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Home My WebLink AboutHERITAGE PARK BLK 2 LT 16H itage Pa k Block Lot #050- 21 1 -64 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP231190 PID Number: 050-211-64 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name PAUL WILLIAM & JANICE NELSON ABSORPTION FIELD ® Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 19443 LAURA LEE CIRCLE, EAGLE RIVER ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 0.6 GPD/SF 12 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 4 Ft. Gravel depth beneath pipe 8 Ft. Subdivision Block Lot HERITAGE PARK 2 16 Fill added above original grade VARIES 0.27 CUT & 0.02 FILL Ft Gravel length 63 Ft. Township Range Section Gravel width 2 Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 1008 Ft2 1 -- Ft. Well 200'+ 200'+ 25'+ TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1500 Gal. Surface Water 100'+ 100'+ Material HDPE Number of compartments 2 Lot Line 51+ 10'+ NA Foundation 10'+ 10'+ LIFT STATION Manufacturer Capacity Gal. Remarks SEPTIC TANK WITH 4" INSULATION Alarm location Electrical installed by Installer JRS PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield Drainfield 3034 CO/MT 3034 Inspector FWC BENCH MARK (Assumed elevation) 100 ft Inspection151 9/12/23 2°d 9/13/23 d Location and description 3rd 9/13/23 41' 9/14/23 TOP OF MH ON-SITE WATER AND WASTEWATER SECTION APPROVAL OF A�1 ,�} Conditional Approval: Date i ' • . *: 49 TH ....:* ..... .... ......... ��.. Curtis Huffman �� Septic A rod p Date}��`��F .: <'` CE 128991 •. 10/ 11/23.. pROFESS16P4 Note: this approval does not include well permit require ents. tYCCv uD/uz/ ! 0) PID: 050-211-64 PERMIT: OSP231190 FMA O C4 0 N CA Ui O N 00 O Lot 17 A -C=32.1' BM B -C=13,6' FCO Dco co DIV A—D=32,2' �/ 99.69 NO B -D=15,1' 97.63 A -E=32,9' 4• INSUL B -E=16,2' � A—F=32.4 97.05 1,500—GALLON 6.88 HDPE TANK B -F=18.5' A -G=45.3' B -G=36.4' A -H=65,4' B -H=74.3' A -I=67.2' B -I=76,4' HERITAGE PARK BLOCK 2, LOT 16 PREPARED FOR: PAUL WILLIAM & JANICE NELSON 19443 LAURA LEE CIRCLE EAGLE RIVER, AK 99577 FIRST WATER CONSULTING AREA SERVED BY PUBLIC WATER. SERVICE LINE IN FRONT YARD. i Lot 7 /-WOOD CO MT MT CO 99.74 FINAL GRADE 100.03 100.0 ORIGINAL GRADE FILTER FABRIC oRc/oL TH1ss2 DRY -8/14/92 96.01 96.01 SEWER ROCK SM/GM —SILTY SANDY GRAVELS W/ SOME m Ram COBBLES SEPTIC SECTION 62,016 eoH SCALEi NTS SUPPORTS SERVICES: OF AL4 i"WES TH '� � 9 DATE: 10/11/23 rtis Huffman ev 04 SURVEY: KGL r CE 128991 w 13030 SUES WAY DRAWN: FWCS10/11/2023e�Af ANCHORAGE, AK 99516 SCALE: 1" = 30'-'ftns3I0ll� AV 907-350-9566 firstwaterAK@gmail.com PAGE: 1 OF 1 MUNICIPALITY OF ANCHORAGE svcnt S 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 F J Department On -Site Wastewater Disposal System Permit Permit Number: OSP231190 Effective Date: 7/28/2023 Work Type: Septic Upgrade Expiration Date: 7/27/2024 Tax Code Number: 05021164000 Site Legal Address: HERITAGE PARK BLK 2 LT 16 G:0055 Site Mailing Address: 19443 LAURA LEE CIR, Eagle River Owner: WILLMAN PAUL D & Lot Size in Sq Ft: 26452 Design Engineer: FIRST WATER CONSULTING Total Bedrooms: 4 This permit is for the construction of: 2 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 Received By: 1 S,5 UE D 7-0 F- Gu/ C Issued By: 01, �_" Date: Date: 4 2 V Z L "2-3 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 050-211-64 Property owner(s) PAUL WILLIAM & JANICE NELSON Day phone Mailing address 19443 LAURA LEE CIRCLE EAGLE RIVER, AK 99577 Site address 19443 LAURA LEE CIRCLE EAGLE RIVER, AK 99577 Legal description (Sub'd., Block & Lot) HERITAGE PARK BLOCK 2 LOT 16 Legal description (Township, Range & Section) Lot Size 26,452 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ® Initial ❑ Single Family (SF) (w/wo AD U) Septic Tank ® Upgrade IN (D) El Holding Tank ❑ RenewalDuplex ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Sign_atoro of property owner or authorized agent) Permit/Rush Fees: S 9 Date of Payment: 151 ZQz 3 Receipt Number: �- 5- DL --u Permit No. 2 3 1 1 9 0 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / firstwaterAK@gmail.com ! !! July 17, 2023 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: HERITAGE PARK BLOCK 2, LOT 16 The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic tank and failed primary field on the above referenced lot. We propose to install a 1500-gallon HDPE tank and the 63’ long by 8’ effective depth deep trench per the attached design to serve the existing 4-bedroom residence. No groundwater was noted in the MOA on-site file, but if groundwater is encountered during installation an epoxy coated steel septic tank may be required. The lot and area are served by public water and the water service line must be staked prior to construction. The design will not impact any of the neighboring properties. Please contact us if you have any questions. Sincerely, Curtis Huffman, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231190, Curtis Townsend, 07/28/23 FIRST WATER CONSULTING HERITAGE PARK BLOCK 2, LOT 16 DESIGN CALCS: NO WELLS WITHIN 200' OF PROPOSED SEPTIC SYSTEM. AREA SERVED BY PUBLIC WATER. STAKE WATER SERVICE LINE PRIOR TO CONSTRUCTION. NO SLOPES >25% WITHIN 50' OF PROPOSED FIELD. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231190, Curtis Townsend, 07/28/23 FIRST WATER CONSULTING DESIGN DETAILS: HERITAGE PARK BLOCK 2, LOT 16 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231190, Curtis Townsend, 07/28/23 FA O Cr; N C,� s UTO Lot 17 0 14.0' Lot 5 S s8 � ss F Lot 16 26,452 S.F. CHAIN—LINK x FENCE ' SEPTIC P1PE5 Lot 6 SEE HOUSE DETAIL o� Lot 15 A N ry RETAINING WALL .� 10' UTILITY EASEMENT Q L= 15.59' R-50.00' L=28.00' L L R=50.00' AA, `� P `► C ! Lot 7 WOODEN FENCE HOUSE DETAIL Scale: 1"=30' 1 STORY RESIDENCE w/ WALKOUT BSMT. 4'. 2.0'x5.2' CANT NOTE: THIS LOT IS SERVED BY A PUBLIC WATER SYSTEM. PLOT PLAN AS BUILT _X SCALE _ 11 — 50' _ GRID _ NW 0055_ _ Protect No. 23-302/Al.... 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, i n c. (907) 522-6476 Phone ken®la ngsurvey.com Professional Land Surveyors jonathan*langsurvey.com of A�q 1i travis®longsurvey.com P'� , • s` I hereby certify that I have surveyed the following described property: LOT 16, BLOCK 2, HERITAGE PARK (PLAT No. 82-39) Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the __=`__ Day of ��Z� _, at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. ... ........ KENNETH G. LANG 0 �QfESSIONA�`,0�� 05�.AW State of Alaska AECC963 Municipality of Anchorage Page __'[ of 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: ~ c~ 97.-0 ?_..~ c~ PID Number: (:~,o 7--1 ~ ~ ~ Na~e:]~T,~ ~ ~ ~ ~;F~__ ~¢ Wastewater System: ~ New ~ Upgrade Address:~j ~ ~5~ ~1~~ , '~'pp~o> ABSORPTION FIELD I No. of Bedrooms: Phone: ~. ~¢ ~ ~ DeepTrench ~ Shallow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRIPTION sci, ,~i.,: ~ .~ ~,~/sq. ,t. ~o~., ~.p,~Z,~,om o,i,ina~ ,r,d~: Block: ~ubdivision: 3epth to pipe bottom from original grads: Gravel depth beneath pipe Lo~: I ~ ~ ~V,~~ ~' Ft. ~' Towns~ ~ Range: Secti~:? Fill added above o~iginal grade: Gravel ,ength: ~ o~ ~ I ~ Ft. G~' Ft. a~ Gravel ~:~ t ~ Number of lines: Distance between lines: WELL: U New ~ Upgr~ ~ Ft. I - Ft. Classification (Private, A,B,C): ~ ~~ Cased To: Total absorption area: ~ Pipe material: ~ ~ Ft. ~t. ~ Sa. Ft. ~So~+/ Driller: ~~~ Date Drilled: Static Water Level:Ft. Installer:~ ~ ¢~ ~~ . Date installed:~ Yield: ~ Pump Set at: Casing Height Above Ground: TANK ,~GPM Ft. Ft. SEPARATION DISTANCES ~ s,ptic ~ Ho~ding ~ S.T.E.P. TO Septic Absorption Lift Holding 3ublic/Private Manufacturer: Capacity in gallons: From Tank Field Statio~ Tank Sewer Lines ~~ Material: Number of C~pa~ments: Well ~ su,f~c~ . -- LIFT STATION Water ~ ~t~t -- +1~o~ Lot Size in gallons: Manufacturer: Line ~' ~0 ~ ~ ~ "Pump on" level at: ~ "~p~: High water alarm at: Foundation ~' I~' ~ -- CurtainDrain ~l~' ~l~ ~ ~ Electrical Inspections pedormed by: Remarks: O~*~L ?~m~ ~ 3-~p~oo~ BENCH MARK Location and Description: ~[ ~ ~ ~0~ ~ ~ ~ ~ ~ ~_~ Assumed Elevation: Inspections performed by: ~u~A~ ~,~Dates: 1st. 9-~z-9~ ~"~ .... Department of Health and Human Services approval .... ~~ ~:~ , Reviewed and approved by: :~,. ~ Date:/o-/~-. ~ ....... =~ .... ' ' ' 72-013 (1/91) MOA 25 Permit No. '~c~o ~j~ o ~o~ Page Municipality of Anchorage DEPARTMENT OF. HEALTH AND. HUMAN SERVICES ENVlRONI~ENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: /.-I (o (~ 'Z. ¢,,e4,["~z ~E~,~. PID No.: 72-013 a (2/gl)MOA 25 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 PERMIT PERMIT NUMBER:SW920269 DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC. OWNER NAME:HERITAGE REAL ESTATE CORP OWNER ADDRESS:207 E. NORTHERN LIGHTS BLVD. ANCHORAGE, AK 99503 PARCEL ID:05021164 LEGAL DESCRIPTION: HERITAGE PARK BLK 2 LT SEC 7, T14N, R1W, SM LOT SIZE: 26452 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 16 DATE ISSUED: 9/03/92 EXPIRATION DATE: 9/03/93 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ISSUED BY: .... DATE: DATE: SITa~ PLA~ DETAILS PROPOSED WAST~WATER ABSORPTIO~ S¥STW. M LOT 16 BLOCK 2 HERITAGE PARK SUBDIVISION PREPARED FOR: LYNN ROBINSON C/O KIT CALLAHAN EAGLE RIVER, AK~ 99577 SCALE: 1" = 100' DRAWN BY CAL CONSTRUCTINO ENGINEERS 3~6-2000 9601 BUDD~ W~RNER DR 69~-9098 A~CHORA~E~ AK, 99516 8-14-92 DRA~/ING # 9~-S1-08-1 SCOPE OF PROJECT: New absorption field is designed for three (3) bedroom system. Lot is served by public water. Due to difference in elevation between proposed house plumbing and septic system location, it is proposed to install a lift station/pump within the house as a part of house plumbing and utilize a standard gravity absorption system. ~SORPTION AREA C~LCULATIONiS: Minimum Required: 3 Bedrooms x 150gpd/bedroom = 450 gpd capacity Soils rating, proposed addition, 0.6 gpd/sf Minimum sizing: 450 gpd - 0.6 gpd/sf = 750 sf absorption area~ Use 3'W x 47'L x 8' D = 752 sf minimum for trenchi/ Trench depth: Bottom = 12' Below grade, w/ 4' cover IMFACT ON ADJACENT LOTS: There are no private or public wells withi'n 200' of this absorption system. The proposed absorption system has no impact upon any adjacent lots as shown on attached site diagram. ~EAL DESIGN DETAILS PROPOSED WASTEWATER ABSORPTION SYSTEM LOT 16~ BLOCiC 2 HERITAGE PARK SUBDIVISION PREPARED FOR: LYNN ROBINSON C/O KIT CALLAH~q EAGLE RIVER, AK, 99577 NOT TO SCALE DRAWN BY CAL CONSTRUCTING ENGINEERS346-2000 9601 BUDDY WERNER DR 694-9098 ~NCHORA~E, AK~ 99516 8-14-92 DRAWING ~ 92-S2-08-1 PERFORMED FOR: LEGAL DESCRIPTION: DEPTH ! 2 3 ,l 9 10 1' 12 13 14 15 16 17 18 19 2O i'~unicipalily ot Anchorage DEPARTMENT OF HEALTH & HtJMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502~0650 SOILS LO6 -- PERCOLATION TEST Township, Range, Section: SLOPE WAS GROUND WATER [iNCOUNTERED? ~ O IF YES, AT WHAT DEPTH? Oep!h to Water Alter ~lmitorino? SITE PLAN Gross Net Depth to Net Reading Date Time Time . Water Drop PERCOLATION RATE '~/~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN '1 ~ FT AND 8 '~ FT COMMENTS ("/~,,~'~'I"~.~ !.'~.~.,'~1,~'1[ '~"~ 672,(~ ~'~ /~'*¢~ "~v ~¥'~'"-'~.-~v'~ ~¢,,,e~'-<J--~'~J~,~.~',~ , PERFORMED BY: ~D¢~%-{'~.'~-;~'*,~) ~-~1 ~'.,~ I (~'~,~-~"~¢~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~;~ t'~" ~ ~' 72-00[ (Rev. 4/85) Lot 17 Lot 5 10' UTILITY EASEMENT \ �Q / L 15.59' R=50.00' E L=28.40' �P,v�RC L Lot 7 WOODEN FENCE HOUSE DETAIL Scale: 1"=30' 16.6-- DECK s.o—DECK x 1 STORY RESIDENCE w/ WALKOUT BSMT. n 2.0'x5.2' CANT NOTE: THIS LOT IS SERVED 6Y A PUBLIC WATER SYSTEM. PLOT PLAN AS BUILT X_ SCALE _ 1 " — -LCL– GRID _ NW 0055_Project No. ___ 23�-30a____ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone kenOlangsurvey.com �I��tNk' Professional Land Surveyors jonathan®longsurvey.com of At. ll lot travisOlangsurvey.com P'� , • , s I hereby certify that I have surveyed the following described property: LOT 16, BLOCK 2, HERITAGE PARK (PLAT No. 82-39) Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. ,.k, Dated this the --!L1 Day of t�c � �—, �� _, at Anchorage, Alaska It Is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. *; 49TH KENNETH G. LANG 9F�� ' No 5202AN i State of Alaska AECC963 MUNICIPALITY OF ANCHORAGE Development Services Department �4 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-211-64-000 Expiration Date: 1/19/2024 Legal description HERITAGE PARK BLK 2 LT 16 Site address 19443 LAURA LEE CIR Eagle River AK 99577 Current property owner(s) WILLMAN PAUL D &NELSON JANICE M X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 10/19/2023 his 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 0 Development Services Department 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. 050-211-64 Complete legal description HERITAGE PARK BLOCK 2, LOT 16 Location (site address) 19443 LAURA LEE CIRCLE, EAGLE RIVER, AK 99577 Current property owner(s) PAUL WILLIAM & JANICE NELSON Day phone 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ® Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ® Plastic ❑ Concrete ❑ Fiberglass Age 0 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed Z 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 $ z_?Q Waiver Fee $ Date of Payment 10 Z 2D Z Date of Payment COSA # 0 S C 2 � � 3' Waiver # COSA Application.doc COSA Checklist.docx COSA Checklist Legal Description: HERITAGE PARK BLOCK 2, LOT 16 Parcel ID: 050-211-64 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA - PUBLIC &/OR CLASS “A” WATER 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 NA 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 NA Date of pumping NEW TANK 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) NA – NEW SYSTEM ALL standpipes present per record drawing Total measured depth from grade 12.02 ft (max) Measured depth to pipe invert from grade 3.73 ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes (MT) go to bottom of effective (ED). If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date NEW SEPTIC 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) 96 in (8’ ED) Effective depth used 0 in Effective depth remaining 96 in Comments/Deficiencies: Approximate total measured depths from existing grade. COSA Checklist.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) - NA 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 FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 10/11/2023 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 10/11/23 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 995t9-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY'DwELLING ParcelI.D. O5'o-At~ - ([ ¥ 1. GENERAL INFORMATION Complete legal description ~'Lo t: Location (site address or directions) Expiration Date: 16: Bl~2: EeritaEe Park S/D 19443 Laura Lee Circle, EaKle River,AK. 99577 ..Current Propertypwner(s) William & gna St:fever Day phone, "- ...Maili'r;gaddress 19443 Laura Lee Circle E~le River, Lending agency Day phone AK 99'577 Mailing address Real Estate Agent Mailing Address Kathy'Olmstead Dayphone 694-4200 ReMax 16600 Centerfield Df. Suite 201, Eagle River 9957- ~M$$othe~ise~queste~HAAwillbehe~byDSD~rp~k~. 2. NUMBEROFBEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank [] Community On-site [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of titJe (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C we{I and may be reissued with new water sample results less than 30 days old. (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 e.'Tors or omissions in the professional en[;ineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of sb'ucture indicated herein. I further vedfy that based on the information obtained from the Municipality of Anchorage flies and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(ara) in compliance with all applicable Municipal and State codes, ordinances, Sm and regulations in effect at the time of installation. 5 & $ ENGINEERING Name of Firm 17n34 [aqle R[vee I.o,~ Road No. 2O,: ¢_agle River~ Aladca ~577 Address Engineer's Printed Name ~ 0 $~,~ 7- C . ~ ~,,,,/~, bedrooms, DSD SIGNATURE L,,"" Approved for /../L Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Odginal Certificate Date: /0 - Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Westewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www,ci.enchorage.ak.us (~07) ~-7e04 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Well type If A, B, ~' C provide PWSID ti/ I Log (Y/N) Date completed · Sanitary seal (Y/N_L,,'''''~ Wires properly protected (Y/N) Total depth ft. Cased to ,/" fl. Casing height (above ground) Date of test FROMT'""' AT INSPECTION Static water level Well production~ WATER ~PI.E RESULTS: ColT colonies/100 mi. Date of sample: g.p.m, g.p.m. Nitrate Collected by: __ mg3. Other bacteria __ colonies/100 mi. B. SEPTIC/HOLDING TANK DATA Tank Type/Material._ ,,_' ~ Tank size "~ gal. Number of Compadments ~ Date installed g~/[ ~.-/~'~ Cteanout, (y/N) Foundation cteanout (Y/N)/~'~ Depression over tank (Y/N) Date of pumping !018~OI Pumper ~r'-~___,.~ ABSORPTION FIELD DATA Date installed ~1~ Soil rating (g.p.d./fl~ or ~/bdrm) .~_~ Total depth ~ ft. ,,. absorption area t0~4t~Monitoring ~//-'~tube Date of adequacy tast (O~ I'~,J01 Results (Pess/Fall)i t -I Fluid depth in absorption field before test "~ in. Water added.~gal. Elapsed Time: i ~"min. Final fluid depth ¢~Z~. Any rejuvenation treatment (past 12 mo.) (Y/N & type) High water alarm (Y/N) System type Gravel below pipe ~ ft. Depression over field ~/t~ For 4 bedrooms N,,, dep. :; C in. Absorption rate >= ._~__~g.p.d. If yes, give date ~ Fo UFT STATION Date Ins_t~.led /~' 'Pump on lever/ in. Datum Size in g~ons. "Pump off" level et Cyciss tested ManholalAccess (Y/N) High water alarm level at Meets alarm & drcult requirements? Septic tank/tiff station on lot '. ~" . J On adjacent lots On adjacent lots Public sewer manhole/cleanont Absorpfion field on lot Public sewer main Sewer/septic service line/ ' Holding tank SEPARATION DISTANCES FROM SEPTI~ TANK ON LOT TO: Building foundation [~ f''/' Property line ~' ~ Absorption field Watermain /t(:~)/d-- Water service line / (~ t[ Surracewater Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~/~) 1'4' Building foundation ~/O I,f. Water main Water Service line f 0 Curtain drain/~Jt--~V~/ Wells on adjacent lots COMMENTS G, ENGINEER'S CERTIFICATION HAAFee $ :~00. Date of Payment Receipt Number (Rev. 12/0o) Waiver Fee $ Date of Payment Receipt Number Date Engineer's Printed Name ,~0~9~,'~- ~". ~'P~/'¢,'~ I certify that I have determined through field inspecffons end mt4ew of Municipal records that the above systems am in cenformence with MOA HAA guidelines in effecf on this date. Surface water ~' ~ t'4''' Driveway, pa~ng/vehicie storage Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 nO. Box 196650 Anchorage, AK 99519-6650 www. ci.anohorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 050-21!-64 · 1. GENERAL INFORMATION Complete legal description HAA# OOO Expiration Date: Lot 16, block 2, Heritage Park Subdivision Location (site address or directions) 19443 Laura Lee Circle CurrentPropedyowner(s) Greg & Teresa Miller Dayphone 694-1560 Mailing address % Barbara Crittenden/16635 Centerfield Dr., E. R., AK Lending agency Mailing address Day phone Real EstateAgentPrudential Vista/Barbara CrittendeE~ayphone 689-6464 Mailing Address 16635 Centerfield Dr., Ea~]e River= AK 99577 Unless otherwise requested, HAA will be held by DHHS for pickup..AA picked up by: r- ~/~/o~ NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well 4 TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] [] Individual Holding Tank [] [] Community On-site [] [] Public Sewer [] 99577 The Municipality of Anchorage Department of Health and Human Services (DHHS) 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 are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. Certificates are valid for one year for propedies 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. 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 Health Authority Approval Guidelines for the Health Authority Approval application show 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 applicable Munick)alau. d_State codes, ordinances, and regulations in effect at the time of installation. ~, 5ENGINEERING 17034 Eagle River Leop Read No. 204 Eagle River, Alaska 99577 Name of Firm Address Engineer's Printed Name Robert Cowan DHHS SIGNATURE / Approved for ~._ bedrooms. Disapproved. Conditional approval for Phone Date bedrooms, with the following stipulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: ~- Original Certificate Date: Reissue Date: Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825"L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 - www. ci.anchorage.ak.us (907) 343-4744 RECEIv(/ MUNIClPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L ./~/,,~Z A. WELL DATA Well type ~/~ If A, B, 0r C provide PWSID ~ Date completed _ _ Sanitary seal Total depth ff Cased to ~ ff ~s~t (~o~ ground) FROM WELL LOG ~ AT I~PECTION Date of test Static water level Well production ~ g.p.m g.p.m WATER SAM PL~ Goliform ~ colonios/tO0 mi ~itra~o ~ m~/I Othor Bactoria~ Date of sample: B. SEPTIC/HOLDING TANK DATA Collected by: colonies/1 O0 mi in. TankTyp.~/Material ,,~/v'/./,~/4,~.,~ / ~--d~-~ ins~ile.d · ' ~ ~./,~.~ / '. ' ' ....... :' cleanout ~ Depression over tank ~ High water alarm ~ Date0f pamp;ng ~/~/~ Pumper ~ ~ C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft2 or fl2/bdrm) ~,~ System type ~~ / ~/ / Length ~ ~ ~ Width ft Gravel below pipe ~ ff Totaldepth //~ Effective absorption area/~ZZfF Monitoring tube ~ Depression overfieid ~ Date ofadequacytest ~ Resuits~Pass/Fail) /~5 For ~edrooms Fluid depth in absorptio~fie~ before test ~"in Wateradde~/~ gal. Newdepth~# in. Elapsed Time:/~ rain Final fluid depth ~/~ in Absorption rate >= ~ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~ /~~ If yes, give date ~ 72-026 (Rev. 01;00)* D. LIFT STATION Date installed "Pump on" level at __ Datum Size in gallons __ Manhole/Acc_Eess . alarm at in level Cycles tested Meets alarm & circuit requirements E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot On adjacent lots Absorption field on lot Public sewer main ._...~-~ Public sewer manhole/cleanout Sewer/septic service line Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Building foundation Water main , Drainage Property line Water service line Wells on adjacent lots Absorption field Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /~) ~ Building foundation /~:0 ~ Water main /0 / Water Service line /0 /¢- Surface water / u"u /+ Driveway, parking/vehicle storage Curtain drain /1,/¢/,/[~//,,/~n~'^! Wells on adjacent lots /0 /¢- F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conform~,nce with MOA HA.~A ~i.~eli~n eff~%s date. Engineer s Printed Name Date HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 01/00)* Parcel I.D. # ' MUNICIPALITY OF ANCHORAGE ' DEPARTMENT OF HEALTH & HUMAN SERVICES '' Div~si°n of Envir°nmentaISe~ices - On-Site Se~ices Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description ,/Y"~'.//,~?~ ,'~f'/'~' ,~"~., ~///~ Location (site address or directions) Property owner Mailing address Lending agency Mailing address Day phone /~/~- Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: /-7/ TYPE OF WATER SUPPLY: Individual well Community well Public water 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. 72-025 {Rev. 1/9:) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify 'that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance .with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm KND 20441 Pta~rnigan Blvd. Add tess E~§le River, AK 99577-8736 Engineer's signature . Phone Date ,_~ ._C~ -- DHHS SIGNATURE ~, ~ ,.~. Approved for ~---~d~. ~) Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: By: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA ~21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-474~ Health Authority Approval Checklist A. ~LL DATA Bo Co Well Log present (Y/N) Total depth Sanitary seal (Y/N) IfA, B, or C. attach ADEC letter. ADEC water system number Cased to ~~nd) Wires properly protected (Y/Ny'------,~ FROM WELL LOG AT INSPECTION Date of test ~ Static water level ~ Well production g.p.m. ~ Coliform ~ Other bacteria Date of sample: Collected by: SEPTIC/HOLDING TANK DATA Date installed ¢/~Z Tank size /Z:-~ Number of Compartments / Cleanouts (Y/N) / Foundation cleanout (Y/N) ,,~ ~/ Depressiou (Y/N) /~t/ High water alarm (Y/N) ABSORPTION FIELD DATA Date installed Length & 7/ ' Width Effective absorption area Date of adequacy test ~/7/~d~ Fluid depth in absorption field before test (in.): / ~ Fluid depth ~:f/~ (ins.) Minutes later: /z/z/d) Peroxide treatment (past 12 mouths) (Y/N) Soil rating (g.p.d./ft2 or fi2/bdrm) Gravel thickness below pipe Monitoring Tube present(Y/N) Results (Pass/Fail) System type lPeeF '~'~ cJL ~' Total depth ,//~7/' Depression over field (Y/N) tic/ For Y bedrooms Immediately after ~gE>gal. water added (io.): .~'/Z" Absorption rate = f_~i) 4 g.p.d. If yes, give date Date installed Size in gallons Manhole/Access (Y/N) ~'-~'--~"Pump off' level at* High water alarm level at* ~'"----~ Cycles tested E. SEPARATION DISTANCES "Pump ofF' level at* __ Absorption field on lot Public sewer main Sexver/septic service line S~DISTANCES FROM WELL ON LOT TO: Septic/holding tat~ o"~ ; On adjacent lots ~ ; On adjacent lots anhole/cleanout Lift SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation '~ Property line '"' Absorption field Water main/service line /~/¢ Suffacewater/drainage /g~t> /'~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Surface water Curtain drain /Vo/v'~ Driveway, parking/vehicle storage area ~O ~ + Wells on adjacent lots ~oO ' + Property line __ F. ENGINEER'S CERTIFICATION I ce,'t!/) that Ihave determined th,'ufield inavections and ,'eview of Municipal ,'ecor~l~.F~.~s~}t.~ a,'e sign=einc°n/b~vnance with MOA Ifil guidelines in effect on thisdate. ' .................................................................................................................. ~:X~:~,[~.- ............. 'HAA Fee $ e.-..~'~J. ~ Date of Payment Rev. 8/95 eSS: haa.wk.doc 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner /<(;'~---':~1~2'~:~' / P~'~'-~-~\ ~'-~¢ Day phone Mailing address Lending agency Mailing address Day phone Agent Day phone Address Un/ess otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 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. 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 (Rev, 1/91) Front MOAI¢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/orwastewaterdisposalsystem is safe, functional and adequate for the number of bedrooms and typeofstructureindicated herein, lfurtherverifythatbasedontheinformationobtainedfrom 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 (;odes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature Phone Date DHHS SIGNATURE ~ Approved for ~"~'~--.(" bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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 DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA ~/21 Legal Description: Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST ¢o r-~-z. ;~,c,,.['Jf-~,~¢_. ~)'O,,-~. Parcel I.D. O~O 7_4) A. WELL DATA Well type -p~St_~/_- Log present (Y/N) Total depth Sanitary seal (Y/N) bj~m~-~, or C, attach ADEC letter. ADEC water system number Date completed Cased to Casing Wires 3roperly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG g.p.m. SEPARATION DISTANCES FROM WELL Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line AT IN! On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RES Coliform __ Date of sampi~: Nitrate Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATAf..~. Date installed 5~-f;'~ ~- Tank size Cleanouts (Y/N) ¥ High water alarm (Y/N) Date of pumping t '7-.,~ o Compartments Foundation cleanout (Y/N) ~/ . Depression (Y/N) /'V ~ Alarm tested (Y/N) /V ¢3 ~ Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot N; (~ To property line ~O' Surface water/drainage On adjacent lots Foundation Absorption field water main/se~vice line 4-) cO ' 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrica codes SEPARATION DIS~'A-r'¢~ FROM LIFT STATION TO: On adjacent lots Manufacturer ~~'~' Manhole/Acces~~_ ~ ~ ~ "Pump off" level at "Pump on" level at ~, ~'~~ Cycles tested Surface water D. ABSORPTION FIELD DATA .// Date installed ~'~¢'F- 12~'z- Length G'~' Width ~ Total absorption area Depression over field (Y/N) rJ Results (pass/fail) ' ' Peroxide treatment (past 12 months) (Y/N) Soil rating C~.6 Gravel thickness_ ~ ' Cleanouts present (Y/N) Date of adequacy test for System type Total depth If yes, give date S ¥ S're'r~ bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain __ On adjacent lots -Fl~o Property line To existing or abandoned system on lot Cutbank -t- ~O' Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date ~- HAAFee$ ,) 7¢ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number 60~ [0~ -'4~)>- 66 g6 00~ gg/~N '1 6~CJ~l ! 00961 OVOa