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MARIE ESTATES LT 3
Mo ie states Lot 3 #051-111-36 Municipality of Anchorage On-Site Water and Wastewater Program · (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPEOTION REPORT Permit Number: OSP161248 PID Number: 017-361-30 Dwelling: [] Single Family (SF) [] Duplex (D) [] Multiple (SF and/or D) Project: [] New [] Upgrade game: TAMARAS LEITIS ~,BSORPTION FIELD ~ddress [] Deep Trench [] Shallow Trench [] Bed [] Mound [] Other ~hone Number of Bedrooms ~oil Rating Total depth from original grade 3 :1.2 GPD/SF 6,0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe Subdivision 8lock Lot 2,0 Ft, 4.0 Ft. MARIE ESTATES, LOT 3 Fill added above original grade Gravel length Township Range Section 1.0 Ft, 38 Ft. Gravel width Beds: Number of Lines Distance between lines SEPARATION DISTANCES 5.0 Ft. - Ft. Tc Septic Absorption LiflStation Holding Sewer Total absorption area Numberoftrenches Dist. between trenches From Tank Field Tank Line 375 Ft2 1 0 Ft. Well 100'+ 100'+ 50'+ ManufacturerTANK [] Septic [] S.T.E.P. [] Holding Capacity surracewater 100'+ 100'+ ANCH TANK 1000 Gal Material Number of compadments Lot Line 10'+ 10'+ NA STEEL 2 Foundation 10'+ 10'+ LIFT STATION Manufacturer Capacity Curtain Drain UN UN Gal Remarks Pump on level at Pump off level at -ligh water alarm at Pump make and model =lectdcal Inspections performed by Tank to Installer PIPE MATERIAL House to tank 3034 drainfield 3034 Mike N. Anderson Drainfield 3034 CO/MT3034 Inspector Mike N. Anderson BENCH MARK (Assumed elevation) 118.5 InspectiOndates: l"t 9-3-16 2.~ 9-3-16 _ocation and description 3,~ 4· back deck E i ' tamp COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL ,,,,~.E,~.r~,._~_~.,~,~.. Conditional Approval: Date ~' Inspection Report_9-1-12.doc Permit No. 0SP161248 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 545-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: MARIE ESTATES, LOT .5 PID No.: 051-111-56 'CO1 %/~_ 4-5 ~_16 . TC01 -46 ~ coz/ ,o ,:------ // ,T/ ,5 ~ /~" ~o~ / / SHOULDER OF SLOPE >25% / / , I ~ SEPTIC I / / ~ % / 1 / Lof 4 / ASB~ILT t ~ k / / SCALE: 1'~50' t ~ / ~ ~, .... . .................... 2 ..... I ~MICHAEL N ANDERSON/~ ,~ ~o~ ~,~: ~,,..-~ .,, ~-..~, Performed For: Legal Description: Municipality of Anchorage Development Services Department Building Safe~y Division On-Sge Water and W~stewa~er Program 4700 E~more Road P.O. Box 190050 Anchorage, AK 99507 :,,~¥~¢:v. ¢i .a rlchoraq ~u.~ (907) 343-7904 Soils Log - Percolation Test · ,,,,o,,._ L ~¢-¢~ ~4~"~ ~ Township, Range, Section: Slope 5- 8- ~0- 12- ~3- ~5- ~7- 18- ~9- 20- COMMENTS Site Plan WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT DEPTH? L O Depth to Water After p Monitoring? E Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE ~,~ Iminuleslinch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND ~'~ FT PERFORMED BY: r~ ¥ '~.~*, I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Permit Number: Tax Code Number: Work Type: On-Site Wastewater Disposal System Permit OSP161248 05111136000 Septic MUNICIPALITY OF ANCHORAGE Development Services Department On-Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (9071 343-7904 Upgrade Permit Effective Dates: September 02, 2016 to September 02, 2017 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Subdivision: MARIE ESTATES Site Legal Address: MARIE ESTATES LT 3 G:1361 Owner/Address: LEITIS TAMARA L PO BOX 670522 CHUGIAK AK 995670522 )artment Site Mailing Address: 24376 SKI RD, Chugiak Lot Size in Sq Ft: 64869 Total Bedrooms: 3 This permit is for the construction of: Y Disposal Fierd Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. isions: An addition percolation test is required prior to construction. The test to follow Table 3-8 of the EPA Design Manual. Received By: ~ ~ Issued By: /~_ ~,¢~ ~)/~_ .~.~ __ MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division On-Site Water & Wastewater Program Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWER/VVELL PERMIT APPLICATION Parcel I.D. 051-111-36 Property owner(s) Tamara Leitis Mailing address Day phone Site address 24376 Ski Rd Legal description (Sub'd., Block & Lot) Marie Estates Lot 3 Legal description (Township, Range & Section) Lot Size 64869 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: ([] all that apply) Absorption Field [] Initial [] Septic Tank [] Upgrade [] Holding Tank [] Renewal [] TYPE OF DWELLING: Single Family (SF) (w/wo ADU) Duplex (D) Multiple Dwellings Privy [] ~or D) Private Well [] Water Storage [] THIS APPLICATION INCLUDES A VARIANCE / WAIVER RI . I ceAify that the above information is correct. I fudher ceAi~ that~~~ce with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: ~-~ ~¢ /Z ~*'iI/A, II) '~ Waiver Fees: Date of Payment: '~"/~//tG, Date of Payment: Receipt Number: ~01.~¢¢}(¢ (~¢,¢~10~)/,;:~-Receipt Number: Permit No. (,r~OI{~I~.-L{~ Waiver No. Permit App_:. ;. :2...;c ~' Aug 29, 2016 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Legal: New Septic system Marie Estates, Lot 3 To Whom it may concern: This is a request for a septic permit on the above referenced lot, tile old system is undocumented and too close to a slope greater than 25 percent. A new test hole ,,vas excavated in tile backyard and lbund various types of gravels, GM. No water was observed during the excavation or after the 7 day monitoring period. The perc rate was 2 minutes per inch at 4 feet below grade. A 5-wide trench has been designed as a replacement trench. The tank will be checked and replaced if it damaged by corrosion. The lot slopes to the northwest at about 2 percent, see the drawing. This replacement system wi II not impact any of the neighboring properties due to the lot layout. Please call me if you [lave any questions. Sincere[y,~ Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 DESION CRITERIA: , ~MOUND OVER 3 BDRM X 150 = 450 OPD SOILS = 450/1.2 = 375 OPD 1.o m OR(; I ~ ~,FI.L~TER FABRIC 375 GA/lO = 38' -2.C '~cr'~- 4.¢ PIPE (1~, TRENCH GM ~SEWER ROCK 6,u DEEP 4,0' EFFECTIVE 5.0' WIDE 38' LONG 15_ SEPT1C FIELD SECllON I I J J 'WELL / x I ~ EX STIN(~ WELL ,, 1/15¢ RADIUS // I EASEMENT, DRY TAMARA LEITIS MARIE ESTATES, LOT 3 Anchorage, Alaska "..,,~ ..... Michael N. Ander n, P.E. DATE: 8/29/2016 (907) 727-88~ / F~: (907) 345-1391 SCALE: 1"=100' / Lof 2...//'''''/' / ~ -- ~" ,._ ..... _--' PROPE~ UNE~ I / / / ............. \ o /--SECONDARY 58'LONG; X 5' / TO BE INSTALLED AT THE ~ ..-'~--'>'~. ..--NEW PROPOSED I .O.OM or THE SLOPE ~.~ ,,~:::::_-'~',/' ADN ~ELD ; /--rE.DE / :~2c~;i_..~-..~ ~ / I I / __:_% OLD UNDODUMENTED ~ -~ .... ~ ~/~ ~ I~z ~--PROPERTY LINE ~ DECOMMISSIONED PER THE T / ~-'t"~',~¥r,r, .... ~---/~'-. -' TANK IF REQUIRED,~ +x z/x( F'~I~Tll, lC. / :': .-~ /~/~ '% / ~ / ..... //\'-,:'~"'4t:/-::::,:. \ / V / I ~ / Lot 4 ," ' ~ Septic Design Prepared for .~,.~.~,,~r._,~,~,~,~,..~._ .,k~,,,F'.~'~/ ~'" TAMARA LEITIS ,,"~. b'. .............. '.'.~ ~;*- MARIE ESTATES, LOT3 ~"~":' 4 ~, ~ Anchorage, Alaska ,, .~,,,..4~..._ ..%..: ......... ~ " ,.,~; ............................. Michael N. ?.E. ~]';~ MICHAEL N. ANDERSONi,~~'- ,,n,,erson, [~A-rE: ~/2~2o~ ..,~ : - ~'~J~u2~'*. / I,:', No.*'C,F 9469 ?', £-,' ~i 4601 NATRONA AVE ~A~V,: ~ '°o~-..V.!/~, ...... :"~_.-' ANCHORAGE, ALASKA 99516 "ei~ ~'~'\Cy~-~.~. (907) 727-8864 / FAX: (907) 345-1391 SCALE: 1 "=50' ~L'T~ E%'~ Development Services Depa~ment .~ 4~ *. On-Site Water and Wastewater Program P.O. Box 196650 Anchorage, AK 99507 ~J~%. MICHAEL N. ANDERSON Soils Log - Percolation Test 1 Pedormed For: .~..~ C .t~, ~ Date Performed: Legal Description: Township, Range, Section: Slope Site Plan 5- 6- 7- 8- 9- 11- 12- 16- 17- 18- 19- 20- WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT DEPTH? L O Depth to Water After p Monitoring? ~ E Reading Date Gross Time Net Time epth to Water Net Drop PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER COMMENTS ~..,,,..~ ~' h~.l~ TESTRUN BETWEEN ~'~FT AND PERFORMED BY: ~ ~f~ I CERTIFY THAT THIS TEST ~AS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: u hi I [; ! P ~-', L i ] Y 0 F t~ N C H 0 R A L~ E BF25 L S{reet. Ar'!chorage~ Riaska 995¢1 .343-4720 F.'ePmi1: Numl]ep~ Da r..e ]:s!~iued: '4/.]~"/9' Engine~_=p D~-~signed =~-~(~L.I:: .,~ VEK, AK 99577 Day F'hone: 694'"'4994 Parcel Id: C~51--111--.]6 Lot Legal: ,SL~bdivzsion-' MARIE ESTATES Lot: 5 Block: Section= 10 Township= 15N Range: ~E _or. Size 6486~¢ ~sq. ~t.. or acres~ Max Bedrooms: This Permit.- 0 Total Capacity: 3 WELt- !...r~g must be -submztted to Mun:[c:i. pality of Anchopage L)e.'par'.'t..~P. el-~t o~ Heal'th anti Human ,E;epvic:ess within 5C) drays c-.,J well, comp].e'Lion. FopCh by %he Municl. paJ. i~Ly o[ Anchopage (MOA) and Lhe Sta~te oF Z ~. ] I ;[i"lBta , i ~ne s'yst.~2[~ ¢.F/ ac(:::c]P(;:fance ~,ai'Lh al I MOA cc]des and regula'L it]ns, afl(] lB compliance NJ, th ILhe design cPi'Eel-ia oF {his pepmi'L. [ wJJ . a(:Jher~ Lc~ ali MOA ~nd State (:W Alaska requir'emer',t,: ICH" the set back ] unde~'s'f.and tha'l t. his l~ermit is valid ~or a maxxmum o¢ o bedrooms. I also unders{and fha4_ the cac~aciiy c}~ the t.o~aI system z~ 5 bedrooms and ar~y enlargement wzll r'~uire an additional uermit. M U Iq ] C ] P A L I ~' v 0 F .~-~ Iq C ~ 0 A' Depart. ruer* cdt H~alth ~ Human Services 8;25 l S't..peet, Anchorage, Alaska 9950]. 34Z;-4720 OwneF Name: HERITAGE I...I[]P'tE:.S/ I"'IREMANS F::'LJND uwner Addr~.~ss: ~8550 EAGL. E RIVER ROAI] EAGLE RIVER. AP:: 99577 Da~ Phor.,e: 694-4994 Parcel Id: I....o~ L.e~.~a].: Subdivision: MARIE ESTATES Lot." Z'~ Block: Secti~Dn: ].0 Township: 15N Range: 1E LcR S'.i. ze 64869 ~sq, {'t. o~ acres) Bedrooms: This Permit: 0 Total Capacity." 3 WELL: Leg ~ust. be submits'Led ~..~ Municipality o~ Anchcmage Department o~ Health ano Hume~ri Services within 30 days o~ well. completion. ]"HIS PERMIT EXPIRES 12/5]./89 AND VALID FOR A SINGLE FAMILY HOME. I CER'T'IF:'Y THAi': ].. I am Familiar with the Pequiremen'Ls Fi.DP on-site sewers ano wells as set {orth by the I~unici. pality of' Ancherage (MOA) and the State of Alaska. I wi].] install the system in acccmdance wJ.'Lh all MOA code~ and Pegulat. ior',.s, and xn compliance with the design criteria o~ this pe;'mit. !: will adhere 'Lo all MOA and S'La'~e o~ Alaska Pequ~_rements fer the set back dis-~tan¢:es F rom an ¥ e;..'.isting wcs,].l, wastewater dispc:,sa] system e~- public sewerage system ~Dn this oP any adjacent or nearby lot. ~- I undeF's~.and that this permit zs raj. id top a maximum o~ o bedrooms. also understand tha't t. he capaci{'F (:)~ the ~o~.al s'Fs{em is 3~ bedrooms any en!argemen~.. ,' ~]. P~[].re an addi'Lional permit ~;igned. , ' DATE: (O~ner) Hf~R]]TA~E~E~ANS F'UND and TEL hiE,. hereby certify t~ot I have'~qxrveyed rl~v following described property: ~u~ tnt m en~roe~:Nmv~ ~_xi~t excerpt v.s indicated. Exclusion Note: It i~ ~}m ~e..,~wmslbiltty of t~he o~'~r t.o dvteznflx~ thn existence of c~enan~s, or r~trictions which da~ nat appear on the recorded sulxtivision plat. Under no clraw~tarrm~ m~l.d any ~kata tmreon be treed ~or cor~tractlon or ~stab].i.~his~ he, malady or fer~-~, li~.~, Bated at Ar, clno~ge, Alaska, th~h~ /g day of ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE ~ UPGRADI MAILING ADDRESS LEGAL DESCRIPTION ~" Z Manufacturer Mat~a~ / of compartments Liq, capacity in gallons ./~ ~ O IF HOME~DE~ Inside length Width Liquid depth ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O Z ~ Manufacturer ~ --N Material Liquid capacity in gallons ~ ~ell Foundation Nearest lot line PERMIT ~ ~ DISTANCE ~ ~ No. of lines . Length of each line TotaJ length of lines Trench width Distance between lines -~ / ~z ~_~ Top of tileto finish grade ~ ~ inches Total effective absorption area , Material beneath tile ~ inches ~ Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ ~ DISTANCE TO: ~ell Building foundation Nearest ]et line ~ Class Depth Driller , Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(si OTHER PIPE MATERIALS p/eF~ C SOIL TEST RATING . INSTALL~ ~" " Z~c~ REMARKS APPROVED DATE LEGAL WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological ~ Geophysical Surveys A , DIR CTI N FROM ROAD iNTERSECTIONS ~. OWNER OF WELL: / : ~ ~ Irrigatlo~ ~ Recharge ~ CommeHoal 8. C~SING: ~ Threoded: ~ Welded I0. STATIC WATER LEVEL: ] f ': ~ ~ ,J~3 IE.GROUTING Well Groute~: ~ Ye* ~ NO ..... 14. REMARKS: DEPARTMENT RPPLIC:ANT SEYERSON, INC: :::52:1 LITTLE DIF'PER LOCATION LEGAL _OT 2:32:-2462 ... ~ ...... SE.!L!RRE FEET TYPE nF --O..I,_ HB_,ORFTIuN .=,~=,T~.d IS: DRRINFIEL[:, I~IRXIMLIi~I N,_IMBE~. OF BEDROOMS 2~ SOIL RRTIN3 (56~ FT./DR)= THE REQUIRED %IZE OF THE '-=,OIL ABSORPTION SYSTEM [)EPTH=: LP-~-~GTH= 75 ~3 E:~ %reEL [)EF'TH THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIEL. D. THE DEPTH OF R TRENCH OR PIT IS THE DISTRN[:E BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOH OF THE EXCRYRTION (IN PEET':, THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETi~THE OUTFBLL PiPE AND THE BOTTOM OF THE EXCAVATION (IN PEET) F~:EQIJ I F-:E[) SEF'T I C: TRf-if~C S I ZE=--- 1Cl~---'l~.3 GRLLOf-.!S PERMIT RPPLI,_.RNT'-' HAS THE RE'='P-~'~_ I8.,_I .¥q 'xf T TO INFORM. 'mT - f'l ,2-., ~. - INm,.RLLHTI.N IN_,FEuTION.= OF ANY WELLS ADJACENT f'O N hlRFR L]F RE'..=;,IE:,ENOES THAT THE HELL HILL THIS E:,EPRRTMENT DUPING THE THIS F'RL]PERTY RN[, THE ']r'l...lt2.} '::--~' --:, -f- ~%tSF"EL-:T :I ,-J~.i:.- ~ Rt:~: E R E tc:~dJ --_f F-: E [:, BR-,f..~-.,.LLtN= OF RNY _-r..~TEr WITHOUT F'INRL IN'--,PE"TT-N RND RF'PRO',/RL BY T'""'=; DEPARTMENT WILL BE SUBJECT TO PROSEC.TION. MINIMUM DISTANCE BETHEEN A HELL RND ANY ON-SITE SEWAGE DISPOSRL SYSTEM iS 100 FEET FOR R PRIVATE NELL OR ±50 TO ~DO FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRIVRTE WELL TO A PRIVRTE SENER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 FEET WELL LOGS RRE RE6!UIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 20 DRYS OF THE WELL COMPLETION. OTHER REOUIREMENT$ MR? APPLY. SPECIFICRT!ONC; AND CONSTRUCTION DIRGRRMS ARE RVRILRBLE TO INSURE PROPER INSTRLLRTION t CERTIFY THRT I: I RM FAMILIAR WITH THE REC,.!UIREMENTS FOR ON-SITE SEWERS Rr'~£:, WELLS RS; SET FORTH BY THE MUNICIPALITY OF ANCHORAGE 2: I WILL I~STRLL THE SYSTEM IN ACCORDANCE WITH THE CODE~ ~- I UNDERSTRND THAT THE ON-SITE ~ENER SYSTEM MAY REQUIRE ENLARGEMENT iF 7HE RESIC-ENOE I5 REMODELED TO INCLUDE MORE THAN 3: BE[:,ROOMS. / ...................... RPP~Z:~T SE'¢ERSON., !NC MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 925 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~ SOILS LOG [] PERCOLATION TEST LEGAL DESCRIPTION: 1 2 3 ~-'~4 5 6- 7- 9 10 I1 12 13 14 15- 16- 17- 18- 20- COMMENTS DATE PERFORMED: SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop '7 PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT CERTIFIED BY: 72-008 (6/79) X MUNICIPALITY OF ANCHORAGE RECEIVED horooy coHJf), that a ~urvo), of the following dosbribod property ~Z/~/~ ~' '/~ ~ and that the jmprowm~nf~ situated thereon are wllhln the proporfy~lln~ ond do'not oy~rJ~p or encroach on t~e prope'rt~ edjec~nt f'h~rofo~fh~t no ~mpro~monts on proporf~ lying odj~c~nf fh~rete encrooch o~ ~he proml~oa In question"and that there are no roadwnys~ transmission Ilne~ or other v[~lble oo=omon,~ on =aid propertl excap, os Indicated hereon. Datod at Anchorag~,Alaska~ ,his. ~ day of ~f~/~/~. CONTRACTING ENGINEERS O, ASSOC. 2_12 E, Intorno~ionol Airpor? Road .Nb §:~,--, ¥/'A LLAr~-. £kIG-IN EERIN~ SHF_..E.'r /c~ OF /o Parcel I.D. 051-111-36 Certificate of On -Site Systems Approval Expiration Date: _n c4 19, Qo-(! Complete legal description Marie Estates Lot 3 Location (site address) 24376 Ski Road Chugiak, AK Current property owner(s) James Cassell & Nancy Wallander Day phone Mailing address Same Real estate agent 2. TYPE OF DWELLING: Ex Single Family (w/wo ADU) El Duplex F1 Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: I Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic 0 - Water Storage n Holding Tank 1771 Community Well 0 Co'mmunity ❑ Public Water System n Public Sewer ❑ Waiver request for: Distance: V �r Received by: Date: AZY�- COSA to be released to the engineer, unless otherwise requested by the engineer. &Mh* ePwuNj 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. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe 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 soil condition, ground water 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 this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. 6. DSD SIGNATURE System #1 Approved for Is bedrooms System #2 Approved for bedrooms Disapproved Phone (907) 745-8200 Date _ 1Ia ape Conditional approval for bedrooms, with the following stipulations: llllli(l(((l(� VVLI r -r-- By: Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: Marie Estates Lot 3 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA N Well log is filed with Onsite (or attached) Date drilled 6117/90 Total depth 207* ft Cased to 207* ft © Sanitary seal is functioning correctly ❑® Wires are properly protected Casing height (above ground) 24 in. Date of flow test for COSA 6/27/19 Static water level at beginning of test 159.6 ft Comments *From 1990 Well Log B. TANK DATA Age of tank(s) 3 years Tank type/material Measured operating fluid level in septic tank 48" 0 Standpipes/foundation cleanout per record drawing Date of pumping 719/19 - D. ABSORPTION FIELD DATA Shallow Trench Which system tested (date installed) 9/3/16 R ALL standpipes present per record drawing Total measured depth from grade 8.0 ft (max) Measured depth to pipe invert from grade 4.0 ft (min) ❑ N/A — pressurized field MR Monitor tubes go to bottom of effective. If not, state depth into effective R 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: COSA Checklist yellow sheet Parcel ID: 051-111-36 Structure served by this system 1 Well production at time of test 3.2 gpm Water storage tank volume n/a gallons Well disinfected for coliform test? ❑ Yes ❑✓ Nc 0_1 Coliform bacteria is Negative Nitrate 10.3 mg/L E]Nitrate less than MRL (ND) Arsenic ug/L ffi� Arsenic less than MRL (ND) Collected by PES Date of Sample 6127/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 6127/19 Results ❑✓ Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 450 gal New depth 0 in Elapsed time 140 min Final fluid depth 0 in Absorption rate '450 gpd Any rejuvenation treatment (past 12 months) If yes, enter date 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' 0✓ Yes if No ft []✓ Yes if No Neighboring Tank > 100' Q Yes if No ft . Private Sewer/Septic Line > 25' Yes if No Absorption Field on Lot > 100' Yes if No ft Holding Tank > 100' Yes if No Neighboring Absorption Fields > 100' Q✓ Yes Animal Containment > 50' Z Yes if No M Yes if No ft Yes if No ft F. ENGINEER'S COMMENTS Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' M,/Yes if No ft Q Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' El Yes if No ft Surface Water > 100' ft ft ft ft ft 9 Yes if No ft Property Line > 5'✓0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑✓ Yes if No ft Private Wells > 100' Yes if No. Water Main > 10' F/-1 Yes if No ft Community Wells > 200' Q Yes if No _ Water Service Line > 10' F71 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' [Z] Yes if No ft If absorption field is under driveway comment below Property Line > 10' F/ Yes if No ft Wells on Adjacent Lots: Water Main > 10' ✓❑ Yes if No ft Private Wells > 100' Yes if No Water Service Line > 10' Q✓ Yes if No ft Community Wells > 200' Yes if No Surface Water > 100'✓� Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION OF A� QST I certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with 49 .1 lS� MOA COSA guidelines in effect on this date. R. koni gds COSA Checklist yellow sheet ft ft ft ft TO: Kelci Boe kelciboe@gmail.com PHONE Nancy: 608-797-7036 DATE OF ORDER 7-10-19 ORDER TAKEN BY CUSTOMER ORDER NO. [:]DAYWORK ❑ CONTRACT ❑ EXTRA JOB NAME/NUMBER JOB LOCATION 24376 Ski Rd. JOB PHONE STARTING DATE 7-10-19 I Lrn1vi3. i rz is nisei ear Hes 111unL11 vn unHaia oaiance CITY. DESCRIPTION OF WORK PRICE AMOUNT 1 Well Camera $400.00 No breeches found No discounts will apply if invoice is not paid within 30 days. If paying with credit card please add a 3.75% credit card fee. If invoice is not paid within 90 days a lien will be placed on the property. Thank you, Bill & Cole Sullivan WORK ORDERED BY: SIGNATURE DATE COMPLETED: 7-10-19 I HEREBY ACKNOWLEDGE THE SATISFACTORY COMPLETION OF THE ABOVE DESCRIBED WORK, DEVELOPMENT SERVICES DEPARTMENT On -Site water and wastewater Section www.muni.org/onsite Nitrate Advisory Certificate of On -Site Systems Approval # OSC191291 Subdivision: Marie Estates, Lot: 3 •i •#51 A water sample revealed a nitrate concentration of 10.3 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. ass` dck� ag Acetas g 9519 56 0_ � � , 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. ON sng�A i�cess.Q. f� Box3� 5 Anc age,3` a�C99519 66'5�winurg Municipality of Anchorage On-Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPRCVAb.~ ~ -.,~ ~ s ~'. Parcel I.D. 051-111-36 Expiration Date: 1. GENERAL INFORMATION Complete legal description Marie Estates S/D, LOT 3 Location (site address) 24376 SM Road, Chugiak, AK 99567 Current Property owner(s) Tamara Leitis Day phone Mailing address P.O. Box 670522 Chu~iak Ak Real Estate Agent /F"~ ~ .~ . 2. TYPE OF DWELLING: [] Single Family (w/wo ADU) ~ Duplex ~ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well [] Individual Water Storage [] Community Glass __Well [] Public Water System [] Day phone TYPE OF WASTEWATER DISPOSAL: Individual [] Holding Tank [] Community [] Public Sewer [] Waiver/Variance r.~'~) for: Z /'~ Distance: COSA to be released to he enginCr, unless o he~ise reques ed by he engineer, COSA Fee $ Date of Payment Receipt Number COSA # 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 ail applicable Municipal and State codes. ordinances, and regulations in effect at the time of installation. Name of Firm MIKE NANDERSON, P.E. Address 4661 NATRONA AVE. Engineer's Printed Name MIKE N ANDERSON, PE Phone 727-8864 Date 09/5/16 6. DSD SIGNATURE / System #1 Approved for. System #2 Approved for Disapproved. Conditional approval for bedrooms. *~,~¢ '. C~- 9~9 bedrooms, with the followin}~x~,ons. = ~ AND = WATER B~._.~ / OriginalCertificate Date: C>[_/t'~_/~ 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. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory COSA blue sheet_lO-lO-12 doc X Nitrat.e A~vis.'ory' -.' Arsenic Ad,gis o'r-y Other',, ,. ,, 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: Marie Estates S/D~ LOT 3 A. WELL DATA Well type Private Date completed 5-17-90 Total depth 207 ft. Date of test Static water level Well production Parcel ID: 051-111-36 IfA, B, or C provide PWSID #__ Sanitary seal (Y/N) _Y Cased to 176 ft. FROM WELL LOG 5-17-90 161 . ft. 8 visual g.p.m, Well Log (Y/N) Y Wires properly protected (Y/N) _Y Casing height (above ground) 24 AT INSPECTION 7/1/2016 146 ft, 1.7+ g,p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/100 mL Nitrate ~ mg/L Arsenic: ND ug/L Date of sample: 9/2/2016 SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1000 gal. Number of Compartments _2 Foundation cleanout (Y/N) _Y Depression over tank (Y/N) N Date of pumping new Pumper new Collected by: Mike N. Anderson Date installed 9-3-16 Cleanouts (Y/N) Y High water alarm (Y/N) N C. ABSORPTION FIELD DATA- 1985 SYSTEM TESTED Data installed 9-3-16. Length 38 ft. Total depth 8~ ft. Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 Width 5 . ft. Eft. absorption area 375 ft2 Date of adequacy test new Results (Pass/Fail __ Fluid depth in absorption field before test new System type 5-wide Gravel below pipe 4.0 ft, Monitoring tube _Y Depression over field _N new For 3__ bedrooms Water added new gal. New depth Elapsed Time: new min. Final fluid depth new in, Any rejuvenation treatment (past 12 mo,) (YIN & type) UNKNOWN new Absorption rate >= new g.p.d If yes, give date LIFT STATION Date installed Size in gallons "Pump on" level at __ in. "Pump off" level at __ Datum Cycles tested __ Manhole/Access (Y/N) in. High water alarm level at Meets alarm & circuit requirements? in. E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main 75'+ Sewer/septic service line 50'+ Animal containment areas 100'+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10+' Water main 100'+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Water Service tine 25'+ Curtain drain 100'+ (None Known) On adiacent lots I00'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank 100' Manure/animal excrete storage areas 100'+ Property line 50'+ Water service line 50'+ Absorption field 10'+ Surface water 100'+ Building foundation 10'+ Surface water 100'+ Wells on adjacent lots 100'+ Watermain NA /¢0',-L Driveway, parking/vehicle storage 10'+ F. 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 MQA CQSA guidelines in effect on this date, Engineer's Printed Name MIKE N. ANDERSON~ PF,, Date 09/6/2016 COSA canary sheet_2-6-15doc Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On-Site Systems Approval # OSC 161404 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block , Lot 3 of Marie Estates subdivision. This inspection revealed a nitrate concentration of 7.73 milligrams per liter (mg/L) was reported for the property's well water sample. 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. 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 mnmonia 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 ~vater 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 progran~. They also have test kits available, which the laboratory uses to perforn~ 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. ~96303¥ 6~0¢-~[~66 u~ooMe~uns§uol~ue)~ 'oN ~oe[o.~d s~oXe^~ns puo9 IDUO!SSe~O~d 'OUl 'SSJrDJ3OgS~' )~ 6UD3 ,09 = .[ 39'¢3g ~ £9[N8 $¥ -- N~FId i ~/-±N3v~'3sv3 Y ~o9 ,~9'LOC ~00,6g.69 N SLNS[{~S~ AllllLO ,0[--~ I 8 ~o9 / / L ~o9 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 3; Marie Estates Location (site address or directions) 24376 Ski Road ': Chuqiak, AK 99567 Property owner Steve Wilde Mailing address 24376 Ski Road Day phone Chugiak, AK 99567 694-1700 Lending agency · Mailing address Agent Address City Mortgage/ Elaine Day phone 263-0700 Day phone Unless otherwise requested, HAA wifl be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: ~xx If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 {Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER. As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm .~' ~- 5' ~"~£'~"/"¢-'~' ~'/(-"- Phone ~ Address . 17g 7'Y -f,-~-,-f_ ,~v~,~ ~,,/' ~.n.,~.t E ,'~. Engineer's signature -~/~,,~/~/ 7 .~,~-'~ Date Se DHHS SIGNATURE Approved for __ Disapproved. __ Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date ~,,2'- ~.~F - The Municipality of Ahchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificate. s based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. MUNICIPALITY OF ANCHORAGE ENVIRONMEh,q'AI. SERVICES DI¥I$1ON Municipality of-Anchorage SEP 2 $19 6 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division R E C;E/ .V E D 825 L Street, Room 502. Anchorage, Alaska 99501. (907)343:4744 Legal Description: A. WELL DATA Health Authority Approval Checklist ,~ ~/~ &~,tE. ~-.~'i'AT6$ Parcel I.D.: Well type ¢&i~J~3"¢ Log present (~N) '3/E. 5 Total depth ;2~ o~/~ Sanitary seal [I~N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~'- J:~--" ~iO Cased to FROM WELL LOG 'J,~J ,~. E,$'r. g.p.m. Date of test Static water level Well production 8. WATER SAMPLE RESULTS: Casing height (above ground) Wires preperiy protected (~N) AT INSPECTION IZ't t- g.p.m. Coliform ¢ Nitrate ~, ¢11 Other bacteria Date of sample: ~ - ;~ - ~j & Collected by: ~ ,¥ ~' E;cJ6,¢~c&~.l~ (. B. SEPTIC/HOLDINGTANK DATA Date installed ~' ~- Tank size j o¢o Number of Compartments 'Z. Cleanouts (~N). Foundation cleanout (~/~ ,/~ Depression (Y/I~ ~ ~, High water alarm (Y~ Date of Pumping ~%~ ~ ~'~ ' -- /~ Pumper Jl~, C. ABSORPTION FIELD DATA Date installed ~ - ~Z- Length" ~ 2 Width "TZ Gravel thickness below pipe Effective absorption area Z,~'~, ~ Monitoring Tube present(~N) .m" Date of adequacy test <:1 - 7-~ - "i~- Results (Pass/Fail) I¢&.~% Fluid depth in absorption field before test (in.); O Immediately after 'fAo gal. water added (in.): Fluid depth ~) (ins) Minutes later: --~ Absorption rate ~ ~'o~ = g.p.d. Peroxide treatment (past 12 months) (Y/~) ~c,'~ ~i~:4~,5 If yes, give date Soil rating (g.p.d./ft~ or fl~/bdrm) ~G ~/E-~. System type Total depth Depression over field (Y~ For ·bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Size in gallons ,,~ Manhole/Access (Y/N) ~vel at* High water alarm level at*_*..,...- *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: ~olding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots I ~.o Public sewer manhele/cleanout Lift station SEPARATION DISTANCES FROM~HOLDING TANK ON LOTTO: Foundation ~' Property line lO J -I-- Absorption field Water main/service line Ioo t- Surface water/drainage Io¢~ ~' Welts on adjacent lots loc' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line i o i~_ Building foundation i o iff. Water main/service line Surface water )oo i Curtain drain Driveway, parking/vehicle storage area Wells on adjacent lots I °°~ .-I-. F. ENGINEER'S CERTIFICATION ' certify that l have determined thru field inspections and review of Municipal re_~d~e ai ~-~[ns are in conformance witl] M~)A, HAA guid~,a'lines in effect on this date. , Engineers Name /[~/~ ~,,[ ~ L ~ ~ ~ ~os~ ~ co ~'~ HAA Fee $. Date of Payment Receipt Number ,~;~ ~--,~ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEAl'TH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1 / / -~}tr) HAA# GENERAL INFORMATION Complete legal description Lot 3; Mari6 Estates Location (site address or directions) 24376 Ski Road Chu~iak, AK Property owner Mailing address Lending agency Mailing address Carole Comeau H~83 Box 211 Eaql6 River Day phone 694-6347 Alaska 99577 Day phone Agent John Bl~ne/ COLDWELL BANKER Address 4105 Tudor Centre. D~v6~ Anchoraqe~ AK Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 '~ TYPE OF WATER SUPPLY: Individual well XXX Community well Public water NOTE: Day phone 561-2488 99508 If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of syste,.m. 72~25 [Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm $ & S E..,IC, I?,~.~IN, J.C,~) . .. ,~.. Address ~,, ,,~i~ [~;.~r, AIB~ka ~9577 Engineer's signature ~~ Phone DHHS~(, SIGNATURE '~-/~ ~/~,~ /~' Approved, for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: The Municipality of Anchorage Department of Health and Human ServiO'es (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate .is issued. The Municipality of Anchorage is not responsible for errors or omissions i,r the professional engineer's work. 72~25 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ ~'~ t'~/~¢.-~_. ¢¢-~-r. ~\~ Parcel i.D. A, Well Data Well type Log present~/N) ',..{ Total depth ~ ""/~ Sanitary seal (~¥N) ~ If A, B, or C, attach ADEC letter. ADEC water system number t---~. Date completed ~1~ ~ Driller ::::~/=,~ ",~,,..~,.~3 Cased to ¢-~'~' Casing height Wires properly protected (~/N) ,../ FROM WELL LOG AT INSPECTION Date of test ~ J \'1 ~t ~ L.~ \1. ~'~,'~ Static water level ~ ~ t ' ~fw ~ Wellflow &o 4,50~ ~<, g.p.m. ¢,~ Pump level1 ¢~ ~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~ ~,..~ \ Absorption field on lot \ Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank o© WATER SAMPLE RESULTS: Coliform ~) Nitrate Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed ~'~ Cleanouts {~N) ,,~ High water alarm (Yin) Date of pumping Other bacteria Collected by: $ & S ENGINEERING 17034 Eagle River Lo~p Road No. 204 Eagle River, Alaska 9~'577 Tank size l. ~ c>~=' Compartments Foundation cleanout (Y~ ~ Depression (Y~ ,a,,/ Alarm tested (Y/N) ~/'~ - ~B Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /oo To property line /o Surface water/drainage On adjacent lots / ,,o / "- Foundation Absorption field '7 t Water main/service line 72-026(3/93)*Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level Meets MOA electric~ Manhole/Access (Y/N) ._._~ "Pump on" level at ~ ..~----"~-Cycles tested Sudace water D. ABSORPTION FIELD DATA Date installed '~- ~ '7--- Length ~ '7... ~ Width Total absorption area ~- ~"-~ Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y~ Soil rating (GPD/FF) ~5'- ~/_ System type '72- ' Gravel thickness '~ ~ Total depth Cleanout present ~N) ~ Depression over field (Y~ ,'-( Results..(~fai[) ,~.,,,~'.5 for --~ Bedrooms c~'" After test ~ ,,/~,./~ /z'/,/'~ ~/,J' If yes, give date "'///~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I c>o To building foundation On adjacent lots Surface water Curtain drain On adjacent lots \ c:,z:, ~ ''~ Property line ~ o ~ ~ To existing or abandoned system on lot Cutbank ~ '7 ' Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certif]/that I have checked, vedfied, or conformed to all MOA and HAA guidelines in effect on the date of this i~.spe, ction. Signature //~ - · , .. ,-nglneers ~ame _,~' , ~, . Date HAA Fee $ / ~ C~ ~'~'~ Date of Payment ~ - ~Z ~ ~.~ Receipt Number ~'Z/Z,~'~.)-~/~'"-~'-~'~' "~ Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back 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. GENERAL INFORMATION Complete legal description Lot 3; Marie Estates Subdivision Location (site address or directions) 24376 Ski Road Property owner Mailing address AHFC ~122347 WA ~84288 Day phone Lending agency Mailing address Day phone Agent Lori Crowder/JACK WHITE COMPAArf Day phone Address lO92R Eagle River Road, Eagle River, Alaska 99577 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 3 X 694-5500 If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72 025 (Rev. 1/91) Front MOA ~21 · '~JoM s,Jeeu!~ue leUO!SSa,toJd @ql u! suofss!wo .~o s.~oJJe Jo,t @lq!suodseJ ].au s! ebeJoqouv `to X~,lledio!unH @q J_ 'penss! s! e~eo!J.!peo e a.~o,~eq e~.ep eZXleUe Jo suoR. oedsu! ~,onpuoo lou ap SHHQ ,to seeXolduJ3 's~.uet.u@.q nbeJ e~.e~.s pue leJepeJ, u!e~Jeo Xj.s!~.es o:~ Jap Jo u! su o!.~n~.R, su! 6u!pueI J !aq~. pue seLuoq ,to sJeseqo.md o~. Xseunoo e se s!q~. seop SH HQ eqj. 'e~Sel¥ ,to e~.e~.S @ql u! peJels!BeJ .~aeu[Bue leuo!sse`toJd ~,uepuedepu! ue /~q e^oqe 9 qdeJBeJed u! ue^i6 suoRe].uesaJdaJ eq:~ uodn ,~lUO peseq se:~eo!,tiueO le^oJddv X~.poq~.n¥ qi. leeH sanss! (SHHQ) saopJeS uet.unH pue q~.l'eeH ,to ),UaLUpedeG e~e.~oqou¥ `to X~.!ledioiunv~ eq/ . S:].UaLUUJOO :suo!,~..elnd!:~.s 6u!,~OllOJ. eq:,t q~.!,~ 'SLUOO.Ipaq JoJ. I.e^oJdd.e I.eUOR.!puoo · pe^oJ dd'es! G 'st. uoo.~peq / / ~ Jo~ Pe^oJdd¥ ..~ 'uoR. oadsu! s!q~. jo a~.ep aq~. ua ~.oej,te u! suoi~.elnSaJ pue 'saou.eu!pJo 'sepoo e~..e~.S pu.e I.edio!unR lie q~-!,~ eou.e!ldLuo3 u! s! t. ua:~s,~s I.esods!p Jal..e,'v',a~,s.e~ Jo/pu.e ,~lddns Jal. e,~ a!.!s-uo eq]. 'uoi~.oadsu! pu.e uo!l. ebi~.SaAU! Xt.u LuoJj. pu.e S@l!~ @Se.~oqouv jo ~].!led!a!un~,N wa4. peu!elqo uoR. eLuJo~u! eq~. ua peseq ~.eq]./;J!Je^ Jaq:pnJ I 'u!eJaq pa!..ea!pu! a.[n~.anJ~.s ,~o ad,~:), pu.e st.uooJpeq ,~o JaqLunu aq~..~o~ a].enb@p.e pu.e I.eUO¢.Ounj 'aJ. es s! LUal. S/,S leSOdS!p .~a~..e..v,a:!.se.~ Jo/pu.e Xlddns Ja:!..e~,, @),!s-ua eq~. :),.eq!. s,~oqs uoil..eo!Idd.e I.eAoJdd¥ ,~.poq~.n¥ q~.leaH s!q~. ,to ~t..u ),..eq~, ,~J.!Ja^ I 'N~Olaq U/~OqS a!..ep uo!!.epfl.e^ aql ,~o s.e pue o~eJaq pax!,t,t.e I.eas Xt.u ~q '9 ~=I:::INI!DN:I Aa NOIJ. O=IdSNI ..'10 ,.LN::IIN~/'¢.I.S '~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: 1-~-~ '~ t'-~,~-Iz~_. ~--%-¢'/x-'¢~_5. %1~ Parcel I.D. A. WELL DATA Well type Log present ~) Total depth Sanitary seal (~N) FROM WELL LOG Date of test Static water level ~ Lo ~ ' Well flow ~'.~ ~K~,~..~ ~-~-~'~.g.p.m. Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Public sewe'r service line WATER SAMPLE RESULTS: Coliform ~ Date of sample: ~', ,~ ~ B. SEPTIC/HOLDING TANK DATA Date installed ~:~ Cleanouts (~/N) High water alarm (Y~) Date of pumping ~"~ J~-~! If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~' ~ I-~ ~ Driller ~',~'~-~ Cased to '~.c.~ -~ i Casing height Wires properly protected ~YN) AT INSPECTION ENV~N~V~N~-^L MAY 1 6 1991 Nitrate gg .CEIVED ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Collected by: Other bacteria ,~o,JE. S & S ENGINEE'IHN~ 17034 Eagle River L~p Road Eagle River, Alaska 99577 Tank size I ~c::,~ Compartments Foundation cleanout (Y/~;]~ ~J Depression (Y,~ Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot / ~0 ~" On adjacent lots To property line /~ Absorption field Surface water/drainage /~ O ~ ~ Foundation Water main/service line 79-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer _ Size in gallons Vent (Y/N) High water alarm level Meets MOA elec~ SEP~ANCE FROM LIFT STATION TO: Iof On adjacent lets Manhole/Access (Y/N) .---------'--'--------~ "Pump on" level at ~el at Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed .~-'- ~ 7.. Length .~Z ~ Width Total absorption area Depression over field (Y.~ Results~/fail) Peroxide treatment (past 12 months) (Y~ Soil rating ~5' ~/~.. System type Gravel thickness Total depth Cleanouts present (~'N) Date of adequacy test '~'- ~ for -['N~.F--~- /~,/~'~/o~/'~.~ If yes, give date bedrooms /DJ`j" SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I 4) o To building foundation On adjacent lots Surface water ..rtain drain E. ENGINEER'S CERTIFICATION On adjacent Jots I c,c, ' ~'' Property line I,D ~ ~'- To existing or abandoned system on lot Cutbank ~ "7 ~ Watermain/serviceline Driveway, parking/vehicle storage area I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of:this.inspection S & S ENG 17034 Eerie River Loop Road No. 204 Signature Eagle River, Alaska Engineer's Name Date ~-'5//(~//~'/ HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91 ) Back MOA 21 Waiver Fee: $ · Date of Payment Receipt Number MUNICIPALITY OF'ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES - - 343-4744 CERT'F CATE OF NSPECTION FOR HEALTH AUTHORITY APPROVAL OF , ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. ~ 051-111-36 HAA# HA900221 AMENDED 1, GENERAL INFORMATION (M6st be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 3 Marie Estates Subdivision Location (address or directions) 24376 Ski Road (b) Property owner Linden Ater Telephone: (home) Business Mailing Address (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Hal Jackson % Heritaqe Address 18550 Eaqle River Road, Eagle River 99577 Telephone 694-4994 (e) Mail the HAA to the following address: (or check here F'l, if hold for pick up.) List contact person and day phone number below: 2, TYPE OF RESIDENCE Number of bedrooms three (3) Single-Family ~:k 3. WATER SUPPLY Individual Well [~x Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site []x Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 ~T~ 'X~T~Tq~TnS peuuT~uo~ s~e~ a~ e~nsuT o~ ?e~zo~ze~ eq 6uT~se~ 3T?oTzed ~ ~e~sebbns ST,~T 'zeA~oq /~uesezd s~T~ ez~ a~q~ 's~poD I~dT2T~n~ le^oJddv leuo!j!puoo ~o suJje/ 0661 leuo!l!puoo pe^oJddes!a xxxx pe^oJddv ~i~fAO~clc~.t~TQ~Cibi~[Ntf 'lV^O~cld'9' SHHO '9 lees s,Jeeu!fiu3 0661 'L eun£ eleG sseJppv LL~66 e:~seI~ /ZaAl~ elbeZ %sez ~teTA%SeZo IgEOI 00£1-969 euoqdele.L ~u.L~eu.[Bu~ U,Le:~unoNLUJ!jJoeuJeN 'uo!loedsu! s!ql ~o ejep eql uo jgejje u! suo[lelnBeJ pue 'seoueu!pJo 'sepoo e~mS pue led!o!unv~ lie q~!M eoue!lduJoo u! s! uJeJSXS lesods!p Je~Me~SBM Jo/pue Xlddns Je~M al!s-uo aq~ 'uoRo@dsu! pue uo!leS!lse^u! XLu LuoJj pue Sel!J eSeJoqouv ~o X~!ledio!un~ eq~ LUOJJ peu!e~qo UO!leLUJO~U! eq~ uo peseq leql XJ!Je^ JeqlJnj I 'uleJeq peleo!pu! eJn~onJls ~o edXl pu~ SLUOOJpeq JO JequJnu eq~ Jo1 elenbepe puc teuo!lounj 'e~es s! LuelsXs lesods!p JeleMe~SeM Jo/pue Xlddns JeleM el!s-uo eql ~eq~ SMOqS leAoJddv X~!Joq~nv q~leeH s!q~ jo uo!leS!~se^u! ~LU leql ~j!Je^ I 'MOleq UMOqS e~ep uo!~ep!leA eql Jo se pue oleJeq pex!~Je lees XLU Xq pe!JllJeo sV NOI.LY~tJO4NI aNY ~J. ya 'No~y~s ~114 'SJ.$t.L '$NOI.LOtSSNI 9NI~I^OB8 ~tJlJ 9NI~t3NIgNi 'g MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING C'~ ~.-~;- ~ / ~ - ~{,~ ' HAA# ~-~ ~ c~('"( "~b. ~ \ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legat Description (include 10t, block, subdivision, section, township, range) Marie Estates, Lot 3 Location (address or directions) 24376 Ski Rd., Peters Creek (b) Property owner Mailing Address Linden Ater c/o Realtor Telephone: (home) Business (c) Lending Institution Mailing Address Telephone Heritage/Hal Jackson (d) Rear Estate Company and Agent 18550 Eagle River Rd., Eagle River, AK 99577 Address 694-4994 Telephone Mail the HAA to the following address: (or check hereY%], if hold for pick up.) List contact person and day phone number below: Mountain Engineering @ 696-1700 " (e) 2. TYPE OF RESIDENCE 3 Single-Famil'~ Number of bedrooms 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality ant status: 4. SEWAGE DISPOSAL On-site:~] Public [] Community [] Holding Tank [] Note: I! community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 'HJOM s,Jeeui6ue leUO!SS~joJd aq) u! SUO!SS!LUO JO sJOJJe JOJ elq!suodseJ )ou s! 96~Joqou¥ Jo Xi!l~dio!unlAI eqJ. 'p@nss) s! ejeou!iJeo ~ eJo~9q el~P eZ/,l~U~ Jo suo!io~dsu! )onpuoo )ou op SHHO ~o Se~oldLU:~ 'siueLueJ!nbeJ eisis pu~ i~J@paj u!8)Jgo/~js))es o) JapJo u! 6u!puel J!~q:l pu~ S@LUOq ~0 sJes~qoJnd o) ~se)Jnoo ~ s~ s!q) saop SHHQ aq.L '~)tsmv jo eleiS eq~ u! p9Je)s!69J J~eu!6ue leUO!SSajOJd)u@pu~d~pu! u9/~q e^oqe ~ qdeJ6eJed u! ue^!6 suoRelu~seJdeJ eq) uodn,{luo p~seq I~AoJdd¥ ~)poqin¥ qil~aH sanss! (SHHQ) S~O!AJeS U~LUnH pue qilgeH Jo )UeLUlJ~de(] 8~l~JOqOUV ~.0/~)!lBd!o!U nlAi eq/ te^oJddv leUOlilpuoo jo swJa.L II~UOl)!puoo poAoJdd~slC] '/:i/' ,~ ,'PO^°'~ddv' MVAO~IddV SHHQ '9 06/Z,/9 ssejppv ~ MUNICIPALITY OF ANCHORAGE (MOA) ~ PAtI~ OF 1~3¢~u~hority Approval (HAA) ........ ,C}JECKL[.S,T - FEBRUARY 1984 ~'~r[,^~ ~.~,~..~ u~v,3,~43.4744 Marie Estates Lot 3 JUN 71990 LegaIDescription: 24376 Ski Rd., Peters Creek A. WELL DA"rA RECEIVED Well Classification Residential Well Log Present (Y/N) Yes Date Completed ~ ' * 207'* Total Depth Z07 Cased to 150' 5/17/90. Unknown DepthofGrouting PumpSetAt Static Water Level If A, B, C, D.E.C. Approved (Y/N) __ 3gpm** Yield n/a 199' Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: >100' To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line n/a Yes Sanitary Seal on Casing (Y/N) Ro Depression Around Wellhead (Y/N) To Nearest Sewer Service Line on Lot Water Sample Collected by Mountain Engineering ; Date Water Sample Test Results Passed - Col±form & Ritz'at, es Comments *Per Well Log 5/19/90 ; On Adjoining Lots >100 ' >100 ' ; On Adjoining Lots >100' To Nearest Public Sewer Cleanout/Manhole n/a >50' 5/28 & 6/4/9O **See Attached Well Adequacy Letter B. SEPTIC/HOLDING TANK DATA Date Installed 5/82* Size 1000. Standpipes (Y/N) Yes Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) n/a Holding Tank High-Water Alarm (Y/N) n/a SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well >100' To Property Line > 80 ' ** To Water Main/Service Line >10' To Stream, Pond, Lake or Major Drainage Course n/a Comments *Per As-Built 5/22/82 No. of Compartments 2* Yes Foundation Cleanout (Y/N) No Date Last Pumped 5/27/90 ; for Temporary Holding Tank Permit (Y/N) n/a To Building Foundation To Disposal Field 7 ' * >5' **Per As-Built Survey 6/9/82 72-026 {Rev 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 5/22/82* Width of Field 72"* Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test 85 sf/bedroom* Type of System Design Length of Field 32'* Depth of Field 8' * Gravel Bed Thickness 4 ' * 2,56 sf* statndpiPes Preseht (Y/N) No Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well > 1 f~ To Building Foundation '> 30 ' Lot n/a To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area > 40' Comments ~<_Per As-_m:±!t 5/22/82 D. LIFT STATION Date Installed n/a Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Deed Trench* .~./21 To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~,/_~. To Cutback (if present) 7 ' ;~** n/a nc visible Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guid( inspection. Signed Company Date MOA No. Mountain Engineering June 7, 19~0 CE89-007 Receipt No. Date of Payment Amount: $ Receipt No Waiver Fee: $ 72~26 {Rev, 7/88) Back id_~ ~'~e'~41~on the date of this ............ ~~ En~neer s Seal 7760 /~ ~ Date of Payment Page 2 of 2 - APPLI(~I~__T FILLS OUT UPPER HA_I~ONLY ~1~ "~ ~Ov~ner~ ~/~_' /~'F~ /~.~.~ ¢'~/~' j ~'~ Phone Mailing ~ddre~ ~/~' '~ ~ ~ , Zip Code ~ ~ ' ~?~/ / ~ ~, Buyer Time Time Time Time ~ ' ~ RECEiVeD