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Home My WebLink AboutFISCHER BLK 3 LT 1AFischer Block 3 Lot 1 A #015-292-04 tMev UDW//IUi Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231112 PID Number: 01529204000 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New Upgrade Name PRICE GARY ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 5200 E 100TH AVE ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 646-4661 3 GPDISFJ Ft LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft Subdivision Block Lot FISCHERBLK 3 LT 1A Fill added above original grade Ft. Gravel length Ft Township Range Section Gravel width Ft. Beds: Number of Lines - Distance between lines - Ft SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sevier Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft' Ft Well 100'+ na ' na 25' + TANK ®septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal SurfacevJater 100'+ I na na Material Number of compartments Lot Line 10'+ na ! na NA PIStc 2 Foundation j 0'-}- na ( na LIFT STATION lvlanuiacturer Capacity Remarks Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank D3034 drainfield Tank to D3034 A Drainfield CO/MT D3034 Inspector NorthRim Eng. BENCH MARK (Assumed elevation) 100 ft Inspection 1-7.6/14I23 dates: 6,'15123 description 2'�.3rd6116/23 E�iona 41h ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date A*OF q V 144 o* :49TH.. f.�............. Septic Syste Steve Eng �u O®� / Approved _ !�/ lr�//,� Date CE -6256 Air Note. this approv l does not include well p Q permit requirements. % S tMev UDW//IUi T r <' 0 x rTl 4 � N Z3 rTl� N o v Nj c`Oo 0 Z v7 Cil V) tj V)Z rD V o rD f 9rDu o ��.,.►�� •��: �1 AW STS yI C+ o C+ o C -- 3 - v n 3- n o J ." n �cD••. � �lll �o ��0 p o; N� ru" eA C F- -9 h u D D ee f d fT1 D IT1 Q z T 3 D � F9 F1 F- -U Z7 0 n o H O r D z _ S 70 J D FTI CD \ � 0 W C 70 --! d waSoq-!1!q- ,OZ m m 0 II W o Q V)V) n � —4 O fU I,— W W FI) Ul W ,-D ro r cn �T7 v z�n �a O -5-5 \ o<+0r0 o -0 rD ��(DT- Q-5 -9 <+ h, --A o n`< w 3 go= = t) V)od-�) MD0� rD n o ro n V)Q V) o- <+:5 M 3 Q <+ 0 ry 0 O D ZY Ln O C+ O N n S n m� Q C o C3 0 -0 :3 reo 0 r0 ,D CID w co .o n ro Q O C, C+ Ln �o n s r N o rD �i- D -5 rD () 3 o ro Q O oo < o m hi fl D C1 � -0 O c Q ro Q Q O ° :5 ppp �� 00 < Q O D ZY Ln O C+ O N n S n m� Q C o C3 0 -0 :3 reo 0 r0 ,D CID w co .o n ro Q O C, C+ Ln �o n s k— I bo 0 N p Cfl O O i EAST 100Th' AVE. OF 49 TH SA4ZK SHANE A. HOLT : m �4P LS -6914 44��°Jes sione� �'ocao ASPHALT DRIVEWAY(LOT 1 B) N 89057'40"W 299.53' THEINFORMA TION HEREON IS FOR THE USE OF ENDING INSTITUTIONS SPEOFICAIL Y TO SHOWANY CONFLICTS BETWEEN EXISRIVG STRUCTURES AND PLAI TED LOT LINES AND70R EASEMENTS, 'ANO IS NO T TO BE USED FOR POST TONING ADDITIONAL STRUCTURES IMPROVEMENTS OR FENCELINES EASEMENTS OFRECORD, OTHER THAN THOSEAPPEARING ON THERECORO PLAT, ARENOT SHOWN HEREON (UNLESS INDICATED) NOTE. FENCELINES THA TMA YAPPEAR ON THIS DRAWING ARENDT TO BE USED TO DETERMNE PROPERTYLINES OR POSITIONADDITIONAL IMPROVEMENTS ANY PA VING SHOWN HEREON MAY BE APPROXIMA TE DUE TO EXCESSLIE SNOW AND70R ICE �Wr 0 0 r w Op O O m AS -BUIL T SURVEY I" = 40' NO CORNERS SET THIS DATE I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY LOT 1A BLOCK 3 FISCHER SUB. ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE,ALASKA THIS 20 TN DAY OF , 2023 125-67 232-21 HOLT LAND SURVEYING 9309 GROVER DRIVE ANCHORAGEAK 99507 MUNICIPALITY OF ANCHORAGE �l»cnt On -Site Water & Wastewater Program �o� t i, ,; C 6)0 Development Services Department �� 7 J Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 01529204000 Property owner(s) PRICE GARY Mailing address 5200 E 100TH AVE Site address same Day phone 646-4661 Legal description (Sub's., Block & Lot) FISCHERBLK 3 LT 1A Legal description (Township, Range & Section) Lot Size 44,997 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) 0 (w/wo AD U) Septic Tank Q Upgrade 0 Duplex ElHolding (D) Tank ElRenewal ElMultiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: 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:.86U Waiver Fees: Date of Payment: Receipt Number: Permit No. 25/e2 3 11 / Z Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc SteveEng.com Fischer B3 L1A SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: The current septic tank has failed- the seepage trench still functions. This lot is close to an acre and on private water well. No adverse impacts are expected from tank replacement. Easements are depicted on the lot. The slope is indicated in the area of the septic system. No conflicts to neighbor properties. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. New 2- compartment, 1000 gallon septic tank. Watertight couplings on inlet & outlet. 5 minimum between the tank and trench. 5 to property lines & 10 to house. 4 of cover or insulation is required for tank; an equivalent of 1 insulation for 1 foot soil cover. Tank & solid pipe must be set on well compacted, stable soil. No large rocks for tank bedding. Plastic/fiberglass tanks require special bedding per MOA- sand or pea gravel. 4 diameter cleanouts with airtight caps are required 1 to 4 from foundation wall, prior to any 90 degree bend in 4 inch line, in 2 nd tank compartment, and two adjacent opposing cleanouts between the tank and the absorption field, not more than 10 from the tank positioned to provide cleanout access towards the tank and towards the absorption field. Manhole Riser required in 1 st tank compartment. All cleanouts must extend to at least ground level. In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron. Insulation must be placed over any pipe installed under driveways or parking areas. Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, Sewer Service Line is minimum 2% slope. Septic Tank to be pumped every two years or when required. Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231112, Deb Wockenfuss, 05/24/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231112, Deb Wockenfuss, 05/24/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231112, Deb Wockenfuss, 05/24/23 an Municipality of Anchorage Page o1 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: �� 1 \� 11`�� ` PID Number: r—"\ \ `�N —Ma a - InLA Name: Wastewater System: ❑ New �c6 t u .1�6pgrade Address:ABSORPTION FIELD Phone: No. of Bedrooms: p Deep Trench sJhallow Trench O Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating Total Depth from original grade: I.2 GPD/Sq FI Lot: Block: Subdivision: Depth to pipe WhomOriginal grade: Gravel depth beneath pi e S FI FI Township: Range: Section: Fill added above original grade: Gravel length: FI Ft WELL: O New O Upgrade Gravel width: Numberoflines: Distance between lines aA Ft I Ft Classification (Private. A.B.C): Total Depth: Cased To: Total absorption area: Pipe material: C\s/6 1Z8S FI. Ft. Co SO Ft Tye Driller: Date Dulled. Static Water Level. Installer: Date installed: ,� 1111-1-42, Ti Ft. aaldG, - ZZ -O)Z— Yield I Pump Set at: Casing Height Above Ground-. I TANK GPM Ft. 1•S Ft. SEPARATION DISTANCES Xeptic ❑Holding ❑S.T.E.P. To Septic AbW1Ptl0n 1.01 Holding ebl,cNmate Manufacturer: Capacity in gallons: From Tana Field Slauon Tank Sewer Lines 4 VIF F 10=5 1 I Material: Number of Compartments: Well 101 II � � `.nG� Z Surface LIFT STATION Water Lot Size in gallons: Manu Line Foundation23 1 "Pump on" level at: "P I" level High wstar alarm at: Curtain Pump Make el Electrical Inspections performed by: Drain BENCH MARK Remarks: Location and Description: {bo.01 OEG T, o. S6v_ 3 0 Assumed Elev bon: Art a ORIC. In s ENGIV&�iAL SOF A4 ' 1i:a11 ,W 4 9,tHr *.: performed by: Vs. HA Dates: i. .0. .... g....9:: oS-22-9tInspections 2nd 9,-2z-�2_I ... .....ee if V. At7sAUN !AA p/ Department of Healt d Hu a rvices apg�y al ( C/ I'<k � • CE-1393 �� ••....•••.;V �� Reviewed and approved by: Date: 72.013 (Rev. 9/91) MOA 25 7 n ( o' KL/NGLEZ St 6�- e Ab. F°A4 TAN r*h;:49-TH *0 do Nocl-o51 O" 141P.%8 ••: ••........ ••••• • PvU'+O �'Ia ODOR li Y. A C -1393 - d C/;le •....•• �� ' FSN• 6wacH.ue� \ � • �. _ I W TSP op orLe I; '}"_ y Y :1 J 4.1 :. ,•leu.. N 4r U dS ki ri J bttculukx,ss. v' 0 i ✓ n h.� aS0 � J YVELA- w d d 4 'xt Sc • o � t_oT IA y I RECEIVED u � i o3 as I Ftu.�C�iB°PatGsR-r . SOo=o4'• 4t3 G 1 So 05 •'� I.:OT t G nicipalit of Anchor Health Human Se )-or-E> polarconsult alaska, Inc. 1503 West 33rd Avenue • Suite 310 ANCHORAGE, ALASKA 99503 (907) 258.2420 Fax (907) 258-2419 JOB wt " "k-"2 SHEET NO. 3 OF 'El CALCULATED BY DATE E'' 2$ CHECKED BY DATE SCALE OO m'rpAlw74. � 4OYAdKK4A! wmf PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW920241 DESIGN ENGINEER:POLARCONSULT OWNER NAME:WILLIAMS LARRY R & LAURI OWNER ADDRESS:5200 E 100TH AVE ANCHORAGE, ALASKA 99516 PARCEL ID:01529204 LEGAL DESCRIPTION: FISCHER BLK 3 LT LOT SIZE: 44997 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 IA THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED: 8/18/92 EXPIRATION DATE: 8/18/93 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: 1. 2. OLD TRENCH WILL BE ABANDONED IN PLACE. ENGINEER MUST VERIFY INTEGRITY OF EXISTING IF TANK IS PERFORATED, IT MUST BE REPLACED PER AMC 15.65. I '% RECEIVED BY ISSUED BY SEPTIC TANK; OR REPAIRED p-alc-ri2• IL9 yDc -10 Cc ncl�ati'2 DATE • b /7 / -Z DATE • 9- / y C/ y No0-o5�• M Pw� soh ¢ueea (Aad '\ PrDfkri �i �II � O\esu l,' •:}�^LtP.AYttt. V21Y�iWAY ''II I=Nceo�tt�5 5' 4v CA r -�. e,,,% c� ✓ Y' N Q�� • "�' N'a oC/• 1 ' / �••e �(� 54.1'. tj L PT, .11�- F M i Z So.S ?�44 7_ di Q IA r •.,-�r,�eN t �0 }� LOT 1 A v� 0 Soo" -o4'• 4t G I SO Cy •�� pAr 102 V. 1u CE•13 •'I. (Aad '\ PrDfkri �i �II � O\esu l,' •:}�^LtP.AYttt. V21Y�iWAY ''II I=Nceo�tt�5 5' 4v CA r -�. e,,,% c� ✓ Y' N Q�� • "�' N'a oC/• 1 ' / �••e �(� 54.1'. tj L PT, .11�- F M i Z So.S ?�44 7_ di Q IA r •.,-�r,�eN t �0 }� LOT 1 A v� 0 Soo" -o4'• 4t G I SO Cy •�� pAr 102 c .. 0 A \ { MUNICIPALITY OF ANCHORAGE 1 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 2644720 ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE a a $�j'2 L NEW O UPGRADE MAILING ADDRESS /-/ G LEGAL DE CRIPTION LOCATI N NO. OF BEDROOMS t) DISTANC O: Well Absorption ares , Dwelling PERMIT NO. Y QManufacturer F Materia No. of Comparugents bL N Liq. ca acity in Irons IF HOMEMADE: In ide len Liquid depth t3 Y DISTAN Well Dwelling PERMIT NO. =?HMaotrfSctumr Liquid tapaci G W m DISTANCE TO: Well �O Foundation Nearest lot line let t L O PERMIT NO. -7qO 7 O � Z Z F ? W No. of Pries Length of each 1!98 0 Total length of lin Trench widt inches Distance betwee lines Q/ f 0 Top of tile to finish grade Material beneath tile inches Total effective bsorp ti W Length Width Depth PERMIT NO. ih W� T pa of Crib Crib diameter Crib depth Total effective absorption area W a D Well g oundation r e A Cl a Depth Driller Distance to lot line *.. PERMIT NO. Q'7 C DISTANCE TO: Building foundation Sewer line Septic tank. r.— // Absorption steals) O r OTHER PIPE MATERIALS SOIL TEST RAf ING F INSTALL C REMARKS C s nor i P , APPROVED DATE LEGAL X79 -7 72-013 (Rev. 3/70 1 `..i r r�� n*rr.��.. wf „4SsU alt f' '�, yin •,: i,"tt dF 4 v.,e.,t3�� ^� �j,e� �ti 6n v-. S"'; ..a e , ,.,, iy• l e • Tr+ i''� U c :-� .� L 1 1. Certified Well For.....&.beit...YiilliB.M.5 .......................... ' Location.. Lot._la..Blk... 3 •••-Elsher Sub. Date completed...l4ox,..2Q, ...1 7.8.. -4 Depth of we11.....2:8.5 a ., . Sae of casing .6.".. .:_ "• Distance to water..... 26Qt _. .. .� Distance to water while pumping ..2E-4 s ....._._ . .... ....„.at rate r of ----- --- ...gallons per hour. Tr i I certify the above true and correct, 1 C �1 �E ✓ 2��v.. 11 _ f�1 _ ”. -Driller DOTTEN DRILLING CO. John's Road SPENARD, ALASKA We advise you to attach this certificate to your deed. [ =t ��,�7^�``.'1'�-.i �, ^+.._ i'>,-'r`n`^,t��TRf�t..��'-�,'l��a ,�'�q�'v��n .�nr' •`� V ♦ eu ; � �1� ^ 9r'. ��°i4f�,� � ��Ttr ^ (r •�,�R f . i�^� �� !H<Pi,i�t .� � �'e e • ir.r-' . 4 r Description of Fotmation *from to Gr vel& Sand -'---34 Sand .�.�- ti��: �._r 34,. 45 2= Hard PanA ,� - - .•�: 148 Soft Cla &'Gravel ��.� 14 157 Hard an brown I 41D ' Hard Pan' brown 'f --'i \`' i ^ 276 285 H 0 .7rr:.1t I certify the above true and correct, 1 C �1 �E ✓ 2��v.. 11 _ f�1 _ ”. -Driller DOTTEN DRILLING CO. John's Road SPENARD, ALASKA We advise you to attach this certificate to your deed. [ =t ��,�7^�``.'1'�-.i �, ^+.._ i'>,-'r`n`^,t��TRf�t..��'-�,'l��a ,�'�q�'v��n .�nr' •`� V ♦ eu ; � �1� ^ 9r'. ��°i4f�,� � ��Ttr ^ (r •�,�R f . i�^� �� !H<Pi,i�t .� � �'e e • ir.r-' . 4 r TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING CSG! FT/BR)= 150 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: CrF=F —r[A1 2r-1 =-F: GF'RkrEL C•EF'TH= F=. THE LENGTH DIMEN'=ION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION CIN FEET). FQE=0 J I FZ EC• E~EF'T I C iwwvs 'c I n== nLC10CA C3FiILLOrJlcc=: PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DUPING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE 'NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. -- TWCD C :2 ? I r4�7,F'EC'-T I IDtJ=-- FiF<E F_EGlU I F= EE-. ;BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL; OR •150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS 'OF THE WELL COMPLETION. '.OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS AFbi AVAILABLE TO INSURE PROPER INSTALLATION. F'EF?U1I T EoKF' I FQE= W.W.T. 107J/ r - SOILS LOG • MUNICIPALITY OF ANCHORAGE n O PERCOLATION DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST Pouch 6-650, Anchorage, Alaska 99502 2762221 SOILS LOG - PERCOLATION TEST G PERFORMED FOR: YJL�LLI A%11 S DATE PERFORMED: LEGAL DESCRIPTION: Sc'�1�i� 5 L �`� uA• �� -rlm� 2 3 w SLOPE SITE PLA ��1 t" PE�k1 f-T�-1Tl I 1 F 31 I i 'BRRAyF' =y 5A-"i'Y SAND 4- 5. 6- 7- 8 •7-8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS_ PERFORMED BY 72008 (7/76) ORAIS Nr" SP w fM i SANDS WAS GROUND WATER L Ij 5 Q ENCOUNTERED? ND O P E IF YES, AT WHAT DEPTH? Irl D. Koryroo NO. 1a23f Reading Date Gross Time Net Time Depth to Water Net Drop r. PERCOLATION RATE TEST RUN BETWEEN FT AND FT CERTIFIED BY: DATE: 51 G�. jO�3o3y Lle-l'o/V MUNICIPALITY OF ANCHORAGE Development Services Department �� Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015-292-04 Legal description FISCHER BLK 3 LT 1A Site address 5200 E 100TH AVE Expiration Date: 10/11/23 Current property owner(s) PRICE GARY WOODFIN & CHARLENE X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: By: �/ fit%,.� �� Original Certificate Date: 7/11/23 z This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 MUNICIPALITY OF ANCHORAGE 04 Development Services Department _17 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 01529204000 Complete legal description Location (site address) FISCHERBLK 3 LT 1A 5200 E 100TH AVE Current property owner(s) PRICE GARY 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 646-4661 3. TYPE OF WATER SUPPLY: X Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: X Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel * Plastic ❑ Concrete ❑ Fiberglass Age new - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed 0 Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ Waiver Fee $ Date of Payment b �2 S/ -, Date of Payment COSA # 0- C -Z 3 (Z I �/' Waiver # COSA Applicafion June 2022 COSA Checklist Legal Description: FISCHERBLK 3 LT 1A Parcel ID: 01529204000 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 11/20/78 Total depth 285 ft Cased to 285 ft ❑■ Sanitary seal is functioning correctly ❑■ Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 5/17/23 Static water level at beginning of test 247.3 ft. Comments B. TANK DATA Measured operating fluid level in septic tank na Date of pumping new ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 8/22/92 ❑■ ALL standpipes present per record drawing Total measured depth from grade 9 ft (max) Measured depth to pipe invert from grade 5 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 Comments/Deficienci COSA Checklist June 2022 Well production at time of test 8+ gpm Water storage tank volume0 gallons Well disinfected for coliform test? ❑ Yes ❑■ No ❑■ Coliform bacteria is Negative Nitrate 0.44 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L XArsenic less than MRL (ND) Collected by NRim Eng Date 5/19/23 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 5/17/23 Results g Pass Fluid depth prior to test 0 Water added 450 gal New fluid depth 4 in Elapsed time 30 min Final fluid depth 0 in in Absorption rate 450 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 48 Effective depth used 0 in Effective depth remaining 48 in in 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 Community Sewer Manholeileanout > 100' � Yes if No ft E Yes if filo ft Neighboring Tank > 100' ❑■ Yes if No ft Private Sewer/Septic Line > 25' ■❑Yes if No ft Absorption Field on Lot > 100' ❑■ Yes if No ft Holding Tank > 100'■❑ Yes if LIQ ft Neighboring Absorption Fields > 100' ❑■ Yes if No ft Water Main > 10' Animal Containment > 50' Yes if No I'll 0 Yes if No ft Yes if No ft Water Service Line > 10' ❑■ Yes if No Manure/Animal Excreta Storage > 100' If tank or field is under driveway comment below Community Sewer Main > 75' ❑■ Yes if No = ft F■ Yes if No ft El N/A — Served by Community Well (not on lot) or Public Water Frorn SeptiOHold ing Tank and Absorption Fields) on Lot to: (Please enter distances if less than required) Building Foundations > 10' ■❑ Yes if No ft Surface Water ;- 100' ❑■ Yes if No ! ft Tank to Property Line > 5' [K Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' Q Yes if No = ft Private Wells ? 100' ❑■ Yes if No ft Water Main > 10' Q Yes if No = ft Community Wells > 200'■❑ Yes if No ft Water Service Line > 10' ❑■ 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, acrd regulations in effect at the time of installation, unless noted otherwise. Name of Firm NorthRirn Engineering PhonLc 694-7028 Engineer's Printcd NamLc Steve Eng Datc COSA checklisi June 2022 6124123 OF S 1 `* 49LH.. *�f s i c, . ; ... Steve Eng�, CE -6256 A -_- 6/2E: CIT Parcell.D. Municipality of Anchorage Development Services Department Building Safety Division on -Site Water and wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519650 www.muni.org/onske (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING 015-292-04 1. GENERAL INFORMATION Complete legal description Fischer Blk 3 Lot 1A Location (site address) 5200 E. 100th Ave., Anchorage, AK COSA# R cDug3 Expiration Date: /m Current Property owner(s) W Lee Renfrew Day phone Mailing address 4141 B Street #208, Anchorage, AK 99503 Lending agency Day phone Mailing address Real Estate Agent Beth Simpson & Co. Alaska Group Day phone 907-865-6565 Mailing Address 101 W. Benson Blvd, Suite 200, Anchorage, AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ✓❑ Individual On -she ❑✓ Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On -she ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite 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 Onsite Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions In the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation, based on procedures outlined in the Certificate of Onsite 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 Finn Watkins Engineering, Inc. Phone 907-349-1851 Address P.O. Box 110443, Anchorage, AK 99511-0443 Engineer's Printed Name Cindy W. Ellis, P.E. Date 10/412008 5. DSD SIGNATURE t/ Approved for _� bedrooms. Disapproved. Conditional approval for bedrooms, with the following Attachments: COSA Checklist _� Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Report Nitrate Advisory Other By: Original Certificate Date: 0 (s • (R« „qS) Municipality of Anchorage Development Services Department Building Safely Division On -Site Water & Wastewater Program 4700 Bragaw, Street P.O. Baa 196650 Anchorage, AK 995/9650 www.muni.arglonsfle (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Fischer Blk 3 Lot 1A Parcel ID: 015.292-04 A. WELL DATA Well type PRI if A, B. or C provide PWSID i = Date completed 1180/1978 Sanitary seal (YIfQ Yes Total depth 285 tL Cased to L85_11. FROM WELL LOO Date of test 118011978 Static water level 260 IL Well production 5 O.P.M. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Nitrate 0.338 mglL Arsenic: 10_006 mgA Date of sample: 8/18108 S. SEPTICIHOLDING TANK DATA Wap Lou (Y" Yes Wires propedy Protected (Y" Yes Casing height (above ground) 1. AT INSPECTION 8818008 288 fL 5.6 g.p.rr Other bacteria 0 colonies/100 mL Collected by: Rocky Trainor Tank Type/Matedal steel septic tank Date installed t OI9178 Tank size 1000 gal. Number of Compartments 2 Cleanoufs (Y" Y -1st Compartment' Foundaton.dennout (YM) Yes Depression aver tank (Y" Nc High water alarm (YIN) WA Date of pumping 981/08 pumper A+ Home Services C. ABSORPTION FIELD DATA Date In sWled 882/92 So -111 rating (g pAA a or ftzlbdrm)1 2 System typo Deep Trench Length 50 ft Wldih 2 R. Gravel below pipe 4 R. Totel.depth 18.0' R ER. absorption area 400 fl' Monitoring the Y Depression over field N Date of adequacy test 8121/2008 Results (Pass/Fall) Pass For 3 bedrooms Fluid depth in absorption field before test 22.6• In. Water addedl2_386 gat New depth j in. Elapsed Time: 133 min. Final fuid depth 39.6 kr. Absorption rate >_ 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N &type) No If yes, give date D. LIFT STATION Data installed NA Size in p pons 'Pump on' level at _In. E. SEPARATION DISTANCES 'Pump ail level at_ In. Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankiliR station on lot 100.0 Absorption field on lot 114 Public sewer main 100+ Sewer /septic service Une 90 Manhole/Access (VIN) High water alarm level at in. Mesta alarm a chars recoremxas9 On adjacent lets 100+ On adjacent lots 100+ Public sewer manhole/cleanout 100+ Holding tank 100+ Animal containment areas 50+ Manure/animal excrete storage areas 100+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10 Property line 40 Absorption field 5+ Water main 100+ Water service line 50+ Surface water 100+"' Wells on adjacent lets 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property Ina 35+ Building foundation 20+ Water main 100+ Water Service line 70 Surface water 100+ Driveway, pwidngNowe swap 20 Curtain drain NA Wells on adjacent kna 100+ F. COMMENTS: 'MT Is 18.0 It deep -10.25 it below the lateral or 8.25' below the bottom of the bench. Fluid depth In trench Is adjusted to bottom of trench - not bottom of MT. "Approved In 1992 and 1998." Creek on northeast O. ENGINEER'S CERTIFICATION.he •' ... s. I certify that I have determined through field inspections and h 491 review of Municipal records that the above systems we in cordormanoe with MOA COSA guidelines in effect on this date. Engineer's Printed Name Cindy W. Ellis, P.E. CI dy W. Ellis Date I09= CE . rusrr i :I COSA Fee S LC Date of Payment1171,0 1% Receipt Number Lk— (Rev. 11ifflM Waiver Fee S Date of Payment Receipt Number EAST 100TH AVENUE F------------------------------------ S 1 S 89058'26"E 299.62' Pxi � Qe, o� OF q-•,p�4� X`49 ............................... SQA,(, 1144&�- c SHANE A. HOLT �^ LS -6914 `�11.Sn• ....- •wY'OO ASPHALT DRNEWAY(LOT I B ) N 89"57'40'W 299.53' THE PSORMATON HEREON 0 FOR THE USE OF LPN WO N8mvT1OHA SPECB%'ALLY TO SNOW ANY COWUCTS BETWEEN EJa8TN0 STRUCTURES AND PLATTED LOT LINES OR EASEMENTS AND E HOT TO eE USED FOR P08RONNG ADORONAL BTRUCTURE801H FEHCELRE0. EASEMENTS OF RECORD. OTHER THAN 71106E BHOWTI ON THE RECORDED RAT. ARE HOT SHHDAM HEREON. NOTE ANY FENCELIHES NONTI ARE LOCATED APPRO)FMTELY AND ARE NOT TO BE USED TO DETERMINE PROPERTY LINES OR LOCATE 8TRUCTURE8. ANY PAVNO BNDMI MAY N APPROMATE DUE TO KNOW CONDMONS AS -BUILT SURVEY SCALE I- • AO lWREFWCERTFYTHATIINVEPERFORMEDA MORTGAGEE'S INSPECTION OF THE FOLLOWWO OEBCRIBED PROPERTY. LOT IA 0.0CK A FECHER ON. ANCHORAGE RECOROMO OWWT, ALASKA AND THAT THE NWSLE MRIOVEAENTS SITUATED THEREON ARE NTTHRN THE PROPERTY INEb AND No VTBIBIE ENCRMGIAENTB EPBT OTHER TINN NOTEO. DATED AT AND40RAGC ALASKA THIS CAY OF SEPTEMBER 9 HOLT LAND eLRtv6YN0 102ST. Fe 12"? ITSSi TEL W,5513 MUNICIPALITYANCHORAGE • '� DEPARTMENT OFFHEALTH &8 HUMAN SERVICES � Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # CLQ 1. GENERAL INFORMATION HAA # �-\ 20 K C) L-\ 9.n1 Complete legal description 4e-1. / A .6k- 3 9ier Location (site address or directions) _52vev '6F• / C e'er` Property owner 13e)l✓ lel' �!` ainS Day phone Mailing address 52-^'n t�' ICO -n' Lending agency Day phone Mailing address Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: O 3. TYPE OF WATER SUPPLY: Individual well 1< Community well _ Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site x Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rw.1191) Front MOA621 S. 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 verity that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm 1424114C%- A) phone Address /1/z50 l*n/We, dw,) Y_r. Engineer's signature 6. DHHS SIGNATURE �Z Approved for bedrooms. Disapproved. Conditional approval for Additional Comments M Date 9z -9-V9 bedrooms, with the following stipulations: Date _ / 7,-10 _'7a- The '7- The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions In order to satisfy certain federal and state requirements. Employees of DHHS do not conduct Inspections or analyze data before a certificate is issued. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. 72a25(n«.U91) e.at Mom RECEIVED Municipality of Anchorage DEC 09 1998 6DEPARTMENT OF HEALTH & HUMAN SERV Environmental Services Division vaLlrr of AnICICESHp ENVIRONMENTAL SERVDIV 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: Z44 /A 3 1+e y' Parcel I.O.: A. WELL DATA Well type Sn /L It A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Y Date completed //-20-79 Total depth ZV5 Cased to 2�S' Casing height (above ground) I �` Sanitary seal (Y/N) Y Wires properly protected (Y/N) Date of test FROM WELL LOG //-2n_ 78 Static water level Z& Well production U'tk — g -p.m - WATER SAMPLE RESULTS: AT INSPECTION Z.G // 7.5 Coliform -IQ Nitrate 0, "7 L4 3 Other bacteria 'L< Date of sample: 1 0 /o 8 Collected by: lll"'i E / A., dd.- 5y,l B. SEPTIC/HOLDING TANK DATA g.p.m. Date installed / 9 79 Tank size 1600 Number of Compartments Z Cleanouts (Y/N)-Y— Foundation cleanout (YM) _ Y Depression (Y/N) ^% High water alarm (YM) A1A Date of Pumping &- /4- 4 Y Pumper M" -Om n 10C C. ABSORPTION FIELD DATA Dateinstalled 9-2--J-92- Soil rating (g.p.djWorft*/bdnn) !'Z System type Ztc�y eA Length fC' —'Width 2 r Gravel thickness below pipe r Total depth / Effective absorption area zMonitoring Tube present (Y/N)-Y-- Depression over field (Y/N) Date of adequacy test 6" / 7 `I Results (Pass/Fall) p435 For 3 bedrooms K Fluid depth in absorption Held before test (in.); 7-hi7-hiofImmediately atter �al. water added (in.): * `� Fluid depth ~ (ins) Minutes later: 2-`1 4,0 s Absorption rate = Y JraV c.p.d. Peroxide treatment (past 12 months) (Y/NIf yes, give date 72.0213 (Rev. 3198)• D. LIFT STATION Date installed Manhole/Acoess (VA High wata;Aarm level at* tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at' SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot /Ce 441 - !C,C 4.- On adjacent lots `Pump off" lQprd On adjacent lots Public sewer main Nd Public sewer manhola/cleanout NA Sewer/septic service line Lam✓ Lift station AJA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ?-3 / Property line !� Absorption field 3 / rf Water main/service line 5 f ! ? Surface water/drainage Wells on adjacent lots do« SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line lbrj Building foundation Water main/service line 2 S Surface water G BOrf Driveway, parkingIvehide storage area 10 "t�- Curtain drain IVrn<. "4,44) h Wells on adjacent lots ,Y RV F. ENGINEER'S CERTIFICATION; I certtly that 1 have determined tlrti Held Inspections and review of Municipal nacor dpjV;bgyQZnstems are in cwrlorrrrance�� I alines in effect on this date. � q .:'lP•'••• S Signature ii _ i # 497 ;9 �J Engineer's Name / • .... ��T• MICHAEL" •• •'•�••/ Date Z- g'�'Y y7F�yNANDCNSCN69: HAA Fee $ �� • �4 0 Date of Payment A 9 ! d Receipt Number JZ 7 7 7 72-026 (Rev. 3t96)" Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE • ^� DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# �c\Q- r10 HAA# 0�\C�MCIL119, 1. GENERAL INFORMATION Complete legal description �\Scuv Location (site address or directions) //'TZ00 E . /oo �TJH// �✓e Property owner 0043 A114 c 1A"4 s Dally phone �134e- -2877 Mailing address 52� /00 "' �✓c. /7,vCN 2 /-iii 9% Lending agency 5EATTt.E Ao re AC e_— Day phone Sr✓Z -5500200 Mailing address ALO 4 • 34 T- A, vC Agent S 0A, ^A s _ ^�oI _ S Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 N 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site 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. 72-025 (A". M) Front MOA 021 5. STATEMENT OF INSPECTION BY ENGINEER ' As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. �LAx'C�.y.SULT7.vc• Phone Z58-Z4Zo Name of Firm Y Address Engineer's signature /D ,�'/N �'NO�AG/C � �• Date J 49L H I. of$* H•••.••• u•, It#Rt! r. nusrAA11 1 'tea CE • 1393:: 6. DHHS SIGNATURE .�rroaIWa" Approved for bedrooms. Disapproved. s, with the following stipulations: Conditional approval for bedroom Additional Comments Al _ i7 Date �f v 0 k '� -)- -� -A-- The The Municipality of Anchorage Department of Heaan ano nu, a 1 — ..,..—• •- • ----- Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-0=(S".1N1) 8-k MOA121 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Le. /A / BceeK 3 F.seaC�rr Parcel I.D. aha – Dy A. WELL DATA Well type i/v0" y/D,1JY If A. B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) %' Date completed //ZZd17B Driller OorrF,i Z�r,�„�G ZS5 ?40� ivsnee �oifr• G� Total depth Cased to asing height / Sanitary seat (Y/N) Date of test Static water level Well flow Pump level Wires properly protected (Y/N) FROM WELL LOG � 2Lo SEPARATION DISTANCES FROM WELL TO: AT INSPECTION 7/2 29i MUNICIPALITY OF ANCHORAGE ",I"^NMENTAL SERVICES DIVISION Z40 ' Jul 1 A-992 RECEIVED Septic/holding tank on lot /,0 Z Fr ; On adjacent lots i0o Absorption field on lot /Z4.<T -r :On adjacent lots /oo Public sewer main No.16 _ Public sewer manhole/cleanout 161�'Alle, Public sewer service line Petroleum tank NOTE: NORSE •PAOCOCM. .IS WITKIN 10' or,,wrLL WATER SAMPLE RESULTS: Coliform Nitrate�6!ly Other bacteria n/on/E Date of sample: 7 Collected by: B. SEPTIC/HOLDING TANK DATA Date Installed /O Z7B Tank size Compa ents Z Cteanouts (Y/N) High water alarm (Y/N) — Date of pumping SEPARATION DISTANCES Foundation cleanout (Y/N) iY� Depression (Y/N) N /� ..._.... tested (Y/NI N �9 Z /'Nei=.CES3�OOt, ING TANK TO: -s44 -ZrP3Z) Well (s)onlot /o Onadjacentlots /ao / Foundation /3.55 To property Ii a '� / r ' Absorption field ZZ Water main/service line Surfac=rainage NONE 72-M(Rw.W)From MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date Installed - %�� Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at, "Pump off' level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: AM. Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA U f", 0M fr`rw— .r",T }SCA11 o Date installed '' Soil rating `ISD FrYWC1 -Svstprn,.A T.PEw� N Length 3B Width 1S r Gravel thickness- G� Total depth 1Z Total absorption area GoG Cleanouts press t (Y/N) Y Depr_essio� over field (Y/N) _C� DDate of adequacy test 7 1Z 1!)ZResults (pass/fail) PASS xfor 3 bedrooms Peroxide treatment (past 12 months) (Y/N) ' If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 2 On adjacent lots ion Property line le To building foundation To existing or abandoned system on lot 410A/C- On adjacent lots /p: CutbanJ 18 ¢em0+10�t Water main/service line voNE Surface water 410Wa— Driveway, parking/vehicle storage area /3 Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on Jg%4p.+� 4Inspection. QEF' A Signaturei,ty��49T" .... .........:.../ Engineer's Name Z4% 15 7 uwe v. auswwAr Date.1393 ; ' �� o •.......•��g`a HAA Fee S Waiver Fee: $ — Date of Payment Date of Payment _ Receipt Number `l� .23 85 305/y/ Receipt Number _ 72-MJRW. W) B. k MOA 21 InI PI VII v nN:FhV v14.0 1 isb� c �r Z �t1 0 N hC)'7 �LS46,� a pP e e• •a lv �w• t • r �.•� eLi :« O to Cr • R • O 4. 0 � �• � � •- cJ Y i !-� ,�„ � • r -M ri U W) Ch ^ a I� ,'"ip' l d a a a N q N a d pq 41 Q N d asto C6 w P. '` 1r1 O 'rn ''aww d N M ~ N d tl A M uµ N A r7 •L"i V y N A � N d b N •ai �A Q q a. '°. Z d d•'9w' '� as 0.0 W r4 •� N a Uca Ch y tl A A C a w a" d ;R.2 o }F4 oe � .•• Fi a •Q " tJ ` r C1 pq ylL V Nb ® Aa O a T b1 O w ►� C M p ,dq .°A�a D+ 0 Lm. o a e N :A -O•. W V M M w a r V O a d P4 �,d a ts tl� H d� qo�a �•. Coe 'd V " Pi ".4 s .,A. ss N Q ••'. o 0 MUNICIPALITY OF ANCHORAGE !d — DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 015-292-04 HAA # HA920438 1. GENERAL INFORMATION Complete legal description Lot lA Block 3 Fischer Subdivision Location (site address or directions) 5200 East 100 Avenue Property owner Bob Williams Day phone 346-2877 Mailing address 5200 East100 Avenue Anchorager Alaska 99516 Lending agency Seattle Mortgage Company Day phone 562-5626 Mailing address 560 East 34th Avenue Anchorage, Alaska 99503 Agent Jeanie Rogers Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: ---'Three (3) 3. TYPE OF WATER SUPPLY: Individual well xxxxxxxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xxxxxxx 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. 72-0251Rw.1A1) Front MOA -21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. l furtherverify 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 Polarconsult Alaska Inc. Phone 258-2420 Address 1503 West 33 Avenue Anchorage Alaska 99503 Engineer's signature Date The upgrade of the on—site wastewater system has been completed. This property is now approved for on—site wastewater and private well. See attached inspection report for on—site wastewater -system. �, k3 d:'•.d'1 4 If there are any questions, please call our office at 343-4744. 6. DHHS SIGNATURE Approved for ��'�� '3) bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments • Date S7' - / _r `� The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72O251Ray.1191) Back MOA -21 i. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lar 1A 1 3 Parcel I.D. 5k)eD. A. WELL DATA Well type T01VATS_ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed 114o,Drillerjt)Qrrrr-t3 bcls � Total depth 285 Cased to + �a 1 Casing height Ifo Sanitary seal (YIN) V Wires properly protected (Y/N) _r Date of test Static water level Well flow Pump level FROM WELL LOG 11IZo �i9 .. 2.feo AT INSPECTION 41 zhz, 2-4o RECEIVED 1!p g.p.m. AUG 31 1992 Munic,pafltyofAnchorage D SEPARATION DISTANCES FROM WELL TO: ePL Health & Human Services Septic/holding tank on lot On adjacent lots 100 -t- Absorption field on lot ItLe ?r ; On adjacent lots NIC) Public sewer main Public sewer service line Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform 4?� Nitrate --0.2?, Other bacteria Date of sample: - 1z lav Collected by: A. 04la, B. SEPTIC/HOLDING TANK DATA Date Installed�3-g_ Tank size UDS Compartments 2 Cleanouts (Y/N) x Foundation cleanout (Y/N) Depression (Y/N) tJ High water alarm (Y/N) Alarm tested (Y/N) Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: / Well(s)onlot totr On adjacent lots 100'Ir / Foundation 13 Topropertyline 411 Absorption field 22- 1' Water main/service line dbJC— Surface water/drainage — 72me1R".SAI) F i MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installedManufacturer_ Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at High water alarm levet Meets MOA electrical codes (Y/N) SEPARATION D i FROM LIFT STATION TO: On adjacent lots off" level at Cycles tested Surface water D. ABSORPTION FIELD DATA I Gvr sl1 -r 'Ta EXtSTIAt�. TArak. Date Installed fi-?ZSoil rating k,2 rfro System type - -r F cw Length Widthy Gravel thickness �+ v -T Total depth -cJ y�r Total absorption area 'i Cleanouts present (Y/N) Y Depression over field (Y/N) IJ Date of adequacy test Results (pass/fail) for bedrooms Peroxide treatment Ipast tz months) (Y/ N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot al On adjacent lots loo+l Propertyline A7_1 To building foundation 2$,� I To existing or abandoned system on lot IZ ) On adjacent lots 1 Cutbank — Water main/service line Surface water Curtain drain E. ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area I°) .-r- I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect 4W th .arOF A c,...... Jr, %' •• Signature i Vj�' Ty date of this inspection. * r •49—....*00.0.. * t Engineer's Name—�E �• d �'tirJ / // Date F, 31- 92— � V. AUSAA ::.F...f � wne v. AusAknN f (� CE -1393 y' HAA Fee $ Date of Payment Receipt Number 72-M (R". 191) 9"k MOA 21 Waiver Fee: $ _ Date of Payment Receipt Number �U 4J. MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE `^LT%I 8 EPTDEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE 1400. N' �� •''`JN!t.:\Tl.: { :..'::CiION - 825 L Streat - Andmraps. Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION NPR 1 6 1979 Telephone 264.4720 F REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWN FRC1L1'ITES DIRECTIONS: Complete all parts on page 1. Incomplete squab will not be prooeated: Plaeaeellow on (10) days star proeOdOy, 1. CO E3tTY OWN R— ' rz t t A�� PHONE MAILIN ADD ESS-_ lSwrl -Ga-1 Two ❑ Five ❑ MULTIPLE FAMILY PROPERTY RESIDENT (If different v from above) _ 4 2. BUYER MAILING ADDRESS S. LENqjNG INSTITUTION ey PHONE l tli f ❑ PUBLIC UTILITY MAILING ADDRESS 4. REALTOR/AGENT PHONE MAILING ADDRESS 0. LFGAII DESCRIPT �L[7C l J ep STREET LOCATION 9 A p U S. TYPE OF RESIDENCE NUMBER F SINGLE FAMILY ❑ One ❑ Four ❑ Other Two ❑ Five ❑ MULTIPLE FAMILY Three ❑ Six 7. WATER SYPPLV 21 INDIVIDUAL' *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior t that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) L SEWAGE DISPOSAL SYSTEM "If individual/on-site, installation date INDIVIDUAL/ON-SITE" give If system is over two (2) years old an adequacy test is required ❑ PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 12ut utsf rtf) 46M THIS SIDE FOR OFFICIAL USE ONLY , INSPECTION APPOINTMENTS DATE RECEIVED TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED ' LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON-SITE EJ PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED IN ALLER ❑Septi4 ank or ❑ Holding Tank Size: /0yo If Tank is homemade give dimensions SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELLTO: Septic/Holding Tank Absorption At" Sevver Lim rrnt a r Abwrption Area to nearest Lot Lir 5. COMMENTS &9— APPROVED FOR �� BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY Title)/ LEGAL DESCRIPTION 72-010 (Rev. 3/78)