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HomeMy WebLinkAboutPOLLOCK HOMESTEAD BLK B LT 1Pollock
Homestead
Block B
Lot 1
#017-112-47
Municipality of Anchorage
Community Development Department Page 1 of 3
On-Site Water & Wastewater Program
4700 Elmore St. o P.O. Box 196650 Anchorage, AK 99519-6650• http://www.muni.org/onsite • (907)343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181056 PID Number: 017-112-47 ❑ New ® Upgrade
Name:
BRYAN AMOS
ABSORPTION FIELD NORTH/SOUTH
® Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address:
15200 POLLOCK DRIVE, ANCHORAGE AK 99516
❑ Other
Phone: No. of Bedrooms:
Soil Rating:
Total Depth from original grade:
(907) 440-2574 4
*1.0/*1.0 GPD/Sq.Ft.
8.5/8.5 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade:
Gravel depth beneath pipe:
SEE DWG. FL
5.02/*7.5 Ft.
Fill added above original grade:
Gravel length:
Subdivision: Block: Lot:
POLLOCK HOMESTEAD B 1
SEE DWG.
40/*20
FL
Ft
owns Ip: anger section:
- - -
Gravel width
Beds Number of lines:
Distance between lines:
2.5/*2.5 FL
-
-
Ft.
SEPARATIONDISTANCES
Total absorption area
400/*300 = *700 TOTAL
umber of trenches:
2
Dist. between trenches
***10'
To
Septic
Absorption
Lift
Holding
PublidPrivate
From
Tank
Field
Station
Tank
Sewer Lines
so. FL
Ft.
well
100'+
**85'+
25'+
TANK i Septic ❑ S.T.E.P. []Holding ❑ Other
Manufacturer:
Capacity:
Surface water
100'+
100'+
-
GREER
1250
Gal.
Lot Line
5'+
10'+
-
N/A
Material:
Number of compartments:
STEEL
2
LIFT STATION
Foundation
10'+
10'+-
-
Curtain Drain
NONE KNOWN
Manufacturer:
Ca
Gal.
"Pump on' level at:
"Pump off' level at:
High water alarm at:
Remarks: *SEE ATTACHED LETTER REGARDING THE DESIGN CHANGE
THAT TOOK PLACE IN THE FIELD. "WR#OSV181017 "'SEE
ATTACHED WAIVER REQUEST.
Pump Make & Motlel
Electrical Inspections performed by:
PIPE MATERIAL EXISTING/
House to tank D3034 Tank to D3034
drainfield
Installer
ARM SERVICES
Drainfield D3034 CO/MT D3034
Inspector GEG, Ltd.
BENCH MARK (Assumed elevation)
100.00 Ft.
Inspection
Location and Description:
Dates: 1 St 5/16/2018 2nd 5/16/2018
3rd 5/17/2018 4th
BOTTOM OF TRIM SW CORNER OF HOUSE
ENGINEER'S SEAL
Community Development Department Approval
�F _oo�oopO
0 �4
. /. ,gsp0
Conditional approval: Date:
©.................. .......... V�
�.. :..................:....0
r A. Garness:
OQ
�� CE-79
A roves
pp Date.
�(
#Ecc aa4��4000�0
Inspection Report_ 1-1-12.doc
PERMIT NUMBER:
OS P 1441wo
V S
A B C
FCO
5.3
19.8
18.1
STI
ST2
24.4
13.7
-
DBL1
31.6
13.9
53.8
DBL2
30.3
15.0
54.5
I I
I I SHED
INEW 1250 GALLON
STEEL SEPTIC TANK-
I
/NEW DRAINFIEI D
/ I MT
/ ZI
w i MT
LU
o
RECORD DRAWING
WELL RADAII AND EASEMENT FLAGGED BY A PROFESSIONAL LAND
SURVEYOR PRIOR TO CONSTRUCTION. BOTTOM OF NORTH AND
SOUTH TRENCH INSPECTED BY MOA ONSITE EMPLOYEE TIM
ECKLUND. SEE ATTACHED DESIGN NARRATIVE REGARDING VERBAL
DESIGN CHANGE WITH ONSITE DEPARTMENT.
CST
/CgRE9
18.1
17.5
ST2
24.4
13.7
-
DBL1
31.6
13.9
53.8
DBL2
30.3
15.0
54.5
FS
31.3
24.6
1 52.0
FD
32.8
25.5
1 52.1
FS
35.6
16.3
1 54.9
C01
34.7
24.5
MT1
35.4
24.1
-
0O2
27.5
46.6
MT2
-
26.3
47.2
CO3
50.1
31.5
68.0
MT3
51.6
32.1
67.3
C04
33.7
59.9
MT4
34.7
60.7
I I
I I SHED
INEW 1250 GALLON
STEEL SEPTIC TANK-
I
/NEW DRAINFIEI D
/ I MT
/ ZI
w i MT
LU
o
RECORD DRAWING
WELL RADAII AND EASEMENT FLAGGED BY A PROFESSIONAL LAND
SURVEYOR PRIOR TO CONSTRUCTION. BOTTOM OF NORTH AND
SOUTH TRENCH INSPECTED BY MOA ONSITE EMPLOYEE TIM
ECKLUND. SEE ATTACHED DESIGN NARRATIVE REGARDING VERBAL
DESIGN CHANGE WITH ONSITE DEPARTMENT.
CST
/CgRE9
\
\
• A ❑
0
T1 EXISTING 2
BEDROOM HOME
T2
DBL1
DBL2
)3 /
MT 02
04
MT /
1
IBSI�AVFR Il
I I
RABBIT CREEK ROAD
L\LI
Y
/AS
IN:
LINE
7017
PARCEL ID NUMBER:
\_41
\\
D LOCATION OF WATER LINE PER GEG
IOy BASED UPON WHERE THE WATER
4R7rO ENTER THROUGH THE BASEMENT
I
\
♦♦��-- N1
.r♦�P'��,...... 1'�♦j♦
�` ♦ J
GARNESS ENGINEERING GROUP, Ltd ..... ...... .. `.♦
- - =--_ _ -I CIVIL & ENVIRONMENTAL ENGINEERS-—_ _
3701 E. TUDOR ROAD. SUITE 101 ' ANCHORAGE. AK 99507' PHONE (907) 3376179' FAX (907)338-3246 'WEBSITE:-gamessengineefing.com .......� ...........
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
BRYAN AMOS 907-440-2574 2 OF 3 ,�♦ ���. , r ..A..., rness..�=
♦ C 795 = i
LEGAL DESCRIPTION: DRAWN BY: ♦♦ •., ♦
POLLOCK HOMESTEAD; BLOCK B, LOT 1 D.J.G. 4��F�'••• Z •�• 4W♦
TYPE OF WORK: DATE: LICENSE/1 pR� Egcz
SEPTIC SYSTEM RECORD DRAWINGS 5/22/2018 #AECC884 ,��►ikiks�♦♦♦ i
PERMIT NUMBER: RECORDOSP 181056 DRAWING wAVI\V
FINAL
GRADE = 96.86-97.06
TOP OF TANK ST1 ST2
AT INLET = 93.74
I NEW 1500 GALLON
INVERT OF BUNG SEPTIC TANK
AT INLET = 93.11
TOP OF TANK AND BOTTOM OF NORTH AND SOUTH TRENCH
INSPECTED BY MOA ONSITE EMPLOYEE TIM ECKLUND. SEE
ATTACHED NARRATIVE REGARDING TRENCH DESIGN CHANGES
T.H.#1
FINAL GRADE = 95.15-95.47
RELATIVE ELEVATION OF
BOTTOM OF T.H.= 77.54
(GW AT 79.54 ON 5/16/2018)
PARCEL ID NUMBER:
017-112-47
2" INSULATION PER CONTRACTOR
TOP OF TANK
AT OUTLET = 93.70
INVERT OF BUNG
AT OUTLET = 92.92
NORTH
FINAL GRADE = 95.39-95.95 T.H.#1
co ORIGINAL GRADE @
HIGHEST POINT = 95.31
FILTER
FABRIC
INVERT OF PIPE = 91.83
— BOTTOM OF
TRENCH = 86.81
RELATIVE ELEVATION OF
BOTTOM OF T.H.= 79.31
(GW AT 81.31 ON 5/16/2018
`,`P,..••••.....�i
GARNESS ENGINEERING
GROUP, Ltd
i *
......• 4 — �... ......... si
_.. _
-- - - CIVIL & ENVIRONMENTAL ENGINEERS __ _-__-
10 0
3701 E. TUDOR ROAD. SUITE 101' ANCHORAGE. AK 99507 - PHONE (907) 337-6179-FAX(907) 33&3246 - WEBSITE: —garne—gnee-g.mm
•
PREPARED
:
ON.-
FILTER
PHONE NUMBER:
907-440-2574
FABRIC
PAGE NUMBER:
3 OF 3
OF
LEGAL DESCRIPTION:
DRAWN BY:
POLLOCK HOMESTEAD; BLOCK B, LOT 1
BOTTOM OF
D.J.G.
TRENCH = 0•
TYPE OF WORK:
DATE:
1
PARCEL ID NUMBER:
017-112-47
2" INSULATION PER CONTRACTOR
TOP OF TANK
AT OUTLET = 93.70
INVERT OF BUNG
AT OUTLET = 92.92
NORTH
FINAL GRADE = 95.39-95.95 T.H.#1
co ORIGINAL GRADE @
HIGHEST POINT = 95.31
FILTER
FABRIC
INVERT OF PIPE = 91.83
— BOTTOM OF
TRENCH = 86.81
RELATIVE ELEVATION OF
BOTTOM OF T.H.= 79.31
(GW AT 81.31 ON 5/16/2018
`,`P,..••••.....�i
GARNESS ENGINEERING
GROUP, Ltd
i *
......• 4 — �... ......... si
_.. _
-- - - CIVIL & ENVIRONMENTAL ENGINEERS __ _-__-
10 0
3701 E. TUDOR ROAD. SUITE 101' ANCHORAGE. AK 99507 - PHONE (907) 337-6179-FAX(907) 33&3246 - WEBSITE: —garne—gnee-g.mm
,
0 ........ j, ,,,,, ,,,, , ,
,. �..................
PREPARED
FOR:
BRYAN AMOS
PHONE NUMBER:
907-440-2574
PAGE NUMBER:
3 OF 3
J7 rey A. Ga ess :��- s
�j
1� �J, .,• E-795 ��w
®.♦ ��O •••• r ��� ��:
LEGAL DESCRIPTION:
DRAWN BY:
POLLOCK HOMESTEAD; BLOCK B, LOT 1
D.J.G.
44,41,
TYPE OF WORK:
DATE:
�, SEPTIC TANK PROFILE
5/22/2018
LICENSE
#AECC884 nl"91 i
1
GARNESS ENGINEERING GROUP, Ltd Advanced r—b,"e�s7t_1,rste,»
-- - ---- ---� CIVIL & ENVIRONMENTAL ENGINEERS -�
D
May 22, 2018
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Design Change and Waiver request for Pollock Homestead; Block B, Lot 1
To whom it may concern:
During the excavation of the south trench at the subject property, buried tree stumps were found
to the east and west of the proposed trench. In short, the trench could only be 20 feet long. Due
to this fact, the trench could not be installed as designed. While onsite with MOA employee Tim
Ecklund, and a conference call with MOA onsite employee Deborah Wockenfuss, it was
determined that the drainrock would be increased to 7.5 feet and an application rate of 1.0
would be used for the entire trench. This would equate to 300ft2 (7.5x2x20) of drainfield area.
With an application rating of 1 gpd/ft2 this would make the southern trench rated for two
bedrooms (150 gpd/ft2 x 2 bedrooms = 300 ft2). The northern trench was installed as designed
with an area of 400 ft2 (5x2x40). Due to this design change, a waiver is needed for separation
distance between the two trenches. We are requesting that your department issue a variance
from the required separation distance of twice the effective (15 feet) down to 10 feet.
Justifications for granting this waiver are as follows:
• The trench was already excavated when the determination to change the effective to 7.5
feet was made.
• The trench was initially excavated with the intent to have 5 feet of effective.
• The trench could not be backfilled, compacted and moved to maintain a 15 foot
separation distance.
• The soil had a percolation rate of 3.5 min/inch. It is likely that effluent will move more
vertically vs laterally.
• The bottom of both trenches was inspected by MOA onsite employee Tim Ecklund.
• The design change was verballed approved by the MOA while onsite.
We are unaware of any adverse impacts this installation and/or waivers would have on adjacent
wells or septic syst ms. If you have any questions, please contact us at 337-6179. Thank you
for your assistance ,
, 1P. E., M.S.
3701 East Tudor Road, Suite 101 *Anchorage, Alaska 99507-1259
Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com
11f
Municipality of Anchorage aY7,
Ueparnncnt
P.O. Box 196650 ® 4700 Elmore Road
Anchorage, Alaska 99519-6650 ® (907) 343-7904 a Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Division
On -Site Water and Wastewater Program
* * * * VARIANCE/WAIVER REVIEW * * * *
Waiver#: osv181024 COSA#:OSC181227
PID#: 017-112-47
Legal Description: Pollock Homestead BILK B Lot 1
Engineer: Garness Engineering Group
Applicant: Brian Amos
Permit#: OSP181056
Your request for a waiver of the required 15 feet horizontal separation from Trench to
Trench has been approved. The approved separation distance is 10 feet.
This waiver approval applies to the existing Trench only. Any fixture upgrade to the on-site
wastewater disposal system will require all separation distances be met or another approval from
this department.
❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this
waiver.
❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected
adjacent property.
❑ Adjacent properties are not affected by this waiver.
............................................... ■ ............................. ■ 1
Waiver is Granted: X Waiver is not Granted:
Date: Approved j
Name oKReviewer
..................................................... ■ ...................... ■ 1
**** VARIAN C E/WAIVER REVIEW ****
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 14700 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: OSP181056
Work Type: Septic Upgrade
Tax Code Number: 01711247000
Site Legal Address: POLLOCK HOMESTEAD BLK B LT 1 G:3137
Site Mailing Address: 15200 POLLOCK DR, Anchorage
Owner: AMOS BRYAN C
Design Engineer: GARNESS ENGINEERING GROUP LTD
This permit is for the construction of:
Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date
5/ ! (� I Tom► a ScH
�{
go Ft Zn�
1 I r 4yuActi
1)clrtrtntcnt
Expiration Date
Lot Size in Sq Ft:
Total Bedrooms:
4/25/2018
4/25/2019
19740
❑ 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 C 5JUP,P5, /tear e1145
6,119
co--4,i/app. rex4c ekoty, ` ©� SCJ fi►'enchCP)�
S(,J t,-cA&K 15hoifcnetl '�o 20' 6v;A 75t et�.
Received B�
Issued By:
to �Id S �arat�vn
Date: /u %
Date:
lH
Municipality of Anchorage
`.. I1)..partmenr
P.O. Box 196650 • 4700 Elmore Road
Anchorage, Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997
http://www.muni.orq/Onsite
Development Services Division
On-Site Water and Wastewater Program
**** VARIANCE/WAIVER REVIEW ****
Waiver#: OSV181017 COSA#: Permit#: OSP181056
PID#: 017-112-47
Legal Description: Pollock Homestead Blk B L1
Engineer: Garness Engineering Group
Applicant: Bryan Amos
Your request for a waiver of the required 100 feet horizontal separation from the absorption field
to the private well has been approved. The approved separation distance is 85.0 feet.
This waiver approval applies to the proposed absorption field only. Any future upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
Waiver is Granted: X Waiver is not Granted:
Date: 7 z J /.9 Approved by: fid
Name of Reviewer
****
VARIANCE/WAIVER REVIEW ****
MUNICIPALITY OF ANCHOR A 89 70
71,
C.---r---ejr:WOW. .;4
Community Development Department i_ ' ne=,907.343-7904`
x: 907- 343-7997
Development Services a.
On-Site Water & Wastewater Program zr°` 6
Mayor Dan Sullivan
i t,
On-Site Sewer/Well Permit Application
For A Single Family Dwelling
Parcel I.D. 017-112-47
Property owner(s) BRYAN AMOS Day phone 907-440-2574
Mailing address 15200 POLLOCK DRIVE*ANCHORAGE,AK 99507
Site address 15200 POLLOCK DRIVE*ANCHORAGE.AK 99507
Legal description (Sub'd. Block& Lot) POLLOCK HOMESTEAD; BLOCK B. LOT 1
Legal description (Township, Section & Range)
Lot Size Sq.Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DEWELLING:
(®all that apply) Initial ❑ Single Family (SF)
Absorption Field ® Upgrade ® (w/wo ADU)
Septic Tank ® Duplex (D) ❑
Renewal ❑
Holding Tank ❑ Multiple Dwellings ❑
Privy Cl (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE/WAIVER REQUEST FOR:
DRAIN FIELD TO WELLDistance: 85 FEET
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 5661 Waiver Fees: 1 D-1
�
Date of Payment: 14— 2.M8 Date of Payment: cf —2S--(8
Receipt Number: 61357 Gk Receipt Number: ?j�
G�j
Permit No. 05e 0Ql0 Waiver No. OS V I O loll
(Rev 01/11)
uanics
GARNESS ENGINEERING GROUP, Ltd `dvanocd Treatment %r
0 CIVIL&ENVIRONMENTAL ENGINEERS��r
April 16, 2018
Municipality of Anchorage
Development Service Department
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Proposed Septic System Upgrade for Pollock Homestead; Block B, Lot 1
To whom it may concern:
The existing 3-bedroom house is served by a private well and septic system. The
drainfield is in a state of failure and needs to be upgraded. Per the request of the owner,
we are designing a 4-bedroom tank and drainfield. One testhole was excavated on the
property and the drainfield is designed around its 30-foot radius. We are proposing to
install a new 1250-gallon steel septic tank and dual deep trench type drainfield.
Comments regarding the design are summarized as follows:
1. SOILS: See the attached soil log shows the soil classifications, groundwater
monitoring, and the percolation test results.
2. DRAINFIELD DESIGN: See attached design drawing for drainfield specifications.
3. SURFACE WATERS: There are no surface water concerns.
4. TOPOGRAPHY: As can be seen on the attached design drawing, the average
topography around the proposed drainfield is less than 25%.
5. WAIVERS: We are requesting that your department waive the requirement of 100 feet
from well to drainfield down to 85 feet. Justifications for granting this waiver are as follows:
• The well is located uphill of the proposed drainfield. If effluent were to overflow, it
would not flow directly towards the well head.
• The well log states "light brown clay gravel, and rocks" from 0-36 feet and 36-410
feet as "hardrock". It also states a total depth of 410 feet and a static water level of
90 feet. Based upon this information, it appears the aquifer is protected to some
degree by the soil profile above the bedrock at 36 feet.
• Water Samples were pulled on 3/2/2018, the results are as follows:
o Arsenic: Non-Detectable
3701 East Tudor Road, Suite 101 *Anchorage,Alaska 99507-1259
Phone: (907)337-6179*Fax: (907)338-3246*Website: www.garnessengineering.com
Page 2 of 2
o Total Nitrate/Nitrite-N: Non-Detectable
o E.Coli: Negative
o Total Coliform: Negative
We are unaware of any adverse impacts this installation and/or waivers would have on
adjacent wells or septic systems. If you have any questions, please contact us at 337-
6179. Thank ,ou for your assistance.
• cerel, ,
Jø ,, . t -mess P.E., M.S.
Pres • t
3701 East Tudor Road, Suite 101 *Anchorage,Alaska 99507-1259
Phone:(907)337-6179*Fax:(907)338-3246*Website:www.garnessengineering.com
(--- -----.
I .
/ \
/
/ \
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APPROXIMATE OLL 1CC
W
' WELL RADIUS I
TIMBERLUX N4:BLOCK 1.LOT 10 ` �I '
POLLOCK HOMESTEAD. Q BLOCK B.LOT 2 POLLOCK HOMESTEAD.
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GOLDENVIEW PARK PHASE Al. Q I N
BLOCK 1.LOT 3
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107
GARNESS ENGINEERING GROUP, Ltd •t!! &
.��CIVIL&ENVIRONMENTALENGINEERS"•...--�`-` 1 0i3701 E.TUDOR ROAD.SUITE 101•ANCHORAGE.AK 99507'PHOE(907)337-6179'FAX(907)338.3246'1NEEBSITE:www.gamessengineeringcom PREPARED FOR: PHONE NUMBER: PAGE NUMBER: y '.-Ga ness :W=BRYAN AMOS 907-440-2574 1 OF 2 CE1ItI.
795c_IPROJECT/LEGAL DESCRIPTION: DRAWN BY: • :�'��<K,•
POLLOCK HOMESTEAD: BLOCK B, LOT 1 L.K.B. •* 0 .............. p\-••4,
TYPE OF WORK DATE LICENSE44.. FESS\ 4,
SITE PLAN 4/12/2018 #AECC884 �sss�
DESIGN CRITERIA: GEG,Ltd.HAS A 8 PAGE SPECIFICATION
NUMBER OF BEDROOMS:4 LETTER THAT PERTAINS TO THIS DESIGN.TO
OBTAIN A COPY OF THE LETTER CONTACT
GALLONS PER DAY(GPD):600 GEG.BY PROCEEDING FORWARD WITH THIS NOTE:THE CONTRACTOR SHALL HAVE THE
WEST EASEMENT AND 85'WELL RADIUS
PERCOLATION RATES:3.0 MIN/INCHINSTALLATION,THE ENGINEER,WELL DRILLER, FLAGGED BY A REGISTERED LAND
ALLOWABLE APPLICATION RATE:1.2 GPD/FT' CONTRACTOR AND PROPERTY OWNER AGREE /
PROPOSED APPLICATION RATE:0.8 GPD/FT' THAT THEY HAVE READ THESE SURVEYOR PRIOR TO CONSTRUCTION.
MINIMUM DRAINFIELD SQ.FT.:750 FT' SPECIFICATIONS AND AGREE TO ACCEPT THE I /
DRAINFIELD DESIGN: TERMS AND CONDITIONS OUTLINED.
MAXIMUM DEPTH: 10 FEET /
WIDTH:2.5 FEET N /
LENGTH:80 FEET(2@40 FEET EACH) C` I
EFFECTIVE:5.0 FEET SHOT_
ACTUAL SQ.FT.:800 FT' C
I U \ / t...
RESERVE SITE DESIGN CRITERIA: EXISTING DRAINFIELD TO REMAIN IN
PLACE FOR POTENTIAL FUTURE USE
NUMBER OF BEDROOMS:4 PROPOSED 1250 GALLON STEP TANK WITH
GALLONS PER DAY(GPD):600 DOUBLE CLEANOUTS AND FS AFTER TANK;
PERCOLATION RATE'S:3.0 MI WINCH FS TO REMAIN ABOVE GRADE N
PROPOSED APPLICATION RATE:'6.0 GPD/FP {.J.
MINIMUM DRAINFIELD SQ.FT.:100 FP 0
'CAT III ADVANCED TREATMENT • I CONFIRM INTEGRITY OF FCO;IF
RESERVE SITE DRAINFIELD DESIGN: NECESSARY,INSTALL FCC
I
MAXIMUM DEPTH: 10 FEET —
'T.: / 1 /
WIDTH:2.5 FEET SHED % • ,s.' aO
LENGTH:10 FEETGRAVEL �•EFFECTIVE:8.0 FEET DRIVEWAY 1::;.,
•--4- 2
ACTUAL SQ.FT.:160 FTS 10'+ .i.
*:.S:OP
<25%i EXISTING 3 ,�y--
PROPOSED DRAINFIELDS� w• 0-%#--- BEDROOM HOME
..---- /
1..1..
/
i\ \ /
/ / /1 /
/ / \
/ :: I
RESERVE SITE--..........77.‘ \ •y-11+FEET /
/ M\ 0 r< \
/ o ti / �. 1po'WELL�DluS \
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ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
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THE PROPERTY LINES AND NO VISIBLE ENCROACHMf:': '
THE INFORMATION HEREON IS FOR THA USE OF LEN2i1H IHSTITLITCONS SPECIE ICALlV TO SHAH ANT EXIST OTHER THAN NOTED•
LORELIcTS BETWEEN EXISTENT,STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS;AND IS DATED AT ANCHORAGE,ALASKA THIS R .1I DAY OF
NO- TO BE USED FOR POSITIONING ADDITIONAL STRICTURES, IPPROVEMENTS, OR FENCELINES.
EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING CN':1E RECORD PLAT , ARE ROT SHOWN MAR;;FI
HEREON I UNLESS INDICATED) 2018
NOTE: FENCELINES THAT MAX APPEAR UM THIS DRAWING ARE NOT TO BE USED TI)DETEP.MNE
PROP'ERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS. HOLT LAND SURVFT IN:;
ANY PAVING SIICAFN HEREON PAT EE APPROXIMATE DUE TC EXCESSIVE SNOW ANU/OR ICC. 9309 GROVER GREVE
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PREPARED BY -
CORWIN $ ASSOCIATES
1000 E. DIMOND BLVD.
SLATE 205
ANCHORAGE, ALASKA 99315
(907) 522-1311
Developmznt Services Nparttn-_nt
_ Building Safety Civision
e f On -Site 'r• mer & Wastew&lzr Proy'r-cm
4700 Fgragaev Street �..
P.O. oo:: 196650
Mark Begich Anchorage, .AK. 99519-6650
Mayor www.muri.ori/on5ite
(907,143-7904
Pump Installation Log
Well Drilling Permit Number: SW_ Date of Issue:
Parcel Identification Number:_
Legal Description
Property Owner Name & Address:
Pump Installation Date:
Pump Intake Depth Below Top of Well Casing/S„Z feet
Pump Manufacturer's Name:
Pump Model: o 5 2
Pump Size hp
Pitless Adapter Burial Depth: I Feet
Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer:
Well Disinfected Upon Completion? [<Yes ❑ No
Method of Disinfection:
Comments:
Anchorage Pump & Well Sergice
Pump Installer Name: 330 East 76th Avenue
Anchorage, Alaska 99618
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.
address
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES 00 —112--
1l2- 4 7
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
`- ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
DISTANCES
TO SEPTIC ABSORPTION WELL
TANK FIELD
Permit No. No. of Bedrooms WELL / p mol
l
LEGAL DESCRIPTION LOT LINE i"i
Lot If
Bloc Sub vision ._.�—
C�IlU `LGGvEEyFOUNDATION /f� qJ
Township. Range, Section '
' Zl P 3 „ 1 '5 fl � f ,� A P ASeway,w DIAGRAM (Show location of well, septic system. properly lines, loupe
%— � / a driveway, water bodies, etc.)
TANKS -� t.. lTf��F
SEPTIC ❑ HOLDING
Capacity in gallons
r No. of CdrnPanments
TYPE OF SYSTEM
T
`TRENCH ❑ BED
❑ W. DRAIN ❑ OTHER
Depth to pipe bottom trona
original grade I•
Total depth bear original grade
7
7 —6 FT
:?
FT
Fill added above original grade
FT
_ _
Gravel depth beneath pipe
if
FT
Gravcl'lenylh I
`+M
Gravel width
FT_
FT
_
Total absorption area
Distance between linen,
SQ FT
/vrI"f
FT
Number of lines
Soil rating
Pipe material
a
Installer
Date Installed
`'
WELLS
PRIVATE
❑ OTHER (Identify)
Gasstion (A.B.C)
Taal De/pth Cased to
�l5al,5
Inslallei
sldlletl
REMARKS:
Ins f,ections Perigrmeby.�'
"Vi_, ce ily that Ilii iinQnspeec�ction was pedurmed according to all
Municipal and Slate guidelines in lon this dale: l 3! � ® �
Health Department Approval: , _ ` e Date:I1—L.�...� �
72-013 (3/85)
0
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WAII I+ WLLL RLCURU
STATE. OF ALASKA
UEPARrMENTOF NATURAL RESOURES
Division of Geological A Geophysical Surveys
DI Illmy Permit No 89-0417
I. OLAI IIIN UI WE LL IPlearn cumplxln 0111,01 1,,, Ib n1 It. I A.0 L NO
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I0 Hnr.,:ryh Subd, neon Lot IRIVrk �J ��9 dl re Section No. Township Nn Rano. E� Meridian i
ANCH - 1POLLOCK I 1 1 $ [I_ nr_���W�' 1
1, it UISIANCE AND OffiECTION FROM ROAD INTERSECTIONS 3. OWNEf{ OF WELL:
" Vince'.Spezialy
Address
Anchorage, AK
SI .ill Addraas onU Anna of Well Location
2 JAI l 1 OG Fest Relow ,l WEI I t) PrH, (final) I a DATE OF COMPLETI(ZNg
Itr 11nn f 1IIl �Zjj
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Hardr6ck36 • 410 7.UBE: M Domestic ❑ Public Supply Q Industry
-----
-Littl.e-xater coming --from crak C] Irrigation E] Recharge ❑comme'leel
in rock C?._125 feet, (] oat Wall 0Other.
Cracks in rock 370 feet to B. CASING: ❑ Threaded [23 Welded
4 e
00-fet. dlom_....6.____In to_36._ft. Depth weight.1-Ibe/It
filum. _ .la
to ------- 11 Depth BtlsYea._.______ It
9. FINISH OF WELL:
Type Open end olamner _._--._.
_ sees _.._
Slot/Mash'Bice..,._.._.__..___....... Length.,M^_
^_ Set between ft and It
_
' Backfilling sees.— gravel pooh
Jilt
�jr1\G�PP� pF�N�Q jE j,�N 10. STATIC WATER LEVEL: 90 fl, 12/2�
_._ ._. _ sees.. _ _ M_.. ��N,..cp1T (''�. _ q.Q -- ❑ Above or M Below land surface Oefe
Equipment wild: Pump -
�+
II PUMPING LEVEL below eerie c• and YIELD
(1 PN fl. after tire. pumping-_g.p.m.
\
!C_%��_. — - ft. after hremping- 9.0 m.
�_ . Pu._
12.OROU11N0 Well Grouted: © Yee rM No
Material C7 Neaf Cement __�j olnor _ ..�
IS PUMP (II available) HR,�- 3f'"r It
Lenglh of Drop PIP* 39 ft. c,poolty, a P m
1427 Subm Q Jet ❑ clonlrlflcol ❑ Other
10 REMARKS' A
#k11. Pumped after 24 hours
4.5 gpm for 70 miriu-Les.
f Ib WATT6 tf i VONI I,' ]:-Ft' 1I_HTI111 A1ION
19. W01e1 remperalure OF O C
I + nett was d1 1,. life, I,ir 1„r1 -d,. ,• n wary a„. Iuj....I Hu, It, I1,1• uesi of my knuwleUye and belleli
Sommerville well drilling A13788
ti , 1, 1 1.n, .. Noma Conlrml Licem.a Number
11,140 Polar Drive, Anchorage, A 99516
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N'li If Shale OW,16, PINK 0,01er, CANARY' Cullamef
MUN1CIPALITY DF ANCHORAGE
Department o[ Health & Human Services
825 L Street, Anchoraye, Alaska 99501 343~4720
ON�SITE SEWER & WELL PERMIT
0�\��/t�n�
Permit Number: 890225 «u�^�,u '�^^~~-
Date Issued: 10/02/89 Engineer Designed
Owner Name: VlNCENT SPEZIALY
Owner Address: 8526 LAKE ITIS PARKWAY
/ ANCHORAGE, AK 995O7
Parcel Id: 017�112-47
Lot Legal: Subdivision:
Section: 34
Lot Size 19740 (sq"�t
Max Bedrooms: This Permit:
POLLOCK Lot: 1 Block: B
Township: 12N Range: 3W
CW acres>
2 ioLal
SEPT1C TANK: Minimum total septic Lank
tank must have at leasL 2 compartments,
+eet requires insu1ation over Lank (,:0
Capacity: 2
Day Phone:
344^7263
capacity: 1,000 gallons. Each seJtic
Depth to Lop o� septic
�ELL: Log must be submitted to Municipality o{ Anchorage Department o[ Health
and Human Services within 30 days f well completion.
PERM�T EP1
Xl|�LS DECEMBER 3� 1989.
ENGINEER MUST NOTIFY 1.) 111 OF INSPEC|ONS AT 343-4744 OR 34 4681
RVE MIN[MUM 16/ SETBACK TO TRENCH ON LOT 2.
OBSERVE APPROPRIATE SET8ACKS TO CURTAIN DRAIN AT GARAGE ON LT 2.
***SEE ADDITIONAL NOTE BELOW.
l CERTIFY THAT:
liar with the requirements r on^`siLe sewers and .1. 1, as set
{orth by the Municipaliiy of Anchorage (MOA) and the State oY Alaska.
2" I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria this permit.
3" I will adhere to a1l MOA and State of Alaska requiremenif set back
distances Iom any existing well, wastewater disposal system or pub1zc
sewerage system on this or any adjacent or nearb; lot.
�. I understand that this permit is valid �or a maximum o� 2 bedrooms. I
also understand that Lhe capacity of the total sysLem is 2 bedrooms and
any enlargement wil1 require �n additional permit"
Signed: � DATE:
�
(Owne1 SPEIIALY
1ssued By: DATE: � /�
This lot meets reserved area for a two bedroom dwelling only. Until
and unless the current ordinance requirements are changed, the proposed
sewer system and well may only serve a two (2) bedroom dwelling. I
understand and agree to this stipulation.
Signed: Date ~ ��
o
rw0 n
& associates,inc.
Consulting Engineers
1000 E. Dimond Blvd. • Suite 205 • Anchorage, Alaska 99515 • (907) 522-1311
September 29, 1989
M$. Susan Oswalt
Municipality of Anchorage
Department of Health & Human Services
825 L. Street, Fifth Floor
Anchorage, Alaska 99501
SUBJECT: SEWER PERMIT FOR LOT 11 BLOCK 1B, POLLOCK HOMESTEAD
SUBD.
Dear Susan:
On this date we performed two (2) soils test (copies of soils
logs enclosed) and a total of three (3) percolation tests. We
were able to determine that the soils on this lot in general
are better than our previous percolation test indicated. Based
on the three tests today and the previous test, we feel
confident in stating that the area selected for the proposed
sewer system and the future reserve area is rated for between
200 and 225 sq. ft. per bedroom.
Based on this information, we recommend that the original
design be altered to a 225 rate and we would like to obtain
approval for a two bedroom house. We would like to go ahead
and install the system for enough area for a three bedroom
house with a future upgrade to three bedrooms to occur in a
year or so.
We have monitored the water level in our original test hole
since August 17, 1989 and, today we still found water in the
monitor tube at 12 ft. We also wish to point out that Lot 2
next door has a sewer system built with a ground level similar
to ours and the trench is nine (9) ft. deep buried three ft.
deep which means that the bottom of the trench is 12 ft. from
the surface. If your departments records were pertinent to
these two lots, the existing system would be flooded and it is
not. We then feel that enough monitoring has been done. THis
is especially true since this is the wettest year on record and
we still only find water 12 ft. deep in the monitoring tube.
We believe that actual water level is more like 15 ft. deep.
We h e co ected all other concerns on our site plan and urge
your pprov of --?the permit for a two bedroom house.
Ver txuly,yo s,
%/
ruce y- �orwin, P.E.
Pe0POC i
SF?''IG Slrl —i�
5'1�IDF_
75' LO K 6
4z" 6-PAVEIL
1,0006,1 TAIWK
RFCFRV
A'a\EA
4177-1--7
A_
LOT 2
I O,ulTo2 P.
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ous� L---
L_OT I
PFO Fz
NZ
0
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rvre -7
PROPOSED SYSTEM: 5' WIDE DRAINFIELD 1,75 NA71VE FILL.
,, #.(3 Bdrm) x (IM sq ft / Bdrm) = b -9"t sq ft 4" PFP_F F;FF
USE 75' LONG x 5' WIDE with 42" GRAVEL = 694 sq ft✓
Use 1000 gal 2 -Compartment Steel Tank, insulate if <4' cover
Use ASTM d-3034 4" pipe; insulate over pipes if <3' cover
,,
Install monitor pipe near middle, and clean -outs at each -6 �{O
end of trench, between house and tank, and between tank
L,
and trench. W d
Minimum of 5' between house and tank, and between tank and -71
trench. *ALL CONSTRUCTION TO MEET M.O.A. SPECS.* I V)
.SEWER SYSTEM • LOCATION PLAN
LOT BLOCK I SUBDIVISION
�Qeer 1 1B POLLOCK HOMESTEAD
SECTION/TOWNSHIP/RANGE
T12N R3W
SCALE,NOTE,
u -g • -� THE ACCURACY OF LOCATION OF EXISTING
1 = 50'
y ✓ fi PROPERTY CORNERS, WELLS, AND SEPTIC
DRAWN BY, SYSTEMS INDICATED IS NOT EXACT.
DIMENSIONS HVE
NORTH JERRY KRESS DETERMINED IBY U ETED OF CLOTHBEEN TAPE AND
- / NOT BY SURVEYING TECHNIQUES.
✓ .� .:4"134 ,. C." PI -�.r� �a o `"-v`,4 -F FY 'f�s+Y24r siy'TP.cQ y's✓
Na
ryPREPARED FORS� 5'
`�S. OC1Q}eV = N,'.' Mr. . Dick Bales
'
SU
SHEET �%
DATE, SHEET OF 1
8/25/89 1
PERFORMED
LEGAL DESC
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2C
COMMENTS
QEN.GINEER'S SEAL)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVIGE5
825 "L." Street, Anchorage, Alaska 99502-0659'%
SOILS LOG — PERCOLATION TEST', Co `'''-''in
Township, Range, Section:
// SLOPE SITE PLAN
W�Ga661�
WAS GROUND WATER — ,(
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? P
E
Depth to Water Alter /4j//4
Monitoring? Date
LU 7'–
/i r/ ZC7 C/�
/Li / O 416 k
ATE PER
FO RM EC!v
Township, Range, Section:
// SLOPE SITE PLAN
W�Ga661�
WAS GROUND WATER — ,(
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? P
E
Depth to Water Alter /4j//4
Monitoring? Date
/ 7"
PERCOLATION RATE 4. /� (minules/inchl PERC HOLE DIAMETER
TEST RUN BETW EN —5 FT AND ,5. 5 FT
PERFORMED BY: /S'INEF
TIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELIN C ON THIS DATE. DATE: /2"���
72-008(Rev.4/85(
ISM
/ 7"
PERCOLATION RATE 4. /� (minules/inchl PERC HOLE DIAMETER
TEST RUN BETW EN —5 FT AND ,5. 5 FT
PERFORMED BY: /S'INEF
TIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELIN C ON THIS DATE. DATE: /2"���
72-008(Rev.4/85(
PERFORMED F
LEGAL DESCRIPT(
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERYWO
825 "L" Street, Anchorage, Alaska 9950
SOILS LOG - PERCOLATION TE'
Sim 114 77
AT, RFORMED:1
Township, Range. Section:
(ENGINEER'S SEAL)
L4bd=uW-1k'j
Municipality of Anchorage
rL�
Department of Health and Human Services dl"1h5
825 "L" Street
Tom Fink,
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
September 21, 1989
Mr, Vincent Spezialy
8526 Lake Otis Parkway
Anchorage, Alaska 99507
Subject: Permit for Lot 1, Blk B, Pollock S/D
Dear Mr. Spezialy,
Your application for a sewer/well permit for the subject lot has
been reviewed by our office. The permit is being denied for the
following reasons:
1. Inadequate reserved disposal area. Based on the soil
rating of 231 sq. ft./bedroom, a total of 9,000 square
feet of lot area must be available to support an
original. and a replacement disposal site. This lot has
a total of 4,275 square feet available, which is
sufficient for only a one bedroom dwelling. There is
no waiver provision for this ordinance requirement.
2. Site plan omits location of sewer system on Lot 2.
There is a record of this system in the department's
files, but the engineer must relate that record to
actual field measurements and show on the site plan all
sewers/wells within 200 feet of the proposed
installation on Lot 1.
3. Insufficient water monitoring. Historical data in the
department's files indicates the lots around yours are
subject to high water conditions during portions of the
year. In cases like this, the department requires
additional water monitoring prior to issuance of a
permit, or may require an "artificial adjustment" of
the engineer's reading.
This office will gladly reconsider your
engineer is able to provide additional
pertaining to the lot. Should you have
denial, please contact Susan Oswalt at
Sincerely,
John W. Smith, P. E.
Manager, On -Site Services
/aen230
application if your
or new information
any questions on this
343-4744.
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0
%por°n
& associates,inc.
Consulting Engineers
1000 E. Dimond Blvd. • Suite 205 . Anchorage, Alaska 99515 - (907) 522-1311
August 25, 1989
Mr. Dick Bales
Six -M Construction
700 West 58th Avenue
Anchorage, Alaska 99518
SUBJECT: LOT 1 BLOCK 1B POLLOCK HOMESTEAD
Dear Mr. Bales:
Attached is a copy of the soil test, perc test, and
sewer system design for the above referenced project.
The pent; test shows that the soil rating is 231 sq.
ft. per bedroom. The Municipality of Anchorage
requires that a minimum of 31000 sq. ft. per bedroom
be set aside in a reserve area for future sewer system
upgrades. This reserve area is based on the soil
rating.
Due to the small lot, we are unable to show the
required reserve area. There is approximately 4,275
sq. ft. of reserve area on t-hi.s.lot. The Municipality
may require a waiver for this.
If you have any questions contact us at 522.-1311.
Very truly yours,
CORWIN & ASSOCIATES, INC.
����-rte
Gerard Kress
Engineering Technician
GK/lb
attachment
100 — NEU
LOT Z
MOIQITOP PIPE
C/o
fI o
101
-\
FRI—V
SEPTIC SYS`f`Et4 10 3BE)7S' LO N6SE
4z° GkAVEL ` \
1000 I TANK LOT I
PEG ER �\\ \ /00-PPnFI%I7D LJELL
AREA
O
J
l
SYMBOL I
0= TEST HOLF
PROPOSED SYSTEM: 5' WIDE DRAINFIELD NEO•FABPIC
NATIVE Fll_L-
(3 Bdrm) x (231 sq ft / Bdrm) = 693 sq ft h PEP.F PIPE
USE 75' LONG x 5' WIDE with 42" GRAVEL = 694 sq ft
Use 1000 gal 2 -Compartment Steel Tank,insulate if <4' cover ±
Use ASTM d-3034 4" pipe; insulate over pipes if <3' cover "'_
Install monitor pipe near middle, and clean -outs at each
end of trench, between house and tank, and betwden tank
and trench. �, N
Minimum of 5' between house and tank, and between tank and W
trench. *ALL CONSTRUCTION TO MEET M.O.A. SPECS.* -7 5 -
:SEWIER. SYSTEW LOCATION PLAN
_. .. - LOT BLOCK SUBDIVISION
1 1B I POLLOCK HOMESTEAD
qg�qy✓'•� OF ®
!'era ®meowfOi 1�
,;i:t�; Ome -
Q em/2aaec� ommoo .aemoomma
es oo �°amoo °m .°..+°
B� Robert E. K q I o S
No. 4149 • E �` Fs
SECTION/TOWNSHIP/RANGE --
T12N IZ3W S'4
Sim = 50' NOTE'
THE ACCURACY OF LOCATION OF EXISTING
PROPERTY CORNERS, WELLS, AND SEPTIC
DRAWN BY, SYSTEMS INDICATED IS NOT EXACT.
NORTI4E DIMENSIONS INDICATED HAVE BEEN
DETERMINED BY USE OF CLOTH TAPE AND
1 NOT BY SURVEYING TECHNIQUES.
D FOR -
Mr. Dick Bales
DATE, 8/25/89 SHEET 1 OF 1
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 •'L'• Street, Anchorage, Alaska 99502-0650
SOILS LOG — PE13COLATION TEST
PERFORMED FOR:(LE_rnNt;T, M I. DIOL_ E�ALE, DATE PERFORM
arae oq�o�G�G'J9 0000000 u^�
1.,-A00000•h5�,.
Robert E. Kn
Ki_ Al en
LEGAL DESCRIPTION:L-OT I F.ZL K ( R Township, Range, Section: 117 KP 7, W <; 34
SLOPE SITE PLAN
6 1' Ul„t PO L LOG K
1 40 M EST E.A D
COMMENTS
�M
'6eAVEL
�ll [�
MUNICIPALITY OF ANCHORAAGE-�
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
5EP 2 1 1989
R` v E I • Us GROUND WATER
ENCOUNTERED?
GND WATEe SCEP
Ar !s'
IF YES, AT WHAT
DEPTH?
Depth to Water After 8' 4
Monitoring? 12 Date: `
Reading Date
-Gross Net
Time Time
Depth to
Water
Net
Drop
.a 2
-7:00
J '
�7 r
s I O
OCT
:7:00
O •
173,
O
It
PERCOLATION RATE -%-`L4 (minutes inch) PERC HOLE DIAMETER , 7.
TEST RUN BETWEEN 3a 6- FT AND 4, S FT
PERFORMED BY:, E 'U t, eesS _ 1 _21 d64-2JE' -CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 017 112 47 Expiration Date: _' " 20 "20a(
1. GENERAL INFORMATION
Complete legal description Pollock Homestead Block B Lot 1
Location (site address) 15200 Pollock
Current property owner(s) Baker Day phone
Mailing address
Real estate agent Day phone
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
F
Private Septic
FX_1
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: NONE q Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
//
COSA Fee $ (10dd r Waiver Fee $
Date of Payment I 0 '2 3 dz oda Date of Payment
Receipt Number (� (0 S 7 � t Receipt Number
COSA # (?R_ 20( 555 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.
Name of Firm C&M ENGINEERING Phone 8545558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 10/18/2020
co
49 TH
.* I
6. DSD SIGNATURE•""'
J;0,/
System #1 Approved for bedrooms r
CHARLES G BALZARKI .
System #2 Approved for bedrooms �r �F� •. • CE -13854 .• ���i
Disapproved isrF�FOP`FiS�1
• • F����'"
p p ili\\-��`-�.
Conditional approval for bedrooms, with the following stipulations:
Yo
` O
F .-
p�`'tG
RV/ICES`��`���1�,
Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: Pollock Homestead Block B Lot 1
If more than 1 septic system on lot: COSA Checklist # 1 of 1
oy7-11 z - `l�'
Parcel ID: Q+F+224-7
Structure served by this system 1
A. WELL DATA
0 Well log is filed with Onsite (or attached)
Well production at time of test 3.2 gpm
Date drilled 1989
Water storage tank volume NA gallons
Total depth 410 ft
Well disinfected for coliform test? ❑ Yes ■❑ No
Cased to 36 ft
R Coliform bacteria is Negative
❑■ Sanitary seal is functioning correctly
Nitrate mg/L ❑■ Nitrate less than MRL (ND)
Q Wires are properly protected
Arsenic ug/L Arsenic less than MRL (ND)
Casing height (above ground) +18 in.
Collected by C.Balzarini
Date of flow test for COSA 10/12120
Date of Sample 10/14/20 ,
Static water level at beginning of test 42 ft.
Comments Previous tests revealed 1.0 gpm flow. Well production may vary seasonally. 2018 earthquake may have improved flow.
B. TANK DATA
Age of tank(s) 2 years
Tank type/material . Steel
Measured operating fluid level in septic tank 49
0 Standpipes/foundation cleanout per record drawing
Date of pumping 5/7/20 ,
D. ABSORPTION FIELD DATA trench
Which system tested (date installed) 2018
WE ALL standpipes present per record drawing
Total measured depth from grade 10 ft (max)
Measured depth to pipe invert from grade 3 ft (min)
❑ N/A — pressurized field
❑■ Monitor tubes go to bottom of effective. If not, state
depth into effective
F Code -required soil cover over field
❑■ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced 1200 gallons
Comments/Deficiencies: water level measurements from 5 effective trench
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 10/1220
Results 0 Pass For 4 bedrooms
Fluid depth prior to test 0 in
Water added 650 gal
New depth 13 in
Elapsed time <1440 min
Final fluid depth 0 in
Absorption rate 600 gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date NA
NO
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'
✓l
Yes
Community Sewer Manhole/Cleanout > 100'
Yes
if No
ft
/ Yes
if No ft
Neighboring Tank > 100' F/ Yes
if No
ft
Private Sewer/Septic Line > 25' 0✓ Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No 85
ft
Holding Tank > 100' F Yes
if No ft
Neighboring Absorption Fields > 100'
Yes if No ft
Water Main > 10'
Animal Containment > 50' 2✓ Yes
if No ft
0 Yes
if No
ft
Yes if No ft
Water Service Line > 10'
0
Yes
if No
Manure/Animal Excreta Storage > 100'
—❑✓
If septic tank is under driveway
Community Sewer Main > 75' Q✓ Yes
if No
ft
Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
✓l
Yes
if No
ft
Surface Water > 100'
Q✓ Yes if No ft
Property Line > 5'
0✓
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
F✓
Yes
if No
ft
Private Wells > 100'
Yes if No ft
Water Main > 10'
✓❑
Yes
if No
ft
Community Wells > 200'✓Q
Yes if No ft
Water Service Line > 10'
0
Yes
if No
ft
If septic tank is under driveway
comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'✓®
Yes
if No
ft
Private Wells > 100' ®✓ Yes if No ft
Water Service Line > 10'
FV -1
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100'✓0
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that / 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. 10/15/20
COSA Checklist yellow sheet
OF ALgS�
49
�r
CHARLES G BALZARIIaI
CE -13854 •����®
���F�pROFESSIONP.
8 9 70
Municipality of Anchorage
On -Site Water and Wastewater Program N
(907) 343-7904 q S E T Y li
Certificate of On -Site Systems ApprCU
Parcel I.D. 017-112-47 Expiration Date:
Complete legal description Pollock Homestead; Block B, Lot I
Location (site address) 15200 Pollock Drive *Anchorage, AK 99516
Current Property owner(s) Brian Amos Day phone 440-2574
Mailing address
Real Estate Agent Nate Baer Day phone 727-1130
2. TYPE OF DWELLING:
M Single Family (w/wo, ADU)
Fj Duplex
F-1 Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual
Individual Water Storage
0
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
D
WaiverNariance request for: 'I "A&\ ±0 -T�,e t\ (� Distance: t6"
Received b z Date:
COSA to be reledsed to Owlengineer, unless otherwise requested by the engineer.
77
COSA Fee $ Waiver Fee $
Date of Payment I
Receipt Number
COSA #
Date of Payment - I __
Receipt Number
Waiver # n5vj2 jo �'vq
As certified by my seal affixed hereto and as of the validation date shown below, ! verify that my investigation,
based on proceduresin the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on+sitevvatar supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. | 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 ayehann is(are) in compliance with all applicable Municipal and State oodna,
ondinenoea, and regulations in effect atthe time ofinstallation.
Name 0fFirm: Phone: 907-337-6179
Address: -3701
Engineer's Printed Name: Jeffrey A. Garness Date:
In conducting this evaluation.EEG provided an engineering evaluation of the well and/or septic system
in accordance with the guidelines and regulations established by the Municipality of Anchorage and
industry practices. The reported results describe the condition of the oysuem/s on the date/s of the
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or
encroachments may exist that were not identified during the evaluation. The operational life ofall wells
and septic systems depend upon a variety of variables, including but not limited to, soil conditions,
groundwater levels (that may fluctuate during the ynar), quality of construction (mauaho|u and
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and
are outside the control ofgE8. Satisfactory test results do not Soommeo future performance of the
system/s; themfore. GEG makes no warranty (express or implied) regarding the future performance of
the well or septic system. GEG makes no representation whether an alternative well or septic system
can be installed on the property in the event either of the current systems fail to perform adequately in
the future. The content of this report is for the sole benefit nfthe /p h retained 8EQ to
perform the evaluation. Reliance upon the information provided in this report byany other person or
party (including subsequent property purchasers) in not authorized, nor will it confer any legal right
whatsoever.
G' DSD SIGNATURE
System #1 Approved for Ll bedrooms
#AECC884
System #2 Approved for bedrooms
Disapproved C,.
(��DditiOD8|@ppF�V��fo[ b�d[Oq08 with the ���
----- -----' ` �� '---- ¥�
Original Certificate Date
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approva|(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:
C{}8ACheck|ist Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
If more than I septic system ismmthe lot:
COSACheoNhst #
Structure served by this system
POLLOCRHOMESTEAD; BLOCK 8.LOT 1 Parcel ID: 017-112-47
I *CASED TO BEDROCK I
K/, 8, or provide PVVS|D# N/A Well Loo HYN>_____
_
Sanitary seal (Y/N)_YES� Wires properly protected (YYN)
Cased to,36ft. Casing height (above ground)
YES
YES
12+ in.
FROM WELL LOG
AT INSPECTION
Date oftest 12%2K89
3/1/18
Static water level SD ft.
19.9 ft.
Well production 4.5 g.p,nn.
1.0 Q -pm-
VVATER SAMPLE RESULTS:
Co|ifonn MEG co|oniee/100nn|. Nitrate ND mg./L.
Collected by: GE8 Ltd -
Arsenic: ^u ug./L. Date ofsample: 3/2/18
B. SEPTIC/HOLDING TANK DATA
TonkTvpe/Mateha| SEPTIC/STEEL
Date installed 5/18'17/2018
Tank size 1250 gal. Number ofCompartments 2
C|eenouts(Y7N) YES
Foundation cleanout (Y7N) YES Depression over tank (Y/N) NO High water alarm (\YN) NO
Date ofpumping NEW Pumper
-
C. ABSORPTION FIELD DATA I -BELOW FINAL GRADE
KU T:H]
Dateinstalled 5/16'1712018 Soil rating rObdrnm\ ^*1�0 System type DEEpTRENCH
Length 40/20 0. Width 2.512.5
ft. Greve( below pipe 5.02/7.5 ft.
Total depth ° ft. Eff.absorption area 708 m2 Monitoring
tube YES Depression over field NO
Date ofadequacy test NEW Raau|ta(Paom/Fai|)
'
PASS For 4 bedrooms
Fluid depth inabsorption field before test __- in. VVoteradded_-gal. New depth _ _in.
Elapsed Time: -_ min. Fina| Ouid depth-_ in.
Absorption nahm >= 600+ g.p.d.
Any rejuvenationtreatment (past 12nno.)(YYN8type)
NONE |fyes, give date ____�___
**SEE ATTACHED LETTER WITH RECORD DRAWINGS REGARDING APPLICATION RATING
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot 100+ —
Absorption field on lot *Ml+
On adjacent lots 1001+
On adjacent lots 1001+
Public sewer main 10+ Public sewer manhole/cleanout
Sewer /septic service line 25+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
ODE
Property line 5!+ — Absorption field 51+
Water service line "10'+ - Surface water 100'+
Wells on adjacent lots 1001+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ — Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water 100'+ —Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
*SEE ATTACHED RECORD DRAWINGS; "ASSUMED, SEE ATTACHED RECORD DRAWINGS
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.
Engineers Printed Name JEFFREY A. GARNESS
Date
(Rev. 10/12/12)
0 'VT -X jel r9r) A--Aaarne L. -V Ar
% E- 795'9 h
LICENSE 111111TAI"a
#AECC884
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N 00 O. W 0909,
POLLOCK DRIVE
Municipality of Anchorage
• — Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage. AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY, DWELLING
Parcel I.D. 017-112-47
1. GENERAL INFORMATION
HAA
Expiration Date:
Complete legal description � Lot 1, Block 'B' , Pollock Homestead
Location (site address or directions) 15200 Pollock Drive
Current Propertyowner(s) Vince Spezialy Dayphone 345-1555
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
15200 Pollock Dr., Anchorage, AK 99516
Day phone
Day phone
Unless otherwise requested, HAA will be held by DSD for pickup. -7,?. Z/7,r,�- G Ar -j-/a I
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑X
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
Individual On-site
Individual Holding tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certi icates may be reissued for a period of up to one year with
valid water samples.) Certificates ere valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further 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.
S & S ENGINEERING
Name of Firm
Address Eagle River, Alaska 99577
Engineer's Printed Name Robert C. Cowan, P.E.
5. DSD SIGNATURE ' .
Approved for bedrooms.
Disapproved.
Phone 6 q Y— a cl 7 9
Date C/7/o.r
i... ............
......
Ah �;
!f '� ROBERT C. COWAN V
tr�� s4 CE.8801
Zi
t i�••..•............'.��'
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date:
(Re,. 1200)
Municipality of Anchorage
Development Services Department
Building Safety Division
OnSlte Water & Wastewater Program
4710 South Bragaw St.
P.O. Box 196650 Anchorage, AK 9951!1.6650
www.danchorage.ak.us
(907) 343.7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ).O T/ Q L K 6 Po!-'ac •c t o.! • sic T O Parcel
A. WELL DATA
Well type PR/VATf
Date completed !Ya/ ri
Total depth ! /o ft.
If A, B, or C provide PWSID # 7
Sanitary seal &N) Y4 f
Well Log C%N)
017 -Irl -y7
YAO r
Wires properly protected(OIN) YA f
Cased to 3! ft. ro Casing height (above ground) / d f in.
FROM WELL LOG
Date of test
Static water level q U ft.
Well production y S g.p.m.
WATER SAMPLE RESULTS:
AT INSPECTION
413110,
A -7 ft.
1. N g.p.m.
Coliform -O--colonies/1O0 rol. Nitrate 0• mg.A. Other bacteria 0 colonies/100 ml.
Date of sample: / 30 / 9 / Collected by:
B. SEPTIC/HOLDING TANK DATA ! 7034 Ent* RIM Lelep Road No. 204
' o RIwK, Alaske
Tank Type/Material
S6-'! c S T C i L 'Date installed / 0 la 0 y
Tank size 1000 gal. Number of Compartments? Cieanouts(%)
Foundation deanoutON) YQ
Date of pumping 7 / a. o ° o
C. ABSORPTION FIELD DATA
Date installed 10ba/19
Length _rt ft.
YL 1'
Depression over tank (YASV� "' 0 High water alarm (Y/D N 0
Pumper N opt 7-14 L Ari A
Soil sang (g.p.d /ft! or a_a 5`
Width `r ft.
S 4Allo✓
System type T R &� cm
Gravel below pipe 3 14 ft.
Total depth 7 ft. Eff. absorption area L/73� ft' Monitoring tube Y6c Depression over field w0
-r/71/a/ Date of adequacy test ResultsPas ail) ?145-1 For a bedrooms
r r n r l„
Fluid depth in absorption field before test") a in. Water added 300 gal. New depth3 9 yin.
Elapsed Time:I 12 min. Final fluid depth 3 �o "in. Absorption rate >- .300 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y1N b type) Now4 kmowr/ If yes, give date
D. UFT STATION
Date installed
"Pump on" level
E. SEPARATION DISTANCES
Size in gallons
at _ in. High water alar level at
Cycles tested Meets alarm 6 circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Senfir tankAift station on lot 100,+ On adjacent lots
On adjacent lots
/00 4-
/ 00
Public sewer manholeideanout w 1.4
Holding tank
N /A
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
,r
Building foundation $ Property line S Absorption field S, 4 -
Water main
NIA Water service line 1014 Surface water I o 0 �f
Wells on adjacent lots I Ot> f
in.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line / 0 14L Building foundation /0 Water main N �A
Water Service line /0 "A Surface water / c o '+ Driveway, padtingfvehide storage oZ o f
Curtain drain &2&_L h'A/0✓M Wells on adjacent lots I OD it
F. 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 HAA gguidetlnes in effect on this date.
Engineer's Printed Name IeaQ c'er C
Date G/7 /of
HAA Fee $
3 00. ov
Date of Payment (-/ V /O
Receipt Number 00 S-405-
(Rev.
S Ges'(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number
r i ROEC�j 1 r
Absorption field on lot
100,+ -
00,+ -
N 1A
Public sewer main
Public
Sewer /septic service line
;t S L
On adjacent lots
/00 4-
/ 00
Public sewer manholeideanout w 1.4
Holding tank
N /A
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
,r
Building foundation $ Property line S Absorption field S, 4 -
Water main
NIA Water service line 1014 Surface water I o 0 �f
Wells on adjacent lots I Ot> f
in.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line / 0 14L Building foundation /0 Water main N �A
Water Service line /0 "A Surface water / c o '+ Driveway, padtingfvehide storage oZ o f
Curtain drain &2&_L h'A/0✓M Wells on adjacent lots I OD it
F. 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 HAA gguidetlnes in effect on this date.
Engineer's Printed Name IeaQ c'er C
Date G/7 /of
HAA Fee $
3 00. ov
Date of Payment (-/ V /O
Receipt Number 00 S-405-
(Rev.
S Ges'(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number
r i ROEC�j 1 r
MUNICIPALITY OF ANCHORAGE
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services —
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel 1. D. # P, 17— 1 l - L-\ l
1. GENERAL INFORMATION
HAA # � 9-QI-)S
Complete legal description
Location (site address or directions) __ �S CQ Po / i'aC`1
Property owner Yt Y1L e -_0_t4 1 Y Day phone 34_'�?--7Z— 70
Mailing address
Lending agency - 1Ttf-- y l-� a Day phone
Mailina address
Agent r) -n 6 O rr ( 'b Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site: X\�_
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA 421
Lin Vow HDea (L6i L 'A08) 5Z0 -6Z
-�aoM s,aaauibua leuolssaloid ay} ui suoissiwo ao saoiaa jol alglsuodsaa
IOU si a6eaououy to Al!!edlolunw aul -ponssi si aleollpiao a aaoleq elep az (leve ao suoijoadsui lonpuoo
IOU op SHHa to saaAoldLu3 -sluawailnbai alels pue leaapal uieuao /lslles oljapao ui suolln1psul 6uipuaI maul pus
sawou to siaseuoind of /\salanoo a se slut saop SHHa aul'e�sely;o alelS aul ul paaals16W aaaul6ua Puoissa{o.id
luapuedopui ue (q anoge g udea6eaed ui u9n16 suoileluasaidai aul uodn Aluo paseq saleoll!laao lenoaddy
Al!joulny ulleaH sanssi (SHHa) soolnaaS uewnH pue ulleaH }o luawpedaa a6eaououy;o Aj!ledlolunw aUl
_ NVIlI1VJ - �
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ainleu6ls s,aaaulbu3
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•uolloadsul slut to alep aul uo loalla ui suollelnbaa pue 'saoueulpio
'sopoo alelS pue ledlolunW Ile ul!m eouelldwoo ui sl wals/\s lesodslp aalennalseM ao/pue Alddns
aaleM alls-uo aul 'uolloadsul pue uo!le6ilsanu1 /\w wool pue salll abeaououy to Al!ledlolunW aul
woo; poulelgo uo!lewaolul aul uo paseq leul/\l!aanaaulanl I ulaaaq paleolpul ainlonalslo ad/\l pue
swooipeq to aagwnu aul aol alenbope pue Ieuollounl 'ales sl wals/\s lesodslp aaleMalseM Jo/pue
/\lddns aaleM ells-uo aul leul sMous uolleolldde Ienoiddy Al!aoulnb' ulleoH slut to uo1le61l69nul
/\w leul Al!aan I 'Molaq uMous alep uollepllen oUl to se pue olaaau pax!lle leas Aw Aq pa!lgJ90 sy
a33NION3 AS N01103dSNl d0 1N3W31`d1S 'S
o Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Li,oI,f� Pn1/4-/r'_l/U//k' ' e,, -I' J�iarce1 1. D. —
A. WELL DATA
Well type If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) ,%
Date completed —
Driller
Total depth A- act
Cased to 0-
Casing height—
Sanitary seal (Y/N)
x Wires properly protected (Y/N) y
FROM WELL LOG
AT INSPECTION
M �
Date of test
z_
Static water level
r a
Z r
Well flow
_ g.p.m.
g. PFA- cJ,
R o
Pump level
wo t/ a
7 �'�t -
JCS ' / rr-1 w
SEPARATION DISTANCES
FROM WELT_ T�
Septic/holding tank on lot
4
9
i
; On adjacent lots _ / G� 4/""
c
Absorption field on lot
I �3 ` ;
On adjacent lots % /f)n
Public sewer main IV / 4 Public sewer manhole/cleanout
Sewer service line Iw 4. Petroleum tank N(21-) `('Z
WATER SAMPLE RESULTS: X/��
Coliform 's Nitrate ©r PM Other bacteria _
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA 0
Date installed l0 l% Tank size ��C Compartments
Cleanouts (Y/N) _ Foundation cleanout (Y/N) /` _
High water alarm (Y/N) —Alarm tested (Y/N)
Depression (Y/N) G_
j'.
Date of pumping �� r, Pumper AlQnf j L rz��� z�i. �
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 27 �On adjacent lots } / OD Foundation _
Topropertyline -h Y' Absorption field— —Water main/service line
Surface water/drainage ©/ZP d 1r),>:e i?r %ci
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE:
C. LIFT STATION
Date installed
Size in gallons
Vent(Y/N) `P_ I
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM
Well on lot
n- ABSORPTION FIELD DATA
Manufacturer
Manhole/Access
on" level at
STATION TO:
On adjacent lots
--' "Pump off' level at
Cycles tested
Surface water _
Date installed Soil rating y tem type '( S "
Length Width ✓ / U Gravel thickness 3 rr� Total depth 7 /
Total absorption area /�- 7 Cleanouts present (Y/N) r
I�
Depression over field (Yp/N) �� Date of adequacy test _�" J C/ Z
Results (pass/fail) 1� (2 CJJ for l -
bedrooms
Peroxide treatment (past 12 months) (Y/N)
SEPARATION ,(DISTANCE FROM ABSORPTION FIELD TO -
Well on lot`'33 ( On adjacent lots /
If yes, give date
Property line
a
To building foundation To existing or abandoned system on lot 1VC91,?`e
On adjacent lots 5 Cutbank k/ �f� L' Water main/service line LIA
Surface water Alad 4�Driveway, parking/vehicle storage area �~ 77
Curtain drain
C1' Nl0 Q F -r I i til eoe)
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
rl f
Signaturei�o
1
Engineers Name r �'/� �® f.6a@a o toQ
9 Feaoeon.�6
Date
to a James r. Si/ic oo Q v
1517 E
G
000.
Op 000
O
HAA Fee $ _ C/ Waiver Fee: $
Date of Payment ( 7 Date of Payment
a
Receipt Number �.c)a �� Receipt Number
72-026 (Rev. 3/91) Back MOA 21
MUNICIPALITY OF ANCHORAGE
• Department of Health & Human Services ils, DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # c-,)/2 - y2 HAA # 41 ( Z —
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include tort, block, subdivision, section, township, range)
LSC T �i�C�iCL l / dZ�
Location (address or directions)
(b) Property owner ����- C�� Telephone: (home)e�Z'7Business
Mailing Address—
(c)
ddress (c) Lending Institution N44' Telephone
�✓ �/T
Mailing Address �
(d) Real Estate Company and Agent
Address ,✓� ��
Telephone
(e) Mail the HAA to the following address: (or check here Q, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENC
Single -Family Number of bedrooms
3. WATER SUPPL;//,"Community
Individual Well ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DI PUSAL
On-site Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88)
Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of 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 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 re /lotions in effect on the date of this inspection.
Name of Firm "f �-�•�,- r /�� Telephone 5 Z —1311
Address /Ol O /)%bZt..GZ_1
Date
6. DHHS APPROVAL "
Engineer's Seal
Approved for 7i bedrooms by J��� �S`"�( Date
Approved _ Disapproved Conditional
Terms of Conditional Approval
CAUTION
!Z/z,/(5q
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
MUN1,9IPALITY OF ANCHORAGE (MOA)
A!,-' "3 ��a�h Authority Approval (HAA)
6HECKLIST - FEBRUARY 1984
343-4744
Legal Description:
BGG?%(`v
A. WELL DATA
Well Classification �� -;�;Z `�Z If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Date Completed �/% A- � Yield Gi %GjiCy%?'
Total Depth 1�' Cased to Depth of Grouting
Static Water Level
Pump Set At
/i
Casing Height Above Ground >./y— Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot /3e_:� ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot Z— ; On Adjoining Lots
To Nearest Public Sewer Line Af To Nearest Public Sewer Cleanout/Manhole tir
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test ResultsJCr/i-��(
Comments A '5 q,m7 4.r_ 7C'
B. SEPTIC/MOLDING TANK DATA
;Date z�'_/d
1P . -
Date Installed I_' �� =Size 660 No. of Compartments
Standpipes (Y/N) e Air -tight Caps (Y/N) K Foundation Cleanout (Y/(N) —L
Depression over Tank (Y/N) /U — Date Last Pumped
Pumping/Maintenance Contact on File (Y/N) IV A" ; for "
Holding Tank High -Water Alarm (Y/N) " —Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well To Building Foundation
i
To Property Line To Disposal Field �, l
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course _
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata {��Type of System Design
Date Installed �C'/ ��%'� Length of Field S
Width of Field Depth of Field
,y Gravel Bed Thickness to
�y— %' /
Square Feet of Absortion Area Statndpipes Present (Y/N)
Depression over Field (Y/N) /(JDate of Last Adequacy Test /(/epi
Results of Last Adequacy Test J
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well=3(T'
To Building Foundation
N
To Property Line
To Existing or Abandoned System on
Lot 64Z ; On Adjoining Lots
To Water Main/Service Line To Cutback (if present) o %i
To Stream, Pond, Lake, or Major Drainage Course IZA
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
"Check Pe
I certify th
inspection
Signed
Compa v°
Date /�
Dirzre'nsions
Manole/Access (Y/N)
"Pump Off" Level at
—, Vent(Y/N)
Pumping Cycles during Adequacy Test.
Bedroom atiin�nj Against HAA Request"
checlverified, or conformed to all MOA and
MOA No. lT ry 5—
Receipt
Receipt No. e70 Date of Payment ('�� (/_ Lc/
Amount: $ ' coca
Receipt No.
Waiver Fee: $
Date of Payment _
72-026 (Rev. 7/88) Back Page 2 of 2
on the date of this
Engineer's Seal
MUNICIPALITY OF ANCHORAGE (MOA) ASA
• Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984 -�
343-4744
Legal Description:
A. WELL DATA
Well Classification A/1 �� If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Date Completed Yield
Yield
Flo
Total Depth AG Cased to Depth pth of of Grouting k/
Static Water Level -/ %� Pump Set At
Casing Height Above Ground. Sanitary Seal on Casing (Y/N) /
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ��30' ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot Z36�' ; On Adjoining Lots
To Nearest Public Sewer Line A To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot _>
Water Sample Collected byy ��ei el�a`L� ; Date
Water Sample Test Results cru / /y
Comments __K ¢ S�,o�t
B. SEPT II
Date Installed /C 2G HSize 040 No. of Compartments 2 -
Standpipes (Y/N) _ Air -tight Caps (Y/N) Foundation Clea/nout (Y//NN) —1
Depression over Tank (Y/N) /v Date Last Pumped
Pumping/Maintenance Contact on File (Y/N) for
Holding Tank High -Water Alarm (Y /N) — Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well �3 D To Building Foundation /
To Property Line Ag� / To Disposal Field <
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course /11
Comments
72-026 (Rev. 7iee) Front Page 1 of 2
C. ABSORPTION FIELD DATA /� i
Soils Rating in Absorption Strata G 2 � �//')mType of System Design r�f� _ C5i�14�46�
-Date Installed Length of Field
Width of Field Depth of Field
Gravel Bed Thickness
Square Feet of Absortion Area "�/
� 72 1�7 Statndpipes Present (Y/N)
Depression over Field (Y/N) �% Date of Last Adequacy Test �Ue�
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well /�C_ / To Property Line
To Building Foundation To Existing or Abandoned System on
Lot - ; On Adjoining Lots X16 0
To Water Main/Service Line �� / To Cutback (if present) L(
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed Di ensions
Size in Gallons Man le/Access (Y/N) —
"Pump On" Level at "Pump Off' Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
"Check Permi d Bedroom atin Against HAA Request"
I certify tha I hecke , ve ' ied, or conformed to all MOA and HAAgt#Iftleffect on the date of this
inspection "t°ro y
11
Signed
..
Compar y /�� - ��a
r Engineer's Seal
Date �Z -
b oe4n¢aaa¢4 oe¢ry�-
MOA No. �� �� r ; J. Cenr9A r 4 a�
CF -55283
�°
a
\ o X 'a
Receipt No. Receipt No.
Date of Payment Waiver Fee: $
Amount: $ Date of Payment
72-026 (Rev. 7/8B) Back Page 2 of 2