HomeMy WebLinkAboutT12N R3W SEC 15 LT 136AMunicipality of Anchorage
On -Site Water and Wastewater Section - (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP2513363 PID Number: 015-484-19
Dwelling: Z Single Family (SF) ❑ with ADU El Duplex (D) Fj Two Single Family Project: M New V Upgrade
Name
Noel & Fledz Lastimoso
TITr RPON FIELD Existing
A0 PT'
c
F-01 De Trench F-1 Wide Trench F-1 Bed F-1 Mound
Site Address
4601 E 104th Ave
Other
Phone
Number of Bedrooms
Soil Rating1
depth from original grade
5
ISF
17rotai
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original g e Gravel depth beneath pipe
�% . "I Ft.
Subdivision Block Lot
136A
Fill added above original grade Gr h
Ft. Ft.
Township Range Section
12N 3W 15
Gravel width
Ft
Beds: Number of Lines
Dista e between lines
Ft.
SEPARATION DISTANCES
To! Septic I Absorption
Holding Sewer
Lift StationTank
Total absorption area
Number of trenches
Dist- between t
From Tank Field
Line
Ft2'
Well
103'
TANK 0 Septic ❑ S.T.E.P. ❑ Holding 171 Other
Manufacturer
Greer
Capacity
1500 Gal,
Surface Water
100+
Material
Number of compartments
Lot Line;'! 10+
NA
Plastic Deep Burial
2
Foundation 10+
L —&T.ATION
Manufacturer
Capacity
Remarks
Gal,
Alarm location
Electric ailed by
Installer
PIPE MATERIAL House totank Tank to
D3034 drainfield D3034
PCN Inc.
Drainfield CO/MT D3034
Inspector Arcterra Consulting
BENCH MARK (Assumed elevation) 100 ft
Inspdates: ection tri 10/17_/_25 2w 10/17/25
Location and description
5 4'"
3d 104&i
Garage concrete floor
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
OF
Conditional Approval: Date
— --- ----
49 714
KENNETH 'MDUMr
Septic System_N
Approved Date 10/24/2025
CE 7116 of
SS1
Note: this approval does not include well permit requirements.
(Rev 05/02118)
Permit Number:OSP251363
Tax Code Number:01548419000
Work Type:SepticTank Upgrade
Effective Date:
Design Engineer:
Site Legal Address:T12N R3W SEC 15 LT 136A G:2536
Owner:LASTIMOSO NOEL Y & FLEDZ L
Site Mailing Address:4601 E 104TH AVE, Anchorage
Lot Size in Sq Ft:78445
Total Bedrooms:5
This permit is for the construction of:
Disposal Field Septic Tank Holding Tank Privy
Non-Public
Water 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. Coodinate with On-Site staff regarding preferred method.
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
10/9/2025
10/9/2026
ARC TERRA CONSULTING INC
Expiration Date:
¨þ ¨¨¨¨
Issued To:
Issued By:
Date:
Date:
10/9/2025
10/9/2025
ARC TERRA CONSULTING INC
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
Municipality of Anchorage Page
Development Services Department
Building Safety Department
On-Site Water and Wastewater Program, 4700 $. Bragaw SL
P.O. Box 19~o50 Anchorage. AK 99519-6650
wvAv.cLancherage.ak.us (907) 343-7904
ON-~ITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW~0399 PID Number:. 015-484-18
Richard and Sonia Hailer WastewaterSystem: New 'Upgrade
3.0400 Finley Circle Anch. AK 9953.6 ABSORPTION FIELD -
345-5198 Five (5) n~.~*~,~,, os~,~,~r,,,,c~ a~ ~
LEGAL DESCRIPTION .8 c.,~,~,' 3.2.5 n.
136 2.5 n. 3.0
3.2N 3W 15 2.5 n. 50 n.
Private 230 .. 230.. 3.,000 F~ ASTM D3034 PVC
Hefty s/ao/oo 188 n Acreal[e Systems 5/24/00
¥': In'''" s'''': Ic"'~' "~ *~"' ¢'"'"~: TANK
10 c,~ n. >2
SEPARATION DISTANCES El Septic n Holding n $.T.E.P. I-1 Other.
T=~"~o Sep§c AbsorptioeLift Ho~ling ~eli~tPrtvate uan~ax
Tank Flek~ Station Tank S*~,U,e Anchorage Tank 3.,500
~ >3.00 >100 N/A N/A >25' Steel Two
~.,.w.~, >3.00' >100' N/A N/A '~ / LIFT STATION
¥
u~ >5' >10' N/A N/A
F,~ >5' >3.0' N/A N/A ~. ~ "~' .
o,~.~ None Noted ~,~..,~o~
~ BENCH MARK
Well is located on ac~jacent lot. Uotl~ lots are ownec~
~,.. ,~. .........-- . Front Door Stoop
100.0
Engineer's Stamp
~ 51:>4100
Department of Health and Human Services approval ~'. ~.. ·
¢~ ~',,'. CE -4381 .' ~'.~
Revi ,e ,ppr0v by: Dote: ¢- **?;p. ........ .'
O~.~,. ~o.~e} ' e,~ Il ,?:£3' F[ S%~,~,''~?
"" ~ '~ t,.
.......... Municipality of Anch6rage' ' Page 2 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DMSION
P.O. Box 196650 ~ Anchorage, AK 99519-6650 - 343-4744
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number SW000399
PID No. 015-484-18
A B
S1 54.1 19.0
S2 56.3 28.7
C4 66.5 35.5
M1 51.7 723.
C5 151.5 72.2
Alteznate ~ te~
Five
T; Bedroom Well
ORAV~L DRIV~
S1
CE -438!
SCALE 1" = 30'
104TH AVENUE
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DMSION
P.O. Box 196650 - Anchorage, AK 99519-6650 - 343-4744
On-Site Wastewater Disposal System or Well Inspection Report
Page 3 of 3
Permit Number SW000399
PID No. 015.484-18
~500 Gal,
/ ~epttc Ta£
.97.2 / [
197.3
Geotextile Fab~t~
Drainfteld Rock
80.0+' 50'
PROFILE ·AS-BUILT
1" = 10'
~97.2 .
~86.9
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT
Initial
Date Issued; Oct 25, 1999
Expiration Date: Oct 24, 2000
Permit Number:. SW990399
Legal Description: T12N R3W SEC 15 LT 136
Design Engineer:. 0014 Anderson Engineering
Owner Name: Richard & Sonia Hailer
OwnerAddress: 10400 Finley Circle
Anchorage, AK 99516-
Parcel ID: 015-484-18
Site Address:
Lot Size: 32200 SQ. FT.
Total Bedrooms: 5 Permit Bedrooms: 5
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either:. A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Date:
[:i'. :-'-:' 'ANDERSON ENGINEERING .i
;i · 'i-. :.i/: .-. ::' P.'O. BOX240773
:~' :':'-: '- ~NCHORAGE,'AK99524-.'::::..i' '~ v.'::l
~: ~:.:. ~::: ,522 7773:~: :~':.':522-6779
October 15, 1999
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
BLM Lot 136, Section 15, T12N, R3W
Septic System Design Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:.
The owners of BLM Lot 136, Section 15, T12N, R3W intend to construct a five bedroom
home on the property. The lot is currently vacant and is crossed by Little Campbell
Creek in the northeast comer. We hereby request a permit to construct a well and
septic system on the lot to serve the proposed house. The attached Site Plan and
backup documentation describe the proposed system and show the location of the well
· and both the primary and alternate absorption trenches.
The testholes placed on the lot revealed well graded sands with some silt. Percolation
rates were very good and ranged from 5 to 12 minutes per inch. No groundwater was
encountered dudng placement of the testholes nor was any noted during the monitoring
period. We have therefore designed a deep absorption trench with 10' of gravel
beneath the distribution pipe. The total depth of the trench will be 12.5' below the
existing ground surface with the distribution piping at 2.5'.
The ground surface on the lot slopes in varying directions at varying grades.. The new
absorption trench will be placed parallel to the slope of the ground in accordance with
Municipal design requirements. Surface grading will be accomplished to assure
drainage is away from the finished trench surface. Little Campbell Creek crosses the
lot in the northeast comer, but is more than 100' from either the septic tank or the new
and reserve absorption trenches. The location of the creek will not impact the facilities
to be placed on this lot.
All wells in the area are more than 100' from the proposed upgrade and no conflicts
with other septic systems were noted. If the system is constructed in accordance with
our design the following statements apply:
The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
· BLM Lot 136, Section 15, T12N, R3W
October 15, 1999
Page Two
The system, if constructed as designed, will have no adverse impact on reserved
space, either surface or subsurface, on any lots located in the area.
The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
118A
136
Well
137
THIS
138
139
E. 104th Avenue
NOTE: No Conflicts with Wells or Septic
Systems in the Area.
Proposed
Well
lternate
.re
Five Bedroom
Ho~e
A.C.
1"=30'
500 Gallog '
.~p t.ic Tank~
Absorption Trench
"
SITE PLAN '~:~.. ...~
SCALE 1" = 30'
BLM LOT 136, SECTION 15, T12N, R3W
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Five Bedroom Home
Perc. Rate: 5 Min./Inch
Application Rate: .8 GPDISF
Anticipated Flow: < 500 GPD
Deep Trench System
1,500 Gallon Septic Tank
10' Drainfield Rock
5 Bedrooms X 150 GPD I .8 GPDISF = 937.5 SF of Absorption Area
937.5 SF/20 SF! LF of Trench = 47 LF Trnch Length
Therefore: Construct a Deep Absorption Trench System With One Lateral
50' in Length with 10' of Dralnfield Rock Beneath the Lateral.
Distribution Pipe in Trench Placed at 2.5' Below the Original Ground
Surface. Total Depth to be 12.5' From Original Ground Surface.
I ~' '.~. Drainfield Rock
TYPICAL DEEP TRENCH SECTION
Grade Area Over Trench to Drain Away.
Provide 3' Cover Over Trench and 4' Over Tank or Insulate.
Maintain 10' Separation From Lot Line.
p~RFOP. M -'-D FOR:
L.~ .'- AL. D?:CRI PTION:
1
2
3-
4
5
6-
?
9-
11
13.
14-
15
16
17-
Muni~pa[ity o! Anchot-~
D--PARTM-~qT OF H-SAJ_TH & HUMAN S-~RVIC-'~:
~:gR 'L' S~reeL An"noraDe. ~Jz:~z
SOILS LOG ~ PE. RCOLA ~'qON T--ST
Sally Long
Lot 1'36 Section 15,
TESTHOLE NO. I
sw/sM
Bottom of
T12N, R3W
Ii lid
PL..aN
t,mai~7 ~1one
I
z: ./7
T~"~' RUN B~'Tw~..-~ ' ~ ~ ~o ~
Perc. Cavity presoaked prior to testing.
Wa'ret D~
e;- I
lYz.' I
I Z'Iz*
I
im~:~a'~.~) p-~t= HO'= Dt,~J~k'TE.R
F~
Anderson . I ~ '-~Le~rY
Michael E. Anderson
1
Muni=~pa~ty of An:ho~ge
D--PARTIVI-~q'T OF H-~LLTH & HUMAN S-LTN1C-"S
1~25 'L' Stree:. Ancnormge. A~z~cz
SOILS LOG -- PE. RCOLA~ON 'l '-ST
Sally Long
LQ~ 1'$6 Section 15, T12N, R3W
TESTHOLE NO. 2
sw/sM
II
I I
I I
10
17-
19
~0
COMMi~ Pert.
Bottom of
IF ¥c~ AT WHAT
NO
~1 I"1 I I I I I I' I I
"/A ~1 I I I~,~f,.I I I I I t
Z:lO
~0
I-
p-2RCO',,.ATION ~.T-_ /Z- immu'.e~'~) p-~R~. HO'~~ DtA~I=--J'~.R .
Cav'it¥ presoaked p:ior 'Lo testincj.
Michael E. Anderson
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: BLM LOT 135, SECTION 15, T12N, R3W
GENERAL:
The scope of this project includes the procurement and
placement of a new 1,500 gallon septic tank. It also
includes the construction of a new 50' long x 3' wide x 10'
effective depth absorption trench at the location shown on
the attached Site Plan, Total depth of the trench is 12.5'
with the distribution pipe placed at 2.5' below the surface.
Construction shall be in accordance with the approved site
plan, design drawings, Municipal Permit with any special
provisions or conditions, and all applicable State and
Municipal Wastewater Disposal Regulations.
The Contractor shall be responsible for obtaining all
underground utility locates and for the layout of the septic
system and verification of the location of all lot lines.
Unless specifically agreed otherwise, the-contractor shall
be responsible for final grading areas subsequently
depressed from soil settling. Property owner shall be
responsible for revegetation of affected areas unless
specifically agreed otherwise.
Contractors installing wastewater disposal systems must
be certified by the Municipal Department of Health and
Human Services for system installations. Owners installing
their own systems must receive prior approval from D.H.H.S.
before beginning system installation.
SEPTIC TANK INSTALLATION
The 1,500 gallon septic tank must be procured from an
approved source and installed at the location shown on the
plans,
BLM Lot 136, Section 15, T12N, R3W
October 15, 1999
Page 2
2. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts
for pumping access.
3. The septic tank shall be sufficiently bedded to prevent
settling or shifting of the tank.
4. All standpipes on the septic tank shall extend a minimum of
12 inches above final grade.
5. Tanks installed without 4' of cover shall have a minimum of
2" of direct burial insulation.
A foundation cleanout shall be installed one to four feet
from the building foundation. Two cleanouts are required
between the tank and the drainfield.
7. Final grading over the tank shall be such that a positive
slope exists away from the septic tank.
DRAINFIELD CONSTRUCTION:
The drainfield shall be constructed to the dimensions shown
on the design. The bottom of the trench shall be within 2"
of level.
Distribution piping must be placed level with perforations
down atop a level bed of drainfield rock. Rock should then
be placed over the pipe to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between
the drainfield rock and the natural soil backfill.
Monitor tubes must be 4" in diameter and installed at the
locations shown on the design. The portion below ground
must be perforated.
5. Contractor shall verify the septic tank and drainfield are a
minimum 100' away from any private water wells in the
area, 150' from a Class "C" Well or 200' from any community
well.
BLM Lot 136, Section 15, T12N, R3W
October 15, 1999
Page 3
Direct bury insulation must be placed over the distribution
system if less than 3' of backfill depth is available. Finish
grade over the trench must be mounded to prevent
settlement or depressions.
7. Grade area surrounding the absorption trenches to drain
away.
A minimum 2' of accepting soil is required below the
drainfield rock for a 5' wide trench. Contractor shall verify
this condition prior to placement of the rock. All pockets of
unacceptable materials must be removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a Municipally approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C.
(perforated and solid), ASTM F810 or H.D.P.E. (perforated,
but not solid) and ASTM D2662 or A.B.S. (perforated and
solid).
3. Insulation shall be at least 2" thick extruded direct burial
polystyrene (Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted
watertight couplings (Caulder, Fernco, or equal).
with
5. A permeable geotextile fabric (Typar, Mirafi or equal) must
be installed between the final drain rock layer and the
native soil layer.
6. Ail drain rock shall be .5" to 2.5" in diameter with less than
3% passing the #200 sieve.
BLM Lot 136, Section 15, T12N, R3W
October 15, 1999
Page 4
INSPECTIONS:
A minimum of two inspections are required by Municipal
Ordinance. These inspections must be conducted under the
supervision of a professional engineer registered in the State
of Alaska. The first inspection must be conducted after the
excavation of trenches, beds or pits and before the installation
of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement
of the geotextile fabric, gravel, distribution piping,
standpipes, cleanouts and insulation. No backfill should be in
place at the time of inspection.
Contractor shall provide a copy of all field
construction notes for use in preparing the
of the completed system.
survey layout and
certified as-built
Municipality of Anchorage
George P. Wuerch, Mayor
Bufldlng Safc~, Division
P.O. Box 196650 · 4700 S. Bragaw Strcct
Anchorage, Alaska 99519-6650 · (907) 343-8301
May 24, 2001http://~v, ci.anchoragc.ak.us
Department of
Public Works
James C. Hefty
Hefty Drilling
3540 Akula Drive
Anchorage, Alaska 99516-2860
Re:
T12N R3W Section 15 Lot 136, P.I.D. 015-484-18
Wastewater Disposal System / Water Supply Permit Number SW990399
Dear Mr. Hefty:
On October 25, 1999, this office issued a permit for the construction of an on-site
wastewater disposal system and water well on the above property. This permit
specifically showed that the well would be constructed approximately 60 feet from the
north lot line and 15 feet from the west lot line on the subject property. On May 21,
2001, we received an as-built inspection report required by the permit from Anderson
Engineering. This as-built shows the location of the well you drilled as approximately 85
feet north of the south property line and 13 feet east of the west property line of an
adjacent piece of property. This is over 170 feet from the permitted location of the water
well and not on the permitted property.
This is a violation of the Anchorage Municipal Code 15.55.040 A. This code states in
part, "No person shall cause or permit the construction of a surface or subsurface water
source for domestic purposes without holding a valid permit issued by the department in
the name of the property owner for the specific property and construction
proposed."
This letter will serve as a Notice of Violation. This will also serve to notify you that
future water wells you construct shall be in conformance with AMC 15.55 or you may be
served with a citation. Citations invOlve a mandatory court appearance and may,
according to code, curtail your ability to drill wells within the Municipality of Anchorage.
If you have any questions or comments please contact me at 343-7905.
Sincerely,
Jeffrey W. Poet
Engineer Technician III
On-Site Water & Wastewater Program
CCC Construction
CHI~L~ L MOLU~
P.O. B~z 770647
TO: Craig and L~ura' ~aws
21735 Glacier Road
Chugiak, AK 99567
bill date: '4/4/97
clean out outlet pipe and-pump ~ank
ada 30 L/F.of 8' deep septic trdnch
pump and line clean
material:
20 yard~ ~ewer. rock @ 25
pipe and fittings
30 L/F 3034 pipe
30 L/F 4" perforated pipe
2 cleanouts
1 90o
I 40~
1Romac coupler
6 sheets 2" x 2' x 8'
.blueboard inuulation
labor:
426B backhoe 9 hours ~ S5
16 ho~rs @ 20
total:
100.00
700.00
60.00
45.00
20.00
10.00
10.00
30.00
90.00
765.00
320.00
$2150.00
Development Services Department
On-Site Water & Wastewater Section
Phone: (907)343-7904
Fax: (907)343-7997
MUNICIPALITY OF ANCHORAGE
015 -484-19
T12N R3W SEC 15 LT 136A
Expiration Date: Parcel ID
Legal description
Site address 4601 E 104TH AVE
Current property owner(s) LASTIMOSO NOEL Y & FLEDZ L
X The On-site system(s) is/are approved for 5 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or conditions:
No comments
By:Isatou B Njie Original Certificate Date: 10/24/2025
This Certificate of On-Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage,
Development Service Department (DSD) issues COSAs based upon representations provided by an
independent professional engineer. The Municipality of Anchorage is not responsible for errors or
omissions in the professional engineer's submittal.
ATTACHMENTS:
COSA Checklist
Absorption Field Advisory
Tank Age Advisory
Other
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Certificate of On-Site Systems Approval
X
OSC251480
9/12/2026
MUNICIPALITY OF ANCHORAGE
Development Services DepartmentPhone. 9017-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate Of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcell.D, 015-484=19
Complete legal description T12N R3W Sec 15 Lot 136A'
Location (site address) 4641 E 104th Ave. Anchorage, AK
Current property owner(s) Noel & Fledz Lastimoso Day phone
2. ON-SITE SYSTEMS SIZED FOR 5 BEDROOMS
3. TYPE OF WATER SUPPLY W Private Well serving # 1 dwellingunits
❑ Other Non-public well as regulated by MOA ❑ Water Storage
❑ Community Well or Public
4. TYPE OF WASTEWATER DISPOSAL: F0 Private Septic ❑ Private Septic serving 2 dwelling units
Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel J Plastic ❑ Concrete ❑ Fiberglass
Age 0 - See advisory if steel or fiberglass older than 20 years
6. ABSORPTION FIELD. ❑ AWWI"S ❑ Bed V Deep Trench ❑ Wide Trench '❑ Seepage Pit
Waiver request for: Distance:
Expedited review requested: ❑
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ 5 Waiver Fee $
Date of Payment j a Date of Payment
COSA # OS G- c5- {- Waiver #
Kx.
COSA Application Apr2025,doc
c-
Received Date/Time 10/17/2025 14:43
10/17/2025 14:13CollectedDate/Time
1255789001
Matrix
SGS Ref.#
Client Sample ID Sec 15 Lot 136A
Client Name
Project Name/#
Printed Date/Time 10/21/2025 8:34ArcTerraConsultingInc
Technical Director Stephen C.Ede
TI2NR3W
Drinking Water
Sample Remarks:
Parameter Results LOQ Units Method
Allowable
Limits
Prep
Date
Analysis
Date InitContainerID
Microbiology Laboratory
M.A10/17/25SM219223B100mLE.Coli Negative 1 A
M.A10/17/25SM219223B100mLTotalColiformNegative1A
2 of 5
SGS logonew.gif
Sample Containers and Preservatives
Container Id Preservative Container
Condition
Container Id Container
Condition
Preservative
1255789001-A Na2S2O3 for Chlorine Redu OK
Container Condition Glossary
Containers for bacteriological,low level mercury and VOA vials are not opened prior to analysis and will be
assigned condition code OK unless evidence indicates than an inappropriate container was submitted.
OK -The container was received at an acceptable pH for the analysis requested.
BU -The container was received with headspace greater than 6mm.
DM -The container was received damaged.
FR -The container was received frozen and not usable for Bacteria or BOD analyses.
IC -The container provided for microbiology analysis was not a laboratory-supplied,pre-sterilized
container and therefore was not suitable for analysis.
NC-The container provided was not preserved or was under-preserved.The method does not allow for
additional preservative added after collection.
PA -The container was received outside of the acceptable pH for the analysis requested.Preservative was
added upon receipt and the container is now at the correct pH.See the Sample Receipt Form for details on
the amount and lot #of the preservative added.
PH -The container was received outside of the acceptable pH for the analysis requested.Preservative was
added upon receipt,but was insufficient to bring the container to the correct pH for the analysis
requested.See the Sample Receipt Form for details on the amount and lot #of the preservative added.
QN -Insufficient sample quantity provided.
10/17/2025
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.. Compete ega descn ton -Lot136~onlSTt2H~W ......... ~ - , ~,., ,
· , ~o~, on ,s ,e a~ress or ~ rec, ons~ -, ........ ,
· , '. ¢ ..Cu~ent Properly owner(s) R~chard and ~nla Hailer, .... > ." -; .' Day phEne .~5198 4,., ' .: :: ~'.- "; ,.';.
', .Real Estate Agent': ": '."~":.' '. .... ;' " .... Da~'ph 6 ':, i .. "'.. ,
Un! soth~n~/~ req,ue ted, .HC, A i/Il;eh IdbYDH~Sfor, pickup HAApick dupby:. ''
'' N~'UB ...... ' .... ': '~ ' ' ' ':.' ~ "":.'": ..... "" ' ' ......
E~tOFBEDROOMs~- :" :" Fi~;e(5i '":' ' ' '": : ....... ; ' .... '
TYPE OF WATER SUPPLY
TYP, E OF. WASTEWATER DISPOSAL ':
3.'.' : -." ; '. : .-'. '...
Individual Well :' "' ' ' ~ ~ .,.. . :'Individual On-site - .. []
Individ~Jal Water Storage [] ': Ihdi~;idual Holding tank~-.~ , ,- i FI ~- ' -
',C0n~munity'iClass ;'Well ' ' '. [-'1: Community On-site ' ' ,rTl ::
Public Water System. ...... [] .... Public SeWei' :'. ...... - . [] ' . . ::.
The Municipality of Anchorage'Depadment of Health and Hur~an Servi~s (DHHS) Issues Cedific~tes of Health
^uthority Approval (HAA) b/~sed only upon the representations'given In p~ragraph 5 b~ an inde~ndent professional
civil engineer regislered in the State of Alaska. Cedificates of Health Authority Approval are required for the trahsfer
of title (except between spouses) on properties served by a single'family' On-site wa~te~vater di~p0sal and/or water
supply system. DHHS also issues HA~ bpon re~ui~st t0 home °Where.' Certificates'~f Health Ahth0rity Approval
are valid for go days from the date of issue for properties served by'a private or Class C well ~nd may be reissued
with new water sample result~ less than 30 days old. Certificates are itatld for one year f6r properties served by,
Class A or B wells or a public waler system. The Municipality 'of ¢~nchorage is not resp'onsibl~ for.eh'oJ's or
emissions in the professional engineer's work. . .. ,. - · ,
.'- 5..'STATEMENTORINSPECTION_ .. ,..,BY~.ENGINEER~ ....', ,:...,-.t..: ...:.,'- , .'. :'..,'.. · .-.-'.: ~,'
'As certified by ~ny sea 'affixed hereto' and as of the yal~dation date shown bel,.o~.,' I ~/enfy tha!. my, m~est~g, at~on.
· ~ based on procedures'.ouflined,in the Health,AuthontY,APpLoyal~G,u~.d.et ,.n~s. ,,for,~.,s H~e~!~ ',Au.~hon. ty Ap.p, a
- ' ~nnl','~l~nn -~'"""' '*k,~* *h., ,.,._~,~o,,*,~t~r ~ nS, wastewater d~s~osa svstem s safe functlona and
~ ' ; 'n~i;nhg fnr tP;R nt~rn~r ¢)f bedrooms and type of sb'ucture nd cared h~eln. I further ve,rify that based ,on the...
· , nformat on obta ned from the Mun c pa t~ of Anchorage ~il~s anti ~-..o~. my mv~s!~.~bo~., and ~ns~ti~n, th.e o9 . ..
;r astewater.ds sa s tern s ncomp~ancewthallappl~.,ableMun~c~pa andState, ,..
s te water su pp y and/o, w po ys.
',- '- '*codes :ordinances 'an~ rc:~ula~ns ,B eff~::t at t.he !,me
· ' Name o! Firm- · · -Ande~on £nameen~.q .... ~ .......
· '. ·:' .- Enginee/"s Printed blame ~' ·:" ~ha,~ E'And-~on,
· -. '. , ~ : ~, , ',.- .. , , , ,
6 DHHS SIGNATURE , ......
, -,,. ~ Approved for,. -/ , bedrooms.
.... D sapproved.., ..... ,, ....
'": ': , r:,^;.,~ ~f,~;,g~",;.,,,;.,-,,,g f,-,,: ~' .~-i ": b~di:d0m'S ,'W th the f6 0wnb'stieu atons:
.... .... . , ....,. , ~.........~'~ .....
..... .
..... . ...... : .... . .,,..,._x,r,. .. ,
......... ,' ',"' ' ' '' - ',:~,.;~o ''UN-.~/I::" -'..~
. "., . . '- · · ,
- .. '
'" '*.°,"2";:
Additional Comments r~ q ...... ~,
· :,', ~'0~ ~ , ,.~c~ ~,~,,.
- .':' .'".
By:
Expiration Date:
(R~. ~0~e)
Attachments:
HAA Checklist X
Septic System Advisory
Welt Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Cedificate Date:
Reissue Date:
M-nicipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Pmgrm~
47OO South Bragaw St.
.P.O. B~x 196650 Anchorage, A,K 99519-6650
HEALTH AUTHORITY APPROVAL CHECKLIST
~ Desc~ption: Let t~, S.ct~on t5, TtZN, R3W
WELL DATA
To{al depth 230 ft.
Date ~ test
Static water level
Well produdton 10
WATER SAMPLE RESULTS:
C~form 0. c~onk~100 mL
Date d sample:' sn'r2001
SEPTIC/HOlDING TANK DATA
Tank Ty~ ~teel
Tank size 1,500, gal.
Foundae~n deanout (~) z
Date of pumping,
C. ABSORPTION FIELD DATA
ifA, B. ~* C provkJe PWSID #
FROM W~ ~ LOG
188 fl.
g.p.m.
c..om~t~ by: UFA
Number oi' Comparlmants ~
De~ressio. ov~r ta~ (Y~N) N_
Date installed ~/24/2000
To~al depth 15 ft.
Date of adequacy test
Parcel ID: 015,484-18
Well Log (Y/N) Y
vwes prope~ protected (Y/N) V '
Casing height (elxwe ground) >24
AT INSPECTION
g.p.m.
in.
water elan~ (Y~) N
~ rMlflg (g.p.d./fl~/bdnn).BOPD/SF System ty1:m D~Tr~ch
ft. Width '3 ft. Gravel below pipe 10
Eft. absorption area 1,000 ~ M~ng tube Y Depression ove~ ~d N
Results (Pass/Fa~
Fluid depth in absoq~flon field before test in. Water added gal.
Elapsed Time: min. Final fluid depth in. ~n rote >=
Any m-juvenaUo~ beatme~t (past 12 ~) (Y/N & b/~e) N If yes, give date N/A
For bedrooms
New depth in.
g.p.d.
D. UFT STATION
Date installed.
'Pump on' tevel at __ in.
Datum
E. SEPARATION DISTANCES
Size in gallons.
'Pump oft level et in.
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot >100'
Abs~xptlon field on lot >100'
Public se~er main N/A
Sewer/sep~ service line
Manhole/A__,~e~___~ (Y/N)
High water elann level at
Meets alarm & cimuff requirements?
On adjacent lots >100'
On adjacent lots >100'
Public server manhole/deanout N/A
Holding tank N/A
SEPARATION DISTANCES FROM SIr-P'~ lC/HOLDING TANK ON LOT TO:
Building foundation
Water main N/A
Wells on adjacent lots >100'
SEPARATION DISTANCE FROM ABSORPTION RFI n ON LOT TO:
Property line. >10'
Water Sewlce line >10'
Curtain drain Nee,, Noted
F. COMMENTS
Proper[y line >5'
Water sewice line >10'
Building foundation ~0'
Smface water >t00'
Weas on adjacent lots >100'
Weil is icaated o~ e~ac~t t0t Bo~ ~ots are owned by ~ aan~ persm.
ENGINEER'S CE~R~ON
I m~ ~t I ~ ~te~
m~w of Mull m~s ~t
~ ~ M~ ~ ~li~s ~ eff~ ~ ~s date.
E~t~S ~n~ Name MI~aM
Da~ ~t
Ge
Absorption flekl. >5'
Surface water >t00'
Wate~ main
Odveway, partdag/Veblc~e ~
Date of Payment
eec . N.m.,,'
(Rev. 'mmo)
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
MEMORANDUM
DATE:
TO:
FROM:
SUBJECT:
May 24, 2001
Jeff Poet
Mike Anderson, P.E.~
Lot 136, Section15, T12N, R3W
Septic System As-Built and Certification
Certificate of Health Authority Approval
Attached is the recorded easement allowing ingress and egress onto BLM Lot 137 for
use of the well. This should complete the necessary documentation for issuance of the
Certificate of Health Authority Approval. Please let me know if you need additional
information.
REC DATE
05/24/2001
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
ANCHORAGE RECORDER'S OFFICE
550 W 7TH AVE SUITE 1200
ANCHORAGE AK 99501'$564
(907) 269'8899
RECEIPT NUMBER
1578489
RECEIPT DESCRIPTIOH
RECORDERS OFFICE FEE
BANK CD/CHECK NUMBER:
0000
CASH AMOUNT=
RECEIPTED AMOUNT:
820.00
820,00
YEAR=2001
BEGINNING BOOK
SERIAL NUHBER INFORHATION
BEGINNING NUMBER : 55505 ENDING NUMBER : 35505
:$8q6 PAGE NUMBER :5ql ENDING BOOK :$8q6 PAGE NUMBER
:542
RECORDING FEES
COPY FEES
PLAT FEES
HANUALS
NON REFUNDABLE
OTHER FEES
COPY SEARCH FEES
HICROFICHE COPY FEES
818.00
FILING FEES
CONFORMED COPY FEES
CERTIFICATION FEES
OVER SIX NAMES FEES
UNAPPROVED FORH FEES
PLAT COPY FEES
INFORMATION SEARCH FEES
82.00
REMITTER:
RICHARD A HALLER
PO BOX 110731
ANCH
AK 99511
COMHENTS:
RECEIPT - DO NOT PAY
NOTE: ORIGINAL RECORDED DOCUHENTS WILL BE RETURNED FROM
HICROFILHING IN 4-6 WEEKS.
B[O38~GPG05~ I
'ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
MEMORANDUM
DATE:
TO:
FROM:
SUBJECT:
May 22, 2001
Jeff Poet
Mike Anderson, P.E. 7
BLM Lot 136, Section 15, T12N, R3W
Septic System As-Built
Certificate of Health Authority Approval
Attached is the surveyed as-built of BLM Lot 136 and BLM Lot 137 showing the well
serving Lot 136. The well is located on Lot 137, but an easement has been created
allowing ingress and egress to the well. Please review this information along with the
other data submitted to obtain a Certificate of Health Authority Approval for BLM Lot
136 and let me know if you have any questions or require further documentation.
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