HomeMy WebLinkAboutSAMPSON ESTATES BLK 1 LT 2Sampson
Estates
Block 1
Lot 2
#051-822-20
I -,pm, 1011 RCF1UI l 1- 1- 14.000
Municipality of Anchorage
Community Development Department Page 1 of 2
On -Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181144
PID Number: 051-822-20 ❑ New ❑✓ Upgrade
Name:
MARK SWENSEN
ABSORPTION FIELD
❑ Deep Trench R,/Shallow Trench E] Bed ❑ Mound
Address
23632 Goliath Drive
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
4
1.0GPD/SF
8.0-6.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3-1 Ft'
Gravel depth beneath pipe
S•OFt.
Subdivision
Block Lot
Sampson Estates
p
1 2
Fill added above original grade
0.5-2.5 Ft.
Gravel length
60.0 Ft.
Township Range Section
Gravel width
5.0 Ft.
Beds: Number of Lines
N/A
Distance between lines
N/A Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
300 Ft2
1
N/A Ft.
Well
210.6
100+
N/A
N/A
192.6
TANK El Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
ANCHORAGE TANK/ORENCO
Capacity
I 1500Gal.
Surface Water
100+
100+
N/A
( N/A
Material
Number of compartments
Lot Line
5.0
25.7
N/A
N/A
FIBERGLASS
2
NA
Foundation
18.8
90.0
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
N/A
NIA
N/A
N/A I
ORENCO
500 Gal.
Remarks See profile drawing
Pump on level at
40 in.
Pump off level at
36 in.
High water alarm at
45 in.
Pump make and model
P2005
Electrical Inspections performed by
J ELECTRIC
Installer
PIPE MATERIAL House to tank 3034 Tank to 3034
drainfield
JR's Septic
Drainfield 3034 CO/MT 3034
Inspector Pannone Engineering Services
BENCH MARK (Assumed elevation) 360 ft
Inspection,,
dates: 1 9/19/18
2"d 9/20/18
Location and description
3rd10/18/18
4th
Southwest corner foundation at siding
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
fl1,4knk
Conditional Approval:
Date
,�
' 'Steven ' . 'PLinnorie''`�
9..
i i
CE 8149
Approved(1�,�A)ZU#
Date
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PANNONE ENG SVC, LLC _ \\ REVISIONS
P.O. BOX 1807 PALMER, AK 99645 OF qC \i
RECORD DRAWING PHONE (907 745-8200 FAX 907 745-8201 ��P�� 9SFy1#+� REV 1: 19DEC2019
SAMPSON ESTATES 131 L2 i*"'
DRAWN JRL MARK SWENSEN$te en•F}.
�.•. �onnone /
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23632 GOLIATH DRIVE t •.. CE 8149
SITE PLAN CHUGIAK, AK 99567 ,�lt��`�
CRNE''WAY
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SCALE
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'.I.D. NO
051-822-20
'ERMIT NO.
OSPi81144
;HEET
2 OF 2
NOTES
I. AS—BUILT FIELD SURVEY WAS
PERFORi'vLED BY HDL, LLC., .1,1AY 18TH
OF 2018.
2. A TITLE REPORT WAS NOT PERFORIMiED.
EASD.41ENTS OF RECORD, OTHER THANI
THOSE SHO4Vb1 ON THE PLAT OF
RECORD, ARE NOT SHOt'.`N HEREON.
LEGEND
ADJACENT PROPERTY LINE
SUBJECT PROPERTY LINE
— ----- PAVED DRIVEW/-,.Y
WOOD DECK
vVELL
SEPTIC SYSTEV, VENT
SEPTIC LIF7 STATION
HER EE -Y CERTIFY THAT i HAVE SURVEYED THE FOL LO`AINIC= DE -Sr, R 8 E D
PROPERTY LOCATED !N' PE7ERS CREEM ALASKA. LOT Z BLOCK 1
SAMPSON ESTATES, PER PLAT Na 84-11 RECORDS OF THE ANCIA00
RECORDING DISTRICT, STATE OF ALASKA,. AND THAJ i',10 EINCROACHIVIEP
E,`dST EX :-::T AS IT !S THE PESPC)NSIB!LITY THE 0","NEi:
TO DETERMNE THE ETTENCE OF OF ANY EASEMENT& COVENANT& 0
RESTRICTIONS WHKH DO NOT APPEAR O'N THE RECORDED SUBDIVISION
PLAT UNDER NO ORCUMSONCES ShQUW ANY OF TE DAN HERE01
BE !JSED FOR CONE TRIUCTI 0-11`4 OF REDN�CES, OR FOR ESTABLISHIN-1:3
PROPERTY B-CLPNIDA.RIES.
— - +, .++ - - I.- ____ I =,)c; nn'
MEMO
SCALE IN FEET
ENGINEERING AS -BUILT SURVEY
Consultants LLc LOT 2, BLOCK 1, SAMPSON ESTATE,
civil - gootachnical - surveying - env;rcnmentBI - material testing PLAT No. 84-10, ANCHORAGE RECORDING DISTRICT
ANCHORAGE MAT -SU KENAI PETERS CREEK, ALASKA
907.564,2120 907746.5230 907.283.2051
3335 Arctic Boulevard, Suite100 AnchAnchorage,A AK 99503 ilmal2e; s KK OF
AECL861 vm^w.HD]Lalaskaxom 1 60' CASE S,
NOTES
1. AS -BUILT FIELD SURVEY WAS
PERFORMED BY HDL, LLC., MAY 18TH
OF 2018.
2. A TITLE REPORT WAS NOT PERFORMED,
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE PLAT OF
RECORD, ARE NOT SHOWN HEREON.
GOLIATH. DRIVE
N 89'58'04" E 92.00'
ELV=371.3' - 10' T&E ESMT
L=25.00'
R=680.00'_
w
C
ELV=372.4�
I
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SAMPSON M
EST l ES
PLA o. �A-
84- 0
-
BLOC
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m
LO
2
LEGEND
n
4
— — t
6'
� 31.4' r�pg-ate
SUBJECT PROPERTY LINE LOT 1
2
30'
PAVED DRIVEWAY
iHED .' I
al
• M
LOT 3
o I�
EXISTING
°O
SHED'S
TO BE
j%%%�/%%/%%G%%%?� WOOD DECK REMOVED
7
SHE
: : ::.
BLDG COR
�30 -
EL - 65.9':
PROPOSED
39.4
2.
LOG COR
COVERED
O FOUND PROPERTY CORNER
I
LV=365.9'
_- WALKWAY
SEPTIC SYSTEM VENT
m
OHO SEPTIC SYSTEM STRUCTURE
31327.s
'v
I^
w
- - TOTAL AREA OF
36'
51,4'
'A - -
DISTURBANCE (4880 SF) -
o
J
s' - I
p
-
l ,560 EXISTING
N
O
0
PROPOSED 2-STORY
O --
- _
I HEREBY CERTIFY THAT I REVIEWED THE FIELD SURVEY COMPLETED IN
Z
w
N
SUN ROOM WOOD HOUSE
�0
-
N
MAY, 2018 ON THE FOLLOWING DESCRIBED PROPERTY LOCATED IN
- 00
- 20 N
_
PETERS CREEK, ALASKA: LOT 2, BLOCK 1, SAMPSON ESTATES, PER PLAT
.550- 1
�, PROPOSED SOIL
No. 84-10, OF THE ANCHORAGE RECORDING DISTRICT, STATE OF
- -
I:2 DISPOSAL AREA
ALASKA, AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED, IT
IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF
OF ANY EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT_
APPEAR ON THE RECORDED SUBDIVISION PLAT. UNDER NO
-
_ -
-
CIRCUMSTANCES SHOULD ANY OF THE DATA HEREON BE USED FOR
CONSTRUCTION OF FENCES, OR FOR ESTABLISHING PROPERTY
BOUNDARIES.
-_- -
10'
��• �� OF. q(qs,�,♦
ELV=314.1'
•'
••49th
AN
N51
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No. 106453 •.•'• %
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PF� A �� r�,.��
Q' 60 � 20
ELV=31 OA'
4W,1
SCALE IN FEET
110 ENGINEERING
PLOT PLAN
l ConsultantsLLc
LOT 2, K 1, SAMPS ESTATE,
civil - geotechnical- surveying - environmental - material testing
PLAT No. 84-10, ORDING DISTRICT
ANCHORAGE MAT-SU KENAI
PETERS CREEK, ALASKA
907.564.2120 907.746.5230 907.283.2051
DATE:
312712025
DRAWN BY:
JJZ
SHEET:
1 OF 1
3335 Arctic Boulevard, Suite 100 Anchorage, AK 99503
AECLS61 www.HDLalaska.com
SCALE: I"= 60'
CHECKED BY: JJZ
JOB NO.:
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP181144
Work Type: Septic Upgrade
Tax Code Number: 05182220000
Site Legal Address: SAMPSON ESTATES BLK 1 LT 2 G:1560
Site Mailing Address: 23632 GOLIATH DR, Chugiak
Owner: SWENSON MARK R & KATHERINE J
Design Engineer: PANNONE ENGINEERING SERVICES
This permit is for the construction of:
Effective Date
Expiration Date
Lot Size in Sq Ft
Total Bedrooms:
t)rhar[m�•nt
7/3/2018
7/3/2019
53783
0 Disposal Field 2 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
✓Special Provisions: An additional test hole shall be done prior to construction of the drainfield to confirm soil
strata and percolation rate of accepting soil layer. If the results require a design change, construction of the
system shall stop pending On-site review and approval of a change order. Please submit stamped and signed
results with the inspection report.
AL'
ct /I yI I$ CO "H- 1: fLv is e 1-o A -0J 0_T S S L? 4e n 6 a.o Q.d o n re s u�.f
1
0 4eo7,-- p-DiP.
�?
Received By: Date:
Issued By: Date: 7 3
MUNICIPALITY OF ANCHORAGE
Community Development Department 6`` ► Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On-Site Water& Wastewater Program
ON-SITE SEWERNVELL PERMIT APPLICATION
Parcel I.D. 051-822-20
Property owner(s) MARK SWENSON Day phone None Available
Mailing address 23632 Goliath Drive, Chugiak, AK 99567
Site address 23632 Goliath Drive, Chugiak, AK 99567
Legal description (Sub'd., Block & Lot) SAMPSON ESTATES B1 L2
Legal description (Township, Range & Section)
Lot Size 53,783 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field ❑X Initial ❑ Single Family (SF) ❑X
(w/wo ADU)
Septic Tank ❑X Upgrade ❑X
Duplex (D) ❑
Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE/WAIVER REQUEST FOR:
Drain field to slope >25% Distance:0
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipa o•es.
ba
(Signature of prope y owner or authorized agEnt)
Permit/Rush Fees: ,6j(o Waiver Fees: A ts-'
Date of Payment: te[it-1113 Date of Payment: (o 111-10
Receipt Number: a37-2C--� Receipt Number: 7-2
Permit No. 0 ttLiq Waiver No. QSV 616.3/
Per I
r f r
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail: Steve anen ak.com
June 20, 2018
Subject: SAMPSON ESTATES B1 L2
Upgrade Septic System Permit Request
Design Narrative
This is a design narrative to issue a permit to install an upgrade septic system for this property. The system will serve an existing
four (4) bedroom house. The system will utilize a new 1500g ADVANTEX (CATIII) w/ AX -20 POD and a conventional drain field.
This lot and the surrounding lots are served by private wells. There are no wells within 100' of the proposed septic system.
1. Soils. PES performed a test hole in August 2018. Ground water was not observed to a depth of 18.0'. Bedrock was not
encountered in the test hole to 18.0'. Based on the results of the percolation test and overall soils appearance, an
application rate of 1.0 GPD/SF was used for an AWWTS system in the area of the test hole.
2. Soil Absorption System Design.
a. See Sheet 1 of the design package.
3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain field. The proposed drain
field upgrade will maintain at least 100 feet from all surface water and drainage ditches.
4. Topography: The existing topography on the lot generally has 5%-10% slope from North to South on the north half of the
property. There is a grade break after the home on the property and the property continues with a slope varying 25%-50% with
a slope of 25% in the area of the proposed drain field. There are NO steep slopes within 50' downhill of the system.
5. Drawing Markings: The Drawings are currently marked "For Construction". A change order is being requested due to results
of PES test hole.
The proposed installation will not affect the future development of this or the surrounding lots.
If you have any questions or concerns, please contact me at 272-8218.
Sincerely,
Steven R. Pannone, P.E.
Owner/Civil Engineer
P . Box! `0121 , '..�hC � t G:�res H9 �t:�r
�': 'y
1
NOTES:
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P'ANNONE ENG SVC LLC
P.O. BOX 102954 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211
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SAMPSON ESTATES 131 L2
MARK SWENSEN "��sra, F2 nnn"isae
CE 8149 •:
23632 GOLIATH DRIVE
CHUGIAK, AK 99567
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REVISIONS
REV 1: 20JUN2018
REV 2: 06AUG2018
CO 1: 12SEP2018
06/14f2018
SCALE
7" = 60'
P.I.D. NO
051-822-20
PERMIT N0.
OSP181144
SHEET
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NOTES: PANNONE ENG SVC LLC REVISIONS DATE
FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 06/14/2018
PHONE (907) 272-8218 FAX (907) 272-8211 REV 1: 20JUN2018 SCALE
49 REV 2: 06AUG2018 1 11 = 60'
SAMPSON ESTATES 131 L2 . . . ....... P.I.D. NO
DRAWN JRL MARK SWENSEN Me an a 051-822-20
1 . CE 8149 PERMIT NO.
SOILS LOG & 23632 GOLIATH DRIVE ....... OSP181144
CHUGIAK, AK 99567 -S—HEET
NOTES -1 2 OF 2
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP181144, Rebecca Carroll, 07/03/18
6/21/18
ENGINEERING
3335 ARCTIC BLVD, SUITE 100, ANCHORAGE, AK 99503
Con
su lta Phone: (907) 564-2120
Fax: 907)564-2122
AGGREGATE/SOILS TEST REPORT
PROJECT NAME:
IN-HOUSE
DATE TAKEN:
5/21/18
PROJECT NO.:
18-400-12
DATE TESTED:
5/22/18
CLIENT:
HDL
TESTED BY:
PC
SAMPLE NO.:
18-P37
REVIEWED BY:
JAB
LOCATION:
TP2-S1 (4.0 ft bgS)
DESCRIPTION:
MARK'S SEPTIC
SIEVE ANALYSIS TEST
IASTM nd�91
SIEVE
SIZE
DIAMETER
I-)
TOTAL
PASSING
6"
152.4
27.5
4"
100.0
• FINES:
3"
76.2
I
2"
50.8
100
1"
25.4
86
3/4"
19.0
78
1/2"
12.7
70
3/8"
9.5
62
#4
4.75
42
#10
2.00
36
#20
0.85
30
#40
0.425
25
#60
0.25
21
#100
0.15
18
#200
0.075
14.3
HYDROMETER TEST
ELAPSED DIAMETER TOTAL%
TIME IMM) PASSING
0
0.5
1
2
4
8
15
30
60
250
1459
2750
CLASSIFICATION:
USC:
FROST CLASS:
COMMENTS:
GRAVEL:
58.2
00.0)
• SAND:
27.5
90.0
• FINES:
14.3
I
80.0
D60=
8.97
D30=
0.89
70.0
D10=
m
60.0
Cu=
CC=
w t7
%.02 mm
Moist.:=
8.1
40.0
Fine Modulus:=
30.0
(ASTM D4318)
Liquid Limit:
20.0 '
Plastic Limit:
10.0 .`
Plastic Index. _
(ASTM C127)
0.0 '
100
Bulk SpG=
SSD SpG=
Apparent SpG=
Absorption=
(ASTM C128)
150.0
Bulk SpG=
145.0
SSD SpG=
Apparent SpG=
140.0
Absorption=
135.0
(ASTM D1557)
Dry Den (U) =
130.0
Dry Den (C) =
SS
M % (U) _
125.0
M % (C) =
120.0
SpG (assumed) _
N -D Test Method =
1.15.0
Silty Gravel w/Sand
GM
110.0
0.0
GRAIN SIZE DISTRIBUTION
10 1 0.1 0.01 0.001
GRAIN SIZE M MILLIMETERS
MOISTURE -DENSITY RELATIONSHIP
2.0 4.0 6.0 8.0 10.0 12.0 14.0
MOISTURE CONTENT (%)
gi
'? ENGINEERING 3335 ARCTIC BLVD, SUITE 100, ANCHORAGE, AK 99503
Consultants Phone: (907)564-2120
Fax: 907) 564-2122
AGGREGATE/SOILS TEST REPORT
PROJECT NAME:
IN-HOUSE
DATE TAKEN:
5/21/18
PROJECT NO.:
18-400-12
DATE TESTED:
5/22/18
CLIENT:
HDL
TESTED BY:
PC
SAMPLE NO.:
18-P36
REVIEWED BY:
JAB
LOCATION:
TP1-S2 (7.Oft bgs)
DESCRIPTION:
MARK'S SEPTIC
SIEVE ANALYSIS TEST GRAIN SIZE DISTRIBUTION
'ASTM -111
SIEVE
SIZE
DIAMETER
(mm)
TOTAL%
PASSING
6"
152.4
53.3
4"
100.0
• SAND:
3"
76.2
90.0
2"
1 50.8
100
1"
25.4
88
3/4"
19.0
78
1/2"
12.7
69
3/8"
9.5
61
#4
4.75
47
#10
1 2.00
40
#20
0.85
32
#40
0.425
26
#60
0.25
22
#100
0.15
18
#200
0.075
14.2
HYDROMETER TEST
rARTM nA991
ELAPSED DIAMETER TOTAL%
TIME (mm) PASSING
0
0.5
1
2
4
8
15
30
60
250
1459
2750
Plastic Index.
0.0
(ASTM C127)
100
100.0
% GRAVEL:
53.3
SSD SpG=
• SAND:
32.5
90.0
% FINES:
14.2
(ASTM C128)
150.0
Bulk SpG=
80.0
D60=
9.05
145.0
D30=
0.69
70.0
D10=
140.0
% Absorption=
m
60.0
Cu=
Dry Den (U) =
Cc=
130.0
wr,
��
50.0
%.02 mm
N
Moist.:=
7.3
125.0
40.0
Fine Modulus:=
30.0
(ASTM D4318)
SpG (assumed) _
Liquid Limit =
115.0
20.0
Plastic Limit .=
110.0
10.0
Plastic Index.
0.0
(ASTM C127)
100
Bulk SpG=
SSD SpG=
Apparent SpG=
% Absorption=
(ASTM C128)
150.0
Bulk SpG=
145.0
SSD SpG=
Apparent SpG=
140.0
% Absorption=
135.0
(ASTM D1557)
Dry Den (U) =
130.0
Dry Den (C) =
N
M % (U)=
125.0
M % (C) =
120.0
SpG (assumed) _
M -D Test Method =
115.0
110.0
10 1 0.1
GRAIN SIZE IN MILLIMETERS
MOISTURE -DENSITY RELATIONSHIP
0.01 0.001
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0
MOISTURE CONTENT (%)
CLASSIFICATION: Silty Gravel w/Sand
USC: GM
FROST CLASS:
COMMENTS:
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
BETWEEN MUNICIPALITY OF ANCHOR -AGE
AND Mark Swenson
THIS MAINTENANCE AND REPAIR AGREEMENT made and entered into as of this
07
Day of September
of 2018 . by and between Mark Swenson
herein the "OlvVNER,." and the Municipality of Anchorage, herein the
In consideration of the mutual covenants contained herein. the
parties to this Maintenance and Repair Agreement agree as folloNvs:
1. Advanced Wastewater Treatment Systems. Municipality grants permission to
Owner to Utilize and operate an Advanced NAIastewater Treatment System
(AWWTS), described as
ADVANTEX Tank with AX -20 pod
located at (legal description).
Sampson Estates, Block 1, Lot 2
2. Definitions.
Alteration, Any change to the design or function of an AWWTS that
includes the installation or removal of any parts, components or pieces not
included in the original construction permit and design.
Certificate of On -Site Systems Approval (COSA). An approval by the
Municipality of existing water and v,,astewater disposal systems given at
the time of property sale and title transfer in accordance with Anchorage
Municipal Code (hereinafter, "AMC") 15.65. These approvals certify that
the systems are adequate for the homes that they support and meet the
codes that were in place at the time of s} -stem construction.
Damage. Any man-made or natural change in a system that would inhibit
the System from performing as designed.
Maintenance and Repair. The scheduled and as needed replacement of
existing parts, components and pieces of an AWWTS that were included
in the original design which would allow- the .1kWNVTS to continue to
perform as designed.
Permit. An On -Sit-, Wastewater Disposal Permit as required by AMC
15.65 to construct and operate an AWWTS.
3. Term. The term of this Maintenance and Repair Agreement shall begin on the
date of approval by the Municipality to operate the installed system or issuance of a
COSA, and shall continue while the AWWTS is in use or is operational Or until the
property is sold or title is transferred by the owner and a new COSA is issued to -lie
L
new owner or transferee ofthe property.
4. Alterations. Installation and Removal of Additional Equipment. Prior to
performing any alterations to all AWWTS, the owner agrees to obtain an On-site
Wastewater Disposal Permit 6-0111 the MLllIiCipaJjt3` in accordance with AMC 15.65,
5. Maintenance and Repairs.
A. Throughout the term of this Maintenance and Repair Agreement. the Owner shall
maintain their AWWTS in a satisfactory condition capable of producing treated
septic effluent in accordance with the equipment's approval for operation in the
Municipality. The owner shall enter into a service agreement with all AWWTS
service and maintenance provider approved by the municipality and the
IllanUfaCtUrer of the AWWTS for the entire term of the AWWTS. In addition. it
shall be the responsibility of'Llie Owner dUrincy the term of this Maintenance and
Repair Agreement, and any renewals thereof., at theowner's sole expense, to pay
for any and all: (1) repair(s), (2) maintenance, (3) adjUStIllent(S). (4) replacement
costs, and (5) inspection costs.
B. Owner agrees to comply Nvith all applicable ordinance.. la\vs, regulations. rules
and orders for the AWWTS,
C. Upon request by the Municipality, the oNvner agrees to provide the Municipality a
written schedule of routine maintenance and repairs which have been performed
on the system. When a record of maintenance is documented and maintained by
the system vendor, the owner agrees to allow the Municipality access to this
information,
D. Owner acknowledges that the fine for failing to maintain and repair all A'W'WTS
may be assessed in accordance with AMC 14.60 for improper discharge.
E. Owner agrees that only maintenance and repair personnel approved by the
Municipality will inspect and make any necessary maintenance, repairs or
permitted alterations to the system.
F. Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS upon 24 hours written notice.
G. Owner agrees that any sale or transfer of title of the property wil I not occur
without a new Certificate of On -Site Systems Approval.
H. 0�vner agrees that the Al_
7
_WTS installation and maintenance requirements as
provided by the Ai IAITS vendor installer and approved by the Municipality are
the governing guidelines for the collStl'LlCti011. maintenance and repair of the
- 1�
Owner's AWWTS.
I. Owner agrees to provide and maintain a telephone connection to the AWWTS as
required by the AWWTS approval.
6. Nonwaivei% The failure Of either party at any time to enforce a provision of this
Maintenance and Repair Agreement shall in no way constitute a waiver of the
provisions. nor in any way affect the validity of the Maintenance and Repair
Agreement or any part hereof or the right of such party thereafter to enforce each and
every provision hereof.
7. Amendment.
A. This Maintenance and Repair Agreement shall only be amended, modified or
chanced by a writing, executed by authorized representatives of the pal -ties. with
the same formality that this Maintenance and Repair Agreement was executed
with, and such writing shall be attached to this Maintenance and Repair
Agreement as all amendment.
B. For the purposes of any amendment modification or change to the terms and
conditions of this agreement, the only authorized representatives of the parties
are:
a. Owner: Mark Swenson
b. Municipality: Director. Community Development or designated authority
C. Any attempt to amend, modify, or change this contract by either an unauthorized
representative or unauthorized means shall be void.
8. Jurisdiction: Choice of Law, Any civil action arising from this Maintenance
and Repair Agreement shall be brought in the Superior Court for the Third Judicial
District of the Starve of Alaska at Anchorage. The laws of the State of Alaska shall
govern the rights and obligations of the parties under this 1\4aintenance and Repair
Agreement.
9. Se-verability. An}, provisions of this ]Maintenance and Repair Agreement decreed
invalid by a court of competent Jurisdiction shall not invalidate the remaining
provisions of the Maintenance and Repair Agreement.
OWNER:
��KBy: rr �..U------- (signature) Date:
(print name)
STATE OF ALASKA )
ss.
THIRD JUDICIAL DISTRICT 1
The forjeaoin;+jinjn/jsttnrfu/jmeS/n/t%�/�as acla�o��rledged before me this day of {�
20JE, 11� t/" a h bI/ dgffjc � OCaR @yIN
YOR Si
NOTARY U'$L/ICJOR ALASKA °>
My Commission expires:
PUBL tee;
or
fon e -A-9 w:
�Y41S4e
MUNICIPALITY:
1
By:('1Ji�� (signature) Date: 3 oZ D i
> Q/�e cC,a— G`rro(I (print narne) Title:
Municipality of Anchorage
Community Development Department Page 1 of 3
On-Site Water & Wastewater Program
4700 Elmore St: • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907)343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP121197 PID Number: 051-822-20 0 New Upgrade
Z v15
Name:
ERNEST & DEBORAH STEPHENS
ABSORPTION FIELD
Address:
23632 GOLIATH DRIVE *CHUGIAK, AK 99567
0 Deep Trench 0 Shallow Trench ® Bed 0 Mound
• Other
Phone: No. of Bedrooms:
(907) 227-8650 3
Soil Rating:
*0.5 GPD/sq. R.
Total Depth from original grad&
SEE DWG. Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade:
SEE DWG.
Gravel depth beneath pipe:
0.53
Ft.
Ft.
Subdivision: Block: Lot:
SAMPSON ESTATES 1 2
Fill added above original grade:
SEE DWG. Ft.
Grovel length:
41 Ft.
lownsnip: — Konge: — Section: —
Gravel width:
26
Bede Number of lines:
5
Diebance between linea:
5 R
SEPARATION DISTANCES
FL
Total absorption area'
Number of trenches:
Dial. between trenches:
— R
To
From
Septic
Tank
Absorption
Feld
Lift
Station
Holding
Tank
Public/Private
Sewer Lines
1066 SQ. R.
—
Well
1001+
too'+
100'+
-
25'+
TANK 0 Septic E S.T.E.P. ■Holding • Other
Surface water
1001+
1001+
100'+
—
Manufacturer:
ANCHORAGE TANK
Capacity:
1250 Gal.
Lot Line
5'+
.. R:
5'+
-
N/A
Material:
STEEL
Number of compartments:
2
Foundation
5'+
101+
5'+
-
LIFT STATION
Curtain Drain
Manufacturer.
Capacity:
NONE KNOWN
ANCHORAGE TANK
1250 Gal.
Remarks: OLD TANK WAS DECOMMISSIOED PER UPC
lump ori Mel at:
Pump off level at:
High water alarm at:
41"
41"
45,E
BED WAS RE-BUILT
Pump Make & Model:
El ctricnl Inspections performed by:
*PER ORIGINAL TESTHOLE
20 OSI 05 HHF
J ELECTRIC, INC.
*WAI
*V.fR REQUESTED;
PIPE MATERIAL
House to tank Tank to
-
03034 SCH40
drainfield
Installer JR'S SEPTIC
Drainfield SCH40 C0/MT D3034
Inspector GEG, Ltd.
BENCH MARK (Assumed elevation)
Inspection
100.00 R,
Dates: 1st 8/10/12 2nd 8/13/12
Location and Description`
3rd 8/13/12 4th -
DOOR THRESHOLD (SIDE/GARAGE)
Development Department Approval
Conditional approval: Date
ENGINEERSCommunity
oob0000
kkk
ooP� .. 4NO
is:.4•if `•-5700
/
Q•.J 1 �-
9 CE
44od pro
000000�o
® D
L'�elernessr 0
3 :' ®oO
fession000
Approvedc� hi fDate F-27-12-
•//
g-/6../Z
(?.SV 1 S ED
PERMIT NUMBER:
OSP121197
AS -BUILT DRAWING
PARCEL ID NUMBER:
051-822-20
A
B
FCO
19.20
29.07
ST1
22.08
56.39
ST2
28.08
59.74
MH
29.83
60.73
MT1
17.50
43.00
MT2
39.47
53.96
MT3
46.50
12.60
MT4
57.95
34.23
SAMPSON
ESTATES;
BLOCK 1,
LOT 1
NEW BED
RE -BUILT
NEW 1250 GALLON
STEP TANK
T
ED
MT4 _
ra—_-- S1MT3 8
I I
I I
I I
I I
I I FCO
I _ EXISTING 3
BEDROOM HOUSE
EDGE OF DRAINRELD IS APPROXIMATELY
17' FROM TOP OF CUTBANK. WITH A
25% IMAGINARY SLOPE STARTING 2.5
FEET ABOVE THE INVERT OF THE
DRAINFIELD THE IMAGINARY SLOPE WILL
NOT DAYLIGHT PRIOR TO 50 FEET.
GARNESS ENGINEERING GROUP, Ltd.
CONSULTANTS & GENERAL CONTRACTORS
3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE. AX 99507 • PHONE (907)337-8179 • FAX (907)338-3948 • 'AFBORE: www.8ammmn9NnmHn9.cam
PREPARED FOR:
ERNEST AND DEBORAH STEPHENS
PHONE NUMBER:
227-8650
LEGAL DESCRIPTION:
SAMPSON ESTATES; BLOCK 1, LOT 2
TYPE OF WORK:
AS—BUILT DRAWING
PAGE NUMBER:
2 OF 3
DRAWN BY:
PNB
DATE:
8/15/12
SAMPSON
ESTATES;
BLOCK 1,
LOT 3
SCALE:
/4
e tr
7954 a;G
42,13,1 .4"45/
n „ I
r0fessio9`oo0`
(Rev. 01/05)
RevysC-D
GARNESS ENGINEERING GROUP, Ltd.
CONSULTANTS S GENERAL CONTRACTORS ----
3701 E. TUDOR ROAD. SME 101 • INCHOR4GE, N( 99507 ' PHONE (907)337-6179 • FAX (907)338-3218 WEBSITE: www.9amevm9ineeringcom
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
DEBORAH STEPHENS 227-8650 3 OF 3
LEGAL DESCRIPTION:
SAMPSON ESTATES; BLOCK 1, LOT 2
TYPE OF WORK:
WAIVER REQUEST (REVISED)
DRAWN BY:
PNB
DATE:
8/27/12
PERMIT NUMBER:
OSP121197
AS -BUILT DRAWING
PARCEL ID NUMBER:
051-822-20
TOP OF TANK
AT INLET = 96.88
ST1
FINAL GRADE = 100.13-100.36
7" INSULATION
ST2 MH
INVERT OF BUNG
AT INLET = 96.26
BED WAS RE -BUILT
MT
TOP OF TANK
AT OUTLET = 96.85
7 FINAL GRADE
= 99.92+
TOP OF SAND ELEVATION IS
ALSO ELEVATION OF ORIGINAL
BOTTOM OF BED.
INSULATION
FILTER FABRIC
MT
0
ORIGINAL GRADE -
LIMITED TO REMOVAL
OF CONTAMINATED
MATERIAL
26' WIDE
TOP OF SAND
= 97.00
BOTTOM OF EXCAVATION
= 96.00-96.33
INVERT OF DISTRIBUTION UNE = 97.53 (AVG.)
THE DISTRIBUTION LINE IS 1.25 INCH PVC WITH
} INCH HOLES SPACED 6 FEET ON CENTER. (6
HOLES PER LATERAL/30 HOLES TOTAL.
GARNESS ENGINEERING GROUP, Ltd.
CONSULTANTS & GENERAL CONTRACTORS
701E MOOR ROAD, SUITE 101 • NICHOMCE AK 99507 • PHONE (907)337-6179 a FAX (007)338-3116 WEBSITE: wngommenolneering.
PREPARED FOR:
ERNEST AND DEBORAH STEPHENS
PHONE NUMBER:
227-8650
LEGAL DESCRIPTION:
SAMPSON ESTATES; BLOCK 1, LOT 2
TYPE OF WORK:
PROFILE AS -BUILT DRAWING
PAGE NUMBER:
3 OF 3
DATE:
8/15/12
19 G-14-2012 22:40 FROM:JR'S SEPTIC PUMPING 9073449821
14 CUIC r.4ow-1 J uecviweisum LIC auriiu &oo page 1
.1 ELECTRIC LLC
6732 E, 99thAVE.
ANCHORAGE, AIC, 99507
Augest 14, 2012
Flintstone Enterprises
1300 Oren St.
Anchorage, Ak, 99515
RE: Earnest Stephens
23632 Golith St. Sampson Estates
Peters Creek, Ak Lot 1 Block 2
TO:338324S P.1
This letter is to certify the 3 Electric LLC wired septic
lift station and alarm at the above address in accordance
with the NEC and MOA codes.
Line Sagge
:7 ELECTRIC LLC
Contr. Lic 1) 34469
On -Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSP121197
Tax Code Number: 05182220000
Work Type: Septic Upgrade
Permit Effective Dates: July 24, 2012 to July 24, 2013
Design Engineer: GARNESS ENGINEERING GROUP LTD
Subdivision: SAMPSON ESTATES
Site Legal Address: SAMPSON ESTATES BLK 1 LT 2 G:1560
Owner/Address:
STEPHENS DEBORAH L & ERNEST L
PO BOX 670993 CHUGIAK AK 995670993
Site Mailing Address: 23632 GOLIATH DR, Chugiak
Lot Size in Sq Ft: 53783
Total Bedrooms: 3
This permit is for the construction of:
Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Special Provisions: The permit includes waiver OSP121198, allowing the drainfield to be a
maximum of 26 feet wide and the drainfield to be a minimum of 20 feet from a 25% or greater
slope.
Received By:Date:
Issued By: Date:
Municipality of Anchorage
P.O. Box 196650 • 4700 Elmore Road
Anchorage, Alaska 99519-6650 . (907) 343-7904 • Fax (907) 343-7997
http://www. mu ni.org/Onsite
Development Services Division
On -Site Water and Wastewater Program
**** VARIANCE/WAIVER REVIEW ****
Waiver#: 05P121198 COSA#: Permit#: OSP121197
PID#: 051-822-20
Legal Description: Sampson Estates. Block 1. Lot 2
Engineer: Garness Engineering Group
Applicant: Ernest & Deborah Stephens
Your request for a waiver of the required 50 foot horizontal separation from the absorption field
to a 25% or greater slope has been approved. The approved separation distance is 20.0 feet.
Your request for a waiver of the required 15 . foot maximum drainfield bed width has been
approved. The approved size is 26.0 feet.
Your request for a waiver of the required 10 foot horizontal separation from the absorption field
to property line has been approved. The approved separation distance is 0.0 feet.
This waiver approval applies to the existing absorption field only. Any future upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
® The affected adjacent property owner(s) have been given a 7 day notice regarding this
waiver. The notice was sent out on 8/27/12.
❑ Notarized letter(s) of non -objection have been received from the owner(s) of the affected
adjacent property.
❑ Adjacent properties are not affected by this waiver.
Waiver is Granted: X Waiver is not Granted:
Date: ciM.47 Approved by.
Rec#: 08328G Amount: $200.00 Date Paid: 7/16/12
•
Name of Reviewer
**** VARIANCE/WAIVER REVIEW ****
GARNESS ENGINEERING GROUP, Ltd.
August 23, 2012
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Rd.
P.O. Box 196650,
Anchorage, Ak 99519-6650
(907) 343-7904
Ref: Lot Line Waiver Request for Sampson Estates; Block 1, Lot 2,
To whom it may concern:
We request that your department issue a 0 -foot lot line waiver from the west property line to the
re -built bed. The separation distance between the bed on Lot 2 and the drainfield on Lot 1
exceeds 10 feet. The encroachment had existed for over 19 years prior to the bed being re -built
and the encroachment was not discovered until after the bed had been re -built and a new as -built
survey was developed. We are unaware of any adverse impacts this waiver would have on
adjacent wells or septic systems.
If you have any quer j,ons, please contact us at 337-6179 Thank you for your assistance.
a
Sin ely,
�
Jeffer}y,A, '
Presid'ntt
ne iE., M.S.
3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507-1259
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.gamessengineering.com
MUNICIPALITY OF ANCHORAGE
Community Development Department I t=
Development Services -
On -Site Water & Wastewater Program
Mayor Dan Sullivan
On -Site Sewer/Well Permit Application
For A Single Family Dwelling
Parcel I.D. 051 la a --DC
Property owner(s) ERNEST & DEBORAH STEPHENS
Mailing address 23632 GOLIATH DRIVE *CHUGIAK, AK 99567
Phone: 907-343-7904
Fax: 907- 343-7997
Day phone 227-8650
Site address 23632 GOLIATH DRIVE *CHUGIAK, AK 99567
Legal description (Sub'd, Block & Lot) SAMPSON ESTATES; BLOCK 1, LOT 2
Legal description (Township, Section & Range)
Lot Size Sq.Ft. Number of Bedrooms 3
THIS APPLICATION IS FOR:
(® all that apply)
Absorption Field
Septic Tank
Holding Tank ❑
Privy ❑
Private Well ❑
Water Storage ❑
THIS APPLICATION IS AN:
Initial ❑
Upgrade
Renewal n
THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR:
SLOPE WAIVER & BED WIDTH GREATER THAN 15 FEET WAIVER.
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.
GARNESS ENGINEERING GROUP, Ltd.
(Signature of property owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Soo
-7-1[col la
Waiver Fees a no -
2 1 Date of Payment:
Receipt Number: 033 d B ei Receipt Number: 083BS
r�sP/ //Q
Permit No.
35plal/q -
Waiver No.
(Rev. 01 /11)
VAR ESS ENGINEERING GROUP, Ltd.
=-.
CONSULTANTS & GENERAL CONTRACTORS
July 12, 2012
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Rd.
P.O. Box 196650,
Anchorage, Ak 99519-6650
(907) 343-7904
Ref: Proposed Septic Upgrade for Sampson Estates; Block 1, Lot 2
To whom it may concern:
The existing 3 bedroom house is served by a private well and septic system. The drainfield is in a
state of failure and needs to be upgraded. We are proposing to rebuild the existing drainfield and
install a new 1000 gallon septic tank or 1250 gallon STEP tank if gravity flow cannot be
achieved. The proposed re -built bed will be 26 feet wide and 41 feet long (same as previous
install). A testhole was excavated on the east side of the property on 7/6/12 to a depth of 10 feet
and groundwater was found to be at 5 feet. Due to separation distance requirements to
groundwater and topography around the testhole it was determined that re -building the existing
bed was the best option for the property
1. SOILS: See the 1993 soil log (attached) which shows the soil classifications, groundwater
monitoring, and the percolation test results.
2. DRAINFIELD DESIGN: See attached design drawing for drainfield specifications.
3. SURFACE WATERS: The proposed re -built drainfield will be installed greater then 100'
from any surface waters.
4. TOPOGRAPHY & WAIVER TO CUTBANK: As can be seen on the attached design
drawing the topography around the drainfield is relatively flat. There is an existing cutbank
approximately 20 feet from the existing bed. We request that a 20' waiver be issued from the
proposed re -built bed to the existing cutbank. The encroachment has existed for 19 years without
any signs of the existing bed daylighting. In short there is minimal risk associated with the
grating of this waiver.
5. WAIVER TO BED WIDTH: The existing bed has dimensions of 26 feet by 41 feet. We are
proposing to re -build the bed with the same dimensions as before, however a request for a waiver
is required for any proposed bed with a width larger than 15 feet. In short, we request your
department issue a waiver to allow a width of 26 feet for the proposed re -built bed. Due to site
3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507-1259
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com
constraints and the fact that the existing bed has served the home adequately for the past 19 years
we believe there to be minimal risk associated with the granting of this waiver. Construction
methods will be incorporated to insure that equipment does not "walk" on the bottom of the
excavated area.
Ground water monitoring (G.W.M.) from 1993 was dry to a depth of 12 feet. After the
contaminated sand is removed, MOA sand will be imported and built to an elevation equal to the
existing bottom of bed or slightly higher.
We are unaware of any adverse impacts this installation and granting of the waiver request
would have on adjacent wells or septic systems. If you have any questions, please contact us at
337-6179 Thank you for your assistance.
erely, 11-4
ettIBJ �
alines , P.E., M.S.
Pres
NO E: Attached is a site plan drawing and a design drawing, which are all part of the design
package for this septic system. (Contact G.E. G. Ltd. for 7 page construction specification letter.)
3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507-1259
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com
/ SAMPSON
/ / •J ,K.. / -,/ ESTATES;
SAMPSON / SAMPSON ,%� 'y \ / /'NBLOCK 4,
ESTATES; / ESTATES; �y;; \ / �\ LOT 26
BLOCK 4, / BLOCK 4, '.j, / SAMPSON
LOT 29 T LOT 28 'N:'jy \1 ESTATES; BLOCK I \
1 4, LOT 27
:. '.
1D0' W9 1 RADIUS /„ `�
RADIO
II i
_Hp 0' WELL RA
Y
-----__
`= -- 7-7-r
-./>\ \/ \\/iX\
/ _LI�T\\\>. \ \
_�
,-' 160 Er- RADI S
—L — 10 WELL •ADIU 100' WELL R DIUSjESTAT
SAMPSON
I I [ BLOCKES;
\ r` / LOT 3 /
\ ESTATES; \ j: �: / /
N. /
GLENN VIEW NORTH S/D; LOT 1 \N.
LOT 13, BLOCK 1, ---
PUBLIC WATER
PUBLIC WATER
PUBLIC WATER
SAMPSON ESTATES TRACT A
SCALE:
1” = 100'
GARNESS ENGINEERING GROUP, Ltd
701 E. TUDOR ROAD. SUITE 101 • ANCHORAGE, AC 99507 • PHONE (907)337-6179 • FAX (907)338-3218 WEDS RE: ww.gamwaenglnearing.cam
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
DEBORAH STEPHENS 227-8650 1 OF' 2
LEGAL DESCRIPTION:
SAMPSON ESTATES; BLOCK 1, LOT 2
TYPE OF WORK:
SITE PLAN
DRAWN BY:
PNB
DATE:
6/28/12
DESIGN CRITERIA:
NUMBER OF BEDROOMS: 3
GALLONS PER DAY (GPD): 450
PERCOLATION RATE/S: *10
PROPOSED APPLICATION RATE: 0.5
MINIMUM DRAINFIELD SQ.FT.: 900
PER 1993 SOIL LOG ON FILE AT MOA
DRAINFIELD DESIGN:
MAXIMUM DEPTH:
REMOVE CONTAMINATED MATERIAL
WIDTH: 26 FEET
LENGTH: 41 FEET
M.0.A. APPROVED SAND FILTER:
EQUAL TO OR HIGHER THAN ORIGINAL ELEVATION
EFFECTIVE: 0.5 FEET
REDUCTION FACTOR: N/A
ACTUAL SQ.FT.: 1066
GEG, Ltd. HAS A 7 PAGE SPECIFICATION
LETTER THAT PERTAINS TO THIS DESIGN.
TO OBTAIN A COPY OF THE LETTER
CONTACT GEG. BY PROCEEDING FORWARD
WITH THIS INSTALLATION, THE ENGINEER,
WELL DRILLER, CONTRACTOR AND
PROPERTY OWNER AGREE THAT THEY
HAVE READ THESE SPECIFICATIONS AND
AGREE TO ACCEPT THE TERMS AND
CONDITIONS OUTLINED.
NOTE: THE CONTRACTOR
SHALL HAVE THE WEST LOT
LINE, AND ALL WELL RADII
FLAGGED BY A REGISTERED
LAND SURVEYOR PRIOR TO
CONSTRUCTION.
PROPOSED INSTALLING
5 LATERAL LINES IN
BED SPACER 5 FEET
APART AND 3 FOOT
SIDE WALLS.
SAMPSON
ESTATES;
BLOCK 1,
LOT 1
TH# 1
EXISTING 1000
GALLON SEPTIC
TANK TO BE
DECOMMISSIONE
PER UPC
EXISTING BED
BE RE—BUILT
INSTALL DOUBLE
CLEANOUTS
PROPOSED 1000
GALLON SEPTIC
TANK. INSTALL
1250 GALLON
STEP TANK IF
GRAVITY FLOW
CANNOT BE
ACHIEVED.
SAMPSON
ESTATES;
BLOCK 1,
LOT 3
GARNESS ENGINEERING GROUP, Ltd.
3701 E. RUDOR ROAD, SUITE 10
-:-: CONSULTANTS & GENERAL CONTRACTORS -- .--..,........_ ..._..__..:
HORACE. AK 99507 • PHONE (907)337-8179 • FAX (907)338-321fi • WEOSRE: www. gomeaxnglneerin4eern
PREPARED FOR:
ERNEST AND DEBORAH STEPHENS
PHONE NUMBER:
227-8650
LEGAL DESCRIPTION:
SAMPSON ESTATES; BLOCK 1, LOT 2
TYPE OF WORK:
SEPTIC SYSTEM DESIGN UPGRADE
(Rev. 01105)
PAGE NUMBER:
2 OF 2
DRAWN BY:
PNB
DATE:
7/11/12
GARNESS ENGINEERING GROUP, Ltd.
701 TUDOR ROAD. SURE 101 • ANCHORAGE,
99507 • PHONE: (907)337-6179 • FAX: (907)336-3246 • WEBSOE: gameeeengineeng.com
SOIL LOG - PERCOLATION TEST
LEGAL DESCRIPTION: SAMPSON ESTATES; BLOCK 1, LOT 2
PERFORMED FOR: ERNEST & DEBORAH STEPHENS
DEPTH ORGANICS
(feet)
1--
-
2 —
2-
3 —
3-
4 —
4-
10
10
11
12
13
14
15
16
17
18
19
20
B.O.
ML W/ SOME CL,
GRAVEL,
COBBLES
TEST HOLE #1
SOIL CLASSIFICATIONS
O�
s°0 0°0°
GW
GP
GNI
GC
SW
SP
SM
SC
DATE: 7/6/12
ORG
ML
CL
OL
MH
CH
OH
DEPTH TO
GROUNDWATER
DATE
DRY
7/6/12
5'
7/9/12
7/9/12
1
1:30
—
SEE ATTACHED SITE PLAN
SCALE:
DATE
READING
CLOCK
TIME
NET TIME
(MINUTES)
WATER LEVEL
READING
NET DROP
(INCHES)
7/9/12
1
1:30
—
6.00"
—
2
2:00
30
1.875"
3.50"
3
2:00
—
6.00"
—
4
2:30
30
2.50"
3.50"
5
2:30
—
6.00"
—
6
3:00
30
2.50"
3.50°
7
3:00
—
6.00"
—
8
3:30
30
2.50"
3.50"
PERCOLATION RATE 8.57 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES)
TEST RUN BETWEEN 2 FT. AND 3 FT.
A FOUR HOUR PRESOAK WAS PERFORMED: ® YES ❑ NO
SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORMED BY:
COMMENTS: PERCOLATION RESULTS ARE WITH IN 1/16TH OF AN INCH
ROB CAMPBELL
PERFORMED BY GEG, Ltd. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WA PE FORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: (2
5.125'
2.5'
FLAT
50'+
SCALE: 1 "=10'
GARNESS ENGINEERING GROUP, Ltd.
6000p0
4p
(
<t•-00 `
00
3701 E. TUDOR ROAD. surIE 101 • ANCHORAGE. AK 99507 • PHONE (907)337-8179 • FAX (907)338-3246 WEBSITE www.gameesenglneeMg.conn
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
DEBORAH STEPHENS 227-8650 3 OF 3
LEGAL DESCRIPTION:
SAMPSON ESTATES; BLOCK 1, LOT 2
DRAWN BY:
PNB
r- A. G.:ness.=
C �3 X04
• 216 2' �cAo
ro f e s 510noa
TYPE OF WORK:
WAIVER REQUEST
DATE:
7/23/12
Jeff Garness
To: Crewdson, James A. (CrewdsonJA@ci.anchorage.ak.us)
Cc: Rob Campbell; Jody Maus
Subject: Sampson Estates, Bl, L2c
Attachments: _0720110347_001.pdf
Jay, attached is a sketch prepared by Jody which shows the location of the test hole. The area for the test hole was
excavated out years ago in order to accommodate construction of the home. According to Rob, the grade at the test
hole is probably 10 feet below the natural/native grade in the area. The drainfield is constructed in an area that is pretty
close to natural/native grade. In short, it is highly unlikely that the groundwater level in the test holes is representative
of the groundwater level at the drainfield site.
The test hole for the drainfield was excavated on 7/12/1993. It was excavated to a depth of 12 feet. No groundwater
was encountered during the excavation or 8 days later when monitored. In regards to the soil percolation rate, the past
performance of the septic system gives us reason to believe that the existing drainfield was adequately sized. The
system was installed in September of 1993 and functioned for 19 years. When inspected in July of 2002 for an adequacy
test, there was 0.5 inches of liquid in the drainfield. A total of 466 gallons was introduced into the drainfield and the
liquid depth rose a total of 3 inches. Sixty minutes later the drainfield recovered to its original level (0.5 inches). Based
upon the life of the drainfield and past performance, there is no reason to believe that it was undersized.
In short, I am asking your department to reconsider the need for additional groundwater monitoring or percolation
tests. The sale of this home is on the fast track, so they need to get the septic system installed ASAP.
Please call or email if you have any questions.
Best Regards... jeff
Jeffrey A. Garness, P.E., M.S.
President
Garness Engineering Group, Ltd.
3701 East Tudor Road, Suite 101
Anchorage, Alaska 99507
Ph: 907-337-6179
Fx: 907-338-3246
website: www.garnessengineering.com
1
L-6-2612 01:32P FROM:PETERS CREEK CHRISTI (907) 688-6893
:LT' WELL
TO:3383246
:a0" _WEL-t. RAUI S 1
100' WELL IIUS SAMPSON j
ESTATES;
/
I BLOCK 1,
/ LOT 3 /
/
1
SAMPSON Ross`
ESTATES; \ trait
BLOCK 1, �
LOT 1'
CSEPTIC
ARI
iJA
2,017
311 641.c,f,.ic5
41.4
6 peltL 6366Lks
likkCOv�*+1
'el\ w4 tJ err
r-
ae
P.1'1
SAMPS1
ESTATE
BLOCK
LOT
p.i Je
ter. o.G 7 53;.$A4
144 7D t.7-Cct
�� R s N
CeFo 5k
029
eer1L1,w ®
1
SAMPSON ESTATES TRACT A
•
Municipality of Anchorage Page of Z
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: S co 930Zio PID Number 061— %aa' -ac)
Name: M A NV Co --4t 2 -CA -1'N,
Wastewater System: k New ❑ Upgrade
Address: Pa Qox 610485 CI --UG AK, 3 9 541-
�7
ABSORPTION FIELD
Phone:
688"--11,56
No. of Bedrooms:
3
❑ Deep Trench ❑ Shallow Trench eJ Bed ❑ Mound 0 Other
LEGAL DESCRIPTION
Soil Rating:
cacn) D S GPD/Sq. Ft.
Total Depth from original grade:
51
Lot: Bltk: Subdivisli9n:
a. Sm(JSq� (^St
Depth to pipe bottom fromooriginal grade:
52- FL
Gravel depth beneath pipe
O -5.Ft.
Township:
-7.151J
Range:Section
1?
1?
N w Yit 5 3
Fill added above original grade:
PC Ft
Gravel widt
Gravethe
l len
41.0
Numbef lines:
Ft.
Distance between lines:
Ft.
WELL:New ❑Upgrade
WELL:
Classification (Private, A,B,C):
PRIVA-- E
Total Depth:
Ft.
Cased To:
Ft.
Total absorption area:
106G SQ. Ft.
Pipe material:
'F -S16) -3°34
Driller:
Date Drilled:
Static Water Level:
Ft.
Installer:
MM4M_ C.:1-1Ncr
Date installed:
5 T ID 93
Yield:
GPM
Pump Set at:
Ft.
Casing Height Above Ground:
2411
TAN K
SEPARATION DISTANCES
,, Septic ❑ Holding ❑ S.T.E.P.
To
From
Septic
Tank
Absorption
Fieelld�.r
Lin
Station
Holding
Tank
Public/Private
Sewer Lines
Manufacturer:
C ProiZA -
Capacity in gallons:
�^.'
i �6 d GAL
14-67
4-166
+ 1C
Material: 5T E fit"
Number of Co artments:
Watere
+(0'
4-104
-- x'
LIFT STATION
Lot
Line
45,
-4•60
Ig'
H"ZS'
Size in gallons:
Manufacturer:
Foundation
4,
13'
—
"Pump on" level at:
"Pu.' 4 • f" level at:
High water alarm at:
Curtain
Drain
�r
+�'
+ZS,
Pump Make ;•. (el
Electrical Inspections performed by: -
Remarks:
BENCH MARK
Location and Description:
Qate-A e SI. Pra
AssumedElevation:
)0Ft
,.:egF 1
()OFAL4®®‘-
®
PW SEAL
it
a
G,5)--2-0-45Z
Inspections by: C s vo 5 Dates: 1st `'"� 93
D
performed S
2nd 9-1-}c13 `
N HENRY H. WILSON 01
1732-E �A,y'Z' Of
0®`b$SSIONp� 'G® Ater
®®®®®
_�
Department of Healthan'd Huma vices approval
-/
Reviewed and approved ` � ' �/ - Date./?/� "`
l
72-013 (Rev. 9/91) MOA 25
WASTEWATER AS -BUILT PAGE 2 OF 2
LOT 2 BLOCK 1 SAMPSON ESTATES PERMIT SW930270
PID #
MODIFIED 5-12--94
(4461,44 M.i.)
A 15.0
B 35.0
C 25.5
D 28.0
FRAME HOUSE
48.0
18.0
41
o
z
INSTALLED MONITOR TUBE 5-11-94
2' H10 IRSJLATION
ORIGINAL GRADE
0
100.0
1000 GALLON
ANCHORAGE
SEPTIC TANK
FINISHED GRADE
0.5' SEWER ROCK
0.5' SEWER ROCK
z
FILTER FABRIC
0)
0.5
BOTTOM OF BED /
4' PERF PIP
96.0
BOTTOM OE TEST HOLE ` 89.5
n5
Permit No 5W 9;0Z-9-0•
Page 2 of
Municipality of Anchorage
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 Description: Z, Z 13I SZ.>rp o.% Es-I-.�-4es
PID No
A 15.0
B 35.0
C 25.5
D 28.0
FRAME HOUSE
48.0
C.
MT
4
PROF' LINE
LATION
1,000 G LION
ANCHORAGE
SEPTIC TANK
ORIGINAL GRADE
-F ALS N
FINISHED GRADE
0.5' SEWER ROCK
0.5' SEWER ROCK -
I= FILTER FABRIC \
BOTTOM OF BED /
_L6.5
BOTTOM DF TEST HOLE ( 39.5)
1
FN
Ph'OFEss)(10-
72-013 A (2/91) MOA 25
AS = I )LILT SURVEY
8,199
LJ
z
I HEREBY CERTIFY THAT A SURVEY OF
LOT 2 BLOCK 1 SAMPSON ESTATES SUB
WAS MADE ON DECEMBER 29 .1993 ,AND THAT THE IMPROVEMENTS
SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND DO NOT
OVERLAP OR ENCROACH ON THE PROPERTY LYING ADJACENT THERETO,
THAT NO IMPROVEMENTS ON THE PROPERTY LYING ADJACENT THERETO
ENCROACH ON THE PREMISES IN QUESTION AND THAT THERE ARE NO
ROADWAYS, TRANSMISSION LINES, OR OTHER VISIBLE EASEMENTS
ON SAID PROPERTY EXCEPT AS SHOWN HEREON. IT IS THE
,RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF
ANY EASEMENTS, COVENANTS OR RESTRICTIONS WHICH DO NOT APPEA
ON THE RECORDED SUBDIVISION PLAT. UNDER NO CIRCUMSTANCES
SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OR FOR
ESTABLISHING BOUNDARY 01? FENCE LINES
CONSTRUCTING
ENGINEERS
HC83 BOX 192A MYRTLE DR
EAGLE RIVER, AK, 99577
RTele. (907) 346-2000
(907)-694-9098
DATE: JAN 27, 1994
SCALE: 1"=60'
GRID:, S3 T15N R1W
AS IHL IALT SL
00
o
cb
�V�EY
S (3a
16-
F
I1
LJ
r)
z
HENRY H. WILSON �v 0'
3082-S
%SSION AL Vt
I HEREBY CERTIFY THAT A SURVEY OF
LOT 2 BLOCK 1 SAMPSON ESTATES SUB
WAS MADE ON DECEMBER 29 ,/993 ,AND THAT THE IMPROVEMENTS
SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND DO NOT
OVERLAP OR ENCROACH ON THE PROPERTY LYING ADJACENT THERETO.
THAT NO IMPROVEMENTS ON THE PROPERTY LYING ADJACENT THERETO
ENCROACH ON THE PREMISES IN QUESTION AND THAT THERE ARE NO
ROADWAYS, TRANSMISSION LINES, OR OTHER VISIBLE EASEMENTS
ON SAID PROPERTY EXCEPT AS SHOWN HEREON. IT IS THE
RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF
ANY EASEMENTS, COVENANTS OR RESTRICTIONS WHICH DO NOT APPEA
ON THE RECORDED SUBDIVISION PLAT. UNDER NO CIRCUMSTANCES
SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OR FOR
ESTABLISHING BOUNDARY OR FENCE LINES
CONSTRUCTING
ENGINEERS
HC83 BOX 192A MYRTLE DR
EAGLE RIVER, AK, 99577
Tele. (907) 346-2000
(907)-694-9098
DATE: JAN 27, 1994
SCALE: 1" =60'
GRID:, S3 T15N R1W
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW930270
DESIGN ENGINEER:CONSTRUCTING ENGINEERS, INC.
OWNER NAME:SLAYMAKER RONALD F
OWNER ADDRESS:2418 EAST 86TH COURT
ANCHORAGE, AK 99507
PARCEL ID:05182220
LEGAL DESCRIPTION: SAMPSON ESTATES BLK 1 LT 2
LOT SIZE: 53783 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
m
-ci3
93
DATE ISSUED: 8/04/93
EXPIRATION DATE: 8/04/94
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 DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
�bf CteGi
DATE: 8//d1
DATE:
8 •3
2
0
J
W
P
2
3
LOT AREA
LESS: PERIMETER SETBACKS,
BUILDING FOOTPRINT
TOTAL AREA AVAILABLE FOR
ABSORPTION SYSTEM
WATER AND WASTEWATER ABSORPTION SYSTEM
040"-
53,Svo sP
29,2)oa sC
2.41,0 co s C
44`:om 11jj
• t
F.'O. 1732-E VS
Juno 22, 19t ;M.. sn
a
r� j ��
SITE; PLAN DETAILS
PROPOSED WATER AND WASTEWATER ABSORPTION SYSTEM
LOT 2 BLOCK 1 SAMPSON ESTATES SUB
PREPARED FOR: MR. :PAUL MEYERS
PO BOX 670495
CHUGIAK, AK, 99567
SCALE: 1" = 100'
CONSTRUCTING ENGINEERS 346-2000
9601 BUDDY WERNER IDR 694-9098
ANCHORAGE, AK, 99516
688-1236
DRAWN BY CAL
7-23-93
DRAWING 8 93-S1-07-6.
ABSORPTION SYSTEM DESIGN DETAILS
36'
t
3'
�
Co
ce
ip
mr---`
.Y(kA
4" K2F(tr
q„ 50 L 1 —
--
Co
CU
N
FRbM tAwY-
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(SC-Grvore 4
44)
4-
0 -
0-
S461,
S46PC TD P¢Eve'.. POl.ibin
"f V PAK
S C1wYxC z0IK
36°
CONSTRUCTION NOTES
1. Bottom of Bed to be scarified prior to placing sewer rock.
2. Contractor to minimize use of mechanical equipment on excavated area.
3. Bed to be level 4. 1" including bottom of bed and distribution laterals.
4. Minimum 2' cover over pipes with 2" HD insulation, or 4' ground cover.
5. Finished installation to be top -soil and seeded.
(!ic-e n,cri
1 4) Q`
OS -�-
FILL
TVPRR
— 25'
4'5oLto M4N)coLq
ABSORPTION AREA CALCULATIONS:
Minimum Required: 3 Bedrooms x 150gpd/bedroom = 450 gpd capacity
Soils rating, proposed addition, 0.5 gpd/sf
Minimum sizing: 450 gpd 4 0.5 gpd/sf = 900 sf absorption area
Bed Design: Use 25'W x 36'L bed (minimum) w/ 5 ea 4" Perf pipes
on 5' centers, each 30' long.
IMPACT ON ADJACENT LOTS: There are no private wells within 100' of this
proposed absorption system. The proposed absorption system has no aIene
impact upon any adjacent lots as shown on attached site diagram.
DESIGN DETAILS
PROPOSED WASTEWATER ABSORPTION SYSTEM
LOT 2 BLOCK 1 SAMPSON ESTATES SUB
PREPARED FOR: MR. PAUL MEYERS
PO BOX 670495
CHUGLAK, AK, 99567
NOT TO SCALE
CONSTRUCTING ENGINEERS346-2000
9601 BUDDY WERNER DR 694-9098
ANCHORAGE, AK, 99516
DRAWN BY CAL
7-23-93
DRAWING # 93-S2-07-6
v
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "I-" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
P L'\ M.ex5
LEGAL DESCRIPTION: L2-51
I
o r5o,,
DATE PERFORMED
Township, Range, Section: N -A-)
1/4
SLOPE
ode, -s e s�Y s k�
lr / PAL
s3tl5N E/0)
SITE PLAN
WAS GROUND WATER
ENCOUNTERED? ND
IF YES, AT WHAT
DEPTH?
Depth to Water Atte nybtrl-s
Monitoring? Date —1'10"'C
S
L
0
P
E
Reading
Date
Gross
Time
Net
Time
Depth to
' Water
Net
Drop
e,
-g- 17-4'3
.0
0
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-
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/
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it66"
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PgaSoA C P
heir %lo 6
PERCOLATION RATE 10t(minutes/inch) PERC HOLE DIAMETER (Rr
TEST RUN BETWEEN 3 FT AND 4 FT
COMMENTS
PERFORMED BY.
�i cJ��r^ C57+'20�s I Cote 2 -
CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE -7,5-q
72-008 (Rev. 4/85)
OM : MMM CONTRPCTING PHONE NO. : G881238
RECEIVED
48 91994
6.46M -6'0'14 0i Anchcrrage---°
Fe eptt PROPinrvices
(!raiftib ttt
'tug
by
moo co, ot.
SULLIVAN WATER WELLS
P.Q. SOX 070272, CHUGIAK, ALASKA W587 • TELSPHQNE 066.2758
:R OF LAND „22 M /7? C4 MYr{.'i. 74G DEPTH OF WELL .•.—
IESS STATIC LEVEL OF WATER rr
.L DESC-RIFFION. 6) r ...13 4, +'rlr',7J^� DRAW DOWN FT,
GALS. PER HR
KININ OF CASING
Starlet Endcd _
IIT NUMBER
OF FORMATION:
t Ft
t_;2_,_ Ft. to_P1
t Ft. to .75 Ft
t. Ft. to 2 F
n Cr‘ Ft. to if; Ft
n /SD Ft to /Ur Ft.
n. J (075 Ft. Ft.
/ 7kFt. to !1Ft.
m /Ft. to iec Ft,
m i 1 Ft
•
From....--- Ft tu.— _ FI•
U%d./%2,01;01./ Ptom I. to,.Ft., ...._..�---•---
eaelW 4 5 C* d d«
%(( 1, l $ea%i .cegeoN .` From—Ft. tn_..Ft.
SA.tt4 C (aa'If.t,4!L From. Ft to Ft
/AU pillA.) From..,.,.._..Ft tom_FI
From . - .... Et. tom,__-. Ft. ----
41:44.4)
m—Ft to Ft..
aro Y S ,,+14,41 Jit. From_ Ft to • ...
^q•at2 ( �J__r1' _bac ✓�Y 4fo i Ft. to—Ft.
C, 1-t?' l u t. •From Ft. to, it
4' 4, LO e2,Loe
.Froth
From —Ft. t$, -- —Ft
From Ft to Ft
From to • Ft • •
Prom Ft. to Ft.
From, . __Ft, to Ft,
m Ft. to ' • Ft.
m•Ft. to—Ft. -
m- -Ft toF't._•
m Ft to Ft._
to Ft. to Ft.
m Ft,
;CL. INFORMATION:
•
From . Ft. to
:•;!'..ktd!tt. r . •� irk, t.::•.;s<rkIslitiiky
EAGLE RIVER, ALASKA
338-5312
JOE GIELAROWSKI
DRILLING CO.
LIFETIME ALASKAN SERVING ALASKA
P.O. BOX 772847, EAGLE RIVER, ALASKA 99577
OWNER OF LAND DEPTH OF WELL
ADDRESS
WELL - SITE
DATE - STARTED
DATE - ENDED
•
STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
GALS. PER HR....r ;:....:;
KIND OF CASING
KIND OF FORMATION:
FROM FT. TO FT. ..^L::3Z;..<;FROM FT. TO FT.
FROM '' FT. TO FT.. ::....... ..s 7,:a7':, FROM FT. TO FT.
FROM FT. TO '' FT. _: ,, '{ FROM FT. TO FT.
FROM ' " FT. TO ... ::.:............ FT..::.:.:::::.. FROM FT. TO FT.
FROM -' =1 FT. TO ')_ FT =' FROM FT. TO FT.
FROM ..u::.::........... FT. TO ' ";:P FT. .2,:;.:.,;.:',.,..-..-,a;:.:;;2....: . -r FROM FT. TO FT.
FROM FT. TO FT. FROM FT. TO FT.
FROM FT. TO FT. FROMMUIiI�IPPTY OF ANCHORAC,
b1 OrHEALTHIt
FROM FT. TO FT. FROM EN FT' ENTAL PROTTECTIOFT. _.---
FROM FT. TO FT. FROM FT. ` JAN 2. 1985 FT.
FROM FT. TO FT. FROM FT t C.E.1.V.EDT.
FROM • FT. TO FT. FROM FT. TO II VV FT.
MISCL. INFORMATION:
L)t Pik
DRILLER'S NAME "'
Municipality
~ U�tmw���m�n��'
sm����������xa�� w�x Anchorage
Development Services
Department
On -Site Water & Wastewater Program
47OOElmore Road
P.O.Box 1gGG5OAnchorage, AK 9951946650
vmwwvxd.nnohoraga.akum e
343-7SO4
CERTIFICATE OF ON-SITE SYSTEMs APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
1. GENERAL INFORMATION Expiration Date:
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
SAMPSON ESTATES;.... BLOCK 1, LOT 2
23632 GOLIATH DRIVE *CHUGIAK, AK 99567
23632 GOLIATH DRIVE *CHUGIAK, AK 99567
Day phone
Real Estate Agent BETH WEISER W1 PRUDENTIAL _ Day phone
Mailing address
Unless otherwise requested, CDSAwill baheld byDSD for pickup.
2. NUMBER OF BEDROOMS:
7G2-3111
TYPE OF WASTEWATER DISPOSAL:
Individual Well Is Individual On-site ��
|nd��ua|VVaterStorage �l |nd��ma|Holding tank
--
CornmunityC|aoa___VVeU [l Community On-site = -1
Public Water System - �l Public Sewer
--
The Municipality of Anchorage Development Services
tment
,(uuu*/mane�on|yD��n - --- h7 -- - - Systems
- -
Approval u/�/�p/ea�nosnonagwen paragnaph4byanindepandent professional civil
engineer registered in the State ofAlaska. Ce��oatoaofOn-G�eGystannaApproval are naqu|na' ------nafer
oftitle (except between spouses) for pnopo�iessenxadbvasing|e4bmi|yon-site vvaotevv8bardin---|-~~~
wateraupp|yoyabann D8Do|auiao {�[)8A '--- -'-~'
� issues suponmaqu�ottohnm�ownero� Certificates of
Approval are valid for 90 days from the date of issue for properties served by a private or Class CvveU and may
bereissued xvithnavvwater samples. ((�e�ifioataemay bereissued for aperiod ofuptoone 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 engineers work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, ) 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 andlor wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. t 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 andlor 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
GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system unde.- 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 soils condition, groundwater 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 of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
Phone 337-6179
Date t
�`3�- OF. A °fffid
TH ..... ��
n
f r. •A ....... ss,* ..
E-79 3
0
other person or party is not authorized, nor will it confer any legal right whatsoever. 11(1{1il
5. DSD SIGNATURE
_AzApproved for bedrooms.
Disapproved.
Conditional approval for
OFAj
rfirr��
y ON-SITE
MATER AND =_
WASTEWATER _
bedrooms, with the following stipulations: % PROGRAM
Attachments: /
COSA Checklist C•� Arsenic Advisory
Septic System Advisory _ Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other
By: Original Certificate Date: ` 1
c
(Rev. 11/05}
CERTIFICATE OF ON—SITE SySTEms /\ppR(}V/1L CHECKLIST
Legal Description: Parcel |[l
A. WELL DATA *PER SURROUNDING WELL LOGS
051-822-20
vVel/type F-Rimr-_ n*.u.orCprovide PVVb|D# ±��-
Well Log (YYN) YES
Date completed __9/93Sanitary seal (YYN) YES
Wires properly protected (YYN) YES
Total depth _20%2_ -ft. Casedhn ft.
Casing height (above ground) in.
FROM WELL LOG
AT INSPECTION
Date oftest 9/93
6/22/12
Static water level 1 ft.
164�
Well production 1 —9 -P.M.
4 9 -P.M.
WATER SAMPLE RESULTS:
Coliform 0_colonies/100 mi. Nitrate 1.94 mg./L.
CnUeobad by:
Arsenic: _-NlD_ug,/L Oeba ofsomp|e:
B. SEPTIC/HOLDING TANK DATA
TankTvpe/K8aterie|
Date installed._
Tank size _l�50}_gal. Number ofCompartments 2
C}emnouta (Y/N) YES
Foundation cleanout (Y7N)YES Depression over tank (YYN) NO
High water alarm (Y7N) YES
Date ofpumping Pumper —
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft`zr 0.5
System type BED
Length 41 ft. Width 26 ft.
Gravel below pipe 0.53�
Total depth _*2�2+ ft. Ef[ absorption area 1068 ft' Monitoring tube YES Depression over field NO
Date ofadequacy test NEW Reou|ba(Pasa/Fai|) PASS For 3 bedrooms
Fluid depth in absorption field before baat _— in. Water added _—_gal. New depth _— .in.
Elapsed Time: _— _min. Final fluid depth — in.
Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12mo.)(YYN&type) NONE |fyes, give date ____—�___
Date installed 8/10-13/12 Size in gallons 1250 — Manhole/Access (YIN)
YES
"Pump on" level at 41 in. "Pump off" level at 41 in. High water alarm level at 45 in.
Datum BOTTOM OF TANK Cycles tested NEW Meets alarm & circuit requirements? YES
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ — On adjacent lots 100'+
Absorption field on lot-- 100'+
Public sewer main N/A
Sewer /septic service line
25'+
Animal containment areas 50'+
Building fbundabon 5'+ — Property line
Water main N/A
Wells on adjacent lots 100'+
NEMEM
*01
On adjacent lots 100'+
Public sewer manhole/cleanout N/
Holding tank N/A
Manure/animal excrete storage areas 100'+
5'+
Absorption field 5'+
Water service line 10'+ - Surface water.
100,+
Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ —Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
WR#OSP121198 (20'T0 EXCESSIVE SLOPES & 26' WIDE BED) *WAIVER REQUESTED.
`
G. ENGINEEWS CERTIFICATION A=7_0F
i certify that I have determined through field inspections and Q q a T x
.•7*.
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date. Jrey Arness.Jute.
Engineer's Printed Name JEFFREY A. GARNESS CE -79 3
Date00p-rof esslo�_G�%'.§
(Rev. 11105)
GARNESS ENGINEERING GROUP, Ltd.
CONSULTANTS & GENERAL CONTRACTORS _:..
65 e I-a\,a10
August 23, 2012
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Rd.
P.O. Box 196650,
Anchorage, Ak 99519-6650
(907)343-7904
Ref: Lot Line Waiver Request for Sampson Estates; Block 1, Lot 2,
To whom it may concern:
We request that your department issue a 0 -foot lot line waiver from the west property line to the
re -built bed. The separation distance between the bed on Lot 2 and the drainfield on Lot 1
exceeds 10 feet. The encroachment had existed for over 19 years prior to the bed being re -built
and the encroachment was not discovered until after the bed had been re -built and a new as -built
survey was developed. We are unaware of any adverse impacts this waiver would have on
adjacent wells or septic systems.
If you have any questions, please contact us at 337-6179. Thank you for your assistance.
'.E., M.S.
3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507-1259
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.gamessengineering.com
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Municipality of Anchorage
Development Services Depettment
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, Ak 99519-6650
www.cl.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-822-20
1. GENERAL INFORMATION
HAA # //nO a-0 e-70
Expiration Date: / (— 2 0 — O &
Complete legal description T,nr 9; Rlnrk 1; Snmpson Estates Subdivision
Location (site address or directions) 23632 Elias Dr.
Current Property owner(s) Tim Sorenson
Mailing address PO Box 670165 Chuoiak, Ax 99567
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_
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
0
Day phone 688-0780
Day phone
Day phone
?_ $.,.__ 512-401-
TYPE
24o -
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
0
0
0
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 ane year with
valid water samples.) Certifid'ates 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. 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 S & S Engineering
Address 17034 N. Eagle River Loop Ste. 204 Eagle River, AK 99577
Engineer's Printed Name Robert C. Cowan
Phone 694-2979
Date i/Sio7-
i ffGINEER y-�s..n4,
`:.
321):::- 114
5. DSD SIGNATURE i'� r•1i ROe(RT C COWAN ; �^
itc j� CE -8801 `-ter
Approved for 3 bedrooms. +tt`^ ~•••....,_..l *.
Disapproved. ,k‘x>>»��-'zh�+''�~�
Conditional approval for bedrooms. with the following stipulations:
Additional Comments
•
& • •• ON-SITE .• •G?
_1;1'; WATER AND n'=
WASTEWATERPROGRAM
• -
�-:
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: I&K P„,t Original Certificate Date: S -- 02
(Pev, 12/001
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lor
2; �/&U- /� $ r1J'roast esr TA Parcel ID: O�/•BU' t)
A. WELL DATA
Well typer% . — If A, B, or C provide PWSID #
Date compleettila -17/
1/ 7 2 J Sanitary seal (WN)
Total depth Z02 -ft.
Date of telt
Static water level
Well production
Cased to 'TtM- ft.
FROM WELL 1,06
-;7'e1'3
/CC ft.
/0 g.p.m.
' Well Log (Y/N) `•/
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
11ZIOz-
/6 ► ` ft.
6.1-
g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi. Nitrate at mg./I. Other bacteria 0 colonies/100 ml.
Date of sample: 1-/M Cl/ Collected by: 5f S ere si 4 Q-falZ r f% -
B. SEPTIC/HOLDING TANK DATA
Tank Type/iiiji4t. irtern c- 4rzGt
Tank size /OM , gal. Number of Compartments !-
Foundation cleanout (Y//N) / yDepression over tank (YIN) • t)
Date of pumping /M/t7 l/ Pumper 0-t7 's
C. ABSORPTION FI LD DATA
_
Date installed q�,r/`J3 Fn:' ' .:n jy.p.d./f 2 or ft2/bdrm)O^C
Length 4/ ft. Width ft.
Total depth 5,5 ft. Eft. /ay rption area /0“ ft2 Monitorin tube Y
,
Date of adequacy test 1 t O Results (Pass/Fail)
r •
Fluid depth in absorption eld before test ../ r in. Water add
Elapsed Time: r/ Omin. Final fluid depth Z• in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) _
Date installed 7/Z7/91
Cleanouts (Y/N) y
High water alarm (Y/N) N
System type ad)
Gravel below pipe O •.0 h.
Depression over field
For 3 bedroorns
gal. New depth 7dr•, in.
Absorption rate >= 4,S U g.p.d.
If yes, give date
D. LIFT STATION `,
Date installed /v P' Size in gallons
"Pump on" level at in "Pump off" level at in.
Datum Cycles tested
E. SEPARATION (STANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/li�.et2Gon on lot SCO it
Absorption field on lot / trJO f
Public sewer main /f/Ar
,veflsC 1 eptic service line 0i'5 f'
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
In.
On adjacent lots / 00 IP -
On adjacent lots / 0 0 11—
Public
't'Public sewer manhole/cleanout l AV/4-
Holding tank A/ / A—
SEPARATION DISTANCES ROM SEPTICIH9L9$N TANK ON LOT TO: /
Building foundation ai — Property line
Water main ./4/-M1- ' Water service line I0 "
Wells on adjacent lots /QO se.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /0 f Building foundation / 0 f` Water main
/ /,
Water Service line �Surface water /0C./ /1.1 fDriveway, parking/vehicle storage 2 +
/
Curtain drain IYAVn fnJAj/ Wells on adjacent lots /C% 4"
F. COMMENTS
Absorption field
Surface water
S
At—
/4 4
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through field inspections and
review of Municipal records that the above systems are
conformance with MOA HAA uidelines fn effect on this date.
b4tot; C. Cows,'
Engineer's Printed Name /
Date g/ 1S/02
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
3 "lJ
02'/ Lr( 714,
Waiver Fee $
Date of Payment
Receipt Number
A I MSti Es *i141180
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # (1 HAA # r,Lo
1. GENERAL INFORMATION
Complete legal description
L ),,fo,, kz.i=3
Location (site address or directions)
Gail zi-1N iDvi C1wci .A
Property owner MPA `91Y\ Day phone 68 s 1236
Mailing address PD�o� b�o4�5 CLogi.2,1<, AK 9956
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA 521
L-5+
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 of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of 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 Co -\s 6-9 ' 'S Phone 46" /694 -966-8
Address 960) e u aAy
We^ n , 1-}�Q3 �iax �9Z A My�rve 9Y
Engineer's signature %�7 • v�"�-v im �L � Date 2-4 - /.7/-
-o,"ea
OFAL\
�� Flov
• i 4 ►YT ... �` lel
6. DHHS SIGNATURE �oA 1732—E G`ww®
OSS! ONA}' E� �
Approved for --g bedrooms. ®®�►'
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
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.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L7'51 Sa...pso 54 Parcel LD.
A. Well Data
Well type ?R VATC If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Date completed Driller
Total depth Cased to Casing height 1.1
z
Sanitary seal (Y/N) Wires properly protected (Y/N)
m v
FROM WELL LOG AT INSPECTION 0t u.) ?�
9
o No
Date of test ro ,:d?:, 7,.
Lo VI Static water level o S
Well flow g.p.m. g.p.m. CV in
Pump levell
Z
SEPARATION DISTANCES FROM WELL TO:
�� ; On
Septic/holding tank on lot I 'adjacent lots +loo'
Absorption field on lot 185' ; On adjacent Tots }1OO
Public sewer main 'f Zoo Public sewer manhole/cleanout -r zoo
Sewer service line 1-100 Petroleum tank +t
WATER SAMPLE RESULTS:
Coliform f' Nitrate O,R`� Other bacteria
Date of sample: )1D19,1 Collected by: C�
B. SEPTIC/HOLDING TANK DATA
Date installed Q 1 93 Tank size Iona Compartments Z
Cleanouts (Y/N) Y Foundation cleanout (Y/N) i Depression (Y/N) I�
High water alarm (Y/N) n/ fi Alarm tested (Y/N)
Date of pumping rvE' Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot I ' On adjacent lots -r 100 Foundation 4
To property line Q'S' Absorption field S Water main/service line +ZS
Surface water/drainage -r 100'
72-026 (3193)' Front
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
11 Vent (Y/N) "Pump on" level at "Pump off - - at
High water alarm level /\/' Cycle
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE F; e IFT STATION TO:
Well on • On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed
9 /93
Soil rating (GPD/Ft2) O. S System type $69
Length 41 Width 2(0 Gravel thickness 1 Total depth9-
Total absorption area /06 6 5•C Cleanout present (Y/N) Depression over field (Y/N) N
Date of adequacy test "—G''" SY5T Results (pass/fail) for Bedrooms
Water level in absorption field before test N P After test
Peroxide treatment (past 12 months) (Y/N) N A If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 16.5' On adjacent lots 1--i O4 Property line ) 2
To building foundation 1 3, To existing or abandoned system on lot ^' A
On adjacent lots 'r- i °es Cutbank -I' So ' Water main/service line .4 --lo'
Surface water +1 O) Driveway, parking/vehicle storage area 1.5
Curtain drain +SOS
E. ENGINEERS CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HM guidelines in effect on t1 : tt of this inspection.
�
s�' OI' Az,,
Signature
Engineer's Name 14c -a3 Qbr 192-P Myv31-1..e Py 995��
Date
I�—G p lv �� ��'"cna� EICNRYI 32i ELSON ��4 /
Air
PA,sslova,i
HAA Fee $ `dZ.
Date of Payment
Receipt Number �S .s� 62. 24.3)
72-026 (3/93)' Back
Waiver Fee $
Date of Payment
Receipt Number