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SOUTHPARK BLK 1 LT 3
oi,..,. t h p r k Block 1 Lot 3 #020-491-03 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES 02o -05J , Environmental Health Division V 20 —0 J r 2� 825 'L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON—SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name------�"a— DISTANCES SEPTIC TANK ABSORPTION -- WELL Address n /J AlROM � C�✓7x.T��'�� /�iG`–ofE WELL >2-ol _FIELD 72csly0 --- Phane(s Permit No. No. of eetlraoms o.dr �— LOT LINE�c. cc)P LEGAL DESCRIPT1W Lot Rlack // Subdivisot�— f —JC il,_t G Township, pence, Section 3'' / 1 K, _�2 --- FOUNDATION > ?-Jon AS -BUILT DIAGRAM (Show location of well, onvcway. water bodies, etc.) septic system, properly lines, foundation, ' TANKS E — ,r F l i V — --- Xr SEPTIC ❑ HOLDING Mae Il twcrCapacity e- i lLy� G— MaterialNo. y`^ /' el in gallons .may —/�✓1-- of Compartments 21 TYPE OF SYSTEM rRENCH ❑ BED ❑ W. DRAIN ❑ OTHER Depth to pipe belled, from original grade ✓ � J FT Total depth from original grade % � FT , _ G t , 0 0 fit?— FII added above original grade I_T � Gravel depth beneath pipe pipe .7 FT Gravel ength J_ Ui FT To__ a_sorptionarea_ SQ FT Gravel width ! J FT Distance between hoes /if�ii' FT Number of tees SoJ rating ���i sp FT Pipo material -- --- — Installer r> (' - - `—Dah;Installed C k iC7-Cell_-) WELLS �t :> ` ❑ PRIVATE v) Cla ssi bctu oo TA—D,c,—.A�� — 5e ism Cased to FT _ FT Inslallei —�Date Installed: lfikj)�e��p 11A)= 3s, &Vf -- 1 _ — REMARKS: — Scale: jr�MIens lions f riJ1 Date: , Et J. — cerdly that this inspection was performed according to all � ---- Date. Municipal and Stale guidelines in effect o 's dale: - v�l �3__ Health DepaAment Approval 72-013 (3/85) (3705) !1UN1 |'flI i. ! \' (J!1 0)N[a\1U|lA(3E Depof Health ,/ Human Services 805 L Rtreet, Anchorage, Alaska 99501 343-4/20 ON-2lTE SEWER PERMIT Permit Number: 70�253 Da�e �ssued: 08 /90 Engineer Designed �wner Name: lUHN[R CON8TRUCTION Day Phone: Dwner Address: P 0 OOX 3�8Y ANCHORAGE, AK vY�4� �:�'rcel [d: 020-WJ1-2V LoL Leg*l: S"�divis1on: SOUTHPARK Lot: 3 dlock: ! Section: 3 Township: 11N Range: 34 Lnt Size 24931 (sq.ft. or acres> Max 8eArooms: This Permii: 4 Total Capacity: 4 �:;FIPTIC TANK: Minimum total sept1c tank capacity: 1,200 gallons. Each septic tenk mus\have at least 2 compartments. Depth to top of septic Vank(s) < 4,1,; Wetrequires insulation over tank(s), PERMIT EXPI9ES p�CEM9ER 31, 1990 bNG[ALL ACCORD1N8 TU ENGIMEER'3 DESIGN. DEVIATIONS MUST BE APPRUvED IN AUVANCE BY DHH5. NCTlFY �HUS OF 11,1SPEUTl0NS AT 343-4744. If CHANGED FRDM 5 TO 4 P:AR ENG R 9/10/90 3EO 1" I am familiar with the requirements for nn -site sewers and wells as set for! U hy the Municipality of Anchorage (MCMI and the State of Alaska" 2. f w111 jnstall the system in accoroanue with all MOA codes and regulal ions, an, I in comf,)liance with the design criteria of this permii` 5" i will adhere to all MqA and State of Alcskin requirements fop Lhe set bac� distaPces from any existing woll, wasiewatar disposal system or public se*erage sysiem on this or any adjacent or nearhy lot" 1. I undarsLand that thin permit is valid for a maximum of 4 bedrooms. l a/so unde/%stand ihaI U)e capaciiy o< Lhe LoC-al sysiem is I bedrooms and any unla,gement will requirp an additional permit, ` �r-y—'-------7[----~--^--~--~------- ~---``-----~--- U)wner) JU�@ER CDNSTF��TION [ssuwd 8y: DATE: �llf060/25Z7xarm = �-et9a c/ 112e J'e/Me �P DF.s/lti T�Fti�rr-/ 150/ X00 .rGO 35,71 usC TpllGh 3 3& 1 3Lb'/ Oi0 DO S/ve 7*` 0 0 r pp o n f�3-1 A • ZL <Sep,/72� Tui k oco S�GT(UJJ i O leeuerve MUNICIPALITY Of ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION SPP 10.1990 RECEIVED � �� BY CbMMUn/iTJ' 0 a/19 rz e Ci m a. x 7'roa x F_-:=1-�/ NOTE Alliamensi ns And Locations Must Be Field Verified Prior To Construction J. T"m 'ER SYSTEM LOCATION PLAN _ 1.0T RL� K SUBDIVISION 0 6ECTIOHIP/RANGE SCALE -NOTE, — 1o1 The Accuracy Or location Of Exisiting And DRAWN BY, proposed eroporty Corners, Walls, and Septic /pJ bys teas Indicated Is Not Exact. Dimensions NORTH C C/G_ Indicated (lave Even Dctnr inod By use or cloth � . Tape and/or Municipal Records, AtW Not By "K, � - vri^,weax>•i;�`v�.rtiititi�5il� .� x Surveying Techniques /ZeX 7umer' DATE, 7124-190 SHEET / OF / ue[�artmento� Hea1th � 3uman �ervlces uLreet, f Inch(Irage` A1ask43-47�� ON-SlTE SFWE� PERMIT i `(]A/l���� Permi1 Numhe,: 9O'�2��} `�LL)'�'w-/c^�J=J D*te [ssued: 08�22/90 Engineer Designed / Uwnur UOIISIMCJ(�[ ION Day Phone:: Owner Add P U �O� 348� !i 1 020 05 J. �V Lok LaquIn wMriviAnns 5UU|MPA|<K L U 0 u� Lot Si 24931 (Sq.ft. or acpaw) Max Oeilf ocamn: plin howmits M T t l c1L S[1I �/�ptic tank mus1 < 4O [zeL r1qP1i 1 11 l A, '11) PIUS I LlI PER�I(�XFlR[S D[C[M8ER 31 1?9O Al INGlNEER'S }ESHN HPP��O;E0 lN AI��NCE DY DHIPS, T hallFY DHHS O| 1NQAqaI lONS AT 313 47 i" 1 am '- rs and we1ls as se� |orLk M i i1 k�f �]A> �e State o| Alaska" 2 I wil . rill It or(-k-tnuo With A I MOA codes and regulations, and i i anne w ith t| is, A nai in critaria of -this permit. J. 1 wi) 1 adhopw Ko A 1 NCO sLa Mquiroments | or the set back Vista I, wastewater Asponal sysLem or public newaraqu nystom on Chin A any adjacent o, neaP&y 1ot. that t| i s valid for a maximum of 5 bedrooms. I alsoundtwnd Chat MY napacUy of the total system is 5 bedrooms and any aniz ment additional permit, Signnd: DAT�: (U�ner URN R C N issued By. PAT6: AV-- pCRCORMCO FOR: Nlunicipalily of Anchorage DEPARTMENT OF HEALTH R HUMAN: 825'L" Street, Anchorage, Alaska 995, SOILS LOG — PERCOLATION LEGAL OESCRIPTION: ! - 1.3 2- (lav/ars'{ 3 4 5 ` t 6- 7- 10 710 11 12 ' c 13 14 15 16 17 18 19 20 COMMENTS `C71t. al 1 11' q,. 8p&jq0 3 i u.2 ;I� Depth to Water Net Drop y /,t .i r ry r � �. 1�'• �" f~3�2�� 1�R>( B1Ib190 'tN em 4, `C71t. al 1 11' q,. 8p&jq0 Range, Section: SLOPE SITE PLAN WAS GROUND WATCH ENCOUNTERED? L IF YES, AT WHAT O J DEPTH? P /U>GwLreE Depth to WZW Rflet /,..,/ �� •7/ �tD Manilarinpl _�_ ..� T-J'f�Cdfc� -rr Reading r -•.l l a ( (U4 9 ;I� Depth to Water Net Drop y /,t .i r ry r � �. .cx,.0 .c�= •, �d. J"• R e � Siff�dd F,`n �ilN 'tN em 4, Range, Section: SLOPE SITE PLAN WAS GROUND WATCH ENCOUNTERED? L IF YES, AT WHAT O J DEPTH? P /U>GwLreE Depth to WZW Rflet /,..,/ �� •7/ �tD Manilarinpl _�_ ..� T-J'f�Cdfc� -rr Reading Date Gross Time Net Time Depth to Water Net Drop PERFORMED BY: A ACCORDANCE WITH ALL STATE AND MUNICIPAL 72-000 (Rev. 41851 PERCOLATION RATE _ (minutwinchl PERC HOLE DIAMETER {ES.y./ IUN BETWEEN/ FT AND _—_FT //�- ACfFErTH(SDA'-(E--OATE: �CZRTIFY THAT HIS TE WAS PERFORMED IN _��z-/�D __— 5�d/rmX/000 = 5 000 0 /���'�i✓e /�J� 5k axf- iienc� 3'GUI ex 7'Deep S'/ 45'/Q c� _q c, // c4: G / G� c � X500 9a k / ] po—xj GN ' p/o 7Un SODO G7 / AeJerve NOTE: P'M i �1�LoTSr-2�ED BY CbMMUNiTY Q Uri Tr2 Q r0 ti UaVE- p �_./v1S�// %r2/lcti All 13`nensi n's And Locations Must Be Field Verified Prior To Construction ` EIS SYSTEM -LOCATION PLAN LOi BLOCK SUBDIVISION SECTION/TOWNSHIP/RANGE e ez t�`v SCALE, l NOPE, The Accuracy O[ Location OC Extslting And DRAWN BY, PcopeseA Property Corners, Hells, and Septic .r �• Systess Indicated Is Not Exact. Bleu:nsions F" •�� ce �'�`�- NORTH C7�t� Indicated have Been Dctcmincd By Uso Or Cloth Tape and/or Municipal Rocords, And Not By Surveying icchnLquea `6jT y f Csq`ueJHCi¢7l— �J'j�� PREPARED FOR, O - umer� ineerc. DATE, 7/?o I SWEET OF LAI-: PERF -OF LEGAL SLUrt 15-a ®o ® m 16- 17 - 6 17- 18- hlo Geou,vo V4Ttz 19 • 'EuCovNTeCED 20 COMMENTS PERFORMED BY: L— C �-a J—. ACCORDANCE WITH ALL. STATE AND MUNICIPAL 72-008 (Rev. 4/85) Net Depth to Net Time Water Drop PERCOLATION RATE -- (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN — FT AND --- FT h ,-CERTIFY THAT T T�PERFORMED IN IN EFFE T N THIS DATE. DATE: — !/! -- o O o O 0 WAS GROUND WATER 10 ®oa ENCOUNTERED? -- 2 e 0 S L 11 moo IF YES, AT WHAT O 3 DEPTH? _— P 12 0 0 P 4-0 0 0 I A goer I� 9 rao%cil Scud' 13 0 0 Monitoring? J7'-$ Date: 5 0 0 0 0 o Reading Date Gross Time 0-0 v 6 o a O O d 7 0 0 g ® 4'0 0 0 9 15-a ®o ® m 16- 17 - 6 17- 18- hlo Geou,vo V4Ttz 19 • 'EuCovNTeCED 20 COMMENTS PERFORMED BY: L— C �-a J—. ACCORDANCE WITH ALL. STATE AND MUNICIPAL 72-008 (Rev. 4/85) Net Depth to Net Time Water Drop PERCOLATION RATE -- (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN — FT AND --- FT h ,-CERTIFY THAT T T�PERFORMED IN IN EFFE T N THIS DATE. DATE: — !/! -- o O o O 0 WAS GROUND WATER 10 ENCOUNTERED? -- d o o S L 11 o u IF YES, AT WHAT O IN DEPTH? _— P 12 O o o % 117o"Depth o a/��i to Water Alter �9 13 Monitoring? J7'-$ Date: 14- 0 0 0 0 o Reading Date Gross Time 15-a ®o ® m 16- 17 - 6 17- 18- hlo Geou,vo V4Ttz 19 • 'EuCovNTeCED 20 COMMENTS PERFORMED BY: L— C �-a J—. ACCORDANCE WITH ALL. STATE AND MUNICIPAL 72-008 (Rev. 4/85) Net Depth to Net Time Water Drop PERCOLATION RATE -- (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN — FT AND --- FT h ,-CERTIFY THAT T T�PERFORMED IN IN EFFE T N THIS DATE. DATE: — !/! -- o O o O 0 WAS GROUND WATER 10 ENCOUNTERED? -- d o o S L 11 o u IF YES, AT WHAT O DEPTH? _— P 12 O o o % 117o"Depth o a/��i to Water Alter �9 13 Monitoring? J7'-$ Date: 14- 0 0 0 0 o Reading Date Gross Time 15-a ®o ® m 16- 17 - 6 17- 18- hlo Geou,vo V4Ttz 19 • 'EuCovNTeCED 20 COMMENTS PERFORMED BY: L— C �-a J—. ACCORDANCE WITH ALL. STATE AND MUNICIPAL 72-008 (Rev. 4/85) Net Depth to Net Time Water Drop PERCOLATION RATE -- (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN — FT AND --- FT h ,-CERTIFY THAT T T�PERFORMED IN IN EFFE T N THIS DATE. DATE: — !/! -- E(PO PERPORMEO rOR:__ LEGAL OESCnIPTION: �. ryr __('f y^'h➢'t !.*,unicipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERV' 'G- IS`� 825'L" Street. Anchorage, Alaska 99502-() 9502 0 e SOILS LOG - PERCOLATION T( / L' 8 Date Gr= Tintc Net Time Depth to Water _ Net Drop 9 10 r' 11 12 13 14 15 16 17 18 19 20 COMMENTS Township, Range. SLOPE 511 L FLAN WAS GROUND WATER ENCOUNTERED? N S IF YES, AT WHAT L _ O DEPTH? P — E _ Depth to Water fine / Mcnilarinp? —Date: 7 l oto m Read,og Date Gr= Tintc Net Time Depth to Water _ Net Drop PERFORMED BY: If 'I ACCORDANCE WITH ALL STATE AND MUNICIPAL. 72-0043 (acv. 41851 PERCOLATION RATE (ttunutwinch) PERC HOLE DIAMETER 1"ES UN BETWEEN FT AND .FT jFFWFE0 RTIFY THATJHIS T TWAS PERFORMED IN S DATE_ DEPT. OF ENVIRONMENTAL CONSERVA'T'ION ANCHORAGE WESTERN DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASRA 99503 FOR: Corwin & Associates Attn: Bruce Corwin STEVE COWPER, GOVERNOR October 19, 1990 PWSID: 0213475 563-6775 According to the records on file in this office, the South Park Subdivision Lot 3. B:Lockc-a Water System is in compliance with the State of Alaska Drinking Water Regulations. Sincerely, 21'A.6-), VERA E. CrAIG Environmental Specialist VEC:pf I roe oU 51�P.Tl .. 0 Z PLOT PLAN l 0-r 4- W �vVNO �/tj1lzJPy6h, 1 LOT' 3 Z4195i:;'F• 'aB /`,v) env 1y C7' 05, 1 dpi 2 AS BUILT X SCALE_1"=3o t�ie'rG I Foupva T1ot L51 Str.P.TIG- ANL-( GRID3�-3� _ SOB Np 90-101 I^I (t3 1731 G rqe Bell Circle L� I• p �j p Anchara a, Alaska 99515 (907) 345-6476 I Hareby certify that I have surveyed the following described property: Lot 'a ,BlockSour+?aR.l� S��oDiY151oN NC,b(Lp Cr LS Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjaceat thereto, that no improvameats on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the Z$lb_Day of SEPTUs At V- , 19 `i 0 , at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. Y.,e:yl ,y KennaLan9 o Q �+i �:�; •• LS - 5202 .�¢�'�✓ °°...r..... at�04• �r,CiY1 i'1"��O�O�' Test Hole #18 Depth in Feet From To 0.0' - 1.5' 1.5' - 6.0' Bottom of Test Hole: Frost Line: Free Water Level: Remarks: G Table A WO #A18753 Logged By: Client Date: 10-28-78 Soil Description Organic Topsoil. Gravelly Sandy Silt, SM/ML, F-4, damp. 6.0' None Observed None Observed Test Hole Logged By Client Verified by Alaska Testlab Bottom of Test Hole: 17..0' Frost Line: None Observed Free Water Level: None Observed Type of Dry Sample Depth M$ Sample Strength Group Unified 1 2.0'-12.0' 4.0 G None C GW Remarks: 1. Type of Sample, G=Grab, SP = Standard Penetration, U = Undisturbed. Test Hole #22 Table A WO #A18753 M=Medium, H=High. 3. Logged By: J.D. Mack study only. 4. General Information, see Date: 1-9-79 Depth in Feet see Sheet 2. 6. From To Soil Description 0.0' _ 1.0' Topsoil. 1.0' - 12,0' Layered Sandy Gravels (GW), and GravelIX Sands (SP), max um aggregate size 511. Bottom of Test Hole: 17..0' Frost Line: None Observed Free Water Level: None Observed m Type of Dry Sample Depth M$ Sample Strength Group Unified 1 2.0'-12.0' 4.0 G None C GW Remarks: 1. Type of Sample, G=Grab, SP = Standard Penetration, U = Undisturbed. 2. Dry Strength, N=None, L=Low, M=Medium, H=High. 3. Group refers to similar material, this study only. 4. General Information, see Sheet 1. S. Frost and Textural Classification, see Sheet 2. 6. Unified Classification, see Sheet 3. m LOT 3, BLOCK 1 Soils and Ground Water One test pit was dug on this lot in January 1979. It encountered one foot of topsoil overlying layered sandy gravels and gravelly sands containing little to no silt. No ground water was observed in this 12 foot deep test pit. It is suspected that this test pit was dug on one of the terrace slopes, slightly east of the location shown on the test hole location plan. These terraces, as discussed in descriptions of soils conditions for Lots 1 and 2, consist of stream deposited sands and gravels. Based on the available information, it is suspected that this is a kame terrace landform. As the glacier retreated a stream formed on the edge of the glacier between the glacier and the adjoining hillside. Further up the hill, on the Southpark Bluff Drive right-of-way, Test Pit 18 was excavated to six feet depth in October 1978. It encountered gravelly sandy silt. Also, Boring 4-1 on Lot 4 encountered similar material to a depth of 16 feet. These silty soils are in the same glacial landform. f No ground water was observed in either Test Pit 22 or 18. In Boring 4-1 no ground water was observed while drilling, however, several days later water was observed at a depth of six feet below the ground surface. It is suspected that this water is from downslope seepage. 4 Location of Septic System The preferred location of the septic system is on the terrace deposit on the western one-quarter of the lot. Soils in this area are more permeable than further upslope and it islnot as likely�,to be a high ground water in this area. 0 Design Absorption Area Based on the information available, it is recommended that the system be designed for 150 square feet of absorption area per bedroom. If clean gravel or sand (less than 10 percent silt) is encountered, the absorption area can be reduced to 12.5 square feet per bedroom. I ) RABBIT CREEK BLUFF PARK MON & ITE. A STA) al Tr --.5r ff-OLJ5 4-1-+c: L T 6S 5 ovl'c, PA'p.,02 000000�1< _�o IN I�.3_2--A LOT. 5 -LOT 4 7 low mus SON "m mwm.;N,n 5-2 LOT ---------- OT Now j 171 LOT 6 -3- LOT 2 rtIgi -`5-3 2 - -I--- Lor -I--- 32' 161- 77 M, i ri rJ W NU X41 F 4]i E� C7I r.G - T C: C a C Ei a 0' C o x qc� Z cE c c a a U�n.1 d U v u c n W, I In I, n M M In CO n O V7; f1 MI r.41, 1 LD "'+.^.�...•nv.r�wuw..�w.•..w..�.r�n.�nnw.+........- -"» ............�..........w-....�.....+w�.�w.-...o....-+..ww....��n�......nel�•n+...�+.r!• —�� ARO11M •11 111011.07 1M77 Y1� - °0 I I w � a s qI a s o s a ?W ..I�I�I �I,�I wI�IWlol 100 100 wlC too, coo I I I I coo "'+.^.�...•nv.r�wuw..�w.•..w..�.r�n.�nnw.+........- -"» ............�..........w-....�.....+w�.�w.-...o....-+..ww....��n�......nel�•n+...�+.r!• —�� ARO11M •11 111011.07 1M77 Y1� - °0 4 a s a s o s a 100 100 too, coo I I I I coo in j a000 iC00 I wo I a z - 000 A00 j � I -110co0o » 100 10 „ ,0_ o to I I I I I `° = t°. w , it II!i I Ijl ` � I to. 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I -� a zt� 00 -1 W ! a) CL0. I 1 cx U44cn 7cn ot`rrt -u O a 01 I .< AN11711 Al Y11Y100 AYIJ Y7• v £ R S R S 01, a a oc 164 .a I N G u 0 ,? U h o c, v0 f•ws.a f n in,I o m v m (" to 20 1 O Q) W Ir P k o: - 11 i t S I I I I ill I 01 I I I I I I I I I 1 IIII I' 1 II III �_I IIII I I Ili Jilll 71 it ' I ' JIj7 1I I} •.r� '.r" iil. IIII y{�t I r i J+-1 rir 1. 111 �1i� IJI 1 i1r 1 i.i1 I'll I�11 111` tll 11 111 1-�i{ I 11,III N 11111111 1• Y1Y11 10,11 Y11� _- 10' 00' O 10 ( VI O AN11711 Al Y11Y100 AYIJ Y7• v £ R S R S o: - 11 i t S I I I I ill I 01 I I I I I I I I I 1 IIII I' 1 II III �_I IIII I I Ili Jilll 71 it ' I ' JIj7 1I I} •.r� '.r" iil. IIII y{�t I r i J+-1 rir 1. 111 �1i� IJI 1 i1r 1 i.i1 I'll I�11 111` tll 11 111 1-�i{ I 11,III N 11111111 1• Y1Y11 10,11 Y11� _- 10' 00' • Municipality of Anchorage s On -Site Water and Wastewater Program (907)343-7904 sar e.v Certificate of On -Site Systems Approval Parcel I.D. 020-491-03 Expiration Date: 1. GENERAL INFORMATION Complete legal description Southpark, Block 1, Lot 3 Location (site address) 4245 Southpark Bluff Dr. ` Current Property owner(s) Barry & Monica Duff Day phone Mailing address Real Estate Agent 4245 Southpark Bluff Dr. Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex rdQV F-1MultipleDwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual Individual Water Storage ❑ Holding Tank ❑ Communi y Crass Well ❑ Community ❑ Public Water System Public Sewer ❑ COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 60-74(4— Date 0-74(O"Date of Payment 1 I;LglI Lj Receipt Number %�J�i( n COSA# QSCfL//(e 12 Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. 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 11/20/2014 of acgt AW TH 6. DSD SIGNATURE System #1 Approved for bedrooms n R: a System #2 Approved for bedrooms t� CE -81491 Disapproved k�� Conditional approval for bedrooms, with the following stipulations: By: Original Certificate Date: The� ca alf 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 E If more than 1 septic system is on the lot: COSA Checklist # 1 of _ Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: Southpark, Block 1, Lot 3 Parcel ID. 020-491-03 A. WELL DATA ,,,,type Public If A, B, or C provide PWSID # AWWU Well Log (Y/N) Date completed Sanitary seal (Y/N) _ Wires properly protected (Y/N) Total depth ft. Cased to ft. Casing height (above ground) in. FROM WELL LOG AT INSPECTION Date of test Static water level ft. ft. Well production 9 - p.m - WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Arsenic ug/L Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Tank size 1,250 gal. Number of Compartments 2 Cleanouts (Y/N) Y 9 - p.m - Date installed 9/12/1990 Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 9/24/2014 Pumper McDonald's Pumping Service C. ABSORPTION FIELD DATA Date installed 9/12/1990 Soil rating (g.p.d./ft2 or ft2/bdrm) 125 SF/BR System type Deep Trench Length 38.5 ft. Width 2.5 ft. Gravel below pipe 7 ft. Total depth 10.5 ft. Eff. absorption area 539 ft2 Monitoring tube Y Depression over field N Date of adequacy test 11/19/2014 Results (Pass/Fail) Pass For 4 bedrooms Fluid depth in absorption field before test 7 in. Water added 626 gal. New depth 14 in. Elapsed Time: 80 min. Final fluid depth 7 in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date D. LIFT STATION Date installed Size in gallons "Pump on" level at in. "Pump oft" level at Datum Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer /septic service line Animal containment areas 0 Manhole/Access (Y/N) _ High water alarm level at Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Water main 10+ Water service line 10+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water Service line 10+ Surface water 100+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS 14 01, t /le- G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Steven R., Pannone Date 11/20/2014 COSA brown sheet 10-10-12.doc Absorption field 5+ Surface water 100+ Water main 10+ Driveway, parking/vehicle storage11 0+ in. Municipality of Anchorage • � Development Services Department Building Safety Division, On -Site Water and Wastewater Program 4700 Bragaw Street 3 k I F E T P.O. Box 196650 Anchorage, 99519-6650 AK www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 020-491-03 COSA # CS C. 1 � 1 c41 Expiration Date: /a -/ 1. GENERAL INFORMATION Complete legal description South park, Block 1, Lot 3 Location (site address) 4245 South park Bluff Drive Current Property owner(s) Robert Spangler & Ann Elizabeth Day phone Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 4245 Southpark Bluff Dr., Anchorage AK gn516 Day phone Day phone ----- —Unless-oMe„rwise;requested; COSA will be held -by -DSD forpickup. - - -- - - -- - -2 NUMBER -OF BEDROOMS: c 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual "pll ❑ Individual On-site Individual Water Storage ❑ Individual Holding Tank ❑ Community Class A Well ® Community On-site ❑ Public Wate'rSystem ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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. Name of Firm Pannone Engineering Services, LLC Phone 272-8218 Address P.O. Box 100217, Anchorage, AK ggS10 Engineer's Printed Name Steven R. Pannone, P.E. Date 12/6/2011 Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & 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 .'„`xx�, ��� OF ��� levels that may fluctuate during the year, and the water usage of the familybeingserved b the system. �� �� . ♦1 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:• g rH • '::♦♦� there are no hidden defects or encroachments. PES can therefore not provide any warranty for future ••.•• •....I..... performance nor give any estimate of how long the system will continue to meet the operational requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed ♦ 2•steven R. Pannone: i above. Any reliance upon or use of this report by any other person or party is not authorized nor will it ♦1�� •°•.• No. CE 8149 •�,••'AV ••, • confer any legal right whatsoever. ♦♦♦ .4W 5. DSD SIGNATURE ������.• 1/ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory "d" RT*UIER PROGRAM i %. nom_ _...� •••-wt a..•. Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: _ Original Certificate Date:, (Rev. 11/0 Municipality of Anchorage ' C'S • i"� Development Services Department Building Safety Division On -Site Water & Wastewater -Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Southpark, Block 1, Lot 3 Parcel ID: -020-&91-03 A. WELL DATA Well type Class'A' Date completed Total depth ft. If A, B, or C provide PWSID # 21-4475 Sanitary seal (Y/N) Cased to ft. FROM WELL LOG Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) in. AT INSPECTION Date Static water level ft. ft Well production g. g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 mL Nitrate mg/L Arsenic: ug/I Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material Steel / Septic Date installed /12/1990 Tank size 1250 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)Sl(_11/ Date of pumping 10/12/2011 Pumper McDonald's Pumping Service C. ABSORPTION FIELD DATA Date installed 9/12/1990 Soil rating (g.p.d./ft2 or fe/bdrm) 12r. sf br System type Deep Trench Length 38.5 ft. Width 2.5 ft. Gravel below pipe 7 ft. Total depth 10.7 ft. Eff. absorption area 53a ft2 Monitoring tube Y Depression over field N Date of adequacy test 12/6/2011 Results (Pass/Fail) Pass For -4 bedrooms Fluid depth in absorption field before test o in. Water added628 gal. New depth8 in. Elapsed Time: 120 min. Final fluid depth o in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION "Pump on" level at Datum Size in gallons in. "Pump off' E. SEPARATION DISTANCES Cycles tested TION DISTANCES FROM WELL ON LOT TO: Septic tank/lift sta�i n-er�c Absorption field on lot Public sewer main Sewer /septic service line. Animal containment areas Manhole/Access (Y/N) _ Hiqh water alarm level at Meets alarm & circuit req On adjacent lots On adjacent lots manhole/cleanout Holding tank Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 15 Property line _ 22 Absorption field io Water main io+ Water service line 25+ Surface water ioo+ Wells on adjacent lots 200+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 17 Building foundation 27 Water main 75+ Water Service line so+ Surface water ioo+ Driveway, parking/vehicle storage 10+ Curtain drain 50+ Wells on adjacent lots 200+ F. COMMENTS G. ENGINEER'S CERTIFICATION I 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. Engineer's Printed Name Steven R. Pannone, P.E. Date 12/6/2011 COSA Fee $ q O Date of Payment 1 a - � 11 C J, Receipt Number C�i l�l � ) (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number •• �i StevenR.••Ponnone�� No. CE 8149 � � ♦♦4A, C fid Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 14 (-3G--oy CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING uq I -b3 Parcel I.D. 020-,I)Ez129 1. GENERAL INFORMATION HAA# Expiration Date: / zs G Complete legal description Southpark S/D Block 1, Lot 3 Location (site address or directions) 4245 South Park Bluff Drive Current Property owners) Mark &.Karen Stanley Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 4245 South Park Bluff Dr., 99516 Day phone Day phone Mary Tutterow / Dynamic Properties Day phone 261-7682 3111 C Street, Suite 100, Anchorage, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class Well ❑ Public Water System 0 TYPE OF.WASTEWATER DISPOSAL: Individual On-site Z Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work. i Municipality of Anchorage I, • Development Services Department _•: ` �: `_ Building Safety Division g A [ T T On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK '99519-6650 www.muni.org/onsite (907) 343-7904. t a . . AUTHORITY APPROVAL ROYAL CHECKLIST J., ` Legal Description: Southpark SID Blk 1, Lot 3 1' ? ' Parcel ID: 020-051-29 A. WELL DATA A �I �V tL I I type If A, B, or C provide PWSID # Well Log(Y/N) Date comp a Sanitary seal (Y/N) Wires properly protected (Y/N) ' Total depth ft. Cased to ft. ? Casing height (above ground) in. FROM WE G AT INSPECTION Date of test I' Static water level ft k i m. I roduction g•P ., 9•P t Wel I , TS: SAMPLE RESULTS: TER SA , WA ; i Coliform ll' colonies/100 ml: Nitrate mg./I.: Other bacteria lonies/1 00 ml. Arsenic: mg./l. Dater of sample:Collected by _. A� B. SE PTICIHOLDING TANK DATA E' I Install 9/ 12190 steel � �` Date instal -- Tank Type/Materials , I 1 i. i Tan siz 1250 gal. Number of Compartments 2Cleanouts (YIN) y r , . I'. YN ria n i h water alarm / ) H ss ion o ve r tank YM 9 Depre ) Y( YIN, . . . nowt ti n c lea 0 unda o ) F ( hland Pumping 9-17-03, Pum er N ort P 9 P i Date of pumping LD DATA C. :ABSORPTION FIE i , k' • 'z, i z �I ) 125 System deep trench 9/12/90 Soil rating :(g.p.d:/ft or,ft /bdrm System Date installed k • I.i - , el below pipe 7 ft• r I Grav 3 2.5 ft. P P 38.5 . , Width Length.38-5ft E - Total depth 10.4 ft. Eff. absorption' areal' 539 . ft2 Monitoring tube Y Y Depression over field n ., j ass For 4' bedrooms !Date of adequacy test 1'23'04 , Results (Pass/Fail) P Fluid de I th in absorption field before test 0 in { Water added '101 gal New depth 9.0 in. P min. 'Final fluid depth 2 in Absorption rate >= 600 g.p.d. ;Elapsed Time: 60 none known If yes, give date Any rejuvenation treatment (past 12 mo.) (Y/N &type) i � I I I r I ' I h i I s 0 Q N a as W A No'r(ai �a►s(�acttclJ._'� Str.P..tl� RNL+`( PLOT PLAN A8'33UILT X __ SCALE V -50I GRID L23' 708 No_"Do-101 Lart4;3a I hereby certify that I have surveyed the followinej described - — ..e — ..... ------ 11 1%mc'sORA(r ---- 1%mc'sORA(rW Recording District, Alaska, and that the improveme within the property lines and do not encroach onto the property adjac improvements on the property lying adjacent thereto encroach on the that there are no roadways, transmission lines or other visible easem except as Indicated hereon. Dated this the LS -11 Day of SePTUMBts'1L , 19 i 0 , at Anchora It is the responsibility of the owner to determine the existence of any or restrictions which do not appear on the recorded subdivision plat. 1731 Georqe Bell Circle Anchorage, Alaska 99515 (907) 345-6476 nts situated thereon. are t' N • • "' I ' , •• L,1 (y eat thereto, that no ,• ��, •o� ' +� surveyed premises and t9 �i : •';; ants on said property is i Ye, Alaska �� :� Kannp Lang � d d �'-'' •. LS - 5202 �¢'S� easements, covenants, '.• • r •: S I AQ+tt'a�r�l"F� a'8� Parcel I.D. # MUNICIPALANCHORAGE • �' 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 1 , 020-051-29' HAA# 1. GENERAL INFORMATION Complete legal description Lot 3; Block 1; Southpark Subdivision Location (site address or directions) 4245 Southpark Bluff Drive Anchoraae. AK Property owner —Bill HillDay phone 345-8065 _ Mailing address 4245 Southpark Bluff Drive Anchorage, AK 99516 Lending agency —_ Day phone Mailing address— Agent __ Day phone Address _ Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: — 4 3. TYPE OF WATER SUPPLY: Individual well Community well xx Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xx 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 (Aev 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 regulatr W,ift&itMspection Name of Firm Address Engineer's signature Alaska Water & Wastewater Consult nts, krm Shall be PAID 5 or prior to, closing for the Engineering Services Provided: 6. DHH6 SIGNATURE Approved for Disapproved. 0 FOUR bedrooms. Conditional approval for Additional Comments W, Phone 331 -&Oe Date 7 l3 9�i bedrooms, with the following stipulations: Date %— 2 2- 99 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-M (Rev. 1/91) Beck MOA X21 KE IV l� Municipality of Anchorage JUL. 21 199 C*D DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division muNIUM.uY or ANC 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907 44 fi4LSERVICE Health Authority Approval Checklist / Legal Description: _ LO 3 blOGk / 56(1Y4164 rk Parcel I.D A. WELL DATA CI05S A w4_// 5� Well type If A, 13, or C, attach ADEC letter. ADEC water Log present(Y/N) Total depth __. Sanitary seal (Y/N) Date of test Static water level Well production WATER SAMPLE, ESU Datecompleted Cased to FROM W17LL LOG Nitrate OHO -n7'�5/ height (above ground) Wires properly protected (Y/N) of sample: _ _ Collected by: B. SEPTIC/HOLDING TANK DATA AT INSPECTION Other bacteria g.p.m. Date installed 19J90 Tank size /x:50 Number of Compartments a Caeanouts(Y N)---- Foundation cleanout (Y)N) _4-- Depression (YO _ High water alarm (Y/N) _ Date of Pumping. �'� 9 9 - _ Pumper 111 �/ __ C. ABSORPTION FIELD DATA Date installed Ct / 90_Soil rating g. .d./f ft2/bdrr /c?5 System type Length Width Gravel thickness below pipe r� _/ —Total depth Effective absorption area _,�5 3 9 Monitoring Tube present ©N) -Y- Depression over field (Y(�i _ Date of adequacy test. %- Results (Pass/Fail) _ / Q15 For bedrooms Fluid depth in absorption field before test (in.);�'' 25 _ Immediately after gal. water added (in.): Fluid depth _ /, 75 " . (ins) Minutes later: 36 Mfr, Absorption rate = _ 6 n -/- g,p.d. Peroxide treatment (past 12 months) (Y/N) ,fie 9JeWP I If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) _ High water alarm level at* _ Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer /seotic.sefiice line On adjacent lots Public sewer Lift station at* SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation /O t Property line Absorption field Water main/service line Surface water/drainage /60 Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /U f Building foundation /O Water main/service line /6 Surface water /00 Driveway, parking/vehicle storage area /6 Curtain drain none- .-n-o a)k, Wells on adjacent lots o� C70 t F. ENGINEER'S CERTIFICATION / certify that 1 h et, r ine field' inspections and review of Municipal in conforman a wit1�A H ideli es in effect on this date. Signature Engineer's Na a f- A �My Date 713 95 --rte HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY ANCHORAGE • '- DEPARTMENT OF HEALTH &HUMAN SERVICES Division of Environmental Services ��79 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. # 020-05/ - 2 1. GENERAL INFORMATION HAA# .;11 LL Q Complete legal description Lf -=3 Location (site address or directions) `/ZU r//'ng Property owner Mailing address Lending agency Mailing address Agent Address Unless otherwise requested, NAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4- 3. TYPE OF WATER SUPPLY: Individual well Community well _X___ Public water Day phone �1a3 G'zD(G Day phone Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site 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(Ro, 1/91) Front MOA 921 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 KND Engineering Phone . Address Ecrfie rive,. AK 99577-8736 Engineer's signature 6. DHHS SIGNATURE , Approved for bedrooms. Disapproved. Conditional approval for Additional Comments — Date /5;/- A /A0 aad��r Konnc;n /A. D,xf*/ CE )/6/ ° bedrooms, with the following stipulations: Date 2 - 3 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and 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. 72-025 (Rev. 191) Beck MOA x21 Municipality of Anchorage �F DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division ,n 825"L" Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 O n PTI t r, la Health Authority Approval Checklist f h rri cry to < 9 Legal Description: .AfL1_-_ Parcel LD.: L}=U n n �t A. WELL DATA T e O O Well type eaLrlttPIf A, B, or C, attach ADEC letter. ADEC water system number Z t i 75 x Log present (Y/N) Total depth Sanitary seal (Y/N) _ Date of test Static water level Well production Date completed Cased to FROM WELL LOG g.p.m. _ Casing height (above ground) Wires properly protected (YM) AT INSPECTION WATER SAMPLE RESULTS: Coliform — Nitrate Other bacteria Date of sample: _ B. SEPTIC/HOLDING TANK DATA g.p.nt. Dale installed *i&6 -- Tank size /Z:Sp Number o�.f//Compartments _ Z _ Cleanouts (Y/N)—y Foundation cleanout (Y/N) _—L__ Depression (YM) N _ High water alarm (YM) t/4 Date of Pumping _ / 25 (n _ Pumper'44& - C. ABSORPTION FIELD DATA / Date installed'_// _ Soil rating (g.p.d.M2 or ftZ/bdrm) /ZS __ System type r het , Length 38. $ _Width 2-6 _ Gravel thickness below pipe % n Total depth 123 Effective absorption area 537 Monitoring Tube presenl(Y/N)Y Depression over field (Y/N) ALA Date of adequacy test / 2S_: Results (Pass/Fail) _�_ For _�_ bedrooms Fluid depth in absorption field before test (in.); Dyj Immediately after 75 gal. water added (in.): 3_ Fluid depth _ D (ins.) Minutes later. 3D _ Absorption rate = _ 150 + _g.p.d. Peroxide treatment (past 12 months) (Y/N) A/ - - If yes, give date AIA — D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer stain Sewer /septic service line On adjacent lots On adjacent lots "Pump off' level at* Public sewer mauhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation le / Property title 97 Absorption field /D Water maitt/scrvice line /D '4- Surface water/drainage /DD f Wells on adjacent lots > Z D 0 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Z8 r Water main/service line / U -F Surface water 160 7 -4- Driveway, parking/vehicle storage area Curtain drain Nf+ Wells on adjacent lots F. ENGINEER'S CERTIFICATION / certify that / have determined thru field inspections and review of Municipal in con/orinance with MOA HAA guidelines in effect on this date. Signature Engineer's Name -, / e ti �/Zy5 Date ZlA HAA Fee $ 3en 0 Date of Payment 112-61,74 Receipt Number v3 �✓ a q 72 Rev. 8/95 OSS: ltaa.wk.doc Waiver Fee $ Date of Payment Receipt Number Property line 17 Kenneth M. CF 711 CUT • t� 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. # 6)—SCA HAA # _ VAR _)L6'\ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) _ _ (b) Property owner—/(��OG Telephone: (home). Ste/ Mailing Address : D•�/���� !� J.�_ on ���5 (c) Lending Institution /" off Telephone Mailing Address /"/'A-1 (d) Real Estate Company and Agent 1-114 Address �n Telephone (e) Mail the HAA to the following address: (or check heren, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Familex 3. WATER SUPPLY Number of bedrooms 16 Individual Well ❑ Communix 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 Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 7M26(aev. vee) Page 1 of 2 Z;o Z abed X399 (BBIL *108) SZO-Z[ -� joM s,aaeu!6ue !suo!ssapoid ayl ui suo!ss!woao sjoajajop a!q!suodsaa lou si a6eaoyouV;o Al!!ed!o!unW aqi •panss! si alsoilgiao a ajo;eq elsp az (!eue 10 suo!loodsui lonpuoolou op SHHO to saa/o!dw3 •sluawai!nbai alels pus !saapal uieliao Alsiles olaapao u! suo!lnl!lsu! 6u!pua! a!ayl pus sawoy;o sjaseyojnd of Aselinoo a ss s!yl saop SHHO ayI e�!se!y;o alelS ayl ul pajals!6ai jaau!6ua!suo!ssa;oad luepuedepu! us lq anoge g ydej6ejed ul uaA!6 suo!leluasaadaa ayl uodn R!uo paseq paled!;uao !enaddV (1!aoylnV yl!saH sanss! 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Aw leyl (p!JaA!'Mo!aq uMoys alep uoilep!!eA ayl po se pue olaaay pax!ppe leas Aw Aq pa!;iliao sV NOIIVWEIOdNI ONV VIVO `HOdV3S 371id `SIS31 `SNOII03dSNI JNIOIAOHd WHIR JNIU33NION3 '9 oho �0� J � J�\G\Q���SP�,S�' GO% e � MUNICIPALITY Hea Health Au horlty Approval ( A (MOA) f*t� 1 0� pti CHECKLIST - FEBRUARY 11 14) `�� 343 4744 (,e v Legal Description: — �° L 3 A. WELL DATA Well Classification—_ �� c-?yLtuut� / /If A, B� C, D.E.C. Approved (Y/N) Well Log Present (Y/N) Date Complete Yield _ Total Depth Cased to _—Depth of Grouting _ Static Water Level Pump Set At — Casing Height Above Ground Sanitary Seal on Casi (/N) Electrical Wiring in Conduit (Y/N) Depression A d Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot _ ; On Adjoining Lots _ To Nearest Edge of Absorption Field on Lot On Adjoining Lots — To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service no on Lot Water Sample Collected — Dat Water Sample Tes sultst� Comments SEPTIC/HOLDING TANK DATA Date Installed 2 qqa Size '� S2� No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) �� Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped Pumping/Maintenance Contact on File (Y/N) �t 0 ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) _ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well Z_Cyn To Building Foundation 2 % To Property Line To Disposal Field __zo To Water Main/Service Line --;> To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev. 7/88) Front Pagel of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design Date Installed ��'L/9�% Length of Field Width of Field 2i Depth of Field �0 5 Gravel Bed Thickness % Square Feet of Absortion Area Statndpipes Present (Y/N) ` Depression over Field (Y/N) N Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well .7 Ze)®! To Property Line /7 / To Building Foundation �� y To Existing or Abandoned System on Lot On Adjoining Lots >`cJ� To Water Main/Service Line tel!] To Cutback (if present) 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 Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N Comments "Check Perm ittgWBed room I certify that inspection. / Signed _/y Date — MOA No. Dimensions Manhole/Access (Y/N) "Pump evel at Against HAA Request" Vent(Y/N) or conformed to all MOA and 6 Receipt No. o S-a0� 13 Jy- 1 3 Y Date of Payment 11-1--90 Amount: $ 170, Pumping Cycles during Adequacy Test. — r 6l , R. a ftp;: �!-race — M. l f 1. Ja Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 1/88) Back Page 2 of 2 on the date of this M �f� Engineer's Seal