HomeMy WebLinkAboutROBANNA LT 2Onsite File
Robanna
Lot 2
PID# 051-281-84
The original well was decommissioned.
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201342 PID Number: 051-281-84
Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ® Upgrade
Name
ROBANNA LOT 2
ABSORPTION FIELD - EXISTING
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
18035 PIONEER DRIVE, EAGLE RIVER
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
5
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
ROBANNA 2
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area z
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft
Ft.
Well
100'+
--
25'+
TANK 2 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER
Capacity
1500 Gal.
Surface Water
100'+
--
Material
HDPE
Number of compartments
2
Lot Line
10'+
--
NA
Foundation
10'+
__
LIFT STATION
Manufacturer
Capacity
Gal.
Remarks
Alarm location
Electrical installed by
Installer DENALI EXCAVATION
PIPE MATERIAL House to tank 3034 d Tan
n k to 3034
ld
Drainfield CO/MT 3034
Inspector FWCS
BENCH MARK (Assumed elevation) 100 ft
Inspection 1s` 9/14/20 2nd 9/16/20
da
Location and description
3rd 4'n
BOTTOM OF SIDING
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
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Conditional Approval: Date
AW ' ' •:�,����
•
•• TSI '•���
•
' ' ' ' ' ' ' '�� ' '
Septic System
Approve -
Curtis Huffman
• CE 128991
Date t/- Zx
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�s • • • •.���`�®®�
�� lFR . ,9/18/202Q. �� Aw
OPROHSSIONA
Note: this approval does not include well permit requirements.
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PID: 051-281-84
PERMIT: OSP201342
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EXISTING
FIELD
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NEW 1500 -GAL
HDPE SEPTIC TANK
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WALL
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EXISTING ^^ate
5BR HOUSE ow
LOT 2
N89'49'10"W X285.93'
PIONEER DRIVE _ SCALE, 1' =30
SEPTIC SECTION
ROBANNA LOT 2
PREPARED FOR:
KURT & ANNA SMOLE
18035 PIONEER DRIVE
EAGLE RIVER, AK 99577
FIRST WATER CONSULTING
13030 SUES WAY
ANCHORAGE, AK 99516
907-350-9566 firstwaterAK@gmoil.com
SCALEt NTS
SUPPORTS SERVICES:
Ar. OF At"1
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®
DATE: 9/18/2020 i�. Huffman.i
SURVEY: JLS , CE 128991Atf
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DRAWN: FWCS ,' 9/18/2020,
AW
SCALE: 1" = 30'FEsslo��'
9/4/2020
MUNICIPALITY F
Development Services Department
On -Site Water & Wastewater Section
Parcel I.D. 051-281-84
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Phone: 907-343-7904
Fax: 907-343-7997
Property owner(s) KURT & ANNA SMOLE Day phone 907-223-4733
Mailina address 18035 PIONEER DRIVE, EAGLE RIVER, AK 99577
Site address 18035 PIONEER DRIVE, EAGLE RIVER, AK 99577
Legal description (Sub'd., Block & Lot) ROBANNA LOT 2
Legal description (Township, Range & Section)
Lot Size 45,345 Sq. Ft. Number of Bedrooms 5
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(IE all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) 0
(w/wo ADU)
Septic Tank
0
Upgrade Q
(D) El
Holding Tank
El
Renewal
Renewal ❑
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: I6�'s. 75 o9w o
Date of Payment: .)
Receipt Number:
Permit No. 05 P ZO)3y 2
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350 -9566 / firstwaterAK@gmail.com
August 24, 2020
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: ROBANNA LOT 2
PHYSICAL: 18035 PIONEER DRIVE, EAGLE RIVER, AK 99577
The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic
tank on the above referenced lot. We propose to install a 1500-gallon HDPE tank per code to
serve the existing 5-bedroom residence. The lot and area are served by private water. The
design will not impact any of the neighboring properties. Please contact us if you have any
questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201342, Deb Wockenfuss, 09/03/20
FIRST WATER CONSULTING
ROBANNA LOT 2
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201342, Deb Wockenfuss, 09/03/20
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688.2759
OWNER OF LAND
LEGAL DESCRI~ION
PE~IT NUMBER
/
DEPTH OF WELL ~ ~
STATIC LEVEL OF WATER FT. ,'~ ~
DRAW DOWN FT,
GALS. PER HR 4,,,F~ '~3
KIND OF CASING ~ ~ O~
KIND OF FORMATION:
From ,/ & Ft. to -3
From ,'~ Ft. to 7
From '7 Ft. to ~'~
From '~ ~/~" Ft. to
From ~-)~' Et, to
/
From'~ / Ft. to 64,
From__ Ft. to
From Ft. to
From Ft. to____Ft.
From Ft. to -- Ft.
From Ft. to -- Ft..
From Ft. to Ft.
From__Ft. to Ft
From__Ft. to Ft.
From__Ft. to___Ft.
From. Ft. to Ft.
From Ft. to Ft.
From__Ft. to__Ft.
From Ft. to Ft.
From Ft. m Ft,
From__Ft. to Ft
Fmm Ft. to Ft.
Fmm__Ft. to Ft.
From__Ft. to.__Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to_ .Ft.
From__.Ft. to Ft._
From__.Ft. to Ft.
From__Ft. to.__Ft.
From Ft. to Ft,
M!SCL. INFORMATION:
~i t0
DRILLER'S NAME /2~d'~ ~
Z
I
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CARLISLE N89'5~'OO"W
GILB£RT I
IlIII Il' I
LOT 2
8.02 ~uiv£
L A I' L
WELL PERMIT SITE PLAN
,. ~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
JPHONE I E3~EW
MAILING_~A/DDRESS~L"'~' i ¢'~'~ ~
~ DISTANCE TO: W~r~ / Abso~on~rea Dwe,]i~ ~ ,~,¢
~ Z Manufacturer ~ ~ Mat~ / ~ of compa~nts
Liq.cap~ in gallons Width Liquid depth
.~ ~ '~ ~ Inside length
I /~ ~ ~ IF HOME.DE: ' ,
~ ~ DISTANCE TO: Wall Dwelling PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ W~0 / Foun*t~ NearT~ linc~ P
~_ N°' °f I~s~ Le~ f~t of*a 'li~ / Total I~¢lin* Trench¢~¢~ //inches Distance 'e*~een ~es
~ ~ ~ Top of tile to f~ Cdc / Material beneath tile r( Total e~t~a~orptiCarea
Length Width Depth PERMI'T NO.
~ /
<~ Type of crib Crib diameter Cr~lde~th/-- Total effective absorption area
/~/~
~ Well Building ~undatfon Nearest lot line
~ DISTANCE TO;
~.. --~ ~Cl~//~ De~ .... ~ . ,~r]~ Distance to lot line PERMIT NO.
~ ~'~t5 //- ,~-
~ ~ / DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
PIPE MATERIALS
, /
~OIL TEST RA
--
APPROVED ~ g~ ~* E:'ISINEZRD~¢4 ' // /
z,c'r,M 1' '1" xu"~ -
DATI::: 1' c!:
CCd?FACT' c:', ..~, c'.
Al.,,. I::i:ASMUBS 01',!
% S&S EI'.IE'JINEERII\IG
!EAGLE RIVER~ AK 995}~'7
694-;T:7977
L..EGAL ¥'~::( "' ' :"
J OT c~"[TF:'~
SUBDtVISION:~ NA
SECTION: 25 TOWNSFIIF:': 15N
5A (SQ~ I:::"I",, OR ACRES)
BLOC]I< .~ NA
l...isted be:Lot,...' are "~
t ....... opt ions av~x:L lab l,:e 'Lo yc:n..t :~.n ....... your
~.,~:..:: :i. g n :i: n g s ep t i ':::
svs'tc->m. . Ct'~(::ose~, '~'~.,~''~,,= opt. ion thai'., best' f i'Ls your si'Le,,
¥' ""'~' ""' .... 4.5
.0!:. Id 'T'n r::"fl::': ~:, ....... ..'.~ 0 z~ 0
........... :,L) ~..~t'! (F:T ) ,~
..:-' ,~ ..~ ..... ~i, ~.,- , F-, ( F' '1' ,,." /',. () 0 ,, 5 3 ,, 5
'T'OTAL DE?TH (F'T~) .,.~("~..- ~ 0 .'.'5 ,, .'"~.. "> ..... ,, ...,:
G,~..~vI:.L.. WIDTH (I:::"1",,) 2. !5 .LB,, ') 5,, 0
, I-u...~vE::l ........ c. NG 1 r, d~' q ~ ) 2!;6 ~ .") ":rz. ,"~ .-'~ ,:. ")
~':z 7,/~ .,i::u ~ .)L,-. ~... (CU. ~;~]~ ~ ~:.' :[ ,, '7 O.'l ,"~ '1
, ,-. I-.,. ....... z ....,u:,r.L~:~, .L. 500. 0 .~-.X. =';'" (', '"~ .~.'.~.e ~ 500 ~ '"' '~"~'
SL':) I I .... F I ..... ~::['t F:'T ,, /B!q'. ) o,= ....
certify tha'L:
I aiii famil:i, ar' ~.~J.'t.h 'Lh,E.:~ r'equ:i.r'ement, s {'ctr' on.-..si'Le se?.~epE~i and ~x~e:l.].~ as set
fE:i"'[.h by the Mur'iicip~'.l. ity c)f' Anchopag~ (MOA) and 'Lhe:, State ~:~{ Alaska.
2, I wJ.].], ins'Lal], the sys'[.(~,!m-:i.n ac:c:opdar'~c:[.:e' v¢:Lth a].l MC)A cc)des ar'id r'egLt].atJ, cJr'is~
a':u']d J.r'I cc)mpJ.:i, ance ~/~:i.'l:.h the design c::pitepia c)f '?.his permJ.'L,,
~B(.:.?t.,,]~z~r'ag(.:~.) SyD't..E.)fii on tl-~:i.s of any adjacent or' near'by lot.
4. I ~...tFideps'l:..ar'~d 'Lha'L 'k.h~s p~,r'.mi.t :i.s vaJ.:Ld fc)p a max:i, mumc:{' ~ b~)(:Ji'gcims and
any enJ. apgemer'It ~,.~.].]. r'equip~.) an addit:i, onal pE.n'm:Lt.
.,.'r!::'~ (."i ~ ]:Fr']"` ¢~'¥'/~"-Tf]l\1 ]:S ' k c?"/~ z'~', r- 't ,c'i:',~:~ EiY " ~::,~ I r-~'~r~'z'c:.
,.-. .... ~, ....., ~,.1,,t~.., .... 1 ....IN AN AREA ,.,[J v,..., u....D MOA ,....,.,!I...DIIqG ...,.,,.,I...~,..
THEN ( '~ ~ AN ~:: ~:: ....... ' ..... zx ~'~, c:'z,,:r ........ m,* A ::'""r"~[
........... R]...,,-.,~.~ PIEFRI'JIT AND .... ~,.,~ t ...... ] .....MLJST BE 't~::,n",x'i'm~zn ,'"~
.......... r, ............ ~; ,,=) .,.~ .... :tiL. TS
I,t,,,..~..,~ .... NOT BI:::' APF:'F;'O 1N~''xL n~ n''., ,, .,.~.., , AN tEL. E: ]TP]:CAL. . ]:NSF'ECTZ~, ,t" '~' ,"ur"r"r'Pr""r'., ..,,~, j; AND
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~ .i. Si,Il= .... ~.,A i 1:::. ,,
PERFORMED FOR: :4Z
LEGAL DESCRIPTION:
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
SLOPE SITE PLAN
¥
10
11
12
13
14
15
16
17
18
19
2O
WAS GROUND WATER
ENCOUNTERED?
0
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
,
PERCOLATION RATE ///,~ (minutes/inch)
TEST RUN BETWEEN FT AND , FT
COMMENTS
~ & ~ E~EiINEERIN~
PERFORMED BYi ~ '~RB 19~,~ ·
PH, 694-2979
UMC�PAU7V OF
Development Services Department
On -Site Water & Wastewater Section
Parcel I.D. 051-281-84
ANCHORABE
Certificate of On -Site Systems Approval
fiRrT�l�Ile��1►1;�1:����CTtJ
Complete legal description ROBANNA LOT 2
Phone: 907-343-7904
Fax: 907-343-7997
Expiration Date: 12 -'N_2D zo
Location (site address) 18035 PIONEER DRIVE, EAGLE RIVER, AK 99577
Current property owner(s) KURT & ANNA SMOLE Day phone .
Mailing address
Real estate agent
18035 PIONEER DRIVE, EAGLE RIVER, AK 99577
2. TYPE OF DWELLING:
® Single Family*(w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
5
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
®
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ t_1 '12. 50 r-ou r0
Date of Payment cl �0
Receipt Number 2-16 l q 3
COSA # C%,C Z0150_.6
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, 1 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY ANCHORAGE AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 9/15/2020
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
_-well. septic.system....Therefore,.any- estimate. of how_long.a.system..wi11.fun ction satisfactor
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting & FWc5
6. DSD SIGNATURE
System #1 Approved for �� bedrooms
System #2 Approved for bedrooms
Disapproved
-49
Curtis Huffman %
�'Ec •. CE 128991
Conditional approval for bedrooms, with the following stipulations:
_IiIII(fill,.
Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Other
COSA Checklist
Legal Description: ROBANNA LOT2 Parcel ID: 051-281-84
If more than 1 septic system on lot: COSA Checklist # _of
A. WELL DATA
® Well log is filed with Onsite (or attached)
Date drilled 6/17/1987
Total depth 64 ft
Cased to 64 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 8/10/2020
Static water level at beginning of test 25 ft.
Comments
B. TANK DATA
Age of tank(s) 0 years
Tank type/material SEPTIC / HDPE
Measured operating fluid level in septic tank NEW
® Standpipes/foundation cleanout per record drawing
Date of pumping NA - NEW
D. ABSORPTION FIELD DATA
Which system tested (date installed) 11/12/1984
® ALL standpipes present per record drawing
Total measured depth from grade 10 ft (max)
Measured depth to pipe invert from grade 4 ft (min)
❑ N/A - pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective
Structure served by this system _
Well production at time of test 4.7 gpm
Water storage tank volume_ gallons
Well disinfected for coliform test? ❑ Yes ® No
® Coliform bacteria is Negative
Nitrate 9.94 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ® Arsenic less than MRL (ND)
Collected by_ FICS
Date of Sample 8/10/2020 -
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _years
Lift station material
Comments:
Adequacy test date 8/10/2020
Results El Pass For 5 bedrooms
Fluid depth prior to test 6 in
Water added 770gal
New depth 13 in
Elapsed time 15 min
® Code -required soil cover over field Final fluid depth 6 in
❑ System presoaked Absorption rate 750 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test) If yes, enter date
Gallons introduced gallons FW'rs
Comments/Deficiencies:. ``
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
® Yes if No ft
Wells on Adjacent Lots:
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
Surface Water > 100'
® Yes
Animal Containment > 50' ® Yes
if No
M Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ®Yes
if No
ft
® Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
® Yes if No ft
Property Line > 5'
® Yes if No ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes if No ft
Private Wells > 100' ® Yes if No _
Water Main > 10'
® Yes if No ft
Community Wells > 200' ® Yes if No
Water Service Line > 10'
® Yes if No ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No
—ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ®Yes if No —ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION\,,
I certify that 1 have determined through field inspections and review AW . _...
of Municipal records that the above systems are in conformance �g . •:�
with MOA COSA guidelines in effect on this date. % *: •� iH
/J• Curtis Huffman
�( �F�, •• CE 128991 .• �`�i
�� ;'�'lF • 908/202Q . •'\G�i
►��PROFESSIONP��.r
ft
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15' T&E ESMT
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30'
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I
ANCHORAGE RECORDING DISTRICT, ALASKA
AS-BUILT OF: 'Q� = FND ALUMINUM MONUMENT
ROBANNA SUBDIVISION @) = FND 518" REBAR
LOT 2 PLAT 87-60
SURVEY CERTIFICATE: 1, John L. Schuller, Have conducted a i \� �D S D [�
/� �F AL \e,1 1 �ti0 LAND
physical survey ofilris property as shown on this dmuvtg and that the // fi . • .. ... •.9� t j
improvements situated hereon are within the property lines and no
enchroachments exist other than noted. Under no circumstance should % * 49�
any inrormation on this drawing be used for construction offences, r a b c C
structures, improvements, or for establishing boundary lines.
U !-'
/ .1..�..... / to
EXCLUSION NOTES: It is the owners responsibility to determine �'� ' :"' �
the existence of any casements, covenants, or restrictions Rfiich / '+IOkN L. SCHULLER: 0
do not appear on the recorded subdivision plat. �, of LS-10408
WORK ORDER NUMBER; ah: SCME E-YA¢: tt; P '•• .�� ,zz* gJ%� 1831 Talkeetna Street
SEPT 18, 2020 1-=30' `01 na / Anchorage, Alaska 99508
20-070 DPAM ar. a�EaEo a rnm Kwars eoa��a ,�rOfession°l L°c (907) 227-1455 office
JLS NW0753 200215\\\�`��� (907) 274-4992 fax
M U H� C 0 PL' 7 V O F A N CC -� 0 Fti 621E
DEVELOPMENT SERVICES DEPARTMENT
On -Site water and wastewater Section -
www.muni.org/onsite
Nitrate Advisory
Certificate of On -Site Systems Approval # OSC201506
Subdivision: Robanna, Lot: 2
907-343-7904
Fax: 343-7997
A water sample revealed a nitrate concentration of 9.94 milligrams per liter
(mg/Q. The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. Please see the attached "Nitrate Fact Sheet" for
important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~"~'~ / -- ~:~ / -- ~'~\ NAA# ~:>~\ ¢~. c;'~ ,:;: (' ,-_,~, ,~
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) ,,/~ ~;.~' /~/4',~2~¢~" ~
Prope~y owner ~,'~¢ ~~¢ ~,~¢¢~d~ay phone
Mailing address
Lending agency
Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of theva]idation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
KND Engineering
Name of Firm 2044t P,,a~m~gan 81vd.
Add ress Eagle Rive~./~,K 99577.873,3
EngineeCs signature
Phone
DHHS SIGNATURE
'¢/ Approved for
Disapproved.
bedrooms.
Conditional approval for bedrooms, with the following stipulations:
Note: The well for this property meets existing State and Municipal Codes.
There are ~iL~Lu~ ~L. IL i~ ~ugg~Led ~hat periodic uesuing be
performed to insure the wells continued suitability. Current nitrate
concentratzon zs ~.~ mg/±. ~FA maximum concentration is 10.0 mg/1.
More information on nitrates is available from the On-site Services Program,
DHHS, 343-4744.
Addition~ Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-O25(Rev. 1/91) Bac[ MOA~21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description: ,,'¢¢~,--/-¢/'2~ .~/~- Parcel I.D.:
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to ~,/1/ I
Casing height (above ground)
Wires properly protected (Y/N)
FROM WELL LOG
AT INSPECTION
Date of test
Static water level
Well production 7 g.p.m. ~', ~ g.p.m.
WATER SAMPLE RESULTS:
Coliform
Date 'of sample:
Nitrate
B. SEPTIC/HOLDING TANK DATA
Date installed 11//'2'////~¢ Tanksize
Foundation cteanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed /I/~/~¢
/
Length .~ ~c~ t Width
Other bacteria Ct2
Collectedby:/~/f,//~--~g'~/~
15-00
Depression (Y/N) /~
Number of Compartments ~- Cleanouts (Y/N) Y
High water alarm (Y/N) ,~//~
System type ~
Effective absorption area z/.5-/_~ Monitoring Tube present (Y/N) Y Depression over field (Y/N) /
Date of adequacy test Results (Pass/Fail) ,'~ ~<_~ For :~ bedrooms
Fluid depth in absorption field before test (in.); ~ Immediately after/~r~gal, water added (in.): ~ 3///7//'
Fluid depth 'E~)r~ (ins) Minutes later: ~,~) Absorption rate = ~',~ .,L, g.p.d.
Peroxide treatment (past 12 months) (Y/N) /g'/ If yes, give date
Soil rating /~*~ o~
~4::) ' ~ Gravel thickness below pipe
Total depth
LIFT STATION
Date installed ~' Size in gallons J
Manhole/Access (Y/N) "../~Pump on" level at* .../~"Pump off" level at*
High water alarm level at* ~ *Datum J
Cycles tested ~ ~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot /d.~ C) 4~
Absorption field on lot /D O ' '~
Public sewer main /d)~ ~
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Sewer/septic service line
· /D~ ''~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
/
Foundation /~) -~ Properly line ./~9 & Absorption field
/ -//
Water main/service line ,2 5 + Sudace water/drainage /E)~ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
/ ! /
Property line /~¢) '~ Building foundation ,/~:) ¢- Water main/service line ~:~ '~
Surface water / tgD ~4-- Driveway, parking/vehicle storage area /D 4~
Curtain drain /d¢~. ',/f'r'/cccOr/ /¢)~) 4- Wells on adjacent lots /,:¢'¢ 4-
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records
in conformance with MOA HAA guidelines in effect on this date.
Engineer s Name
Date /~.//~'~/~
Date of Payment '~/~z~ ,/~7~t~ //
Receipt Number E¢//~,~7'/
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
APPLIC ',IT FILLS OUT UPPER HAL'' ',ONLY
Property Owner /'---~ ~ . . - Phone
/
Mailing Address .~r~" ,~ ,/~.~,,~' ..-~ ~ .... X/,~ : .,~', ....... :'? .~ ~.~ Zip Code
Buyer /':~_~ ,~L,~..~,? ~' :~ :
.: . -:- ..f ~/' Zip Code
Address ·., ;~ ~,~.,~ ? ~ ~,, ( / /,, .~ '~,, (~ / j ,,:; ,~; z, ...... ~,.
~ // · ~ Phone
Lending Institution ~.~ - ~' ~ z /. /~.~.~, .~ ..~.
Address Zip Code
· Phone
Realty Co. & A~nt /,~ ~ /.'/'~ _, ,~-~,/ ~ /:/~ . ~ ~_.
Address .... '/':: ?.~ -' ,( ;"-" /¢ '3. /~ ¢ ,~ '.!,~ ~:-' ;~¢ Zip Code
Street Locati~
Type ~ Resi~nce
~/Single Family
~ Multiple Family No. of Bedroo~
~ Other
Water Supply
~lndividual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that d~te, give well depth (attach Icg if available).
~ Public Utility
~ndividuai . - Year Individual Installed:
B Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OOESSlNG CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
( ~ AP.ROVED BEDROOMS ~ 'CONDmONS OP APPROVAL
(') DISAPPROVED
( ~} CONDITIONAL~.P~ROVAL,*
.-..~ ~,,-/~ ,~_/~.~ ~~ '
Soils Rating Date Sewer Installed Well To Absorption Area Weft Log Received
Well to Tank Septic Tank Size