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SKYLINE VIEW BLK 1 LT 21
Skyline View Block 1 Lot 21 #051-192-34 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: OSP231211 Work Type: SepticTank Upgrade Tax Code Number: 05119234000 Site Legal Address: SKYLINE VIEW BLK 1 LT 21 G:1159 Site Mailing Address: 19343 IRIS ST, Chugiak Owner: WARTMAN ADAM B & Design Engineer: C&M ENGINEERING SERVICES This permit is for the construction of: Effective Date Expiration Date S. i r fi Departmcnt Lot Size in Sq Ft: Total Bedrooms: 7/25/2023 7/24/2024 15750 ❑ 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 Reeeivez# jr _ T `5UeA fiU C`� %� Date: Issued By: e� Date: Z� Z 3 Municipality of Anchorage S __ Ur.partmerlt P.O. Box 196650 • 4700 Elmore Road Anchorage, Alaska 99519-6650 • (907) 343-7904 a Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Division On -Site Water and Wastewater Program * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV231039 COSA#: PID#: 051-192-34 Permit#: OSP231211 Legal Description: SKYLINE VIEW BLK 1 LT 21 Engineer: CM Engineering Your request for a waiver of the required 5 feet horizontal separation from the septic tank to the absorption field has been approved. The approved separation distance is,3;�S, feet. 32 g�rn w This waiver approval applies to the proposed septic tank only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. ............................................... ■ ............................. ■ 1 Waiver is Granted: X Waiver is not Granted: Date: 25 23 Approved by: Name of Reviewer **** VARIAN C E/WAIVER REVIEW **** MUNICIPALITY OF ANCHORAGE XU514 Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051 19 234 Property owner(s) WARTMAN Mailing address Site address 19343 IRIS Day phone Legal description (Sub'd., Block & Lot) SKYLINE VIEW BLOCK 1 LOT 21 Legal description (Township, Range & Section) Lot Size 15,750 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (M all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑ Septic Tank ❑ El Upgrade 0 (w/wo ADU) Duplex (D) El Holding Tank El Renewal F] Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: NONE Distance: NA I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. C&M ENGINEERING (Signature of property owner or authorized agent) Permit/Rush Fees: 4 - Waiver Fees: Date of Payment: Receipt Number: Permit No. 0SP2.3 J'2 Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc C&M ENGINEERING SERVICES Ph: 907-854-5558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Proposed Septic System for SKYLINE VIEW L21 B1 Dear Reviewer, The above referenced property is currently served by an older septic system with a leaking tank that needs to be replaced immediately. We are requesting an expedited review of this application. Our review of available documentation and field investigation show that this project will not adversely impact any nearby Wells, Wastewater disposal systems, replacement disposal sites, or drainage flowing onto and off of the subject property. As shown on the plan, the tank will be greater than 5’ from the house foundation. The tank will be of MOA approved construction. The design layout and waiver requirements are based on a Greer poly tank. The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover or a minimum of 4’ of cover without insulation. The repair must be performed by a moa certified installer in accordance with MOA requirements. We are proposing to move the tank outside of the well radius. The contractor is required to excavate lines and verify grades prior to purchasing the tank. If drop can not be achieved, we will submit a change order to set a step tank further outside of the well radius. The tank location encroaches slightly on the end of the leachfield. We are requesting the distance be waived to a distance of up 3.24’ for a length of up to 5’ of the trench wall. This will have little impact on the function of the leachfield due to the small area of impact and the very free draining soils. The options for tank replacement are extremely limited on this lot. Repair of the proposed system will not negatively impact adjacent lots. Upon completion of the installation, a record drawing will be submitted showing the location of the new tank, leach field, well, and other applicable features. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini@gmail.com with any questions or concerns. Sincerely, Charles Balzarini, PE 7/18/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231211, Deb Wockenfuss, 07/25/23 CHARLES G BALZARINI CE-13854REGISTEREDPROFESSION A L E N GINEER 7/8/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231211, Deb Wockenfuss, 07/25/23 CHARLES G BALZARINI CE-13854REGISTEREDPROFESSION A L E N GINEER 7/20/23 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231211, Deb Wockenfuss, 07/25/23 72-013 (Rev. 3178) U 0 / MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO -LECTION ENVIP,ONME.NTAL ENGINEERING DIVISION J 825 L. Street - Annhorage, Alaska 99501 Telenhone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM ANIS/OR WFI.I_ INSPECTION REPORT NAME._. PRTC EW 70 C _❑ UPGRADE MAILING ADDRESS &;�� LEGAL DFSCRIPTIONI LOCATION NO. OF BEDROOMS V _ We) Absorption ar a s Dwelling PERMIT NO. DISTANCE TO: f��� c�'-�ij UX 7 a z UJ ti Manufacturer �� � Material £ �.- No, of compartments -Z w Liq. capacity in gallons t' IF HOMEMADE: Inside length �-�-� Width --�-- Liquid depth ® DISTANCE TO: Well Dwelling PERMIT NO. Oz F Manufacturer Material Liquid capacity in gallons DISTANCE TO: Well 1 Foundation Nearest lot line PERMIT NO _ LU Q iO.�l u. Z No. of lines Length f each line / Total length of lines � / Trench widthDistance between lines A4P° inches '— H Top of file to finish grade ( Material beneath the f / Total effective abs rption area Length Width Depth PERMIT NO. w 0 Q I- Type of crib Crib diameter — — Crib depth Total effective absorption area aFL N Well Building foundation Nearest lot line DISTANCE TO: a :a CI Depth c Driller Distance to lot line PERMIT NO. LU-- DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER 4019.3- PIPE MATERIALS _ b SOIL TEST RATING vz INSTALLER REMARKS Wa IL s a — - -- I5 r - .e APPROVED /j DATE LEGAL 72-013 (Rev. 3178) U 0 THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM in-ii;� 12:1 EE 1:1 -w- 1-1 17" L. EPT INN Q 0- 1-0 "1 Q oil Fol AW, D. THE LENGTH DIMENSIOH IS THE LENGTH (IN FEET) OF THE TRENCH OR EARA INFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE BETNEEN THE SURFFiC� OF THE ��OUND HND THii,,: BOTTOM OF THE E�CHVHTION (IN FEET) THERE IS NU SET HIDTH FOR TRENCHES THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRHVEL BETWEEN THE OUTFRLL PIPE HND THE BOTTOM OF THE EXCHVHTION (IN FEET). iv? �WIN �T pl:'��E: IF.' K T=" -A- I C: ����� ����� �R. P��� PERMIT APPLICANT HH5 THE RESPONSIBILITY TO INFURM THIS �EPHRTMEHT DURING THE HNSTAIMATION OF ONY WELLS HDJHITENT TO THIS PROPERTY HND TME NUMBER OF R�SID�NCES THHT THE WELL WILL SERYE � Q! :4 ��������X Q�� ���� ��W�U 1��� �_� BHCKFILLING OF ANY SYSTEM NITHOUT F1NAL INSPECTION AND HPP1:;;!01�1.711 �Y THIS DEPHRTMENT NILL BE SI TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL HND RNY ON-SITE SENRGE DISPOSHL SYSTEM IS 10G FEET FOR H PRIVHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM H PRIVHTE WELL TO H PRIVHTE SEWER LINE IS 25 FEET 9ND TO H COMMUNITY SEWER LINE 151 75 FEET. WELL LOGS HIRE REQUIRED HND MUST BE WTURNED TO THE DEPHRTMENT WITHIN 30 DHYS O� TH� NELL COMPLETION OTHER RE1]:!1 MAY SPTi:CIFICHTlUNS RND CONSTRUCTION DIHGRHMS RRE HYHILHBLE TO INSURE PROPER N. 170 Eiz in? U-1 x "I - ET X T" Y W FEE AT Ex DEE P0 EE 1-1 ED FE FO: Zo WX J. So W2 SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION CI PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 -� SOILS LOG - PERCOLATION TEST PERFORMED FOR: �V-er&4 l_ . C_ K II✓,S DATE PER FORMED:,1u L, LEGAL DESCRIPTION: Z— rt> 5 oiLTY --,13 4 5 6 '7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS PERFORMED 72-008 (6/79) avcz- I �S W/) /5 41/gg 1 o7T0r") 0, - Robert A, rV! j , � No. 145 • ON 40FES 5") Fi r WAS GROUND WATER�S ENCOUNTERED? ((( L 0 P IF YES, AT WHAT E DEPTH? Reading Date Gross -rime Net Time Depth to Water Net Drop 5 PERCOLATION RATE TEST RUN BETWEEN CHUGIAK, ALASKA 688-3199 'A VI I L&1";RILLING 4 *0 0!kp WE SERVE ALL ALASKA POST OFFICE BOX 42 - CHUGIAK, ALASKA 99567 OWNEROF LAND.......................................................•-------........................ ADDRESS................................ ................................................................... WELL— SITE.............................................................................................. DATE— STARTED...................................................................................... DATE— ENDED............................•---...........------.......................................... KIND OF FORMATION: 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: KODIAK, ALASKA 486-4826 DEPTHOF WELL.......................................•-----......---................................. STATIC LEVEL OF WATER FT................................................................ DRAWDOWN FT......................................•-•-•---......................................... GALS. PER HR........................................................................................... KINDOF CASING..........................::.:........................................................ FROM....................... FT. TO ....................... FT.................................. FROM....................... FT. TO ........................ FT................................. FROM....................... FT. TO ........................ FT................................. FROM....................... FT. TO ........................ FT................................. FROM........ •............. FT. TO ........................ FT................................. m C O F Z FT FROM ....................... �..................... FROM......� l�. ^ Y C FT.�'64.................... FT................................. FROM........ .... FT. 7.9...---•--.......... FT ................................. FROM.........;2.....��FT. TS :? ................ FT. ................................ FROM......... ..... cta T .... ............... FT................................. I ....................... FROM....................... FT. TO FT.................................. FROM....................... FT. TO ........................ FT................................. DRILLER'S NAME................................................................................................................... SRS 41,G 0r„/ 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/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. 051-192-34 COSA# 686688 Expiration Date: :7 — / 1. GENERAL INFORMATION Complete legal description _SKYLINE VIEW. BLOCK 1. LOT 21 Location (site address) 19343 IRIS ST. EAGLE RIVER. AK 99577 Current Property owner(s) CHERYL L. CHARNESKI Day phone 907-688-9600 Mailing address PO BOX 671401. CHUGIAK, AK 99567 Lending agency Day phone Mailing address Real Estate Agent SHARI BOYD Day phone 762-5863 Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual Holding Tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ArcTerra Engineering & Surveying, Inc. Phone 868-3792 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH 111. DUFFUS Date 04/09/2008 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 occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. M 911-11II&KC32L•j1lll44 _J,ff0' Approved for _ 3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: ON-SITE • ' WASTEWATER Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other By: OX Original Certificate Date: 4-17— 0 A (R" l Municipality of Anchorage • Development Services Department _ Building Safety Division Onsite Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SKYLINE VIEW. BLOCK 1. LOT 21 Parcel ID: 051-192-34 A. WELL DATA Well type PRIVATE If A. B, or C provide PWSID # _ Well Log (YIN) y Date completed 19.62 Sanitary seal (Y/N)y Wires properly protected (YIN) y Total depth 245 ft. Cased to 40+ ft. Casing height (above ground) -15+ in. FROM WELL LOG AT INSPECTION Date of test 1982 _03/21/2008 Static water level 50 ft. 185 ft. Well production 5.0 g.p.m. 4.08 g.p.m. WATER SAMPLE RESULTS: Coliform _colonies/100mL Nitrate _5.81 mg/L Other bacteria colonies/100 mL Arsenic: NP—mg/I Date of sample: 03121/08 Collected by: ArcTerra B. SEPTIC/HOLDING TANK DATA Tank Type/Material ,+tic/Steel Date installed 07/22/1982 Tank size 1000 gal. Number of Compartments 2 Cleanouts (YIN) yFoundation cleanout (Y/N) Y Depression over tank (YIN) ly High water alarm (YIN) N_Date of pumping 03/21/08 Pumper $AnjUU C. ABSORPTION FIELD DATA Date installed 1982 Soil rating (g.p.d./ftp or fethdrm)11L System type Dye Trench Length g}fL Width _2 ft. Gravel below pipe gft: Total depth a ft. Eff. absorption area a17,fe Monitoring tube Y Date of adequacy test 03/21/08 Fluid depth in absorption field before test Q- in. _ Depression over field N Results (Pass/Fail) _Pass For Lbedrooms Water addedA7Q gal. New depth 221in. Elapsed Time: l5min. Final fluid depth Q in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) NIf yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN) "Pump on" level at—in. 'Pump off" at_in. High water alarm level at—in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: i Septic tank/lift station on lot 1ee1f* q 0 On adjacent lots 100'+ Absorption field on lot 100'+ Public sewer main 75'+ Sewer /septic service line 25'+ Animal containment areas 101+ On adjacent lots 100'+ Public sewer manhole/cleanout 1001+ Holding tank 100'+ Manure/animal excrete storage areas 1001+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 51+ Absorption field 51+ Water main 101+ Water service line 10'+ Surface water 1001+ Wells on adjacent lots 1001+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 101+ Water main 10'+ Water Service line 101+ Surface water 1001+ Driveway, parking/vehicle storage 10'+ Curtain drain 10'+tNoneKnownl Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION V-* I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name KENNETH M. DUFFUS I�44 Date 04/09/2009 COSA Fee $430.00 Date of Payment Ll I glQ���� Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number ir. Tr .6/ _ ;a Municipality of Anchorage • Development Services Department Building Safety Division —� On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 080088 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 1, Lot 21 of Skyline View subdivision. This inspection revealed a nitrate concentration of 5.81 milligrams per liter (mg/L) was reported for the property's well water sample. 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. a•: :. • ly*� a s� 'zo N o, t a�y� USG �0 tA.rT. M • iYErE�PT/F/G.9T/Gy/ L� �S ASBUILT-NO CORNERS SET THIS DATE. SEWARD & ASSOCIATES LAND SURVEYING 688-4566 1 HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE, FOLLOWING DESCRIBED PROPERTY: /��-to ` Kt pF Ate � s�FO• torzi Ez v / DATEl AND THAT NO ENCROAC4I ENTS EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE '`� TM OWNER TO DETERMINE THE EXISTENCE OF ANY GRID �" •••••• ....... EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI- ♦ousns e.t s.�.E j VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB' �M 1�. •, tS- 9 fi AV ANY DATA HEREON BE USED FOR CONSTRUCTION �- -� ♦f `'2y OF FENCE LINES, OR FOR ESTABLISHING BOUND- ZD,�� + � ARY LINES. DRAWN: ��*q'w T'� Municipality of Anchorage CO. Ik..c 196650 • Anchorage, Alaska ffik51)•6650.47(X) Ehuorc %, al Office. (tX)7) M1b9."M • Ivs: (!X)7) 34.3-M) help://xM�c.munl.org Mayor Mark Begich Dcvcloluncrlt Services Dcparimcnt April 18, 2008 Kenneth M. Duffus, P.E. KND Engineering, Inc 20441 Ptarmigan Blvd. Eagle River, AK 99577 Subject: Waiver Request for Skyline View, Block 1 Lot 21 Waiver Request WRt1: 080019 Parcel ID 4 051-192-34 IIA080088 Dear Kenneth M. Duffus, P.E.: Ment Y�Sl^L rfi11J J Department Your request for a waiver of the required 100 feet horizontal separation from the septic tank to the private well has been approved. The approved separation distance is 94.0 feet. This waiver approval applies to the existing septic tank to private well separation only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. If there are any further concems or questions regarding this waiver, please call our office at 343-7904. Sincerely, /t�G` Gilot� Deb Wockenfuss Civil Engineer On -Site Water & Wastewater Program C0111inunity, Security, Prosperity Municipality of Anchorage Development Services Department • Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchoragc.ak.us (907)343.7904 Waiver Review Worksheet WR#:080019 PID#:051-192-34 HA/Permit# IIA080088 Date Received: April 18, 2008 Legal Description: Skyline View, Block 1 Lot 21 Engineer. Kenneth Al. Duffus, P.E. KND Engineering, Inc 20441 Ptarmigan Blvd. Eagle River, AK 99577 Applicant: Cheryl Charneski Waiver Requested: 94' between the well and septic tank. Criteria: Geology A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Points: 7.4 3.3 1.5 0 2.8 Total: 15.3 r......................................................................... Waiver is Granted: X Waiver is not Granted. List Conditions or Reasons for above: See attached worksheet. Date: 4/18108 By: Deb Wockenfuss Name of Reviewer Rec#:01 6971 Amount: $920 Dale Paid: 4118t2008 Skyline View, Block 1 Lot 21 Parcel ID: 051-192-34 Waiver for 94 feet from tank to well Issued April 18, 2008 General 1. From the water sample, total coliform was 0, and total nitrates was 5.81 mg/L. 2. The well head Is located upgradient of the septic system. Any overflowing sewage would move away from the well head. 3. The location of the system is in a visible area and any surfacing effluent will be seen and corrected. ADEC Criteria Points Water Table Depth of static water level in well 185 feet Assumed bottom of tank 9 feet 176 feet 1'(76/190) + 7 7.4 Soil Sorotion Soil descriptions from well log of subject property Permeability Soil descriptions from neighboring well log for subject property DEC PTS Depth From Depth To Thickness Caic. Pts Sand and Gravel 0.75 9 34 25 0.11 hardpan 6 34 84 50 1.70 Sand and Gravel 0.75 84 96 12 0.05 Clay 6 96 103 7 0.24 Hardpan 6 103 165 62 2.11 Clay 6 165 185 20 0.68 176 4.90 4.9 Permeability Soil descriptions from neighboring well log for subject property Horizontal Seoaration 94 feet between septic tank and well x=19/25+2.0 Total Points 15.3 2.76 As per ADEC waiver guidelines, with a point value of 15.3, no bacterial pollution is possible but chemical pollution is possible but unlikely from household chemicals. DEC PTS Depth From Depth To Thickness Calc. Pts Sand and Gravel 1 9 34 25 0.14 hardpan 0 34 84 50 0.00 Sand and Gravel 1 84 96 12 0.07 Clay 0 96 103 7 0.00 Hardpan 0 103 165 62 0.00 Clay 0 165 185 20 0.00 0 0.00 176 0.21 0.2 Water Table Gradient - Engineer wishes to assume the worst case scenario. Assume - 0.0 Horizontal Seoaration 94 feet between septic tank and well x=19/25+2.0 Total Points 15.3 2.76 As per ADEC waiver guidelines, with a point value of 15.3, no bacterial pollution is possible but chemical pollution is possible but unlikely from household chemicals. i ;' '•, � .. - _ - r ,,a. ... r_ �� . _ky f.�I-" T � i ii 1 �. L ✓�� 9 t t ,. � _- •. .. � i ,... G; - .. . - _ .. 1 s �:. _.. __ „��_�f ._.1. - . �.- __ .�� - � - ,5�� ,,��r d. ;.'. i'. 1' �� �� �� i �. . e•� Ds' 1' - • 1 r ,_ ,. 1 •M��L' . t 4'. ,. 1 . f �� �I � d � � 7. �sv�� j. ... AAROW PUMP & WE11 SERVICE, LLC P.O. Box 110496 Anchorage, AK 99511 Office: (907) 346-9355 • Fax (907) 333-8976 Eagle River: (907) 622-9335 CUSTOMER r J3 e f / l L iNOCAe ILL A, 0. 800( (1,� -2rt/o q 5 / C "!1 a lir A/ ? / ~y % L INVOICE N° 07991 // JOB SITE -1 5`�0t /37ya/ RD 7-0/32 12 31/ 3 r; s , Ritc. Awed J L-76a-�si6 (-l/ 1?CQ DATE O � WELL DEPT/ SwL/ �+/� / VX CHI�DjMATEO PUMP DEPTH SR'1OS`O-N fff/✓S OUAAMtTY DESCRIPTIIOONd�y PRICE - AMOUNT A /. r100 LA ve r Cr to -e ev ,l LABOR HOURS RATE AMOUNT TOTAL MATERIAL TOTAL LABOR VIORK ORDERED BY DATE COMP. TOTAL LABOR PAY THIS AMOUNT Thank You SIGNATURE (I Hereby Acknowledge the Satisfactory Completion of the Above Described Work and agree that If above work is not paid for In 90 days I agree to allow Aarow Pump & Well Service, L.L.C. the right to remove unpaid for equipment and charge for labor already performed & labor to remove unpaid for equipment.) TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS. April 14, 2008 ARXERRA Jeff Poet, On -Site Engineering Technician Municipality of Anchorage Development Services Department On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 AND SURVEYLNG, INQ RE: SKYLINE VIEW BLOCK 1, LOT 21— WELL/SEPTIC TANK WAIVER Dear Jeff, Per your request, we have re -verified the separation distances between the septic tank to the well located on the referenced lot. Per the Mark Seward, LS as -built survey dated March 25, 1993—the septic tank first compartment cleanout was measured at 96'+/- to the subject property's well. We are therefore requesting that a waiver to 94 feet between the referenced well and septic tank be granted at this time. This well and septic are located on the opposite sides of the house and have been in operation for 26 years. Per ADEC Separation Distance Waiver Guidelines for SCRO: • Water Table (185' static water level on 03/21/2008) • Soil Sorption (See well log) • Permeability (See well log) • Water Table Gradient (0%) • Horizontal Separation (94) 7.40 points 4.70 points 2.40 points 2.00 points 2.70 points The point total indicates that the well would almost sure to be free or no contamination possible from any form of household sewage contamination. It appears that the elevated nitrate levels (5.81 mg/L) of the recent water analysis of March 21, 2008 are not just isolated to the referenced well, but to the local area in general. WAIVER FEES: 99-y DATE OF PAYMENT: OS RECEIPT NUMBER: 106271 SKYLINE VIEW, BLOCK I, LOT 21 April 14, 2008 Page 2 of 2 We respectfully request that the waiver and the Certificate of On -Site Systems Approval be granted. If you have any questions or require additional information, please contact me at 868-3792 / FAX 868-3793. Respectfully, ATt'SR:= Engineering & Surveying, Inc. Kenneth E. 20441 FTARJIICAN BIND • EAG ME RIVER, AK 99577-8736 • 1111(907) 868-3791 • FAX (907) 8683793 Municipality of Anchorage 0 Development Services Department Building Safety Division k;^ 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. 051.192.34 HAA # & U / 0,5r<3 Expiration Date: ::)— - /3- O f 1. GENERAL INFORMATION Complete legal description ; SKYLINE VIEW BLOCK 1. LOT 21 Location (site address or directions) 19343 IRIS ST. EAGLE RIVER, AK Current Property owner(s) VALERIE WEAVER Day phone 552.4698 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address o_V_ AV ;7-7-zic1!e Day phone BONNIE KING WI KING REAL ESTATE Day phone 688.2276 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ 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 Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results 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 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. Name of Firm KND Engineering Phone 696-6111 Address 20441 Ptarmigan Blvd. Eagle River, AK. 99577 Engineer's Printed Name Kenneth M. Duffus Date 11/07101 5. DSD SIGNATURE Approved for 3 bedrooms. Disapproved. Conditional approval for EER S bedrooms, with the following stipulations: %1 P Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: /!v/ �(-i% I �*-✓/ Original Certificate Date: (Rev. 12h1o) Municipality of Anchorage • Development Services Department Building Safety Division On-Site Water & Wastewater Program ' • "' 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Skyline View Block 1. Lot 21 Parcel ID: 051.19234 A. WELL DATA Well typerip Kate If A, B, or C provide PWSID # _ Well Log (Y/N) Y Date completed 1982 Sanitary seal (Y/N) Y Wires property protected (Y/N) Y Total depth eft. Cased to 40+ ft. Casing height (above ground) 18'+ FROM WELL LOG AT INSPECTION Date of test 1982 811101 Static water level 50 ft. 185 ft. Well production 5.0 9-p.m 5.29 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 2.91 mg./I. Other bacteria 0 colonies/100ml Date of sample: 10124101 Collected by: KND Engineering B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Date installed 7122182 Tank size 1000 gal. Number of Compartments 2 Cleanouts Y_ Foundation cleanout 1(_Depression over tank N High water alarm NA Date of pumping 811101 Pumper J.R.S C. ABSORPTION FIELD DATA Date Installed981_2 Soil rating (g.p.d./ft' or fe/bdrm) 115 sg.ftJbdrm System type TRENCH Length 44 ft. Width 30 ft. Gravel below pipe 4.0 ft. Total depth §_ ft. Eff. absorption area 352 f? Monitoring tube Y Depression over field N Date of adequacy test 811101 Results (Pass/Fail) PASS For 2_ bedrooms Fluid depth In absorption field before test QqY_ In. Water added45O gal. New depth24 in. Elapsed Time: 15 min. Final Fluid depth DRY in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date D. LIFT STATION Date Installed NA Size in gallons Manhole/Access (Y/N) 'Pump on" level at _ in. 'Pump off" level at _ In.High water alarm level at In. Datum Cycles tested Meets alar & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 1001+ Absorption field on lot 100'+ On adjacent lots 1001+ Public sewer main 751+ Public sewer manhole/cleanout JD0'+ Sewer /septic service line 25'+ Holding tank 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line'L"+ Absorption field _ 5'+ Water main 10'+ Water service line 1D'+ Surface water 1001+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 25'+ Curtain drain 50'+ Wells on adjacent lots 100'+ F. COMMENTS /���l�t�� i -`-_c OF Al _ 1. G. ENGINEER'S CERTIFICATION I certify that I have determined through yield inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineers Printed Name Kenneth M. Duffus J � 1t r 9Li ty� ?' .rte to 1r'rebtia ,. t r' Date 11107101 HAA Fee $ 30 O Waiver Fee $ Date of Payment f/ 0-7/0 1 Receipt Number r'Z5r85 (Rev. 12100) Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES ram Division of Environmental Services low 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 1. D. # � - � C)a' HAA # 1. GENERAL INFORMATION Complete legal description Lot 21; Block l; Skyline View Subdivision Location (site address or directions) 19343 Iris street Eagle River AK Property owner Scott Cottrell Day phone 688-0104 Mailing address P.O. Box 670613 Chugiak, AK 99567 Lending agency Day phone Mailing address Agent Caroline Greiner/ Remax of Eagle River Day phone 694-4200 Address Unless otherwise requested, HAA will be held for pickup. 2. 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. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xxx 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 021 5. I STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S & 5 ENGINEERING Phone Cir N -P-0j ? 17034 Eagle River Loop Road No. 2D4 Address Eagle River, AlaskR 995ZZ d Engineer's signature DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for Additional Comments EWA Date S_ ), /9 S' -n 1 ROBERT C. COWAN t CE -8801 bedrooms, with the following stipulations: 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 Stateof Alaska. The DHHS does this as acourtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-M (Rev. 1/91) Back MOA #21 RECEIVED Municipality of Anchorage �,My 0 4 1998 2 0*DEPARTMENT OF HEALTH & HUMAN SERVIC Environmental Services Division MUNICIPALITY OF ANCHOw,Ge 825 L Street, Room 502 • Anchorage, Alaska 99501 ErNYRgVri 5 P44Es DIVISION Health Authority Approval Checklist Legal Description: LOT ZI Sial;„,(,ylt�u Qo Parcel I.D.: A. WELL DATA Well type Egi VANE _ If A, 13, or C, attach ADEC letter, ADEC water system number Log present (9N) 65 Date completed / r1 Total depth �� Cased to0� Casing height (above ground) /R f Sanitary seal (79N) FROM WELL LOG Date of test Static water level Well production GJ. 0 WATER SAMPLE RESULTS: Wires properly protected(9N) V65 AT INSPECTION g.p.m. -4.1 g.p.m. Coliform C�� Nitrate 3.57- Other bacteria 0 5 & S ENGINEERING Date of sample: yq Collected by: Z�F IZO34 Figle Rover r o� p Ro?d N,,,2p4 ;ale River, Alaska 99577 B. SEPTIC/HOLDING TANK DATA Date installed W, _ Tank size _j6W Number of Compartments CleanoutsON) W-5 f1f,fWW14 '(APIC j fl WAI A Foundation cleanout&) �jge7 Depression (Y/@ rJO High water alarm (yd r ' Date of Pumping 410190 Pumper jig C. ABSORPTION FIELD DATA Date installed _ Soil rating (g.p.d./ft2 or ft2/bdrm) ll518R_ System type IJr✓�� Length J:j Width 56 Gravel thickness below pipe 4 Total depth g 2 Effective absorption area Monitoring Tube present(&)–V5 Depression over field (Y'o Date of adequacy test Results as Fail) PA55 For, )HOE bedrooms Fluid depth in absorption field before test (in.); J)Li�t4— Immediately after .77� gal. water added (in.): W' Fluid depth ��_ (ins) Minutes later: _51�_ Absorption rate = g.p.d. Peroxide treatment (past 12 months) (Y/N) orve ou*► If yes, give date 72-026 (Rev. 3/96)* D. LIFT STAT Al Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot (W + On adjacent lots Absorption field on lot Inca On adjacent lots 1 bo Public sewer main tJ�A Public sewer manhole/cleanout r1�A I Sewer /septic service line 'L5 r Lift station `ill, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation �i + Property line 10 t Absorption field t� Water main/service linei� Surface water/drainage 40d' -� Wells on adjacent lots 100, fi SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line lo building foundation t0 ft Water main/service line _ Ib Surface water p I Db 1+ Driveway, parking/vehicle storage area 10 `t Curtain drain tJ nr4 e d0:!4rA Wells on adjacent lots JOC2 rt F. ENGINEER'S CERTIFICATION i certify that 1 have determined thru field inspections and review of Municipal in conformance with H7guidepes in effect on this date. Signature � Engineer's Name lV 6q rL✓ZT Cl0 UV Date S /r / 01 1 HAA Fee $ 300-00 Date of Payment ` / l Receipt Number 0 3-� OZ g 7 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number ROBERT C. COWAN , are 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 furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water ol supply and/or wastewater disposal system'is in with all Municipal and State codes, ordinances, and regulations in effect on the date `of this inspection. Name of Firm s A S ENGINURING, Phone 17034 Eagle River Loop Road Mm 204 Address Eaalo Engineer's signature - Date 2,4 19 ,t'-' p t , pt Ilii'. `{c4°•,t{�, .•ir,�ni��•. `4°..>l• .: l I ROURT C. COWAN s tr. yj t:• • CE - 8801 + i' vnNNlWvallvci unk:ayca yaac Willy uNWn MV icNIVQWIIaauWnw y,vml III tjQIQy,aNll U auuVa Uy all n,ucNcnucnL - rt"413 Of ssional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes an'44 el tendril institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not coin" 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. ' 72-0= (Rm. 1/91) Beck MOA #21 , Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L -C --"f 21 f`JL-4 I 5v-�L_( 1'`a Parcel I.D. A. Well Data Well type F{��P�S% If A, B, or C, attach ADEC letter. ADEC water system number IIb Log present ON) Date completed \' 1 Driller X'X�s Total depth s Cased to LAD`4- Casing height Sanitary seal 6N) Date of test Static water level Well flow Pump levell FROM WELL LOG So E SEPARATION DISTANCES FROM WELL TO: Wires properly protectedON) �/ ... AT INSPECTION z 1 4 to` rill CD ( o �.p.m. 1p .3 F _J g.p.m. < '__05 z �Ft 1p rn f � k Z < N_ C rt z_ Septic/holding tank on lot t 0 o � � ; On adjacent lots 1 b c>\+ Absorption field on lot 1 no ; On adjacent lots k l c�o� Public sewer main � Public sewer manhole/cleanout 4 Sewer service line 2S tk Petroleum tank ZS WATER SAMPLE RESULTS: Coliform D Nitrate Z.S Date of sample: 1-2� -`lam �Z�1 - `I� Collected by: B. SEPTIC/HOLDING TANK DATA Date installed 1 11d-1-- Cleanouts(&N) Tank size ) oe:� Foundation cleanout(WN) Other bacteria S & S ENGINEERING !7034 Eagle Rivep Loop Read No. 204 Eagle River, Alaska 99577 Compartments Z Depression (Y/(W High water alarm (Yt� ^� Alarm tested (Y/N) Al A Date of pumping 2 -2 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: per .:�- SPoo L_ Well(s) on lot l oa t -F On adjacent lots t 0� to Foundation To property line 1' Absorption field 5 Surface water/drainage 72-026 (3/93)* Front Water main/service line CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION 015TAICE FROM LIFT STATION TO: on lot D. ABSORPTION FIELD DATA On adjacent lots Manufacturer Manhole/Access (Y/N) Cycles tested off" Level at Surface water Date installed l -I SZ Soil rating (GPD/Ft2) 115 �'/15c.- _System type Length �Width `�_,' Gravel thickness Total depth e.�' Total absorption area Cleanout present ON) Depression over field (YIW ti Date of adequacy test 2- 1 --,1 7 Results fail) fPc-�, s for Bedrooms Water level in absorption field before test 11 C) After test �I Peroxide treatment (past 12 months) (Yo V-,. o,,� � If yes, give date ►� `A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 1 045> k On adjacent lots 10 o Property line Is ' To building foundation C�� To existing or abandoned system on lot On adjacent lots �� Cutbank ' Water main/service line 1 0 E Surface water 1 c)o t Driveway, parking/vehicle storage area Curtain drain FID. E. ENGINEER'S CERTIFICATION 5-e k k /certify that/ have checked, verified, or conformed to all MOA and HAA guidelines in effegj mom"Zta t(�of this inspection. Signature ����✓/ Engineer's Name �a�¢.2.7 - Co wJ4�✓ Date HAA Fee $ 06 , 0,P Date of Payment _�=7-" 9,s— Receipt Number 72-026 (3/93)' Back U Waiver Fee $ Date of Payment Receipt Number P011' T CE -8301 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. # LJ) )1 1 c1 Q -2A HAA # VJ G)9 )C)1 1. GENERAL INFORMATION Complete legal description Lot 21; Btodk 1'; ' Sk.yZine View 19343 I)Li.e Chugiak, AK 99567 Location (site address or directions) 19343 Ikisa Chugiah, A.Ca6ka 99567-- -- -- -- Property owner Matk KeUy Day phone 688-9861 Mailing address Bax 911, Chu.giak, AK 99567 Lending agency Mailing address. Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 �N 3. TYPE OF WATER SUPPLY: Individual well XXXy Community well Public water Day phone Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX 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 H21 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 furtherverify 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 ENGINEERIN ? Phone Name of Firm 3 Address Eagle River, Engineer's signature 204 6. DHHS SIGNATURE 4-_ Approved for _3 bedrooms. Disapproved. Conditional approval for �Ort2.� Additional Comments Date )es ' `) Y ", ��•;.tip•% ,' '' o.'N f' bedrooms, with the following stipulations: %IITIC The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-0251Rev, 1/91) Back MOA 921 Municipality of Anchorage Department of Health & Human Services �} HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: 1 x �Parcel I.D. A. WELL DATA Well type &VdAf[i� If A, B, or C, attach ADEC letter. ADEC water system number tL Log present (Y N) Date completed `1-b-�_ _ Driller Total depth 2A15 Cased to qo } Casing height X21, Sanitary seal ©'N) Date of test Static water level Well flow Pump level FROM WELL. LOG l0%162- sb J f� o SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot \ o o 1 Wires properly protected(a/N) AT INSPECTION ✓ 3 r 2 S-` ?3 gy 168' 7 L 3o Z n o r'P1 g.p.r�' 3� y �k g. p. � N f n LJK I/" Un rT1 C44 N� On adjacent lots \ om Absorption field on lot \ o O ; On adjacent lots Public sewer main a Sewer service line ZS%)r- WATER SAMPLE RESULTS Public sewer manhole/cleanout Petroleum tank Coliform b 1100 h 9 Nit'r d �� `� • Other bacteria 3 , ,� , ra e S & S ENGINEERING Date of sample: Collected by: 17034 Engle R ,0QPaR*ad No 204 Eagle River, Alaska 99577 S. SEPTIC/HOLDING TANK DATA Date installed SCA % "2' Tank size Compartments Cleanouts (2)fN) Foundation cleanout('�YN) -,I_ Depression (Y/gb _ High water alarm (Yo t1 Alarm tested (Y/N) 1 Date of pumping `S' Z (� Pumper 1�5 �J ?-t P EQ -5 " SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: k lk �) Well01 o k s) on lot � On adjacent lots \0 o Foundation To property line It Absorption field 115' Water main/service line �b Surface water/drainage _ \ o 0 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) Meets MOA electrical codes (Y/� SEPARATION �ANCEM LIFT STATION TO: lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested . Surface water _ Date installed Soil rating �_�s ��- _System type's Length ��t Width 3 �'� / Gravel thickness 1 Z Total depth t Total absorption area Cleanouts presentoYN) J Depression over field (Y/N — Date of adequacy test Results ass ail) yds 1 for -T-A 6.� -5) — bedrooms /I Peroxide treatment (past 12 months) ( ) o-�ro V-Aoy& &� If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot o a tOn adjacent lots— leo 1 Property line k 1 To building foundation 1 0 1 To existing or abandoned system on lot `p On adjacent lots ''0 Cutbank a IN —Water main/service line lu�� Surface water t d o Driveway, parking/vehicle storage area �a t Curtain drain Akc E. ENGINEER'S CERTIFICATION I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature S & 5 ENGINEERING -17024 Eag a River Loop rr oop Road No. 204 Engineer's NaRVle River, Alaska 99577 Date �_, HAA Fee $ 17 D ` cFL' Date of Payment 3 Receipt Number �� S 72-026 (Rov. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number APPLIC W FILLS OUT UPPER HAL ONLY Time Property Owner #-;f/'f'_ fQ { if �•. �' , c.J� % �_U l�> �• C'fJ/A f;, J Phone Mailing, ddressj�;X /. Zip Code Date ,.� �i Date Date (-�' Buyer' 41/xvr,/.,. Jr)- 1, -�a LA40. Address ��y ,;/� ;, - ,. Zip Code Inspector Lending Institution ��.� ./,:��/(i �t,•/a /.-fJ���. Phone Address _ /- . Zip Code 2(j, Realty Co. & Agent ,.;r ' f -��f ..-/ � .._.. JY-��'. Phone Address '!- > a - , � ..�.. ,� Zip Code �l % ...- "l lz%[ 'e Legal Description Yrci Field Notes: Street Location Type of Residence ENVIE: ; i;, :I .,A. ! ,O F J EJ -Single Family l ❑ Multiple Family No. of Bedrooms ❑ Other RKE IV ( 3) APPROVED BEDROOMS Water Supply ( ) DISAPPROVED P,Individual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. ❑ Community For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility DATE Sewer Disposal BY: 0 -Individual Year Individual Installed: Date Sewer Installed ❑ Public Utility When Connected to Public Utility: ❑ Holding Tank Well to Tank Septic Tank Size [ ovo NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. M crt�q _('�' Time Time Time Time Date Date Date Date (-�' Jr)- 1, -�a LA40. Inspector Inspector Inspector1(�) Inspector �\ A. Yrci Field Notes: MUNICIPALI-IY OF ANCHORAGE ENVIE: ; i;, :I .,A. ! ,O F J RKE IV ( 3) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( )CONDITIONAL A OVAL' �� '� r Y{ DATE BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received I -� i�2�-" Well to Tank Septic Tank Size [ ovo 72023 (3162)