Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
FAIRMOUNT LT 9
Municipality of Anchorage .',':' Development Services Department :~[k~l"" Building Safety Division '~ ~' On-Site Water and Wastewater Program, 4700 S. Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 Page of v~vw.ci.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: .~5~OJ~)-~2~ PID Number: O! 7-- [ ! ~ --~:~P - "aT~jZ.[~.~_l' ~.[-)/:~__~ WastewaterSystem: J~New [] Upgrade ~,e,~ 74;) I .~.g~i'~ ~---P~_~J~ ~/ ABSORPTION FIELD Phon,:~,,~ ~ __705 ~ NumberolBedroom~ nDeepTtench OShaliowTranch abed ri Mound ,~Othe,: SOil Paling: Total Depth Irom ort~nal grade: LEGAL DESCRIPTION O - ~ ~,o,a, ~ . ~:~ r,. ,,. ©,- 2.._. ,ownsh,p: ~, ~ g Pange:~) W $ection: ~ L]L Fat etlded eho. ~'tgmal ~'~ ~' ,~-~grade: FI. (3rd. Lengths ~) '/ Ft. Well: ~[New [] Upgrade c-,e¥~..th:l~ ru ...~e. of li.es:.~ o,~.~.~w.. ~,0.:~ SEPARATION DISTANCES ~ Septic ~ Holding ~S.T.E.P. ~ O~er: T~ Septic Abso~tion Mft Holding =ubli~vate k~nula~rer: ~ ~paoly: Tank Field S~,on Tank 8~,Line 4 ~t~, . 1~ ~..~eW.,., >)~' ~10~' ~)~, ~/~ LIFTSTATION th. .~ ,.. Engineers S~mp Inspections performed by:.J~M~ 6~~. Dates: 1st A~p, 9 /O ~Z Development Se~ices Depadment Approval ~.~; Lot 2, Meyers' ~D~F~)c ~ Subdivi sion ..... ° o I'1 :..: ~ J B6tlomless Intermittentl Ve ~ J ~ J Filter Location .~1%'1.:~. · ' WELL & SEPTIC SYSTEM SITE PLAN $¢a~e: *' - G~/d: 3i33 1 2_' ~zz3' ~0 TT~/~d. LE~5 Z/IA) h HEFTY DRILLING 354O AKULA DRIVE ANCHORAGE, ALASKA 99516 (907) 345-0593 SVodivlslea/USS: PAG~ 02 STATE OF ALASKA DEPARTMENT OF NATURAl, RESOURCES MININ'~;, LAND, WATER HYDROLOGIC 8UR¥£¥ WATER WELL LOG l~illin$ Slan=d./c' Hctcd: / :. Se~loe %or %of ½~ ..% Drillins methocl:~,~Ah' rom% O C~blo tool Other Well ~e: [] Public suppl~, 0 Domes~k. Kl Other Depth of hole: 2ad~ fl, Cub~ s~cup: t:~ R ~Ic w~ { fr~.~t lop of cajJuE~ R ~ . ~p~ ~el a y~M: · f~ a~r h~ al 8~ R~v~ ~: ~. M~ of~nl: ~nt ~: ' ~tt~: Well ~e ~n~ ~: ~ ~ ~ ~ ~n ~le ~ Volume from R, to Pump intake ckpth: R Ptenp size bp: .Brand name: Wis well d~iflfected upo~ completion'/ n Yes, Me~xl of dlsinfectJon: D~I ~kt ~o~nts/d L~.laimers: Well D~II~ N~me: C<.T,~,any 1,4at~m: H~FTY DRILLINI~i IqAa~li~ Add _ret=_~: 3540 AKULA DRIVE ONo W!.thln. the Cie/of Anchor!e~. it j~ rea~t~ed that m cmY c~lbe-well In~ ~ I July 3, 2002 Municipality of Anchorage George P. Wuerch, Mayor Building Safety Division P.O. Box 196050 · 4700 S. Bragaw Street Anchorage, Alaska 99519-6650 · (907) 8/t8-8801 h ttl)://~x~vw,ci.anchomgc.ak.us Mike Schick 5701 Rabbit Creek Rd. Anchorage AK 99516 Subject: On-Site Water and/or Wastewater Permit. Permit Number: SW010325 ~L~gal Description: Fairmount Lot 9' Dear Mike Schick: An On-Site Water/Wastewater Permit, number SW010325, issued by this office for a single-family system, will expire on August 16, 2002. This permit ;vas valid for 365 calendar days. If this was a ;veil permit and the well has been drilled, a well log must be sent to this office for documentation of the installation and to close the permit. If this permit ;vas for a wastewater disposal system, an original as-built inspection report must be sent to this office for review, approval and documentation. This as-built inspection report must be signed by the licensed Professional Engineer ;;'ho inspected the installation of the system. As-built inspection reports are required to be submitted within 30 days ofthe completion of the system. If no system was installed under this permit, and you are still planning to install a well or wastewater disposal system, a new permit must be obtained from this office. A new permit for a second y~ar may be issued for a fee orS100.00 if the renewal application is received on or before the expiration date of the original permit. When applying for a new permit, the fees are: $400.i)0 for a wastewater permit and $150.00 for a well permit. If you have any questions, please call this office at 343-7904. On-Site Water and Wastewater Program Eno: Copy of permit HEFTY DRILLING 3540 AKULA DRIVE ANCHORAGE, ALASKA 99516 (907) 345-0593 City/Borough: ~ Subdivision/USS: ' ' " '*: '~ f ;'%1 ') ~0 t ,"~; Mcridian. Township Lat N.. Long: W STATE OF ALASKA I)EI)AI¥1'M ENT OF NATURAL RESOURCES MININ(';, I.,ANI), WATER IIYDROLOGIC SURVEY WATEI{ WI';I,L I,O(; Drilling Startcd:/D / J.'.l.I 0/, Completed: t/gl/~,~ q/ BOREIlOLE DATA: (frmu ~rouml sm'Ewe) Deplh Material: Type, Color & wetness I From I T._.o ,..9., n-.l' - ,. c.,,i.,, ,,., [. · -->-~ ,,'c4 45 days,.l:~y~¢~ jut accypti!h, lc. (AK stalulcs 38.05.020, 38.05.035/ ~8.020, 46.15.020 and AK rcgulalions I I AAC 93.140). DEPARTMENT OF NATURAB RESOURCES Mining, Land & Water ilydrologlc Survey 550 W 7th Ave., SuRe 900A Anchornge, AK Telephone (90~) 269~639 and FAX (907) 562-1384 Drilling method:,~3.,Air rotary, F1 Cable tool, Other Well use: [] Public supply, rl Domestic, [] Other Depth of hole: 20~ fl, Casingstickup: Casing type: <~ t- .L Thickness . Casingdiamctcr: ~. inches Caslngdepttv I.incr type: Diameter: inches Depth: Slaticwater~f,',,,,~ hmofcasim,): ~}~. fton I'umpiug I,:vcl & yield: feet aller 'hours at Recovery ral¢: '~ gpm, Method of testing: Dcvclopmcnt method: Duration: ft inches ft · gpm Well inlak¢ opening typc: [] Open cad, [] Open hole O Scrccned; Start: fl, Stopped ft Scrccn typc: Slot/mesh size [] Per foraled;Start: ft, Stopped ft Stall: fl, Stopped fl Nolo: · ,, Grout type:' ~.4' ,, [,~ ~;:/.' ,.,~. Volume DePth; from ft, to ft Pump intakc deplh: ft Pt,rap Si7.c hp, Brand name: Was well clisin£cctcd upon complctlon? [] Ycs, Method of disinfcction: [~No Driller con~l.?~nts/disclaimers: ,,~' Well Driller Name: Company Name: HEFTY DRILLING Mailing Address: 3540 AKULA DRIVE City:. ANCHORAGE .Sta. te~ ALASKA Zip: 99516 Phone Number :,..~ 1~907)345-0593 / ~ Drillers Signature: ~X~// ~,~ ........ . , Within the City orAnchorage, it is required that a copy oflhe well log be seiki lo thc approprJat~ c[~ office within 60 days nnd that another copy of Ihe wcll log bc sent to Iht ~vclll~r~pe~ o~ner within 30 days. Date of Issue: / / Parcel Identification Number: Is well located ~1 approvcd permit location? OYcs or O No MUNICIPALITY OF ANCHORA GE Deve/opment Services Department On-Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (gO7) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT Initial Date Issued: Aug 16, 2001 Expiration Date: Aug 16, 2002 Permit Number: SW010325 Legal Description: FAIRMOUNT LT 9 ~ Design Engineer: 0027 James Sizemore & Associates Owner Name: MIKE SCHICK Owner Address: 5701 RABBIT CREEK ROAD ANCHORAGE, AK 99516- This permit is for the construction of: [] Disposal Field [] SepticTank [] Holding Tank Parcel ID: 017-112-02 Site Address: 005701 RABBIT CREEK RD Lot Size: 41940 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 [] Privy [] Private Well [] Water Storage All construction must be In accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify 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. 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 ON-SITE SEWEPJMVELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 017- I I Z - 0 Z Permit Number Property owner(s) /V~ P, //Y~iX~' ~ ~/"~ Day phone Mailing address (1) 5'701 Rt~SB/T" £REEI~ ROmP Mailing address (2) Zip Code ~ Legal description (Lot, Block & Sub'd.) L ~ ~ ~ ~; ~ O ~¢ Legal description (Section, Township & Range) ~ ~ - ~, ~ ] ~_ ~, Lot Size ~-~t ~ Acres/Sq. Ft..~ 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 fudher certify that this application is being made for a Single Family Dwelling and is i~,accordance with applicable Municipal Codes. ~'nature of property owner or authocEed agent) Permit Fees: Date of Payment: Receipt .umber: (Rev. 12/00) Waiver Fees: Date of Payment: Receipt Number: PROBABLE IMPACTS TO ADJACENT PROPERTIES A) WELLS The proposed Bottomless Sand Filter disposal System has been used for the past few years in the Anchorage area. The system meets current Municipal Wastewater Disposal Regulations. The proposed syster will be greater than 100 ft. from the proposed well on this lot and the adjacent lots. Therefore there should be no adverse impacts on wells from this system. B) WASTEWATER SYSTEMS The system is designed in accordance with current M<unicipality of Anchorage regulations. There should be no adverse impacts to adjacent wastewater disposal systems. C) RESERVED SPACE/SURFACE AND SUBSURFACE There is enough space on this lot for a replacement disposal system and still maintain the protective distances between wells and disposal systems. D) DRAINAGE The location of the disposal system will not interfere with the drainage on thi lot. The are disturbed during construction will be graded and contoured to prevent ponding of water and disruption of drainage on the lot. Lot 2, Meyers ~5=7%~= =~ I Subdi~sion o Proposed ell I --~ 1500 Gal STEP Tk. ~ Th 1 Proposed Dr~ve > ----Proposed 12' x 30' Bottomless Intermittent Sand Filter Repl&'c~men~ ~and ' J Filter Location I JAMES SIZEMORE & ASSOCIATES LOT 9, FAIRMOUNT SUBDIVISION PROPOSED WELL & SEPTIC SYSTEM SITE PLAN Chkd. By: Grid: 3137 4" Line from house 1500 Gal STEP Tank ,~,~/ Flushing Valve & Enclosure ~--3/4" PVC lateral w~ 1/8" orifice 2' o.c. < From Air Compressor "'~From STEP Tk. 1/4" PVC Manifold JAMES SIZEMORE & ASSOCIATES LOT 9, FAIRMONT SUBDIVISION PROPOSED SEPTIC SYSTEM DE~AILS Scale: 1' - 10' Drawn By: Date : ' Chkd. By: GRID: · Munlcipalily o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: 5 8 7 8 9 10 11 13 14 15 16- 17- 18- 19- 20- DATE PERFORMEE SLOPE III III III lIP1 II '1 .Ib l WAS GROUND WATER ENCOUNTERED? SITE PLAN IIIIIIII1-.'1 II I Gross Net Depth to Net Reading Date Time "Time Water Drop }-ri, Il 7-~ /~:~.O --. ~l_. , PERCOLATION RATE '--~'~ ~ tminutes/inch) PERC HOLE DIAMETER ~-~ TEST RUN ~ETWEEN ~ © FT A.D _5-,5' FT COMMENTS ACCORDANCEW~TATEA;;~IC,/^~D~,NE~;/EOT;N~.;SLEi LE: "7"' 72-008 {Rev. 4/85) WASTEWATER DISPOSAL SYSTEM LOT 9, FAIRMONT SUBDIVISION 1.0 GENERAL 1.1 The scope ofthis project consists of installation ora 1500 gallon STEP Tank and a 12' x 30' Intermittent Bottomless Sand Filter. The Step Tank, and related pumps and controls shall be purchased from Anchorage Tank. The piping, air Compressor and alarms shall also be furnished by Anchorage Tank. 1.2 Construction shall be in accordance with: the approved site plan and design drawings and specifications, Municipality of Anchorage Permit with any special provisions or conditions, Manufacturers diagrams for pumps & alarms. Deviations from the approved design drawings shall be coordinated and approved by the engineer conducting the inspections. 1.3 All construction procedures and material used to construct the system shall comply with Municipal and State Regulations. 1.4 The homeowner shall be responsible for finish grading and seeding disturbed areas after the system is constructed. 2.0 INTERMI'I~FENT SAND FILTER PACKAGE 2.1 The pressure lines, flushing piping and valve, pumps and associated timers, switches and alarms for this system shall be obtained from Anchorage Tank. The 12' x 30' Intermittent Bottomless Sand Filter is the system specified for this job. 3.0 MATERIAL SPECIFICATIONS 3.1 Electrical Required timing and control devices shall be those supplied with the sand filter package. All necessary conduits, buried electrical wires, connections and switches shall meet the National Electrical Code Specifications. Connections to existing electrical service must be designed and fabricated by a licensed electrician. 3.2 Air Pump The air compressor and pump shall be a Thomas Industries, Inc. Model No, 5070 linear air pump, or equal product. Fittings must be air tight and capable ofwithstanding a 20 psi maximum operating pressure. A T shall be placed downstream of the air compressor, and a gage calibrated to read between 0 and 10 psi shall be installed where it can be easily read. 3.3 Piping Pressure piping shall be schedule 40 PVC conforming to ASTM D-2241 or polyethlene pipe shall conform to ASTM D-2239-74 at 160 psi. Air diffuser line shall be three quarter inch (3/4") HDPE. Arctic Air line, external to the filter shall consist of minimum R4 dual wall HDPE constructed with urethane foam, ~A" HDPE with one inch (1") foam pipe insulation jackets and four inch (4") PVC outer shell, or an approved alternate. All pipe shall have two inch (2") insulation, two feet (2') wide over areas which have less than four (4') of soil cover. 3.4 Pea Gravel Locally available, washed three eighths inch (3/8")pea gravel is suitable for use in the ISF. Material must have 100 % passing the three eighths inch (3/8) sieve, and must have less than 20 percent (20%) passing the one quarter inch (1/4") sieve, and less than one percent (1%) passing the//8 sieve. One quarter inch (1/4') pea gravel with round particles and less than one percent (1%) passing the//8 sieve is an approved substitute. 3.5 ISF Sand An approved source of ISF sand is Central Paving Product's "Winter Road Sand" available at the Palmer yard. Substitutes must have less than two (2%) passing the #100 sieve, less than one percent (1%) passing the #200, and have I00 percent (100%) passing the #4 sieve. A coefficient of uniformity Cu~4 is recommended. 4.0 ENGINEERING INSPECTIONS 4.1 The contractor shall coordinate with the engineer at least 24 hours prior to start of construction. 4.2 The engineer will be available during construction ofthe system to make necessary inspections. ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT MEMORANDUM OF UNDERSTANDING THIS MEMORANDUM OF UNDERSTANDING made and entered into as of this day of ~'t. tl,-( 20 , by and between L-, , herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY." In consideration of the mutual covenants contained herein, the parties to this Memorandum of Understanding agree as follows: 1. ADVANCED WASTEWATER TREATMENT SYSTEMS. Municipality grants permission to Owner to utilize and operate an Advanced Wastewater Treatment System / (AWWTS), described as ~'¢~9'x~v~t'' ' located at /-o'"P" ?/ /, Anchorage, Alaska. 2. Definitions. A. Alteration. Any change to the design or function of an AWWTS that includes the installation or removal of any parts, components or pieces not included in the original construction permit and design. Prior to performing any alterations to an AWWTS the owner must obtain a Wastewater Disposal System Construction Permit from the Municipality pursuant to AnchOrage Municipal Code (hereinafter, "AMC") 15.65 Certificate of On-Site Systems Approval. An approval by the Municipality of existing water and wastewater disposal systems given at the time of property sale and title transfer in accordance with AMC Page I of 5 15.65. These approvals certify that the systems are adequate for the homes that they support and meet the codes that were in place at the time of system construction. C. Damage. Any man-made or natural change in a system that would inhibit the system from perforating as designed. D. Maintenance and Repair. The scheduled and as needed replacement of existing parts, components and pieces of an AWWTS that were included in the original design which would allow the AWWTS to continue to perform as designed. E. Permit (Construction). An On-Site Wastewater Disposal System Construction Permit as defined by AMC 15.65. F. Permit (Operating). An Advanced Wastewater Treatment System Operating Pea'mit. An annual permit, issued by the Municipality, that allows the Owner to operate an AWWTS, upon meeting all requirements of this agreement, the conditions of the 'Operating Per~xfit, the requirements of the On-Site Wastewater System Construction Permit and all relevant provisions of AMC 15.65. 3. Fee. O~vner shall pay to Municipality an annual fee of 2 C~g'o ($ (~ .00), payable on or before the issuance of the operating pe,t,it and annually thereafter. The annual fee is due on or before the anniversary date of the approval by the Municipality of installed system. Page 2 of 5 4. Term. The term of this Memorandum of Understanding shall be for the life of the AWWTS. The term begins on the date of approval by the Municipality of the installed system and shall continue while the AWWTS system is in use or operational or until the property is sold or title is transferred by owner and a new certificate of on site approval is issued to the new owner or transferee of the property. 5. Alterations, Installation and Removal of Additional Equipment. Owner agrees not to make any alterations, removal of parts or additions to the AWWTS without a Construction Permit from the Municipality. 6. Maintenance and Repairs. A. Throughout the tetni of this Memorandum of Understanding, the Owner shall maintain AWWTS in good repair. In addition, it shall be the responsibility of the Owner during the term of this Memorandum of Understanding, and any extensions or renewals thereof, at the owner's sole expense, to pay for any and all: (1) repair(s), (2) maintenance, (3) adjustment(s), (4) replacement costs, and (5) inspection costs. Further, owner agrees to comply with all applicable ordinances, laws, regulations, rules and orders for the AWWTS. B. Owner agrees to provide the Municipality a written schedule of routine maintenance and repairs which have been perfot~xed on the system pursuant to the terms and conditions contained in the O~vner's AWWTS Operating Pen~fit. This schedule shall be submitted to the Municipality annually upon the renewal of the pet'mit. The schedule of maintenance and repair contained in the Owner's AWWTS Operating Permit is: Page 3 of 5 C. Oxvner acknowledges that the fine schedule for failing to maintain and repair an AWWTS are codified in AMC 14.60. D. oWner agrees that only maintenance, repair personnel certified by the Municipality will inspect and make any necessary maintenance, repairs or pemdtted alterations to the systems. E. Owner agrees to'grant the Municipality reasonable access to test and inspect the AWWTS upon 24 hours written notice. F. Owner agrees that any sale or transfer of tire of the property will not occur .without a new Certificate of On-Site Systems Approval. G. Owner agrees that the relevant provisions of the standard specification guidebook for AWWTS is the governing professional guidelines for the construction, maintenance and repair of the Owner's AWWTS. 7. Nonwaiver. The failure of either party at any time to enforce a provision of this. Memorandum of Understanding shall in no way constitute a waiver of the provisions, nor in any way affect the validity of this Memorandum of Understanding or any part hereof, or the right of such party thereafter to enforce each and every provision hereof. 8. Amendment. A. This Memorandum of Understanding shall only be amended, modified or changed by a writing, executed by authorized representatives of the parties, with the same formality as this Memorandum of Understanding was executed and such writing shall be attached to this Memorandum of Understanding as an amendment. '~ Page 4 of 5 Be conditions of this contract, the only authorized representatives of the parties are: For the purposes of any amendment modification or change to the terms and Owilel;. Anchorage: Purchasing Officer C. Any attempt to amend, modify, or change this contract by either an unauthorized representative or unauthorized means shall be void. 9. Jurisdiction: Choice of Law. Any civil action arising from this Memorandum of Understanding shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Memorandum of Understanding. 10. Severability. Any provisions of this Memorandum of Understanding decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Memorandum of Understanding. OWNER: MUNICIPALITY: By: Title: Date: STATE OF ALASKA ) ) SS. Trap, r) mmcm. InSTruCT ~The foregoing instmmym~)gFoS,q~>vledged before me this~__.~'~ay of x,~bb{ ~ , 20(~{', by Municipal~~e. ~~ ~' P~LIC/~ t~ t ~ MUHMPAU TY OF A�HCHO RAGE 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. 017-112-02-000 Legal description FAIRMOUNT LT 9 Expiration Date: Site address 5701 RABBIT CREEK RD Anchorage AK 99516 Current property owner(s) BOUTSOMSI UBON X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for Comments or advisories: 10/12/2023 bedrooms, with the following stipulations: Original Certificate Date: 7/12/2023 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 Nitrate Advisory Tank Age Advisory X Arsenic Advisory Other COSA Approval_June 2022 MUHMPAUTY ANCHORAGE °.tom 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. 017-112-02 Complete legal description Fairmount Lot 9 Location (site address) 5701 Rabbit Creek Road, Anchorage, AK 99516 Current property owner(s) Ubon BoutSomSl 2. ON-SITE SYSTEMS SIZED FOR '4' BEDROOMS Day phone (907) 351-1544 3. TYPE OF WATER SUPPLY: ❑® 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 22 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: X AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑Q 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 / Waiver Fee $ Date of Payment 7/ �2�2 3 Date of Payment COSA # _0� 2G) 2.9 C) Waiver # COSA Application—June 2022 Fairmount Lot 9 017-112-02 3.6 10/24/01 206 N/A 147 18+ 6/13/23 Forge Engineering 63 5/31/23 STEP 9/1/22 A+ Home Services 4/11/02 3.3 N/A N/A N/A N/A 22 Steel 7/7/23 0/0 840 2/2 1440 0/0 > 600 2.5 0 2.5 Benjamin Schiller, P.E.7/11/23 (907) 522-7773 MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and entered into as of this 16 Day of X 7 e of 20 cl, , by and between Not f ka ? 60 (G lo . herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as Rja +fpm I e 55 to twm i t4g j j �a s cl located at (legal description) Fa; (moo I, � LQ 2. Maintenance, Repairs and Alterations. (Owner is required to read, understand and initial each section) 7e-1;1 Throughout the term of this Agreement, the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in �accordance with the equipment's approval for operation in the Municipality. y!// It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to $600). Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, /�j�repairs or permitted alterations to the system. All Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. 05/18/2018) Pagel of 3 Owner acknowledges that the Municipality may request records of maintenance and repairs from the manufacturer's representative or maintenance provider. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS. The Municipality will give at least 24-hour notice. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the Owner's AWWTS. Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7. Severability. Any provisions of this Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev. 05/18/2018) Page 2 of 3 OWNER�j� "-(signature) By: ' � a, PC, a f AQ q Ga (G h (print name) STATE OF ALASKA THIRD JUDICIAL DISTRICT Date: 6-x • ?0 a:5 V;' <' NOTAFY ss. = PUBLIC:' The foregoin instrument was acknowledged before me ON 20a, by�l NOTARY PUBLIC FOR AL SKA My Commission expires:,__=j 2 la Z (rev. 05/18/2018) signature) .)rint name) Date: a� Title: Page 3 of 3 • PS).VnitY 196650 Amchora e, A 99519-6650 • http://'wvNnu.rnuni.org/buildimg iYSL]NICIFALITY o' ANC�tO�C+y "' Com�z�aumity Developn:►e�t Department • dn�Sitc Watet� & Wa9tewater rograxx► P: 90'7-3437904 • I .907-343 7997 Intermittent Dosing Sand Filter Maintenance Log ownerl%,c ' �.0" 5i,_� Street Address C P1D Phan GJ "' Legal iDesc. sont C �' 5 *Pumping completed Gs]o inches -pumping: required es o .Sludge level S _ Absorution Field: kk -Flushing valves per approved. designtnto -Liquid level D _ ,inches *All flushing valves opened, distribution lines flushed, and flushing valves closed Lift station: -pump basket clear �d es no •Biotube effluent filter cleaned no incises High level float setting inches -Reference point -Timer float setting.,_inches minutes -pump on-_ -seconds -Pump off___. .Cumulative lifetimf, cycles -Cumulative run time hours -Operation satisfac ;Dry gLno Air SyMtem. -3 si •Air pump filter ned 6j�L_no *Air pressure cle< *Air system operation sfacto no satisfacto -Date of latest inst,< iIl or rebuild Alarm Svsterl�: -Dedicated electri - al circuit es no -Audible and visual alarm inside dwelling es no In -Alarm system operation -Float setting satisfacto not satisfacto Comments: . 1P yxte4_V .......cSk�o.�1..... .......' ........'........................ ................. ......... ............ ........... ................... I .... ...,... .... Maintenance Prg, !,rider: Tech nic_WM !� f �Date of maintenan Company BIL_ `�2 ►rv�- _ _��__ Signature IDSF Maintenance i_ g_040313.d0c (NOTE: SCALE: 1"=40') M UNI(C pA UTY OF ANCHORAGE A OCA DEVELOPMENT SERVICES DEPARTMENT o �i On -Site Water and Wastewater Section www.muni.org/onsite Septic 'Tank Advisory Certificate of On -Site Systems Approval # OSC231240 Subdivision: Fairmount Block: , Lot: 9 907-343-7904 Fax: 343-7997 The septic tank for this property is 22 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. MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 017 112 02 1 Certificate of On -Site Systems Approval GENERAL INFORMATION Complete legal description Fairmont Lot 9 Location (site address) 5701 Rabbit Creek Current property owner(s) Michael Schick Expiration Date: � - 3 (9 -Z0zl Day phone Mailing address Real estate agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Q Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSAFee $ gl�.50 Coyj�_ f` Date of Payment �� / % �� D'� d Receipt Number DV -7 g L COSA# 0 SCa d l 6 J3 5 Waiver Fee $ Date of Payment Receipt Number 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 C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 12/16/2020 o .A/ �1 *: 49 TH •.* 6. DSD SIGNATURE System #1 Approved for bedrooms ' ' ' ' ' ' ' ' • • ' ' ' >:HARLES G BALZARINI System #2 Approved for bedrooms � �Fc •. CE-13854Am .• �`�i Disapproved illFOpROFEWQO Conditional approval for bedrooms, with the following stipulations: M 'i/)Itt�,t,�•,�"tile' Original Certificate Date: :fid - ZD 2 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 Checklist blue sheet COSA Checklist Legal Description: FAIRMONT LOT 9 Parcel ID: 017-112-02 If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 2001 Total depth 206 ft Cased to 147 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) +18 in. Date of flow test for COSA 12116/20 Static water level at beginning of test 75 ft. Comments B. TANK DATA Age of tank(s) 19 years Tank type/material STEP Measured operating fluid level in septic tank NA ON Standpipes/foundation cleanout per record drawing Date of pumping 12/15/20 D. ABSORPTION FIELD DATA 2001 IDFS Which system tested (date installed) 2001 ❑ ALL standpipes present per record drawing Total measured depth from grade 5 ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective Well production at time of test +5.1 gpm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ❑ N ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by C.Balzarini Date of Sample C. LIFT STATION OR Required maintenance completed Age of lift station 19 years Lift station material STEEL Comments: OWNER INDICATED THAT TANK MAY BE FIBERGLASS. ENG NOTABLE TO VERIFY MAT'L Adequacy test date 1216/20 Results QPass For 4 bedrooms Fluid depth prior to test 0 in Water added 600 gal New depth 2 in Elapsed time 15 min ❑ Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 600 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NA date of test) If yes, enter date y NA Gallons introduced NA gallons Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' 121 Yes Community Sewer Manhole/Cleanout > 100' Q Yes if No ft M Yes if No ft Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' F✓ Yes if No ft Absorption Field on Lot > 100' 0✓ Yes if No ft Holding Tank > 100' M✓ Yes if No ft Neighboring Absorption Fields > 100' ❑✓ Yes if No ft Water Main > 10'✓❑ Animal Containment > 50' Z✓ Yes if No ft M✓ Yes if No ft ❑✓ Yes if No ft Water Service Line > 10' ❑✓ Yes if No Manure/Animal Excreta Storage > 100' If septic tank is under driveway comment below Community Sewer Main > 75' M✓ Yes if No ft ❑✓ Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 121 Yes if No ft Surface Water > 100' Q✓ Yes if No ft Property Line > 5' M✓ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5'✓❑ Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Main > 10'✓❑ Yes if No ft Community Wells > 200' ❑✓ Yes if No ft Water Service Line > 10' ❑✓ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ®✓ Yes if No ft If absorption field is under driveway comment below Property Line > 10' 121 Yes if No ft Wells on Adjacent Lots: Water Main > 10'✓❑ Yes if No ft Private Wells > 100' Q✓ Yes if No ft Water Service Line > 10' El Yes if No ft Community Wells > 200' 0✓ Yes if No ft Surface Water > 100'✓0 Yes if No ft F. ENGINEER'S COMMENTS DECK FOUNDATION ENCROACHES ON SEPTIC TANK TO WITHIN 3 -FEET THE FOUNDATIONS ARE DEEP SONOTUBE FOUNDATIONS WHICH KEEP THE DECK BEARING FORCES OFF OF THE TANK. G. ENGINEER'S CERTIFICATION 1 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. 12/18/20 COSA Checklist yellow sheet d : 49 TH .. •:�` ��� • • CHARLES G BALZARNI FFG' CE -13854 ,••c�`�� �� ROFEMQ -� NILWKIPAL17V CIP A. C '-nIIUv,-,!A-, - C=,tuujiry Ourve ku pm=tDcp a =--zl, * C3U-9ite Wa—tcr& gtwn P: W-34�--7W.- - F: ,'%IJ i-7997 w PO, BLix 1966$4Ar,,Acm4gt.A7K 9951? -C,650 - httpIAvwiY.1nu.,1i.r )rr;bijjj4fiMg Intermittent Dosing Sand Filter Maintenance Log Owner fy) L K- Street Addre-ss Phone Legal Gc,,;c. PID T;jrjk.,, -sludge le; e'l fy., i r, r h e S- -Pumping: requiY-2red -Pumping completed 1 nO Abn�qn F�leld- -Liquid level III' lnchcr. -Flushing valves per approved desicgr nn© -All flushing valves oporj, distribution line I'mished, and flushing valves clw-v2!rj Lfft station: -Pump basket cAcaneden no -Biotubeefflut filter cleaned /'L 110 .Timer float setting ALinciii!,.. -High level float setting, inches -Reference point ,Pump on__ �$econds -Porn* off 2r7 minutes -Cumulative lifetirne cychn�_ -g -Curnulat"Ve run tirne _3 3 J,wrs _ho- -Operation satisfactory no Air System: C- -Air purrip filter cleaned no -AIr preswre --PSI -Date of late,�t install or rebuild Air!wstern operation AlArm System: -Dedicated electrical C'TCUI't (YeV no -Atidibk- and visual alarm inside dwoffing no -noat setting q,toes -Marr, System operationC-<66fnto not satisfactory Comments: ............ ... .................................... ................... ........ ............. ............... .......................... ...... ................. .................. ...... ...... ....... .................... ............... ................................. ....... ---11- ......... ...... - ... I ....... -1 ... ......................... ........................ ...... ................... ................. ........... ........ .................. I ...... ............. ....... - ......... ....... ............... ....... ........ I ............... ............................ .................. ................ 1-1111- ......... ......... ........ Maintenance Provider-, ieohnjoian 004t I&Ak,,5fr- Date of Company Aploz�,lf,;� s,2.-r4-� Signature 113SF I, - r �.7, Q,!, G,. �, I ' �. � r., [41 Ji■A [r7i 14�=.�I Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Cosa for Fairmont Lot 9 Dear Reviewer, This letter provides supplemental information for the COSA for Fairmont Lot 9. The inspection report on file indicates that the septic was approved for 3 -bedrooms. The inspection report also shows that the septic was installed in accordance with the approved permit which was for 4 - bedrooms. Based on a application rate of 2 for the IDSF, 300 square feet of absorption area would be required for 4 -bedrooms. The 12x30 bed has 360 square feet of absorption area, so it is sized sufficiently for 4 -bedrooms. The Inspection report on file also indicates a wastewater application rate of 0.8 gpd/sgft. Based on the IDSF design guide, the correct application rate is 2 gpd/sgft.The COSA should be approved for 4 -bedrooms consistent with the system design and previous COSA approval. Since the system was constructed, a deck was built in close proximity to the tank. The deck has sonotube foundations which reportedly extend to a depth of 6 -feet or more. The below sketch assumes that any bearing forces extending from the tank would be imposed at a 45 degree angle from the edge of the sonotoube. The sketch shows that the bearing forces from the sonotube do not impact the tank. We have determined that approval does not pose a discernable risk to health, safety, or the environment. f` I F C r v �s U Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini(c_gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 12/28/20 O C:) TM 49 CHARLES G BALZARINI 6,•. CE -13854 ��li� PROFESSIO�P�'-a.A� 1IUNICIPALI I Y OFAiNCHOid11*GE ,k])VA NCED }V :kS'TEWATLIt '1'R[ AUNIENT SYSTl N-1 A I Al INTIs `IANC E,, AND REPAIR AGREEMENT "1'1!15 MAINTENANCE., AND REPAIR AGR1sEMENT, herein the "AGREEMENT" made and exutered into as of this fe,, Day of'r 01' 20 ZO , by and between ' herein the "OWNER," and the unieipality of Anchoragc, herein the `,MUNICIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: Zn Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as INTERMITTENT DOSING SAND FILTRATION SYSTEM located at (legal description) FAIRMOUNT LOT 9 Maintenance, Repairs and Alterations. (Owner is required to read, understand and initial each section) Throughout the term of this Agreement, the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The ANVWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. It shall be the responsibility of the Owner during the tern of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to 5600). Stiff Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. 05i1S/201 8) Page l of Owner acknowledges that the iMunicipality may request records of maintenance and y repairs 1Torn the manufacturer's representative or maintenance, pro% -ides. Owner acknowlcclges that the fine for failing to maintain and repair an AWWTS nlay be assessed in accordance with AMC 14.60.030. r Owner agrees to grant the �-w1unicipality reasonable access to test and inspect the AWWTS, The N—lunicipality will give at least 24-hour notice. _Ir Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. C AI Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing truidelines for the construction, maintenance and repair of the Owner's AWWTS. Owner- agrees to maintain remote monitoring of the AWWTS as required by the AN�VNVTS approval. �. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and shall continue tivhile the AWWTS is operational or until title is transferred. 4. \onwaiver. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. Severabilirir. Any provisions of this Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. s rel . O5'1 Sr'2U 18 j Page 2 of 3 OWNER: _ By; (signature) Date: 0',-267' .961,)U (print name) STATE OF ALASKA ) ) ss. THIRD JUDICIAL DISTRICT ) The foregoing instrument was acknowledged before me this 2-M"day of De,- , 2020 , by Flcs ��k,,,,r U a(/41' II► STATE OF ALASKA .„ NOTARY PUBLIC FOR ALASKA My Commission expires: C'5-11(,IZS INTUNICIPALITY: By: t/1,% 1 d.- ignature) NOTARY PUBLIC Flamur Limani My Commission Expires:L/,1 M Date: 2'� U` 'ZCD (print name) "Title: (rev. 05/18/201 S) PaLle 3 ol•3 Municipality of Anchorage Development Sen/ices Department Building Safety Division On-Site Waler and Wastewater Pr.ogram 4700 South Bragaw St. ' ' P.O. Box 196650 Ancho~ge, AK 99519-6650 www.ci.anchorage.ak, us " (907) 343-7904 O g us ALi I riORITY rtr r rtuv/-~L CERTIFICATE OF HEALTH -' ' ^ :"'"" -' ' -: ......... "'I-:"OR A SfNG[Ei::^i',4iLYY}WELLING ......... '- Parcel I.D. OJ7-It'Z-& " HAA# 0%0 · Expiration Date: ] ~ GENE~L INFORMATION Complete legal des~p~ ~,, .~ ~ ~ Lending agency , . Day phone Mailing address Real Estate Agent Day phgne Mailing Address Unless otherwise requested, HAA will be held by DSD lor p~ckup. . NUMBER OF BEDROOMS: ~ .3..TYPE OF WATER SUPPLY:; ' Individual W~II --- 'Individual Water Storage · ' ,Community Class Well Public Water System · TYPE OF WASTE'WATER DISPOSAL: Individual On-site ,,~ Individual Holding tank Communi~ On-site [] Public Sewer [] The Municipality of Anchorage Development Sen4ces Department (DSD) Issues Certific~.tes 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. Cer',Jfi~tes of Heelth Authority Approval are required for the transfer of title (except be[ween spouses) for properties sen/ed by a sing!e-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certific~tas of Health Authority Approval sre valid for 90 days from the date of issue for properties served by a privete or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period or' up to one year with valid water s~mples.) Certificates are valid for one year for properties sen/ed by Class A or B we!Is or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the prcfessionsl engineer's wcrk. STATEMENT OF INSPECTION BY ENGINEER · '. As certified by my'seal aff'Lxed hereto and as of the validation date sho~vn below, I verif7 that my investigation, based on' procedures outlined in the Health Authority Approval Guidelines for this application, sho~ that the on- site water supply and/or wast~water.disposal system is(a=:e) safe, fbhcticinal and adequate for the number 6f · bedrooms and type of strucbJra indicated herein. I ~rth~r ve.rify that l~as. ed on. the information obtained from the Municipality 'of Anchorage files and from my in.v.estiga, b.'0n..;.a.nd.~sP~, tion,' the on-site water supply and/or DSD SIGIqATURE ' wastewater disposal system is(ara) in compliance with all a~pr~cable Municipal and State codes, ordinances, ..;.%-'.' ' . . ' . ' · ' .. '. ~'.'~;.~:_~:~i!-".-...:.. : ' ' '·'"": /, · ... ?..~...........:,..:.:...;.-.:..:.-.......~:~,,-:~...,~,~,.-~.,~,.~. :~3~;~ ~.-~ ~ :' · ......: .. '. :...::....~ :....: '.i.'.".--..~,,i.'~~. , -: . ...., ~ ~: :-'~ -..~. . . :::bedrooms;with the fol[o~n~'stipulations ..... ..'- -- Septic System Advisory:' . · Well Flow Advisory Supl~ler~ental Engineer's Report · Other· (Rev. 01/~2} Original Certificate Date:. 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: A. WELL DATA we, type If A, B, or C provide PWSID # Parcel ID: / 7'- ) J"'~. '""0 ~ Well Log (Y/N) Y Date completed .[.~- Total depth Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~) colonies/100 mi. ,Sanitary seal (Y/N) .~' Casedto !L-t7 ft. FROM WELL LOG · ~) Nitrate/' ] mg./I. Wires properly protected (Y/N) Y C.asing height (above ground) ~./-~. in. AT INSPECTION Other bacteria ~:~ colonies/100 ml. Co Arsenic: mgJL Date of samPle& Z~ -~.~ Collected by:._/~ ~ ;~7 ~'~'.. Tank T~elMaterial. ,' ,,';~,~., . . ( Date installed ...~-- 1 . Tank size I ~:gaL- ' '% . Number 6f Oompadments ~ Cleanouts (Y/N) Foundation c~no&"(WN) ~ ~eP~es~on over tank ~/N) ~ High water alarm (Y/N) Date of pump~ ~ Pumper ABSORPTIO~kD DA~A , ." Date installed ~ ~[1%~il r~tin0':.{g.p.d./fl' or ff~Ndrm)~ System t~e ~ . .~7. ~ .'~ . .... Length : ~ O fl.' Width / ;7~ fl. Gravel below pipe 0'-~ ft. Total depth ~,0 fl. Eft. absorption area~ff= Monitoring tube. ~ Depression over field Date of de ~,~ a quacy leo, Results (Pass/Fail) For ~bedrooms Fluid depth in absorption field before test in. Water added gal. New depth in. Elapsed Time:. min. Final.fluid depth in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & t~e) If yes, give date D. LIFT STATION . Date installed "4-~-' "Pump on" level at Datum j:z~_,, '"/--[7. o Size in gallons ~ ] ~,,.~) "Pump off" lave! at .~;'~iin. Cycles tested ~..-..--- Manhole/Access (Y/N) , ~ High water alarm level at ~ O Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM W~ELL ON LOT TO: Septic tank/lift station on lot., 1/(~ Absorption field on lot fL~/'~ ! Public sewer main., /'~//~ Sewer/~ ~c~,.e / ~ f' ~ ~ On adjacent lots Or, adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main Property line ':~-" _~ _ Absorption field Water service line _ ~ 0 Surface water ' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / f,-~/ ~Building foundation ~ (~ [ Water main Water Service line J"~ Surface water /J~.'J~)}/'~----- Curtain drain Driveway, pnrking/vehicle storage _ ~/' ~ Wells on adjacent lots `.% [(~]~ I F. COMMENTS G. ENGINEER'S CERTIFICATION ,,~~ review of Municipal records that the above system., are in conformance with MOA HAA ~uidelines in effect on this date. ~'n~ineer's ~rinted N_.,ame Date of Payment~ ' ~.. ~ - 0 ~ Reoeipt Number ~'7 ~ 7 / ~ ~ (Rev. 12/o~) ~' ' Waiver Fee $, Date of Payment Receipt Number FAIRMOUNT SU[~D. LOT 8 /I I I / / / / / / /\ / 8/// // AI,~TEC. ~10 W. 41ST SUIT[ 101 907-561 ear, I~/l~/'~et