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OLIVER LT B
Oliver Lot B #051-232-81 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP191346 PID Number: 051-232-81 Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade Name ABSORPTION FIELD STEVEN T. SHREIBER Site Address ® Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound 189924 BEVERLY AVE., CHUGIAK, AK ❑ Other ADVANTEX Phone Number of Bedrooms Soil Rating Total depth from original grade 3 2 GPD/SF 10 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision Block Lot '3.3 Ft. 6.7 Ft. OLIVER B Fill added above original grade Gravel length Township Range Section VARIES 0.16- 0.88 Ft. 20 Ft. Gravel width Beds:Number of Lines Distance between lines SEPARATION DISTANCES 3 Ft. Ft. To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist.between trenches From Tank Field Lift Station Tank Line 268 Ft2 1 Ft. Well 50'+ I 50'+ 25'+ TANK ® Septic 0 S.T.E.P. 0 Holding EI Other ADVANTEX Manufacturer Capacity Surface Water 50'+ 50'+ ORENCO / ANCH. TANK 1500 Gal. Material Number of compartments Lot Line 10'+ 10'+ NA FIBERGLASS 2 LIFT STATION Foundation 10'+ 10'+ Manufacturer Capacity Remarks ORENCO 1500 Gal. Alarm location Electrical installed by ENTRY PL&C PIPE MATERIAL House to tank 3034 Tandank to 3to 034 Installer NORTHERN EXCAVATION Drainfield 3034 co/MT 3034 Inspector FWCS/ MNA BENCH MARK (Assumed elevation) 100 ft Inspection 1s' 9/16/19 2nd 9/17/19 Location and description dates: 3'0 9/17/19 4'" 9/18/19 BOTTOM OF DOOR TRIM ON-SITE WATER AND WASTEWATER SECTION APPROVAL —F r S mp OF AL t Conditional Approval: Date /��.... 1 / 4:- .49TH iN * � �% Septic System $ % .MICHAENoL N.CE 9AN489DERSON:4, / Appr vedd - . / tel/ /11 I 1 Date /V (il N ..11/lf3/ ' Note: t-Is approval does not include well permit requirements. \`_�� (Rev 05/02/18) OLIVER LOT B PID: 051-232-81 PER IT: OSP191346 NK NCE �G�\ x WELLS QckO d Cn 12.3,t DECK I N I 2a.2' ro paii - Ix i ill 10.1' 10.1' CANT SHED cn O l,I1I tii a 1 9, kV.--. N N v 38R RESIDENCE ' --WOODEN FENCE P1 --APPROX. 100' WELL 40.S �'r . FCO 1 f. °' DECK 1 TF 6.5'x8.0' C D C6 CO SHED =1 G 7. .................. CO OCA 01- . MH I MH INSTALLED NEW TRENCH NEW 1500-GAL - - _ - TANK Sc AX20 POD. TH19-1 25.3 26.3' -------- --..-Y CO VO CO CO W N a 2 STORY (..\_i 4SS�OFO 00 rn GARAGE N CGO 0 ' O / pl �fi S SCALE: 1' = 30 Co` FCO ` CO� MT CO A-C=42.4' C MH MH B-C-18 1 98.33 \ 5t FINAL GRADE /9 1 NA RA A-D=48.4' Ano POD - • 91,23 B-D=28.7' 87.89 \@7_90 A—E-60.4' 94'90 1.500 GALLON NEW FIELD FIBERGLASS B-E=48.9' TANK A-F=60.4' 81.23 §1,33 90.41 1H19-1 B-F=49.8' NO GRNO. A-G=78.3' SEPTIC SECTION WIR. B-G=67.7' Boll SCALE: NTS PREPARED FOR: SUPPORT,SERVICES: 40411.\\ 4 OF AZ;STEVEN SHREIBER ���� ;`�� OLIVER LOT B FWIP TH %� 911 18924 BEVERLY AVE., CHUGIAK, AK 99567 C - * 49— 0 Michael N. Anderson, P.E. DATE: 11/8/201914/006054461K4 MICHAEL N. ANDERSON / �1 Q+� No. CE 9469 `_4/ 4661 Natrona Ave. s AI oska 99516 DRAWN: FWCS t ,�, 11/8/2019 Anchorage, X �OPESStD�P`' i (907)727 8864/FAX: (907)345 1391 SCALE: 1" = 30' \`_O Electrical installation of Lift Station power and Control Power Lighting And Control LLC 13841 Savage Dr. Eagle River ,Ak 99577 907-242-5211 Plc chambers@ gmail.com Project: 18924 Beverly Ave(Electrical installation of Advantex) Description The power and control for the installation of the Advantex system was installed according to the latest nec code requirement. Oct 29,2019 Note.I have the remote alarm installed in the entry closet to be plugged into the receptacle being shared with the water softener. The cat 5 has also been brought into the closet to be extended when new owners have a permanent location for their muter.To bedone by others. Aaron Chambers Sent from my 'Phone BEVERLY DRIVE .....1___—_. _ _____. _ ______. _ ______ .i. ______. _ ________ _ ________ ,. N 1 • -,........, - -N„ b.0 to S 89'58'56"E 163.89' - - - - - - - - RETAINING WALL \_ • 15' T&E EASEMENT J \ IPp I f Q- . x j o�Cc,� RpJf.. . . O CHAIN-LINK xG RP` FENCE �. : : . .•' :-.• �• anlELlS: (N PR�- E 5d I x DECK , Ma 112,3 24.2 ' 10.1'x10.1' J x \ 2. CANT •. �'`���, SHED 1.3'x3.0' CANT � i i / x • KW4. I N 16.1 [ >- WOODEN x .• RESIDENCE W 1.3' CANT FENCE o o I IA \ 108.7'/ o Lot 161 . • 3 I TREATMENT POD Lot A Lu0 DECK ". m I Iv cv HED 22.2' i 4 o 1 1 io co o �i SEPTIC PIPE iNao o z - SEPTIC •• .g: t PORCH fa srrx;_ MANHOLES PIPES I . 25ft .3 26.3 • • N2STORYu x • • u GARAGE I • • 26.3' • • TOP OF SLOPES x -• . • • • • • :• Lot B • • 49,181 S.F. x •I • x N 89'58'01"W 164.04 Lot 167 Lot 166 NW-110- 54— Pro ect No. 19-285�A2 AS BUILT1______30— GRID _ 1.2-.-4W-1-15-A___PLOT PLAN X SCALE 11500 Daryl Avenue. Anchorage, Alaska 99515-3049 • Inc • (907) 522-6476 Phone �ooOOpp Lang & Associates , (907) 522-4625 Fax 71-OF A °op Professional Land Surveyors jonothanOlangsurvey•com ooK�.• ,i_ .�- p.�;• 49TH �� '•:910 I hereby certify that I have surveyed the following described props 0 * LOT B. Oecor SUBDIVISION (PLAT No. 84-448) adjacent thereto, that Anchorage Recording District. Alaska, and that the Improvements situated thereon aro within the property lines and do not encroach onto the property jKENNETH G. no improvements on the property lying adjacent thereto encroach on the surveyed il) - premises and that there are no roadways. transmission lines or other visible nn0�.' l6 �(� l� • except as Indicated hereon. VO4 "P • .,I,$-5208.••0500© easements on said property 2.� C� Day of ��-���`` at Anchorage. Alaska 4p ARo�sSioN�+-`Aon Dated this the easements, °°�OOOOd�c' cois the ven covenants, or• o restrictions of twhich do not appearhe owner to onthe reco dedosubdivision plat• AECC963 „`�,�,•""'ro„ MUNICIPALITY OF ANCHORAGE On-Site Water &Wastewater Program 0 i tt' " POBox 19&850 4700ReedElmore Reed Anchorage,Alaska g9$19.6650Phone: (907)343.7904 F=ax.(907)343.7997 °” r► • L http.!'t w rr tecg/vnsTte i epar menet On-Site Wastewater Disposal System Permit MgXe? Permit Number: OSP191346 Effective Date: 8/19/2019 Work Type: Septic Upgrade Expiration Date: 8/18/2020 Tax Code Number: 05123281000 Site Legal Address: OLIVER LT B 054. Site Mailing Address: 18924 BEVERLY AVE, Chugiak Owner: SHREIBER STEVEN T Lot Size in Sq Ft: 49181 Design Engineer: AMde�son ( ns ✓eti�la Total Bedrooms: 3 9hte,i., This permit is for the construction of: Disposal Field © 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 (18AAC8O) 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: In lieu of a sieve analysis to confirm insitu is not GP or GW, On-site shall be present at drainfiedd bottom of hole inspection to confirm lrnsitu is consistent with submitted samples. 8/19/19 Received By: Date: r 4 r`f Issued By: j Cate: / r 1 fi E MUNICIPALITY OF ANCHORAGE f (l . tr ) w' K r Development Services DepartmentPhone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-232-81 Property owner(s) STEVEN SHREIBER Day phone 9072408924 Mailing address PO BOX 770688 EAGLE RIVER, AK 99577 Site address 18924 BEVERLY AVENUE, CHUGIAK, AK 99567 Legal description (Sub'd., Block & Lot) OLIVER LOT B Legal description (Township, Range & Section) Lot Size 49,181 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (Z all that apply) Absorption Field X Initial Single Family (SF) [ (w/wo ADU) Septic Tank ® Upgrade Duplex (D) ❑ Holding Tank ❑ Renewal Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. FWCS - Brent Western (Signature of property owner or authorized agent) Permit/Rush Fees: 1/45-q6— Waiver Fees: Date of Payment: 'l '/i 9 Date of Payment: Receipt Number: Receipt Number: Permit No. 03P1913''!!Ye Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Michael N. Anderson, P.E. Civil/Structural Engineering and Construction 4661 Natrona Ave. Anchorage, Alaska 99516 Phone 345 -3377 / Fax 345 -1391 Support Services Brent M. Western 907-440-4601 August 6, 2019 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 RE: SEPTIC SYSTEM UPGRADE PERMIT LEGAL: OLIVER LOT B PHYSICAL: 18924 BEVERLY AVENUE, CHUGIAK, AK 99567 The septic field has failed and we request a septic permit to upgrade the system on the above referenced lot. We propose to install one deep trench with and Advantex system to serve the existing 3-bedroom residence. The design is based on the recent test hole conducted on July 31, 2019. The slopes are moderate at 10-15% at the proposed upgrade location. The lot and area are served by private water. The design will not impact any of the neighboring properties. Please contact Brent M. Western or me if you have any questions. Sincerely, Michael N. Anderson, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191346, Deb Wockenfuss, 08/19/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191346, Deb Wockenfuss, 08/19/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191346, Deb Wockenfuss, 08/19/19 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP191346, Deb Wockenfuss, 08/19/19 I I I I i \ J� \ YO x -x o O^ N O J � ' J � 3 � U V z � _ I � m I Z / N Y W U Z U / \ J W O IZ Z W % \ Q S / I � N w IL 0 N W 0 ■• t � JC v P*� .& "° o'• .'v w ate' m �• y N CD Oo. �: rJ �44p�6=•�.: .Y . boa O z o w u � O 0 IL` c° c ox L ° maw o avC4 N N Z �nN o U i II ,� 0 V/ YL! vU, +- N xi IU C J M N V) Q r� Y O •V) z N S 0) o C o CL J \ w U 6 Y \Z y � O z w o« 0 o O \ 3 } U 27.9• I U N 16.0• aw w )a- I Z / N Y W U Z U / \ J W O IZ Z W % \ Q S / I � N w IL 0 N W 0 ■• t � JC v P*� .& "° o'• .'v w ate' m �• y N CD Oo. �: rJ �44p�6=•�.: .Y . boa O z o w u � O 0 IL` c° c ox L ° maw o avC4 N N Z �nN o U i II ,� 0 V/ YL! vU, +- N xi IU C J M N V) Q r� Y O •V) z N S 0) o C o CL J ° y F 6 Y U y � O W C o« a } U 27.9• n 16.0• O W w c o H � o Ea «gid s o m n c N Wfy Q O q 48.2' +oma `o o cv c1 °a _ in I Z / N Y W U Z U / \ J W O IZ Z W % \ Q S / I � N w IL 0 N W 0 ■• t � JC v P*� .& "° o'• .'v w ate' m �• y N CD Oo. �: rJ �44p�6=•�.: .Y . boa O z o w u � O 0 IL` c° c ox L ° maw o avC4 N N Z �nN o U i II ,� 0 V/ YL! vU, +- N xi IU C J M N V) Q r� Y O •V) z N S 0) o C o CL J ° Y m O O o« a v � m m o `o°Zo w c o o Ea «gid s o m n c 0 C 0 Q O q +oma `o o cv c1 °a m no°o a s �3 a c o `o ;� o° o ° a00 m 0 m C9 v Eo om 0 .0 > `0.m 9 «° m o e ° r° o o ° o ° E-�„m ° m0 o°a`m «� Cc « O m -0 0 C ° oarm 0 I ° -Co O ° `v �o0« 09 Fo "To O m a `o a «ooc o- z m w 3 m o 0 v�ooS.o° �c rgc Q a m o z"ava ° aa c1 a,X O c oNa am >• > °t D «; *c° L O C 3. 0 1 E p O — m c 0 2 Dw-c«o. 2'v 46 En W ' 0 L I O n w O0.-[�° too°a0 90 0 0 n `o O U O O O j m w1 O m C to rEEe m�CP0 ” => L Q 3 C G O C S 0 McKay Well Drilling P.O. Box 878148 Wasilla, Alaska 99687-7704 �� �� / Phone 376-5058 Data Well Owner Phone Well Location Size Casing Depth of Hole Cased to feet Static Water Levelfeet� Well Test Gal per Minute for Hours V` Date of Completion 1 --- _L_ RECEIVED AUTHORIZATION TO DRILL I hereby authorize McKay Drilling to proceed with the above work. Payment shall be made in the following manner: Rig up Minimum —feet. @ per foot Balance due upon completion. In the event it is necessary to insitute legal proceedings to collect any amounts due on this con- tract, I agree to pay an additional sum of fifteen percent (15%) of the original contract price. Plus attorney's fees, and cost for legal proceedings. Name Date Address WELL LOG FEB 41 2000 UniClPahty of Anchors —1— Nwarth 8L Human berviCeS AUTHORIZATION TO DRILL I hereby authorize McKay Drilling to proceed with the above work. Payment shall be made in the following manner: Rig up Minimum —feet. @ per foot Balance due upon completion. In the event it is necessary to insitute legal proceedings to collect any amounts due on this con- tract, I agree to pay an additional sum of fifteen percent (15%) of the original contract price. Plus attorney's fees, and cost for legal proceedings. Name Date Address RECE,VED OCT 2 3 Z000 MUNICIPAL[P{ OF: ANCHORAGE ENVIRONMENTAL SEBVICES DIVISION · P.O. Box 110378,Anchorage, AK 99511, · 907-345-4000 · 90%345-3287 Fax· As-Built Log Job No.:~}0-164 .Permit No.:N/A OCT 23 2000 Health & Hu~a~ ~e~ea · Well Owner: Mt'. & Mrs. Steve Shreiber · Legal Description: 18924 Beverly Drive- Chugiak, AK · Use of Well: Domestic · Size of Casiug.. 6" ·Depth of Hole: 78' · Cased To: 53.50' · Static water level 49' below top of casing. · Well Finish- Open end ( ); Screen (X); Perforated ( ) · Screen/Perforation description: K-packer & 5" riser 48'-54', 0.020" slot SSS 54'-59', 5" tail & plate bottom 59'-80' · Wellpumping test at 1 gallonsper minute for qf drawdowu.£rom static level. 24 hours with 3 · Notes: 1.) All measurements are from the top of the casing. 2.) Installed screen assembly. 3.) Pulled casing back exposing SSS · - · Date o. fcompletion: 09-05-2000 Del}th iii fe~t from ground surface. 0 TO 80 TO TO TO TO Well Log Details of formations penetrated, stt. e of material, Color alld hardness. Exisitmg well 46' /K-)acker TO TO TO TO TO TO 3i294; 5.66' Riser 5.25' SSS 21.03' Tail TO TO TO TO 78' NVv'WA Certif/ed Co~traetOr .... Certificate No's. 814 gt ~73 Ad- A4eans Water/././ · ,W~II Name: TERRASAT, INC, (Shreiber Well) File Name: P:~20010-~'I\RAWLOG~I\SHREIBER. HDR Location: 18924 Beverly Drive, Chugiak, AK Elevation: 0 Reference: Ground Surface :eet I gamma 1 o box flee !0 6O II I~ ill -_-!: ..~.;: -20 _ ~ ~ ~ '-':' "~-i' ~ ;;-~' -- MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650. Anchorage. AK 99519-6650 (907) 343-4744 ON-SITE WATER SUPPLY PERMIT Initial Date Issued: Dec 02, 1999 Expiration Date: Dec 01, 2000 Permit Number: SW990424 Legal Descdpfion: OLIVER LT B Design Engineer:. 0000 None Required Owner Name: Steven Shreiber Owner Address: PO Box 770688 Eagle River, AK 99577- Parcel ID: 051-232-81 Site Address: Lot Size: 49181 SQ. FT. Total Bedrooms: 2 Permit Bedrooms: 2 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Pdvy [] PdvateWell [] Water Storage 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 ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either. A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: ,,~/~ ~ Date: Issued By: ~ Date: /16/ .I/4' BLNI BC R.I.P., Oo 8'A. Q.G. / / I I / 4I ~ / / I / I I / ~ I ,,,' ,~. .... HEIGHTS I SUBD. I I I I I I I PO.3 SC, o~^:o~,~o ~c I o~ ,~-ooe,P,o.,'~.I I i I 146A I ..I I _L __ 49,181 S.F. Z i House F"-I .~9,184 S.F. % 164.04 164.04 N. 89° 58' Ol"W. 328.08 (3ZB.el)- PROP. 167' NOTE: 5/8"x $O"REBAR SET AT ALL LOT CORNERS EXCEPT AS NOTED. BLM RECORD DATA ( ) 1468 I 168 I 166 I 3~i.14 PROP. ~ ~..,- si' o,-w. /(1"'"' BY P.RO~,*'~ I'~ I I I ~3 IS.~B ,J 159A ~.,.,~._,,. BASIS OF z BEARING PLAT ~ S~TE SEWAGE ~A~ SYST~ ~D~R WiLL I~ECTI~ RE~flT . ~' , . · $~ ............... 1 ...... ~' [ ..... ~ ....................................... ~ ..... -'~ ' ' "' ~:t - · i~'~ ............. ,, ... ,...., ? ',~-~] ~ .~%.~ ~ ........ --- [_ . --'7/~/ /~ ......... ' ,' 264-472'~' -- * * '~ HA"NDWRITTEN P~RMIT * * ~ ON-SI~E SEWER pERMIT ,e of Soil ~orption System I~: ~ol~ing Tank:.~ T~enoh~ Drainfield= ~-- seepage Bed~ ~ Soil Rating(sq,ft/br) :im~ N~er of Bedrooms: ~ The Required size of the Soil ~sorption System he length a~ension is the %eng~h(in fee~) of ~he trenoh or ~ai~fiela. The eDth of a trench or pit is the aistance b~tween the surface o~ the groun~ .he bottom of ~he exo~va~ion(~ ~ee~). There i~ no set wiclth for ~he gr=vel ~egth is the m~im~ ~ep=h o~ gravel betwmen the out~all '.he bottom of the exoavation (in ~eet) · * * REQUIRED SEPTIC(~ TANK SIZE ~ __ GALLONS * ~i= mpp].ican~ has the responsibility to in~o'~ this department during the ~tallation inspections of any wells a~Jacen~ to this property an~ the n~er residen~eS that the well will serve, * * * TWO(~) INSPECTIONS ARE REQUIRED * * * ckfill~g of any system without ~inal inspec~iOn and approv~X by this ~epartl .1[ be $ub~ec~ to ,n~t distance between a we%l a~d any on-si~e sewage disposal system is 100 ~r a private well or 150 to 200 feet from a public well depending upon the to a private ~ Dublic well. Minim~ dis~ce f~om a,private well Well logs are required t 25 ~eet and to a co~uni~y sewe: line ~s 75 feet, ~d must be ~eturned to this depa=~men: w~thin 30 days of ,~he well :her requirements may applY. Spaoifioa~ions and construction diagr~s are ;a, ilab[e ~o insu=e prope~ " ~ ~ PERM[T EXPIRES D~CEMBER ~l, 1 9 ~ 3 e e ~ [ certify ~hat: requi~eme~%t~ for on-site sewers and' wells (1) I ~ f~iliar with set fo=th by the MunicigalitY of ~chorage, ~he resSden~e is rgmodelmd to ~nclude mor~ ~nat~.a ~ '" ' I~sued by: Applioant Date ~ 10704/1995 15:56 90?6941211 S AND S ENGINEERING PAGE 04 O & E ~4,.,..NEERING & DEVELC,, MENT CO. IIOIL LO(2 3,_.__ 6...__. PLOT PLAN MUNICIPALITY OF ANCHORAGE o 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. 051-232-81 1. GENERAL INFORMATION Complete legal description OLIVER LOT B Expiration Date: Location (site address) 18924 BEVERLY AVENUE, CHUGIAK, AK 99567 Current property owner(s) STEVEN T. SHREIBER Mailing address Real estate agent PO BOX 770688, EAGLE RIVER, AK 99577 2. TYPE OF DWELLING: ❑ Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Private Well Private Septic Water Storage ❑ Community Well _ ❑ Public Water System ❑ Waiver request for:, Received by: 3 COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Date of Payment Receipt Number (2R5-3_5VQs COSA# 015C10i IS 33 Day phone Day phone TYPE OF WASTEWATER DISPOSAL: Private Septic Holding Tank ❑ Community ❑ Public Sewer ❑ Date: Waiver Fee $ Date of Payment Receipt Number Waiver # Distance: 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 ANDERSON CONSTRUCTION & ENGINEERING Phone 345-3377 Address 4661 NATRONA AVENUE, ANCHORAGE, AK 99516 Engineer's Printed Name MICHAEL N. ANDERSON, PE Date 11/6/2019 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by KS and Anderson Construction & Engineering. 6. DSD SIGNATURE System #1 Approved for 3 bedrooms System #2 Approved for bedrooms Disapproved OF Z4 49 TH *. Of � I I, JIUCHAEL N. ANDERSON.- 1 No. CE 9469 1 .111 //6/19 p .. ' \ " tSSIOV0 Conditional approval for bedrooms, with the following stipulations: By:4 Original Certificate Date: 1112,0ZI The Municipality of A horage 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 Checklist blue sheet Legal Description: OLIVER LOT B Parcel ID: 051-232-81 If more than 1 septic system on lot: COSA Checklist # _of _ Structure served by this system _ A. WELL DATA NORTH / SOUTH WEL ® Well log is filed with Onsite (or attached) Date drilled 11/21/1995 N WELL 11979 SWELL Total depth 78 / 325 ft Well production at time of test 0.62 / 1.26 gpm Water storage tank volume 2 X 250 gallons Well disinfected for coliform test? ❑ Yes ® Nc Cased to 53.5 / 200 ft ® Coliform bacteria is Negative ® Sanitary seal is functioning correctly Nitrate mg/L ® Nitrate less than MRL (ND) ® Wires are properly protected Arsenic ug/L ® Arsenic less than MRL (ND) Casing height (above ground) 12+ in. Collected by FRES Date of flow test for COSA 11/6/2019 Date of Sample `"—'�"'� 10/31/2019 Static water level at beginning of test 47 / 40.8 ft. Comments 907 WATER WELL SERVICES PERFORMED WELL FLOW TESTS & SERVICED WELL HEADS & WATER STORAGE SYSTEM - BOTH WELLS SERVE THE HOUSE. B. TANK DATA – NEW FRP ADVANTEX Age of tank(s) NEW years Tank type/material SEPTIC / FIBERGLASS Measured operating fluid level in septic tank ® Standpipes/foundation cleanout per record drawing Date of pumping NA – NEW TANK D. ABSORPTION FIELD DATA – NEW FIELD Which system tested (date installed) 9/17/2019 ® ALL standpipes present per record drawing Total measured depth from grade 10.16 ft (max) Measured depth to pipe invert from grade 3.49 ft (min) ❑ N/A – pressurized field ® Monitor tubes go to bottom of effective. If not, state depth into effective ® 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 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date NA – NEW FIELD Results ❑ Pass For bedrooms Fluid depth prior to test _ in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) N If yes, enter date FW 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' ® Yes Community Sewer Manhole/Cleanout > 100' ❑ Yes if No 50+ ft ® Yes if No Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' ❑ Yes if No 50+ ft Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' Surface Water > 100' Animal Containment > 50' ® Yes if No ® Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Wells on Adjacent Lots: Property Line > 5' ® Yes if No ft Private Wells > 100' ® Yes if No Absorption Field > 5' ® Yes if No ft Water Main > 10' ® Yes if No ft Water Service Line >®Yes ' if No ft 10Community Wells > 200' ® Yes if No _ _ Surface Water > 100' FI Yes if No 50+ 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' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® 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' ® Yes if No ft Community Wells > 200' ® Yes if No Surface Water > 100' ❑ Yes if No 50+ ft F. ENGINEER'S COMMENTS of .AZ G. ENGINEER'S CERTIFICATION'Of l certify that / have determined through field inspections and review *4 9 of Municipal records that the above systems are in conformance 0. with MOA COSA guidelines in effect on this date. MICHAEL N. ANDERSON. Grp No. CE 9469 11/18/19 00 " ......Air P,k'ESSIo o, ft ft ft ft ft ft ft 10 MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and entered into as of this Day of November of 20_L9__, by and between Josh &Angela Mursu herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as AdvanTex Treatment System located at (legal description) OLIVER LT B 2. Maintenance., Repairs and Alterations. (Owner is required to read, understand and initial each section) Throughout the term of this Agreement, the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS shall be maintained in a satisfactory forming as designed and producing treated septic effluent in condition capable of per accordance with the equipment's approval for operation in the Municipality. It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to $600). Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. 05/18/2018) Page 1 of 3 r` Owner acknowledges that the Municipality may request records of maintenance and repairs from the manufacturer's representative or maintenance provider. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. CIAOwner agrees to grant the Municipality reasonable access to test and inspect the AWWTS. The Municipality will give at least 24-hour notice. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the Owner's AWWTS. Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. N ©nwaiver. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Lazy. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7, Severability. Any provisions of this Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev. 05/18/2018) Page 2 of 3 OWNER: LBy: r? nature) Josh A. Mursu and/or Angela M. Mursu (print name) STATE OF ALASKA THIRD JUDICIAL DISTRICT The 20)1 Date: ss. ged before me this /clay of%�r'`'% ETAMMY FA'.YPU OR.ALAASY PUB!_1C L. KROUS Commissi expires: -OF ALASKA xpires October 1 2022 MUNICIPALITY: By: �� — (signature) (print name) Date:gh g Title: (rev. 05/18/2018) Page 3 of 3 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. # ~,~'3A- ;~)-h'~\ 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA # _4 Lot 160 B Oliver Subdivision Location (site address or directions) Property owner _~a.L_-ty ,:lason Mailing address _1 8~_24 Baverly Ave. Chu~k, Ak 18924 Beverly Ave. Chu(iiak, Ak 99567 Day phone 688-5511 9.~ 67 Lending agency (~-.l~r ~r' i"¢'/(")~'~-"T(~.%-~--'~' Day phone ~ ~-' *%'~'?~ . Agent_ EE,~'X A~Dg.~.~' CqA ¢ Day phone ¢, ) / kc ~/ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~' - TYPE OF WATER SUPPLY: Individual well Community well NOTE: · 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 NOTE: Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. o 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 inves!Lgation 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 DHI ~ons~l~tinq Enqineers Phone _344-__~138__~5 ,. _ Address 800_E. ~n~d. Suit~ %/54~nchoraqe, Alask~ 9~515 ~nglRe ~ ~ o DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. Tl~e DFIHS 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 engineers work. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501. (907) 345-4744 Legal Descriptiou: A. WELL DATA Health Authority Approval Checklist Well type i>--_¢.L~._.~, Log present (Y/N) Total depth ?-~T3,.~%' Sanitary seal (Y/N) Date of test Static water level Well production WATER SAMPLE PdS:SULTS: If A, B. or C, attach ADEC letter. ADEC water system uumber Date completed }c'~ '~<~ Q) Cased to '~ Casiug height (above ground) FROM WELL LOG g.p.ln. Wires properly protected (Y/N) ¥'~(.~ AT INSPECTION ~ O.,2S" g.p.m. Coliform Nitrate O./0 Other bacteria Date of saulple: ~'~--,~L9- q ..~ Collected by: ~k.)~<-~7' I IO ~ \(..--~[---.~, B. SEPTIC/HOLDING TANK DATA Date installed C_~,=c~%~%¢ ~ ~ Tank size It,_DO,~ ct-q., ,Number of Compamnents <,~/3 . Cleanouts (Y/N) i~_~~ Foundation cleanout (Y/N) '~4~---,~('-~ Depressiou (Y/N) Date of Pulnpiug */'c~/- ~'¢ Pumper ,...'~ ~>, c. AnSORmON n mD pATA Date installed ~:: ,'~o~(~DSoil rating (g.p.d./fl: or fl2/bdrm) High water alarm (Y/N) [,,3 [ ~ Systmn type Width ~ Gravel thickness belo~v pipe ~a tff~ Total depth Effective abso~tion area ~¢,9~ ¢~ Mouitoring Tube present(Y~)~ Depressiou over field (Y~ ~(~ Date of adequacy test ¢'/¢~3 Results (PassWail) ¢A%55 For Fluid depth iu abso,tion field before test (in.);~i/q t, ~ hmnediately dte~' gal. water added (in.): Fluid depth ~" Minutes later: /~///0 (in.) Absorption rate = r~5o '~ .g.p.d. Peroxide treatment (past 12 months) (Y~) ~ ~ if yes, give date bedrooms Do LIFT STATION Date installed Manhole/Access (Y/N) ~ Size in gallons High water alarm level at* "P~**Dilttllll "~ Cycles tested "Pump off' level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot iQ_~ Public sewer main ~x...) I ~-~ Sewer/septic service line ' On adjacent lots : On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Fouudation }CB' (2) Property. line Q:(5~ .+0-'~ Absorption field Water mare/service line U)[/-~ Surface water/drainage NS//~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundatiou Surface water Curtain drain Water main/service line \",3 Driveway, parking/vehicle storage area Wells on adjacent lots [ i ~ F. ENGINEER'S CERTIFICATION Engineer's Name arid review, this date. systems are Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number HAAFee $ t~Od) , c'~) WATER WELL ADVISORY HEALTH AUTHORITY APPROVAL NO. During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Lot _~Q_~_ Block ~ of OL\~ ~i~Du3~lO~ Subdivision, the well's productivity was determined to be 0.~. gallons per minute. The minimum well productivity required by this department <AMC 15.55) for a ~ bedroom residence is O,~ gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of [he well may fluctuate. Restriction of noncritical water uses such as washing cars and Wat'ering lawns and gardens may be required, This advisory must be attached to all copies of t'he subject Health Authority Approval. P.O. BOx 413 [4gle Rtver. ,~ 99577 #ovead)er 7~ 1984 S AND S ENGINEERING PAGE Tebbefl Spurttand, P.(. 03 .I~EU._.AND SE.P. TIC SYSTTN AOEQU~CY TEST ~Z~L: Lot 1~0 B, TISN, RI~ Sectton TO LGC~TION: 91rch~od Loop RESZDEHCE: Single Family, Three Bodreoms HATER SYSTEH: On stte ~ell test p~mped et 1.7 GPH for 4 hours. Nell has potential of 5 GPH flor rets. SEPTIC SYSTEH: From l4untctpel Records: Tank: 1,000 gallons Absorption System: Htde Oralnfteld) 40 feet long, G feet deep, 2 feet of ~ock, 5 feel wtde Absorption Ares: 256 square feet Sotl Rating: 65 Znstalla~tofl Date: 1gU3 DATE OF TEST: 11/6/44 (l(e11) TEST PROCEDURE: The ~e11 ~es pumped at 1.7 6PH for 4 hours wl~h noticeable drop tn pressure et end of test tndtcatt~g the ~e11 vas pumped dry. After 24 hour recovery period the ~el1 wes pumped at S GPH for a total of 230 §allons befor~ same pressure drop was reached, Indicating a well yield of 0.033 GPH adequate for 3 bed~oems by ~untctpal set standGrds. TEST RESULT; Both ~ell and septtc system meets the requirement1 of the Hunfctpallty of Anchorage for residential use as of the day the system was tested. There ts no guarantee that systems wtll conttnue to meet these requirements. The operational 11re of 411 well and septic systems depends on the locaT sol1 conditions, g~ound- ,stet levels that may fluctuate durtng the year, and the water usage of ~he famt~y being served by the SyStem. 10/04/1995 15:56 9076941211 S AND S ENGINEERING PAGE 82 Re: DLH Lot 160 O Seplratlon #alver On behalf of our client, Chuck OliveT, we are requestfng a waiver of mall to septtc tank separation dtstance to an nO' separation. The ~e11 ts reported to be 325 feet deep, cased to ~00 feet. seated fn bedrock, and has a measured stattc water level oflgO' belo~ casing. The well Is cased to at least thfs depth 090'), Subject ~ell was drtlled in 1976 and there ts no ~ell log available by either driller or owner. The septic system was Installed In 1963 and It was comrm3n practtce at that ttme to allow an BO~ separation to the septtc tank while maintaining 100' separation to the Teach fteld, In fact the Huntctpol~ty Inspection report enclosed shows a wetver approved tn the remarks section, The tank and fteld were Installed by a licensed, reputable Installer with approved materials and tank mechanical couplings are Installed. The tank ts located downslope from the well so all surface runoff ts directed away from the ~e11. It t5 our belte¢ that thts waiver w171 not endanger the ~11 wa~e~ quality and ask that the state uphold the Hunfctpal granted wa~ve~ o¢ 80'. Please contact our office t~ there are any questions. Sincerely, /~ e~ Spurkland, P.E. cc: Chuck 011var £nci: Plot Plan gater Sample Sewer System As-Ou~lts Sotls Log A,,~r,O,.xu~/,~ST~,~,, DISTRICT Q~FIr'~ "~I~:~T SUITE 303 437 "F c ,_--~' , ....... .~.,.~E, AL~,St,,~. 99501 274-2533 Hove,mber 19, 1984 Tobbin Spur?.land, P.E. 203 ;lest 15th Avenue "C" Suite 203 Anchor~_~e, Alaska 99501 SUBJECT: Waiver Horizontal Soparation between Well and Seotic Tank, Lot BL~q Lot 160 - B (8S21--WA-065) Dear i,lr. Spurkland: The r~.n- ~m -' . ~r~.ent has reviewed ~ne subject waiver remuest and hereby waives the horizontal separation between the well and septic tank to 80 feet on the subject property for a 3 bedroom single family residence only. Si ncerely, / '~ ~'. Erickson District c,qjneer gEE/dd Tobben Spurkland P.E. D H I CONS ULTING · Civil Engineering · Surveying MUNICIPALITY OF AiNCHC,.) 'lu-~- ENVIRONMENTAL ,SERVICES DIVISION O,::T 1 0 1B98 ·Planning October 10, 1995 W.O.: 95225 Mr. Jim Williams Department of Health and Human Services P.O. 196650 Anchorage, Alaska 99519-6650 RI--: Lot 160B, Oliver Subdivision/Additional information as requested Dear Jim, As requested, we are providing the following additional information for the above property: 1 ) Water well: The well is six inches in diameter and reported to be 325 feet deep with casing 'to 200 feet. The remainder of the well below the casing is drilled in bedrock. At the time of our test, the statk; water level was 221 feet. There are four 180 gallon Conaire, Model Number CA220ES bladder tanks located in a crawl space underneath the house. During the test, water was flowed from a hose spigot at a rate of 5 gallons a minute for the first two hours at which time the flow rate was reduced to 2.5 gallons per minute for the remainder of the test. Since water was being drawn from the storage tanks as well as the well, we could not determine the actual flow rate of the well based on the flow measured at the hose spigot. Therefore, we use the recovery data to determine the flow rate reported on Health Authority check list. The well recovered 10,3 feet in one hour. This calculates out to be 0.25 gallons per minute. This meets the minimum standard set by the Municipality for a two bedroom house. 2) Septic system: The leach field was tested for a two bedroom home. At the start of the test, there was ¼ inch of water standing in the monituring tube. We added 310 gallons of water. The water level in the monituring tube 800 East DJmond Blvd. Suite 3-545 Anchorage, Ak. 99515 Ph (907) 344-1385 Fax (907) 344-1383 raised 2 inches (total depth of water 2¼"). Water level after 24 hours was ¼ inch. Therefore, the system absorbed the required 150 gallons per bedroom for a two bedroom house. 3) Waiver: The Municipality records indicate that a waiver between the septic tank and the well was applied for on November 8, 1994 by Mr. Tobben Spurkland and that a well waiver was granted on November 19, 1994. I believe the above address all of your question. (-~--V-e~y truly you(;Sl~ngi e,ers Dee High, Principal cc: Gail High, DHI Patty Mason 225dwl 0o.ltr 800 East Dirnond Blvd. Suite 3-545 Anchorage, Ak. 99515 Ph (907) 344-1385 Fax (907) 344-1383 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 1. GENERAL INFORMATION Complete legal description Location (site address or directions) 18924 Beverly Ave. Property owner Mailing address Lending agency Mailing address Agent Address Ray Debbie Chandler 18924 Beverly Avenue Day phone 688~9709 694~8815(w) Eagle River, AK 99577 Day phone Lyn Kile/ Target Rcalt~ Day phone 694-2388 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 2 ~ 3. TYPE OF WATER SUPPLY: Individual well XX× 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: XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Fronl MOA ¢t21 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 an~re.,~m., my investigation and inspection, the on-site water supply and/or wastewater dispos~sy~ste~ is in compli~-nce with all Municipal and State codes, ordinances, and regulations in~.e~ the date of this inspection. Name of Firm_ /~¢_//~_~.~.-~.~~'~///~"--~ Phone 4~'¢>~"- ¢--¢'7 ¢' Address /' ~le River Loop Roa~l No. 204 -i:nginee r'ss'gl tuCe ~_~ - Date -/'//~/., DHHS SIGNA'I'URE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date 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. 72-025(Rev, 1/91) B~ck MOA ~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L--,,:,-r ~z~ ~:::L..,.,f~_.- ~1,~ Parcel I.D, A. Well Data If A, B, or C, attach ADEC letter. ADEC water system number Date completed --~ \ ~ -'/~ Driller Cased to ~'- '¢--O o ~ Casing height t Wires properly protected ¢~/N) Well type PC- Log present (Y~ i , Total depth Sanitary seal (~N) g.p.m. Date of test Static water level Well flow Pump level1 FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ..~ ~ c> ~ \ Absorption field on lot \ ~ c) AT INSPECTION Public sewer main Sewer service line WATER SAMPLE RESULTS: ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Coliform ~ Nitrate Date of sample: / (.~, ~. ~O Other bacteria Collected by: ~"~'---~ :~ ''',~ -~'"'-~LdU-~, B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts~YN) ~ High water alarm (Y,~ Date of pumping '-~ Tank size \ oz::~o Compartments Foundation cleanout I~N) '-// Depression Alarm tested (Y/N) '---t'/ / 6, ~ c¢ $ Pumper -~_,~- ~ ~--¢~..s SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ¢ O To property line / Surface water/drainage / Foundation -~/ Water main/service line 72-026 (3/98)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N). "Pump on" level at ~"-L~evel at High water alarm level ~',,y~sted Meets MOA electrical codes (Y/N) SEPARATION DIS..T. ANC~ROM LIFT STATION TO: We one'lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length .~L~ Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y~ Soil rating (GPD/F:t2) Width ~'~ / ~ ~ .-~ ¢' Cleanout present~/N) ~. 2-.¢ ~ ?-- Results~fail) Gravel thickness ~ ~.<- ¢/¢,~ System type ~- ~ Total depth L_¢ ~ Depression over field (Y~) ~--/ for '-~' Bedrooms After test ,/--,,-/¢ ~-(,-/ If yes. give (:late ,"'¢'//~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ o ~ To building foundation On adjacent lots Surface water Curtain drain On adjacent lots Propertyline Cutbank To/existing or abandoned system on lot Water main/service line Drive. w/a., parking ehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conFd~ed to all MOA and HAA guidelines in effecton the date~ this inspection. Signature Engineerls Narn~3.~c~/E~gle,k~ver Loop Road No. 204 Date Eagle ~ Alaska 99577 ////~/¢ ~/~. HAA Fee $ ,~ O~) ¢ ~ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (3/g3~* Sack