HomeMy WebLinkAboutLAKE HILL ACRES #1 LT 23
MUNICIPALITY OF ANCHORAGE
Development Services Department El Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On-Site Systems Approval
Parcel I.D. 051-052-19 Expiration Date: 6--2--S7-117
1. GENERAL INFORMATION
Complete legal description LAKE HILL ACRES#1 LOT 23
Location (site address) 24525 GRACE STREET, CHUGIAK,AK 99567
Current property owner(s) TENHAGEN FAMILY TRUST... Day phone
Mailing address 22921 SHELTERING SPRUCE AVENUE, CHUGIAK,AK 99567
Real estate agent Day phone
2. TYPE OF DWELLING:
❑ Single Family (w/wo ADU)
❑ Duplex
0 Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3(6-BR SYSTEM)
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Private Septic
Private Well ® Holding Tank LJ
Water Storage ❑ Community ❑
Community Well ❑ Public Sewer ❑
Public Water System ❑
Waiver request for: Distance:
Received by: — Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 561) Waiver Fee $
Date of Payment (3/1[6-1lq Date of Payment
Receipt Number * l0q3 Receipt Number
COSA# (-SC!9 104 S.- Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On-Site staff may visit the site to verify the information submitted.
Name of Firm ANDERSON CONSTRUCTION & ENGINEERING Phone 345-3377
Address 4640 SHOSHONI DRIVE,ANCHORAGE,AK 99516
Engineer's Printed Name MICHAEL N. ANDERSON,PE Date 2/8/2019
OF A
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6. DSD SIGNATURE 49TH •;�
System #1 Approved for bedrooms •
System #2 Approved for bedrooms / MICHAEL N. ANDCR5CN.;
959
Disapproved � �,�Fp'I" ' �'‘',`���'..
Conditional approval for bedrooms, with the following s� �' '•'�.
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PROGRAM ? I
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By: 1 t �-�- �G _ 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 Chechhst blue sheet
COSA Checklist
Legal Description: LAKE HILL ACRES#1 LOT 23 Parcel ID: 051-052-19
If more than 1 septic system on lot: COSA Checklist# of Structure served by this system
A. WELL DATA—*PER MOA RECORD DOCS
❑ Well log is filed with Onsite (or attached) Well production at time of test 6.3+ gpm
*Date drilled <1971 Water storage tank volume NA gallons
*Total depth 210+/- ft Well disinfected for coliform test? ❑ Yes Z No
*Cased to 40+ ft ® Coliform bacteria is Negative
® Sanitary seal is functioning correctly Nitrate N P mg/L ❑ Nitrate less than MRL (ND)
Z Wires are properly protected Arsenic N57 ug/L ❑ Arsenic less than MRL (ND)
Casing height (above ground) 18+ in. Collected by FWCS
Date of flow test for COSA 2/7/19 Date of Sample 2/7/2019
Static water level at beginning of test 185 ft.
Comments
B. TANK DATA— 10/1971 — 1795 GALLONS C. LIFT STATION - NA
Age of tank(s) 47.5 years ❑ Required maintenance completed
Tank type/material CONCRETE Age of lift station years
Measured operating fluid level in septic tank 64 Lift station material
® Standpipes/foundation cleanout per record drawing Comments: Tank levels appear operational w/in 10" of
Date of pumping 2/7/2019 top of tank
D. ABSORPTION FIELD DATA—25'L x 25'W x 12'ED—208 sf/br= 1200 SF
Which system tested (date installed) 10/1971 Adequacy test date 2/1/2019
Z ALL standpipes present per record drawing Results El Pass For 6 bedrooms
Total measured depth from grade 15_ft (max) Fluid depth prior to test 9 in
Measured depth to pipe invert from grade 3.3 ft(min) Water added 980 gal
❑ N/A—pressurized field New depth 29 in
❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 1080 min
depth into effective 11,7
® Code-required soil cover over field Final fluid depth 10 in
El System presoaked Absorption rate 900+ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies: ED & Invert based on top of crib to bottom of crib depth. Appears measureable MT depth is
within 1' of the 12' ED (11.7' +/-).
COSA Checklist yellow PRVT W&S copy.docx
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' Community Sewer Manhole/Cleanout > 100'
Z Yes if No ft ® Yes if No ft
Neighboring Tank > 100' ® Yes if No . ft Private Sewer/Septic Line>25' ® Yes if No ft
Absorption Field on Lot> 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft
Neighboring Absorption Fields> 100' Animal Containment > 50' Z Yes if No ft
® Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes if No ft Z 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 Wells on Adjacent Lots:
Property Line > 5' ® Yes if No ft Private Wells > 100' ® Yes if No ft
Absorption Field > 5' ® Yes if No ft
Water Main > 10' ® Yes if No ft
Community Wells > 200' Z Yes if No ft
Water Service Line > 10' ® Yes if No ft
If septic tank is under driveway comment below
Surface Water> 100' ® Yes if No ft
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' ❑ Yes if No 0 _ ft Wells on Adjacent Lots:
Water Main > 10' Z 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' Z Yes if No ft
F. ENGINEER'S COMMENTS
**Per MOA IR & Record Docs
efN. ®ems®Iid‘
G. ENGINEER'S CERTIFICATION ,`4.•.• A .'Q >w
I certify that I have determined through field inspections and review r. .:49TH '
of Municipal records that the above systems are in conformance
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011,
with MOA COSA guidelines in effect on this date. el '
d
1 7.2.....MICHAEL N. ANDERSON r
COSA Checklist yellow PRVT W&S copy.docxf C 9469 . /
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ASBUILT SEWARD & ASSOCIATES LAND SURVEYING 694-0829
I HEREBY CERTIFY -THAT I HAVE SURVEYED THE SCALE.
FOLLOWING DESCRIBED PROPERTY: �� '�� -4.,T OF At '%4
,.�.�f'. Yi«- �Sr�.B.<i�f.�-.s�l4 ,-arz3 - DATE: ,a '''*. . '�
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS .7,`�-/.7 4W ' • "• , ••.`st. t
INDICATED. IT IS THE RESPONSIBILITY OF THE 0-,:• �' . 4
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID: '`
EASEMENTS, COVENANTS, OR RESTRICTIONS 4:�au�s6� �• '��' , ...-e
_
WHICH DO NOT APPEAR ON THE RECORDED SUBDI- Duane Mark Saw•rd
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD F� ���/ I A• LS-69 8/-
ANY DATA HEREON BE USED FOR CONSTRUCTION >f 2� - „?,. cite
OF FENCE LINES, OR FOR ESTABLISHING BOUND- ` .`.
ARY LINES. DRAYY� s t ° a� t;
J
POST IN A CONSPICUOUS PLACE xn e n t
ALL WORK MUST BE INSPECTED ° Sc .•
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Field Inspection Request required 2 working days in advance of starting work . �'
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and 2 working days in advance for final inspection. Call(907)343-8206 :'. i r'r v
(voice recorder)for scheduling. Permit is not valid without the call-in and also €] :.'1
must include the one call ticket(utility locate)number. D e p a t't m e ri t
MUNICIPALITY OF ANCHORAGE
RIGHT OF WAY DIVISION
4700 ELMORE ROAD
TELEPHONE(907)343-8240
RIGHT OF WAY PERMIT R191148
Type: Encrchmnt Grid: Date Issued: 2/22/2019
Construction Start: Last Update by: PWMER
Last Updated: 02/22/2019
Permittee: TENHAGEN FAMILY TRUST "
Contact Person: Carol DeFrees,907-529-7341 Primary Inspector: -.OU�t/Lead 343- g24d
Site Address: 24515 GRACE ST,Chugiak-@ Miller Road
Legal Description: LAKE HILL ACRES#1 LT 23 G:1561
Original Work
Description: Encroachment of a well 8'Into 15'Utility Easement along the NW property boundary.
Financial Summary
Fee Description QTY AMT
Permit 1.00 120.00
Total Fees: 120.00
See reverse for requirementslremarks.
I have read and understand both sides of this permit. I agree to the terms and conditions;and I certify that all work will
comply with federal,state,and municipal codes and regulations and the provisions of this permit.
Signature: � SPA Date: le: alIci
MATANUSKA ELECTRIC ASSOCIATION, INC.
RIGHT OF WAY EASEMENT
Whereas Matanuska Electric Association Inc. (MEA),an electric service cooperative,
is not presently utilizing a plat dedicated fifteen feet (15 ft) wide utility easement and
supplemental five feet(5 ft)wide slashing[clearing]easement, within Lot 23, Lake Hills Acres
Subdivision No. One(1),for electric distribution purposes,
Whereas MEA may invoke the use of said plat easement (s) for electric distribution
and clearing purposes,
Whereas a well improvement within said plat easement conflicts with the use of said
easement(s),
Whereas the landowners agree to further encumber the southerly twenty five feet(25
ft)of a five feet(5 ft)wide slashing [clearing]easement with the electric utility rights described
in this easement,
Whereas MEA, will provide a recordable Letter of Non-Objection to said well
improvement where it is presently located,
NOW, THEREFORE KNOW ALL BY THESE PRESENTS, that the undersigned, Ella May
Tenhagen, Trustee of the TENHAGEN FAMILY TRUST, whose address is 24515 Grace
Street, Chugiak, Alaska 99567,for a good and valuable consideration, the receipt whereof
is hereby acknowledged, do hereby grant to MATANUSKA ELECTRIC ASSOCIATION,
INC., a cooperative corporation (hereinafter called the"Grantee")whose post office address
is Box 2929 Palmer,Alaska 99645, and to its successors or assigns,the right to enter upon
the lands of the undersigned, situated in the Anchorage Recording District, State of Alaska,
and more particularly described as follows:
MEA's easement is as follows: A five feet (5 ft) wide easement lying adjacent to a plat
dedicated fifteen feet(15 ft)wide utility easement, and over the southerly twenty five feet(25
ft) of a five feet (5 ft) wide slashing [clearing] easement, within Lot 23, Lake Hills Acres
Subdivision No.One(1), according to Plat 64-90,Anchorage Recording District,Third Judicial
District, State of Alaska,
being in Section 3,Township 15 N,Range 1W,S.M.,and to construct,reconstruct, re-phase,
repair, operate and maintain on, over or under the above described lands and/or in, upon or
under all streets, roads or highways abutting said lands, an electric (or telecommunication)
transmission and/or distribution line or system; to inspect and make such repairs, changes,
alterations, improvements, removals from, substitutions and additions to its facilities as the
Grantee may from time to time deem advisable, including, by way of example and not by the
way of limitation:the right to increase or decrease the number of conduits,wires, cables, hand
holes, manholes,connection boxes,pedestals,transformer enclosures;to cut,trim and control
the growth by machinery or otherwise of trees and shrubbery located within said line or system,
or that may interfere with or threaten to endanger the operation and maintenance of said line
or system (including any control of the growth of other vegetation in the right of way which
may incidentally and necessarily result from the means of control employed); to keep the
easement clear of all buildings, structures or other obstructions.
The undersigned agree that all poles, wires and other facilities including any main service
entrance equipment, installed in, upon or under the above described lands at the Grantee's
expense shall remain the property of the Grantee, removable at the option of the Grantee.
The Grantee, its successors or assigns, is hereby expressly given and granted the right to
assign said right-of-way and easement herein granted and conveyed, or any part thereof, or
interest therein.
TO HAVE AND TO HOLD unto the GRANTEE, its successors or assigns,together with the
right of ingress to and egress from the premises for the purpose herein granted.
The undersigned covenant that they are the owners of the above described lands, and that
the said lands are free and clear of encumbrances and liens of whatsoever character except
as may appear of record as of the date set forth below, and those held by the following
persons: n/a
51—
IN WITNESS WHEREOF, the undersigned has set their hand and seals this o2 1 day of
.-12: A..c`cz.�,, , 2019.
&i ( CO.,e - Q0iJ Grantor
CAROL DEFREES -Trustee
STATE OF ALASKA) SS-
Third Judicial District)
THIS IS TO CERTIFY that on this"7,'.3 .day o "@.► )% , 2019 before me, the
undersigned, a Notary Public in and for the State of Alaska, sul commissioned and sworn as
such, personally appeared CAROL DEFREES, Known to e and to me known to be the
individual(s) named in and who executed the foregoing instrument and acknowledged to me
that he/she/they signed and sealed the same as a voluntary act and deed for the uses and
purposes therein mentioned.
IN W \ . • WHE•E• , ,ave reunto set my hand and official seal the day and year first
a.. •
i $ AL M.MANUEI LOPEZ,JR.
O,` , Notary Public
Notary 'u.` irt v . o 'las,� State of Alaska
My Commission Expires Oct 27,2021
My commissl. pi es
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W/O_ Subd Lot 23 Lake Hill Acres Plat 1964-90_
P/S Misc Map
Quad
Pole Easement
Return to: MEA, PO Box 2929, Palmer, AK 99645 Rev.,Ui2
MATANUSKA ELECTRIC ASSOCIATION, INC.
LETTER OF NON-OBJECTION
February 21, 2019
Carol DeFrees
22921 Sheltering Spruce
Chugiak,Alaska 99567
Re: Lot 23, Lake Hills Acres Subdivision No. One(1), Plat 64-90, Anchorage Recording District
Dear Mrs. DeFrees,
MEA has no objection to the encroachment of a water well located in the utility easement as depicted on the
attached as-built survey drawing, and a supplemental 25 feet by 5 feet easement, and subject to the
following conditions:
1. The improvement will in no way restrict or limit the current or future ability of MEA to fully enjoy the
benefits of the easement for any and all utility purposes that it presently enjoys under the easement,
excluding a buffer area two feet(2 ft) in diameter from the center of the subject well improvement.
2. MEA will be held harmless by the landowner from liability for any and all damages or injury to any
person or property that may result from the existing and future use of the easement by MEA, its
contractors, or assigns.
3. MEA will be held harmless by the landowner for any and all liability arising out of or relating to any use
of the easement by others under a Letter of Non-Objection.
4. The Ian.•wner will be liable for any damages caused to MEA facilities by the improvement in the
ea- -m_ t.
.'• ner-will-be-responsible4or-any-spesiaf-seestcastioc-aests-i rred-by-ME-A-die-to-the-
i • -- --sereerat-Mitigated by landowner provided supplemental 25'x 5'easement.
IP
6. The landowner will assure compliance with all applicable safety codes relating to the improvement in
the easement.
7. Use of this letter by the landowner, their successors or assigns will constitute acceptance of these
conditions.
8. Alteration of these conditions shall validate this letter.
9. This letter is not effective unles- it is recorded in the Anchorage Recording District before ownership of
the referenced property is ch. ged from the above named landowner.
Sincer
Manny .pe
Land Services .nager
STATE OF ALASKA)SS-
THIS IS TO CERTIFY that on this 201h day of February,2019, before me, the undersigned, a Notary Public
in and for the State of Alaska, duly commissioned and sworn as such, personally appeared
Known to me and to me known to be the individual(s) named in and who executed the foregoing instrument
and acknowledged to me that he/she/they signed and sealed the same as a voluntary act and deed for the
uses and purposes therein mentioned.
IN WITNESS WHEREOF, have hereunto set my hand and official seal the day and year first above written
•
fficial Seal
a STATE 0 ALASKA
. .ry •ublic in and of Alaska My commission expires 27J Wary Public
Return to: MEA, PO Box 2929, Palmer,AK 99645
ENSTAR
Natural Gas Company
A DIVISION OF SEMCO ENERGY
-,.- Engineering Department,Right of Way Section
Natu:ul Gas Company 401 E.International Airport Road
P.O.Box 190288
Anchorage,Alaska 99519-0288
(907)277-5551
FAX(907)334-7798
February 13,2019
Subject: Letter of Non-Objection: Well
Lot 23, Lake Hill Acres Subdivision First Addition
To whom it may concern:
ENSTAR Natural Gas Company has no objection to the existing well encroachment into the fifteen foot
(15 FT)wide utility easement,coincident and parallel to the northwest lot line of Lot 23, Lake Hill Acres
Subdivision First Addition,according to Plat No.64-90, located within the Anchorage Recording District,
Third Judicial District,State of Alaska.
Acceptance and use of this letter of non-objection by yourself, your heirs,your assigns,or your
successors,will constitute agreement to the following stipulations:
• Landowner/Contractor working near ENSTAR gas facilities shall contact the Alaska Digline,
Inc.,(907)278-3121 or 811 for line locating two(2)business days prior to any related
excavation. This service is free of charge.
• ENSTAR will be held harmless,now and forever for any damages or injury to any person or
property as a result of this encroachment.
• Any ENSTAR facility damaged or destroyed,as a result of this encroachment will be repaired at
no cost to ENSTAR.
• Any costs incurred by ENSTAR for special construction necessitated by this encroachment will
he borne by the land owner.
• All applicable safety code regulations will be observed and maintained.
• This letter of non-objection will in no way preclude ENSTAR from full use and enjoyment of its
rights within any portion of its right-of-way.
Sincerely,
CA14-10,CA-C&__
Cassie Acres
Right of Way and Compliance Technician
ENSTAR Natural Gas Company
....../Z—__
7GCI
February 12,2019
Carol DeFrees
24515 Grace Street
Chugiak,AK 99567
Re: Letter of Non-objection
Dear Carol DeFrees:
Subject to your agreement to indemnify the company as set forth below,GCI Communication Corp has
no objection to the previously installed well encroaching within the 15ft utility telephone&power
easement of Lot 23,Lake Hill Acres Subdivision,First Addition,also known as 24515 Grace St,city grid
NW 1561,GCI WO# 19-0001-09.
This letter of non-objection in no way precludes GCI Communication Corp from full use and enjoyment
of any rights it may have within any portion of the utility easement and or the right-of-way,including
unlimited access for servicing its facilities. Also any additional and extraordinary costs incurred during
any future required construction,repair or reconstruction of GCI's facilities to accommodate any or all of
the encroachments shall be paid by the property owner.
By signing below,you agree to indemnify and hold GCI Communication Corp harmless, now and
forever,for any damage,costs,expense(including reasonable attorney's fees),liabilities and injury to any
person or property occurring as a result of the encroachment.
Please indicate your acceptance by signing and return' g this letter to me at the address below.
Sincerely, �/l �'� r4
fj
A� pILX?e p�01 oZOIq
Date
rkus Kofoid
Manager
Outside Plant Design&Data Management
GCI Communication Corp
5151 Fairbanks St.
Anchorage,AK 99503
907-868-6168 Office
907-868-8580 Fax
. MTA
NON-OBJECTION TO EASEMENT ENCROACHMENT DOCUMENT
By this document Matanuska Telephone Association; Inc. (MTA) declares that it has no objection to the
encroachment of the well located in the platted utility easement of Lot 23 of First Addition Lake Hills Acres
Subd., Plat Number 64-90, filed in the Anchorage Recording District, State of Alaska.
Please be advised that MTA through the issuance of this document does not forfeit any of its rights to the use
of the area cited. In the exercise of these rights MTA will, if needed, upgrade, maintain,repair, and/or replace
buried or aerial telecommunications facilities within the easement. Any repairs that may be required to the
encroachment as a result of utility construction will be.borne by the property owner of record. This document
does not authorize the placement of any additional encroachments within the easement area. Property owners
are required to obtain utility locates before doing any kind of work in the utility easements and will be liable
for any damages caused by their construction work in the easements.
This document is in no way an agreement to vacate any portion of the utility easement and should not be
interpreted as such.
Issued for Matanuska Telephone Association, Inc. this 18th day of February,2019,by,
2 .
ri 'r ,Jessica Burnett, Right of Way Agent
.....)z,ttfac...c.,
THIS IS TO CERTIFY,that on this 18th day of February,2019,before me the undersigned,a Notary Public in and
for the State of Alaska, duly commissioned and sworn as such, personally appeared Jessica Burnett known to
me and to me known to be the individual named in and who executed the foregoing instrument and
acknowledged to me that he signed and sealed the same as a voluntary act and deed for the uses and purposes
therein mentioned.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal the day and year first above written.
`, OFF CAL Not is in and for Alaska
Molly 4"""" My commission expires: °t` i t l apace
` ' *tory Pt.tkAbte otAlaska
P.O Box 3550 Palmer,Alaska 99645 mtasolutions.com 907.745.3211
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. # ~O~ 1-
1, GENERAL INFORMATION
Complete legal description
MUNICIPAEITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
MAY 08 1997
LOt 23; Lake
EIVED
Location (site add ress or directions)
24515 Grace St.
Chugiak, AK 99567
'"-.::'% Finis She!doD
'- P, ?ope~(y. ov.,ner
; '*~mhng address :,, ~.0. sox 67~087
4~,,_ Lending agency"~;
.{, Mmhng address.* .-- ~
'Ag~nt"~ [:'- ..... · '"
Address
Chuqiak,
Day phorm_
Day PhOne
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XXX
RECEIVED
MAY 08 1997
Municipality of Anchorage
DepL Health & Human
NOTE:
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL: - '"
. If community well system, provide written confirmation from State ADEC attest-
~ ndividual on-site
i-~olding tank ;,._ ,.: .....
Community on-site .
Public sewer · . ' ' ..... -
If community wasfeWafer system, ·provide Wriffen confirmation from Sta~e' ADEc
attesting to the legality and status of system.
NOTE:
72~)25 (Rev. 1/91) Front MOA#21
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 n umber 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.
$ & $ ENGINEERING
Name of Firm ........ ._ ,... .... , ~. ~..~.~ ~ .n~ Phone 6 q/1/ ~ 2"e/ 7 c/
Address Eagle River, Alaska 99577
Engineers signature r~ Date. ¢''/~'/4~ 7
DHHS SIGNATURE
./~/
Approved for ~'
Disapproved.
Conditional approval for
Additional Comments
bedrooms.
bedrooms, with the following stipulations:
Date 22 -
': ~he Mu~'i~ip:~iit~ of An'~6iage Department of Health and Human Services (DHH$) issues Health Authorib/
APProval Ceitificate~':~b~seal 0nly Upon the repreSentat ons g Yen n paragraph 5 above by an ndependent
profe~ional eng ~eer reg stered n the State of A aska 'The DHH$ does this ~s a Courtesy to purchasem of homes
~nd their lehdi~g institutions in order to s~tisf~ certain federal and state requirements, EmpioYees of DHH$ do no~
conduct inspections or analyze dnt~ before a certificate is issued, 'The Municipali~/ of Anchorage is not
responsible for errors or Omissions in the professional engineer's work. '
72-O25(Rev, 1/91) Back MOA~21 ·
Legal Description:
A. WELL DATA
Well type
Log present (Y/~) /~o
Total depth ~. ~ o ~ ~,~
Sanitary seal (~)N)
Date of test
Static water level
Well production
MUNICIPALITY OF ANCH~
Municipality of Anchorage ENVIRONMENTAL
DEPARTMENT OF HEALTH & HUMAN SERVICES MAY 0 8 19!
Environmental Services Division
825L Street, Room 502. Anchorage, Alaska 99501. (907) 343~
E IV
E
D
Health Authority Approval Checklist
~'1 LAr,,~ J~,~-~. ~,c¢,~$ Parcel I.D.:
-i
I'f A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to
FROM WELL LOG
Casing height (above ground) I'Z.* '~
../.
Wires properly protected (Y/N) N/A
AT INSPECTION 'fo Fo~-
g.p.m. ~.~ g.p.m.
WATER SAMPLE RESULTS:
Coliform (~
Date of sample: ~/%/q "l
B. SEPTIClHOLDING TANK DATA
Date installed I ~ / -7 t Tank size
Foundation. clean°ut (Y~) I'~ o
Date of pumping ~ - t~.-<~-1
C. ABSORPTION FIELD DATA
Date installed ~, ~1/'7 I
Length.. ~ Width
Effective absorption area
Date of adequacy test
Nitrate O, I <3
COllected by:
/
/~- Other bacteria
I;7034 Eagle River Loop Road No. 204
Eagle River~ Alaska 99577
I "7 ¢l ~ Nq.,mbe, r of Compartments J Cleanouts ((~N). Y~..S.
Depression (Y/~ ~o High water alarm (Y~) ~o
Pumper ~.~. Cu~OmlG
Soil rating (g.p.d./fFor~ ,~,o8
Gravel thickness below pipe
System type
Total depth
l 'ZoO Monitoring Tube present (~N) '¢~ Depression over field (Y~) ~
~ - t"5- ~'~ Results (l~Fail) t:>A~; For ~'
Immediately after%SOo gal. water added (in.):
Absorption rate = c~130't g.p.d.
~,,~oo,J If yes, give date ~ ~'
Fluid depth in absorption field before test (in.);
Fluid depth ~,0a (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N)
High water alarm levelling/ *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT, TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main '" ~/A
Sewer/septic service line
"Pump off" level at*
M~tli0ip.a. liiy of Anchorage.
8e~ioe~
.. on 8djaoent lots
On adjacent lots I o~
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation /~/A /"N,~ ~o~ ' *
to4 Lo'r / · Property line -~ ~ + Absorption field
Water main/service line I o14- Surface water/drainage ~ al°l+ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
. ,, .1^ '(,:'
Property line O Building foundation ~' ) Water main/service line
Surface water I 00 t- Driveway, parking/vehicle storage area
Curtain drain ¢o~ c- k¢~ Well~ on adjagent lots
ENGINEER'S CERTIFICATION
I certi~ that l have determined thru field inspections, and review of Municipal reco~,~'ab'~
in conformance with MOA HAA gpidelines in effect on this date.
Signature ~~. ~~ '
Eng neers Name /~4~ ~ ~. ~ ~d~
-~ /~ ' ~ ~ ...
s / r
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
MAY-O?-1997 10;40 CT&E ESI ANCHORAGE 909 561 5301 P,03/03
CT&E Enoironmental.Seruices Inc.
Laboratory Divisio~ ~.~':~'.~'~.~".~'.~"~
Drinking Water Analysis Report for Total Coliform Bacteria 2oo w..otter o6v,
Anchorage. AK 99518-1605
READ INSTRUCTIONS ON EEl~ER, YE SIDE I~EFORE CO£LECTING SAMPL£ Tel; (907) 562-2343
MUST BE CO~iPLETED.B.Y WATER SUPPLIER
O PUBLIC WATER SYSTE~ I.D. #
Fax: (907} 561-5301
I TO BE COMPLE'i'ED BY LABORATORY
Analysis shows thi~ water SAMPLE to be:
'~_. Satisfactocy , ,
a Unsatisfacto~
KPRIVATE WATER SYSTE~I
170,14 £~grs R!~ ~ Rea~l~ Ni$ MIJ
"""°[~agle River, Alaska 99~'Z
SAMPLE DATE: ~
~lonth Day
SAMPLE TYPE:
o~ Routine
Repeat Sample (for routine sample
with lab ref. no. )
O Special Purpose
SAMPLE LOCATION
Year
O Treated Water
Untreated Water
Time Collected
Collected By
Date Received
Time Received
Analysis Began '-~ / 7_..
Sample over 30 hours old. results may
be unreliable
Sample too long in transit; sample should
hoe be over ~I1 hours old at examlnadon
to indicate reliable results. Please send
new sample via special delivery mail.
Analytical Mcthod: ~ Membrane Fihcr,
· 15 M.MO-MUG
Number orcolonies/t00 mi,
Lab Ref. No. Result* Analyst
Time;
Client notified of un~atiSfnetory results:
Phoned Spoke with
Tim<
COmr0en[s:
BACTEIU. OLOGICAL WATER ANALYSIS RECORD
tXl~JO-311JC Result: lots| Coliform E. Coil
Membrane Filter: Direct Count 0 Colonies/tO0 mi
Verification: LTB 8GB COLIFIRAI
Feral Coliform C. onfir.mstioa
Final ,Membrane Filter Results .C) · ~ /~ ~,
ColirorlnllO0
'' ' ~ ~ ~-t- T
¢/ TWO TO FOLLOW
MAY-O?-i~9? 10:~0 CT&E ESI
~t~__ C T&E Envi ronmen talSe rv ic es ln c.
ANCHORAGE
90? 561 5J01
P,02/03
CT&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
Sample Remarks:
972173001
S & S I~gineeri~g
Lot 23 Lake Hills Acres
Lot 23 Lake Hills Acres
D~nking Water
Client PO//
Printed Date/Time 03/07/97 08:22
Collected Date/Time 05/02/97 11:30
Received Date/Time 05/02/97 13:45
Technical D~rector: Stephen C. I~de
Released By .
CT&E Microbiology Drinking Water Program certification s~ams is provisional as of 4/8/97.
Nitrate data posted as Nitrate + Nitrite. Sample pr~se~ecl at the lab,
Paramcter Results PQL Units Hethod
Ritrate-N 0.100 U
TotaL coliform 0
Allowable Prep Analysis
Limits Date Date Inlt
0.100 mg/L S818 4500-NO3F 10 max
co[/lOOmL $~18 9222B
05/06/9? JBL
05/02/97 R~V
GR["~'~ER ANCHORAGE AREA BOROUr''~i
DEi-~FITMElYT OF ENVIR01YlYlENTAL D. UALY1,
3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE FROM WELL
LIQUID CAPACITY / .~ ~'"~'~' GALLONS.
MAILINGADDRESS ,~/~,r~Z~.~./~:'.~'~'''
LEGAL DESCRIPTION
NUMBER OF
MATERIAL ~:~//'V'~'/".~-- .~'~.,~-.~,~-~J' COMPARTMENTS.
INSIDE LENGTH ~ / /
INSIDE WIDTH '~'~
SEEPAGE SYSTEM: SEEPAGE PIT:
LIQUID ~.~ ~ "/
DEPTH..~~
NUMBER OF PITS / OUTSIDE DIAMETER //- OR WIDTH
LINING MATERIAl ~'/V'~""'"~'~'"~/"/~-"r' ~ " - /
~ ~:~/J~'/~'~-~-/~e.~)ISTANCE FROM WELL
NEAREST LOT LINE ~ TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
, LENGTH "~'~'~ , DEPTH /'~"~' /,
BUILDING FOUNDATION~-/ZZ~
SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL ~ ~LOT LINE
LINE
DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE
TOTAL LENGTH
, OF LINES
IN. TOTAL EFFECTIVE
IN. ABOVE TILE
WELL:
LOT LINE
--'~'"~""?'/~ 'z';/' ~'J3cf' / c%" ~DISTANCE FROM WATER
TYPE ~~ DEPTH ~f~/~, ~/~, BUILDING FOUNDATION.~ SAMPLE //~ , NEAREST
~ / NEAREST ~ SEPTIC ~' SEEPAGE / OTHER /~
~ SEWER LINE ~ ~ , TANK /~ -- , SYSTEM /~ , CESSPOOl/~ , SOURCE~
DISTANCES:
DIAGRAM OF SYSTEM
/
.,,,._. ,/ _ t
GRHAi~2R ANCHORAGE: ARE:A BORudGH
DEPARTMEN"(' OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD POUCH 6-6~O
ANCHORAGE. ALASKA 98~02
TELEPHONE 279-Se86 ~/~
SEWAGE DISPOSAL., SYSTEM -- APPLICATION AND PERMIT
PERMIT NO.
INSTALLATION O~: SEPTIC TANK SEEPAGE PIT .. DRAIN FIELD , OTHER
TYPE AND SIZE OF FACILITY TO BE SERVED :~J~ T~/~
fINANCED THROUGH / TO BE INSTALLED BY
SOIL TEST RESULTS ./~/~' ~p/jd~ ~f~/efl~ NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION.
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPage Pit
SEPTIC TANK TO SEEPAGE PIT WALL
SEPTIC TANK ~/
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK
DRAIN FIELD
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
, DRAIN FIELD
, SEEPAGE PIT ~)' /
, DRAIN FIELD
SEEPAge PIT /'~/~...2
ALSO CONSIDER AREa WELLS.
, BEEPAGE PIT /'~
SePTiC TANK, ~ ~/ . seEPagE Pit ~/"~'~::;~
T~) ~IVER, LAKE, STREAM.
, DRAIN FIELD.
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP Of
EXCAVATION S FEET INTO UNDISTURBED SO~L.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
OR
LICENSED DESIGNER
SEEPAGE AREA SIZE /~--~/~J~;~/~ TYPe
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
OATE /6/~//~/~//// APPLICANT'B SIGNATURE ' . -~'~}}
PerfornTe'd For Robert Brazell
Legal Description: Lot23 Block__
This Form Reports Soils Log ×
GRE~"~'~R~ ANCHORAGE AREA BOROUGH
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99502
Date Performed
Subdivision Tatro
CASE #
9/21/71 ,
lF~-~'co 1 a t i On Test
Depth
Feet
Soil Characteristics
Brown clayey silt
Gray silty sand w/ fine gravel
(SM)
Gray sand (SP)
with silty sand seams and containing
scattered gravel
..... --- ~ ? --'1 ..... ~ .............
ii:l! I ~ /
!
W~s Ground Water Encountered? no
If Yes, At What Depth?
Reading Date ,] Gross Time j' Net
Time Depth to H20
Percolation Rate Minute
Proposed Installation: Seepage Pit × Drain Field
Depth Of Inlet
COMMENTS:
Net Dro
Depth To Bottom Of Pit ~r Trench
208 square feet of drainag~ area is required per bedroom.
lest Performed By R. E. Carlisle
Data Certified Bj,':National Testing ~ervices Inc.
OF~flA'[~P, AN~HOF~AO~ A~A
D~PT. OF ~NVINONM~NI'^k