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BOREALIS LT 2
Borealis Lot 2 #015-203-12 r Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program, 4700 S. Bragaw SL P.O. Box 196650 Anchorage, AK 99519.6650 Page of www.cd.anchorage.akus (907) 343.7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number. S\V Ol O y-13 PID Number. D 15 —..03 — 1'1- Nam, u -e f 1 Wastewater System: []New upgrade .aaess, 4Q1pl,ie, Or -e e- ABSORPTION FIELD Pnaw. Nunder M Betroama O Deep Trervn O W.H. T..h O Bed 13 MnaM 0 DOW. SW paaq TOW Depet tram "nal weft: LEGAL DESCRIPTION P F Blas, L' _ SubdiMsin: � Depth to pip, balOm than Ong-111-111w.ft: Gravel depth berweh Pipe: ] B La I Q BID, FI. FI TowtNiP: Ra^W: Swim Fd added a drivel weft: Gravel L&Vh: FI. FI. Gmel reran Number of arta: Dwlance DehvaSn IMS: Well: ❑ New ❑ upgrade FI. FI Cwsrrraecn (Prwale. A B. CF Taal Depen: Cased W: Taal abaapeat area Ppm Matenal'. FI. FI FF order Data Ddea Stswwatar Laver: telader0010 A+ MWled: ^./ —01 F1 Y,old Panp Sat Casaq HepM +Gran¢ TANK GPM FI. FL SEPARATION DISTANCES b(Septic ❑ Holding ❑ S.T.E.P. ❑ Other. To Septic Absorption LIR Holding PubbrlPrivat Mereaacarar: l capautr: ICOOGW. Fran Tank Field Station Tank Sever nnG�ror a.a,.b; wan �K, % y OC I Malone: 11 SttG Number of COmprulwMs: o� LIFT STATION swra�.weler >I0•o $ue. ManulaMew. La LM Gel 'Pwrp ai eve w. -Pure Or Muer al. Hph weer earrrl n Foutdelon 6 O n. N M. N I N PWMarta 6 Model Punt,V aed by tral tupete, pMm EwcbM CC~ Drain Rar^ad`• BENCH MARK 1 Cit -d./4 t. �a.�Sl�c.tO q Uuv-iii,44a, Laaacn and Desdrpeac l h - NSwnM Ewvaaon. Y • FL tCC Engineer's Stamp 01 .CI �LJ „asp.. R. Inspections performed by: S Dates: 1" tt' %7-� t i''`' ^' '........ v.• ma ` ......r Development Services Department Approval �S, M,'. Tp -+•m Reviewed and approved by: Date: ZZ - I q -o1 `@��.� •ae,•• °��� �•�,: I� ALPHA CIRCLE f RPLACED 1000 GAL S.T I B O AD c- 971 ENLH MARK 92. 2.0B I I1000 O.LL. Sant TAW I I S I I I 1 LAC 9 FT C 21 FT LOT 3D 19 FT LOTI D 19 FT — — COMMUNITY WATER SYSTEM TW 4 U I S <c I � I LOT 3L — — La TALUS DRIVE 25 0 25 50 75 100 125 150 SCALEr 1' = 50 FT. TOBBEN SPURKLAND P.E.I I BOREALIS SID LOT 2 I I SEPTIC SYSTEM AS BUILT 203 W 15TH. AVENUE DATE.• DEC. 10, 2001 ANCH. AK. 99501 PAUL MEDIA SHEET 2/3 CRID:2736 (907) 279-3916 4920 ALPHA CIRCLE PERMIT 0 SVOI0473 PID # 015-203-12 BOR00022BV6 S II.27-Of @ IA:0% MUNICIPALITY OF ANCHORAGE Development Services Department Ort -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ONSITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Nov 26, 2001 Expiration Date: Nov 26, 2002 Permit Number: SWO10473 Parcel ID: 015-203-12 Legal Description: BOREALIS LT 2 Design Engineer. 0007 Tobben Spurkland, PE Site Address: 004920 ALPHA CIR Owner Name: PAUL MEDIA Lot Size: 16800 SO. FT. Owner Address: 4920 ALPHA CIR Total Bedrooms: 3 Permit Bedrooms: 3 ANCHORAGE, AK 99516-2252 This permit is for the construction of. ❑ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction must be In accordance with: _. 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). ( Not required for a Water Supply Permit only). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either. A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: 1 Issued By: Date: 11— Zb -- O 1 I � r w , Date: 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.ci.anchorage.ak.us (907)343-7904 ON-SITE SEWERMELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcell.D. Property Mailing address 0 A0� Permit Number SWO/O¢ 7 3 Day phone *bY�- og�3 _ Mailing address (2) Zip Code Legal description (Lot, Block & Sub'd.) Legal description (Section, Township & Range) Lot Size 16 Sao Acre q.Ft Number of Bedrooms THIS APPLICATION IS FOR: ❑ Sewer Only ❑ Well Only ❑ Sewer and Well ❑ Water Storage Sewer Upgrade THIS PROPERTY CONTAINS: ❑ Hot Tub ❑ ❑ Jacuzzi Water Softening Unit ❑ Swimming Pool Therapy Pool ❑ I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of properly owner or Permit Fees: agent) d Waiver Fees: Dale of Payment: 16tol0/ Date of Payment: Receipt Number: Receipt Number: (Rev. 12100) T.SPURKLAND P.E. 203 WEST 15TI I. AVENUI: SUITE 203 ANCI IORAGE, ALASKA 99501 (907)279-3916 Fax (907) 276-6013 Municipality of Anchorage November 26, 2001 Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage AK. 995169-6650 Subject: Septic System Upgrade Lot 2 Borealis S/D PID 015-203-12 Gentlemen; We request a permit to replace the existing 1000 gal. septic tank for this lot. The tank collapsed during pumping on Friday. The replacement of this tank will not have any additional adverse effect on the adjoining properties. Drainage patterns will not be changed by this replacement. There are no wells within 100 feet of the tank. The replacement of this tank will not prevent any future installations or up -grades of the septic systems and /or wells on the adjacent lots. Yours truly, li Tobben purkland P.E. ALPHA CIRCLE O R REFI E 100p CAL S T. 1 � 1 - LOT 3 COMMUNITY WATER SYSTEM LOTI- - TNA US .P4/' ' .P ' </lc I � I -- LOT3-- LO TALUS DRIVE 25 0 25 50 75 /00 125 150 SCAL£I I' = 50 FT. ITOBB£N SPURKLAND P.E. I I BOREALIS S/D LOT 2 I I SEPTIC SYSTEM DESIGN 203 W 15TH. AVENUE DATE: NOV. 26, 2001 ANCH. AK. 99501 PAUL MEDIA SHEET ?/3 GR/D:2736 IAn• l n1n :nuc /09/1 AIDIIA /'lD/HC I PERMIT Il SVOIOXXX PID O XX BOR00022.DV6 -Io knee. olio) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 82.5 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE ❑NEW _ HC.r4.. A 1 � _ Uv kAIT'k /� `, Arles. A TA 7 L_o Int ;RADE MAILING ADD ESS -5 9- C2 I " C " S-r P - " E>b LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS �/ 9 7 oG C) x/ f✓IieC � DISTANCE TO: Well Absorption area Dwelling PERMIT NO. UY n~ 22 Manufacturer Material No. of compartments wF Liq. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth z DISTANCE TO: Well Dwelling PERMIT NO. = z Fa Manufacturer Material Liquid capacity in gallons -i= W DISTANCE TO: Well Foundation Nearest lot line O PERMIT NO. 8� _03a'6 J LL Z No. of lines Length of each line Total len th of lines Trench width Distance between lines I- Z ;2C)n inches 1. Top of tile to finish grade Material beneath tile Total effective absorption area Length Width Depth PERMIT NO. LU C7 oQ a w Type of crib Crib diameter Crib depth Total effective absorption area LU � DISTANCE TO: Well Building foundation Nearest lot line Class Depth Driller Distance to lot line PERMIT NO. J W Z' DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS A57M D 0 f er SOIL TEST RATING 3 9 INSTALLER 44v5 ff REMARKS Io o K ,• ••••••n �xueeee•e• 4� o. 2225-L APPROVED DATE LEGAL Lor �t B0121_AL-IS q'h4 -Io knee. olio) M ILJ 1`14 1 1 F"" #-'4 [.-,, 1 -11--V' (:3 #=' CA P4 C, " (:] FR lf=� C-4 E." : � DEPARTMENT F HEALTH AND ENVIRONMENTAL ]TECTI ON ���t0�, 825 u STREET, ANCHORAGE, AK 995o1 v 264-4720 ` CJ t%4 1 1- $_ F.*,.- FE F:;t P""FL f=z P1 I -ir 850326 06/19/85 ' ` % JACK WHITE CO. BARBARA TAYLOR _�__ _ ______ _..___ .__ / v PERMIT NO: 850326 DATE ISSUED: 06/19/85 ` APPLICANT: % JACK WHITE CO. BARBARA TAYLOR ADDRESS: 3100 C STREET, SUITE 100 . ANCHORAGE, AK 99503 CONTACT PHONE: 563-5500 LEGAL DESCRIP: SUBDIVISION: BOREALIS SECTION: 22 TOWNSHIP: 12N LOT SIZE: 30000 (SQ.FT, OR ACRES) MAX BEDROOMS: 3 � LOT: 2 BLOCK: 0 RANGE: 3W Listed below are the options ** available to you in designing your septic system. Choose the option that best {its your site. . __________________________ ' -rF:�c EE mc�K-� . E�EEY3 W ~ nF:^oo ][ UNJ DEPTH TO PIPE BOTTOM (FT.) 4.0 4.0 4.0 GRAVEL DEPTH (FT.) 8.0 0.5 3.5 TOTAL DEPTH (FT.) 12.0 4.5 7.5 GRAVEL WIDTH (FT.) 2.5 26.0 5.0 GRAVEL LENGTH (FT.) 66°0 50.0 113.0 ** GRAVEL VOLUME (CU.YDS.) 52.0 48.2 83.8 TANK SIZE (GALS) 1,000.0 ** 1,000.0 ** 1,Coo. 0 ** SOIL RATING (SQ.FT./BR) 349 284 349 GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS ______-_________________________________ I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) 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 all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system o'r public ' sewerage system on this or any adjacent or nearby lot. 4. I understand that this permit is valid for a maximum of 3 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 ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTG WILL NOT -BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED DATE: _______________ __-.__ ����������_ ____________ �_APPLICANT: JACK AITE CO. BARBAR TAYLOR ISSUED BY DATE: MUNICIPALITY OF ANCHORAGE 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 PHONE ® NEW Warren Sanders 277-8353 ❑ UPGRADE MAILING ADDRESS 1100 W. 53rd Anchorage, AK 99504 LEGAL DESCRIPTION Lot 2 Borealis Subdivision LOCATION NO. OF BEDROOMS Alpha Circle 3 Well Off• Absorption area Dwelling PERMIT NO. 2x DISTANCE TO: 1Water 91 15' 780507 Man ke al No. No. of�ompartments w< Greer y Liq. capacity in gallons 1000 IF HOMEMADE: Inside length Width Liquid depth D Y DISTANCE TO: Well Dwelling PERMIT NO. Jaz Z Liquid in = F Manufacturer Material capacity gallons W.11 O Foundat3n t Nearest Inline PERMIT NO. W = DISTANCE TO: Water 1 No. of lines Total Ienfgth of lines Trench width Distance between lines LL Z Length of each line P Z W 1 ---- 47 60 inches ------ F Top to finish Material beneath tile Total effective absorption area of tile grade p r 84 • inches 658 Sq. Ft. Length Width Depth PERMIT NO. W U H Type of crib Crib diameter Crib depth Total effective absorption area IL Wa W y Well Building foundation Nearest lot line DISTANCE TO: J Class Depth Driller Distance to lot line PERMIT NO. J W Building foundation Sewer line Septic tank Absorption area(s) DISTANCE TO: OTHER ,0. PIPE MATERIALS Castiron & plastic perforated pipe SOIL TEST RATING 150 Sq. Ft. Rer bedroom ' INSTALLER H&MExc atin . d. a REMARKS c a. `. 1 OOW9Otletll L& LL11 , R 1. �fr��0 �q u• �� 1� B V.L• �q td:° 51Yfk59 �ryp a.00. O O. 40 0000009000 • O 0 Neal A. Yjausam 4 No. 168b -E fi"`ir�l: APP ED DAT LEGAL 72-01n (Rev. 3/78) 1 / t�U r4 I��I F�n�I�� ��F= ����������� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 'L' STREET, ANCHORAGE, HK. 99501 264-4720 r -A l 'r U ��UL-JUF-*_ F=F::F;:"r-*l T -r PERMIT NO. ( 780507 ) APPLICANT UBRREN SANDERS. 1100 W. 53RD 99504 277 8]5] LOCATION LEGAL L2 BOREALIS 5/D LOT SIZE 16800 SQUARE FEET TYPE OF SOIL HBSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = ] SOIL RATING (5Q FT/BR)= 150 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: E'UF:l'-r"= jL "R L_ U r-4 C3 -r "= �NE. �Fr---* F-1 %-P U I_ Us Fzl' -r 15t THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH 15 THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). Fe U CZ! U I Fe U� ������ ����� ����= ���� �Fl����� PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. _r t4 k__l < f::" > I r4fE; F=* U 1 13 " "H. �F.C. U IR- E_= 1_1 1 F -C U F -..-O BACKFILLING, OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL/ OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F="U- F-l.'tl I -F F=-:: 4. F:I" I F;R! U E; C, U 0 U M E3 U F.." ��" ����� I CERTIFY THAT 1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ]: I UNDERSTAND THAT THE ON-SITE SEWjR,SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS. SIGNED: AvyVA ANT WARREN SANDERS ISSUED BY`��-)\\ ------DHTE- ��� ~-�- ^-ca'-- Y]. 2 SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST / 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: 1�C 1,&L41 r'&AP—RA A" T_/A-/Q ATE PERFORMED: 6 LEGAL DESCRIPTION: LOT �Z T� 0 YZ-� L✓ S DEPTH SLOPE SITE PLAN (FEET) dl�_CJA N� I I i 1 �l 2 3- _ � A- hl D �i S I I --T 4- 5 6 7 8 9- 10 11 12 13- 14- 15- 16- r 3141516 17 18 19 "477'N�224 2: E �- 20 COMMENTS WAS GROUND WATERS ENCOUNTERED? _�U_ L O P IF YES, AT WHAT E DEPTH? Reading Date Gross Time Net Time Depth to Water Net Drop to 1 L 316 3. 5 qO 6- L/0 PERCOLATION RATE ! 0 (minutes/inch) TEST RUN BETWEEN FT AND '!� FT PERFORMED BY: CERTIFIED BY: V i DATE: i `d' 2, 72-008 (6/79) .w.a..WaX1.xv:«,..s.wi..r+eu..ant..,...... .»., .. ., .:.-_ ., ,.4 ... ,..., ..n... «...,,....... .... ...,di .,.ow.,.......+ �onstwation "Ona test Is worth r thotiseed opl+e�o+rs' 2204 Cleveland Anchorage, Alaska 99503 Date Performed med For_Y� rr��1 `_�rc��cQr°, er_ 1 �escri nti on: Lot A _Bl ock______Subdi vi s i onPercolation Test/�� pis Form Reports Soils Lon eS Deoth Feet Soil Characteristics 4, ^--L , 6 8 --- Aroe v; 5%#x 0 r,4 a Q �;4%'Vd 11) --- 12 --- 1.8- '8....- 20— 20..-- Was Was ground Water Encountered?I�10 If Yesq At what Depth? Readinq i Date 1 Gross Time MMSd�� ��pr� r� M �" Net Time Depth to H2O I Net Dro Percolation Rate Minute pram Field Proposed Iota at an: Seenaae Pit Death of Inlet Depth o ottom Of Pik Or rent . CnmVENTS: lS�" t-� ry- �rc�/irbf�� / • .. i Data Certified Test Performed By �� gy: Date: x. — �"" . Development Services Department p p Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015-203-12-000 Expiration Date: 12/26/2023 Legal description BOREALIS LT 2 Site address 4920 ALPHA CIR Anchorage AK 99516 Current property owner(s) LOWE KIMBERLY K & MATTHEW J X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 9/26/2023 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 Absorption Field Advisory Nitrate Advisory Tank Age Advisory X Arsenic Advisory Other COSA Approval_June 2022 MtlJHMPHUT ll OF Development Services Department On -Site Water & Wastewater Section Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 015-203-12 Complete legal description BOREALIS LOT 2 Location (site address) 4920 ALPHA CIRCLE, ANCHORAGE, AK 99516 Current property owner(s) KIMBERLY & MATTHEW LOWE Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: ❑ Private Well ❑ 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 22 - 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 $ S C) Waiver Fee $ Date of Payment / �!� Z �' Z 3 Date of Payment COSA # ( 5C 3 2- Waiver # COSA Application.doc COSA Checklist.docx COSA Checklist Legal Description: BOREALIS LOT 2 Parcel ID: 015-203-12 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA - PUBLIC &/OR CLASS “A” WATER Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume NA 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 Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank 50” Date of pumping 9/11/2023 Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA E / W TRENCHES Which system tested (date installed) 6/21/1985 ALL standpipes present per record drawing Total measured depth from grade 11.4 ft (max) Measured depth to pipe invert from grade 6.5 ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes (MT) go to bottom of effective (ED). If not, state depth into effective 2.3’ / 6.1’ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) N If yes, enter date Adequacy test date 9/11/2023 Results Pass Fluid depth prior to test 15 / 25 in Water added 600 gal New fluid depth 27 / 48 in Elapsed time 1420 min Final fluid depth 13 / 21 in Absorption rate 450 gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) 96 in (MOA 8’ ED) Effective depth used 81 / 44 in (Missing ED + Final Fluid Depth) Effective depth (ED) remaining 15 / 52 in Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots, visual observations of perf pipe / sump & appears approximately 5.7’ of east trench & 1.9’ of west trench ED is missing. The shorter east trench appears to be operating in the upper levels & the 1978 trench MT was dry. COSA Checklist.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) - NA Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ 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 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 Surface Water > 100’ Yes if No ft 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 F. ENGINEER’S COMMENTS 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 9/15/2023 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 & 9/15/23 M UH C ° A UTV OF A IHC HOR A OCA DEVELOPMENT SERVICES DEPARTMENT 0,. 907-343-7904 On -Site Water and Wastewater Section Fax: 343-7997 www.muni.org/onsite Septic 'Tank Advisory Certificate of On -Site Systems Approval # OSC231362 Subdivision: Borealis Block: , Lot: 2 The septic tank for this property is 22 years old. The average life of an asphalt coated steel septic tank is 20 years. Typical replacement costs are $10,000 or more, not including engineering, surveying or MOA permitting fees. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. 0 N Lot 3 ALPHA CIRCLE — — -(I- — — 1 8.2'x8.2' SHED 10' UTILITY EASEMENTS Lot 3 Lot 2 Lot 1 MORTGAGE SURVEY _X_ SCALE _ 1�• —30'_ GRID _ SW _2736 Project No. 23-36361 ___ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone �``\ kenAlongsurve�qy.com �� NA, .kProfessional Land Surveyors jonathan®langsurvey.com oF. Ali� trovisOlangsurvey.com I hereby certify that I have surveyed the following described property: C#3.'• LOT 2, BOREALIS SUBDIVISION (PLAT No. 73-146) *; 49TH ••*�� Anchorage Recording District, Alaska, and that this Mortgage Location Survey Is a • • • • • • representation of the conditions that were found on the date the survey was performed. F I This survey does not constitute a boundary survey and is subject to any inaccuracies • • • • • • • • 0 that a subsequent boundary survey may disclose. The information contained hereon shall �/ • KENNETH G. LAN • , o not be used to establish any fence, structure, or other improvements. I{� c�� 0 15202 .' c� / I , 223 ��'Fp ��� �'L3 A Dated this the ______ Day of ��}���+ at Anchorage, Alaska p �p 1, fES5lOt1AL �. 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. State of Alaska AECC963 Municipality of Anchorage • Development Services Department Building Safety Division Onsite Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onshe ,(907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel LD. 015-203-12 • COSA #_ ffll��n 1. GENERAL INFORMATION Expiration Date: Complete legal description Borealis S/D Lot 2 Location (site address) 4920 Alpha Circle, Anchorage, AK 99516 Current Property Owner(s) Brad Debner 6 Shantell Media Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 18813 Highway 1, Keosauqua, IA 52565 Holly Murray / Northern Trust Real Estate Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage 11 Community Class A Well 21 Public Water System El Day phone Day phone Day phone 751-2688 TYPE OF WASTEWATER DISPOSAL: Individual On-site ✓� Individual Holding Tank Community On-site Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite 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 Onsite 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,cal on, based on procedures outlined in the Certificate of Onsite 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 -she 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 Watkins Engineering, Inc. Address P.O Box 11D443, Anchorage. AK 99511.0443 Phone 349-1851 Engineer's Printed Name Cindy W. Ellis, P.E. Date 2/22/07 S. DSD SIGNATURE _JC Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the foliowl Attachments: COSA Checklist x Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: �— 7 (R" 11m) Municipality of Anchorage ° Development Services Department Bulking Safety Division On.Ske Water& Wastewater Program 47W Bragaw Street P.O. Box 198850 Anchorage, AK 99519.8850 www.muni.orglonske (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Borealis SID Lot 2 Panel ID: 015.203.12 A. WELL DATA Web type A B A, B, or C provide PWSID # 210788 Wes Log (Y" Date Sanitary seal (YIN) _ Wires property protected (YIN) Total depth Cased to ft. Casing height (above ground) In. FROM G AT INSPECTION Date of test Static water level ft. ft. Web production g.p.m. 9.p.m. WATER SAMPLE RESULTS: Colkortn colonies/1W mL Nitrate mg1L Other badene colonleaH00 mL Arsenic: mgA Date of sample: _ Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Materlal steel septic tank Date installed 11/17/01 Tank sae 1000 gal. Number of Compartments ? Cleanouts (YIN) Y Foundation deanout (YIN) 1, Depression over tank (YIN) N High water alarm (YIN) NA Date of pumping 2120/07 Pumper Nortigand Pumping, Ino. C. ABSORPTION FIELD DATA Date installed 8/21185 Sok rating (g.p dJfe or ft=Ibdrm) 349 System type deep trench Length 20+45=W ft. Width 2.5 ft. Gravel below pipe 8.0 ft. Total depth 118 R Eft. absorption area 1058 Monitoring tube Y Depression over field N Date of adequacy test 2120107 Results (PasslFak) Pass For 3 bedrooms Fluid depth in absorpWn field before test 0 hr. Water added2476• gal. New depth 40 in. Elapsed Time: 120 min. Final fluid depth 30 in. Absorption rate x 450 g.p d. Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date D. LIFT STATION Data installed ,Size_ in== s Manhole/Access (VM) 'Pump on' level at —in. 'Pump ofP leve High water alarm level at in. Datum Cycles tested Meets alarm 6 araml requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on krt NA On adjacent kits Absorption field on krt-� On adjacent kits Public sewer main Sewer /septic service line Animal containment areas Public sewer menhole/cleanout Manurelanimai excrete itome areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10+ Property line 20+ Absorption field 10+ Water main 10+ Water service fine 10+ Surface water 100 + Wells on adjacent lots 100 +/200+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property tine 10+ Building foundation 20+ Water main 10+ Water Service fine 10+ Surface water 100• Driveway, paddngtvahide storage 40 Curtain drain NA Wella on adjacent lob 100 +/200+ F. COMMENTS: 'House has been vacant, so a presoak was conducted with the test. On 2/21, the field was dry. Tested the 1985 field. G. ENGINEER'S CERTIFICATION I car* that I he" detemnaMrough field mspedbns and 49i� ned review of Munk4lDal records that Me above systems are in conformance with MOA COSA guidelines In effect on this date. t Cin W. Eills Engineer s Printed Name Cindy W. EIAs, P.E. CE. ig677 f Data 2/22/07 9pq.LL COSA Fee E 430 Date of Payment 2 — a -�?-' rD % Receipt Number (Ray. 1105) Waiver Fee E Date of Payment Receipt Number a Municipality of Anchorage Development Services Department •'g= Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. OIS - ZO3 — f Z HAA# Expiration Date: l 0— S- O 6 1. GENERAL INFORMATION Complete legal description L.6 4, Z, 6erea1;'r s 1A Location (site address or directions) V9 W A/A7 ha Ce rrl Current Property owner(s) Paul /Ytol; et Day phone ? 1 S• 090 7 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address g92o /4_�9e. h 9,94- 1,< A• lui kr. jE64e Day phone pQ� /'lcarrr y Rcc„ liy fP ec- Day phone e V0 - M0,6' 391 /410T«rJc,� /dd t.�k �G3. A� c4a�T� �c99sr�3 Unless otherwise requested, HAA will be held by DSD for pickup. Pl ~&, e"11 o wn e-- ut ?'IS-oyO_? t0htn MAA a rraay fa/' - J7;ck -4w/2 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class _A Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site 0 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 andlor 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. 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 Health Authority 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. NameofFirm FlatL&g 7-LC,4A;CR/ SQf.,;-ei Phone 3vS'-�3rs Address 11S'30 Ec,4o Sl._. Anc4e:PnF , Ak 99s160' Engineer's Printed Name -A&-ce6,7 E. rrccole r3, Pgcu— '•1.1.•• irV•: �j I CIT ............. 5. DSD SIGNATURE • iY.E00pRE F, AfOORF �� f•` 3_IC Approved for bedrooms. r :..,.,••Ceu3se� • �` !; � •• Disapproved. _ rr,•�,.,;_.;,`•,�S Conditional approval for bedrooms, with the following stipulations:'" Additional Comments Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: Original Certificate Date: S O (Rev 01107( Municipality of Anchorage ° • '� Development Services Department Building Safety Division ° , • , I I On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST' Legal Description: i.o f 2, 8o r Na (it C lb Parcel ID: OPS - 2a 3 -12 A. WELL DATA Well type A" If A, B, or C provide PWSID # 2/07Ag� Well Log (YIN) Date completed _ Sanitary seal (YIN) _ Wires properly protected (YIN) 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 g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform colonies/100 ml. Nitrate Mg A. Other bacteria colonies/100 ml. Arsenic: _ mg /I. Date of sample: _ Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material 5-ge0e/'!c I S%«( Date installed Tank sizeUf au gal. Number of Compartments 2_ Cleanouts (YIN) Y Foundation cleanout (YIN) Y Depression over tank (YIN) N High water alarm (YIN) N. A, Date of pumping 9 /11 /OS Pumper A + C. ABSORPTION FIELD DATA Date installed 7/ Zir/7d Soil rating (g.p.d.W or fe/bdrm) Ija7 01 System type 7-rytcl Bd�^• Length y7 ft. Width S ft. Gravel below pipe 7 ft. Total depth 13. S ft. Elf. absorption area LS s ft= Monitoring lube ti Depression over field N Date of adequacy test /o/i2- r3/4A,S- Results (Pass/Fail) PA;9- For _: bedrooms Fluid depth in absorption field before test 1Y in. Water added8?08 gal. New depth/ in. Elapsed Time:L%$ min. Final fluid depth L2. / in. Absorption rate >= y6'6 g.p•d. Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date 11.A. NGTE; 7A;,f /Vt ". Of [on �Cr.e f ec/ on 16c o� i�..a ( tnnclr, T/•¢ jtrltc f+"Mch ur9►ao% tA&/ war Jkntp /7Bs j+r110"C a rectnl- ar/ uacyy /vt 1°y Conwin� Co /Ft /nJla/l�oC a n<w "/3uf/ Ryn'�GC�v, vo/vt / �t4fwn . 1'rCnC/!J dICO LCJ .n9 div D. LIFT STATION N. A. Date installed "Pump on" level at _ in. Datum E. SEPARATION DISTANCES Size in gallons Pump off" level at _ in. Cycles tested Manhole/Access (YIN) High water alarm level at Meets alarm 8 circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: V. A. Septic tank/lift station on lot On adjacent lots Absorption field on lot Public sewer main Sewer /septic service line On adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 7 S" F Property line S Absorption field 7 S—' Water main to Water service line > to Surface water tuo • Wells on adjacent lots > 100' ut!' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Is,,/ i Z' Building foundation > to' Water main > to Water Service line �> lo' Surface water > i4po' Driveway. parking/vehicle storage > to 1 Curtain drain _Nbnt Sten Wells on adjacent lots > ice' /'aoa• F. COMMENTS in. G. ENGINEER'S CERTIFICATION i p�'••,lu ; - n r' e 9TH I certify that 1 have determined through field inspections and i yr: •, • .. .... review of Municipal records that the above systems are in d conformance with MOA HAA guidelines in effect on this date. i:•„f;,,,�,,,� F nnpooa F. Al )ORE = rd Engineer's Printed Name TA c[a r1[ F. Mc, CZ -3582 Date Oc46Ser 13. ZOOS HAA Fee S H30=e Waiver Fee $ Date of Payment to / 19 / �/G.n^r Date of Payment Receipt Number Receipt Number (Rev. 12/01) 6VOL)q ►honYkav�ner u,� i�lzU1as .ea•ose •ram woos aax (.sero) •'.OHIO eWMa WxOI rcwc en+acT /91 - pHA CIA. nK•IT waa anal j T w wa,r cn+al N89' 15.1- 111-V /20.00' Y• 's • O a6 313 3 aj HOUSE' ,fig' fie, O 9 Sae tea. • 0 0 .9T I o A �t _ —0 10't!M FSS &jr N 89. 38' 3S "W /20.00' SURVEY CERTIFICATION p��ttla�e - Prepared by PLOT PLAN Robert E. Johns, Jr. & Assoc. 1 IrrY •.Ob M t r... Hw•IyY eMY•d •.,. w .•.err r r w r r... I••P'(� ....,,• •441, I(( -�- �# I -J� • •, �. Professional Land Surveyors 1700 BRINK DR r rs, ., ti .•.� « r e. erI r.Y I 0. ANCHORAGE. ALASKA 99504 Scale: 11I - 30 F Nec. Lot S.F. Rec. Plat FRO No. FOUNDATION AS 0 49t 0� •• •• ""/ i -BUILT Le L+weeA.e�•eYweyMl r«ari .. .... ••••••• ••• ... M Dote Sure d: 10 -17 -OS Drawn Dy. REJ CRecked by. r we w« M r w :.. ROBERT . JOH IS..I� � Date Drawn: 10-17-05 Grid: 2736 W.O. F X353 :.^ ..r..:..•..w•.u�r weA w... 9 :, e I ��or4121-5 FwasmucnraEAseuLr L er.l L a« Jr. e.rY e�IKY M I ;•'*er �� a ••'•.. ,.•' SJ4 ei, "M,44 Legal Description: LOT ��°"'°^° ����'' 1L�uI� Borealis Subdivision ❑ LOT amvEY SURVEY TYPEB ❑ SYM[ OLS FOUNDATION AS -STRUCTURE ❑ FINAL# AST Rc A5-Bue.T wo eo —1 a SET MAR DRAINAGE ASPHALT --OT LAN .. O R.AT PIAN ... AS-aM.T ... LOT a1RKT ... TOPOpMPHY , o���� FOUND AR 4D ~ WOOD FENCE "� CONCRETE S- I T NO A � METAL FENCE173 •l"J ASSUMED ELEV.69 PLOT PLANS k LOT SURVEYS NOTE; IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO CONSTRUCTION. TO VERIFY PROPOSED BUILDING GRADE RELATIVE ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS. DRIVEWAYS, ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS "ICH DO NOT APPEAR ON THE RECORDED ONLY. SNOW MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. SUBDIVISION PLAT. ALL DISTANCIFS ARF Rrr P IN- F UNDER NO CIRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES. THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL LIASIUTY ONLY FOR THE COST OF THE SURVEY. LISTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE. on -Site Services Section P.O. Box 196650 Anchorage, .Alaska 99519-6650 343-4744 72-025 (Rev. 1/81) Front MOA 821 Conditional approval for ' bedrooms, with the following ,.stipulations [ice - �Y 3y b nal' tomments t £ Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L.C2T a, lc c>tks A1.1 S, Parcel I.D. Q 16 — .1.0 — 12. A. Well Data Well type I/ /'"+C 61 If A, B, or C, attach ADEC letter. ADEC water system number j/ ® 7 (6Z:, Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump levell Date completed Cased to FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Driller Casing height _Wires properly protected (Y/N) o z i"' r AT INSPECTION 5,! Ln O -n p m A Z i7 n G" g.p.m. g.p.m. V G" O m Z Septic/holding tank on lot > A0 -a> ; On adjacent lots Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed � � 78 Tank size 10ro Compartments Cleanouts (Y/N) X Foundation cleanout (Y/N) Depression (Y/N) lklC High water alarm (Y/N) t//A Alarm tested (Y/N) 1 TZA Date of pumping t�y` Pumper A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: l Well(s) on lot Nl.4 On adjacent lots N/�4 Foundation 17 To property line so Absorption field 1 L% Water main/service line Surface water/drainage PJ 1 72-026(3/93)•Front CONTINUED ON BACK PAGE C. LIFT STATION NIA Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Surface water Date installed S � Soil rating (GPD/Ft2) 3 4 4 System type Length 10 Width .2 , b"" Gravel thickness '� �T•S Total depth I �. Total absorption area 1 15 & Cleanout present (Y/N) V Depression over field (Y/N) IW Date of adequacy test VS 0 q4!!� Results (pass/fail) POt !� for _Bedrooms it Water level in absorption field before test , After test I b �� r Peroxide treatment (past 12 months) (Y/N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot Nl", On adjacent lots N�/� Property line 10 To building foundation 02 11 To existing or abandoned system on lot 7 Z o On adjacent lots >'' !!sip Cutbank 0 v1 <,..- Water main/service line > . Surface water IWy v1 A- Driveway, parking/vehicle storage area > 20 Curtain drain NID E. ENGINEER'S CERTIFICATION 1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name I o 6 e v% 5 py f 61k VJ Date g131 HAA Fee $ C � ` CfD Date of Payment Receipt Number 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel 1. D. # ; 1� �E1 \ `� HAA #` 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 2: iia Location (address or directions) 4920 A.Lpha Ci4cte (b) Property owner HOMEQUITY/Leake -- Telephone: (home) Business Mailing Address HOMEQUITY NO: 2149-30003 (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent JACK WHITE COMPANY ATTN • $atban.a PyLken Telephone (e) Mail the HAA to the following address: (or check here MKif hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eagle Rinner Loop Road No. 204 Eagle River Alaska 99577 2. TYPE OF RESIDENCE Single-FamilyXX 3. WATER SUPPLY Individual Well ❑ Number of bedrooms 3 �' Community CKX 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-siteKk 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. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING iiaSPECTIONS, TESTS, FILE SEARCH, DH CA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th1'3 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 regulations in effect on the date of this inspection. Name of FirANG Telephone m X34 �ag1e River Loop ;Zoaa itiG. 204 Address Lag � 9577 Date d j ng , 9 h ac,� s �' 6. DHHS APPROVAL r Approved for _bedrooms by _ Date ' Approved Disapproved Conditional Terms of Conditional Approval .� .... /� . .. . ,lmFyq� +. The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 7/88) Back 'age 2 of 2 MUNI*EALTH A ~ALITY OF ANCHORAGE (MOA) � & Health Authority Approval (HAA) 1: V1 PROTECTIONECKLIST - FEBRUARY 1984 343-4744 = i'' 2 5 199th RECEIVED A. WELL DATA Legal Description: L-, t 2 Well Classification C- M_ 44. t ry I tA4 If A, B, C, D.E.C. Approved (Y/N) MUP.i1Cu'F Well Log Present (Y/N) Date Completed Yield Total Depth Cased to Depth of Grouting Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Septic/Holding Tank on Lot Zoo f ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot 2-00 t ; On Adjoining Lots To Nearest Public Sewer Line a.) o, To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ; Date Water Sample Test Results Comments p (,k) S 1 Z 11 `7 O C. A.C. h e (� �C AA0voA B. SEPTIC/HOLDING TA14K DATA � ?1,.i$ Date Installed 77 - Te Size - ( 0 0 No. of Compartments Standpipes (Y/N) 4—Air-tight Caps (Y/N) ! Foundation Cleanout (Y/N) Depression over Tank (Y/N) p,) Date Last Pumped Q — IEL- Pumping/Maintenance Contact on File (Y/N) 4)1A ; for N/A Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: r l s To Water -Supply Well To Building Foundation To Property Line �!`� + To Disposal Field To Water Main/Service Line to To Stream, Pond, Lake`1-f %to&_ S & U or Major Drainage Course 'k J n/Q&�- Comments �' AAP i c � 5 72-026 (Rev. 7/88) Front Page 1 Of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 3 Type of System Design LC Date Installed (p - Z / 5 Length of Field 70�,4 / (e,% Width of Field Z O f Depth of Field �- Gravel Bed Thickness F) Square Feet of Absortion Area / 0L2 Statndpipes Present (Y/N) M Depression over Field (Y/N) Results of Last Adequacy Test Date of Last Adequacy Test :Z- Z7-20 ,. — 7-2 Q --)I--- _. SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well CD t To Property Line lot To Building Foundation Z To Existing or Abandoned System on Lot r ; On Adjoining Lots '�o i - To Water Main/Service Line Io f To Cutback (if present) A-)/ 14 To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area 3d �+ 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 Dimensions Manhole/Access (Y/N) **Check Permitted Bedroom Rating Against HAA Request" I certify that I have checked, verified, or conformed to all inspectiog.& S ENGINEERING Signed 17034 Eagle River Loop Road No. 204 Eagle River, Alaska Company Date 2 -5� "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. MOA and HAA guidelines in effect on th o` "p date of this MOA No. C I- vo Receipt No. -�?�� -7 -7 Date of Payment -75-- ell Amount: $ �- a '2 ; t.,. F vj . I Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE WESTERN DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 FOR: S & S Engineering Attn: Ray STEVE COWPER, GOVERNOR October 12, 1990 PWSID: ;211708 563-6775 According to the records on file in this office, the Borealis Alpin Subdivision Water System is in compliance with the State of Alaska Drinking Water Regulations. Sincerely, Richard Sundet Environmental Specialist RS:bas MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 2 Borealis Location (address or directions) 4920 A1vha Circle (b) Applicant Name Cris Net son _ Telephone: Home 345-4668 Business 271-5701 Applicant Address 4920 Alpha Circle (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ® ; Buyer ❑ ; Other ❑ (explain); _ (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Jack White Barbara Taylor Address _3701 "C11 Telephone -1)0j-55UU (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single-Family)U Multi -Family ❑ Other Number of Bedrooms (3)Thrpe 3. WATER SUPPLY Individual Well ❑ Community ® Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite [3 Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) 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 regulations in effect on the date of this inspection. Name of Firm Address Date Telephone Engineer's Seal This office has received written confirmationfrom the Engineer (Tobben Spurkland, P.E.) that the conditions of June 15, 1985 have been met. Therefore, this propert meets MOA requirements. 6. DHEP APPROVAL Approved for _WThree_ bedrooms _ ate June 26, 1985 Approved XX Disapproved Terms of Conditional Approval Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations 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 requirements. 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. Page 2 of 2 72-025 (11/84) 1216' 5' - MUNICIPALITY MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE L 1. General Information Application Date 17le5 (a) Legal Description (include lot, block, subdivision, sectio , township, range) a o 1Ze-A LLC, s o c a 7'/aA , e:K Location (address or directions) --- t4420 AtvLa Ci 3q5-q6/oF!r 271-570 (b) Applicants Name Cris KI-C-6ma Telephone - Home Business Applicants Address 9t Z O Al, La v. el •.c,._ (c) Applicant is (check one) Lending Institution ; Owner/bakl4er-1_17t ; Buyer E::] ; Other [� (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent U4/ko-t Address C.� Telephone 's (o `j 6-57 6 © (f) Mail the HAA to the following address: 2. Type of Residence Single -Family Number of Bedrooms 3. Water Supply 90 aL Multi -Family 3 Other (describe) Individual Well M Community D�j Public M 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 I Community E::1 Holding Tank M 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] 5. 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. Name of Firm o �d.LLi/ �LGl�ir.� �� Telephone Address O� LI% Date ''ash (ENGINEER SEAL) d� * 49TH ' 6. DHEP A d o. 2 ?_ Approval Qr�, %� JUNE 25, 1971 01C70/77 � //� /77 /may /• 1 , eved for bedrooms By lL �,Z 1.�,.ucC`8� ;.,��ae.•.;�; - b'.� Approved Disapproved Conditional_ Terms of Conditional Approval�-L�L,�{ ''---- (j_AAA , ��- � uc . m �-� -max -� 0���-� 4j' (=L = ' /,Y-, 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] 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 A. WELL DATA Well Classification Co W r !tw— ✓ Well Log Present (Y/N) Total Depth Cased to MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MAY 71985 RECEIVED Legal Description: � 01;2, 90ag L(.S S EC- a 2 . T12 -M6 e � If A, B, or. C, D.E.C. Approved(Y/N) Date Completed Yield Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (YIN) Separation Distances from Well: To Septic/Holding Tank on Lot A u-eo On Adjoining Lots To Nearest Edge of Absorption Field on Lot ,tow ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected By Date Water Sample Test Results Ccmrents B. SEPTIC/HOLDING TANK DATA Date Installed q 78' Size d-a�eNo. of Compartments 2 Standpipes (YM) Air -tight Caps (Y/N) Foundation Cleanout (Y )� Depression over Tank (Y/N) Date Last PumpedApr,'( � � & S Pumping/Maintenance Contract on File (YM) N for V—A Holding Tank High -Water Alarm (Y/N) VA- Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well ,26-0 fi To Building Foundation To Property Line I5 t To Disposal Field To Water Main/Service Line f" To Stream, Pond, Lake, or Major Drainage Course NO NE Comments Receipt # Date Paid: Amount: C(Do [ Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata %1 Type of System Design %k4e, Date Installed„Qti /gid' —Length of Field 7 Width of Field Depth of Field 3 Gravel Bed Thickness 7 Square Feet of Absorption Area to Standpipes Present (Y/N) 'y Depression over Field (Y/N) Date of Last Adequacy Test A�.� l l985 Results of Last Adequacy Test _�p j Separation Distance from Absorption Field: ,1 To Water -Supply 'Abll To Property Line To Building Foundation 30 To Existing or Abandoned System cn Lot No On Adjoining Lots To Water Main/Service Line To Cutbank (if present) NO t4 L=— To To Stream/Pond/Lake/or Major Drainage Course tic (Z To Driveway, Parking Area, or Vehicle Storage Area �2 Comments D. LIFT STATION a 0 0 C Date Installed Dimensions Size in Gallons "Pump' On" Level at High Water Alarm Level at Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes(Y/N) Comments ** Check Permitted Bedroan Rating Against HAA Request ** I certify that I have checked, verified, or, confornad to all MOA HAA Guidelines in effect on the date of this inspection / w.. . Tom.. lit. 5/ Or A/�Z� Signed Date ` Z �S ��ii..... �v 1r Company MOA No. ,..h. EN .. S •1 *: 44FH • A i > s .. . KB1/d5/s 2225-E I�+i JUNE 25, 1971 s k` [Page 2 of 21 _ Vi 2-15-84 CONSULTING ENGINEER 203 W. 15th AVE "C" SUITE 203 ANCHORAGE, ALASKA 99501 TELEPHONE: (907) 279-3916 MUNICIPALITY OF ANCHORAGE JUNE 24,1985 DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Re: Conditional Health Authority Approval, Lot 2, Borealis Subdivision. Madame; On May 7, 1985 a conditional approval was given for subject lot. The conditions for the approval have been met. The existing trench has been abandoned and a replacement trench installed per the attached As-Builts. Please furnish this office with an unconditioned approval. Yours HILL SHEFFIELD, GOVERNOR DEPT. OF ENVIRONMENTAL CONSERVATION Telephone: (907) Address: ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 274-2533 ANCHORAGE, ALASKA 99501 DATE: 2 2 44XX FS PWS 1 .D.# 2 10 7 f C To Whom it May Concern: According to records on file in this office the 1614 ro r, It t Orme. Water System is in compliance with the State Drinking Water Regulations Sincerely, �f 77�/ PQIQ Z ANCHORAGE, ALASKA 99501 CONSULTING ENGINEER TELEPHONE: (907) 279-3916 Barbara Taylor Jack White Company 3201 "C" Street Anchorage, Alaska 99501 Ref: Lot 2 Borealis Subdivision Dear Mrs. Taylor: We regret to inform you that the septic system on the above referenced lot did not pass adequacy due to surge load failure. After charging the system with 100 gallons of fresh water the sewerage level in the monitor tube was in danger of spilling over onto the ground. The system appears to absorb the quantity of effluent necessary to maintain a limited family usage, but fails based on surge load criteria. This can be due to blockage in the perforated leach pipe or blockage at the soil/gravel interface in the trench. The owner, Chris Nelson, will attempt to chemically remove the blockage at which time we can retest the system. Failing this a conditional permit can be issued based on the limited absorbtion rate available and funds escrowed to complete a new leach field at spring construction season. At that time a soils report and construction inspection will be required. If we can be of any further assistance please don't hesitate to call. Sincerely, wo. Tobben Spurkland, P.E. 40 � � G�] g�r��3G�3dG�GJD� Poco CONSULTING ENGINEER MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND SOCIAL SERVICES SUBJECT: LOT 2, BOREALIS SUBDIVISION CONDITIONAL APPROVAL OF SEPTIC SYSTEM. 203 W, 15th AVE "C' SUITE 203 ANCHORAGE, ALASKA 99501 TELEPHONE: (907) 279-3916 MAY 7, 1985 Gentlemen; On behalf of my client, Jack White Co, I request a -conditional approval of the septic system installed on Lot 2, Borealis Subdivision. As the attached report shows the existing system does not meet the absorption requirements of the Municipality, however it does meet the needs of the residents of the dwelling. When inspected and tested no overflow or other conditions posing an health hazard was observed. Funds has been put in an escrow to upgrade the system after breakup. Tobb Spurkland P.E. cc Jack White 5.GAL DESCRIPTION DATE RECEIVE INSPECTION APPOINTMENTS ry-, A . TIME TIME TIME DATE DATE DATE ❑ Two ❑ Five ❑ MULTIPLE FAMILY INSPECTOR INSPECTOR INSPECT ❑ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled COMMUNITY MUNICIPALITY OF- ANCHORAGE MUNICIPALITY OF ANCHORAGE I DEPT. OF ,"ACTH & DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECE MtONNMENTAL R„UTE-CTION 825 L Street - Anchorage, Alaska 99501 .� a N 10 1930 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 R E C E v E D REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER"F�ACI�I DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE MALLING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 22ga ,C 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION PHONE MAILING ADDRESS 4. REALTOR/AGENT PHONE MAILING ADDRESS 5.GAL DESCRIPTION dam" d�t �L« ,� s Jnl STREET LQCATION 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS P SINGLE FAMILY ❑ One E] Four F-1Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY Three ❑ Six 7. WATER SUPPLY ❑ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM XINDIVIDUAL/ON-SITE** Q �! YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER `l9ioik - DATE INSTALLER 41 W\ ❑Septic Tank or ❑ Holding Tank Size: 1 000 If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL T^ 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS PROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY 72-010 (Rev. 6/79)