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HomeMy WebLinkAboutLAKEWOOD HILLS #4 BLK 1 LT 5Lakewood Hills #4 Block 1 Lot 5 #015-134-27 GARB HD.I G' TER ANCHORAGE AREA BORO 'i UtrHRTMENT OF ENVIRONMENTAL QUALI I , 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING �7 NAME �yL�-1±�lefJ`�\3 ADDRESS %-OX_-l:3isJl'SL/'d"PHON 9'cS'Lyf? 9 ES LOCATION �t;21(�_ =�Q= �"' Errl-ninTl SEPTIC TANK: O �iuTrt NUMBER OF DISTANCE FROM WELL �)_ _MATERIAL��G/1'F,T �sjOl/+/cafi� COMPARTMENTS LIQUID LIQUID CAPACITY_/0jriV ___GALLONS. INSIDE LENGTH `— _INSIDE WIDTH DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS --OUTSIDE DIAMETER OR WIDTH /_-�3-_ , LENGTH , DEPTH LINING MATERIAL,,`qeoV&fljC& L11�G- -- . DISTANCE FROM WELL._t00'.1 �u_al403/2 j ,'BUILDING FOUNDATION_ #, i NEAREST LOT LINE - 0 l4OF$ I TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) SQ. FT. TILE DRAIN FIEI D• DISTANCE FROM W NUMBER OF LINES ABSORPTION AREA DEPTH: TOP OF TILE TO FINISH GRADE FOUNDATIO ISTANCENETWEEN LINES SQ. FT. L,�4GTH OF EACH L NEAREST LOT LIN TRENCH WI TOTAL LENGTH OF LINES IN. TOTAL EFFECTIVE MATERIAL BENEATH TILE_ IN. ABOVE TILE WELL:�pp DISTANCE FROM _ WATER _ TYPEJ_L'S_o , DEPTH BUILDING FOUNDATION.__ SAMPLE NEAREST > NEAREST — SEPTIC _ SEEPAGE OTHER LOT LINE /01?64wpEASEWER LINE. TANK,, 4 � flti&L?a(:Lt, SYSTEM1Qf7�s1L/ ,"CESSPOOL SOURCES_ DISTANCES: 1/ m DIAGRAM OF SYSTEM w ♦ r � w {� f30 �� toT DATE l!crg '�" /-%?/ 721 GAAB-HD-2 GREATE._ _kNCHORAGE AREA )ROUGH HEALTH DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 279.2511 SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT Case No. -' NAME OF APPLICANTL1' C zj Pe .ice MAILING ADDRESS PHONE NQ. RESIDENCE ADDRESS LEGAL DESCRIPTION LOCATION OF INSTALLATION CJ4� — 11E'd APPLICATION TO INSTALL: SEPTIC TANK__SEEPAGE PIT -, DRAIN FIELD , OTHER TO SERVE THE FOLLOWING FACILITY ����y���a FINANCED THROUGH TO BE INSTALLED BY_Z/Ly_( �Iy a tc,`rlq PERCOLATION TEST RESULTS 2'S ANTICIPATED DATE OF COMPLETION0_CdK, BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT THIS IS TO SERVE AS ,�%� 16Li Z,'C PERMIT TO INSTALL A er P.4 AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED `P2 /a�P.Zla� 7�& C/,'o-a�.� , SEPTIC TANK SIZE /llbo TYPE 6,1011-6'62 SEEPAGE AREA TYPE 92401-ezt, DIAGRAM OF SYSTEM P'gTANCES: '' HEALTH AUTHORITY OR LICENSED DESIGNER I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the above described system is in accordance with said code. DATE 6L A z ` /M APPLICANTS SIGNATURE Locktt GREATER ANCHORAGE AREA DOROUM HEALTH DEPARTMENT CASE N 377 EAGLE STREET ANCHORAGES ALASKA 99501 Performed For C c k)Q,%A 't I Date Performed -%z ti Legal Descripon: Loth Bloc d v,szon 1+ire wc� Sa,v t'w 4 This Fcrm Reports a: Soils Log x •'rerco lation Test Depth Feet 7 8 q (O Was Ground Water Encountered?-- �; If Yes, At What Depth Soil Characteristics �� � Sc,r�C.cA O'r'��cv»�Cs—Mu:s.c'4r.• � �� ' �� �i ' G• �C\,�,V C\ V'a.V � 1 Vel, K ij- rhe O� �--0� �ot��Es �clricn� 1Yai� 0 T)p Location Sketrh Reading , Date (Gross Time Net Time pepth Te �i2p N©t Drop Proposed Installat'� o i'seepage Pit Depth of Inlet m -,...Drain Field Test Performed By, Data Certified by:�� Date: �. ®9 �i Reading , Date (Gross Time Net Time pepth Te �i2p N©t Drop Proposed Installat'� o i'seepage Pit Depth of Inlet m -,...Drain Field Test Performed By, Data Certified by:�� Date: �. ®9 • '� Municipality of Anchorage n On -Site Water and Wastewater Program (907) 343-7904 ~ S CTI CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 015-134-27 Expiration Date: d5 & 1. GENERAL INFORMATION Complete legal description LAKEWOOD HILLS #4 BLOCK 1, LOT 5 Location (site address) 10641 ELIES DRIVE ANCHORAGE, AK 99507 Current Property owner(s) DON & DEBORAH MORRISON Day phone Mailing address Real Estate Agent 2. TYPE OF DWELLING: 10641 ELIES DRIVE, ANCHORAGE, AK 99507 ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class _ Well ❑ Public Water System ❑ Day phone ti�ov �� � apt4 TYPE OF WASTEWATER DISPOSAL: Individual Holding Tank ❑ Community ❑ Public Sewer ❑ WaiverNadance request for: Distance: Received by: �,t%�r,Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 62_� ` Date of Payment Receipt Number COSA# CrDC-114 I-�-M(e Waiver Fee $ Date of Payment Receipt Number 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 ARCTERRA CONSULTING, INC. Phone 868-3791 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 11/10/14 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future ���\ occupants or can ArcTerra guarantee that no unseen OF Al- \ encroachments, deficiencies or discrepancies exist. / �v *14�T[{ 6. DSD SIGNATURE (I— c ' 'A KENNE .. U 'LIS System #1 Approved for-3bedrooms. 7116 . �. 100 System #2 Approved for bedrooms. �'JI/I �Ror'isstoh^X, i Disapproved. Conditional approval for bedrooms, with the following stipu�at1?ns: � tY OFAA%:rri,_ AND Original Certificate Date: i 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. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheer_10.10.12.dm If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system _ Certificate of On -Site Systems Approval Checklist Legal Description: LAKEWOOD HILLS #4 BLOCK 1, LOT 5 Parcel ID: 015.134-27 A. WELL DATA' Well type PRVT If A, B, or C provide PWSID # Date completed PRE'73 Sanitary seal (Y/N) Y Total depth 138 ft. Cased to 135 ft. FROM WELL LOG Date of test Static water level Well production ft. 9.p -m. WATER SAMPLE RESULTS: Coliform NEG colonies/100 mL Nitrate lo. 3q mg/L Arsenic: NA ug/L Date of sample: 111512014 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC 1 CONCRETE Tank size 1000 gal. Number of Compartments 2 Foundation cleanout (Y/N) Y Depression over tank (Y/N) N Date of pumping 1115114 Pumper ONE STOP C. ABSORPTION FIELD DATA Well Log (Y/N) Wires properly protected (Y/N) Y Casing height (above ground) 12+ in. AT INSPECTION ft. Collected by: ARCTERRA Date installed *1012211971 Cleanouts (Y/N) Y High water alarm (Y/N) N Date installed 1012211971 Soil rating (g.p.d./ft2 or fe/bdrm) 95 System type CRIB Length 13 ft. Width 13 ft. Gravel below pipe 6 ft. Total depth 10.9 ft. (Measured 11/5/14) Eff. absorption area 312 ft2 Monitoring tube Y Depression over field N Date of adequacy test 111512014 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 17 in. Water added 510 gal. New depth 47 in. Elapsed Time: 1305 min. Final fluid depth 20 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at _ in. Datum Size in gallons "Pump off"level at _ in. Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 501+ Absorption field on lot 100'+ Public sewer main 75'+ Sewer /septic service line 251+ Animal containment areas 501+ SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots 1001+ On adjacent lots 1001+ Public sewer manhole/cleanout 1001+ Holding tank 1001+ Manure/animal excrete storage areas 1001+ Building foundation 5'+ Property line 51+ Absorption field 51+ Water main 10'+ Water service line 101+ Surface water 100'+ Wells on adjacent lots 1001+ ABSORPTION FIELD ON LOT TO: Property line 101+ Building foundation 104 Water main 101+ Water Service line 101+ Surface water. 1004 Driveway, parking/vehicle storage 104 Curtain drain 50'+ (NONE KNOWN) Wells on adjacent lots 1001+ F. COMMENTS *WELL DATA PER MOA DOCS 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. i OF Z Engineer's Printed Name KENNETH M. DUFFUS , Date 11/10/14 *f¢.q TH COSA brown sheet_10.10-12.doc F� 'P I(ENN 7116 / El','SSIO�+�' .� in. Municipality of Anchorage 04 Community Development Department _a < r Development Services Division s A E r r On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # OSC141596 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 1, Lot 5 of Lakewood Hills #4 subdivision. This inspection revealed a nitrate concentration of 6.39 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. mrooaa rsosn naOl Rlaa N.allo seISAaI soE ..nra g,.,tA sErA ..oNa serol / 30 r s ry Qqa�, 3JG,3g'3z, e o / cosr .. VEW Cy Q E%VING HOUSE p I 6 v NryeDz I O a WELL J JT.y I e s Iw .- I> W y g34Jg. 4 I rn O 0 N SYr9 T � UNDER NO CIRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES. THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL UABILITY ONLY FOR THE COST OF THE SURVEY. LISTED DISTANCES PREVAIL OVER SCAUNG. REPRODUCTION MAY CAUSE ERRORS IN SCALE. El LOT SURVEY SURVEY TYPE SYMBOLS ❑ FOUNDATIDN AS -BUILT F� • SET REBAR DRAINAGE R...,.....J ASPHALT ❑ FINAL STRUCTURE AS -MALT TOr LOT $IIRIEPOGRAM ❑ FL... Y 6-9 a MOOD FENCE CONCRETE .... a-... O FOUND REBARI PIAT ... ... OO a ASSUMED ELEV. -X--K--X- METAL FENCE ® WOOD DECK Ae- TT ... O OMIIERS T El RECERTIFICABON AS- T ... NO C010IMS SET PLOT PLANS & LOT SURVEYS NOTE: IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE SHOWN.. FENCES, WELLS, SEPTIC CLEANOUTS. SIDEWALKS, DRIVEWAYS. TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE ETC.. ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED. SURVEY CERTIFICATION r,.rrp♦♦ OF ♦ Prepared by Robert E. Johns, Jr. & Assoc. LOT PLAN Ikriy Land Surveyors Dray vn le+•. oarlesr r•.n+r I= +O1•' •'r = I'r+'"' ^'° +,a I �P�"""'•""•••.,, Professional Mw Wq r ••IeCW W. a M M m,w• N,•.• ., M pr, +,r a u. •n 0.01. •♦♦1 • 1100 Brink Drive. ANCHORAGE, ALASKA 99504 I:•..wrr .r aewN. a ^•'�•° e'^'•0 n. .snYrn Ar 49th ••T ,/ Scale: a — I 1 60 Rea Lot S.F. Ree. Plat File No. FOUNDATION AS -BUILT...... E Keen a +Nn. +_ erar •rur e,a ,•, • •�•� - /, / — Date Surveyed 'ed` prawn b " Checked b -•.... .�.....Ya«. , + 11/04/14 REJ IMK rrrire., ea M N M a q.••:•••••� sn.,r.r mI w+nn.en ++,.., er.rr7' .e..aonnn rN nw. ,e /'• s ROGER . JOH R. W, P ,. :: o / Data Drawn:Grid: 11/05/14 2540 W.0 14-531 STRUCTURE AS -BUILT 4� 2� _S ��FINAL �v♦�f♦e''ey••,p� �.o•� ateL 9al Deet lo: Le.s»men.ia.rwAArn.., ar..- eewrree+y .awNNra uwe! I ra Lot 5 Block 1•••....... ao• ♦��iofe„sk,��:��� LAKEWOOD HILLS #4 111 �r,5 $L • "� Municipality of Anchorage $R 4 On -Site Water and Wastewater Program a ` .n ; •`� (907) 343-7904 A E„ Certificate of On -Site Systems Approval Parcel I.D. 015-134-27 1. GENERAL INFORMATION %��i �Ssl✓ °� Expiration Date: 3 ~ �Z %- /3 Complete legal description Lakewood Hills #4 Blk1 Lt5 Location (site address) 10641 Elies Dr., Anchorage Ak. 99507 Current Property owner(s) Steve&Shelia Markley Day phone Mailing address 10641 Elies Dr., Anchorage Ak. 99507 Real Estate Agent 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well El Individual Fx� Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request Received by: !/ // - Date: f) - 9 1 Z COSA to be releasedfo fhe,engineer, unless otherwise1quested by the engineer. COSA Fee Date of Payment Receipt Number COSA # O S S I D_! 3 Waiver Fee $ Date of Payment Receipt Number 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 Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone Date /Z1 k2 Z 1 6. DSD SIGNATURE System #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, with the following stipulations: By: Original Certificate Date:/ g� _ 2— The Municipa ty 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. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet f - G c If more than 1 septic system is on the lot: COSA Checklist # _of _ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Lakewood Hills #4 Blk1 Lt5 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed Pre 73' Sanitary seal (Y/N) Y Total depth 138 ft. Cased to 135 ft FROM WELL LOG Date of test - unknown Static water level ft. Well production 9 - p.m -WATER SAMPLE RESULTS: Coliform Neg colonies/100 mL Nitrate 7.19 mg/L Arsenic ND ug/L Date of sample: 12/12/12 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Concrete Tank size 1000 gal. Number of Compartments 2 Foundation cleanout (Y/N) Y Date of pumping 5/30/12 C. ABSORPTION FIELD DATA Parcel ID: 015-134-27 Well Log (YIN) N Wires properly protected (Y/N) Y Casing height (above ground) 18 in. AT INSPECTION 5131/12 105 ft 5.7 g.p.m. Collected by: PES Date installed 10/22/71 Cleanouts (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) NA _ Pumper Northland Pumping Date installed 10/22/71 Soil rating (g.p.d./ft2 orftz/bdrm) 95 sf/bd System type Crib Length 13 ft. Width 13 ft. Gravel below pipe 6 ft. Total depth 12.6 ft. Eff. absorption area 312 fe Monitoring tube Y Depression over field N Date of adequacy test 5/31 /12 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 458 gal. New depth 32 in. Elapsed Time: 1440 min. Final Fluid depth 0 in. Absorption rate , 450+ g p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at in. High water alarm level at Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tanknift station on lot 50+ Absorption field on lot 100+ Public sewer main 75+ Sewer /septic service line 25+ Animal containment areas 100+ On adjacent lots 100+ On adjacent lots 100+ Public sewer manhole/cleanout 100+ Holding tank 100+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Water main 10+ Water service line 10+ Wells on adjacent lots 100+ 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 100+ 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 COSA guidelines in effect on this date. Engineer's Printed Name Steven R Pannone Date 12f Z6R COSA brown sheet 10-10-12.doc Absorption field 5+ Surface water 100+ Water main 10+ Driveway, parking/vehicle storage 10+ in. Municipality of Anchorage Community Development Department Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 121220 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 1, Lot 5 of Lakewood Hills 94 subdivision. This inspection revealed a nitrate concentration of 7.19 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. • Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 015-134-27 1. GENERAL INFORMATION Expiration Date: Complete legal description Lakewood HMIs #4 BIk1 Lt5 Location (site address) 10641 Elies Drive, Anchorage Ak. 99507 Current Property owner(s) Steve & Shelia Markley Day phone Mailing address 10641 Elies Dr., Anchorage Ak. 99507 Real Estate Agent Day phone 2. TYPE OF DWELLING: F Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual 7 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Date of Payment Receipt Number COSA# O -';C I Z / D ;- (0 Date: Waiver Fee $ _ Date of Payment Receipt Number, 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 Certif icate of On -Site System s 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 Phone 272-8218 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. Date 12-0 VfWJ Conditional approval for bedrooms, with the following stipulations: By: i Original Certificate Date: 9 _.2 q" 12 Theunicipalit of orage Development Sew ices 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 blue sheet 9-0-02.doc If more than 1 septic system is on the lot: COSA Checklist # _of _ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Lakewood Hills #4 Blk1 Lt5 A. WELL DATA Well type Povat Date completed Pre'S Total depth 136 ft Date of test Static water level Well production If A, B, or C provide PWSID # Sanitary seal (Y/N) Y Cased to 40 ft. FROM WELL LOG Unknown Parcel ID: 015-134-27 Well Log (Y/N) N Wires properly protected (YIN) Y Casing height (above ground) 18 in. AT INSPECTION 5/31/12 ft. 105 ft. g.p:m. 5.7 g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Other bacteria colonies/100 mL Arsenic: VN ug/L date of sample: is Collected by: PES B. SEPTIC/HOLDING TANK DATA Tank Type/Material Concrete Date installed 10/22/71 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Date of pumping 5/30/12 C. ABSORPTION FIELD DATA Depression over tank (Y/N) N High water alarm (Y/N) N/A Pumper Northland Pumping Date installed 10/22/71 Soil rating (g.p.d./ft2 or ftz/bdrm) 95 gpd/sf System type Crib Length 13 ft. Width 13 ft. Gravel below pipe 6 ft. Total depth12'6 ft. Eff. absorption area 3122 fe Monitoring tube Y Depression over field N Date of adequacy test 5/31/12 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 458 gal. New depth32 in. Elapsed Time: 1440 min. Final fluid depth 0 in. Absorption rate >= '4'50+ g.p,d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at _ in. Datum E. SEPARATION DISTANCES WELL ON LOT TO: Size in gallons "Pump off' level at _ in. Cycles tested Septic tank/lift station on lot 100+ Absorption field on lot 100+ Public sewer main 75+ Sewer /septic service line 25+ Animal containment areas 100+ Manhole/Access (YIN) High water alarm level at Meets alarm & circuit requirements? On adjacent lots 100+ On adjacent lots 100+ Public sewer manhole/cleanout 100+ Holding tank 100+ Manure/animal excrete storage areas 100+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Water main 10+ Water service line 10+ Wells on adjacent lots 100+ 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 100+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that t 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 COSA brown sheet 9.1-12.doc Absorption field 5+ Surface water 100+ Water main 10+ Driveway, parkingtvehicle storage 110+ in. Municipality of Anchorage Community Development Department Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 121220 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 1, Lot 5 of Lakewood Hills #4 , . subdivision. This inspection revealed a nitrate concentration of 6.44 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. Municipality of Anchor • Development Services Depa' n Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 035-334-27 COSA # nSti'a L`k ';�,C Expiration Date: q 1. GENERAL INFORMATION Complete legal description Lakewood Hills #4 Blk 3 Lt s Location (site address) 3o643 Elies Drive Anchorage, Ak. 445o7 Current Property owner(s) Steve & Shelia Markley Day phone Mailing address Lending agency Mailing address Real Estate Agent _._Mailing Address____ 3o643 Elies Drive Anchorage Ak. ggS07 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: Day phone Day phone -- —_TYPE OF WATER SUPPLY: ---TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual -On-site - -- -- Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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. (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 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 Phone 272-8218 Address P.O. Box 1002-17, Anchorage, AK 99S10 Engineer's Printed Name Steven R. Pannone, P.E. Date 12-49 & (-2— Engineers "2__ Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & 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 .�0� 0- q� �Ot♦ � levels that may fluctuate during the year, and the water usage of the family being served by the system. ��,� ................•..; � 1� These conditions are outside the control of the evaluator of this system. All systems eventually fail and � �?,r•' `C9 # satisfactory test results do not guarantee future performance of the system, nor do they guarantee that i ' �pj there are no hidden defects or encroachments. PES can therefore not provide any warranty for future �•••••^• ••• ••• ••••h•••••00 perfonmaoce nor give any estimate of how long the system will continue to meet the operational ��tyyy requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed � :Steven R. Pannoneri above. Any reliance upon or use of this report by any other person or party is not authorized nor will it �1s� No. CE 87 49 _i confer any legal right whatsoever. 5. DSD SIGNATURE �O�,O.�sio :•��� Approved for __ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: �_� Original Certificate (Rev. 11 y� Municipality of Anchorage o • '� Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lakewood Hills #4 Blk 1. Lt 5 Parcel ID: 015-134-27 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed WE -71 Sanitary seal (Y/N)v_ Total depth 236 ft. Cased to —(o ft. FROM WELL LOG Date of test t9MI<n9® W N Static water level ft. Well production g.p.m. WATER SAMPLE RESULTS: Coliform _colonies/100 mL Nitrate 6. 43 mg/L Well Log (Y/N)* KA 0 Wires properly protected (YIN) Y Casing height (above ground) 18 in. AT INSPECTION 5/31/2012 ft. 5.7 g.p.m. Arsenic: 0"'N ug/I Date of sample: 5531 - la Collected by: YES B. SEPTIC/HOLDING TANK DATA Tank Type/Material concrete Date installed 10/22/1971 Tank size i000 gal. Number of Compartments 2 Cleanouts (Y/N) Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (YIN) N Date of pumping 17 Pumper N&Q-'ZAZ-A Z' Mit NGr. C. ABSORPTION FIELD DATA Date installed zo/22/1973. Soil rating (g.p.d./fe or ft2/bdrm) 95— System type Crib Length 13 ft. Width 13 ft. Gravel below pipe 6 ft. Total depth 22.6 ft. Eff. absorption area 3i2 ft' Monitoring tube Y Depression over field N Date of adequacy test 5/31ho12 Results (Pass/Fail) Pass For 3 bedrooms Fluid depth in absorption field before test o in. Water addedr58 gal. New depttt�in. Elapsed Time: 144o min. Final fluid depth o in. Absorption rate >= 4co+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) n If yes, give date D. LIFT STATION Date insta e "Pump on" level at Datum Size in gallons in. "Pump off Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot co+ Absorption field on lot zoo+ Public sewer main ioo+ Sewer /septic service line zc+ Animal containment areas ioo+ Manhole/Access (Y/N) water alarm level at Meets alarm & On adjacent lots ioo+ On adjacent lots zoo+ Public sewer manhole/cleanout aoo+ Holding tank ioo+ Manure/animal excrete storage areas zoo+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line r+ Absorption field 5+ Water main zo+ Water service line zo+ Surface water ioo+ Wells on adjacent lots ioo+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line io+ Building foundation io+ Water main io+ Water Service line io+ Surface water. ioo+ Driveway, parking/vehicle storage io+ Curtain drain 50+ Wells on adjacent lots zoo+ 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 ' 49TH conformance with MOA COSA guidelines in effect on this date. i .............. No8149 CE 8149 , Engineer's Printed Name Steven R. Pannone. P.E. �� Steven R. . Date /ZO& �� . COSA Fee $ `l qb— Waiver Fee $ _ Date of Payment Coll�llla Date of Payment Receipt Number GB �`tS� Receipt Number, (Rev. 11/05) 13 R9 Municipality of Anchorage ar°� Community Development Department Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 121220 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 1, Lot 5 of Lakewood Hills #4 subdivision. This inspection revealed a nitrate concentration of 6.93 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. Jun 121204:52p Markley 907-336-1143 p.1 z JZ co 00 ' W '+V0 nf* ,. W>QO) oz .V cy QW na _R 44 OiL R¢ ne 1 X LLI VEm`��° �xx LL QCmr U Q 907-336-1143 p.1 z 0 a I Qo m H w1 Z W � o W Q O F ! S 6 C m FC O , s o � 0 z \ s° a _ 0 An A Pannone Engineering Services LLC Steven R. Pannone, Principal Registered Professional Engineer E-mail: steveftanenzak.com June 22, 2012 Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program 4700 S. Bragaw Street P. 0. Box 196650 Anchorage, Alaska 99519 Subject: Lakewood Hills No. 4, Block 1, Lot 5 Well Camera report Ladies and Gentlemen: I am writing to report the finding of my investigations of this well. On June 21, 20121 inserted a camera into the well head and lowered it to a depth of fifty feet. The casing was solid with no perforations to depth. The pit -less adapter appeared to be in good shape and properly installed to prevent ground water from entering the casing. The well was disinfected after the work was performed. If you have any questions or concerns, please contact me at 272-8218. Sincerely, R Steven R. Pannone, P.E. Owner/Civil Engineer Attachments Mailing: P.O. Box 100217, Anchorage, AK 9951.0-0217 Physical_ 332 East. Manor, Anchorage, AIC 99501 Telephone: (907) 272-8218 FAX: (907) 272-3211 �nl Municipality of Anchorage Development Services Department —� Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ek.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING/ Parcel I.D. 015-134-27 HAA # >L%�� 00 YS Expiration Date: S- /SS- 0 -9- 1. 1. GENERAL INFORMATION Complete legal description rLot Location (site address or directions) 10641 Elies Drive, Anchorage, AK 99516 Current Property owner(s) Becky & Curtis Brock Day phone 346-3488 Mailing address 10641 Elies Drive, Anchorage, AK 99516 Lending agency Day phone Mailing address Real Estate Agent Patty Martin/Prudential Vista Day phone 273-7745 Mailing Address 4241 B St., Anchorage, AK 99503 Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to home owners. 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 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. 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 Health Authority Approval Guidelines for this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system Is In compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Finn Pannone Eng. Svc. Phone 272-8218 Address P.O. Box 102954, Anch, AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. Date Engineers Comments: In conducting an adequacy test, l attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & 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 arc outside the control of the evaluator of this system All systems eventually fail and satisfactory tat results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. PPS can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. Tbc content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized nor will it confer any legal right whatsoever. 6. DSD SIGNATURE Approved for _3 bedrooms. Disapproved. zl[oto2 Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory X Supplemental Engineer's Report Well Flow Advisory Other By:� j��/ j� / �c-� Original Certificate Date: .2 - / 5 - o ) Expiration Date: Reissue Date: 1R. 11W Municipality of Anchorage Development Services Department Building Safety Division On -She Water and Wastewater Program 4700 South Bragaw Street P.O. Box 190050 Anchorage, AK 99519-8850 www.cLanchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot 5 Block 1 Lakewood Hills 94 Parcel I.D.: 016-134-27 A. WELL DATA Well type P If A, B, or C provide PWSID # Dale completed f"t- I., r 'b VT seal Y Total depth 1313 It Cased to eft FROM WELL LOG Date of test Static water level Well Log hi Wires properly protected Y Casing height (above ground) 16 in. AT INSPECTION 1/27/2002 It 107 ft Well production g.p.m 4.2+ g.p.m WATER SAMPLE RESULTS: Coliform ___Cl_colonies/100 ml Nitrate _±.n 3 mgA Other bacteria � colonies/100 ml Date of sample: 218/2002 Collected by: Laura Pannone B. SEPTICIHOLDING TANK DATA Tank Type/Material Concrete Date installed 10122/1971 Tank size 1000 gal Number of Compartments Cieanouls Y Foundation cleanout Y Depression over tank N High water alarm 1_ Date of pumping 9/5/2001 Pumper Northland Pumoing C. ABSORPTION FIELD DATA Date installed 10/22/1971 Soil rating (g.p.d.W or WAxdnn) 95 System type Crib Length eft Width 13 ft Gravel below pipe 6 ft Total depth j" ft Effective absorption area 312 fl? Monitoring tube Y Depression over field h Date of adequacy test 1/2712002 Results (Pass/Faiq P Fort bedrooms Fluid depth in absorption field before test ¢7 in Water added450 gal New depth7l in. E.3 Elapsed Time: 11440 min Final fluid depthiWin Absorption rate >= 4W g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date (Rev. 11)98) D. LIFT STATION Date installed Size in gallons 'Pump on' levet at in'Pump otr level at Datum Cycles tested Manhole/Access in High water alarm level at _ in Meets alarm 8 circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: S' RF1svrtr.7D Septic tank/lift station on lot 63 On adjacent lots 100+ Absorption field on lot 113 Public sewer main 100+• On adjacent lots 100+ Public sewer manhole/deanout 100+ Sewer /septic service line 25+ Holding tank 100+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 32' Property line 10•+ Absorption field 72' Water main 25'+ Water service line 26'+ Surface water 1000+ Drainage 100+ Webs on adjacent lots 100+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 35 Building foundation 110 Water main 100+ Water Service line 100+ Surface water 100+ Driveway, Parking/vehicle storage 15+ Curtain drain 100+ Wells on adjacent lots 100+ F. COMMENTS 4>Yl. ZM G. ENGINEER'S CERTIFICATION 1 certify that I have determined through Held inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on ttus date. Engineer's Printed Name -_Steven R. Pannone PI: Date 21 tOLvL HAA Fee $ Date of Payment Receipt Number '16779 5� (Rev. 7IM) Waiver Fee $ Date of Payment Receipt Number `-FZ'= ���� TS 8o9c vsdo c7P. 1 s �1 49TH 0 }w.w.w .w•w.w.w•w .: M3:Steven R. Pannone•�`i !!\� No. CE 8749 rE2_i MUNICIPALITY OF ANCHORAGE M E M O R A N D U M SEPTIC SYSTEM ADVISORY HEALTH AUTHORITY APPROVAL NO. 0:�L D D 4-5- Prior 'S Prior to a recent adequacy test on the septic system for this lot, 67 inches of standing water was observed in the absorption field. This indicates that approximately 9% of the absorption area is inundated. Although this system passed the adequacy test, the remaining life expectancy may be limited. This advisory must be attached to all copies of the subject Health Authority Approval. .7 1V "A(U►1• r �Fy :......... ; . Sri. _. � . o � t • ASBU/L T " � I v. Nor/ W/C y 1 �Cf M•r 1 Al 1 t• Cy(/ohe. . w tp Fe nCC 1 UI 0 0 1-{-L-;-}-i-J 1 1 Ll •�-jI1�•It +0 Nr lc�t:"S sir. 77C. 3T I hereby artily that 1 how curve ed the following described properly, lot 7 pwck Addition LANF1•.'CCD N2 LS S.YLr��¢Anchr reeerding Precinct, Alaska. and that the Improvement situated thereon are within the properly lines and do nor overlap or encroach on the property lying adjacent thereto, that as Wisrovement an property lying edloceM'theseto encroach on be premises in question and that there ore no roadways, tronsmissloa lines or other visible easement on sold property except as Indicated hereon. Anchorage, Alaska '�ycY �`%7% .. • ' eecexroclf'oo .29 JA M. 2002 OF 0, . Want Wdonen , Ae 1 s •s No. 1308-S •CP % e f' ,, 5904SSt01i ht +. 0�S/ 3 5�')--7 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section township, range) ! 4 MEN'" Location (address, or directions) 166f,1/ 4uZ--5' Dk. (b) Property Owner YA ,` 6 ft Telephon Home Business Mailing Address (c) Lending Institution a&,<&1' lLL Telephone Mailing Address �/ (d) Real Estate Company and Agent / A AW7- Address Telephone Z - 76s3 (e) Mail the HAA to the following address: or: Check here ❑cif hold for pick up. List contact person and day, phone number below. TYPE OF RESIDENCE Single-Familyy)41 Number of Bedrooms IN 3. WATER SUPPLY Individual Wel Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite( 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 441 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 regulations in effect on the date of this inspection. Name of Firm'Gf Telephone Address / 33 ljpv� lWeW Date 6 Se 6. DHHS APPROVAL Approved for �� 3 bedrooms by Date a o Approved /I 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 rRev 8/86) Back MUNICIPALITY OF ANCHOr 1 ENVIRONMENTAL SERVICES Dlti.,IONNUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) JUN 16 1988 CHECKLIST- FEBRUARY 1984 264-4720 RECEIVED Legal Description: 7�5' /3coe/r/ e ah /ACLS OV T/z.w Wei ybe' / A. WELL DATA Well Classification /�/� � If A, B, C, D.E.C. Approved (Y/N) /' Well Log Present (Y(9 Date Completed FeC /97JT Yield Total Depth /3(o 1�4 FCased toDepth of Grouting .4) /04 Static Water Level 66 /0(0'!5r Pump Set At 'i i Casing Height Above Ground f Sanitary Seal on Casing(Y N) Electrical Wiring in ConduitON) Separation Distances from Well: / Depression Around Wellhead (ye To Septic/Holding Tank on Lot d On Adjoining Lots To Nearest Edge of Absorption Field on Lot 10 'f- ; On Adjoining Lots To Nearest Public Sewer Line % To Nearest Public Sewer Cleanout/Manhole %4 To Nearest Sewer Service Line on Lot n /L ¢ Water Sample Collected by 116" Water Sample Test Results Comments /?OJ 7Z`S7' 2. e,"&b `Td 5,71oM og 7a &bgoex- /- r SWL iNb/Cr}7vs i(o idce/+ii1b I%C5 /98ove- /06.5. ,,,Jo ,W6wv,1& 46 beaTaC_7A >;21A/6 Ftc�J TcST, B. SEPTIC/HOLDING TANK DATA Date Installed Size /CrM No. of Compartments 7_ Standpipes (Y ) Air -tight Cap(Y ) Foundation Clean t&) __��t Depression over Tank (Y& Date Last Pumping/Maintenance Contract on File (Y/N) ; for t4 Holding Tank High Water Alarm (Y/N) �/) Temporary Holding Tank Permit (Y/N) AJ19 Separation Distances from Septic/Holding Tank: To Water -Supply Well To Building Foundation j To Property Line To Disposal Field To Water Main/Service Line /O To Stream, Pond, Lake, or Major Drainage i Course /or _/__ Comments SO / ?4sQ&7,e6b Page 1 of 2 72-026(11/84) LSB/ t Javb 14ALs C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 95r Type of System Design Date Installed 71 Length of Field /3 , Width of Field /3 Depth of Field �O s P Square Feet of Absorption Area Depression over Field (Y6) — Results of Last Adequacy Test Ae&ud4�rC ravel Bed Thickness fa Standpipes Present 0N) Date of Last Adequacy Test Separation Distance from Absorption Field: r To Water -Supply Well To Property Line To Building Foundation Lot 0' To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Da d Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) — Comments to -7v To Existing or Abandoned System on On Adjoining Lots To Cutbank (if present) Dimensions Manhole/Access (Y/N) "Pump Off" Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent (Y/N) ng Cycles during Adequacy Test. Meets MOA I certify that I /h/a he ed, v rified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Date —/S Company iTr`�� MOA � OZ ee� OF At Receipt No. 1907 CUS o?04� r$LCr.�.•••..°°. thy+ O p � Date of Payment * • ,*✓ Amount: $ l -J Y'(.(iE%iC/7l �.7.io2 d ��/ / SOC _J� • 1 • • e . • ° ° ° f�S=' 0 • ROY C. REID, JR. CE -225i Page 2 of 2 �� /p P •R...•°1�� A41' t 72-026 (11/84) 5. LEGAL DESCRIPTION DATE RECEIVED INSPECTION APPOINTMENTS STREET LOCATION TIME TIME TIME 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS I p C')t 0 DATE DATE DATE ❑ MULTIPLE FAMILY [] Three ❑ Six 7. WATER SUPPLY INSPECTOR INSPECTOR INSPECTOR ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well �1 X llr MUNICIPALITY OF ANCHORAGE ��LLDEPT. OF HEALTH Y< IONMENTAL PROTECTION DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTM 825 L Street - Anchorage, Alaska 99501 ;u ;„� ® INDIVIDUAL/ON-SITE** APR 2 f 4`�C;;< ❑ PUBLIC UTILITY ENVIRONMENTAL SANITATION DIVISION Telephone 264.4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTYOWNER PHONE K. Richard Hazen 345-2365 MAILING ADDRESS SRA Box 2095—B Elies Drive PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE J. T. Braddock MAILING ADDRESS P.O. Box 11050 Phoenix Arizona 85061 3. LENDING INSTITUTION PHONE 1st National Main Branck Debbi NewcTent 265-344 MAILING ADDRESS P.O. Box 720 Anchorage Alaska 99510 4. REALTOR/AGENT PHONE Coldwell Banker Jack White Co. Clair Ramsey 77-1553 MAILING ADDRESS 3201 C St. Anchorage, 99503 5. LEGAL DESCRIPTION Lot 5, Block 1, Lakewood Hills STREET LOCATION E1ies Drive 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS �l SINGLE FAMILY ❑ One ❑ Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY [] Three ❑ Six 7. WATER SUPPLY �Ro KI INDIVIDUAL* ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM ® INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) K� � • , CG�SSIEV THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON-SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED% /b _7 f INSTALLER ❑Sept' 7.ac or ❑ Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE 5 K) BY 72-010 (Rev. 6/79) i121y 3, 1.9i),3 vx 1,iox 21095--), UK;; Drim /.mcjIovaq-.,, TP)07 Subjuct: Tat 5, f1lock 1, Tak(mood Mills Approval,W)l WIC KJANWARI cicmur and wave r Eacilitics camics-, ho (p.-cultod u'lli(AT_ the itains Jwvo bc'oil olectri.CM- wire'."; to BIO 1q J3. h�ad jo vi.01at.ion of Me Municirmlity of 2\n(,3.h) :(Agc (,odc-i a(ld jaw- t, 1-)o (�Ylca";(]d in colidtli't. F!111(' tjCtty: r(2porL noods to to this office Nom UICS Myna Litur 5033 B Krack, For Our swical. timk. jawma with a recuipt (iepiirtmollt, ;1,u a6t)qui.icy neads to be oil tjle 1.@r -chilly alma. n1iis tusL will det.(.r)aj.lw ii: 1-.�1` iysl-,(!iil adc(-juat,--� itcc0)-,.0,wj to Witional Stalwarcho. 11 listing of teM-, i,!; r(?pori-. ilocc!"i co ixmJj11-Jk-,L(1d to this o1. 1(G3 for our mviava 1.11c,iu;e notity %)arta"Mit kor it reAmp(Sion when Ulc 'I ol � e ()c �11 IwIve b ( corrcxted e aA+,' any CIU ME; 0:1,.N.ce a'c ;I J. I I (.-,"r (� 1. Y , 2,wr;ocijtto MI C3 In a it re ALASKA bUIROWNAL COnTnOL SCI dUS, InC. Engineerinq & Environmental Studies MAY 11 1983 MUNICIPALITY OF ANCHORAGE DEPT. OF H'�ALIII <: ENVIRONMENTAL PROTECTION MAY �.:. JACK WHITE COMPANY/CLAIRE RAMSEY 3201 C STREET RECEIVED ' 1 W l f E ANCHORAGE AK 99503 SELLER — RICHARD HAZEN BUYER— SUBDIVISION—LAKE WOOD HILLS BLOCK -1 LOT -5 ADEQUACY TEST FOR SEWER SYSTEM THE TYPE OF ABSORPTION SYSTEM IS A SEEPAGE PIT WITH AN AREA OF 312 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 675 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 3 BEDROOM HOME. THE SEPTIC TANK WAS PUMPED ON 5/11/83 . SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF THIS 3 BEDROOM HOUSE. .4 OF 44 �1e AV ni�- A0 :491H i •••sets I .0/st w ••.//.j /•/• • / //// q /I 4® �� o. Leroy C eid, Jr, l ��Jl'•� No. 2 1•E p r� 008 O 1000 IS ADEQUATE FOR 1200 West 33rd Auenue, Suite B • Anchorage, Alaska 99503 • (907) 276-1361 nu - i ------ -MuNICIP rr?–' k1UNIIWIPALITY OF ANCHOFiAGE DEPT. OF I °ALT i & - = GEPARTAS-NT OF HEALTH & Ef!`:.RON'MENTAL FRGTECTICgNVIRONMENTAL P,.., _CTIO ` �� 825 L Strnvt - Anchore , Al.�cka 99501 _ _NHN Elies Drive I ,JAN 1 1 Iwo �- ENVIRONMENT;'L ENGINJEERIING DIVISION SINGLE FAMILY One a l=our J Other_— Telephone. 264-4720 El kfiULTIPLE FAMILY REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND I SI:`:';% ( FACILITIES 431 fDI RECTICF:S: C�,n:p!ete ail pars pr, po-?,= 1. Incomplete requests %vili not be processed. Ple,se s:io., —_—_---- ,,,n iS0) days for prate>sine. ��I ------- 1. PROPSisTY Oi'%'h:ER — FHO.'JE�.__ Home ug ity Inc. _ 277-1553 IAWl-I' GADDRF.SS INDIVIDU'ALlON-SITE" 3201_ C St. Anchorage --- ------ PROPERTY RESIDENT (If different from abo%e) ___ rriOlJE ----- 2. E;UYER NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSINIG CAN BE INI T IA-r'm MAILING ADDRESS 3. LEPID1NG IN-STITUTIOfV Alaska Nation Bank of the North _ `272-4531 _ V7N LING ADDRESS _ Pouch 7-010 Anchorage, 99510 3301 C. St. -'--- ---- 4. REALTOR/AGENT --- 21-fONc Jack White Co. Clair J. Ramsey 277-1553 MAILING ADDRESS 3201 C St. Anchorage, 99503 5. LEGA DESCRIPTION �I Lot 5, Blk 1, Lakewood Hills ser -,=_Er LocATlav --- _ _NHN Elies Drive I 6. TYPE OF RLSIDENCE _ NUMBER CF �EDR^OA15 SINGLE FAMILY One a l=our J Other_— – Tv, o _' Five El kfiULTIPLE FAMILY >4 Three �:J Six 7. 1'.'ATFR SUPPLY -- �---'-"�' q �p INDIVIDUAL* ATTAC1l 1t I't LL LOG. Av,,oll log I$ rf ylllreC.f 'or ell 14'ell$ Cillied E, COMMUNITY since June 1275. For vvells drilled prior to that date, give %well L; PUBLIC UTILITY " depth (attach log if available.) T" 8. I AGL DISPOSAL SYSTEM (� "If INDIVIDU'ALlON-SITE" individual/on-site, give installation date—m �. – •l�4 f–Ii'C4c_/Lo If system is over tv.,o (2) years c!d on adequocy test Is rcqu red PUBLIC UTILITY by this De pa.rtrnent. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSINIG CAN BE INI T IA-r'm ry" THIS SIDE FOR OFFICIAL USE ON' 1 _—_ DATE RECEIVED INSPECTION APPOIN'T!:1EN'TS T L'.'E i .� i L DAT E I DATE I I NSF ECTOR INSPECTOR. I H SPECTOR D I P. E:: T I:': \S_ 1. TYPE OF RESIDENCE i NUMBER OF BEDROOMS SINGLE FAfv11LY i" ONE THREE ❑ FIVE ❑ OTHER __j r,'ULTIPLE FAMILY _ ❑ TWO F�— FOUR O SIX I 2. )"MATER SUPPLY PERMIT NUMBER ^ E-1 INDIVIDUAL DEPTH OF WELL CO NIMUNITY L— DATE DRILLED :J PUBLIC UTILITY _ Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER _'INDIVIDUAUOIN -SITED ATE uPUBLIC UTILITY Connection Verified INSTALLER CSeptic Tank or OHolding Tani: Size: If Tank is homemade SOILS RATING give ain,ensions: TYPE OF TANK. MANUFACTURER TOTAL ABSORPTION AREA NIATERIAL 4. DISTANCES Septic./Holcno Tank lAbsorption Area Line Nearest Lot Line�� (Sewer Ahsorpticn Area to nearest Lot Line 5. COMMENTS APPROVED FOR 3 BEDROOMS =' CONDITIONAL APPROVAL j!e 1er must accompany certificate) DISAPPROVED D:.: _----------- —/ BY (Title DESCRIPTION— --— -yG� --- 6)5IOZ.gJ WORK AUTHORIZATION AND AGREEMENT 0 R&M CONSULTANTS, INC. (FIXED FEE) ENGINEERS GEOLOGISTS PLANNER. SVRV[VORS This agreement made this Lqi day of ( h%� ( /k 19by and between 644-IR j M � �t/!-t</ 7� Cc) • hereinafter called "Client", and R&M Consultants, Inc., hereinafter called "R&M", WITNESSETH• t authorizes R&M to perform the following services (use additional Description of property benefited by services (use additional sheets if required): 1—or 5 Ad G o / K aur CG sr C11012/1(!!�7 ' 3. Legal owner: 4. Client agrees to pay R&M a fixed fee of 4 1155 for those services listed in Item 1. In consideration for such fee R&M agrees to furnish and perforin these services in an expeditious manner and in accordance with accepted professional standards. 5. If services require more than one month to complete, client agrees to make monthly progress payments for work completed. Monthly invoices submitted to the Client by R&M shall be equal to the FEE times the percentage of the total services completed during the month. 6. Client agrees to pay R&M interest at a rate of one percent per month (12 percent per annum) and any cost of collection on any invoice unpaid 30 days after the date of billing as shown upon the invoice. 7. Client recognizes the inherent risks and uncertainties connected with the performance of geological, survey, engineering, materials testing, inspection, foundation investigation, and other forms of related services and in addition recognizes the risks associated with any construction or undertakings related to such professional services. It is agreed that Client will limit any and all liability or claim for damges, costs of defense, or expenses to be claimed againstR&M to a sum not to exceed $100,000 or the amount of R&M's fee, whichever isgreater, on aceountof any breach of contract, design defect, en -or, omission, or professional negligence. Further, the Client agrees to notify any contractor, subcon- tractor, engineer, architect, financier, or purchaser who may perform work, engage in financing, or make a purchase in connection with any design, services, report, specifications, study, or advice prepared by R&M of such limitation of liability for breach of contract, design defects, errors, omissions, or professional negligence. In addition, Client agrees to require as a condition precedent to the performance of work, finanacing, orpurchase, by any party, a like limitation of liability provision as to design defects, errors, omissions, or professional negligence, of such party, and any liability of the Client and R&M to such third party arising out of such design defect, error, omission, or professional negligence shall be allocated between the Client and R&M in such a manner that the aggregate liability of R&M for such design defect to any and all parties, including the Client, shall not exceed $100,000 or amount of R&M's fee, whichever is greater•. 8. The Client and R&M each binds himself or itself, and their respective partners, successors, legal representatives and assigns to the other party to this Agreement, and to the partners, successors, legal representatives and assigns of such other party in respect to the Agreement. Neither the Client nor R&M shall assign or otherwise transfer his or its interest in this Agreement without the written consent of the other party to this Agreement. 9. R&M may, at its discretion, stop work in the event that any invoice payments are not received by the time due. Any waiver by R&M of its rights under this provision at any one time shall not be considered a waiver of any future right to enforce this provision. Client may terminate this Agreement at any time by giving R&M written notice thereof. In which case, R&M shall be paid in full for all services performed to the date of termination. ACCEPTED AND AGREED TO: Chent Signaur�' .--G•C�ti);.y�r� �- Title R&M CONSULTANTS, INC. Signature Title t MUNICIPALITY OF ANCHORAC DEPARTML OF HEALTH AND ENVIRONMEN PROTECT ION � p 8.25 L Street, 7%mchorcige, Alaska 99501 2'79•-25.11., ext. 224 or 225 C CA Date Received: June 23, 1977 --------_,..--•--- - --•fes= --�=-1-�• #2: 'Vi.mc � _ nom- - 1f3: T• lG Da Le 6-24 77 Friday Date (o- _�� 5 DOtC� 7 /-J-7 1:n Sp Pr t Insp r Insp l PE,QUEST FOR APPROVAL OF INDI:VIDUAh SEWER. AND WA'I'T IR Lendir..g In:;titut.i_on Request: Alaska National Bank of the North Mailing Address: Pouch 7-010 99510 phone: 278-4581 Frop,erty Owner: Ralph Mc Kenzie phone: 344-6336 mailing Address: Star Route A Box 95 99507 Legal Description: Lot 5 Block 1 Lakewood Hills Subdivision #4 Single Family Residence: (x) Number: of. Bedrooms. Three Multi.p.le Family Itesi.dence: ( ) Number of Bedrooms: Well_ System: Tndiv.idual Well () Coimmini.ty/Publ.i.c 5ysten ( ) Permit if Depth of T^7ell7.3.6'__._...._,._.__..__. 'Kell :Log on Fila ( ) Const r.uc t -ion Bacterial. Analysis Sctvagc' I?:i-slx�s.:]:L Syst-ern: On --site Sy::;t-em (x) Pu1.)i...c UL -1. J. Ly ( ) 1)ermi.L ;F Installed /U`'r) 1 ln,stalle.r T S I' i LrL�� Size e) C) a.r Manuf.cture ,.. , i. - c. i Ib S;m j)tjon Area dolls Rale ���� Ma i. m. ial. 7. DJ.SL-anc, s : We L to Septic '.L'ank � � to AA?SO:Cpt].OIS Area ;/ /0(`) to Sr :, er l.i_l:e Nearest I,c) 1_ine AhsorpL'Lon Area to Nc best Lot'. L,:Lne C,,J- _. )moi �7 •_ I`i z_ 0 Paye Two Department of Health and Environmental Protection Request for Approval of Individual Sewer. and Water_ Facilities Legal Description: Lot 5 Block 1 Lakewood Hills Subdivision #4 Comments: Affadavit Attached: f ) / Letter Attached: ( ) Approved: ! ; Date: c _-- Disapproved: Date: Department Worksheet: �130f7? C) � 4 \\ ,V�, a 4, �„ ,.,ft , 0C� 2. Property Owner:_-_ Ralph Mckenzie Mailing Address: SRA Box 95___ Day Phone: 344-6336_ 3. Nameof Buyer: John A Edwa Mailing Address: Day Phone:._ 274-1530 4. Name of Lending Institution:_._Alaska _National Bank of the North Mailing Address:_Pouch_ 7-fl-2flx 010 _ Phone:._ 278-4581 5. Name. of Realtor or Agent:-- Paul Barrows_(Area Realtors)____ Mailing Address:_ 3300 C Street Phone: -278-2525 6. Legal Description: Lot 5 Blk 1 Lakewood Hills #4 S/D Location:__Elies Drive of Upper Omally 7. Type of Facility to be Ins pec ted:No. Bdrms. 3 8. Water Supply Type of Supply: Public Utility If Individual, number of dwellings presently served If Individual, depth of well 136 feet 9. Sewage Disposal System Type of System: Public Utility If Individual, date of installation ---- 72-003(3/76) I Individual X Individual (on -site) --X DEPARTMENT MUNICIPALITY OF ANCHORAGE OF HEALTH AND ENVIRONMENTAL. PROTECTION r "' I 825 L Street, Anchorage, Alaska 99501 2.79-2511, ext. 224, 225 REQUEST FOR APPROVAL OF INDIVIDUAL. SEWER and WATER FACILITIES 1. Type of Inspection: VA __FHA___ .CONY X 2. Property Owner:_-_ Ralph Mckenzie Mailing Address: SRA Box 95___ Day Phone: 344-6336_ 3. Nameof Buyer: John A Edwa Mailing Address: Day Phone:._ 274-1530 4. Name of Lending Institution:_._Alaska _National Bank of the North Mailing Address:_Pouch_ 7-fl-2flx 010 _ Phone:._ 278-4581 5. Name. of Realtor or Agent:-- Paul Barrows_(Area Realtors)____ Mailing Address:_ 3300 C Street Phone: -278-2525 6. Legal Description: Lot 5 Blk 1 Lakewood Hills #4 S/D Location:__Elies Drive of Upper Omally 7. Type of Facility to be Ins pec ted:No. Bdrms. 3 8. Water Supply Type of Supply: Public Utility If Individual, number of dwellings presently served If Individual, depth of well 136 feet 9. Sewage Disposal System Type of System: Public Utility If Individual, date of installation ---- 72-003(3/76) I Individual X Individual (on -site) --X