HomeMy WebLinkAboutMARIE ESTATES LT 5Onsite File
x �.
Municipality of Anchorage
On-Site Water and Wastewater Section • (907)343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191024 PID Number: 05111133
Dwelling: ❑I Single Family(SF) ❑with ADU ❑ Duplex(D) ❑ Two Single Family Project: ❑ New ❑■ Upgrade
Name
Van Ryn ABSORPTION FIELD
Site Address 0 Deep Trench ❑Wide Trench ❑ Bed ❑ Mound
24128 Temple Drive ❑Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
529-1282 4 0.8 GPD/SF 11-14 Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot 4-7 Ft. 7 Ft.
Marie Estates 5 Fill added above original grade Graq len th
Township Range Section 0 Ft. 6 - ,+}Ft.
Gravel width Beds:Number of Lines Distance between lines
SEPARATION DISTANCES 3 Ft. - - Ft.
To
Septic Absorption Holding Sewer Total absorption area Number of trenches Dist.between trenches
From
Tank Field Lift Station Tank Line /33 -7 t2 1 _ Ft.
Well 100'+ 1001+ na na 25'+ TANK I]Septic ❑S.T.E.P. 0 Holding 0 Other
Manufacturer Capacity
Anchorage Tank 1250 Gal.
Surface Water 100'+ 100'+ na na Material Number of compartments
Lot Line 10'+ 101+ na na NA Steel 2
Foundation 101+ 101+ na na LIFT STATION
Manufacturer Capacity
Gal.
Remarks
Alarm location Electrical installed by
PIPE MATERIAL House to tank D3034Tank to D3034
drainfield
Installer
Dean Drainfield D3034 CO/MT D3034
Inspector BENCH MARK (Assumed elevation) 100 ft
Inspection Location and description
dates: 1 4/1/19 2nd 4/15/19
31d
4/16/19 4th Deck
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineers Stamp
Conditional Approval: Date
Septic System _
Approve• _ Date -3 -17 Siz s ft,
Note: this approval does not include well permit requirements.
(Rev 05/02/18)
AS-BUILT MEASUREMENTS
A B
ST1 59 76
ST2 66.5 83.5
DCO 70 86
Div Valve 73 89
C01/MT1 119 138
CO2/MT2 85 85
a Alternate Site Is
Decommissioned Old Existing Trench +
Septic Tank 17' Extension, 8' Effective
PER UPC &
r Replaced w/ 1256-Talton
Septic Tank
Temple Dr Double Cleanouts
L2 Well>100' l
Ii � CDl/MTi I
5% -slop
POM
h _>
15()/ 1 flIN
0
J
4 Bdrn •
20\Slop I -
-01,,ole Well o \ 1,
\ Ty 5 I I Well o
Driveway 5 . 4,,t0._
CI , 20 Slop
5% lop
a) IVew Trench
Ti
L
I "
I .1._
o. Duplex Well
a, Lot 6 Septic o
P.,
(Well
NOR THRIM _�••1'0 �k 1' = 50'
ENGINEERING =�P�`"""""" �, MARIE ESTATES
* .. Pik LOT 5 RECORD
SteveEng. com ;•* '49 I' *
Po Box 770724 0:�' LAYOUT
£ogle River, Alaska 99577 ,- , CC- 6 WASTEWATER
907. 694. 7028 � �"
' l �f` UPGRADE SEPTIC 5/23/19 rof 3
..
Foundation Cleanout Elevation @ 97.5'
/ Tank Cleanouts Elevation @ 93.5'
Fin ade Opposing Cleanouts Between Septic Tank & Trenches
4 Foot Cover /''
or Equal
'
_„Elevation @ 932' k"J
Elev ion @ 93'
1250 Gallon Mounded Cover To Match Terrain
11\
@ 94
levation 'Anchorage Tank'
Or Equal
Monitor Tube
Solid Pipe leanout
North End Final/Original Ground @ 97' I I
South End Final/Original Ground @ 100'
4'-7,
Filter Fabric
Elevation @ 93'- ::' i"i_,:�.i i
ilij
...f. i:•:•:•:•:•:
i i:•:•:•:•:•:
7, p :.:.: 11-14'
.-..
': Azevet i:•:
..-.....
iv
Drain Rock !=' tAVO:t.0.0t
r:i r:•:•:•:•:•:
Elevation @ 86' •=•=•-�-'•'•
TH Elevation @ 80' (Dry @ 4/1V19) I'.' '='='''`"'
3'
NOR T H R I M d � d .
:�P�`� � �', TRENCH END VIEW
ENGINEERING ,m . �•, MARIE ESTATES
SteveEng. com(* .49 I. . 4 SEPTIC TANK PROFILE
Po Box 770724 ,' ,..: i: SEPTIC SYSTEM LOT 5
Eagle River. Alaska 99577 �ti,,� 72,3/r7 =- _._Dote: "" BrSEScok: 1' = 5 SHEET:3 o f 3 -+907.694.7028UPGRADE RECORD 5/23/19 ro
I SE
S❑ILS LOG - PERC❑LATI❑N TEST
NICRTFRI Date Performed: 4/1/19
ENGINEERING
Performed For: Cameron
Legal Description: Marie Estates Lot 5
DEPTH
(FEET)
T.H. Location: See Attached Test
Organic
1 gBoring Location Map
0 0
2 - 0. 0 SM Silty Sand
3 -
4 - .0. W/
5 -
0
Gravel
6 - Groundwater? Seeps
7 - CDepth --
8 -- Water Depth
9 . 0.. . After Monitoring. None Date: 4/11/19
10 - # Date Gross Time Net Time Depth Net Drop
11 - 1 4/11 0 -- 6' ----
12
-12 - . 2 4/11 30 30 min. 4' 2'
13 - 0 3 4/11 30 -- 6" --
14 - 4 4/11 60 30 min. 3,5" 2.5'
15 - 5 4/11 60 -- 6' --
16 - C 6 4/11 90 30 min. 3,5" 2.5"
17 - 7 4/11 90 -- 6"
18 - 8 4/11 120 30 min. 3.5' 2.5"
"
19 - 9 4/11 120 -- 6 --
20 - - - 10 4/11 150 30 min. 3.5' 2.5"
21 - Percolation Rate 12 min/in Perc Hole Diameter 6"
Test Run Between 4' & 5'
Comments: Pre-Soaked- Measured To Nearest 1/16".
Performed By NorthRim Eng, ICERTIFY THAT THIS TEST WAS
Performed in Accordance with All State/Municipal Guidelines in Effect
ON THIS DATE. DATE: 4/29/19
N OR THRI M ��+�`,`'�
-•'.\i,7412 Marie Estates TH3
ENGINEERING ';P•'
SteveEng. corn * '49m * LOT 5
Po Box 770724
'"""° TESTH❑LE L❑G
Eagle River. Alaska 99577 �+417= �
907.694.7028 / GEOTECHNICAL 4/29/19 Il:
"°" 'r`0MUNICIPALITY OF ANCHORAGE Nen,-
On-Site
e„tOn-Site Water&Wastewater Program
�..+�, PO Box 196650 4700 Elmore Road i..
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
/ bi
http://www.muni.org/onsite
\
Department
4"C H OP PGS I
On-Site Wastewater Disposal System Permit
Permit Number: OSP191024 Effective Date: 2/13/2019
Work Type: Septic Upgrade Expiration Date: 2/13/2020
Tax Code Number: 05111133000
Site Legal Address: MARIE ESTATES LT 5 G:1361
Site Mailing Address: 24128 TEMPLE DR, Chugiak
Owner: VAN RYN CAMERON T&WENDY L Lot Size in Sq Ft: 50297
Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
E Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy 0 Private Well 0 Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72)and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions: 1. The proposed disposal field is too deep for test hole submitted. The Engineer shall do a
test hole prior to construction of the field to confirm separation to impermeables and ground water. Construction
may proceed at your own risk before the 7-day ground water monitoring is complete. Please submit stamped
and signed results with the inspection report. If the results require a design change, construction of the system
shall stop pending On-site review and approval of a change order.
2. The entire subsurface disposal field and/or alternate is not within a 30 foot radius of a percolation test. The
Engineer shall do an additional percolation test prior to construction of the disposal field. Please submit stamped
and signed results with the inspection report. If the results require a design change, construction of the system
shall stop pending On-site review and approval of a change order.
.4�///
Received By: Date:
Issued By: Date: 021"26 15
•
•
• ,`H 11NICIPALITY OF ANCHORAGE
I,j•
Development Services Department 6Pii.�1e !07-343-7904
On-Site Water & Wastewater Section � -343-7997
ti
FEB 06 2019 1.
ON-SITE SEPTIC/WELL PERMIT APPLICA
Parcel I.D. a 5I l//" 3
Property owner(s) V 4t'' f{ /r Day phone 52 ?—/2 cPZ
Mailingaddress 21//2 �i�/!/l �L U
Site address S A
Legal description (Sub'd., Block & Lot)
Legal description (Township, Range & Section)
Lot Size 54/ 277 Sq. Ft. Number of Bedrooms
APPLICATION IS FOR: APPLICATION IS AN: ( TYPE OF DWELLING:
(® all that apply)
Absorption Field ' Initial El
Family (SF) -
(w/wo ADU)
Septic Tank i�� Upgrade
Duplex (D)
Holding Tank ❑ Renewal / ❑
Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature o perty owner or authof?! agent)
Permit/Rush Fees: 41s9S•oo Waiver Fees:
Date of Payment: 02106/+q Date of Payment:
Receipt Number: OK 1(01) Receipt Number:
Sp
Permit No. 0 Ill024 Waiver No.
G:1Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
T FR IM
ENGINEERING SteveEng.com
Steve Eng,PE, PH
907-694-7028
SteveEngPE@gmail.com
Date: 2/5/19 Number of Pages:
To: MOA On-Site Services /
Subject: /14a.f"! E-�r�f t ,. L-
Septic System Upgrade
During a COSA inspection it was discovered that all the drain-field cleanouts had standing water,
indicating failure. A new design is submitted to mitigate this damage. A previous soil test reveals
SM/GM and no groundwater; water well logs depict no bedrock at depth. The design calls for a
new trench and a new septic tank. The existing trench can be used for a future alternate site
providing an extension is constructed.The water wells and easements are depicted on the drawing.
The terrain is generally a flat slope at the trench site, but drops off to the east. The system design
size is a single family at 4 bedrooms.
Please review the wastewater system design for the existing single family home. I have included
design plans & specs, design guidelines, & soil test. If there is need for additional information or
clarification please give me a call.
Thanks-Steve
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ENGINEERING "
SteveEng.com '°'
M ;E'states Lot 5
SPECIFICATIONS & DESIGN GUIDELINES e
4eop
Wastewater System Sizing: This is an existing 3-bedroom, single family home. 1'A11`le"
developed subdivision. This is a large lot but with limited area available for septic system
replacement. The owner desires a new septic system for 4-bedrooms. A new trench is
planned+new 1250 gallon septic tank. The preious trench site can be used for alternate
trench site. No adverse impacts are expected from trench/tank upgrade.No conflicts to the
other lots will take place by this septic system construction upgrade. A previous soil test
reveals SM/GM. An application rate of 0.45 GPD/FT2.Trench Length= 1333.33 FT2/7'x 2
=95.5' trench,7' effective. Two water well logs depict undergound strata with no bedrock
to substantial depth. A new 1250 gallon septic tank will be installed; Decommission old
tank per UPC. Water wells are drawn.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications(AMC)& State of Alaska Drinking Water
Regulations and Wastewater Regulations.
• Two compartment,New 1250 gallon septic tank. Install Double Cleanouts.
Decommission old tank per UPC.
• 10' minimum between the tank trench,tank to house. 10' to property lines,
• 3' of cover or insulation is required for trench; 2" Minimum thickness for insulation
can substitute for 1' cover.
• Tank& solid pipe must be set on well compacted, stable soil.
• 4 inch diameter cleanouts with airtight caps are required 1' to 4' from foundation
wall,prior to any 90 degree bend in 4 inch line, in each tank compartment, and two
adjacent opposing cleanouts between the tank and the absorption field, not more than
10' from the tank positioned to provide cleanout access towards the tank and towards
the absorption field.
• All cleanouts must extend to at least ground level.
• In solid pipe runs,ASTM D-3034 may be used in lieu of cast iron.
• Trench to be placed level, minimum of 4' to groundwater,6' to bedrock from
drain-rock.
• Drain rock to be %2 inch to 2 inch screened. Drain rock to be distributed uniformly
throughout the trench.
• Perforated pipe to be installed level with perforations down.
• Silt barrier(filter fabric)to be installed above the drain rock.
• Smeared trench sides must be raked or scarified before drain rock placement.
• The finish grade must be mounded to promote drainage away from trench.
• Insulation must be placed over any pipe installed under driveways or parking areas.
• Approved pipe materials include cast iron,PVC ASTM D3034, PVC ASTM F789,
ABS ASTM D2661,
• Sewer Service Line is minimum 2%slope.
• Septic Tank to be pumped every two years or when required.
• Insulation board to be extruded direct burial polystyrene(Dow Styrofoam HUequal)
DESIGN NOTES:
1. Total Depth of Trench is 14'.
2. Sewer Service Line minimum 2% slope.
3. Private Water Wells In Area- Measure Prior To Construction.
4. Decommission Old Tank Per UPC.
5. Locate Sewer Service Line- Replace If Necessary.
6. If No FCO Found, Add DCO Before The Tank.
7. Alternate Trench Is Existing Trench + 17' Extension.
Alternate Site Is
Decommission Old Existing Trench +
Septic Tank 17' Extension, 8' Effective
PER UPC &
r Replace w/ 1250-gallon
Septic Tank
Temple Dr Double Cleanouts I
L2 Well>100'
I ( /
4 57. �.0 0/MT COI
Pow
e^U� Weill0• 0'
I ( /
Well2o \
\ THT 9 5 ( I Well o
Driveway 5 . l0•- 1
. • 20K. Slop I I I
CO2/M p
o,
5� -'- ew Trench
Ti
L c \
w
a \ Duplex Well
cy L-I-, ot 6 Septic o
(Well
11
NOR THRIM _.••�'� ~ ''4 1' = 50'
ENGINEERING 4`..'• MARIE ESTATES
SteveEng. com * •491 * LDT 5 DESIGN
PO Box 770724 v.. Stew �; LAYOUT
Eagle River, Alaska 99577 �,� Ef/47 , W A S T E W A T E R
907. 694. 7028 UPGRADE SEPTIC Dote: SHEET:
2 of 3
,
•
Foundation Cleanout
Tank Cleanouts
Fin ^ate de Opposing Cleanouts Between Septic Tank & Trenches
4 Foot Cover
or Equal
1250 Gallon
"Anchorage Tank' Mounded Cover To Match Terrain
Or Equal Monitor Tube
Solid Pipe leanout
DESIGN NOTES:
1. Depth of New Trench is 14'.
2. Septic Tank & Solid Pipe to be Placed on Compacted, • • 4'-7'
•
Stable Soil, Free from Boulders. Filter Fabric � '
3. Sewer Service Line is Minimum 2% Slope & 3' Cover.
4, Water-Tight Couplings. ! ! !! !!
:j •'',•: .. (ENGINEER AL).
:S SE
•
• C'G
t �^
Municipality of Anchorage -oma ;J
DEPARTMENT OF HEALTH & HUMAN SERVICES �' .„.!,:A,„,,0.,,,,,,,,,,,,9.0,..
825 "L"Street, Anchorage, Alaska 99502-0650 ," . p�,ichn�:) E. Anderson ' .•-•1
SOILS LOG — PERCOLATION TEST c�:�:;A aaut -E �,'.0 y
G '':,�: icr I . 9S
PERFORMED FOR: ING2 L-O^1 G�/�l Y DATE PERFORMED:
LEGAL DESCRIPTION: GOr 5 /4AR.rE CST Township, Range, Section:
r
r,Ea� , SLOPE .5„...2,4,P1214,11u�
1 T I _
.m- ''. N
o:
2 No i =c
3 , o• .', U
°
st a - :Q SM/61 M ` o i
5 - ' • - C
O
II 'CZ
( f/Z -r-t73
' A ,
•oNt
'
10 — •� /✓I DO. b rr�Sfi WAS GROUND WATER A I
p �, 7 1Sg: ENCOUNTERED? / L' ,
11 — •u •. S
L •
d IF YES,AT WHAT �o
Q • , • DEPTH? p \
12 - • . E \
o •
13 -•• • •
Depth to Water Atter/44E /
_ Monitoring? Date: 30 9s
o ,
14 - d Reading Date Gross Net Depth to Net
Time Time Water Drop
15 -- ' 4 / 1Z I. ' /D % 2b -- ', /L " — -
° ,d Z 10: `><o £.0 5'r IV L "
16 - •4, 'o +r"3 //-(?U ZIO S ')G -pi/ 1,
18 — &T<D i✓1 or
/off •
•
19 -
20 - ' 6
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
�
-� TEST RUN BETWEEN FT AND 9'/ FT
—
COMMENTS -L` SJ' 4O C /�itCi.SQ�Q11•f-4 Pc-ion.Z. r —77,S11"14 .
�a1�u� �,
PERFORMED BY: I .<<....x..— • THAT HIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: iz_q_s
72-008(Rev.4/85)
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ASBUILT-NO CORNERS SET THIS DATE. SWARD & AS$OCIATBS LAND SURVEYING 694-0$29
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE' �� / 4��,ax,� `
FOLLOWING DESCRIBED PROPERTY' "�� OF A(:q'
ia,Q. rex 'r's e4ef mar -5--•
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS DATE: / Y �kQ. '. *„. '•.cS'fi�4
INOICATEII, IT IS THE RESPONSIBILITY OF THE �r ,�,'• • • .r
OWNER TO DETERMINE THE EXISTENCE OF ANY ( D: '`
I •
EASEMENTS, COVENANTS, OR RESTRICTIONS .,‘,.‘r./.,_.1.1.7 . '•. " '/;
WHICH DO NOT APPEAR ON THE RECORDED & DI- ---- - Ou .Mut s..wrd p
VtsION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB' •
�� r3 . '.. Ls-091B • A
ANY DATA HEREON BE USED FOR CONSTRUCTION �^ i}y' •...
OF FENCE LINES, OR FOR ESTABLISHING BOUND- DRA j 'sa l`-- "
4.
ARY LINES. Q 'si+.a.a.,./,r
Municipality of Anchorage Page / of '
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650-e Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
N.~: ~ ~/~ ~~~ Wa~tewater System: D New ' ~p~rade
Address:
~ ~~ ~, , ABSORPTION FIELD
Phone: ' ~ NO. of~Bedrooms: ~p Trench ~ Shallow Trench. ~ Bed ~ Mound ~ Other
Total Depth from original grade:
Lot: ~ Block: --. , 8u~v~ion~ ' _ Depth to pipe ~Eom from 0riginaf grade; Gravel ~ep h beneath pipe
Township:, J Range: ' Section: Fill added above original grade: Gravel length:
wm~ ~~""'':~~ New B Upgrade' Gravel width: Number of lines: I Ois~
Classification (Private, A,B,C): : Total Depth: Cased To: Total absorption area: Pipe material: ~
Ft. Ft.--/~ ¢ ~ ~ SO. Ft.
Ft.
Yield: GPM IPumpSetat: Ft. C"'n'~"'~"'*~0'"6'°u;;: TANK
SEPARATION' DISTANCES ~eptic ~~ Holding ~ S.T.E~.
From Tank FieNd Station Tank ~ewer Lines
Well ~/~' ~' ~/~ ~ >~o' Materia,~ Number of Compadments:
· SudaCewater >/~ >/~¢' ~/~ ~/r >/co' LIFT STATION ~/~
Line -- ,
Foundation ~ '"' 2~' ~/~ //¢ / "Pump on"levelat:~'levelat: I Highwateralarmat:
Cu~ai. ' __/__. , Pump ¢ Electrical Inspections pedormed by:
Drain
Remarks: BENCH MARK
Location and Oescription:
I Assumed Elevation:
ENGINEER'S SEAL
72-013 (Rev. 9/91) MOA 25
~PermltNo.' '~t~<~-~/~" Page 'Z- of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description:
./
Permit No. ~Cc/ c~-~:)/ (,. %_., Page
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
'WATER W'~: RECORD
STATE OF:ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geologic'al ~ Geophysical Surveys
Anch Marie Est'. ~ , of g, al sC] ~"' wc] ....
~ lc. DISTANCE ANO DIRECTION FROM ROAD II';TERSECTION$ ~. OWNER OF W~LL: Hr. Nick
j2. W~LL LOG J Feel 8elD, 4. WELL DEPT~: (final) ~. DATE OF COMPLETION
~ Material Type ~ Too gotlom f ~
~ Sand and gravel 2 1OD ~ua.. ~u.,,.. ~eo...
, Sand and gravel 125 126
,J ~and and gravel. ~ z27 ~34 diam. la. to fl, Depth SIl=kup
g. FINlSK OF W~LL:
Sand and gravel ] 135. 148 r~,,:
__fl, after ~rl. pumping g.p.m.
~ ft. alter ~ra. pumping
: Proddctipn of 2'GPM
Aulhorlzld Reprllenlallve / '
Farm OZ'WWR (ll/SJ) . Co~ Distribution: WHJ~-SI~Ie DGGS~ PINK-O~tller, CANARY-CuIt~mer
flUG-02-95 WED 16:04
TRYOK NYHfiN & HfiYE$
907 276 7679 ?,01/01
NORTHERN TESTING LABORATORIES, INC.
~ FA~RBANI~ 6TAEET FA~I~IKS, ALA~iCA. ~?
~ ~g~nee~ng
Our Lab ~e F1502~2
Locat£ea/~rO~act; .
Your 6ample ~D~ Lot S Nacre ~state~
Report Da~o:
Date Attired: 05/16/gs
Date $~p~ed; 06/14/95
T[m~ ~m~pled: 1200
Oulleet~d By; Ken
Date Datv
mg/~~ ~ ...... . ~. ~
0,68 0,0! 06/23/g5
Vice Proeid~nt:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF'HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW950165
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NAME:NECRASON CONRAD FRANCIS &
OWNER ADDRESS:24128 TEMPLE DR
CHUGIAK, ALASKA 99567
PAGE 1 OF 1
DATE ISSUED: 7/14/95
EXPIRATION DATE: 7/14/96
PARCEL ID:05111133
LEGAL DESCRIPTION:
MARIE ESTATES LT
LOT SIZE: 50297 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80) ·
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4o FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS
RECEIVED BY: ~'%/~
ISSUED BY: / f- '
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, ALASKA 99524
July 1, 1995
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 5, Marie Estates Subdivision
Septic System Design
Impacts to Adjacent Properties
Dear On Site Services Engineer:
The absorption trench serving the home on the subject lot has failed and
must be replaced. Unfortunately due the setback requirements for wells
on this and adjacent lots, very little room is available for a replacement
trench. We are, therefore, proposing to reconstruct the existing trench at
the location shown on the attached Site Plan.
The soil in this area was originally rated at a percolation rate of 20
minutes per inch. An actual test performed on the soil indicated a rate
closer to 45 minutes per inch. The absorption area requirements of the
new trench are therfore greater than those of the existing trench. All
contaminated materials removed from the existing trench will be either
buried onsite or properly disposed of at an approved site.
We hereby request a permit be issued to construct the new absorption
trench at the location shown. Construction at this location will have no
adverse impacts on adjacent lots or affect the surface drainage on this lot.
Once the new trench is in place the area will be regraded to its present
condition.
If the system is installed as designed the following statements may be
made:
The system, if constructed as designed, will have no adverse impact
on the wells in the area or those to be constructed in the future
inlcuding the Class "C" Well currently located on Lot 2 of Marie
Estates Subdivision.
Lot 5, Marie Estates Subdivision
July 1, 1995
Page Two
The system, if constructed as designed, will have no adverse impact
on existing septic systems in the area or those to be constructed in
the future.
o
The system, if constructed as designed, will have no adverse impact
on reserved space, either surface or subsurface, on any lots located in
the area.
The system, if constructed as designed, will have no adverse impact
The current drainage pattern will
on drainage patterns in the area.
be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
LOT 5, MARIE ESTATES
4g.~O
SITE PLAN'
SCAEE 1" = 50'
NO0o
0
I r--/~
141.00
r~
JOB
LOT.'5, MARIE ESTATER ~H~E~ "°m °~
- CALOU~,E0 SV ~ ~4 DATE
NO SCALE
CHECKED BY DATE
........ ~ ............ ! ........... ?'"SCOPE OF WORK
SYSTEM PLAN
NO SCALE
Verify Integrity of Existing Septic Tank, . ·
Remove All Remnants of Existing Absorption .... ~' ~
Trench Including Sidewall Contamination .........
Bury Contaminated Materials Onsite or Provide a
Proper Disposal Area, .....................
Install New Line From Septic Tank, - :
Place New Drainfield Rock On Uncontaminated
Surfaces In Accordance With The Attached Typical ...... i .....
Deep Trench Section and to the Dimensions Shown .........
Above,
Lot 5, Marie Estates Subdivision
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Three Bedroom Home
Perc. Rate: 45 Min./Inch
Application Rate: .45 GPD/SF
Deep Trench
1,000 Gal. Septic Tank (Existing)
Min. 2' Accepting Soils
3 Bdrms. X 150 GPD / .45 GPD/SF = 1,000 SF of Absorption Area
1,000 SF / 16 SF/LF = 62.5 LF Length
Therefore: Construct a Deep Trench System With 8' of Drainfield
Rock and 63' Long at the Location Shown on the Site Plan.
Distribution Pipe Placed at 3.5' Below Original Ground Surface.
Existing Absorption Trench to be Completely Reconstructed.
Remove all Existing Drainfield Rock, All Contaminated Sidewall
Material and Place New Drainfield Rock on Uncontaminated
Surfaces.
TYPICAL DEEP TRENCH SYSTEM
(NO SCALE)
NOTE:
Trench to Be Installed Paralell to Slope.
Grade Area Over Trench to Drain Away.
Remove Ail Remnants of Existing Absorption Trench
Prior to Placing New Drainfield Rock.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 %" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
1
2
3
11
12
13-
14
20
DATE PERFORMED:
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
Depth to Water After./
Monitoring7 /v/o,,,lC_..- Date: ~/,~C)[~'~'
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
-- (minutes/inch) PERC HOLE DIAMETER __
TEST RUN BETWEEN ~:~ FT AND FT
PERFORMED BY; .~' /-'J.4-/',~Z.~ ' '~. '~" ~~¢fl~I~THATTHISTE/, ST WAS PERFORMED IN
72'-008 (Rev. 4/85)
i,~ ' 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
NAME PHONE I~W
LEGAL DESCRIPTION ~O'X ,6~ ~X/~ ~
LOCATION NO. OF BEDROOMS ,~
Well Absorption area~ /.~ D~ellin~ I PERMIT NO.
~ ~ Manufacturer ~ ~,~ Material~.~_~ ~ No. of compartments
~ ~ DISTANCE TO: Well ~/_ Dwelling PERMIT NO.
O ~ ~ Manufacturer/~ Material Liquid capacity in gallons
I We]l/(~f ~ ~ ~ Foundation~ ~ Nearest lot line Z~ / PERMITNO. ~ ~
~ No. of lines Length ~h ~ne ' Total I~t~f I~es Trench w,* Distance between lines
~ / riches
Total effec~ive~sorp~n area
Top of tile to finish grade ~ /' Material beneath tile
inches
-/
Length Width ~ Depth PERMIT NO.
~ · Type of crib Crib diameter ib depth Total effective absorption area
~ Well Buildiog foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO,
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PI PE ~AT~A LS T~'~'~
SOIL TEST RATIN~/ / /
INSTALLER
REMARK8 [[ ~ ~'
/ 1
~DATE LEGAL ~ g~ ~ *," ~ ~'-
72-0~!~ (Rev. 3/78)
MUNICIPALITY OF ANCHORAGE~
Department~--~ Health and Environmenta~ ~rotection
825 ~ Street, Anchorage, AK. ~9501
264-4720 ~- ~
~ * * * HANDWRITTEN PERMIT * *
Permit ~ ~ ~0N-SITE SEWER PERMIT
Applicant: C~-~/~/~ ~¥ ~~/~ Mailing Address: ~,~, ~'/~
Location: 7~/~/~~ ~Z Phone Number: ~~ ~ ~'~'
Legal Description: /g7~ ~~ ~' .~, ~3 Lot Size: ~/~/~, '-
Type of Soil Absorption System Is:
Trench: ~. Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: ~ .... Soil Rating(sq.ft/br) ~/~
The Required Size of the Soil A~sorption System
DEPTH LENGTH ~,~i GRAVEL DEPTH ~ WIDTH
The length dimension is the length(in feet) of the trench or 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 = /00~ 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(2) 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 8 3 * * *
I certify that:
(!) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I w~.~_~.~ll the system in accordance with codes.
(3) !~nderstan~ that thee,site sewer system may require enlargement if
~he res~Id~ce isir~e~da/led to include more that 3 bedroor~s.
Signe~: Issued by:
Date: ~-- / ~ -- ~,~
SWP/024 (i/si)
PERMIT NO.
[:,EPRRTMENT ' .... HERLTH RND EN',,,'IROI'.,IPIENTRL ":.')TECTION
825 "~.. S.TREET., RNCHORRGE., RK'. '.~'.!~ d:l.
2'?D-25~L~.
)
MF F L I L. MN I
LOCRT I ON
I..EGRL
~RUL N SLIMRI"!
TERRVLE CIRCLE
L5 MRRIE Ec,'[HTE-,
2'£.4¢~ I,.IES.T 8E~]"H FIVE
LOT S. I D'.".E
T"r'F'E OF S'OIL. RES.OF.'E:TIL]N S'¢STEM IS.: TRENCH
I'"IF¢'-"II"IUM N_It"1E, EE nF E:EDROOMS. = 4
S.OIL RRTING ':'5]! FT,.-"E:R)= ..L,:~..
THE RE])_IRE[, S.IZE OF THE SOIL RE:S.ORF'TION S.'¢S'I'EI'd IS.:
IE:, E F,"'F ~-I--- :t. (-.'~ L. IL=-'] ~-J~ ,L3 '"F ~-t= 5::L ,.3RR%"EL_ i:~ lB F" '"lf" IH
I
THE LENGTH E:,TMENS.ION IS. THE LFNGTH (IN FEET) OF TFIE T~!~,NCH OF..'. F:,RRINI--tEL£:,.
]"HE DEPTH OF R TRENC:H OR PiT IS THE DIS.TRNCE BETI.,.IEEN T'tE S.IJRFRCE OF THE
GROI_INE) RNE:, THE BOTTOM OF TFIE E,=-,L.H, MT ION IN FEET).
THERE IS. NO '.--.,ED- NIDTH FOR "RENCHES.
~F..PI,EL. BETI,t THE OIJ"['FFIL. L F'.T. PE
THE IS.F.'.RVEL E:,EPTH IS. THE MINIMUM [:,EPTH OF F' '-'-
RND THE E:OTTOM OF THE E::.OZ:R',,,'RTII]N ,:: IN FEE .
8RCKF:i:LLING CF RN"r' S.'-r'~TEM T,..I,I'f'HOL~'FxINRL- II'.!%f SC: 'ION RI",tE:, FtF'I::'R,%~ B'¢ THIS'
· .1_E~E~ FEET F~F.: R PRI',,,'IRTE !.-IE_L OR\,2E~6~ F'EE4~ FOR R pIIBLIF: t,.l.F..%[ .... / ,,
I CEF.:T Z F'r 'i"HRT
:1.: ~ RM FRPIiLIRR I.,.IITH THE R~iSIL.IIF.:EMENTS. F~:.~F.: ON-S S.EI..IEF..=~; FIND WEL. LS RS S.ET
FORTH 6"¢ Tt~E MUN Z C: I PRL I ]"'Y' O,F RNCHORRGE/
2: I NILL If~'~S.TFILL THE S"r'S.T~M IN FtCCOF/~:'RNCE THE COE:,ES..
Z-':: ~ UND~ THRT -rHE O~.4-S.ITE S.E~.~ER S."r'~ MR"r', REL.-.!UiRE ENL. F~RGEMENT IF THE
F.':ES'DE'~ ~Z~ELyE~,~/~-I~I']F':E ,~t~ 4 E, EE:R,]OMS..
":' -' .....................
I S.'RUED B'¥'.. [' RTE'
PERFORMED FOR:
LEGAL DESCRIPTION:
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, A~aska 99501 264-4720
SOILS LOG- PERCOLATION TEST
DATE PERFORMED:
PERCOLATION
TEST
1
2
3
4
5
6
7
8
9
10
11
12
13-
14-
15-
16-
17
18
19
2O
COMMENTS
SLOPE SITE PLAN
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
PERFORMED BY:.
72-008 (8/79)
.~' (minutes/inch)
__ FT
J~u?. 5, 1976 /"~-'.,
GEOIDGY: ~he Chugiak ar~a is 1~ wit~ ~e ~ ~.~a ~l~d, a
~h~ ~et ~l~d ~ysi~c s~~ ~t ~ ~k ~let.
~jor Pl~s~ gla~ ~ ~ong ~ ~ns~t or s~_~nt 1~
s~ ~d ~1~ ~si~ ~y ~,~ ~e p~t ~hy of
~ s~~ g~l~c ~t of ~ si~ ~ ~ ~ ~ of ~e Peter's C~k
F~ ~ it ~<~ t~u~ ~e la~ Pleis~e la~r~ ~r~e de~si~.
of ~s ~sit ~ ~,~o~y s~ ~d s~ney ~ ~l~s ~d
~1~ ~d s~d p~a~ b~ silt ~d ~ ~t ~ p~t ~ p~ a '
b~r for ~ s~s. ~bbl~ ~d ~bl~ ~ ~d ~er ~ ~ar.
S~~ ~I~f~: ~ ~d ~r o~r ~ si~ ~ner~y ~ of from
6 ~s ~ a f~t of o~c s~t ~ed~ ~ts~ ~e s~ ~d g~a~ls
~rlay ~ s~a~ to ~ of f~m 6 ft. to 10 ~. ~n~y. ~s l~er is
~e~ ~h ~bbles ~d so~ ~de~. ~ ~ e~ sot~ e~t ~r
(lo~ 3 & 4) ~e~ is a layer of ~de~ at a ~h of 5 to 6 ~. ~t wo~d
not ~1~ ~e ~]1 ~ ~et~, e~ a~r 5 se~ at~s. A ~r~la~on
~t ~ at--ed at ~hese ~ lo~ ~d ~.e hol~ ~d not ~ ke~ ~1 of
w~r, d~ ~ ~e e~ll~t ~nage. ~ 10ft. ~e ~il is g~ly
~ ~ ~ sli~y ~r silt ~n~n~. No y~o~ wa~r w~ fo~d ~ ~y
of ~ holes ~pt ~ 917. ~e wa~r ~t ~ ~s hole a~d to
f~ ~lt~ng sn~ j~t ~ ~ s~fa~. ~e l~er ~ of ~s ~le ~d not
h~ e~n~ of wa~r.
~la~on ~s~ we~ ~ on ~se ~st ~les ~t ~ to ~ ~e ~st
~il ~n~s. ~e ~s~ of the ~r~la~on ~ts s~ ~at e~ ~e ~t
hol~ %~d s~ ~de~ scene pi~ satisfa~ly.
~ ~s ~ rat~ a~r~g ~ ~e ~ed ~ils ~si~on Sync,
~ ~d by ~e ~s~ of ~e ~la~on ~s~, ~e ~~ ~ysis,
~ ~e~e of ~ ~l~st ~d ~s obse~ti~. ~ d,~al so~s cl~sifi-
~ ~ sh~, it is d~ to the ~s~on lis~ ~ ~ U~ ~ils
~sifi~on ~io~, b~ ~ ~1 ~es a soils rang is gi~, b~
on ~e ~ysis ~ndu~ ~d ~o~d ~ ~e ~si~ fi~ ~ ~ ~t~ p~y
~e~ for fi~g s~s~a~ ~s~s~. ~e si~ of ~e lo~ ~e~s
~ ~n~on of ~e ~s ~d ~e ~i~i to ~so~ w~ wa~ ef~.
~I~: ~e so~s ~rly~g ~s p~s~ s~sion ~1 s~ s~
s~fa~ ~s~s~ ~is~ ~[~ ~ p~rly ~si~ ~d size. ~e~ is
s~~t ~m on ea~ lot ~r ~i~ ~s~s~ ~, shoed ~e ~i~
~ f~l.
~e so~s ~ s~le wi~ ~s~ ~ fo~on ~g ~a~ for ~i~
s~~s. ~e so~s ~ ~e~y ~1, ~2 rat~ for f~ s~p~i~, w~
is
S O~S ~s %~ ~ ~ ~e ~t-of~ for ~e p~s~ ~a~ ~d ~ ~11
~ ~si~ ~d ~ns~ ~ ~t ~e ~t ~~ for ~ ~~on
~r ~ so~s ~~d.
Pi~ ~n~ ~e ~i~ed if ~y ~i~ or ~ca~o~ of ~ ~ta
.<
.: : : : : ~
0 0 ~ 0 0 0 0 0 0 0 0 C
o o o o o o o o o o S S
MUNICIPALITY OF ANCHORAGE
Development Services Department=TT Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051-111-33-000
Legal description MARIE ESTATES LT 5
Site address 24128 TEMPLE DR Chugiak AK 99567
Expiration Date: 10/13/2023
Current property owner(s) IGEL CHRISTOPHER JAMES &MELISSA E
XThe On-site system(s) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
Original Certificate Date: 7/13/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval_June 2022
MuHm p i� u u y Or -
Development Services Department
On -Site Water & Wastewater Section
I P0
U,5_
!\ HCHO RAGE
Phone: 907-343-7904
Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 051 111 33
Complete legal description MARIE ESTATES LOT 5
Location (site address)
24128 TEMPLE
Current property owner(s) IGEL
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: ❑® Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ®❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: ®❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 4 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench 0 Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ SSU Waiver Fee $
Date of Payment 713 -a Date of Payment
COSA # (D S C- 2- 3 / 2 2 Waiver #
COSA Application_ June 2022
COSA Checklist _ IkI--3 -(goo
Legal Description: MARIE ESTATES LOT 5 Parcel ID:10 G
If more than 7 well and/or septic system on lot, provide separate checklist. Structure served by this system 1
A. WELL DATA
0 Well log is filed with Onsite (or attached)
Date drilled 1985 Total depth 240 ft
Cased to 240 ft
❑■ Sanitary seal is functioning correctly
❑■ Wires are properly protected
Casing height (above ground) +18 in.
Date of flow test for COSA 6/2/23
Static water level at beginning of test 74 ft.
Comments old well decomissioned
B. TANK DATA
Measured operating fluid level in septic tank 51
Date of pumping 5/30/23
❑ Required maintenance completed, if AWWTS
Comments: level measured before pumping
D. ABSORPTION FIELD DATA
Which system tested (date installed) 2019
Q ALL standpipes present per record drawing
Total measured depth from grade 14 ft (max)
Measured depth to pipe invert from grade 7 ft (min)
❑ N/A — pressurized field.
❑ Per record drawings, field is insulated.
Q Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) NA
If yes, enter date NA
Comments/Defici
COSA Checklist June 2022
Well production at time of test +2 gpm
Water storage tank volume 500 gallons
Well disinfected for coliform test? ❑ Yes 0 No
0 Coliform bacteria is Negative
Nitrate 3.3 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by C.BALZARINI
Date 5/30/23
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 6/2/23
Results M Pass
Fluid depth prior to test 2 in
Water added 600 gal
New fluid depth 8 in
Elapsed time 1440 min
Final fluid depth 2 in
Absorption rate 600 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 84 in
Effective depth used 2 in
Effective depth remaining 82 in
COSA Checklist_June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F.ENGINEER’S COMMENTS
G.CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Phone
Engineer’s Printed Name Date
C&M ENGINEERING
CHARLES BALZARINI, PE 6/9/23
MUNICIPALITY OF ANCHORAGE
Awe
Development Services Department 1`1 Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On-Site Systems Approval
Parcel I.D. 05111133 Expiration Date: ? —I 1
1. GENERAL INFORMATION
Complete legal description Marie Estates Lot 5
Location (site address) 24128 Temple Drive
Current property owner(s) Van Ryn Day phone 529-1282
Mailing address
Real estate agent Owner Day phone 529-128
.,
2. TYPE OF DWELLING: '
H Single Family (w/wo ADU) n MA)/ 2 Z019
Duplex
Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well X Private Septic
Water Storage ❑ Holding Tank ❑
Community Well U Community n
Public Water System I I Public Sewer I
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer
COSA Fee $ 0156 Waiver Fee $
Date of Payment 5/a3//9 _ Date of Payment
Receipt Number Ce55CI _ Receipt Number
COSA# 0_5 CA 115'5- Waiver#
r D
*
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On-Site staff may visit the site to verify the information submitted.
Name of Firm NorthRim Eng. Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date 5/24/19
1_141
ber/\ ..**, °.1/iry
0.7
."9' A
6. DSD SIGNATURE
System #1 Approved for �' bedrooms . _ / ;
Y PP _ . �_
Steven W. Eng � ��
C,
System #2 Approved for bedrooms � ;` 17✓ �•`,
LOP
Disapproved �� 0 e,�OFES`�l�e'�`0p'
614
Conditional approval for bedrooms, with the following stipulations:%o'0
n, st9
pee
o ,o i F
F
i
0 -1, 0
J 1
By: �^ - ` Original Certificate Date: —3—/?
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 Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Choc,'SI t ,e sheet
COSA Checklist
Legal Description: Marie Estates Lot 5 Parcel ID: 05111133
If more than 1 septic system on lot: COSA Checklist# of Structure served by this system
A. WELL DATA
■❑Well log is filed with Onsite (or attached) Well production at time of test 3 gpm
Date drilled 8/12/85 Water storage tank volume 0 gallons
Total depth 240 ft Well disinfected for coliform test? ❑ Yes ❑■ No
Cased to 40+ft Coliform bacteria is Negative
[' Sanitary seal is functioning correctly Nitrate 0.9 mg/L ❑ Nitrate less than MRL (ND)
❑■ Wires are properly protected Arsenic ug/L ❑■ Arsenic less than MRL (ND)
Casing height(above ground) _ 18 in. Collected by NRimEng
Date of flow test for COSA 4/24/19 Date of Sample 4/24/19
Static water level at beginning of test 186 ft.
Comments
B. TANK DATA C. LIFT STATION
Age of tank(s) new years ❑ Required maintenance completed
Tank type/material Steel Age of lift station years
Measured operating fluid level in septic tank new Lift station material
❑■ Standpipes/foundation cleanout per record drawing Comments:
Date of pumping new
D. ABSORPTION FIELD DATA new
Which system tested (date installed) new Adequacy test date new
MALL standpipes present per record drawing Results Q✓ Pass For 4 bedrooms
Total measured depth from grade 11-14 ft(max) Fluid depth prior to test in
Measured depth to pipe invert from grade 4-7 ft(min) Water added na gal
❑ N/A—pressurized field New depth in
[' Monitor tubes go to bottom of effective. If not, state Elapsed time min
depth into effective
M Code-required soil cover over field Final fluid depth in
❑ System presoaked Absorption rate gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months)
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
0✓ Yes if No ft n Yes if No ft
Neighboring Tank > 100' 0✓ Yes if No ft Private Sewer/Septic Line > 25' 0 Yes if No ft
Absorption Field on Lot > 100' 0✓ Yes if No ft Holding Tank > 100' ✓0 Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' 0 Yes if No ft
E Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' 0 Yes if No ft ✓0 Yes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' 0 Yes if No ft Surface Water > 100' I Yes if No ft
Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots:
Absorption Field > 5' 0 Yes if No ft Private Wells > 100' ✓0 Yes if No ft
Water Main > 10' ✓0 Yes if No ft Community Wells > 200' ✓0 Yes if No ft
Water Service Line > 10' 0 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' 0 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' 0 Yes if No ft Private Wells > 100' ii Yes if No ft
Water Service Line > 10' 0 Yes if No ft Community Wells > 200' [' Yes if No ft
Surface Water > 100' 0 Yes if No ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION OF 41. 'hi
i'��� ' '',.0"Z' %
I certify that 1 have determined through field inspections and review r c, ,•` 4, •••. q
of Municipal records that the above systems are in conformance with o,k =: .'4, • t
MOA COSA guidelines in effect on this date. j..... picit
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or
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COSA Checklist yellow sheet ,"k®e.`10.`i44P
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ASBUILT-NO CORNERS SET THIS DATE. SEWARD & ASSOCIATES LAND SURVEYING 694-OH:'
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE: .,+�v.c
FOLLOWING DESCRIBED PROPERTY: ��a ,,.4._....,.....13.v.‘,4,..
OF A/°%%
/�/le&5-.,��%TC%Slims t0—' .— DATE: , / .a�t . 1• ••, ?s'b'k,
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS �s`YS �^ •' r;}-d ••-.''f 4
INDICATED. IT IS THE RESPONSIBILITY OF THE . 4`�Lt y
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID: .y �1 r `G %
EASEMENTS, COVENANTS, OR RESTRICTIONS ,VA'-'r-'dV ..'Til-'. �• ` -' .�ys `
WHICH DO NOT APPEAR ON THE RECORDED SUBDI- • ;4 Duen. Mark 5e�,rd +.47
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD F6 �� �� +f!• l.S=.6 zi;J`�' Ar
:
i ANY DATA HEREON BE USED FOR CONSTRUCTION �,7. ss/li. 5 +
OF' FENCE LINES OR FOR ESTABLISHING BOUND- '+ r; \-1'4.7"P
ARY LINES.
DRAWN:
�1\��T Q�
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 DW [LING i
Parcel I.D. O 5'7' - I t I - 3 3
Expiration Date:
1. ,GENERAL INFORMATION
,~ cCompletelegaldescrlpbon Lot ";. ~l~r~
:.,;,' ',.~ ., '..~;,.
..... '.,Location(siteaddres'sordirections) 24128 Temple Dr, Wa~illa
,',-,:~Curren.tP[o. pertyowj~er(s) /like & Vfornrt~ '~'61ey_:. Dayphone wk 269-686fi
;;'.. .. ..'.'. ~ ,, ,..
.;...,.,.Maflngaddre~s'' 1181 tm. Balsam"C'~'. Wastlla. AK 99656
Lending agency Residential llortgage Dayphone 222-8821
Mailing address ,- 1400 W. Benson stJe'200 Anchorage) AK "
Real Estat~ Ag~n~ ,~ .,.. ."- '" ................ Da~ phSde ..........
Mailing ~,d'dr(~ss ' .'
2. NUMBER, OF BEDROOMS: 3 - *
' * "' ' .T~_'.i~E OF WASTEWATER DISPOSAL
. . 3; TYpE oF WATER SUPPLY: ......... .: ...... :..._ :
Individual ~/~,er ~t'oi:~' Y',,; ; Indigidual Uoldin nk
.~ ' ..... Comm~inity Cl&s§ ....... Well~ .... i[] ................ Community'On-site ...............
- ,Public Water System :- ............... L [] ._. Public Sewer []
i ,, The Municipality 'of Anchd~ge- De,)~16p~nent Services Depa~ment (DSD) Issues Certificates of Health Authority
-Approval.(H..~.) based only':ulSon the'representations 9iven in paragraph 5 by an ndependent professional civil
_engineer reg.stered in th6 Stare'of AJeska. Certificates of Health Aothority Approval are req{~ired for the transfer of
: ' titie (ex,e-lit ~e~e~n-s"j~hqe's) foi"propertie~'i;~'ed by~a'single family on-site waste~ter di~pds~t and/o? water
: , supply system. DSD alsoi~sues ~ upon request to homeowners. Certificates of Health/~thority App?oval are
,~ ".., ~,alid for 90 days from th~*date of issfie for properties served by a private or Class C well and may be reissued with
~ ' )' ~ "fi6w'~vate? sam~)ie res,iJlts es's_th~,3.0, days oJd; (Certifi~:~e~ may ,b'~ reissued for a period'of up t,d.'6ne year with
.' .' · ' ' '; ~'v~lid water's~im~16s~). 'C~'r:tificat~s~ar~ ,.'~lid'for on6 year:fo~ p'rb'perties served by Class A o~' B w'~lls'or a public
, , ' Water system. The' ivi~ni~ip~lity of'An~orage'*i~' not res'pog~ible' for errors or omissiohs in ~{he 'lJi'ofessional
:' . engineer's work. :,','. ' ' ~ * ' ~" -'.: ' '.",'.' : .... ,.r',-.
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(ara) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm s & $ ENGINEERING
17034 Eagle River Loop Road No. 204
Address Ea~le Rivet,. A~n~
Engineer's Printed Name R~/~.,,I,~- C.
Phone
Date
5. DSD SIGNATURE
~ Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, w~th the following stipulations~'-
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
, Well Flow Advisory
X
Maintenance, Agreements~
Supplemental Engineer's Report ,.
Other
· 'Original Certificate Date:
M~_micipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastawater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cLanchorage.ak.us
(~07) 343-?~4
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Well tyPe~__~ V~/'~"~"~ if A. B, or G provide PWSID # *~'
Da~ ~mptet~~ S~i~ ,~ ~) ~
TO~i dep~ %qO ff. Ces~ ~ ~ T
FROM W~L LOG
Date of test
Static water level
Well production
g.p.m.
wa~ Log (WN).L//~'~
Casing height (above ground) ~' ~"~in.
ATINSPECTION
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi.
Date of sample:
O
I
SEPTIC/HOLDING TANK DATA
Nitrate j, I q mg./I.
Collected by: ¢ 4 ~
I
Other bacteria 0 colonies/100 mi.
Date installed
Tank T~,p~laterial
Tefik size /DOC.) gal.": . Number of Compartments ~ Cleanouts (Y/N)
F0u~dati°~ c~eanout (YIN)~_,~ Depression over tank (YIN) NE.) High water alarm (Y/N, ,/~/~"
Date of pumping l[ /*~0 Pumper *'~-'S
ABSORPTION FIELD D~TA
Det; ta,led, . _/ qC'Soara, g (g.p.d.m or f /bdrm)d'4CSystem type T~C ~
Len~ 6 ~ ff. W~ ~ - ? fl. Gravel bel~ pipe ~ fl.
Total depth/~- ~"it. Eft. a~orption area/~)?~.-~ Monitoring tube
Dam ~ adequacy ~t ~
R~ults
(P~Fa~l)
Fluid dep~ in abs~I {fl,d .fore t.t~. Water add~ ~ga,.
Elaps. Time: ~Mn. F~al fluid d~h ~ M. Abs~pfion rate >=
~y rejuvenation ~ent (p~t 12 mo.) ~ & ~pe)
Depression over field /~4~)
For .~ bedrooms
New depth~"~ in.
4~) g.p.d.
If yes, give date "--'
O. UFT STATION /
Date installed /~ Size in gallons
'Pump on" level at / in. 'Pump off' level at
/
Datum / Cycies tested
E. SEPARATION DISTANCES
in.
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
~~-~ J' ~ Holding tank
SEPARATION DISTANCES FROM SEPTI~ TANK ON LOT TO:
Building foundation ~ ~ Property line ~ ~' Absorption field
Water main /~) ~' Water sewice line / O ,P' Surface water
Wells on adjacent lots
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots / OO ,,--
sewer manhole/cleanout
Public
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line t/~) t
~" Building foundation /~)
Water Service line / C.~ ~' Surface water /'~)(~) ~ Driveway, paddng/vehicle storage
Curtain drain /~0/4~ ~'~/o'~ Welts on adjacent lots ~
F. COMMENTS
G. ENGINEER'S CERTIFICATION ~-~~
conformance with MOA HAA guidelines in effecf on this date. ~~_ :
c
Date ~ / ~ lQ [ 't?,~-,~-.... ....... .,:'~ 'C" ,~
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
009310
Waiver Fee $
Date of Payment
Receipt Number
· _ ,,~:- .. ~----~.~'.... ~ MUNICIPALITY OF ANCHORAGE : . , .~ ·...
-': -' ' ":". ~' (~'~/ ' DEPARTMENT OF HEALTH & HUMAN SERVICES
'- ~ .~ ,~".-~'~ ~J ~ .. ~- Division ~of Environmental Se~ices
' ' ;:'.~'.'? :'::-'~'~?~L~ -::; :~.~,;;'~':'*~.~'Od~Site Se~ic~s Section' : "- ':' : ~'' ~':'~ ;~';:";:::: ::
_ .~ ,. - -.~ -.',.;,~ .,1: ~u P.O;Box 196650'?Anchorage, Alaska 99519-6650; '-;?.~;%~;': .'?..'
....... : ;-. ;:~CERTIFICATE OF HEALTH AUTHORI~ ...... ., ;~.:-' ,~ ......
'" '':-":" ...... A~PRO'~AE FoR A SINGLE FAMIEY DWELLING "' ' '
Parcel I.D. ~ .~:' · :;~- -:" A ';~; ';~" ~-,~ '''~.; ' -
':- :~" ".'"';" .---.' -_-t; ' ~'.. · -~', . , .'.' ~,. · ..... . -' . .
....... Complete legal description,-~~- ~ ~' ~/~ --~.-.~S~S --. .... , .:.
..-. - Property ow.ge[~ ~/~.r/,_~ -4-, ~,[~r~j c,~-4 ~ ~s o ~ Day phone"
.:'~'Lenama-aaencv ........ ' ...... , ,='.-"" '
, . _ ~_~___., , . Day phone"
...-. ;-.,-s~;Maili'ngaddress?.;,=;:;-,.,¢.?~.,,~,:~-?:-- _;-..-:,~;47~.-v:;-,::: ,,:~;,:;-,~.
' ' '.: ¥'....-'. ...... = =, :.~',_,. :,~ d ua wel .. :-.___.. _-
'." :"-:-::':-;':' NoTE~:'J-"/f bbm~n~'~¢~'il'~';~bmj-¢P'rovide bri~n-Confirmation from
' ../ "' '::::-:'..:~;:;;~:;:'in~ to:t~e [eg~'~t'.~nd'~b~ of system.. ~':~'¢~
'4. TY¢E ;' '~ASTEWATERDISPOsAL: ." .... '
' -- _ ' . : ' '. ,; -.:,~-'.'.,. ;:?:',; "' ;(.t;;?.-. ,~Z~¢4~ :': : .;:;.': ,.-__ {' .,'. ~: ' _ '.
· " :"-'* NOTE:':' r*lf com~Unit~'~ag~ate~s~tem;;p~6~ide' wri~e~
.. ..... : ...... a~est~ng to'the legah~ and status of system.
. ._. ... ?..., ,...-:' ·. - ...
. .. .... .;:.~(..;'.
5. STATEMENT:OF INSPECTION BY: '* '~'; ~'~ ~'
ENGINEER,.~ ':': ......... ~ ~ ,-.'-. ....... -?, ;.'?~ ~i ..' -./~.:.: ~- . ' ..
. :.- . ~:~i;.~:~ ~:?~,:.~,..:- _~ ~::,_7~,~? .,? :}.~;.~;:hb:~V~:~ .. ..... ...' _.A. ,.,.. ~. ~._,.~ . . -.
AS cedified b~'m'y seal affixed hereto and as of the validation date shown below, I veri~ that my ~:-'
._ investigation of this.~ealth Authori~ 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 ~pe of structure indicated herein. I fuKherveri~ that based on the information obtained from
the Municipali~ of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater'disposal system is in comp liance with all Municipal and State codes,
ordinances, and regulations ineffecton the date of this inspection
..... - ~ame of Firm :'?'/-~ 0 ~Xo ~ '".-~ ~', ~ ~'-
""' ,'::, ~C?:'`::'':v:?~:?'~ :':?~"~': '/. ~.: ,~;: 'o ;-,' ' ' [~ 2-'~ ' ;, .~,T~' ~.~-'~'..~'~ ..... "'-'
. ........ ,.,, . ..... ~ ,... . ~ .
b~drOoms~?*~.~-::':'.::"~'~;:.~?~..~?7::?~ ~'~.~¢:, ::~:~+~';-.,.~i~=~i,;e-,~ ?~-' .:....?.~, ,.~..
. · : : ?,: , ~:.~::: .,. , ~:.': . ;,.,:
The Music Pal ~ of ~h~horag¢ Debarment of Health and Human Sem,ces.(DHHS):, ssues Hca th Author ~
~pko~ab~ificates based only:upon the representabon~ given:m pamgraphj5 above by an independent
,prof~'~onal eng~n~r registered ~n the State of Alaska. The DHHS does th~s as a cou ~esy to purchasem of homes
andtheirlending nsttutons norderto~t s~ceda nf~eralandstat~uiremegts. EmplOy~so'fDHHSdonot
condu~t inspections or analyz~ data ~foro a co~ificato i~ ~uod~:Th~Mun~lpal~ of Anchora~ i~ not
responsible for errom or omi~ions in the profe~ional engineers work;" ? :: :-~ ':::.::. ,: , ::' :
Municipality of Anchorage
,Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Parcel I.D.
A. Well Data
Well type ]~izpJ A'I--~.
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Y Date completed ,~/]~)/~S" Driller A/)~
~'"/-0~ Cased to 7__t./.O f Casing height
Y Wires properly protected (Y/N) Y'
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG AT INSPECTION
L)~ ~-~,~ oW~J g.p.m. [,~-'St g.p.m.
~.7__K'/ E-ZS; /
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
/
Absorption field on lot ! O0
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform '(9
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed ~/~
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Nitrate
/~ /'a.~//..._ Other bacteria
Collected by: ,/-J ,/-/~ ~
Tank size /~ O00 ~--~4-4- Compadments -7'--'~'~O
Foundation cleanout (Y/N) Y Depression (Y/N)
/%J'~fJ ~' Alarm tested (Y/N)
'7/J¢; / ~7~ Pumper ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot IZ-~/ """
On adjacent lots ~> J~/ Foundation
'"'-' Absorption field ~/I
To property line ,~, ~'0 ~
Water main/service line
Surface water/drainage ~ I.S'/.) /
C.,ONTINUED ON BACK PAGE.
72-026(3/93)*Front ,~ : :': ~' ., !:"i !;;., '. ;:~ ~ - ~!' ,~,: ~! '!~ 2~i: 'i,~'
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes
"Pump on" level at__
Manufacturer
"Pump off" Level at
Cycles tested
FROM LIFT STATION TO:
lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed 'l/~- ~l/~5~ Soil rating (GPD/Ft2) ~ ~b-"
Length ~,' ;// ~
Width 5' ./-r~ 7 Gravel thickness
Total absorption area /~ f) "-/Z_ F'r;, ~Cleanout present (Y/N) ,kC/
Date of adequacy test /~bJ ~-~J~;'~ Results(pass/fail)
"~ Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
System type ~) e'~"¢
Total depth /%~,
Depression over field (Y/N)
for /~'~ Bedrooms
After test
If yes. give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /00" Property line '"'
On adjacent lots "z ! ?--~ !
To building foundation ~ ? ! /~//~
To existing or abandoned system on lot
On adjacent lots ~ -5~0 / Cutbank '>' 5-0 ~ Water main/service line
!
Surface water ~, ,/5-'0 Driveway, parking/vehicle storage area
Curtain drain /k/O/,J ~'
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect~i~,r~'~!'~'~i?~'f;t~i~ inspection.
Signature
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number