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HomeMy WebLinkAboutARVESON LT 1Arveson Lot 1 #015-273-06 �. Municipality of Anchorage DEPATTMENT OF HEALTH & ENVIRONMENTAL PROTECTION POUCH 6.650 ^ ANCHORAGE, ALASKA 99501 INSPECTION REPORT ON ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL NAME WCL � _Vk 'r -W R LOCATION Jr-_R0TTIE RV -I -18d''1 ADDRESS S.R A Q�30x PERMIT NUMBER LEGAL DESCRIPTION PHONE(S) 3[�gti 0_0LEGAL 1:I AQ.\3E50IJ *OF BEDROOMS SEEPAGE SYSTEM ❑ TILE DRAINFIELO A ;�.4 vrS LENGTH EACH T A 3�u DISTANCE BETWEEN LINES TRENCH WIDTH DEPTHS: IFILLBELOWTILE TILE TO GRADE ENEEN FILL ABOVE TILE ❑ SEEPAGETRENCHOR ❑ PIT`, 01 A NIA N 1A WIDTH LENGTH DEPTH l i ::L V-1 ❑ LOG CRIB I ❑ RINGS - DIA. FILL MATERIAL DEPTH TOTAL FF . ECTIVE ABSORPTION AREA: SPA- $0. FT. WELL REMARKS (Z \`S `�� DATE `X\ APPROVEDB 4%)IZ_ 72012 (9/77) SYSTEM DIAGRAM I , ENEEN i i i l i SYSTEM DIAGRAM I , i i i l i I , I i � i t ; f LOT: I BLOCK: SUBDIVISION: `QV,Esor3 Il�1' DEPHR.TMEN'f 0`01iEALTH AND ENVIRONMENTAL F'^'fECTIUN '825 'L oTREET ANCHORAGE, AK. 99' - 'i 279-2511 WELL ""L> Clt-J—E I I-EF-EEwkte� _kF-Lf;�-r-l:c - PERITI I NO. ' ( 77847 ) n Y ' APPLICANT kIIL�EP. UITTBREFJDER SP,N BOY, 47o Y LUUHT IUN JL Vl'lt N LEUHL L1 HRVESON SD LOT SIZE 'TYPE OF SOIL HBSURBTION SYSTEM IS: TRENCH �n � a °3UfIn MAXIMUM NUMBER OF BEDROOMS = 3 SOIL THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: a/ 349 22- • s� 160O SQUARE FE -1 )J): ff\l )p- V& •)_ �s J�(18 L]EF"-1-H= 121 2.4 CiiF:11ti:'EL LIEF' 7 H= Lam.' THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF H TRENCH OR PIT I5 THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AFJD THE BOTTOM OF THE EXCAtiiATION (IFJ FEET). THERE I5 NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH I5 THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFHLL PIPE AND THE BOTTOM OF THE EXCAVATION (IFJ FEET). f?Et-!L_! 11-SEL7 QEF•"1" I C "I-F=it+lf� E• I �E= 14 -+►-+ate l �HLLUt,f�: Fst�CF�HGE F•LFit•JT t7iF'T I cjrj .A PACKAGE PLANTMAY BE INSTALLED AT THE PER.MITTEE'S OPTION SUBJECT TO THE FOLLOWING CONDITIONS: 1. EITHER A CLASS I OR II NSF APPROVED PLANT MAY BE IFJSTHLLED. 2. H CONTINUOUS MAINTENANCE AGREEMENT IS REQUIRED. IF A MAINTENANCE AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED TO ENLARGE THE SOIL ABSORPTION SYSTEM AND/OR YOU MAY BE SUBJECT TO PROSECUTION. ' ---------------------------------------- -1 - -1-WCI C 2 ] I t+1�F-ECT I ut+IS. RF — F-: - !l_f I REO --- BHCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE l•JELL COMPLETION. OTHER REQUIREMEFJTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE HVHILRBLE TO INSURE PROPER INSTALLATION. F-EF-ZM I T EXP' I FEES OE9!'EME3ER 31s 1•_ r r I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMEFJTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: 1 WILL INSTALL THE SYSTEM IFJ ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE I5 REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. ' SIGNED: -A4ze-j/--luwliln4- ISSUED APPLICANT WILBER DITTERENDER e> V3. 0 v �\, 1 GARY PLAYER VENTURES CONSULTING GEOLOGIST BOX 476-M, STAR ROUTE A • ANCHORAGE, ALASKA 99307 • PHONE 344.7071 SOILS LOG 0. F# ed for W II�IJ�JPJV�O tJ( Date � S/-7 0 2 4 6 16 18 20--,, Total Depth of Excavation _Material at Total Depth �II�J Soil Type Water Level Remarks 5M SolMd cii Gvtwcl C'leo„, Sows j I- s' ( Ianis a is o 1posJtova o-� 6w Groundwater 0 Not Reached Depth, if Reached Classification Method �Q visual () Sieve Analysis Bedrock 0 Not Reached Depth, if Reached Qj Gary F. Player, Consulting Geologist GARY PLAYER VENTURES S CONSULTING GEOLOGIST BOX 476•M. STAR ROUTE A • ANCHORAGE. ALASKA 99507 • PHONE 344.7071 Performed for W� Location �— 0 '- I o' wo l\ 0 2 4 6 w 8 v w M 10 --'•c�-12 a a 14 16 18 20 Soil Type Water Level SOILS LOG v es Suko Remarks 1 /'1'/-7-1 V -C Total Total Depth of Excavation IL Material at Total Depth Groundwater Bedrock Not Reached kNot Reached Depth, if Reached Depth, if Reached Classification Method Visual G 'z' ( ) Sieve Analysis ( ) Gary F. Player, Consulting Geologist S wv-'A G\'eoW�) W e \` Sw Ci (a.,u e \ c \-e� , w 0- G W Total Total Depth of Excavation IL Material at Total Depth Groundwater Bedrock Not Reached kNot Reached Depth, if Reached Depth, if Reached Classification Method Visual G 'z' ( ) Sieve Analysis ( ) Gary F. Player, Consulting Geologist a E r'.�sE 0 Vol .�o Oen' tn�t'i .... 1405 West 15th Aw. ZIA Anchonpe, Alnki 99501 . 9070011 IN� .DIV 1277 807 / 177 1001 START/Q DATELETE �� TIME - DRILL LOG CASINGDRILLING /U Sor / / i ' k G /.. NAMEuJiMOR 1211-N0. J ( �% d " PHONE / JOB LOCATION [ )u �) .0"edlyl TIME WELL LOG DEPTH - WELL LOG 211 10,414910 v o , A F1 J71 y' - STATIC LEVEL /�,S / GPM•VIELD Municipality of Anchorage On -Site Water & Wastewater Program (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 015-273-06 Expiration Date: A, G 1. GENERAL INFORMATION Complete legal description ARVESON S/D LOT 1 Location (site address) Current Property owner(s) Mailing address Real Estate Agent 11100 JEROME STREET, ANCHORAGE AK, 99516 JEFFRY & NATALYA JABUSCH Day phone 301-3852 11100 JEROME STREET, ANCHORAGE, AK, 99516 JAY OSBORNE W/ REAL ESTATE BROKERS OF AK Day phone 2. TYPE OF DWELLING: Single Family (w/wo ADU) g ❑ Duplex UB10V1ITTA ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 MAR 4 2914 345-4563 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site n Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: nZa / / Distance: Receivedby: t Date: 3 A01f- COSA to be released to the en//e.,, unless otherwise requested by the engineer. COSA Fee $�5 Date of Payment N r Receipt Number �r f )Nrl �r COSA # (/ iq1 C)(0 T Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the C'er'tificate 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 GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK, 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local sods condition, groundwater levels that may fluctuate during the year, and the water usage o1 the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 6. DSD SIGNATURE System #1 Approved for 3 System #2 Approved for Disapproved. Conditional approval for bedrooms. bedrooms. bedrooms, with the following Phone 337-6179 Date f Q� lIof r y Ay�A. C�rn'e- . rC5-7Q53 e G s I c0 lr" e -. LI l.Gp ' ry to � 4�t\�Professioo 00 Original Certificate Date: \\\llllillll(!!( OF Mcy`� Ows\li ��'c� WP�E WR ER o= �AgTE Q aM �; _<S Th M nicipality or Anchorage Develop, emit Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upo the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTCHMENTS: COSA Checklist Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other (Rcv 11rtK1 If more than 1 septic system is on the lot: COSA Checklist # _of_ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: A. WELL DATA ARVESON S/D; LOT 1 Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 12/13/1977 Sanitary seal (Y/N) YES Total depth 172.33 ft. Date of test Static water level Well production Cased to 17233 ft. FROM WELL LOG 12/13/1977 120 ft WATER SAMPLE RESULTS: Coliform U colonies/100 ml. Arsenic: JLla- ug./L. B. SEPTIC/HOLDING TANK DATA N itrate U• 13 qmg./L. Parcel ID: 015-273-06 Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 2/21/2014 124 ft Date of sample: 2/20/2014 Tank Type/Material SEPTIC/STEEL 4.42+ Collected by: GEG, Ltd. Date installed 10/24/1977 Tank size 1000 gal. Number of Compartments E Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) N0 �1High water alarm (Y/N) N/A Date of pumping 9/12/2013 Pumper S I + PUMPING C. ABSORPTION FIELD DATA Date installed 10/24/1977 Soil rating (g.p.d./ftbr /bdrm 1125 System type TRENCH Length 24 ft. Width 3 ft. Gravel below pipe 8 ft. Total depth * 17.9 ft. Eff. absorption area 384 ft2 Monitoring tube **YES Depression over field NO Date of adequacy test 2/21/2014 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test <61 in. Water added 1355 gal. New depth <61 in. Elapsed Time: = min. Final fluid depth <61 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date **MT ONLY EXTENDS 2.92' INTO EFFECTIVE DEPTH. TOTAL DEPTH AND LIQUID LEVELS ARE CALCULATED BASED UPON LATERAL LINE INVERT ELEVATION SHOT. SUFFICIENT WATER WAS INTRODUCED TO DEMONSTRATE THAT THE DRAINFIELD ABSORBED AT LEAST 450 GALLONS DURING TEST PERIOD (335 MINUTES). DEFICIENT MT NOTED ON PREVIOUS COSA AND HAA APPROVALS. D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN)_ "Pump on" level at in. "Pump off' level at wa er alarm level at Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot *82+ On adjacent lots 100'+ Absorption field on lot *82+ On adjacent lots 100'+ Public sewer main N/A Public sewer manhole/cleanout N/A Sewer /septic service line 25'+ Holding tank Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Water service line 10'+ Building foundation 10'+ Water main N/A Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *PER EXISTING WAIVER !Ser-- No oht 43-!&t0J-r 1�40V" Q�6nSZD1+t(r SFP1'c g,Gr; dF vrtKn»wn+ aP� 6r�r G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's PrintedName JEFFREY A. GARNESS Date ?Jq 1 1 `- (Rev. 11105) prof essioV . 0 too w z aged N O'08'Oo"w 79.14 zn ❑a o= 2 � a Q1 �C A 01 m H < P' •--_._.. _ _�..___ � ' _ — — •--__ _ __ _ — _ __ �wo?i:g r >a T U BZSE-969-L06 0 6007!/01:03NNVJS31b'0 t'8'trZZ.,#37 saiezoossy I auuogso i7T:91 bT02 6T qaj 1p Sy CM O A A pR \ �j0 �a tt \o 1\t� t� � t s, Wp � 1 0 6007!/01:03NNVJS31b'0 t'8'trZZ.,#37 saiezoossy I auuogso i7T:91 bT02 6T qaj Feb 19 2014 16:14 Osborne & Associates LEA,22464 DATE SCANNED: 1011312009 0 907-696-3528 --JEROME STREET. - I -z_ gill 907-696-3528 --JEROME STREET. - swst, m"c36'90.6 N page 2 gp gill swst, m"c36'90.6 N page 2 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.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-273-06 COSA # D f)0 Expiration Date: 1. GENERAL INFORMATION Complete legal description ARVFSON. LOT1 Location (site address) 11100 TEROME ST.. ANCHORAGE. AK 99516 Current Property owner(s) HARWOOD & KATHRYN TONES Day phone Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Day phone TERRI I3ARRUS Day phone 562-3638 Unless otherwise requested, COSA 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 Onsite Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of 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 NI. DUFFUS Date 03/25/2008 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 OF q� �11 system will function satisfactory for current or future W`'z occupants or can ArcTerra guarantee that no unseen JW CACP; encroachments, deficiencies or discrepancies exist. py, ,e. _ _ •:9 I, 6. DSD SIGNATURE ✓ Approved for bedrooms. Disapproved. bedrooms, with the following Attachments: COSA Checidist X Arsenic Advisory Septic System Advisory Well Flow Advisory Nitrate Advisory Maintenance Agreements Supplemental Engineer's Report Other By: n ��. Original Certificate Date: 3 " 02 ' d CY (11M. IIJ05) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: ARVESON. LOT 1 Parcel ID: 015-273-06 A. WELL DATA Well type PRIVATE If A. B, or C provide PWSID # _ Well Log (YIN) y Date completed 12/13/1977 Sanitary seal (Y/N)y Wires properly protected (YIN) y Total depth 172 ft. Cased to 172 ft. Casing height (above ground) min. FROM WELL LOG AT INSPECTION Date of test 12/13/77 2/25/2008 Static water level 120 ft. 129 ft. Well production 3 g.p.m. 3.6 g.p.m. WATER SAMPLE RESULTS: Coliform _9_colonies/100mL Nitrate 0.166 mg/L Other bacteria - colonies/100 mL Arsenic: _tMmg/l Date of sample: 3/11/08 Collected by:ArcTerra B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel/Greer Date installed 10/1977 Tank size 1000 gal. Number of Compartments 2 Cleanouts (YIN) yFoundation cleanout (YIN) y Depression over tank (YIN) N High water alarm (YM) N_Date of pumping 2/25/08 Pumper McDom lds C. ABSORPTION FIELD DATA Date installed 1011977 Soil rating (g.p.d./fe or ftp/bdrm)12�_ System type Deep Trench Length _aft. Width JI ft., Gravel below pipe 12.ft. *(Per MOA Docs) Total depth 22 ft '(Per MOA Docs) , Eff. absorption area MIfe ' Monitoring tube Y Depression over field hl Date of adequacy test 2/25/08 Results (Pass/Fail) Pass For 3_bedrooms Fluid depth in absorption field before test 9 in: Water addedA7Q gal. New depth 3¢k&ln. Elapsed Time: JUmin. Final fluid depth 9_ 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' levet at—in. 'Pump off' level at—in. High water alarm level at—in. Datum Cycles tested Meets alarm 8 circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot • 82'-10" Absorption field on lot • 97-4" Public sewer main 75'+ Sewer /septic service line 251+ Animal containment areas 50'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manholelcleanout 100'+ Holding tank 1001+ Manure/animal excrete storage areas 1001+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 51+ Water main 301+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 1001+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation0l + Water main 101+ Water Service line 10'+ Surface water 1001+ Driveway. parkingtvehide storage 10'+ Curtain drain 50'+fNoncKnown) Wells on adjacent lots 1001+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name KENNETH M. DUFFUS Date 03/25/2008 COSA Fee $430 00 Date of Payment����/ Receipt Number f rr (Rev. 111105) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. " P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-279-0 HAA # E)s nIKo Expiration Date: Q — S 0S 1. GENERAL INFORMATION Complete legal description Arveson, Lot 1 Location (site address or directions) 11100 Jerome St_, Anchorage, AK 99516 Current Property owner(s) James_ A Janet Adams_ Day phone 644-0111'_4 Mailing address Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address 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 ❑ Y� 1 »�1 �4'L>;� 1 �i'L• Y 1 �;7 r7 69 � �I'1i\ R i Individual On-site Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ W kn The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 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. n 7�173:f . . 'r.n696-611111 •.. 1 a ..� . .. Engineer's Printed Name Kenneth M Di ffun Date 5/3/05 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 In land 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, KND can not give any estimate of how long a system will function satisfactory for current or future occupants or can KND guarantee that no unseen encroachments, deficiencies or discrepancies exist. 5. DSD SIGNATURE _1-" Approved for bedrooms. Disapproved. Conditional approval for Attachments: HAA Checklist Septic System Advisory Well Flow Advisory bedrooms, with the following WATT • �- PROGRAM X Maintenance Agreements Supplemental Engineer's Report Other By:� 0 6_e� Original Certificate Date• Municipality of Anchorage Development Services Department Building Safety Division On -Site Water b Wastewater Program 4700 South Bragaw, St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ei.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Arveson. Lot 1 Parcel ID: 015-273-06 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 12/13/77 Sanitary seal (Y/N)Y_ Total depth 172 ft. Cased to 172 ft. FROM WELL LOG Date of test 12/13/77 Static water level 120 ft. Well production 3 9 -p.m WATER SAMPLE RESULTS: Well Log (Y/N) Y Wires property protected (YIN) Y_ Casing height (above ground) 2 4 " AT INSPECTION 133 ft. 3.8 g.p.m. Coliform _JL—cotonies/100 ml.Nltrate 0.113 mg./1. Other bacteria 0 ootonies/100 ml. Arsenic: -M mg./1. Date of sample: 4/26/05 Collected by: KND Engineering, Inc B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL/Greer Date installed 10/1977 Tank size 1000 gal. Number of Compartments Z Cleanouts (Y/N) Y Foundation cleanout (YIN) Y_Depresslon over tank (Y/N) N High water alarm (Y/N) N Date of pumping 9/16/04 Pumper A+ Home Services C. ABSORPTION FIELD DATA Date installed 10/1977 Soil rating (g.p.d./fe or ftp/bdnn) 125 System type TRENCH Length _L4_ ft. Width -3— ft. Gravel below pipe 12— ft. Total depth 27. ft. Eff. absorption area 264 fe Monitoring tube Y Depression over field N Date of adequacy test 9/22/03 Results (Pass/Fail) PASS For J, bedrooms Fluid depth in absorption field before test 0 in. Water added 460 gal. New depthQin. Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN 8 type) N If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) 'Pump on" level at in. 'Pump ofr level at_ in.High water alarm level at in. Cycles tested Meets alarm & circuit requirements?. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankilift station on lot 82'-10' Absorption field on lot 97'-4' Public sewer main 7S'+ Sewer /septic service line 2S'+ On adjacent lots 10 0 ' + On adjacent lots 100'+ Public sewer manhole/cleanout _ 10 0'+ Holding tank _ 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5 ' + Absorption field 5 ' + Water main 10'+ Water service line 10'+ Surface water 100'+ 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/vehide storage 10 ' + Curtain drain 50'+ Wells on adjacent lots 10 0'+ F. COMMENTS G. ENGINEER'S CERTIFICATION 1 certify that I have determined through Neld inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name _ Kenneth M. Duffus Date HAA Fee $430.00 Waiver Fee $ _ Date of Payment �f!`+`1b Date of Payment Receipt Number Receipt Number. (Rev. IMI) Municipality of Anchorage • Development Services Department � Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 2�IJ�Z l / Parcel I.D. DtS_9730& HAA # G Expiration Date: / 14e Lf 1. GENERAL INFORMATION / Complete legal description Location (site address or directions) cc)JZ�70y - Si Current Property owner(s) tVkZ7. 4ep?-CIL I, - Far- Day phone �1G 1' 34319 Mailing address Lending agency . Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: ' TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site Ec 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 Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 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/cr 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 Address Firm _i�£3 lT P E�-r�� r Phone /o7G r 'oc!✓sTo�.l �,Gc ,�C�i4r cj`r sl Engineer's Printed Name _P4z&_.11 Fn �cTc=r..t Date Com- 5. DSD SIGNATURE 0' a `/ Approved for 3 bedrooms. ......••.•...... O 9RENT P. EARN Disapproved. �Q �' CE 9126 Conditional approval for bedrooms, with the folloir>?�QSRk4wifPO- Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory By: (R.v.07A1) X :; nN.slTF WATER AND _V ;;TCrw A;rr-Q PROGRAM Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: 4aAg ro-r 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.ci.anchorage.ek.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: � �T A'Q-yr;'� --7a6 . _ Parcel ID: 01!5 O-7 :300 A. WELL DATA well type ,R�J1/A'7C If A, B, or C provide PWSID # _ Well Log (Y/N) J67e, Date completed P j�1-17 Sanitary seal (YJN)� Wires property Proceed (YIN) Total depthEZ-Lft. Cased to 12-Z- ft. Casing height (above ground) _in. FROM WELL LOG AT INSPECTION Data of test % ZZ b �✓ Static water levet ft. R Well production g.p.m. 3' S g.p.m. WATER SAMPLE RESULTS: Coliform -E co►onies/1 00 rN. Nitrate � mg.A. Other bacteria -G- colonies/100 ml. Arsenic: %—W mg.A. Date of sample: Q=94 -o3 Collected by: R�i.G'?JT P- CFAT&O B. <jEPTI OLDING TANK DATA Tank TypelMaterial `57EXZ- G 9f6F-- Date installed CI t`Z% Tank size 1� .,( gal. Number of Compartments Z Cleanouts (YIN) i�-'s, Foundation deanout (YM) %IVS Depression over tank (YIN) 4 � High water alarm (YM) �4 0 Dateofpumping q'a7ro3 Pumper C. ABSORPTION FIELD DATA Data installed OCT 7 Soil rating (g.p.ddfe 0 fLzAxt l a -S System type 7 -12;C -t -ICU Length '�?4 ft. Width �3 ft. Gr4yel below pipe I-,- 1t. Total depth 2,%- ft. Eff. absorption area 2E[Je Monitoring tube Depression over field 0io Data of adequacy test Results (PasstFail) For 3 bedrooms Fluid depth in absorption field before test "'Bin. Water added gal. New depth' in. Elapsed Timer -min. Final fluid depth -2 -in. Absorption rate >gt�_g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) ? PEPI-t( OF N4LXJ 11W Wim, -I1.t6E 15 131 *-tvfl,\ o'p Tpe (c6(• I� SM,v If yes, give date Avk,t w PA-rA) 'vc,- Is►lar Fe -U lP 1r-' Tu0c . STATION Date installed atlore 'Pump on" level at _ in. 'Pum o Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: epdc tan Ht station on lot —22(–( 0w / Absorption field on lot 9-7L 4 if Manhole/Access (Y/N) water alarm level at in. Meets alarm & On adjacent lots t On adjacent lots (� 5 Public sewer main t`tt-*Jc Public sewer manhole/cleanout N I �t _- r septi service line 7/o Holding tank TJ[G SEPARATION DISTANCES FRO EPTI TANK ON LOT TO: / / r Building foundation 7 Property line a7 / Absorption field ^'S Water main oyf—� Water service line 54 Surface water rI&f-It; 0 05ERVXD r Wells on adjacent lots 10-3 SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: /( Property line off- Building foundation OWater main 0C4,16 r / Water Service line G _ Surface water Driveway, parkingNehide storage Curtain drain K4W/J Wells on adjacent kit'I s I JI _ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and ................. review of Municipal records that the above systems are in P. EATON conformance with MOA HAA guidelines in effect an this date. t. -A- Engineer's Printed Name. Date CZ:7r- 1--3c 7 HAA Fee $ Date of PaymentI DI I LI ID 3 Receipt Number (Rev. 12101) Waiver Fee $ Data of Payment n I I L Receipt Number SS I APR 2 2 1994 C41 >� /3.i•Y/ le a 20, AS-IUILT SL'P.VEY OF AG1k%J1 r',``'� ............: ash 1/ 'y�•x'•91 *1491!1 tits S�tw. . So. Shone A. Holl °i •••, IS 6914 QJ`�'oO OFESS un L)A f9cO ••••'.....N•••O•'Je THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS EASEMENTS OF RECORD, OTHER BETWEEN EXISTING STRUCTURES AMD PLATTED LOT LINES THAN THOSE SHOWN ON THE OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING RECORDED PLAT, ARE NOT ADDITIONAL STRUCTURES OR FENCELINES SHOW HEREON ,3 331 33 " 1 hereby certify that I have performed a Mortgage@*& Inspection of the following described property: LOT 1, ARVESOM SUB. I Anchorage Recording District, Alaska and that the Improvements situated thereon I are within the property lines and do not overlap or encroach on the property I lying adjacent thereto, that no Improvements on property lying adjacent I thereto encroach on the promises In question and that there are no roadways, I transmission lines, or other visible casements on said property except as I indicated hereon,t�,Dated at Anchorage, I Alaska this ,?I day of /%Pr// 1192Y. "C85-1-014 I HOLT AND ASSOCIATES LAND SURVEYORS 5323 BRENT P. EATON, P.E. CIVIL ENGINEER 2670 Brookstone Loop • Anchorage, Alaska 99515 • Phone 349-3777 October 14, 2003 MUNICIPALITY OF ANCHORAGE Attn: Dan Roth P.O. Box 196650 Anchorage, AK 99519-6650 Subject: Lot 1, Arveson Dear Mr. Roth: This letter is to request that a separation distance waiver be issued for the subject property. The distance from the well to the septic tank and trench drain field is less than the required 100 feet (see attached drawing). The well and septic system were tested on September 22, 2003, and found adequate for three (3) bedrooms. At this time a sample of water from the subject well was analyzed for coliform and nitrates by CT&E/SGS North Ameerica, Inc. The result of this analysis was 0 colonies/100ml, and 0.146 mg/I Nitrate. The above results indicate no apparent health hazard associated with the current physical location of the well and septic system; both of which have been installed in their current location since 1977. Also attached please find a copy of local well and septic location information, available well logs from neighboring properties and the well log for the well in violation. If you have any questions, please contact me. Brent P. Eaton, P.E. CASPE\DOCUMENTRE58EMWANER LMERDOC ,7 m u R-TT"M� ��P T Gf��.1 � LOGIE'(�• • ``� Io clKl mJ Do�S r ; E `• Nor 4� - 1177 �4sG1UILr. \\^4 s 7 r a ip;s�M �•' G.' 91 +� ti �od'r✓ 79./Y i. v .%avow— 3 be ,' FOr- VANW, t-ar 1 APW-S�J jo -14—�j 6 10/22/2003 DZunieipalit3, of Anchorage Mark Begich, Mayor Building Safety Di%isiolt P.O. Box 196650 • 4700 Bragaw Street Anchorage, Alaska 99519.6650 • (907) 343.8301 • rxx (907) 343.8200 Brent P. Eaton, PE 2670 Brookstone Loop Anchorage, Alaska 99515 Subject: Waiver Request for Arveson Subdivision Lot 1 Waiver Request #WR030095 Parcel ID #015-273-06 HAA Number HA030526 Dear Mr. Eaton: Your request for a waiver of the required 100 feet horizontal separation from the absorption field and septic tank to private well has been approved. The approved separation distance is 82.0 feet. This waiver approval applies to the existing absorption field and 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 concerns or questions regarding this waiver, please call our office at 343-7904. Sincerely, 1 J Goodall i 1 Engineer On -Site Water R Wastewater Program Municipality of Anchorage Development Services Department � Building Safety Division On-Sitc Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343.7904 WR#: 030095 PID#: 015-273-06 Date Received: 10/14/03 Legal Description: Arveson Lot 1 Engineer. Brent P. Eaton. P.E. Qg.'71ILII•3=UMT- - t Waiver Review Worksheet HAM 030526 Permit#: Waiver Requested: 82 foot waiver from the Septic Tank to the Well and 97 foot waiver from the Absorption Field to the Well Criteria: Geology A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: Points: ............................................................................. Waiver is Granted: Waiver is not Granted: List Conditions or Reasons for above: SEE t44 WEA Pb i nr n c ,+/c c &140 - Date: By: ..... ..................... ............................. .......................� Rec#:143 18 Amount: $1000.00 Date Paid: 10114/2003 \ \ l Jr 3 f Z- WArEr� TA9aE S,2aole�r7- S lop-;> (c% %DwmcJ wAfE•t cotsncr 001t"toNiA•1 SEp4AAfi0N _ 2t C o•yc 1. S ; o -y (AAN7 WAIJEQ 2.3 6MNC TOTAL /q.85". WoVIVER C72AAME7 I D,AGcrEo ky Tt , lic.sc Dom=` 71° WELD 4 SFr71c 14AVE 6hr5rE0 S�AfcF l9?i• AND Mo Cod; f -al kAve AP?EAAeP,Aja 'OTrlE28A[TE?jA AAtp vQzI (-Dv (.e,)el lv;t^" * C s. L-JA7'iif2 T49LE f°Di*JTS STAric LJAre&C r. 13orrom o'F•f-EPric FIEIO 2Z Fr. F H H W W W N N N ooe Soil, 5or&j3rio-J N O O _r C; �r I /og ys{Vo8)�i 8,° t�rg) 3St/�ad)2sfCi `= d)lo e Ky 2•S \ \ l Jr 3 f Z- WArEr� TA9aE S,2aole�r7- S lop-;> (c% %DwmcJ wAfE•t cotsncr 001t"toNiA•1 SEp4AAfi0N _ 2t C o•yc 1. S ; o -y (AAN7 WAIJEQ 2.3 6MNC TOTAL /q.85". WoVIVER C72AAME7 I D,AGcrEo ky Tt , lic.sc Dom=` 71° WELD 4 SFr71c 14AVE 6hr5rE0 S�AfcF l9?i• AND Mo Cod; f -al kAve AP?EAAeP,Aja 'OTrlE28A[TE?jA AAtp vQzI (-Dv (.e,)el lv;t^" * w jA/AlllE2 A60JEST FM f1✓ElZWV LOr t WA(OrA REq✓FjT NUMSE/l: W/t050015' (/JNIVF_o, AzovESr FOR 7NE AIATEA, I,IF(.L.ON r/% 5t$JEc7- Lor 7V -iEPrlc rANk of 82 '. -4N0 W6TEQ WEU- oN r0aJEC r LOT' TO SEPrec FIEc.p QF 17'. Sc Pr/c TANK OATH — THE SEPT lc T -A V t oN 4VEoLSoA/ x-07' ( wA3 /NtTRlIEO Iry% /9i`qL TNF 5o(t. THe rANk /S CO'VSTAVC-TED IN' /5 S W Spic 5 . T//E 5011- i3 SAND, C IFA1I/ WCcc (��,4oEo/ pEB6tY. T/iS Solc Sl-lovU TREAT rAW SEprlc 7A,vk EFPt.VyNi' ,NA RE/A•7/U,EIy S//aZr DiSTA^/c E . DATR TNC NAroe a HIF�L I/V -60r v,,.t.F 0VES Tlo-/ Wk3 OR 1f7„✓A /lY CvvTrAL,cTLb /N TH. TH: DEPTH of TI{E wEtt, l5 /72 Fr. 'Wks uGGt. Plop, cE5 3.8 JpiN worrK A Sr.*ric OF IJ3 fEE7. SINCE T./,S WiLc- NAS QSN lA,5rACI-EO T//EaE //Al dEEN 'V40 er^aje &cvjit$ of eol;fo&..j, OTHP/2 gRcrs`R%A. AND cwly . l,((, ^^q/&- ei J;TRArE. ' -DEPT. 1L ht MUNICIPAL/Y OF ANCHORAGE ENVIBOti:+ENTAL FF.JIL Cl' l /� STREET LOCATION DEPARTMENT OF HEALTH i ENVIRONMENTAL PROTECTION EES L Street • Anchorage, Alaska 99801 g p Jhl SET 1 • SINGLE FAMILY I c 1 U ENVIRONMENTAL ENGINEERING DIVISION ❑ MULTIPLE FAMILY ❑ Three ❑ Six Telephone 264.4720 tkdlr rI V REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITI S DIRECTIONS: Complete all parts on page 1. Inaah too requests will not M praeaseed. Meas allow ton (101 dws for Processing. 1. PROPERTY OWNER ❑ PUBLIC UTILITY depth (attach log if available.) PHONE ? i OACM ac "If lndividual/on•site,give Installation date j MAI LINGnXbr.&A ESS NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. PROPERTY RESIDENT (If different from above) PHONE Z. BUYER PHONE ( -C MAILING AD REBS �1 g960 a�o�l 1 3. LE DING INSTITUTION PHONE %-P-- u 010. MAILING ADDRESS 4. REALTORIAGENT PHONE MAILING ADDRESS S. LEGAL DESCRIPTION 1L ht t.rV Las tl !] lis Ln STREET LOCATION E. TYPE OF RESIDENCE NUMBER OF BEDROOMS SINGLE FAMILY ❑ One ❑ Four ❑ Other N.. Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY �0 INDIVIDUAL' *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to at ate, give well ❑ PUBLIC UTILITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON•SITE'e "If lndividual/on•site,give Installation date j ❑ PUBLICUTILITY by this Department NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-0110(7/78) a�F CCI UCe l VG `�lt`31'1 MG'�Lif �L��1 Ll�h.TC1 . l� X31 THIS SIDE FOR OFFICIAL USE ONLY INSPECTION APPOINTMENTS DATE RECEIVED , TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLICUTILITY Connection Verified PERMITNUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ONSITEDATE 13 PUBLIC UTILITY Connection Verified PERMIT NUMBER INSTALLED INSTALLER SOILS RATING 1 DSeptifjankor ❑Holding Tank Size: IfTank ishomemade give dimensions: TYPE OF TANK MANUFACTURFji, TOTAL ABSORPTION AREA MATERIA` 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area w Seer Line Nearest Lot Line Absorption Area to nearest Lot Line S. COMMENTS 4--KPPROVEDFOR _ BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY Title LEGAL DESCRIPTION /Lil l 0 (MeV. 3/ W ) /'1 MUNICIPALITY OF ANCHORAGY -� DEPARTML , OF HEALTH AND ENVIRONMEN PROTECTION 825 L Street, Anchorage. Alaska 99501 264-4720 #1: Time 1:30 p.m. #2: Time Date 1-24-78 Tuesday Date Insp Pratt Insp Date Received: January 23, 1978 #3: Time Date Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: Coast Mortgage Company Mailing Address: 4797 Business Park Boulevard Phone: 279-0665 2. Property Owner: Wilbur H. Dittbrender Phone: 349-2235 Mailing Address: Star Route A Box 476-Y 99507 3. Legal Description: Lot 1 Arveson Subdivision 4: Single Family Residence: (x$ Number of Bedrooms: Three Multiple Family Residence: ( ) Number of Bedrooms: 5. Well System: Individual Well (xi Community/Public System ( ) Permit # Construction Depth of Well 172' Well Log on File ( ) Bacterial Analysis 6. Sewage Disposal System: On-site System (x$ Public Utility ( ) Permit # Installed 1977 Install//et �o Septic Tank Size k©m© Manufacturer My,c- Absorption Area Soils Rate \ Material 7. Distances: Well to Septic Tank to Sewer Line Nearest Lot line to Nearest Lot Line a to Absorption Area Absorption Area Page Two ' Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 1 Arveson Subdivision Comments: Affadavit Attached:/Letter Attached: ( ) Approved: `. n Q�(/ _ Date: c Disapproved: Date: Department Worksheet: i L.1. (. u6t:Odo 11VV1 IVNOILVNN31KI 10I ION1161 '+dV (OP!, Jew* •K7 0301AOIJ 35MA03 30NVdn5N1 ON 008L W"i Sd z .... _............. _....... 01.11M01 "I 0'V -) Atl3A1130 1Y133dS_, 0 4 t�......... ..... .._........ .......................... A1N0 33SS3800V Ol 130_ M3A1 ISH •"""""' AIUP .asSame .I IYM1!I8P iam 2331ANIS ISE •• IYNYIIY/ YNYA IY. .1Y0'W.V� .l NOYS •L' 1AI3334 IS9 """""' AIUP qtw Y71P 1 a ANMPp VIM MY013tl YI P. I f^ 5371 1VM011100Y S03 S13Utl3S 1CA61I., i lao3 du aNr 31Y1s'•o•a Cil •ON ONY 173tl1i CD 1 snld) aDC—IItlW a31d112133 2104 ldl333a •' MUNICIPALITY OF ANCHORAG L cb Department of Health and Environmental Protection ;� n (*7--i�equest 825 L Street, Anchorage, Alaska 99501264-4720 for Approval of Individual Sewer and Water Facilities 1. Property Owner: G/, �luY �;��/1>"Cl�lr�t°✓ Mailing Address: 544 Phone: 3Yr/-223 S 2. Name of Buyer: Mailing Address: Phone: 3. Lending Institution: ae 5-f , Mailing Address: y7 9 7 u ai„s/o �ar/.//1�GQ Phone: 272:D / tis 4. Realtor/Agent: Mailing Address: Phone: 5. Legal Description: yyro" 5 u kel Street Location: ilroe& MC wel o (V "Irn7 X11 6. Single Family Residence: (y' Number of Bedrooms: Multiple Family Residence: ( ) Number of Bedrooms: 7. Water Supply: *Individual Well Public/Community System ( ) If Individual Well, well depth 17.2 if Community System, name of system 8. Sewage Disposal System: "On-site System (Public System ( ) If On-site System, date of installation: �1,znX % 7 *NOTE: A well log is required on ALL wells drilled since 6/75. **If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fee of $25.00 must accompany each request before processing can be initiated. 3/77