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MONTGOMERY LT 4
Montgomery Lot 4 #051-193-03 Municipality of Anchorage Development Services Department ©} Building Safety Division On-Site Water and Wastewater Program, 4700 S. Bragaw St. 1 P.O. Box 196650 Anchorage, AK 99519-6650 Page i of-> www.ci.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: _��a 70 6 1 PID Number: 05-1—M-03 Name: / Veit rlcl SJelk/rWastewater System: ❑New Upgrade Atltlress' n 3 14 -Street Ailriwe (7'j6/ ABSORPTION FIELD Number of Bedrooms: \ Phone: 'a S -Sn {a, L,,, Deep Trench p Shallow Trench p Bed ❑Mound C;i/ ❑ Other: LEGAL DESCRIPTION Soil Rating: Total Depth from original grace: •�/ Block: Lot: TownsltiP: Subtlivision� • GPD/Ft' to pipe bottom from ginal gra�E, Ft. De / Ft. Gravel depth beneath pipe: Range; atldetl abovetanginal �dpth 11'• 6 Ft. Gravel Length a� Well; ❑ New El Upgrade e Ft. Gravel width: Ft. Number of lines: Distance between lines: Cl as ¢a4on (P vote. A, 8, ):• y/- Total DepN: Cased to. KfS//r / E /W�t'!e' FL Ft. Ft. Total absorption area: ^ �D ' Ft. JPijye Mat ep�'/aI Q (/] Dnller. Date Dniled: Static Water Level:Installer. Ft. cJS) Ft? yy // 7�wGPdXCE4U'�T/✓/G Dale InsWlletl:'-7 /f� / —�"V7 Yield: pSet an Casing Above Grountl: ! GPM Ft. Ft. TANK SEPARATION DISTANCES l(Septic ❑ Holding ❑ S.T.E.P. ❑ Other: o Septic Tank ift tion Holding Tank ubifc/Pnvate Sewer Line Manufacturer: Cevy/Ji' �7�' LeST-/L capacdy: C.i--4B Gal. I��t --i +-1 t (�J �.�°" Material: �DP� Nyyper of Compartments: ol!ter + ad LIFT STATION ' lze: an acturec`Pump on' level at: "Pum oP High water alarm aCin. in. in RRemls _y�Pump w Make a Electdpl Inspections perfgmed by: � S T/C a/7I: LJASBENCH MARK �v'Location b�,� and Deschpbon:,� ,W u, �.D,psunned `7 Elevation: Ft. En P �..OF S& S ENGINEERING Inspections performed by: 17034 Eagle RiverLoop Rad, NoD2f{4 at 3 r L a es: 1 T d µ9. 1 s,. ».J. ' 2nd ��-Q "y^ �•.p.;.. Development Services Department Approval ROBERT C. COWAN..... yj ��� CE Reviewed and approved b PP Y Date: e.. 11'00)1Ilk,y'ROFESS%�1`*� -8801 @' 741t� r PERMIT No. SW040201 PAGE 2 OF 3 Municipalit of Anchora e DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 4, MONTGOMERY S/D P.I.D. N0. 051-193-03 LOT 14-/ SHERMAN STREET 2' POWER EASEMENT w cn z > > O 0 0 � a a w >a � U O � c� J J 3 0 SPO o IL 0- DECK 41AJ,T EXISTINGSEPTIC HOUSEAREA-NEW TRENCH (RILINGNEWATH FOUNDATION) DELI & DBL2A �ALT• SITE TFCO ST1 � ON HDPE �SEPTICATANK \ 10' UTILITY EASEMENT — _ _ _ — _ — _ _ — —— _ — — _ _ — _ — ----� SEPTIC AREA LOT 9 LOT 3 SCALE: 1" = 30' p \ ROBERT C. COWAN J `4 ��C, ^ a-8901 r, �R PERMIT No. SW040201 PACE 3 OF 3 DEPARTMENTUOF pHEALTH ANDhHUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P,0. Box 196650 •Anchorage, Alaska 99519-6650 • Telephone 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 4, MONTGOMERY S/D P.J.D. No. 051-193-03 ST1 ST2 99.8' FINAL GRADE 2" INSULATION NEW 96.8' 1000 GALLON POLYETHYLENE 96.5' SEPTIC TANK A B FCO 9.0' *1.0' _ST _1 9.0 36.5' ST2 1 2.0 37.0' TMT 14.0' 38.0' DBL1 13.5 35.5' DBL2 13.0' 33.5' C01=99.1' C01 14.0' 26.5' CO2=98.8' CO2 32.0' 12.5' NTT —1 26.0' 16.0 * = HOUSE OFFSET FINAL GRADE -72" INSULATION C01=96.5' SR CO2=96.5' N. T. S. C;ice /t • h i MT1=91.5' C;, MT . NO WATER FOUND /A �}� Rp9OT C. AN 84.5' B.O.H. r�tPsr��, CE-w0i :r} I S Municipality vAnchorage (ENGIN rvi $ A Development Services Department Building Safety Division ri On -Site Water and Wastewater Program _ _ 4700 South Bragaw St. p 3 ROBERT G COWAN P.O. Box 198650 Anchorage, AK 99519-6650 c^ www.muni.org/onsfle e��.''. C:"8801 {�'4 (907) 343-7904.. Z�d`�1 V Soils Log - Percolation Test Performed For: JC` J K t +J57 A Date Performed: Legal Description: Ln -r ii W N" c-6 M e9L -j S1 "7 - man Depth (Feet) ga_&, -4l6S I- 2- 3- 16-M .. 8- •'O 9- 10- 11- 12-1 - 10- 11-12- o 15- , 16- 17- 18- 19-1 6- 17-18-19- Immuvevincnl HERO HOLE DIAMETER TEST RUN BETWEEN FT AND C_FT COMMENTS PERFORMED BY:, S43 E/Jaij PAl i. -I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUID LINES IN EFFECT ON THIS DATE, DATE: I I 1 1 1 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? ^ L Depth to Water After O Monitoring? ,Day P E Date:7 ,r o y Immuvevincnl HERO HOLE DIAMETER TEST RUN BETWEEN FT AND C_FT COMMENTS PERFORMED BY:, S43 E/Jaij PAl i. -I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUID LINES IN EFFECT ON THIS DATE, DATE: _-� •Ems _--�� aTLi Immuvevincnl HERO HOLE DIAMETER TEST RUN BETWEEN FT AND C_FT COMMENTS PERFORMED BY:, S43 E/Jaij PAl i. -I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUID LINES IN EFFECT ON THIS DATE, DATE: MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Initial Permit Number: SW040201 Legal Description: MONTGOMERY LT 4 Design Engineer: 0003 S & S Engineering Owner Name: Verna Jenkins 0 xot( Date Issued: Jun 17, 2004 Expiration Date: Jun 17, 2005 Parcel ID: 051-193-03 Site Address: 022630 SHERMAN ST Lot Size: 13464 SQ. FT. Owner Address: 1342 H STREET Total Bedrooms: 2 Permit Bedrooms: 2 ANCHORAGE , AK 99501-4361 This permit is for the construction of: ❑✓ Disposal Field 0✓ Septic Tank Holding Tank [:] Privy E] Private Well ❑ Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3, The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. ADDITIONAL TEST HOLE NEEDS TO BE PERFORMED DURING CONSTRUCTION IN THE LOCATION OF THE PROPOSED ALTERNATE SITE. THE TEST HOLE TO BE PERFORMED DURING CONSTRUCTION WILL DETERMINE WHETHER THE ALTERNATE SITE WILL REQUIRE A STANDARD SEPTIC SYSTEM OR AN ALTERNATIVE WATEWATER SYSTEM. THE ASBUILT SITE PLAN NEEDS TO SHOW WHAT TYPE OF SEPTIC SYSTEM REQUIRED FOR THE ALTERNATE SITE, ALONG WITH THE TEST HOLE. Received By: Date: C /1 y/o'y Issued By: i 11 Date: 4� o -hoe Municipality of Anchorage` P.O. Box 196650 • Anchorage, ,Vaslai 99519-6650 • Tclephone (907) 343-8301 • liax (907) 3438200 4700 6ragxw Strcet • Anchorage, Alaska 99507 s a v c r v aINZmuni.orlr Mayor Mark Begich Building Safety Division 6/18/2004 S&S Engineering 17034 North Eagle River Loop Eagle River, Alaska 99519 Subject: Waiver Request for Montgomery Lot 4 Waiver Request 4WR040040 Parcel ID 4051-193-03 Dear Bob Cowan: Your request for a waiver of the required 10 feet horizontal separation from the absorption field and septic tank to property line has been approved. The approved separation distance is 1.0 feet. This waiver approval applies to the existing absorption field and septic tank to property line 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, J Goodall ivil Engineer On -Site Water & Wastewater Program Community, Security, Prosperity 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) 313-7904 ON-SITE SEWERPNELL PERMIT APP;JcATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 1_); I - If? 3'0T Permit Number SW Property owner(s) ��eYY1a (JE✓1 k lns Mailing address (1) Ia3I ti,',��,be��N L! rG/C Mailing address (2) Afy4w,,ay M9 Day phone '�Q3' 5009 Zip Code g0i3-/5 Legal description (Lot, Block & Sub'd.)/03/ -4. ! %_17190/ iL4 --f/Y J � Legal description (Section, Township & Range) LotSize� 13i�6 Acre /Sq.Ft Number of Bedrooms THIS APPLICATION IS FOR: Sewer Only ❑ Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade THIS PROPERTY CONTAINS: Hot Tub ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. S & S ENGINEERING 17034 Eagle River Loop Road No. 204 raffia River. Alaska 99577. (Signature of property owner or authorized agent) Permit Fees: Date of Payment: Receipt Number: (Rev. 12/00) h`Go.J° �r n /0 0 S-3763 Fees: Date of Payment: /-7j� o.r 6 A,) /') y Receipt Number: O S 3 3- 6 3 EngineexiHG ROBERT C. COWAN, P.E. uau ASA CIVIL ENGINEERS (907) 8942979 FAX (907) 694-1211 June 3, 2004 HEALTH AUTHORITY APPROVALS MUNICIPALITY OF ANCHORAGE Development Services Department P.O. Box 196650 SEWER&WATER Anchorage, AK 99519 MAINDUENSIONS REFERENCE: Lot 4, Montgomery Subdivision SEWER& WATER INSPECTION It is requested that you issue a permit to replace the existing septic tank with a new 1000 gallon septic tank and install a new trench to serve the existing two bedroom dwelling on the referenced property. ENGINEERINGSTUDIES AND REPORTS A test hole was excavated, and the approximate location of the test hole is located on the attached site plan. At the time of excavation 5/28/04 no water was found. After monitoring, ground water was not found. WELL INSPECTION &PLGWTEST We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic tank. The installation of this trench will not prevent any future development on any of the adjacent properties. SITE PIANS If you require additional information, please contact us. Sincerely, ROAD DESIGN _ R/V ?ow6.�E. SOILTEST RCC/b]] Enclosure PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSALSYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 S& June 10, 2004 ROBERT C. COWAN, P.E. ROBERT A. SHAFER, P.E. CIVIL ENGINEERS (907)694.2979 FAX(907)694-1211 HEALTH AUTHORITY APPROVALS MUNICIPALITY OF ANCHORAGE Development Services Department SEWER&WATER P.O. Box 196650 MAIN EXTENSIONS Anchorage, AK 99519-6650 SPPECTION�R REFERENCE: Lot 4; Montgomery Subdivision INS Request you grant a waiver on the referenced property for the horizontal separation ENGANDSSTUDIEs distance between the new septic tank and the south line at 1 foot, and the EIEPOR REPORTS property new leachfield and both the south and the west property lines at 2 feet. Please be advised that the house rests on a non -conforming piling and cinder block WELL INSPECTION &FLOWTEST foundation. We do not anticipate any adverse effect on the referenced property or the adjacent properties. SITE PLANS If you require additional information, please contact us. ROAD DESIGN Sincerely,, SOILTEST /)V/Z, Robert C. Cowan, P.E. RCC/ts PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SRE WASTEWATER DISPOSALSYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP • SURE 204 • EAGLE RIVER, ALASKA 99577 . 1 " = 40' DESIGN SITE -PLAN N W Cn �I � aw nonA S AL oda �sr ar,o i N 0 0 0 � ama� N S.az " 0* xmr �- Z o m ��sA lYP za �mm-0 A Ro �om < A C Orr p� 00 mom. Q aa� 3 \Nom �v cn�ol� .0> A^ nn°—' mz ONm o = O U7 9ac no ypo d m Q ;Q C Ingo imcm ZN 4 m N a / nco O xzo g �C m T✓ m 0 N I V' o _r x GRAVEL DRIVE n ro' µ 150' WELL RADIUS -' o /p (APPROX. LOCATION) -o Qi 0 of p, y to oa F 113Mo S�IOda m Q o i c� oi mz F� Z i o.mXp` Q// aZ > s D_p r� K�mn O 0, 0, v7 A� r >� --�--- -=moo m Q r, o� C @ �`., V I,F\ •a4 e.G�e O •�ia+A rn 014 _� _________ !, t" = 40' DESIGN SITE -PLAN N W Ui J 0 ids AL .0 Z.0 r^A O fTl M F•--1 m hl zo oosm tii , , Gi fTl fTl -O (7 pt.d �+JJ +'Ox SADrO �•� �om < 'mho b o_ yc F w v_N d m r o^ 0Fm Q Yo aA \ N 0 U' 1 NNU, ? ~ Ike CACA m N Mom_ D m yaFv�, $n zio� Z7 O ~ s10 ODF µ n 2f Nod GRAVEL DRIVE � O m aN s rn C7 a� w 150' WELL RADIUS (APPROX. LOCATION)- Z' LED 1 "1�3M .00I c; �F�` 01 m A 5(110Va r Pq0 m Q < °o, n I-�--�I N y D Z , x o m ;Econ o z FAZM m m << o m0 0 A o �N> m u O z Dn y wz, It o.= o ' I�AdtB j.n 11 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.muni.org/onsite (907)343-7904 Soils Log - Percolation Test r_ Performed For: V o C Legal Description: Z.tj'j- Depth Depth to Water Net Drop (Feet) G 1- z- 3- r® 4- 5- O . 10 3 6 �TM7- y- 0 10- 0 11- 12- 0 13- 14- Is- 16 - 17 -1 3- 14-15- 16- 17- M n ROBERT C. COWAN i )�cl. CE -8801 l,. I (iL,r/7r 1� WAS GROUNDWATER yy�� ENCOUNTERED? s IF YES, AT WHAT DEPTH? L Depth to Water After .tel O Monitoring? / Dale: /p 4 Reading Date Gross Time Net Time Depth to Water Net Drop ASoR�C G Ci- �o r® 7� 10 3 4 10 r o 4 )1 1 1l2" " SZ) io Io,,(2' -, (00 J0 1 ((o' '' 4° PERCOLATION RATE ( (minmeelinc) // PERC HOLE DIAMETER TEST RUN BETWEEN FT AND (p FT COMMENTS JJ PERFORMED BY: y S CA.lis % A.ICTELf IrJ%y I CERTIFY THAT THIS TE PERFORMED W PERFORMED IN ACCO DANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 47 '7 A �0 ( S& HEALTHAUTHORITY APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELLINSPECTION &FLOWTEST SITE PIANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WASTEWATER OISPOSALSYSTEM DESIGN ROBERT C. COWAN, P.E. CIVIL ENGINEERS (907)694-2979 FAX(907)694-1211 ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Lot 4, Montgomery Subdivision June 3, 2004 GENERAL: 1. The scope of this project includes the replacement of the existing septic tank with a 1000 gallon septic tank and installation of a new trench to serve the existing two bedroom residence located on the referenced property. 2. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. 3. The contractor shall be responsible for obtaining any necessary underground utility locates. 4. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: 1. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 17034 NORTH EAGLE RIVER LOOP • SURE 204 • EAGLE RIVER, ALASKA 99577 Page 2 Lot 4, Montgomery Subdivision June 3, 2004 3. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. 5. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. 6. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: 1. Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed -up) before gravel (sewer rock) placement. 2. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. 3. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. 4. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. 5. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. Page 3 Lot 4, Montgomery Subdivision June 3, 2004 MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipal approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). 5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. 6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. 7. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements, which ever requirement applies. Page 4 Lot 41 Montgomery Subdivision June 3, 2004 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. 2. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre - construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER 1_ I •es+aana`nil6. of r"^.: rii`. fYMO dva MUNICIPALITY OF ANCHORAGE Department of Health and Environmental Protection 825 L.,'Street, Anchorage, AK. 9,101 264-4720 Permit # �Aog-9a # # # HANDWRITTEN PERMIT # # # WELL AND'ON-SITE SEWER PERMIT gg Applicant: 41-14.si�� L��s>1� 441ne�s Mailing Address: Location: / Phone Number: 6 9cl_ Legal Description: om76ory1c S Lot Size: /✓'�4L -- Type of Soil Absorption System Is: T'C 1 Ld Trench: X Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: Soil Rating (sq. ft/br) The Required Size of the Soil Absorption System Is: c5 e,7TV U DEPTH 2 D LENGTH k0 -.e) . GRAVEL DEPTH 5,6' WIDTH 2 s The length dimension is the length(in feet) of the trenchgor drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). # # REQUIRED SEPTIC(HOLDING) TANK SIZE _ / ��� GALLONS Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. # # # TWO M INSPECTIONS ARE REQUIRED # # # Backfilling of any system without final inspection.and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. # # # PERMIT EXPIRES DECEMBER 31, 1 9 3 I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that 3 bedrooms. Signed: _ Issued by: 41� Applicanti/�d �, ,s Date. SWP/024(1/81) o Date Gross Time SOILS LOG Depth to Water Net Drop MUNICIPALITY OF ANCHORAGE - DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ❑ PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: U /LL�I /�L ��V�� ` „/eJ' DATE PERFORMED: j Rvt �r "� V �` %✓ % (,4 �a `'°-� "t /� ��/ LEGAL DESCRIPTION:---------1�!% SLOPE SITE AN PTH 0 v -yd 1 L�S Gni 2 r' 3 �� c 4 NFj 6 s� e. '' t i -/0 8 c� ! 10 4k C O 11 u s 12 `o 13 14- 15- 16- 17- 18- 19- 20 4151617 18 19 20 COMMENTS PERFORMED BY: ' 72-008 (6/79) G Ale e�ppii lIDD�� AA i aQ�eos ep�epYoq.L4� ee 117 �4"'k F `ca _ oa�c euc �f�nrl i.. 5hakr ,4•.,, �a. 1r�sa•c ,• ;; r9F Snune rs V={+QaC �•�t� 9 WAS GROUND WATER n\ S ENCOUNTERED? L O P IF YES, AT WHAT E i DEPTH? Reading Date Gross Time Net Time Depth to Water Net Drop / V ORCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT CERTIFI DA ` U -N LJ PQ .1 �F--- ��m �.- k --*-i c-:'. F-7 DEPARTMENT OF HEALTH AND'ENVIRONMENTAL PROTECTION .825 L' STREETv ANCHORAGE, AK 99501 264~472O PERMIT WO: 850533 DATE ISSUED: 08/22/85 APPLICANT: GEORGE J. JENKINS ADDRESS: BOX 670141 ' CHUGIAK, AK 99.367 CONTACT PHONE: 688~9662 LEGAL DESCRIP: SUBDIVISION: MONGT8MERY LOT: 4 � SECTION: 16 TOWNSHIP,.- 151\1 RANGE: 1W � LOT SIZE: 13200 (SQ.FT. OR ACRES) BLOCK: NA I certify that: ^ I. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. � 3. I will adhere to all MOA and State of' Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage system" (--)n this or any adjacent or nearby Iot. � SIGNE8 DATE: �7~ ~� APPLICANT: ISSUED BY , DATE: January 10, 1986 TO: Permit Applicant P. G. e6X 6c0 t�L/1 A NCwORAG F.l_i�,SKA 79502 -c -65C (907? 264-4111 DEPARTMENT OF HEALTH & HUMAN SERVICES Subject: Permit # 850533 Lot 4 Montgomery Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1985. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system the original as -built inspection report(three part form) must be sent to this office for review and approval,and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/ljw enc: Copy of Permit ' � ���I F ���. �� ��������� ` DEPARTMENT OF HEALTH AND ENVIRONMENTAL PR, OTECTMIN, , ~ 825 L STREET, ANCHORAGE, AK 99501 ` 264~4720 1::*"I���3E MEZ El EH: IfuQ11 EEIF, ;-lc �E-7. 11- U-- IF" l,,E---'F:` 111-11 1� PERMIT NO: DATE ISSUED: �APPLICANT: �ADDRESSt CONTACT PHONE: 840970 HAND WRITTEN 11/30/84 C/O,S & S ENG/G ALASKA CUSTOM HOMES SRB 196X EAGLE RIVER. AK 99577 694~2979 LEGALDESCRIP: SUBDIVISION: MONTGOMERY LOT: 4 � SECTION: 16 TOWNSHIP: 104 RANGE:' 144 " LOT SIZE: 13464 (SQ^FT" OR ACRES) ' BLOCK: NA I certify that: 1" I am familiar with the requirements fl -or on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska, 2. I will install the�system in accordance with all MOA codes and pegulations, and in compliance with the design criteria of this permit, 3" I will adhere -Lb all MOA and State of Alaska requirements �or the set back distances from any existing wastewater disposal system or �ublic sewerage system on this or any adjace:t op nearby lot. IF A LIFT STATION IS INSTALLED IN AN AREA BY MOA BUILDING CODES� �THEN (1> AN ELECTRICALPERMIT AND INSPECTION MUST BE OBTAINED; (2) AS�BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN^ ` SIGNED APpLICANT: C/O S & S ENG/G ALASKA CUSTOMHOMES ISSUED BY ^ " DATE: DATE: e o ti POU(`H 6-650 in ic 'npal, c4 i ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 Andra a e TONYNOV.'LES MA YOP DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit #: 840970 January 31, 1985 TO: Permit Applicant SUBJECT: Lot 4 Montgomery Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as -built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Keith E. Bandt, Supe visor Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 Municipality of Anchorage Development Services Department • -� Building Safety Division ,� On -Site Water and Wastewater Program `O 4700 Bragaw Street : " 7 P.O. Box 196650 Anchorage. AK 99519-6650 www.muni.orglonsite (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-193-03 COSA #_ 010303 1. GENERAL INFORMATION Expiration Date: _1/- 1 *3 - O % Complete legal description Lot 4, MontPomery Subdivision Location (site address) 22630 Sherman Street Eagle River, AB Current Property owner( s) Holly Myre Dayphone (907) 301-4224 Mailing address PO Box 243744 Anchorage, AR 99524 Lending agency Day phone Mailing address Real Estate Agent _Dean Nelson/Dynamic Prov Day phone (907) 775-6569 . Mailing Address 165 E. Parks Hiphxay, Suite 103 Wasilla, AB 99654 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 2 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 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 Onsite Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4.. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, 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 Pinard EnFineerim Phone (907) 357-3647 Address PO Box 871347 WasMa, AK 99687 Engineer's Printed Name Paul E. PJnaal Date s• Vo0 Dooaese OeN 5. DSD SIGNATURE `'e�T©II••e1 dOOoee°•'i Approved for bedrooms. ••, Disapproved. Conditional approval for bedrooms, with the following stipulations: i .• nio CITG � � : WATER AND • �r'' Additional Comments a Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineers Report Other By;/t/ Original Certificate Date: R 1 3— 4 7 (Rev. 11105) Municipality of Anchorage ' Development Services Department _ Building Safety Division 'Onsite Water 8 WSstewater Program 4700 Bragaw, Street h P.O. Box 198650 Anchorage, AK 99519.6650 www.muni.org/onsfte �1 (907) 34_3,7W4 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: _ Lot 4. Montaom y Subdivision Parcel ID: 051-193-03 A WELL DATA Wen type .Pst H A. B. Or C provide PWSID # _ Well Log (YM) _ R Date completed _VAk Sanitary seal (YM) Y Wires properly protected (Y/N) Y_ Total depth 314+ ft. Cased to __40 ft. Casing height (above ground) 18 in. FROM WELL LOG Date of test NA Static water level HA Well production HA WATER SAMPLE RESULTS: AT INSPECTION 7/18/07 ft. 156.8 ft. g.p.m. 4.7 g.p.m. _Coliform O, colonkW1A0-mL Nitrate 3.02 mg/L Other bacteria 0* 00l0n1es/10GmL - Arsenio AD mon Date of sample: 7/18/07 Collected by Pinard Engineering ` B. SEPTICIHOLOING TANK DATA *8/1/07 Re—sample by Pinard Engr. Tank TypelMaterial Septic/HDPE Date Installed 7/1 /04 Tank size 1000 gal. Number of Compartments _2 Cleanouts (Y/N) T Foundation deanoui (YM) _X Depression over tank (Y/N) JR High water alarm (YM) AA Date of pumping 12/5/06 Pumper JRe Punpine C. ABSORPTION FIELD DATA Date installed -711/04 Son rating (g.p.d./f? or fe/bdrm)1. 2 gpd/1'System type _ Deep Trench Length _ 25 ft. Width I ft. Gravel below pipe 5 ft. Total depth _ 7 ft. Eft. absorption area 2.Qftz Monitoring tube _i Depression over field _N Date of adequacy test 7/ 18/07 Results (Pass/Fail) Paan For 2_ bedrooms Fluid depth in absorption field before test 0_0 in. Water added gal. New depth3_5 in. Elapsed rune: 180 min. Final fluid depth 0.0 in. Absorption rate >= 100+ g.p.d. Arry reiuvenation treatment (past 12 mo.) (YM 6 type) Annn Knnvn H yes, give date D. LIFT STATION SA - Date Installed Size in gallons - Manhole/Aoe,( flN) 'Pump on' level at _ in. Datum E. SEPARATION DISTANCES 'Pump off' level at _ in. Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankAtft station on lot 100'* Absorption field on lot 1001+ Public sewer main NA Sewer /septic service line 251+ Animal containment areas NA High water alarm level at Meets alarm & circuit requirements? On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout NA Holding tank NA Manure/animal excrete storage areas NA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5' Property line 1 ' Absorption field 5 r r Water main NA Water service line 101+ Surface water 100 + Wells on adjacent lots 100' + SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: in. 2' Building foundation 10' Water main NA Properly line Water Service line 10' + Surface water 100' + Driveway, parkinglvehicle sloMe 25' Curtain drain NA Wells on adjacent lots 100' + F. COMMENTS in 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 COSH guidelines in effect on this date. Engineer's Printed Name Paul B Pinard Date 8/7/07 COSA Fee $ Date of Payment / Receipt Number 98�Jo3 (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number 00'"000664.04 Ili C'M"d . '�0- •. s SCS Re0 1073429001 Client Name Pinard Engineering Project Name/# Lot 4 Montgomery Client Sample ID Lot 4 Montgomery Metria Drinking Water PWSID 0 Sample Remarks: All Dates/rimes are Alaska Standard Time PrintedDate/Time 07/31/2007 14:03 Collected Date rime 07/18/2007 0:05 Received Date/rime 07/18/2007 10:30 Techoical Director Stephen C. Ede • Allowable Prep Analysis Parameter Resdts PQL Units Method Container ID Limits Date Date Init Metals by ICP/14S Arsenic ND 5.00 ug/L EP200.8 C (<10) 07/24/07 07/28/07 Mll f Waters Department Total NitratelNitrite-N Microbiolocv Laboratory Total Colirorm 3.02 18 OD, No Coli 0.100 mg/L SM204500NO3-F D (<10) coVl00mL SM209222D A (<1) 07/20/07 IDS 07/18/07 SDP SCS Reca 1073804001 Client Name Pinard Engineering Project Name/N Lot 4 Montgomery Client Sample ID Lot 4 Montgomery Matrix Drinking Water PWSID 0 Sample Remarks: Paramcter Results Microbiology Laboratory Total Coliform 0 All Dales/Times arc Alaska Standard Time Printed Date/fime 08/07/2007 13:29 Collated Date/time 08/01/2007 21.15 Received Date/time 08/02/2007 10.40 Technical Director Stephen C. Ede PQL Units Medad ooVIOOmL SM209222D Allowable Prep Analysis ComainerlD Limits Date Date Init A (<1) 08/02/07 SDP JUL 25,2COT 02:OCP AXCUSTCMDLTK 9075614224 ClInr[uoi WTI ed7laa"JI .VM irowif. PnC£ 81 ins Pmnpby IO 8M 772415 Esv.4 ILw AY 42377 (»>25%44.4 Setv$ce Agreement N4mber. 021029 Orddr Wk 29.Mw.20W M9IMarKYtlHR Se1Nco UDId DS"Dcc2006 12:0 IidMM9A —�—, TOCtivj" Osul PO e0K 2477" Am UlKn .. 10002 MAL L " AWnr$00.A1( QM243744 T`— Not 3u T4r a.• 0 CW7)901-4224 ll w Kana M 77w Roplat Nr to we am 45.. t�D4 OrLiMOmr4RIn Gw aor OIO Glee,i 4avy �, 7t0"N 92070 3keKean swat wa Ca..w.r" 3e�r 02/21ZOW 10009 —. ChAlk. AK DD597 flII ed 6 PAnPad Tank I t:s ramal (0071 001.4224 Addotiono Loca00.7Co41mr44 Da-V.rr 7 y ._ ... Qoons Plonned: 1000 3rd Mems en AOM . Orem w.W f ■ 017 Como by DW 1VLLC DDA%= Gat Actimp �^ Btyft ® Eatk or Mtmo HJse l 3eMaeas Typ# 4ty Prla s 4 Tim? 3e[tk 3r ,m 15K 1 5135.0C Mo snQ. , OOuhlo hnk: r-, Puep Lyaem:Wj flames i t ❑ Dallies OW eT 0 ERMnfICA ACtysl f t 75.00 4M7rraN TYMI TrrY T-' " 7r iM.t C.rRY Tr.l tMIKIrICNfr; flb.0e WCC te.4a ft7f 00 A&jd Cl pv CYMfKM Yra 4 qa l�Nly eYnY71w.� rM TMS F s 4%.()P'47 AOIr r UFW abrr+Nei T"rI frMs+r i1.P�wwN Drt. A...rWM Ati lv-!u� OMR ARArr 4� rru Y4Me ArwNNRnN+NmtuM: AN�nrr. tom. Orw 4RR� 4Y MwM Cr1 a' 9-I�M aw tlr P+Ir ARM a7 DRYS Map .v M LMwr COLI!CTRCga. ab m F. Mer CKw,AR 111 -. . J7L 7.1,7201 01.7L: JK5—f1PFIK6 9.^,90444821 rs^ 2 page 1 £"d 6w9L5i, QC6) t,n%lptd tie,i(U d£. £0 LO ;L Inf CCf PINARD ENGINEERING �y P.O. Box 871347 Wasilla, AK 99687 (907) 357-ENGR (3647) ADEQUACY TEST LOCATION: Lot 4, Montgomery Subdivision APPLICANT: Holly Myra PO Box 243744 Anchorage, Alaska 99524 SEPTIC TANK TYPE/SD:E: HDPE/1000 Gallons, per MOA Records ABSORPTION SYSTEM: Deep Trench, per MOA Records DAILY FLOW: 2 BEDROOMS x 150 GAL/BR - 300 Gallons TEST DATA Id�1 JOB NUMBER: 07.186 DATE OF TEST: 7/18107 FIELD STAFF: PJ Pinard NUMBER OF BEDROOMS: 2 SCUM: 0.0' SLUDGE: Minimal NEEDS TO BE PUMPED: Yes No XX CURRENTLY IN USE: Yes No XX Time Flow Rate Volume I Cumulative Volume Septic Tank Septic Tank Soil Absorption System Comments PM (GPM) (GALS) (LALs) Liquid Level ' p Level Monitor Tube 1' a SAS Level Monitor Tube 3' a SAS Level 3:05 5.3 - 3.0' 0.0' Start Flow -Meter 136330 3:20 5.3 so e0 3.1' 0.1' 0.0' 0.0' 136410 3:35 5.3 8o 160 3.1' 0.0' 0.1' 0.1' 136490 3:50 5.3 80 240 3.1' 0.0' 0.1' 0.0' 136570 4:05 5.3 80 320 3.1' 0.0' 0.2' 0.1' 136650 4:20 5.3 80 400 3.1' 0.0' 0.2' 0.0' 136730 4:35 - 80 480 3.1' 0.0' 0.3' 0.1' Stop Test - 136810 RECOVERY Data Time ST MT SAS MT 7/18 6:35 PU 3.0'/-0.1' 0.07-0.3' 'ALL MEASUREMENTS IN FT. TEST: PASSED XXX FAILED COMMENTS: There was no measurable liquid In the SAS MT prior to beginning the test. With the addition 01480 gallons to the system (more than the design daily flow). the levet rose to 0.3'. A recovery measurement taken 2 hours after stopping the flow showed that the level had returned to the stating condition. Reviewed by: Paul Plnard '� Date: 7/27/07 LOCATION: Lot 4, Montgomery Subdivision DRILLER: Unknown DATE WELL COMPLETED: Unknown WELL DEPTH: 314' STATIC WATER LEVEL (top of casing): 158.8' PINARD ENGINEERING P.O. Box 871347 Wasilla, AK 99687 (907) 357-ENGR (3647) WELL FLOW TEST JOB NUMBER: 07.186 DATE OF TEST: 7118107 FIELD STAFF: PJ Pinard Time Elapsed Time (Minutes Static Water Level Flow Rate m Cumulative Gallons PUMDed Remarks 2:45 PM - 156.8' 5.3 - IStart Test - Meter 136220 3:00 15 162.4' 5.3 80 136300 3:1530 160.3 5.3 160 136380 3:30 45 159.9' 5.3 240 136460 3:45 60 162.5' 5.3 320 136540 4:00 4:15 75 90 164.0' 158.9' 5.3 1 5.3 1 400 480 136620 136700 4:30 105 162.7' 5.3 560 136780 4:45 120 162.0' 4.7 640 136860 5:00 135 160.5' 4.7 710 136930 5:15 150 162.2' 4.7 780 137000 5:30 165 163.8' 4.7 850 137070 5:45 180 164.2' 4.7 920 137140 6:00 195 163.1' 4.7 990 137210 6:15 210 ---T6-4.6' 159.4' 4.7 1060 137280 6:30 6:45 225 240 162.1' 4.7 - 1130 1200 137350 Stop Test 137420 RECOVERY Average Flow Rate: 5.0 qpm Comments: DURING THIS TEST, THIS WATER SUPPLY WELL WAS CAPABLE OF PRODUCING 5.3 GPM. THIS TEST DOES NOT CONSTITUTE A WARRANTY OR GUARANTEE THAT THE WATER SUPPLY SYSTEM WILL CONTINUE TO FUNCTION AND PRODUCE AT THIS RATE. Reviewed by: Paul Pinard -� Date: 7127107 Municipality of Anchorage • Development Services Department Building Safety Division oz On -Site Water and Wastewater Program ` 4700 South Bragaw St. : a 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 Parcell.D. 051-193-03 HAA# Expiration Date: d 1. GENERAL INFORMATION Complete legal description Lot 4; Montgomery Subdivision Location (site address or directions) 22630 Sherman S t . E- F. 9951 - Current Property ownei(s) Verna Jenkins Day phone 333-3183 Mailing address 13412 H St. Anchorage, AK 99501-4361 Lending agency Day phone Mailing address Real Estate Agent Gerry Crowley Day phone 727-7777 Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site Im Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal 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/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 S & S Engineering Address 17034 N. Eagle River Loop Ste. 204 Phone 694-2979 le River, AK 99577 Engineer's Printed Name Robert C. Cowan Date 7��Jn'1 ROBERT C. COWAN 5. DSD SIGNATURE CE -8801 Approved for _ bedrooms. 1y lei) ....r s.t�;; Disapproved. iZw`�a Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By:/% � /y Original Certificate Date: GA1 (Rev. 01102) Municipality of Anchorage ,E i«^.. -..e. . .,e..m✓,. -n .w...aF. su x. u. +} 41-8, Development &i ices �Depar Building Safety Division .k� , .cranchorage.ak us _ t� PPROVAL CHECKLIST `�s'+<�"h'YW,&:='�Ya`m+Yy,S.�%ae.' 'Z�I GVl\�2 Parcel ID': ©61 "513 r�3 if A B or C provide Mn ft Well Lo Y/N A) ) "etlY.�'dWA's� SYdWl'-' Sv wn ` :..uL..g.� .... .._ . /VlC Sanitaryseal (Y/N) - Wves properly protected (Y/N) �e,X r 4 _ ft Casetl to ft Casing height (above'ground) 1 c°i in. r.:,"` w;zrsF`7-6 ft, QI in g:p.m. � r `f g.p.m. ':`: rw •, � ,.' s6t�'%R'a�:`£"e,.�`.5��°'5�%+'`+rv''.xw�`f`�'u.�°��,a,w."'�L�tit.�."."5��....'�1,'s ,. TM,,,.i z colonies/100 ml Nitrate mg /I. Other bacteria colonies/100 ml. ,( Collected by: / NEC� a rig ena TI L {r �j� ��.Date installed 6Z50 6'( 0 o gal. Number of Compartments 2 Cleanouts )nou ( Depression ove�ru�tank (Y/N) High water alarm (Y/N) ^� �) Soil rating (g.p.d./ft2 or ft2/bdrm) System type�^�C ff _ft. Width Z / ft. Gravel below pipe 7 ft. ft Eff. absorption are6z—�5D ft2 Monitoring tube y Depression over field N test �� Results (Pass/Farl) _�SS For 2 bedrooms �oTption ie a ore tes m Water added gal. / New depth_ in. rnin fluid depth m Absorption rat > g p.d. treatment (past 12 mo.}'(YIN &type) " If yes, give date Size in gallons Manhole/Access (Y/N) in. "Pump off' level at _ in. High water alarm level at in. Cycles tested Meets alarm & circuit requirements? A-` On adjacent lots JOE) On adjacent lots 00 Public sewer manhole/cleanout Holding tank -,]/,4 ,Property line i � Absorption field fi Water service line 1 i% Surface water l Co 0 T r 4- Building foundation Water main `/ r- Surface water j d T Driveway, parking/vehicle storage r' Nea✓a/ Wells on adjacent lots y mx UQ 4 6x, ON ...ai*� �.r`#. Uva.,i:vti "�a! iLflai.. l/SY micipal records that the above systems are in r L with MOA HAA guidelines in effect on this date. r' .... ' -. -� C. COWAN / 4, ; r+ q. Ri70ER'f r �,.� ce - scot r�� printed Name �Oe3✓ea7,T C �aHeRr� Oa sT •. .•`�� ,. Date of Payment 3 _ Receipt Number JUL-08-2004 1311 S&S ENGINEERING carnes aan 1011 0 ."„' r3c AS -BUILT I hereby certify that I have surveyed the following described propertyeH? 7- r}. • Anchorage Recording precinct, Alaska, and that the improve. mens situated thereon are within the property lines and do not overlap or encroach on the property lymg adjacent thereto, that no improvements on property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines -or other vis*)Ie easements on said property n„ except as indicated hereon. Dated at eagle giver, Alaska this b k day of ROBERT C. JOHNSON 7! y SCALE: Registered Land Surveyor No. 889•LS `' ::t";,� .:,'•;�j;,,i� 7„ 2..•42' Box 77-D45fi,Eagle River, Alaska 99571 phone (`)[1'!1694-2543 FOTRL P.02 r SG$- SGS/CT&E ENVIRONMENTAL SERVICES Drinking Water Analysis Report form1*.t ria READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING _. MUST BE COMPLETED BY WATER SUPPLIER PUBLIC WATER SYSTEM ID# I /I (, RIVATE WATER SYSTEM 0 Send Results Send mvolce Welty Sy lem NamNCOmpOlry Nama G �NG11��n;G eemia N.me CwNa<INBmi PboroN m er •�•���••�•��•� Mailing AWrtas Fex Number MaiNnp AtlMesa Up Co e Cl1y Smk Lp C.ae SAMPLE COLLECTION: Fw �s.. ra®emw ewnno Data: Memh a.y r..r Time: I 00e) A Location: ' ;moo Collector. f3 Send Results 200 W. POTTER DRIVE ANCHORAGE, ALASKA 99518 Tel: 907-562-2343 Fax: 907-561-5301 mas7sdq- []Send Involve W.ler SysMlr NameMemperry Name eemia N.me Ph.. Number Fax Ntlmbe. Mailing AWrtas city State Up Co e SAMPLE TYPE: 4'Routine ❑ Treated Water ❑ Repeat Sample ❑ Untreated Water (refer to lab no. ) Special Ptirpose Transported to Lab By: ESame as collector Other: rnleahis. rens wa TO BE COMPLETED BY LABORATORY Sample Receiving: Date: `- 2— fr o� E] Sample over ao hours gid; ❑ RUSH SAMPLE Time: /03 '7r? Results may be unreliable Temp: q,,,,K� ❑ 4e nourwalver Phone #: Delivery Method; c—l _._._ ��°r Remote Loca' s Fax #: Received By: ,���IrT comments: .........................................................................<...........................,........,................................ Bacteriological Water Analysis Record: [Da nt to ADEC: MMO-MUG (PIA) RESULTS: ANC:F:BK JUN — Analysis Began &1 1-7M Total Coldorm: teTme: Analyst; 17;0 z0_ E. Coli: Sent to Client: Phoned 0 /Faxed Date/Time: Spoke with. Analytical Method: MEMBRANE FILTER RESULTS: Direct Count JCJ C01onies1100m1 I Membrane Filter Verification: MMO-MUG (PIA) r— *urcxnerm -(LTB: BGB: rr�I L'C! Satisfactory r..mcauwm { EC: ❑ Unsatisfactory TNTC . Toe Num.rom le C.., Reported By: Date[Time: fps lot os .om.. ean.da SlnnaWre T \tpetra\public\DOCUMENT\FORMS\MicrolColi Form 121703.xis Form # FW- 0053 12/17/03 SGS Ref.# Client Name Project Name/# Client Sample TD Matrix Sample Remarks: 1043751001 S & S Engineering L4, Montgomery S/D L4, Montgomery S/D Drinking Water Laboratory Analysis Report All Dates/Times. are Alaska Standard Time Printed Date/Time 06/30/2004 13:56 Collected Date/Time 06/28/2004 12:00 Received Date/Time 06/28/^2004 16:13 Technical Director i S en C. Ede PQL Units Method Container ID Allowable Parameter Results Prep Analysis Limits Due Date blit Waters Department Nitrate.N 3.89 0.100 Microbiology Laboratory Total Coliform 0 mp/L EPA 300.0 B (<=10) coU100mL SM209222B A (<=1) 06/29/04 JJB 0628/04 DKC :F rmiro� i SI• "Iru�; LaboratoryDivision 200 West Potter Drive, Anchorage. AK 99518-1605 0907)562-2343 562-2343 f NM 561 5301 w ..sgsenvironmental.com Member of the SGS Group ISociBtB G4nErale Je Surveillance)