HomeMy WebLinkAboutMOUNTAIN SHADOWS BLK 1 LT 7Mountain
Shadow
Lot 7
17-401-11
Municipality of Anchorage Page 1 of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 9 Anchorage, Alaska 99519-6650 0 Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number:' PID Number:
Name:
Wastewater System: El New ErUpgrade
Address:
ABSORPTION FIELD
Phone: 1Zr_ 9,
No. of Bedrooms:
0 Deep Trench 0 Shallow Trench Ej�ged C1 Mound El Other
_3
,
LEGAL DESCRIPTION
Soil Rating: 61
Totat Depth from original grade:
/ 1_1}k
GPD/Sq. Ft.,
—
Lot: Block: Subdivisio
7
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
g
Ft.
Ft.
Township:
Range:
Section:
de:
Fill added above original grade:
Gravel length:
T
1
-f Ft.
Ft.
WELL: New 0 Upgrade
Gravel width:
Number of lines:
Distance between lines:
Ft.
7 Ft.
Classification (Private, A,B,C):
Total D
Cased To:
Total absorption area:
Pipe material:
T1
/Ft.
Ft.
SO. Ft.
/
Driller:
Date Drilled:
Static Water Level:
Installer:
Date installed:
j
Ft.
Yield:
Pump Set at:
Casing Height Above Ground:
TANK
GPM
Ft.
Ft.
SEPARATION DISTANCES
0 Septic 0 Holding 01s"T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:
Capacity in gallons:
11Z4521)
From
Tank
Field
Station
Tank
Sewer Lines
Well,
/2
Material:
Number of Compartments:
Surface
lx�f
LIFT STATION
Water
Lot
Line
1
Z 7
A -
/
Size ill
n gallons:
Manufacturer:
Foundation
1,01
Pump on" level at:
P
UTP.9ft" level at:
High water alarm at:
Curtain
Pump Make & Model
Electrical inspections performed by:
Y.-T�
Drain
BENCH MARK
Remarks:
Location and Description:
Assumed Elevation:
1.0115- Ft
InspectionsIle; Z
Dates: is performed by:
"of
0 W
%
2nd.
T K0
AF_,11-E)
0 E 817
Department of Healh and Human Services approval
Reviewed and approved by: Date:
A 1� I-
79-ni q M A/Q1 I MnA 25 \1 \ I
Permit No. Page 2 of 4
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 - Anchorage, Alaska 99519-6650- Telephone 343-4744
On —Site Wastewater Disposal System and/or Well Inspection Report
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Permit No. Page 3 of 4
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 - Anchorage, Alaska 99519-6650- Telephone 343-4744
On —Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: LOT 7, BLOCK 1, MOUNTAIN SHADOW SUBDIVISION PID No.:
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Permit No. Page 4 of 4
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 - Anchorage, Alaska 99519-6650 - Telephone 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
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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
ON -SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Permit Number: SW020331
Legal Description: MOUNTAIN SHADOWS BILK 1 LT 7
Design Engineer: 0069 Douglas T. Kenley, PE
Owner Name: Steve McKeever
Owner Address: 12831 Michael Dr.
ANCHORAGE , AK 99516-3336
Date Issued: Sep 05, 2002
Expiration Date: Sep 05, 2003
Parcel ID: 017-401-11
Site Address: 012831 MICHAEL RD
Lot Size: 29192 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
✓� Disposal Field E./ 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 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
�0123102 SFCE EA/ GINprK.5 4tiFA10 D 1943_16v ro✓ra,G 94'e ro ,q
H/ 6-1?4 k i0®re r/o,� off' c o r- Tv ova/t9 4 S 6itp iti r,-rj_ o,9/6 ,IA"i1L
)Pp //Y/S AElP.0 •T I-,4r lfruotp �a /e, �M Ftib�b VJr s®G.v Yr�1 T.c-D 97G T" 2.3 02-
Received By:
Issued By:
Date: ❑' <'
r
Date: / s o 2
Municipality of Anchorage
Development Services Department
Building Safety Division 46,
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 tC_
www.ci.anchorage.ak.us
(907) 343-7904
ON -SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 61 7 - q&- I I I Permit Number SWO2033/
Propertyowner(s Day phone ZY.:5;'-
Mailing address (1
Mailing address
Legal description (Lot, Block & Sub'd.)
Zip Code
Legal description (Section, Township & Range)
Lot Size Acres/ ag.E
Number of Bedrooms
2-77-9
THIS APPLICATION IS FOR:
Sewer Only P� Well Only ❑
Sewer and Well D Water Storage ❑
Sewer Upgrade El
THIS PROPERTY CONTAINS:
Hot Tub El Jacuzzi R
Swimming Pool ❑ Water Softening Unit El
Therapy Pool ❑
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.
(Signature of property owner or authrrized agent)
Permit Fees:
Waiver Fees:
Date of Payment: 60 >-bo-z- Date of Payment:
Receipt Number: 02- -f'5 C 1 Receipt Number:
(Rev. 12/00) �F u
Douglas T. Kenley, P.E. 9960 E. Puffin Drive, Palmer, Alaska 99645 (907) 746-1073
October 23, 2002
Mr. Dan Roth
Municipality of Anchorage
On -site Services
Re: Mr. Steve McKeever, Owner
Lot 7, Block 1, Mountain Shadow Subdivision
Anchorage, Alaska
AMENDMENT TO SUBMITTED DESIGN
PERCOLATION TEST RESULTS
On October 21, 2002, the site was excavated to install the bed to the depth of where the sand liner was to be
placed, at which time a vein of water was encountered. Construction was stopped and re-evaluation was
made as to what could be done. After consultation with your office, it was determined to move the location
of the bed, at which time additional perc tests were done. Three tests were done in the area of the new
location, with two of the perc tests being less than a minute per inch and one just over a minute per inch.
However, noticing the layers in the other area, which is roughly 5' lower, we noticed a different type soil in
that area. A perc test was done down there, yielding a perc rate of 5 minutes per inch. This determined to
leave out the sand liner because of the layer that would be under the new location that would in effect do the
same thing as the sand liner. (See attached percolation results and plan view showing new location.)
If there should be any questions concerning the percolation rate or characteristics of the site, please call me at
(907) 746-1073 or 243-5372.
Sincerely,
'D
Doug T. Kenle P
PE#8176
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0DUK3,A A,,,S' T. KENLEY !,,sE,
STEVE McKEAVER
mm
LOT 7, BLOCK 1, FAT. SHADOIN SUMM&ON'
ANCHORAGE,ALASKA
-env
10MV 9" . .
SEZ),T"_ -7
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES e T. KEKV
825 L" Street, Anchorage, Alaska 99502-0650
CE 6176
SOILS LOG - PERCOLATION TEST
14- f-.-! _' I
PERFORMED FOR DATE PERFORMED: 9/,�) /).X
LEGAL DESCRIPTION: /0,1' ZT own Ship, Range. Section:
DEPTH SLOPE SITE PLAN
tFEET)
Vo
6, AIL
T_
N
2 -
3 -
4
5 -
2
6 -
7 -
8 -
9-
WAS GROUND WATER
10 ENCOUNTEREO?
11
12
13
14
15
16
17
18
19
2A.
S
L
IF YES, AT WHAT 0
DEPTH?
Depth to Water After
Date:
21e,'J-
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
_Z �0_7
r, - 14
/10 -ge(
=3j
= 1�3
�7
20 PERCOLATION RATE kmIn.Ie5/.nch) PERC HOLE DIAMETER
L—'11 TEST RUN BETWEEN FT AND FT
/2-7 / 4
COMMENTS
CERTIFY THAT THIS TEST WAS PERFORMED IN
PERFORMEOSY
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE
I `
e Municipality of Anchorage - TH �
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650 4'
--SO&S LOG -- PERCOLATION TEST
Oar
PERFORMED FOR r DATE PERFORMED _ 7�1Fi—
LEGAL DESCRIPTION: �� T' �k �"/..trda$�!��ShIP. Range, Section:
DEPTH SLOPE SITE PLAN
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
N
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? P
E
Depth to wjta Mer
Date:
Gross
Net
Depth to
Net
Reading
Date
Time
Time
Water
Drop
7J�
/
PERCOLATION RATE 1m.n.iesirnch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT ANO FT
G' t CERTIFY THAT THIS TEST WAS PERFORMED IN
PERF ORMEO BV _.��..--
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE
(ENGINE A- 5
• Municipality of Anchorage i
DEPARTMENT OF HEALTH & HUMAN SERVICES A
825 "L" Street, Anchorage, Alaska 99502-0650
t
�I`LS-L*G -�- PERCOLATION TEST 6�9
PERFORMED FOR:>.f✓"r5
DATE PERFORMED. %
LEGAL DESCRIPTION: ��'�f�� Township, Range. Section:
DEPTH SLOPE SITE PLAN
1
2
3
4
5
6
7
8
9
to,
12
13
14
15
16
17
18
19
20
7
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT L
0
DEPTH? P
E
Depth to Water Atler
MONIA(inp7 031e:
PERCOLATION RATE " r� '(rnmulesnnch) PERC HOLE DIAMETER
TEST RUN BETWEEN '' FT AND '� FT
COMMENTS
PERFORMED BY "'-�-�-- I CERTIFY THAT THIS TEST WAS PERFORMED IN
____ _ ere reewinu�w�r�aa� rru)nFLINESINEFFECT ONTHIS DATE. DA7E'
®a
n (ENGIN 'S S
°
' 9 amx-v2u v °
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502.0650 l% DO1 o KEG
tiSOtL-S-•L@O-- PERCOLATION TEST °°®CE8176
PERFORMED FOR J��� '/ DATE PERFORMED::,
LEGAL DESCRIPTION:Township, Range. Section;
DEPTH _ SLOPE SITE PLAN
1-
2-
3-
4-
5-
6-
7-
8-
9'
10
11
12
13
14
15
16
17
18
19
20
/ 2-'X%' !
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH? —
klith 10 WjIv Mer
Monitoring? 0>Ile:
Date Gross
Reading Time
I Net Iater Depth to I Net
Time WDrop
PERCOLATION RATE /r tminutesrnch) PERC HOLE DIAMETER
TEST RUN BETWEEN �+ 2 FT AND — FT
COMMENTS
�/ I CERTIFY THAT THIS TEST WAS PERFORMED IN
PERFORMED BY
....m.rIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE'
�1IV'GtNE R'S5 r
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 -L" Street. Anchorage, Alaska 99502-0650 J
PERFORMED FORDATE PERFORMED
LEGAL DESCRIPTION: Township, Range. Section:
SLOPE SITE PLAN
DEPTH
iFEET)
1
2
3
4
5
6
7
8
9
WAS GROUND WATER
10 ENCOUNTERED'
11
12
13
14
15
16
17
16
19
20
r
IF YES, AT WHAT
DEPTH?
®eplh to Waler After
nave, _..—
PERCOLATION RATE t
rn,nvIe5/,ncnl PERC HOLE DIAMETER
7 FT AND F7
TEST RUN BE WEEN 2 �J
COMMENTS
CERTIFY THAT THIS TEST WAS PERFORMED IN
PERFORMEO BY -'
GUIDELINES IN EFFECT ON THIS DATE, DATE
Douglas T. Kenley, P.E. 9960 E. Puffin Drive, Palmer, Alaska 99645 (907) 746-1073
August 19, 2002
Mr. Steve McKeever, Owner
Lot 7, Block 1, Mountain Shadow Subdivision
Anchorage, Alaska
PERCOLATION TEST RESULTS
AND
GENERAL SITE INVESTIGATION REPORT
On July 28, 2002, an adequacy test was conducted on the well and septic system of the above -referenced
property. The well passed, but the septic system was found to be in a failed condition. The 27,540 sq. ft. site
was inspected in support of this application for approval to upgrade the on -site wastewater disposal system.
The inspection consisted of soils percolation tests and an overall conditions survey of the property.
The site is located at 12831 Michael Drive. The immediate area that has been selected for the replacement
wastewater disposal system has an average slope of 1 to 2%. The site is sparsely treed with birch and spruce
but is heavily treed with small alder on the back side of the lot. On -site observation and physical survey show
that there are no water wells or private wastewater disposal systems within a 100' radius of the proposed
system.
On August 5, 2002, a test hole was dug to a depth of 17'. See attached soils log. Moist soils were
encountered at 12' below grade. The perc hole was dug at 3.5' below grade. The perc result was faster than a
minute per inch. After the 7-day monitoring period, the water level was 46.5" from the bottom of the hole or
approximately 13' from grade. It is proposed to use a 15' wide x 6" E.D. x 38' long bed with a 2' deep
MOA-approved sand liner. A new 1250 gallon step tank is to be used in the upgrade. The approximate lift
from tank to bed is 5'.
With a reference taken from the deck as 100.0', the bottom of the replacement bed will be located at 95' and
the sand liner at 93'.
The proposed system will have no measurable impact on surface or sub -surface drainage, or on drainage
from adjacent lots. It appears that there is no potential for contamination of adjacent water wells or streams
from known sources. Also, the proposed development will not cause any neiboring lots from future
development.
Attached please find proposed design drawings for the replacement system. If there should be any questions
concerning the percolation rate or characteristics of the site, please call me at (907) 746-1073 or 243-5372.
ncerely,
nDougl s T. Kenley, E.
PE#8176
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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 _FP
HOIINE
EW
❑ UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
' ' R� Lb
NO. OF BEDROOMS
U Y
DISTANCE TO:
Well
Absorption area
� )
Dwelling
40
PERMIT NO. ,
a Q
wF
Manufacturer
Material
No. of compartments
Cn
Liq. capacity in gallons
IF HOMEMADE:
Inside lent
k
Width
Liquid depth
0 ='
J0z
DISTANCE TO:
Well
Dwelling
PERMIT NO.
O Z H
Manufacturer
Material
Liquid capacity in gallons
w z
DISTANCE TO:
Well
Foundation
Nearest lot line
PERMIT NO.
U.Z
F Z w
No. of lines
Length of each line
Total length of lines,
Trench width
inches
Distance between lines '
c F
0
Top of tile to finish grade
Material beneath tile
inches,
Total effective absor tion area
w
C7
Length
Width
Depth
PERMIT NO.
a N
w°
Type of crib
C ' is ter
Crib depth
Total effective absorption area
DISTANCE TO:
W 11
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PERMIT NO. o1
w
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLE
aCc
r
REMARKS
c
r
R VED DATE LEGAL
s
' al 0 w; x on; 1: F� 1 R.. 1: -r �,_,,, ��� p"! R:; i-i 4 At 10 E�Z
� DEPHRTMENT OF HEALTH HMD ENVIRONMENTAL PROTECTION
825 'L' STREET, ANCHORAGE, AK. 99501
` 264-4720
[} ��
u -��/--/�(/%.
f"A El R.. 0. foe P44 K!" 1:1 3117 F
01 REE
1-1 FEE TV! ��Fit ���
51.3 /_��
PERMIT N8� ( 78 )
" / u
^8077
/-JLbA\
APPLICANT DENNIS MICHELE 5306 ARCTIC
BLYD
99502 279-495]
LOCATION MICHHEL RE,
LEGAL. L7 B1 MIN SHADOWS 5/1.)
LOT SIZE 22000 SQUHRE
FEET
TYPE OF SOIL ABSORB TIOh.! SYSTEM IS: TRENCH
MAXIMUM NQMBER W BEDROOMS = ] SOIL
RHTIN8
(SQ FT/BR)- 125
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM
IS:
EJ KEE ro, -T- bi= :3.111 ��E P-4 K11 -1- 4-5
oil lot 50
HE! t.. ��LF, E,�=
�
THE LENGTH DIME45IO4 IS THE LENGTH KIN
FEET) OF
THE TRENCH OR DRHINFIELD.
THE DEPTH OF H TRENCH 8R PIT IS THE DISTANCE
BETWEEN
THE SURFRCE OF
THE
GROUND HND THE BOTTOM OF THE EXCAVATION
(IN FEET)
THERE 125 NO SET WIDTH FOR TRENCHES.
THE GRAVEL. DEPTH IS THE MINIMUM DEPTH OF
GRAVEL
BEAWEEM THE OUTFHLL
PIPE
Fir-,) THE BOTTOM OF THE EXCAVATION (1N FEET).
Fit TO: I0 R-A I Fit EE: E0 �FEZ �" -y- :1 M17 �-,A; ��$in CE) (JEN Nil fj J_ k_ CIE 141 §E�;:
PERMIT HPPLICHNT HHS THE RESPO14SIBILIT9 TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION IN5PECTION,S OF HNY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT' THE WELL WILL SERVE.
-I- f"j 1:3 < 21 > 1 1: i1C`__§ PEE FT! PEE nit RJ 1: FT? PEE I>
BHCKFILLINQ OF ANY SYSTEM WITHOUT FINAL INSPECTION HND HPPROYHL BY THIS
DEPHRTMEWT WILL BE SUBJECT TO PROSECUTION,
MINIMUM DI5THNCE BETWEEN H WELL HND RNY ON -SITE SEWAGE DISPOSAL SYSTEM
100 FEET FOR H PRIVATE WELL/ OR
150 TO 200
FEET FROM H
PUBLIC WELL DEPENDING
UPON
THE TYPE OF PUBLIC WELL
WELL LOGS
HRE REQUIRED
FINE) MUST BE RETURNED
TO THE
DEPARTMENT WITHIN 1:0 DAYS
OF THE WELL
COMPLETION.
OTHER REQUIREMENTS
MAY
APPLY, SPEC! FICRT!
ONS
HND
CONSTRUCTION DIAGRAMS ARE'
AVAILABLE
TO INSURE PROPER
INSTALLATION.
oil FEE TO: �1 1- FEE ON F" :1 To! FEE 0; KIN EE ED EH 01 E3 FEE !T? i0v 0-^ �YEN ��
I CERTIFY THAT
1: I RM FAMILIAR WITH THE
REQUIREMENTS
FOR
ON -SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY
OF
HNCHORHGE
2: I WILL INSTALL THE SYSTEM
IN ACCORDANCE
WITH THE CODES.
3: I UNDERSTAND THAT THE ON
-SITE SEWER SYSTEM
MHY REQUIRE ENLARGEMENT IF THE
'REST 1 DENCE I MORE THAN ] BEDROOMS.
SIGNED: _... ..... ... ....
___________
-APPLICANT DENNIS MICHELE
��
I5SUED BY __ ______DHTE_��-l��a����____ Y].2
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
Pouch 6-650, Anchorage, Alaska 99502 276-2221
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: /�°° Q �% DATE PERFORMED:71
LEGAL DESCRIPTION: G` ✓ ;✓i /i( f`P/'f"C Y c
DEPTH
(FEET) ......,� .....-.- .,. ..,
1
2
3-
4-
5
�. 6-
7
8-
9
10
11
�`- 12
13
14
15
t i
16
17
18
19
20
COMMENTS
PERFORMED BY:
u� L
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
CERTIFIED BY:
DATE:
1111171111111111
72-008 (7/76)
Dotten Drilling Co.
BOX 10056 JOHN'S ROAD ANCHORAGE, ALASKA 995o2 PHONE 3"-1952
-0, 1 T or,
Location: Lot 7, block 1,-Q2yjjjqn 6hsdows sub. div.
V'Iell clrilled: Oct. 19'78.
Drilled by: �Vayne Rotten.
Total deptb: 1101. fine diameter: 6" ID.
Production: 4-5 GPM. 3tatic level: 3Y from ground.
Gravelly till
0 24
Weathered rock �4 36
Led rock; ripe refus-1 i 36'.
Parcel I.D. 017-401-11
Certificate of On -Site Systems Approval
Expiration Date:
Legal description MOUNTAIN SHADOWS BLK 1 LT 7
Site address 12831 MICHAEL RD Anchorage AK
Current property owner(s) THRASHER & CHRISTIANSON
7/18/2025
The On -site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories: during future COSAs, confirm water levels in the nearby
groundwater monitor tube to ensure 1978 trench is not encroaching groundwater.
Original Certificate Date: 8/21 /2024
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory X
Tank Age Advisory X Arsenic Advisory
Other
COSA Approval_June 2022
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 017-401-11
Complete legal description MOUNTAIN SHADOWS BLOCK 1 LOT 7
Location (site address) 12831 MICHAEL ROAD, ANCHORAGE, AK 99516
Current property owner(s) MICHEAL THRASHER & PAMELA CHRISTIANSON Day phone
2. ON -SITE SYSTEMS SIZED FOR 3 BEDROOMS
3. TYPE OF WATER SUPPLY: Z Private Well F Private Well serving 2 dwelling units
0 Private Well serving 3+ dwelling units R Community Well or Public
R Water Storage
4. TYPE OF WASTEWATER DISPOSAL: Z Private Septic F1 Private Septic serving 2 dwelling units
❑ Holding Tank R Community Septic or Public Sewer
5. SEPTIC TANK: Z Steel F-1 Plastic E] Concrete F] Fiberglass
Age 22 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: R AWWTS F] Bed M Deep Trench 0 Wide Trench R Seepage Pit
Waiver request for:
Expedited review requested: r_1
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On -site staff
to verify the accuracy of the information provided.
COSA Fee $ Waiver Fee $
Date of Payment t Date of Payment
COSA # 05C Z 4 1 Z7Z2 Waiver #
COSA Application.doc
COSA Checklist.docx
COSA Checklist
Legal Description: MOUNTAIN SHADOWS BLOCK 1 LOT 7 Parcel ID: 017-401-11
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 Oct 1978 Total depth 110 ft
Cased to 36 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 7/18/24
Static water level at beginning of test 30 ft.
Well production at time of test 2.2 gpm
Water storage tank volume NONE gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 8.23 mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by Date 7/18/24
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank NA*
Date of pumping 7/18/24
Required maintenance completed, if AWWTS
Comments: FLOATS*
C. LIFT STATION
Required maintenance completed
Age of lift station 22 years
Lift station material STEEL
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 8/31/1978
ALL standpipes present per record drawing
Total measured depth from existing grade 10.3 ft (max)
Measured depth to pipe invert from grade 6.1 ft (min)
N/A – pressurized field. (1978 trench pressurized to gravity)
Per record drawings, field is insulated.
Monitor tubes (MT) go to bottom of effective. (ED)
If not, state depth into effective 3.8' ft
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) N
If yes, enter date
Adequacy test date 7/18/24
Results Pass
Fluid depth prior to test 3 in
Water added 550 gal
New fluid depth 13 in
Elapsed time 30 min
Final fluid depth 3 in
Absorption rate 450 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 72 in (MOA 6’ ED)
Effective depth used 29 in (Final Fluid Depth + Missing ED)
Effective depth (ED) remaining 43 in
Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots &
appears approximate with 2.2’ OR 26” ED missing. Tested older trench that was in use. The bed MTs were dry. The perforated
test hole MT near the 1978 trench was dry on 7/18/2024 & on 8/20/2024.
COSA Checklist.docx
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 FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 8/20/2024
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
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
8/20/24
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 307-343-7904
Y� irvm
On -Site Water and Wastewater Section q Fax: 343-7997
www.muni.org/onsite �
Septic Tank Advisory
Certificate of On -Site Systems Approval # OSC241273
Subdivision: MOUNTAIN SHADOWS Block:1, Lot: 7
The septic tank for this property is 22 years old. The average life of an asphalt
coated steel septic tank is 20 years. Typical replacement costs are $15,000 or more,
not including engineering, surveying, MOA permitting fees or site restoration.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
This is an example of what the metal of a 30 year old steel tank MAY look like.
Mailing Address: :P.�Io �sox:1966504Anchor6ge;-Alaska 99519-6650munh org `.
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907-343-7904
On -Site water and wastewater Section Fax: 343-7997
www.muni.org/onsite
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC241273
Subdivision: MOUNTAIN SHADOWS, Block: 1, Lot: 7
A water sample revealed a nitrate concentration of 8.23 milligrams per liter (mg/Q.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for
important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
MailinAtl6650 * www muni gx16AgAdress P'O. Bolaska 99519g
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Owner
Septic Tank:
Lift Station/Pump Vault
Maintenance Log
Street Address3�
-Sludge level inches -Pumping: required es no -Pumping completed yes no
Lift station:
-Pump basket cleanedtsn
-Effluent filter cleaned es no _
-Control floats cleaned -Proper float settings confirmed e no
-Operation satisfactory
Alarm System:
-Dedicated electrical alarm circuit es no -Audible and visual alarm inside dwelling
-Alarm system operation satisfactory not satisfactory
Manhole Riser
-Ground water intrusion at riser to tank connection esgho
-Ground water intrusion around pipe penetrations es
-Manhole lid: Functional a no Insulated es no
Other
-Weep hole function ee no
Properly Secured es
-All manufacturer required inspections and maintenance complete ves no
Comments:
Qualified Maintenance Provider:
Technician GjJ l3oJtf< ,� r-
Company y i0.e
Signature
Date of maintenance Ct
Date 1
Municipality of Anchorage
Development Services Department
Building Safe~ Division
On-Site Water and Wastewater Program
4700 Sou~ Bmgaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
~.ci.anchomge.ak. us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
1.
GENERAL INFORMATION
Complete legal description ~ ~ ~/, ~ ~/~ ~ ~ ~ ~ /'~ ~
Location (site ~ddress or directions) /~/~2¢~'/~/~, ~~,~,
Current Prope~y owner(s) ~¢//~ ~c ~//~ __ Day phone_
Mailing address
Lending agency _ Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherMse requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY: '
Individual Well []
Individual Water Storage []
Community Class ~ Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On..site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of 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 pedod 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 vedfy 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 ail applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm ,/~¢¢~'~' ¢/~5' ~ /~/2 ~z/
Address ¢'¢Z,¢ ~.. /2~. /~/2 /.~r:, /2~¢//¢~ ~,~,
Engineer's Printed Name ,~,z~',¢/,,¢.¢ 7~.
DSD SIGNATURE ~
"'/ Approved for ..~
Disapproved.
Conditional approval for
Phone
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By:
(Rev. 01/02)
Original Certificate Date:
Ea'"sed T~me ": .... ::min' · · ~2 'flh~ oepth' · ' · in' 'Abso,p~6 r~te >=
LIFT STATION
Date installed
"Pump on" level at/~¢~n.
Datum
Size in ga one /~'6
"Pump 'off" 'level' at
Cycles tested
' Manhole/Access ~Y/N)
High water alarm level at _.__/~ ..........· n
Meets .alarm & circuit requ remen,s~... ~y~. .
Septic tank/liE station on lot //,2
Absorption field on lot /-¢~
Public sewer main
Sewer/septic service line
SEPARATION DISTANCES FROM' SEPTIC/HOLDING TANK ON 'LOT TO:
Buildin§ foundation ,~//~ Property line ~' AbS~rpfl0n field
Surface water
On adjacent lots /'~'~' ,-~"
On adjacent lots
Public sewer manhole/cleanout
Holding tank /Y,/'.4
SEPARATION DISTANCE FROM ABSORPTION
1',~ ~ x / ~/~
COMMENTS
Building fot~hdati-0n
Surface water /d ~
Wells on adjacent lots
Driveway, parking/vehicle storage '~"~' ~'
G, ENGI.NEER'S CERTIFICATION
I certify that I have Oetermined through field inspections and
review of Municipal records that the above systems are in
conformance wi.',h MOA HAA guide!ines in effect on this date.
DateEngineer'sl~, ' '~'~' - '''~Z) Z'P '.~,e.d Name ,..,~,.: ~/~.~' ~ ~/'7/,~y..
HAA Fee..$:
Date of Payment 1 2..,/¢
Receipt Number
(Rev. 12/01 )
Waiver.Fee $
Date of'Payment
Receipt Number
Yk. FILI
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL FNGINEERING DIVISION
825 LStreet - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
'~AME -- ~" TPHONE
~AI LING ADDRESS
~GAL DESCRIPTION
~CAT~ON ~ ~ ~O. OF~EDROOMS
~ Well Absorption area Dwelling PERMIT~O.
DISTANCE
TQ:
~ ~ Manufacturer
~ ~~ Material ~ N°' °f c°mpartments
~Liq. capacity in gallons Inside len~ Width
O ~ ~ Manufacturer
~ - ~ ~terial Liquid capacity in gallons
~ Well Foundation Nearest lot line ~O
~ DISTANCE TO: t~O GO PERMIT NO.
_ ~ ~ ~ ~ 2 No, of lines t Length of each line~ Total length of line~ ~ Trench width Distance between lines ~ ]
Top of tile to finish grade ~ Materiel beneath tile Total effective abso~tion area
uJ Length Width Depth -- PERMIT NO.
~ Typeofcrib C ar ter Crib depth Total effective absorption area
~ DISTANCE TO: Building foundation Nearest lot line
~ Class ~ Depth Driller Distance to'lot line ~ PERMIT NO,
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER _
SOIL TEST RATING
INSTALLER -
- ~ DATE LEGAL
72-013 (Rev.~/TR)
GFi:Oi_IIqI::' I:::11",1ti:' 'I'HI:: [ii~OT'!"OH Ol::: 'I'IIE: I:i:;'::Cl:::l',,,'l:::l'i :!:ON ,:::!:I',t
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f:lH[::' F!"ll!i!: E',CF'i'TOH OF: '!-!"l!:ii: ~:!:XC:FI',,,'f::Ft ii: O!",! ,:: ): I",! t:::'!!!il'ii:l'
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I'"t :1: I".! :!: !'IlIH I):t~ :;~;'Ff::IHC:I: ?~?,I::Tt'.It:t[:H t::1 I.,.IE:L.L FIND
::t. OO F'!~:l:"f I:::'()1:~: I:::1 !:::'t:;:]:',,"l:::lf'~: 1.'!:1..I : Cfi:::
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t'::I",,'I:':i :i: L..I:::II?I.J:: '1'O ): N:~;I.JI:;~:[: I::'f;~:l::)F:'[:b~: ]: t",ff?'!'l:::lt .I I':tT
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99502 276-2221'
[] PERCOLATION
TEST
SOILS LOG - PERCOLATION TEST
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WRAT
DEPTH?
,, /
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND -- FT
PERFORMED
/
DATE:
72 008 (7/76)
Dotten D~illing Co,.
BOX 10056 JOHN'S ROAD ANCHORAGE, ALASKA 9~o~ PHONE 344-1952
Location: Lot 7, block l,
,',ell drilled: Oct. 1978.
Orilled by: ~¢a,yne Dot-ten.
Total d~oth. 110' l~i~e d'
. · za,neter:
Fz'odmction: 4-5 G?~¥[. ~;ta~;ic level:
Gravelly till
',¥eathered rock
0 24
2'4 36
'r DA~E RECEIVE[}
I NSPECTI ON APPel NTM ENTS
'~ME TIME TIME
-~-AT E DATE DATE
INSPECTOR -
INSPECTOR INSPECTOR
MUNICI~*gNCHO~GE
-- u~,l. oF I: "!iii &
MUNICIPALITY OF ANCHORAGE ~NVIRONM[NM.L
DEPARTMENT OF HEALTH · ENVIRONMENTAL PROTECTION
825 L Street- Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER ~ PHONE
MAILING ADDRESS
~OPERTY RESIDENT (if different from above) PHONE
2, BUYER PHONE
MAILING ADDRESS
~ LENDIN~ IN~TITUTIO~ I -- I PHONE
~AI LING~D~RESS~
4, REALTOR/AGENT ~ PHONE
I
MAILING ADDRESS
LEGAL DESCRIPTIONz
6. TYPE OF RESIDENCE
~_~SI NG LE FAMILY
[] MULTIPLE FAMILY
7l WATER SUPPLY
~,~l.-~ I N DIVI DUAL*
COMMUNITY
[] PUBLIC UTILITY
NUMBER OF~BEDROOMS
[] One [] Four [] Other
[] Two [] Five
,/~ Three [] Six
* ATTACH WELL LOG; A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[~/SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[~/"iNDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEW. AGE DISPOSAL SYSTEM PERMIT NUMBER
[](t'¢JDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY ~':~[: 7 ~
Connection Verified INSTALLER
[~]~'~tic Tank or [] Holding Tank
Size: /¢ ~)~ (~ If Tank is homemade SOILS RATING
give dimensions: / ,~- ~b
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
72-010 (Rev. 6/79)
'~UNICIPA(.ITY (;; ' ~ .... .
zxN( r~ORAGE
Telephone 2644720 -'
MUNICIPALITY OF ANCHORAGE ~EPT. q;, . =:I &
13EPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION,vl;.LU ..;,, .':t ,\._ ;i ~.h !!CT!Oh(
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
DIRECTIONS: Complete all parts on page 1. Incomplete request~ will not be processed. Please allow ten (10) days for processing, PHONE
...OPERTY OWNER .3
MAlt. lNG/~R ESS ~
~ROPERTY RESIDENT (If different from above)
PHONE
PHONE
3AILING ADDRESS
/,7
3. LENDING INSTITUTION
·
PHONE
PHONE
~ 7q
REALTOR/AGENT
MAILING ADDRESS
5. LEGAL DESCRIPTION
'7 ,gzK /
STREET-LOCATION
S. TYPE OF'RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] One [] Four
[] Two [] Five
~ Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all w'ells drilled
· since ,June 1975. For wel!s drilled prior to that date, give well
depth (attach log if available.) C~ ~,q c~ ~¢~ ~
**If individual/on-site, give installation date .~'¢./O~. i/qO'¢~
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72.010(3/78) :"~'b
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
, INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO .[] FOUR [] SIX
2. WATER SUPPLY PERMIT NUMBER
[] INDIVI DUAL "DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED ('~/
,3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
I--1 INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified "iNSTALLER
[]Septic Tank or []Holding Tank
Size: (O~O If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER ~_~
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line ~ Nearest Lot Line
WELL TO:
I
Absorption Area to nearest Lot Line
5. COMMENTS
[~]-/APPROVED FOR _~-~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE I BY (Title)
LEGAL DESCRIPTION
72-010 (Rev, 3/78)
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE.
¢~--..~:~-L--. DEPARTMENT OF HEALI'H & ENVIRONMENTAl. PROTEC'I'ION DEPT. C:.: j~':~,.",Ll",-I &
825 L Street - Anchorage, Alaska 99501 ENVIRONh,'~:NL ,L ,":,. ~'.CTION
~4r;~ ENVIRONMENTAL ENGINEERING DIVISION
%%~¢~1 T~lephono 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE~[~'['_[~B
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
~F~-~F~'E~7 ........ ~ ..................................................................... l PHONE
MAILING ADDRESS
MAILING ADDRESS
LENDING INSTITUTION
PRONE
MAILING ADDRESS
4. REAL¥OR/AGENT
PHONE
MAll_lNG ADDRESS
5. LEGAl. DESCRIPTION
~6~, TY¢FF¢O~ 'RES[DEN~ NUMBER OF BEDROOMS
El] One E] Four
[~SI N G L E FAMILY [] Two [] Five
[] MULTIPLE FAMILY [~ Three [] Six
Other
WATER SUPPI.Y
[/_,~ INDIVIDUAL~
I~ COMMUNITY
PUBLIC UTILITY
8, SEWAGE DISPOSAL SYSTEM
fL,~k-~j N pi Vi DI.JAL/ON-SITE*~
F_.-J PUBLIC UTILITY
* ATTACH WELL LOG. A well loft is requited for all wells drilled
since June 1975, For wells drilled prior to that date, give well
If individual/on-site, give installation dar
If system is over two (2) years old af~ adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
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