HomeMy WebLinkAboutPATRICIA BLK 1 LT 14PatPicia
Block 1
Lot 14
#012-464-21
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP231200 PID Number: 012-464-21
Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade
Name
LEROY & SARA SMITH
ABSORPTION FIELD - EXISTING
Trench El Wide Trench El Bed El Mound
Site Address
10030
10030 GEBHART DRIVE, ANCHORAGE
El Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
I Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
PATRICIA 1 14
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft'
Ft.
Well
200'+
--
25'+
TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
ANCHORAGE TANK
Capacity
1500 Gal.
Surface Water
100'+
--
Material
EPDXY STEEL
Number of compartments
2
Lot Line
10'+
__
NA
Foundation
10'+
__
LIFT STATION
Manufacturer
Capacity
Gal.
Remarks Tank insulated. Installed 1500-gal tank with 2
MHs for current functionality & future flexibility.
Alarm location
Electrical installed by
Installer OWNER
PIPE MATERIAL House to tank 3034 Tank to 3034
drainfield
Drainfield CO/MT 3034
Inspector FWCS
BENCH MARK (Assumed elevation) 100 ft
Inspection 15, 8/24/23
dates: 2 a 9/9/2023
Location and description
3rd 4`h ITOP
OF MH
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
4��t�t�l
�
_�OF A
Conditional Approval: Date
�! Q ' •:�,1�
.!F.r
.. 4..TM ....:..
� " " " " " " •
Septic Syste
Approved
r� '• Curtis Huffman ; /
?'���•. CE 128991 •*,%�i'�
Date10/25/23
Note: this approval does not Include well permit requlrem nts.
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PID:012-464-21 PERMIT:OSP231200
FIRST WATER CONSULTING
PATRICIA BLOCK 1, LOT 14
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP231200
Work Type: SepticTank Upgrade
Tax Code Number: 01246421000
Site Legal Address: PATRICIA BLK 1 LT 14 G:2528
Site Mailing Address: 10030 GEBHART DR, Anchorage
Owner: SMITH LEROY K & SARA A
Design Engineer: FIRST WATER CONSULTING
This permit is for the construction of:
Effective Date
Expiration Date:
»Zenr
U �
Department
Lot Size in Sq Ft:
Total Bedrooms:
7/19/2023
7/18/2024
6976
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
f�/C
Received By: n - Date:
Issued By: t'`— Date: % 3
3
MUNICIPALITY OF ANCHORAGE
0 f
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 012-464-21
Property owner(s) LEROY & SARA SMITH Day phone
Mailinq address 10030 GERBART DRIVE ANCHORAGE, AK 99515
Site address 10030 GERBART DRIVE ANCHORAGE, AK 99515
Legal description (Sub'd., Block & Lot) PARTRICIA BLOCK 1 LOT 14
Legal description (Township, Range & Section)
Lot Size Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
(® all that apply)
Absorption Field ❑
Septic Tank
IN
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
APPLICATION IS AN
Initial
❑
Upgrade
Renewal
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
TYPE OF DWELLING:
Single Family (SF)
(w/wo AD U)
Duplex (D) ❑
Multiple Dwellings ❑
(SF and/or D)
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Sig_nature:-of_pKop(jrty owner or authorized agent)
Permit/Rush Fees: L 2-,S- Waiver Fees:
Date of Payment: /to /-?o 2 3 Date of Payment:
Receipt Number: 01 01/� Receipt Number:
Permit No. S Z � 1 ZCWaiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / firstwaterAK@gmail.com
!
!!
July 6, 2023
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: PATRICIA BLOCK 1, LOT 14
The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic
tank on the above referenced lot. We propose to install a 1500-gallon epoxy steel septic tank
per the attached design to serve the existing 3 -bedroom residence. The 1500-gallon steel tank
with dual manholes or risers is to be installed due to shallow groundwater and for future
consideration or flexibility. The previous existing carport was constructed as a garage and has
had no known encroachment issues and will need to be addressed in the future. The design will
not impact any of the neighboring properties. Please contact us if you have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231200, Curtis Townsend, 07/19/23
FIRST WATER CONSULTING
PATRICIA BLOCK 1, LOT 14
DESIGN DETAILS:
NO VISUAL APPARENT WELLS WITHIN 200' OF PROPOSED
SEPTIC TANK & NO KNOWN SEPARATION ISSUES. THE
PUBLIC WELL TO THE WEST & ANY OTHER WELLS MUST
OR REQUIRED SEPARATIONS MUT BE STAKED PRIOR
TO SEPTIC CONSTRUCTION.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231200, Curtis Townsend, 07/19/23
MUNICIPALITY
OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Septic System Owner -installer Agreement
The On-site Water and Wastewater Section (On-site) may issue an approval for a homeowner
to perform work on an on-site wastewater disposal system to serve that individual's owner -
occupied, single-family or duplex home if the homeowner meets and agrees to the following
requirements:
1. The property owner and excavation equipment operator may perform work on no more
than one owner -installation project in a 12 -month period.
2. Owner's projected active involvement with the installation:
Permit No. OSP231200: work with engineer, purchaser, run excavator, comply with
permit and engineer design
3. The name of the excavation equipment operator: Leroy Smith & ,lames Caswell
4. 1 agree that there will be no monetary compensation for installation services rendered.
5. The name of the inspecting engineer: Brent Western First Water consul
6. 1 agree to discuss the following items with the inspecting engineer:
a. Permit design criteria and specifications.
b. Inspection requirements set forth in AMC 15.65.070.
C. Advance notice given to the On-site Water & Wastewater Section for all required
municipal inspections (AMC 15.65.070A).
7. 1 agree to have the project -specific On-site Wastewater Disposal System Permit available
at the construction site for the duration of all related work.
8. 1 agree that if the system is an advanced wastewater treatment system (AWWTS), I will
obtain additional installation instructions and approval from the equipment distributor.
Not a AWWTS.
As owner of (legal description) Patricia Blk 1, Lot 14
1 agree that the information above is true and accurate.
Owner's printed name: Leroy K Smith
Owner's signature: ,dcwg i swa4/ Date: 7/20/2023
W. 1 0 0TH AVE
A
A
16.5' PUBLIC USE ESMT
BK 1260 PC 160-2
S89°58'50"W 120.00
39.4'
X X X X X X X X z X X-------X-----X
d co
x
� 26.0'
PAVED
Cox M� Qiw Ca
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L X Li 00 >
t) rC
9 SEPTIC
x VENT FCO 0� LLl
( t YP) o z U7 (D �---
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X_ 0 SOT 14N =
DECK �. O L
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o
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SHED ® 26.0' KEYBOX
X 0°
-----X X—X------X X X X X
SBLJp � ss i 30
50 W 120.00
1
1
I ANCHORAGE RECORDING DISTRICT, ALASKA
AS -BUILT OF:
PATRICIA SUBDIVISION
LUT 14 BLOCK 1 PLAT 69-54
SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a
physical survey of this property as shown on this drawing and that the
improvements situated hereon are within the property lines and no
enchroachments exist other than noted. Under no circumstance shoulc
any information on this drawing be used for construction of fences,
structures, improvements, or for establishing boundary lines.
EXCLUSION NOTES: It is the owners responsibility to determine
the existence of any easements, covenants, or restrictions which
do not appear on the recorded subdivision plat.
WORK ORDER NUMBER: DATE: SCALE. E-MAIL:
SEPT 27, 2023 1 " =20' schullerOok.net
23-063-1 DRAWN BY: CHECKED BY GRID NUMBER: BWAGE
JLS SW2528 230320
A"WAM
pF ^ LXl L ��'
0111,
®.. 49TH •.'�%' �,
. • • . . . . • . . . . • • • • • s • • • •• •� N I Z
?A G i ti
..1 ...................:..
, .
.OHN L. SCHULLER.- o /
LS-10408for
��, • . • , . • ,�� �' 1831 Talkeetna Street
�� �•« `."�. Z► ,� Anchorage, .Alaska 99508
1 O fess�vn=\ ® (907) 227-1455 office
��� (907) 274--4992 fax
F-'-- Municipality of Anchorage Page I.._.of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744.
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~v~ ~i'~'/OO~"~ PlO Number: ~ {2..-- '~-~
Name: ¢::~'~"L'T[~ ~ .~pgrade .
~ ~ ~ Wastewater System: D Ne . ..
Address: -, ~[¢~b~,~
{ oo 3 o ~~~ O~' We ~-~ ABSORPTION FIEE~,[,.;;{~'~.r
Phone: ~_ /~&~ No. of rooms: D DeepTrench ~ShallowTrench B Bed B:~uh~,,~-'U Other
LEGAL DESCRIPTION so, Ratine:,~ GPO/Sq. Ft. Total Depth~,from'r~rlgl~l:~e~3:,;;:?H~(~ '
Block: Subdiv~ion: Depth to pipe boffom fr~m original g[~e: Gravel depth beneath pipe
Lot: ~'~ ~ ~%~f~tA ~. 6 ~'~ Ft. * ~;-;,,, Ft,
Township: Range:~ I Section: Fill added ab~original grade: Gravel length:.
~ ~ Et. ~'~ Et.
WELL: C New ~ Upgrade Gravelwidth: / / Numb~r of lines:
5 -~'~ ~t. , ~ ~t,
, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Ft. ~t. 'g ~ SQ. Ft, ~3~)~ ~ ~ ID
~ j Ft. ~+ ~ ~ ~~ Date Installed ,
Yi~ at: '~asing Height Above Ground: · ~
SEP~TION DISTANC~ ~ Septic ~ ~ S.T.E,P.
~~~ Absorption Lift Holding Public/Private Manufacturer: Ca
From Field Station Tank Sewer Lines
~ Material: Number of Compa~ments: ~
SudaCewater >SOO[ %t~¢ ~/~ ~ i& >10¢ % LIFT STATION', , ::':-',,':'
Lot o~rer:
Foundation II t~ ~[~ ~/A ~ ~ "Pump °n" level at: ~ I High water ala~ at:
Cu~ainDrain ~[~ .... ~ - I , ,
Rema[ks: . % BENCH MARK
~- ¢ 'X ~ k]"O' ' iZ ' ' Location and Description:
/ EN~I .... ' '
Inspections pedormed by: ~ ~ d~3S Dates: 1st ~ ~ .'/. :'~
2nd ~/~ ~~;~" '
,,-, , ~,
.
Depadment of Health. an~ Human Se~ices approval --' '-"-"~:¢*' ""',-'
Reviewed and approved by' Date' %-/F-~7 ~1~ ~,
72.013 (Rev, 9/91) MOA 25 'i
PERNIT NFl, SV/970067
PID NO' 012-484-21
AS,, BU]]I T
CD = 16'
BI] =
AE = 37,7
BE = 35,3
AF = 39,3
BF = 42,2
=-NEW TRENCH 52,5' x 6 FEET WIDE, AND 12 FEET x 5 FEET WIDE,
TOTAL ABSORPTION AREA = 375 SQUARE FEET,
WEST 100TH AVENUE
/-ALTERNATOR VALVE 16,5' PUBLIC USE EASENENT
/ r-DOUBLE C/0 C/0
l /~: ....... ,~','1~
~ ~ CARPDRT
X-C/O "F~
HDUSE
~_EXlSTING
EXISTING
BED
SEPTIC UPGRADE AS-BUtL5
LOT 14, BK 1, PATRICIA S/D,
~NERAL LDCATIDN
DF KEY BDX,-~
o
1000 GALLDN SEPTIC TANK,
Ld
r~
I
W
PREPARED FOR: NIKE CARLTON
PREPARED BY~ ALASKA V/ATER & WASTEWATER
DATE~ 4/30/97 I DRA~IN~ GARNESS I SCALE, 1' = 20'
PERMIT NO: SW970067
PID NO: 012-464-21
AS-BUlL T DWG.
MONITORING TUBE (TYP.)
PERFORA TED IN DRAINROCK.
COVER = 96.8+
__ 2 INCHES OF BOARD INSULATION
FABRIC SILT BARRIER
DRAINROCK
BCREENED PER M.O.A
SPECIFICA
94.25 ~
93.75 ~
5 TO 6 FEET WIDE
SEE PLAN VIEW
INCH DIA., ASTM F810
PERFORATED PIPE. HOLES
DO WN.
GROUNDWATER AT ELEVATION OF 89.5 FEET ON
4/29/97. BOTTOM OF TRENCH I$ GREATER THAN
4 FEET FROM GROUNDWATER, AND 6 FEET FROM
IMPERMEABLE SOILS. THE OLD BED IS AT ELEV
OF 93.50.
AS-BUILT DRAWING: LOT 14, PATRICIA S/D.
PREPARED FOR: MIKE CARLTON
ALASKA WATER & WASTEWA TER SERVICES
DATE: 4/30/97 DWN: GARNESS SCALE:
NTS
BENCHMARK IS TOP OF
BACK DOOR THRESHOLD.
ASSUMED ELEVATION
= 100.00.
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW970067
DESIGN ENGINEER:ALASKA WATER & WASTEWATER SERVICES
OWNER NAME:CARLTON MICHAEL N & TURA K
OWNER ADDRESS:10030 GEBART DR
ANCHOR_AGE, ALASKA 99515
DATE ISSUED: 4/18/97
EXPIRATION DATE: 4/18/98
PARCEL ID:01246421
LEGAL DESCRIPTION:
PATRICIA BLK 1 LT 14
LOT SIZE: 6976 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18A~AC72) AND DRINKING WATER REGULATIONS (iSAAC80).
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 PROVISIONS:
RECEIVED BY:
ISSUED BY:
DATE:
DATE:
-2/-97
Alaska Water & Wastewater
8471 Brookridge Drive ~ Anchorage N Alaska 99504
(907) 337-6179 - Fax (907) 338-3246
Consulting Engineers
RECEIVED
April 9, 1997 APR '1 0 lgS [
Municipality of Anchoraoe
D ~ ~
ept, Health & Human Services
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
ReP Sewer Upgrade for Lot 14, Bk 1, Patricia S/D.
To whom it may concern:
The existing 3 bedroom house is served by private septic system and AWWU water. The
drainfield will not pass an adequacy test at this time (surcharged), and must be upgraded prior to
the sale of the house. Comments regarding the proposed upgrade are summarized as follows:
1. SOILS: Attached is a log which shows the soil profile, and the percolation test results. The
accepting soil is a clean sand that perks faster than 1 minute/inch. In short, the soils are very
good.
2. TRENCH DESIGN: Do to the space constraints, I am proposing to install a 6 foot wide
trench, rather than a 5 foot wide trench. Although the performance will not be as good as a
conventional 5 wide trench, I am going to compensate for this by installing an alternator valve so
that flow can be periodically diverted between the old bed, and .the new trench. The design is
summarized as follows:
a. Percolation Rate: < 1 minutes/inch.
b. Allowable Application Rate: 1.2 gallons/day/fi2
c. Number of Bedrooms: 3
d. Design Flow: 450 gallons per day
e. Minimum Absorption Area: 375 fi2
f. Effective Depth: .5 feet
g. Reduction Factor = 1
h. Width: 6 feet minimum
i Minimum Length: 62.5feet.
j Effective absorption area = 375 ft2
Do to the limited space available, and the fact that the actual perimeter of the existing bed is
unknown, it is possible that the new trench may be slightly closer than 10 feet from the existing
bed. This should not be a serious concern since the wastewater tends to move downward rather
rapidly in porous soils, and does not migrate laterally to any great extent. In short, it is my
opinion that the subject encroachment will have no adverse effect.
3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed septic
upgrade.
4. TOPOGRAPHY: The lot is essentially flat, consequently, there are no slope concerns.
I am unaware of any adverse impacts this installation would have on adjacent wells or septic
systems. If you have any questions, please contact me at 337-6179, or on my digital pager at
1-800-481-1162~/Thank you for your assistance.
/I
Sincerely, ~
j~rness, P.E., M.S.
Prin~p~l I
Mike Carlton Design Package.wps
~DTS TD TI- NORTH D~
AVENUE ARE'N~N LAKE V~ w4 TERR,~CE 8Ut~3IVISIDN,
ALL THE LDTS~RE SERI~ D BY,~ITY WATER AND ~
FRDM THE NDRT~ ~ SEPTIC SYSTEMS,
WEST IOOTH AVENUE
NEW I)RAINFi
SDUTH ANCHDRAGE 11APTIST
CHURCH S/I), LOT 8, UN]]EVELDPEI]
GENERAL LDCATIDN DF NEIGHI~DRS SEPTIC SYSTEM-////
LOT 12, BK 1
PATRICIA
UNDDEVELDPED.
LOT 11, BK 1
PATRICIA
UNDEVELOPED,
~W
~Z
n_j
SEPTIC UPGRADE:
PREPARED FOR:
PREPARED BY~
DATE: 4/9/97
LOT 14, BK 1, PATRICIA S/D,
MIKE CARLTON
ALASKA ~/ATER & WASTEWATER
DRA~/N| GARNESS SCALE~ 1" = 100'
NOTE~ THE CONTRACTOR SHALL BE RESPONSIBLE FOR LOCATING THE
EASEMENTS SHOWN, AND ENSURING THAT THE NEW DRAINFIELD DOES NOT
ENCROACH INTO THE EASEMENTS,
THERE IS A FENCE WHICH PARALLELS THE WEST PROPERTY LINE, AND
THE PUBLIC USE EASEMENT TO THE NORTH, CONTRACTOR SHALL MINIMIZE
DAMAGE TO THE FENCES, PORTIONS OF THE FENCE MAY HAVE TO 3E
REMOVED FOR EQUIPEMENT ACCESS, NATURAL GAS LINE
PARALLELS THE
/-NORTH SIDE OF THIS
WEST iOOTH AVENUE / EASEMENT LINE,
VALVE /
/
16,5' PUBLIC USE EASEM~T
/
C/O
TRENCH, 6' WIDE AND 62,5' LONG,
W
:/O
I
EXISTING
BED
C/O
CARPORT
HOUSE
THE WATER SERVICE
LINE COMES IN
FROM THE STREET,
EXISTING 1000 GALLON SEPTIC TANK,
INVERT OF EXISITING C/D PAST TANK
~IS 94,6, BENCHMARK IS THRESHOLD
DF BACK DOOR, ASSUMED ELEV, = 100,00
m
SEPTIC UPGRADE~
PREPARED FOR:
PREPARED BY~
DATE: 4/9/97
LOT
MIKE CARLTON
ALASKA WATER 8, WA§TEWATER
-7953 .: ~
THE TRENCH SHALL HAVE A MINIMUM LEN(~TH OF 82.5 FEET, AND A TOTAL
EFFECTIVE ABSORPTION AREA OF 375 SQUARE FEET.
MONITORING TUBE (TYPO
PERFORATED IN DRAINROCK.
NOTE: BOTTOM OF TRENCH,
EXCAVATION SHALL BE LEVEL.
MAX. VARIATION OF 2 INCHES
BETWEEN HIGH & LOW SPOTS,
DRAINROCK SHALL BE
SCREENED PER M.O.A
SPECIFICATION$.
94.25
93.5
EXCAVATE DOWN TO SANDY
SOILS. IF NECESSARY, FILL
WITH NATIVE SAND TO DEPTH
OF 93.5 FEET.
BACKFILL WITH NATIVE SOIL AND MOUND.
TOPSOIL & RESEEDINO SHALL BE RESPONSIBILITY
t OF HOMEOWNER. IF HOUSE IS BEING SOLD,
i SELLER SHALL O00RDINATE WITH BUYER.
~ ..... PROVIDE 2 INCHES OF BOARD INSULATION
I ---- FILTER FABRIC SILT BARRIER
IF SOIL COVER IS LESS THAN 3 FEET.
INSULATION SHALL COVER THE ENTIRE
WIDTH OF THE TRENCH,
6 FEET WIDE
NOTE:
1. TRENCH SHALL RUN PARALLEL TO THE SLOPE CONTOURS.
2. FOR LOCATION OF CLEAN-OUTS AND MONITORING TUBES
SEE THE SITE PLAN.
3. CONSTUCTION PRACTICES, AND MATERIAL SPECIFICATIONS
SHALL COMPLY WITH ANCHORAGE MUNICIPAL CODE 15.65,
"WASTEWA TER DISPOSAL REESULA TIONS".
4, INSTALLATION SHALL COMPLY WITH SPECIAL PROVISIONS
NOTED ON THE SEWEI~ PERMIT.
'~----4 INCH DIA., ASTM F810
PERFORATED PIPE. HOLES
DOWN. PLACE 2 INCHES
OF DRAINROCK OVER TOP
OF PIPE, AND ACROSS
ENTIRE WIDTH OF TRENCH.
PIPE SHALL BE INSTALLED
LEVEL (WITHIN .0t FEET).
BENCHMARK I$ TOP OF
BACK DOOR THRESHOLD.
ASSUMED ELEVATION
,,, 100,00,
DETAIL FOR 6 FOOT WIDE SHALLOW TRENCH:
PREPARED FOR: MIKE CARLTON
ALASKA WATER & WASTEWATER SERVICES
DATE: 4/9/97 DWN: GARNESS SOALE:
NTS
PERFORMED FOR:
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPAR'rMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Township, Range, Section:
1
2
3
4
5
6
~q o.~ 8
10
~2
15-
17
2O
SLOPE
WAS GROUND WATER
ENCOUNTERED? "~ ~-.~
S
IF YES, AT WHAT /.H ~
DEPTH? (~ '~ -- p
E
~eplh to Water After
Mnnil~rinfl?...... ~ _ Date:
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE '~' I (minutes/inch) PERC HOLE DIAMETER
~EST RUN BETWEEN ~''25' FT AND ~'~' FT
COMMENTS ~;F__.,~,~:+-~-- '~. ~&~ o~ ~ D~. I~V~ I~
PERFORMED BY: 3¢ ~'¢"'4~-~'~'~"~C'~ I ~¢~'-~__'~,4~,1~.~'~
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE,
72-008 (Rev, 4/85)
CERTIFY THAT THIS TE,~T WAS PERFORMED IN
DATE:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME.J~ ~. IPHONE J E~EW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
. ~ BEDROOMS
kiq.~a~in ~aHons IF HOMfiMADfi: InsMe length ~idth Uquid de~th
Manufacturer g~ ~ Material Eiquid capac~W in ~allons
~ Well Foun~tion ~ ~/ Nearest lot line PERMITNO.
~ ~ DISTANCE TO: ~/~ /¢ /~~ /~ ~/ ~O
~ Nd. of lines ~ Length of eac~7 Totalle~¢oflines Trench width : Distance between lines
~ TOp of tile t~¢graOe Material beneath t(le Total effective absorption area
' Length Width Depth PERMIT NO.
Type of crib Crib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
Class Depth Driller Distance to lot line PERMIT NO.
DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER ~tC ~T,~ ~T~
PIPE MATERIALS ,
SOl L TEST RATING ~ ~ ~ , ·
INSTALLER ~ ~ ~: ~
REMARKS 2 ;I~;i :~. ~'~,~ ~'1,
,
I
I
APPROVED '" ~ DATE LEGAL
72-013 (Rev. 3/78)
DEPARTME]~IT' [)F HEAl, TH AND ENVIRONMENTAL PROTEC]"ION
' ~'~ ~- .... A K 9 9 5 0 1
EIc~ L STREET, AN[,HORAGE,
~:.64-47~0
(] ~] --- ,:=. ][ 'T'E S I::: ~,',~ E] R F' tEE I~
F'ERM I 'l" NO:
DATE: I,.~,:~LJE. D:
8,,.K.L,~68
09/06/85
APPI_ I CANf':
ADDRESS:
CONTACT PHONE:
JIM LAMSON
440 W _90TH
ANCHORAGE, AK
786-8120
99515
L.EGAL DESCR I F':
L,.OT SIZE:
MAX BEDROOMS:
SUBDIVISION: PATRICIA
SECTION: 1:.~ TOWNSHIP: 12N
7020 (SQ, FT. L]R ACRES)
LOT. 1,4 BL. OCK: 1
RANGE: 4W
Listed below are the options available to you in designing your :septic:
system. Choose the'option 'Chat best. F:i. ts youn site.
EE D
4.5 4.0
0.5 1.0
5.0 5.0
9.0 5.0
56.0 79.0 **
25.4 22.0
000.0 ** 1,000.0 **
150 150
DIEF"I:'H 'T'O F"IF'E BO'T'TOM (FT.)
GRAVEL DEPTH ,(FT. )
']"()']"AI... DEPTH (FT.)
GRAVEl .... WIDT'H (FT.)
GRAVEL LENGTH (F'T.)
GRAVEL. VOLUME (CU. YDS.)
'T'ANI< SI ZE (GAI...S)
,:~J..}IL RAI"ING (SQ. F"I'. tBR)
** E~RAVE.I... I....EI,IGIH > 75 FT, REQUIRES MUL. TIPLE RUNS (NOT EXCEEDING 75 F'T. IzACH" .... ' )
*~. T'AIxlK HUST HAVE AT L.EAST TWG COMF"ARTMENTS
I c:er.'Lit'y 't. hat:
:t.., t am Familiar, with the nequir'ements £or' onrsite seweps and wells as set
£oPth by the Mun:icipal:Ety o£ Anchor'age (MOA) and the:. State of Alaska.
2. I will install the system in accoPdance with all MOA codes and regulat:i, ons,
and in compliance with the design c~-itePia et' this per'mit.
3,, I will adhere t.o all MOA and State of Alaska nequ'iremen{s £or the set bacl.::
distances Fnom any e;.,'isting well,, wastewatep disposal system er' public
sewer'age system on this oP any ad.jat:ent on near'by lot.
4,, I under'stand that this penmit is valid fop a maximum o~' 3 bedr'ooms and
any enlangement w~l]. r'equire an additional pePmit.
IF A LIFT STATION ].,~ 1NS1ALLED IN AN AREA COVERED BY MOA BUll~DING CODES,
THEN (1) AN ELE,],CTRICAL PERMIT AJ)~ INSPECTION MtJST BE OBTAINED~ (2) AS--BUI[ ""S
WILL. NO]' BE~
EL. EC.;TRiCAT~]:'~4(]'¢b]I) WITH~ ¢~[..EC]~RICAL INSPECTION RE'.POR~'AN[; (:5~' ~HE ....
S ]: aNED ~~~ DATE: ~--d ~
AI:::'Pt.... I CAI'4"[': ~'1~ LAMSON
ISSUED BY ~~~.~X~ DATE: ~7~ ~..~ ~~ ¢ ~
LOCATION
SOILS LOG
HOLE NO. ~ /
DATE ~/9~
BY *~
DEPTH /,~ ~'
WATER TABLE
UNIFIED
CLASS
DESCRIPTION
LOCATION
SKETCH:
GRI() N(~
LEGEND
SYMBOL
TEST HOLE
WATER TABLE
FROZEN
MATERIAL
ALL FROST CLASSIFICATION
BASED ON THE .O2mm --. 50%
OF 'i"HF -~ZOO UNLESS
OTH E RWISt~T NOTED
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 1. D. 012-464-21-000
Expiration Date: 10/27/2024
Legal description PATRICIA BLK 1 LT 14
Site address 10030 GEBHART DR Anchorage AK 99515
Current property owner(s) SMITH LEROY K & SARA A
X The On-site system(s) is/are approved for 5 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
Original Certificate Date: 10/31/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA ApprovaIjune 2022
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
i
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 012-464-21
Complete legal description PATRICIA BLOCK 1, LOT 14
Location (site address) 10030 GEBHART DRIVE, ANCHORAGE, AK 99515
Current property owner(s) LEROY & SARA SMITH Day phone
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ® Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ® Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age NEW - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ® Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ 550
Date of Payment /' � _Z2
COSA # Q_`)C �, 3Jq 09
Waiver Fee $
Date of Payment
Waiver #
COSA Application.doc
COSA Checklist.docx
COSA Checklist
Legal Description: PATRICIA BLOCK 1, LOT 14 Parcel ID: 012-464-21
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA - PUBLIC &/OR CLASS “A” WATER
Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank NA
Date of pumping NEW TANK
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 4/30/1997
ALL standpipes present per record drawing
Total measured depth from grade 4.4 ft (max)
Measured depth to pipe invert from grade 3.4 ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes (MT) go to bottom of effective (ED).
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 6/13/2023
Results Pass
Fluid depth prior to test 0 in
Water added 450 gal
New fluid depth 1.5 in
Elapsed time 25 min
Final fluid depth 0 in
Absorption rate 450 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 6 in (MOA 0.5’ ED)
Effective depth used 0 in (Final Fluid Depth)
Effective depth remaining 6 in
Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots &
appears approximate.
COSA Checklist.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) - NA
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No * ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No * ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
*Approved 1997 MOA septic field is just adjacent to the carport cement slab that was existing at the time of permit design,
install & approval in April / May 1997 with no known issues for the past 26 years. The 1997 field is 10’+ to building
foundation. The field is also 10’+ to the northern 16.5’ public use easement line per as-built & 1997 inspection report.
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 10/25/2023
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
10/25/23
Municipality of Anchorage
Development Services Department
Building Safety DMslon
On-Site Water & Wastewater Program.
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www.ct.anchorage.ak.us
(9O7) $4~-7004
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 012 -464-21
'h GENERAL INFORMATION
Complete legal description
ExplratJon Dat~:
PATRICIA SUBDMSION; LOT 14~ BLOCK
Lo~Uon(sltaaddressordimcflons) 10050 GEBHART DRIVE ANCHORAGE~ AK.9915
Cun'ent Property owner(s) BOBBLE JUSTICE Day phone 242-8779
Mailing address
Lending agency
Mailing address
Real Estate Agent
5714 COLLEGE DRIVE
ANCHORAGEf AK 99504
Dayphone ·
EI.NNE BALES w,/ ASSIST A SALE Dayphone ' 338-2482
Mailing address
Unless otherwise requested, HAA wfll be held by DSD for plckup.
2. NUMBEROF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authoflty
Approval (HAA) based only upon the representations given In paragraph 5 by an Independent prefesslonal civil
engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of tiUe (except between spouses) for proper'des served by a single family on-sita wastawater disposal and/or
water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date ef Issue for properties served by a private or Class C well and may
be reissued with new water sample results less than 30 days old. (Cer'dficates may be reissued fora period of
up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B
wells or a public water system. The Municipality of Anchorage Is net responsible for errore or omisslons In the
professional engineer's work.
Note:Alaska Water and Wastewater Censuitants, Inc. shall be pald $850.OO at, or prfor
to closing for the engin~erfng sen4ces provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validatLon date shown below, I verify that my
Invesb'gation, based on procedures outlined in the Health AuthodO/ Approval Guidelines for this application,
shows that the on-site water supp~/ and/or wastewater disposal system is(are) safe, functional and adequate
for the number of bedrooms and ty~e of st,~cture indicated herein. I further verify that based on the
information obtained from the Munidpali~y cf Anchorage tiles and from my Invesb'gation and Inspac~'on, the
on-site water supp~y and/or wastewater disposal system Is(are) In compliance with all applicable Municipal
and State codes, ordinances, and recJula~ons in effect at the t~me of installation.
Name of Firm ALASKA WATER &: WASTEWATER CONSULTANTS, INC.
Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504-
Engineer's Printed Name ,JEFFREY A. GARNESS. p.F'.
Phone. 557-6179
Date ~ /?--/0 [
Engineer's Comments:
In conducting this evaluat~n, AIMWC, Inc. atlernpted to provide a th~reugh,
consc/enlious engfnsering ana~sls of the system in accordance wf~h ADEC and MOA
DSD Guidelines & Regulations. The reported results described the l~en'orrnance of ~he
system under the cond~ons encountered at the lime of the test, and separation
distances measured to readiO/ identifiable features. The oparalional life of all wells and
seplic systems depend on the Iocal soils cond~on, groundwater levels that may
fluctuate during the yea~', and the water usage of the family betng sen/ed by the system.
These condiEons are outside the con~'~l of the evalua~or of the system. Satisfactory test
results do not guarantee future performance of the Wstem, n~ do they guarantee that
there am no hidden detec~ or encraach/nents. AWWC., Inc. can therefore not provide
any wan'anty or future estimate of how long the system will conlinue to meet the
operalional raquiremente of the ADEC or MOA DSD. The content of this report Is for
the sole benelit of the ovm~' listed abow. Any reliance upon or use of this rapa[t by any
other person or parly Is not authc~zed, n~' will lt confer any legal right wha~x~ver.
DSD SIGNATURE
I..-" Approved for '~
Disapproved.
Conditional approval for __
P~ro f es s~o~°~=~
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Manitenanca Agreements
Supplemental Engineer's Reort
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety DM~On
On-Site Water & Wastewater Prngmm
4700 8outh Bnlgaw 8L
P.O. Box tg6650 A~cl~arage. AK ggMg-6650
www.cLanchomge.ak.u~
Legal Dnsc~ption:
A. WELL DATA
Cw
HEALTH AUTHORITY APPROVAL CHECKLIST
PATRIClA SUBDMSION; LOT 14.~ BLOCK 1, ParcellD:. 012-464.-21
PUBLIC WATER
Well type ff A, B, or C provide PWSID~ Well ~ ~...~
Date completed ~res p~pedy protected (Y/N)
Total de . Cased to ff. Casing height (above ground) in.
FROM Wi=! ~ LOG AT INSPECTION
Da, of,st
Static water Mvel / ft.
W~a~g~t~'"'"-~ g.p.m. ..J g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/lO0 mi. Nitrate __mgJL. ~ nm O0 mL
Date · Collected by:.
8EPTIC/NOLDING TANK DATA *PER NORTHLAND PUMPING
Tank Type/Material STEEL
Tanksize 1250 gal. Number of Compertments 2
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO
Date of pumping *9/15/00 Pumper.
Date installed 12/31/85
Cleanoute (Y/N) YES
High water alarm (Y/N) N/A
NORTHAND PUMPING
System type TRENCH
Grovel below pipe 0.5 .ft.
Depression over field NO
For 3 bedrooms
0 in.
g.p.d.
Now depth
Absorption rate >= 450+
NONE KNOWN If yes, give date
ABSORPTION FIELD DATA ~
Date installed 4/2~-,Io/~? ,Soil rating i~or ~Fndrm) 1.2
Length 64.5 fl. Width 6 lt.
Total depth 4.~ lt. Eft. absorption ama 375 lt~ Monitoring lube YES
Date of adequacy ~est 2/22/01 Results (Pass/Fall) PASS
Fluid deqth in absorption field before test 0 in. Water added2834gal.
Elapsed Time: 0 min. Final fluid depth 0 in.
Any rejuvenation treatment (pest 12 mo.) (Y/N & t~e)
O. UFT STATION
Fe
Data installed Size in gallons _ M~ _~
"Pump on" level at in. "Pump off' ~n. High watar alarm level at in.
~ Cymes tasted Meets alarm & circuit requirements?.
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/tilt station on lot100'+
Absorption field on lot. 100'+
Public sewer main N/A
Sewer/septic service line 25'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/deanout
Holdlrtg lank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5% Property line 5'+
Watar main 10'+ Watar service line 10'+
Wells on adjacent lots 100'+
Absorption field
Surface watar
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+
Watar sen, ice line 10'+
Curtain drain NONE KNOWN
COMMENTS
Building foundation. 10'+
Surface watar 100'+
Wells on adjacent lots. 100'+
100'+
Watar main. 10'+
Driveway, parldng/vehicie storage 1'+
G. ENGINEER'S CERTIFICATION
I certify that I have detarmined through field inspections and
revfew of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Pdltad/Name
Date
HAA Fee $
Data of Payment
Receipt Number
(~ev. l~0o)
Waiver Fee $
Data of Payment
Race pt Number.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
HAA #
Location (site address or directions) I
Property owner /~'1~
Mailing address ~,--~ ~-- ' ~:~_~ '
Day phone
32(, 7- / g/~--
Lending agency
Mailing address
Agent ~J
Day phone
P~ O ~.f~ ,//P--'~v'~ o(z_O,~ay phone
Address
Unless otherwise requested, HAA will/be held for pickup.
NUMBER OF BEDROOMS: ~ ~'
TYPE OF WATER SUPPLY:
Individual well
Comm unity well
Public water
NOTE:
ing to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAL:
NOTE:
If community well system, provide written confirmation from State ADEC attest-
RECEIV:ED
Individual on-site ~ ,~:
Holding tank MAY 0 ~ ]~)?"~ ..;3
Community on-site MuniciPality et Agchorago
Public sewer Dept. Health;;~q.Human Services.
t! community wastewater system, provi~e written confirmation from State A
attesting to the legality and status of system.
72-025 (Rev, 1/91) Front MOA#21
~-= w.~,~ & ~f this
idgC'FJr./ \
Engineer's signature .
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 ~tructure 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 dispos~.l system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date inspection.
Approved for 3
Disapproved.
Conditional approval for
Name of Firm
DHHS SIGNATURE
bedrooms.
Phone .~'~ 7-'~ / ']~
Date _
bedrooms, with the following stipulations:
Additional Comments
By:
%: .'. !~ I ;~'t~ "~ // Date _3"--~ /
,,- ' '~ 'ty . ~!- age Department of Health and Human Services (DHHS) iSSues Health Authority'
AjSpr°val C~tifi ;,~t¢~'b~sed bniy upon the representations given in paragraph 5 above by an independent
Prof~SSi°i~al en~li~r ~egistered in the State of Alaska. The DHHS does this aS a co
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
A. WE,, OA A I-[ 0
Date of test ~~~
St_atlc waler I_evel ~-'"~ ~
Well production ~ g.p.m. ~~, g.p,m.
WA.T. ER SAMPLE 7 __ ~
B, ~)~,~T i C ;~I~:NG TAN K DATA Collected by: ~
Date installed ~ Z//'~'' Tank size ~,.~-~
Foundation cleanout (Y/N) ~F--~
Date of PumPing ~'~/~/~'~ Pumper
c. ^..O..T,O.
Date installed ~-/;~1/c~.,
/
Length ~ .!~' Width
Effective absorption area
Date of adequacy test
[~'~-'~ Number of Compartments ~ Cleanouts (Y/N) ..
Depression (Y/N) ~13 High water alarm (Y/N) h,J t~
Soil rating
Gravel thickness below pipe
Monitoring Tube present (Y/N)
Results (Pass/Fail)
(g.p.d./ft2 o~) /' ?- System type
Fluid depth in absorption field before test (in.);
Fluid depth / (ins) Minutes late.r~'''~
Peroxide treatment (past 12 months) (Y/N) ~
Immediately after
Absorption rate =
If yes, give date
~ /' Total depth '~¢- ~ ~ t"~'~ ·
. Depression over field (Y/N)
For ..~ bedrooms
fgal. water added (in. :)T'""
.g.p.d.
72-026 (Rev. 3/96)*
STATION
Date installed Size in
Manhole/Access (Y/N)
High water alarm level
E. SEPARATION DISTANCES
level at*
*Datum
"Pump off" level at*
EIVED
SEPARATION DISTANCES FROM WELL ON LOT TO:
on adjacent lots
Absorption field on lot ~~.~~ ~
Public sewer main s ~manhole/cleanout
SEPARATION DISTANCES FROM SEPTIC/H~NK ON LOT TO:
Foundation I
!
Water main/service line
SEPARATION DISTANcE FROM ABSORPTION FIELD ~TO:
Property line J
Absorption field
Surface water
Wells on adjacent lots
MAY 0 5 1997
Municipality of Anchorage
Dept. Health & Human Services
I¢J~5- IPSP- /
Curtain drain
Building foundation. J'~'/~' ~ Water main/service line
/
Driveway, parking/vehicle storage area I
J~'-"J°~J/~J Wells on adjacent lots ~' ~-~O /
are
F. ENGINEER'S CERTIFICATION
I certify that I have dele~mined th~ eld inspections and review of Municipal records
,nconforman~t~/~~~ ~_~neffectonthisdate.
Signature
Engineer s Name
HAA Fee $ ----~-~.-~
Date of Payment ~-~-~ .,~.~
72-026 (Rev. 3/96)*
Waiver Fee $
. Date of Payment
Receipt Number
MUNICIPALITY OF ANCHOEAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ~<-~ .~
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Bus ines s
(b) Applicants Name J~ ~%~ Telephone- Home -~
..... . ,, .
Applica~ :~d'ress. ~' ~ 0 ~, ~W ~
Buyer ~ ; ' Other~ (explain); ~ ~~ ' '
(d) Lending Ins~titution ~/~
Telephone
Address
(e) Real Estate Co.-& Agent
Address
Telaphone
(f)
Mail the HAA to the following address:
2. Type of Residence
Single-Famtly.~.
Number of Bedrooms
Multi-Family ~-~
Other (describe)
3. Water Su.pp1X .
Individual Well~ Community~-~ Public.~.
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage D.isposal .,
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
Ensineering. Firm Providin~ Inspections, Test.s, File Search, Data and Information
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 shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the ~umber 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 regula-
tions in effect on the date of this inspection.
Name of Firm
Address
Date
DHEP Approval
Approved for
Approved Q~/
JAMES B. ROBERTS,
360 West Benson
Anchorage, A~'
~edrooms
Disapproved
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHE~i ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH"5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
b~NTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FO~ ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
RR4/ej/D18
[Page 2 of 2]
'~ ' (DHEP~ SEAL)
7-19-84
A®
MUNICIPALITY OF
DEPT. OF HEALT~
ENVIRONMENTAL p,~C)T~C HO
iOCT 2 1986
Well Classification
Well Log P~esent (Y/N)
Total Depth
Static Water Level
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description: ho~ J~- Blo~l
If A, B, c~ C, D.E.C. Approved(Y/N)
Date Ccmpleted Yield
Cased to Depth of G~outing
Pump Set At
Casing Height Above Ground
Eleetzical Wiring in Conduit (Y/N)
Separation Distances f~cm Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Se~r Line
Cleancut/Manhole
Water Sample Collected By
Water Sample Test Results
Cc~rents
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On AdjoiningLots
To Nearest Public Se~r
To Nearest Sewe~ Service Line on LOt
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed 'l~/, ")/~'5
I I Size
Standpipes ~) y Ai~-tight Caps
P~ing~intenan~ ~n~a~ ~ File (Y~)
Holding Ta~ High-Wate~ Ala~ (Y~) ~ ~a~y Holdi~. Tank ~it (Y~) ~/~
~ation Distan~s ~ ~ptic~olding Tank:
To Building Foundation ~ mdv~- ~ 5J,[~
To Disposal Field ~ ~
To Stream, Pond, Lake, caz Major D~ainage
[Page 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA
Da
Soils Rating in Absorption Strata
Date Installed ///~ ~/~
Width of Field
Square Feet of Absorption A~ea ~(~7
Depression over Field (Y/N) A/
Results of Last Adequacy Test ~./~
O -5~/~_. TyPe of System Design __~
Length of Field ~g.~ ~r]r
Depth of Field 5:63 -~
Gravel Bed Thickness / ~-7-
Standpipes Present (y/N) ~/
Date of Last Adsquacy Test /~ ~/
Separation Distance f~cm Absorption Field:
To Wate=-Supply W~ll ~J/~ To Property Line IO ~ '
To Building Foundation N//~ [D~~ To ~ Abandoned System cn
Lot ~O~ .. ~ ; On Adjoining Lots
To Water Main/Service Line l,~. O,~ ~4- . To Cutbank(if present) ~3~/~
To Stream/Pond/Lake/°r Major Drainage Course
To Driveway, Parking A=ea, or Vehicle Storage A=ea
%%\
Date Installed p3/~
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Ccmuents
Manhole/Access (Y/N
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test. Meets MOA
Cc~pa~y ~.,.~. ~ ~,,"".'.-'."~
~60 ~e~t Benso~ Blvd., ~207
KB1/dL/s Anchorage, AK 99503
** Check Pemunitted Bedrocm Rating Against HAA Request
I certify that I have checked, verified, c= conformed to all MOA HAA _G~_.~'_~ in effect
d'(,...'% "'.. * * ° · ' * ·
; '...
[PaGe 2 of 2]
MOA No. ~_~/_~~~
2-15-84
VICINITY MAP
CERTIFICATE OF OWNERSHIP E~ DEDICATION:
NOTARY~S ACKNOWLEDGEMENT:
2?
SURVEYOR'S CERTIFICATE:
NOTES:
TYPfCAL MARKINGS
BRASS CAppED MCN.
SET THIS SURVEY
LEGEND:
· GLO or BLM br~3ss cap
CURVE DATA
DTI001280
PLAT OF
PATRICIA SUBDIVISION
DICKINSON -OSWALD & ASSOCIATES
ENGI N E~RS - SURVEYORS
.~S NINTH ~VE - ANCMORAGE, ALASKA
~_ , ...... 1g0-66 :