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MCCABE WEST LT 5
McCabe West Lot 5 #018-231-31 MUNICIPALITY OF ANCHORAGE On-Site Water & Wastewater Program o°�nr4 S, PO Box 196650 4700 Elmore Road _ ►`` e Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite IVM Department On-Site Wastewater Disposal System Permit Permit Number: OSP241040 Effective Date: 3/28/2024 Work Type: SepticTank Upgrade Expiration Date: 3/28/2025 Tax Code Number: 01823131000 Site Legal Address: MCCABE WEST LT 5 G:2936 Site Mailing Address: 13343 PEAKVIEW CIR, Anchorage Owner: SIOK JEROME P ALASKA Lot Size in Sq Ft: 53711 Design Engineer: FIRST WATER CONSULTING Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing ? sem, eco• +o Issued By: Date: Date: 3 z Z MUNICIPALITY OF ANCHORAGE Development Services Department G` Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 018-231-31 Property owner(s) JEROME & SUSAN SIOK... Day phone _ Mailing address 13343 PEAKVIEW CIRCLE, ANCHORAGE, AK 99516 Site address 13343 PEAKVIEW CIRCLE, ANCHORAGE, AK 99516 Legal description (Sub'd., Block & Lot) MC CABE WEST LOT 5 Legal description (Township, Range & Section) Lot Size 53,711 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (M all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) El (w/wo ADU) Septic Tank 0 Upgrade Q (D) El Holding Tank ❑ RenewalDuplex ❑ 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: -022-15- Date 2 2-SDate of Payment: 3 Z Receipt Number: Z 'L Permit No. 0_'5P2912-10 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 ! !! March 21, 2024 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: SEPTIC TANK UPGRADE PERMIT LEGAL: MCCABE WEST LOT 5 The owner has requested that we obtain a septic permit to upgrade the existing aged steel STEP septic tank on the above referenced lot. We propose to install a 1500-gallon HDPE tank per the attached design to serve the existing 3-bedroom residence. The recommended 1500-gallon HDPE STEP tank to be installed for current functionality and future consideration or flexibility. No groundwater was noted in the MOA on-site file, but if groundwater is encountered during installation an epoxy coated steel septic STEP tank may be required. The lot and area are served by private water and any encroaching wells, easements, existing field … must be staked prior to construction to verify separations. 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 OSP241040, Deb Wockenfuss, 03/28/24 FIRST WATER CONSULTING MCCABE WEST LOT 5 DESIGN DETAILS: NO WELLS WITHIN 100' OF PROPOSED SEPTIC TANK Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241040, Deb Wockenfuss, 03/28/24 72-013 (Rev. 9/91) MOA 25 Municipality of Anchorage Page —L of z 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 Permit Number: Sw4clolol PID Number: Name: Wastewater System: ❑NewUpgrade X_ /c c J w 7, 6– Address: ABSORPTION FIELD 13391 e C/a c //ZCLE Phone:-- No. of Bedrooms: $,Deep Trench NShallowTrench []Bed ❑Mound ❑ Other .OcyOKA(rF /L qq5/x' LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: S O.4s GPD/Sq. . Ft. Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe S c C /3E GtJGsT S%/� Z' Ft. 3 Ft. Township: Range: Section: Fill added above original grade: Gravel length: /•3 Ft. //(Q/ Ft. WELL: El New ❑ Upgrade Gravel width: NumberZoflines: Distance �toweenlines: ' S Ft. Ft. Ft Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: .9Sr,4" A0VR•rC— L1E)6(3T Ft. Ft. 4 OL SO. Ft. OP3039 �✓L Driller: Date Drilled: Static Water Level: Installer: Date installed: Ft. 7WO-0 Yield: Pump Set at: Casing Height Above Ground: V TANK GPM Ft. Ft. SEPARATION DISTANCES Septic wST ❑Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines &,e --C: A /000 WeIN /OS/ ll71 /2Q' 215- 4- Material: S%eec Number of Compartments: Z /00 LIFT STATION Watere /0011 Lot 17'6 ` /171 �y1 Size in gallons: Manufacturer: Line 6_00 c/to (sE R,u Foundation 5 ` 17 ' Z, 0 1 ..Pump on" level at: 2P ++ "Pump off' level at: / 8 " High water alarm at: 34 " Curtain�Q ,U G K�iJ W.tJ Pump M ake &Model Electrical Insp ciions performed by: X. Drain QS/ oS H/1 .- BENCH MARK Remarks: Location and Description: %ORF ceG.E N S.W. Sii7c O/= fi'v vS E Assumed Elevation: O.Q Ft ENGINEER"S $,BAL p ; .„ 17034 Cagle River Loop Road, No. 204 Inspections performed, by: Eagle River, Alaska "577 Dates: lst �9 a 2nd ,V - ti - 99 A.a Department of Health and uman es approval, 79� Reviewed and approved by: Date: JG 72-013 (Rev. 9/91) MOA 25 Permit No. SW940101 Page 2 of 2 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: McCABE WEST SUBDIVISION, LOT 5 PID No.:01823131 SCALE 1" = 72-013 A (2/91) MOA 25 Col MH VNEW 00 92.3' 97.7' CO2 68.0 1 D.V. 69.0 1 CO3 72.0 2 M.H. 73.5 2 MT1' 44:0 2 MT2 91.0 7 MT3 58.0 1 1 -94.6' € 93.9' A 79.9' NO WATER FOUND �pl SEPTIC TANK o` (INTEGRITY VE32IFIED 4/94) DIST1 ENGkNEEP,`.1`S SEAL { A'0�%� j y l t J PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE oleo 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:SW940101 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:GOULD MICHAEL A & JILL T OWNER ADDRESS:13341 MC CABE CIR ANCHORAGE, AK 99518 PARCEL ID:01823131 LEGAL DESCRIPTION: MCCABE WEST LT 5 LOT SIZE: 53711 (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: DATE ISSUED: 4/28/94 EXPIRATION DATE: 4/28/95 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 OR 343-4681 AFTER BUSINESS HOURS 4. 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 P ISSUED BY: DATE : DATE : r' tr J Q M F- 0 no H d J Ln 0 F Z w J U Z ,LWSR 'IILLII o i ----------------� 2; Joy J Q >"Zw a H #: r s w I I P4 f " 5S E" oxw y `t Y K CZ E, SNI In z f o� o Q r-� Q =J0 U-� Q w I FaW 3t a < N 1- O J N N YYi 5 'a O Pa. EF s t: W Il LLJ 0 t Iw / � ELN- 31tlJ3 s �E v O z FO oz Z F-�3 QQo = a v= Z O U) 00- W �N NO1.1 Na O 0` WwmW=Lww z0 O� N d' W~ �_ Z MazZL,» w N— �w¢ oS�zow� Q N N p F 2 O W F LuU0 uW�wC�mz0 h Z JNa N w QWwN>ZZwd of z N w.N V)U0-VDO o N Z Ln VT cj� 0�wa0 DLLI a H �OmNwLI Z� U Om77O U O d$ 0 �oaC)U)> z =z ONO V) V) F=F- LLJW � �o Q �U- o F -H W ozz W m Wp�N Q d�0 � O J OECD' FEW � Z r� H 0000 w d UZ" � 0,W (� o _ (� Lr)W � d W a w `� I I LLJ 0 LW © E" �o M D r� If a � z C) m w �d C7 Q M tr J Q M F- 0 no H d J Ln 0 F Z w J U w W d M J U V O V 2� J mU 1( / OU O O 1 ,, O o f N'dl d 311S Z } phi �pLLN >Q iw �rF .Nza WZ zg W✓e2 Up��U WF-QTi�� $XQWO rwazo J°l� �J Z ,LWSR 'IILLII o i ----------------� Joy J Q >"Zw a H a w I I P4 f " z E" oxw o a CZ E, SNI In z f o� o Q r-� Q =J0 U-� Q w I FaW N 1- O J N N WNL OW a'H O Pa. EF N N� o W a- c W Il LLJ 0 t Iw / � ELN- 31tlJ3 s �E w W d M J U V O V 2� J mU 1( / OU O O 1 ,, O o f N'dl d 311S Z } phi �pLLN >Q iw �rF .Nza WZ zg W✓e2 Up��U WF-QTi�� $XQWO rwazo J°l� �J Z Zmp 0 WDnw Joy J Q >"Zw z I- Mom oZ d f " LL) V) J O w��� E" Ld = o Q I I F-1 0< J Lo W I O O z f o� o Q r-� Q =J0 U-� �N� L��O Q OLLI N 1- O J N N ON Z~ J J Q � o��zzQa N N� o W a- c W Il LLJ 0 t rr, ELN- 31tlJ3 a09 — uj �9C�f RIVER, A0' HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSALSYSTEM DESIGN April 26, 1994 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 'L' Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: McCabe Subdivision West; Lot 5 ROBERT SHAFER, P.E. ROGER SHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 Request you issue a permit to upgrade the septic system serving the three bedroom house on the referenced property and issue a. conditional Health Authority Approval An adequacy test performed on the existing system for Health Authority Approval purposes found the absorption capacity of the existing system to be inadequate. A conditional Health Authority Approval is requested until the system can be upgraded by 1 July, 1994. A test hole was excavated and a percolation test performed in the area of the proposed upgrade. The approximate location of the test hole is located on the attached site plan. The monitoring tube within the test hole has been checked and found to be dry. Attached is the proposed upgrade design. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your review, please contact us. A.-SRafer, P.E. jk 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 y Y;ZQILX+`iiS. ��yl+ y. > za oMOD W=nw i• �- Z �\a MOM o • 'tR• n � it i`'. O = "! I Z Z Q = aN zag }m- A � 1 I In Fw- O 0ZaJ�acn 0Ld cn �oNd I+ � o J\ooaQ i� 4I v r - Q o 0 90 W w O] J av U v � � U M O J LLY4921 z>sn .oT W W U I a w E- o I x w O"`. a CZ z ,n H �Fh-. W U) N F POi I o i w > aH a F wrr I co IW El an / of VV 0 I NVId 311S z tJ-4 rno WT�• 0 64 � Q Cl WW ,Z,7 wo- WL Zn�o WO WHO �w zo ¢0 1 O 10 0 o z > za oMOD W=nw ,zz v -o t� - F- �- Z �\a MOM o o� � 0 O = U2 I Z Z Q = aN zag 0 N of:Q d Mi In Fw- O 0ZaJ�acn 0Ld cn �oNd O o J\ooaQ i� v a w W m w= o W r - Q o 1-00 2d d- iJ� d- W~XZ W0— ��i D Lo Z\ CL Q1 aZ ZL�E5J 2�wQ � 0aZQUoWr <.< N04 Ur of F. a. Lo0X I w F-- W J VI 0 g�w(�°�zc �W N �r H W > Z Z W d K J Q O� Q N �1-o w N a Z U O 2 N(n Z a Q h Ln Vl~ick- �?crY 1— of �OO1 Z3: -o C)od5' OJ " 3 a U~ W z v-- O U N> F Z F to mv=i ¢ F Ff C) Z wco a Woo Z 0<1 w ozW j oar z zEa o�w W w o' Q C7 \co Ul > o H U) I- P: W (k ZI—I O �- �-•� Q'+ �Or wQ Od p Q' to w—LLJ xW ate> Li o II o II o� w d � Q LnLnM U QNO Q m z � O VOi w Mlnd Lu Q 0 90 W w O] J av U v � � U M O J LLY4921 z>sn .oT W W U I a w E- o I x w O"`. a CZ z ,n H �Fh-. W U) N F POi I o i w > aH a F wrr I co IW El an / of VV 0 I NVId 311S z tJ-4 rno WT�• 0 64 � Q Cl WW ,Z,7 wo- WL Zn�o WO WHO �w zo ¢0 1 I \ UZ > za oMOD W=nw w = Q CD II �- Z �\a MOM o o� � ��Q� oCL O W U] m F O o w° w = Q CD II Q O NQ M Z p J w 1 O O O = U2 I Z Z Q Q w =JO UVB S 0 N of:Q d Mi In Fw- O 0ZaJ�acn N o J\ooaQ i� N a V) \ o 0 �JLLa 1-00 2d d- iJ� OL a =\\ W zn :2 J r d - ��i D Lo Z\ CL Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST V � PERFORMED FOR: �I� uLlb �+ DATE LEGAL DESCRIPTION: /.OTC--, ��/IC _ J/�% Township, Range, Section: y `1iM0&E5'S SEAL) s5 N^ Y � i`: ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL REFERENCE: McCabe Subdivision West: Lot 5 GENERAL: 1. The scope of this project includes the installation of a 500 gallon septic tank effluent pumping (S.T.E.P.) system and two five foot wide pressurized distribution drainfields to serve the existing three bedroom residence on the referenced property. The existing septic tank is to be excavated to verify integrity. If of poor integrity, the tank is to be replaced with a 1250 gallon septic tank effluent pumping (S.T.E.P.) system. 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. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. 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. 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' of cover shall be insulated. Page Two McCabe Subdivision West: Lot 5 April 26, 1994 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' 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/DRAIINFTELD 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 (roughed -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 and installed approximately in the locations shown on the design. 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 Three McCabe Subdivision West: Lot 5 April 26, 1994 MINIMUM MATERIAL 1. Any septic tank proposed for installation must be constructed by a Municipally 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, Fernco, or equal). 5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140/N, 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. Page Four McCabe Subdivision West: Lot 5 April 26, 1994 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: 1. 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 contractor's 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 contractor's activities. Final acceptance of the contractor's 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 72-013 (Rev. 3/78) z 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 �&NEW i G 349. 'S -I /Kj ❑ UPGRADE MAI LING ADDRESS PO BOA 1 L2 9S! 1 LEGAL DESCRIPTION L OCLUES7s/ 12-w S? --7 LOCATION NO. OF BE�OOMS Well ! Absorption area Dwelling ! PERMIT NO. V DISTANCE TO: d0 .J ® 14 _Y wQ Manufacturer Materi�E� No. of compartments ~ L to Liq. capacity in gallons 2_® IF HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. J a Z = z Fa,- Manufacturer Material Liquid capacity in gallons D w= DISTANCETO: Well /©®r Foundatiq� Sr " NearestlItlin PER TNOO,4 J LL Z No. of lines Length of each lirye f{-1, Total lepp��th tones Trench width Distance betwee lines F z w �!-Ir Snches F Top the to finish Material beneath Total 0 of grade /— S.S tile ` effective a sor_d area [f. - Length Width Depth PERMIT NO. w a F wa Type of crib Crib diameter Crib depth Total effective absorption area y DISTANCE TO: Well Building foundation Nearest lot line J ClassP�t IVA�`� Depth Driller Distance to lot line PERMIT NO. W DISTANCE TO: Building fo ndption Sewer line / Septic tank loci Absorption area(s) OTHER PIPE MATERIALS !.� C i X6A) u3 o SOILTESTRATING INSTALLER F c. 1. 2't tvT EX�-S�t-1►� �, uQvr WA REMARKS 0.'4j 3 13 U - w, ! 0 2 () a (- ®! G3 ,4 pE O U E f-9,6 C. 0 L 5 N. Ili Ise 's 14 hi CA T n nl 1. W 4 l APPROVED DATE LEGAL :fw 61Z718f L5- spfMCC_A4C1Lli&sem -ri2N j43kj S Z_- 72-013 (Rev. 3/78) z ` r"� ' 4 | ^| � �l ILA r -A I (::� 1 IF` 1--'o L_ 1: -r"-e CH F= ����" Cl F---' n C3 E__- DEPHRTMENT OF HEALTH HND ENVIRONMENTAL PROTECTION ` 825 L STREET/ HNCHQRHGE/ AK 99501 264-4720 ` / ��1 -T- E: �����F,�- t-4 E--- 0 L_ � PERMIT NO: 840143 , DATE ISSUED: 04/05/84 ! APPLICANT:� GEE JHNIGO ' ADDRESS: � PO BOX 111223 , | AkICHORH{E� 99511 � CONTACT PHONE: 2<45-5140 � ^ ~ � LEGAL DESCRIP: SUBDIVISION: MCCHBE Wo . LOT: 5 ` BLOCK: NA � SECTION: 27 ' TOWNSHIP: ` �2N RANGE: ]W � | LOT SIZE: 5]171 (SQ.FT. OR ACRES) | MHX BEDROOMS: ] ' LISTED BELOW ARE- THE OPTIONS AVAILABLE TO YOU IN DESIGNING | YOUR SEPTIC | SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE. ' �`4�� . 9 nn ������»� �� ������][�� . DEPTH TO PIPE BOTTOM (FT. ) 6.0. 6. 5 6.0 ` GRAVEL DEPTH (FT. > 6.0 0�5 2. 0 " TOTAL DEPTH (F^[ ' ) � 12� 0 ��0 E{0 ~ � GRAVEL WIDTH (FT. ) 2,5 > 19.0 � 5.0 . GRAVEL LENGTH (FT � ) � ]8 0 � ]6 0 , 6I0 ' i GRHVEL VOLUME (CU.YDS ) 22.8 25. ] 29.1 ' TANK SIZE (GALS) 1/000.0 1,000.0 ** 1,000.0 ** ^ SOIL RHTING (SaFT. /�R) 150 150 150 ' ** TANK MUST HAVE-- AT LEAST TWO COMPARTMENTS ` I CERTIFY THAT: 1. I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPAL ITY OF ANCHORAGE (MOH) AND THE STATE OF ALASKA. 2 -ILL. THE SySTEM IN ACCORDANCE WITH ALL. MOH CODES HNDR��QUL��TI8N5/ I WILL INST AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. ` I I WILL ADHERE TO ALL MOH AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES FROM ANY EXISTING WELL/ WASTEWATER DISPOSAL SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR ANY 8DJHCENT"OR NEARBY LOT. 4. I UNDERSTAND THAT 'THIS PERMIT IS VALID FOR H MAXIMUM OF 3 BEDROOMS AND ` ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. ' JF H LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOH BUILDING CODES., THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED.; (2) HS-BUILTS WILL NOT BE APPROVED WITHOUT HN ELECTRICAL INSPECTION REPORT/ AND (]) THE ELECTRICAL WORK MUST BE DONE BY H LICENSED ELECTRICIAN. SIG N ED DATE: HPPLICHNT: ~ ISSUED BY DATE: \ -`_» ALASKA ENVIRONJ� NTAL CONTROL SERVIC' .�, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907)561.5040 JOB L S M `AST SHEET NO. OF CALCULATED BY l,7 rK DATE ` CHECKED BY DATE PERFORMED FOR: LEGAL DESCRIPTION: DEPTH �1 r� . SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION X PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST 9 10- 12 0 12 13 S ODY 14 51 UT GRAvE. 15 ; 16 17- 19- 20- COMMENTS 71920 COMMENTS PERFORMED BY: 72-008 (6/79) NOIRE �I 001ME ■11■■ 11151111110 Date (N R usT aROWN Net Time Depth to Water (LP) DARK B pwl 12D �3°�8�3:OSJ !� � 3 e 03� 3I LTY (19/4015L 4 -?Z 0, ram Tq P) wkFT.S 5 0 COMMA/ 6 V ,$I ' Cs P/��) 7 �14c 9 10- 12 0 12 13 S ODY 14 51 UT GRAvE. 15 ; 16 17- 19- 20- COMMENTS 71920 COMMENTS PERFORMED BY: 72-008 (6/79) NOIRE �I 001ME ■11■■ 11151111110 Date tI Net Time WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? I DATE PERFORMED: ' _ (Mu"A' 57 8# -02 SITE PLAN i I I Reading Date Gross Time Net Time Depth to Water Net Drop 12D �3°�8�3:OSJ !� � ..x•'70 e 03� PERCOLATION RATE � 6 0 -(minutes/inch) RW" TFCT RI IN FT FFN FT AND e FT CERTIFIED BY:�e ���� DATE:vZ O WELL LOG `Date Drilleds 6-5-R4 Static Water Level 53 feet Draw Down nt/e feet Type Material Drilleds 0 feet to 15 Sand, Travel 15 feet to 16 Surface water �ea•e Jar,i.gc I' P!cGabc t'es t Gallons Per Minute 1"� Total Feet of Lasing R5 16 feet to 60 4nnav gavel w/clay 60 feet to 62 2£'Dm 62 feet to 80 Sandv clay w/gravel. 80 feet to 84 course sand 85 fPetJsand F -ravel w/water, 30 spa. Hefty Drilling S.R.A. Box 1553 H Anchorage,Alaska 99507 Municipality of Anchorage • -�1 Development Services Departm Building Safety Division _ On -Site Water 8 Wastewater Program 4700 BStreet P.O. Boxox 19 196650650 Anchorage, AK 99519-6650 www.munl.org/onsite (907) 343-7904 TIFICATE FOR A Parcel I.D. O 19 -- a 31 - 3 / 1. GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address OF ON-SITE SYSTEMS APPROVAL SINGLE FAMILY DWELLING COSA# 070 Expiration Date: ' 2 - b 7 McCABE WEST SUBDIVISION: LOT 5 13343 PEAKAEW CIRCLE 0 ANCHORAGE, AK 99516 JERRY & KATHLEEN DOWLING Day phone 13343 PEAKVIEW CIRCLE + ANCHORAGE. AK 99516 Day phone 243-3984 CYNDIE PARTCH w/ PRUDENTIAL JACK WHITE Day phone 440-7775 3801 CENTERPOINT DR. 1200 " ANCHORAGE. AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well 0 Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site N 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 On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (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 Systgms 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 infon1%tion obtained from the Municipality of Anchorage riles and from my investigation and inspection, the on-site alter supply and/or wastewater disposal system fs(are) in compliance with all Spplicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. % Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LID. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines 8 Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily ldenbTfablo features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system.) These conditions are outside the control of the evaluator of the system. Satisfactorytes) results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE _kZf"" Approved for ? bedrooms. Disapproved. Date ct 2c 6 i.::...'i. ........ '-Jet r y Corn ss.: 0 Conditional approval for bedrooms, with the flowing stipulations: Attachments: COSA Checklist C� Septic System Advisory Well Flow Advisory Nitrate Advisory J Arsenic Advisory Maintenance Agreements Supplemental Engineer's Reort Other (R"AIMS) ON-SITE . WATER AND WASTEWATER0. : PROGRAM KI '•. Original Certificate Date: — -07 VA 7A r (R"AIMS) ON-SITE . WATER AND WASTEWATER0. : PROGRAM KI '•. Original Certificate Date: — -07 Municipality of Anchorage ,,all I. Development Services Department 8uddit Safety Olvow On -Site Water d Wastmater Program 4700 8mgaw St. P.O. Box 19WW Andwrage, AK 99519 -WW www.danchorage.sk.us (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: McCABE WEST SUBDIVISION: LOT 5 Parcel ID: 019-231-31 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 6/5/1984 Sanitary seal (Y/N) YES Total depth 85 ft. Cased to 85 ft. FROM WELL LOG Data of test 6/5/1984 Static water level 53 ft. Well production 30 g.p.m. WATER SAMPLE RESULTS: Coliform 0 oolonies/100 mi. Nitrate 7.49 mg./L. Well Log (Y/N) YES Wires property protected (YIN) YES Casing height (above ground) 13 in. AT INSPECTION 7/17/2007 46 ft, 6.19 g.p.m. Other bacteria 0 oolonies/100 ml. Arsenic: ND ug./L. Date of sample: 7/17/2007 Collected by: GEG Ltd. B. SEPTICIHOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 6/27/1984 Tank size 1250 gal. Number of Compartments 2 Cleanouls (YIN) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) YES Date of pumping 7/17/2007 Pumper McDONALD'S PUMPING C. ABSORPTION FIELD DATA 5/4/1994/ SHALLOW TRENCH/ Data installed Q/27/19a4 Soil rating .p.d. r�0.45 150 System type DEEP TRENCH Length 41.5/2 O 58 ft. Width 3/5 ft. Gravel below pipe 3/6 ft. *5.92-7.04/7.08-7.83/ 1000 Total depth 11.5 ft. Eff. absorption area 49 ft= Monitoring tube YES Depression over field NO Date of adequacy test 7/17/2007 Results (Pass/Fail) "PASS For 3 bedrooms Fluid depth in absorption field before test L in. Water added 230/576 gal, New depth 0/33 in. Elapsed Time: 132 min. Final fluid depth L in. Absorption rate >= 450+ g,p,d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date "TESTED 1994 SYSTEM TRENCH 1/ TRENCH II ADDED 230 GALLONS TO TRENCH 1 AND R REMAINED DRY D. LIFT STATION Date installed 5/4/1994 Size in gallons 500 Manhole/Access (Y/N) YES "Pump on" level at 31 in. "Pump otP level at 29 in. High water alarm level at 41 in. Datum BOTTOM OF TANK Cycles tested 3 Meets alarm ti circuit requirements? YES E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots Public sewer main N/A Sewer /septic service line 25'+ Animal containment areas 50'+ Public sewer manhole/cieanout N/A Holding tank N/A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line *8' Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicie storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS *WAIVER REQUESTED 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 PrinNarrte JEFFREY A. GARNESS Data �{ti 0 COSAFee& L/130. (DO + 175 �uSN Date of Payment I P. I 107 Receipt Number j GO 7 (Rw. 11105) �. Waiver Fee S 115 Date of Payment &9 La 7 Receipt Number 22)74 at, Municipality of Anchorage Development Services Department ,�; �• �:�v; j Building Safety Division ' On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 070378 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Lot 5 of McCabe West subdivision. This inspection revealed a nitrate concentration of 7.49 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. GARNESS ENGINEERING GROUP, Ltd. ---- CONSULTANTS & GENERAL CONTRACTORS r September 20, 2007 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650, Anchorage, Ak 99519-6650 (907) 343-7904 Ref: Lot Line Waiver for McCabe West Subdivision; Lot 5, To whom it may concern: We request that your department issue a 8 -foot lot line waiver from the south property line to the existing drainfield. Letters of non -objection from the utility companies are attached. An application for AN encroachment permit has been submitted to the MOA ROW staff. We are unaware of any adverse impacts this waiver would have on adjacent wells or septic systems. If please contact us at 337-6179. Thank you for your assistance. , M.S. 3701 E. Tudor Road, Suite 101 • Anchorage, AK 99507-1259 Ph: (907) 337-6179' Fax: (907) 338-3246' Website: www.gamessengincering.com Municipality of Anchorage Development Services Department • 4 Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. ci.anchoragc.ak.us (907)343-7904 Waiver Review Worksheet WR#: 070048 PID#:018-231-31 Date Received: 7121107 Legal Description: McCabe West Lot 5 Engineer: Jeffrey Garness HA#:070378 Permit#: Waiver Requested: 8 feet separation distance absorption field to property line. Criteria: Geology Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation Total: ..........°..°.......a........................................................9 Waiver is Granted: List Conditions or Reasons for above: Date: I — D-0-07 By: _ ..868666666866988 wages mass seem Rec#: 7/21107 Amount: $175.00 Waiver is not Granted.- Date: ranted. Date Paid: 7/21107 ............................r Municipality of Anchorage 4,_ r_ �•, w L'0. I4:x 1!X)(:-11 •.lnchurq.!c, .\la+k:: !X651!LIA:41 •7Ncphnnt (!X)7) 33:4-KN11 • 11i.x (!X)71313-K(X) 471M1 llmgmr Simcl •.lnchun:gc, ,\lu+kn !X.Ailli uAM..nnm Wrg ,llnryor Mark Ilcgicll Iluildhu, Safety Dhisirni 9/24/2007 Jeffrey Gamess Gamess Engineering Group, Ltd. Subject: Waiver Request for McCabe West Lot 5 Waiver Request #WR070048 Parcel ID #018-231-31 HAA# 070378 Dear Engineer, Your request for a waiver of the required 10 feet horizontal separation from the absorption field to the property line has been approved. The approved separation distance is 8.0 feet. This waiver approval applies to the existing absorption field 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, Jeffrey W. Poet Engineering Technician On -Site Water & Wastewater Program Community, Security, Prosperity ■ ■ SEP -10-2007 10:21 PRUDENTIAL JACK WHITE Pt ■ a 11SIHE R _ € is 3ai_ E3 8 N 4 ja vt6a L 9 ° ° 3a T= �. IlE ; - I - air,.� rr e e:gga � E9 it Air..j �Ig • G ! tug ,p P.01i01 n n c 'O �U e 1 M f � cpjO -7- ---------------- 1%` Mc CASE EAST Sif A. I TOTAL P.01 I. Ahmicipali%r of Anchorage .; � L e 14). IGrt 1!NN:MI •.\nchnmA!c, Alaska !MA719IN:MI. 371N1ltoil;ux tii rrc) 011iac: (!N)i) 343 SU)1 •Pus: (!Nli) a3a t:;NN1 hllp://ew��.nmui.urg Mayor,Vark Begich Development Scr%ices Dcptirtrrrcnt September 21, 2007 Jerry and Kathleen Dowling 13343 Peakview Circle Anchorage, Alaska 99516 Dear Property Owners: RE: Encroachment: Septic system Drainficld and Shed In Utility Easement McCabe West, Lot 5, Grid 2936,13343 Peakview Circle picot IV?_II _I IAM' Departnient The Right of Way Division has reviewed a request for a letter of non -objection to an existing septic vent pipe which encroaches approximately one (1) foot into the len (10) foot Utility Easement, and a portable 6'x8' shed, which sits entirely within the same Utility Easement, located along the south property boundary. On the as -built survey dated 20 August 2007, submitted with the request, the petitioner has shown the septic vent pipe and portable shed. This letter of nonobjection is issued with stipulations, and by using it the petitioner is agreeing to the following: 1. Municipality of Anchorage (MOA) will be held harmless, now and forever, for any damages or injury to any person as a result of the encroachments. 2. All applicable codes and regulations will be observed and maintained within the easement. 3. This letter of nonobjection will in no way preclude MOA from full use and enjoyment of its rights within any portion of the easement. 4. Additional and extraordinary costs incurred during any future required construction, repair or reconstruction of MOA improvements to accommodate any or all of the encroachments shall be paid by the property owner. S. Obtain letters of nonobjection from the following utilities: ® ® Anchorage Water&. Wastewater Utility Chugach ® Alaska Communications Systems ❑ Electric Association, Inc. Matanuska Electric Association, Inc. ❑ ® Matanuska Telephone Association Enstar Natural ❑ Municipal Light & Power ® Gas Company GCI Cable of Alaska ❑ Eyecom (Girdwood Cable TV) ❑ No letters required All letters of nonobjection should be retained in your permanent files. If you have any questions, please call me at 343-8033. Sincerely, Concur 4'Io7 (2t�'D fF5 cc /,*ti Jack L. Frost, Jr. Right of Way Supervisor ContJntinity, Security, Prosperity G.IA+rluomrefSrnJrn)ROIILVw wM1iarrlw Irnrrsl,N�laM1r Plot. LaS. Dow{dv.da Municipality of Anchorage o • Development Services Department Building Safety Division On -Site Water and Wastewater Program u e 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 019 - 2 3 t- 3 t 1. GENERAL INFORMATION HAA# �iAO�l�b/3 Expiration Date: / O - / %- 02 Complete legal description Lot S� I`f c Cct 6 e Guu t 5 /b Location (site address or directions) / 3 3 Y3 1`1` -c Cu4.e Ce -C (e ��rt Current Propertyowner(s) R4clh6tr0/ �Scr/ly /wAnson Dayphone 31VS'-0o66' Mailing address Lending agency Mailing address Real Estate Agent Mailing Address 13 3 Y3 /`rc Cccye Circ le Lt/or/' i-Aclia ose 49,9 5— '_<-c/ (jun t' AIvolG FS (30 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 3 Day phone Day phone TYPE OF WASTEWATER DISPOSAL: Q Individual On-site ❑ ❑ Individual Holding tank ❑ ❑ Community On-site ❑ Cl Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below. I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system Is(are) safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm r luf fob Techn%ce l SCr✓r(�j Address fHS3o C-e_4v S�•. /�"Gtib�Gya Engineer's Printed Name Theo -c -10--e i-roo✓"� 5. DSD SIGNATURE Approved for Disapproved. Conditional approval for Additional Comments Phone 99x/6 Date OF Aij 6.. 4 c . ...................:.. ThM RS F. ►1CCRE J x �,1 } ••. C: - 309 i3` ENGINEERS STAMP bedrooms. L,`��+: •....... bedrooms, with the following stipulatb=F(a1 01 J • ON-SITE c= WATERANO ; m: _. WASTEWATER PROGRAM ' SEAS�\\\` 01111 Note: The well for this property meets existing State and Municipal Codes. There are nitrates present. It is suggested that periodic teat-img be performed to insure the wells continued suitability. Current nitrate concentration is 5.15 mg/I. EPA maximum concentration is 10.0 mp/I. NInre information on nitrates is available from the On -Site Services Program, at 343-7904. Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory By: z�/ /LI nz_� (R". 12M) Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: '7— //-0 .7' Municipality of Anchorage ° • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343.7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L.ot 5^ Parcel ID: Orfs - 23/ - 3/ A. WELL DATA Well type P&' f if A, B, or C provide PWSID # = Well Log (YM) Y Date completed 6 /f / dy Sanitary seal (YM) Y' Wires properly protected (YM) Total depth t3S_ ft. Cased to -Of -ft. Casing height (above ground) / 2 in. FROM WELL LOG AT INSPECTION Date of test 6 (Sr / 6Y / Z81Zoo Z Static water level S-3 ft. S Z ft. Well production 30 g.p.m. 6.36f- g.p.m, WATER SAMPLE RESULTS: Conform _O_cotonies/100 ml. Nitrate S. !i ngA. Other bacteria O colonies/100 ml. Date of sample: 6 / Zb / O 2 Collected by: B. SEPTIC/HOLDING TANK DATA Tank Type/Material S Pp t; c / Sf�e e I Date installed 6 / 27 / B y Tank size LZSW gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (YM) Y Depression over tank (YM) Al High water alarm (Y/N) Date of pumping 7 /S / 0 Z Pumper A t C. ABSORPTION FIELD DATA Date installed S/y!9 y Soil rating (g p•d./ft= or ft'Ibdrm) _42._YS- System type S4+1/a w 7 -re. A Length / / if ft. Width S' ft. Gravel below pipe 3 ft. Total depth 5- ft. Elf. absorption area Lapp ft' Monitoring tube Y Depression over field N Date of adequacy test 6 174 /a, L Results (Pass/Fad) Pori For 3 bedrooms NIS Tr. - p o Fluid depth in absorption field �efora teest�$ in. Water added gal. New depth 22.s in. 3 a Elapsed Time: 6s min. Final fluid depth ?,at In. Absorption rate >= -y(S'o g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Nune knc a of If yes, give date Al- .4. i D. LIFT STATION Date installed Size in gallons S UU Manhole/Access (YIN) Y "Pump on" level at 26 in. 'Pump off' level at L_ in. High water alarm level at 3 Y in. Datum /6 0Pl vow/ f Cycles tested > to Meets alarm a circuit requirements? Y_ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/fiR station on lot 103'1116, On adjacent lots > I u a' Absorption field on lot Ito, On adjacent lots > f042 ' Public sewer main Y-4- - Public sewer manhole/deanout ' ' N• 4. Sewer /septic service line '> Zd" Holding tank N. r}, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation S Property line YS-' Absorption field S' Water main > (U' Water service line > IUSurface water > I ua Weiss on adjacent lots > f Ua' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 19, Building foundation 17' Water main > IO' Water Service line > rfi ' Surface water > I coo ' Driveway, parkingfvehide storage > 10 ' Curtain drain /✓oM Seen Wells on adjacent lots > F. COMMENTS &Came 1h[ 4,100'-s fylc �OF R c4jea on eJ nom! 44Ae�fi hid f'1�! '�.� ,...•.,cdt., ra %rna/ fu:/ i^�L �L,�P an !'+Yn t4 r++IfJ �f4•// a`'i":� `+�� Or C4 Vlas aG/lyyW y (^o-` of ;me n~,el d••^>t'•/� �r�:•49;H G. ENGINEEWSCERTIFfCATION Svl vn, �.rt ��...............•.;,.,i I ceFfi y that I have determined through field inspections and ........ • .:••••t•+ review of Municipal records that the above systems are in if 7Hi0007: F. MOORED• • p conformance with MOA HAA guidelines /n effect on this date. '4k, Lf 'S35°? . • e,ka g ' Engineer's Printed Name Ttitoafa� /�• /`tua�� F•���,�;�.•,.►: w Date Tu f y 7, Z Uo 2 HAA Fee $ 3 7S" r ud Waiver Fee $ Date of Payment 7/7/p a Date of Payment Receipt Number Receipt Number (Rev. 12/00) -`..,• c. Oo ::111 IIs ;blrt5d Jti�� wrllrF W. tiX 14 `!. ``L`CAJ '�. Lrr,ratitewv or< 199Y rrji ryr Acw Gnir y" cutelI clerwtn ritrcfr plgtFcd S� S Sc --17 J4 *t' onto /h, iy Tom-! "cror- 7(7/oz. Ar - yup/i Bart I " v S0' .11f•.\by elwll�l'elO Wi�•�•rlxlta�jt`.�f7r•���.i�•..\ .•77�Y aa_.—� Utto/Nlllon was dude On 1,1Li..;j,•.[��V.. ,• aN 4UI the 4nyrOV4MAA11 /11Wtad IhW*OA Am w4hln 1114 AMPOlty IIA41 1A0 . oro net O*Vl10 W anuaadn On 140 Voleafly Iy" $4401311herN0. Ihel ho 1nr0YM^aAI1 an OtOPanyIYlA9 odl~t V.atMo on eaanonII»po, tai} M "11110A lad lnll that& $to no INQM Y/. etanatnlal,en halt at 11141 twow snean ntt on lefd Dreowly /11401 as Ind"tod huaan. 11 Is th/ rV"nSWflrY Of IM drnN 10 dalatmin/ Ina fabtaAaa of any •alae►au. COtwnInte. a faalrlCIIOna wlfkAdO not 1P0e41 OA"recorded au0dl..laen pat• VWU MO CIrO0I11411Cae 1nOUld any 0111 ninon 4t ula0 101 ►»auwubnafaroala9111h1nlb0unp0yj!�yCfl*F fRA" D.I aunctwrapa, grata. lM1j'a.. Oq N?. . I> �_ CONITAUCTIHOINOINIC11t.INC. A"UILT &W Ml walnal w. /✓.MOnOa.Ataltl aG,lit Qe pt a, 1x.2000 1lLa0/0 �. , . _ • . '.. - .. . u ail eS►lrr. •►►1(•►: Ej4 li0,xnJ4r lia.!ru.ul{a�� A oe> • sn s t.o Iib too 3 4 h MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 018-231-31 1. GENERAL INFORMATION Complete legal description Lot 5 Mc Cabe We Location (site address or directions) HAA# HA940211 13343 McCabe Circle West Property owner Mike & Jill Gould Day phone 345-4975/345-7842 Mailing address 13343 McCable Circle West, Anchorage, Alaska 99516 Lending agency Day phone Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water Three (3) XXXXX Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: XXXXXX 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. 72-025 (Rev. 1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S & S Engineerin Phone 694-2979 Address 17034 Eagle River Loop Road, Suite 204, Eagle River 99577 Engineer's signature 6. DHHS SIGNATURE a xxxxx Approved for Three (3bedrooms. Disapproved. Conditional approval for Additional Comments Date bedrooms, with the following stipulations: CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025(Rw. 1/91) Beck MOA #21 .,..wvnuuc.�ativannaa..�.�.,..�.__�.. _ .. _. _. _... ,.. ..,.,_ _.._.. .._.... _._.. 5... STATEMENT OF INSPtvTION BY,. ENGINEER Y As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system. s 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. S & S ENGINEERING ' Name of Firm 17 34 Eagle River L,Phone Eagle River, Alaska 577 Address Engineer's signature" Date ' 2;S� 5yS e•n 7U ` l /_ /� w . 7- Hcr A -7Tl9 cNG O D�ly�j 76 �99`- +'i h , 4 E.D_.9p , f V ks v%♦'1 rffi)i), I iQ ,J�Ee4t 4Y f s,Y)' 'U.V- 6," DHHS SIGNATURE rU "rL�u �a tt'` �1'fJF.ba u1q'� Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments ---- BY: Date 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 ordertosatisfy certain federal and state requirements. Employees of DHHS do not qcon duct_;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. 72-025(Rev .1/91) Back MOAM21 Municipality of Anchorage s Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST -7/ s A/fin /� � Legal Description: G� C (. A �9 m 5\o -7 I.D. A. Well Data Well type /' va- /e If A, B, or C, attach ADEC letter. ADEC water system number �— Log presen(Y/) Date completed . l Driller__D_ e I �-Cc, Total depths Cased to rG% Casing height /2 Sanitary sea (Y/) Wires properly protected m FROM WELL LOG Date of test 2 -710 Static water level /3 Well flow �7"� /U' 9•P•m• Pump levell SEPARATION DISTANCES FROM WELL TO: AT INSPECTION 4 /*7 t -n n 3.6 g.p.m.� tA (x 14 Septic/hag tank on lot ; On adjacent lots 167 f M Absorption field on lot /0 ,0 f ; On adjacent lots Z( 6 1 Public sewer main N 14 Public sewer manhole/cleanout_ lf-� /� Sewer service line 2 S Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate 3� 6 9 S $ 911R54�IG Date of sample: .5 %% `% Collected by: 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 B. SEPTICA46tONG-TANK DATA Date installed /CJ 4 I Tank size /dOO Compartments z Cleanouts (Y/) GAJ'''A Foundation cleanou (Y/) e s Depression ( /N High water alarm (Y/N y"' Alarm tested (Y/N) Date of pumping 1���4 !2c/`% Pumper - 7-- SEPARATION DISTANCES FROM SEPTIC/Wet""08 TANK TO: Well(s) on lot /O1' �,� On adjacent lots /OD G Foundation t To property line l0 Absorption field 5- 4/L Water main/service line Surface water/drainage 72-026 (3/93)* Front �- CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N Vent (Y/N) "Pump on" level at "Pump off" Level at High water alarm level I s to te� Meets MOA electrical Y/N) SEPARATION DISTANCE FROM _LIFT TSSTATION TO: Well on lot / On adjacent lots 'Surface water D. ABSORPTION FIELD DATA Date installed /0 6 Z Soil rating (P ) /50 S t System type /'►� Length Z Width 36 Gravel thickness rLZ Total depth / Z Total absorption area 6 Cleanout presentY/) ( Depression over field (Y/N) 'PT Date of adequacy test Z �! Results (pass/fail) % �� c for 3 Bedrooms i N Water level in absorption field before test 8 -5—//, '�� � After test Peroxide treatment (past 12 months) (Y/N) Jv v If yes, give date SEPARATION DISTANCE FROM ABSORPTION I ELDTO� Well onlot ,v U On adjacent lots l U Property line F I To building foundation 20 To existing or abandoned system on lot /Vy N lr r On adjacent lots 2 r Cutbank hJ V �J r— Water main/service line LO f r r Surface water ! Driveway, parking/vehicle storage area /0 f Curtain drain N 1 N 6 IT wc7 Gv N E. ENGINEER'S CERTIFICATION HAA Fee $ W .' Date of Payment '2-(0 Receipt Number Sx5-0 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # L - I HAA # 0 QS1 Ll 0,Q l l 1. GENERAL INFORMATION Complete legal description Lot 5,• McCab`e"Subdi.vision We6t Location (site address or directions) 13343 McCabe Ciac✓'e We6t Anchonaat. AK Property owner Mike and JiU Goutd Day phone 345-4974(h) 345-7842 w Mike Mailing address 13343 McCabe Citcte We6t Anchwtage, AK 99516 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well XXX Community well Public water NOTE: If community well system, provide written confirmation from: State ADECattest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site XXX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. z 72-025 (Rev. 1/91) Front MOA x21 . 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm 17034 Eagle River Loop Address Engineer's signature 6. DHHS SIGNATURE Approved for Disapproved. By: Conditional approval for Additional Comments Phone .204 /---- - Date S 4.1 .t / < l bedrooms. bedrooms, with the following stipulations: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the 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. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: HcGQFt) E L-ZIr7" S A. Well Data '5U6D . Le-) 6��/_Parcel I.D. D/D zz, / Well type 'F4' /A If A, B, or C, attach ADEC letter. ADEC water system number �/-;4_.� 1 Log presen (Y N) q Date completed `�_Driller 72EL I A Total depth 1 / Cased to 8 / Casing height Z �r Sanitary se (Y N) Wires properly protecte (Y N) FROM WELL LOG AT INSPECTION Date of test /T f / / 2� I RECEIVED Static water level / / Well flow 9•p•m• 4P g'p'm' MAY 91994 Pump levell / �C J 10"'("pahiy QJ Anchorage Dept. Health & Human Services SEPARATION DISTANCES FROM,WELL TO: Septic/Ism tank on lot On adjacent lots Absorption field on lot ; On adjacent lots _ P Public sewer manhole/cleanout// 1A Petroleum tank /k= •♦ Public sewer main Sewer service line WATER SAMPLE RESULTS: / Coliform C/ Nitrate 3- �o 4CS L' Date of sample: 31 2 �j �%� Collected by: B. SEPTIC/SANK DATA r❑ 17034 !*Ate River Loop Road, No. 204 Eagle River, Alaska 99977 Date installe 7�-//0)8 i Tank size /0-0Z Compartments 2 Cleanout (Y ) Foundation cleano tt'( /N) Depression (Y/� High water alarm (Y/N) LD. /76 Alarm tested (Y/N) Air Date of pumping -3/9 Pumper SEPARATION DISTANCES FROM SEPTIC/FTANK TO: Well(s) on lot On adjacent lots / 6D f Foundation To property line / Absorption field —Water main/service line Surface water/drainage / CONTINUED ON BACK PAGE 72-026 (3/93)' Front C. LIFT STATION Date installed _14 - Manufacturer fQn.lG A q e 7 -A/, , Size in 11 ns OTE) Manhole/Acces (Y ) Ven N) "Pump on" level at 29 / "Pump off" Level at I/7 High water alarm level :2�2 4 Cycles tested Meets MOA electrical code fi (y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot / Z,n On adjacent lots / 0_0 f Surface water D. ABSORPTION FIELD DATA /6D I_J_ Date installed 5/ S� ! Soil rating (GPD/Ft2) System type Length / / �O / Width Gravel thickness / Total depth `J / Total absorption area present Yk1) Depression over field (Ye z"l Date of adequacy test Resultsl(pass/fail) X-�1_60 SLS?2wfor Bedrooms Water level in absorption field before test After test Peroxide treatment (past 12 months) (Y6 /�• If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: / / Well on lot ! � 7 On adjacent lots 100 ,/ Property line /q To building foundation J --� To existing or abandoned system on lot /d On adjacent lots 90 '-r Cutbank t JCI -AC Water main/service line /4� r Surface water 1 67) I -L Driveway, parking/vehicle storage area 5212 '-1- Curtain drain �/L E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all S & S ENGINEERING Signature 17-024 Eagle Rove, Loop R( Engineer's Name Eagle River, Alaska 99577 Date HAA Fee $ Date of Payment Receipt Number 72.026 (3/93)' Back and HAA guidelines in effect on the d,at bf his inspection — 1 R Waiver Fee $ Date of Payment Receipt Number �.ngrnp� ROBERT SHAFER, P.E. ROGER SHAFER, P.E. May 1994 CIVIL ENGINEERS y 7, (907)694-2979 FAX 694-1211 REcti VFZ) HEALTHAUTHORITY APPROVALS A Municipality of Anchorage sir,,,; , 91984 spar' me t of Health and Human Services Department e H@a fh''l`y qP.Se art 50 a�® Anchorage, Alaska 99519 r,,r�es SEWER & WATER MAIN EXTENSIONS SEWER & WATER REFERENCE. McCabe West Subdivision, Lot 5 INSPECTION ENGINEERING STUDIES ANDREPORTS A Conditional Health Authority Approval (HAA) was issued on April 24, 1994, for the referenced property. All work required for the conditional HAA has been completed. WELL INSPECTION 8 FLOW TEST Attached is the On-site Wastewater Disposal System and/or Well Inspection Report for your approval. We request you issue a final Health Authority Approval for the referenced property. SITE PLANS If you have any questions or require any additional information, please contact US. ROAD DESIGN Sincerely, SOILTEST Rob rt A. Shafer, P.E. PERCOLATION TEST RAS/LSU/lsu STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 M MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) L-5 m t coo WEST -50f> T►2 N P 3w pec 7 Location (address or directions) 13391 c C CIE? (b) Applicant Name Qlye . J ltd l C3 ® Telephone: Home Business 356 -5'7 yo Applicant Address py o)( 11122---5AlycA 4K F w (c) Applicant is (.check one): Lending Institution D ; Owner/builder ; Buyer D ; Other D (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address _ Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family 0.1 Multi -Family D Other Number of Bedrooms 3. WATER SUPPLY Individual Well 1K Community D Public D Telephone Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite Public D Community D Holding Tank D Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Pagel of 2 72-025 (11/84) 0 5. ENGINEERING FIRM PROVIDING ,NSPECTIONS, TESTS, FILE SEARCH, DA) AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval 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.#Fs Name of Firm rj[lf�Tdd !/Y`,5�® Telephone Address W�� �L �® T ic'—r A/01' Date DHEP APPROVAL Approved for bedrooms by � Approved Disappro Condit' Terms of Conditional Approval ��:®&,Q% 0 A4 4 44 97N E-2 1 a..... �s0!`rDSStiililal 15PA VL V Date° -- CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DFIEP 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. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE DEPT. O F HEALTH MUNICIPALITY OF ANCHORAGE (MOAT ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST -FEBRUARY 1984 18 1966 264-4720 p /^ Legal Description: j 1�y R3�f _ 5�c 27 A. WELL DATA Well Classification E 1V 01(/1DUPrL If A, B, C, D.E.C. Approved (Y/N) Well Log Present (®N) DatecompletedYield .0 CPM Total Depth sa / Cased to Depth of Grouting Static Water Level Gid Pum Set At P i Casing Height Above Ground 2 i2 Sanitary Seal on Casing &N) Electrical Wiring in Conduit ('N) Depression Around Wellhead (Ya Separation Distances from Well: To Septic/Holding Tank on Lot �o' f ; On Adjoining Lots To Nearest Edge of Absorption Field on Loth ; On Adjoining Lots To Nearest Public Sewer Line At To Nearest Public Sewer Cleanout/Manhole t N/A To Nearest Sewer Service Line on Lot 4 Water Sample Collected by1if9 !TG1�11GK ; Date Water Sample Test Results s AT1 SFitcyR f Comments B. SEPTIC/HOLDING TANK DATA Date Installed 2 7 Size 12-50 No. of Compartments a Standpipes J N) Air -tight Caps (ON) Foundation Cleanout(9N) Depression over Tank (Ye Date Last Pumped AIA Ar Pumping/Maintenance Contract on File (Y/N) % ; for A�A) Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: / To Water -Supply Well To Building Foundation 5 i To Property Line 1 / To Disposal Field S To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course n ` Comments 4-- SEE C0QF1CRlF 001'- ©CGUpollyGY Page 1 of 2 72-026(11/84) I s mG 668G w�5sr C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata %,50 Type of System Design 7 -AE C Date Installed — 6/2 %f 9 � Length of Field -11,5, Width of Field 3 Depth of Field 12' Gravel Bed Thickness KI Square Feet of Absorption Area Standpipes Present ON) Depression over Field (Y/A J� Date of Last Adequacy Test /VIM Results of Last Adequacy Test Separation Distance from Absorption Field: i To Water -Supply Well To Property Line To Building Foundation To Existing or Abandoned System on Lot N/fiOn Adjoining Lots 12 +- // To Water Main/Service Line iV�p To Cutbank (if present) N/A To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Dimensions Size in Gallons _ Manhole/Access (Y/N) "Pump On" Level at "Pump Off" el at High Water Alarm Level at Vent 1Y/N) Tested for V Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments _ ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I h c c�k , veri ed, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Date 6 Company �� C MOA No. 2 OF A44%4 + 4 A ••eHe•*•e Receipt No.q• Date of Payment IS c6 or * o 49TH •of �a /@****s• . e►• •e•ee ee' Amount: $ ( / En i Seal k(1 !� o' All C. REID, J . • D Page 2 of 2 �-Cgf':Af�rsitia'' Ce'R!, OF OCcdPRacY 72-026 (11/84) S 1 %E- 1°QW