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RAYMOND TEDROW BLK 1 LT 5A
P-aymond Tedrow Block 1 Lot 5A #050-155-53 Municipality of Anchorage Development Services Department Building Safety Division +. - On -Site Water and Wastewater Program, 4700 S. Bragaw, St P.O. Box 196650 Anchorage. AK 99519-6650 PageI of www.ci.anchorage.sk.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit 5W01010 S PID Number. G5a-1'5S— 53 /Numbeer.. Nae. r Ke F'OS7 mI r 1 Wastewater System: ❑New Ig Upgrade 733 7 ontG �o ! CS -,9107 ABSORPTION FIELD F'nau: N~a eaapana: O Daae rwWn 011,s1ww.TraRlt OBed pMaaq OOmer: LEGAL DESCRIPTION Sod Rapp aal bane "nal a: Depth ba Tq ifp ,p p el p Loi C, Stmiviabrt '%, Depdn to PFa bW= am agnal grad.: 6 Gravel Capp boreatIn pipe: 3 1 �/ A MC(! 1C %O FI. FI. .n Toalup: Range: Baalan. FC added abm anginal graft. O Ft. Gr"A � IQ1 Ft. Well: ❑ New ❑ up Gravel wddn: r Numwralirs: omni ettw«n lwa: ✓L FI. Fl. CdsrdeI!; (Pmala. A 9, Taal Depdn: Cased W. Total Wv*pem ata D a5 P Malan '/�`zn Cp D3o.� /? AI Ft. Ft Fla s Drder. Dana D.W: Si Wster Level: , a /C� r I�4L�J�� Dad Mta9ad: 57115 o % Ft Troll: Pumpsal.t C"'N"" o"AE G'"e: TANK CPM FL Fl SEPARATION DISTANCES {$.Septic ❑ Holding ❑ S.T.E.P. ❑ Other. To Septic Absorption Lift Holding PublidPrivate Ma"'ljjt�K ZC cp.d/yy�7 From Tank Field Station Tank Sewer Lyle f,.•}f.0-j_A6e, WGel. waa X01+ 00\ i Malanel Num. a cpmpa u wx.: a 1 Surace water 10014-1001-t- LIFT STATION La un. �o, a 'I.Waaur. 5a. GatFoundawn I / U -7 3 \ L •Pdrp one lanai al: •Pump olr aNpn watt 8141"'101. Q 1 n N. Pump Maks. Elocu" ftpKpOna WWM@d by detain talo o/ plGie Qn �(.'t� • Ramaks: F—)03TIr•(. S•EPr1 c. q,..1t BENCH MARK PkQ CA�tNEO � R/3ArOON{D, lonkan ant aampkac (� �J. 1 /. ISPlIO O�SILi//) o�nf B 00 FL S & S ENGINEERING 17034 Ea Road No. 204 Inspections performed by: Eagle River Loop r Dates: 1"—-0/ Rive., Ra 2 �— I �— 0� iA _ ...... ....., y rT !VC ` ROBERT C. COWAN Development Services Department Approval F�`"c� :` CE -Bao) �l�N Reviewed and approved by: Date: !r'2.� D/ 1+11 �c p'' _• : ;;�; �1q, r••: (R.. IM) L..• �•� PERMIT No. SWO10108 PAGE 2 OF 3 Municipality of Anchoraqe DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 •Anchorage, Alaska 99519-6650 • Telephone+ 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 5A, BLOCK 1, RAYMOND TEDROW P.I.D. No. 050-155-53 1 ti-, C.) � y� O~ 81 1 v V v v E I��v �wvv I 2v ?V � ry EXISTING ' FENCELIKE EXISTING TRENCH I 0• I TH 00] 01 all V (dVER1ER VALVA 1 NEn080• CRL2 rt 1000 c•LLON SEPTIC TANK TI RA�1US wE,L I CO3 LOT 6 ,5o I LOT 4 I 0N I rRN 1 I TING �Q' 1 2 BEDROOM '!� SCALE: 1' 40' MONTE ROAD .... y i {I• `WATER SERVICE LINE jy / 1 0 n•'•1�'•T . 03 -P ROBERT C. COWAN 01 c, CE • 8801• F77 7 7�k` -yn� PERMIT NO. SW010108 PACE 3 OF 3 DEPARTMENT ANDhHUM9AN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 *Anchorage, Ataska 99519-6650 • Tetephone 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LECAL LOT 5A, BLOCK 1, RAYMOND TEDROM P.I.D. NO. 050-155-53 FINAL GRADE CO1 ST2 93.2'// I NEW 1000 GALLON SEPTIC TANK MTI COI = 99.7' CO2 = 98.6' FINAL GRADE INSULATION L'L•�Y ........... • ••2 = •R MTI = 90.G' • 0.6' OF DIRT FELL IN MTI A NO WATER FOUND 82. ' B.O.H. 100.0' 2" INSULATION 93.0' N. T. S. MUNICIPALITY OFANCHORAGE Development Services Department On -Site Water& Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ONSITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Permit Number: SWO10108 Legal Description: RAYMOND TEDROW BLK 1 LT 5A Design Engineer: 0003 S & S Engineering Owner Name: MIKE FROST Owner Address: 17337 MONTE ROAD EAGLE RIVER. AK 99577-8107 This permit is for the construction of: Q Disposal Field ❑ Septic Tank Date Issued: May 10, 2001 Expiration Date: May 10, 2002 Parcel ID: 050-155-53 Site Address: 017337 MONTE RD Lot Size: 22494 SO. FT. Total Bedrooms: 2 Permit Bedrooms: 2 ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must be In accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3_ The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by catling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: Date: Z�j - Date:IF 5--/0 -0/ 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 ON-SITE SEWERMELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. CJ So - S 5 5 - 0,3 Permit Number SWO/O/OR Property owner(s) M I V\ T-, F R n 5� Day phone Mailing address (1) 9310 EmlErNIA St , L-mhnra82- I- V- 996:LS Sblailingaddress (2)/7337 /10/VrE D. Zip Code 99577-8/07 Legal description (Lot, Block & Sub'd.) L o*_ 5 A . Block7t . _� ry m inrl 7"t & r aw Legal description (Section, Township & Range) Lot Size,[ Acres Number of Bedrooms Z 22,49 Sf. Fr. THIS APPLICATION IS FOR: Sewer Only ❑ Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade D? THIS PROPERTY CONTAINS: Hot Tub ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. 5 & 5 ENGINEERING 17034 Eagle River Loop Road, No. 204 Eaale River, Alaska 99577 (Signature of property owner or authorized agent) Permit Fees: 301 0. Waiver Fees: Date of Payment:g 4t; / 00 Date of Payment: Receipt Number: Oo -7 S o 1 Receipt Number: (Rev. 12/00) S& NEALTNALOHMTY APPROVALS SEWER& WATER ►WNMENSONS SEWER & WATER NSPECRON EN(, NEERNGstums ANDREPORTS WELLNSPECTION & FLOW TEST SITE PLANS SOI TEST PERCOLATION /EST STRUCTUVL& WCHA AL NSPECTWNS CNSNE WASTEWATER DISPOSALSYSTEM DESIGN ROBERT C. COWAN P.E. CML ENGINEERS (907)694-2979 FAX(907)694.1211 April 19, 2001 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 5A, Block 1, Raymond Tedrow Subdivision It is requested that you issue a permit to upgrade a septic system to serve the two bedroom dwelling on the referenced property. One test hole was excavated and a percolation test was performed on 4/2/01. The approximate location of the test hole is located on the attached site plan. Ground water was monitored and after seven days the hole was dry as shown on the attached soils log. We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent properties. If you require additional information, please contact us. Sincerely, 14�/z 4,., Robert C. Cowan, P.E. RCC/jhm Enclosure 17034 NORTH EAGLE RIVER LOOP • SURE 204 • EAGLE RIVER ALASKA 99577 III LOOP ROAO KA 99577 14-7979 1-1711 LOT 5A, BLOCK 1, RAYMOND TEDROW S D'oF,'/'��; y JNAwx Ri: _nECKEO Of MIL SHLLI: ti ..✓............�4z�KI J.H.M. R.C.C. 5-10-01 1 OF I `-c�;'' DESIGN CRITERIA: STRUCTURES. EASEMENTS. OR ENCROACHMENTS 1TO 2 BDRM = 300 GPD SHOWN ON THIS SITE PUN ARE AS SHOWN ON ....' ......•.,.:••••••:� SOILS = 1.2 CPD/SQ.FT. AN AS -BUILT SURVEY DRAWN BY:iW14� f 300/1.2 =250 SQ.FT. REQ'D. ROBERT C. JOHNSON 0 VERIFY EASEMENTS.REQUIRED SEPARATIT IS THE ON T BILTY OF THE CONTRACTOR ROBERT G CO 10' DEEP WAN ••� TRENCH CRITERIA: DISTANCES. AND PROPERTY LINES PRIOR TO C C 8301 }:•d CONSTRUCTION. 3' EFFECTIVE( : C.SY I <„ („ It�f..'�.............•••;;` �>` 5' WIDE E I Jy y y y 1j `J�...__..•-•,." ;" 29' LONG CONTRACTOR IS REQUIRED TO W 08TAIN UTILITY LOCATES Sl I v v v PRIOR TO ANY EXCAVATION WORK. o I V p ALL PORTIONS OF SYSTEM I O O i WITH LESS THAN 3.5' OF COVER REQUIRE INSULATION. EXISTING FENC IN EXI NCH PROPOSED N[] VITH1N 0 WfOt4S TRENCH I 11P1' 10 0 INSTALL I rw. TH T C DIVERTER VALVE N lo' M __ INSTALL 4 I ISTING CLEANOUT I INGLE ate. WE�1' RAOWS 150 z a r_ E- CO W v SEPTIC TANK I m x Im N d LOT 5A, BLOCK 1, RAYMOND TEDROW S D'oF,'/'��; y JNAwx Ri: _nECKEO Of MIL SHLLI: ti ..✓............�4z�KI J.H.M. R.C.C. 5-10-01 1 OF I `-c�;'' DESIGN CRITERIA: STRUCTURES. EASEMENTS. OR ENCROACHMENTS 1TO 2 BDRM = 300 GPD SHOWN ON THIS SITE PUN ARE AS SHOWN ON ....' ......•.,.:••••••:� SOILS = 1.2 CPD/SQ.FT. AN AS -BUILT SURVEY DRAWN BY:iW14� f 300/1.2 =250 SQ.FT. REQ'D. ROBERT C. JOHNSON 0 VERIFY EASEMENTS.REQUIRED SEPARATIT IS THE ON T BILTY OF THE CONTRACTOR ROBERT G CO 10' DEEP WAN ••� TRENCH CRITERIA: DISTANCES. AND PROPERTY LINES PRIOR TO C C 8301 }:•d CONSTRUCTION. 3' EFFECTIVE( : C.SY I <„ („ It�f..'�.............•••;;` �>` 5' WIDE E I Jy y y y 1j `J�...__..•-•,." ;" 29' LONG CONTRACTOR IS REQUIRED TO W 08TAIN UTILITY LOCATES Sl I v v v PRIOR TO ANY EXCAVATION WORK. o I V p ALL PORTIONS OF SYSTEM I O O i WITH LESS THAN 3.5' OF COVER REQUIRE INSULATION. EXISTING FENC IN EXI NCH PROPOSED N[] VITH1N 0 WfOt4S TRENCH I 11P1' 10 0 INSTALL I rw. TH T C DIVERTER VALVE N lo' M __ INSTALL 4 I ISTING CLEANOUT I INGLE ate. WE�1' RAOWS 150 z a r_ E- CO I EXISTING 1000 GALLON v SEPTIC TANK I I a 0 x Im N I 5 1 1 MONTE ROAD WATER SERVICE LINE .. Ju44NEg SSEfLjv e Municipality of Anchorage , DEPARTMENT OF HEALTH & HUMAN SERVICES ✓ "�: _ i' =fit 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST r—`��'L_:. ROLERT C. COWAN t,^c MM i1' ' .., PERFORMED FOR: jMle o?11G1i �5- DATE PERFORMED: %v LEGAL DESCRIPTION: G� �A3YHONO Township, Range. Section: ld-nrzo4 $• DEPTH SLOPE SITE PLAN 2 3-- 16- 17- 18- 19- 20 (FEET) �- 4- 45 5 f, a .Y 6- 7- 781011 8- 10- 11 12- 213 13- 14 15- 5 1617181920 Ll COMMENTS WAS GROUND WATER — 1� O ENCOUNTERED? S IF YES, AT WHAT N A 0 DEPTH? P E Depth to Waler Meer /a/o Monitoring? _D� y Due: _1 ==mmm�. �.. PERCOLATION RATEZ-45�(minutevmch) PERC HOLE DIAMETER TEST RUN BETWEEN —A— FT AND---7--FT S & S ENGINEERING PERFORMED BY:•River I cop Road No 1041 •'/ , ���� CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE wif+nklig WEAWIA)MGIPAL GUIDELINES IN EFFECT ON THIS DATE. OATS 72-008 (Rev. 4185) �.. PERCOLATION RATEZ-45�(minutevmch) PERC HOLE DIAMETER TEST RUN BETWEEN —A— FT AND---7--FT S & S ENGINEERING PERFORMED BY:•River I cop Road No 1041 •'/ , ���� CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE wif+nklig WEAWIA)MGIPAL GUIDELINES IN EFFECT ON THIS DATE. OATS 72-008 (Rev. 4185) r MUNICIPALI'¥Y OF ANCHORAGE /~"~' '~ DEPARTMENT OF HEAIiTN & ENVI RONMENTAL PROTECTION ,~~~~ ENVIRONMENTAL ENGINEERING DIVISION 825 LStreet-Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WEI,L INSPECTION REPORT NAME ~PHONE ~ NEW LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS DISTANCE TO: ~ < ~~ Materi~'~--~__ ~ ~ N°' of compartments ~ ~ Liq. capacity in gallons Inside length Width Liquid depth ~ ¢ ¢ ~ IF HOMEMADE: Well Dwelling PERMIT NO. O ~ < Manufacturer .... Material Liquid capacity in gallons ~% DISTANCE TO:' '~ Well ~¢~ .... ~ Foundation~ ~ ¢ Nearest Iot~¢~ti~e~ PE'~MIT NO. ~ ~ ~ No. of lines ~ Length of/each~ liQ~ Total length/¢ of~lines Trench width~o inches Distance between Hnes P ~ ~ Top of {~'le to finish grade -~ Mateda~ beneath ~iTe ff Total effective ~s~ption area ' h~ngth Width Depth PERMIT NO. ~ ~ Type of cri~ Crib diameter Crib depth TotaJ effective absorption area ~ Well Buildin9 foundation Nearest lot Hne ~ DISTANCE TO: ~ Buildi~9 foundatfon Sewer line Septic tank Absorption area(si ~ DISTANCE TO: PIPE ~ATE~IALS SOIL TEST~ATIN~ / 1 ~ ~ ~ - REMARKS i O, APPR O'~"E D ~ . DATE LEGAL F:'ERHIT NO. F:tF'F:'L. :[ CAiq]" MFI'I"T FIMLii'.,E)SOIq :.:.;F.:i::'t ::I..:..:.~6X ERGLE F;: I ',,,'EF.: L(]CF:IT I 01',! MONTE: LEGF!L L. CiT 5 BI_.K ::1.. RFI"r'MCIN[:' TEE:'ROkl :'E;I.JE~ LOT TYPE OF ':SI:: I[... RE',SOF,::PT:I:EIN ""' '" MF:IX I MLtM I",IUME',ER OF' E:E[:,RCH]fi'"IS = Z SO I L RIRT I NG ':: St]:! THE [?.[i]f..l!U ~[ [;i:EI]:, [~; ]] Z[~' Ii:IF' THE '.E;O I L RE:SORF'T ]: ON E;Y?FEM I S: ........... ~: ~ ........ ;;"'""" ....-'" L.. I]:::.F' 1! }E::~ ~.:~.E LJ:::~ T' IF-'I~ == :':j:i~ I~ E::" ["" ~ C}.'[ ]" ~'""'~ :=:=: "~>¢=:?-' ..:, ~ -. n'-', *." ~=. L. '"'" .:t, .7.': S E; C'i 'ZE, I. IFIRE FEET :1.4 C'~ ~ THE LENGTH [:, I i'"lEN:iii; ! ON I !-~; 'I'HE: LENI]TH ( I f',l F'EET ::, OF T'HE TRENCH OF:: [:,RF1.1' I'.4F' I EI...D. THE [:,EF'TH OF FI 'I"RENCH OR F'I]" ]:S THE I}ISTFINC:E E:E:THEEI'-,[ THE ':_";URF:FIC:E O1::' THE GROU['4[:, [:tN[)THE BOTTOM OF THE EXCFt',,,'FYI'ION ,::IN FEET::,. 'T'HEI:~:Ii~: IS IqO '.'~E]" P]I[:,TH F'OR ]'RENCHE'~5. THE GRF:IYEL [:,F-PTH I::.:.; THE I"IZIqIMUM DE:PTH OF GF;'.FI',,,'EI_ 8ETP.IEE]'.~. THE OUTFt::ILL. F']:PE FII'.,I[) THE E',OTTOM OF ]'lYE [F. XCRYF~T Z Of.,t ,'.: :[ 1"4 FEET ::,. :'I:::RM '[ r~`' F:IF'PL. I C:FII",F[' F'IFIS TI"IE PF *"F' -i'Y-:' ..... r._.z ......... ]:PILITY TO INFE~RM TFI]:S [:,EI::'FIR'T'MEIqT [:'U[~':I:NE'~ THE :[ NSTI::II.~.LI::IT I ON '[ f'~!'_: PECT ]i ON:iS OF' l::llqY !-4ELLS, F:I[:'JFIC:EIqT 'TO 'I'H I S I" F: . F [:.F~ 1 '~ FIND THE: .::,El'., E. NJME',ER 3F I:;['.ES:;IE'EHZ[:":~ 'I"HF:IT THE I.'.ff~l_.l... I.,-!~LL. ~ ...... ' '" ........................ '".fi'- II....H IC]i ,:: 7,;E:: :::'~][: 8"'-.1~ ~E;; It:::::" Ei.:Z: [(:]'.:: -~" Z ¢'..:'1 ~"-,., "~'; I1:'":11 I~' : E~.: ~:~". [FZ I~"~." II.J] ]: If -=.. [::2 [... ' ....................... E FI: I-::F:' ]: I. [. T I'.,lr3 CIF F:li'.,IY :.SYS'f'EM H I 'I'HOUT I::" ]: NFIL ]; HSF'E:: T Z 3H FIN[:, KIF F F..': , F'tL Ei',Y TH I Si; [)EPFII:;;:'I'MENT I,J:[LI... E',E SIJE',JEC]' 'l"CI PR]v:.;E['::U]"'[Cd'.,I. !'"tZhtIMUM C, ]; STI:::INCE E:ETI.,.IEE:N R P.IELL FII",I[:, FINY ON-SITE: SEP.II::IGE [)ISF:'OSRL SYSTEM IS :~..~e~ FEET' FOR Fl F'F;'.tYF:ITE P.IEL. L. OR ::t. SE~ 'TO ;;!'.~3E~ FEET FROM FI F'I..I[9L. ZC t.,]EL..L. E:,EPENC.,ING IJF:'OI'.4 THE TYPE OF Pt..IBL.]:C HELL.. f,'tZ!'.,IZf"II.Jf"t C, ZST'RhlCE FROM F! F'RZ',,,'F:ITE I.,.IEI_.L. TO I:a F'RZ',XW['E SEP.tER L]:NE ZS 25 FEET FIN[:, "['O I::1 COh'IP'IUNZTY SEI.,.IER LINE 'IS 75 FEET. OTHER [?.Eli:iii l REI'"IENTS f'lRY Fff:'F'LY. SF'EI]: I F I CFIT l ONE; FqN[:, CON:STRUI:::T 101'.,I [:, l FICif;['.FII'"t% FIRE: F:I',,,'F~ I [...I:~B[..E TO :[ f.4E;I_IF;:E F'ROPER I N:E;TFtL..I_.I::IT :[ CIr.,I. I C':ERT I F"~.' THF:tT :1..: ]: FII"'! F!::tP'IIL. IFIF;: [,.lI'l"l.~l THE: I;;:[i~]!I..Ii[4IEP1EEf-,I"f':E; FOR ON-::SITE L":.;E[,.tER.S Rf.,I[:, I,.!ELIu..:~.; FtS .SE'T' FORTH E',Y "I'HE MUi'.,IZCIF'FIL.:[TY OF FINCHCIRF:IGE. ;i:-:': I I,.IIL. I... INSTFII..L THE :FJYS]'IEM II'.,I RCCOR[:,RNCE: t.,.IITH THE CODES:;. ]:: ]: UI'.,I[)ER:E;]"F:tN[:, THFIT ']"bILE ON-.-E;ITE '.E;[:JI.,.IER SYSTEM MF:IY RE[;~UIRE ENLF. II~?.GE]'"IENT :I:F' THE RESIDEI',ICE IE; REi',IEd}ELEI} TO INCL. U[.',E MOF:'.E THRIq ]::: BE[:,ROOMS. MUNICIPALITY OF ANCHORAGE , 825 L, Street, Anchora~le, Alaska 99501 264-4720 ~'~ SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: .5 1 2 3 14 15 16 17 18 19 2O //~ SOILS LOG [] PERCOLATION TEST DATE PERFORMED: SLOPE SITE PLAN Robert A, GROUND WATER .~/0 :OUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop / / COMMENTS PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT CERTIFIEDB ~,,,~:~/~ /~'~ 72-008 (6179) \ • Municipality of Anchor P �' On -Site Water and Wastewater Progra (907) 343-7904 Certificate of On -Site Systems Approval-" Parcel I.D. 050-155-53 1. GENERAL INFORMATION Complete legal description Ra Location (site address) Expiration Date: q- ( Z-/ and Tedrow, Block 1, Lot 5A 17337 Monte Road Current Property owner(s) Guernsey, Roy Day phone Mailing address Real Estate Agent 5801 Chisana Way Anchorage, AK 99507 2. TYPE OF DWELLING: Fx] Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 2 Day phone ET 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑ Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System 0 Public Sewer ❑ Waiver/Variance request for: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 521P.00 Date of Payment V2_1 / /E ILP Receipt Number 0 Zl 3U COSA# OS&M5lA Waiver Fee $ Date of Payment Receipt Number Waiver # Parcel I.D. 050-155-53 Municipality of Anchorage =� a On -Site Water and Wastewater Program < r' (907)343-7904 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Complete legal description Expiration Date: % `1_1�2""-/ (G Raymond Tedrow, Block 1, Lot 5A Location (site address) 17337 Monte Rd. Current Property owner(s) US Bank National Association Day phone Mailing address Real Estate Agent 4801 Frederica St. Owensboro, KY 42301 2. TYPE OF DWELLING: n Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 2 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System WaiverNariance request for: � r }i Received by: Day phone TYPE OF WASTEWATER DISPOSAL: Individual 0 Holding Tank ❑ Community ❑ Public Sewer ❑ COSA to be released to the,6ngineer, unless otherwise requested by the engineer. COSA Fee $ 52—(P— Date J —(PDate of Payment 11131/1,1 Receipt Number 6`AI�JO COSA# 0se/ y r6r05' Date: Waiver Fee $ _ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed heretoand as of the validation date shown below, I verify that my investigation, based on procedures outlined. in the Certificate of OK�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 Ume of installation. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may Fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator ofthis system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we Cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone 6. DSD SIGNATURE System #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved Phone (907) 272-8218 Date 9/17/2016 Conditional approval for bedrooms, with the following stipulations: �� WASTEWATER oz- BY �� Original Certificate Date: Z O 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 blue sheet . , If more than 1 septic system is on the lot: COSA Checklist #. I of Structure served by this system I Certificate of On -Site Systems Approval Checklist Legal Description: Raymond Tedrow, Block 1,, Lot 5A Parcel ID: 050-155-53- A. WELL DATA Well type Public If A, 8, or C provide PWSID # AWWU Well Log (YIN) Date completed Sanitary seal (YIN) _ Wires erly protected (YIN) Total depth ft. Cased to ft. asing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test. Static water level ft. Well production / g.p.m. WATER SAMPLE RESULTS: Coliform cp nies/100 mL Nitrate mg/L Arsenic ug/L Date of sample: Collected by: ft. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 5/15/2001 Tank size 1,000 gal. Number of Compartments 2 Cleanouts (YIN) Y Foundation cleanout (YIN) Y Depression over tank (YIN) N High water alarm (YIN) N Date of pumping �l 11 Z ��� 1(9 Pumper_Z_/ZS PC, K C. ABSORPTION FIELD 'DATX Date installed 5/15/2001 Soil rating (g.p.d./ftz or ftZ/bdrm) 1.2 GPD/SF System type Shallow Trench Length 29 ft. Width 5 ft. Gravel below pipe 3`0 ft. Total depth 8.9 ft. Eff. absorption area 250 ftz Monitoring tube Y Depression over field N Date of adequacy test 9/8/2016 Results (Pass/Fail) Pass For 2 bedrooms Fluid depth in absorption field before test 0 in. . Water added 305 gal. New depth 0 in. Elapsed Time: 60 min. Final fluid depth 0 in. Absorption rate >= 300+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) No If yes, give date 1\ D. LIFT STATION Date installed "Pump on" level at Datum 'Size in gallons _ in. "Pump off' level at Cycles tested in Manhole/Access(Y/N)' High water alarm level at in. Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot On adjacent lots Absorption field on lot On adjacent lots Public sewer main Public sewer manhole/cleanout Sewer /septic service line Holding tank i Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Absorption field 5+ Water main 10+ Water service line 10+ Surface water 100+ Wells on adjacent lots 200+ 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 50+ Wells on adjacent lots 200+ F. COMMENTS Survey on File /i� 5 J / LL� / b F� d, �' (✓ �fs,... -OwT 2't'c,�iPwn. .l1,Oc:..St � '7-LJ.-�.L �-SC..rP21. c d i /`C� ior5, G. ENGINEER'S CERTIFICATION l certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Steven Pannone Date 9/17/201'6 COSA canary sheet_2-6-15.doc 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 Pannone Engineering Services LLC Address P.O. Box 100217, Anchorage Alk. 99510 Engineer's Printed Name Steven R Pannone 6. DSD SIGNATURE _1/ System #1 Approved for ,�Zbedrooms System #2 Approved for bedrooms Disapproved Phone (907) 272-8218 Date 1/2/2014 Conditional approval for bedrooms, with the following stipulations: By: /� t/l/7 . c� I// �p--L�- � Original Certificate Date: The 4t nici lit of chorage 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 bale sheet f '., c If more than 1 septic system is on the lot: COSA Checklist # + of Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: Raymond Tedrow, BLock 1, Lot 5A A. WELL DATA Well type Public Date completed _ Total depth ft. Date of test Static water level Well production Parcel ID: 050-155-53 If A, B, or C provide PWSID # AWWU Well Log (YIN) Sanitary seal (YIN) _ Wires properly protected (YIN) Cased to ft. Casing height (above ground) in. FROM WELL LOG AT INSPECTION ft. ft. g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Arsenic ug/L Date of sample: B. SEPTIC/HOLDING TANK DATA Collected by: Tank Type/Material Septic/Steel Date installed 5/15/01 Tank size 1,000 gal. Number of Compartments 2 Cleanouts (YIN) Y Foundation cleanout (YIN) Y Depression over tank (YIN) N High water alarm (YIN) N Date of pumping I Pumper I I< S L ( 0" _ 1i Y C. ABSORPTION FIELD DATA Date installed 5/15/01 Length 29 ft. Total depth 8.6 ft. Date of adequacy test Soil rating (g.p.d./f:2 or ftz/bdrm) Width 5 1.2 GPD/BR ft. Eff. absorption area 250 fe Monitoring tube 1 /2/2014 P System type Shallow Trench Gravel below pipe 3 ft. Y Depression over field N Results (Pass/Fail) aSS For 2 bedrooms Fluid depth in absorption field before test 0 in. Water added 500 gal. New depth 5 in. Elapsed Time: 30 min. Final fluid depth 0 in. Absorption rate >= 300+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) No If yes, give date D. LIFT STATION Date installed Size in gallons "Pump on" level at in. "Pump off' level at in. Datum Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot _ Public sewer main Sewer /septic service line Animal containment areas SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (Y/N) _ High water alarm level at Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank Manure/animal excrete storage areas Building foundation 5+ Property line 5+ Water main 10+ Water service line 10+ Wells on adjacent lots 150+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water Service line 10+ Surface water 100+ Curtain drain 50+ Wells on adjacent lots 150+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 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. Engineer's Printed Name Steven R. Pannone Date 1/2/2014 COSA brown sheet 10-10-12.doc Absorption field 5+ Surface water 100+ Water main 10+ Driveway, parking/vehicle storage 110+ in. LOT 4 10.0' 7.0'- 0 0 8.4' Wood Fence 7.0' M 0 n LOT 5—B2 f®I I SCALE 1 " = 20' 0' 10' 20' 40' LOT 5—B1 39°59'00"E 149.98' Wood Frame Fence • �Diverter • • CO (TYp- 9) • E;�4' x 4' CMU RAYMOND TEDROW SUBDIVISION (82-322) • i rs j O 2—Level Wood OF ���� 1'4 Frame c 16.1' Residence On Concrete Block Foundation 19 Deck Below) Cantilever LOT 5—A BLOCK 1 1—Level Wood Frame Shop Wood Fence N89°59'07 Wood Frame Found 3 1/4" Aluminum Cap (.7' Below Grade) - MONTE ROAD -- LOT 1 LOT 4 W 0 r7 PREPARED FOR: PANNONE ENCINEERI AS—BUILT awN. DATE GRID JSP 1/16/2014 NW 015: FILE N0. F.B. 2014 JOB N0. 1401 PG. 1402 KARABELNIKOFF SURVEYING (909) 337 W 0 s w N 1n w W I hereby certify that an accurate survey of the following described property: OF ���� 1'4 RAYMOND TEDROW SUBDIVISION 83-322) ( ..... .. 00 •' LOT 5A P• •, p® BLOCK 1 49TH : a! was made on January 6, 2014 and that the improvements d situated thereon are within the property lines and do not overlap or r'l encroach on the property lying adjacent thereto, that no '. LeeKarnbelnikaff. y1 improvements on the property lying adjacent thereto encroach on No. 3143-5 the premises in question and that there are no roadways, transmission lines or other visible easements on said property except shown on the as indicated entshdraw those recordplatmaynot appearonthisdrawing. Anchorage Alaska, this 8th day of January 2014. LOT 1 LOT 4 W 0 r7 PREPARED FOR: PANNONE ENCINEERI AS—BUILT awN. DATE GRID JSP 1/16/2014 NW 015: FILE N0. F.B. 2014 JOB N0. 1401 PG. 1402 KARABELNIKOFF SURVEYING (909) 337 W 0 s w N 1n w W Municipality of :Anchorage • Development Services bepartment 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 ALITHOM APPROVAL FOR &SINGLE FAMILY DWELLING":'_` Parcel t D D✓r4 •%5� — S3 �• , r, �., j HAA 1 ` � Iq . D O.,2 3 ' Expiration Date: = 2 D 2 1. -..GENERAL INFORMATION [jt.c c -k Complete,legal description Goy; �fy ay6 ZZIP t Location (site address or directions) Current Property owners) �.Mailin9address Lending agency Mailing address Real Estate Agent Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3.. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class Well ❑ Public Water System $� S/D Day phone :Z*i- 1%jge Day phone'_ Day phone TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health 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. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is 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. l 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 6 / �� ���� Name of Firm 17034 Eagle River Loop Road No. 204 Phone Eagle River, A vZ a 99577 Address Engineer's Pr'• ' a N �8��2-T� l drNA-r'/ _ Date S Z3 O l 5. DSD SIGNATURE Approved for bedrooms. Disapproved. Z RCEERT C. COWAN Cc -8801 Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other It/ -A� OBy: fi: (Rev. 1200( Municipality of Anchorage ' Development Services Department Building Safety Division On -Site Water 6 Wastewater Program 4700 South Bragaw Sl. P.O. Box 196050 Anchorage, AK 99519.6650 www.d.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST • (3,A � K 1 � Legal Description: LOT 5AfS -f P110Al0 � E' TZ 0 VJ / Parcel ID: Oso - 1-55- - 5-3 A. WELL DATA ee,,wL /A-vV JQ Well type _ If A, B, or C provide PWSID # _ Date completed _ Total depth ft. Sanitary seal (YM) — Cased to ft. Well Log (Y/N) properly protected (Y/N) Casing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test Static water level Well production g.p.m. g,p-m- WATER SAMPLEZU1.TS: Coliform colontes/100 mi. Nitrate mg./l. Other bacteria colonies/100 ml. D of sample: ICollected by: B. SEPTICIHOLDINo TANK DATA GN &-%-J TankType/Material Tank size 1QM gal. Number of Compartments Foundation cieanout (Y/N)* Depression over tank (YMNCi) iNar 06 Date of pumping /V E- wV Pumper Date Installed �J J 0 / Cleanouts(Y/N) T E J High water alarm (YM) / C. ABSORPTION FIELD DATA Date installed ✓�" D f Soil ratingp.d r ft=/bdrm) ri System typer��H Length 2g ft. wlda, S ft. /GJ_�vel below pipe Total depth ft. Eff. absorption area MW Monitoring tube 2 Depression over field i' Q Date of adequacy testes Res (Pass/Fail) IqI5 For 3 bedrooms Fluid depth in absorption field before tes _ In. Water added_ gal. New depth_ in. Elapsed Time: _ min. fluid depth _ in. Absorption rate >= g.p.d. Any rejuvenation healme past 12 mo.) (YM 8 type) If yes, give date D. LIFT STATION Date installed in gallons Manhole/Access (Y/N) r `Pump on" level at n. 'Pump otP level at _ in. High water alarm level at in. Datum Cycles tested Meets alarm & droutt requirements? E. SEPARATION DISTANCES h/ a SEPARATION DISTANCES FROM WELL OiN,11.0T TO: NIA Septic tankAlft station on lot Absorption field on lot Public sewer main Sewer /septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC&XMXlW 3 TANK ON LOT TO: Building foundation rJ f- Property line S4- Absorption field S Water main _� �% 7Water service line ► Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: '/ O /O + Property line %� f Building foundation Water main r �t Water Service line /O •i- Surface water ZDD f Driveway. Parkinglvehide storage / O Curtain drain &&./it/!!t/N Wells on adjacent lots IAO t F. COMMENTS G. ENGINEER'S CERTIFICATION r Gj�'r "• ¢'!�1 7ti7y I candy that I have determined through field Inspections and ; review of Municipal records that the above systems are in ji• - conformance with MOA HAA guidelines in effect on this date. . . .....•.., `�� y� / Engineer's Printed Name Rail Bi l o W*ll '� &FAMP. �f� O� %,4 CE caNAN... - 8801Date lit 1 . :�• HAA Fee $ 3 O O -r Waiver Fee $ Date of Payment S'�f Date of Payment Receipt Number a o t IF i Receipt Number (Rev. 12/00) r MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES O DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL CU tfJ OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date Sep.temben 11, 1987 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 5A; 8.2och 1; Raymond Tedrow Subdivision Location (address or directions) 17337 Monte (b) Property Owner MGIC NA -70292586 Telephone: Home Business Mailing Address SeUen,/Bosch - Buyer/Hughes (c) Lending Institution Key Pati. is Mortgage Telephone Mailing Address Anchorage, Ataska (d) Real Estate Company and Agent RE/MAX OF EAGLE RIVER - Joyce Porte Address 16600 Centeit4ietd A i.ve, Suite 201, Eag.2e Raven, Akaska 99577 Telephone 694-4200 (e) Mail the HAA to the followino address: or: Check here In, if hold for pick up. List contact person and day phone number below. S & S ENGINEERING/694-2979 17034 Eagte Raver LooI2Road, Suite 204 Eagte River, A2aAa 99577 ordered by Joyce Porte 2. TYPE OF RESIDENCE Single-Familya Number of Bedrooms 3. WATER SUPPLY 3 Individual Well D Community ❑ Public W Connected to Pub.Pi.c WateK at .thi4 time. 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 XX Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (Rev 8/86) Front 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation dates h own 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 g 9 ENUMMM6 Telephone 6 ��' z-,;;�7% Address 17034 Fanle River Loop Road No. 204 Date Eagle River, Alaska 99577 ,)k A. Short Nu 14'. 14374 :r64 6. DHHS APPROVAL Approved for fhrr� bedrooms by `� �7"" °" Date Approved L� Disapproved Terms of Conditional Approval Conditional CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (Rev 8/861 Back A. WELL DATA Well Classification MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Descri tion: �,ffe'r If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Date Completed Total Depth Static Water Level Cased to Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Depth of Grouting — Pump Set At Yield Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Separation Distances from Well: i To Septic/Holding Tank on Lot �� `�— ; On Adjoining Lots I To Nearest Edge of Absorption Field on Lot On Adjoining Lots To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments B. SEPTIC/HQLDTNG TANK DATA To Nearest Public Sewer To Nearest Sewer Service Line on Lot Date Date Installed a ) Size �� No. of Compartments Standpipes D\1) Air -tight CapsON) Foundation Cleanout (Y/P Depression over Tank (YeW Date Last Pumped `✓ e'� Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) N/ Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/PeWiftg Tank: To Water -Supply Well To Property Line To Water Main/Service Line o To Building Foundation To Disposal Field — To Stream, Pond, Lake, or Major Drainage Course x Comments TSS � ��iZoe� V `� P t rr'Y.st Page 1 of 2 72-026111/841 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata �V'+O:t/_12 iType of System Design Date Installed s,�y�� I Length of Field S Z r _ r r Width of Field Depth of Field Gravel Bed Thickness r Square Feet of Absorption Area q Standpipes Present <DN) Depression over Field (Y/(K�1 Date of Last Adequacy Test Results of Last Adequacy Test `5 � -:>— �> -F-yl, Separation Distance from Absorption Field: To Water -Supply Well Zoa L4 - r To Building Foundation Lot /f' To Water Main/Service Line I t. To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Install Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments To Property Line �FD i To Existing or Abandoned System on On Adjoining Lots 71>o I -f" ToCutbank (if present) ;3 I__), Dimensions Manhole/Access (Y/N) "Pump Off" Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent(Y/N) Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signgrk g ENGINEERING Date 4 Eagle River Loop Road No. 204 Com Nrver, MOA No. W 2 Receipt No. �� D — OG Date of Payment /O ��/ `% �• Amount: $ 1 CIO a3ni3D38 Page 2 of 2 Z9616 r 100 72-026 (11/84) NOISIAIO S3DlAa3S 1V1N9VVN0dIAN3 30V"4f NV 30 .1111VdIJINnw 'rime Time Date Date Inspector Inspector Inspector Comments Conditional Approval Date Sewer Installed Permit No. Septic Tank Size · S"--~¢ ( Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Welt to Tank APPLICANT FILLS OUT LOWER HALF ONLY iPhone Buyer Address Lending Institution Address Realty Co. & Agent Address Legal Description Street Location Phone Phone Type,of"Resldence ~-[] Single Family [] Multiple Family [] Other No. of Bedrooms Wate[/9~pply El Individual © Community [] Public Utility Sewag,ed3isposal El Individual © Public Utility Z] Holdin~l. Tank ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available.) \CU3\ Year Individual Installed: When Connected to Public Utility:_ NOTE: THE INSPECTION FEE Mus'r ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. b. ,~ RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE -DATE DATE MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE D~PARTMENTOFH~ALTH~ENVIRONM~NTALPROTECTION DEPT. OF IdEAl_TH 82B L Street - Anchorage, Alaska 99501 J~NVIRONMENTAL (~) ENVIRONMENTAL SANITATION DlVlSlONTelephone 264-4720 AU(~ DIRECTIONS: Complete all parts on page 1. Incomplete reqnests will not be processed, Please allow ten (10) days for processing. 1, PROPERT~NER / PFIONE P~OPE~TY ~E8IDENT (If different from abova) PHONE 2, BUYE~ PHONE MAILING ADD~ESS 4. REALTOR/AGENT '--' ~ PHONE MAILING ADDRESS 5, LEGAL DESCRIPTION STREET LOCATION ,~ING LE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] One E~ Four ~J~, Two E~] Five [] Three [] Six [] Other 7. WATER S~PPLY '"~. ~NDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available.) 8. SEWAGE DISPOSAL SYSTEM ~:~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY /pg-/ YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, 72-O10 (Rev. 6/79)~f~//'/:~ THIS SIDE FOR OFFICIAL USE ONLY 1, TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2, WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM []INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tankor [] Holding Tank Size:_l e~ ('~ '~ If Tank is homemacle give dimensions: NUMBER OF BEDROOMS [] ONE [] THREE [] FIVE [] TWO [~] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOGRECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING TYPE OF TANK MANUFACTURER .~, ./..~ 4. DISTANCES WELL TO: OTHER Septic/Holding Tank Absorption /~rea Sewer INearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS DATE ~ APPROVED FOR J BEDROOMS [] CONDITIONAL APPROVAL (Petter must accompany certificate) [] DISAPPROVED