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HomeMy WebLinkAboutVALLI VUE ESTATES #2 BLK 3 LT 39Valli Vu lock 3 Lot 3 015-$41 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program, 4700 S. Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 Page of www.ci.anchorage.ak, us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: OSP101196 PID Number: 015-341-29 Name; RI~SSEI,I, &.lO¥ KUCINgK~ Wastewater System: [] New [] Upgrade Address: 10231 LONE TREE DRIVE. ANCH.. AK 99507 ABSORPTION FIELD Phone: Number of Bedrooms: 3 [] Deep Trench [] Shallow Trench [] Bed [] Mound [] Other: LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: 1.13 avg. GPD/Ft2 12 Ft. Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe: 3 39 VALLI VUE ESTATES #2 4.5 Ft. 7.5 Ft. Township: Range: Section: Fill added above original grade: Gravel Length: 1.47 - 2.41 Ft. 37 Ft. Well: [] New [] Upgrade Gravelwidth: 3 Ft. Number oflines:l I Distance between lines:.. Ft. Classification (Private, A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material: PUBLIC Ft. Ft. 407 Ft2 Sch 40 & D3034 Driller: Date Drilled: I Static Water Level: Installer: Date Installed: Ft. Mike Anderson 10/05/2010 Yield: GPM Pump Set at: Ft. Casing Height Above Ground: Ft. TANK SEPARATION DISTANCES [] Septic [] Holding [] S.T.E.P. [] Other: Fro'Fromm To Septic Absorption Lift Holding )ublic/Private Manufacture~ Capacity: ~ Tank Field Station Tank Sewer Line Anchorage Tank 1000 Gal. Well 200'+ 200'+ NA NA 25'+ Material: Number of Compartments: Steel 2 / Surface Water 100'+ 100'+ NA NA ~ / LIFT STATION Lot Line 5*+ 10'+ NA NA/~ Size: ~ Manufacturer: Gal. Foundation 5~+ 10~+ NA NA "Pump on" level at: 'Pump off' level at: in. High water alarm at: in, in. Curtain Drain NA * 50'+ NA NA Pump Make & Model Electrical Inspections performed by: Remarks: · .o.e k.ow. BENCH MARK Location and Description: Previous existing septic tank decommissioned per UPC. Garage Slab Assumed Elevation: Only 5.5' effective used to calculate absorption area. 100 Ft. Average parc rate of 1.13 gpd/sf used (3.5' of 1.2 gpd/sf & 2' of 1.0 gpd/sf) Engineer's Stamp Inspections performed by: ArcTerra Dates: 1st 10/05,2010 2nd 10/05/2010~~'~" Development Services Department Approval Reviewed andapprovedb,~.~/~"" /~,//~ )~Date: ,2-/~"' (Rev, 12/00) AS-BUILT SYSTEN DETAILS/SITE PLAN PerMit nsPiOii96 VALLI rUE ESTATES fi2, BLOCK 3, LOT 39 PID~ 015-341-29 ~ D/W 3-BE HOUSE / / ~ ~ ~ ~ SCALE= 1' = 30' ~A-C=~4,5' ~A-D=a4' ~nnn~ n ~ nn ~ ~ FINAL GRADE ;9_E=5~ ~ moo GAL ;A-F=84,5' ~~AN~ SEUER RaCK / g 10331 LaNE TREE DRIVE ~ ANCHURAGE, AK ~9507 ~ RELD BOOKS ~ ~ , x Permit Number: Tax Code Number: Work Type: On-Site Wastewater Disposal System Permit OSP101196 01534129000 Septic MUNICIPALITY OF ANCHORAGE Development Services Department On-Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Upgrade Permit Effective Dates: September 21, 2010 to September 21, 2011 ' Design Engineer: ARC TERRA CONSULTING INC Subdivision: VALLI VUE ESTATES #2 Site Legal Address: VALLI VUE ESTATES #2 BLK 3 LT 39 G:2538 Owner/Address: KUCINSKI RUSSELL M & JOY C 10231 LONE TREE DR ANCHORAGE AK 995076921 Site Mailing Address: 10231 LONE TREE DR, Anchorage Lot Size in Sq Ft: 26813 Total Bedrooms: 3 This permit is for the construction of: Y Disposal Field Y SepticTank N Holding Tank N Privy N Private Well N 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close 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 Bragaw Street P.O. Box 196650 Anchorage, Alaska 99519-6650 www.muni.org/onsite (907) 343-7904 ON-SITE SEVVER/VVELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-341-29 Property owner(s) RUSSELL & JOY KUCINSKI Mailing address 10231 LONE TREE DRIVE Site address 10231 LONE TREE DRIVE Day phone Zip Code 99507 Zip Code 99507 Legal description (Sub'd., Block & Lot) VALLI VUE ESTATES #2 BLOCK 3, LOT 39 Legal description (Township, Range & Section) Lot Size 26813 Sq. Ft. Number of Bedrooms 3 THIS APPLICATION IS FOR ([~ all that apply): Absorption Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage [] THIS APPLICATION IS AN: Initial [] Upgrade [] Renewal [] I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. ARCTERRA (Signature of property owner or authorized agent) Permit/Rush Fees: $530.00 Date of Payment: 9/13/10 Receipt Number: O O (Rev. 11/05) Waiver Fees: Date of Payment: Receipt Number: ~ ' ~~ ~ CONSULWING, INC : '~,. ~ ,~,n~. Y' n?~ 212 E. 51 st Ave, Anchorage, AK. 99503 ' ~o~}~ ?~,~,~Office (907) 868-3791, Fax (907) 868-3793 September 13, 2010 Municipality of Anchorage Development Services Department On-Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 Subject: Upgrade Sewer Permit - Valli Vue Estates #2, Block 3, Lot 39 Gentlemen: The owner has requested we proceed forward to obtain a septic permit to upgrade the failed leachfield on the subject lot. The general slope of this lot is from east to west at a grade of approximately 0-3 %. On September 2, 2010 a testhole was performed to investigate soils and groundwater. The results of this test are attached for your review. The proposed upgrade will serve the existing 3-bedroom house. We propose to install one 35' long deep trench. Groundwater was not encountered during excavation or at monitoring. The property and adjacent lots are served by public water with on-site wastewater systems. There is no surface water within 100' of the proposed system and there are no known curtain drains within 50'. We do not expect there to be any adverse effect on adjacent lots by the development of this system. If you have any questions, please contact me at 868-3792/FAX 868-3793. Respectfully submitted, ArcTerra Consulting, Inc. Kenneth M. Duffus, P.E. Attachments: On-Site Sewer Application Wastewater Absorption System Details/Site Plan Soils Log/Percolation Test Owner/Contractor Specs 20441 PTARMIGAN BLVD · EAGLE RIVER, AK 99577-8736 · PH (907) 868-3791 · FAX (907) 868-3793 WASTEWATER DISPBSAL SYSTEM DETAILS/SITF PLAN VaLLT X/LIE ESTATES :II:P, BLFICK 3, LFIT 39 I ~ ~ , -~' ,' I/ L oowREo--/~/'~ ,~~ _ LOT 59 o \ / /,,g B LK 3 /'~,~t~'~ ~ ~ ~ ~.,a~,~. I / -,~~x~s~o SEmlC ~ I ~ ? ~ 0 I -0 : z:-- ~ © .~ ScaLe: 1'= 30' ~' DESIGN DETAILS PAGE I DF / 3 BBRN X 150 GPB = ~50 GPB ~~ ~.Ac¢~..¥r~'~ ~"'/~T' 450 GPB/I,a GPD PER SQ, FT, (~,7 NIN/IN,)= 375 SQ, FT 5, ~m/6-a,~ ~.~y~ F~'9- (375 / ~ x (5,5' GRAVEL) = 34,! FT, TRENCH ~ '19~ EF?~C;Iw~' D~P~ .,A~'USE 1 TRENCH - 3~' (L) X 8' (W) X 7.5' (D) ~:~ ""~ Tot:al. depi;h oF system is 1~' MO.X 'From or'igirmJ. 9r-ade. ~ ~,, Tot;~( depth o? 9r'ave~ 1oe[ow distril0ution pipe is 7.5' . ~ Nn PU~LTC WELLS: ~/~TH~N EO0' OF .o P.OPOSE~ ~YST~-.. N O T E S: Nn PR~V^TE WELLS mTmN aO0' Or ~ PROPOSE~ SYST~ eXCEPT ~S NOT~. l, INSTALL NEW 1000 GAL & INSULATE TANK IF <4' COVER. NO SEPTm SYSTEMS mTmN aO0' OF e PROPOSED VELL EXCEPT AS NIITED. B. INSULATE TRENCH WITH a' HB BURIAL FDAN IF < 3' OF FILL, ~ NIN, ~' FILL WITH INSULATION, >3' COVER NO INSUL REQ, = 3. CONTRACTOR WILL ENSURE NAXINUN ~% SLOPE INTO SEPTIC TANK, _ 4, CONTRACTOR WILL ENSURE ALL SEPARATIONS TD ADJACENT ~ WELLS, SEPTICS EASENENTS, PROPERTY LINES, ETC.., I ~ T ANCHORAGE, AK 99507 .' .. ~ ' ~E~ BOOKS ~ " "~ ~mm STAKING KMD . ~ ' ~ /~e ~TINO, 3~ / AC~'mm FILE ~ No.: 10-154 / ' AK. 99577-~1 WASTEWATER DISPnSAL SYSTEM :DETAILS VALLI YUE F-STATES :1:1:2, BLEICK 3, LF1T 39 / × \ / \ / -x..,.<× \ ~ / I ,/ / ~-~ iF ........ // // ~ /, ~~ L_~_,~_-- i I I FLAG PROPERTY LINES ~ EASEMENT S PRIOR TO CONSTRUCTION PREPARED FDR: RUgSELL & JDY KUCINSKI 10231 LONE TREE DRIVE ANCHORAGE, AK 99507 FIELD BOOKS DR~V~: BMW BOU.O,mY: BOUNDAR'~ ST~NG: STAKING C~£C~ED: KMD ASaU,LT: JLS o^~ 09/13/2010 DWi. F~Le G~ID: 2558 ^c~ MM FILE NO.: 10-154- / / / / / / // / / / / I / II / / / I / / i I i I i ! ! ScaLe: 1"= 100' PAGE P DF P ~ :ai~~ ~ ©ONSULTING, IN(3 :'x. ~ ~..- '~f 212 E. 51st Ave, Anchorage, AK 9950J ' ~,7~ ~ ,*~./Office (907) 868-3791, Fax (907) 868-3793 SOILS PERCOLATION TEST Performed for: RUSSELL KUCINSKI Date Performed: Project: VALLI VUE ESTATES NO. 2 LOT 39, BLOCK 3 2- 3. 4. 5- 6- 7- 11- 12- 13- 14- 15- 16- TEST HOLE # TH 10-1 Org/OL SP/GP mod dense-consolidated sand increasing w/depth w/cobbles to 6"+ SM/GM SW -perc rate at < 1 min /" Depth (Feet) 18. B.O.H. 19- HOLE PRESOAKED 20- PRIOR TO TEST SEE ATTACHED SITE PLAN FOR HOLE LOCATION Was Ground water encountered? NO Depth to water after monitoring? NO What depth? NA Date? 9/9/2010 Reading Date Gross Net Depth to Net Time Time Water Drop 1 9/9/10 1:00 - 6,, _ 2 1:10 10min 2" 4" 3 * 1:11 - 6" 4 1:21 10 min 2 2/16" 3 14/16" 5 * 1:22 6" 6 1:32 10 min 2 3/16" 3 13/16" 7 * 1:33 6" 8 1:43 10 min 2 4/16" 3 12/16" 9 * 1:44 6" 10 1:54 10 min 2 3/16" 3 13/16" 11 * 1:55 6" _ 12 2:05 10 min 2 4/16" 3 12/16" · Water Added Percolation Rate 2.7 (min/in) Perc Hole Diameter 6" Test Run Between 4 feet and 5 feet I, Kenneth M. Duffus, certify that this test was performed in accordance with all State and Municipal guidelines in effect on this date. GREAiER ANCHORAGE AREA BORuJGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE ~OWb,nx ~ FROM WELl_ · MANUFACTURER ~ MATERIAL INSIDE LENGTH NUMBER OF COMPARTMENTS INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY ¢,'~0,~ GALLONS. TILE DRAIN FIELD:~~- DISTANCE FROM WELL FOUNDATION. NUMBER OF LINES ABSORPTION AREA DEPTH: TOP OF TILE TO FINISH GRADE TOTAL LENGTH NEAREST LOT LINE OF LINES ~ DISTANCE BETWEEN LINES TRENCH WIDTH ~IN. TOTAL EFFECTIVE ~' SQ. FT. LENGTH OF EACH LINE DEPTH OF FILTER MATERIAL BENEATH TILE__ IN. ABOVE TILE IN. WELL: TYPE _ BUILDING FOUNDATION CESSPOOL APPROVED. CONSTRUCTION NEAREST LOT LINE_ NEAREST , SEWER LINE__ OTHER SOURCES DISAPPROVED REMARKS DEPTH SEPTIC SEEPAGE ., TANK SYSTEM _ DISTANCE FROM: DISTANCES: DIAGRAM OF SYSTEM INSTALLED By:C~ ~ SEWER LINE DEPTH: PIPE MATERIAL: LOT SLOPE: REMARKS: G.A.A.B. Form LQ-032 F'ERHIT NO. DEPARTHENT uF HEALTH AND EN'v'IRONNENTRL p'ROTECTION 25±6 E. TUDOR R[:'.., ANCHORFIGE., RK'.. 9'_-35t37 276-222i 76780 ) FFLI CHN [ LOCAT I ON L. EFiAL T I I"IBER ENTERPR.I SE~ LONE TREE B,R L39 B-~. VALLI ',,,'LIE LOT SIZE ~:49-'1922 ~.6,_,1-:. SCgJRRE FEET '--I RBSORBTION .=,%=,TEM I:,. TF. EN_.H T'¢PE OF :,LIL ':: "- "-' ' " FT,- E~..- i~.- f,IR:,::It,'II_II','t NUME, ER OF BE[:,ROONS = 3. =,uIL RRTING (SQ - "';" .... 'THE REQUIRE[:' SIZE OF THE SOIL RBSORPTION S'¢STEN IS: TAE LENGTH DIHENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR [:,RRINFIELD. THE DEPTH OF ~ TRENCH OR PIT IS THE DISTRNCE BETHEEN THE SURFACE OF THE GROUND RN[:, THE BOTTON OF THE ENCRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE NININUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTON OF 'THE EXCRVRTION (IN FEET::,. F;Ei;~U I ~:ED, SEF"T I C: T 8RCKFtLLING OF RN9 SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL E:'T' TNIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUH [:,ISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL S'¢STEI"t IS $E~E~ FEET FOR R PRIVRTE HELL OR 288 FEET FOR. R PUBLIC WELL SF'ECiFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSUR. E PROPER I NSTRLLRT I ON. F"ED:D'I I 'T "./RL Z [:" F-CiE: I t: FORTH B'¢ THE MUNICIPRL. IT'¢ OF RNCHORRGE. 2: I WILL INSTRLL THE S"r'STEN IN RCCOR[:'RNCE NITH THE CODE":;. ]:: I UNDERSTRND THRT ]'HE ON-SITE SEWER S"r'STEN MR"? REC!UIRE ENL. RRGEMENT RESIDENCE IS REMODELED TO INCLUDE MORE THRN 2: BE[:,ROOMS. ---- RPF'LIC~NT TIMBER ENTERF'R YSES /-/ CERTIF"r' THRT " - _,EWER.:-, RND WELLS RS; _,El I RM FRMILIRF-'. WITH THE REQUIRENENTS FOF.: UN---,ITE ~' '"- '::'" I F THE 2516 K, ii udor Rgad Anchorage, Alaska 99507 276-2221 8() L~ 1,0(; PIClCOI,ATION Performed for __Timber E_n%.orprises .... This form reports: Soilslog ~ .... - ........ %-~EbiTFi5ii'-E~st ............. Depth Feet ] Topsoil 2 - sw (89) 3 - sw (87) 4 ~ sw (85) 5 - sw (as) 6 - SW (85) 7 - sw (8~) 8 - sw (85) 9 - SW (I25) ]0 - sw (z25) ]] - sw 12 - 13 - 14 - FI att Was 9round wa~er encountered? If yes. at what depth? Reading Date Gross Time Het Time Ueptn to Wat. r Net Urop Pefco] a[ion role m~nu[e. - 'Proposed ins tal 1 ai~? '~qe Pi t Dra i,, Fie Id COHf IEh I'S: ......................... I::Q 0,10 ((;/7,1)~5~fi~rd 'A.' DF~Sfi- 'P.E. ~£c-h-~-r~--A-j-~'a~fi'-P.T. ............. ca L- 0 - CL Q Q Q U N En >+ CO rN V J C 0 O a� U W U ti O 0') LO C7 ~ Y J Q Ch N J co m O N � � U W Q H � Q 0 W U) W W O� W f— ::) W J 0 J -J N C] O Q � U � U)) J U) T Q Jx W Q U w F- 0- 2 0_ U) C: yO L a) Q 0 Q c Q) 7 U C`') 0 a) 0 a CL M U) a) c O Q) 00 A Le, I ^� i f OO o`` 0 CL 0 U) m a v CL ' 3 (n O E 0 O s ~ p v N U O .N H C d C m _ O 'U) 0 0 C Q. +O+ C N _L .2 '_ O E 0 (on O .0 _ Q Cl): c O ° N 0 O 3 as E a •u, N > OM C CL Qi m C O " Q CL E0 CL CD W Q to >, CO U? O 4- OO �; v 0 N d 0 CD E°0. CL O 0 C - A s, ' Lo- N O O O ai L O C .0 U H E m N O s a N d L CL L O s _ a To rn (3) ^� I _ I SF IZT t'MJ 0 0 CY) d7 N � oo A Z O � � N CO O LO LL Z O J Q Q UJ Z w a 0- T - m M O J M U O m N it U) LU Q W W W ~ Z) W - O J J J _ > `') N C O o U N N N m -o c� rn � U) a) N = 0 O U U .i a) C O ca �I A 0 a) 0 0 Q U O 0 v J C U a a 0 U _U m Q C L ) 4) O N V/ (0 m O m >, CV d U CL :b_ L ❑ (Q •5 O O CY) E U O 3 O E O Q U o U (A - U)._. C N El O (D C O E LlQ. � rnCD d U u) ❑ ❑ U O a) L� r V > M m ❑ L a '^ V/^` Ca/�) W U) 0 El ^, L (D o w _ m > w > 0 ❑ EI- - m a /CN m J ❑ L �_ ❑ O I 0.0 M >_ cA O N s a_a O i m ;� O ❑■ ❑ Elcan d y c 0 ❑ w J ❑ IL w w ❑ -a N Q 46 (n c CO ca -i a) d w wa) ■❑ w N v w H w ~N U Z o Q O ° � co C � a) O LL O H cn w W U O a >, a a a cn L O CO > a) M co Q Q > N M L6 (6> W m .� 0 a) 0 0 Q U O 0 v J C U a a 0 U COSA Checklist_June 2022 COSA Checklist Legal Description: Parcel ID: 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 Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade 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 Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: 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’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ 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’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ 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 Phone Engineer’s Printed Name Date C&M ENGINEERING CHARLES BALZARINI, PE 8/16/24 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-341-29 GENERAL INFORMATION Complete legal description Location (site address) Expiration Date: VALLI VUE ESTATES #2 BLOCK 3f LOT 39 10231 LONE TREE DRIVE ANCHORAGE, AK 99507 Current Property owner(s) RUSSEL & JOY KUCINSKI Day phone Mailing address 10231 LONE TREE DRIVE ANCHORAGE, AK 99507 Lending agency Mailing address Day phone 2. NUMBER OF BEDROOMS: ._3. ~PE OF wATER SUPPLY: Individual Well IndividUal water Storage community ClaSs A_.. Well public .Water System Real Estate Agent RAY DAHL Day phone 257-0429 Mailing Address 110 WEST 38TM AVE., #100, ANCHORAGE, AK 99503 Unless otherwise requested, OOSA will be held by DSD for pickup. 3 TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding Tank [] Community On-site [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3792 Address 20z141 PTARMIGAN BLVD./EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 10/25/2010 Engineer's Comments: This investigation was completed in com pliance with ADEC and MOA regulations. The asSessment Of the condition of.the well and :sePtic applies only to the conditions as of the day t~sted. 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. DSD SIGNATURE ~'"' Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X [ STEWAT : f Arsenic Adviso Maintenance Agreements Supplemental Engineer's Repod Other By: (Rev. 11/05) Original Certificate Date: ~- / $ '~ / / Municipality of Anchorage Development Services Department Building SafetY Division On-Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 wwvv. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: VALLI VUE ESTATES #2 BLOCK 3, LOT 39 A. WELL DATA Well type PUBLIC - 'A' Date completed Total depth ft. If A, B, or C provide PWSID # 210605 Well Log (Y/N) Sanitary seal (Y/N) Cased to __ff. FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform colonies/100mL Nitrate Arsenic: mg/I Date of sample: B. SEPTIC/HOLDING TANK DATA g.p.m. mg/L Other bacteria Collected by: Parcel ID: 015-341-29 Wires properly protected (Y/N) Casing height (above ground) in. AT INSPECTION g.p.m. colonies/100 mL Tank Type/Material Septic/Steel Date installed 10/05/2010 Tank size 1000 gal. Number of Compartments _2 Cleanouts (Y/N) _Y_ Foundation cleanout (Y/N) _Y Depression over tank (Y/N) __N High water alarm (Y/N) N Date of pumping NA- NEWTANK Pumper ABSORPTION FIELD DATA Date installed 10/05/2010 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.13 Length 37 ft. Width 3 ft. Eft. absorption area 407 fie __ System type Deep Trench Gravel below pipe 7.5 ft. Total depth 14.41 ft. (Measured 10/07/10) Monitoring tube Y Depression over field N Date of adequacy test NA - New Tank Fluid depth in absorption field before test Elapsed Time: min. Final fluid depth in. Results (Pass/Fail) Pass Water added__ gal. in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) _If yes, give date __ For ~ bedrooms New depth in. g.p.d. D. LIFT STATION Date installed Size in gallons "Pump on" level at __in. "Pump off' level at __in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer/septic service line Animal containment areas Manhole/Access (Y/N) High water alarm level at in. Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5% Water main !0'+ Wells on adjacent lots 200'+ Absorption field 5% Surface water 100% Water main 10'+ Driveway, parking/vehicle .storage Wells on adjacent lots 200'+ Property line 5% Water service line 1-0'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 1-0'+ Water Service line 1_0'+ Surface water 1-00'+ Curtain drain 50'+ (None Known) COMMENTS 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 KENNETH M. DUFFUS Date 10/25/2010 Date of Payment ~/~ / Ii Receipt Number O~ ~ ~., Waiver Fee $ Date of Payment Receipt Number (Rev. 11/05) LOT 40 LOT 58 COVERED ENTRY CONC D/W COVERED._/''/ ENTRY SEPTIC · VENTS (TYP) 10· 55"g DECK 'X35' EXISTING HOUSE 5'2. 2'x13' CANT DECK LOT 59 BLK 3 2g.5' I ANCHORAGE RECORDING DISTRICT ASBUILT OF: VALLI VUE ESTATES UNIT NO 2 LOT 39 BLOCK 3 PLAT 77-296 SURVEY CERTIFICATION: I, John L. Schuller, have conducted a physical survey of this property as shown on this drawing and that the improvements situated thereon are within the property lines and no enchroachments exist other that noted. EXCLUSION NOTES: It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. Under no circumstance should any information on this drawing be used for construction of fences, structures, improvements, or for establishing boundary lines. WORK ORDER NUMBER: [DATE: [SCALE: IE-MAIL: IOCT 7, 2010 I 1"=50' I I I o.s 12sss I 100354 ~= FND ALUMINUM MONUMENT t~) = FND 518" REBAR ~,a [~L LAN/) 1831 Talkee[na Street Anchorage, Alaska 99508 (907) 227-1455 office (90?) 274-4992 fax 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAPllLY DWELLING Parcel I.D. 01 5-54-1 -29 1. GENERAL INFORMATION Expiration Date: Complete legal description Location (site address or directions) Current Property owner(s) Mailing address Lending agency MaiIing address Real Estate Agent Mailing address 10231 TERRY OSBACK 10231 LONE TREE VALLi VUE SUBDIVISION #2; LOT 39, BLOCK 5 LONE TREE DRIVE * ANCHORAGE, AK Day phone 258-5782 DRIVE * ANCHORAGE, AK Day phone ALAN JONES w/ REAL ESTATE STORE Dayphone 823 W 53rd AVE * ANCHORAGE, AK 99518 561-4-944- Unless otherwise requested, HAA will be held by DSD fer pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well [] Individual On-site [] Individual Water Storage [] Individual Holding tank [] Community Class "A" 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 $ to closing for the engineering services provided. STATEMENT OF INSPECTION BY ENGINEER at, or prior 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 ali 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. Date Engineer's Comments: In conducting this evaluation, AKW~VC, 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 afl wefts and septic systems depend on the local softs condition, groundwater levels that may fluctuate during the year, and the water usage of the ramify being served by the system. These conditions are outside the control of the evatuator 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. AKWWC, /nc. can therefore not provide any warranty orfuture estimate dhow 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. 3,37--6179 t DSD SIGNATURE Approved for Disapproved. Conditional approval for Attachments: HAA Checklist Septic System Advisory Well Flow Advisory bedrooms. bedrooms, with the fllowing stipulations: Manitenance Agreements Supplemental Engineer's Reo~ Other (Rev. 12/011 Original Certificate Date: 'in. __ 5edf0,oms '68.5')in.: g.p;d., ive..da~e, ...,.:,~ .~: .... D..- LIFT STATION Date installed "Pump on'! 'level' at Datum SEPARATION DISTANCES C~ycle.s'..teste~ .:...:~- i' ' ·. .,-, Meets.a arm & circuit requirements? in. SEPARATION DISTANCES PROM WELL ON.LOT TO: Septic.tank/lift station on lot AISso~ptio'h field on lot Public sewer main Se~ef/e;~t. lc sed/ide line' On adjacent lots :(~n. A~ijA'c:~fit-lots '" ..... Public sewer ma'nhole/cleanout 'SEPAI~,'~IO~'.'b:J~TAI~C'E~ ~R~"'~.'~PTIC/HOEDIN~:.TANk ON'.~o'T':TO: Building ¥oun~f~;tion 5'+' ' Property line' -.5'+' Absorption field Water main 10'.+ "Water §ervice line :,~'~'~0'-I; ' S'u*rf~ce water 1.00'+ Wells on adjacent lots' 2'00'+., SEPARATION DI'STANCEFROM ABSORPTION FIELD ON LOT TO: ' Property line' I'O'-F ' Water .service line -10!'+ Curtain dr~iri 'NON'E;"'K:N~O~'I~I.:. 'COMMENTS"' "Bbildiog foundation .10'+-:'- Water main -1'0':{- ' Surface water 1QO'+ DrivewaY', p~io~iv'eh'iC'ie'sto~:~e:'' "/I 0'+ Well~fon'..~i~jacent lots. 2'O'd'~' ' ' *H20.'LINE" was PROFESSIONALLY LOCATED. AND THE'.' SEPARATION...DISTANCE.., VERIFIED G: EN'~INE ER'S'C ER'~=[~ic~TI6N /.certify that./...have.., determined through.field inspections and .... re~ie~.OfMbfiiSip~7.~b.~o?d's'.~h~'t th&.ab!~'v~ ~ybtb~S:b;"e':ih" conformance with 'MOA;HAA g~idelines in effebt' on'this date, Engineer's Printed. Name J'EFERE~.: 'A;.,:, GARNESS. ... Date' ~' payment l~-:J~.~: 0:~' Date el'Payment'"' ....... .' 7..-' Receipt Number'"" Z~'~i~'':' '':'''';:''':j ' :'l~c~',~i~'"':'~'"' ' ' ' ..... (Rev 1.2/0:1) . . . :. '~. ? = · :. :.. f .: .?.'.'.,~ ' .'~~> -... .... ~ · LAND 440 WE.ST ,EN(~I~mEERS AS--BUiLT OF: I.~(;AL'O£SCr~IPtlON: i~) ~,~s2,, LOT 39, BLOCK ,3 · ,~,~,~6 VALLI VUE ESTATES UNIT NO. 2' , ..... ~.. .:.. .. :.~. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HU MAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description tot 3 ~ Location (site address or directions) ~0~' 3 ! Lo~,,C ~E DRAY[ ,~ -' 6~,ne'r:~-~Y~ 5TOc~/~[ Dayphone ~ ~ ~-~ ~ rope~y ,.. Mailing address '1~'0 ~ 3 I L~ 7A6~ ~,v~ ~ ~z~o~ ~ ~1~ Lending agency Day phone Mailing address Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: -~ ~'' TYPE OF WATER SUPPLY: Individual well Community well X Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. '- ' TYPE OF WASTEWATER DISPOSAL: Individual on-site 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. 72~25 ,Rev. 1/91) Front MOA#21 STATEiV1ENT OF INSPECTION BY ENGINEE[:L As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Hea~th Authority Approva~ 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 heroin. I further verify th~qt based on the information obtained from th~ M~ r~k:.ipality of Anch~'~'~:~t.~e files ~nd from my inves:.igation and inspection, the on-site water suppi.,, and/or w~r~tewate~ ,.,;~posal syste¢~ is in comp;i;~nce with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. S & 5 ENGINEERING Name of Firm i/03zl~-.'~jte R i¥ urt;m:~E f,.. ~ ,'.~ ,,. 204 Phone ~q ~/ -~-e '7 q Address Eagle Eiver~ Alaska ~29572' Engineer's signature ~ Date ~-//I ~/ / ¢/7 ,SIGNATURE Disapproved. Conditional approval for bedrooms. RQBERT C. CE-8801 bedrooms, with the following stipulations: Additional Comments By: · -'- Tht..' Municipality ~f Anchorage Department of Flealth and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent profe~ional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's 72~.5(Rev, 1/91) Back MOA~'21 MUNICIPALITY OF ANCJ-IORAGI~ ENVI~'ONMENTAL SEi~vICES DIVISION Municipality of Anchorage hP~ 1 4 19~ DEPARTBENT OF HEALTH & HUBAN SERVICES Environmental Semites Division · R EC E I Vi 825 L Street, Room 502 * Anchorage, Alaska 99501 (907) 848-4744 Health Authority Approval Checklist Legal Description: LO 7' ~ BL~ ,,~ V,~-{ Vu~_~ ~ ;3 Parcel I.D.: (3 A. WELL DATA Well type ¢ A If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well production WATER SAM PL~~TS: Coliform ~ Nitrate D~o~ sample: B. ~'~HOLDING TANK DATA Date installed Ii / O/'7 ~ Tank size ~ 0 o O C= Date completed Cased to ~ht (above ground) ,,,,~Wires properly protected (Y/N) FROM WELL ~ g.p.m. Collected by: AT INSPECTION bedrooms Other bacteria Number of Compartments .__ Foundation cleanout ~N) ¥~- $' Depression (YA~ ,~' o Dateof~P~mping '7 /~ i 'J ~ (o Pumper I ABSbRPTION FIELD DATA ;'. Date installed Ii / <~ / 7'C 'i, Soilrating (g.p.d./ft2o~ I;;L~- Systemtype Length 3 ~/ Width -I~ Gravel thickness below pipe ~o / ' Total depth Effective absorption area ~/:~ ~' F~ Monitoring Tube present {~/N). ¥ ~ ~'' Depression over field (Y,(~ Date of adequacy test ~//° / °~7 aesult~Fail) /)~- ~' ~ For Fluid depth in absorption field before test (in.); ~' ~ & /' Immediately after(~ ~gal. water added (in.): Fluid depth ,~' ~ ~/';~ (ins) Minutes later: 7 ;;I. Absorption rate = ~ ~o -f- .g.p.d. ~ C eanouts {~N). High water a arm (Y/~. /v O /c ,~w~' If yes, give d~t~ '-- Peroxide treatment (past 12 months) (Y/N) ~"~'~¢ 72-026 (Rev. 3/96)~* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons "Pump on" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot ~ewer manhole/cleanout Public sewer main Se~~ Lift station SEPARATION DISTANCES FROM~T?T~HOLDING TANK ON LOTTO: ~ d- Absorption field ? Foundation 7 Property line ~' ~' / Water main/service line /o '4- Surface wateddrainage / o o -h Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Properly line Surface water Curtain drain Building foundation ] 0 '¢- Water main/service line Driveway. parking/vehicle storage area ~o ~,~ ,,.' Wells on adjacent lots 9. o o "/- ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records t~h~C~ {~v,~{~ms are in conformance with MOA HAA guidelines in effect on this date g Engineer's Name /v0~.~ ~. C ~,,.~ Date ~''~/ff/ HAA Fee $ '~ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPAUT¥ OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (includ~ lot,, block, subdivision, section, to~'nship, range) Location [address or directions) (c) Business Applicant Address Applicant is {check one): Lending nstitution []; Owner/builder [~; Buyer []; Other [] (explain); . Address ;~ ~-O ~. -.~-+ ~"J~.'~ (e) Real Estate Company and Agent /~//~' Address Telephone Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDE~I~4'E Single-Family [1~ Multi-Family [] Other Number of 3edrooms 3. WATER SUPPLY Individual Well [] Community [~Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Onsite[~ P~blic [] Community Note: If community'we[I system, must have written confirmation from the State Depadment of Environmental Conse~ation '. 5.~ ENG NEERING FIRM pReY DING INSPECTIONS,TESTS, F.L,,E.$E~RCH ,DAT~.AN,.D !~E~RM.,ATI~N , ~: .;. ~ 'i~ =As certified by my seal affixed hereto and as of the validation da!e shown belov~, I verdy that my ~nveshgabop of th~s Health i :Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate 'for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection.. ~I NameofFirm (~.~''[-D'J~N''~]' Q-~(I-~d/'~-~ · Telephone Engineer's Seal DHEP APPROVAL . Approved for 7"~/~_ Condition~i. Approved ~,~ Disapprovea Terms of Conditionm Approval CAUTION The Muncipality of Anchorage Department of Health and ~nvironmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to setisty certain federel and state requirements. Employees of DHEP 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, Page 2 of 2 72-025 [11/84) "~ MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE (MOA) DEPT. OF HEALTH & ENVIRONMENTAL PROTECTIOh HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 i ~; 1 0 1986! 264-4720 WELL DATA Well Classification If A, B, C, D.E.C. Approved {Y/N) / Well Log Present (Y/N) Date Completed Yield Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Welh To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date t Comments SEPTIC/HOLDING TANK DATA Datelnstalled JI/~/?(~'X- Size Standpipes (Y/N) ~"~'~ .lAir-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /¥/~ Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line IOdO No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) .~Or To Building Foundation /~1 To Disposal Field /(~ ! T° Woato~rr sMeai n/S e~C2/~ n e Comments To Stream, Pond, Lake, or Major Drainage Page I of 2 72-026{11/84) ABSORPTION FIELD DATA Soils Rating in Absorp, tior) Strata Date Installed ////¢/~7~'~ Width of Field .4/f ~ Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ,~0 I ..~ TO Building Foundation /~" Lot To Water Main/Service Line Type of System Design Length of Field Depth of Field Gravel Bed Thickness ~zc-cZ,- --/¢~.~--~j.S, tandpipes Present (Y/N) Date of Last Adequacy Test To Stream/Pond/Lake/or Major Drainage Course To Property Line To Existin~ or Abandoned System on ; On Adjoining Lots '7-~ To Cutbank (if present) To Driveway, Parking Area, or Vehicle Storage Area Comments''¢¥- ~'O f~ b~lJ~ D. LIFT STATION Date Installed _( Dimensions Size in Gal. Ions ~ Manhole/Access (Y/N) "Pump On' Level at\ "Pump Of~be at~"~'~'~ ~ High Water Alarm LevelN"C~'t~a _ __ .-..----'""~Ve n t ( Y/N ) ~ Tested for '"'"'"'"'~? ~,~'¢"'~-~ Pumping Cycles during Adequacy Test..,~eets Electrical Codes (Y/N~)_~- ~-~ ~ Comments~/ ~ MOA ** Check/:~ OomFl~n~ (~ ( Receipt No. Date of Payment Amount: $ Page 2 of 2 72-o26 (~ 1/841 / ;d Bed. Coom Rating Against HAA Request ** ~ h e.~k'~, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. ~Xc''''~ ~. ..... Date , f Engineer's Seal