HomeMy WebLinkAboutSWANSON LT 3Swanson
Lot 3
#051-221-38
~ 0 0 0 0 0 0 0 0 0 0 0 0
~-~ I.~ hi I ~ .I P' R L z ~ 0 F I~ N C H I R ~z~ !B ~i~
Departmeo't c~ Health ~ Human Services
82~ L St. Pemt,~ ~4ncnorage. Alaska 99501 343'~
0 N - S E ~l E W E L L P E R M I T
F:'~rmi'[. IqLtmber: 89C2:'?] Upgrade
}al, F:'hone:
694-2:'.979
F-'au" c:e J ~d,~
I....o't l__eq a i: ,%t tb d -i. v i s i (::)n ~ SW~NS[)N Lo'L: S L~ 1 oc: k:
Sec'Lion: I7 ['ownsh].p: 15N Range: 1W
I...ot. Size 1()6800 ~sq. {t. c)r acres)
~:~eclro(]ms: This Permit: ~..~ Total Capacity: :3
WELI.~ Log must be s~ubmi{t~d to ~!unicipa].ity ol Anchorage Department ol Healt~
and Human Services wit. bin 30 days of we].l completJ, on~
!NSI'AL[ PER A'rTACHED AF'PROVED SI'TE PLAN. i:F EXISTING WELL IS
REMAIN IN USE NO CROSS CONNECTION WILL BE PERMITTED. WELL HEAD
qAV NOT BE PLACED IN A CORRAL. LED AREA CIR IN SUCH ~ MANOR AS TO
:~L:~CEIVE SURFACE [:ONTAMINAT]iON. I-HIS c-'E~:~MIT IS ISSUED FOR THE
!!:'XISTING :!; BEDROOM SINGLE FAMILY DWELLING [INLY AND EXPIRES ON
DECEMBER :3:!., 1989.
I CER'I"IFY THAT:
I an~ familiar with '[.he) requ~.remen'!:.s fop on-site sewers and wells am set.
¢orCh by 'bhe Mun:[cipal].'r.y o¢ Anchorage (MOA) arid {he StaCe o[' A].as~.::a.
2. I will ins{all the system ~r~ acc:oPdance wiCh a].l MOA coctes and egulat:i, ons,
and ~n mompliance ~ith t. he design critepza of this pen~z{,,
:]; I w~.]l adhere te ail MOA and St. aCe o~ A].amka Pequ:[nements fop the ~set back
distances Cr'o~ any e~.~istinc] ~,elt, was'f, ewa{en d~.spos,~l system c~f public
~.. I under, stand that. s perm:it :i.s valid lop a maxi, mum of 0 bedr'ooms. I
any enlargem~:'----~ wii~ pequire~' an additional permit.
DATF" ~
(Owner~ M:[ TIN
......... .......................... .... ......
ALITY OF ANCHORAGE
t O DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street-Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAILING ADDRESS [] UPGRADE
I ~o. OF ~E~OO~S
0 ~ ~ Manufacturer Material Liquid capacity in gallons
N°'°f lines I Length of ~ine/~ T°ta'~' o~lin~ Trenc idth Distance b~7i~
~ Length Width Depth ' PERMIT NO.
~ -- Crib depth Total eff~tive absorption area
~ ~ Weft / ~ Building foundation Nearest lot line
m DISTANCE TO:
~ DISTANCE TO: ~uildJng foundation Sewer line Septic tank AbsorptJon area(s}
OTHER I
REMARKS
PERMIT NO.
RPPLICRNT
LOCRTION
LEGRL
MLIP~ I C I PRL I T~' OF RNCHORRGE
DEPRRTMENT ~E~LTH RND ENVIRONMENTAL ITECTION ~~':J~
825 III~TREET~ RNCHORRGE, RK. ~ ,~,/~)~-~¢~)
ON--S I TE 5E~IER PER~II ~ ~~
(sees18) 7
~ICHREL ~RRTIN~¢ PO BOX Z564~T ~¢¢-~9&~ ~J. d/~
LOT SIZE 10008 SQURRE FEET
TYPE OF SOIL RBSORPTION SYSTEM IS: TRENCH
MRXIMUM NUMBER OF BEDROOMS
SOIL RRTING
THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM
I>EPTH= 8. l..ENGTH= ;:~:0 GRFlVEL_ DEPTH=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUND ~ND THE BOTTOM OF THE EXCRVRTION (IN FEET>.
THERE IS NO SET WIDTH FOR TRENCHES
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE
RND THE BOTTOM OF THE EXCRVRTtON (IN FEET>.
RE!~LI T RED SEPT I C TFli'-.II< S I ZE= 1000 GFILLONS
PERMIT 8PPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE
INSTRLLRTION INSPECTIONS OF RNY WELLS RDJRCENT TO THIS PROPERTY RND THE
NUMBER OF RESIDENCES THRT THE WELL WILL SERVE.
TWO ( 2 ) INSPECT I OI~JS FIRE REQU I RED
BRCKFILLING OF RNV SYSTEM WITHOUT FINRL INSPECTION RND RPPROMRL BY THIS
DEPRRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS
100 FEET FOR R PRIVRTE WELL OR i50 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC NELL.
MINIMUM DISTRNCE FROM R PRIVRTE NELL TO R PRIVRTE SEWER LINE IS 25 FEET RND
TO R COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE
RVRILRBLE TO INSURE PROPER INSTRLLRTION.
I CERTIFY THRT
l: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH BY THE MUNICIPRLITY OF RNCHORRGE.
2: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
3: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THRN ~ BEDROOMS.
SIGNED'
RPPLICRNT MICHREL MRRTIN
V4. 0
"';:":~ t._ 3 ..S~AnJ,-S
r'lblr'4-L L: i I-~i~4L- [ , 'T' . ]J
E:,EPRRTI~I~NT ~HEALTH ~ND ENYI~.NrlENTAL
· 5~- '"~ST..EET.. ANCHORAGE, BK.
_ ,~' ~b4-4,
PERM fT NO. (
3CA T l ON
ABSORPTION
r'PE OF :
OF BEDROOMS = ~ SOIL RATING
~',..~ I f'll..lll
NUMBER
REQUIRED SIZE OF THE 50IL .ABSORPTION S'¢STEM IS:
C~PJ--'_:; ][ T'E :E. Et.4ER
LOT SIZE/O O~-O SC.¢JRRE
F'ERr-1 I T
FEET{
,~SQ FT,./BR)=
'EF'TI-I--- (~ LEr-J,3TH== ~_~/ L] F--: FI '-.-' E L [:' E P TH ::: _.)'---
THE LENGTH DIMENSIOH IS THE LENGTH (IN FEET;, OF THE TRENCH [DR ORRINFIELD.
THE [:,EPTH OF R TRENCH OR PIT IS THE DISTANCE BETHEEN THE SURFACE OF THE
GROLIND AND THE BOTTOM OF THE ENCRb'ATION (IN FEET).
THERE IS WO SET WIDTH FOR TEiENCHES.
THE GRAVEL DEPTH IS THE MINIHLIM DEPTH OF GRAVEL BETHEEH THE OUTFRLL PIPE
AHD THE BOTTOM OF THE EXC:RVATION (IN FEET).
:ET_----:Li I RED- '_:;.EF' T I C
3RtlIT APPLICANT HA:, THE REbP_Nz, IBILIT, TO INFOF.:H THIS DEF'RRTMENT [:,URIHG THE
~STAL[_RTION IN_C;F'ECTIONS L-IF ANY HELLS ADJACENT TO THIS PPOPERT'¢ Rt.~[:, THE
.MBEE nF RESIDEHCES THAT THE WELL HILL SER\,'E.
TI-.I~]~ ( 2 _-" ]: I'-I_-C-PE L--:T I]] r--i ~.] RE:E F~:Et.-] LI I F-: E [;.
~CKF'ILLING OF RN'¢ SYSTEM WtTHCIUT FINAL INSPECTION AND RPPROVRL BY THIS
~F'RRTf'IEtlT HILL BE SUBJECT TO F'PFJSECLTI]N. s
;NIMUM DISTANCE BETWEEN A HELL AND RH¥ ON-SITE SEHRGE DISPOSAL SYSTEM IS
)t3 FEET FOR R PRIVATE WELL OR 15~ TO 2ElO FEET FROH R PUE:LIC WELL DEF'EN[:,INm]
)CmH THE TYPE OF PUBLIC WELL
;HIMUM DISTANCE FROM R PRI\,'RTE HELL TO R PRIVATE ~EHER LINE IS 25 FEET RH['
) R COMMUHITY ~EHER LINE IS 75 FEET
][_L. [_OGS ARE REQUIRED AND HUST E:E RETURNED TO THE [:,EF'RRTMENT WITHIN ]:E~ DRYS
; THE HELL COMPLETION.
7HER REQUIREMENTS MRS' RPF'L~'. SF'ECIFICRTIONS AND C:ONSTRI_ICTION DIAGRAMS fiRE
CRILRALE /0 IN?JRE PROPER INSTALLATION.
P E F-: r.1 ][ -r E ~-< F' Z F-: E; S [:, E C- E I-.1 E: E I~: _]: :'L _. :1. '_:,- :_~. ,~
C:ERT I F'¢ THAT
I 8f'1 FAr-IlLIRR HITH THE REL).I_IIREMENTS FOR OH-SITE SEWERS fiND WELLS RS SET
)RTH B'¢ THE MIJHICIPRLIT'T' OF ANCHORAGE
I HILL INSTALL THE SMSTEM IN ACCORDANCE WITH THE I]ODES.
I UHDEF.'STRND THRT THE ON-SITE SEHER S'¢STEM i'lRb' REC~UIRE ENLARGEMENT IF THE
:SIDEHCE IS REMO[:,ELED TO If:,CLU[:,E MORE THAH 3 BEDE'OOMS
V 4. t3
825 "L' STREET
ANCHORAGE, ALASKA 99501
{907) 26,:!-4111
December 31, 1979
Michael Martin
Post Office Box 3564
Anchorage, Alaska 99501
Permit ~ 790629
Subject: Lot 3 Swanson Subdivision
A permit issued by this department for well and/or sewer
system has expired.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal ordinance.
If you have drilled the well, a well log should be sent
to this department to document the installation date.
If an engineer has inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files.
If there are any further questions, please contact this
office at 264-4720.
Sincerely,
Les N. uchholz, R.S. ~ ....
Senior Environmental Speci~i~st
LNB/ljw
enc: Copy of Permit
I'~l~_J~,t'"!- I C: :I:,i~Fi L T T~-" L--~F
DEFRRTMENTIHERLTR RND ENVTRI])NMENTRLIITEC':I'ICiN
· - ' '. 825 .'"E~ STREET, FINCHORRP~E. RK
- - ~
--, C~!'-4--:5 ]E TE SEI-%IEER F'ERI'.I 1E T
,PERMIT NO. ( ~90629 ) ' ' ·
flFPLICANT .MICH~E~ MARTIN P 0 BC~,'. 356'4 DT 27E 27C~E~
LOCflTION 6ENDIN BIRCH R[)
LEGBL LS: SHRNSON S [:, . LOT SI,'E .~L~000 _,MLIHRE FEET
YPE OF .=,UIL RBL=,ORPTION _,T_,TEI.'I I_. TRENCH
MRXIMLIM NUMBER OF BEDROOMS = ~:' SOIL RRTING '-'."SE! ET,-'"BR)= ±00
'PHE REG!UIRED SIZE OF THE SOIL RBSORF'TION SVSTEM IS:
C'EF'TH= 8 LEI~ISTH- Z~L G RR~-,.'EL C"EF"TH=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET)-OF THE TRENCW OR [)RBINFIEL[)
· THE [)EPTH OF B TRENCH OR PIT IS THE DISTBNCE' 8ETHEEN THE SURFBCE OF ]]HE
GROUND ~BND THE BOTTOM OF THE ENCBVBTION (IN FEET)
THERE I5 NO SET HIDTH FOR TRENCHES.
-THE GRB'¢~L DEPTH IS THE MINIMUM DEPTH OF GRBVEL BET~4EEN THE uJTFBLL PI~FE
8ND THE BOTTOH OF THE E)4CB~/BTtON (IN FEET)
F:EL%~.Li ][ RED SEF'T I C TRfq[:C S I ZE-- t~8~
PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO. INFORM ~HIS DERRRTMENT DURING -THE
INSTRLLRTION INSPECTIONS OF RN9 WELLS RD..IRCENT TO THIS PROPERTb'
NUMBER OF RESIDENCES THRT THE HELL HILL SERVE. "
--2-- Tbll] ' (2 ::' I f'~SPECT I O~S, RRE. E:E,~'I=! ! RED :
BRCi~ILLING '0~' RNb' S~'STEM HITHOUT FINRL IN~PEF:TIAN']RND RPPRAVRL
DEPRRTMENT HZLL BE SUBJECT' TO PROSEcuTIoN' ' , --
MINIMUM DISTRNCE BETHEEN R WELL RND RNa' 'ON-SI-TE SEWRGE D.~SPOSRL S~'STEM
$¢8.FEET F~R R PR!VR~-HELL OR t58 TO 2¢8 FEET FROM R .PUBLID WELI~ DEPENDING
UF'ON'"THE T~PE OF PUBLIC HELL
OTHER REQUIREMENTS MRb' RPPL9. SCEcIFI-C:~I'ON~ RND CONSTRUCTION
RCRIL~LE TO INSURECPROPER INSTRLLRTION.
PEBfq I T E~(P'I RES DECE ME:ER~=.1..'
I ~CERTIFM THRT '
i:. I 'R~ FBf~IILIRR :WIZR THE-REBUIREMENTS'FOR DN~SI~E SEHER~ ~N[:, HE[~ 'g Rq qET
FORTH B~" THE MUN[C~PRLZT~¢ OF ~C:~ORBGE; ' .., '-
2: I WILL INSTRLL THE"¢'¢~TEM IN ~CC:GR[:RN~gE WITH T~E C:OBES
3:: I UNDERSTRND THRT THE ON-SiTE-SEWER sMsT~M MR9 REgiU~RE ENLRRGEHENT ~F THE
RE:BIDENCE IS REMODELED TO INCLUDE M~RE THRN. ~-BEDROOMS.
,IuNED .... '
RPPL I CRNT MICHREL MRRTIN .... ¢, ' .
ISSUED B~' ..................... ] ....... ==D~E__z___: ........
PERMIT NO.
TYPE OF SOIL RBSORBTION SYSTEM
MRXIMUM NUMBER OF BEDROOMS
LOT SIZE /~0¢¢0 SQURRE FEET
SOIL RATING
DEPTH= LE[4GTH= ~-- GRR%¢EL [)EPTF4= ~
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFRCE OF THE
GROUND RND THE BOTTOId OF THE EXCRVRTION (IN FEET),
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE
RND THE BOTTOM OF THE E~CRVRTION (IN FEET).
RE(~UIRED SEPTIC TFINK SIZE= /¢oO 6RLLOf~S
)ERMIT RPPLICaNT HRS THE RESPONSIBILITY TO INFORM THIS DEPBRTMENT DURING THE
[NSTRLLaTION INSPECTIONS OF RNa' WELLS RDJaCENT TO THIS PROPERTY' RND THE
~UMBER C~ RESIDENCES THaT THE WELL WILL SERVE.
TI40 < 2 ) I ~-ISPECT 101'4S IRRE REQU I RED
~aCKFILLING OF BNY SYSTEM WITHOUT FINRL INSPECTION aND BPPROVaL BY THIS
)EPaRTMENT WILL BE SUBJECT TO PROSECUTION.
IINIMUM DISTANCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS
.O0 FEET FOR R PRIVATE WELL.: OR
.50 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL
IELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN _~0 DRYS
THE WELL COMPLETION.
ITHER REQUIREMENTS MRs/ RPPLY. ~SPECIFICaTIONS aND CONSTRUCTION DIRGRRMS RRE
IYRILaBLE TO INSURE PROPER INSTRLLaTION.
' PERbl I T EXP I RES DEL'].EblBER _~:-.±.. I _'~-7~'~
CERTIFY THRT ,
: IRM FRMILIaR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
ORTH BY THE MUNICIPRLITY OF RNCHORRGE. ~
: I WILL INSTRLL THE S~STEM IN RCCORDRNCE WITH THE CODES.
: I UNDERSTRND THRT THE ON-SITE ~ENER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE
ESIDENCE IS REMODELED TO INCLUDE-MORE THRN ~ BEDROOMS.
................
........
· St~v'en A. Johnson
P.O. Box 76'
Chugiak, AK 99567
Phone: 907-688-3085
PERFORMED FOR:
SOILS LOG - PERCOLATION TEST
LEGALDESCR.'T, ON: L o.t- *~ ~,'~,~'
SLOPE
4 i00
11
12
13-
SOILS LOG
E] PERCOLATION
TEST
WAS GROUND WATER
ENCOUNTERED? /~
IF YES, AT WHAT
'To~,A L~p*~ I'x' OEPT.~
E
14
15
16
17
18
19
20-
COMMENTS
PERFORMEDBY: -~e~..
Date Gro~$ Net Depth to
Time Time Water
PERCOLATION RATE (minute~/inch)
TEST RUN BETWEEN FT AND FT
72-008 17/76)
Ge bG
• '� Municipality of Anchorage r¢p
On -Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 051-221-38
1. GENERAL INFORMATION
Complete legal description Swanson Lot 3
Expiration Date: _)2-2,�z2
Location (site address) _ 1.8110_Bending Birch Dr. Chugiak, AK
Current Property owner(s) Kristian Moistner Day phone
Mailing address
Real Estate Agent
18110 Bending_ Birch Dr. Chugiak, AK
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY:
Individual
Individual Well
®
Holding Tank
❑
Individual Water Storage
❑
Community
❑
Community Class _ Well
❑
Public Sewer
❑
Public Water System
❑
Waiver/Variance request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee
Date of Payment
Receipt Number
COSA #___--
Date:
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
6.
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm .ARCTERRA CONSULTING INC. Phone 696-6111
Address 20441 PTARMIGAN_ BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date _ _31/3 -
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition
of the well and septic applies only to the conditions as of the day tested. The t and absorption rates may change due to subsurface
conditions that may not be observed from the surface, changes inland It bll(t*, teristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served byy���993`�et�al. o �r',�ional life of all well and septic systems are
subject to these various and dynamic characteristics and are outsi(ZZVtp;htrol of the
evaluator of the well and septic system. Therefore, ` V\��cc T
ArcTerra can not give any estimate of how long a ` ON-SITE
�i
system will function satisfactory for current or future J
occupants or can ArcTerra guarantee that no unseen= g WATER AND Z Jl�, _1
encroachments, deficiencies or discrepancies exist. o WASTF_u''ATER
PROISKAM o` TFr /'' �J*
DSD SIGNATURE��A�FN7 SERvG)
System #1 Approved for,
bedrooms. KENNETH 71
System
S.
System #2 Approved for bedrooms. ,'T44b
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
By: v�-�� ' 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 blue sheet 10-10-12.doc
Legal Description:
Swanson Lot 3
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 12/18/89
Total depth 400 ft
Cased to 20 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 16 in.
Date of flow test for COSA 2/14/22
Static water level at beginning of test 35 ft.
Comments
B. TANK DATA
Age of tanks) 42 years
Tank type/material. Septic/Steel
Measured operating fluid level in septic tank 49"
11 Standpipes/foundation cleanout per record drawing
Date of pumping 2/23/22
D. ABSORPTION FIELD DATA
Which system tested (date installed) 10/29/1980
ALL standpipes present per record drawing
Total measured depth from grade 8 ft (max)
Measured depth to pipe invert from grade 3 ft (min)
❑ NIA — 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
Comments/Deficiencies:
COSA Checklist yellow sheet
Parcel ID: 051-221-38
Structure served by this system
Well production at time of test 5.4 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes Nc
Coliform bacteria is Negative
Nitrate 3.23 mg/L ❑ Nitrate less than MRL (ND)
Arsenic 8.24 ug/L ❑ Arsenic less than MRL (ND)
Collected by Arcterra Consulting
Date of Sample 2/11/22
FT STATION
❑ Requi aintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 2/14/22
Results Q Pass For 3 bedrooms
Fluid depth prior to test 1 in
Water added 450 gal
New depth 9 in
Elapsed time 600 min
Final fluid depth 1 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 ft
Wells on Adjacent Lots:
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
[iz 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'
Surface Water > 100'
® Yes
Animal Containment > 50' ® Yes
if No ft
® Yes
if No
ft
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:
Absorption Field > 5'
Yes if No ft
Private Wells > 100' ® Yes if No ft
Water Main > 10'
®Yes if No ft
_ ____v -__..__--_- _..__-- ..
Community UVells > 200' ®Yes ifNo 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 ft
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l certify that 1 have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
COSA Checklist yellow sheet
Septic Tank Advisory
Certificate of On -Site Systems Approval #OSC 221068
Subdivision: Swanson Lot 3
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this COSA / property is 42 nears old. A leaking septic tank may be a source of contamination to
the aquifer. Typical replacement costs range from $10,000 to $15,000
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of a 16 -year-old septic tank.
Mailing Address P O Box 396650 *Anchorage, Alaska 99519 6650 *www muni org
•t17_•-� Municipality of Anchorage
On-Site Water and Wastewater Program
SEP i< SLI/
(907) 343-7904
•
Certificate of On-Site Systems Approval `<< Oc 6 9 u c`'
Parcel I.D. 051-221-38 Expiration Date: 2-2? _1 7
1. GENERAL INFORMATION
Complete legal description Swanson Lot 3
Location (site address) 18110 Bending Birch Dr.
Current Property owner(s) Ruel Hooper Day phone
Mailing address PO Box 770761 Chugiak, AK 99567
Real Estate Agent Day phone
2. TYPE OF DWELLING:
O Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: - Distance:
Received b • 4E6 /.� �� � I Date: /2Ls// 7
COSA to be released to the engingin~ otherwise requested.he engineer.
COSA Fee $ 6 Waiver Fee $
Date of Payment 4JI11 tt Date of Payment
Receipt Number OMMI Receipt Number
COSA# 05CMCWI 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.
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.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 9/8/2017
OF ACq l
6. DSD SIGNATURE '''-
System #1 Approved for 3 bedrooms %Steven Ft.'Pannone •
CE-8149 1/
System #2 Approved for bedrooms 4o
Disapproved 'k OFESSCCO- ' '
Conditional approval for bedrooms, with the following stipulations:
C a.-120_/
1:6p.P 2O
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4 T H
ON.SITE
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PROGRAM R
____ c '.�G,• -
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By: ` VA". - � Original Certificate Date: _( - z I
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: lItt
COSA Checklist X Nitrated is
Septic System Advisory Arsenic Wit
Well Flow Advisory Others Vit
COSA blue sheet_t - . ,.
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: Swanson Lot 3 Parcel ID: 051-221-38
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (YIN) Y
Date completed 12/18/1989 Sanity -- /N) t Wires properly protected (YIN) Y
ail
Total depth 400 ft. Cas-• •e117/4- '.NOP' Casing height (above ground) 12+ in.
FROM WELL LOG ,R• AT INSPECTION
Date of test 12/18/1989 8/8/2017
Static water level 390 ft. 24 ft.
Well production 2 g.p.m. 2.5 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 mL Nitrate 3.95 mg&
Arsenic ND ug/L Date of sample: 8/8/2017 Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 10/29/1980
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N/A
Date of pumping 8/4/2017 Pumper JR's Pumping
C. ABSORPTION FIELD DATA
Date installed 90/29/1980 Soil rating (g.p.d./ft2 or ft2/bdrm) 100 SF/BORN System type Deep Trench
Length 37 •� ft. Width 2.5 ft. Gravel below pipe 5 ft.
Total depth 9)•2\ ft. Eff. absorption area 3ft2 Monitoring tube Y Depression over field N
Date of adequacy test 8/8/2017 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth 0 in.
Elapsed Time: 120 .min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment,(past 12.mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off" level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100+ On adjacent lots 100+
Absorption field on lot 100+ On adjacent lots 100+
Public sewer main 75+ Public sewer manhole/cleanout 100+
Sewer/septic service line 25+ Holding tank 100+
Animal containment areas 50+ Manure/animal excrete storage areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+
Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
Survey on file.
G. ENGINEER'S CERTIFICATION 1 ����oku
I certify that I have determined through field inspections and 'r��'�P' ��� ��°0
review of Municipal records that the above systems are in * �,
conformance with MOA COSA guidelines in effect on this date. • ' i -:-
Engineer's Printed Name Steven Pannone '';S}ever IR.'Oanriorie 4
Date 9/8/2017 opxCE-8149 . 'r/
COSA canary sheet_2-6-15.doc
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ai
CANYON DRIVE
PLOT PLAN ___ AS BUILT X SCALE _17_ = 60' GRID NW 1057__ Project No. 17-351/A1
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates , Inc . (907) 522-6476 Phone ��a�0p�%
(907) 522-4625 Fax a
Professional Land Surve ors kenOlangsurvey.com �F � � �Q
Y jonathanOlangsurvey.com , - suQ
ov, - -...1.– ''''-"HOA
I hereby certify that I have surveyed the following described property: OI .' 49TH /N • V
LOT 3, SWANSON SUBDIVISION (PLAT 76-175) v * . . * 4
Anchorage Recording District, Alaska, and that the improvements situated thereon are �' f• D
within the property lines and do not encroach onto the property adjacent thereto, that 0 0
no improvements on the property lying adjacent thereto encroach on the surveyed IA L' Q
premises and that there are no roadways, transmission lines or other visible �A KENNETHt Q�
easements on said property except as Indicated hereon. V0 's� 0
F' ' 4
Dated this the Day of – - ___.._.__, at Anchorage, Alaska �LlbOpR°gess•-•' . �
It Is the responsibility of the owner to determine the existence of any easements, "��pCp.a
covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963
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; Swanson Subdivision
Location (site address or directions)
18110 Bending Birch
Property owner
Mailing address
Lending agency
Mailing address
Chu~iak, AK
Chris Brems and Mark Johnson Day phone 688-5935
~P.O. Box 670825 ChugiaL AK 99567
Day phone
Agent' Eva Loken/ REMAX PROPERTIES
Address 16600 Ce~erfield Drive, Eagle River,
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well XY, X
NOTE:
Day phone 694-4200
AK 99577
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
XXX
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72*025 {Rev. 1/91} Fronl MOA #21
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Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
Parcel I.D.
A. Well Data
Well type
Log present
Total depth
Sanitary seal
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~.-~ t~ -~'=[ Driller
Cased to '~/~c~' '~_~. Casing height
Wires properly protectedd~N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1 ~ ~,<~ '~
SEPARATION DISTANCES FROM WELL TO:
Septic~/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
g.p.m.
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform. -~ Nitrate
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Other bacteria
Collected by:
s & s ENGINEERING
17034 Eagle I(iver
Eagle River, Alaska
Date installed
Cleanoutst~N) '~
High water alarm (Y~
Date of pumping
Tank size
Foundation cleanout~N)
Compartments
Depression ('~
Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Weif(s) on lot ~ ~(::, [ ~ On adjacent lots
To property line I.~-'z..~ Absorption field
Sudace water/drainage \ ~ c,
Foundation
Water main/service line
72-o2s (~3)* Fro~t CONTINUED ON RACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N) ~
SEP~STATION TO:
WeE'on lot On adjacent lots
Manufacturer
Manhole/Access (Y/N) ~
.Sudace water
D. ABSORPTION FIELD DATA
Date installed '~, ~> ~
Length "~"1 ~ Width
Total absorption area '5 '~ ~
Date of adequacy test ~) ,~ ~
Soil rating (GPD/FF) I.o c:=, ~'/~'e--' System type
,Gravel thickness ~ ' Total depth
Cleanout presentlY/N) ~/ Depression over field (Y~
Results~fail) ¢,~.~ for
" After test
If yes, give date
Water level in absorption field before test /
Peroxide treatment (past 12 months) (~i)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Bedrooms
Wellon lot \o~
To building foundation
On adjacent lots '~
~' Surface water
Curtain drain
E. ENGINEER'S CERTIFrCATION
On adjacent lets ~ ~o ' 4- Property line
Lo ~ ~ To existing or abandoned system on lot
Cutbank ~/~ Water main/service line
['~ Driveway, parking/vehicle storage area ,z/-
I cern'fy ~hat I have checked, verified, or conformed to all MOA and HAA guidelines'in effe~,
Signature
Date
HAP, Fee $ / 7D, r/Z_o
Date of Payment
Receipt Number
72-02S (~93)' Back
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # ;~'~/- ~/- O~/'~ NAA # ,////~ - ~'~ ~ ~..~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
LOT 3, Swanson Subdivision;
Location (address or directions)
NHN Bending Birch, Chugiak,
(b) Property owner
Mailing Address
(c) Lending Institution
Mailing Address
Mike g Cind~ Martin Telephone:(home) Business
17034 Eagl~ Riu~ Road~ Eagl~ River, Ak. 99577
Telephone
(d) Real Estate Company and Agent Re/Max of Eagle River Attn: Eva Loken
Address 16600 Centerfield Drive, S~te 201 Eagle River, Ak. 99577
Telephone 694-4200
(e)
Mail the HAA to the following address: (or check here ~if hold for pick up.)
List contact person and day phone number below:
S & $ ENG'~NEEEING
17(;34 Eagle River Loop Road
;a_ale River, Alaska 99577
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms $
3. WATER SUPPLY
Individual Well [~X Community [] Public []
Note: !f 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 ~ Poblic [] 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
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,O MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
C~PALF[¥ o~,~J.~. FEBRUARY 1984
MENTAL 5ERVtCE$ DIVIS~j~.4744
',,-r' Legal Description: Z,o~
,:,. 2 1989
A. WELL DATA R E C E I V E D
Well Classification :~l/dO I~. /L~"~ ~ '~ 114 If A B, C, D.E.C. Approved
Well Log Present (Y/N) ~ DateC0mpleted I ~ -/
Total Depth ~Oo ·Cased to ~ o ~ Depth of Grouting
Static Water Level ~o~ I~ ' PumpSetAt
Casing Height Above Grpund I~ 't ~ tA" ~
..... Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) :~ .~' ; ~ Depression Around Wellhead (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
To Nearest Sewer Service Line on Lot
Water Sample Collected by ~'~
Water Sample Test Results
Comments ~ J,~.~ .[¢ d'~_<,c~
; On Adjoining Lots / CO -1"
lO0'~- ' '
; On Adjoining Lots /
To Nearest Public Sewer CleanouUManhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed- ! 74:~O Size ~No. of Compartments
Standpipes (Y/N) ~ - Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ' ~) " Date Last Pumped ' t',,~ -
Pumping/Maintenance Contact on le (Y/N) : ; for
.H° ding, .. ~ahk H. .gh'Water Alarm (Y/N) - ~[~t Temporary Holding Tank Permit (Y/N)
~EPXhA i0~ D ST* ~E ANK ', T I ~CES FROM PT C/HOLD NG T
:; ~W~eFZS~p[K,~elt'-, -f / O0 ,¢ To Building Foundatl6-h': -.- '1 .~ '
,..:,TO Prop¢I~ L,me ., :. J ~ ~ To D~sposal Fmld
.... - .' - ,t . . ·
TO Str~ Ppnd~ ¢~ke or Major Drainage Coume / ~
72-026 (Rev. 7188) Front
Page:l of 2
ABSORPTION FIELDDATA
Soils Rating in Absorption Strata
Datelnstalled ! ~ 80
Width of Field [~
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last.Adequacy Test
Type of System Design '-! ~'~'.~Jc~ ~
Length of Field '~, "~' ' ~
Depth of Field ~
Gravel Bed Thickness 3)
Stathdpipes Present (Y/N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION'FIELD:
To Property Line ~.~ ~
To Existing or Abandoned System on
; On Adjoining Lots ~ O~/~
To Cutback (if present) Mot ,~re 5¢~'~-
To Water-Supply Well ! OC~ / '/-
To Building Foundatio~ (~ ~
Lot ~Ord(~,
To Water Main/Service Line · ~.~ ~ '
To Stream, Pond, Lake. or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed .
\
Size in Gallons ,,~
"Pump On" Level at ~,,~, ~
High WaterAlarm Level at . '
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimer~sions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (WN)
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 guidelines in effect on
inspection.
Signed
Company
Date
MOA No.
_~ & $ Lm~IGINEERING
17034 Eagle River L~oop Road No. 204
Eagle KlVer,
Receipt No. ~__.?
Date of Payment
Amount: $
Receipt No.
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/881 Back
Page 2 of 2
MUNICIPALIT~ OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPAETMENT OF HEALTH A~D ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1..~eneral Information Application Date 11-6-84
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 3, Swanson S/D
Location (address or directions)
Last house on Bending Birch Road, Chugiak
(b) Applicants Name Michael Martin Telephone - Home688-27~iness 276-8989
Applicants Address Box 621, Chugiak, Alaska 99567
(c) Applicant is (check one) ne ing Institution
Buyer ~--~; 0ther~-~ (explain); Owner/bu/lder
(d) Lending Institution Alaska Mutual Bank Telephone 694-957i
Eagle River Br., P O Box 771068, Eagle River Ak 99577
(e) Real Estate Co. & Agent
Address '
Telephone
(f) Mail the NAA to the following address:
2. ~7pe of Residence
Single-Family.~.
Number of Bedrooms
3. Water Supply
Mal~i-Family~-~
3
Other (describe)
Individual Well ~ Co~muni~y ~ Public ~--~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Sewage Disposal
Onsite~ Public~ Community~--~ Holding Tank[--~
Note: If community well system, must have written confirmation from =ha S~aCe
Department of Environmental Conservation attesting to ~he legality and status.
[Page 1 of 2]
5. En~ineerin~ Firm Providin~ Inspectlons~ 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 wsstewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure iD~icated herein.- I further verify that,
based on the information obtained from the MuDicipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in affect on the date of this inspection.
Name of Firm
Telephone.
Address
Date
~HEP Approval
Approved fo~'hree(3) bedrooms
Approved XX Disapproved
(ENGINEEH SEAL)
ORIGINAL WORKSHEET AND
SIGNATURE FROM ENGINEER
IS ON FILE WITH THIS
DEPARTMENT. FOLLOW-UP
LETTER FROM ENGINEER IS
ON FILE.
Conditional
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE I~PARTMENT OF HEALTH AND ENVIROI~iENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGI~ 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN 'r~tz STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THi~IR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF I~tEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OH OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RA4/eJ/D18
[Page 2 of 2]
7-19-84
MUN'~ICIPA~ITY OF ANCHORAGE
DIVISION OF ENVIRONmeNTAL HEALTH
DEPARTMENT OF HF~TH AND ENVIRON~NTAL PROTECTION
APPLICATION FOR HE~TH AUTHORITY APPROVAL CERTIFICATE
1. General Information. Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions) _
(b) Applicants Name fl'C~e~ ~(Ph'"l TeleEhone_ ~0~~ ~3~
(c) Appli~an~ i~ (check on~) ~ndl~ Institution ~; ~er/~uilder
~uyer ~ ; Other ~ (ex~lain); ' '
(e) Real Estate Co. & Agent
Address
(f)
Telephone
Mail the HAA to the following address:
2. Type of Residence
Single-Family~
Number of Bedrooms
3. Water Supply
Individual Well~'~'-[
Multi-Family~-~
Other (describe)
Community~-~ Public~-~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
0nsite~--~ Public~-~ Community~--~ Holding Tank~--~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
$
En~ineerin~ Firm Provldin~ Inspections~ Tests, File Search~ Data and Informatio,,
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 regula-
tions in effect on the date of this inspection.
Name of Firm ~/~/~ ~--A;6i~_yA~ [~L"~,~C,. Telephone
Date /Z, Iq g
(ENGINEER SEAL) f~ .'3Y' '~ -v .....
DHEP Approval ~.' k%. 4381.E
Approved for bedrooms By~:~., r~'~ '~~7
~pproTed ~ D~sapproved ,, Condtrlon~ ,~'
Te~s of Conditional Approval F~/_ ,~~d~<,~.~/~
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE If, ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classification
Well Log P~esent~'~)
Total Depth z ~o ET Cased to
Static Water Level z~
Casing Height Above Ground
Wiring in Conduit ~/N)
Electrical
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Se~r Line
Legal Description:
If A, B, or C, D.E.C. ~proved(Y~)
Date ~leted Yield ~$
~ - /~ ' ~pth of G~ting
~ ~t At
Sanit~y ~al on Casing
~ession ~ound ~l~ead (Y~
; On Adjoining Lots 1o~ ~r,
~o?rti ; On Adjoining Lots /~z-~
TO Nearest Public Sewer
Cleanout/Manhole ~/~r /¢,' ..4..~; TO Nearest Sewer Service Line on Lot 4z~/,,.,, .,x,e.¢-4
Water Sample Collected By .Qu~ ~6.-~¢F~e~ ; Date ,~//~/~>~
Water Sample Test ~sults
Con, rents
B. SEPTIC/HOLDING TANK DATA
Date Installed /fiFO Size ~m No. of Compartments
Standpipes (~N) Air-tight Caps ~N) Foundation Cleano~t
Depression over Tank (Y~ Date Last Pumped /0/&/~
Pumping/Maintenance Contract on File (Y/N) ~.~ ; for
Holding Tank High-Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line /Z ~7-
Course
To Building Foundation /z~E~-~
TO Disposal Field ~7~
To Stream, Pound, Lake, c~ Major Drainage/~/
Cozr~ents
Receipt
Date Paid:
Amount:
[Page 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /mU Type of System Design
Date Ir~talled /~/~ Length of Field 7~.~/--
Width of Field ~-~r~ Depth of Field ~
Grave 1 Bed Thickness o~'
Squai~e Feet of Absorption Area .~?~s~r Standpipes Present ~N)
Depression over Field (Y~ Date 9~f last Adequacy. Test
Results of last Adequacy ~%st ~ /~S_~ .i ~.
Separation Distanoe frcm Absorption Field.-~
To Water-Supply Well J~? ~r TO Property Line
To Building Foundation G ? ~. To Existing or Abandoned System on
Lot //~/~ ; On. Adjoining Lots /~ ~-~ ~
To Water Main/Service Line ~7 Fr To ~tbaPk(if present)
Co~an~nts
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested fo~
Electrical Codes(Y/N)
Din~nsions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles dl~ing Adequacy Test.
Meets MOA
Comments
** Check Permitted Bedroc~a RatinD Against HAA Request **
I certify that I have checked, verified, o~ ~onformmd to all MOA-H~A Guidelines in effect
on the date of this inspection. ·
Signed 7~~ (.~ ~;~4~-~ Date
Ccmpany ~//~/~4 ~'~O~F~3~.~Z~76 MOA No.
KB1/dS/s
[Page 2 of 2]
2-15-84
INSPECTION APPOINTMENTS £ .~-~ ~-~
TIME TIME ~ ~ ~4'1~., ~ ~-"~'
MUNICIPALI~ OF ANCHORAG~
MUNICIPALITY OF ANCHORAGE DEPT, OF HEALTi~ &
) ENVIRONMENTAL SANITATION DIVISION M~R
Telephone 264-4720
RECEIVE
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
M/~ING ~DDRESS
2, BUYER PRONE
I
MAI~NG ADDRESS ,
5, LEGAL DESCRIPTION
6. TYPE OF RESIDEN~:E NUMBER OF~BEDROOMS
[~/' SINGLE FAMILY [] One [] Four [] Other
[] Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six
7. WATER SUPPLY
~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth {attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE** / ,~'[?~ YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-01.0 (Rev. 6/79) ~.~%/,
.'~- THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]Sep?c,f~(~Tanl~r [] Holding Tank
Size: ,~'~' If Tank is homemade SOILS RATING
give dimensions:
WELL TO:
5. COMMENTS
I~'~PPROVED FOR _ ~ BEDROOMS
[] CONDITIONAL APPROVAL {letter must accompany certificate)
DATE [] DISAPPROVED
72-010 (Rev. 6/79)