HomeMy WebLinkAboutGILLEAN LT 114BMunicipality of Anchorage
On -Site Water and Wastewater Program - (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191234 PID Number: 051-144-50
Dwelling: ® Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ® Upgrade
Name:
OSCAR & TRACY RODRIGUEZ
ABSORPTION FIELD - EXISTING
❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
24531 HOMESTEAD ROAD, CHUGIAK
❑ Other
PhoneNumber
of Bedrooms
Soil Rating
Total depth from original grade
2
GPD/S F
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
GILLEAN 114B
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
ToTotal
Septic
Absorption
Lift Station
Holding
Sewer
absorption area
2
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft
--
-- Ft.
Well
100'+
NA
NA
NA
NA
TANK ® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER
Capacity
1000 Gal.
Surface water
100'+
NA
NA
NA
Material
HDPE
Number of compartments
2
Lot Line
5'+
NA
NA
NA
NA
Foundation
10'+
NA
NA
NA
LIFT STATION
Manufacturer
Capacity
Gal.
Curtain Drain
NA
NA
NA
NA
Remarks Existing septic tank decommissioned
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
per code, new tank installed 5' from &
connected to existing field.
Pump make and model
Electrical Inspections performed by
PIPE MATERIAL House to tank 3034 Tank to 3034
Installer NORTHERN EXCAVATION
drainfield
Drainfield CO/MT 3034.
Inspector FWCS / MNA
BENCH MARK (Assumed elevation) 100 ft
Inspdectes: 1tions 9/11/19 9/12/19
Location and description
Zna
3rd 4`h
BOTTOM OF SIDING
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Conditional
OF. ALS
Approval: Date
MICHAEL N. ANDERSON: 4
No. CE 9469
9113/19-.•-�,cs'�
Appro d Date —
1110PEss100ti AV
inspection Keport_y-i-iz.00c
GILLEAN LOT 114B
PID: 051-144-50
PERMIT. OSP191234
A -C=36.1'
B -C=60.4'
A -D=44.1'
B -D=66.4'
SCALE: 1' =
SEPTIC SECTION
PEPARED FOR: SUPPORT# SERVICES:
OSCAR & TRACY RODRIGUEZ
GILLEAN LOT 114B F .5
20214 STEFFES ST., CHUGIAK, AK 99567
Michael N. Anderson, P.E. DATE: 9/16/2019
4661 Natrona Ave. DRAWN: FWCS
Anchorage, Alaska 99516
(907)727 8864/FAX: (907)345 1391 SCALE: 1" = 30'
SCALE: NTS
OF AL,4,
*�
49TH
-
A MICHAEL N. ANDERSON
N. CE 9469
Atf
nssto0'
„c,, MUNICIPALITY OF ANCHORAGE
On-Site Water& Wastewater Program \-,N- 3,;.
, PO Box 196650 4700 Elmore Road •`'r-P,4,,,'..:,!4,0f.-.:,-.` 1+.'
Anchorage,Alaska 99519-6650 Phone,(907)343-7904 Fax:(907)343-7997 _^`
V- http://www.muni.org/onsite i
Department
• 'C HORN°.
On-Site Wastewater Disposal System Permit
Permit Number: OSP191234 Effective Date: 6/19/2019
Work Type: SepticTank Upgrade Expiration Date: 6/18/2020
Tax Code Number: 05114450000
Site Legal Address: GILLEAN LT 114B G:1258
Site Mailing Address: 20214 STEFFES ST, Chugiak
Owner: RODRIGUEZ OSCAR H & TRACY E Lot Size in Sq Ft: 44938
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 5
This permit is for the construction of:
❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage
•
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions: Prior to COSA approval, a letter of non-objection is required for the bed in the easement.
Received By: Date: 6/19/19
Issued By: t),,A vvO ,....-7.7,-z...--
/ Date: 6./9/9
ePthAIS
MUNICIPALITY OF ANCHORAGE
Development Services Department
3 Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051-144-50
Property owner(s)
SOCAR & TRACY RODRIGUEZ Day phone 9073018893
Mailing address 20214 STEFFES STREET, CHUGIAK, AK 99567
Site address 20214 STEFFES STREET, CHUGIAK, AK 99567
Legal description (Sub'd., Block & Lot) GILLEAN LOT 114B
Legal description (Township, Range & Section)
Lot Size 44,938 Sq. Ft. Number of Bedrooms 5
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Single Family (SF)
Initial ❑
Absorption Field (w/wo ADU)
Septic Tank Upgrade Duplex (D) ❑
Holding Tank ❑ Renewal Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage n
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
FWCS - Brent Western
(Signature of property owner or authorized agent)
Permit/Rush Fees: Waiver Fees:
Date of Payment: 4`12J19 Date of Payment:
Receipt Number: 0/19610 Receipt
/ Receipt Number:
Permit No. Q S PI I o�.3Y Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Michael N. Anderson, P.E.
Civil/Structural Engineering and Construction
4661 Natrona Ave. Anchorage, Alaska 99516
Phone 345 -3377 / Fax 345 -1391
Support Services
Brent M. Western
907-440-4601
June 12, 2019
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: GILLEAN LOT 114B
To whom it may concern:
The owner has requested we proceed forward to obtain a septic permit to upgrade the
aged septic tank on the subject lot. The tank and existing field are sized as 5 bedrooms,
but the existing house is only 2-bedrooms.
The lot and area is served by a private water and the proposed tank will not impact any of
the neighboring properties due to the lot layout. Please contact Brent M. Western or me if
you have any questions.
Sincerely,
Michael N. Anderson, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191234, Deb Wockenfuss, 06/19/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191234, Deb Wockenfuss, 06/19/19
/V10i- coal
MUNICIPALITY OF.ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE water storage unit ' PERMIT
PERMIT NUMBER:SW960298
DESIGN ENGINEER:
OWNER NAME:HOOLAHAN SHAUN P & PATRICE A M
OWNER ADDRESS:P.O. BOX 671402
CHUGIAK, AK 99567-1402
PARCEL ID:05114450
LEGAL DESCRIPTION:
GILLEAN LT 114B
LOT SIZE: 44938 (SQ. FT.)
NUMBER OF BEDROOMS: 2 THIS PERMIT: 2
THIS PERMIT IS FOR THE CONSTRUCTION OF:
water storage tank within the dwelling.
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
DATE ISSUED: 9/16/96
EXPIRATION DATE: 9/16/97
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
z 4,_(�T45
diL
DATE:
07/6/76.
DATE:
20214 Steffes Street
Chugiak, Alaska
Lot 114B, Gillean Subdivision
Section 9, T15N, R1W, S.M.
September 12, 1996
A water storage tank is to be installed on the above property as a
means of supplementing production from the existing well. The tank
to be installed is manufactured by Burch Manufacturing Company,
Inc. (see attached specification sheet). The specific tank will be
Model Number FDA 712MT, having a capacity of 1140 gallons. The
pump will be installed within the crawl space of the house near the
point where the piping from the existing well enters the structure.
The location of the existing well and septic system is shown on the
attached as -built. Ancillary equipment associated with the
installation of the storage tank will include a jet pump, pressure
switch, and pressure tank. The installation will be conducted by
Scott Linguist of Pure Glacier Bottled Water (DEC Approved) along
with a certified plumber. All work will conform to applicable
Municipal codes.
Shaun P. oolahan
Patrice A.M. Hoolahan
puRCII
NC.
The Easy, Economical Way
to Store or Haul Liquids
Multiple Uses. Ideal for
feeding livestock, crop
spraying, mixing fertilizer,
pesticides or herbicides, the
Burch Kolaps-A-Tank is at
home on the farm or ranch.
For parks, nurseries — anywhere water
sources are scarce, the Kolaps-A-Tank
provides a mobile, reliable source of water.
Plus it's FDA approved for drinking water for Versatile Capacity. The Burch Kolaps-A-Tank
human consumption. can be handled easily by one man and yet
Unmatched Economy. The Kolaps-A-Tank is holds from 525 to 1340 gallons! It can be filled
the least expensive means devised to haul and emptied in minutes with a centrifugal
liquids on virtually any vehicle you have force pump or drained by gravity flow. Seven
available. Initial cost is substantially lower sizes are available to fit pickups and many
than any comparable fiberglass or poly tank standard wagon boxes. On hayracks, the
on the market. For value, you can't beat the Kolaps-A-Tank is self-supporting. Just thread
Kolaps-A-Tank. The first tanks made are still rope over tank, through D -ring guides, and tie
in the field after years of outstanding service. down.
ko1ps
a -tank
Superior Strength. Made
of rugged PVC (polyvinyl
chloride) coated nylon, the
Kolaps-A-Tank resists chem-
ical contamination, mildew,
rot, and solar heat exposure.
It's electronically heat sealed and capable of
withstanding severe outdoor exposure,
including – 40° temperatures!
Convenient to Fill, Drain Quality 1'/2" gate
valve is mounted on 8" PVC extension pipe for
easy draining. Big 10" diameter flexible sleeve
on top makes tank simple to fill.
SPECIFICATIONS
Compact, Easy to Store Even the largest
Kolaps-A-Tank can be folded up and stored in
an 18" x 18" x 18" carton.
Model No.
Approximate Size
Gals.
Liters
Approx.
Shipping Wt.
Lbs. KG
FDA 50MT
40" x 50" x 12" (102cm x 127cm x 30cm)
73
276
11
5
FDA 73MT
80" x 73" x 16" (203cm x 185cm x 41cm)
275
1040
23
10.4
FDA 98MT
65" x 98" x 18" (165cm x 249cm x 46cm)
525
1987
33
15
FDA 610MT
6' x 10' x 2' (1.83m x 3.05m x .61m)
800
3028
42
19.1
FDA 712MT
7' x 12' x 2' (2.13m x 3.66m x .61m)
1140
4315
58
26.3
FDA 714MT
7' x 14' x 2' (2.13m x 4.27m x .61m)
1340
5072
64
29
FDA -approved models meet Food and Drug Administration 21CFR121.2514 of subpart F of the Food Additive
Regulation, making it safe for drinking water used for human consumption.
From covered wagons to
turkey saddles .. .
Burch Manufacturing has been making
quality textile products for agriculture,
industry, and more for almost 100 years. If a
product you need can be made of canvas or
vinyl coated nylon — chances are we can
sew it, heat seal it, or silkscreen it. Send us
your specifications and we'll be happy to
provide you with a free estimate.
Sales and Service:
A(:KT R1
URCH
MANUFACTURING COMPANY, INC.
618 First Avenue North Box 876
Fort Dodge, Iowa 50501 Phone: (515) 573-4136
FAX 1-515-5734138
Manufacturers of canvas and sunthetic textile products since 1882.
Ai; D'O 7 `?40 "'W.. /498/ (P[AT) 1
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ANl1A1�7�
,l
MUNICIPALITY OF ANCHORAGE
72=013 (Rev. '%me)t).`" .,,s
f r \`
i
-/-t(
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
NAME ( // ✓ `gym / I/ rcd q `� J C rr- C
//�/ /% //'/ /��/)//9s ! �j
PHONE
6// 9.-Z- 2)5
❑ UPGRADE
MAILING ADDRE S -
L� " hi,,, �-/i
LEGAL DESCRIP IO -. ,�,�
L /'l c,_ /LL (/p- S .0
/
LOCATION 41 _ /
/(JO /Z,,,,./cna� 7-/S1 /) / / k
NO. OF BEDROOMS
I- Z
a Q
wF
y
DISTANCE TO:
Well
/ 7(
Absorptioa.arer
6
Dwelling
/ j- 'z / /J
PERI§1 N,// _
'K+ ,-S .,��
,3
Manufacturer /J7
V
/ L
Ma},leri /�
G/ ee— /
No. of compor nts
Liq. c acit in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
6 z
-10
0 Z G
s I-
DISTANCE TO:
Well
gw,elli
1
PERMIT NO.
Manufacturer
Material
Liquid capacity in gallons
TILE
DRAINFIELD
TRENCH
DISTANCE TO:
Well-
Foundation
Nearest lot line
PERMIT NO.
No. of lines
Length of each lite
pial length of lines
ilial
/ ,
Trench width
inches
Distance between lines
Top of tile to finish grade
Material beneath tile
inches
Total effective absorption area
SEEPAGE
Length % X31
Width (
De / L l 6, G� / Lr
Nj}
PERT7N� J5_.1 �i'"JJ c
Type of crib
Crib diameter _-
Cr depth
ve absorptio je
Total effective
DISTANCE T0:
Well// c.� (
k�
BuildiniV/d /ion
/i
Nearest lot line 0
w
Class T, x t 3.De
th L
Driller
Distance to lot line
rERMIT NO.
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
i
PIPE MATERIfA.S
ti 6
wk
1'
7
04':::-...-"•••••,......
I
/
SOIL TEST RATI�IG� /�n,� �//
G-
22t......
INSTALLE
.'c
REMARKS
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APPROVED 1E'i,,,to.4 DATE
AV- 4'�y/
i
SRO leo)",.,
72=013 (Rev. '%me)t).`" .,,s
Box 1369, STAR 1Zcou-riE A Aztec»®RAGE, ALASKA 99502
344-7714
440 Peet.
SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF
DRILLED AT THE RATE OF 825.00
PROPERTY OWNER
PER FOOT. ChaAge .o4 400 �t olt ly.
MLt. & MA4. Shaun & Law= Roo.Lahan 694-5039 263-4238
LOCATION OF WELL SITE Et* Bdk. Sub.
DRILLER Betnce CLai44 4 Rampa t »4LLl rng Wonk4
WELL LOG:
0 18' Silty. 4andy. c Laty with 35% gtaveL .fn.the Ptmati.on.
18----45' lfatdpan. R cemented g.. avel.
45----66' R wet clay, with a 4and4 .Une gtaueL at 65 ./.t. Ue.ty. 4itto
66----90' R btu€ clay. with .thin a..ea s 4 Pim 4and. Wet mate.t,ra.L. Ue4y. 44t4.
90---107' Conq,Lome tate. R brtoken nock. maten.Lal. Some good gtaue.L. Ro water pneoent.
107--440' Bedtock.. R 4ed,inentaty. nock.. Ro watet 4hawinq an* where along until.
365 .Ut. Production ptaued .ta be 3/4 gPIR- Wa tett tn. ,that a tea a4 out 4 a ponoud
type ma te44a ... Le44 than 1/2 gm dnc4tea4e 4n. pnodu .Uon b1. 400 .t t. Rew Wa te.4 y2e ld
at 424 .to 432 a a gnorutlat & ponoua .type na.tetiai. At Leant 1/2 gPR .inc.t nae tn.
production. Tata . Watet y.i e ld 4 90 gal,Lona peri bona. Thio Wel may. aLLo dm prone
with nae to oue4. 100 gallon/3 pelt haat duttng 4one month4 4 .the yea r. R.lao .the yield
w i.LL d ecteaa a during d t.Let .time. the year. Wate& ieueL d o back up o w Uh n 40
.stet 4 .the 4utace..Ln a 24 hout time plane. Ouet 600 ga ton4 4 wate..t ta ne4e ure
an cult necove 4. 1.6 gaU.on4 pet Ao.t in ne4ehue.
One Hoioe Subne o.41,Le Pump. 4hauld be .i.n tai ed .to 400 & tawe)ied to within 20
4 .the bottom it needed. 9.t may. be 4t ty 4he:4 .the pump p .ice put .to eta4e to 440 A.
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
Co44 4 Dtitling: $25.00 pelf .#.une4 400 4. $10,000.00 82,500 paid !Manch 30.th,84
WRITE CHECK PAYABLE TO RAMPART DRILLING WOR -f!.. THE SUM OF 17,500_00
We guatan teed quad.Lty & quo/U.1 tl0 on .thin We tL. . L J ` C1
THANK YOU VERY MUCH.
DATE fa.. ch .30th., 1984
BERNIE CLAUS OF RAMPART DRILLING WORKS
SERVICE CHARGE 0 F 1%z% PER MONTH WILL SE ASSESSED ON PAST DUE ACCOUNTS
_
rel PAPA C: �����kr" f_D P-JC:0-i iF# Cri�
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECT ION
825 L STREET, 8NCH8RHGE, HK 99501
264-4720
01%1—�I 1- E E la IF: ��IL. IL_ la IR: ri -r
PERMIT NO: 8407?.55
DATE ISSUED:, 05/18/84
APPLICANT:
ADDRESS:
CONTACT PHONE:
C/O S & S ENQ'G SCHMIDT BR8a EXCHY
SRB 196X
EAGLE RIVER, HK 99577
6q4~2979
LEGAL DESQRIP: SUBDIVISION: GILLIAN LOT: 114-B BL8CK:J0
SECTION: 9 TOWNSHIP: 15N RANGE: 1W
LOT SIZE: 44928 (SQ.FT. OR ACRES)
LOT LOCATION: KAREN
MAX BEDROOMS: 5
LISTED/BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING. YOUR SEPTIC
SYSTEM CHOOSE THE OPTION THAT BEST FITS YOUR SITE
17F;:HEP-4C.1-1
DEPTH TO PIPE BOTTOM <FT. ) 4.0
GRAVEL DEPTH <FT. ) 26}
TOTAL DEPTH (FT. ) 60
GRAVEL WIDTH (F'[ ) 2.5
GRAVEL LENGTH (FT. ) 157.0 **
GRAVEL VOLUME (CQ.9DS. ) 73:
TANK SIZE <G8L5? 1/500.0 **
SOIL RATING (SQFT. /BR) 125
4. 0
0, 5,
4. 5
43`1250
Ca FAR
4.0
' 2.0
60
50
08 0
40.7
50ci.0
125
**
**
** GRAVEL LENGTH } 75 FT. REQUIRES MULTIPLE R S (NOT EXCEEDING 75 FT. EACH)
** TANK MUST HAVE AT LEAST TWOCQMPGRTMENTS
I CERTIFY THAT:
1. I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH By THE MUNICIPALITY OF ANCHORAGE (M08) AND THE STATE OF ALASKA:
2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS;
AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
3. I WILL ADHERE TO RLLAQA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK
DISTANCES FROM ANY EXISTING WELL' WASTEWATER DISPOSAL SYSTEM OR PUBLIC
SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT.
4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 5 BEDROOMS AND.
ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA _BUILDING CODES/
THEN (1) AN E aL~L PERMIT AND INSPECTION MUST BE OBTAINED;�2) GS-BUILTS
WILL NOT BE W6ROVE WITHOUT AN E ECTRIC8L INSPECTION REPORT; AND (3) THE
ELECTRICAL MUc� `^ 08N BY ^ LICENSED ELECTRICIAN.
APPLICANT:SIGNED
ISSUED BY
10 5 & S ENQ'6 SCHMIDT RR0s EXCAV.
DATE:
DHTE:7/��/�
/»
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: P`hI
LEGAL DESCRIPTION:
/-c7 i'
CZL�NINAIC.
S1'N IX( Cig.E4v' 1-
)06 44
.)Co4 R,
11
12
13
14
^X�qv
15 ter 0? 41
_ •en
16
17
18 Uret+att A. 81.,rp,Sae
No. 14B7-.9
19•?�tS ".
20
COMMENTS
ft go' volcifsS0VAIN
i$EX
PERFORMED B 511V4j11414'' 441
A
72-008 (6/79)
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SLOPE
SOILS LOG — s
LI PERCOLATION
TEST
DATE PERFORMED: 45! � —Hi'
6/1,t,,,,AJ Seo
r/L'
S
L
0
P
E
SITE PLAN
ti
/2
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
i
/11
i
PERCOLATION RATE
TEST RUN BETWEEN
A
FT AND
(minutes/inch)
FT
DAT D�i 7//f
PERFORMED FOR:
LEGAL DESCRIPTION
10
11
12
13
4
15
16
17
18
19
DEPTH
(FEET)
ti`c v
COMMENTS
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 2644720
SOILS LOG— PERCOLATION TEST
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A. SOILS LOG
❑ PERCOLATION
TEST
DATE PERFORMED: 70 6)(1 e
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PERCOLATION RATE
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PERFORMED 8Y: .S 4/1.16 -1 Vii. F/_ 't lt�
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CERTIFIED B
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Municipality of Anchorage
Department of Health and Environmental Protection
825 L Street, Anchorage, Alaska 99501
264-4720
TWO INSPECTIONS REQUIRED:
First: Absorption trench excavated
Second: Septic system ready for backfill
BED REQUIREMENTS
Install Bed Per Permit Specifications
Cast Iron Cleanout - 1' to 4' from foundation
solid pipe
SEPTIC TANK:
Must be insulated with 2" high density
burial type styrofoam or equivalent
Two Compartment, Municipal Approved, Set level
5' Minimum undisturbed earth between tank and
trench, and tank and foundation. Tank must be level.
Two Compartment Municipal Approved,
set level, must be insulated
Tank and solid pipe laid on well -compacted earth
Cleanout required prior tc 90° bends before tank inlet
Cleanout required 2' from foundation wall
Inlet and outlet with water -tight mechanical couplings
Two cleanouts on tank with air -tight caps
All cleanouts must come to at least ground level
ASTM D3034 may be used in place of cast iron
solid pipe
distribution box or connection
must be set on compacted earth
and must be level
DRAINFIELD AND PIPE:
Minimum distance between drainfield on adjacent lots 30'
Excavation to lot line minimum 10'
Bed installed across slope
i/z' to 2'/o" screened gravel
Perforated pipe set level, holes down. Pipe must be level.
Bottom of bed level
2" gravel over perforated pipe
Gravel extends to edges of drainfield
Minimum 3-6' between distribution pipes
The outer distribution pipe shall be 3' from the bed sidewall
Solid pipe under driveway, insulated (see insulation)
100' from tank or drainfield to river, lake or stream
Barrier material between gravel and backfill when insulation not used
Cast Iron Standpipes
INSULATION:
2" high density burial type polystyrene or equal over
lines and bed when earth backfill is less than 3';
over any line (s) installed under a driveway and/or
parking area; over all septic tanks.
bed bottom
must be level
perforated distribution
pipe holes down
must be level
DISTANCE REQUIREMENTS OF WELLS FROM TANK AND TRENCH:
Individual, single family - 100'
Class C - Under 25 service - 150'
Class A, B - Over 25 service - 200'
Further design and installation information is available upon request.
72-024 (2/83)
ets 46,
% t
stand pipe
perforated
in bed, solid
above bed,
with top cap
-6'it
3' - 6' ft.
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051-144-50
Legal description Gillean Lot 114B
Site address 20214 Steffes St
Current property owner(s) Rodriguez
Expiration Date:
12-16-22
X The On-site system(s) is/are approved for 2 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
By: �---- Original Certificate Date: '2-1
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory X
Absorption Field AdvisoryNitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA ApprovaUune 2022
MUHMP A UTV OF AHCHOFRICSE
Development Services Department 0 Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I. D. 051-144-50
Complete legal description GILLEAN LOT 1148
Location (site address) 20214 STEFFES STREET, CHUGIAK, AK 99567
Current property owner(s) OSCAR & TRACY RODRIGUEZ Day phone
2. ON-SITE SYSTEMS SIZED FOR 2 BEDROOMS
3. TYPE OF WATER SUPPLY: ® Private Wel l—❑- Private -Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ® Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ® Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 3 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ® Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ 5510
Date of Payment 8'13 1 ) 2-
COSA# SC Z?,IyV2
Waiver Fee $
Date of Payment
Waiver #
COSA Application—July 2022 copy.doc
COSA Checklist
Legal Description: GILLEAN LOT 114B Parcel ID: 051-144-50
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA
® Well log is filed with Onsite (or attached) Water storage tank volume 1,140 gallons
Date drilled 3/30/1984 Total depth 440 ft Well disinfected for coliform test? ❑ Yes No
Cased to 440 ft ® Coliform bacteria is Negative
Sanitary seal is functioning correctly Nitrate 3.07 mg/L ❑ Nitrate less than MRL (ND)
® Wires are properly protected Arsenic ug/L ® Arsenic less than MRL (ND)
Casing height (above ground) 12+ in. FWH
Date of flow test for COSA 8/29/2022 Collected by
Static water level at beginning of test 87 ft. Date 8/26/2022
Well production at time of test 0.31 gpm
Comments WATER STORAGE BLADDER IN CRAWL SPACE ISOLATED FOR WELL RECOVERY
B. TANK DATA
Measured operating fluid level in septic tank 50"
Date of pumping 8/256/2022 — ONE STOP
❑ Required maintenance completed, if AWWTS
Comments: NEWER HDPE 1000 S.T. IN 2019
D. ABSORPTION FIELD DATA
Which system tested (date installed) 5/20/1984
® ALL standpipes present per record drawing
Total measured depth from grade 3.7 ft (max)
Measured depth to pipe invert from grade *3.2 ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
® Monitor tubes go to bottom of effective.
If not, state depth into effective
® Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced 750 gallons 8/27/22 date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 8/29/22
Results E Pass
Fluid depth prior to test 0 in
Water added 1000 gal
New fluid depth 6 in
Elapsed time 15 min
Final fluid depth 0 in
Absorption rate 450+ gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) fj in
Effective depth used 0
Effective depth remaining 6 in
Comments/Deficiencies:*ASSUMED — NO FIELD COS, BUT PERF PIPE VISIBLE IN MT. NO KNOWN FROST
ISSUES. WET PRESOAK — WATER BEGAN TO BACK INTO S.T. AT 750 GALLONS. ADDED 1000 GALLONS ON
DRIER DAY THAT QUICKLY ABSORBED WITHIN MINTUES & PER CODE
COSA Checklist—July 2022 copy.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100'
® Yes if No ft
Field to Property Line > 10'
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No ft
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No ft
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No ft
Neighboring Absorption Fields > 100'
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
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No ft
Tank to Property Line > 5'
® Yes if No ft
Field to Property Line > 10'
® Yes if No ft
Water Main > 10'
® Yes if No ft
Water Service Line > 10'
® Yes if No ft
F. ENGINEER'S COMMENTS
Wells on Adjacent Lots:
Private Wells > 100' ® Yes if No ft
Community Wells > 200' ® Yes if No ft
If tank or field is under driveway comment below
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer's Printed Name CURTIS HUFFMAN, PE Date 9/20/2022
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting & fkcs
COSA Checklist—July 2022 copy.docx
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. .. .... ..........
Curtis Huffman
�4'c�`•.. CE 128991
��G�slF�• , . 9/20/202.2.��C�.�
F�pROFESSIOO ,Aw
Municipality of Anchorage
Development Services Department
Building Safety Division T Y
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci. anchorage. ak. us
(907) 343-7904
Water Well Advisory
Certificate of On -Site Systems Approval (COSA) #OSC 221442
During a recent COSA on-site inspection and test of the potable water
supply well on Lot 114B of Gillean subdivision, the well's productivity was
determined to be .31 gallons per minute. The minimum well productivity
required by this Department (AMC 15.55) for a 2 -bedroom residence is .21
gallons per minute. Although the subject well currently exceeds this
minimum requirement, all parties concerned are advised that the production
capacity of the well may fluctuate. Restriction of non-critical water uses
such as washing cars and watering lawns and gardens may be required.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
EPLANS
MUNICIPALITY OF ANCHORAGE
Development Services Department_ Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051-144-50
1. GENERAL INFORMATION
Expiration Date: 12--2-q —
Complete legal description GILLEAN LOT 114B
Location (site address) 20214 STEFFES STREET CHUGIAK AK 99567
Current property owner(s) OSCAR & TRACY RODRIGUES Day phone
Mailing address
Real estate agent
20214 STEFFES STREET CHUGIAK AK 99567
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
®
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 6-5D
Date of Payment
Receipt Number
COSA# aSC IV I-135'
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm ANDERSON CONSTRUCTION & ENGINEERING Phone 345-3377
Address 4661 NATRONA AVENUE ANCHORAGE, AK 99516
Engineer's Printed Name MICHAEL N. ANDERSON PE Date 9/12/2019
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by Nfand Anderson Construction & Engineering.
6. DSD SIGNATURE
System #1 Approved for .3
System #2 Approved for
Disapproved
Conditional approval for
bedrooms
bedrooms
bedrooms, with the following
OF ALS
*49 TH
MICHAEL N. ANDERSON.
Gj No. CE 9489
N*..9/12/19•.. ,cs�
AW
MSSIOK�
Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory ___ Other
COSA Checklist blue sheet
Le- S&IMIT:Ta71
Legal Description: GILLEAN LOT 1148
Parcel ID: 051-144-50
If more than 1 septic system on lot: COSA Checklist # _of _ Structure served by this system _
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled 3/30/1984
Total depth 440 ft
Cased to 440 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 6/10/2019
Static water level at beginning of test 267 ft.
Well production at time of test 0.42 gpm
Comments
B. TANK DATA — NEW TANK
Age of tank(s) 0 years
Tank type/material SEPTIC / HDPE
Measured operating fluid level in septic tank
® Standpipes/foundation cleanout per record drawing
Date of pumping NA — NEW TANK
Water storage tank volume 1,140 gallons
Well disinfected for coliform test? ❑ Yes ® No
® Coliform bacteria is Negative
Nitrate mg/L ® Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
Collected by
0
Date of Sample 9/9/2019
C. LIFT STATION - NA
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA — 43'L x 22'W x 0.5'ED — 100 SF/BR = 946 SF
Which system tested (date installed) 5/20/1984
® ALL standpipes present per record drawing
Total measured depth from grade 3_6 ft (max)
Measured depth to pipe invert from grade *3.1ft (min)
❑ N/A — pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective
Adequacy test date 6/10/19
Results N Pass For 3 bedrooms
Fluid depth prior to test 1_5 in
Water added 750 gal
New depth 3_5 in
Elapsed time 1260 min
® Code -required soil cover over field Final fluid depth 1_5 in
❑ System presoaked Absorption rate 450+ 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: "Assumed — no field cleanouts. WES
COSA Checklist copy 2.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'
® Yes
if No
Community Sewer Manhole/Cleanout > 100'
If absorption field is under driveway comment below
® 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'
F. ENGINEER'S COMMENTS
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 Wells on Adjacent Lots:
Property Line > 5' ® Yes if No ft Private Wells > 100' ® Yes if No
Absorption Field > 5' ® Yes if No ft
Water Main > 10' ® Yes if No ft
Water Service Line > 10' ® Yes if No ft Community Wells > 200' ®Yes if No _
Surface Water > 100' If septic tank is under driveway comment below
_ ®Yes if No ft
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No
_ ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
Ar OF ALS
G. ENGINEER'S CERTIFICATION r;'.�
1 certify that / have determined through field inspections and review J01* :'49TH
of Municipal records that the above systems are in conformance
with MOA COSA guidelines in effect on this date.
A MICHAEL N. ANDERSON.-
No. CE 9469 .-
COSA Checklist copy 2.docx 9/13/I '
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MATANUSKA ELECTRIC ASSOCIATION, INC.
LETTER OF NON -OBJECTION
September 23, 2019
Oscar and Tracy Rodriguez
20214 Steffes Street
Chugiak, AK 99567
Re: Lot 1148 Gillean Subdivision (Plat 82-207, Anchorage Recording District)
Dear Oscar and Tracy Rodriguez:
MEA has no objection to the encroachment of a septic line located in the utility easement as depicted on the
attached as -built survey drawing dated 9/17/19, 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.
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 landowner will be liable for any damages caused to MEA facilities by the improvement in the
easement.
5. The landowner will be responsible for any special construction costs incurred by MEA due to the
improvement in the easement.
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 invalidate this letter.
9. This letter is not effective unless it is recorded in the Anchorage Recording District before ownership of
the referenced property is changed from the above named landowner.
Sincerely, �@�
Manny o
t
Land Servi�eS Man
e
STATE OF ALASKA)SS-
THIS IS TO CERTIFY that on this 23 day of September, 2019 before me, the undersigned, a Notary Public
in and for the State of Alaska, duly commissioned and sworn as such, personally appeared
Manny Lopez
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 REOF, I have hereunto set my hand and official seal the day and year first above written
�ae�IYNNS���.
Notary Public in and of Alaska My commission expires`;! O TAR,
Return to: MEA, PO Box 2929, Palmer, AK 99645LIG
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PLOT PLAN AS BUILT I -IL SCALE 1" 330' GRID NY? 1258 Project No. 19-540/A1
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates inc. (907) 522-6476 Phone 0000Op
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Anchorage Recording District, Alaska, and that the Improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
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PLOT PLAN AS BUILT I -IL SCALE 1" 330' GRID NY? 1258 Project No. 19-540/A1
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates inc. (907) 522-6476 Phone 0000Op
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(907) 522-4625 Fax
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that I have the following described
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I hereby certify surveyed property
LOT 1148, GILLEAN SUBDIVISION (PLAT No. 82-207)
49TH
Anchorage Recording District, Alaska, and that the Improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
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no Improvements on the properly lying adjacent thereto encroach on the surveyed
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premises sand that there are no roadways, transmission lines'. or other visible
easements on sold property except as Indicated hereon.
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Dated this the 1-1 Day ofc°'°'�Yi- eta at Anchorage, Alaska �� Oo
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It Is the responsibility of the owner to determine the existence of any easements,
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covenants, or restrictions which do not appear on the recorded subdivision plot.
AECC963
0
Well Water Advisory
Certificate of On -Site Systems Approval # OSC191435
Subdivision: Gillean Lot: 1146
This well's productivity was determined to be .42 gallons per minute. The minimum
well productivity required under (AMC 15.55) for a 3 -bedroom residence is .31
gallons per minute or 150 gallons per day per bedroom. Although the subject well
currently exceeds this minimum requirement, the production capacity can
fluctuate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Parcel I.D. 051-144-50
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Expiration Date:
Complete legal description Glllearl, Lot 1148
Location (site address) 20214 Steffes St.
Current Property owner(s) Caple Family Trust Day phone
Mailing address
20214 Steffes St. 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:
5
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well i] Individual E
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request foa Distance:
Received by:
COSA to be released to the engin unless otherwise requested by the engineer.
Date:
AZ oi_
COSA Fee $ 4524. —
Waiver Fee $
Date of Payment Ca I n 15 (- Date of Payment
Receipt Number 60183°1n Receipt Number
OSUS 1211 Waiver#
COSA #
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 informationobtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply
and/or wastewater sial system is(are) in compliance with all applicable Municipal and State. codes, ordinances, and regulations in effect at
the timegtailai
In condu g�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
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name
Steven R Pannone
6. DSD SI NATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for
By:
The
(907) 272-8218
Date 6/5/2015
§levan. Niririorie
CE -8149.
JWbll
bedrooms, with the following stipulations:
klkltl^Utt^!trr
``\\\ P��w vt lIVC/ r„
` ON-SITE fi
a z WAl tK
t a WASTEWATER oz
PROGRAM
JI�,0
F�})SER� etc3\
A
Original Certificate Date: (e '? 2 "' 1
ici>-li tof orage 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
Septic System Advisory
Well Flow Advisory
COSA blue sheet C -- .t c
Nitrate Advisory
Arsenic Advisory
Other
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: Gillean, Lot 114B Parcel ID: 051-144-50
A. WELL DATA
Well type Private If A, B, or C provide PWSID #
Date completed 3/30/1984
Total depth 440 ft
Date of test
Static water level
Well production
Sanitary seal (Y/N)
Cased to 440 ft
FROM WELL LOG
3/30/1984
40
1.5
ft.
g.p.m.
WATER SAMPLE RESULTS:
Coliform e colonies/100 mL Nitrate N llbmg/L
Arsenic !J / f) ug/L Date of sample: 5/28/2015
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Tank size 1,500 gal. Number of Compartments 2
Foundation cleanout (YIN)
Date of pumping 6/1/2015
C. ABSORPTION FIELD DATA
Date installed 5/20/1984
Depression over tank (Y/N)
Pumper JR's Pumping
Well Log (Y/N)
Wires properly protected (Y/N) Y
Casing height (above ground) 12+
AT INSPECTION
5/28/2015
369
1.8
Collected by: PES
ft.
g.p.m.
in.
Date installed 5/20/1984
Cleanouts (Y/N)
High water alarm (Y/N) N
Soil rating (g.p.d./ft2 or ft/bdrm) 100 SFIBR System type Bed
Length 43 ft. Width 22 ft. Gravel below pipe 0'5 ft
Total depth 3.5 ft. Eff. absorption area '948 ft2 Monitoring tube Y Depression over field N-
5/28/2015 Pass 5
Date of adequacy test Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption field before test 0
Elapsed Time: 180mina Final fluid depth in. Absorption rate >= 750+ g.p.d.
in. Water added 7S6 gal. New depth 1 in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No 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 leval.at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 100+
Absorption field on lot 100+
Public sewer main 75+
Sewer /septic service line 25+
Animal containment areas 50+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+
Water main 10+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+
Water Service line 10+
Curtain drain 50+
On adjacent lots 100#.
On adjacent lots 100+
Public sewer manhole/cleanout
Holding tank 100+
100+
Manure/animal excrete storage areas 100+
Property line 5+
Water service line '10+
Building foundation 10+
Surface water 100+
Wells on adjacent lots 100+
Absorption field 5+
Surface water 100+
Water mai10
n+
Driveway, parking/vehicle storage 10+
F. COMMENTS
1,140 Gallon water storage bladder in crawlspace.
Survey as -built on file.
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 thiszlate.
Engineer's Printed Name Steven R. Pannone
Date 6/5/2015
COSA canary sheet 2.6-15.doc
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. # US 1 0-14 —5-6 HAA # 0Q(71-1 t' » n
1. GENERAL INFORMATION
Complete legal description
Lot 1148; G -i J can Subdvi Lon
Location (site address or directions)
20214Se.(14e6
Chug;ial2 AK
Property owner Shaun & Pa ttee. Hac.Pahan C/O RFSS Day phone
Mailing address 8200 Humbo.dt Ave S. Suite 204 Minneapot . MN 55431
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup. _
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
2
XXX
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 (Rev. 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
Address
Engineer's signature
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Phone 6 q'/— 7 9
144/2
6. DHHS SIGNATURE
Approved for 2 bedrooms.
Disapproved.
Conditional approval for
Date / /6 // 7
. la z a
� . l � •.;'i � dr
°s/' ss sc •sir .e{.�yr�
ROBERT C. COWAN t
4 c \ CE -8£01
.v
V .-r
.4v
N
bedrooms, with the following stipulations:
Additional Comments
CAUTION
Date/2g-77
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 engirieer 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. 1/91) Back MOA #21
MUNtoirALITY Or d- iNt.rtuo'
LNVIUONMENTAL SERVICES DiVi 'ON
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES JAN 07 1° 1, 4
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 3444L4
Health Authority Approval Checklist 1 `'
Legal Description: Lr) r ti`k 6 &n t-� %prA +3 Parcel I.D.: 06 - `� -
A. WELL DATA
Well type €e\lcc-C' If A, B, or C, attach ADEC letter. ADEC water system number
-27 o Zs ti
Log present OTN) \I
aiW
Total depth
Date completed
.` �k
Cased to IJ Casing height (above ground) 1
Sanitary seal ON) \.j Wires properly protected&N)
FROM WELL LOG AT INSPECTION
Date of test
Static water level v�
Well production (7 E 0 'f to, C'
WATER SAMPLE RESULTS: 140 (.p -Lf
Coliform C.) Nitrate 0 , \ 0 Other bacteria i
Date of sample: '°)(-1 I2,-3' "fit° Collected by:
B. SEPTI/HOLDING TANK DATA
Date installed `- Li Tank size Number of Compartments Z- Cleanouts N) ti
5 & S ENGINEERING
agle Rlver Loop Road No. 204
Eagle River, Alaska 99577
Foundation cleanout (a�l N) Y
Depression (Y/,(g) r High water alarm (Y/N)
Date of Pumping - Pumper s-, `P,S rltQ 1 i./
C. ABSORPTION FIELD DATA 1
Date installed ';--9-o —if4 Soil rating (g.p.d./ft2 or ft2/bdrm) k. 1312 System type 3€._.n
Length A3 Width 22i Gravel thickness below pipe b,.3 Total depth 6.Ss
Effective absorption area 92/-/, Monitoring Tube present QN) y Depression over field (Yid
Date of adequacy test 7- IJ - q & Results as ail) / `� For 4 bedrooms
Fluid depth in absorption field before test (in.); 0 W Immediately after /CO®gal. water added (in.):
o J -Y
Fluid depth (ins) Minutes later: / 7� Absorption rate = %i g.p.d.
Peroxide treatment (past 12 months) (WV /`-)-)A.),6 (L-A4).--)/111yes, give date ,94
72-026 (Rev. 3/96)* ,_ coL7, ..y %3 j c 2 44-. p/a L�/iot
11
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N) "Pump on" level at* p-eff"Hevet-Nr* —
High water
�'
teelalarm level at* *Datum
C,yel s tem sP
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Se tic holding tank on lot 1 ' 0
`A-- On adjacent lots 1 ov \'-
Absorption field on lot 1D D `� On adjacent lots 1 Oa ty
Public sewer main '> I h Public sewer manhole/cleanout 1 /31 A
Sewer /septic service line 2� 1 { Lift station `►�
SEPARATION DISTANCES FROM4EPTIQ'HOLDING TANK ON LOT TO:
Foundation I 0 k Property line 1 v 1 Absorption field S
\-
Water main/service line 10 Surface water/drainage 1,0 A * Wells on adjacent lots l oo, t
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line 1a Building foundation \ o Water main/service line 1O \
Surface water l ll C�\ Driveway, parking/vehicle storage area ' D �'
Curtain drain
N ° atz, i�iJo�vr�
F. ENGINEER'S CERTIFICATION
Wells on adjacent lots /
I certify that 1 have determined thru field inspections and review of Municipal reco Oa�tthe re's Mems are
in conformance wi h MOA HAA gtyidelines in effect on this date. �,� c� , ti i
Signature G°✓
�'
ii,
-i "9 ROBERT C. COWAi•1= a tc, 1
Date //47 �i % dOB�OA,. CE - 8E01 . �, I/
Ate
HAAFee$3 " (--TZ)
Date of Payment E} / /n % / 7
Receipt Number
72-026 (Rev. 3/96)*
7 il/z/95-
Waiver Fee $
Date of Payment
Receipt Number
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. # - 1 l-1 \ -
HAA # P`Tml'i--l1nlr)
1. GENERAL INFORMATION
Complete legal description
Lot 114B; G,�t.�ean SUbdAlvizion;
Location (site address or directions) 20214 She{ ;es Scee
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Shaun P. Hoo&ahan g Laura L.
P.U.Pox 671402 Chugiaiz, Afz. 99567
Day ohone 680-4968
Wz #263-4238
LiN0,4 _53-0700
Cita Mok.tgage ATTN: -146141:"^ Day phone
Anchorage, A2a612a
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY:
Individual well XX
Community well
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
Holding tank
Community on-site
Public sewer
XX
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system. .
72-025 (Rev. 1/91) Front MOA 921
b. bTATEMENT OF INSPEf ",'ON 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
Address
Engineer's signature
17034 Eagle River Loop Road Nei, 204
Phone
Date
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
B
Additional Comments
Phe 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. 1/91) Back MOA n21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: 1-o1- X14 % /01►t,L-E41-4 AP Parcel I D
A. WELL DATA
Well type P0-+`/D��
Log present'N) f
Total depth 44.0`
Sanitary seal (ON)
If A, B, or C, attach ADEC letter. ADEC water system number �!A
Date completed 3"30 - Driller F.1,1>c -k'FA- I✓'1 ✓
Cased to
Casing height
Wires properly protected 4 /N)
1
1.72.14-
FROM WELL LOG AT INSPECTION
55 c
Date of test 3 ' ,g 4 1 - 7-5---`%2- 7Z7 o z
rn
-55
Static water level v�- '2-21� i1 c. m
Well flow cid //e'' (a i- tiip `c491- ka3110 d-3Tmc.,4 nm
•
O
1 < C D
Pump level U� �77'L '-1 1 1 N y"
® O O
G D
SEPARATION DISTANCES FROM WELL TO: "m
O
Septic/holding tank on lot I, nim t ; On adjacent lots Nom‘"" Z
Absorption field on lot 1 C70"k" ; On adjacent lots tifl014-
Public sewer main ��� Public sewer manhole/cleanout `ps.
Sewer service line 2-- t d- Petroleum tank `25 k'�
WATER SAMPLE RESULTS:
Coliform
Date of sample: 1-2-61 -612.-
•
Nitrate 4.D. Other bacteria n�fl aE
B. SEPTIC/HOLDING TANK DATA
Date installed ��?"-D "84 Tank size 1'7 £ Pte- Compartments 2
Cleanouts ON) Foundation cleanout (9/N) y Depressionn (Y/�j
High water alarm (Y,4 Alarm tested (Y(�'j
Date of pumping 11 -°t Pumper ?g--
Collected by
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 1-c, c>On adjacent lots db 1
To property line 1 b jr
Absorption field
sI
Surface water/drainage 1 r» ‘4
72-026 (Rev. 7/91) Front
Foundation log}
Water main/service line
/e2/j// 9/4/$ $ l�
Aeer/A407n<f
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Acces
Vent (Y/N) "Pump on" level at "Pump off" level at
High water alarm level Cycles tested
Meets MOA electrical cod /N)
SEPARATIO
(STANCE FROM LIFT STATION TO:
on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed '- 2-0 84
Length
Soil rating
tyo System type
Width 22-1 Gravel thickness c). Total depth 4-, C
Total absorption area l41J9k1 Cleanouts present
Depression over field (Y6 4
Result /fail) rAeSS
Date of adequacy test l I - 1
for 65) bedrooms
Peroxidetreatment(past 12 months) (Y/.45'4 /(”A -10G.-1 •1 If yes, give date ''7i -
OD (d k -CZ v t:S71 (2, A 2 (3 . %<P�'1ZacV-L-
SEPARA I N DISTANCE FROM ABSORPTION FIELD TO:
Well on lot l C>t> t
To building foundation
)tit
On adjacent lots
1bo t
Property line jn1-I-
To existing or abandoned system on lot
I�
On adjacent lots 3 o Cutbank Ila.- Water main/service line 1 o1-\--
Surface water t Driveway, parking/vehicle storage area `� a
Curtain drain r -L I Dr
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
V
S & 5 ENGINEERING 4,� 'e,e' " ,/ y,` D
17034 Eagle River Loop Road-No.204 ,�a'° { ? „,z'
Signature Eagle River, Alaska 91S/7,0 to �'9v �0 r o�y_j
Engineer's NameL.
�� .aeG°ar 4Je °ye
Date
HAA Fee $
Date of Payment f/ ' Date of Payment
Receipt Number t 4 / I(530 Receipt Number
72-026 (Rev. 3/911 Back MOA 21
tt;4,4,'41 4J`' 60 on yyU °e.l;0,
S' �flf' L'a StQr,.
2
Waiver Fee• $
Attachment
Health Authority Approval
#HA920066
February 5, 1992
During a recent Health Authority Approval on-site inspection of
the well and septic system on Lot 114B Gillean Subdivision, the
well flow test showed the well's productivity of 0.30 gallons
per minute. The minimum well productivity required by this
department to satisfy the requirements of Municipal Codes (AMC
15.55) and Health Authority Approval guidelines, is 150 gallons
per day per bedroom. This equates to 0.1042 gallons per minute
per bedroom or 0.21 gallons per minute for a two (2) bedroom
residence. The recently determined productivity of 0.30 gallons
per minute marginally satisfies this requirement. The
financing entity and prospective buyers should be made aware of
the marginal productivity of the well, and recognize the
probability of an inadequate water supply during certain times
of the year.
There are measures which can be taken to minimize the adverse
impact of the low well productivity, such as:
1. A water storage tank serving as a supplemental reserve
reservoir.
2. Curtailment of non-critical water uses (washing cars,
lawn and garden watering, etc.).
3. Installation of water saving devices on showers and
toilets.
4. Restricted or controlled use of laundry facilities and
dishwashers.
5. Self imposed water conservation practices.
6. Connect the new well into the existing water collection
and storage facilities for the old well.
While the subject well meets the minimum MOA requirements, the
comments herein contained should be attached to the Health
Authority Apprevalrtification and all copies thereof.
Robert W. Robinson
Civil Engineer
On-site Services
ljm:398 2/05/92
5 & 5 ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
n7 =20
1/16
�.4 clew\
Vv
-•- �^ t1
- :�
1 •moo
Sba l__
e ��
veAtiA u-)/ s
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
Application Date34UC,-
1. General Information
(a) Legal Descriptions (include lot, block, subdivision, section,)Al/(A)
township,/range)
/
c -c-> [, J -%-1 .5
Location (address or directions)
(b) Applicants Name ,5 /4 lf// 40C,a4ephone — Home ` Business
Applicants Address /3t W,
(c) Applicant is (check one) Lending Institution ; Owner/builder
Buyer ; Other [f (explain);
(d) Lending Institution /40/V /i446- S - L_- T,qA(Telephone
Address
(e) Real Estate Co. & Agent
,4- 9 ci C
Address
Telephone
(f) Mail the HAA to the following address:
2. Type of Residence
Single—Family iv Multi—Family
Number of Bedrooms _
3. Water Supply-
Ind'vidual Well
Other (describe)
Community Publics l
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
Onsite
Public Ti Community Holding Tank El
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]
S. Engineering Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein. I further verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
sem
Name of Firm. 6-(/ e _ � mJc—
Address /,7 )L I) L-kU/()) 4
Date I21 4-L%(
6. DHEP Approval
Approved for bedrooms By
Approvedv ) Disapproved
(ENGINEER SEAL)
Telephone C/9 6-.S 6
c.
*e1C�/terC' l�`32;�___
oo00oocoUo�U CN (�/V
0
0000F. • �•r'
0
Pyr
®„ 00 ' .000O000000
0 THOMAS R. SMITH
2248-E
91 000000
Conditional
Terms of Conditional Approval
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 IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
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A. WELL DATA
JNICIPALITY OF ANCHORAGE
Iy DEPT. Of HEALTH &
MUNICIPALITY OF ANCHORAGE (MOH,-
PROTECTION
HEALTH AUTHORITY APPROVAL (HAA) AUG 1 5 1g84
CHECKLIST - FEBRUARY 1984
RE_ IV
Legal Description: 7 /" SEC_ Ci
/ 4--.4A/ SUS (1,S1(,6'd 1\4 '6.)
Well Classification //11 /b)/vff-L- If A, B, or C, D.E.C. Approv/
ed(Y/N) /VA -
Well Log Present (Y/N) V/ S Date Completed 3-3o- 2f Yield 5-,945:P/4
Total Depth 44 0/ Cased to 440 / Depth of Grouting A /4
Static Water Level 1-0 / Pump Set At 466 /
Casing Height Above Ground /10 / Sanitary Seal on Casing (Y/N)YCS
Electrical Wiring in Conduit (Y/N) V S Depression Around Wbllhead (Y/N)/UCD
Separation Distances frau Well:
To Septic/Holding Tank on Lot /0 7 ; Cr: Adjoining Lots /1)0
To Nearest Edge of Absorption Field on Lot //5 ; On Adjoining Lots >7 Or /
To Nearest Public Sewer Line 41/4 To Nearest Public Sewer
Cleancut/Manhole �/// To Nearest Sewer Service Line on Lot A;74
Water Sample Collected By C, ki_(ck- ; Date /j/_ -C Ac el
r
Water Sample Test Results 54 7 15 ,C,4c- 0/2 v f
Camnents, 4_771"C -/L2) Wc-'l-L 4_06- () 1'ii LL- C45«4 C 1 (AaOI-L=
eiq /I I2 e::: A -G 7_ anhole 6.24 )/AK, -/ V 7 '/..- r/ rr),;"/c /0Q ' 0 To `e777--;',9-11)
4/EEL3s�iz`/ /'S/ C461/V6 7//CE-/T,
B. SEPTIC/HOLDING TANK DATA
Date Installed 00784 Size /z7)( (-A-C_ No. of Compartments 7
Standpipes (Y/N) y1 Air -tight Caps (Y/N) Y/ Foundation Cleanout (Y/N) "/c--5
Depression over Tank (Y/N) ,) C Date Last Pumped /X7,71 S7S 72l
Pumping/Maintenance Contract on File (Y/N)Ai/4 ; for ,r
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply 4eii /i 7- " To Building Foundation /
To Property Line
-z.
To Water Main/Service Line
Course '/�
AI/4
To Disposal Field ,moi
To Stream, Pond, Lake, or Major Drainage
Convents 4774 c& -&-A
4-s -{3U/c /
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C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 5,17 o 0-
Width of Field Z2 �
Square Feet of Absorption Area
622
Type of System Design 867Z)
ngth of Field Z -f, 7 /
Depth of Field 4,,5
Depression over Field (Y/N) ,4Q Date
Results of Last Adequacy 'Ibst A)/A
ravel Bed Thickness G,
Standpipes Present (Y/N) yfTS
of Last Adequacy Test AI/,4
Separation Distance from Absorption Field:
To Water -Supply Well
To Building Foundation
Lot ii//4
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course A14
To Property Line
70
To Existing or Abandoned System
On Adjoining Lots >/ OD r
rn
N S To Cutbank(if present)/ -//4
To Driveway, Parking Area, or Vehicle Storage Area >700
Commentsz
D. LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles erring Adequacy
Electrical Codes(Y/N)
Comments
Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed6"Date / (cl/
Company ,c( S'C}%'/iva k S /-4)C MOA No. % 4 )O
KB1/d5/s
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