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HomeMy WebLinkAboutROBINDALE LT 7Robindal Lot 7 #051-053-02 Municipality of Anchorage On -Site Water and Wastewater Section • (907) 343-7904 Page of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211042 PID Number: 051-053-02 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name A ORPTION FIELD Angelia Hamill ❑ D Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 4030 Rambler Rd Other Phone Number of Bedrooms Soil Rating JTotal depth from original grade 3 /SF FL LEGAL DESCRIPTION Depth to pipe invert from original a Gravel depth beneath pipe Ft. Subdivision Block Lot Robindale 7 Fill added above original grade Gr length Ft. Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Dist between lines Ft. SEPARATION DISTANCES To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between t hes From Tank Field I Lift Station Tank I Line Ft' Well 1001+ 1001+ TANK ❑ Septic ❑✓ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER Capacity 1000 Gal. Surface Water 1001+ 1001+ Material PLASTIC Number of compartments 2 Lot Line 55+ 51+ NA LIFT STATION Foundation 10'+*I 10'+* Manufacturer Orenco Capacity 250 Gal. Remarks *5'+ From the car port Alarm location Garage Electrical installed by Northern Excavation PIPE MATERIAL House to tank Tank to D3034 drainfield D1785 Installer Northern Excavation Drainfield CO/MT D3034 Inspector Arcterra Consulting BENCH MARK (Assumed elevation) 100 ft Inspection 1st Location and description dates: 4/2/21 2nd 4/2/21 3'd 4/3%21 41h SE Building roof courner ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp if Conditional Approval: Date �Pe�''""�""'"'�, �1lk s s 49TH O K f 7 KENNETH M. FFUS Q i Septic System Approve 1.�, '' Date r— fI�%+.� CE r jar+ Note: this approval does not include well permit requirements. •#144111111k E (Rev 05/02/18) AS -BUILT SYSTEM DETAILS/SITE PLAN PermitlEISP211042 ROBINDALE LOT 7 PID# 051-053-02 ExlsnN I � HOU 0 carr DECK 8� o SEPTIC PIPES �\ 10' UTILITY ESMT • TH A -C=29.2' B -C=20,1' A -D=31,8' -94.09. 94 B -D=24,1' > ; W A -E=26.6' J B -E=10,3' J U A -F=27.0' a B -F=11.6' 1250 GAL STEP TANI OFA_ L *14 PREPARED FOR: HAMILL 22719IR❑BINS❑N RD r .49 TH CHUGIAK, AK � � 1 TH S RELD BOOKS COMPUTED: KENNC -7 id- BOUNDARY: N A DRAM: KSD �wA7 STAKING N A CHECKED: KMD "• ASBUILT: DATE: 4 6 p FCsslol � D'6G. FILE: cwD: NW15E ACAD Flt- FILE JOB N°' 21003 VnlnmPe Arr• arrn Chnrar� Ctnrnno I 1 C C — Jnri v M' 1 nt SCALE: 1' = 30' SCALE: NTS o X 2 o O O �� n oto w o r'' y �3 B .+ 2 CD =r 0 C7 n p ry Qo w.• w cr Z (D 5- .� r -y p Q• oCD CD • ro ry O E3y w c .'1_. S n CL S., 4 CD ry =, co ^ y "0 Er ry SCHULL co00 y o ~ a ¢ sf �toto p o� y� I _�Z- N � O co r, n cn(D N �p cr 'l r•('r'C �� 00 m< --Im oD o-< mr M 0 D 0 Z m O U) DD z 0 m _D m� 00 ox z� _o 0m 0 z P z 00 Ut O CA t CA N O ,Oz ,0� MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP211042 Work Type: SepticTank Upgrade Tax Code Number: 05105302000 Site Legal Address: ROBINDALE LT 7 G:1561 Site Mailing Address: 24030 RAMBLER RD, Chugiak Owner: HAMILL ANGELIA D Design Engineer: ARC TERRA CONSULTING INC This permit is for the construction of: Effective Date Expiration Date: cnt ri, R Q , f 1�epartinent Lot Size in Sq Ft: Total Bedrooms: 2/23/2021 2/23/2022 19074 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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 3 Special Provisions: 1. The carport is to be removed per the permit. 2. The excavator is to located the edge of the bed to confirm that the 5' separation between thetank and field will be met. 3. There is an addition on the back of the house that is not on the survey on file. For the COSA, the field to addition foundation separation will have to be confirmed. A waiver may be required. Received By: Date: Issued By: Date: ON-SITE SEPTICMELL PERMIT APPLICATION Parcel I.D. 051-053-02 Property owner(s) Angelia Hamill Mailing address 22719 Robinson Rd. Chugiak, AK Site address 24030 Rambler Rd. Chugiak, AK Legal description (Sub'd., Block & Lot) Robindale Lot 7 Legal description (Township, Range & Section) Day phone Lot Size 19,074 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION 1S AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) (w/wo AD U) Septic Tank E Upgrade EDuplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ 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. Dea Duffus (Signature of property owner or authorized agent) Permit/Rush Fees: $225 1 Waiver Fees: Date of Payment: '_91a 3 20 a � Date of Payment: Receipt Number: DO `i � 2S G Receipt Number: Permit No. OSP211042 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211042, Deb Wockenfuss, 02/23/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211042, Deb Wockenfuss, 02/23/21 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~. C:~ t (~)~ PID Number: ~ [~)~"2-- Name- Wastewater System: [] New ~-.LJpgrade ~,;~ ~,c. ~::~ 't~:~:~~ ~, ~ ABSORPTION FIELD ~,~+~ of ~ Deep Trench ~ Shallow Trench ~Bed ound ~Other Soil Rating: Total Depth from original g~ LEGAL DESCRIPTION ~,~ ~.~,...,. L~t: ~ ~ ~ ~~Subdivisi°n: ~ Depth to pips bottom fro~dgi~gr~de:. Ft. Gravel depth beneath pipe ,~' Ft. Township: Range: Section: ~ ~ill added above original grade: Gravel length: Gravel ~ Number of liys: ~ Distance between tines: WELL: m ~' .... m, '~nrade ~ ~ ~ ~ ~1~1 ~' F,. CI~ Total absorption area: ~ipe material~ · . NO~ NO' NOTE ~,~d,o: "'. / ~( / /~ ~StaticWaterLevel: I~ ~ateinstafled: Driller: ~' ~Ot ~' I. "' -: ] Ave GrouFn~ ~~~ ' Yield: P~m~Se~ ~-- ~ Casing Height bo : , TANK GP~ ........... I Ft. ~ S.T.E.P. To S~ ~ A~~-:I~ r Holding Public/Private Manufacturer: From Tal -- Fmld Stat n Tank Sewer Lines we,, 100'1~~ 1~~ ~ ~,+ M~,~.,~,: ..mb.ro, Co~,..~e.ts: s.rf. OOw.t.r ~ 100~ ~¢9 ~ ~ LIFT STATION Lot ~ / ~ '- ' ' : ' -:" ' ' '-: ' '-- ' ' - ' .' .ne ¢~ 10 ¢".'" ~;."~,¢'~'- .~' /'~ '.".-:,'--. Foundaton f N ' .. {_~ ~-~_[.~( / ~~~ . , ....,.~mat: C~ain ' ' ; ' ' ~''~*) ' ~ ' ' ' ,r ,n '-. ' ." ' . ' _'. ; :.-'' '.'"','-" ''.¢ ~ · . :-. . , , . '0 ¢ ' '- :, · ~. '.- - ~:: .. - .. ,. Insnections~ ~erformed bv'~.. ~5{~~. . Dates'. ~st 2nd Department of Health and Human Services approval Reviewed and approved by: ,/~~ ~~ Date: Permit No. -~l I ~);;~2~ L ~ Page ~" of ~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report 72-O13 A (2/91) MOA 25 Box 670694 Chugiak, AK 99567 Phone:(907)~ N-~ 001255 DATE //~ P.O. NUMBER TERMS QUANTITY DESCRIPTION PLEASE PAY BY THIS INVOICE. NO STATEMENT WILL BE SENT. PRICE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW910328 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:ALLIANCE BANK OWNER ADDRESS:24030 RAMBLER RD DATE ISSUED:10/ll/91 EXPIRATION DATE:10/ll/92 PARCEL ID:05105302 LEGAL DESCRIPTION: ROBINDALE LT LOT SIZE: 19094 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: Tom Fink, Mayor Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 January 10, 1991 F.D.I.C. 440 East 36th Avenue Anchorage, Alaska 99503 Subject: Lot 7 Robindale Subdivision Permit #900378, PID #051-053-02 The subject permit, issued by this office for a single family well and/or on-site wastewater system has expired as of December 31, 1990. A new permit must be obtained from this office for a well and/or on-site wastewater system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this office for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site wastewater system, the original as-built inspection, report (three-part form) must be sent to this office for review, approval and documentation. All inspection reports must be submitted within 30 days of construction completion. When applying for a new permit, the fees are: $90.00 for an on-site wastewater permit; $50.00 for a well permit; $140.00 for a combined on-site wastewater and well permit. If you have any que~stions, P r/~ _r am Manager Off-site Services please call this office at 343-4744. JW/ljm:200 enc: Copy of Permit "Kids Are Our Future" HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN ROBERT SHAFER, P.E. ROGER SHAFER December 3, 1990 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ATTN: Robhie RobinSon 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot 7; Rohindale Subdivision; ~UNrCJPALiTY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION RECEIVED Request you approve the revision to the design of the on-site septic system proposed for the referenced property. As you may recall, you visited the property in July as part of reviewing the permit request. The excavator was preparing the site and the two of you observed very wet conditionS in the area proposed for the septic upgrade. There was a fair amount of surface water traveling across the ar~a. On July 26, 1990 you telephoned our office with your observations and concerns. Shortly thereafter, we visited the site and traced the surface water to its origin on Lot 14 located adjacent to and south of, the referenced property. The water was coming out of a seepage pit cleanout cut off at ground level. Lot 14 waS vacated some time in April and apparently the water from a toilet waS left running. This continual addition of water into the septic system,~, caused it to saturate and overflow onto the ground surface. It is difficult to estimate how long the septic had been overflowing when you observed the water but it must have been quite a while since the water was not malodorous. In September the water was turned off to the house on Lot 14. Shortly thereafter the surface water dried-up. On November 12, 1990 we measured the water level within the test hole monitoring tube at 10 ft. below the ground surface. As can be seen from our design we propose an elevated bed with the bottom of the bed at ground level. This is because subsequent to our origina~ design we have observed a sump pump within the crawl space of the house. Although the crawl space is dry at this time, we have observed water stains on the footing 4'-5' below the ground surface. We suspect these high water levels occur during the spring. 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 Page Two Lot 7; Robindale Subdivision; December 3, 1990 Attached for your review is a revised site plan/design. If you have any questions, please contact us. Sincerely, mTA.SHAFER, P.E. Municipality o! Anchorage ~-- ~ ~¢ I ~g~ DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 /'"~ so,.s.o - .E.COL^;.O. VEST /7 ~c~ c~-~- I~--~/~~-~ DATEPERPOR~;~¢~O PERFORMED FOR: LEGAL DESCRIPTION: ~ 1 ~--~.~Pl~'~T°wnship, Range, Section: SLOPE SITE WAS GROUND WATER ENCOUNTERED? 11 S L IF YES, AT WHAT O 12 DEPTH? p E Depth to Water. r.r.r~er..~. , 13 " Monitoring? ' ~'~-'~ Date: "~ "~¢~~ Gross Net Depth to Net Reading Date Time Time Water Drop ~ ~'.,¢¢~ '~,=,~,~. ~f~," '"~,./¢..- 14 15 16- 17- 18- 19- 20- PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEE ~ ET AND 7 ET COMMENTS N~ / :~cF;ZDM);c:~t&~?~i~:;~i~, p~L ,:,Gji:~~~DACT::TIFY T~/~I~TTCJS PERFORMED IN 3'1VOS h 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 EW ~UPGRADE LEGAL DESCRIPTION LOCATION Well DISTANCE TO: Manufac;~urer £ 'q p 't ga ohs /~ o 0 ~OMEMADE~ DISTANCE TO: Well Manufacturer Well U~STANC~ TO: No, of lines Length o~ ea¢h line Top ot tile to Tinisn~rade Type of crib ' DISTAnt[ 10: ~oll ]Cl~ Depth ~ TO: Building foundation X7 AbsorlStion area Dwelling Material~ Inside length Width' ~'0/'~ Dwelling Foundation Total length ,,~ I~es Material beneath tile Depth Material Nearest lot I~e/ Trench widtj3 ~ Z-~ inches inches NO. OF BED~.~IMS P E.~d~l I T NO. No. of c~mpar~_.~nts Liquid depth PERMIT NO. Liquid capacity in gallons P E R~J.T NO. Distance between lines Total effective absorptio~ area 5~7~ o - PERMIT NO. Crib depth Total effective absorption area Building foundation Nearest lot line Driller Distance to lot line PERMIT NO, Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING 'NSTALLERjo/.,. L,,-,"5 REMARKS APPROVED DATE 7-/? -~. LEGAL PER!'d :[ T NO. C, EF'RRTMEiqT .' HERL.'!L.'-4 RF,![:, EF,!V :£ RE!N.UEN'TFIL . ROTECT l ON: ' ~-2~;2.5 ." I_ ." ::.;TREE"['. F:h~.~r':HFIP."Rr~I-:', RK. .'.:.~950d.. t. ~ iL..../ 2 6:4 - ::~ 7 2 O RPPL i C:R.U T L. OC:RT Z LEGRL. [:,C)NRL.[:, R 8RR'.r' L7 ROR!NDRLE S,-."t} SR2BOX 59?4 CHUGI'RK 995E'7 LOT S;iZE 222222 SCcURF.:E FEET TYPE OF SOIL REg:SORP"['!ON S'.?STE.U iS: "f'REI'-~.C:H MRX'IML.IM UL!PiE~ER OF E~EE:,RO0r,iS; = ]: SC~i,L.. RR'T'ING ,::SC-:! FT,.."E',R>= :t. TD THE REQUIRE[:, SIZE OF THE :BOIL F!E,'SORPTZON SYSTEM IS: THE LENGTH DIMENE;iOi'-,i IS THE LENGTH <Zhl FEE"['::, OF THE TRENCH OR [:,RF:[INFIEL[.'.'. TFIE [:,EPTH OF R TRENCH OR F'IT !S TF!E [:,!STRNE:E E',ETWEE:N THE: SURFRCE OF THE !3F.'.OUN[:-' RN[:, THE BOTTOM OF: THE EMC'F:!VF~T ~ O.N ,:.' :[ N FEET). THERE !S NO :'ii;ET i.4:[[.'-'TH FOR TREHCF!ES. THE GF.:F¢,,,'EL. [:,EPTH :[:..-7, THE MINIMUM [:'EPTH OF: GF::FI',,,'EL BETI.,~EEN THE OUTF'F~LL Pi'PE RN,5 THE BOTTOM OF' THE EXCFIVPYF:[ON ,:.'IN FEET). PERM Z'T' F:ff:'F'L l C:Fi!'-,FF FIRS THE RESF'ONS t B ! L I T'¢ 'l"O ! NFORM ]"H Z S DEF'FIRTMEI"CF [:,UR !'.UG THE INSTRLLRTZO!'-4 t I'.,!SPECTZOi'.,kS OF F!h!:¢ P]EI._LS RE%:rRc:ENT "['O THIS PROPEF.:T',-? FIf-,t[:, THE i'-,iLIi"!E:ER OF F'.ES![:,ENCE:':'.'; THRT THE NEL..L HILL SERVE. ............ '"F' ]-,.!! ~:2~ ,,::: ;;~ ]::~ Z ~"..,~I SS-E; P' CZE C::: "T' % CD ?-,-~! '.'E.::; .~:~ ~qi: Ei% F~-:: E.=..] ~G:~ L.~ ]E ~:~'_' EC' E> .......... E',RC:KFZL. LZ?.,IG O? Fti'-,!~?' S?STEM I-,]!THOUT F'iNRL INSPECTION FIN[:, RPF:'ROVRL E?¢ TF!!S DEPRF).TMF.'?.,F? !qILL.. E;E ZUB..:fECT TO F-'ROSECLITION. M]:HZMt. JI':! E.',!S']"RI'.,IC:E E:ETi.4EE?.,! R iqEEL. L. J..00 FEET F'C.'!R R F'R!VRTE NELL OF;: ±50 TO 200 FEET FROM R PLIBL. ZC !.4ELL E:,EPEND:fNG UPON THE T'¢PE OF PUE~Li'C kiEL[ .... t"'ltJ'.~lt'dLlJd [:,iSTRNE:E FROi"! R PRi'v'FCi'E klELL TO R F'RI',,,'Ft7'E SE].,.i£R LINE IS 25 FEET RI'.,I[.'.', TO R COMMLINZ"["¢ SEi.,.!EP.'. L..:[NE :[:5 '?5 FEET. !.,.JELL. LO(]"Z RF.:E Fi:EQUiREB, RND i"RJST E~E RETURNEE:, TO "['FIE [:,EPRRTMENT P.!I'TF!i?4 ]1:0 i}R?S OF ]"FIE klEL.L COidPL. ET!O?4. O]rHER P'::E(.:.!U l RE?iEi"'4TS MR'T' RF'F'L?. SPEC I f.:' i CF:ITl ONS Ri"~.D CONSTRUCT ! ON E:, l RGRRMS IaRE .RVRIL.F!BL.E TO INE';URE F'ROPER !NS"['F!LLFFF :[ C:ER]"IF'¢ THRT :~: i RM FRi"!iLIFhq: P.iiTH ]"FIE REC!LilREMENTS F'OR ON-Z:[TE SEI.,.IERS RND 1.4EL. L.S F!S SET FORTH B'¢ THE MUN:[CZPRL. IT? OF RNCHORRGE. ;2.: I F.!ILL. INSTRL.L TFiE S'¢STEM th! RC:COR[:,F¢-,E::E t4ZTH THE CO[:,ES;. 3: Z UNDERSTRND THRT TFIE ON-SITE SE:HER S?STEM I'dR'¢ REQUIRE ENLF:IRGEMENT IF THE RESIDENCE I~EMOE:,E[ ~~:LUE:,E MORE THFIN ]: E',EE:,R'.OOMS. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENV, I RONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST SOILS LOG PERCOLATION TEST I 2 5 6 7 ~8 PERFORMED FOR: LEGAL DESCR,PT,ON: NL- ,qravd SLOPE DATE PERFORMED: SITE PLAN 10 11 12 13 14 15 Ca M.- _'q¼~ ~i hy, sandy_, U¥'~-V~I WAS GROUND WATER ENCOUNTERED? 19 2O S IF YES, AT WHAT DEPTH? '7 %4 f,-, i~ Gross Net Depth to Net Reading Date Time Time Water Drop +~0 ,o:87:~ ~ ..~ '0 iO:qT:3O i6 :,sR :oo J O , l ~ . eHzO l l:Ol:OO -~ ,~O li:zz:oo lo ,1~0 .IZO PERCOLATION RATE ~ '2,, (minutes/inch) TEST RUN BETWEEN ~'~ . FT AND 3,,~ FT PERFORMED BY:~VIA(, ~;~P~P~ L~/~I~ -.~0¢~M~O~4 CERTIFIED BY: DATE: by DOC Co, dba SULLIVAN WATER WELLS P,O, BOX272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 OWNER OF LAND ADDRESS .i ,;: LEGAL DESCRIPTION DATE-Started '/' PERMIT NUMBER DEPTH OF WELL :'/? .~'/*' ~STATIC LEVEL OF WATER FT. r, ¢4:~::~ : DRAW DOWN FT. Ended ?' ·" · :, :, ;': GALS. PER HR KIND OF CASING KIND OF FORMATION: From From From. From From From From From From Ft. to, ' Ft. Ft. to, , Ft. Ft. to .. J Ft. - ....... ' Ft. to Ft. Ft. to ~ Ft. Ft. to? (~ -,Ft Ft. to.___Ft Ft. to; '- Ft. Ft. to Et Ft. to Ft From. Ft. to Ft From Ft. to Ft. From Ft. to Ft From Ft. to. Ft From Ft. to. Ft. From _Ft.m _Ft. From Ft. to Ft. From Ft. to Ft._ ~From Ft. to Ft. From Ft. to Ft. From Ft. to Ft, From Ft. to Ft From Ft. to Ft. From Ft. to Ft. From Ft. to___Ft. From__.Ft. to Ft. From Ft. to Ft. From__Ft. to Ft. From Ft. to Ft From Ft. to___Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From__.Ft. to Ft~ MISCL. INFORMATION: Municipality of Anchorage On -Site Water and Wastewater Program ` (907) 343-7904 S A F E T Y CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-053-02 Expiration Date:" 1. GENERAL INFORMATION Complete legal description Robindale Lot 7 Location (site address) 24030 Rambler Rd. Chuqiak, AK Current Property owner(s) _Angelis Hamill Day phone Mailing address 22719 Robinson Rd. Chuqiak, AK Real Estate Agent Day phone 2. TYPE OF DWELLING: M Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class _ Well ❑ Public Water System ❑ WaiverNariance request for: 3 TYPE OF WASTEWATER DISPOSAL: Individual Holding Tank ❑ Community ❑ Public Sewer ❑ Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ _5 _ _ Waiver Fee $ Date of Payment��� Z �Z� _ _ Date of Payment Receipt Number 9_q3 % Receipt Number COSA # O S C 1 11 10 I Waiver # Distance: 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. Name of Firm ARCTERRA CONSULTING, INC. Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577__ Phone 696-6111 Engineer's Printed Name KENNETH M. DUFFUS Date Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. 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, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future N. \ occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. e OF 4 6. DSD SIGNATURE System #1 Approved for bedrooms. ? ``EN.\L' 71'6 ` System #2 Approved for bedrooms. ,cT\fi�, �••"i _ Disapproved.\a Conditional approval for bedrooms, with the following \\` �klTYO�ifi��i 9 � By: Vw r M A -y -1/v GF11 1 ZAP Original Certificate Date:_ 1 -1—N -24 -- The ! rN-2 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 engineers work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory _ Arsenic Advisory Well Flow Advisory Other COSA blue sheet -10-10-12 doc Legal Description: Robindale Lot 7 If more than 1 septic system on lot: COSA Checklist # A. WELL DATA Well log is filed with Onsite (or attached) Date drilled 7/6/82 Total depth 181 ft Cased to 181 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 29 in. Date of flow test for COSA 2/17/21 Static water level at beginning of test 172 ft. Comments B. TANK DATA Age of tank(s) New years Tank type/material Septic/Steel Measured operating fluid level in septic tank New Standpipes/foundation cleanout per record drawing Date of pumping New 4/2/21 D. ABSORPTION FIELD DATA Which system tested (date installed) 10/15/91 ALL standpipes present per record drawing Total measured depth from grade 4.8 ft (max) Measured depth to pipe invert from grade 4.3 ft (min) ❑ N/A — pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Parcel ID: 051-053-02 of Structure served by this system Well production at time of test 4.9 gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes E Nc Coliform bacteria is Negative Nitrate 9.90 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L N Arsenic less than MRL (ND) Collected by Arcterra Consulting Date of Sample 2/22/21 C. LIFT STATION Required maintenance completed Age of lift station New years Lift station material Plastic ..1C�i717, U a l;3 Adequacy test date 2/17/21 Results Q Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 450 gal New depth 5 in Elapsed time 800 min Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 450+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet 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' Yes if No ft 0 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 97 ft Holding Tank > 100' ® Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ® Yes if No ft ® Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ® Yes if No ft ® Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No ft Property Line > 5' ® Yes if No ft Wells on Adjacent Lots: ® Yes Absorption Field > 5' Yes if No ft Private Wells > 100' ® Yes if No ft Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft Water Service Line > 10' ® Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below Property Line > 10' ® Yes if No ft Wells on Adjacent Lots: Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No ft Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft Surface Water > 100' ® Yes if No ft F. ENGINEER'S COMMENTS *5' Separation from carport. G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet IN. itrate Advisory Certificate of On -Site Systems Approval # OSC 211169 Subdivision: Robindale Lot 7 A water sample revealed a nitrate concentration of 9.9 milligrams per liter (mg/Q. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. �, �Ma�lmg Address P O Box 196650*;Anchorage, a�aska 9959 6650 � vuww{muni org $ �' From Northern Testing Laboratories, Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening, or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. `- �" MaihnggAddress P O Box 196650 *Anchorage; Alaska 99519 6650,* www�lmun� orgy Municipality of Anchorage Development Services Department Building ~afety Division On-Site Water & Wastawater Program 4700 Sout~ Bmgaw SL P.O. Box 196850 Anchorage, AK 99519-6650 www.cLanctxxmge.ak.us CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAHILY DWELLING Expiration Date: Parcel I.D. 051-055-02 1. GENERAL INFORMATION Complete legal description LOT 7; ROBINDAL£ SUBOMSION Location (site address or directions} 24050 RAMBLER ROAD * CHUGIAKt AK Current Property owner(s) .Mailing address Lending agency Mailing address Real Estate Agent Mailing address TOM AND BONNIE DAVIS Dayphone P.O. BOX 672256 * CHUGIAK, AK 99567 688-6778 Day phone . CAROLINE STREANO w/ COUNTRY REALTY Day phone P.O. BOX 671923 * CHUGIAK, AK 99567 688-8500 Unless otherwise requested, HAA w#l be held by DSD for pickup. 2. NUMBEROF BEDROOMS: 5 3. TYPE OF WATER SUPPLY: Individual Well ~ Individual Water Storage Community Class Well ~___ Public Water System TYPE OF WASTEWATER DISPOSAL: Ifidlvidual On-sita Individual Holding tank Community On-site Public Sawer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the represenlal~ons given in paragraph 5 by an Independent professional civil engineer registered In the Slate of Alaska. Certficates of Health Authority Approval ara required for the transfer of title (except between spouses) for properties served by a single family on-sita wastawatar disposal and/or water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties sewed by Class A or B wells or a public water system. The Municipality of Anchorage Is not responsible for errors or omissions In the pmfasslonal engineafs work. Note: Alaska Water end Wastewaler Consultants, Inc. shall be paid $1,110. O0 at, or pdor to dosing for the engineering sarvfces provided. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto end es of the valida§on date shown below, I verify that my Investiga§on. based on procedures outlined In the Health Authority Apprevel Guidelines for this application, shows that the on-silo water supply and/or waMewater disposal system is(are) safe, funcfional and adequate forths number of bedrooms and type of structure indicated herein. I further verify thet based on the Infeffnation obtained from the Munidpaliiy of,anchorage tiles and from my lnvestigation and inspection, the on-site water supply end/or wastewater disposal system is(are) In compliance with all applicable Municipal and State codes, ordinances, end regulations In effect a~ L, .~e U, ree of Installation. NameofFirm * ALASKA WATER &: WASTEWATER CONSULTANTS, INC. 6901 DEBAER ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFi~EY A. GARNESS, P.E. Engineer's comment~: In conducing ~ evalueUon, /A Wt, t~, Inc. aftemp*ted to provide e'UX:~°ugh, consdenUous engineering analy~s of Um system In ecconfance with ADEC and MOA DSD Guide#nee & RngulaUon& The reported results dosc~fbed the performance of the system under the condlgons encountered at the Ume of the te~ end seperaUon distances measured to med#y Idenllflable features. The operational life of all wells and septic systems depend on the local sells condl~n, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the ~stem. These cond/Uons sm ou~de the conbo/of b~e evaluator of the system. Sat/~actory test results do not guarantee futura performance of the sy~em, nor do they guarantee that them are no hidden dofec~ or encroachmenL~ A WWC, Inc.. can therefore not provide any wa~renty or futore e~Jmale of how long the sy~em will conUnue to meet the operational requirements of the ADEC or MOA DSD. The content of this rupert is for the sole benefit of the ownor tisted above. Any mllence upon or uae of this report by eny other pere. on or perfy is not authorized, nor will lt confer any legal right whatsoever. Phone 357-6179 5. DSD SIGNATURE Approved for ~ Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: Attachments: HAA Checklist Septic System Advisory '. Well Row Advisory Manitenance Agreements Supplemental Engineer's Reort Other Original Certificate Date: Municipality of Anchorage Development Services Department On-S~ wirer & W. stevm~r Program 4700 ~ufh Bragaw St. p.o. B~x lg6850 Anchorage, AK g951 g-~650 Legal Dascrl~on: A. WELL DATA Well type ~'A~ Oatecompleted 7/6/1982 ~anltery~eal(y/N)YES Toteldepth 181 ft. Canedto 181 ff. HEALTH AUTHORITY APPROVAL CHECKLIST LOT 7; ROBINDALE SUBDNSION Panel ID: 051-053-02 IfA, B, otc provide PWSII~ N/A Wen L~O (yfl'O ~ N;~.~.~ 4.13 moji.. Otherbecteda Collected by:. AWWCt INC. *IN CRAWL SPACE Totaldepth 4.+ .ft. Eff. ab~3~ioaema1200 It! Monlt~lngtube YES Oate of adequacy test 9/14/2001 Resulte(Pass/Fall) PASS Fluid depth In abaoq~ou field before test * ~ Water added 751 gal. Etepsed Time: * min. Final fluid depth * In. Absorption rate A~ mJuvenafiou tmalment (past 12 mo.) (Y/N & type) NONE KNOWN 24+ In. Date Wed 7/12/1982 (3eanoute (Y/N) YES High w-a~ei' ala1111 (Y/N) N/A JR's PUMPING 0 colonies/100 mi. *SEE AI'TACHED L~.i I~J< DESCRIBING ADEQUACY TEST. Soil mfing ~ ft'/bdrm) 0.4 System 13q3e BED Width VARIES lt. Grawl below pipe 0,5 It. Coliform 0 colonies/100 mL Date of ~imple: 9/13/2001 e. 8EPTICMOLDINO TANK DATA Tank Type/Matedal 5'TEEL Tankalze 1000 gal. NumperofCompa~lente 2 Foundation cinanout (Y/N) ~ Dapmsalon over tank (Y/N) NO Date of pumping g/14/2001 Pumper C. AB$OEF310N FIELD DATA Date Installed Length 70 Depression over field. NO Fro' 3 bedroum~ Newdeplh * In. 450+ g.p.d. ffyes, give date - FROM WELL LOG Date of tl~t 7/6/1982 Static water level 1 O0 ,ff. Welt producfion 12 g.p.m. WATER ~VIPLE RESULTS: w~s propee/protec~ Ca~ng be~ht (above ground) AT INSPECTION 9/14/2001 173 It. 4.9+/- g.p.m. D. UFT 6TATION Date instal]ed 10/15/1991 'Pump ofl' level at 41 in. Datum BOT[OM OF TANK E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WFI I ON LOT TO.' Size in gallons 500 'Pump off' level at 31 In. High water alarm level at, 45 .in. Meets alarm & dmult requlmmente? YES ~AIVER I~WR970003. ~*FROM EDGE OF MANHOLE LID TO EDGE OF WELL ON LOT 8, On adjacent lots. *'101.7' On edjacent inte. 100'+ Public sewer manbele/cteanout Ho;d~g tank Septic= ~ station on lot. *95' Abseq:)tion field o;t lot, *95' Public sewer main N/A Sewer/septic sendce line 25'+ Absorption field 5'+ Surface water. IOO'+ Building foundation 10'+ Water main N/A SEPARATION DISTANCES FROM SEPTIC~OLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Water main N/A Water sen~ce line lO'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSOR~¥1ON FIELD ON LOT TO: Pmper'q line 1 O' Water service line Curtain drain F. COMMENTS 1 o'+ Surface water 1 oo'+ On'veway. parldng/vehlde storage ' 10'+ NONE KNOWN Wells on adjacent lots. 100'+ G. ENGINEER'8 CERTIFICATION I certify {hat I have determined {hrough field I~one and review of Municipal mcetrls {hat the above ~/~tema am In conformance ~ MOA HAA guidelines In effect on {hie date. F_ngln~l:e Pllnlu] N? l~. Date ~ JEFFREY A. GARNESS HAA Fee $ ~00. Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number, ALASKA WATER & WASTEWATER CONSULTANTS, INC. September 17, 200 I, Municipality of Anchorage Development Service Department On-Site Water & Wastewater Program 4700 South Bmgmw Street P.O. Box 196650 Anchorage, Alaska 99519-6650 (907) 343-7904 Ref.' Septic Adequacy Test for Lot 7, Robindale Subdivision To whom it may concern: On September 14, 2001, we performed a septic adequacy test on the drainfield for the referenced property. The septic system consists ora 1000 gallon septic tank, a 500 gallon lift station, and a bed type dminfield. Although the drainfield is served by a lift station, the bed uses a gravity flow type distribution. Prior to our test, the west monitoring tube (MTI) was found to be dry and the south monitoring tube (MT2) was found to have 5 inches of liquid level. Prior to our test, the septic tank and lift station were pumped. Elevation shots ~vere also taken and found that the elevation for the bottom of MT1 to be 89.88 and the bottom of MT2 to be 89.83. The average elevation ofthe cleanout inverts ~vas 90.47. Approximately 15 gallons of water was first added to MTI in which the monitoring tube filled to almost the ground surface. The flow was than switched to MT2. An additonal 100 gallons was added to this monitoring tube which caused the liquid level to rise to 17.5 inches total. No water at appeared in any ofthe cleanouts during this time. Given the fact that the liquid level was over the allowable I 0 inch level for testing in the monitoring tube, the flow of water was switched to the west cleanout. An additional 636 gallons was added to the west cleanout with no liquid level showing in all the other cleanouts. During this time, the liquid level in MTI dropped back to being dry and the liquid level id MT2 dropped to within I inch of the starting liquid level reading. On September 17, 2001, we returned to the property and found that the liquid level had dropped a half inch from the starting liquid level reading taken on 9/14//2001. It is our opinion that the normal operating liquid level in MT2 is approximately 5 inches at this time (still 0.22 inches below the average invert elevation). 6901 Debarr Road, Suite 2B * Anchorage, AK 99504 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com 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. GENERAL INFORMATION Complete legal' description Location (site address or directions) Property owner Mailing address Day phone Lending agency Mailin. g address Agent Add ress Day p'hone '..: DaY phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual welt Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 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. 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. NameofFirm ~]~-//~--/-~ ~"~--~'/'/~--¢/~ ~/¢'¢~one ~ ,....~-~'~-/~-~.____~ ~ Address Engineers signature~¢~~ DHHS SIGNATURE Approved for Disapproved. '~/'//~ ~' bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS} issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work. 72-025(Rev. 1/91) Back MOAt21 LegalDescription: L om ? Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES - Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist ~u~ic,~^u i ~ Parcel I.D.:. A. WELL DATA Log present (Y/N) Total depth Sanitary seal (Y/N) y If A, B, or C, attach ADEC letter. ADEC water system number Date completed ?'-- ~ '~ ~ Cased to ,J>' ~(~ / Casing height (above ground) Wires properly protected (Y/N) Date of test Static water level Well production FROM WELL LOG AT INSPECTION 7-(,-T' ?, / ~ g.p.m. ~' '~ g.p.m. WATER SAMPLE RESULTS: Coliform ~ Date of sample: ~-¥~- ~ Nitrate, Collected by: ~' ~ Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~l'~"~_~anksize ~C~O Nujrnber of Compartments ~_ Cleanouts(Y/N) Foundation cleanout ~/N) ' Depression ~/N) ~ High water ala~ ~/N) ~' Date of Pumping OC~ ~?¢~Pumper ~ & ,~ ~//~ C. ABSORPTION FIELD DATA Date installed /~[~ c~[ Soilrating (6}/ft=orfF/bdrm) ~"~" Systemtype Length ~ ~ Width. ~/~1~' (~-'~-7 ~') Gravel thickness below pipel (~ '~- '-~ Total depth. ~ Effective absorption area / ~-~C;~ Monitoring Tube present(~) ~"C~Depresslon over f eld (Y/N) /~/ Date of adequacy test-/~ ~ '~-- ~ ~'Results (Pass/Fail) ~ ~-~,,~ For ,~::~ bedrooms Fluid depth in absorption field before test (in.); (~ Immediately afte~(~gal, water added (in.): / ~ / Fluid depth ~,~ (ins) Minutes later: ~ Absorption rate = ~' ~ ~'~ g.p.d. Peroxide treatment (past 12 months) (Y/N) /~/(~ ~ /L~/~(~¢ If yes, give date 72-026 (Rev. 3/96)* LIFT STATION Date installed /'~--~ ~ / ~ -- ¢ / Manhole/Access (Y/N) y(¢.-~ Size in gallons "Pump on" level at* $ ) High water alarm level at* Cycles tested b E. SEPARATION DISTANCES 200 ' "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot (7¢'~/ ~q-- ) ~ Absorption field on lot ? ¢' (-Jr') ~ Public sewer main /~//A Sewer/septic service line '~-;~ [ (4-) *Datum On adjacent lots On adjacent lots Public sewer manhole/cleanout /'~./4 / Lift station ~' ~ /OO/(+ ) · / SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~,~ (' Property line //¢'~ / ~'¢' ) Absorption field. ~ / Water main/service line ~?---'© ('/-)Surfacewater/dra,nage ~)t(~/Wellsonadjacentlots Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots ~/~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ' / ~ [ Building foundation / 4/ Surface water ]¢..~( (h~) cu'*"draL"` I certify that I have determined thru field inspections and review of Municipal records t~a,t.-the,ab.e~ systems are ~-nglneer s Name , ~-' HAA Fee $ Date of Payment / Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* ROBERT C. COWAN, RE. ROBERTA. SHAFER, RE. CIVIL ENGINEERS HEALTH AUTHORITY APPROVALS SEWER&WATER MA~N EXTENSIONS SEWER &WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELL iNSPECTION &FLOWTEST SiTE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ONS]TE W~STEWATER DISPOSALSYSTEM DESIGN June 30, 1997 (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OFANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Lot 7; Robindale Subdivision RECEIVED JUL 1 1997 Municipality of Anchorage Dept. Health & Human Services A Conditional Health Authority Approval (HAA) was issued on 2/27/97 for the referenced property. All work required for the Conditional HAA has been completed. The cleanouts have all been extended: 1) double cleanout between septic tank and leachfield 2) cleanout for lift station 3) cleanout at end of the bed. Fill was brought in at the east end of bed to provide 3 ft. minimum cover, c Please issue a full Health Authority Approval at this time. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/gk 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~' 3 -c2 '~- HAA# /-/~ 1. GENERAL INFORMATION Complete legal description Lot 7; Robindale Subdivision Location (site address or directions) 24030 Rambler Road Chugiak, AK Property owne¢-.:~ ~ Jack Frost ..~'Maiiing.addresS ~?.0. Box 671176 Chug±ak, Lending agency ;. C±ty Mortgaqe (~.R) · Mailing address ..... AK Day phone 99567 Day phone 688-0312 696-0701 Agent '~,ddress Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 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 ¢F21 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. S & S ENGINEERING , Name of Firm ~7~ _~g!-_ R!wr .== ........... Phone G ¢4 ~ - ~-q 7 ¢/ Eagle River, AlasEa 99577 Address , ,~ Engineer's signature ~. v ~ - REQUEST YOU ISSUE A FULL HEALTH AUTHORITY APPROVAL AT THIS TIME. ALL ITEMS REQUIRED IN THE CONDITIONAL H.A.A. DATED 2/27/97 HAVE BEEN SATISFACTORILY COMPLETED " DH~/SIGNATURE ~" Approved for Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesyto 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~ · /"~ MUNICIPALITY Of ANCHORAGE 1~'~2~'~) DEPARTMENT OF HEALTH & HUMAN SERVICES · \~.~!~')'/ Division of Environmental Services P.O. Box 196650 Anchorage Alaska 99519-6650 CERTIFICATE OF HEALTH AUTHORITY APPROVALFORASNGLEFAMLYDWELLNG ' 1. GENERAL INFORMATION Lot 7; Robindale SubdiviSion Corn Dlete legal description Location (site address or directions) 24030 Rambler Road Chugiak, AK Property owner Mailing address Jack Frost Day phone 688-0312 P.O. Box 671176 Chugiak, AK 99567 Lending agency Mailing adSreSs City Mortqaqe (Eaqle River) Jeannie Mee Day phone 696-0701 ' ' ' 'Nancy s~ahly/ Aurora Properties Agent Address Day phone 688-0312 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS,' 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTEi If community well syste'rn, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site xxx Community on-site ~: . ' NOTE: - If community wastewater system, provide Written confirmation from State ADEC atteSting to the ·legality and status of systeml 72~O25 [Rev. 1/91) Front MOA#21 , ' = STATEMENT OF INSPECTION BY ENGINEER. As certified by my seal affixed heret° 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 safel 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 flies and from my investigation and inspection, theon-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. S & S ENGINEERING - Name of Firm Eagle River, Alaska 9~)577 Address Engineer's signature Date ~' / I~/~ 7 _ REQUEST YOU ISSUE A CONDITIONAL HEALTH AUTHORITY APPROVAL DUE TO WINTER CONDITIONS' THE DOUBLE CLEANOUT LOCATED BETWEEN THE SEPTI_C TANK AND THE LEACHFIELD NEEDS TO BE EXTENDED ABOVE GRADE.~ THIS WORK WILL BE COMPLETED NO LATER THAN 15 JUNE 1997. ~ ,q~-$o g~-~-~'~ c~-~4,"aOo'7- Co v ¢_./~ , . . . DHHS SIGNATURE ' -_ __ Disapproved. .~, o ~:.~e .... ~x,, ~. X Conditional approval for j3 bedrooms, with the following ebpuiatlons: Additional Comments · ]~he Mu~icigality of Ah'~horage Department of Health and Human Services (DHHS) issues Health Authority App[~oval Certifi~a.,,t~ based only upon the representations given in paragraph 5 above by an independent Professional engi~r registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and tl~eir ending 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) ~ck MOAt¢21 Legal Description: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Env ronmental Services Division 825 L Street, Room 502 · Anchorage, A aska 99501 · (907) 3~744 Health Authority Approval Checklist · PALe ~'//O Parcel I.D.: A. WELL DATA Well type Log present Total depth Sanitary seal If A, B, or C, attach ADEC letter. ADEC water system number Casing height (above ground) Wires properly protected Date completed Cased to zoo ~.¢ FROM WELL LOG AT INSPECTION Date of test Static water level J Go Well production I Z g.p.m. 'WATER SAMPLE RESULTS: Coliform ¢ Nitrate Date of sample: I / 2-/'l '/ Collected by: B. SEPTIC/HOLDiNG TANK DATA Date installed -'./~17-'-~ Tanksize Foundation cleanout (Y~.~ __ ~ 0 Depression (Y~ Date of Pumping ~/,{/,~'1 Pumper C. ABSORPTION FIELD DATA Date installed 1~ Length '7o Width Effective absorption area I~¢o Date of adequacy test I / 6,/~ ~f Fluid depth in absorption field before test (in.); Fluid depth ~ 'j (ins) Minutes later: Peroxide treatment (past 12 months) (Y~i) /~¢~'~ I g.p.m. Other bacteria Cf S & S ENGINEFJ:,'iNG 17034 Eagle River Loop Road, No. 204 Eagle River, Alaska 99577 Number of Compartments 2 Cleanoutsd~'/N). High water alarm (Y~]~ Soil rating ~or fF/bdrm) O. '-/ System type ¢~ 0 Gravel thickness below pipe o.,~ Total depth Monitoring Tube present (~/N) "/P--~ Depression over field (Y/:~) Results (~"4¢/Fail) ¢A5 ¢ For ~' bedrooms Immediately after e~o gal. water added (in.): Absorption rate = L/5-O ~ + g.p.d. ~¢0¢/,JIf yes, give date 72-026 (Rev. 3/96)*' LIFT STATION Date installed I O/J~/~'1 Manhole/Access ~/N) "/~ .~ High water alarm level at* '-/'¢" Cycles tested '~ Size in gallons "Pump on" level at* ~' / "Pump off" level at* *Datum ¢,,r~'or4 ,,~ r'~. J[ E. SEPARATION DISTANCES Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line SEPARATION DISTANCES FROM WELL ON LOT TO: On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~ Property line ~ + Absorption field Water main/service line /¢~- Surface wateddrainage /¢¢/-k Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /0 / Surface water I o¢~ 4- Curtain drain t,.] /A Building foundation /~// Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal record2~ ~'~¢~?~ ~s are in conformance witt~ MOA HAA guidelines in effect on this date. z~/ ~-~"'~ '"~¥~% Engineer's Name /d~¢XT. C. Co~ (~ ~-d,~;~:'5'~'~ HAA Fee $. Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ ~¢~' ~ Date of Payment c>~rh~,.- , Receipt Number ~¢¢,/~ ~,¢I-~.~) ROBERT C. COWAN, RE. ROBERTA. SHAFER, RE. February 14, 1997 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN EXTENSIONS MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Lot 7; Robindale Subdivision SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOWTEST SITE PLANS ROAD DESIGN SOILTEST Request you issue a Conditional Health Authority Approval on the referenced property due to winter conditions. The conditional approval is requested because the double cleanout located between the septic tank and the leachfield needs to be extended above grade? This work will be completed no later than 15 June 1997. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/gk PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ONSITE W~STEWATER DISPOSAL SYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP * SUITE 2[)4 · FAC=I F RIVFR Al A~I<'A ClQ~77 Rick Mystrom, Mayor Mun capaliW of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 March 3, 1997 Robert C. Cowan, P.E. S & S Engineering 17034 Eagle River Loop Road Suite 204 Eagle River, Alaska 99577 Subject: Waiver Request for Lot 7 Robindale Subdivision Waiver Request # WR970003, PD #051-053-02, HA970008 Dear IV;tr. Cowan: Your request for waivers of the required 100 foot horizontal separation of an on-site wastewater disposal system to a private well has been approved. The approved separation distances are the private well to the septic tank, leach field and lif~ station of 95 feet. This waiver approval applies to the existing on-site wastewster disposal system to well separation only. Any future upgrade to either will require all separation distances be met or another approval from this department. If there are any further concerns or questions regarding this waiver, please call our office at 343-4744. amncerely' 'q , es 1a. Williams Civil Engineer On-Site Services JPW:ljm/Frost MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR~ ~l%~q-]fJ~ PID~ 051-053-02 HA~ HA970008 Date Received: February 18, 1997 Legal Description: Lot 7 Robindale Subdivision Engineer: Robert C. Cowan, P.E., S & S Engineering Applicant: Permit 17034 Eagt~ River Loop Road, Suite 204, Eagle River~ Alaska Jack Frost 99577 Waiver Requested: Waiver request of 95 feet from septic tank/leachfield/£/~-~ Criteria: 1. Geology: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: Special Conditions: Points: 3, Other: Waiver is Granted: ~ Waiver is NOT Granted: List Conditions or Reasons for above: Date: ~/~/~- Rec #: 02444/5389 Amount: $ 920.00 Date Paid: Feb 18~ 1997 SF_-P?K_ Z~sP. /Z&/a3~.-(, = O' ?-S z,o IOO., ~.o HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & PLOW TEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE W,~,ST EWAT ER DISPOSAL SYSTEM DESIGN ROBERT C. COWAN, P.E. ROBERTA. SHAFER, RE. February 14, 1997 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services Attn: Jim Williams P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Lot 7; Robindale Subdivision Mro Williams, Request you issue a waiver for the separation distance from the well to the septic tank~leachfield at 95 feet. The mitigating factors involved which support the issuance of the waiver are as follows: o Only a Small portion of the leachfield is at a higher elevation tha~ ~he well. All other portions of the system are either at the same elevation or at a lower elevation. This would alleviate any 'surfacing effluent from reaching the well head. The house is located between the welL'~nd the septic system which would also alleviate surfacing ef~16ent from reaching the well head. From the well log a consistency of silt, clay and sand was encountered during the drilling of the 182 ft. deep well. This silt, clay and sand would help in filtering the effluent prior to reaching the aquifer. 4. Attached are neighboring well logs which reinforces that a deep aquifer exists relative to the septic system. In our opinion the separation distance requiremnt prescribed by 18 AAC.021 is not necessary in this case. If you require additional information please contact us. Sincerely, Robert C. Cowan, P.E. RCC/gk ENCLOSURE 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 MUNICIPALITY OFANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lo~ 7, Robin~al~ S/D Location (site address or directions) 24030 R~r~ble.~ Lane. Property owner Mailing address Lending agency Mailing address Agent Ad dress F.~. ~.C. -- Ann Gainey 4-4ni~ Rn~?.zS. nq¢' A~,h_~_,,nge, A?n,5_~n Day phone 289-5~75 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: $ "~ TYPE OF WATER SUPPLY: Individual well ~'~ Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: XX Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA 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. ~ & S ENGINEFI~IN¢- 7034 Eagle Ri,vet Loop Roa~l No, 204 Name of Firm Address EngineeCs signature DHHS SIGNATURE ./~. Approved for'~'~-'~ ('~) bedrooms. Disapproved. Conditional approval for Phone bedrooms, with the following stipulations: Additional Comments //_ ;,~o~_--- ~z~u-¢._.~ Date By: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72,4)25 (Rec. 1/91) Back MOA ~'~1  Municipality of Anchorage DePartment of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: [~¢2~ "~ ~1-~::;~¢'<t~ Parcel I.D. (¢) 5~'/ A. WELL DATA Well type ¢¢1 Log present ~¢~N) Total depth Sanitary seal.N) If A, B, or C, attach ADEC letter. Date completed Cased to \ '~ ¥ FROM WELL LOG Date of test ' Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~. ~ Absorption field on lot \ ~ Public sewer main I'~ ~¢.~ Sewer service line ~ 1'3L~ ADEC water system number '~7'~ t¢ '~ (~>''Z~- Driller Casing height Wires properly protected~N) AT INSPECTION g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank 4.0 _~o WATER SAMPLE RESULTS: Coliform E;~ ¢-'~P ~'/~ "'~¢ Nitrate Date of sample: ~' ~¢-~ '- ~t~ ~-'~7 ~'~'P///~ Other bacteria Collected by: ~ ~' ~ ~-~---~" B. SEPTIC/HOLDING TANK DATA Date installed "~ ~ / '7_ ~ .~"2~-~ Tank size= Cleanouts ~) 7 High water alarm (Y/N) Date of pumping I ~:;~- ~-- ~ --- °1 ~ \ ~ ~. J Compartments . Foundation cleanout~(:~i~N) ~ Depression (Y~ ¢-4 Alarm tested (Y/N) Pumper '"~-¢ ~'~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \~ On adjacent lots ~ 6;;i~Pt ~ Foundation TO property line ~¢~/~ Absorption field Surface water/drainage 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Ve nt~..~4) "-/ High water alarm level Meets MOA electrical codes~/N) '~ SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot ~ On adjacent lots "Pump on" level at Manufacturer Manh¢.. la/Access ~) "Pump off" level at ~v~ Cycles tested /~Z::E~ Ir~ Surface water ~ L~E:::~ D. ABSORPTION FIELD DATA Date installed \ O ~ Width ' "/~T' t~a I abso r ptio n area Depression over field (Y~ Results (pass/fail) Peroxide treatment (past 12 months) Soil rating Gravel thickness ~, ~-I L~.~, f~. Total depth Cleanouts present ~) Date of adequacy test for System type bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~. ~ To building foundation On adjacent lots ~ Surface water '~ Curtain drain On adjacent lots /.~I~r- Property line 1 To existing or abandoned system on lot Cutbank ~'¢~ Water main/service line Driveway, parking/vehicle storage area 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. $ & S ENGINEERING Signature NameE~¢e River, Alasi(a ~$7~ Engineer's HAA Fee $ // /~'~ ~ Date of Payment //-- ~') '-~' ~ /~ Receipt Number ~.--~. ¢~_~- .'~-~,-~. Waiver Fee: $ Date of Payment Receipt Number APPLIC .NT FILLS OUT UPPER HA[:")DNLY Property Owner Buyer Phone Address Zip Code Lending I~stitution A[~_~.~.._~C.~ ~-~ [~ ~ ~ Realty Co. & Agent Address i Type of Resi~nce ~ Single Family ~ Multiple Family No. of Bedroo~ ~ ~ Other Zip Code Phone Phone Water Supply ~ Individual [] Community [] Public Utility Sewer Disposal ~t~ Individual Public Utility [] Holding Tank IA'CI-ACH WELL LOG. A we~l log is required for ali wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available). Year Individual Installed: ~ When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE iNITIATED. Time Time Date ~ Date ~_~/ Date Field Notes: ~(~ APPROVED BEDROOMS 'CONDITIONS OF APPROVAL '~} DISAPPROVED ( ) CONDITIONAL APPROVAL~ Soils Rating Date ~wer Installed Well To Absorption Area