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HomeMy WebLinkAboutT12N R3W SEC 23 W2SE4NW4SE4 PTN PARCEL 13T12N R3W Section 23 Parcel 13 W2 SE4 NW4 SE4 #015-231-12 I t Municipality of Anchorage Page—I—of-_ DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Perm' Number: SV-,' q 10116 PID Number: 016—A'61- 15—A'61-Name: Name: Wastewater System: ❑ New El Upgrade Address: ABSORPTION FIELD Phone: No. of Bedrooms:El 345- ag -[ ❑ Deep Trench Shallow Trench ❑ Bed Mound ❑ Other LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: rS GPD/Sq. Ft. Lot: Block: Depth to pipe bottom from original grade: Gravel depth beneath pipe III- S E 9 Ft. Ft. Township:t Range: Section: Fill added above original grade: Gravel length: a 2 J Ft. Qq Ft. WELL: ❑ New ❑ Upgrade Gravel depor.. w;d{As ~J Numberoflines: Distance between lines: Ft. Ft. Classification (Private, A,B,C): Total Depth:Cased To: Total absorption area: Pipe material: Ft. Ft. %D SC. Ft. F A 10 Driller: Date Drilled: Static Water Level: Installer: '\ Sv Date insta led: Ft. ACTto- F Yield: Pump Set at: Casing Height Above Ground: u TANK GPM Ft. Ft. SEPARATION DISTANCES XSeptic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lift Holding PubIIC/P,ivate Manufacturer: �, Capacity in gallons: From Tank Field Station Tank Sewer Lines 04A�`/ 1 5E) Well 10 b Material: 1 Number of Compartments: 2 Surface water -' — —' -' '- LIFT STATION N A Lot — Size in gallons: Manufacturer: Line o20 1 b — Foundationq0 } 6.0 - -- —. .. "Pump on" level at: "Pump off' level at: High water alarm at: CurtainN Pump Make B Model Electrical Inspections performed by: Drain /_t Remarks: BENCH MARK L!Y iN� LIT Locationr1and Description: '�loLZL it, Ire_# �10,C 1��✓✓1 jj &a.vi 1 LL --F D.1� 6-1''cfr-r. d1�, Assumed Elevation: Ob Ft lF,N6iMEEBn&....S�,EAL 7, / ��• Inspections performed by: Dates: lst `$` ' q 3 Fnc �.0 3 2nd 8 g t Department of Health and Human Services approval ! 64-f-rGt Reviewed and approved by: Date: 4 72-013 (1/91) MOA 25 10' CEA Easemt. 96.8 FNDA. C.O, 84.0 GWMT IUlJbLN �WUKKLHIN" "" SEPTIC SYSTEM AS BUILT 6751 W. DIMOND BLVD. Nj/2, SEI/4 SECTION 23, T12N R3W DATE: AUGUST 26, 1991 ANCH, AK. .99502-3904 SHEET -P/2 GRID -2734 l F 10' CEA Eo ser t, m x R100,00 h) \ s weu E�tv t Q m A N I 3 a+ { II ......... ................ 0 20 40 60 80 100 SCALE, I' = 40 FT, Rl 96.8 FNDA, C.O. TOBBEN SPURKLAND P.E. SEPTIC SYSTEM AS BUILT 6751 W. DIMOND BLVD. N1/2, SE -114 SECTION 23, T12N RAI DATE- AUGUST 26 1991 ANC H^ AK. 99502-3904 SHEET -2/2 GRID-P7.?4 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW910176 DATE ISSUED: 7/01/91 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. EXPIRATION DATE: 7/01/92 OWNER NAME:BROWN WILLIAM C & REBA L OWNER ADDRESS:3565 SAILBOARD CIRCLE ANCHORAGE, ALASKA 99516 PARCEL ID:01523112 LEGAL DESCRIPTION: T12N R3W SEC 23 W2SE4NW4SE4 PT N LOT SIZE: 43597 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED ISSUED BY DATE: :z_ o ^ 4�;l DATE: 7-2-91 051 M. DIMOND BLVD. ANCHDRASf, ALASKA 99502-3404 (907) 248-5095 SEPTIC SYSTEM DESIGN NIZ2 SEIl4 SECTION 23 T12N R3W_ MITCH WAGNER No Ground Water- or Impervious !._sayer to 1.1 ft. Use Wide "frtrr:::h Soil Rating. From test[ June 10, 1991 9 & 12 main/in =- .8 gal/ft day at 5 ft. Required Area per Bedroom: 150/.7 .:: :187.5sq. f't.. . 177.5/5 57.5 l.ft. Use 06 :inches of rocs: Reduce length i.'S'y' .58 37.,5 k.' .57'- 21.75 l..ft Finished Floor" Elevation Lowest Floor- 105 Ground Surface at Absorption Field 10 Number of Bedrooms 4 Length of Trench 4 x 22 _,: 88 ft.. SYSTEM COhiFISLJRATIOhI WIDE TRENCH TOTAL LENGTH TOTAL WIDTH TOTAL DEPTH ROCK DEPTH ADDITIONAL FILL SEPTIC TANK Septic System Design N1/2, SEI/4 SEC. 23 T12N RYW pu. 1. 88 FT - 5 FT - 5 FT. 36 IN_ i FT. 1250 GAL. The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general drainage of the area. Ponding and/or concentration of surface runoff will not result from this installation. Septic System Design N1/2, SEI/4 SEC. 23 T12N RM pg.2 (ENi'aINEER'S SEAL) % e Municipality of Anchorage ' " " DEPARTMENT OF HEALTH & HUMAN SERVICES a :, ... 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST ��YyY PERFORMED FOR: BILL 320WiN DATE PERFORMED: LEGAL DESCRIPTION: N)L- SE Iy Township, Range, Section: Sec„ ,Q,aj, —11 Q3Le/ 1 01UPA N I CS 2 LOA M 3 SAN ON/ 4 SILT 5 - ML s - Si 14z'y SA+4 D -- 9 �••::+ FtNE SAetVp 10 11 ..y Sp ML 12 13- 14- 15- 16- 17 314151617 18- 19 20 COMMENTS SLOPE WAS GROUND WATER 1``b ENCOUNTERED? N1 IF YES, AT WHAT DEPTH? Depth to Water AIt4r t a Monitoring? �D•`.t) gate: SITE Reading Date Gross Time Net Time Depth to Water Net Drop b (tl•4 1: 5 3 -- 10, 1 �rLl b'/L F1 f7' S., Lio Li 5 a 17'!y r ZD t°1� `r: so is ,Y"rL I -,/y PERCOLATION RATE —2— (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN 5 FT AND /L FT PERFORMED BY: IS I V —'� CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: -L.' I t 14Q 1 72-008 (Rev. 4/85) 1 -7-/74 'f3 e Municipality of Anchorage pGe DEPARTMENT OF HEALTH & HUMAN SERVICES a � I 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: RILL. 2na,,M DATE PERFORMED: `- -I Qf LEGAL DESCRIPTION: tai I�i Sff ILI.f Township, Range, Section: C-e-C- H SLOPE SITE PLAN 1 %� ,& 4444NIC 5 2 3 4 _, 5 S07*7'0 r or= HVL.L 10 WAS GROUND WATER Vp ENCOUNTERED? 11 ANetDepthtoNet IF YES, AT WHAT 12 DEPTH? 13 Depth to Water After Monitoring? 14 15- 16- 17- is - 191 516171819 20 COMMENTS No Date: S L O P E r".1 Reading Date Gross Time Drop Vp ANetDepthtoNet y a r ' �/ r e PERCOLATION RATE (minutes/inch) PEERC HOLE DIAMETER TEST RUN BETWEEN a� FT AND —5Z12LFT PERFORMED BY: Y.,S I V ---L CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: /l L ekI 72-008 (Rev. 4/85) F' E'41NEER'SSEAI?� n e Municipality of Anchorage r DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: Or Lk Be.O ULm DATE PERFQRMEk- I QQI LEGAL DESCRIPTION: IN tI'a.4 �E V4 Township, Range, Section: �,c- a7j 112N,123 Iilv Nvmvs. SLOPE 10 4,—" WAS GROUND WATER A O .r+ ENCOUNTERED? N 11 00-rYo01 pF IF YES, AT WHAT 12DEPTH? ;401—a Depth to Water r 13 Monitoring? Date: G 2y a 14 15- 16 17- 18- 19- 20-1 7181920 COMMENTS Reading Date Gross Time Net Time Depth to Water r �.ViCi �1 �� 2 _ 40 3 _/rocGa 101, a 40 4 5 _ .I LL 6 �- 7 15 8 -30 r� 9 SLOPE 10 4,—" WAS GROUND WATER A O .r+ ENCOUNTERED? N 11 00-rYo01 pF IF YES, AT WHAT 12DEPTH? ;401—a Depth to Water r 13 Monitoring? Date: G 2y a 14 15- 16 17- 18- 19- 20-1 7181920 COMMENTS Reading Date Gross Time Net Time Depth to Water Net Drop mr o'Z:20 -- 5:&0 5:&0 4 0 IN a 40 zv LL 15 `! -30 r� N PERCOLATIONRATE (minuies/inch) PERC HOLE DIAMETER TEST RUN BETWEEN -35 FTAND FT PERFORMED BY: Ts I 1.S- CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: T&"de' 4 i/ 72-008 (Rev. 4/65) 10' CEA Ea--,-wrt 5 - — r'rY�1;c�sPd lq / O 5I f^�.�� 413 11f 1 105,6 t ' TEs tht e 'I F.x�sw ir•u;zc» Ueo..'a Cut CCAL 1' - 40 FT. PPI 1449 IULQiEN WUNKLANL1 F'�L� SEPTIC: SYuEM I1E-I,N 6751 W+ DIMOND DLA/D, p/1,1'e, SECTJILTV i',3; ?.2N R3V D61 -E, ARIC 0� 1391 ANCH AK, 5'3502-3904 ens. oao.-cnoc 11 SHEET, fir GR[L1I,=`Z", 4 88,00 Wde Tr e,.w�hr 88' 0M 5' XEP 12,9) .90.1 spptic torA- F Ex_5t, 6rcu?d 4" W� Co ver.. TOBBEN SPURKLAND P, E, I I SEPTIC SYSTEM DES:JGN 6751 b/, DIMOND BLVD. I I MIA F-1/4, Z� ?MN CV DATE: q#E cy} JQ9Rj ANCH: Ah', 93502-3904 I ITLS±. ,R3V SHEET P/P GRID 7.34 r-"/ 016W 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 - PHONE1�NEW 4S 7 ❑ UPGRADE MAILINGDDRESS' A :SFA S — L 5-07 LEGAL DESCRIPTION ®'� Z I/z SEYI S� � Pff'_HCD C erc LOCATION — c NO. OF BEDROOMS 4 DISTANCE TO: WellI �O t Absorption Dwell; PER NO. Uy f F-2 W Q Manufacturer Material c No. of compartments yf Liq. capaciin allons Inside length IF HOMEMADE: U Width Liquid depth q 6 DISTANCE TO: Well Dwelling PERMIT NO. ==F Manufacturer Material Liquid capacity .;.gallons W = DISTANCE TO: Well(��i Foundytior�,,, f- �i Nearest loft line PERMITNO. c)? �5 j LL Z Z.Ic No. of lines Length. of ea h line Total length of lines Trench width Distance be an lines F inches OF Top of tile to finish grade/ _Or 6 Material beneath the �O q - Total effe tive absorption area -7 inches zsQ Fnr w Length Width Depth PERMIT NO. Qa F W6 W Type of crib - Crib diameter Crib depth Total effective absorption area � DISTAN O: well Building foundation Nearest lot line J Class Depth Driller Distance to lot line - PERMIT NO. J W � DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS - D_ 303 SOIL TEST RATING 8S — (00 INSTALLER OG.1I ec_ S %N REMARKS _ Z " lm i �+US W IiS VIED G / C.o. t v �yMh w 0 !Is iit6! DEPT. OF ENVIRONMENTAL PL144 r - - - DEC 9 i APPROVED - DATE LEGAL Ir RECEIVED 12 011 .. - - 1Rev. 3/78, mu" I 1= IL_ I TY cm= i==tMiCFdhF;�RciE DEPARTMENT HEALTH AND ENVIRONMENTAL TECTION 825 'L' STREET, ANCHORAGE, AK. 99501 264-4720 C3 F— I TE f3EWEFZ F�EFZM I T PERMIT NO. C 820943 APPLICANT MIKE WESTFORDXROBERTS 1207 E 74TH 99502 349-2526 LOCATION ATTACHED IS COMPLETE LEGAL DESCRIPTION LEGAL LOT SIZE 999999 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER. OF BEDROOMS = 4 SOIL RATING (SQ FT}BR)= 85 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: E}EF`r"= 1;2 2nPl E3FZFl EL iS THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION CIN FEET). THERE I5 NO SET WIDTH FOR TRENCHES, THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION CIN FEET). f2EG!lJ I FZEE] QEF T I l:!' Tf l"K 'sl PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPORTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. --- TWKDI <L2> nFzZE F@EQIJ I FZEE> --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN :A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 'FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL: MINIMUM DISTANCE FROM R PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F'EF;ZM I T EXP I FREES E]EGEMF3EFz sus ASO I CERTIFY THAT 1: 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. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. V4. 0 ' SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION TEST 625 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: ��� DATE PERFORMED: LEGAL DESCRIPTION: SLOPE SITE PLAN 1 Jr3-h6V 9/�T 2- 3- 5- 3 5 -o 7 J�ndr,1 V`r�vG✓ 8 � !rl/OCG�i/oKa/ 9- 10- 11 1011 WAS GROUND WATER / S b ENCOUNTERED? /✓iJ L 0 X12 P E IF YES, AT WHAT 13 DEPTH? 14- 15- 16- 17 415 1617 18- 19- 201 81920 PERFORMED 72-008 (6/79) James Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE 'IhST RUN BETWEEN CERTIFIED (minutes/inch) FT AND FT , JAMES B. ROBERTS, PE, RLS ENGINEER & SURVEYOR [907) 349-2526 LEGAL DESCRIPTION That portion of the N 1/2 of the SE 1/4, Section 23, T. 12 N., R. 3 W., Seward Meridian, Alaska, Anchoraqe Rec r Ing District, more par ic- ularly described as follows: Commencing gt the center -south 1/16th corner of section 23; thence N 89 56' E along the 1/16th section line 777.70 ft.; thence N 00 04' W 286.2 ft. to Corner No. 1 and the True Point of Beginning; thence N 890 56' E 208.8 ft. to Corner No. 2; thence N 00 04' W 208.8 ft. to Corner No. 3; thence S 890.56 'W 208.8 ft. to Corner No. 4; thence S 00 04' E 208.8 ft. to Corner No. 1 and the True Point of Beginning, thus embracing one acre of land, more or less. Municipality of Anchorage tax parcel 015-231-12 1207 East 74 th Avenue Anchorage, Alaska 99502 r-- APPLI T FILLS OUT UPPER HA NL' Y Property ewnerc t I I IC vICIC' � - - C1\l\� 1 � � I. �C—���' 1—{�jL� Phone - Melling Address - — P - Zip Code Date .Buyer Date - Address - _ -Zip Code Lending Institution - - - Phone Address Zip Code Realty Co. & Agent Inspector - Phone Adpress - Zip Code Leal Description �- ��'' Sjreet Locat �-.. .. �., -X c't ?Ype 'Resilgille -- - ENVIRONi,AENTAL PROTECTION Single Family - - ❑ Multiple Family - - No. of Bedrooms ❑ Other RECEIVED Water Supply - `CONDITIONS OF APPROVAL (X ). CONDITI NAL APPROVAL' A -Individual DATE ATTACH WELL LOG.A well log is required for all wells drilled since June 1975. ❑ Community Forwells drilled prior to that date, give well depth (attach log if available). O Public Utility - - Sewer Disposal II �-Individual ._. 1 Year Individual Installed: 0 , L ❑ Public Utility - - When Connected to Public Utility: ❑ Holding Tank - - NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time —time Time Date - Date _. Date - Date _ -Inspector Inspector - Inspector Inspector L Field Note's: -. © MUNICIPALITY OF ANCHORAGE pYo (� DEPT. OF HEf LTI I E: 40 �fi� u � L % -S�. - ENVIRONi,AENTAL PROTECTION C'A S / ✓7/ z�r /rte %S E NOV g °Od7 RECEIVED ( - APPROVED BEDROOMS ( I DISAPPROVED - `CONDITIONS OF APPROVAL (X ). CONDITI NAL APPROVAL' `f DATE Solis Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank - Septic Tank Size 1 MU CPA UTY OF AHCHORA GE Development Services Department ? 7 Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015-231-12-000 Expiration Date: 2/19/2025 Legal description T12N R3W SEC 23 W2SE4NW4SE4 PTN PARCEL 13 Site address 11840 COUGHLAN WAY Anchorage AK 99516 Current property owner(s) LUND TREVOR & RONDA X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 3/11/2024 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory x Nitrate Advisory Tank Age Advisory X Arsenic Advisory Other COSA Approvaijune 2022 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 015-231-12 Complete legal description T12N R3W Section 23 Parcel 13 W2 SE4 NW4 SE4 Location (site address) 11840 Coughlan Way Current property owner(s) Trevor & Ronda Lund Day phone 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: V Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: © Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 33 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench © Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ .J 5d Date of Payment COSA# �SG2 �f 105y Waiver Fee $ Date of Payment Waiver # COSA Application—June 2022 COSA Checklist Legal Description: T12N R3W Sec 23 Parcel 13 W2 SE4 NW4 SE4 Parcel ID: 015-231-12 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled Unk _Total depth 85+* ft Cased to 40+ ft ✓❑ Sanitary seal is functioning correctly ./❑ Wires are properly protected Casing height (above ground) 31 in. Date of flow test for COSA 2/29/24 Static water level at beginning of test 57 ft. Comments *Per GEG 2014 testing data B. TANK DATA Measured operating fluid level in septic tank 49" Date of pumping . 2/19/24 ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 7/8/91 ❑✓ ALL standpipes present per record drawing Total measured depth from grade 6.2 ft (max) Measured depth to pipe invert from grade 3 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ✓❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Well production at time of test 3.6 qpm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes 0 No ❑✓ Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/LArsenic less than MRL (ND) Collected by Arcterra Consulting Date 2/23/24 FT STATION ❑ Require nti Age of lift station _ Lift station material Comments nce completed Adequacy test date 2/29/24 Results EZPass Fluid depth prior to test 32 in Water added 600 gal New fluid depth 35.5 in Elapsed time 1440 min Final fluid depth 32 in Absorption rate 600 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 36 in Effective depth used 32 in Effective depth remaining 4 in Comments/Deficiencies: Field isoperating within the last 10% of its capacity, COSA Checklist -June 2022 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' 0 Yes if No Community Sewer Manhole/Cleanout > 100' Yes if No ft ✓❑ Yes if No ft Neighboring Tank > 100' ./❑ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No ft Absorption Field on Lot > 100' EZ] Yes if No ft Holding Tank > 100'✓❑ Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50'✓❑ Yes if No ft 0 Yes if No ft ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ©Yes if No ft Q Yes if No ft ❑ N/A — Served by Community Well (not on lot) or Public Water From SeptiC/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100'✓❑ Yes if No ft Tank to Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' F/]Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' ✓❑ Yes if No ft Community Wells > 200' Q Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Arcterra Consulting Engineer's Printed Name Kenneth Duffus 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. COSA Checklist June 2022 Phone (907)-696-6111 Date -� �/ fdTy r_%sweaIr"mill 1,40 j r F KENNET M OF J JV Ji AF *■f yd, C 71 fi i MUV%C0 P L UTV OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT o , On -Site Water and Wastewater Section www.muni.org/onsite Septic Tank Advisory Certificate of On -Site Systems Approval # OSC241054 Subdivision: T12N R3W Block:Section 23, Lot: Parcel 13 907-343-7904 Fax: 343-7997 The septic tank for this property is 33 years old. The average life of an asphalt coated steel septic tank is 20 years. Typical replacement costs are $10,000 or more, not including engineering, surveying or MOA permitting fees. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. 'N\I 9M(MP U u Y OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT 0,1( On -Site water and wastewater Section www.muni.org/onsite Septic System Absorption Field Advisory Certificate of On -Site Systems Approval # OSC241054 Subdivision: T12N R3W, Block: Section 23, Lot: Parcel 13 907-343-7904 Fax: 907-343-7997 Prior to the absorption field adequacy test, 32 inches of standing water was observed in the absorption field. This indicates approximately 90% of the absorption area is inundated. Although this system passed the adequacy test, the remaining life expectancy may be limited. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. Municipality of Anchorage On -Site Water & Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I. D. 015-231-12 Expiration Date: 1. GENERAL INFORMATION WZ Se4 141vy 564 PTN Complete legal description T12N R3W SEC 23 4. �; N v CL=T TN PARCEL 13 Location (site address) Current Property owner(s) Mailing address Real Estate Agent 2. TYPE OF DWELLING: 11840 COUGHLAN WAY *ANCHORAGE 99516 DALE LEHMAN Day phone N/A Day phone ;' .s.. Single Family (w/woADU) ��� t ro El Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) JUL 1 6 N14 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: 349-1006 TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site 0 Individual Water Storage ❑ Individual Holding tank U Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: COSA Fee $ Waiver Fee $ Date of Payment —71) ('111 (� Date of Payment Receipt Number o�—I'a Receipt Number COSA# 056—N)3Ji Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever 6. DSD SIGNATURE System #1 Approved for System #2 Approved for Disapproved. Conditional approval for bedrooms. bedrooms. Phone 337-6179 Date oo;;�op p4 00�Y�-F .9s 4p �....... .... .........� �O -A f y G Hess: G [)49. C 3 m p bedrooms, with the following stipulations: ```P�\Cy OFtl!ir 1yyfrpp ON-SITE G� =� WATER PND c� WASTEWATER p^ �; J�2 pROGRAtJI r By: Original Certificate Date: 7- Thenicii alit or Al rage Devel^p,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatations 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. ATTCHMENTS: s COSA Checklist e� Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other 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: T12N R3W SEC23 W2SE4NW4SE4 PTN PARCEL 13 A. WELL DATA Well type PRIVATE Date completed UNK Total depth *85+ ft, ParcellD: 015-231-12 *PER GEG 2014 TESTING DATA **PER SURROUNDING WELL LOGS If A, B, or C provide PWSID# N/A Well Log (Y/N) NO Sanitary seal (Y/N) YES Cased to **40+ ft. FROM WELL LOG Date of test Static water level ft: Well production g.p,m, WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate N 2 mg./L. Arsenic: NO ug./L. Date of sample: 7/2/14 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1250 gal. Number of Compartments 2 Wires properly protected (YIN) YES Casing height (above ground) 12+ in. AT INSPECTION 7/2/14 56 ft. 3.76 g.p.m. Collected by: GEG. Ltd Date installed 7/1991 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO Jigh water alarm (Y/N) N/A Date of pumping Ll.t I Pumper AAC,nano C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE Date installed 7/8/91 Soil rating (g.p.d./ft2or/bdrm 0.8 System type SHALLOW TRENCH Length 94 ft. Width 5 ft. Gravel below pipe 3 ft. Total depth *5.5 ft. Eff. absorption area 810 ft' Monitoring tube YES Depression over field NO Date of adequacy test 7/2/14 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 13 in. Water added 865 gal. New depth 20.5 in. Elapsed Time: 1190 min. Final fluid depth 118.5 in. Absorption rate >= 600+ g,p.d, Any rejuvenation treatment (past 12 mo.) (YIN & type) NONE If yes, give date — D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. "Pump ofr level High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Sewer /septic service line 25'+ Public sewer manhole/cleanout N/A Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water *96' Driveway, paridng/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *MANMADE POND ON T12N, R3W, SEC 23, PARCEL 12, IS 96' FROM MT2 G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Date -1 kliq Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw, St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-231-12 HAA# At4y,)_03ao2 1. GENERAL INFORMATION Expiration Date: 2/ 100 i— Complete legal description T12N R3W, SECTION 23; W2, SE4, NW4, SE4, PARCEL 13 Location (site address or directions) 11840 COUGHLAN WAY * ANCHORAGE, AK 99516 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address PETE & KATHY SMITH Day phone 344-2336 11840 COUGHLAN WAY * ANCHORAGE, AK 99516 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 Day phone Day phone 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (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. Note: Alaska Water and Wastewater Consultants, inc. shall be paid $ at, orprior to closing for the engineering services provided. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, i verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, AWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AWWC, Inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE Approved for q bedrooms. Disapproved. Conditional approval for bedrooms, with the fllowing 337-6179 Date 7 10 02 ((fIW((((i O )N -SITE �yC Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other By: X Original Certificate Date: �rT (Rev. 12101)] Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: T12N R3W, SEC. 23; W2, SE4, NW4, SE4, PAR. 13 Parcel ID: 015-231-12 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (YIN) NO Date completed 1983' Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 95+ ft. Cased to 40+ ft. Casing height (above ground) 24+ in. FROM WELL LOG AT INSPECTION Date of test 5/14/2002 Static water level N YtE ft. 59 ft. Well production g.p.m. 5.2 g.p.m. WATER SAMPLE RESULTS: Coliform --(I—) — colonies/100 ml. Nitrate O' 2 mg./L. Other bacteria-4—colonies/100 ml. Arsenic: —NLA-- mg./L. Date of sample: 5/14/2002 Collected by: AKWWC, INC. B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Date installed 7/1991 Tank size 1250 gal. Number of Compartments E Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 5/16/2002 Pumper CHUGACH SEWER & DRAIN C. ABSORPTION FIELD DATA Date installed 7/1991 Soil rating .p.d./ r ftlbdrm) 0_8 System type TRENCH Length 94 ft. Width 5 ft. Gravel below pipe 3 ft. Total depth 5.5-6.75 ft. Eff. absorption area8� 00 ft' Monitoring tube YES Depression over field NO Date of adequacy test 5/16/2002 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 8 in. Water added 737 gal. New depth 13 in.n Elapsed Time: 1235 min. Final fluid depth 8 in. 4 Absorption rate >= 600+ g,p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed "Pump on" level atin. E. SEPARATION DISTANCES Size in gallons High water alarm level at Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main N/A On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout N/A Sewer /septic service line 25'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION V v' .• i certify that I have determined through field inspections and 0 review of Municipal records that the above systems are in "' conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Na JEFFREY A. GARNESS woe . 11 C7953 d , Y U�+ Date Jif z3 DZ tJAae v6Aap+b fPS810 HAA Fee $ 315 Waiver Fee $ _ Date of Payment 7— 10- 021 Date of Payment Receipt Number g29 52 Receipt Number (Rev. 12101) Jul 10 02 09:04a Butler & Butler .� LOT 8 DIRT ROAD. - S 89'56'00" W T 10_CEA EASEMENT I_____________ i i 4 EXCLUSION NOTES: It is theoxn.... ..... rsbPlfy !o determine the existence of day eosemenlo. ab..nanl., or wbl<tims . n 'n' s/S'PB W/c/.PQ s/b' RR CAROL BUTLER :Minh do not appear an me recorded subtlideian plot, NOTE: p, ps' M.uOn. a WONUMENT with RE/MAX PROPERTIES i ,ylp N T"<K N I PE,6E- —x— x — O SURVEY CERTIFICATION: LANTECN has O O WOOD O[Dx9- A aduaba here Moxng and that the impr situatedthere- a ©- O an Ides dna no envoaM- an ore rithin the Aran lines 0 rn i 05 N i QS AS—BUILT OF: LEGALOESERIPTIX.: CONSTRUCTION SURVEYORS -PLANNERS -ENGINEERS CO m 73.8 O i I I G I i E''IR EXISTING HOUSE 1 30 907-278-1584 p.2 LOT 1 WE5TFORD . LANE s' t Y i al i 111 P 1 �O 1111 1 1 � ll1 N 89'56'00" E 208.80' 449 •, Uo�� M•Dre LS -10392 iea._ ...... am1l IZ am EXCLUSION NOTES: It is theoxn.... ..... rsbPlfy !o determine the existence of day eosemenlo. ab..nanl., or wbl<tims . n 'n' s/S'PB W/c/.PQ s/b' RR CAROL BUTLER :Minh do not appear an me recorded subtlideian plot, NOTE: p, ps' M.uOn. a WONUMENT with RE/MAX PROPERTIES .,ad W eircuatces mould any data her.an be m under n man ,ylp N T"<K Canavclion or Ipr ¢lablishinq property lines. PE,6E- —x— x — SURVEY CERTIFICATION: LANTECN has vv�CWMEIG- phYsKal survey of IGT. property as sha.a on this WOOD O[Dx9- aduaba here Moxng and that the impr situatedthere- a ©- an Ides dna no envoaM- an ore rithin the Aran lines ACN LTE T- 0 no ments axial oMer than naiad (,ghy{I,_ [ CApW ­11. WeID11 WELL - AS—BUILT OF: LEGALOESERIPTIX.: CONSTRUCTION SURVEYORS -PLANNERS -ENGINEERS 440 WEST BENSON BLVD. B 103 (lox) 561-6626 A PORTION OF THE N1/2, SE 1/4, SEC. 23, T12N, ANCHORAGE, ALASKA 99503 (907) 562-5291 R3W, S.M., ANCHORAGE RECORDING DISTRICT wMx MDER NUUUER: JUNE 7, 2002e K1��3u rtn 99 99 THIRD JUDICIAL DISTRICT, STATE OF ALASKA 2002—L-189 m e. ww 2739: 51/ 0M0.µ apt. 2]39 551/R MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES M Division of Environmental Services Mli 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. # 015— 23i — 1 /J— HAA# k i:�qlL-'-A 1 1. GENERAL INFORMATION Complete legal description � Location (site address or directions) Property owner �r�� `� Day phone Mailing address Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup 2. NUMBER OF BEDROOMS: V 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site X Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev- 1/91) Front MCA #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 ofthisinspection. Name of Firm Y o Ca�-�"I 61-, Phone ✓� — 3 Address Engineer's signature Date 1 A -v 9-R oza�- 1n —j7 v. J 6. DHHS SIGNATURE gd6®®®®oa XApproved forbedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By:Date WTIC 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 orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA 921 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST f�itz_I-II n Legal Description: e < - Parcel I.D. 6' 1 ti - 31 A. WELL DATA Well type h If A, B, or C, attach ADEC letter. ADEC water system number N" Log present (Y/N) IV Date completed c VWL,•.nc Driller WC� 15�rc �4 Total depth l rr Cased to C1 tj Casing height t rl — fr21, MUN�!ICIP}}LITY OF ANCHORAGE Sanitary seal (Y/N) YNires pro erly protected (WN) _Ehm t .cFRv r_ FcIWSIGN Public sewer main NIA Public sewer manhole/cleanout Sewer service line > U Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate -/Z—D Other bacteria Date of sample: F (`t `t 1 Collected by: S �� ,_ZX:L_ B. SEPTIC/HOLDING TANK DATA Date installed 7/✓ L `' t Tank size j �_ -55 C_ Compartments Cleanouts (Y/N) ;10— Foundation cleanout (Y/N) L Depression (Y/N) High water alarm (Y/N) ti� Alarm tested (Y/N) Date of of pumping I4 Pumper WX-�. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot iC, k On adjacent lots i 1 C' Foundation h/6 r- - To property line ,�L' _ Absorptionfield )� * Water main/service line Surface water/drainage N/A 72-026 (Rev. nsi) Front CONTINUED ON BACK PAGE FROM WELL LOG AT INSPECTION DEC 1 I j991 Date of test /7. ql /^ E C E / x Static water level � _YIf61 , Well flow g.p.m. 9.p -m. Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot i o L; ; On adjacent lots i I a t Absorption field on lot L C3 / ; On adjacent lots J Public sewer main NIA Public sewer manhole/cleanout Sewer service line > U Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate -/Z—D Other bacteria Date of sample: F (`t `t 1 Collected by: S �� ,_ZX:L_ B. SEPTIC/HOLDING TANK DATA Date installed 7/✓ L `' t Tank size j �_ -55 C_ Compartments Cleanouts (Y/N) ;10— Foundation cleanout (Y/N) L Depression (Y/N) High water alarm (Y/N) ti� Alarm tested (Y/N) Date of of pumping I4 Pumper WX-�. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot iC, k On adjacent lots i 1 C' Foundation h/6 r- - To property line ,�L' _ Absorptionfield )� * Water main/service line Surface water/drainage N/A 72-026 (Rev. nsi) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surface water _ Date installed/��) �d ( Soil rating < <� System type U21)e �� Length �_ Width 1 Gravel thickness Total depth 15 Total absorption area `f %moi Cleanouts present (Y/N) I/ Depression over field (Y/N) N Date of adequacy test Results (pass/fail) f" z'+-h� for bedrooms Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCEFROMABSORPTION FIELD TO: ,T Well on lot I L) On adjacent lots > If yes, give date CKc Property line I C' i t To building foundation c) - To existing or abandoned system on lot & On adjacent lots > / ' Cutbank l0e h ' Water main/service line 7�— Surface water tql/�, Driveway, parking/vehicle storage area -IL, L Curtain drain N//A E. ENGINEER'S CERTIFICATION I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in Signature) Engineer's Name -d e, LI, e:q �w c /lClec _ �tz Date bo e, HAA Fee $ Date of Payment 12-x/- `j Receipt Number =-23(2-2 % y� 72-026 (Rev. 3/91)Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number &r it tttea'dateot.this inspection. RJ1 ''T