HomeMy WebLinkAboutWEST ADDITION KNIK HEIGHTS BLK 1 LT 2WEST A Ol)ITION
KNIK HEIGHT5
lock I
Lot 2
! 7-035
-25
Municipality of Anchorage
Community Development Department Page 1 of 2
On-Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650•http://www.muni.org/onsite•(907)343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181256 PID Number: 017-035-25 ❑ New El Upgrade
Name:
PAUL&VICTORIA RASMUSSEN ABSORPTION FIELD
Address
❑ Deep Trench ❑Shallow Trench ❑ Bed EI Mound
12601 ELMORE ROAD ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grad-
5 GPD/SF Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel.:. beneath pipe
Subdivisionwe5f MI, 4-i on Rn tl[I- ,clock Lot
F. Ft.
1 2 Fill added above original grade Gravel length
Township Range Section Ft. Fl.
Gravel width Beds:Number of Lines Distance between lines
SEPARATION DISTANCES Ft. Ft.
To Septic Absorption Lift Station I Holding I Sewer Total a rption area Number of trenches Dist.between trenches
From Tank Field Tank Line Ft2 Ft.
Well 119.2 N/A N/A N/A 110.5 TANK El Septic ❑S.T.E.P. ❑Holding ❑Other
Manufacturer Capacity
Surface Water 100+ N/A N/A N/A GREER 1500Ga1.
I Material Number of compartments
Lot Line 82.9 N/A N/A N/A STEEL 2
I NA
Foundation i 11.4 N/A N/A N/A LIFT STATION
Manufacturer Capacity
Curtain Drain I 50+ i N/A N/A N/A �al.
Pump on level at Pump off level at igh water alarm at
Remarks TANK REPLACE ONLY
in. in.
Pump make a oriel Electrical Inspections performed by
to
PIPE MATERIAL House to tank 3034 Tank drainfield
3034
Installer
BEEKS CONTRACTING Drainfield CO/MT 3034
Inspector PANNONE ENGINEERING SERVICES BENCH MARK (Assumed elevation) 465.0ft
Inspection
1st 11/18/18 2" 11/19/18 Location and description
3rd 4"' NE BOTTOM HOUSE TRIM
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp
-.�.... 'VW.,
�� OF Agkl
Conditional Approval: DateAP"� !Qs �1
/�,kcoP• N . -.. it
i G /
Or 1 ?4i '
Steven l . I annorae Ai
tl��,•. CE ;1;42
Approved G Date I ^2 G—V �tl„„'� =`.�►�
\\�1
Inspection Report_1-1-12.doc +
I \ " N 1
11 1 \ N ' NO WELLS OR SEPTIC W/1 200' - N. \ 1-- -. j:'•"- `�` \///
I— —
• 450 \ \`55 \ \ \ I tt • ii
1 ' 1 a 455 460 01 _ _ \ \ \ 1 i X%»}#*t
I. r F I _44405 ., I\ 1 �. •/r ,'1: ',
It 470_ \ j
a 61.
475 TRUE TH " .EC : 1'= 50'
- •
• ° • I, l - 465 - - \ \ \�/
l I I
° / / if ` \ 51 I I \ \
/' —
i «1 / \ 4' CONCRETE SIDEWALK o 1 N \ ^I -
•I / �t/, 4 ON GRADE \ N /
[\ I � 1
/ - r ° ` / INSTALLED 1500g SEPTIC TANK
I; % ,� 1 �R'vE`waY -----7------- - W/ DCO AFTER CONNECTED TO END cS �- \
`° C 4 a° 'a
l OF EXISTING TRENCH CST
/ 4
I o I • 4 ` • a• \ 11.1 7..►_ \ I ( i \ �<Cs cam \
1 Il \ IX I I 1 r ��� , I L ~ ` v
• D 119.2 —
o 1 WELL (E) 5 GDR
SFD t I ! 1 II I
M —� REMOVED 1500G SEPTIC . F.
\` 1 M TANK E PER MOA CODE f I I
\ `I ` \ \ 47C/ I I 1 \ t Q Cv�
/ i•
\ --"4-- N. 1 _ _N_ _ I \ _ ..-- /
; `sic. I \ _5 U�il�Esmt �` I I
\ 1 , _
�— \ �� .� i A B
\ E ` - / - - \
w -- - \ N 7 H 1 Ti 30.6 34.5
\ a / N N I` \ w 1 I T2 35.6 39.5
k\- WELL (E),..----/-19 i \ N \ \ I DCO 37.5 41.3
\ of
z�
—w —W — WATER LINE / Q 0 0 0 1, ,o
WELL RADIUS 0 z z z J z
CO
-SS -SS - NEW SEPTIC 0 J W J 0 w
U 0 U 0 0
- OG. FG. - - -
-
465.0
ABBREVIATIONS
TH TEST HOLE _ _
(P) PROPOSED 1500g
(E) EXISTING 460.4 / SEPTIC \ 460.2
CO CLEAN OUT NO. TANK PROFILE
MT MONITOR TUBE NO.
TYP TYPICAL SCALE: NTS
NOTES: PANNONE ENG SVC, LLC Dote
RECORD DRAWING 11/19/2018
P.Q. BOX 102954 ANCHORAGE, AK 99510 �' ••" .
PHONE (907) 272-8218 FAX (907) 272-8211 Scole
*I - 1� .* 1" = 50'
••'ffi'��+'�l►'� ••• P.I.D. NO
KNIK HEIGHTS WEST ADDITION B1 L2 �►1\I/ - I .7-035-25
DRAWN ACP PAUL & VICTORIA RASMUSSEN 4}even R. =bn '.e• PERMIT NO.
CE 8149
12601 ELMORE 'rt'• .. OSP 181256
•SITE PLAN ANCHORAGE, AK ' l �; , Sheet
2 OF 2
N,"°""'r, MUNICIPALITY OF ANCHORAGE
\\ On-Site Water&Wastewater Program
PO Box 196650 4700 Elmore Road _ /.
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.org/onsite
IA a
I)cpartmcnt
9NCtiQRPGE
On-Site Wastewater Disposal System Permit
Permit Number: OSP181256 Effective Date: 8/10/2018
Work Type: SepticTank Upgrade Expiration Date: 8/10/2019
Tax Code Number: 01703525000
Site Legal Address: WEST ADDITION KNIK HEIGHTS BLK 1 LT 2 G:2836
Site Mailing Address: 12601 ELMORE RD, Anchorage
Owner: RASMUSSEN PAUL D & VICTORIA Lot Size in Sq Ft: 59138
Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 5
This permit is for the construction of:
❑ Disposal Field C1 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72)and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions: ***The tank is to meet the minimum 5' separation to the deck supports.
Received B k$ ���� Will� Date: S 13 •
40
Issued By: ; / . � _ . / Date:
epoas
MUNICIP A LI Y OF A NCHORAGE
Community Development Department ` / Phone: 907-343-7904
Development Services Division — Fax: 907-343-7997
On-Site Water& Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 017-035-25
Property owner(s) Paul & Victoria Rasmussen Day phone
Mailing address P.O. Box 1546 Girdwood, AK 99587
Site address 12601 Elmore Road
Legal description (Sub'd., Block & Lot) West Addition Knik Heights B1 L2
Legal description (Township, Range & Section)
Lot Size 59,138 Sq. Ft. Number of Bedrooms 5
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field ❑ Initial ❑ Single Family(SF) ❑X
❑X Upgrade
X (w/wo ADU)
Septic Tank
pg ❑ Duplex (D) ❑
Holding Tank ❑ Renewal ❑
Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE/WAIVER REQUEST FOR:
Dis tance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: c2/5" Waiver Fees:
Date of Payment: g/"n/a Date of Payment:
Receipt Number: /� c n Receipt Number:
Permit No. 0 S /p n/ .5Z Waiver No.
Permit App__;- ::...'c
Municipality of Anchorage
On-site Water and Wastewater
Pannone Engineering Services «c REVIEWED FOR CODE COMPLIANCE
OSP181256,Deb Kbcxenruss,08/10/:
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail:steve@panengak.com
August 8, 2018
Subject: Knik Heights West Addition B1 L2
EMERGENCY Tank Replace Permit Request
Design Narrative
This is a design narrative for a permit to install an upgrade 1,500g Septic Tank to replace an existing
1,500g Septic tank to be issued for this property.The existing tank has completely failed. It will be
decommissioned per code. Currently the lot is developed. The proposed system will utilize a replacement
1,500g septic tank that will be connected to the existing drain field. The existing tank is located
approximately 100'+from the well. The proposed tank will be placed outside the existing well radius. All
required separation distances will be met.
1. Upgrade Tank Design.
A foundation clean out installed if needed.
The tank will be located: 5'+ from any property
10'+from building foundation
10'+ from any water line
100'+from any surface water
100'+from any private wells
200'+from any public wells
The proposed installation will not affect the future development of the surrounding or existing lots.
If you have any questions or concerns, please contact me at 907.745.8200.
Sincer-
teven R. •annone, P.E.
Owner/Civil Engineer
}
Municipal of Anchorage
1 On-site -end-Wastewater
1 - P 1 I 1 \ r` \ - "
/ I I l IZEVIEVVED F CGDE CONPIJANCE
I / \.-.e.:�:.
I I I 1 i N \ _ , r OSP18 to enfuss.08/1N
j 1 II i N 1 — ��/
445 \ / N
II \\ 1 A \ N \ �7 1 `.. iv. -�-'
1 \ ` NO WELLS OR SEPTIC W/I 200' - N \ i'• ` ; 1'.- -
450 455 460 465 - ` N. - \ \ RUE N TNj.iSFALV l'=50'
I / N \ ' I 1
° (• M �'�\ — 2 _ \ \' I 1
I. r � I �I 465 N I\
4 \A` a I , � \ ^ �\ \ 470£: \ I ♦
L • 075 480
1 - 465- \ N.
I ! <°!•, / 4' CONCRETE SIDEWALK• \
I •; / 1 . ON GRADE -\ I\ N
/ .. / 1
p I I I1 E ° ` INSTALL 1500. SEPTIC TANK (P)
<7 I I I / W I DRIVEWAY r 3• W/ DCO AFTER CONNECT TO END N
cN
1 I I •I / ,, I < G 7. ea. .< ° ° OF EXISTING TRENCH
° 1 .1I \
II \1 < O----� iiir7.84--- 1 1 I I ..
i
119.2
I 1 r II
\ < I (� 5 BOR � ' -....7.-....7. ~ 9 I _N_
I \ o WELL SFD 1 I I
1 1 � N yV1 —� REMOVE 1500G SEPTIC r — — —
1 \ N M TANK (E) PER MOA CODE (I I
O 1 \I \ . / I• I rl 1 r
\ \ / \ N 470 / I \
I J i \• N
N
I /
LJ
\I � I ----
- -/- / III \
N. / I / — \
i N N 5'UikEsmt ,A i
1 I -� �_ � � 'rte �� I \
I \ � � N\ I I
\ W I - - , \ _ � N N — , 3 wi I
— ^\ I ` - - E. ! WELL (E) Th N \ N1 \\
\ -I I - 1 \ \ 0 1 i
\ <I \ \ \ \
\ � 1 N 1 I t- - - - -
1 z I \ l � � \ I / , —
1a I \ N ,
I I - - -
1 •- • I
• /I I I
ABBREVIATIONS
TH TEST HOLE 1\ I I I
(P) PROPOSED I I
EXISTING I 1�w `— W --
(E) —W w - WATER LINE / I
CO CLEAN OUT NO. I QV / WELL RADIUS I
MT MONITOR TUBE NO. 4, —SS —SS — NEW SEPTIC I
TYP TYPICAL rrj7"� I
Ii
NOTES. PANNONE ENG SVC, LLC Dote
FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 IA 8/10/18
PHONE (907) 272-8218 FAX (907) 272-8211 e•'°•' �4 Scale
*:49 Di i. %it r = 5o'
•••••.i • P.I.D. NO
KNIK HEIGHTS WEST ADDITION B1 L2 .�. 017-035-25
°•P,leven annone
DRAWN ACP - PAUL & VICTORIA RASMUSSEN CE 8149 PERMIT N0.
12601 ELMORE i.•,... .•••
SITE PLAN
ANCHORAGE, AK °':i Sheet
1 OF 1
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP181256, Deb Wockenfuss, 08/10/18
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP181256, Deb Wockenfuss, 08/10/18
NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchora~.]e, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE
UPGRADE
MAILING ADDRESb
LEGAL DESCRIPTION
LOCATION
l, x /5'3'2.
Well
DISTANCE TO:
Manufacturer ~.~
I Liq. capacty ngaHons[
/~'(~ O ,~ ~ u,v,~ ...... :
DISTANCE TO: We
Absorption area
Inside length
Dwelii~g
Dwelling
/Width
nufacturer
DISTANCE TO:
No. of lines//
Top of tile to finish grade
Length
Type of crib
Width
:rib diameter
Foundation
Total length Cb~es
Material beneath tile
Depth
Crib depth
Well
DISTANCE TO:
:lass Depth Driller
Building foundation Sewer line
DISTANCE TO:
OTHER
Building foundation
NO. OF BEDROOMS ~'~
PERMIT NO..7 ? O2¢F3
~o. of compartrnents,~
Liquid depth
Materia! Liquid capacity in gallons
,/ Total effective absor.~otio~] area
inches ' ,,...,'~
Distance to lot line
Septi~tank
PERMIT NO.
area
PERMIT NO.
1Absorption area(s)
PIPE MATERIALS
SOIL TEST RATING
REMARKS
DATE LEGAL
PL I C:[:INT
,lC F:IT I ON
EGFtL
DEPRRTMENT OF' FIEFtI_TN FIND ENVIRONME:N'rFtL PROTECTION
825 '"L" STREET, RNC:HORFIGE, FIK.
'FOR. LF 14.[,,x,E rR
1_2 8:..t KNIF.: HEI.~t.tr.:
LOT t~ I Zlir: ': ¢Z ~'_-]OO S(::!UFIRE FE:Et'
TYF'E OF =,[Jll,,. ftE,_,LF..E, TION S'¢STE:M I''=''
:,: TRENC:H
MRXIMIJM NUMBER OF BEDRC.'.ME ;= 5 SOIL RFITING (';};2. FT/GR)= ~
THE f.EG]_IF..ED ::,I~.E OF THE SOIL. HB~OF..FIIUN ×,r_,rEM IS:
[::::. E: F::~ T' g. dl ~: :IL :::i~ L E ~'-~ ~ "lF E41 ~-= ~ ~C-~ R FII ".,P' !i~ I1_ ....
THE LENGTt4 DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRFI~NFIELD.
THE: DEPTH OF FI TRENCH OR PIT ][5 'THE DISTRNCE BETHEEN THE SUR. FRC:E OF' THE
GROUND FIND THE BOTTOM OF ]'HE EXCFIVtaTION (IN FEET).
TNERE IS NO SET HIDTH FOt;.'. TRENCHES.
THE GRFIVEL DEPTH IS THE MINIblUM DEPTH OF GRRVEL E:ETWEEN THE OUTFRL. L.. PIPE:
FIND THE BOTTOM OF' ]'HE EXCRVFITION (IN FEET).
R.E..=,F ul'..I.=, I E: I L.][ T'¢ TO I NFCIRM TH I S [:,EPFIRTMEI'.~T DI...IR I ~'.,IG 'THE:
F'ERM 1 1' RF'F'L ! CFtNT HF, IS THE '-'- "-
INS]'FILLF'ITIOI'.,I INSPECTIONS OF FtI'.,Fr' I,.IELL:::; r3D_TFtC:ENT TO TI-tI... PF.'.OPERT'¢ RND THE
C;r-r~ ,~r~
NIJMBER OF RESIDENCES THFIT THE I,,.IEI..L HILL
MIN~HUH DISTRNCE E;ETWEEN FI WELL RND flN'¢ ON-SITE SEHRGE D]:SF'OSRL S~'STEM
¢1.00 FEET FOR R PRIVflTE WELL¢ OR
:LSO TO 200 FEET FROM I:t PLIBI. ZC: WEL.L DEF'ENDiNG LIF'ON THE T"dF:'E OE' F'UE:Ir__~C b. IELL.
NELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPflRTMENT
OF THE WELL COMPLETION.
O'['t4ER REQUIREMENTS r,lR'~' RPPL'¢. SPEC:[F[CRTZONS RND CONSTRtJc'r~oN [:,~RGRRMS FIRE:
FIVRILRBLE TO INSURE PROPER INE;I'RLLR'I'~ON.
I. bERT I F"r' THRT
::L: .f. FIM I:rRMILIFIR HII"H 'f'HE REQUIREMENTS FOR ON-SITE ::,E!-.IEE .... FIND HELLS FIS SET
FORTH E:'¢ THE MIJNIC:IF'F~It-IT¥ Of:'" FINIZ:NIDRFt3E.
2' I klILl_ INSTFtLL THE S'¢STEM :[f',t flL. L. URE. RNCE HI'FH THE bODE;,.
<- ]: UNDIERE;TRND THRT THE ON-SITE .: .......... ~...,TE. fl MFI"r' REGUIRE ENLFff.~E. flEN'f IF THE
RE'.E;IDEN]:tE IS REMODELED TI]I INC:L, UDE MORE THFIN 5 E:EI)RCIOMS.
/
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99502 276-2221
SOILS LOG- PERCOLATION TEST
[] PERCOLATION
TEST
SLOPE SITE PLAN
10
11
12
13
14
15
16
17
18
19-
20-
COMMENTS
WAS GRQUNO WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND FT
72-008 (7/76)
SlX INCH WATER WELL DRILLED AND CAGED OUT TO THE DEPTII OF
DRILLED AT THE RATE OF /?'/:9~00 PER FOOT,
PROPERTY OWNER ._._]l~y ...... Ze~,_f~ ...... :~._Z~2,~_~_..9~5.t)7_.._..~,~.~,~
LOCATION OF WELl., SlTE._._Z)Jb:~:~'t ~_~_Z ..... 5~t ..... ~'z~,~:~__..~
~ELL LOG:
life,/& .S'e_r~.L: ~,?0o O0
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING,
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF
THANK YOU VERY MUCH,
BERNIE CLAUS OF' RAMPART DRII~.LING, WORKS
DATE
E PLA-AIS
�;!c Municipality of Anchorage
On-Site Water and Wastewater Program
(907)343-7904
Ski e* r
Certificate of On-Site Systems Approval
Parcel I.D. 017-035-25-000 Expiration Date: 3 _3 --i q
1. GENERAL INFORMATION
Complete legal description West Addition Knik Heights B1 L2
Location (site address) 12601 Elmore Rd
Current Property owner(s) Paul & Victoria Rasmussen Day phone
Mailing address 12601 Elmore, Anchorage, AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
Single Family(w/wo ADU)
El Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well El Individual El
Individual Water Storage El Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 5Z14, Waiver Fee $
Date of Payment 11/23-la Date of Payment
Receipt Number 66(13Y6 Receipt Number
COSA# dSJ(', )Y l4, D Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined
in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater
disposal system is(are)safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply
and/or wastewater disposal system is(are)in compliance with all applicable Municipal and State codes,ordinances,and regulations in effect at
the time of installation.
In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system.These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system.The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 745-8200
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R Pannone Date /9//
9FQs �
r�P• 'f'
6. DSD SIGNATURE •'• fg#4�� "' f
System #1 Approved for bedrooms j %Steven k.'Ponnone• ore
System #2 Approved for bedrooms �� '• CE-8149
Disapproved !`k\ ••••cii\t+�
Conditional approval for bedrooms, with the following stipulations:
, VI hry�i
ON-S1(E �,•
WATER ANS
WASTEWATER
pROGR '
cS
rfr .Ar Si-R\I\c.G
By: 22
�^^ Original Certificate Date: ^J -1
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA)based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet t . _
If more than 1 septic system is on the lot:
COSA Checklist# i of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Descr;pt;on: West Addition Knik Heights B1 L2 Parcel ID:017-035-25-00
, A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log(Y/N) Y
Date completed 10/17/79 Sanitary seal (Y/N) Wires properly protected(YIN) Y
Total depth 275 ft. Cased to 275 ft. Casing height(above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 10/17/79 7/14/18
Static water level 245 ft236 ft.
Well production 8 - 9 g.p.m. 7.5+ g.p.m.
WATER SAMPLE RESULTS:
Coliform Neg colonies/100 mL Nitrate 1.64 mg/L
ND 7111118&11116118 GEG & PES
Arsenic ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic / Steel Date installed 11/19/18
Tank size 1500gal. Number of Compartments 2 Cleanouts(Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm(Y/N) N/A
Date of pumping N/A (new) Pumper
C. ABSORPTION FIELD DATA
Date installed 7/6/79 Soil rating (g.p.d./ft2 or ft2/bdrm) 100sgftlbdrm System type
deep trench
Y Yp
Length 40 ft. Width 3 ft. Gravel below pipe 7 ft.
Total depth138* ft. Eff. absorption area 5 +ft2 Monitoring tube Y Depression over field N
Date of adequacy test 7/14/18 Results(Pass/Fail) Pass For 5 bedrooms
Fluid depth in absorption field before test 45 in. Water added 802 gal. New depth 70 in.
Elapsed Time: 125 min. Final fluid depth 58 in. Absorption rate >= 750+ g.p.d.
Any treatmentYes - RIDX **
rejuvenation (past 12 mo.)(Y/N &type) If yes, give date
D. LIFT STATION
Date installed N/A Size in gallons Manhole/Access(Y/N)
"Pump on"level at in. "Pump off level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 1001+ On adjacent lots 1001+
Absorption field on lot 1001+ On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 100'+
Animal containment areas 50'+ Manure/animal excrete storage areas 1001+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 11. Property line 82.9 Absorption field 101+
Water main 101+ Water service line 101+ Surface water 1001+
Wells on adjacent lots 1001+
ABSORPTION FIELD ON LOT TO:
101+ 11
Property line Building foundation 10 + Water main 10 +
10,+
Water Service line 25'+ +Surface water 100 Driveway, parking/vehicle storage
Curtain drain none known Wells on adjacent lots 100'+
F. COMMENTS PI\k C-LacKLIS i /nIF0 ( cePr Sep-174 i t- //t )FeoniGa17vS$6-/5,See A G(ve1.
* Below existing grade at sump. Sump extends 80" below the invert
**Per owner, they add RIDX every few months
G. ENGINEER'S CERTIFICATION �4"�'+"`NN
__'�•OF ALgskk
I certify that I have determined through field inspections and �"'g'�P' •
`4;, yff
review of Municipal records that the above systems are in j*;'q9t T I 4" •_*0,
conformance with MOA COSA guidelines in effect on this date. 1 'v !� •••-
Steven Pannone ��:
Engineer's Printed Name ` •Steven •. •onnine• /
11/26/18 r♦ ,' CE-8149
Date � lea?4A••'
COSA canary sheet_2-6-15.doc
•
4a:�.slaAxnasszuuxaxs;ac." ...a , '✓,�'^. c— Y"•.S^-:_a,=- t.4'',.,�... ,rMisk^�Sasc Iw.r stia,:unaF:r. !IMMO:CS:
GARNESS ENGINEERING GROUP, Ltd
ENGINEERING-,SALES'CONSULTING s ��s- » �:_ 'dvo,,c d Trc"2tmenrSystem
Oea_!er
November 26, 2018
Paul Rasmussen
12601 Elmore Rd.
Anchorage,AK
Subject: West Addition Knik Heights; Block 1, Lot 2 — Well & Septic Adequacy Test for 5-
Bedroom Home
To whom it may concern:
Per your request, an adequacy test was performed on the well & septic system serving the subject
property. Our findings are summarized as follows:
SEPTIC: The system consists of a 1500-gallon steel septic tank, a 3-foot wide, 40 foot long
trench type drainfield with an effective depth of 7 feet. On the day of our test 7/14/18 the sump at
the end of the trench had 45 inches of liquid in it. The sump only extends approximately 80
inches below the invert. Eight-hundred and two (802)gallons of water were introduced into the
drainfield over a 105 minute period, causing a liquid level rise of approximately 25 inches in the
sump (resulting in a 70 inch liquid depth). After a 125 minute recovery period the liquid level in
the sump dropped 12 inches. Based upon this data, it appears that the drainfield meets the MOA
required absorption rate for a 5 bedroom home (750+gallons of absorption per day).
WELL: The well on property has a total depth of 275 feet. The static water level was 236 feet
below the top of casing(BTC) on 7/14/18. After pumping out Eight-hundred and two (802)
gallons of water, over a period of 105 minutes, the water level dropped marginally to 241.9 BTC.
Based on this information the well is producing approximately 7.5+gallons per minute which
exceeds what the MOA requires for a 5 bedroom home(0.52 gallons per minute).
If you have any questions, please contact us at 337-6179.
Sincerely o 44 � •.f-
4 1
� *`u•
!A1� ...•..... . ... i
, �, JJ fr- archer►arness:,�?,
Jeffr . G. ess, P.E., M.S. �'i• lo.C -79 3:��,��2� i'
Pre d,,nt �.•.. i, 2(,� ,
PROFESSI0-, �
3701 East Tudor Road,Suite 101 `Anchorage,Alaska 99507-1259
Phone: (907)337-6179*Fax: (907)338-3246*Website: www.garnessengineering.com
I -
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1 � -- Pry.
Dry. Ease. per Doc
1i - 2003-080479-0 ' i
iUS SURVEY j }
LOT 1A-2 FEET
'ti ti Plot No. 2010-91 •
• N 89'45'58" E 278.34'
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nd St co l IN
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278.50'-- =
., Uti.. Ease.
NOTES -. --- ,. -- LUT .., .� --_. _ -- ____ — _ ] 1
-All dimensions shown are grid bearings and ground distances,record boundaries are per Plats 2010-91 &75-198.
-49th Star has conducted a physical survey of the property and all details shown on this Asbuilt Survey are correct. Under
no circumstances should any data hereon be used for construction or for establishment of property lines.
-It is the owners responsibility to determine the a istence of any easements,covenants,or restrictions which do not appear
on the recorded subdivision plat.
��S BUILT SURVEY LEGEND .,mss.-y ..
49th Star Surveying
1 0 Property Corner 321 Fireoved Drive
Lot 2, Block 1, West Addn. - " utility pole Anchorage,AK 99508
Knik Heights Subd., Q Tele/Comm/Sec.Ped. (907)891-6111
Anchorage, Alaska Jeremy@49thstarsurve in com
g 1 4v Well y g
•
W.O. 18005 DATE:12/02/18 i
I (' Septic System Vent
SCALE: 1".50'
1
Municipality of Anchorage
Development Services Department
Bulldlng Safety Division
On-Site Water & Wastewatsr Program
4700 South Bmgaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www. cLanchorage.sk.us
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D. 017-0.35-25
1. GENERAL INFORMATION
HA
Expiration Date: / '
Complete Isgaldescrlplion kNIK NDCHTS WEST; LOT 2, BLOCK 1
Location (slte address or direclJons) 12601 ELUORE ROAD
Current Property owner(s) KEN EVANS
. Mailing address
Lending agency
Mailing add _res_s
Reel Estate Agent
Mailing 'address
Day phone 345-5927
Day phone
Day phone
Unless o~henvise requested, HAA will be held by DSD for plckup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OFWATER SUPPLY:
Individual Wall
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
IndMdual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Heelth Authority
Approval (HAA) based only upon the representetlons given In paragraph 5 by an Independent professional civil
engineer registered In the Stele of Alaska. cortfficates of Health Authority Approval are required for the Iransfer
of title (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 well 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 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 dale shown below, I vedfy that my
investigation, based on procedures oullined 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 structure indicated herein. I further vedfy that based on the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm ALASKA WATER & WAST[WATER CONSULTANTS. INC. Phone
Aad ess' 6901 D~BARR ROAD, SUITE 2B ' ANCHORAGE, AK 99504
Engineer'~ Prir~ted Name JEFFREY A. CARNESS. P.E. Date
357-6179
Engineer's Comments:
In conducting this evaluation, AWWC, Inc. attempted to provide a thorough,
conscientious engineertng analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results desc/fbed the performance of ~he
system under the conditions encountered at the time of the test, and separetion
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarentee future perfon'nance of the system, nor do they guarantee that
there are no hidden defects or encreachments. AWWC, Inc. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use cf this report by any
other pereon or party is not authorized, nor will it confer any legal #ght whatsoever.
5. DSD SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
bedrooms.
WATERANU :
WAST ATER :
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Manitenance Agreements
Supplemental Engineer's Reort
Other
(Rev. 12~)
Original Certificate Date: /0 ' / ~'~)/
MUnicipality of Anchorage
D.e_velopme~,t.._Se~!ces Depadment
HEALTH AUTHORITY APPROVAL CHECKLIST
~e~ ~0~!71197g ~~
T~ de~ r 275 ~ ~ ~ 275
~~. ._-- ~s, ~o , , :g.p~
~IDA. 017-035-25
C~lng helgM (~ ~nd) ~ 12+
AT:INSPECtION
8/~o/2om,. ,,
238 ~ It,
6.22+~ __ g.p.m,
AW~'CI INC. r- , ,
Ckeno.ts(Y/.) YE~ ,
8ystemtype , TRENCH'-,
Gmvelbelowplpe,- 7 It,
Depression owr ~ld NO
For ¢ bedrooms
New dep~- 39 :In;
6oo+ ~g.p.d.
~ yes, ghee da~e
D, UFT 81'ATION
'Pump ~ at ~ High water alarm level at In.
~ Cycle~ tested Meets alarm & drcult requirements?-
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Se~c tanldlllt ~talion on lot. 10o'+
Absorplion I~eld on lot. 100'+
Public sewer main N/A
Sewar/sepl]o ~,dce line 50'+
On adjacent lots. 100'+
On adjacent lots. 100'+
Publlo sewer manhole/cinanout
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO.'
At--on field
Surface water
Pmpe~y line ~'10'+
Water eervlce line 25'+
Curtain drain NONE KNOWN
F. COMMENTS
Building foundal~on 5'+ Propertyllne ~ 10'+
Water main N/A Water sewlce line 25'+
Wells on adjacent Ints 100'+
SEPARATION DISTANCE FROM ABSORFTION FIELD ON LOT TO:
Bulldlng foundation 1 o'+
Surface water 100'+
We~ on adjacent lots. loo%
100'+
Water main N/A
Ddveway, paddngNehlcle s~orage 25'+
* PER 1979 INSPECTION REPORT
G. ENGIN~ C~R~ON
HAAFoe$ ~C:~. oo
(R~. 12~0o)
Waiver Fee $
Receipt Number
LOT lA
s 89'~'o~' w
so' '
~-m ~d LOT 2 I
Z~-.- ........ ~..~1~:'~-~ ,' m
'"~2;'~ ~
~.-m. ............. .~ ~. - -- --- .... ~' , ~ -
LOT 3
LOT 2. BL~K 1, J~"~' ~"'"~: ~ ~ ~"'
~ ~-L~ITY"OF~ ANC
._.. ' MUNICIP HORAGE
": ~-' . (~J'~/L~' DEPARTMENT OF HEALTH & HUMAN SERVICES
.,',,~ .................~. ~. Division of Env ronment~i Services :. '
J
· . ' P.O.'Box 196650 Anchorage.Alaska~ 99519-6660
Parcel I.D. #
CERTIFICATE OF HEALTHAUTHOR ITY
APPROVAL FOR A SINGLE FAMILY DWELLIN
GENERAL INFORMATION
:' Compl~e legal description
','~ ' "Loc~t~n (site address Or d rections) 1
· ~ ,,;, ~-. M~Jmng ~ddr~,.,. C/O Jack W~ 0o. 3201 "C" S~ S~e 100 An~ora~¢, AK. 99503
""':-:~:~ .~:~)~UMBER OF BEDROOM
ndivi
· ~,.:.'~';'L~.',~t ..~ ·-h:- :;'. '. ' .. . ., . , .. ?~,:. r.: .:., · ...~,. . , ~ -.. ~ _~ ) ~ . . . ...~ .~ ~. .
: '.' ... .... ;.:.,., ;,: NOTE: ~:, If commum~ was~,~e~s~stem,: prowde>wri~en confirmation 7rom State ADEC ,-~; .'
' .{-' '.~',."- -'- '.:., -, -' .' a~estmg to the legah~and status of system. '.- '. :,.;: :~,-: ' ~:. -:'-'. ..... ..'._;"
· :~:~ ...-
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the va dation date shown below, I verify that my
investigati°~'0f this Hea th Auih0rity Approval application shows that'the on-site water supply
and/or Was~ew~ter d sp0sa sys~'iS.Safel funct onal and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based On the information obtained from
the Municipality of Anchorage files and from my invest, i_,qation and inspection, the on-site water
supply and/or wastewater disposal system is in complietnce with ail Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection. '
Name of Firm , ...................... ~ ,,_ ,~, Phone
Eagle River, Alaska 995?7 ',
ROBERT C,- COWAN
., .... /.;~ ~:~:', ~' ~ ........................................ .
.... .'- . CE'8801 '..
· - 8.': DHHS SIGNATURE "'~ ......... ?'"':1'":' ;. ' ."~" ........ .' ::' ':--';:" -"'
.... ' ' : · ' · /~-".'. ~'~-:: "',~"(,'.~
': ':"~"'? ~ '~'~'" ' "~"" ';"': :: "~'"'~' ~"'"'~'~ ....... ";~ "':'~ ~ ~e~' ~: ""'6; ~-"? :~ b~rboms;'~'with, the' followin
u on 'ihb' re m~ntat on~'g ~eq ~ ppra~mph 5 above· by an independent ~
in the State of Al~ka. The DHHS do~ this as a cou~esy to purchasem of homps ~"'
rder to ~tls~ ce~in f~eral and st~te'~u~mm~'nt~.'Employ~s of DH HS do not-'
" ' -,--~' -~,-'--fore"a ce~ificate is'i~u~ The Municipali~ of ~gC.~.~rage ~s. not...
' responsible for errom o'~ ~mi~i0ns n the prom~onal eng~.~rs , · ,':.?',-,'-'-, ~..',::--": :' ',. ;'::',~,,;;.~:'~:; ~ ~.' :~ '.-. ,,
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825'%" Street, Room 502 · Anchorage, AIaska 99501 · (907) 343~4744
Health Authority Approval Checklist
Legal Descriptioo: Lo F ~ flL kz I l<tv~ I[rki-J 1~¢3F Parcel I.D.:
A. WELL DATA
Well type /~/~,
Log present
Total depth ,'7),
Sanita~, seal (~N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed / '~ /''7 / '2cj
?
Cased to ~ ~ f Casing height (above grouud)
Wires properly protected (~)
FROM WELL LOG AT INSPECTION
Date of test I ~ /,? [ 7¢) c~ / t ~ / ~} 3-
Static water level U / ~ ~2 3 J
Well production ~ To ¢~ g.p.m.
WATER S~LE RESETS:
Coliform 0 Nitrate
Date of sample: r~/~ ,V /9 $--
B. SEPTIC/HO/DING TANK DATA
Date installed "/ / C / 7~ Tank size / 5' o 0
Foundation cleanout (~/N) ¥ t ~ Depression (Y/{~ __
Date of Punfping q ]/~ ].~} S- Pumper 2~ ~' //om 4
~) , ;t '2- Other bacteria O
S & S ENGINEERING
I Collected by: .
i?O'Z41t~YRiver L~ep Koad Ne. 204
Eagle River, Alaska 99577
Number of Compartments 2- Cleanouts (~N)_ Y~! J
tv ~ High water alarm (Y/(~ ~, o
,re,(' v, c.~' d
C. ABSORPTION FIELD D3hTA
Dateinstallcd '? /~ / '~q Soilrating (g.p.d,/ft:o k5
Length t/o Widtl~ '~ Gravel thickness below pipe
System type
Total depth
Effective absorption ~'ea ff o o
Date of adequacy test q / t(, / 0/3-'
Fluid depth in absorption field before test (m.); i ~ hnmediately afterTq"~gal, water added (in.):
Fhdd depth (' q 7L Minutes later: ~ ' ' ' : ' ' '
(; .: (m:) Absdrptmn rate = -1 90 4 .g.p.d.
Peroxide treaUnent (past 12 months) (Y/N) u [ ~ If yes. give date ~
Monitoring Tube present(c~D%l) ~'~9' Depression over field (YffL'~) /,~ o
Results ~_a?sFFail) t°4- i J For '~ bedrooms
q 0
ID O
o
Do
LIFT STATION
Date installed
Mauhole/Access (Y/N)
High water alarm level at*
Size in gallons ~-'~
"Pum~ at~af~~'~ "Pump off' level at*
~ *Datum
Cycles._je~slzd~-
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/l~fld-i~g tank on lot / 0
Absorption field ou lot / 0
Public sewer mare A/
Sewer/septic service line
; Ou adjacent lots
: On adjacent lots
Public sewer manhole/cleauout
SEPARATION DISTANCES FROM SEPTIC/HOb~ TANK ON LOT TO:
Foundation ~ -P Property line ,F -/- Absorption field
/
Water main/service line Surface water/drainage /oo -~- Wells on adjacent lots
Building foundation
Snfface xvater
Curtain drain
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Water main/service line
Driveway, parking/vehicle storage area ga 3
Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
/certify that l have determined thru field ina~ections and re, Jew of ~funicipal rec~ ~e a~ ,.?~ are
in conformance with MOA ~ guideJines in efJact on this date.
Signature 7~-~, ~'~
/ /
..................................................................................................
HAA Fee $ 4.-~00, OO
DateofPayment ?_)c{_.p../_c/5
Receipt NuC)m;¢~'q/3/6/6
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner
Mailing Address
(c) Lending Institution
Mailing Address
Telephone: (home) 3¥5--~8¢ Business
Telephone
(d) Real Estate Company and Agent
Address ¢~ ~00 ~_onr~c*,~-
Telephone ~ 7~- ~7~/
(e) Mail the HAA to the following address: (or check here I~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family[] Number of bedrooms
3. WATER SUPPLY
Individual Well I~
Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status,
4. SEWAGE DISPOSAL
On-site (~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Re,/. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of thevalidationdateshown below, lverifythat my investigation of this
Health Authority Approval shows that 'the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
NameofFirm ~'/,~/-,'~/' 7r'ec~n~( .~'¢r-~,;c.~ Telephone ~
Address ) ~.¢'_~0 ~'c. bo .$-/'..., /)-~Of~VC-g ~ /z)-/-:r ~)¢).>'-'/0/
Date ,.,9-pr'',/ /d'., IC)~O
Engineer's Se~l
6. DHHS APPROVAL
Approved for ~ bedrooms b
Approved ~'~isapp roved Conditional
Terms of Conditional Approval
Date 4~7/~/~
The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The MunicipalityofAnchorageisnot responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
~ MUNICIPALITY OF ANCHORAGE (MOA')
[, "~{1[1~-~,~Healt~ Authority Approval (HAA)
APR :1. 7 ].990 Legal Description: A.~/ ¢/.,
R E C E I V E D
Well Classification~,'v¢ ~ If A, B, C, D.E.C. A~proved
Well Log Present (YIN) ~ Date Completed (0 {~7 (7~ Yield
Total Depth ~7~ Casedto ~7~ Depth of Grouting ~,A.
Static Water Level ~ ~ ~ Pump Set At ~ 8 7
Casing Height Above Ground ~0 ~' Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) F Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot I1~~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot I Z¢' ; On Adjoining Lots
To Nearest Public Sewer Line ~ foo' To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot ~ 8~'
Water Sample Collected by __F(~ ~n~( ~ ; Date ~ /
Water Sample Test Results ~}~¢.~¢~- 0 Eol¢~¢m~¢oo~,
Comments O¢A,~ ~1 ~ t-~J~ on ~/~/9~ ~A~¢¢X
B. SEPTIC/HOLDING TANK DATA
Date Installed 7/¢/~ Size ~%~qCL_No. of Compartments
Standpipes (Y/N) Y (.~) Air-tight Caps (Y/N)
Depression over Tank (Y/N) N
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N) N,
Foundation Cleanout (Y/N)
Date Last Pumped _J_{
; for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well I ~C'
To Property Line ;::- (o'
To Water Main/Service Line ~" ~'
To Stream, Pond, Lake or Major Drainage Course ;:> fcc,,
Comments
To Building Foundation
To Disposal Field
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed '~/ox'/ 79
Width of Field -~J
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
/¢~frm Type of System Design
Length of Field qO '
Depth of Field II '
Gravel Bed Thickness 7/
Standpipes Present (Y/N)
Date of Last Adequacy Test
f_,,~- ..,c' ,be,,froor,~r
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot /% 4.
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments R ~.5,~e,~c ~ oc c,~?'r,~rX ~¢
-~-ten c4
To Property Line fie2
o o. To Existing or Abandoned System on
; On Adjoining Lots ';~ 3'o
To Cutback (if present) N,
D. LIFT STATION /'4,
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA g..?;Jerfff'i~§'~[f~,~[ect on the date of this
inspection.
Seal
Receipt No. ~ / -~ Receipt No
Date of Payment ~' ~/~- ~ Waiver Fee: $
Amount: $ ./'~ ~ ~) Date of Payment
72-026 (Rev. 7/88)Back Page 2 of 2
DAT~'I~ECEIVE D
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DtT Ft " 7--/
,NSPECTOR ,NSPECTOR I ' NSPEC,~{%SL-~/.,~
r ~
~NYi~NMENL~L F;qo r~CTION
) DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street- Anchorage, Alaska 99501 JUL. 1980
Telephone 264-4720 '- -- -
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing,
1, PROPERTY OWNER ~ PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) ~) PHONE
2, BUYER PHONE
MAILING ADDRESS
~'LENDING INSTITUTION PHONE
MAILING ADDRESS
,. LEGALDES.,.."T,ON &cT ?>/_, 1
STREET LOCAT ON
6. TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OFtBEDROOMS
[] One [] Four
E~] Two [] Five
[] Three [] Six
[] Other
7, WATER SUPPLY
[2~] INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG, A well log is required for ell wells drilled
since June 1975: For wells drilled prior to that date, give well
depth (attach log if available.)
8, SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE** [ ~ ,'~ C~ YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified. iNSTALLER
[]Septic Tank or []Holding Tank
Size: /-~) ~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line I Nearest Lot Line
1
WELL TO:
Absorptioh Area to nearest Lot Line
5. COMMENTS
/
APPROVED FOR ~ BEDROOMS
F~ CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY