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KASILOF HILLS BLK 7 LT 16
Kosiloff Block 7 Lot 16 #015-132-21 Municipality of Anchorage Page 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: ~u'-)°~5°°t~/ PIDNumber: ol5 Name: ~Z:)^,.,~c> ~. ~~ Wastewater System: ~New ~ Upgrade Address: ~H~ / ~ ~, ~%~o -~A~A~. ~o~ ABSORPTION FIELD Phone: ~o. of Bedrooms: ~ ~Deep Trench ~ Shallow Trench D Bed D Mound ~ Other LEGAL DESCRIPTION so, Rating: Total Depth from original grade: ~.~ GPD/S~ Ft. Lot: . Block: Subdiv~ion: Depth to pipe bottom from original grsde: Gravel depth beneath pipe Ft. ~ Ft. Township: Range: Section: Fill added above o,riginal grade: Gravel length: WELL: ~ New B Upgrade Gravelwidth: ~/ Number of lines: Distance belween lines: FI. / ~ Ft. Classificat~ (Private, A,B.C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Drilled: Static Water Level: Installer: Date installed: Yield: I Pump Set at: Casing Height Above Ground: .,. TANK SEPARATION DISTANCES ~Septic ~ Holding U S.T,E.P. TO Septic Absorption Lift Holding >ubgc/Privale Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~ ~( ho~.A~ -t~ ~ Material: Number of Compartments: Surface , Water ~(;)O~ ~Oo'+ ~ ~ ~ LIFT. STATION LineL°t ~ ~ I ~1 i ~ ~ ~ Size in gallons: Manufacturer: Foundation ~ f+ ~ O I~ ~ ~ ~ "Pump on" level at: J "~~t: High water alarm at: Curtain Drain -- ~ ~ ~JO~. ~ ~d¢~octdcallnapectionsperformodb~: ~emarks: B~GH kocation anO Doscdp~ion: Assumed Elevation: 17034 Eagle River L~p Road, No, ~04 ' ~7 /7, ',3,~ ~ Inspections performed ~gle River, Alaska 99577 Dates: 1st. ~ · t o.~ ',),~~~,,,.~'~' 2nd ~' ~ ~ 'q s~ ~ ~ ~ ~o,,,~ c cowA~ ~,~ ~ ~ CE-8801 Department of Health and an Services approval ' ...... '"' Reviewed and approved by' . , Date' ~-~-'~ "~ ....... 72-013 (Rev 9/91) MOA 25 Permit No. sw950061 Page . 2 of 2 Municipality of Anchorage 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 LOT 16, BLOCK 7, KASILOF HILLS S/D 01513221 Legal Description: PID No.: ST1 NEW 1250 GAL NEw 1250 GAL. SEPTIC TANK ST2 FINAL:. GRADE MT l ~03 78.6 ,~ 74.0' ' NEW TRENCH FCO 34' __. ST1 37' 42' ST2 41' 4.6' C01 42' 49' C02 44' 51' · '-005 ~'-'47''~'' "85~-' C04 68' 41' MT1 48':: 82' MT2 66':~ 44' NO WATER FOUND SCAL]~ f' = 40 100' WELL RADIUS WELL o ROBERT C, COWAN CE-8801 72-013 A (1/93) ' Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Services Division Telephone: 343-4744 ON-SITE SERVICES FEE DOCUMENTATION Date Paid: ~'~- ?- ~g Name of Payer: (Name on Check) M~!iling Addr(J§s: (Off of check) Legal Description(s): Permit Number: Receipt #: OS-- (),~ 1 6 Type of Payment: (Indicate Amount Paid) Health Authority: '~--~-~L3 Excavator Permit: Sewer & Well Permit: Engineer Permit: Well Permit: Sewer Permit: Copy Request: 72-034 (Rev. 10/87) Pumper Permit: Well Driller Permit: Tank Manufacturer: (Waste Treatment) DISTRIBUTION: WAIVERS: Lot Line: Well to Tank: Well to Field Field to Surface Water Tank to Surface Water WHITE--MASTER FILE CANARY--PROGRAM FILE LOCATION OF WELL ~ BOP, oua'. J SUBD~ISION LOCATION/SKETCH: DEPTHS MEASURED FROM:~]casing top r]ground surface S£G~ION QTR~ II WELL OWNER: WELL DEPTH: Depth of hole; STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION OF MINING & WATER MGMT WATER WELL RECORD I · · M£RIDI/~N DATE OF COMPLETION BOREHOLE DATA: Material Type and Color Depth From To -/ DEPT.H.,T.O STATIC WATER LEVEL: _ ¢ ,~. ft below ,~. top of casing ground surface METHOD OF DRILLING: ,~L air rotary [~ cable tool I--I other USE OF WELL: [] domestic [] irrigation [] monitor [] public supply [] other. __ CASING S'nCK.UP: Diem: to Casing type:. '-~,~,,-J~' - ~ ,=in. to ~'~ft WELL INTAKE OPENING TYPE: [] open end [] screened [] perforated J~. Open hole REC.' r~eot. Health CONTRACTOR INFORMATION: & Human Iervice" Registe'red Business Name r. /' / ~'? ' '¢' "/ "'- / '7 ~.,,~'~' Z, ,/ "). , /~/Z:~'.--~-~.-.': ,..~ /',,."-~'...,..?:... ,...-' - 1, - _ S]gnaJure of Authoriz~'d Re$f~'esenta[ive . Date Depths of openings: ~ to ft SCREEN TYPE: . Diem: in. Slot/Mesh Size: Length:~ . ft GRAVEL PACK TYPE: Volume used: Depth tO top: GROUT TYPE: Volume: Depth: from ft to ft DEVELOPMENT MEI~HOD: ,:/~..,',--"L. _,.. Duration: /~.,./'-~.., PUMPING LEVEL AND YIELD: · ~'-fi~..~ ft after ,;.~ hfs pumping ~' gpm PUMP INTAKE DEPTH: ft Horsepower: WELL DISINFECTED UPON COMPLETION? [~YES [] NO REMARKS: PLEASE MAIL WHITE COPY OF LOG TO: DNR/DIVISION OF MINING & WATER MGMT PO BOX 107005 ANCHORAGE AK99510-7005 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PAGE 1 OF PERMIT NUMBER:SW950061 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:BIEGEL DAVID R OWNER ADDRESS:2320 TASHA DRIVE ANCHORAGE, AK 99502 DATE ISSUED: 4/27/95 EXPIRATION DATE: 4/27/96 PARCEL ID:01513221 LEGAL DESCRIPTION: KASILOF HILLS BLK 7 LT 16 LOT SIZE: 30000 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL 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 (iSAACS0) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVIS ION~: RECEIVED BY: ISSUED BY: / DATE ROBERT C. COWAN, RE. ROBERT A. SHAFER, RE. HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN E)~TENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM DESIGN April 20, 1995 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Lot 16; Block 7; Kasilof H,C6~ Request you/ssu¢ a pe;unitto drill a w~llandinstalla septic system to 6~rue the proposed fowt bed~oon~ hou~ on the ref~eneed prope~. TeAt hole~ were, excavated and percolation test~ performed. The, approximate, locations of the teat hole~ are located on the, attached site plan. At the, t,,~e of excavation no wate~ was encountered and after seven day ground water monitoring, the monitoring tub~s were found to be, dry. This property has enough area for a future, septic upgrade which can be seen on the, attached site, plan. The, proposed 1250 gallon septic tank is to be, place, out~ide the, well protective radius. The. attached site. plan depicts the, location of the. proposed tank. If you require additional information, please contact us. Sincerely, ROBERT C. COWAN, P.E. RCC/gk Enclosure, 17034 NORTH EAGLE RIVER LOOP · SUITE 204 , EAGLE RIVER, ALASKA 99577 0 Z 0 NVld Ills :31¥08 PERFO*MED FOR: '~UL- Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG m PERCOLATION TEST LEGAL DESCRIPTION: L..C'~?..' /'~,, ~"'~¢ /~:~'~,/(-.~1c:TOwr~ship' Range, Section: /-//LL~ SLO.E S~TE PLAN OR.Nits' ENCOUNTERED? 7 8 9 10 11 12 13 14 15 16- 17- 18- 19- 20- S L IF YES, AT WHAT ~ O DEPTH? p E Depth lo Waler Alter ~,,,~?/ Monitoring? Date: -I N Gross Net Depth to Net Reading Date Time Time Water Drop : 13 I0 ~,~ ~/~" Va~ '. ~ /o., 3~¢~ ~ ~ PERCOLATION RATE ':;~'"~ tm,nutes/inch) PERC HOLE DIAMETER COMMENTS ERFORMED BYi ~ \ \~ p ~ ~ ~ , .vJ\_,~, j\/% ~. ] CERTIFY THAT. THIS TEST WAS PERFORMED IN ACCORDANCE WI~H ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG m PERCOLATION TEST p ER FORM E D F O R: "~EZ~ b,(.,_. ~t¢~1',.¢~. ~,,..~ 2 4 7 8 9 10 11 12 13 14 15 16 17 18 19 2O DATE PER FOR ~Sb':~'~:.'~ ~lCCt ~Township, Range, Section: S~T. WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT ~" O DEPTH? p E I~onJtoring? , Date: Reading Date Gross Net Depth to Net Time Time Water Drop ~3~ ,~o" ~/~ ---I~' PERCOLATION RATE ~O {mmutes/~nch) PERC HOLE DIAMETER TEST RUN BETWEEN -~ FT AND ~ F1 ACCORDANCE WIikT'H ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THISDAT~=. DATEi ~/~"O/~' ~-- 72-008 (Rev. 4185) HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN E~TENSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE P[~,NS ROAD DESIGN SOILTEST PERCOLATtON TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM OESIGN ncnee m ROBERT C. COWAN, RE. ROBERTA. SHAFER, P.E. ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 REFERENCE: Lot 16, Block 7, Kasilof Hil2Ls S/D GENERAL: 1. The scope of this project includes the installation of a 1250 gallon septic tank and a leachfield trench to serve 'the proposed four bedroom residence for the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP . SUITE 204 o EAGLE RIVER, ALASKA 99577 Page Two Lot 16, Block 7, Kasilof Hills S/D Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over 'the trench must be mounded to prevent the formation of a depression after settling. Page Three Lot 16, Block 7, Kasilof Hills S/D MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Typ9 of Pipe Perforated Solid Cast Iron ASTM D3034 (PVC) ASTM F810 (HDPE) ASTM D2662 (ABS) Yes Yes Yes Yes Yes No Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). Se A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. Ali. leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.Co requirements. Page Four Lot 16, Block 7, Kasilof Hills S/D INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of 'the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted a't least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.0.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and 'the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/OWNER Tom Fink, Mayor / un c pality Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 January 8, 1991 Allisa Crandall and Lee Damron 6200 Bubbling Brook Circle Anchorage, Alaska 99516 Subject: Lot 16 Block 7 Kasilof Hills Subdivision Permit #900279, PID #015-132-21 The subject permit, issued by this office for 8 single family well an~/or on-site wastewater system has expired as of December 31, 1990. A new permit must be obtained from this office for a well and/or on-site wastewater system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this office for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site wastewater system, the original as-built inspection report (three-part form) must be sent to this office for review, approval and documentation. All inspection reports must be submitted within 30 days of construction completion. When applying for a new permit, the fees are: $90.00 for an on-site wastewater permit; $50.00 for a well permit; $140.00 for a combined on-site wastewater and well permit° If you have any question~, Pr~ ~anCger On site Services please call this office at 343-4744. JW/ljm:200 enc: Copy of Permit "Kids Are Our Future" /, / ~ ~? / ~ :.SEWE~. SYSTEM ' LOCATION PLAN. · DRAWN BY,~d SYSTEMS INDICATED IS NOT EXACT. NORTH DIMENSIONS INDICATED HAVE BEEN DETERMINED BY USE OF CLOTH TAPE · ~'~: .............. '-~?':?~::~.~?, r';~:v..:'~: ". ?:.:.~..'~':~.-~':~.~.~'..:~-~:v ~'?.~ HOT ElY SURVEYING TECHNIQUES- DEt~AtTTMENT OF lq ~EALTH & HUMAN 825 "L" Sttzeet, Anchorage. Alas SOILS LOG -- PERCOLATION TIE.~ 1 2 3 4 5 6 7 9 10 11 12- I3--- 14- 15- 16 I7 I8 19- 2'0- COMMENTS. Township, Range. Section: SLOPE WAS GROUND WATER .., ENCOUN'rEaEO? DEPTH? SITE PLAN PERCOLATION ~tATE T~T RUN OETW'F_EN PERFORM60 BY: ACCOR0.,~JqC6 VctTi4 ALL ST^i'~ AN0 ~UN(C;PAL GU[OEL(I 72-0~ (P,c~. 41851 (m/~u~e~g;~/~: PERC I40LE DIAMETER TIFY TI4AT T~(S T.~.ST WAS pERFORMEO (N R&M ENGINEER!NG 8: GEOLOGIC,' ,L CONSULTANTS 229 EAST 51st. AVE, -- P.O1 BOX 6087 - ANCHORAGE, ALASKA 99503 TELEPHONE 907-279-0483 TELEX 090 -35419 Civil Engineers Geologists Land Surveyors JAMES W. ROONEY, P. E. MALCOLM A. MENZIES, P.E., L.S. JAMES H. WELLMAN, P.E. RALPH R. MIGLIACCIO Engineering Geoio9ist. August 11, 1973 R & M No. 36644 Mr. Leo Sawyer Box 10105 Klatt Station Anchorage, Alaska Re: Test Hole and Soil Log Report for Sanitary System Block 7, Lot 16, Kasiloff Hills Subdivision Dear Mr. Sawyer: We are submitting herewith a description of the soil stratifi- cation at the subject site and our comments regarding soil conditions encountered. This investigation was performed in accordance with your request of August 10,1973~ and those pro- cedures outlined in a letter dated Septei~er 13, 1971 by Mr. Rolf Strickland of the Greater Anchorage Area Borough Department of Environmental Quality~ A single test hole was put down within the Lot 16 area for the purpose of defining general subsurface soil conditions for the proposed sanitary system. Excavation was accomplished with an auger type drilling rig and the test hole was extended to a total depth of 15 feet below ground surface° The follow~ ing stratification was determined from samples provided by the driller and left at 'the site for subsequenl~ inspection by R & M personnel on August 10, 1973. De__p~hs Soils Classification 0' - 1' Organic sandy silt - 1' - 7' Silty sand some cobbles SM 7' - 10' Fine sand some gravel GM 10' - 15' Sandy silt trace gravel! ML No bedrock was encountered in the hole. Ground water was not encountered in the tes~ 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. 015-132-21 1. GENERAL INFORMATION Expiration Date: <E — ZS-- 2-I Complete legal description Kasilof Hills Sub, Block 7, Lot 16 Location (site address) 10241 Stroganof Drive Current property owner(s) Lisa Maserjian/JOSeph Carr Day phone (907) 444-6516 Mailing address 10241 Stroganof Dr, Anchorage, AK 99516 Real estate agent 2. TYPE OF DWELLING: Day phone ❑e Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Private Septic ■❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 650 Date of Payment a o Receipt Number 09 5 y y 6 Waiver Fee $ Date of Payment Receipt Number COSA # 05G2 � J2 6 1 Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller Date 5/19/21 OF ACq !l r���P• . . sf.9t�� 49TH �. .. ... 6. DSD SIGNATURE � •--- System #1 Approved for _LL bedrooms BenjarmrrvSchiller / System #2 Approved for bedrooms %���T�� CE•12592AW Disapproved �l�pROFESSI*�.� Conditional approval for bedrooms, with the following stipulations: —�4����- WATER AN rn TL V" ATER z J i��iJJ T SERV\C� By: Original Certificate Date:rZs 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 Septic System Advisory Well Flow Advisory COSA Checklist blue sheet Nitrate Advisory Arsenic Advisory /� Other_SA-eel-i—Lutc 0c, Aak;,S�uy Se {' afka c�:� Legal Description: Kasilof Hills Sub, Block 7, Lot 16 If more than 1 septic system on lot: COSA Checklist # A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 5/16/95 Total depth 204 ft Cased to 36 ft ❑ Sanitary seal is functioning correctly ❑® Wires are properly protected Casing height (above ground) 18 in. Date of flow test for COSA 5/11/21 Static water level at beginning of test 36 ft. Comments B. TANK DATA Age of tank(s) 26 years Tank type/material Steel Measured operating fluid level in septic tank 52 Q Standpipes/foundation cleanout per record drawing Date of pumping 9/23/20 A+ Home Services D. ABSORPTION FIELD DATA Deep Trench Which system tested (date installed) 5/15/95 Q ALL standpipes present per record drawing Total measured depth from grade 12.2 ft (max) Measured depth to pipe invert from grade 3.6 ft (min) ❑ N/A — pressurized field FE -1 Monitor tubes go to bottom of effective. If not, state depth into effective n Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 015-132-21 of Structure served by this system Well production at time of test 3.0 gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 1.41 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by Forge Engineering Date of Sample 4/26/21 C. T STATION ❑ Require intenance completed Age of lift station years Lift station material Comments: Adequacy test date 5/11/21 Results Z Pass For 4 bedrooms Fluid depth prior to test 29 in Water added 626 gal New depth 31 in Elapsed time 1440 min Final fluid depth 27 in Absorption rate '600 gpd Any rejuvenation treatment (past 12 months) If yes, enter date e E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' F,71 Yes Community Sewer Manhole/Cleanout > 100' 7✓ Yes if No ft F7 Yes if No Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25'✓0 Yes if No Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100' F/ Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' ❑✓ Yes if No M Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' E] Yes if No ft✓❑ Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' F/ Yes if No ft Surface Water > 100' ft ft ft ft ft ®✓ Yes if No ft Property Line > 5' F,71 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑✓ Yes if No ft Private Wells > 100' Yes if No Water Main > 10'✓❑ M✓ Yes if No ft Community Wells > 200' 0✓ Yes if No _ Water Service Line > 10' 0 Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' 1 El Yes if No ft If absorption field is. under driveway comment below Property Line > 10'✓0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' ®✓ Yes if No Water Service Line > 10' M✓ Yes if No ft Community Wells > 200' ❑✓ Yes if No Surface Water > 100'✓0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that 1 have determined through field inspections and review Of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet •Benjarr�rySchiller �F� • . , C E 12592 . • ����� �� �J>F�• • 5/19/21. ,'���, ft ft ft ft MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT On -Site Water and Wastewater Section v»m/xu.nnuni.ore/onsite Septic Tank Advisory Certificate of On -Site Systems Approval #OSC 211261 Subdivision: Kasi|ofHiUs B 7 lot 16 Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 26 years old. Typical replacement costs range from $8,000 to $11,000 This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 20 -year-old steel tank MAY look like. 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 I ~"~ -~,~./ NAA# .~. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner '~.~--~ <--(., Mailing address Day phone Lending agency Mailing address Agent o Address Day phone Unless 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 MOAt¢21 5. STATEMENT OF INSPECTION BY ENGINEER o 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. NameofFirm ' l~'/~n ~yvv-~'-..\¢.~ ~ ~ Phone ~~/~ Address ~ % ~ ~ ~ ~ ~ -~ EngineeYssignature "~ - ~~~-Date ~0/~/¢~ DHHS SIGNATURE ~ Approved for FO c] l~ bedrooms. Disapproved. Conditional approval for bedrooms, with th-e 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 Municipality of Anchorage 0C'l' 0 5 ~99.~ ~.~ DEPARTMENT OF HEALTFI & HUMAN SERVI~E~S.,,..,~,,,, ',,,I ~,,,~. ,,~,.,.~,~ Environmental Services Division /JF.~)NMt;N~Ai, ~kl~Vlg~ 121¥1~ 825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 343-4744 Health Authority Approval Checklist Legal Description: A. WELL DATA Well type ~--~. Log present (Y/N) Total depth If A, B, or C, attach ADEC letter. ADEC water ~ystem number Date completed ~//'7 / ?~ Cased to ~ ~ Casing height (above ground) Sanitary seal (Y/N) Wires properly protected (Y/N) ~ Date of test FROM WELL LOG ~ ~ r"? ~ q' ,,~ AT INSPECTION Static water level ,?- ~) Well production WATER SAMPLE RESULTS: Coliform Date of sample: q'/~ Nitrate g.p.m. Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed J~/l?>lq~' Tanksize ~..¢~ Number of Compartments ~ .Cleanouts (Y/N) ~/ Foundation cleanout (WN)_ ~// Date of Pumping ~/¢~/'~,P' C. ABSORPTION FIELD DATA Date installed ~ //~ Length ,~ ~, Width Effective absorption area /¢~ Date of adequacy test ¢?//~1 Fluid depth in absorption field before test (in.); Fluid depth ~ (ins) Minutes later: Depression (Y/N) I",/ High water alarm (Y/N) _Pumper ~4¢~. ~,.& Soil rating (g.p.d./fF or fF/bdrm) Gravel thickness below pipe Monitoring Tube present (Y/N) ~ Results (Pass/Fail) %[> O, J:5 System type '-(~-'¢~', (~ . _ Total depth. · Depression over field (Y/N) For /7/ Immediately after ~¢-o gal. water added (in.): Absorption rate; = > ~,-0-(:;:) .g.p.d. Peroxide treatment (past 12 months) (Y/N) /~ If yes, give date g.p.m. ]~: lw[ bedrooms 72-026 (Rev. 3/96)* LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons "Pump on" level at* *Datum "Pump off" level at* Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot ) On adjacent lots On adjacent lots Public sewer main t-.(~ Public sewer manhole/cleanout Sewer/septic service line '> ,."). '.'~' Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 1~1 Property line ~ / O Absorption field Water main/service line ~' ~,~'- Surface water/drainage /"h'//¢ Wells on adjacent lots I~..~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ( ~ / Building foundation ,~,.~ Surface water Curtain drain F. ENGINEER'S CERTIFICATION Water main/service line Driveway, parking/vehicle storage area ~ ~'~ Wells on adjacent lots /~:~.~ I certify that I have determined thru field inspections and review of Municipal records that the above system~are in conformance with MOA HAA guidelines in effect on this date. Signature Engineer's'Name Date of Payment ,,¢ >,'~/¢ ,¢O' Receipt Number <:::?'/~'¢~>'¢~ ~'/~'-~7'/--~ ) Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* 3C:-I--02-19E~rE~ 14: 19 C:I-8:E E'.3 ! ' ~ Ci'&E Erlvi:onrnent~l Service.~ Inc, RNCHRF,'FtGE CT&E Ref.# Client Name l*roj~'~ Name/~' Client Sample Matrix Ordered By PWSiD 98537 i o02 Tobben Spurkland P,E, Wa L16/B7 Kasilof Hills Dri~:~lg Water Clfent PO,~' P~lated Date,rTIme 09/25/98 14:03 Collex~ted Ihlte/Time 09/21/98 t 2:10 Received Date/Time 09/21/98 16:00 Technical Director: SteDhen {;. Ede fi[to~aDt¢ Pl'ep ;¢ t v,. ,, Parcel I.D. it 1. 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 OENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ,. HAA# ' Location (sitg~ddress or directions) 2320 Tasha Drive F ~'"" ' B~'o~ib~t</6wfler _Da~[d"~L~el Day phone Mai~iffgaddre~s ~~06, Ancho:aqe, AA 9951[ ~.~,~,,~,,,~ .... ~.~-~° .... ~Res~'~t ~.e. ~ ~ . ,. ~ortgage~arren. _ ~ssett Day phone 565-5338 M~i.l. ing address 1~00 ,west Benson Blvd., Anchorage, AK 99503 Agent" ' .:',' ,o' Day phone Address 222-8800 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: NOTE: NOTE: 72-025 (Rev. 1~1) Fron! MOA#21 Individual well Community well Public water xxx If communily well system, provide written confirmation from State ADEO attest- lng to the legality and status of system. 4, TYPE OFWASTEWATER DISPOSAL: Individual on-site ~ .... commUnity on-site ..... :: - '~::¢¥ If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 5. STATEMENT OF INSPECTION BY ENGINEER Name of Firm S & s ENGINEERING · : 17034 Eagle River Loop Road No. 204 Address Eaale River, Alaska 99577/ ..Engineer,~signature : ~?/ff~_~,~47~,~~ .~' '. 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. . Phone · :~.~i ~ .~ ' ~' 6;: DHHS SIGNATURE bedrooms. i::' l'/ Approved for .... Disapproved, Conditional approval for · ii. bedrooms, with tho following stipulations: Additional Comments This certificate re.btaces th~ c~ndftional certificate issued 9-8-98. By: The Municipality of Anchorage Department of'Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska, The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state 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-(~5 [Rev. 1/91 ) 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 015-132-21 HAA# HA950372 1. GENERAL INFORMATION Complete legal description Lot 16 Block 7 Kasilof Hills Location (site address or directions) 10241 Stroganof Drive Property owner Mailing address Day phone Lending agency Tanya - Residential Mortgage Mailing address Day phone 122--8837 Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Four (4) Individual well x,xxx Community well Public water 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: XX>,LXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~25 (Rev. 1/91) Fronl 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 Phone Address Engineer's signature Date DHHS SIGNATURE Approved for bedrooms. Disapproved. xx Conditional approval for Four bedrooms, with the following stipulations: ~[oney shall be placed in escrow for the amount of an upgrade system, including MOA permit fee, engineer design fee and construction costs. A full inspection by an engineer including adequacy test, well flow test and water samples shall be completed by October Conditional approval to be lifted and monies released from escrow. Additional Comments By: · ' ' · ,'~- ...... - Date 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 th is 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~ (Rev. 1/91) B~ck MOAi¢21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES~ Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501;. (907) 34~E, F74141 ]998 Municipality of Anchorage , Health Authority Approval Checklist Dept. Health & Human Services I_egalDescription: L0716 I.~Coc~ '7 1(43'//-~A /¢/~-cj ParcelI.D.i 01,¢~"~)3~ A. WELL DATA Well type /)/~ Log present Total depth If A, B, or C, attach ADEC letter. ADEO water system number Date completed ~"~//g / ~/~ Cased to % (~ z-o /~.;J4~c~ Casing height (above ground) Sanitary seal (~¢/N) Y/~-~ Wires properly protected (~/N) Ye J- Date of test Static water level FROM WELL LOG AT INSPECTION Well production g.p.m. WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Collected by: B. SEPTIC/HOLDING TANIC DATA Date installed 3~//5- /¢4 3'~- Tank size ) ;~0 Foundation cleanout (~/N) t/x'~ 2> Depression Date of pdml~in.g.' ~(.2-':./;~ ~ Pumper C. ABSORP, TION FIELD DATA ' : / ' Date i'nstalled 5-- ~ $- / ~/~" Soil rating r fF/bdrm) Length; ~6 / / Width. Other bacteria 0 s & S ENGINEFRING 17034 Eagle I~iver Loop ~,oac~ [~o, :~ule River, Alaska 99577 Number of Compartments ~ Cleanouts~'/N) Y~'~)_ High water alarm (Y~)~ ©- ~ System type 'TR/~o~ Gravel thickness below pipe (4 / Total depth Effective absorption area ~ ~o '¢ ~r~'Monitoring Tube present (~/N) ~/¢~'~ Depression over field (Y,~ /~' o Oate of adequacy test (:'1//o / q ~' Results~...~,~/Fail) /4--t$ For /"/ .bedrooms Fluid depth in absorption field before test (in.); / ' 6" Immediately after/o ~ 7 gal. water added (in.): ~ ' ~ '¢ Fluid depth '~'~ ~' ~/'~'' (ins) Minutes later: ;)- ~ Absorption rate = (~ o 8 /~ .g.p.d. Peroxide treatment (past 12 months) (Y/N) /'' o,-, ~t g-"J~'~ If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested ~ SEPARATION DISTANCES Size in gallons ~ ..... "Pump on" level at* ..,,.---~"-'~ump off" level at* .~tum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot ] o 0 / 4~ On adjacent lots Absorption field on lot ,200 t~,, On adjacent lots /0 Public sewer main A//~ x~' ,'~ ' ' -" Public sewer manhole/cleanout /'/ Sewer/septic service line '~-. 3-- /,-,L Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~'- -/~- Property line ,['- ;3 Absorption field. ~'~ Water main/service line /o ~¢- Surlacewater/drainage /oo ¢-~ Wells on adjacent lots /oo "~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line '2- I Building foundation / 0 -~- Water main/service line Surface water / ~ o Y- Driveway, parking/vehicle storage area Curtain drain ~ 0 ..~/~ ~< ,ye ~ ,~/ Wells on adjacent lots ? ,~ o ENGINEER'S CERTIFICATION I certify that lhave determined thru field inspections and review of Municipal record,!r"~1~_~~ems are ~.,',,~ .... in conformance with MOA HAA~guide~nes in effect on this date. Engineer's Name ~/~¢.,~ E. ~0,¢~ HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waive~ Fee $ Date of Payment Receipt Number SEP-17-g8 OB:SI FROU-CTE E~iVIRONMENTAL 4~t~J~, C F~E E,lvironm~nt~lSe rvic~s I,,c. T-308 P 02/06 F-364 CT&E ReF.~ Client Name Froject Name//! Client Sample ID Matrix Ordered By PWSED Sample Rcmmks: 985134001 S & S Engineenng kt 16 Blk 7 Kasilof Hills Lt 16 BIk 7 Kusdof Hills Drird~ng Water 0 Client PO# Printed Date/Time 09116/98 10:56 Collected Date/Time 09110/98 09:45 Received Date/Time 09/10/98 10.35 Technical DirectOr: Stephen C. Ede PQL upirs He~hoO AttouaBte Prep AnalySiS Limft~ Date Dare Init lo[at CoLiform O 0,155 cut/lOOn:L SHi8 9ZZZB O.lO0 .Q/L EPA 300.0 09/10/98 WP lO .mx 09/12/9B 09/11/98 RMV ....... ~-_..., ..~.~,, ....... . ,:./~i-~.,~,,... DEPARTMENT OFHEALTH & HUMAN SERVICES - . '.-.: : '.~, .... .'.' Dlvl~on of'Environmental'Servmes '.:.':,; ;;.. '."'.:.. '.'~ ........ ".. ?i.z.,:.~. ·On-Site services Section ' ........ "' "P.O; Box 196650~''~Anchorage; Alaska .' 99519-6650 CERTIFICATE OF H~a, LTH AUTHORITY ..... ' ........................ ~,PPROVAL FORA SINGL~ FAMII'Y'DWELLING Parcel:kD;:~ ,.01~'-/-~5-"~i .... A 1. -: GENERAL INFORMATION ..... "' ; "'. '; ............ ..- - - ....T..' ...... Compl~'ie~'al description " '; -?.', ';,'"' .'7 . ..... ; ................ ' .......... . .. locati rite adi:lress or'directions): · I0241' St, to~anof D~,~v~ AK 99516 545-2355 .-. . .~:. ;. ,, :?:'4~,,,.: '~PE OF WASTEWATER DISPOSAL: , ~, , Ho ding tank.. ....... ., . :' '..:: ;,.'::~[ ;~'~('.~'" ~ r 5~:~.~' '~ ~L:,:,',~,,:(~¢.~:~ '~,'~': :¢' ,:. ~',7..~:~' ~ .'~ .... -' ';::: ' NOTE: If commum~ wastewater s~stem, prowde wn~en c~nfirmat~on from State · 5. STATEMENT.~OF INSPECTION BY ENGINEER;i.. · i ~:·.'/ i'. *.' ,.~;:%..' .... As certified bY;'~, seal affixed heretoand as of the ~/alidati(~' date si{own beiow, I ~erify that 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 theMunicipality of Anchorage files and from my inves.ti, gation 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 S & s ENGINEERING ........... ;: phone**., ~"~ ~/- ~-ff '7 ~ ]7~34 Eagle River Loc~ Road Ne. 204 T ' ~e R~er, Alaska 9957~ / ' ;:'' ·"="~-' ''~ ~'-,'' *?:?-: ' ;':'':' ' ' .......... Engineer's:signature . .. ' ~ "Date/~:'~'/'~'¥/~ -.' . -' ~.2 ',r~ ~ //'3' . . , ' '"" ' " ~''~' : ....... ~ '~' '/C> '~' · .............. ~'''r-.','.:.~.',.;'(.F. '.~:;0':' '~;.--' ~ .'L..~--''r'"~: ' .' '.[: ~-~ ~e M~nibipali~ of~fichorage Depa~ment'of Health and Human Se~ices'(DHHS).i~ues Health AuthoriW . ~L ~'~-:~poroval ~e~iflc~i~' b~sed on y upon the 'representations given· in :pamgmph.5 above ~by an independent _'.- r'~t,,'~'~e~ion' ~l;en~'c~gister~ in the State of Alaska. The OHHS does this as a couAesy to p'urch~em of homes :, · ' ,.', and t~ r~nding inst tutions m order to ~tls~ ce~am federal and state r~u~remen~. Emp oy~s of DHHS do not .. - conduct nsp~tions or ana ~e data before a ce~ f cate Is i~u~. The Municipali~,of Anc?rage is no~ . respons b e for errom or om ~ OhS m the profess~ona eng n~fs work. .:.. - ..... '.:, ;',,~ ~ ~,;'~; ~' ~'~'.,':.;~ :,~. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L~T [(,¢ ,'Pobo~v. -/ [~A'btLOF ~-ItL~-SParcel I.D. A. Well Data Well type '--Pr<~v'^-t ¢ If A, B, or C, attach ADEC letter. ADEC water system number Log present ~N) Total depth Sanitary seal ~N) Va Date of test Static water level Well flow Pump level1 Date completed ~- ~-/- ~ Driller Cased to '~(~' Casing height Wires properly protected (¥~/--'N) k/~.$ AT INSPECTION .g.p.m. ~ g.p.m. FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/hc, ldk,'~ tank on lot Absorption field on lot 1 ~ ~ Public sewer main -7 ¢ ~ Sewer service line ~- ~ ~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ~-- WATER SAMPLE RESLILTS: Coliform Date of sample: Nitrate B. SEPTIC/~ TANK DATA Date installed ~. ~., ~' Tank size t ;~-O %~,- Compartments ~- Cleanouts~N) L/~.% . Foundation cleanout {~N) "'/ES Depression (Y~ I'.Jo High water alarm (y~N~, k Jo -~- b J//A --' Alarm tested (Y~)~ k.)o --I'-~'/,,'J, ~ Date of pumpir~g ~//~ -~'. ~d.¢..~ ,'~ ,A~a/~ Pumper SEPARATION DISTANCES FROMSEPTIC/~TANK TO: Well(s) on lot ~'~ On adjacent lots To property line ' 5~' Absorption field Surface water/drainage / Foundation Water main/service line 72-026 (3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SE PARA~~TO: , W~ell-on-'~i On adjacent lots Manufacturer Manhole/Access (Y/N) ~ "Pump~ at'~ .Cycl~ Surface water D. ABSORPTION FIELD DATA Date installed Length ~ ~ Width Totalabsorption area Iooa~ ~ Date ot adequacy test ~;~A- /'b/,:5~,.' Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) SEPAR^TION DIST^NGE FROM ABSORPTION FIE[_D TO: Soil rating (GPD/Ft2) O. C~ .System type ~=~ T~-H Gravel thickness ~ ~ Total depth Cleanout present(~N) '~% Depression over field (Y,{~ Resu,s (pass/fail) .~ for /Y Bedrooms ~ After test If yes, give date / ./ t t ~ Well on lot I~ I On adjacent lots ioo -f Property line ~.1 To building foundation to~ ~- To existing or abandoned system on lot ~ On adjacent 10ts (~ ~ Cutbank ~o ~-~ Water main/service line /© ~' Surface water I oo -~- Driveway, parking/vehicle storage area 25 Curtain drain E. ENGINEER'S CERTIFICATION I cerb'fy that I have checked, verified, or conformed to all MOA and H/aA guidelihes in effect on the date of this inspection. Signature Engineer's Name Date HAAFee$ ~00 ' ~'/~ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number CT&E Ref.~ Matrix Client Sample ID CT&E Environmental Services Inc. Laboratory Division 9 .3388-1 Laboratory Analysis Report WATER L16 B7 KASILOF HILLS S/D Client Name S & S ENGINEERING WORK Or~er 17071 Ordered By B. COWAN Printed Date 08/15/95 @ 09:52 hrs. Project Name Collected Date 08/11/95 ~ 12:18 hrs. Project# Received Date 08/11/95 ~ 13:00 hrs. PWSID UA Technical Director STEPHEN C. EDE Sample Remarks: SAMPLE COLLECTED BY: JOHN. Qc Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 0.32 mg/L EPA 353.2 10. 08/14/95 CMR * See Special Instructions Above UA = Unavailable ~* See Sample Remarks Above NA - Not Analyzed ~= Undetected, Reported value is the practical quantification limit. LT ~ Less Than ~ = Secondary dilution. GT ~ Greater Than 200 W. Potter Drive, Anchorage, AK 99518-1605 --Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA