HomeMy WebLinkAboutEAGLE RIVER VALLEY RANCHETTES LT 12B ~'~,REATER ANCHORAGE AREA BOROUGH~'~
HEALTH DEPARTMENT CASE
327 EAGLE STREET ....
ANCHORAGE, ALASKA 99501
Performed F~r ~,~. '~-D~nk;.s ('~ C~=~,~ Date Performed I~-
This Fo~ RepoP=s a. Soils Los ~ -. · -Pe~cola~ion Te~
Depth
Feet
Soil Characteristics
Was Ground Water Encountered?
If Yes, At What Depth ....
Reading
Date
Gross Time
Minute
Proposed Installation: Seepage Pit
Depth Of Inlet ~,
COMMENTS: ~ r~ r, ~
Test Performed
Net Time
Location Sketch
floL ~l~o,,~. ~. 41,o ,.,est: ,
L-I---I~--I ~t---1~1 I' I
I ! I I I I I I, I
I I ! I J "1 ! I i
I ! !, !' I~ ] I I I
I.. II, I I ...... I,, I't !
Depth To H20
~ Drain Field
Depth To Bottom Of Pit Or TPench
Date:d"~ /~--~,- Fi')
Net Drop
M UHMPAUTY OF AHC HORAG
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. 050-222-31
1. GENERAL INFORMATION
Expiration Date: -7-` 7 -20-2- V
Complete legal description EAGLE RIVER VALLEY RANCHETTES LOT 12B
Location (site address) 18943 MAN 0 WAR ROAD, EAGLE RIVER AK 99577
Current property owner(s) JOSHUA MATTHEW ZANONI Day phone
Mailing address
Real estate agent
18943 MAN 0 WAR ROAD, EAGLE RIVER AK 99577
2. TYPE OF DWELLING:
❑ Single Family (w/wo ADU)
® Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
®
Public Sewer
❑
Waiver request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550
Date of Payment
Receipt Number 3 0'1
COSA# OSC9_q13� Y
Date:
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 7111122
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 •�i ^,Q
well and septic system. Therefore, any estimate of how long a system will function satisfactory ��P•'' !�
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &TH
F4105 .*
.. .......
6. DSD SIGNATURE
• . Curtis Huffman
System #1 Approved for bedrooms�s., CE 128991
lFR•.a/11/2z•'���
System #2 Approved for bedrooms ill��\\SSOW
Disapproved
Conditional approval for bedrooms, with the following stipulati ` k((((((((f/((
WTY OF
�J ON grrc
0 WATER AND m
PROER o
By: Original Certificate Date: -7
G
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
Legal Description: EAGLE RIVER VALLEY RANCHETTES KIT 12B Parcel ID: 050-222-31
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA — PUBLIC WATER
❑ Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) _in.
Date of flow test for COSA
Static water level at beginning of test _ft.
Comments
Age of tank(s) 24 years
Tank type/material SEPTIC / POLLY
Measured operating fluid level in septic tank 48"
® Standpipes/foundation cleanout per record drawing
Date of pumping 7/7/22 ONE STOP PUMPED
(S. FORK INSALLED POLY 130ON TANK 7/17/1998)
D. ABSORPTION FIELD DATA
Which system tested (date installed) 5/16/2003
® ALL standpipes present per record drawing
Total measured depth from grade 14.8 ft (max)
Measured depth to pipe invert from grade _ft (min)
® N/A — pressurized field
Structure served by this system
Well production at time of test _gpm
Water storage tank volume_ gallons
Well disinfected for coliform test? ❑ Yes ❑ Nc
❑ Coliform bacteria is Negative
Nitrate _mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by_
Date of Sample
C. LIFT STATION
® Required maintenance completed
Age of lift station 19 years
Lift station material STEEL
Comments: 500 -GAL LS INSTALLED 5/29/2003
(SERVICED BY LARY BETTS)
Adequacy test date 7/7/2022
Results El Pass For 4 bedrooms
Fluid depth prior to test 26 in
Water added 600 gal
New depth 38 in
® Monitor tubes go to bottom of effective. If not, state
depth into effective ASSUMED 11'ED Elapsed time <1440 min
® Code -required soil cover over field Final fluid depth 25 in
❑ System presoaked Absorption rate 600+ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test) If yes, enter date
Gallons introduced gallons FWC�
Comments/Deficiencies: �-k., ;p
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
® Yes
if No
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
❑ Yes
if No ft
Neighboring Tank > 100' ❑ Yes
if No
ft
Private Sewer/Septic Line > 25' ❑ Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No
ft
Holding Tank > 100' ❑ Yes
if No ft
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' ❑ Yes
if No ft
❑ Yes
if No
ft
ft
If septic tank is under driveway comment below
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑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'
® Yes
if No
ft
Surface Water > 100'
® Yes if No ft
Property Line > 5'
® Yes
if No
ft
Wells on Adjacent Lots:
® Yes
Absorption Field > 5'
® Yes
if No
ft
Private Wells > 100'
® Yes if No ft
Water Main > 10'
® Yes
if No
ft
Community Wells > 200'
® Yes if No ft
Water Service Line > 10'
® Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No
_ ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No —ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
PER PREVOIUS COSAs & MOA RECORDS THIS SEPTIC SYSTEM WAS INSTALLED PER ADEC STANDARDS
G. ENGINEER'S CERTIFICATION
I certify that l 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.
We
yk ; • 7H • ;stir
.. .. .... ..........
Curtis Huffman
�<sr,�•, CE 128991 •�`��.
MUNICIPALITY OF ANCHORAGE
Development Services Department
0�11�tftE
Phone:907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Lift Station/Pump Vault
Maintenance Log
Owner Street Address)
Septic Tank:
-Sludge level �/ ches *Pumping: required e� s'N o
Lstation:-Pumping completed es no
Lift
*Pump basket cleanedriesno
-Effluent filter cleaned es o
*Control floats cleaned •Proper float settings confirmed es no•Operation satisfactory
Alarm System:
-Dedicated electrical alarm circuit Yes no -Audible and visual alarm inside dwelling es no
-Alarm system operation satisfactory not satisfactory
Manhole Riser
-Ground water intrusion at riser to tank connection es no
-Ground water intrusion around pipe penetrations es no -Weep hole functional ve no
-Manhole lid: Functional a no Insulatedes no Properly Secure yes I no
Other
-All manufacturer required inspections and maintenance completed hes 1 no
Comments: ,,
Qualified Maintenance Provider:
Technician
Company
Signature
Date of maintenance,
ff
MUNICIPALITY OF ANCHORAGE
o�
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. 050-222-31
1. GENERAL INFORMATION
Expiration Date:
Complete legal description EAGLE RIVER VALLEY RANCHETTES LOT 12B
Location (site address) 18943 MAN 0 WAR ROAD, EAGLE RIVER, AK 99577
Current property owner(s) JOSHUA MATTHEW ZANONI Day phone
Mailing address
Real estate agent
18943 MAN 0 WAR ROAD, EAGLE RIVER, AK 99577
2. TYPE OF DWELLING:
❑ Single Family (w/wo ADU)
® Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
®
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550 Waiver Fee $
Date of Payment I 13 X6.2 2 Date of Payment
Receipt Number 6 3 10 1 Receipt Number
COSA # O S C q a l `i g Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name _CURTIS HUFFMAN, PE Date 7111122
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 �i
well and septic system. Therefore, any estimate of how long a system will function satisfactory ��Q; • • ' •!�
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting & F41CS % *. TM '.
/ . ... .. .........
6. DSD SIGNATURE
I / Curtis Huffman
System #1 Approved for lI bedrooms �r��F��s.• CE 128991 . AM
System #2 Approved for bedrooms �ll\F� RO POFESSI��"
Disapproved
Conditional approval for bedrooms, with the following stipulate l`�kk(((((((ff(((
gy OF
WATER A A►n
Original Certificate Date: 7 Z 6 — ;>
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
Ilk
Legal Description: EAGLE RIVER VALLEY RANCHETTES KIT 12B Parcel ID: 050-222-31
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA — PUBLIC WATER
❑ Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) _in.
Date of flow test for COSA
Static water level at beginning of test _ft.
Comments
B. TANK DATA
Age of tank(s) 24 years
Tank type/material SEPTIC / POLLY
Measured operating fluid level in septic tank 48"
® Standpipes/foundation cleanout per record drawing
Date of pumping 7/7/22 ONE STOP PUMPED
(S. FORK INSALLED POLY 130ON TANK 7/17/19981
D. ABSORPTION FIELD DATA
Which system tested (date installed) 5/16/2003
® ALL standpipes present per record drawing
Total measured depth from grade 14.8 ft (max)
Measured depth to pipe invert from grade ft (min)
® NIA — pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective ASSUMED LVED
® Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced_ gallons
Comments/Deficiencies:
Structure served by this system
Well production at time of test _gpm
Water storage tank volume_ gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate _mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by_
Date of Sample
C. LIFT STATION
® Required maintenance completed
Age of lift station 19 years
Lift station material STEEL
Comments: 500 -GAL LS INSTALLED 5/29/2003
(SERVICED BY LARY BETTS)
Adequacy test date 7/7/2022
Results R Pass For 4 bedrooms
Fluid depth prior to test 26 in
Water added 600 gal
New depth 38 in
Elapsed time <1440 min
Final fluid depth 25 in
Absorption rate 600+ gpd
Any rejuvenation treatment (past 12 months) N
If yes, enter date
__ FWES
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
® Yes
if No
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
❑ Yes
if No ft
Neighboring Tank > 100' ❑ Yes
if No
ft
Private Sewer/Septic Line > 25' ❑ Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No
ft
Holding Tank > 100' ❑ Yes
if No ft
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' ❑ Yes
if No ft
❑ Yes
if No
ft
ft
If septic tank is under driveway comment below
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑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'
® Yes
if No
ft
Surface Water > 100'
® Yes if No ft
Property Line > 5'
® Yes
if No
ft
Wells on Adjacent Lots:
® Yes
Absorption Field > 5'
® Yes
if No
ft
Private Wells > 100'
® Yes if No ft
Water Main > 10'
® Yes
if No
ft
Community Wells > 200'
® Yes if No ft
Water Service Line > 10'
® Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No
_ ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No —ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
PER PREVOIUS COSAs & MOA RECORDS THIS SEPTIC SYSTEM WAS INSTALLED PER ADEC STANDARDS.
G. ENGINEER'S CERTIFICATION
I certify that l 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.
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
Street Address Jy,3� vj ()"r,
-Sludge level inches -Pumping: requiredes no -Pumping completed gs no
Lift station:
-Pump basket cleanedtes
no *Effluent filter cleaned a no
-Control -floats cleanedno -Proper float settings confirmed (ap no
Operation satisfactory & no
Alarm Svstem:
*Dedicated electricalalarm circuit (�R no -Audible and visual alarm inside dwelling yes no
•Alarm system operation (atisfactor not satisfactory
Manhole Riser
*Ground water intrusion at riser to tank connection es no
,Ground water intrusion around pipe penetrations es no
-Manhole lid: Functional es no Insulated es no
Other
*Weep hole functionaltes no
Properly Securedes
•All manufacturer required inspections and maintenance completedes no
Comments:
Qualified Maintenance Provider:
Technician _: CC L,J �" cmc_ Date of maintenance1.065%AgX2
Company _<Z<?yq t ce S
Signature
Date 1S �' I
COSA Checklist yellow sheet
COSA Checklist
Legal Description: Parcel ID:
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date of Sample
Comments __________________________________________________________________________________
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA ______________________
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field
Monitor tubes go to bottom of effective. If not, state
depth into effective
Code-required soil cover over field
System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Adequacy test date
Results Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
Comments/Deficiencies:
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100’
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
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Property Line > 5’ Yes if No ft
Absorption Field > 5’ 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 septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10’ Yes if No ft
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
If absorption field is under driveway comment below
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
F. ENGINEER’S COMMENTS
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.
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org
Lift Station/Pump Vault
Maintenance Log
Owner Street Address
Septic Tank:
•Sludge level inches •Pumping: required yes no •Pumping completed yes no
Lift station:
•Pump basket cleaned yes no •Effluent filter cleaned yes no
•Control floats cleaned yes no •Proper float settings confirmed yes no
•Operation satisfactory yes no
Alarm System:
•Dedicated electrical alarm circuit yes no •Audible and visual alarm inside dwelling yes no
•Alarm system operation satisfactory not satisfactory
Manhole Riser
•Ground water intrusion at riser to tank connection yes no
•Ground water intrusion around pipe penetrations yes no •Weep hole functional yes no
•Manhole lid: Functional yes no Insulated yes no Properly Secured yes no
Other
•All manufacturer required inspections and maintenance completed yes no
Comments:
Qualified Maintenance Provider:
Technician Date of maintenance
Company
Signature Date
*/41&$5*0/#:$.&/(*/&&3*/(4&37*$&#:"306/%5)&$-0$,16.1*/(456$,'-0"5
$033&$5&%
. . ~: ........ ; . ~ ~ .... ,DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION '
, ':~ :' r': ~ '~,..?' '!:'-":* ......~, ~DIVISION OF ENVIRONMENTAL HEALTH~'.'.~::!?'
-7',.:: , ;:' i' ' "~ CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAl~:':
; ~ ' ' : '' ]:: r' I : .... "'~ . OF ON-SITE SEWER AND WATER FACILITY
::' :(a) Legal DeScriPtior~ (include lot, block, subdivisiOn, sectior~, t~Wnship,:range)
~ Location (address or direction .' ,' ,' ' :
(b)
Applicant Name
Applicant Address
Telephonel Home ' ~94-~770 ' ' ' Business ..~7~-4~
P. 0. Bo~ 77-£992, E~g[e I~v~, A~6~ 99577 .Ezt, 224
(c) Applicant is (check'one): Lending Institution []; Owner/b'uilder ~; Buyer []; Other [] (explain);
(d)
(e)
:.
Lending Institution ..~C~.,c,c,c~f ru.c,cO,cC '' Telephone
Address AYLC/tO.&~P_., A~ct6ka. - ATTENTZON: Bob He,66
Real Estate Company and Agent
Address
Telephone
(f) ,X/J~3 the HAA to the following address:
S i S Eng~n~e. ring
SRB 196X
EaglcRZuer, R~t6~t 99577
2. TYPE OF RESIDENCE
Single-Family []~ Multi-Family []
Number of Bedrooms 4
WATER SUPPLY
Other
4.I
Page I of 2
Note: If community well system, must have written co'nfirmation from the State Department of. Environmenta! Conservation
attesting to the legality and status. . ... ,: .
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legalit~ and status. ' ~',~
72-025 (111841
',':,: -' ,S -;ENGINEERING FIRM PROVIDING i~$p, ECTION~~'D_A~..T.~
~ Ascertifedbymysealaffixedheretoandasoftheval,dationdateshownbelow Ivenfythatmy,~nvest~gabonofthsHealth ,,' -!
~i' Authority Approval shows that the on-rote water supply and/or wastewater d~sposal system is sa!e, funct~o[tal and adequate
'? for the number of bedrooms and type of structure indicated herein, I further verify that based on the information obtained
i:'. 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, ordinancesi'and regulations in effect on
; !he date of this inspe~i~p$ ENGINEERING
Name of Firm SR-B-"I'~X
Address I=--~_G I.-E R!VERr.AK99577
Date
Telephone
Approved Disapprovel~/ Conditional ' ' '
Terms of ConditiOnal Approval ......
'~' Page 2 of 2
, 72-025 (11/84)
!The Muncipality of Anchorage Department of Health and En~,ironmental Protection'iDHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
'analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work,
WELL DATA
.... ~TY OF ANCHORAGE (MOA)
MUNt~.. ~ ~ ~H~~THORITY APPROVAL (HAA)
EI, NiI['ONML'NI'N' r ~KUST- FEBRUARY 19M
t~L ~ i ~9~ 2~4720
Well Classification
Well Log Present (Y/N) ' Date Completed
Total Depth Cased to Depth of Grouti~,g/.
.
Static Water Level . _ P~.~t At .
Casing Height Above Ground San~ary ~-~a/'on Casing
If A, B, C, D.E.C. Approved~y,~
Yield
(Y/N)
Electrical Wiring in Conduit (Y/N) '
Separation 'Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Clean(~ut/Manhole
Water Sample Collected by
Water Sample Test Results
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearefit/Oublic Sewer
To Near~t~:~ver Service Line on Lot
/ /~ ; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed Size
Standpipes~ Air-tight Caps
Depression over Tank,{~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (WN)
Separation Distances from Septic/Holdin!LT..ank:
To Water-Supply Well '~'o c>~ '~' J.~r~.t
TO Property Line /0 / ~'
To Water Main/Service Line "~O I ~-'
No. of Compartments
Foundation Cleanout (~'
Date Last Pumped
Course
Comments
; for ~.
Temporary Holding Tank Permit (Y/N)
To Building Foundation /cf/'
·
To Disposal Field ~,~ I
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026{11/84)
Co ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /~
Date Installed / '~"~ ~ '~
Width of Field ,~.//e~ ~
Square Feet of Absorption Area
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
/..4' ~C. Standpipes Present~,l~
Depression over Field/rY'/~ Date of Lest Adequacy Test
Results of Last Adequacy Test '~
Separation Distance from Absorption Field:
To Water-Supply Welt ~3-~
To Building F:o'undation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Existing or Abandoned System on
; On Adjoining Lots ..~ t ~
To Cutbank (if pr/esent)
To Driveway, Parking Area, or Vehicle Storage Area
LIFT STATION ' ' ·
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA.and HAA guidelines in effect on the date of this inspection.
SR S 196X MOA No. ~>.~(..,~D,~ '
C°m~LE RIV, EJ~AK 99577
Receipt No. .~C..~ L( Q-[ ~
Amount: $ ~
Page 2 of 2
72-026 (11/84)
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 09501
BILL .~IEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
Pws ~.n.~ 2/,OS.'~ 7
To Whom it May Concern:
According to records on file in this office the
RANCHETTES
Water Regu]ation$
EAGLE RIVER VALLEY
Water System is in compliance with the State Drinking
Sincerely,
Distric~ng~neer
'
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date ~.,~//,9C'/~(~ ~
1. GENERAL INFORMATION
(a)
Legal,Description (include lot, bl~k, subdivisij1Q, section, township, range)
Location (add~ess o: directions) ~ - , ~
(b) Ap plica n t N a m ~c~'~,.)
Applicant Address
(c) Applicant is (check one): Lending Institution []; Owner/builder~; Buyer []; Other I-'1 (explain); ;.
(d) Lending Institution ..,~__.d~..~ ~:)~..~ Telephone
Address ....
(e) Real Estate Companyand Agent
Address
. Telephone
(f)/'"~the HAA to the following address:
S & S En[i;neering
SRB 196x
2. TYPE OF RESIDENCE
Single-Family~ Multi-Family []
,. Number of Bedrooms
Other
WATER SUPPLY
Individual Welll-I Community[] Publicj~
Note: If community well system, must have writt(~n confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
onsite..[~ Public'l-] community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page I of 2 72-025 (11~e4)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/Or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm _~ ~. e. ~.,,~t._~r!n9 Telephone
Address SRB 196x
Eagle ~iver. Z~laska
Date
Approved for ~-- bedrooms by ~ "~-~---~- ~. ~ -~-e ~Date ~'."~/''~
Approved " Disapprove~
Terms of Conditional Approval ~XI~
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by,an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
· institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
· professional engineer's work,
Page 2 of 2
72-025 (11/84}
MUNICIPAUTY OF ANCHORAGE (MOA) '
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Descr~tion:
~/~/~
MUNICIPALW! OF ANCHORAG':
DEPT. OF HEAL~'H &
ENVt~CNME;'ITAL PROTECTION
A. WELL DATA
Well Classification w~...~ J~,~. 1
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from 'Well:
To Septic/Holding Tank on Lot ~.4~/~
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line Cleanout/Manhole
If~B, C, D.E.C. Approved~N)"
Date Completed Yield
Depth oJ ?r/e/uting
~/~'~ Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest sewer service Line on Lot
Water Sample Collected by
Water Sample Test Results
; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes
Depression over Tank,~.¥~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic~ Tank:
To Water-Supply Well
To Property Line
To Water Main/See,,iee Line
Course
Size /2~-'4.3 No. of Compartments ~ ~'
Air-tight Caps 0.~' Foundation CleanoutJ~ ~
Date L~t Pum~d ~'/q~
~ ;for ~
~ Tem~rary Holding Tank Permit (Y/N) ~
To Building Foundation //~'~
To Disposal Field '~'e-~? ~' ~'
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field ,~.~
Square Feet of Absorption Area
Depression over Field (Y~N)~
v
Results of Last Adequacy Test z~,r~*~',--'<''~-''''~
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation ~. C:) ' ./..-
Lot /,./
To Water Main/Service Line ./4p ' ./
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
/ ,/ /
Type of System Design
Length of Field ~'D
Depth of Field /",-~
Gravel Bed Thickness
Standpipes Presen~..~N)
Date of Last A, dequacy Test
To Property Line /O ..~
To Existing or Abandoned System on
; On Adjoining Lots .~,D ' ./--
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
///'~ Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that.~ h. at/e,z:hecked~ verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed SE~ lg/,,, Date 2..,~7..-'7_... ~ C
Company Er,~le ~;ver, '~laslca 995"/7' MOA No. ,~'5"~o ,_~ ..~'~--~'.~,~,_
Receipt No. ~"7 ~ C~ ~ <~' -- ~'~"'"~( ' ~" ~-
Date of Payment ,'~* Q ~-'~-~'(~, ~.Tv.~~' ~ "~,S' ~/
Page 2 of 2 ~ ~<~h- '"'~ ,.,~t~ --
72-026(11/84)
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT DFFICE
437 'E" STREET, SUITE 303
ANCHORAGE, ALASKA ggs01
BIL! SHEFFIELD, C, OVERNOR
Telephone:
Addre$,~:
274-2533
To Whom it May Concern:
Water System is in compliance with the State Drinking
Water'Regulations
Sincerely,
DA~ ~ RECEIVED
' INSpEcTION APPOINTMENTS
TIME TIME .~,
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
ANCI~ORAGE ' IClPALITY
MUNICIPALITY
OF
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT~I{~ OF ANCHORAGE
825 L Street - Anchorage, Alaska 99501 DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
ENVIRONMENTAL SANITATION DIVISION
. Telephone 2644720 OCT 1 $ lgal
.EooEsT
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be proce~ed. Please allow ten (~0) days for processing.
1. PROPERTY OWNER J PHONE
I~AILING ADDRESS
PROPERTY RESIDENT {IY'dilferent trom above) PHONE
2. BUYER PHONE
M~I~EI NG ADDRESS
~. ,ENOINS '.STITUT'ON
MAI L'~ NG ADDRESS
4. REALTOR/AGENT I PHONE
I
MAILING ADDRESS
5. LEGAL DESCRIPTION
/---o7- /~ ~
STREET LOCATION --
6. TYPE OF RESIDENCE
[] SINGLE FAMILY
~M~ LTIPLE FAMILY
7. WATER SUPPLY
L.J PUBLIC UTILITY
NUMBER OF,BEDROOM_~.--
I"-1 One ' ~ Four
I-'1 Two I'-1 Five
[] Three [] Six
[] Other
* 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.)
~ s~',AOE O,S~AL SYSTEM
[] INDIVIDUAL/ON-SITE** /y 7~) ~ YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
~'~U'T, PLE FA~LY [] TWO ~ FOUR' [] S~X
PERMIT NUMBER
2. WATER SUPPLY
CMIVIDUAL DEPTH OF WELL
MUNITY DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or [] Holding Tank
Size: 1'7,-,~d) If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK ~ MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCES SepticlHolding Tank IAbsorption Area ISewer LineI Nearest Lot Line
WELL TO:I '
Absorption Area to nearest Lot Line
APPROVEDFOR'_ 4r BEDROOMS
CONDITIONALDisAPPROVED APPROVAL-- (letter must accompany, certificate)
72-010 (Rev. 6/79)
EXCAVATION
ROBERT A. SHAFER
WORK
October 8,
CIVIL ENGINEER
694.2979
1981
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMI~NTAL PROTECTION
Leo Hantz
5025 Bryn Mawr
Anchorage, Alaska
Dear Mr. Hantz,
99504
OCT g 1981
RECEIVED
Reference: Lot 12B: Eagle River Valley Ranchettes
A sewer system adequacy test was performed on the
system located on the referenced property as you re-
quested. The septic tank was pumped and verified
to have a capacity of 1250 gallons. The seepage
pit was charged with a 1000 gallons of fresh water
and after a period of 24 hours all the water, which
had been added to the system had percolated out.
It can be concluded from this test that the waste
water disposal system serving the four h~droom
duplex located on this prgperty is currently functioning
adequately. However, the system cannot be guaranteed
against subsequent failures.
If we may be of further service, please do not hesitate
to call.
cc: Alaska U.S.A. Federal Credit Union
Municipality of Anchorage
Department of Health and Environmental Protection
$R8 196X EAGLE RIVER, ALASKA
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received 5/9/74
Time of Inspection
Date of Inspection 5/.9/74
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
1. Approval'requested by:
Mailing Address:
2. Property Owner:
Mailing Address:
FOR
VA
Kassler and Compan,¥
319 5th Ave. Anchoraqe AK
James Tompkins
NHN Man of War
Phone: ~?~-~fll
Phone: 694-?~6
3. Legal Description:
4. Location: Man '0 w~r
5. Type of facility to be inspected puplex
6. Well Data: Con~nunity
A. Type
Lot 12B E~gle River Valley Ranchette~
No. of bedrooms 4
Lo~s
B. Depth
D. Bacterial Analysis
28'
B. Installer Tuck
Size l~O 2. Manufacturer
Absorption Area 49'xSO'xT' 2. Material
, Sewer Lines.
C. Construction
7. Sewage Disposal System:
A. Installed 1970
C. Septic Tank: 1.
D. Seepage Pit: 1.
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
C. Absorption area to nearest lot line
· Absorption area
, Other contamination
, Absorption area
21'
EQ-034 (1/74) Page 1 of two pages
Pa~2'of two pages - Re .it for Approval of Individual _r & Water Facilities
Legal Description
Lot 12B Eaqle River Valley Ranchette~
Comments
Approve~ Disapproved Date 5/9/74
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED Date
EQ-034 (1/74)