HomeMy WebLinkAboutELMORE #2 BLK 12 LT 1D
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PAUZ L.*'018 1'► 3 3o noo
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201270 PID Number: 018-173-30
Dwelling: ❑■ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑■ Upgrade
Name
Jeri C. Thompson
ABSORPTION FIELD
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
14701 Teton Place Anchorage, AK 99516
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
223-5554
3
Existing GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Elmore #2 12 1
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
AbsorptionHolding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Lift Station
Tank Line
Ft 2
Ft.
Well
>100'
N/A
N/A
N/A >25'
TANK 9Septic ElS.T.E.P. [:1 Holding [:1 Other
Manufacturer
Greer
Capacity
1,000 Gal.
i
Surface Water
>100-
N/A
N/A
N/A
Material
Plastic
Number of compartments
2
Lot Line
>5'
N/A
j N/A
N/A NA
Foundation
�>10'
N/A
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Remarks Tank is insulated with 2" foam.
Gal.
Tank replacement only under this permit.
Alarm location
Electrical installed by
PIPE MATERIAL House to tank D3034 Tank to D3034
drainfield
Installer
A+ Home Services
Drainfield EXISTING CO/MT D3034
Inspector L. Tidwell
BENCH MARK (Assumed elevation) 100 ft
Inspection15 8/11/20
Location and description
2 nd
Threshold of back door.
3.d 4,h
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
om
................ ®m
Conditional Approval: Date
0
10
................................................
MICHAEL E. ANDERSON V
Septic System10
Ar
�� J,•: No. CE -438t .,� ��ff
Approved Date /O
®®�F,p°••..,,8/18/20 ,,>••'�r�'®
Note: this approval do not include well permit requirements.
kNev uoiuzviut
1"=100'
2CO - DOUBLE CLEANOUT
MH - MANHOLE
SV - SEPTIC VENT
CO - CLEANOUT
LEGEND
PERMIT # OSP201270 PID # 018-173-30
ELMORE #2, BLOCK 12, LOT 1
A B
MH 51.8
SV 56.2
2CO 57.7
A
B
CO 67.4
43.2
47.9
49.6
61.0
147th AVENUE
8/18/20
FEET
0 100 200
FLAG POLE
SHEDTENTON PLACECREEK (LOCATION
SCALED FROM PLAT)
10' DRAINAGE EASEMENTS
10' UTILITY EASEMENT
10' DRAINAGE &
UTILITY EASEMENT
NEW 1,000 GALLON SEPTIC
TANK w/20" MANWAY.
THREE BEDROOM HOME
EXISTING WELL
EXISTING WELL
EXISTING WELLMHSV2COCO
PLAN AS-BUILT
EXISTING TANK
DECOMMISSIONED IN
PLACE PER MOA CODE.
100' WELL RADII
PROFILE AS-BUILT
(NO SCALE)
91.9
87.5
92.4
95.6FCOMH SVPERMIT # OSP201270 PID # 018-173-30
PROPERTY LEGAL DESCRIPTION
8/18/20
1500 GAL
SEPTIC TANK 2CO91.7
2" INSULATION
I
GRAVEL.
SEPTI
FIAG PIPES
POLE
I
MNHOUE
75 4'.
79.1'
-
SEE HOUSE
DUAL
WELL
)Ot
a
m
Z
I
O
x 12.7'
Z
O
3�SHED
HOUSE DETAIL
(7
0
a
Scale: 1" = 30'
m
o
o
0
Lot 1
86,920 s.f.
I
A
2.0' CANT
o DECK B 3'
CREEK (LOCATION
SCALED FROM PLAT)
I
10' DRAINAGE
EASEMENTS /
10' DRAINAGE &
/
/ UTILITY EASEMENT
/ 10' UTILITY EASEMENT
S 89'56'17"W 212.00'
30.00' i Lot 7
I �
Lot 6
2 STORY
RESIDENCE
OE 2K W 0—
,BELOW DECK
3.0' . 8.6' -
LANDING
2.0'
PLOT PLAN AS BUILT -2L SCALE 1" -=50* GRID SW 3036 Project No. 20-364/A2
11500 Daryl Avenue, Anchorage, Alaska 99 51 5-3049
Lang & Associates, inc. (907) 522-6476 Phone 000pOp�O
(907) 522-4625 Fax oo O A / 4�0
Professional Land Surveyors ken*langsurvey.com o •. _`9 Q
jonathan*langsurvey.com o0P ..• .•S QO
I hereby certify that I have surveyed the following described property:
LOT 1, BLOCK 12, SECOND ADDITION TO ELMORE SUBDIVISION (Plat No. 69-96)
Anchorage Recording District, Alaska, and that the Improvements situated thereon are
within the property Imes and do not encroach onto the property adjacent thereto, that
no Improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission Imes or other visible
easements on said property except as Indicated hereon.
Dated this the � 8111 Day of -�L2a , at Anchorage, Alaska
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat.
�............
KENt)ETHiG�"�J .: a
I_S-5202.•' r�Jo
p Npc
IIIA PESSIONAA- �o
AECC963
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: OSP201270
Work Type: SepticTank Upgrade
Tax Code Number: 01817330000
Site Legal Address: ELMORE #2 BLK 12 LT 1 G:3036
Site Mailing Address: 14701 TETON PL, Anchorage
Owner: THOMPSON JERI C
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date:
Lot Size in Sq Ft
Total Bedrooms:
�»cnr
�o
n
r,
DCiltll'Ytlllnt
7/29/2020
7/29/2021
86920
❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: Date:
Issued By: Date:
3
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 018-173-30
Property owner(s) Jeri C. Thompson
Mailing address 14701 Teton Place Anchorage, AK 99516
Site address
Same
Day phone 223-5554
Legal description (Sub'd., Block & Lot) Elmore #2, Block 12, Lot 1
Legal description (Township, Range & Section)
Lot Size 86,920 Sq. Ft. Number of Bedrooms Three (3)
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) ❑X
(w/wo ADU)
Septic Tank
❑X
Upgrade ❑X
(D) E]❑
Holding Tank
❑
RenewalDuplex
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 't j a 7 5 (Cod ► a -19
Date of Payment: 2 _ 2--3 - 2 c?
Receipt Number: 09 11 79
Permit No. 01's P R01 "�70
Permit App_-'-:-
. _..:c
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
July 23, 2020
MOA Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Subject: Elmore No. 2, Block 12, Lot 1 – 14701 Teton Place
Well and Septic System Design
Dear On-Site Services Engineer:
The septic tank on the subject property has passed its useful life and must be replaced. We are
submitting this application for a permit to construct a new septic tank. The attached site plan
identifies the location of the home and the proposed and existing septic tank sites. No conflicts
exist between this proposed tank location and any other well or septic system, whether on this lot
or adjacent lots.
The new septic tank will be placed near the same location as the existing tank. Storm water
drainage will not impact this site.
Wells on this and adjacent lots are shown. The new tank will be a minimum of 100’ from all wells
and surface water, and more than 5’ away from the absorption trench. No surface water is within
100’.
Please refer to the attached plan sheet for the septic design. If this design is followed, there will be
no adverse impacts to adjacent properties.
Sincerely,
Michael E. Anderson, P.E.
7/23/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201270, Deb Wockenfuss, 07/28/20
1"=100'
NOTE:
NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE
PROPOSED SEPTIC SYSTEM
ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC
SYSTEMS.
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
ELMORE #2, BLOCK 12, LOT 1
147th AVENUE
7/23/20 FEET
0 100 200
FLAG POLE
SHEDTENTON PLACECREEK (LOCATION
SCALED FROM PLAT)
10' DRAINAGE EASEMENTS
10' UTILITY EASEMENT
10' DRAINAGE &
UTILITY EASEMENT
DECOMMISSION EXISTING
SEPTIC TANK PER U.P.C.
PLACE NEW 1,000 GALLON
SEPTIC TANK w/20" MANWAY.
CONNECT TO EXISTING
ABSORPTION TRENCH.
THREE BEDROOM HOME
EXISTING WELL
EXISTING WELL
EXISTING WELLMHSV2CO Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201270, Deb Wockenfuss, 07/28/20
Development Services Department
Pudding Safety Civision
On -Site Water —' Wastewater Frogr ar
^^�4700 Bragaw Street
\ '
P.O. Box _96650
Mark Begich Anchorage. AK 99519-6650
Mayor rrnnv.mum.org/onsite
(907)343-7904
Pump Installation Log
Well Drilling Permit Number: SW_ Date of Issue:
Parcel Identification Number:
Legal Description/ Mp Property Owner Name & Address:
II ( LOO t i C7� nr 1 L
b l .Z 1 1 AO cj-.o
Pump Installation Date: q- / _ / e/
Pump Intake Depth Below Top of Well Casing: '73 feet
Pump Manufacturer's Name: /} 7 p;4CJ"aw,0&9
Pump Model: -6OF 54-WIZ—
Pump Size �2 p
Pitless Adapter Burial Depth: /0 feet
Pitless Adapter Manufacturer's Name: W1r4R rr rJSowJ
Pitless Adapter Installer: ,,_) 4
Well Disinfected Upon Completion? Ives ❑ No
Method of Disinfection:
Comments: e
Anchorage Purrlp & Well Service
Pump Installer Name: 330 East 76th Avenue
Anchorage, Alaska 99518
Phone: 907-243-0740
Fax: 907-243-0742
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
�.+ MUNICIPALITY OF ANCHORAGE r
DE, ATMENT OF HEALTH AND HUMAN SER, ES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 P14 /0- 4z,?E
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
DISTANCES
SEPTIC L)(fS% •• ❑ HOLDING
FROM
SEPTIC
TANK
ABSORPTION
FIELD
WELL
address
147o I TEra+.' ISL 4x" Ar— 174"ys7il
WELL
n
!�-'
is
x 4vM1 tt i4 t t
Phone(s)'1J Qs.. �o �Al
333-Z2K7XL.r
Permit No.
860764
No. of Bedrooms
3
LOT LINE
LEGAL DESCRIPTION
Lot
!
Block
Z
Subdivision
G --LM;; �
FOUNDATION
Sq +
Or
❑ TRENCH ❑ BED Vk W. DRAIN ❑ OTHER
Depth to pipe bottom from Total depth from original grade
original grade 4-- FT FT
Township, Range, Section
AS -BUILT DIAGRAM
(Show location of well,
septic system, property
Imes, foundation,
TANKS
SEPTIC L)(fS% •• ❑ HOLDING
Manufacturer
Capacity m gallons
14-714l""
A r,.7
Material
No. of Compartments
TYPE OF SYSTEM
0
❑ TRENCH ❑ BED Vk W. DRAIN ❑ OTHER
Depth to pipe bottom from Total depth from original grade
original grade 4-- FT FT
eP o
r
0„
toJ
Fill added above original grade
FT
Gravel depth beneath pipe
2- FT
Gravellength
.S2- FT
Gravel width
S FT
Total absorption area
'3-2 S SQ FT
Distance between lines
FT
x+
Number of lines
Soil rating
2S SQ FT
Pipematerial +•f2JG. 0_3o34-
+r Pd� D- 272-9
Installer
, / 29.5 ln7(,-WWres
-0ate Installed
/2" Sb
�I
WELLS °
PRIVATE ❑ OTHER (Identifvl
Classification (A, B,C) Total Depth Cased to
// 3 FT /� FT
Installs, Date Installed.
%/• N• W.4, le Or -114, -4 is 2-
R E M A R K S:
-
REMARKS' ald A) Af/I pr w' 4. r
A:
If
'30% fib Scale: /`r =/OJT °
Inspections Performed by. 89
52..E J"iJ • /9+�G !+'»` /2. P. SeAi, �_ °�"�aoa®0000,
a n'
Date', 'i --/Z- 84 j ,sn
v, 3 04
P
sodaieom0000-
certify that This inspection was performed according to all 9. We
Municipal and Slate guidelines in effect on this dale: 'ryz -1411
Q
^1 / p, �d00P9A004
0.
Health Department Approval: r `" � Date. � ' eL• '+i ce„ft"'plizZaa
72-013 (3/85)
MUNICIPALITY Of ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 'L STREETP ANCHORAGE, AK 99501
o. 264-4720
ON-SITE SEWER PERMIT
PERMIT NO: 860164 UPGRADE
DATE ISSUED: 06/11186
APPLICANT: MIKE DEGUIRE
ADDRESS: 14701 TETON;PLACE
ANCHORAGEf AK 99516'
CONTACT>PHONE:` 333-2275
LEGAL OESCRIP SUBDIVISION: ELNORE
SECTION: 34 TOWNSHIP: 12N
LOT SIZE: $6920 (SQ.FT. OR ACRES)
LOT: 1
RANGE: 3W
BLOCK "12:
I CERTIFY THAT:
1. I AM FAMILIAR WITH THE REQUIREMENT'S FOR ON—SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE (MOA) AND THE STATE Of ALASKA.
2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS.
AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
3. 1 WILL ADHERE TO ALLMOAAND STATE. OF ALASKA REQUIREMENTS FOR THE SET BACK
DISTANCE'S FROM ANY EXISTING WELL. WASTEWATER DISPOSAL SYSTEM OR PUBLIC
SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOS.
If A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING, LODESO
THEN (4) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT,` AND (3) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN -
SIGNED DATE:
----�!==-- - --- - .---
APPLICAMIKE DEGUIR£
ISSUED BY--- _ DA.TE:
a l ( ('0
SED
Le �f4 3'�.S
!S' �
I\'
i
\ r MUNICIPALITY OF ANCHORAGE f ;
1 DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
\ 825 L Street - Anchorage, Alaska 99501 Telephone 264-0720
ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
J AmSirons /
PHONE
XNEW
❑UPGRADE
MAILING ADDRESS
SRA Box 3163 9950
LEGAL DESCRIPTION
E.IMbrt S,.)6 b1l L.►
LOCATIONNO.OF
14�and TatOh Co Q.44),
BEDROOMS Z
J .
U
DISTANCE TO:
Well 100 �}
Absorption are
Dwelling
Dwelling S L '
PERMIT NO. 8 ZO 4q 1
O
�X
2Q
~
r
Manufacturer V r�tr
Material $}ecI
No. of compartments
N
Liq. capacityin gallons
00
IF HOMEMADE:
Inside length
Width
Liquid depth
6 5e
—10Z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
0 f
Manufacturer
Material
Liquid capacity in gallons
O
w=
DISTANCE TO:
Well
100 i'
Foundation
87
Nearest lot line
i
PERMIT NO. Lt9 I
82.0
W LL Z
H? cc
No. of lines1
Length of each lie
Total length of lin s
14
Trench width
40 inches
Distance between lines
I..
O
Top of tile to finish grade
1- r W a t<
Material beneath the
IQ — 24 inches
Total effective absorption area
U7 tif
W
Length
Width
Depth
PERMIT NO.
Wd
Type of crib
Crib tliameter
Crib depth
Total effective absorption area
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
Pv( CI
14
SOIL TEST RATING
85 t1 V 6A,m
T e 1c
INSTALLER
E'XCPJa4tOn o M
ik
D • e.
REMARKS
e.
Ilk
r
zs
71
OJS
Let
1
z 72
APPROVED DATE LEGAL
Oct12./$z Elmore svb a 12. L_�
72-013 IRev. 3/78)
M�_�t1Ir Ii FiLITV F= Fit-4CF�EF=l GE
DEPARTMENT HEALTH AND ENVIRONMENTAL :OTECTION
225 'L' STREET, ANCHORAGE, AK. 49501
254-4720
!JELL Fit-JG� I TE �EWEF< FIEF= M I T
{ PERMIT NO. C 220491 )
APPLICANT J. ARMSTRONG/HIGHLAND D SRR BOX 3163 99507
LOCATION
LEGAL L1612 ELMORE LOT SIZE 222222 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: DRAINFIELD
MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SC! FT/BR)= 25
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
GSE = TH= --. t LEt-4QTH= 4!S C�EF'TH= 1
THE LENGTH DIMENSION IS THE LENGTH <IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET).
THE TFt_Et-aCH W IOTH I'S 8.yG��=1 FEET.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION CIN FEET).
Ft_Ec!!U I FRED S EP T I C -rn"F' � I .=E= 1F-ll+l0 1C,RLLOt-1S
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DUPING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER, OF RESIDENCES THAT THE WELL HILL SERVE.
--- TWA C . ? I r4 F'ECT I 10 FiF<E FR. EGoU I F?EGti
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM R PRIVATE I -JELL TO A PRIVATE SEWER.. LIME IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE.DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO IN=URE PROPER INSTALLATION.
F='EFRM I T E: tiF=' I REE C>ECEtlEEF2 1 �4c �'
I CERTIFY THAT
1: 1 AM FAMILIAR, WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT THE Ohl -SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS.
SIGNED
ISSUED BY
APPLICANT J. AP,MSTP,ONG!HIGHLRND DESSIGN
L
V4. 0
1 I< SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-0720
SOILS LOG - PERCOLATION TEST �- H
PERFORMED FOR: MIICs= 1D sc^G-LIRG DATE PERFORMED: `—II -8C
LEGAL DESCRIPTION: I- � T I t 13 t.. Qc-K 1 Z / ac L 1•-l. u ICs= $'s. A.
SLOPE SITE PLAN
IFEET) If /112A ?o vsell 1--
1
12
13
14
15
16
17
18
19
SM—$c
sa-„1y
15W-) 15ea-1�4
4IA-ew
...a
CE -1411 - y"
WAS GROUNDWATER S /
ENCOUNTERED? e!F5 O
P
IF YES, AT WHAT r E
DEPTH? I
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
-BL
-7:15'
o
/Z.zo
O
J
I'
7:4>
30
Z- 77-
n.sZ
7:517/J
/2.89
0.77
3
6:05,
/Cs
20 PERCOLATION RATE 4.1 (minutes/inch)
TEST RUN BETWEEN . 3 FT AND � FT
COMMENTS s!�/'euw a/ws�%u• fMsnr �:we1 yUr 16,E 7 =.-.y>, .+.o Sw✓.
^.;'e'� Ami / 2 i Q 13 /C n , ry
PERFORMED BY:%}J2F4i %✓s�s-. �ti/.... CERTIFIED BY -22 /- - --:J DATE: 6-IZ—/6
72008 (6/79)
Z vi, 3
n SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
❑ PERCOLATION
TEST
T H -z
PERFORMED FOR: M 1 KL C 1.(,1 QE DATE PERFORMED:
LEGAL DESCRIPTION: L'� 1 ( r 3L•. cIG IZ� GLF�Lw P-�'� S��D•
T SLOPE SITE PLAN
Fq QNt4wlt5— Ser w.l tC
1 J t
2
3- .
71>
I
8
9-
10-
11 1011
12-
13-
14-
15-
16-
17-
18
213141516 18
19-
20
9 20
-5 4-4.3
S< -..s .3 s t•1-4-2
Gn-t-mow
s. --t+., .f Wee..
eaban 0. '.Co -ill - - f
CE -1411
s'%so
;•' '-
4p„FiY+�?S� �c1
WASGROUNO WATER S
ENCOUNTERED? Y9-3 L
0
P
IF YES. AT WHAT r E
DEPTH? II
Reading
■■■■■■■■■■
Gross
Time
Net
Time
Depth to
Water
Net
Drop
■■■■■■■■■■
■■■■■■■■■■
.■■■ME■■■■
..MEND■.■■
MUMS■■■■■■
mommoommmm
MEMMINEME
IN
MINNIMEEMEMIN
MEEMEEMENIM
WASGROUNO WATER S
ENCOUNTERED? Y9-3 L
0
P
IF YES. AT WHAT r E
DEPTH? II
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
' I PERCOLATION RATE (minutes/inch)
I.._l TEST RUN BETWEEN FT AND FT
COMMENTS 50 at. U� 4r'
PERFORMED BY: CERTIFIED BY:rK-l— DATE: /
72.008 (6/79) 3
., (�) ( 1 yl� SOILS LOG
MUNICIPALITY OF ANCHORAGE
\ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 2644720
SOILS LOG — PERCOLATION TEST
❑ PERCOLATION
TEST
1 H -I
PERFORMED FOR: M I e L-7 O C- b{AI Rb DATE PERFORMED:
LEGAL DESCRIPTION: LD T I . 13 L.o e.ec IZs IZ'L.11 44R+* 5-&30.
o�r1 _ 1 _ _ .n _/' SLOPE SITE PLAN
IFEETiI A s+-'1erY.J -tells". Z...
1 IeWN
2
3-
4-
5-
6-
7
45 67
J
8-
9-
10-
,5g,
910
Sws1' -V-p S-'.1' b �wh,-moi
:54.4-J-)
bw
SRa gS4;IaR or- lus
' 11 t jWe WASGROUND WATER ,' S
11 }+e'^,_.a ENCOUNTERED? GS L
O
P
12 IF YES, AT WHAT I / E
DEPTH?
13-
14
15
16
17
18
19
R SC:'w T: ire
OMMMUMMEN
Date
Gross
Net
a wwwmlm■
Net
■
IL_JI
If"W`®fnn
Time
Water
Drop
Vo
f
al.C3�
ST RUN BETWEEN FT AND
FT
Pc::smh
$S ..
M■
NIMI
.5 ,at S�.nA-L.�
wit `irawrG
I Sit s✓'7c wt It 1�/1G..tfi'��.ss..��x��
/a �.i'.t, faJ✓►k./w–s�'w
acs�! .
0
E Al G .Z�
I rJsf.J4
CERTIFIED BY: ,7RJRQ c�+eGL�...,:
DATE:S
MUNNANNNNU
�Ls�..a1
r
a� &;:-.,4cl�.-G�A4
NNEENEEMON
S 14 Ear I eF 3
HNNEWMENNE
wooffiNFE.■■
■ EWSMS.■■■
■ KINME.■■
■■
%41
Reading
Date
Gross
Net
Depth to
Net
1a
IL_JI
Time
Time
Water
Drop
Vo
f
al.C3�
ST RUN BETWEEN FT AND
FT
pp
COMMENTS 5
$S ..
11
+�1'/' ^
.5 ,at S�.nA-L.�
wit `irawrG
I Sit s✓'7c wt It 1�/1G..tfi'��.ss..��x��
/a �.i'.t, faJ✓►k./w–s�'w
acs�! .
0
E Al G .Z�
I rJsf.J4
CERTIFIED BY: ,7RJRQ c�+eGL�...,:
DATE:S
ups
�Ls�..a1
r
a� &;:-.,4cl�.-G�A4
72.008 (6n9)
S 14 Ear I eF 3
.iw
i
20
{
IL_JI
PERCOLATION RATE
(minutes/inch)
al.C3�
ST RUN BETWEEN FT AND
FT
pp
COMMENTS 5
$S ..
�TEe Ys^'4.a w'11s.s 4 a aeG.�
+�1'/' ^
.5 ,at S�.nA-L.�
wit `irawrG
I Sit s✓'7c wt It 1�/1G..tfi'��.ss..��x��
/a �.i'.t, faJ✓►k./w–s�'w
acs�! .
PERFORMED BY: AItt;W
E Al G .Z�
I rJsf.J4
CERTIFIED BY: ,7RJRQ c�+eGL�...,:
DATE:S
ups
�Ls�..a1
•L y.,.�1 --f z aG yr i, ,-�1, ^-
a� &;:-.,4cl�.-G�A4
72.008 (6n9)
S 14 Ear I eF 3
n
t 1 X SOILS LOG
PERFORMED FOR: M s Kc' I) C r t,.. Ys.ir DATE PER
❑ PERCOLATION
TEST
T -z-
LEGAL DESCRIPTION:L. ^" 1 ILi LULIC 1'L L. LNtss l'Lts Sr -a -b0-
_ SLOPE SITE PLAN
EE TI as , DI'�hs(f r p,A r CY�•
1 s..4 ...rk.
2 TSP s.rf, b•,,_., l d^�
3
4
✓ � aa,d.� g�.�•d
12
13
14
15
16
17
3 12 a es dav- arlcss
ply -e
r. -?ii
; H.(a
18 ,r z -
q� :•• CE -1411
WAS GROUND WATER
ENCOUNTERED? G S
IF YES, AT WHAT
DEPTH?
�i
G
i - 7-5-A
Reading
MUNICIPALITY OF ANCHORAGE
\I -
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Depth to
Water
825 L. Street, Anchorage, Alaska 99501 264.4720
-
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: M s Kc' I) C r t,.. Ys.ir DATE PER
❑ PERCOLATION
TEST
T -z-
LEGAL DESCRIPTION:L. ^" 1 ILi LULIC 1'L L. LNtss l'Lts Sr -a -b0-
_ SLOPE SITE PLAN
EE TI as , DI'�hs(f r p,A r CY�•
1 s..4 ...rk.
2 TSP s.rf, b•,,_., l d^�
3
4
✓ � aa,d.� g�.�•d
12
13
14
15
16
17
3 12 a es dav- arlcss
ply -e
r. -?ii
; H.(a
18 ,r z -
q� :•• CE -1411
WAS GROUND WATER
ENCOUNTERED? G S
IF YES, AT WHAT
DEPTH?
�i
G
i - 7-5-A
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
e4
•z
20 C 1g
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS SGe Zjti-/
PERFORMED BY: i-PE7► bA) 6/,L/r:-Z'72saJ6 _CERTIFIED BY:/ ilh� DATE: 5- 3"-0 6
n
G,..,.....a-...mss-..,..L /1.slr,-... �•a�a.L. Ile 7 �s .... t ..s e-L..yLL-s S.. -Ir �.[t... 4
72-008 (6/79)
.1144;'=-r Z . F 3
- SOILS LOG
MUNICIPALITY OF ANCHORAGE
40\I DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION O PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 2644720
\ — SOILS LOG — PERCOLATION TEST
PERFORMED
LEGAL DESCRI
y /op So; 11-
2-
3 -
ODD 2 {„oawr beouyH
3
_a. ,4off 0 VIL.y Course ar.L�
. w - - - An
5 L044 -A. (tali 4&066* �•ir f�� .-if
6-
. :L `-4)
. -;-4)
..
o: IG tY/
J
10 12t614bV#A 04 4.
11
Date
Gross
Time
WAS GROUND WATER
Depth to
Water
Net
Drop
ENCOUNTERED?
12
IF YES, AT WHAT
DEPTH?
13
1a ?Pdt OF At %%I
t5 y~�•'�9�1
16-
i *.-.49M*
17 o. 2225-E '! i
UNE 25, 1971 i
19
tit
V.
DATE PERFORMED: 9-12-6
■■■■■■■■■■
NNEMMMMMMM
NEWEEMMEN
■■■■■■■■■■
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
20
PERCOLATION RATE (minutest
t+/. T�ESTT%RUN BETWEEN , AFT AND FT
COMMENTS .7f t4pt'i� alras;dL4J PMLfJN�f i. f.y�y
11 / _ _. _- '
PERFORMED BY: I ;JDU'r��LNG' CERTIFIED BY: T JP UY'k l4stax
72-008 (6/79)
*Z4 t
DATE: S-12-81
_ �• INVOIC N �^
40T I gl6cle In ELNiorzZ :5vspivlslDly 1419
Pei?mir v, A2 z652
N j!,/e,,v,e %'i-s,,�'v� T•Oc 33? -►575
SOLD TO Jim [/fBox-
STRKWCy 344 -17741 SHIPPEDTO .W- IS1��GllJlC--P L L1�IA
STREET 6 NO. J jz ✓? ox- a 1 & 3 STREET d NO. ��i{A lvI f_L1G�eY1S_LL� :
i�
CITY oc4 12 i _! n lS"c22 CITY Ar- WS5C'4
CUSTOMER'S ORDER
SALESMAN
10Th 0-f
TERMS it
T. N r
P.O.B.
DATE
i Z =
CC
" fNeoN wr >Tc
TA
Oar
.. ... ..
aiACL1 AcZ-V WrTt, U-1es C1 Rayld
�_�� S<�✓iclH SiIT C,Y�vFI. 67itr2 —
2 — 51LT �9YNU uf�1l�. sjj�
,y�VFiIL, l,�"711ri !NI l Tr) Fiver S
c? -e i ?) 1 Y1
S 7t Al`;0
MUNICIPALITY OF ANCHORAGE
co
ENVIRU: L'd_h. A.- :1,Q,.- TION
OCT 21 1982
RECEIVED
-:� INVOICE
a
!
MUNICIPALITY OF
Development Services Department
On -Site Water & Wastewater Section
Parcel 1. D. 018-173-30
ANCHORAGE
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Phone: 907-343-7904
Fax: 907-343-7997
Expiration Date: VZZ/O'�ZQ
Complete legal description Elmore #2, Block 12, Lot 1
Location (site address) 14701 Teton Place. Anchorage, AK
Current property owner(s) Jeri Thompson Day phone (907) 223-5554
Mailing address
Real estate agent
14701 Teton Place, Anchorage, AK 99516
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Private Septic
I -El
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 0 `w c) Waiver Fee $
Date of Payment �-/ai 1o2OAD Date of Payment
Receipt Number 0 9- 3 Receipt Number
COSA # OC6 G a �1`"I Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering Phone 907-522-7773
Address 1399 W. 34th Ave., Ste. 100 Anchorage, AK 99503
Engineer's Printed Name Michael E. Anderson, P.E. Date 8/27/2020
m� . �F q4;s8®��
6. DSD SIGNATURE ®••••g't-"h�
0 ............. ............................... p
System #1 Approved for bedrooms MICHAEL E. ANDERSON
No. CE -4381 ��•�Zs
System #2 Approved for bedrooms8/27/20
®sem'••.. • �,��
Disapproved ®�®�®®PROFESS\
Conditional approval for bedrooms, with the following stipulations:
By: Original Certificate Date: cl /_/oAQ
The Municipality of Anc rage 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
COSA Checklist yellow sheet
COSA Checklist
Legal Description: Parcel ID:
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
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 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 of Sample
Comments __________________________________________________________________________________
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA ______________________
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade 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
Adequacy test date
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)
If yes, enter date
Comments/Deficiencies:
Minor blockage noted in drainfield line. Does not appear to affect system operation. ****Monitor tube appears
to extend 10" below 24" effective depth.
**
Elmore #2, Block 12, Lot 1 018-173-30
6.23
8/20/1982 None
113
110
.206
16 Forge Engineering
6/25/20
45.5
8/19/20
Coliform retested on 8/27 after disinfection.
<1
Septic/Plastic
New
New Construction - 8/11/20
Gravity Flow System
5' Wide Trench
6/20/86 6/26/20
3
71"0
37" 554
14
1440
*****
0
>450
None
NA
✔
COSA Checklist yellow sheet
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 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
From Septic/Holding Tank on Lot to:(Please enter distances if less than required)
Building Foundations > 10’Yes if No ft
Property Line > 5’Yes if No ft
Absorption Field > 5’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 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
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
If absorption field is under driveway comment below
Wells on Adjacent Lots:
Private Wells > 100’Yes if No ft
Community Wells > 200’Yes if No ft
F. ENGINEER’S COMMENTS
G. ENGINEER’S CERTIFICATION
I certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
9/9/20
✔✔
✔
✔
✔
✔
✔
✔
✔✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
( ' MUNICIPALITY OF ANCHORAGE n
DEPARTMEwT OF HEALTH AND ENVIRONMENTAL Ph.. rECTION
DIV19IOk OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL.
OF ON-SITE SEWER AND WATER FACILITY ;
264-4720
Application Date^l g 8/4-
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions) rt''
(b) Applicant Namely : PeCC 4XA Telephone: Home 34- --IMIZ3 Business 333-2-Z >�
Applicant Address 7—e-4h gol affG
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder,E!r-Buyer ❑ ; Other ❑ .(explain); '
(d) Lending Institution _2�-�fiy /34-.K /¢K-- Telephone 7--> A —6 3a�
Address 3 6 .2-L" S :5.C 131`
(e) Real Estate Company and Agent �-
Address
Telephone
(f) Mail the HAA to the following address:
`t'
2. TYPE OF RESIDENCE
Single -Family Multi -Family ❑ Other
Number of Bedrooms 3
3. WATER SUPPLY
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 DISPOSAL
Onsite g Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the Stale Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72025(H`)
r.
n
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation dale 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 number of bedrooms and type of structure Indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this Inspection.
Name of Firm �04 E'✓� /yG�zJaI� Telephone 3
Address f L-0 2 L^ i 41 +4 4971-e- 203 ..x • f�7C 9`!J7 Sj
Date A — / T—gg.'
6. DHEP APPROVAL
Approved for Tf' 3� bedrooms by _
ro X Disapproved
Terms of Conditional Approval
Conditional
CAUTION
Engineer's Seal
Date `X el'(•
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations 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 requirements. Employees of DHEP 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. ;I '
Page 2 of 2
72-M 111/84)
n �UNIGPAUTY Of ANCHORAG:
DEPT. OF HEALTH 81
MUNICIPALITY OF ANCHORAGE (MOAr EWIRONMENTAL PROTEC1101"I
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984 JUN 18
2844720 jam_
Legal Description: Lz+T / RKU_V'��
%L M a>17 15;4c fZ 0
A. WELL DATA
Well Classification 'P-11" rRA— If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) y Date Completed 7_2 �g Z Yield Z 59- e� ^n
Total Depth /t'3 Cased to //0 Depth of Grouting
Static Water Level 46 Pump Set At
Casing Height Above Ground Sanitary Seal on Casing (Y/N) Y
Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N) 61
Separation Distances from Well:
To Septic/Holding Tank on Lot / e ;On Adjoining Lots .
To Nearest Edge of Absorption Field on Lot / S r ; On Adjoining Lots —
To Nearest Public Sewer Line
Cleanout/Manhole —
Water Sample Collected by
Water Sample Test Results
Comments
B.SEPT HOLDING TANK DATA
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Date
Date Installed 4 Al Size No. of Compartments
Standpipes (Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N)
Depression over Tank (Y/N) A ) Date Last Pumped 4-1 3— $ice
Pumping/Maintenance Contract on File (Y/N) 41 ; for
Holding Tank High -Water Alarm (Y/N) e� Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
r
To Water -Supply Well / Zo To Building Foundation
To Property Line 3S r To Disposal Field
To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course X% ZD J
Comments
Page t of 2
72-026(1184)
W
C. ABSORPTION FIELD DATA
—_\
Soils RatingAbsorption Strata �
• In P X25 /(-?. Type of System Design
Date Installed 4 ^/ '—iS Length of Field' r
Width of Field Depth of Field 1
Gravel Bed Thickness Z 1
Square Feet of Absorption Area 3.73 Standpipes Present (Y/N) y
Depression over Field (Y/N) A% Date of Last Adequacy Test N12�
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well //S f To Property Line
To Building Foundation Sb
Lot
On Adjoining Lots
To Existing or Abandoned System on
To Water Main/Service Line To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course ✓ « l u
To Driveway, Parking Area, or Vehicle Storage Area t
Comments
D. LIFT STATION Allle�—
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at _
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
'Pump Off' Level at
•• Check Permitted Bedroom Rating Against HAA Request ••
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I have checked, verified, or conformed to all MOA and HAA guideli nes in effect on the date of this inspection.
Signed/�el-��i�cl�.��+Date 6
Companyri�Ka :;2 MOA MOA No.
Receipt No.��g 35
Date of Payment
Amount: $
i.s�Q�••'••••i•••gi� Engineer's Seal
49M':
sits
Page 2 of 2 �� s �i.r a ti+rle� .t•
�i CE -1111 r
!• o
72-026 (11,84) ', ••••••••••••iAV
1
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1207 EAST 74th.Ave. Sullo 203
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344-3944
1 1 MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTEdTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date d — 7,3' 8 6
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
-Z / z A!Fleg ^e_
Location (address or directions)
/ 4 7 'Cle Tc7".r
(b) Applicant Name /0• Telephone: Home 3 45-.5'.t8 a Business 333— 2zZ�'
Applicant Address ¢-2 o I Meaty Ax 99.s/1 -
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution 15Z A&77 -,4oZ Telephone Z?
Z tr �S
Address 3 6 n-�. — S v . G< -e/' 13r.
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
G.r.! c.,,,f,�.; ��• --,�i „� "7� 56 3— / o � 3 e.-, 3 49 - G o7S
,�r sGz-z/t►
tie A5'311-
2. TYPE OF RESIDENCE
Single -Family Multi -Family ❑ Other
Number of Bedrooms 3
3. WATER SUPPLY
Individual Well Community ❑ Public ❑
Note: II community well system, must have written confirmation from the Stale Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the Slate Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-02anIM)
5. ENGINEERING FIRM PROVIDINu INSPECTIONS, TESTS, FILE SEARCH, DA1N AND INFORMATION
As certified by my seal affixed hereto and as of the validation dale 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 number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my Investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm r'� ���ss�� Telephone 6_143=1003
Address
Date
6. DHEP APPROVA C�,
Approved for bedrooms by
Approved Disapprove
Terms of Conditional Approval
Conditional
CAUTION
Engineer's Seal
4!
�'~+AA%R!
" (W At fie.
RSPV • i
1006..09000.40 .......
Roth D. 1XV11d1m0 '" 6
• CE -1411
;ate'••..•..•' tr."".�
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) Issues Health Authority
Approval certificates based solely upon the representations 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 requirements. Employees of DHEP 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.
Page 2 of 2
72-025(11/94)
MUNICIPALITY OF ANCHORAGE (AAO..,
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
M:R4;CIPALIM OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
Legal Description: � Z 4JIg 1 V E D
F�ir,o�� Sc��. � .4.�c.l.Di•a �r
Well Classification ��rtiya�r� If A, B, C. D.EC. Approved (Y/N)
Well Log Present (Y/N) Date Completed dk4 zo /47,92- Yield ZSG Dom+
Total Depth / / 3 Cased to Depth of Grouting —
Static Water Level ¢4 Pump Set At
Casing Height Above Ground Sanitary Seal on Casing (Y/N) Y
Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot / 2.0
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot / 2S" * ; On Adjoining Lots
To Nearest Public Sewer Line — To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot —
Water Sample Collected by _4 D 5aA;41,",9 ; Date Q- 2 2-861
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed 87 Size1d�_ No. of Compartments Z
Standpipes (Y/N) t Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Y
Depression over Tank (Y/N) /`/ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) /V ; for
Holding Tank High -Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank
Temporary Holding Tank Permit (Y/N) —
To Water -Supply Well To Building Foundation
To Property Line 8 S. S' t To Disposal Field --S-
To
STo Water Main/Service Line To Stream, Pond, Lake, or Major Drainage
Course ✓.O+- 2. 0
Comments S+ -A'!� s AreA4
Page 1 of 2
72-0260li84)
C. ABSORPTION FIELD DATA
In
Soils Rating in Absorption Strata 8 S 47�g Je Type of System Design% ��-= A
Date Installed Al, AV B �
7. Length of Field /-�
i
Width of Field S Depth of Field d 1 't
Gravel Bed Thickness f8 = 2�i or
Square Feet of Absorption Area ZSZ Standpipes Present (Y/N) Y
Depression over Field (Y/N) A/ Date of Last Adequacy Test d-2-7r8�
Results of Last Adequacy Test AJC ¢"sach-A _ n • w4,/ . / ff/^ - 6/Jc ��,•y�c�
Separation Distance from Absorption Field:
To Water -Supply Well _/-A-5 / = To Property Line Iq
/
To Building Foundation
Lot
To Water Main/Service Line
To Existing or Abandoned System on
On Adjoining Lots
To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course 0 "r 7-o
To Driveway, Parking Area, or Vehicle Storage Area '7 S r :L
-
Comments 01 � +, A V„ .;, -iI&m -4. W.: L if 41-4 40 aeoye
d 4-d /o-vz g z may o4!2: ,.s -,�. t. a �
{j aJ w.J.d 4V-At b4.sC ,..ffI �f 7-6-.1'e-41.1'e-41�J<
/ / /i • �./�
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at —
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access(Y/N)
_ "Pump Off' Level at
•• Check Permitted Bedroom Rating Against HAA Request ••
Vent(Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed of Date ¢- 2 2 --
Company
-Company.�1cs.><.a>Es MOA No.
Receipt No
Date of Payment y ' -,� 11 -6
Amount: $ [n -Z;- (St
Page 2 of 2
74-026 (11.84)
�•, r 1l�M 0. a^/R+p
CE-1411
yt
Engineer's Seal
APPLIC`NT FILLS
OUT UPPER HAIO"`ONLY
Property i Owner �
�I ../c/ �C.i ��^� �'V C
�,
Phone
/
Q7
7yJ
Mailing Address S
Zip Code Q
Buyer /14yee- /%��`',,ru%C
Date
Address
Zip Code
Inspector
Lending Institution /� �7i>`C..a� �=/�
Phone
Inspector
Inspector(/
Address
Zip Code rte.
Realty Co. d Agent �-� tri �u ., ��, y�,/N�!
Phone
Field Notes: II
Address �' j
„
�/Zip�Code
Lepel Description LoY �/� /.2%""• /'� irc%
TI -Q n �4 S
Street Location
DFn c- I•.. T„ P.
Type of Residence
C3-� a Family
❑ Multiple Family No. of Bedroom
❑ Other
OCT 21 1932
Water Su 1
ndividual Sao 4q)-
ATTACH WELL LOG. A well lop Is required for all wells drilled
since June 1975.
❑ Community1
For wells trilled prior to that date• give well depth (attach lop
If available).
❑ Public Utility 1 M--
-CONDITIONS
Sewer Disposal
g �?
cl. aT-"-'
❑ Public Utility
Year Individual Installed:
When Connected to Public Utility..,
DATE It -B L
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
`3 A cmnn.
Time
Time
Time `
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector(/
Field Notes: II
ILOA�A
UNICIPALITY OF ANCHORAGE
.{-
TI -Q n �4 S
DFn c- I•.. T„ P.
°
ENVIR );J:.._t.. A._ :..U• :TION
OCT 21 1932
RECEIVED
( ) APPROVED BEDROOMS
-CONDITIONS
OF APPROVAL
( ) DISAPPROVED
(3) CONDITIONAL APPROVAL'
��-yY.L,.r.1.a�0<�`-.�C�LC.4�h%
e(�/, _
_ ,
DATE It -B L
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well Lop Received
6 " If •A- `Z L—
Well to Tank
Septic Tank Size 14006
ina aea
November 2, 1982
Highland Design Inc.
SRA Box 3163
Anchorage, AK 99502
Subject: Lot 1 Block 12 Elmore f2nd Add
Approval for the individual sewer and water facilities cannot
be granted until the following items have been completed:
The water analysis report needs to be submitted to this
office from the Chem Lab, 5633 D Street, for our review.
A four (4) inch cleanout needs to be installed to the
leaching area.
Please notify this Department for a reinspection when the
noted discrepancies have been corrected. If there are any
further questions, please call this office at 264-4720.
Sincerely,
Robert C. Pratt
Associate Environmental Specialist
RP216/p/EF1
