HomeMy WebLinkAboutNORTH WOODS PHASE 2 BLK 1 LT 8North Wood
Phas
lock I
Lot 8
051-741
-27
;/
Municipality o£Anchorage ...--r
Development Services Deparlmenl ' ".
Buildihg Safety Division
On-$ile Water and Waslewater P~rogram, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage. AK 99519-6650 Page
~.cl. anchorage.akus (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Pe,mit Number: 6 ~O~O0 ~ d PlO Number:
"-- ~ &~r ~ ~ ~ ~ Wastewater System: ~ New ~ Upgrade
~ ~B~ ~h;~;~u~;ct~. ~r:~ ~.~,~K ~q~ 57-5~ ABSORPTION FIELD
Well: ~ New ~ Upgrade
'~ ~~s~.. ~. ~t 'TANK
SEPARATION DISTANCES ~ septic D Ho~m.g D S.T.~m. D Other:
~ Seplic Absorption Lift Holding PU~t~ M~:e ~ , C~tv
,-- e' 7' · m.s".l
BENCH ~ARK
..
S & S ENGiNEER;NO ~ )/ ~%..,~
Insp.ection~ p erf ormea'-oy: ~~ 170~ E,gle River Lo~ R~d, No.~ Ua~s:
Develbpmept Services Department Approval
Reviewed and approved by: ~///~/ ~ ~Date:
PERMIT NO. SW020096
PAGE 2 OF
Municip. ali't of' Ancho,r'gg.e'
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONHENTAL SERVICES DIVISION
P.O. Box 196650 eAnchor'~ge, At~sk~ 99519-6650eTeteohone~ 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 8, BLOCK 1, NORTH WOODS #2 PJ.D. NO. 051-741-27
TH//1 ·
EXISTING 1000
GALLON SEPTIC TANI --
rco~
---NEW PUMP BASIN
LOT 9
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40'
LOT 7
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C. COWAN
CE.8801
PERMIT NO. SW020096
PAGE 3 OF 3
UnlClpoh~ o¢ .A.n c:h.o.c ~ g e
DEPARTMENT OF HEA~TH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 OAnchoPoge, AI(3sk(~ 99519-G650®Telephone, 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
L~'CAL LOT 8, BLOCK 1, NORTH WOODS #2
P.I.D. No. 051-741-27
FINAL GRADE.-~
ST1 %
93 5'// EXISTING 1000
' GALLON
SEPTIC TANK
$T2 CO 1
MTI
100.6'--~
,~...--FINAL GRADE
~-~ 2" INSULATION
DISTRIBUTION PIPE
97.9
~MT1 = 96.4'
A ~
fCC 29.0' 22.0' -
~T1 36.5' 16.0' -
~T2 42.0' 12.0' -
201 44.5' 10,0'
~4H 46.5' 9.0' -
· ~T - 70.0' 48.5'
·
WATER FOUND
85.9' B.O.H.
86.9'
PRESSURE DISTRIBUTION SYSTEM:
PUMP = 20 051 05HH - 5 STAGE (~30 CPM)
Me~ 24 02 04:28p flllted 81aske Electric
May 24, 2002
Elec~cal work performed ~ r~u~st of:
On behalf of:
To v&om it may concern:
TWEED Excavating & Consm~cfion
17034 E~Ic River Loop Rd, Suite 202
Ea~le River, Ahska 99577
S & S Eng~eet~g
The eleclrieal in.stallation of Ibc 1~ station at lot 8, block 1 - Northwood, located in Peters Creek, Alaska
was performed by a licensed electrician, ia accordance with lhe current national electric code.
Under penalty ofpe~ury, I certify the above information to be mae and correct.
S~ncc~-ely,
ALLIED ALASKA ELEC'ERIC, LLC
Sanette L Bwwnf ~
~t/Owner
Tweed Excavating & Construction
File
P.O. Box $76310, Wa~illa, Alaska 99687 O~fwe (~07) $73-3595 / Cell 252-$657 /Fax SrJ-JS94
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bregaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: May 08, 2002
Expiration Date: May 08, 2003
Permit Number: SW020096
Legal Description: NORTH WOODS PHASE 2 BLK 1 LT 8
Design Engineer: 0003 S & S Engineering
Owner Name: LARRY FINGAR
Owner Addrass: 22336 WHISPERING BIRCH DRIVE
CHUGIAK. AK 99567-5449
Parcel ID: 051-741-27
Site Address: 022336 WHISPERING BIRCH DR
Lot Size: 58333 SQ. FT.
Total Bedrooms: 2 Permit Bedrooms: 2
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. Ail requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
5.'Th~ following special provisions. ,
:; THE EXISTING BED SHALL BE PERMANENTLY DECOMMISSIONED OR GROUND WATER MONITORING '
~,"DONE ON MAY 15, 2002 IN ACCORDANCE WITH AMC 15.65.
Municipality o.f Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www .cl.anchorage .ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Permit N u mb e r SW Z_...~0_~q_.(z__
Property owner(s) ~.~/Z./Z."/ ~""J~-/~--- Day phone
Mailing address (1) ~'~)~, {/~/..1, ,SP',C--"a..-I~-/~-' '7~tr'z-Ct4;
Mailing address (2) Zip Code
Legaldescription(Lot, Block&Sub'd.) ~0~ ~ ~10~ ~ It ~OF +~ ~00~
Legal description (Section, Township & Range)
Lot Size~~ S Acre~ Number of Bedrooms ~
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Well Only ~
Water Storage
~] Jacuzzi ~[]
Water Softening Unit
[]
I certify that the above information is correct. I further certify that this application is being made for a
Slngle Family Dwelling and is in accordance with applicable Municipal Codes.
S & $ ENGINEERING
(Signature of property owner or authorized agent)
Permit Fees: t~ O O. ~ '
Date of Payment: 5-/"/
Receipt Number: 0 ~.~
(Rev. 12J00) I ~
Waiver Fees:
Date of Payment:
Receipt Number:
ltmq
May6,2002
ROBERT C. COWAN. P.E.
CML ENGINEERS
(907) 694-297B
FAX (907) 694-1211
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot 8, Block I, North Woods Subdivision /~ Z_
It is requested that you issue a permit to upgrade a septic system to serve the existing
two bedroom dwelling on the referenced property.
A test hole was excavated and a pemolation test performed on 4/30/02. The approximate
location of the test hole is located on the attached site plan. At the time of excavation,
water was found at 6 feet. Ground water was monitored and after seven days water was
found at feet as shown on the a~tached soils logs.
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
areas or drainage patterns by the installation of the proposed septic system. The
construction of this system will not prevent any future development on any of the adjacent
properties.
lfyou require additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E.
Rccroii
Enclosure
17034 NORTH EAGLE RIVER LOOP · SUITE 204 * EAGLE RIVER, ALASKA 99577
DRAINFIELD
3.5' DEEP
1.5' EFFECTIVE
5.0' WIDE
41' LONG
LOT 8, BI,OCK 1,
B.J.J. R.C.C.
DESIGN 'ERIA:
2 BDRM = 300
SOILS = 0.8 GPD
300/0.8 = 375 SQ.FT, D,
CRITERIA:
THtlA
N()RTII ~'OOI)S
5-15-02
CONTRACTOR IS REQUIRED TO
OBTAIN UTILITY LOCATES
PRIOR 1'O ANY EXCAVATION
WORK.
DOUBLE
CLr'ANOUT~
£XlSTING 1000
GALLON SEPTIC
FCO
S
1 OF 1
300
PUMP
BASIN WITH S.T.E.P.
LOT
PRESSURE DIST. DATA:
1) LATERAL 39' LONG 1.25"~
30) 3/16"~ HOLES 0 15.5" APART
MANIFOLD 1.25"~
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LOT 7
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(APPROX)
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CE-8601
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Municipality o~ Anchorage e~~'s'~ '~.~,,,p~,
Development Servlces Depadment I ~?' "~ ~ ~
Bu~dngSafe~sl~ ~~--~~~'h~ ~ ~ ~ ~.,
......... 6650 ....................... * ........ *'*~
P.O. Box 1966~ ~ge. ~ ~u- I ~ ; I ·
~ ~ ROBEET C COWAN ~
(~7).3-7~ I '/J~,:',.. ~-ss~, ..~
I ' ~' "' "''' '
Soils
Log
Percolation
Test
I
2-
3-
4-
5-
6-
7-
8-
9-
10-
1~-
12-
13-
14.
15-
16-
17-
18-
19-
20-
/ I Silo Plan
COMMENTS
WAS GROUND WATER
ENCOUNTERED? ·
IF YES, AT WHAT DEPTH?
Depth to Water After
Monllorlng?
Date:
Reading Dale Gross Time Nel Time Depth lo Water Net [hop
/--
/0 Io I1" 5"
/o /o ~7~"
io /o ~"
PERCOLATIO~I RATE
TESTRUNBETWEEN ~;~.~"" FT AND 4.¢ FT
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON TNIS DATE. DATE:
Municipality of Anchorage
Development Services Department
Building Safety Dtvislo~
On-Site Water and Wastewaler Program ~3s,~--.v. ~ .................
P.O. Box 196650 Nlchorage. AK 99519-6650
't "~.-, % ./,rD ""
Soils Log - Percolation Test ,
Slope Site Plan
9-
10-
11-
12-
13-
14-
15-
16-
17-
18-
19-
20-
COMEIENTS
~H
WAS GROUND WATER
ENCOUNTERED?
IF YES. AT WHAT DEPTH? .
Depth to Water After
Reading Date Gross Time Net Time Depth to Water Net Drop
o 0 ~'
0 0
PERCOLATIOH RATE ~ (mmum~nc~! PERC HOCE DIAMETER
TEST RUN BETWEEN~. FT AND ~"-- FT
PERFORMED IN ACCOR~)ANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ,,,~'"/~- ~ "Z..
ROBERT C. COWAN, P.E~,
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
CML ENGINEEI'~
(907) 694-2979
FAX (907) 694-1211
REFERENCE: Lot 8, Block 1, North Woods Subdivision -~ 2_.
May 6, 2002
GENERAL:
The scope of this project includes the installation of an absorption bed to
serve the existing two bedroom residence located on the referenced property.
Construction shall be in accordance with the approved site plan and design
drawings, Municipal permit or ADEC Authority to Construct with any
special provisions or conditions, and all applicable State and Municipal
Wastewater Disposal Regulations.
The contractor shall be responsible for obtaining any necessary underground
utility locates. ·
Unless speciftcally agreed otherwise, the property owner shall be responsible
for final grading areas subsequently depressed from soil settling. On all
leachfield mound systems, the property owner shall be responsible for
ensuring a satisfactory vegetation growth over the mounded area.
Contractors installing waste~vater disposal systems must be certified by the
Municipal Health Department or ADEC if required, for system installations.
Owners installing their own systems must also receive prior approval from
the Municipal Health Department.
SEPTIC TANK INSTALLATION:
A septi6 tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two 4" cleanouts for pumping access·
The septic tank shall be sufficiently bedded to prevent settling or shifting of
the tank.
All standpipes on the septic tank shall extend a minimum of 12 inches above
final grade.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, A~J~KA 99577
Page 2
Lot 8, Block 1, North Woods S/D
May 6, 2002
4. Septic tanks installed with less than 4 ft. ofcover shall be insulated.
A foundation cleanout shall be installed one to four feet from the building foundation.
In the line between the tank and the leachfield there shall be two adjacent cleanouts.
These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank.
The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout
shall be to clean toward the septic tank.
Final grading over the septic tank shall be such that a positive slope exists away from
the septic tank.
LEACHFIELD BED INSTALLATION:
Excavate the proposed Bed Area to the depth shown on the design. The bottom of the
excavation shall be within 2 inches of level. If the bottom of the excavation becomes
smeared, it must be raked or scratched (rafted-up) before gravel or sand placement.
Ifa sand layer is required, place sand over entire excavation to the required depth shown
on the design. The top of the sand layer must be within 2 inches oflevel.
Sewer rock shall be placed uniformly throughout the entire bed. Perforated distribution
pipe must be installed level with perforations down. Gravel depth below the perforated
pipe shall be a minimum of six (6) inches. Gravel depth above the perforated pipe shall
be a minimum of two (2) inches. The total gravel depth throughout the entire bed shall
be a minimum of twelve (12) inches.
The perforated distribution pipes must be no more than six feet apart. The distance
between the outermost perforated distribution pipes and the sidewall of the absorption
bed must be no more than three feet.
Silt barrier material must be installed between the final gravel layer and the native soil
backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill.
Monitor tubes shall be of four (4) inch diameter, installed at the locations shown on the
design, and extend a minimum of 12 inches above final grade. The portion of the
monitoring tube extending through the gravel depth shall be perforated six (6) inches
below the bottom of the horizontal distribution lines. The monitoring tube should not
extend below the bottom ofthe gravel surface.
7. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation
must be installed when the backfill depth is less than thirty-six (36) inches. The finished
grade over the bed must be mounded to prevent the formation ora depression after settling.
8. A mound system is to have the upper six inches oftop soil and be seeded for vegetation.
Page 3
Lot 8, Block 1, North Woods S/D f~ ?''
May S, 2002
MINIMUM MATERIAL SPECIFICATIONS:
Any septic tank proposed for installation must be constructed by a Municipally
approved septic tank manufacturer.
The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
Type of Pipe Perforated Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F8 i 0 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be approved by the inspecting
engineer.
Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam Ill or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco,
or equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
igth '
pass n e #200 steve.
When sand is being used as a filter material, its gradation specifications must conform
to current MOA or ADEC requirements.
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the installation ofthe
wastewater disposal system. These inspections will occur as follows:
The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any gravel. A septic tank may be
set in place, but may not be backfilled before this inspection.
The second inspection must be conducted after the placement of the silt barrier,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
Page 4
Lot 8, Block 1, Notlh Woods
May 6, 2002
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting
engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a
pre-construction meeting will take place on-site. The inspecting engineer will not coordinate,
direct or control in any way the contractors activities.
The ogler shall contract with the contractor to perform the work outlined in these
specifications and plans and in accordance with the attached MOA permit or ADEC Authority
to Construct. There will be no contractual arrangement existing between the contractor and S &
S Engineering.
S & S Engineering shall be the owners representative and will inspect the work as
stated above to document the contractors activities. Final acceptance ofthe contractors
work rests with the oxvner.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor
to carry out the work in accordance with these construction documents. S & S Engineering's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incident to this project.
CONTRACTOR / INSTALLER
~-~ MUNICIPALITY OF ANCHORAGE ~
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
LEGAL DESCRIPTION
LOCATION
Manufacturer ~ '
ILiq. capacity in gallons c u~c~A ~=
/~2~2o ........ ~ ..... :
D STANCE TO' Well
' I
Manufacturer
Well
DISTANCE TO: I
No. of hnes I Length of each hne
Top of tile to finish grade
Length ~ j Width , /
Type o~ J Cri.~er
PHONE
Absorption area Dwelling
¢~' ~ / Material
Inside length Width t~'~: ~
NO. OF BEDROOMS
PERMIT NO.
No, of compartments
Liquid depth
Dwelling PERMIT NO.
Material Liquid capacity in gallons
Foundation Nearest lot line PERMIT NO,
Total length of lines Trench width Distance between lines
Material beneath tile
inches
Total effective absorption area
inches
Depth ~ ~.~ PERMIT~)) ~- //~ ~:'~ NO.
Crib depth-
[~NEW
[] UPGRADE
Building foundation
Driller
Sewer line
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO.
Septic tank Absorption area(s)
OTHER
PIPE MATERIALS .
SOIL TEST RATING
INSTALLER
REMARKS I.) ¢
72-013 (Rev. 3~78) 0 ~---~/ '
DATE LEGAL
//9
" - DEPARTMENT HEALTH AND ENVIRONMENTAL .;OTEF:TIF '~3N-~
' ~ ' ' ' 825 "1-" STREET, ANCHORAGE., AK. 9950t~Q,/~~ "~
"~4-4720
PERMIT NO. ( 82105b )
aPPLICANT STEVEN L SKRGSS CONST PO BOX C, CHUGIAK 9--q75~,,-''%~GBB-28J.1
LOCAT I ON
LEGAL LSB'I NORTHWOODS I I
LOT SIZE 999999 _,QLRRE FEET
TYF'E OF SOIL ABSURFTIUN =,-r_TEM IS: DRRINFIELD
MAXIMUM NUMBER uF BEE. R_ICM_ = ? _uIL RATING (._,Q FT/BR)=
' - "' - ' I '-' '~ I S
THE REQUIRED SIZE OF THE SOIL HB=.URPTIEN .~z_TEM :
[:'EPTH= 7- LEi%I6TH= 77 GF-.'R %-'E L [:.EPTH= __- -:"'
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THE TREt4C:H L. JI[)TH I5 5. 0E~0 FEET.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET)
REL-J. LI I REE:, SEF"T I C TR[-~K $ I ZE= t01ZI0 6RLLOI'-.IS
PERMIT APPLICANT HAS THE RESPUN=,IBILIT~ TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSFECTILN=, OF ANY WELLS ADJRE:ENT TO THIS PROPERTY FIND THE
NUMBER OF RESIDENCES THRT THE WELL WILL
TWO ,~ 2 ) I FISPEL'~-"~ I l_~r-J$ ARE RE~LI I RFD
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE _,LIBJE_.T TO PROSECUTION·
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A'PRIVRTE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO R PRIVATE SEWER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET·
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
I CERTIFY THAT
:L: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
-~: I UNDERSTAND, THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN -?- BEDROOMS.
, '"~ ~ ~' ~-' C ~ " '
S GN D:_.
O & E ENG,.NEERING & DEVELO, MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oysler Earl Ellis
694-2774 SOIL LOG 688-2280
8__
9__
13
14
Depth (feet)
0
Soil Characteristics
's P- 5/t4-
2.20
Ground Water Encountered: Yes
Proposed Installation:
Comments:
~' No If yes, what depth
Drain Field
Seepage Pit
Performed by:
PLOT PLAN
PERC. TEST
•
a �E e
• Municipality of Anchorage °
On-Site Water and Wastewater Program 2` "
(907) 343-7904 s A E T Y
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
t
Parcel I.D. 051-741-27 Expiration Date: Cjc '-Zl r1
1. GENERAL INFORMATION
Complete legal description NORTH WOODS PHASE 2 BLOCK 1, LOT 8
Location (site address) 22336 WHISPERING BIRCH DRIVE, CHUGIAK,AK 99567
Current Property owner(s) ARNOLD &JOY CULBERSON Day phone
Mailing address 22336 WHISPERING BIRCH DRIVE, CHUGIAK,AK 99567
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 2 (TESTED AS 3)
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Individual
Individual Well ❑ Holding Tank ❑
Individual Water Storage ❑ Community ❑
Community Class Well ❑ Public Sewer ❑
Public Water System
Waiver/Variance request for: Distance:
Received by: ,, • Date: 7/4-//'
COSA to be released to the engineer, unless othy�11'requested by the engineer.
COSA Fee $ S Waiver Fee $
Date of Payment (p1 /il Date of Payment
Receipt Number (A (00 Receipt Number
COSA# 0(e.1 1 (7 Waiver#
•
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER,AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 6/23/2017
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 ��\
encroachments,deficiencies or discrepancies exist. OF Az
Ar
* 4 9 JiH K
6. DSD SIGNATURE /- -
Amm�= �'3.
System #1 Approved for bedrooms. �� t:Et`r:r. pis DL!�US71
System #2 Approved for __ bedrooms. 4 if", ���� ;� ()��
'�bFF;ssio':O"
Disapproved. � 41.'
Conditional approval for bedrooms, with the following stipulations:
.��( OF A!N ,
U
S1�E C
Wp\l'ER AN ER zo
_ S70A
'7� W PROGRAM U
•,<„,
.c
j.
By: � �^-� Original Certificate Date: 7 5 r1 7
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 X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12.tloc
If more than 1 septic system is on the lot:
COSA Checklist# of_
Structure served by this system ,
Certificate of On-Site Systems Approval Checklist
Legal Description: NORTH WOODS PHASE 2 BLOCK 1, LOT 8 Parcel ID: 051.741.27
A. WELL DATA — PUBLIC WATER
Well type If A. B, or C provide PWSID # Well Log (Y/N)
Date completed Sanitary seal (Y/N)Y Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform olonies/1 00 mL Nitrate v15 g/L
Arsenic: D ug/L Date of sample: _4/2,..0 7 Collected by: 4yG'/e-r IA
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC /STEEL W/LS Date installed 10/1982&5/21/2002
Tank size 1000&280 LS gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) Y
Date of pumping 6121/2017 Pumper ONE STOP
C. ABSORPTION FIELD DATA
Date installed 5/21/2002 _ Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 System type SHALLOW TRENCH
Length 41 ft. Width _5 ft. Gravel below pipe 1.5 ft.
Total depth 4.5 ft. (Measured 6/22/17) Eff. absorption area 263 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 6/22/2017 Results (Pass/Fail) PASS_ For 3 bedrooms
Fluid depth in absorption field before test 7 in. Water added 450 gal. New depth 16.5 in.
Elapsed Time: 1440 min. Final fluid depth 7 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed 5/21/2002 Size in gallons 280 Manhole/Access (Y/N) Y
"Pump on" level at 48 in. "Pump off' level at 51.5 in. High water alarm level at 44.5_ in.
Datum TOP OF LS CASING Cycles tested 2 Meets alarm &circuit requirements? Y
E. SEPARATION DISTANCES - PUBLIC WATER
WELL ON LOT TO.
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 200'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 200'+
F. COMMENTS
Vacant system presoaked per code prior to testing.
G. ENGINEER'S CERTIFICATION
I certify that l have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date. 411 OF �
AarL `1
Engineer's Printed Name KENNETH M. DUFFUS
Date 6/2312017 ` 49 TN .40/1
x'%37/
9 KEN L'TH , . DU' /
COSA canary sheet_2-6-15.doc 1 �� e /4.4'
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. (~ I'- "-) L~ { _ ~
1. GENERAL INFORMATION ~'~
Complete legal description Nort¢oods ~ S/D,4~k-~'L'~
Location (site address) 22336 Whispering Birch Dr., Chugiak, AK
Expiration Date:
Current Property owner(s) Hans Leukuma
Day phone 688-0407/H, 350~9519/C
Mailing address
P.O. Box 671965, Chugiak, AK 99567
Lending agency
Residential Mortgage
Day phone 694-8818/0, 317-8814/c
Mailing address
11901 Business Blvd., Eagle River, AK 99577
. RSa[ Estate Agent FSBO
,,': Mailing AddreSs P.O. Box 671965, Chugiak, AK 99567
Unless'otherwise re:'q'uested, COSA will be held by DSD for pickup.
2. NUMBEROF'BEDROOMS: 2
Day phone 688-0407/H, 350-9519/C
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~ Well
Public Water System
[]
[]
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding Tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
· samples:) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Douglas T. Kenley, P.E.
Address 9806 E. Northstar Circle, Palmer, AK 99645
Engineer's Printed Name
DSD SIGNATURE
~'/ Approved for
Disapproved.
Conditional approval for
Phone (907) 746-1073
Douglas T. Kenley Date '7_ '-/ . [ I.
bedrooms, with the following stipuleS: '
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(Rev. 11/05)
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date:
Municipality of Anchorage
Development Services Departmerrt
,Building Safe,Division
On-Site*Water & Wastewater Program
4700 Eimore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www. munLorg/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: No~lhwoods#2 S/D, Block 1, Lot8
A. WELL DATA
Well type Public
Date completed
Total depth
Well production
WAT .
Coliform / colonies/100 mL Nitrate
If A, B,-or C provide PWSID # Well Log (y/N)
seel (Y/N) ....... V~re~ p~e.y pro~ed~
SanitarY
Cased to ~ __ff. Casing' hei~round) in.
FROM WELL LOG ~cTIO~
~ mg/L Collected byi
B. SEFnC./HOLDING TANK DATA
Tank Type/Material Septic/Steel/*
Date insteik~d 10/82-5/21/02'*
Tank size 1000 gat.
Foundation cleanou.t (Y/N) Y
Date of pumping. ~,'3/8/11
Number of Compartments 2 ~ .._.Cleanauts (Y/N)
Depre~i?n og~r tank (Y/N) N ' High water alarm (Y/N)
Pumper JR'S Pumping
Y
Y
Length 41
Total depth 4.4
Date of adequacy test
Fluid depth in absorption field before test 0. ir~...
Elapsed Time: 75 min. Final fluid depth , ,4
Any rejuvenation tmatmem (past 12 mo.) (Y/N & type)
~ rating (g.p.d./f~or'f~2/bdrm) 1.2
fL Width 5 fL
Eft. absorption.area 263 .fi2 Monitoring tube
7/6/11 . Results (Pass/Fail) Pass
Water added, 493 gal.
,, in. Absorption rate >=
System type Shallow Trench
Grav~ beJow p~e 1,5
Y Depreseion over field N
, N
For 2 bedrooms
New depth6-7/8 in.
300 g:p.d.
If yes, give date ....
UFT STATION
Date inStalled 5/21/02
'Pump on" level at., ,46, in.
Datum Top of lift station casing
E. SEPARATION DISTANCES
Size in gall~.ns. 280 -
"Pump off' level at 51.5 in.
Cycles tast~:] ~ 3
SEPARATIO~i.. DISTANCES EROM~ ,LL ON LOT TO:
Septic tank/lift station on lot
Absorption 'field on lot
Public sewer main ~
Animal containment areas 50+~ff.
Manhole/Accass (Y/N) ,,,
High water alarm level at 44.5
Meets alarm & circuit requirements? Y
in.
On adjacent lots
On adjacent~' '
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
l~+ff.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK'ON LOT TO:
Building foundation 8 ft. Property line 53 ff.
Water main 10+ ff. Water service line lO+'ff.
Wefts on adjacent lots'i, 200+ fL
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 42 ft. Building foundation 20 fi.
~ater ~ line 1~+ ff. Surface water 100+ ft.
Cai"lain drain None known Wells on adjacent lois ' 200~
100+ lt.
Water main 10+ 'ff.
Re~ Numar
(Rev. 4110)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak, us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY'APPROVAL
FOR A SINGLE FAM'I~.Y'D~VELLi~G'."..i.,
Parcel I.D. ¢,,O.C'/-'7~[- ~-7
.l. GENERAL INFORMATION
:' Complete legal description LO 7-
.... "Location (site ~'~ldress or directions)
Current Property owner(s)
HAA #
Expiration Date:
Mailing address
Lending agency
Day phone
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ;Z
3. TYPE OF WATER SUPPLY: '
Individual Well J--J
Individual Water Storage []
Community Class J~ Well []
Public Water System ~
TYPE OF WASTEWATER DISPOSAL:
Individual On-site J~
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
flue (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 hcmeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a pdvate or Class C we!l and may be reissued with
new water sample results. (Certificates may be reissued fcr a pedcd of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B we!Is er 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 vedfy 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 vedfy that based on the information obtained from the
Municipality of Anchorage flies 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.
ENGINEERING
Name of Firm 17034 E~ile River Loop Read No. ~0~ Phone.
Address £~le River, Alaska
Engineers Pdn~ed'Name ~08~ ~- ~o~ Date ,,
5. DSD SIGNATURE
Approved for
Disapproved.
×X Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Money in the amount of 1.5 times the high bid of a minimum of three bids
from approved contractors shall be put in escrow to construcl' a new
,wc~stewater di~pos(~l ~y~lem pur~uunl to p~,'m;l ' SWO20096 " " '
[lUntUci' ul lu~l~u.
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other £g~T Ivu~E~, 5c~O~OOq~
Odginal Certificate Date: ,~1~1~
·m ~
Municipality of Anchorage
Development Services Department
Building Safety DMston
On-Glta Water & Wastawater Program
4700 South Bmgaw GL
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(g07) 343-7g04
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescdption:L07- ~' ,G~.oc~c I /vdAT-H l~,o/O.c ~. ParcellD:.O~"/-'Tffl-~7
Re
WELL DATA
Wall type ~
Date completed
Total depth
Date of test
Static water level
Wall production
WATER 8.~~:
If A, B, or C provide PWSID # ~/3ool Wall Log (Y/N)
SanltaP/seal (Y/N) Wires properly p~
fL Cased 1o fL ~ (above ground) in.
FROM WELL LOG ~.~AT INSPECTION
J g.p.m, g.p.m.
Nitrate mg./I. Other bacteria __
Date of sample: Collected by:
colonies/100 mi.
e. SEPTIC/HOLDING TANK DATA TankType/Matedal Se.,e;-jc. / s;'7-~.~. &
Tankilze )ooo gal. Numbar of Compadments ~-
Foundation cleanout (Y(.~0 ~uo Depression over tank (Y~.~)/v e
Oataofpumplng ,~/~.~/o ~- Pumper. 1'/Z j
C. ABSORFTION FIELD DATA'
Date installed
Cleanouts (~fN)
High water alarm
Date installed/e/~"~. Sail rating (g.p,d./ff~ or~~_~O
Leng~ · * ,~ ~. fL Width '5 ~" fL
Total depth fl ~'/ fL Eft. absorption area/0~ ~ ~ Monitoring tuba
Data of adequacy tast '~/,~%fl/o~- Results(Pass/Fall) F,~/-. '~'
Fluid depth in absorption field before test )~- in. Water added -- gal.
Elapsed Time: min. Final fluid depth
Any rejuvenation fl~lment (past 12 mo.) (Y/N & type).
~stem ~ ~ ~ O
Gravel below pipe CO - 5'- ff.
Depression over field ~v o
For ~-' ,bedrooms
Now depth" in.
in. Abaorpflon rate >= $#r~,,~O g.p.d.
~ If yes, give data ~
D. UFT STATION
Date installed
Size in gallons ~
'Pump on' leve~ in. High water alarm ~vel et
Da~_~m Cycles tested Meets alarm & circuit requirements?
ee
SEPARATION DISTANCES
SEPARATION DISTANCES FROI~I WELL ON LOT TO:
Septic tanYJliff station on lot
Absorption field on lot
Public sewer main
On adjacent lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
· /
Building foundation
Water main I
Water sewice line /o
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line I 0 + Building foundation J o -/.- Water main
Weter Service line !0 -f- Surface water JoO ')- Driveway, parkingNehlcle~tomge
Wells on adjacent lots
Curtain drain
F. COMMENTS
in.
G. ENGINEER'$ CERTIFICATION ~ .~.
revfew or Municipal mcoro$ met the above systems am in ,~.-~'"'~....~/~?,..~,~..~
I-IAA Fee $
Date of Payment
Receipt Number
(~ev. ~2m~)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P,O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 05' I -'7 '/I - ~'-7
1.:' i3ENER~L INFORMATION
7.- Complete legal description Lo 7'
· ' Locatk/r~ (site address or directions)
Current Property owner(s)
· .. Mailing address
Lenc~i~g agency
HAA # 14 ,~ 0 ~-0 t $ 0
Expiration Date: _A"-- 3 o - (.3 '~
Day phone
¢o 5',¢- o/77
Day phone
Mailing address
Real Estate Agent
/vM~fl,~ ~,~,~.c,~,.~ '-VtSr,~. Dayphone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ~
3. TYPE OF WATER SUPPLY: '
Individual Well []
Individual Water Storage []
Community Class ~ Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Deve!opment Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates cf Health Authority Approval are required for the transfer of
title (except be,Wveen 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 prcperties sewed by a private or Class C well and may be reissued with
new water sample results· (Certificates may be reissued for a pedod of up to one year with valid water samples.)
Certificates are valid for one year for properties se.wed by CZass A or B we!Is or a public water system. The
Municipality of Anchcrage is not responsible fcr errors cr 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 vedfy that based on the information obtained from the
Municipality of Anchorage flies 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 $ & $ ENGINEERING Phone
370,14 Eagle River Loop Road No, 204
Address
Engineer's Pdnted Name R0p/~A7- C. ~'o,,.u,4.,,., Date, ,?'/,~'~/o "'--
O.q r e,~o, ,'-',,,,,~.~. )./~. ~. /'~ ,~. ~,.,~, .s'~',Z. 4 .
DSD SIGNATURE
J Approved for ~
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-~fiite Water & Wastewafer Pro, mm
4700 South Bmgaw SL
P.O. Box lg6650 Anchorage, AK 99519-6650
www.cLanchorage.ak.u$
(907) 343-79O4
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDascflption:LeT <~ f~LeC~ I HoAr/t~/OO/J #2_ ParcellD:
A. WELL DATA
Well type ~
Date completed
Total depth ft.
Date of test
Static water level
IfA, B, or C provide PWSID #L.~ J ;)oo / Wall Log (Y/N) fj
Sanitary seal (Y/N) Wires pmpe~ pm~/N)
Cased to tt Cesing~.l.l~ (above ground) in.
FROM WELL LOG ~,,~K~NSPECTION
ff.
J g.p.m. ~; g.p.m.
1Nell production
WATER SAMP .....
Coliform ./'"'- colonies/100 mL Nllmta mg.A. Other bacteria
~ mg./t. Data of sample; Collected by:
B. SEPTIC/HOLDING TANK DATA ' "
Tsok Type/Matadal
Tank size / 4o O gal. Number of Compartments
· 'Fsunda~ion deanout~N) ¥~ Dapm~ion over tank (Y~)
· oate of pumping 3/~-~/ oo.. Pumper
C. ABSORPTION FIELD DATA
Le~gth, ~1 ft. Wtdm
colonies/100 mi.
Date installed
Cioanouta ~1)
High water alarm
Total depth .
Date of adequacy test ~/~ -/~ ~/ Results (P~.~~
Fluid depth in absorption field be~ Water added gal.
Elapsed Time: ~lnal fluio dep~ in. Absorption rate >=
Any~atment (past 12 mo.) (Y/N& type) If yes, give date
System type $/J4~.L,I ~
Gravel below pipe / - ~ ft.
Eft. absorption area~.6.~ ~ Monitoring tube >Y.-,~ Depression over field ~' ~
For ~ bedrooms
New depth in.
g.p.d.
D. LIFT STATION
'Pump on' level at ~ ~' in,
Datum 7-~/ ~ /~
E. BEPARATION DISTANCES
Size in gallons ~t.
'Pump off' level at ~'l*-;"in.
Cycles tested
Manhole/A~cess ~/N) ¥~
High water alarm level at '~- ~ in.
Meets alarm & circuit requirements? '~ ~'.
SEPARATION DISTANCES FROM WELL ON LOT TO: C oa ~u,., ~ y
On adjacent lots
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
~eanout '
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~ Property line [' J Absorption field
Watermain /0 '/- Water service line /O '''/- Suffacewater
Wells on adjacent lots ~ {) O '+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
PropeAy line ~ ~- / ~ '
Building foundation ~-O Water main / 0 -F
Water Service line / 0 -A Surface water ,/O O -/- Driveway, parking/vehicie storage O ·
Curtain drain~a~'e *:"~"~ Wells on adjacent lots ~-4)0 -/
F. COMMENTS
G. ENGINEER'S CERTIFICATION
, cer~ tha,,.ave ~aterm,... ~..u.,.o,.,..~o.. a.d~'};/ ~:;" ~"'~'~\'
review of Municipal records that the above systems are in
conformance w#h MOA HAA guidel/nes in effect on this date.
~ ,~... c~...o.'-/..~.~
Data -f"/~'
HAA Fee $ Waiver Fee $
Date of Payment Data of Payment
Receipt Number Receipt Number
(Rev. ~2/0e2
H~IY-~-L:~2 10:t2
~.S ENG IhEF_R I NG
cj~'] 694 1211 P.02
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT, ARE NOT SHOWN HEREON,
THE INFOI~MATION HEREON I$ FOR THE USE OF
[ENDING INSTITUTIONS SPECIFiCALLy TO sHOW
ANY CONFUCTS BETWEEN EX~$TINO STRUCTURES
AND PLATTED LQ'I' LINE8 DR EAEEMENTa AND IS
NOT TO BE USED FOR POSlT~ONINQ ADDrlqONAL
S"~RUCTURES OR F£NCELINES.
"ASBUILT" Nocorne~$ set Book Pg F/CC
~ ~., / ~OT~ P.~
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
CS"i ~'-1 HI- ~'7 HAA# ,~'~1 ~-~' ~"\~ ~ -~, -~
1. GENERAL INFORMATION
Complete legal description
Lot 8; Block I; North Woods Subdivision #2
Location (site address or directions)
Property owner
Mailing address
Matth~v Werner
22536 Whisperinrq Birch
Chugiak, AK
Day phone
Lending agency
Mailing address
Day phone
Agent
Address
.,' Don McKenzie Real Estate
13135 01d Glenn Hwy. Eagle River, AK
Day phone
99577
694-9055
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well
Community well ×XX
Public water
MUNiCiPALITY OF ANCJ-tORAOt~
ENVIIiONMENTAL SERVICES DM$1ON
JUN 13 t995
RECEIVED
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
XXX
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 #21
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 s & S ENGINEERING
17034 Eagle River Loop Read .No. 2(',4
Address Ea~_le River, Alaska 99577
Engineer's signature -~ . _ ,,/--~..-
Phone
Date
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
AdditiOnal Comments
/
By: ~/~/...¢..~,.--~/...~-.,'.-~2,~,~,~.,~-._ Date g //~/-' f
Mumcipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Certificates based only upon the representations given in paragraph 5 above by an independent
L""'~J meer registered in the State of Alaska. The
D H HS does this as a courtesy to purchasers of homes
~-~,~,m(:j ,nst~tutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
~'z'~"='~-"~,~ns or analyze data before a certificate is issued. The Municipality of Anchorage is not
en'~s o, om~s~ons in the professional engineer's work.
825"L" Street.
Legal Description: L-o-C ¢ ~D~tc- [- /~h::)~ 2 Parcel LD.: ~>~l
A. WELL DATA .. - ::
Well ~e IfA. B o~C
Log present (Y~ : Date complete4
Total depth C~sed to
Sanitary seal (Y/N) - - -
FROMSWELL LOG
AT INSPECTION
Date of test
Static water level
Well production g.p.m. - . g.p.m.
WATER SAMPLE
Coliform Nitrate
Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA :.
Date installed {,O ~'7-~ ' Tank s3ze [ oD 0 Number ofC0mpartments' Z Cleanouts [CAN)
Foundatiqn~.~leaflO'~(~.~, / Depression (Y~) p/ HigtiWater.~larm~(Y/N)
Date of, pumping ~ ~ I% c~:~ ~mper 2,~fe~ . (~OOaf, ~ h
C. CBSOR~ION .... . ...... ~ )
6ate installed to ~ a~ ~' Sdl rating (g p d/fl2~or a%am) System me
Len~ ~ W~dm.?~ ~ Gravel tMckness beloW p~peO,m~on~ 'TotM depth
O~q~ ~Moffitbrin TUbe~;ese ~'~ De ressionoverfi;ld
EffectiVe abso~tion~ ~ area ] ,: g p. n~.:. ~ p ~
Date of adequacy test ~-x~ ~ b. Result~aij) ~ For ~ ' bedrooms.
Fluid depth in abso~tion field before.test (m.): . hmediately ~e~ ¢-~al. mate~ a~ded (in.):
Fluiddepth It~ (ins',l Minutes ~iate~: ~ Abso~tionmte =' *.~ ~: , g.p.d,'
Peroxide treatment (past 12 months) (~ /O ~ ~ ~ ~a ~ [f yes, give date '
D, LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N) "Pump on~
High water alarm level at* ~ *Datum
"Pump off' level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ~ On adjacent lots
Absorption field on lot : On adjacent lots
Public sewer nmin ......~ manhole/cleanout
S~ervice line Lift station
SEPARATION DISTANCES FROM~rrI'-OHOLDING TANK ON LOT TO:
Building foundation ~.. i4- Property line Io ~ ~' Absorption field
Water main/service line \o ~- Surface water/drainage ~ o~ ~ ~- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation ~ o ~&
Surface water ~,c> ~
Curtain drain ~ g~o o90
Water main/service line
Driveway, parking/vehicle storage area 5-~
Wells on adjacent lots ~ ~ x P- Property line
F. ENGINEER'S CERTIFICATION
1 certi~ that I have determined thrufield inspections and review of Municipal recora~~ems are
in conJbrmance with MOM HAA guidelines in effect on this date. ~~""~C,~n$,
Signature ~ ~ ~ ff~gt~ ~ '}~
....................................................................................................... ~'~&'mxx-~"~ ..........
HAAFee $ ~ "~, ~ Waiver Fees
Date of Payment ~ Date of Payment
Receipt Number ~~ ~ ~ ~ Receipt Number
Rev. 8/95 DSS: haa.wk.doc
J J i
APPLIC-~NT FILLS OUT UPPER HA(-~ ONLY
Proper~y oW P,~,r Phone
Buyer ,/~~ ~ ~..~'~,~,j~,--~ ·
'~ Zip Code
Address
Lendinglnstitution ,~,~L,~,~,.~/?_ ~'~ ~'"~.,~. ~ Phone
Address r)-) ~'--~'0 ~ R,'~.~.-~ ~ Zip Code ¢ 7~-'~)
· - Phone
Realty Co. & Agent ~0~..~~
Address F~,~ )/'~,/~. ~ /-.~.~:~,,~. ~I J,~ ~ Zip Code
Street Location
Type of Residence
[~ngle Family
[] Multiple Family No. o[ 8edroom~
[] Other
Water Supply
[] Individual . ATTACH WELL LOG. A well log is required for all while drilled since June 1975.
[~'ommunity For wells drilled prior to that date. give well depth (attach log if available).
[] Public Utility
Sewer Disposat
Year Individual Installed:
u dividual
blic Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time ~,~
Date Date Date Date ~
Inspector Inspector Inspector Inspector
Field Notes:
J~UNIClPALITY Of ANCHORAGE
DFPT OF I~E&l-T~l &
ENViROi qMs:i,4 i-AL p¢.O i ECTION
gOT ~ lg8~
RECE! ED
( '~.~APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL AP.~,~ROV~,L*
DATE f O~--- ~1~ ~c~ ~
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
/0~-9 Z.- We,,toTan~ Sep,c T~.~ S,zs
72-023 (3182)