUTION. MINIMUM DISTRNCE BETHEEN R HELL RND RHY OH-SITE SEHRGE DISPOSRL SYSTEM IS 100 FEET FOR IR PRIVRTE HELL OR :L50 TO 200 FEET FROM R PUBLIC HELL DEPENDING UPON THE TYPE OF PUBLIC HELL. MINIMUM DISTRNCE FROM iR PRIVRTE HELL TO R PRIVRTE SEHER LINE IS 25 FEET RND TO R COMMUNITY SEHER LINE IS 75 FEET. OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. PERM I T E~-'P I RES DECEr'IBER 3"1.. ~LgE:2 I CERTIFY THRT l: I RM FRMILIRR HITH THE REQUIREMENTS FOR ON-SITE SEHERS RND YELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE. 2: I HILL INSTRLL THE SYSTEM IN RCCORDRNCE HITH THE CODES. ~: I UNDERSTRND THRT THE ON-SITE SEHER SYSTEM MRY REQUIRE ENLIRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN 4 BEDROOMS. SIGNED' RPPL ICRNT DOB GOULD V4. 0 PERMIT HO. RPPI ICANT BOB GOULD MUr-4 I C I t RL I T~" OF Rr-JCH~,RRGE ~ DERRRTMENT OF HEALTH RHD ENVIROHMENTRL ~PROTECTION ~~ 825 'l' STREET, ANCHORAGE, AK. 9~vO1 ~ ~ ~ ~ 2~4-4720 ~ ~ 0~--5 I TE ~E[4ER PEAr'11 T ~~~ TRENCH LOT SIZE 108000 SQUARE FEET ..~ / IE]:L.3D I00 FEET UPON THE MINIMUH TO R CC OTHER RVRILRE~LE TO r,IRXIMUM NIJMBER OF BEDROOMS = 4 ~OIL RRTING FT?BR>= THE REQUIRED SIZE OF THE SOIL RBSORF ,: DEPTH= ~_,.14 LEI'-IGTH=, ..?\ %.EL DEP~= THE LENGTH DIMENSIOH IS TH~LENG~ ' ~<IN {ET> OR THE TRE"~cH~RDRRIHFI~LD.~ THE DEPTH OF R TRENCH OR PI~ IS ]IE D~ ~r'~CE BETHEEN T~RFRCE OF T~' GRO~HD AND THE .,OI~OM OF T~SEXC, :RT~ (IN FEET). THERE I5 NO SET HID~H FOR TR~NCHE ~/ . THE GRAVEL DEPTH IS~THE~NI~JM [ ~_OF GFRVEL ~TI~THE OUTFR~L~F~ INSTALLATION IN~PECTI~r~$ OF AHY~HELLS RDJRC~HT~HIS ~pE~:T~RND THE BACKFILL G OF ANY SY~TEe~OUT FIt.~L~N~ECTION Af~PROVRL BY THIS DEPRRTM, HILL BE ~UE,ECT TO PRO~EC~ --~ MIHIMUM ~NCE BETH5 ~N 8 HELL RHD.RNY OH-SITE~GE DISPOSAL SYSTEM R PRIVATE HELL OR /2~ FEET FROH R PUBLIC HELL DEPENDING OF PUBL', ~ HELL. NCE FROM R F'RIVR~ _L TO R PPI VRTE SEHER LIHE SEHER _INE ET. RPPI RHD CONSTRUCTIOH DIAGRAMS ARE PERF'I I T E DE/~EI"IBER ~-1~ '1982 I CERTIFY THAT ~.~.,~ i: I RM FAMILIAR H ,THE REQUIR=,~-,,,S FOR OH-SITE 'SEHERS AND HELLS RS SET FORTH BY THE MUNICI ITY OF ~ORRGE. 2: I HILL INSTALL THE SYSTEM I~RCCORDRNCE HITH THE CODES. ~: I UHDER5TRND THAT T~O~ITE SEHER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDEHCE IS REMODELED~LUDE MORE THRH 4 BEDROOMS. , ...... RFFLICRNT BOB GOULD :. ISSUED BY .... -- - V4. 0 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTtt AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchor,ge, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~'} SOILS LOG r-I PERCOLATION TEST 1 2 3 4 5 6 7 8 9- 11 13 OATE PER,ORMED= SLOPE SITE PLAN WAS GROUND WATER ENCOUNTE.EO, IF YES. AT WHAT DEPTH? 15 16 17 18 19- 20- Gross Net Depth to Net ~Reading Dale Time Time Water Drop ·, PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT PERFORMED BY: ~. ~. CERTIFIED BY: 72-008 (6/79) ' co I? I? r— CDC) CD W, LO N O N a� c O .Q x W 0 O O I NT C''? N N C) a) U (0 N O LO Q � 0) 2- -J O U C J Q m z J O °o 0— z J O Lu m 0 U o c � O 2 U U) a) 0 � a c� a) J (1) J N E O O a� 071 0 A N (D O L O cn .N C a) E O ., 4-- 0 0 CL 7 r Y L U) a a O 3 a) m a� •� = Q O cn O X E ~ 0 U L O O p 0 C .N v •� a) O U)i> ?' C O. .N Q j O 4� V •r o a) a D > > o N N C O Q U =goo12 (n a N 0 3 Q- .N 3 z Q N > C O_ -0 O O M 0 i L . Q o Q Q N (n O v a� X 0 C (C L O (n � U) 4— U) .Q 4Z �� .Q O cn4.1N fn y E M O Q� O Q 2 > QO cn O Ln 4 QJ Lo.(n QL U a) L L O O > a) +-' 0o c Q a) N -c o (1) O (n FF- Q - Q v _ (CZ O Y c� (a U Q I— O o w o = c C) w G) CD I— N cy') ce) C ) C7 00 rn rn Z C) 00 C) Q CY) N O N L Z C) J Q � w Z v d TMI Z J 0 0 a. z w 0 U o cTfl c VJ O cna L U N N (D a� 70 cu Q) N Q) m C: 0 a 0 O U U a) C O a ca 59 A T LL a) > NO O O a) a) d N O a) N — (n (6 a) O m > N a U CL •Ql L ❑c.) cB :3 O O73 _ a)Q U U cn U) C ❑ N w O E v :3o U) ElC' ani U) 0) d U ) cu _ Ll C O Q) (1) -a 0 LL > M a) c6 n0 - C �/� VcI 0) V ^` a) C W > L O a) L O U m a m. a) a) � _� ❑ a) n c _ ca 0 a) Q � u - O > fn U O N R a. � O0. c a) El Ela 41 �o UO -o ❑o ¢ ElE� c = w M w ❑ _0 Oa. cn Qa) U) c U) cu -i a) aa)i >, E w w ❑ a) w =3 U w w H to FLaa) L L N Y Z o Q �M > a) 0 H O O v v cn a a P O ami T >, w CO > CL `m O F cn Q a M ate) N M tt ui co > W m Z T LL a) > NO COSA Checklist_June 2022 COSA Checklist Legal Description: Parcel ID: 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) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. 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) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist_June 2022 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’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ 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 Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F.ENGINEER’S COMMENTS 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 Phone Engineer’s Printed Name Date C&M ENGINEERING CHARLES BALZARINI, PE 9/5/24 �* r� 0 (3) rn rn M M nX O Ql LL uj 0 O V Z Q LL i� ® l a � � a Z o LU :N U 41 � v � Q i d w M 0 C) S � v G w V ( r 6 N w c Ln C O ►- LIO Cw � O C B a � � O v J LU 'rnLU 3 0 0 v Q E x4- ca E _A X CO O 4 L 4 ca O O U O Q M 4-J0 O i bA O u E r�, rH ow�a C O C wA = '_^ m 4-�: V) v a u W Q C U Q1 N in 4 � m � Y .L - 0 O C -0 v v �- N N a O LnO S > +� v4� v t }' S boLn Q1 Cli 4J }' N O v s 4- M N N C d o m d m m O O O '> N V iLi a) U ami 4- N p _U O V)m co d O +j d1 t N v t 4-i +N+ cn O ateJ m C _E N Q u Ln- cn — Q1 >_ Q ai Ln a 4� 0 0 O w N �- to O U v � C u N 0 Ln 4� O c� `n 0- CE C o O woU t O " N > E 4- Ln tin a N f0 > o 4i aJ +� Ln C i NO > Ln Ln 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORI'I'~ APPROVAL FOR A SINGLE FAMILY DWELLING -3,/ 1o GENERAL INFORMATION Complete legal description LoG SA; 8Zock 4: ¢;mpSe~t. PoZ)~C 3. Location !site address or directions) 6960 ~1. Di~ond 8~ud. Anchoraqe, AK Property owner Robot Gou.~d Mailing address C/0 ..T~zck Wh.~Ce Co. 3201 "C" St/[¢ct Day phone Su.~. 100 Anchorage, AK Lending agency Mailing address. Day phone Agent B~bct/~ Rcz~e~//./czck W~J.t~ Co. Address 3201 "C" S:t~.e~C Su. CCe. 100 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: Individual well XY, X Community well Public water Day phone AK 99503 565-5500 O_ o tv' 99503 e NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAl' Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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 invest, i.,qation 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 $ & $ ENGINEERING Phone ~" ~/'-t - '~- c7 "7 ¢! ]7034 Eagle River Loop Road No. 204 Address E~,ale~7,.,./ ,7/__ 7~Rlver ,AI~'~ a 99~..~7"~/, ' /' 6. DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: 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 requiraments. 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. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street. Room 502 · Anchorage. Alaska 99501· (907) 343-4744 Health Authority Approval Checklist /:7,5/; q~.,,, p,~e// A. WEIA., DATA Well ly~ To~ Date of test Static wat~ I~vel Well production WATER SANIH.~ I~SULTS: Co~ro..0 Ni~ ~ ./O ~ ~ B. .~EFTIC/;iC.L~iC~TANK DATA C. AB~ORI~ION l,',~:t.n DATA Length ~ 3 · Width q~- ''/ O~l ~ ~l~ pi~ ~ ~on ~ ~/~ ~o~to~ Tu~ p~n~Y~ R~ ~ ~ ~don field ~om ~ (~.); O R~d d~ O (ira.) ~ut~ h~: ~ O Soft rating (g.p.dJ~or t~Axlnn) /.~,5- G ! Total depth Depression over field (Y~) ,~O For ~/ bedrooms Immediately after/$/° gal. water added (in.): Absorption rat~ = /3,,,-'~/~° g.p,d. Peroxide treatment (past 12 months) (Y/N) z.~ ,o ~'~ o~.,~ If yes. give d~re D. LIFT STATION Date i,staflcd Size in gallons lVianhole/.Ac-,a~s (Y/N) ~Pum~Pump off" level E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: SepticJ~..r,:~as-tankon lot / OO ~ -~- ; On adjacent lots Al~oq)fion field on lot / ~o · .-/- : On adjacent lots P~blic sewer ma~n /O~ · -~- Public sewer mn n hole/cleanom ~/scpti¢ s~vice linc -~ ~' '-]' L~ station -- SEPARATION DISTANCES FROM SEP~IC~..'~'...D~;~ TANK ON LOT TO: Wat,'r maln/s~vi~ lin~/O '~. Smfa~ wat~'/cl~inago / O~' "~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FI~I J~ ON LOT TO: Building foundation / ~ ' 7t'' Water main/~vi~ line / Su~ace water / 0 0 ' ~ Driveway. pa~ing/vehicle storage area / 0 Curta/ndrain cf~, ,~'~.t ~,.,o',r,~ W¢llsonadjat~*nt Io~s /~0 · ~ Propcrtyline F. ENGINEER'S CERTIFICATION I ceftin, that I have determined thrufleld inspections and review C Co of Municipal Rev. 8/95 OSS: haa.wk.doc Waiver Fee S Dam of Payment Receipt Number ' APPLIC..NT FILLS OUT UPPER HAt"'~'ONLY Property~wner Robert ~. and Edte H. Gould * Phone Malllng/.,dre~ 4792 Business Park Boulevard. Anchorage. Alaskaz~p.~?503 ;62-2400: /,'/ Address Zip Code Lend,ng~.s.~t,o. First tlational Bank of Anchorage Phone Address 646 West Fourth Avenue, Anchorage, Alaska z~pc~99501 76-6300 Realty CO. & Agent Phons Address ~{/A Zip Code Legal Descrlptlon Lot' 3A. Block 4. C~cmpbell Point Subdivision StreelLocati(~ 6960 West Dt~nd Boulevard, Anchorage, Alaska Type of J~eeldence ; · .; ~ . ~. ./ ~ J . .... : t ~ /~ Single Family Multiple Family NO. of Bedrooms '~ [~ Other Water Supply n[~nclvldual ATTACH W~LL LOG. A we41 log Is required for all wells drilled since June 1975. mmcmlty For wells drilled prior to that date. give well depth (attach log If available). [~ Public Utility ~. Sewer Disposal 982 ~/Indlvldual Year Individual Installed: [:] Public Utility When Connected to Public Utility: C] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Fle~d Notes: ~ IeKUNIC1PALtTY OF ANCHORAGE _3 ~ DEPTo OF Hc-^till Ei,.tViRO,.X~,A= NTAL pROTECTION JUH 2 3 RECEIVED ( ) DISAPPROVED , ,CO.D,T NA APP.OVA" L (-' Boils Rating Dale Sewer Installed Well To Absorption Area Well Log Received w.,,,oTank S.p,,cT..,S,,.