Press Alt + R to read the document text or Alt + P to download or print.

No preview available

The URL can be used to link to this page

Home My WebLink AboutTUNDRA JEWEL RANCH LT 4Tundra Jewel Ranch Lot 4 #051-193-13 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201128 PID Number: 051-193-13 Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade Name Danelle Jefson & Frank Vieth ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 23030 Sherman Street Chugiak, AK ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 688-9433 4 EXISTING GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Tundra Jewel Ranch 4 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Fe Ft. Well >100' N/A N/A N/A >25, TANK N Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1,250 Gal. Surface Water >100' N/A N/A N/A Material Number of compartments Lot Line >5' N/A N/A N/A NA Plastic 2 Foundation >1 0' N/A N/, N/A LIFT STATION Manufacturer - Capacity Remarks Tank Only Permit. Gal. Alarm location Electrical installed by PIPE MATERIAL House to tank D3034Tank to D3034 drainfield Installer ARM Services Drainfield D3034 CO/MT D3034 Inspector J. Millette BENCH MARK (Assumed elevation) 100.0 ft Ist 7/1/20 Inspect Location and description 2 ndion Bottom of siding. 3`d 4th ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineers Stamp Approval: Date iConditional ••' �� 49th ........ .e°s.un-1 .....r, nouwn un...so.mm..0 av..nw MICHAEL aE.. .ANeDnERSGnN A NoCE-4381 ; All Septic System Date ,•p. •u•.0, 8/7/20 0Approved +�F Note: this does include approval not well permit requirements. tKev 05weri 6) NOTES: ASPHALT P'AVE'MENT ANP] CONCRETE IMPROVEMENT LOCATIONS AIRE APPROXIMATE DUE TO SNOW COVER. THE RECORD PLAT DOES NOT LIST ANY BEARINGS. NORTH AND EAST WERE HELD. _... __ IL-------- _-- SHERMAN STREET 138' MORTGAGE SURVEY x SCALE _ 1" - 3D' _ GRID _ NW 1 159 Project No. _ 2--1451AMJ�_ q 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 - Lang & H s s o C{ a f P S, inc. (907) 522--6476 Phone . (907) 522-4625 Fox � F q� Professional Land Surveyors kenolangsurvey.com' jonafhanOlongsurvey.com��'' I hereby certify that I have surveyed the following described property - LOT b, TUNDRA JEWEL RANCH SUBDIVISION (Plat No. P-581) Anchorage Recording District, Alaska, and that this Mortgage Location Survey is a representation of the conditions that were found on the date the survey was performed. This survey does not constitute a boundary survey and is subject to any Inaccuracies that a subsequent boundary survey may disclose. The Information contained hereon shall not be used to establish any fence, structure, or other improvements, Dated this the Day of at Anchorage, Alaska It Is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. 491H y� KENNFH P LANG, �� a� .�S-5202 , GO AECC95: �15,RROAD ESERVAT10N 0 - }} T 0 GRAVEL U')'? UTILITY POLE 0) WELL -� D!E ^--- 0/E D/E -- D/E -- - r� 7.5' x $,3'- D/E OD/E %OVERHEAT? UTILTfY LiNE / W1iH 7' EA5EMENT E�-D/E- -Z0" D/E p 0/E D/E -- j- 54.3' i` .-,i 0.2• 10,2'- SHED STORY RESIDENCE 12.0' x 12.0' DECK r WiTH DAYLIGHT V � Lot 5 10• BASEMENT I D, 35.3' 33.8' ,.DIr 3.2' CANT SEPTIC MANHOLE\ 1.8' x 2.4' CANT ` WOODEN FENCE M Lot 4 N SEPTIC PIPL% 16,161 s.f. fi Lot 20 60' MORTGAGE SURVEY x SCALE _ 1" - 3D' _ GRID _ NW 1 159 Project No. _ 2--1451AMJ�_ q 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 - Lang & H s s o C{ a f P S, inc. (907) 522--6476 Phone . (907) 522-4625 Fox � F q� Professional Land Surveyors kenolangsurvey.com' jonafhanOlongsurvey.com��'' I hereby certify that I have surveyed the following described property - LOT b, TUNDRA JEWEL RANCH SUBDIVISION (Plat No. P-581) Anchorage Recording District, Alaska, and that this Mortgage Location Survey is a representation of the conditions that were found on the date the survey was performed. This survey does not constitute a boundary survey and is subject to any Inaccuracies that a subsequent boundary survey may disclose. The Information contained hereon shall not be used to establish any fence, structure, or other improvements, Dated this the Day of at Anchorage, Alaska It Is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. 491H y� KENNFH P LANG, �� a� .�S-5202 , GO AECC95: MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http:l/www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201128 Work Type: SepticTank Upgrade Tax Code Number: 05119313000 Site Legal Address: TUNDRA JEWEL RANCH LT 4 G:1159 Site Mailing Address: 19448 WILDWOOD DR, Chugiak Owner: JEFSON DANELLE P & Design Engineer: FORGE ENGINEERING This permit is for the construction of: 171 Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: 5/27/2020 5/27/2021 16161 ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either. a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: '� J Issued By: Date: �� 7 Date: 4 PO BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) May 20, 2020 MOA Development Services Department On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Tundra Jewel Ranch, Lot 4 – 23030 Sherman Street Septic System Design Dear On-Site Services Engineer: The septic tank serving the 4-bedroom home on the property has exceeded its useful life and must be replaced. We are submitting this request for a tank replacement permit. The attached site plan identifies the location of the home and the well, septic location and proposed septic tank site. No conflicts exist between this proposed site and any other well or septic system on this lot or adj acent lots. Wells on this and adj acent lots are shown. The new tank will be a minimum of 100’ from all wells and surface water, and more than 10 feet away from any permanent foundation. The proposed site is more than 5’ away from any deck or stair supports. Please refer plan sheet for the septic design. If this design is followed, there will be no adverse impacts to adj acent properties. Sincerely, Michael E. Anderson, PE 5/20/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201128, Rebecca Carroll, 05/27/20 CO 10050 0 FEET 1"=50' 4-BDRM HOME NOTE: NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS. CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND TUNDRA JEWEL RANCH SUBDIVISION, LOT 4 SHERMAN STREET 5/20/20 WILDWOOD DRIVEEXISTING WELL EXISTING WELL EXISTING WELL EXISTING WELL DECOMMISSION EXISTING 1,250 GALLON SEPTIC TANK PER MOA CODE. PLACE NEW 1,250 GALLON SEPTIC TANK w/20" MANWAY. MHSV 2CO CO EXISTING ABSORPTION TRENCH TO REMAIN IN USE. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201128, Rebecca Carroll, 05/27/20 MUNICIPALITY OF ANCHORAGE y DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 1 ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 - ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT / NAME !//CA'✓S ^� - N I-WDLE P� 2ZJ A WW NEW MPGRADE MAILING AD SS 0. S iron o -z d-Dk z 0/1zc !ez4'. Y , LEGAL DEStRIPTION (l AJ0 /2 i3 ELc/CL [_ LOCATION NO. OF BED OMS DISTANCE TO: Wely� ?/ /[J Absor ey-f, Dwelling_ (f. � PERMI,ZND� `-- v �Y A.1-2 Manufacturer M e / No. of com mems W� V) Liq. each in allons G IF HOMEMADE: Inside length Width Liquid depth Y DISTANCE TO: Well Dwelling PERMIT NO. .JazA In Manufacturer .. Material Liquid capacity in gallons DISTANCE TO: Fou ryja / WX)0 z Nearest in PERMIT N = 2 No. of lines / Length e�fh Ijha/, Total 1!n f Ynat Trenr, , idth I•r Distance b-r.{wee lines H W ` L •- c- cS 0 inches N �7 H Top of til tcifinj� grade t9rial be ath the / LL 2 Total effectiv b ption area —2 L inches �ZJ Length Width Depth PERMIT NO. tu t7 a d W Type of crib 4y1b dia et Crib depth — Total effective absorption area V) Wel Building foundation DISTANCE TO: Nearest lot line J CIay6 / C/ it pt ( er V Distance to lot line PERMIT NO. J W � DISTANCE T0: Building fou ation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS G SOI L T ST RATI IyG� Z go O 0 INSTALLER` ' O� REMARKS / G IV. t I No. 1457-E Z-P., ." . .V `• "Y fOY••1.N1•. �. t.V _ eA�?OFE'5S1 1� APP D DATE. LEGAL ... $ & F:�RINgERJNG W 1pnv 74 (Rev. 3/78) Phf• 6 7J C-0577 ^ _ .MUNICIPALITY OF ANCHORAGEk) Department( I Health and Environmenta.?rotection N J/ 825 L Street, Anchorage, AK. 99501 264-4720 PermitHANDWRITTEN PERMIT •. r , WELL AND/OR N -SITE SEWER PERMIT Applicant: 010%(% &AC11_CbU0F/ Mailing Address: Location:/Phone Number: / 6�8" ZZy Legal Description: G-7 TOU01?4 Type of Soil Absorption System Is: LL Lot Size: Trench: '_ Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: ¢ Soil Rating(sq.ft/br) Z ✓l_ The 13-quired Size of the Soil Absorption System Is:' DEPTH LENGTH `7 2 GRAVEL DEPTH WIDTH 3`a The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = 21's GALLONS Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * *.* TWO(2) INSPECTIONS ARE REQUIRED'* Backfilling of any system without final inspection.and approval by this departmen will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee for a private well or 150 to 200 feet from a public well depending upon the type of.public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. -Specifications and construction diagrams are available to insure proper.installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 3 3 I certify that.:' (1) Lam familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will1 stall t system in accordance with codes. (3) I unQer d t t the on-site sewer system may require enlargement if th re e' s remodeled to include more that 3.bedrooms. Signe v Issued by: plicant Date: SWP/024(1/81) municipality of Anchorage n POUCH 6-650 ANCHORAGE, ALASKA 99502-0650 (907)264-4111 TONY KNOWLES, MAYOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION <Permit #: 820998 January 31, 1983 TO: Permit Applicant Subject: Lot 4 Tundra Jewel Ranch Subdivision A permit issued by this department for an individual well and/or on-site sewer system has expired as of December 31, 1982. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal Ordinance. If you have drilled the well, a well log needs to be sent to this department for documentation of the installation date and to close the permit. If a private engineer inspected the installation of the on-site sewer system, please have them send us the as-builts for our files and documentation. If there are any further questions, please call this office at 264-4720. Sincerely Robert C. Pratt, R.S. Acting Program Manager Sewer and Water Program RCP/ljw enc: Copy of Permit SWP/057 MUN I O I [;DfRL_ I TV OF At,7GH�`tRAiGE �2� DEPARTMENT C HEALTH AND ENVIRONMENTAL .OTECTION 825 'L' STREET, ANCHORAGE, AK. 99501 `.. 264-4720 Or-J—S I TE SE4•JER F=*ERM I T PERMIT NO. C 820998 > APPLICANT JAN BLACKBURN BOX 521 CHUGIAK 99567 688-2201 LOCATION 1 LEGAL L4 TUNDRA JEWELL Rc�uch 10. LOT SIZE 99999 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER. OF BEDROOMS = 4 SOIL RATING CSQ FT/BR>= 125 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: C?EF=`TH= :3-0 LEtJGTH= 42 (3FZf=i%.0EL— E>E:F="TH= 1S THE LENGTH DIMENSION IS THE LENGTH CIN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS 140 SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION CIN FEET). REQLJ I REF> SEF='T 10 Tf=l "K S I =E= 1255 F3 GALLONS PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. --- TWO C 2? ARE REQU I FIEF? --- BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY ON—SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F=ERM I T FEE :,4F=n I RES [>ECCEMBER :3:::L.- :i_S�S2 i I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELLS AS SET I FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON—SITE SE14ER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED: ISSUED B' V4. 0 SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 0 PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: �J lrJ l ac e bar tA DATE PERFORMED: 2, LEGAL DESCRIPTION: L-- T ��l /% o /s/i J cGy -C L 1 F PPTjI SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9 10 • 11 12 13 14 15 16 17 18 19 20 COMMENTS Snows' ®r,,a�■ Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT Gs 3n Z SRB PERFORMED BY: s'.r. ;t Al_Ask,& �� CERTIFIED By/ DATE: ' i 1-2�TJ 72.008 (6/79) PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW920287 DATE ISSUED: 9/15/92 DESIGN ENGINEERS & S ENGINEERING EXPIRATION DATE: 9/15/93 OWNER NAME:BLACKBURN JAN OWNER ADDRESS:P.O. BOX 670530 CHUGIAK, AK 99567 PARCEL ID:05119313 LEGAL DESCRIPTION: TUNDRA JEWEL RANCH LT 4 LOT SIZE: 14097 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: THIS PERMIT COVERS THE WELL DRILLED ON THE SUBJECT LOT ON 2/13/86. THE WELL LOG IS NOW ON FILE. RECEIVED BY: DATE: ISSUED BY : `, U� DATE: �'�� o O O !� �^ N`� S' O� 10.400'E /02.23' lt� •, o r'rq `� : •. 114 10 12�1 CA 2 r w zvl —I— 39 _v A c� �� ti itis . to L4 s C� n I z C I N O" W /o2.a7 I t�a� vco � N Z Or J4(14 Ju o ftk -CD CO+10 im "r , ! I oCRa coco co tv T Is Er © lt1 70 i( w C n1 aco p o a 1 •iti±O,t'eg 'T1 co co -4 ti 45 NtQ .+. Ci \ u i i ry O B. v t o p�a yoR a •:� cq" 0..! iL o« ay . Er t rx -a cM tv i0 P pa rA 9 lx7 M O � tis O o .o 0 0 o n o a a o 0 : 1 f O i _ sia so w i sra 1r(J ? t••. i. � �o i i N }� ; w �� i o i. t •t - i t ! i 0 0 0 0 0 0 0 0 0 0 0 0 sj • i i � i i0 i f j � i i :a M n � i �� ;•: i Y ;a �. : in iA i~ r iY f ice• •V H . )'3 i cy ?�' j•i N i tb7 !W n n M f • t.: 10 I W : V :.• ?3 r. :i %-0 rt ti K � n z x x x x� x x z A y z O O O O 0 O O O 1 t I i ! •4 H H -; .•a .a H •-; H H H C O O O O O O O O O O O 3 t jRkEIVED i i StP+9944 ° [ an,cjlaitc=y ot, nctkbragb i bept. Health & Human Services i M fr' H v 2 7� O V tis O :ry [ F hf � : 1 f O i _ N LA ii so w i •A i • i i 3:� s i. t •t - i t ! i 0 0) X. C Cm w> (D D A 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 Parcel I.D. 051-193-13 Legal description TUNDRA JEWEL RANCH LT 4 Site address 23030 SHERMAN ST Chugiak AK Current property owner(s) WHITLOCK Expiration Date: 5/11/2025 X The On -site system(s) is/are approved for 4 bedrooms Conditional approval for Comments or advisories: LIZZ bedrooms, with the following stipulations: Original Certificate Date: 7/10/2024 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) islare in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approvaijune 2022 Certificate of On -Site Systems Approval Application �%Wo ��. 1� 4 41 1. GENERAL INFORMATION Parcel I.D. 051-193-13 Complete legal description TUNDRA JEWEL RANCH LT 4 Location (site address) 23030 SHERMAN ST, CHUGIAK AK Current property owner(s) WHITLOCK Day phone 2. ON -SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: * Private Well ❑ Private Well serving 2 dwelling units El Private Well serving 3+ dwelling units R Community Well or Public r-71 water Storage 4. TYPE OF WASTEWATER DISPOSAL: [JE-1 Private Septic R Private Septic serving 2 dwelling units F-I Holding Tank F1 Community Septic or Public Sewer 5. SEPTIC TANK: nE Steel R Plastic [:] Concrete 11 Fiberglass Age 4 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: Fj AWVVTS ❑ Bed IN-] Deep Trench Fj Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: F 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 $ _650 Date of Payment 2o 2 Z COSA# 4 2_ Waiver Fee $ Date of Payment Waiver # COSA Application —June 2022 COSA Checklist Legal Description: TUNDRA JEWEL RANCH LT 4 Parcel ID: 051-193-13 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _ A. WELL DATA X Well log is filed with Onsite (or attached) Date drilled 2/13/86 Total depth 253 ft Cased to 253 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 5/11/24 Static water level at beginning of test 214 ft. Comments B. TANK DATA Measured operating fluid level in septic tank 48 Date of pumping 5/11/24 ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 914182 ❑ ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade *6 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑ Monitor tubes go to bottom of effective. If not, state depth into effective **48" ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Well production at time of test 3+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes 1011 No Q Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date 7/5/24 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 5/11/24 Results Q Pass Fluid depth prior to test 0 in Water added 600 gal New fluid depth 1 in Elapsed time 1440 min Final fluid depth 0 in Absorption rate 600 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 72 in Effective depth used 24 in Effective depth remaining **48 in Comments/Deficiencies: *CO/MT HAS FILLED UP THE BOTTOM 2' OF PIPE, ALL STAND PIPES PRESENT ** ACCOUNTING FOR THE 24" IN THE MT/CO... COSA Checklist June 2022 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100' Q Yes if No ft FO-1 Yes if No ft Neighboring Tank > 100' no Yes if No ft Private Sewer/Septic Line > 25' Q Yes if No ft Absorption Field on Lot > 100' M Yes if No ft Holding Tank > 100' Q Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' Q Yes if No ft Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' E Yes if No ft rml Yes if No ft ❑ N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Fleld(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q Yes if No ft Surface Water > 100' 0 Yes if No ft Tank to Property Line > 5' Field to Property Line > 10' Water Main > 10' Water Service Line > 10' []o Yes if No ft ❑ Yes if No *0 ft Yes if No ft (j Yes if No ft Wells on Adjacent Lots: Private Wells > 100' Community Wells > 200' Foil Yes if No ft 0 Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS * SEE MOA WAIVER, ALL STAND PIPE PRESENT G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, 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 /4/ 1,%c 6t.An a cr, oq Phone 727-8864 Engineer's Printed Name 4 u 4-r, (F_, Date 7 / 4-I t .. \ r, fi�.w 1• Y •� of ♦ ffwfwl.wf'1 wwl/iwwff♦ .d 'w MICHAEL N. ANDERSON ;� /0 �� ti '. C 9469 , •wwww• COSA Checklist June 2022 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 051-193-13 Certificate of On -Site Systems Approval Expiration Date: J 1. GENERAL INFORMATION Complete legal description TUNDRA JEWEL RANCH LT 4 Location (site address) 23030 SHERMAN ST, EAGLE RIVER AK Current property owner(s) JEFSON Mailing address PO BOX 1591, PALMER AK Real estate agent 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Q Private Septic Q Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ 550 Waiver Fee $ _ Date of Payment ._ Ll A oh -z_ Date of Payment Receipt Number 020"�5I COSA # Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 4-92-22 6. DSD SIGNATURE #04* • C it 41!j i ,r .. . .... . ... • •.• .. . . . . System #1 Approved for 4 bedrooms System #2 Approved for bedrooms ' .. Disapproved N Conditional approval for bedrooms, with the following stipulatit''aq ``�.� OF A* r(, WATER AND WA� M SERv By: CGvt &;,2 iM Original Certificate Date: 2/,�0�2 _91 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet 0 _, Legal Description: TUNDRA JEWEL RANCH LT 4 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 2113/86 Total depth 253 ft Cased to 263 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 3111/22 Static water level at beginning of test 214 ft. Comments B. TANK DATA Age of tank(s) 2 years Tank type/material Measured operating fluid level in septic tank 48 ❑ Standpipes/foundation cleanout per record drawing Date of pumping NEW TANK D. ABSORPTION FIELD DATA Parcel ID: 061-193-13 Structure served by this system Well production at time of test 3.3+ gpm Water storage tank volume -0— gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 3.53 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 3/11/22 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Which system tested (date installed) 9/4/83 Adequacy test date 3/11/22 ❑ ALL standpipes present per record drawing Results ❑✓ Pass For 4 bedrooms Total measured depth from grade 12 ft (max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade *6 ft (min) Water added 600+ gal ❑ N/A – pressurized field New depth 0 in ❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 1440 min depth into effective ❑ Code -required soil cover over field Fina! fluid depth 0 in ❑ System presoaked Absorption rate 600 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) Gallons introduced 0 gallons If yes, enter date Comments/Deficiencies: CO/MT HAS FILLED UP THE BOTTOM 2' OF PIPE, ALL STAND PIPES PRESENT CASA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Q Yes Community Sewer Manhole/Cleanout > 100' O Yes if No _ It O Yes if No ft Neighboring Tank > 100' Q Yes if No _ ft Private Sewer/Septic Line > 25' ❑✓ Yes if No _ ft Absorption Field on Lot > 100' E] Yes if No _ It Holding Tank > 100' 23 Yes if No _ ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' 0 Yes if No _ ft M Yes if No It if No _ It _ Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 0 Yes if No _ ft ❑✓ Yes if No _ ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No _ It Surface Water > 100' 0 Yes if No _ ft Property Line > 5' Q Yes if No _ ft Wells on Adjacent Lots: Absorption Field > 5' ❑ Yes if No _ It Private Wells > 100' ❑✓ Yes if No _ It Water Main > 10'✓❑ 0 Yes if No _ ft Community Wells > 200' Yes if No _ It Water Service Line > 10' F/1 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' 0 Yes if No _ It If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No *0 ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No _ ft Private Wells > 100' Yes if No _ ft Water Service Line > 10' F/1 Yes if No _ ft Community Wells > 200' Yes if No _ ft Surface Water > 100' 0 Yes if No _ It F. ENGINEER'S COMMENTS * cFF nnnA tA/Al\/FR AI I STANn PIPE PRESENT 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. COSA Checklist yellow sheet Municipality of Anchorage • s� - On -Site Water &Wastewater Program (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-193-13 Expiration Date: J 1. GENERAL INFORMATION Complete legal description TUNDRA JEWEL RANCH LOT 4 Location (site address) Current Property owner(s) Mailing address Real Estate Agent 19448 WILDWOOD DRIVE *CHUGIAK, AK 99567 MATTHEW TEEL Day phone 19448 WILDWOOD DRIVE *CHUGIAK, AK 99567 ANN ROBERTS W/ PRUDENTIAL Day phone 2. TYPE OF DWELLING: Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: 230-5980 TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual On-site IN Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ Received by: d'� COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 4�qD Date of Payment a 01 -y -I 3 C Receipt Number 01251_ s %% —�_ COSA# 0SC\3113(03 Date: s' 3 Waiver Fee $ I SSD Date of Payment 'A Receipt Number bani 1 Waiver# O f) 13 baA 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. i further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's. Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 6. DSD SIGNATURE �G System #1 Approved for bedrooms. System #2 Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following 337-6179 Date 3-7 t OF y.. a 795 0 ` The Municipality or Anchorage Develop, emt 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. ATTCHMENTS: COSA Checklist Septic System Advisory Nitrate Advisory Arsenic Advisory Well w Advisory Other By' (Rev 11105) Original Certificate Date: OF ��' ON-SITE �� MATER AND �o WASTEWRTER o� The Municipality or Anchorage Develop, emt 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. ATTCHMENTS: COSA Checklist Septic System Advisory Nitrate Advisory Arsenic Advisory Well w Advisory Other By' (Rev 11105) Original Certificate Date: If more than 1 septic system is on the lot: COSA Checklist # _of_ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: TUNDRA JEWEL RANCH LOT 4 Parcel ID: 051-193-13 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (YIN) YES Date completed 2/13/86 Sanitary seal (Y/N) i t S Wires properly protected (Y/N) N G S Total depth 253 ft. Cased to 253 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 2/13/86 12/27/12 Static water level 223 ft. 211 ft. Well production 5 g.p,m, 3.84+ g,p.m, WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 3.57 mg./L. Collected by: GEG. Ltd. Arsenic: ND ug./L. Date of sample: 12/28/12 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 9/4/83 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 12/21/12 Pumper JRS PUMPING C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE Date installed 9083 Soil rating (g.p.d./ft`or/bdrm 125 System type TRENCH Length 42 ft. Width 2.5 ft. Gravel below pipe 6 ft. Total depth *11.83 ft. Eff. absorption area 504 ft2 Monitoring tube **YES Depression over field NO Date of adequacy test 12/27/12 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 0 in. Water added 1080 gal. New depth 12 in. Elapsed Time: 150 min. Final fluid depth 5 in. Absorption rate >_ Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE **SUMP ONLY EXTENDS 47" BELOW THE INVERT OF THE DRAINFIELD. If yes, give date _ g. p. d. D. LIFT STATION Date installed Size in gallons Manhole/Ac cess (YM "Pump on" level at in. "Pump off" Level High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAift station on lot *95 On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main Sewer /septic service line Public sewer manhole/cleanout N/A Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line *0' Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parkingtvehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *SEE ATTACHED WAIVER REQUEST \.fin C)S � \ �%D 2-4 G. ENGINEER'S CERTIFICATION r certdythat I have determined through field inspections and �' T review of Municipal records that the above systems are in ..... conformance with MOA COSA guidelines in effect on this ...... ...... date. Q fr A. Garn s: Engineer's Printed Name JEFFREY A. GARNESS �O 9 E ;LIa7/13 �Op .)� 1.'. 0.�c��oa Date 4n_aA_ _ o (Rev. 11106) 4� t ASBUILT SEWARD & 1 HEREBY CERTIFY THAT I 1 AVZ SURVcrEU TSE SCBE" FOLLOWING DESCRIBED PROPERTY: 7�z+ nk.V.r�✓� . 44-4g,v�5 � AND THAT NO FNCR HMENTS UIST EXCEPT AS / INDICATED. IT 1S THE RESPONSIBILPTf OF THE )',AN, ER TO DETERMINE THE EXISTENCE OF ANY GRID- RIDSASE -EASEMENTS, ENTS, COVENANTS, CR RESTRICTIONS rc'6v //sr HHICH DO AICT APPEAR ON THE RECORDED SUBDls /]SION PLAT UNDER NO CIRCUMSTANCES SHOULD FB* Ash" DATA mvwN BE u aED FCR cowrRUCTm 3F FENCE LINES, OR FOR ESTABLISHING BOUND- FAQ Dvaea Mazk Seward L � d Municipality of Anchorage P.O. Box 196650 0 4700 Elmore Road Anchorage Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997 http://www.muni.or_q/Onsite Development Services Division On -Site Water and Wastewater Program n,rne s Department **** VARIANCE/WAIVER REVIEW **** Waiver#: OSP131024 COSA#:OSC131063 Permit#: PID#: 051-193-13 Legal Description: Tundra Jewel Ranch, Lot 4 Engineer: Garness Engineering Group Applicant: Mathew Teel Your request for a waiver of the required 100 feet horizontal separation from the septic tank to the private well has been approved. The approved separation distance is 95.0 feet. Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 0.0 feet. This waiver approval applies to the existing system only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. ® The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of non -objection have been received from the owner(s) of the affected adjacent property. ❑ Adjacent properties are not affected by this waiver. .................................. a... a......................00.00............. Waiver is Granted: X Waiver is not Granted: Date: /s 3 Approved IAC Name of Reviewer ..................................................................0000......... Rec#: 08241G Amount: $1,050.00 Date Paid: 2/28/2013 f February 26, 2013 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Rd. P.O. Box 196650, Anchorage, Ak 99519-6650 (907)343-7904 Ref: Lot Line & Well to Septic Tank Waiver Requests for Tundra Jewel Ranch; Lot 4, To whom it may concern: LOT LINE WAIVER REQUEST: We request that your department issue a 0 foot lot line waiver from the south property line to the existing drainfield. The existing drainfield on Lot 4 has a separation distance of approximately 0.5 feet and neighboring property (Skyline View Estates; Block 2, Lot 20) has a separation distance of 10 feet per moa records. In short, the drainfield on the subject lot has a separation distance of at least 10 feet to the drainfield on the neighboring property. WELL TO SEPTIC TANK WAIVER REQUEST: The well on the subject property is approximately 98 feet away from the existing 1250 gallon septic tank on the subject property. We request you grant a 95 foot separation distance waiver from the well on the referenced property to the septic tank. The following items are justification for the waiver: • The well and septic system are on opposite sides of the house. If effluent were to surface, it would be unable to travel back towards the well head. • The existing encroachment has existed for over 17 years. • Attached is the well log for the referenced property. The well depth is 253 feet. The soil appears to be variations of gravel, sand, and some clay. • We are only asking for a 5% variance. • Recent water samples results indicated no bacteria present and nitrate levels to be 3.57 mg./L. In short, the water quality is within MOA, state, and EPA requirements. Based upon the aforementioned facts, it appears that there is minimal risk associated with the granting of these waivers. We are unaware f any adverse impacts this waiver would have on adjacent wells or septic systems. If you have any u t��s, please contact us at 337-6179. Thank you for your assistance. .E., M.S. 3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507-1259 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengincering.com SHERMAN St et \ 100 FOOT WELL RADIUS ^^—/ r. TUNDRA JEWEL EXISTING 4 EJ RANCH LOT 5 \ BEDROOM HOUSE w HE SHED6 a HI 3 J ED TRENCH ORI \ ORIENTATION B OCK 2,EOT iDi� F SKYLINE VIEW S/D; BLOCK 2, LOT 20 SKYLINE VIEW S/D; BLOCK 2, LOT 12 � GARNESS ENGINEERING GR®U9 Ltd. p 4CONSULTANTS & CONTRACTORS *I 3701 E. 1000R ROM, SURE 101 • MCMWE. M 9 507 PHIXE 90)Jt-6179 (gO38 3NJ24WEBSITE xwx.gnme a nginaenng.com 0 ! Y� PREPARED FOR: PHONE NUMBER: PAGE NUMBER: MATTHEW TEEL 230-5980 1 OF 1 f A. Gar esS:' LEGAL DESCRIPTION: DRAWN BY: n� X40 TUNDRA JEWEL RANCH LOT 4 PNB e .'','coo �4� TYPE OF WORK: DATE rofessi000q� O WAIVER REQUEST 2/26/13 O�o0�0 Feb 26 13 09:16a Sullivan Water Wells 907 688 2759 p.2 ,— I V r !r/:J ff VU WCommunity Development\uevelopme, taerncesomiun�y �a��y �.,� �+w ••�_• •-••� ..v�w I Municipality of Anchorage Community Development Department 47DO Elmore St. • P.O. Box On -Site Water and Wastewater Program 196650 Anchorage, AK 99519-665D • http:ltwww.muni.org/onsite • (907) 343-7904 Well Decommissioning Log Legal Address: / �P Subdivision I u"C?�`� 'e,1 1 i- 9�(�i�L3 W lGl LJV&)d1 �a"�cBlock Lot 7 R Section I Lot On-site Water 8 Wastewater rogram certified contractor pertorming the well decommissioning � j. Vii• / �j' Name: / / // nom[Signature. Compan�c'�I �1 Well decommissioning date (� ✓ /I _ / Melhod ordecommissioning: AMC 1 5.5JA6OLi a. ❑ b. ❑ c. I Location: Use the spam below to provid�l • North arrow a drawing of the property showing the followmg items; Decommissioned well, • Other water wells on the properly, Two separate swing -lie distances Note: The swing -tie distances shall for each well shown ori the drawing, he measured from either permanent slmctures or the property comers. A JD L"Ie-Cc vv W e uJ e1� X e— yc� l �))) - -> L)6 o . 3 7 r rh/ ! ; I I rl nmmi�innmo form. one WCommunity Development\uevelopme, taerncesomiun�y �a��y �.,� �+w ••�_• •-••� ..v�w r 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. # 1'1S I - t 9 23 ' t �' HAA # VA Q01 Q fl!, 19. 1. GENERAL INFORMATION Complete legal description Lot 4; Tundra Jewel Ranch Subdivision Location (site address or directions) 23080 Sherman, Chugiak, Alaska Property owner Jan Blackburn Day phone Mailing address * P.O. Box 670530, Chugiak, Alaska 99567 688-2201 Lending agency Day phone Mailing address Agent Day phone . Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 4 '-� 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 XXX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 12.025 (Nev. 1191) From MOA X21 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 Address '7C34 Eagle River Loop Road No. 204 Exg!e River. Alaska 99577 Engineer's signature Date 6. DHHS SIGNATURE Approved for Disapproved. bedrooms. of '491H ;too ROGER I HAFER •i No. 8 15 0906 to 0fES5�a��' Conditional approval for bedrooms, with the following stipulations: Additional Comments itinr 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 theirlending 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. 72-0251Rev. 191) BaCk MOA 021 . -1 11 - - - .. ......... Municipality of Anchorage Department of Health & Human Services.. . HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: RA.,ie-A %Wcel I.D. A. WELL DATA Well type Vkthkft: If A. B, or C, attach ADEC letter. ADEC water system number....Its Log present&N) f Date completed Total depth —Cased to Casing height Sanitary seal q/N) Wires properly protected &N) FROM WELL LOG AT INSPECTION, uJ 0 Date of test 6 o Li6 LU < Static water level z 0 Well flow 4- LU 9 -P.M. 051. Pump level to &j� mb��C)R WW Iry ?o. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot rk On adjacent lots Absorption field on lot V6 On adjacent lots oo -k- Public sewer main Public sewer manhole/cleanout A. Ir Sewer service line 2 S Petroleum tank ZS WATER SAMPLE RESULTS: Coliform D COL. Nitrate pA Other bacteria Date of sample, Collected by: B. SEPTIC/HOLDING TANK DATA Date installed —Tank size 1250 Compartments 71 Cleanouts'(?iN)'�i'; Foundation cleanout O/N) Depression (YAQ High water alarm (YA —Alarm tested (Y/N) Date of pumping cl 7, Pumper 4 (L45e'pp6t.' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Je- Well(s) on lot A c>v> On adjacent lots —Foundation Toproperty line — Absorption field _Wa'ieFrhain'/servic*e line Surface water/drainage 0 72-026 (Rev. 7/91) Front (CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level a Manufacturer Manhole/Access (YA t "Pump off" level at _ Meets MOA. electrical cc /N) SEPARA DISTANCE FROM LIFT STATION TO: . , on lot - D. ABSORPTION FIELD DATA On adjacent lots Cycles tested Surface water Date installed 83 Soil rating Q— System type �rz,��e-ia Length 4'Ti Width 3DB Gravel thickness - �� Total depth In T66I absorption area �o'f ¢ Clea nouts present (SYN) Depression over field (Y/©) Date of adequacy test Results ( as fail) p�SS —for 6>(A9-%% bedrooms Peroxide treatment (past 12 months) (YQ �� gL! �� If yes, give dateJaI SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot lobtk Onadjacentlots 1c�1+ Propertyline S t To building foundation iy To elxisting or abandoned system on lot On adjacent lots 3fl t Cutbank`� Water main/service line 161 Surface water 1 (76 Driveway, parking/vehicle storage area 3ot� Curtain drain E. ENGINEER'S CERTIFICATION t I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect `00, Or A _ -% � P. �a, • ...... a •,qs�h as �491M , i....u•.u•uw•w•wi •• S & S ENGINEERING Signature 17C34 Eagle River Loop Road No.204 ase River, Alaska 99577 Engineer's Name Date HAA Fee $ j! 7 - - Waiver Fee: $ Date of Payment �1s_!� " 1 Date of Payment Receipt Number / Receipt Number 72-M (Rev. 3/91) Back MOA 21 of this inspection. )GCR JPHAFER ? f No. 15 � '� � f''•. ••a..•'