HomeMy WebLinkAboutSOUTHFORK NORTH BLK 2 LT 7Southfork
North
Block 2
Lot 7
#078021 -11
Meth Beg/oh
Mayor
Development Services Deportment
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650 <`
Anchorage, AK 99519-6650
wwwmwei.oro/onsite
(907) 343-7904
Pump Installation Log
Well Drilling Permit Number:
Parcel Identification Number: -
Date of Issue: 1/4.3
Legal Description
I,
sou7n j ,k Mor'ti
Block
V-
Lot
7
Property Owner Name & Address
sleeenBrunk VC
1911 Shim River
99g77
Pump Installation Date: 0 B - 20 - 07
NIA feet
Pump Intake Depth Below Top. of Well Casing:
Pump Manufacturer's Name / eeLAi71Uuse
Pump Model: It I D 88
Pump Size 4 hp Sha
LGoW IdeLL
feet
jel Pirop.
Pities Adapter Burial Depth: /tiff
Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer. IV
44
Well Disinfected Upon Com➢le�ion? 0 Yjs Yt No
Method of Disinfectio AO "*
Comments aid/ is pLowing CISfan/WAS L near 4p of sm. • leder
aAla eLre e "4 p stn OM, redid a Ye Leve"
n V- 4pf ,be iaurd heyea, A� a tempt- was rep e to �l-en j'o
St>bmetsiae pump, Bp Shallow 1ud i Jed' puny, leas ir�llkc/in OMWL S,ce,
Pump Installer tut S / ey P cyan en
/Name:
Company: Li2eF4 ei7lerprises
Melling Address: PO. Box 77/23 6
city:tac�Lt Mete- State: 4k zip: 9957?
Attention: The pump installer shall provide a pump installation log to DSD within 30 days of pump installation.
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage, A1C 99519-6650
Www. ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
V
Page of
Permit Number. SW020394
Name:
Art Clark
Address:
3111 C St.. Suite 100. Anchorage. AK 99503
Plane: Number of Bedroom:
261.7600 3
LEGAL DESCRIPTION
Lot Subdmebn:
7 SOUTHFORK NORTH
Range: Section:
Bbd
2
Township:
Well:
❑ New ❑ Upgrad
f len tcaaon (Pmts. A. B. C):
Private
aar tea V
YW:Pup Set
GPM
Front e
To
From
Total Depth: Cased to:
FL FL
Date Orated: Static Water Leve:
Ft.
I Cass» Height Above Ground:
F1. FL
SEPARATION DISTANCES
Septic Absorption
Tank Field
Wag 100'+
Surface Water 1004
La Lha 5'+
Foundabon 5'+
Calan Drain NA
Ra qU.
*none known
100'+
100'+
10'+
10'+
*501+
Lift Holding
Station Tank
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
New tank & field insulated • Old field & tank abandoned
PID Number. 078-021-11
Wastewater System: 0 New ® Upgrade
ABSORPTION FIELD
O Deep Trench ® Shallow Trench 0 Bed 0 Mound 0 Other:
Sod Rating: Tar Depth Iran orpn» grade:
1.2 GPD/Ftr 2.0
Depth to pipe bottom from original grade:
1.5 Ft.
Gravel depth beneath pipe:
0.5
Fe added above olgkw grads: Gravel Length:
1.5.2.6 +l- Ft.
Gravel wcth: Number dimes:
5 Fl. 3
Tobe eoaopoon area: Pepe Mateo»:
375 Fr D3034 & SCH40
frwWler. Dale Installed:
South Fork Const. 10/2212002
FI.
FL
75 Ft.
Distance between lines:
10 FL
TANK
® Septic ❑ Holding El S.T.E.P.
Public/Private Manulaaar
Sewer Line Anchorage Tank
Malenet:
25'+ Steel
X
Inspections performed by: KND Engineering. Inc.
UFT STATION
Su:e. Manufacturer.
1250 Gr. Orenco
'Pump on leve at. 'Pup off level at
44" n. 42"
0 Other.
Capwaty:
1250 Gs.
Number a Compamnenb:
2
High water slam, •L
M. 48"
Pup Make & Model Rectal Impectnm pMams by
Franklin 244504011• • 112HP Ed Electric
BENCH MARK
Lacaben and D.awpoon:
Door sill
In.
Assumed Llevabon.
100 FL
Engineer's Stamp
lllllllllllllllllll
Dates: 1st 10(22/2002 j >Rf • *
/.•..� ......•.. are •.�
2°° 10/2212002 J . .it d. • i
Development Services Department Approval ,��emne:n AL.Wjk
pReviewed and approved by i lit• / e c Date: l 0 ' 3f c'�2- 44J�Fee•CE7116 ���(Rei. 1200)10 .......vP,ROFESSIO .� .
Ih
' �I
A—C= 23.7'
B—C= 54.1'
A—D= 31.5'
B—D= 61.7'
A—E= 35.7'
B—E= 57.5'
A—F= 42.4'
B—F= 57.0'
A—G= 53.6'
B—G= 50.9'
A—H= NA
B—H= NA
AS—BUILT SYSTEM DETAILS/SITE PLAN Pernit SW020394
S❑UTHFORK NORTH SUBDIVISION, LOT 7, BLK 2 PID11078-021-11
EXISTING 1250
CAL S.T.E.P. TANK
• If�lT�i
IMILANOW
D
FINAL GRADE
02-1
LOT 7
1OIi1DR TUI[
C9jEj1,5)..,,e
IE1T r- I Ir•n.-....•—.—^ .IOIOIRIbIb Ik�IbIL-�
FILTER FUK\ PLATA.
250 GAL
S.T.E.P.
TANK
Iu
SCALE: NTS
•-arcs L9S i
• KENN
CE -7118 I .' Ze,
•...
sstoNn�
��i
SEWER ROCK
SCALE: 1' = 50'
vYKT
96.0 g t
ll Ir
TRENCrH 11
95.5 )1
IV \..� Nd11...11Y.ilMlY.ilY..li
zs
IOBII04 TUK
FINAL GRADE
FILTER FAwK.N.
00.2
E 1(ylIC�91C"I 4'
/I4LLATAI
VYKf
C96.10-) C96.IOy 1
SEWER ROCK I Ir
TRENCH 2
95.6 95.60
Iru�..11CjIClt]It'lIF-II.-•.I F-.IF-IIFyIFyIGIC I
25•
MONITQ TUK
FINAL GRADE
02.3
FILTER r.nK Slk$I�IF�IF�Ic�le"T�
\ /MILL1fY.
SEWER ROCK
TRENCH 3
8.7 98.7
H Ip1r7ICICICIt11.".I:"III--III--IIFYIF�ICI II --I
087.53)
PREPARED FOR:
LESS BAILEY
1635 CENTERFIELD DR STE. 103
EAGLE RIVER, AK. 99577
FIELD BOOKS tawul[u
ec"fraBr. SEWARD
SEWARD
SEWARD
DC KO:
4E -A° FILE 01109.DWC
STNIMG
ASBDILT:
p ATM: VBG
pKOKEDt. KMD 20441 PTARMIGAN BLVD.
DLR: 10/29/02 EAGLE RIVER. AK 99577-8736
t
I Ir
SCALE: NTS
END ENGINEERING
ID.
'D13 "": 01109 (907)698-8111/FAX (907)898-8111
Sent By: South Fork Construction;
694 1122;
Oct -31-02 11:30AM; Page 1/1
SOUTH FORK CONSTRUCIOli
P.O. BOX 770567
EAGLE RIVER, ALASKA 99577
(907) 694-4351 FAX (907) 694.1122
October 29, 2002
Re: Electrical connection - septic lift station
Lot 7 Block 2 South Fork North
South River Drive
To Whom It May Concern:
1
1
J
On. October 29, 2002, the electrical portion of th
septic lift station installation on the above ref enced
property was performed by Dan Janke of Souti Fork
Construction, and inspected by Duane Bruns Df Ed' .Electric.
Please call if you have further questions.
Sincerely,
Dan Jan
South Fork Construction
1
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ONSITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Permit Number: SW020394
Legal Description: SOUTHFORK NORTH BLK 2 LT 7
Design Engineer: 0070 KND Engineering
Owner Name: Art Clark
Owner Address: 3111 C St. Suite 100
Anchorage , AK 99503-0000
icyzz•@/I°-'
Date Issued: Oct 08, 2002
Expiration Date: Oct 08, 2003
Parcel ID: 078-021-11
Site Address: 001911 SOUTH RIVER DR
Lot Size: 61998 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
E Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ 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 ).
g, 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.
Received By�..i!�rt
Issued By:
Date:
Date:
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 SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 078-021-11 Permit Number SW
Property owner(s) Art Clark Day phone
Mailing address (1) 3111 C St. Suite 100, Anchorage, AK 99503
Zip Code
Legal description (Lot, Block & Sub d.) South Fork North, Lot 7, Block 2
Legal description (Section, Township & Range)
Mailing address (2)
Lot Size 61,998
Acres/Sq.Ft. Number of Bedrooms 3
THIS APPLICATION IS FOR:
Sewer Only 0 Well Only
Sewer and Well 0 Water Storage
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub 0 Jacuzzi
Swimming Pool 0 Water Softening Unit
Therapy Pool 0
O
..
••rar•
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.
(Signatile of property owner or authorized agent)
Permit Fees: Waiver Fees:
Date of Payment: l0/3/17, Date of Payment:
Receipt Number: 024:2C Receipt Number:
(Rev. 12/00)
I[CND ENGINEERING
20441 PTARMIGAN BLVD.
l)
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
October 3, 2002
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Septic Upgrade - South Fork North, Block 2, Lot 7
Gentlemen:
The owner has requested we proceed forward to obtain a septic permit to upgrade and
replace the subject property's existing septic system, which has been identified as in
failure. On September 25, 2002 one testhole was performed for the proposed system.
The results of this test are attached. The general slope of this lot is from east to west at a
grade of approximately 5-15%.
We have designed our system utilizing the existing testhole that was excavated for the
existing 3 -bedroom house. The lot is served by an individual well, located on the north
central portion of the lot. We propose to install three 5' wide shallow trenches. Water
was not encountered during the excavation, but at monitoring groundwater was
measured at 7.5'.
There are no public or private wells within 200' of our proposed system location except
as noted. 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 696-6111/FAX 696-8111.
Respectfully submitted,
3(i\ID Engineering, Inc.
Kenneth M. Duffus, P.
Attachments: On -Site Well and Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
WELL & WASTEWATER DISPOSAL SYSTEM DETAILS/SITE PLAN
SOUTHFORK NORTH SUBDIVISION, LOT 7, BLK 2
NO PUBLIC VCLLS VITHIM 2W Dr
PROPOSED SYSTEM
PC PRIVATE VEILS WITHIN CBD• K
PROPOSED SYSTEM EXCEPT AS ACTED.
PC SEPTIC SYSTEMS WITHIN tar Or
PROPOSED WELL EXCEPT AS NOTED
Aur ``C' ▪ O▪ F, Az 1
*.4 TH t
I• KENN DUF - .01
t •• CE -7118 .' •�� x
11`,x...' .....•'. 'i
0
DESIGN DETAILS
3 BDRM X 150 GPD = 450 GPD
450 GPD/1.2 GPD PER SO. FT. (2.13 MIN/IN.)= 375 S0. FT
(375/5'(W)) (0.5' GRAVEL) = 75 FT. TRENCH
USE 3 TRENCHES - 25 (L) X 5' (W) X 0.5'(D)
Total depth of system is 2.0' Fron original grade.
Total depth of gravel below distribution pipe is 0.5' .
PRESSURIZED SYSTEM DESIGN DETAILS
1. RESIDUAL HEAD = 5'
2. HOLE SIZE = 3/16' = 1.00 GAL. PER HOLE e 30 PSI
3. 30 GALS (PUMP DELIVERY)/1.00 GALS./HOLE = 30 HOLES
4. 75 LF LATERAL/30 HOLES = 2.5' SPACING PER HOLE
5. ALL HOLES SHALL HAVE CAPS INSTALLED PER MANUFACTURES SPECS.
NOTES:
1. USE 1250 GAL S.T.E.P. TANK, INSULATE IF <4' OF COVER.
2. INSULATE TRENCHES WITH 2' HD BURIAL FOAM.
3. CONTRACTOR VILL ENSURE MINIMUM 2% SLOPE INTO SEPTIC TANK.
4. ADDITIONAL FILL VILL BE ADDED OVER SYSTEM TO ACHIEVE
MIN. 3' COVER IF REQUIRED.
5. CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT
WELLS, SEPTICS, LOT LINES, FOUNDATIONS AND ALL OTHER SETBACKS.
5. SURVEYOR MUST FLAG PROPERTY LINE AND MARK WELL RADIUS.
PREPARED FOR:
LESS BAILEY
1635 CENTERFIELD DR SK. 103
EAGLE RIVER, AK. 99577
FIELD BOOKS cawuao:
DRAWL VBG
OCKCO MAD
.sa,ILT: SEWARD BATE: 10/3/02
a"B: SW1059
AGAR war. 01109.OWG ''DB "P' 01109
"scum SEWARD
sT„MNG
DPC. Alt:
Scale: 1'= 100'
�q}PAGE 1 OF 2
MID ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
. , 1 . V V 1 .. . V
KND
WASTEWATER DISPOSAL SYSTEM DETAILS
SOUTHFORK NORTH SUBDIVISIDN, LOT 7, BLK 2
0 0 0
PROPOSED
GAL S.T
250
TANK
ARY SYSTEM
\2
11'
ArakC)°F 440
A •
T"7 1.
KENNETH M. DV
CE -7118
{
-' FESStONt•-
11'
PREPARED FOR:
LESS BAILEY
1635 CENTERFIELD DR SK. 103
EAGLE RIVER, AK. 99577
FIELD BOOKS
"a"c"n SEWARD
su"+m:
"ma?: SEWARD
DC DU:
cwwrza
D""d:
acaCD:
DAR:
v8G
KMD
10/3/02
coo SW1059
"c" D "u 01109.DWC 'Ds MP' 01109
02-1
Scale: 1'= 20'
END
2 OF 2
1p�AV D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER. AK 99577-8736
(907)698-6111/FAX (907)696-8111
KND ENGINEERING, INC.
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
1
SOILS PERCOLATION TEST
Performed fon. Les Bailey
Project: South Fork North Lot 7, Block 2
Depth
(Feet)
''tif
ln< = B O H
ORG — brown, moist
604414141414111 '
I 7:4 Kenna --- ufru,
t�
�# IS% CE7116 "st
,a_
1 \`p`AOFESS\UNP+`/
Date Performed: 9/25,023'
TEST HOLE # 2002-1
SEE ATTACHED SITE PLAN
FOR HOLE LOCATION
Was Ground water encountered? NO
CM/GP — med dense, gray,
damp, w/ cobbles to 1' Depth to water after monitoring? 75
moisture increasing w/depth
11-
12-
13-
14-
15-
16-
17-
18-
19-
20 -
Reading Date Gross
Time
1 9/25/02 1:00
2 1:10
3 • 1:11
4 1:21
5 • 1:22
6 1:32
7 • L33
8 1:43
9 • 1:44
10 1:54
11 • 1:55
12 2:05
• Water Added
Net
Time
What depth? NA
Date? 10/02/02
Depth to Net
Water Drop
10 min 3"
10 min 3 1/16"
6"
10 min 3 4/16"
2 15/ 16"
212/16"
10 min 3 5/16" 2 11/16"
10 min 3 6/16" 210/16"
6"
10 min 3 5/16" 211/16"
Percolation Rate 2.13 (min/in) Perc Hole Diameter 6"
Test Run Between 15 feet and 2.5 feet
I, Kenneth M. Duffus, certify that this test was performed in accordance with all State and Municipal guidelines in
effect on this date.
MUNICIPALITY
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I. D. 078-021-11
1. GENERAL INFORMATION
Expiration Date: _L(-2-) Z I
Complete legal description SOUTHFORK NORTH BLOCK 2, LOT 7
Location (site address) 1911 SOUTH RIVER DRIVE, EAGLE RIVER, AK 99577
Current property owner(s) TREVOR J. JONES
Mailing address
Real estate agent
Day phone
1911 SOUTH RIVER DRIVE, EAGLE RIVER, AK 99577
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER
DISPOSAL:
Private Well
®
Private Septic
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.
COSA Fee $ 550 Waiver Fee $
Date of Payment ;wa Date of Payment
Receipt Number 1 13.1 Receipt Number
COSA # OSC211018 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 01/15/2021
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to r� OF Ak"'
these various and dynamic characteristics and are outside the control of the evaluator of the r •�(� `
well and septic system. Therefore, any estimate of how long a system will function satisfactory g�Q:• •• •
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting & FWr,S * . lli . •'*
6. DSD SIGNATURE r Curtis Huffman
System #1 A roved for r�� c� CE 128991
S
C' Y
Appbedrooms ��i�l��Fo .1/15/29 •�F�
System #2 Approved for bedrooms 1� PROFESSV
Disapproved
Conditional approval for bedrooms, with the following skp! (((((fry((
�� �
j= ON-SITE
WAT
,AIASTEvyATER
PROGRPM
0,0
K"\ Original Certificate Date:
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
r
Legal Description: SOUTHFORK NORTH BLOCK 2 LOT 7 Parcel ID: 078-021-11
If more than 1 septic system on lot: COSA Checklist # _of _ Structure served by this system _
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled 6/15/1984
Total depth 60 ft
Cased to 60 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 24+ in.
Date of flow test for COSA 10/5/2020
Static water level at beginning of test *0 ft.
Well production at time of test 4+ gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® No
® Coliform bacteria is Negative
Nitrate 0.545 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
S
FWfi
Collected by FRE
Date of Sample 1/13/2021
Comments *Artesian plug — appears in good working condition at time of testing.
B. TANK DATA
Age of tank(s) 19 years
Tank type/material STEP / STEEL
Measured operating fluid level in septic tank *FLOAT
® Standpipes/foundation cleanout per record drawing
Date of pumping 10/5/2020
D. ABSORPTION FIELD DATA
Which system tested (date installed) 10/22/2002
® ALL standpipes present per record drawing
Total measured depth from grade 3_8 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
C. LIFT STATION
® Required maintenance completed
Age of lift station 19 years
Lift station material STEEL
Comments: *FLOAT LEVEL 42"
Adequacy test date 10/5/2020
Results Z Pass For 3 bedrooms
Fluid depth prior to test 0 in
Water added 450 gal
New depth 3 in
Elapsed time 30 min
® Code -required soil cover over field Final fluid depth 0 in
❑ System presoaked Absorption rate 450 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test) If yes, enter date
Gallons introduced gallons
Comments/Deficiencies: Similar to 2009 adequacy test — tested upper trench (lower 2 trenches saturated).Fes-
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'
® Yes if No ft
Wells on Adjacent Lots:
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
Surface Water > 100'
® Yes
Animal Containment > 50' ® Yes
if No
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No
ft
® Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
® Yes if No ft
Property Line > 5'
® Yes if No ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes if No ft
Private Wells > 100' ® Yes if No _
Water Main > 10'
® Yes if No ft
Community Wells > 200' ® Yes if No _
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'
® Yes
if No
—ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATIONAW Lk
1 certify that / 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. TW ....':.... ..........urtis Huffman
��$ FFG/�,• CE 128991 •.0AW�
\w� pROFES SIONPti���
ft
ft
MUNUPAUTY OF ANCHORAGE
t
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Owner
Lift Station/Pump Vault
Maintenance Log
Street Address .1 t )1 S_ R \ v e.r U xw e
Septic Tank:
-Sludge level 0 inches -Pumping: required es no -Pumping completed e no
Lift station:
-Pump basket cleaned es no -Effluent filter cleaned es no
-Control floats cleaned Cel no -Proper float settings confirmed es, no
-Operation satisfactory es no
Alarm System:
-Dedicated electrical alarm circuit Kes no -Audible and visual alarm inside dwellin est no
Alarm system operation satisfacto not satisfactorV
Manhole Riser
-Ground water intrusion at riser to tank connection yes o
-Ground water intrusion around pipe penetrations yes aJ -weep hole functional est no
-Manhole lid: Functional es no Insulated es no Properly Secured CYRRL.no
Other
-,All manufacturer required inspections and maintenance completed Qes no
Comments: ..
Qualified Maintenance Provider:
Technician Lchy-c-Y W. sa+I-s' Vic— Date of maintenance)
Company k �-5 serverLP_
Signature
Date /
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
COSA # Ni 100002,
Parcel I.D. 078-021-11
1. GENERAL INFORMATION
Complete legal description SOUTHFORK NORTH BLOCK 2, LOT 7
8Rr,vr tiFSIT,t'n1
Expiration Date: 1-4/8/p
Location (site address) 1911 SOUTH RIVER DRIVE, EAGLE RIVER, AK 99577
Current Property owners) STEVEN BRUNK
Day phone
Mailing address 1911 SOUTH RIVER DRIVE, EAGLE RIVER, AK 99577
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
O Individual On-site
❑ Individual Holding Tank 0
❑ Community On-site 0
❑ Public Sewer 0
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 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 01/04/2010
Engineer's Comments: This Investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes Inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a 40,_7<c)
"Ys S
OF AI , \,
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen /4S
encroachments, deficiencies or discrepancies exist.GJ V. ' '7
, .41
5. DSD SIGNATURE
C-7- Approved for 3 bedrooms.
Disapproved.
`� 442ssioN►y
Conditional approval for bedrooms, with the following stipulations:
S 9 tJ xe,r '70 G (In Ll cwt /9n, Site
7410K Air 6f. fl J ✓ res,, / tS.
et -t- 3 11.3- 79og
. _FAke
•• o
C.; •
^ATE •;�c
ND r
•• rER
••-
1; •
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
By: c� Calc -c%
(Rev. 11/05)
-4 444
•
4 •
O .
Arsenic Advisory %)
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: 1/c%4 0
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
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: SO[TTHFORK NORTH BLOCK 2, LOT 7 Parcel ID: 078-021-11
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID # Well Log (Y/N) Y
Date completed 6-15-1984 Sanitary seal (Y/N) Y
Wires properly protected (Y/N) Y
Total depth 60 ft. Cased to 60 ft. Casing height (above ground) 24+ in.
FROM WELL LOG AT INSPECTION
Date of test 615/1984 12/15/2009
Static water level 0 ft. • 0 ft.
Well production 20
g.p.m.
3 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100mL Nitrate 0.67 mg/L Other bacteria .0 colonies/100 mL
Arsenic: _mg/I Date of sample:12/15/09 Collected by: ArcTerra
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEP/Steel Date installed 10/23/02 Tank size 1250 STEP gal.
Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
High water alarm (Y/N) Y Date of pumping 12/29/09 Pumper Roval Flush
C. ABSORPTION FIELD DATA
Date installed 10x=2/02 Soil rating (g.p.dift2 or ft2/bdrm)1.2 System type SHALLOW TRENCH
Length 75 ft.t, Width 5 ft. Gravel below pipe 0_5 ft. Total depth 4 ft. (measured 12/15/09)
•
Eff. absorption area 375 ft2 Monitoring tube Y Depression over field N
{
Date of adequacy test 12/15/09 : Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 0 " in. Water added 450 gat. New depth 5 in.
Elapsed Time: 5 min. Final fluid depth 0 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed 10/23/02 Size in gallons 1250 Manhole/Access (Y/N) Y
'Pump on level at 44 in. 'Pump off" level at 42 In. High water alarm level at 48 In.
Datum Bottom of Tank Cycles tested 2 Meets alarm & circuit requirements? Y
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 1001+ On adjacent Tots 100'+
Absorption field on lot 1001+ On adjacent Tots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 1001+
Sewer/septic service line 25'+ Holding tank 100'+
Animal containment areas 50'+
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+
Water main 10'+
Property line 51+ Absorption field 5'+
Water service line 10'+ Surface water 100'+
Wells on adjacent Tots 1001+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 10'+ Water main 10'+
Water Service line 10'+
Surface water 1001+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+ (None Known) Wells on adjacent Tots 1001+
F. COMMENTS
1
* Artesian plug at wellhead. **system is operating in the too third trench (lower two trenches saturated).
Arg›. -CF a1 , 11
I certify that I have determined through field Inspections and I' 4S tq
review of Municipal records that the above systems are in 2Lry 9 " AILS
conformance with MOA COSA guidelines In effect on this date.14
Engineer's Printed Name KENNETH M. DUFFUS �1 � 14
\ii,,b.:"."I
G. ENGINEER'S CERTIFICATION
Date 01/04/2010
COSA Fee $490.00 Waiver Fee $ I '
Date of Payment 1/14//0 Date of Payment
Receipt Number 01562(. Receipt Number
(Rev. 11/05)
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 ID. D. 078-021-11
1.
GENERAL. INFORMATION
Complete legal description SOLTTHFORK NORTH BLOCK 2, LOT 7
gRa'r oesrrc'J
cosA # 4A 100002 --
Expiration
DtXZ
Expiration Date: 1'1/07D
Location (site address) 1911 SOUTH RIVER DRIVE, EAGLE RIVER, AK 99577
Current Property owner(s) STEVEN BRUNK
Day phone
Mailing address 1911 SOUTH RIVER DRIVE, EAGLE RIVER, AK 99577
Lending agency
Mailing address
Day phone
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System0
0
Well 0
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.
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS
Phone 868-3792
Date 01/04/2010
Engineer's Comments: This investigation was completed In compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes Inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
5. DSD SIGNATURE
c -Z. Approved for 3 bedrooms.
Disapproved.
Conditional approval for
Ar
se" OF 114its, k
• • r. t,.
align
Ar
Ilkkitirtssiot03# i
bedrooms, with the following stipulations:
t Buytt- to COn la cit ,On- S"J`e ett 39-3-7goq
i10v 4rctNIc_ rest, lfs. .FAM:
..1)
: r:,;"TE
v •
;ND .
rER
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
By: per i!44M
(Rev. 11/05)
a•
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
4
Original Certificate Date: Ift1 / U
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
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: SOUTHFORK NORTH BLOCK 2, LOT 7 Parcel ID: 078-021-11
A. WELL DMA
Well type PRIVATE If A, B, or C provide PWSID # Well Log (YM) Y
Date completed 6-15-1984 Sanitary seal (Y/N)Y Wires properly protected (Y/N) Y
Total depth 60 ft. Cased to 60 ft. Casing height (above ground) 24+ In.
FROM WELL LOG AT INSPECTION
Date of test 6/15/1984 12/15/2009
Static water level 0 ft. , • 0 ft.
Well production 20 g.p.m. 3 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100mL Nitrate 0.67 mg/L Other bacteria 0 colonies/100 mL
Arsenic: _mg/l Date of sample: 12/15/09 Collected by. ArcTerra
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEP/Steel Date Installed 10/23/02 Tank size 1250 STEP gal.
Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
High water alarm (Y/N) Y Date of pumping 12/29/09 Pumper Royal Flush
C. ABSORPTION FIELD DATA
Date installed 10/27/02 Soil rating (g.p.dJft2 or ft2/bdmi)1_2 System type SHALLOW TRENCH
Length 75 ft.i •a Width 5 ft. Gravel below pipe 0.5 ft. Total depth 4 ft. (measured 12/15/09)
Eff. absorption area 375 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 12/15/09 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth In absorption field before test �" In. Water added 450 gal. New depth 5 -in.
Elapsed Time: 5 min. Final fluid depth 0 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed 10/23/02
"Pump on level at 44 in.
Datum Bottom of Tank
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+
Size In gallons 1250 Manhole/Access (Y/N) Y
'Pump off' level at 42 In. High water alarm level at 48 in.
Cycles tested 2 Meets alarm & circuit requirements? Y
On adjacent Tots 1001+
Absorption field on lot 100'+ On adjacent Tots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout
Sewer /septic service line 25'+ Holding tank 1001+
d
100'+ i
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+
Water main 10'+
Property line 5'+ Absorption field 5'+
Water service line 10'+ Surface water 1001+
Wells on adjacent Tots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+
Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water 100'+
Curtain drain 50'+ (None Known)
Driveway, parking/vehicte storage 10'+
Wells on adjacent Tots 100'+
F. COMMENTS
* Artesian plug at wellhead. **System is operating in the top third trench (lower two trenches saturated).
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are In
conformance with MOA COSA guidelines In effect on this date.
Engineer's Printed Name
Date 01/04/2010
KENNETH M. DUFFUS
COSA Fee $490.00
Date of Payment 1/q//0
Receipt Number Of 57;2— C.... -
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
lee CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 078-021-11
HAA# Hf7C7cs-y'
Expiration Date: / — 3 j - O 3
1. GENERAL INFORMATION
Complete legal description SOUTHFORK NORTH BLOCK 2. LOT 7
Location (site address or directions) 1911 SOUTH RIVER DRIVE. EAGLE RIVER. AK 99577
Current Property owner(s) ART CLARK Day phone 261-7600
Mailing address 3111 C ST. STE. 100. ANCHORAGE. AK 99503
Lending agency Day phone
Mailing address
Real Estate Agent LES BAILEY • PRUDENTIAL VISTA ER Day phone 689-6451
Mailing Address 16635 CENTERFIELD DRIVE STE. 103. EAGLE RIVER. AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
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 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 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 Health Authority Approval Guidelines for this
application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional
and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all
applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm KND ENGINEERING, INC
Address 20441 Ptarmigan Blvd., Eagle River, AK 99577
Engineer s Printed Name Kenneth M. Duffus
5. DSD SIGNATURE
Approved for 3 bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Phone (907) 696.6111
Date 10/30/02
€OFAc�11
dam; 41
of
s 4 a , \
.«..r, r ✓
O(.'\ Kenney.) .:. Ln.(f� //,t ,,14.• .4
s •\ C: 7116 LJ 4.tt
bedrooms, with the following stipulations:
`((1ii(U1f��76
1/41/4k
`c:• ON -E • �'
WATERSIIAND rn
WASTEWATER
PPnGRAM
%�� ti6FUT SEN Cr::\. `�
)/, 1))11111
Maintenance Agreements
Supplemental Engineer s Report
Other
By:/// Iti it-e--c%Original Certificate Date: / 0 - 3 I - G 2
(Rev. 01/02)
r
Municipality of Anchorage
Development Services Department
Budding Safp(ypiyision
Onsite Water & *aateWater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cianchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: SOUTHFORK NORTH BLOCK 2. LOT 7
A. WELL DATA
Well type private 11 A, B, or C provide PWSID # Welt Log (Y/N) Y
Date completed 611511984 Sanitary seal (Y/N)y_ Wires properly protected (Y/N) Y
Total depth JLft. Cased to eft. Casing height (above ground) 2'
FROM WELL LOG AT INSPECTION
Date of test 8115/1984 11/27/01
Static water level 0' ft. 3' (frozen) ft.
Well production 20 g.p.m 5+ g.p.m.
WATER SAMPLE RESULTS:
Conform gcolonies/100 ml. Nitrate 0.590 mgJt. Other bacteria a colonies/100 mi.
Arsenic: ,)jB mgJI. Date of sampte:10124/2002 Collected by: KND Engineering
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEP I STEEL Date installed 10/23102
Tank size 1250 gat. Number of Compartments Z Cleanouts (Y/N) !
Foundation cleanout (Y/N) Y_Depression over tank (YIN) LHIgh water alarm (YIN) Y
Date of pumping NA - NEW TANK Pumper
C. ABSORPTION FIELD DATA
Date installed 10/22102 Soil rating (g.p.dJf or ft2/bdrm) ,1,2 System type SHALLOW TRENCH
Length 75' 13x25) ft. Width 5 ft. Gravel below pipe 0.5 ft.
Total depth 21 ft. Eff. absorption area 375 ft2 Monitoring tube Y Depression over field N
Date of adequacy test NA -NEW SYSTEM Results (Pass/Fail) PASS For L 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.) (Y/N & type) If yes, give date
Parcel ID: 078-021.11
D. LIFT STATION
Date installed 1012312002
Pump on level at 44in.
Size in gallons 1250 Manhole/Access (Y/N) Y
Pump off levet at a_ in.High water alarm level atm in.
Datum BOTTOM OF TANK Cycles testedi. Meets alarm & cfcult requirements? Y
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/Iift station on lot 100'+
Absorption field on lot 100'.
Public sewer main 75'+
Sewer /septic service line 25'+
F.
G.
On adjacent lots 100'+
On adjacent lots 100'.
Public sewer manhole/cleanout
Holding tank 100'.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'. Property line 'l
Water main 10'+ Water service line 10'+
Wells on adjacent Tots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'.
Water Service line
Curtain drain 50'+
COMMENTS
New sanitary seal & artesian olua added b well.
ENGINEER S CERTIFICATION
Building foundation 10'.
10'+ Surface water 100'+
Wells on adjacent lots 100'+
I certify that I have determined through field inspections and
review of Municipal records that the above systems ere in
conformance with MOA HAA guidelines in effect on this date.
Engineer s Printed Name Kenneth M. Duffus
Date 10130102
HM Fee $375 + S150 Rush Fee
Date of Payment 10/30/02
Q 2.5—
Receipt Number
(Rev. 12/01)
100'.
Absorption field 5'+
Surface water 1001+
Water main 10'+
Driveway, parking/vehicle storage 25'.
Waiver Fee $
Date of Payment
Receipt Number
... .....
•N P .' Favi
'%i'efloFESSIt 4
,vl�/1�i�y�/O/�aL o�r���y� S9
,frcr'977,7 Erna✓ 7%741-
%71 - gyp__
'. , MUNICIPALITY OF ANCHORAGE
•
• � \ DEPARTMENT OF HEALTH &ENVIRONMENTAL PROTECTION
`(� ENVIRONMENTAL ENGINEERING DIVISION
\\\ 825 L Street -Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME j��!- -5_-5\l
P_H/OOrN,E c�
4=4I---251
S=` 7` 17 /
iFEW
❑ UPGRADE
-4�c:A -P— ��'�R--AI \
MAILING D RESS -
4 ESN /4 i �`-'i=g__ J NIA • 4.13 IQt (,,,'< , 2., ,4
LEGAL DESCRIPTION/ i
L -c.3- 7 SLK Z SatY JL;- J o 4114
LOCATION4 _
Ste- _ 3 £r i /3 / g i ,
NO. OF BEDROOMS
SEPTIC
TANK
DISTANCE TO:
/
Well /
/ as—
AbSorlition area /
Dwelling
30
PERMIT NO l
Cf O 6/ ?—
manufacturer
/�} ��
Maaial
No. of compartments
�[�..e-
Liq. capacity n gallons
HOMEMADE:
Inside length
Width,
Liquid depth
IF
,-._
�-'
JL.Z
Oz G
2 (-
DISTANCE TO:
Well r
Dwelling
PERMIT NO.
Manufacturer
A
Material
Liquid capacity in gallons
TILE
DRAINFIELD
TRENCH
DISTANCE TO:
Well
j
Foundation
Nearest lot line
PERMIT NO.
No. of lines
Length of each j.i 4e)
A
Total length of lines
Trench width
inches
Distance between lines
Top of tile to finish grade
Material beneath tile
inches
Total effective absorption area
SEEPAGE
PIT
Length J6 /
Width /
l c,)//,, Gs s, tQ,
Q eA io/,a6
PERMI-[�VQ./,i64,,.y
j
Type of crib
Crib diameter
Crib depth _
Total effectiveffabsorption area
4
iG,
7t
DISTANCE TO:
Well /
/�L,:
Buildin a on
g�
Nearest lot line 1
/e,
J
J
Class
EX /S'
Depth '-
Driller
Distance to lot line
PERMIT NO.
DISTANCE TO:
"'"""g f'"-�n
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
/----°r."
Wi
t
IAAF
_.fiv
INSTALLER
D&AJ GO/ ,
VV���s
�_
REMARKS
_S 5-7-6-777 /A/SCC)L,A-1-
I
r 4"..
°• 0, �#'. ",
`606
hey
as -_..:.1 4f vsn7.�
of .�-�S s of
f
-
/ /'.
%4:./
0
0-
ANCH02AGE
NI
"Who'll A. 511ufa, MUNIC.IPA_I'Y
- it,'., No. 1457-E c� DEP-.
' ' 6.-•‘ -' •,, ( ENVIRONMENTA
Dr I
CALT-I1
PROTECION.
&
.:f
aN n0>�` [AUC
3/
EIVED
R:
APPROVED aA a ; ` to atiltkk. 441tICA DAT
SPIE) 136i /10Y/
A)) l//wel
/ _'A
PH. al -nn � /3-/ ,
72-013 (Rev. 3/78)
I
PSk)
MLI1P41 I IC IF" f -A L... -1-"Y" ' C3 Fr' AI CDFAC3 FR 4-C3�-
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHQRAGE, AK 99501
264-4720
El I '7- la-. :17-3IF.�11,14EIEFR OAD IF" ��FzcU�-I-.�
PERMIT NO: 840612
DATE ISSUED: 07/24/84
APPLICANT: C/O S & S ENG'G. DEAN CONSTRUCTION
ADDRESS: SRB 196X
EAGLE RIVER, AK 09957
CONTACT PHONE: 694-2979
LEGAL l}ESCRIP: SUBDIVISION: SOUTH FORK NORTH LOT: 7
SECTION: 3/4 TOWNSHIP: 13N RANGE: 1W
LOT SIZE: 61998 (SQ.FT. OR ACRES)
MAX BEDROOMS: 3
BLOCK: 2
Listed below are the options available to you in designing your septic
system Choose the option that best fits your -site.
_
EgEEI3
DEPTH TO PIPE BOTTOM (FT.) 2.5 **
GRAVEL DEPTH (FT.) 0.5
TOTAL DEPTH (FT.) 3.0
GRAVEL WIDTH (FT.) 17.0
GRAVEL LENGTH (FT.) 34^0
GRAVEL VOLUME (CU.YDS.) 21.4
TANK SIZE (GALS) 1r000.0 **
SOIL RATING (SQ.FT./BR) 125
** DEPTH TO PIPE BOTTOM < 3.5FT. REQUIRES INSULATION
** DEPTH TO PIPE BOTTOM < 4.0 FT. MAY REQUIRE A LIFT STATION
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
I certify that:
1. I am familiar with the requirements for on-site sewers and wells as seL
forth by the Municipality of Anchorage (MOA) and the State of Alaska"
2. I will install the system in accordance with all MOA codes and •regulations,
and in compliance with the design criteria of this permit"
3° I will adhere to all MOA and State of Alaska requirements for the set back
distances from any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot"
4" I understand that this permit is valid for a maximum of 3 bedrooms and
any enlargement will require an additional permit"
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA -BUILDING CODES,'
THEN (1) AN ELECTRICA RMIT AND INSPECTION MUST BE OBTAINED; (2) AS_BUILTS
WILL NOT BE APPROV w WIT DUI ��N ELECTRICAL INSPECTION REPORT; AND (3) T����
ELECTRICAL WORK IS BE Y A LICENSED ELECTRIOIAN.
' DATE.
forA0( --''_ ���'��^�^��CO^�TRUCT-~^' � ENG'0. ���� CONSTRUCTION
�
APPL�CANT: Cmr *
SIGNED
ISSUED BY
DATE: ��
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
L 7 g
DATE PERFORMED:
s-; /' k
r SOILS LOG
SVo
❑ PERCOLATION
TEST
C) J" �c / c
WI
- PS/ /5'd7
10
11
12
13whf. Of 11
15
16
1431 -17 • r.mak,
�<"• .,,,...v rte` s4
&;FC PRli; •
18 a'a SLOPE
�;-
19
20
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SITE PLAN
NEENNEENNE
Nommoomm
Ntricroammom
Nommumumni
imimmomum
v■■■■.111■■■
yes
O
P
f2 1 E
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
/14_
PERCOLATION RATE
(minutes/inch)
�j///
TEST RUN BETWEEN / FT AND FT/-
COMMENTS X4..) N/ ri.)Q/sv %i /6Jd `J -P c_ /-
7//g/e--34
PERFORMED BY: 1063-t.
f'ewa:0U ii)VEi, ALASKA 1'5:11
I. pI1, 1594-207t)
72-008 (6/79)
CERTIFIED BY:
DATE:
ATION OF WELL
(Please complete either la, Ib or lc.)
• WATER WELL RECORD
- STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological a Geophysical Surveys
Drilling Permit No.
A.D. L. No.
la.
Borough
Anch
Subdivision
Lot
Block
Ib.l I/4 qtrs.
—ofsof —of �
Section No.
Township N 0
s❑
Range E ii
W❑
Meridian
Ic.
DISTANCE
Street Address
AND DIRECTION FROM ROAD INTERSECTIONS
Well # 4 7/`T«
and Area of Welt Location
3. OWNER OF WELL: Mr. Carl Disotell
Address: Eagle River, Ak.
2. WELL LOG
aloes
Sur4. WEL�I0DEPTH: (final)
Feet BSurface (�U
5. ATE OF C�OMPLET108N4
(j -15 —
Material Type
Top
ft.
Bottom
Soil, (Jraver
0
4 6. 0 Coble tool XL/RotaryEl Driven ❑Dug
Cravel, .boulders, silty
4
20
■ Auger ■Jetted ❑Bored ❑ Other :
clay
s�
7. llXX x� Domestic J PublicSupply❑ Industry
Gravel, silts , water
20
22 ❑ Irrigation ❑ Recharge II Commerical
Gravel, silty clay, bould-
22
57
II
Test Well • Other:
ers
8. CASING ❑ Threaded ❑ Welded
Gravel, silt, water
57
65 diem. 6 in. to 60 ft. Depth Weight 17 lbs./ft.
diem. in. to ft. Depth Stickup ft.
- -
9. FINISH OF WELL;
Type: Diameter;
Slot/Mesh Size: Length:
Set between ft. and ft.
Backfilling Grovel pack
I.
3 10, STATIC WATER LEVEL: Ar1ke sial',. 6 Y5 / 8L
u
®®
`' Date
�JO Above or ❑ Below land surface
6
°t - \' Equipment used:
lOtikl
10V: .
,� u (A� PUMPING LEVEL below land surface and YIELD
iJ
j® (\dd1DCI
it. after hrs, pumping g.p.m.
Nci
• sopiOVI
ft. atter his. pumping g.p.m.
12.GROUTING Well Grouted: ❑ Yes ❑ No
-
hlateriat: • Neat Cement ❑ Other:
13, PUMP: (if available) HP
Length of Drop Pipe ft. capacity g.p.m.
O Subm. ❑ Jet O Centrifical O Other
14. REMARKS: Artesian ; flows 5 GPM
Production of 20 GPM
16. WATER WELL CONTRACTOR'S CERTIFICATION: ❑ F • C
15. Water Temperature
_o
This well was drilled under my jurisdiction and this report Is true to the best of my knowledge and belief;
Magnuson. Drilling AA 5385
Registered Business Nome Contract License Number
Address: P.O.-Box 770504 agle River, Ak. 99577
Signed:
,,
j"''" O�000:A De: June 15, 1984
'
Form 02- WWR (11/61)
//%J
Authorized Representative
Copy Distribution: WHITE - Stote DGGS, PINK -Driller, CANARY -Customer
•°N 1D301 S9Sf1
3-g
' MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES_
Division of Environmental Services •
On -Site Services Section
.O. Box 196650 Anchorage, Alaska ..99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
017R- DV-
GENERAL
21
GENERAL INFORMATION
Complete legal description
HAA# 9t71- °Li**$:C.
Lot 7; Moak 2; South - Fon.fz NOkth SubdLvLson
Location (site address or directions)
Property owner
Mailing address
Nf(N South Cteek Wave
Eagle Riven, AK
Stan and Nona HitDay phone 696-5456
P.O. Box 140603 Anchorage,AK 99514
Lending agency Day phone
'Mailing address
Agent -
Add ress
gent
Address
Unlessotherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system. ,o`',.t 'i.'?.1,,
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewerfJ, i)1;71+'
,1,11}„1' ,
NOTE: . If community wastewater system, provide written confirmation from State 4ADE'
}
attesting to the legality and status of system
72-025 (Rev.1/91) Front MOA 7,21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.•
GI
N.�: its .– a
Name of Firm s&sENPhone �`� /7y
—YTOS2s'Eagte-River Loop Rodd No. 2O�i
Address Eagle River, Alaska 99577
Engineer's signature
Date el- /a10 0 /9 /
DHHS SIGNATURE "'"ti
'A ROBERT C. COWAN 4. „;;
ri
Y Approved for J bedrooms. is^"', CE -8801 `.
�
Disapproved. 1 ``�pr;oess�0�' '
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
A
The Municipality of:Anphorage Department of Health and Human Services (DHHS) issues Health Authority
`A
�provai bertifie.t s based only upon the representations given in paragraph 5 above by an independent
`pregsiiopal engineer registered in the State of Alaska. The DHHS does this as a courtesyto purchasers of homes
andtheir lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not •
, conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions In the professional engineer's work. ,t . l
•
�r.
%S t ff ;
FSS
Date y 28
CAUTION
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lo -r7 EN- &Ili Parcel I.D.
A. Well Data
Well type FR.-\\)kcf�- If A, B, or C, attach ADEC letter. ADEC water system number '1 IA
Log present (SON) '-( Date completed La -1 s -811 Driller P'\ c-'.- os o�
Total depth l' Cased to 1v b 1 Casing height 12»
v (
Sanitary seal (OI) 7 Wires properly protected(N) '
FROM WELL LOG AT INSPECTION tv
Date of test l., - t S - LI gl - )� -`i 40E 73 _z
co
m rnm -v
Static water level [5-1 ci / N i
Well flow 20 g.p.m. g.p.m. p o
co < z
Pump levell OK- `,i` rri -0.3D o
SEPARATION DISTANCES FROM WELL TO: vi o
D rn
Septic/holding tank on lot A ca, `'r ; On adjacent lots 1. •zo
Absorption field on lot t 0 0 � �
1 ; On adjacent lots t o a '-'4"- Public sewer main y Public sewer manhole/cleanout
Sewer service line
25 ' Petroleum tank -2_5- ' 4 --
WATER SAMPLE RESULTS:
Coliform 0 Nitrate D , 54 Other bacteria 0
Date of sample: c1-12)-`14 Collected by: `s k S 4<-.
B. SEPTIC/HOLDING TANK DATA
Date installed 43-3-S4 Tank size t b v 0
CleanoutsoN) Foundation cleanout al)
High water alarm (Ye_
Date of pumping - 1 - `'I 4-1
Compartments 7—
Depression
Depression (Y/O rt
Alarm tested (Y/N)
Pumper =O. pd o L -
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Weil(s)onlot tbnk�
To property line 1 n'
Surface water/drainage
72-026 (3193)' Front
On adjacent Tots
Absorption field
1 0 O (y
1 0c> t� Foundation
t S Water main/service line 3a
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at "Pump off" Level at
High water alarm level Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed g - 3 s
Soil rating (GPD/Ft2) 12S � I B System type
N
Length 2 e < Width 2<>' Gravel thickness l9 Total depth -51
Total absorption area 7 Lo n Cleanout present aN) / Depression over field (Y.0 r/
Date of adequacy test q - / 7 -i g Results,( fail) P,453' for 3 Bedrooms
Water level in absorption field before test s ++ After test s
Peroxide treatment (past 12 months) (W d�
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot//a"f-- On adjacent lots / Oo `
To building foundation 17/4
If yes, give date
Property line )0
To existing or abandoned system on lot
/J/4
On adjacent lots 30 / Cutbank `'-1/ Water main/service line 3c' /
Surface water /o6 / Driveway, parking/vehicle storage area I/a /
Curtain drain J L
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HM guidelines in effe ( jCis inspection.
Signature
Engineer's Name
l D C3 E-2 i C. 1, erw ii.-)
Date CO -0 6147
' lwor tmmN
4;,\ CE -8801 r`
HAA Fee $
Waiver Fee $
Date of Payment ) --Date of Payment
Receipt Number 37,/( L" % / �> Receipt Number
72-026 (3/93)' Back
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
HAA # Y71 1
Parcel I.D. # CT`19; -- n.D 1 - ( 1
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 7; Mock 2; South Fonfz Non.-th
Location (address or directions)
NHN South Riven VnLve, 7.5 H.i.2and Road
(b) Property owner AHFC # 79805
W.A.#84241
Telephone : (home) Business
Mailing Address
(c) Lending Institution Telephone
Mailing Address
(d) Real Estate Company and Agent JACK WHITE COMPANY ATTN: Ka -thy, 02m3.iead
Address 10928 Eag.2e Riven Road E#g.2e Riven, A2as(za 99577
Telephone 694-5500
(e) Mail the HAA to the following address: (or check here X( if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family CSX Number of bedrooms 3N4
3. WATER SUPPLY
Individual Well'g Community ❑ Public ❑
Note: If community, well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ®X Public ❑ Community ❑ Holding Tank 0
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88)
Page 1 of 2
Z }o 3 a6ed
>peg (89/L ,ed) SZO-ZL
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suo!sslwo JO saoaaa ao} elq!suodsaa lou si a6eaoyouy to,llledioiunW ay1 •panssi sl aleoi}ilaao a aao}aq elep az/(Ieue JO
suoi}oadsul }onpuoo lou op SHHa to sea/(oIdw_3 'slueweainbaa awls pue ieaapa} ule}aao (}sl}es of aapao ul suoilnlllsul
6ulpuai JOT pue sewoq }o saaseyoand of Aselanoo a se siyl scop SHHO ayl 'e�{sely }o els1S el -11 ul paJelsl6aa
Joeul ue leuolssa}oad luepuedepu! ue /(q anoge g gdea6eaed ul uen!6 suolleluasaadea au; uodn 'quo paseq paleoi}laao
lenoaddy,lpaoylny tmeaH sanss! (SHHa) seolnaas uewnH pue queeH }o luawlaedea a6eaoyouy }o /(llledlolunvl eq.!.
Ieuoillpuoa
/G—b/—elea 7vi
Ienoaddy leuoll!puoO to swa01
penoaddes!a x penoaddy
/.q swooape tNa)} panoaddy
'1VAOaddtl SHH(7 '9
- e-
1
'uolloadsul siyl }o alep ay1 uo loolle LAI suoneIn6aa pue 'seoueu!pao 'sapoo alels
pue Iedioiunlnl Ile yl!M eoueildwoo ul s! wals/(s resodsip aaleMa}seM ao/pue , iddns aaleM ops-uo ayl 'uoiloadsu!
pue uoi}e6llsenul /w woa} pue sail} a6eaoyouy }o /(thedlolunlnl ayl woa} paule}go uollewao}u! ayl uo paseq
ley} A}iaan Jegvn} 1 •ulaaaq paleo!pu! aanlonals }o adAl pue swooapaq }o aagwnu eql ao} evenbepe pue Ieuoiloun}
'ales s! wals/(s lesodslp aalemelseM ao/pue /iddns Jelemletila}Is-noose pue le oddV/wayl`d y11411e01-1s!q }o uolle6l}senul /�w }eyl /}laan 1 ',mpg uMoys alep uollepuen ay} } y p }}eI (q pamJeo sv
NOIlb'WHOJNI aNb' diva 1HO1:1d3S 31Id `S1S31 `SNOLLO3dSNI ON101A01:1d Wald ONIa33NION3 '9
auoydelei
2L566 31se110f'1°Ard °hien
'OZ "IN ;COU d00-1
'J11ie13BNION2 S ? S
oleo
ssaappy
waiy }o ewsN
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
\-'.``' \ms CHECKLIST - FEBRUARY 1984
' R --`1a. 1� ��®
4,'S)-•\9"
Q�343 4744
A. WELL DATA
Well Classification c6r fJC( ie- (-/i Mil ti If A, B, C, D.E.C. Approved (Y/N) 46_.
Well Log Present (Y/N) Li Date Completed Co / e4 Yield (o - 1 gem
Total Depth to 5 Cased to (20 Depth of Grouting ( 3 - 7 -q()
Static Water Level (z Pump Set At Ul(
is
Casing Height Above Ground 30 Sanitary Seal on Casing (Y/N) Li
Legal Description L 0t 7 aIOGk'2. i
�r7vlI/� (`p rf( Aior t
Electrical Wiring in Conduit (Y/N) (1 Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot (0 S ; On Adjoining Lots / 0o
To Nearest Edge of Absorption Field on Lot ( 00'
; On Adjoining Lots / 00 rf
To Nearest Public Sewer Line /J/w To Nearest Public Sewer Cleanout/Manhole 1J/!A
To Nearest Sewer Service Line on Lot .2. 5 f
Water Sample Collected by J 4y� EN)1 i n)cefii j ; Date 3 - S- q( 1
Water Sample Test Results £✓i h S�� C -± (' - a ✓'rGtc(r►v -I-) r /�/'?, . I I
c 5
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed3./_Size / 000 No. of Compartments 2 --
Standpipes (Y/N) t Air -tight Caps (Y/N) L( Foundation Cleanout (Y/N) /
Depression over Tank (Y/N) A/ Date Last Pumped 3 - 3 - �! 0
Pumping/Maintenance Contact on File (Y/N) /0/IA ; for A)Ilel
Holding Tank High -Water Alarm (Y/N) x1(lA Temporary Holding Tank Permit (Y/N) N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
(05 r
To Water -Supply Well
To Property Line
(of
To Building Foundation
To Disposal Field
30
r
(S
To Water Main/Service Line 3 0
To Stream, Pond, Lake or Major Drainage Course /404
Comments �q!C AoMPeCI y l? Ce s pool t'UmP/Nn
72-026 (Rev. 7/88) Front
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 1 2 S TA/ Type of System Design
Date Installed 9 / 84 Length of Field 3
Width of Field Depth of Field ?i
aed
Gravel Bed Thickness (9 "
Square Feet of Absortion Area [oO Statndpipes Present (Y/N)
Depression over Field (Y/N) /.) Date of Last Adequacy Test - /
Results of Last Adequacy Test > A fiSfoeforct - £ ed , oon^
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well / DO
To Property line / (r)
To Building Foundation 41 2 ' To Existing or Abandoned System on
Lot !O/ A ; On Adjoining Lots 0 `f
To Water Main/Service Line To Cutback (if present) AVIA
To Stream, Pond, Lake, or Major Drainage Course / DO f
(
To Driveway, Parking Area, or Vehicle Storage Area '-(o I
Comments /4nuSe (,)t,4G/4Ail - ..)ti Stell Pec - Sof1k cl bif (ot/'
p c -5.1 -IN ,
i
2) O
D. LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at : Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
"Check Permitted Bedroom Rating Against HAA Request*"
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effec,t4ort hecdate of this
inspection.1 {
Signed 1yth,4 Ed i k'vc Lcop Chad No, lu«
Company Eagle River, Alaska 99577
Date /2 -
MOA No. C 7= Id .- c 9
Receipt No
-�s L.)„-sS77
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION •
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
ROBERT SHAFER, P.E.
ROGER SHAFER
Manch 3 1990
Ma. Kath. Otmatead
JACK WHITE COMPANY
10928 Eagte Riven Road
Eagte Riven, ALaaka 99517
REFERENCE: Lot 7; Brock 2; South Folk North
NHN South Riven Dn.i.ve, Eagte Riven
AHFC # 79805
CIVIL ENGINEERS
(907) 694.2979
FAX 694-1211
seoiueS uewnH 8 421oeH ';der
e6e4oyauy to 41tietlforunyy
1661 L eIVW
a3AI3a3?
Dean Kathi,
At your nequeat an adequacy teat was pensonmed on the septic ayatem
setvLng the nesereneed pnopenty on Manch 1, 1990.
waxen was added to .the ayatem white water Levet meaaunement6 were taken
bnom .the mon-iton.Lng tube Located within the teaehSLeLd. From thia teat
.it was deteun.Lned .the ayatem .ca currently Sunction.Lng adequately On a
3 bedroom house. However, the system .is not guaranteed against
subsequent Sa Lute.
The septic tank was pumped on Manch 3, 1990 by JR'a Ceaapoot Pumping.
During the adequacy teat a Stow teat was pensonmed on the weft. The
water Levet was meaaung.d within the weft at 9 St. below the top os the
eaaing. A meter was connected neat the pnesautce tank and the Snow
tanned on Ott. Wet 5 m.inutea the water Levet dropped to 14 St.
where it tema.ined throughout the donation os the teat (see report
attached). From this teat we Sound the weft to cunnently produce a
minimum o4 6.6 gaLlona per minute (GPM). Th.ia Stow nate La not
guatanteed to /amain conatent, aubaequent van,iatLona can occur.
Water aamptea were taken and tested Son cot,Lsonm bacten.ia and n,itkatea.
The neautt6 were aatiasaetony.
During out site visit thele was a queatLon naiaed concerning the
eeaaa.i cation os the apparent water drainage teaveLting within the
/Load ditch along the Stott os the pnopenty.. IS th.ta water
e2asaii ied as a aunsace water soutce then the •6eptie system L4 Located
too ceoae and .La in v.i.otatLon os Regulation 18 AAC 12.021.
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
Page Two
Lot 7; Bloch 2; South Fork North
NUN South Riven Pave, Eagle Riven
AHFC # 79805
Manch 3, 1990
However, we undenb.tand .this road drainage tobe benved moUtZy by b.Zeed-ob44
from 1Zowing artesian wett4 in .the area. 'Puking our bite v.iait6 on
February 18, 1990 and Manch 1, 1990 there wa6 no water `obbenved 'Stowing
through the ditch. It appear6 .this .i6 not a traceabte btneam tt butaty.
Periodic flow from the road ditch appear6 to dissipate .into sheet 'Stow a6
it trave.ZU into the .tundra to the west o4 the property. Therefore, we do
not fee.Z this road ditch L6 to be ctabb.i4ied ab a bur4aee water bounce 6o
no viotation exits.
14 you have any questions, or of we may be o4 further 6erv.ice, p.Zeabe
contact u6.
.SHAFER, P.E.
01, gm
S
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # - - I i HAA # c31 f`:U \
1. GENERAL INFORMATION
Complete legal description Lot 7; Mock 2; South Faith Month.
Location (site address or directions) NHN South Riven. Vn-ive (7.5 KLeand Road)
Property owner A.H. F. C. #79805 Day phone 561-1900
Mailing address 520 Ea4. 34th Avenue Anehanage, AFz. 99503
Lending agency Day phone
Mailing address
Agent KathL 02m4tead JACK WHITE COMPANY Day phone 694-5500
Address 10928 Eag.2e Riven. Road, Eagle Riven, Ata3Fza 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XX
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
xx
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm Phone
S & S ENGINEERING
Address 17034 Eagle River Loop Road pNo. 9Q4
Eagle River, Alaska 99577
Engineer's signature Date 12-1
•
*4T%� •
*��ff
11
11 : • . • .4 c . . ` • • .
A°9: •55
ROG �J. SHA ER, P.E •. 41
G)• 04215 • S. /0
11 ®ika,AO0O
ESS\ �—.
6. DHHS SIGNATURE
Approved for / bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
By. JO Hr t St --t rlt-+
Date t2 -12-41 q/
' CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA N21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: r -t�-ti te..e/s4r54 Parcel I D
A. WELL DATA
Well type F AtV AerC-
Log present ?N) \l
Total depth Leo
Sanitary seal &N)
If A, B, or C, attach ADEC letter. ADEC water system number
y
,1.
Date completed to " IS- S 1 Driller P'` k[9.11.1 Jsa r i
Cased to
loo'
FROM WELL LOG
Date of test Lo' \S -$r
p'
Static water level
Well flow
Pump level
v1L
SEPARATION DISTANCES FROM WELL TO:
1k,
Septic/holding tank on lot 1 On
Absorption field on lot
Public sewer main
Casing height 12 "4 -
Wires properly protecteda/N) i
gpm
OC)t.t-
�lP�
AT INSPECTION
12 -ID -91
L.1
MUNICIPALITY OF ANCHORAGE
€PIVIRONMENTAL SERVICES DIVISION
Jt--
p �ml.8 i991
RECEIVED
; On adjacent lots 10C,14-
; On adjacent lots
Public sewer manhole/cleanout '11A•
5
Sewer service line 2 Petroleum tank
WATER SAMPLE RESULTS:
ra1,l
Coliform /i Do w111
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed ce9
Cleanouts ON) l
High water alarm (Y6
Nitrate
Collected by.
Tank size 11:2 't
Other bacteria /4D f--1
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Foundation cleanout/N) !
(Date of pumping > • - ' D
t OS Iv JkC-b - 4 -r S t
SEPARATION DISTANCES FROM SEPTIC/HOLDING
Well(s) on lot 1 o0
Compartments
7 -
Depression
Depressionn (Y�Q
Alarm tested (..Y./-14)--
Pumper
�G/N4)--
Pumper
� - 6-E-SS1'a 0 1_—
IPJv-APi,-LU
TANK TO:
On adjacent lots 6 0e \ Foundation 3a 1
To property line ) b Absorption field 1S - i Water main/service line 31D'
Surface water/drainage \
72-026 (Rev. 7/91) Front
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at "Pump off" level at
High water alarm level Cycles tested
Meets MOA electrical codes
SEPARATI
I on lot
ISTANCE FROM LIFT STATION TO:
D. ABSORPTION FIELD DATA
Date installed
On adjacent lots Surface water
Soil rating lvs 4/Zvr,
Length Width Zo Gravel thickness
Total absorption area 1 Lo (a Cleanouts present/N) y
System type
l�fr�D
Total depth
Depression over field (YL
Results „ail) 1944-4S
Date of adequacy test 11— r i1 -9
for '1r�ri - C3)
Peroxide treatment (past 12 months) (Y& ' M' AlC l (4 0141 If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
bedrooms
Well on lot too t -r On adjacent lots ltDo t k- Property line 1
To building foundation 4v\ To existing or abandoned system on lot ' lP-
On adjacent lots �� \� Cutbank �iWater main/service line
I`+
Surface water o o Driveway, parking/vehicle storage area 4 o
Curtain drain ) )p‹
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in eftect:onth ipte of this inspection.
Signature
S & 5 ENGINEERING
17034 Eagle River Loop Road No. 204
eagle. River, Alaska 99577
Engineer's Name
e —9
Date
HAA Fee $ /70
Date of Payment /2- /3-6V
/ , l
Receipt Number - - %3 (95-)y)
72-026 (Rev. 3/91) Beck MOA 21
Waiver Fee• $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information 0
Application Date
(a) Legal Description (include lot, bloc subdivision/, section,�jytownship, range)
; Zs ,amu/s/G3 / `/b
Location (addres or directions)
(b) Applicants Name
Telephon me
C)
/es?
Business
Applicants Address ,6/50-7-6--e,
(c) Applicant is (check one) Lending Institution
Buyer! [; Other (explain);
(d) Lending Institution
Address
(e) Real Estate Co. & Agent
; Owner/builder
Telephone
Address
Telephone
(f) Mail the HAA to the following address:
2. Type of Residence
Single -Family
Number of Bedrooms
Multi -Family
3. Water Supply
Individual Well
Community
Other (describe)
Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite Public
Community
Holding Tank
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation f)this Health 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 regula-
tions in effect on the date of this inspection.
Name of Firm
Address
Date
Telephone
rsk
(ENGINEER SEAL)
6. DHEP Approval
Approved for ` bedrooms B,
Approved
A•
140. 14.51 -a
Disapproved Conditional
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS 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 SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. 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.
(DHEP SEAL)
RR4/ej/D18
(Page 2 of 2] 7-19-84
MUNICIPALITY OF ANCHORAG=
\--.J DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
A. WELL DATA /n
Well Classificati , 0R i VA7i
Well Log Present (Y
Total Depth 6„j
Cased to
!SEP 17 '1984
R E pADz
Lep,1 Description:
C
If A, B, or C, D.E.C. Approved(Y-- — —�j
6 /r f Yield 1.4-1
Date Completed
Static Water Level /9'les eul Pump Set At
ft
Depth of Grouting
(.l i
Casing Height Above Ground
Electrical Wiring in Conduit
Separation Distances from Well:
To Septic/Horlding—ank on Lo
To Nearest Edge of Absorption Field on Lot/n9
Lot
30
Sanitary Seal on Casing
Depression Around Wellhead
/z?s ; On Adjoining Lots /OD 1
To Nearest Public Sewer Line
Cleanout/Manhole
; On Adjoining Lots /04.9 4
Water Sample Collected By
Water Sample Test Results
Comments
To Nearest Public Sewer
on Lot
To Nearest Sewer Service Li
SG i&g--ed- —; Date �O/N
B. SEPTIC/HOLDING TANK DATA
Date Instal d
Standpipes
Depression over Tank
Pumping/Maintenance Contract
Holding Tank High -Water Alarm
/ Size /c2)c�
Air -tight Cap
No. of Compartments
Date Last
on i
File (Y/N)Z /'-
(Y/N YU/1''—
Separation Distances from Septic/Holding
To Water -Supply Well /O
To Property Line /0 •-.
m
To Water Main/Service Line
Course
Comments
d
Te
Tank:
To
To
Foundation Cleanou.®/N)
for
mporary
n7/ -Lt
Holding Tank Permit
(Y/N)
Building Foundation
Disposal Field /6
To Stream, Pond, Lake,
cr Major Drainage
Receipt # ,27k 2yR
Date Paid: 9-0-/1`y
Amount: 41-, c,f>
[Page 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /-5� Type of System Design
Date Installed Y/ PLength of Field 3j'
Width of Field ( Depth of Field
Square Feet of Absorption Area -/-7V
Depression over Field (Y;
Gravel Bed Thickness
Results of Last Adequacy Test
Standpipes Present ® )
Date of Last Adequacy Test
e
Separation Distance from Absorption Field:
To Water -Supply Well /0° ( To Property Line /U /-
To
To Building Foundation j/2_ I To Existing or Abandoned System cn
Lot // l I'- ; On Adjoining Lots /6.)19 /
To Water Main/Service Line ,3(:) To Cutbank(if present) xi / li-
(K
To Stream/Pond/take/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Ac9ss (Y/N)
"Pump On" Level at "Pump)) f" Level at
High Water Alarm Level at � Vent (Y/N)
Tested for Pumpipe'Cycles during Adequacy Test. Meets MOA
Electrical Codes(Y/N)
Comments
** Check Permitted droan Rating Against HAA Request **
I certify that I ha'e checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date ,6f th'. ii tion.
Signed/
Comp&y?
KB1/d5/s
e aV ENGINEERING
SRO 193X
'gr4(1 RIVERS ALASKA
Ts5'7i
�. Pli. 3941-P.,)19
[Page 2 of 2]
2-15-84