HomeMy WebLinkAboutEAGLE CREST #1 TR A LT 68Onsite File
A &4% Oft A
maximum 14 bedroom CV,%>Aapproval.
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Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP171240 PID Number: 050-304-23
Dwelling: ® Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ® Upgrade
Name:
ELDA GALLEAR TRUST...
ABSORPTION FIELD
® Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
19252 FIRST ST., EAGLE RIVER, AK 99577
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
5
1.2 GPD/SF
11 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
3 Ft.
Gravel depth beneath pipe
$ Ft.
Subdivision Block Lot
EAGt,E S i I IWAcr- A
Fill added above original grade
Varies 1.75 — 2.0 Ft.
Gravel length
41 Ft.
Township Range Section
Gravel width
3 Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
656 FtZ
1
-- Ft.
well
100+
100'+
NA
NA
25'+
TANK M Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
ANCHORAGE TANK
Capacity
1 1500 Gal.
Surface water
100'+
100'+
NA
NA
Material
STEEL
Number of compartments
2
Lot Line
5'+
10'+
NA
NA
NA
Foundation
5'+
10'+
NA
NA
LIFT STATION
Manufacturer
Capacity
Gal.
Curtain Drain
NA
*50'+
NA
NA
Remarks *None known. Diverter to existing crib
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
S.T. decommissioned per code. S.T. & field
Insulated. Connected to Public Water.
Pump make and model
Electrical Inspections performed by
Cn►t� CA16) 0A1Af /St crSEA rp),c 4 N-13,2 cvCA-.
PIPE MATERIAL House to tank 3034 Tank to 3034
drainfield
Installer Northern Excavation
Drainfield 3034 CO/MT 3034
Inspector ARCTERRA
BENCHMARK (Assumed elevation) 100 ft
Inspeection 1" 9/11/2017 9/11/2017
Location and description
2nd
ction
3`d 9/12/2017 4t" 9/13/2017 1Door
Sill
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engin
„ . OF Al �
Conditional Approval: Date
AO
r KENNETH ni. D 'FF' r /
csT 71
ApprovedD� �r;d(X Date �9
�Sw/
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F'L'S�lO,,�.l'Aw
eer's Stam
inspection Keport_a-i-iz.aoc
isv�I�
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r maill
moi►/i
AS -BUILT SYSTEM DETAILS/SITE PLAN Permit❑SP171240
EAGLE CREST 1ST ADD LOT 68 TRACT A PID#050-304-23
* TH
I
/ KE FUS .'
` CE 71 W�
�$w i
f .��/47•'
A�OFESSIO�AS'
MONITOR
TUBE FINAL GRADE =97.5
FILTER FABRIC\ / INSULATION
2,50 92,5(
SEWER ROCK
.4.50 TRENCH 1 B 5
41'
PREPARED F❑RI
ELDA GALLEAR TRUST
19252 1ST STREET
EAGLE RIVER, AK 99577
FIELD BOOKS
A -C=23,5'
N 9,:�4
DRAWN: BMW
B —
C
= 6 , 0'
2 CLEANOUT CLEANouT
Q
A -D=29.0'
AGAD FILE: EGL—CRST
JOB No.: 17-189
o
B -D=16.5'
W W
; o
V)
A-E=31,0'
o N 1500—GA
B -E=27,5'
cu SEPTIC
TANK
FCS
A -F=46.5'
o
B -F=62.0'
94,76
m
B -G=60,0'
SCALE: NTS
I
* TH
I
/ KE FUS .'
` CE 71 W�
�$w i
f .��/47•'
A�OFESSIO�AS'
MONITOR
TUBE FINAL GRADE =97.5
FILTER FABRIC\ / INSULATION
2,50 92,5(
SEWER ROCK
.4.50 TRENCH 1 B 5
41'
PREPARED F❑RI
ELDA GALLEAR TRUST
19252 1ST STREET
EAGLE RIVER, AK 99577
FIELD BOOKS
COMPUTED:
BOUNDARY: NA
DRAWN: BMW
STAKING: NA
CHECKED: K M D
ASBUILT: HOLT
DATE: 09/18/17
DWG. FILE
GRID: NW0055
AGAD FILE: EGL—CRST
JOB No.: 17-189
ANODUT 9550
ORIGINAL GRADE
VARIES
01
T
D•
NO GRND. WATER
7850 BON
SCALE, NTS
Municipality of Anchorage
Community Development Department
On -Site Water and Wastewater Program
4700 Elmore St. - P.O. Box 196650 Anchorage, AK 99519-6650 - hftp://www.muni.org/onsite - (907) 343-7904
Legal Address: -- <—�
14 -, / 70-411- Block c k
Subdivision ��a Lot (---D
T R Section Lot
On-site Water & Wastewater Proqram certified contractor performinq the well decommissioning:
V
Company:
Signature:
Well decommissioning date Method of decommissioning: AMC 1 5.55.060L 1 a. F-1 b. F-1 C.
Location: Use the space below to provide a drawing of the property showing the following items;
• North arrow
• Decommissioned well,
• Other water wells on the property,
• Two separate swing -tie distances for each well shown on the drawing,
Note: The swing -tie distances shall be measured from either permanent structures or the property corners.
G:\Community DevelopmenADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Well Decommisioning form.doc
MUNICIPALITY OF ANCHORAGE
On-Site Water& Wastewater Program 'S.;
PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.org/onsite r.
i Department
�'YCHoaP4E
On-Site Wastewater Disposal System Permit
Permit Number: OSP171240 Effective Date: 8/28/2017
Work Type: Septic Upgrade Expiration Date: 8/28/2018
Tax Code Number: 05030423000 61/707 (t.
Site Legal Address: EAGLE CREST#1 TR A LT 68 G:0055 q- (L- 1/ 16?
Site Mailing Address: 19252 FIRST ST, Eagle River
Owner: GALLEAR ELDA P DEC OF TRUST Lot Size in Sq Ft: 17820
Design Engineer: ARC TERRA CONSULTING INC Total Bedrooms: 5
This permit is for the construction of:
EI Disposal Field E✓I 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:
1. The Well Decommissioning Log is to be submitted prior to Inspection Report approval.
2. Note on the Inspection Report that the undersized crib may not be tested for any future COSAs.
Received By: Date: v! leb�
Issued By: N k/of, �.., Date: g7/0-07
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On-Site Water & Wastewater Program
ON-SITE SEWERNVELL PERMIT APPLICATION
Parcel I.D. 050-304-23
Property owner(s) ELDA GALLEAR TRUST... 854-1236
Day phone
Mailing address
19252 FIRST STREET, EAGLE RIVER, AK 99577
Site address 19252 FIRST STREET, EAGLE RIVER, AK 99577
Legal description (Sub'd., Block & Lot) EAGLE CREST #1 , TRACT A, LOT 68
Legal description (Township, Range & Section)
Lot Size 17820 Sq. Ft. Number of Bedrooms 5
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field 1'11 Initial ❑ Single Family (SF)
(wlwo ADU)
Septic Tank Upgrade 11Duplex (D) ❑
Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature o rty owner or authorized agent)
Permit/Rush Fees: 569 Waiver Fees:
Date of Payment: �l/$f r7- Date of Payment:
Receipt Number: GORLIDReceipt Number:
Permit No. ( Spit-/acid Waiver No.
Permit App_9-1-12.doc
?,CTE
v4
ARC T ERRA
,.4R CONSULTING, INC
,f�4tsuLtING•� ,� 212 E.51st Ave,Anchorage,AK. 99503
»sn
Office(907)868-3791,Fax(907)868-3793
August 18,2017
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Upgrade Sewer Permit—EAGLE CREST#1 TRACT A, LOT 68
The owner has requested we proceed forward to obtain a septic permit to
upgrade the existing 4-bedroom septic system to 5-bedrooms.
The general slope of this lot is from northeast to southwest at a grade of
approximately 7-12% over the septic area. On August 10, 2017 a testhole was
performed to investigate soils and groundwater. The results of this test are
attached for your review. We propose to install a deep trench. Groundwater was
not encountered at excavation or at monitoring.
The property's existing well will be decommissioned and subsequently
connected to public water. Adjacent lots are served by private water. There is no
surface water within 100' of the proposed system and there are no known curtain
drains within 50'. We do not expect there to be any adverse effect on adjacent lots
by the development of this system. If you have any questions, please contact me
at 868-3791 / FAX 868-3793.
Respectfully submitted,
ArcTerra Consulting,Inc.
11/11ft -d
Kenneth M. Duffus, 'W:'.
Attachments: On-Site Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
20441 PTARMIGAN BLVD • EAGLE RIVER,AK 99577-8736 • PH(907)868-3791 • FAX(907)868-3793
WELL & WASTEWATER DISPOSAL SYSTEM DETAILS/SITE PLAN
EAGLE CREST 1ST ADD LOT 68 TRACT A
WANT
ELIT
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' ' LOT NI
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v LT 73
a
.-
•
0
6
0
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0
W
1
03
10
O
FLAG PROPERTY LINES
• WELL RADII & EASEMENTS
• PRIOR TO CONSTRUCTI❑N scale: 1'= loo'
ND Swf� >2S-64 DESIGN DETAILS PAGE 1 OF 2
a 5 BDRM X 150 GPD = 750 GPD
41/N /a` OF 750 GPD/1.2 GPD PER SQ. FT. = 625 SQ. FT
a (625 / 2 x (8' GRAVEL) = 40 FT. TRENCH
PIUPAS s.1 Sr USE 1 TRENCH - 40' (L) X 2' (W) X 8' (D)
a Total depth of system Is 11' max from original grade.
O Total depth of gravel below distribution pipe is B' .
NO PUBLIC WELLS WITHIN 200' OF
o PROPOSED SYSTEM NOTES:
0, NO PRIVATE WELLS WITHIN 200' OF
ID PROPOSED SYSTEM EXCEPT AS NOTED. 1. INSTALL NEW 1500 GAL & INSULATE TANK IF <4' COVER,
• PROPOSEDC WELL E C PTHAS 2Nar EnF 2. INSULATE TRENCHES WITH 2' HD BURIAL FOAM IF < 3' OF FILL.
MIN, 2' FILL WITH INSULATI❑N, )3' COVER NO INSUL REQ.
3. CONTRACTOR WILL ENSURE MINIMUM 27, SLOPE INTO SEPTIC TANK.
4. CONTRACTOR WILL ENSURE ALL SEPARATI❑NS TO ADJACENT
0 WELLS, SEPTICS EASEMENTS, PROPERTY LINES, ETC...
eL
_�FS� TT\\
• Apr oc� . . • 1 �, PREPARED FOR: CTE aa
ELDA GALLEAR TRUST �R f`��
,Lj , , 19252 1ST STREET C' �� ��r
r •>Ar / y T 1\ * Y EAGLE RIVER, AK 99577 1�
IIN �!!� eil- • # FIELD BOOKS COMPUTED: _ $
+ ! u.
O � BOUNDARY:NA DRAWL BMWco �" "
o •
CE-?
1 • .15//11.17 srA IG: NA KMD ,* j •71
ASBUILT: DATE tii•... Q{
o bFEssto�N' HOLT 08/18/17 Fi m
E `` DWG. F1LE CRb NW0055 <F en, AI .,,c., �,
ZACAD FILE`EGL-CRST 48 Na: 17-189 yER, x.9957'i
WASTEWATER DISP❑SAL SYSTEM DETAILS
EAGLE CREST 1ST ADD LOT 68 TRACT A
i
STAKE WELL RADII I
x a
& PL PRIOR TO I z &o
CONSTRUCTION x
I e
L..., CO x DECOMMISSION EXIST.
OPIMOOk10'+— �` I
>7ll""� WELL & CONNECT
TO PUBLIC WATER y
o
` it1, O
ID
�11. I , ��� a
O DECK ' WELL
I.' 56.6'
60.2'
o.
1, . `MT
a v TN17-1 FAMILYts
SINGLE {
- DECOMMISSION EXIST. lk. 4—BR FRAME HOUSE
w 1250-GAL S.T.
& cos \ CO
1$ 's; c0 60.2'
o }�
J.
o M
�` �j •
cog CO Ic,o 0. H. 'ECK
E INSTALL DIV. -
0
TO EXIST. 26.2'
' CRIB
w INSTALL NEW 1500-GAL
ro
La S.T. & FCO
0 U
CO
O
J
\ Y
a CAT III RESERVE
o z 4GPD/SF = 10'+L X :ED
< 74z
USMT /EXISTING CRIB L 0 T 6 8
0
0
a
t
u
U
10' UT1UTY EASEMENT
c▪' CHAIN LINK FENCE
w\° X—X—X X—X—X—X—X—X—X—X—X—X—X—X—X—X—X—X
S 89'56'00" E 132.00'
J
FLAG PROPERTY LINES
lz
3 WELL RADII & EASEMENTS
PRI❑R TO CONSTRUCTION sate: 1'= 20'
IT ou"
4r.04
` PAGE 2 OF 2
40
W / (SC. OF A4 , 1 PREPARED FOR: gCTER
` ELDA GALLEAR TRUST ti �q �,
�,� 7, 19252 1ST STREET ° �4� ���,
ci
* 9TH * T EAGLE RIVER, AK 99577
� V
o / IEINETfi m. Irk- . / MELD BOOKS ,�
I
`� 4477 BOUNDARY:NA DRAM": BMW = " . ,s/s.
% CE-711•//�?' yti{� sr"I�c NA KMDii � �t+� A ULT:. HOLT D�1E08/18/17P.u `'�'ES31Ct1 Ii0t.1
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DWG. nLE: aao C c �,
E f N W0055 P o 1� ¢�
��� '•it�F,'SU-TINC' 6
ACD FILE EGL-CRST ,pe"°.: 17-189 ' AK. 99577--
�"c� R-a =sem e.
ARCTERRA
ERRA ���' �; �
CONSULTING, INC 1 �� '7
' ¢ 212 E.5I" Ave,Anchorage,AK.99503 ' * 4• Tit f\
b,,v ,,�`�'Office(907)868-3791,Fax(907)868-3793 'W V 1
YrA DLII NG. �I
Ml11-
�. KENNETH M. Du.j x
SOILS PERCOLATION TEST , `' 7 16
•(.4'-'Al
1r% /6 / e
Performed for: ELDA GALLEAR TRUST Date Performed:08/10/17 ` f '> -sstotit`'
Project: EAGLE CREST #1 TRACT A LOT 68 TEST HOLE# TH 17-1
Depth
(Feer.- SEE ATTACHED SITE PLAN
FOR HOLE LOCATION
I ' Org/OL
d ' Was Ground water encountered? NO What depth? NA
1
Depth to water after monitoring? NO Date? 8/17/17
l
0 SP/gp/sw-gw trace of silt with sand Reading Date Gross Net Depth to Net
Ca and density increasing w/depth Time Time Water Drop
(I I 8/10/17 1:00 - 6" -
2 1:10 10 min 3/16" 5 13/I6"
ca
3 * 1:11 - 6" -
,) 4 1:21 10 min 5/16" 5 11/16"
10 5 1:22 - 6" -
d
II 6 1:32 10 min 6/16" 5 10/16"
12 7 1:33 - 6" -
,a
13- 8 1:43 10 min 5/16" 5 11/16"
14- 9 1:44 - 6" -
15 I() 1:54 10 min 6/16" 5 10/16"
16 11 * 1:55 - 6" -
17- 12 2:05 10 min 6/16" 5 10/16"
B.O.H.
18- * Water Added
19- Percolation Rate 1.7 (min/in)Pere Hole Diameter 6"
HOLE PRESOAKED
20- PRIOR TO TEST Test Run Between 6 feet and 7 feet
I, Kenneth M. Duffus, certify that this test was performed in accordance with all State
and Municipal guidelines in effect on this date.
GRE~'-~. ANCHORAGE AREA BOr'.~H
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCAT,ON I~£~" ,,f ~,e~/,.,i., l,,.,~ LEGAL DESCR,PT,ON ~"~' r~d/q ~
SEPTIC TANK: /-"(/""""~
DISTANCE ' I
~ROM WELL ~,?_2~ MANUFACTURE.
MATERIAL
INSIDE LENGTH
INSIDE WIDTH
LIQUID DEPTH
NUMBER OF
COMPARTMENTS
IIQUID CAPACITY J~;~'{~ GALLONS.
SEEPAGE PIT:
N,MBEROF ~ D,AM~ER ~0___LORW,OTH /~/. /' ' ~'
PITS LENGTH ~"', DEPTH
LINING MATERIAL ~O (.~ CRIB SIZE: DIAMETER ~ DEPTH DISTANCE FROM:
BUILDING FOUNDATION ~v , NEAREST LOT LINE ~)t TOTAL EFFECTIVE
__ ABSORPTION AREA (WALL AREA)
WELL ~/
ADDITIONAL ABSORPTION
WELL:
TYPE CONSTR.CT.ON DEPT. D.STANCEFROM:
BU'LD'NG ' ¥
FOUNDATION q ~lf NEAREST SEPTIC ~7
LOT LINE ~1 NEAREST I SEEPAGE
. SEWER LINE TANK SYSTEM
CESSPOOL
OTHER SOURCES
APPROVED DISAPPROVED REMARKS
DISTANCES:
INSTALLED BY:
PIPE MATERIAL,'
LOT SLOPE=
REMARKS:
Form No. EQ-031
DIAGRAM OF SYSTEM
0~. 2, 1~'~3
r,-~, ~
Gre~l'Er ANCHorage Area BOI~UgH
SEWAGE DISPOSAL SYSTEM
INSTA'.'-'TIO" '.OCATION /"~~
APPLICATION AND PERMIT
MAILING ADDRESS Z~/ /~"~ ~/
FINANCED THROUGH TO BE INSTALLED BY
::::::::::::::::::::::::::
OTHER
NOTE:; T~HIS PERMIT I$ i,~,OT VALID WITHOUT SOIL TE~ST
FINAL INSPECTION= 24 HOUR NOTICE: REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
HEALTH DEPARTMI~NT AUTHORITY WILL BE SUBJECT TO PROSECUTION.
TO NE^.EST LOT L'.S.
DIAGRAM OF' SYSTEM
WATER MAIN TO SEPTIC TANK SEEPAGE PIT
DRAIN FIELD ,
Fl't'rED WITH AIRTIGHT REMOVABLE CAPS.
CONFORM TO ~3OROUGH REGULATIONS REGARDING INSTALLATION.
-/
' ~ 8- E EIvGINEERING E~ DEVELO~'M£NT CO.
Russell Oyster
694 -2774
Civil Engineering
Soils b Foundations
Box 90. Davis St., Eagle River, Alaska 99577
694-2774 ot 3.13-5240
SOIL LOG
£a# Elis
333-5240
Surveying
Land Development
Perfomed for: Name: ~ '~-~.~(~ ~.~%~_~y~x~- Tel. No.
Hailing Address: ~ \~
Legal Description: ~ ~.~
Depth (feet) Soil Characteristics
0
3
6
7
8
10
11
12
Ground Water Encountered: Yes__ No ~'~;-If yes, what depth
Proposed Installation: Seepage Pit ~ Drain Field
Con~nents: ~--~.~ ~_c~-.,~tt-. thT'k-'~->~ ~'~ ~' ~ ~%~
CERTIFICATE OF ON-SITE S
Parcel I. D. 050-304-23
Ii I I EC FWi, VA
777
i 4wwp
SEP 18; �2017
WTO-WITU
C C,
U
"",�
z
0
C,
0
6 o
Expiration Date: 1 1,20 1
Complete legal description EAGLE CREST #1 TRACT A LOT 68
Location (site address) 19252 FIRST STREET, EAGLE RIVER, AK 99577
Current Property owner(s) ELDA GALLEAR TRUST
Mailing address
Real Estate Agent
Day phone
19252 FIRST STREET, EAGLE RIVER, AK 99577
2. TYPE OF DWELLING:
Z Single Family (w/wo ADU)
F1 Duplex
Fj Multiple Dwellings (Single Family and/or Duplex)
KIIINAc • �*_, 0 �*, I �
4. TYPE -OF WATER SUPPLY:
Individual Well D
Individual. Water Storage 0
C .._� I
om-1munity�Class Well F
Public Water System
WaiverNariance request for:
Received by:
COSA to be released to the
5
Day phone
Individual
0
G
❑
,0!N
❑
Public Sewer
❑
'N� C T Y,,,e
C C,
U
"",�
z
0
C,
0
6 o
Expiration Date: 1 1,20 1
Complete legal description EAGLE CREST #1 TRACT A LOT 68
Location (site address) 19252 FIRST STREET, EAGLE RIVER, AK 99577
Current Property owner(s) ELDA GALLEAR TRUST
Mailing address
Real Estate Agent
Day phone
19252 FIRST STREET, EAGLE RIVER, AK 99577
2. TYPE OF DWELLING:
Z Single Family (w/wo ADU)
F1 Duplex
Fj Multiple Dwellings (Single Family and/or Duplex)
KIIINAc • �*_, 0 �*, I �
4. TYPE -OF WATER SUPPLY:
Individual Well D
Individual. Water Storage 0
C .._� I
om-1munity�Class Well F
Public Water System
WaiverNariance request for:
Received by:
COSA to be released to the
5
Day phone
Individual
0
Holding Tank
❑
Community
❑
Public Sewer
❑
unless otherwise requested by the engineer.
COSA Fee $ �W. &0
Date of Payment.
Receipt Number
COSA# Q :5 (ML67-
Distance:
Date: ?—/1—/-7
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY..ENGiNER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 9/18/2017
THIS COSA DOCUMENT CANNOT BE USED TO TRANSFER TITLE UNLESS ALL VENDORS (ENGINEERING. SURVEYING, CONTRACTORS, ETC... ASSOCIATED
WITH THIS COSA ARE PAID IN FULL AT OR BEFORE CLOSING. Engineer's Comments: This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested.
The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use,
local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the
system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function
satisfactory for current or future occupants or can ArcTerra guarantee.that no unseen QP '
encroachments, deficiencies or discrepancies exist. IMP,
q'
Of
�l
System #1 Approved for J� bedrooms. "-
___,,_KEN 'F;'i'H t;F • US
System #2 Approved for
Disapproved.
Conditional approval for
bedrooms. s
7t 6
X,
bedrooms, with the following stipulations:
By: 86.0, &X Original Certificate Dater 1 �O 17
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
COSA blue sheet-10-10-12.doc
X Nitrate Advisory
Arsenic Advisory
Other
If more than Imeptic system isomthe lot:
COSAChecklist # —of
__
Structure served by this system
Jill lill'' I I UPON lJ 1111JJJJl J11,11111115 Ji illillir iiiiiJJll 1111111 illill I
1! Jill
Legal Description: EAGLE CREST #1 TRACT A LOT 68 Parcel |D: 050:304-23
A. VVELLDATA–pUBUC
Well type |fA.8.orCprovide PVVS|D#Well Log (YYN)
Date completed Sanitary seal (YYN)y Wires properly protected (Y7N)
Total depth ft. Cased tu__ft. Casing height (above ground)
__
FROM WELL LOG AT INSPECTION
Date oftest
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform no|oniea/100 mL
Arsenic: ug/L
ft.
9 -p -m.
Ndratemg/L
Date of sample:
B. SEPTIC/HOLDING TANK DATA
TankTypo/Mebsha| SEPTIC I STEEL
Tank size _1500_ gal. Number nfCompartments 2
Foundation cleanout (YYN)y Depression over tank (YYN) X
Date ofpumping Pumper
rill
Collected by:
Date installed 9/1112017
Ckaanouts(Y/N)
High water alarm (Y/N)
mm
��
Date installed Soil rating (g.pd...mz or*...~~nn)1��_ System type DEEP TRENCH
Length ft Width 3 ft. Gravel below pipe _8ft.
Total depth ��ft. (measured 9/13/17) B[absorption area 656 ft2 Monitoring tube y Depression over field IN
Date nfadequacy test Results (Paao/FaiU___ For bedrooms
Fluid depth in absorption field before test in. Water added___gal. New depthin.
Elapsed Time: min. Final fluid depth in. Absorption rate >= g.pd.
Anynejuvenotiontremtmemd(paat12moj(0N&b/pe) |fyes, give date
________
D. LIFT STATION
Date installed
"Pump on" level at
Datum
IS,
Size in gallons __
"Pump off' level at
Cycles tested
in
(Y/N)______
High water alarm level sd____
Meets alarm & circuit requirements?
IM
E. SEPARATION DISTANCES
-PUBUCVVATER
WELL {}NLOT TO:
Septic tank/lift station onlot
Onadjacent lots
Absorption field on lot
0nadjacent lots
Public sewer main
Public sewer manhole/cleanout
Sewer /septic service line
Holding tank
Animal containment areas
Manure/animal excrete storage areas
SEPTIC/HOLDING TANK {}N
LOT TO:
Building foundation
Property line _T±
Absorption field
Water main
Water service line
Surface water
Wells onadjacent lots _j08'+_____
ABSORPTION FIELD {JNLOT TO:
Property line
Building foundation _10y±Water main
Water Service line _j0'+
Surface water
Driveway, parking/vehicle storage _YO'+_____
Curtain drain Wells onadjacent lots _2O0'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that / have determined through field inspections and
review of Municipal n*omds that the above systems are in
conformance with MOA COSAguidelines /neffect onthis date.
Engineer's Printed Name — KENNETH M. DUFFUS
Ooba 911812017
COGAcanary oheet-2-045do
am
STREET
NOT USED FOR THIS SURVEY NO CORNERS SET THIS DATE
I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWINGDESCRIBED PROPERTY
LOT 68, TRACT A, FIRST ADD'N. TO
EAGLE CREST SUB. ( PLAT 63-70)
THE INFORMATION HEREON I5 FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES.
EASEMENTS OF RECORD OR OTHER RI6HT5 OF WAY, OR ANY ENTITY NOT ON THE RECORD PLAT
ARE NOT SHOWN HEREON, UNLESS NOTED.
NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
ANY PAYING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE.
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EXIST OTHER THAN NOTED.
DATED AT ANCHORAGE,ALASKA THIS _15TH DAY OF
SEPTEMBER , 2017.
13549, FB 183-67,184-24
Ln
m
in
-r
zo
0
0
0
z
HOLT LAND SURVEYING
9309 GROVER DRIVE
ANCHORA6E,AK 99507
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. It (~-g./~ ° .'3'A%[~ - .~
1. GENERAL INFORMATION
S C,o,m. plet.e legal description
HAA It
Lot 68~ Trac~ A; E~9~ Cr~t
Location (site address or directions)
· Property owner
Mailing address
E~da ~a~an~ Day phone 694-22 ~4
19251 F,/..r6t Str~e.~, E~g~ Rluer, Ala.~ka. 99577
Lending agency CITY ~n~Tq4qF _~_,,_~_~_ ~¢~_ Day phone
Mailing address E~gt.e I~Zu~ B~.c~nchr E~9,~e I~Zu~.A, A~..
Agent Day phone
696-0701
Address
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well ....
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
Name of Firm
Address
Engineer's signature
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 applicatio .n 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 o! 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.
S & S ENGINEERING Phone '
17034 Eagle River Loop Road No. 204
Eagle Rlver~ Alaska 99577
DHHS SIGNATURE
X Approved for
__ Disapproved.
__ Conditional approval for
Date '7
bedrooms.
bedrooms, with the following sbpulations
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 certilicate is issued, The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work,
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~ G.~ "T"~--'I' ,~, Parcel I.D.
A. WELL DATA
Well type'~//'~
Log present (:~/N)
Total depth
Sanitary sea. N)
Date of test
Static water level
Well flow
Pump level
If A, B, or C, attach ADEC letter. ADEC water system number
y Datecompleted ~Z-'ZJ,..-.'/~ Driller ~
"~"'2. Cased to "~'~"~ Casing height
"~ Wires properly protectedd~) ~
FROM WELL LOG AT INSPECTION
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
SEPARATION DISTANCES FROM WELL TO:
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank ' t~c=. r-J'~. ~---~ t~3
WATER SAMPLE RESULTS:
Coliform ~ Nitrate J. I,, ~.5//~ Other bacteria
Date of sample: "7-1~-'~'7-' Collected by: ~ S
SEPTIC/HOLDING TANK DATA
Date installed .' ~5/Z'" ''/~ Tank size
Cleanouts ~N) "~ Foundation cleanout (Y~),
Compartments
Depression (Y~;~'
High water alarm (Y/N)
Date of pumping
SEPARATION DIS,~'ANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot "~- ~c~'~ I
On adjacent lots
To property line ~'c>~ "~ Absorption field "~"7 I.J~ Water main/service line
Surface water/drainage
?2-o26 (Rev. 7/9t) Fmn~ CONTINUED ON BACK PAGE
C. LIFT STATION · -.
Date installed
Size in gallons
Vent (WN)
High water alarm level
Meets MOA ele(~trical codes (WN)
"Pump on" level at
Manufacturer·
Uanhc~le/Acces~ (Y/N)
'Pump ofF' level at
Cycles tested
. SEPARATION DIS'I:ANCE FROM.LIFT STATION TO:
Well on lot ' ' ' On adjacent lots
7
D. ABSORPTION FIELD DATA
Date instailed '~ ' ~:'"~'"~"~ Soil rating
'Length Width
Total absorption area -
Depression over field (YZ~
Surface water
Gravel thickness ,
Cleanouts presentd~TN)
Date of adequacy test
for
'If yes, give date
System type J~'&~
Total depth
Results (pass/fail) '~/'~
Peroxide treatment (past 12 months) (Y~ "-~
SEPARATION DISTANCE FRoM ABSORPTION FIELD TO: , '.
Well on lot ~:~ ~'~ On adjacent lots I ~ I~.., Property line ~ '~-'~.
TO building !oun.?ation '.. ,~..../I~. '~o ex}sting or abandoned system, on lot I~/~'
On adjac;nt lots '~',2~::? ~ ' Cutbank I'J' /"~' ' Water main/service line
Surface water I ~t.~. DrivewaY, parking/vehicle storage area 7
Curtain drain ~ ~ ~-.~.. )~l'c,l~ ~
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA
Signature
Engineer%,Name
Date
S & $ ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577 .
bedrooms
e of this inspection.
Waiver Fee: $ .__,.~'~ o' ~'
Date of Payment ~'/-r~ ~
Receipt Number C:~,.~'~ <
Tom Fink. 825 "L" Street
Mayor P.O. BOX 196650 Anchorage, Alaska 99519-6650
343-4744
August 18, 1992
Roger Shafer, P. E.
S & S Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Subject: Waiver Request for Lot 68 Tract A Eagle Crest S/D
Waiver Request %WR920041, PID %050-304-23, HA920465
Dear Mr. Shafer:
Your request for waiver(s) of the required 100 foot horizontal
separation of a septic system to a private well has been approved.
The approved separation distance(s) are from the private well
to the seepage pit on property a distance of 96 feet.
This waiver approval applies to the existing septic system to
well separation only. Any future upgrade to either will
require all separation distances be met or another approval
from this department.
Sincerely,
Daniel J. Roth
Civil Engineer
On-site Services
Concur:
ohn Smith, P.E'.
/~-hogram Manager
On-site Services
ljm:%6
nor
II
~'o 7-~L
2./
2.?
/,% .~
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
ROBERTSHAFER. P.E.
RCGERSHAFER, P.E.
July 29, 1922
CIVIL ENGINEERS
(907) 694 2979
FAX 694.1211
RECEIVED
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SER¥ICES
825 L Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
JUL 2 9 1992
Municipality of Anchorage
Dept. Health & Human Services
REFERENCE: Lot 68; Tract A; Eagle Crest subdivision
Request you issue the attached Health Authority Approval and grant a
horizontal separation distance waiver for the distance between a
private well and a seepage pit located at 96 feet.
The original well was drilled on the property in October, 1964. The
well was then deepened in February, 1973. The septic system was
permitted and inspected in August, 1973 with the lesser separation
distance noted.
We feel the requested waiver may be granted for the following reasons:
The well is relatively deep at 252 feet and cased to 223 feet.
Inspection of the well logs show several clay layers which
would impede the migration of effluent into the very deep
aquifer.
As can be seen from the attached site plan with topographical
contours, the well is located approximately 12 feet vertically
above the seepage pit. Inspection of the topographical map for
the area suggests that effluent from the seepage pit would
travel away from the well.
Bacteriological and nitrate sampling from the well showed
satisfactory results with a relatively low nitrate level of 1.6
mg/1. This suggests that after nearly 20 years of use, there
is little to no influence on the well by septic effluent.
4. The seepage area is located as far from the existing well as
possible and still remains on the property.
If you have any questions or require additional information, please
contact us.
Sincerely,
PJ~S/ss
17034 EAGLE RIVER LOOP, SUITE 204. EAGLE RIVER. ALASKA 99577
I,EG^L LOT 68, TRACT A, EAGLE CREST SUBD., ADDN. No. I
DRAWN L. $. ULSHER IcKD' R.J.S. I DA?£ ]SliT.
7/11/92 I OF' I
STREET
· SHAFER
No. 8215
;T 69
LoT 68
EX/ST. 1250 GAL
SEPTIC TAIVK
II LOT 6~
Illctlll I~II.oII lid Illl: _ _
loll /llll lifted II-- ~ hlllml, iii)It ~ III/Ill&
v
IIILLErl IAYIlIAL Lit
tlltt fill lid
Illflll II loot
Ilu delo~l;tloo of SIeoIO poNtfOted
{sloe of mtoflol, IllOf, blfdllll l! d~llllol, o# fltof ooolool)
A D D R E S S .........~[ ~..~ ~ .~....:.{.~...M...~...2....~..~.~ :.~ ............................................
W E r L.--S I T E .....~ ..~ .~...e......]~.$..~....o...~.. L .....~. ~ .~ .o..---~--' ......................................
DATE--STA RTED.......~.~..~..O...b- .~...X'..L..~ ~..~..4. ...........................................
V AT E~END E D....D.~..~ O.b.~.~.....1~.6.4 ...................................................
KIND OF FORMATION:
FROM.....0.. ................. Pr. TO.._.2~ ...........
r~OM-.21 .............. Pr. ~O.~...32 ............. Pr-.c~ay,-.grave~
LOG OF DRILLING by A & L I) RI LLI NG COM PANY .
D~FrH OF w~_l~l...fee.~ .......................................
STATIC LEVEL OF WATER FT......~.~...~.~..t ....................
DRAW DOWN FT~...4.0....~.~.~..~ ..............................................
GALS. FER lla.....9.~...gl~On~...~.~....~.O~.. .............
KIND OF CASING.....6.....-.....~/~.~....e. .......................................
· . .............. ~o3k, sand, gravel
FROM,...~.~ ............. A~. ~ro..._..40. ............. Pr_.san~,~...~alL grave~OM . ~. To ........................ .rT .................................
FROM.....40 ............. Ff. TO......60. ............. Pr....f. lne...sani ....... FROM.....Zi9 ............ Pr. ZO....[.g.7. ............ rr_...c..[.a.g.,....g..r...a..;
FROM....~ ............... Pr. TO.......G2 ............. Pr~..~a~,....~-'.r.~Mol FROM.....[2T. ........... Pr. TO....L~.~ ............. Pr......s....a.j'!~.,.g..r..a...v..;
FROM_..62 ............... Pr. TO......~.7. ............. Pr-.2Og.'-: ........................ FR 0 M......'....--..7..7..7...7...~; ~ 5.7..7...-....'..7..7...7...-.pr.....~/..~...g~[ .... £.
~ROM....6~L .............. ~r. To.....ftS. ............. Pr_.:art,l,._cla~.,.. bouJJ~9:m~ .......................... Pr. TO ......................... Pr ..................................
rROM.....~5. ............... Fr. ~o.......5.7..-..L/.2Pr~..~,...gcU~.~, FROM .......................... Pr. TO .......................... Fr ..................................
~/v, g~L. ~.m.
FROM....87.~l/2..Pr. TO......~i ............. Pr~..o.l~ya....b.a,.~lz.e :'$ FROM .......................... Fr. TO ......................... Fr ..................................
rROM....gL ............... Fr. ~O......96 .............. Fr...coarse...s.an~,l~2 FROM.. Fr. TO ......................... Fr ..............................
· gP..~',X~, '"'
FROM....C3g ............... Pr. TO......I.06. ......... Pr....ClO~ ........................ FROM .......................... Pr. TO ........................ L.Fr ..................................
FROM-..~L0~ ............ Fr. TO..-...i~L~ .......... FT.-..I~:~{I,~,r...~O,~ ]. FROM .......................... Pr. TO ......................... Fr ..................................
MISCL. INFORMATION:
The casin.~ was ~:cri'o~te~ at 87-1/2 feet, at 9~ feet, at 95 feet,
anl at 119 feet. ~.
DRILLER'S NAME .......... ..I.!..e...~.....~ .:......~..~ ..1.. _~..v_..~....~.'.".~. .................
JVJ-W DRILLING, Inc.
~. O. ~ox 4-1928 · 2811 Dmwson
A C
/~CHORAGE, A/~s. sKA
DRILLING LOG
I'1' I 'I
Well Owner
£~d:m C~lle-.r
Use of Well_ .:")'.
· Location (addre~ of: Township, Range, Section, ff known; or distance ma~n road
Size of casing A r)epth of ]Iole.-~SZ. feet Cased to ~.~ feet
Static water leve~ ~ I;,~ it. (Above) (below) land surface. Finish of well (check one). open end ( );
.qcre~n (' . .); Perforated ( ~ ).
· '... · · ~ $3.: '1'~1 '177 q~ ,17~
Well p'umping test' t~t'~'gallon~ per (hbur)
of drawdown from static level.
Date of completlo~ ~-
Depth in feet from
ground surface
o 'TO 1 .~:l
(minute) for__l hours with ~ .ft.
, (~.~.,,.~. F~r~' WELL LOG
Give details of fcrmatlon., penotratcd, slle of matcrlal, color and hardness
TO
:. 6-'t
I7034 Eagle River Loop Road
Eagle River, Alaska
'* ~IELL FLOW TEST DATA SHEET '*
LOCATIONOFWELL(Leg&IDescrlptlon}: [~ ~ ""~"~ /~-
WELL DEPTH; '~'~ ' FT. CASING: ,~,~.. ,~t FT.
DATE DRILLING COMPLETED: ~' ~'~ DRILLER;
STATIC WATER LEVEL ~op of Casing): ~ ~ ~ t
ROBERT A. StlAFER
CIVIL ENGINEER
¢94
DATE oF ~EST: "7-'"/ --'~ ?-.
SCREEN:
CLOCK ELAPSED TIME SINCE DEPTH TO DRAWDOWNI PUMPING
TIME PUMPING STARTED/.__ -WATER, FT. RECOVERY RATE, OPM REMARKS
STOPPED, MIN.
10
20
45
55
60(t hour)
1~ (3 hou;s)
2~0
~ECOVE~Y
t 0 0
10
15
25
3o
35
Comments: ~ ~?~_.o~C.~--~ I.~ C~ ~'t.// Flow is not Guaranteed
Subsequent Variations
Can Occur.
?29.0 72
ACCF2SS
2,0 726.0
APPLI~ ~IT FILLS OUT UPPER HAL~'ONLY
'Address Zip
Realty ~. & A~nt ~ ~ ~one
Address ~ ~ ZI~
00t~m
5ewer Disposal
Time Time Time Time
Inspecto~ Inspector Inspector I~sp~tor
('~) APPROVED ~DROOMS 'CONDITIONS OF APPROVAL
( ) DISAP~OVED
( ) CONDIT~NAL APPROVAL'
$TA~'E 4T
EXCAVATION WORK $RB 196X
CIVIL ENGINEER EAGLE RIVER, AK 99577
DESCRIPTION '* AMOUNT
1
EXCAVATION
ROBERT A. SHAFER
WORK CIVIL ENGINEER
694-2979
August 2, 1982
Mr. Eldon Gallear
P.O. Box 1003
Eagle River, Alaska
99577
Dear Mr. Gallear,
Reference: Lot 68: Tract A: Eagle Crest Subdivision
A sewer system adequacy test was performed on the system located
on the referenced property as you requested. The septic tank was
pumped and according to Municipality records has a capacity of
1250 gallons. The seepage pit was tested by charging the system
with 1000 gallons of fresh water and after a period of 24 hours
464 gallons had percolated out of the crib.
It can be concluded from this test that the waste water disposal
system serving the three bedroom residence located on this property
is currently functioning adequately. ~wever, the system cannot
be guaranteed against subsequent failure.
If we may be of further service, please do not hesitate to call.
Sincerely,
/ROBERT A. St5%F~R, P.E.
cc: Ranier Mortgage
Municipality of Anchorage
Department of Health and Environmental Protection
SRB 196X EAGLE RIVER, ALASKA
/AL
July 30, 1982
Eldon Gallear
P.O. Box 1003
Eagle River, AK
99577
Subject, Lot 68 TP.T A Eagle Crest Sub.
Approval for the individual sewer and water facilities cannot
be granted until the.following items have been completed,
The water analysis report needs to be submitted to this
office from the Chem Lab, 5633 B Street, for our review.
Expose the well for our inspection to determine proper
construction, also to insure minimum distance requirements
are met between the well and sewer system.
The septic tank pumped with a receipt submitted to this
department.
Please notify this Department for a reinspection when the
noted discrepancies have been corrected. If there are any
further questions, please call this office at 264-4720.
Sincerely,
RP175/p/EI{
Robert C. Pratt
Associate Environmental Specialist
TO BE COMPIJ:~I:D BY WATER SUPPUER
WATER SYSTEM:
.*-.. ~- /j LO. NO.~
~ .f~'i,',.- .... '*~ ~d ?.t~'.-. ,
SAMPLE DATE:
Mo.
PhMle No.
Z~) Corn
SAMPLE TYPE:
[:] Routine
r-I Check Sample (for routine simple
with tab rof. no. ' )
I-I Special Purpose
Ct Treated Water
[] Untreated Water
~AMFLE
NO. LOCATION
I ~ ¢ ['~: ~ /~"
3I I
,I I
.I I
TO ~3E COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
'[:~Satisfactory
[] Unsatisfactory
[] ~ample too long in transit; sample should
not be over 48 hours old at examinstion
tp indicate reliable results. Please send
new sample.
· Received / *' ~ ~
Tinge Received '*/~ ~"
Analytical Method:
Ct Fermentation Tube
Ct Membrane Filter
Lab Ref. No, Result*
I
I ~
I I-~
Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
INSPECTION APPOINTMENTS
rIME TIME TIME
DATE DATE DATE
MUNICIPALITY OF ANCHORAGE
(~/~"~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTfi~T~A[iTY OF AN~O~GE
825 L Strut - A~hor~, AIa~e ~1 DEPT. OF HEALTH &
E~I~ONMENTAL
t. PROPERTYOWNER ~ P ONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from abo~) PHONE
3, [ENDING INSTITUTION PHONE
4. REALTOR/AGENT J PHONE
I
MAILING ADDRESS
LEGAL D~.SCRIPTION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
/,~ i--'lOne ,~ Four
SINGLE FAMILY [] Two Five
r-'l MULTIPLE FAMILY I-3 Three [] Six
[] Other
7. WATER SUPPLY
,~ INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
* ATTACH WELL LOG. A weJl log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
(attach log if available.)
depth
/~:;:~,~--~ YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
72.010 (Re~. E/79)
THIS SIDE
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] .SINGLE FAMILY r"l ONE I'-I THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] S~X
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified, LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE ' DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or I--'l Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4o DISTANCES WELL TO: SepticlH°idm' Tank IAb$°rpti°n Area ISewer li"e INear~s` /Or L'ine
Absorption Area to nearest Lot Line - ·
5. COMMENTS
[] APPROVED FOR BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY
72-010 {Rev. 6/?9)