HomeMy WebLinkAboutUS SURVEY 3200 LT 12C-1U
3200
Lot 120-1
090- 04 !
-57
Municipality of Anchorage Page of
On-Site Water and Wastewater Program • (907)343-7904
ON-SITE WASTEWATER INSPECTION REPORT
PID Number: 090 7
Permit Number: OSP191050 Project: New Upgrade
Dwelling: Single Family (SF) Duplex (D) Multiple (SF and/or D)
Name: ABSORPTION FIELD -EXISTING
Jason Smith & Kimra Widmer
Address AK 99540 Other Deep Trench Shallow Trench Bed Mound
132 Rand Drive, Indian, Soil Rating Total depth from original grade
Number of Bedrooms Ft.
Phone 3 GPO/SF
Depth to pipe invert from original grade Gravel depth beneath pipe Ft.
Block Lot Ft.
Su
LEGAL DESCRIPTION
UbdivisionS SURVEY 3200 12C-1 Fill added above original grade Ft.Gravel length
Ft.
U
Range Section Beds:Number of Lines Distance between lines
Township Gravel width Ft.
Ft.
SEPARATION DISTANCES Total absorption area Number of trenches Dist.between trenchesFt.
To Septic Absorption Holding Sewer Ft2 --
Lift Station Tank Line
Tank Field
From TANK Septic S.T.E.P. Holding Other
MII 100'+ NA NA NA NA Capacity
Manufacturer
Surface Water 100'+ NA NA 1250 Gal.
NA ANCHORAGE TANK
Number of compartments
2
Lot Line 5'+ NA NA NA NA
NA LIFT STATION Capacity
Foundation 10'+ NA NA Gal.
Curtain Drain NA NA NA NA
Pump on level at Pump off level at High water alarm at
Remarks Existing septic tank decommissioned in in.
er code new tank installed & in.connected to Pump make and model Electrical Inspections performed by
existin• s stem.
to 3034
PIPE MATERIAL House to tank 3034 draTianfink to
Installer MIKE N. ANDERSON Drainfield CO/MT 3034
FWCS / MNA BENCH MARK (Assumed elevation)
100 ft
Inspector Location and description
Inspection 151 3118119 2 3/19
dates: 3o� 4, Top of RR Tie Retaining Wall
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL i,) OF
or�� _ ......ii s�
Ilk
Date ��
Conditional Approval: 49 TH ,N//7.7446fritiAi*�/
*
p •.MICHAEL N. ANDERSON. /
�i vs,
No. CE 9489 G�W /
1�•• . .. ties
p OF'ESS10t��
so Date —�� N��+�
Appro•-• Air
_ t.,-....I
Inspection Report_9-1-2.doc
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1250-GAL S.T.�C
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CO
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(Ni
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COOP�1� 'o O
• O
in
EXISTING FIELDS
W
LLJ
N �
SCALES 1' = 20' (\i
SEPTIC SECTION
A-C=30.0'
B-C=49.6' 0011--coz
A-D=3 5.4' 1.9:7181
co1 Te02
B-D=57.5' _ °T81 °
CONNECTED TO EXISTING SYSTEM
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9T.°s a\)
1,250 GALLON
STEEL TANK
SCALE: NTS
LEGAL: US SURVEY 3200 LOT 12C-1 OF ALS
��� x'11
PID: 090-041-57 PERMIT: OSP191050 i( �'
JASON SMITH & KIMRA WIDMER l* .49IH 1� * /
132 RAND DRIVE INDIAN, ALASKA 99540
N. ND
Michael N. Anderson, P.E. DATE: 3/19/2019 ` MICHAEL NO. CE A9489ERSON:1:1'0j
4601 Natrone Ave. DRAWN: FWCS 11
Anchorage, Alaska 99516 * FEssio0'.
(907)727 8864/FAX: (907)345 1391 SCALE: 1" = 20' �01160‘,7411
MUNICIPALITY OF ANCHORAGE m�"c (
V
JH`CtPn if=y Oe C` �L
"� On-Site Water&Wastewater Program .
PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 V + f
yk f http:llwww.muni.orglonsite
4NCHORPGE
On-Site Wastewater Disposal System Permit
Effective Date: 3114!2019
Permit Number: OSP191050 Expiration Date: 3/13/2020
Work Type: SepticTank Upgrade
Tax Code Number: 09004157000
Site Legal Address: US SURVEY 3200 LT 12C-1 G:4455
Site Mailing Address: 132 RAND DR, Indian 37548
Owner: SMITH JASON M D & Lot Size in Sq Ft:Total Bedrooms: 4
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING
This permit is for the construction of: 0 private Well ❑ Water Storage
❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage
18AAC72Municipal
and Dank ng Water Regulations (18AAC80)e Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Dodel Regulations ( )
3. The wastewater code requires inspections Prov de Inotification bytcallingThe
(907) 343-7904shall
(2417) the Development
Services oDepartment per AMC 15
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: MOA currently has this house appraised as a 4-bedroom. Existing drainfields are sized
for a 3-bedroom house. Prior to future COSA approval,the bedroom count shall be resolved with MOA Property
Appraisal or drainfield(s) upgraded as required.
Date:
Received By: ///di/
�� 9
0001roir
Date: 3
Issued By:
MUNICIPALITY OF ANCHORAGE
(,,
v...1-
Phone: 907-343-7904
Community Development Department '' Fax. 907 343 7997
Development Services Division
Or-Cite 1/llatnr R \Alactpwatnr Prry ram
ON-SITE SEWER/WELL PERMIT APPLICATION
090-041-57
Parcel I.D.
907-529-4660
Property owner(s)
Jason Smith & Kimra Widmer Day phone
132 RAND DRIVE , INDIAN, AK 99540
Mailing address
132 r i- NL.' IJrt , ii\ibimiN, NYS 99540
Site addressUS SURVEY 3200 LOT 12C-1
Legal description (Sub'd., Block & Lot)
Legal description (Township, Range & Section) 3
37,548
Lot Size SQ Ft. Number of Bedrooms
APPLIGA-TION IS FOR:
APPLIGA I ION IS AN: 1 YPE OF DWELLING:
(®all that apply) Single Family (SF) 1111
Absorption Field CiInitial H (w/wo ADU)
Septic Tank Upgrade ic
Duplex (D) C
Holding Tank H Renewal C Multiple Dwellings ❑
Ell
(SF anti/nr 0)
Privy
Private Well 7
Water Storage n
THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
t(Si .. .re • operty owner or authorized agent)
Permit/Rush Fees: 4215. 00 Waiver Fees:
Date of Payment: 83 01 11 Date of Payment:
Receipt Number b453 D _ Receipt Number:
Permit No,
CP Waiver No.
Permit App_9-1-12.doc
Michael N. Anderson, P.E.
Civil/Structural Engineering and Construction
4661 Natrona Ave. Anchorage, Alaska 99516
Phone 345-3377
Fax 345-1391
March 5,2019
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
�nrhnrnC.P .Ainckn 0951Q Kh50
•
Fax 249-7847
Re: New Septic Tank Permit
Legal: US SURVEY 3200 LOT 12C-1
The owner has requested we proceed forward to obtain a septic permit to upgrade the
aged septic tank on the subject lot. The proposed upgrade will serve the existing 3-
bedroom house.
The lot and area is served by private water and this system will not impact any of the
neighboring properties due to the lot layout. Please contact me if you have any questions.
Sincerely,
4/17,11/
Michael N. Anderson,P.E.
DESIGN CRITERIAI
DECOMMISSION EXISTING SEPTIC TANK & INSTALL NEW 1250—GAL SEPTIC TANK 10'+
FROM FOUNDATION & PROPERTY LINE, 5' FROM EXISTING FIELDS, 100' FROM PRIVATE
WELLS 8& MAINTAIN ALL OTHER REQUIRED SETBACKS, INSTALL DOUBLE POST—TANK
I .-: D !Tc' nn.!T? TNC`I " A.Tr T '"V 1r 1 '7' Ti i' ni '" nr rn\ irn
7- c ,x I x _
T&E ESMT \ GRAVEL
X D/W n
WELLs WELL® \ GRAVEL riN
N
X CSC D/W
9� J
WELL®
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pFC�
O N _
r...77, DECOMMISSION EXIST.
O ---NtO S.T. & INSTALL NEW •
1250-GAL S.T. '----#CO CO
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L i i HICKEN�<'L° � --F Os tO
w� COOP rn 00 0
M CV
Cn EXISTING FlELDS
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Zo WLOT 12C-1 �o
PAGE 1 OF 1
Septic Design Prepared for oF, `� \
JASON SMITH & KIMRA WIDMER /'4f At
JASON
US SURVEY 3200 LOT 12C-1 ��� �'
Y101 i
INDIANr, ALASKA 4* 49TH /� * A
_/A1.1
Michael N. Anderson, P.E. CHAEL N. ANDERSGN.
DATE: 6/12/2018 No. CE 9489 '
4601 Natrone Ave. DRAWN: FWCS 1 3� S/A9�"�'
Anchorage, Alaska 99516 ssiot, i
(907)727 8864/FAX: (907)345 1391 SCALE: 1" = 40' \\\`41:1111°'
Municipality of Anchorage Page
· '-DEPARTMENT OF HEALTH AND HUMAN SERVICES
· ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal Systemi and/or Well Inspection Report
PermtNumber~ .~,_~J~4-O IO.-~ PIDNumber: Oc~o~4- I~.
Name; ~1~ ~~ Wastewater System: U New ~Upgrade
Address: (~OO ~~ C~. ~[~ ABSORPTIONFIELD
Phone: ~--~+ ~No. of~drooms: ~DeepTrench ~ Shallow Trench ~Bed DMound DOther
Soil Rating: Total Depth from original grade:
LEGAL DESCRIPTION {, ~ GPD/Sq. Ft. ~.~
Township: I Range:,~~ I ,ection:~ Fill added above original grade: Gravel length, t
TIoM I.~/ ~ Ft. Ft.
~ ~ Number of lines: Dislance between lines;
~ New B Upgra 6rave~. width: ~1 ~ Ft. ~ ¢/~ Ft.
Classification%: Total absorption area: Pipe material:
~~t. CasedTo: Ft. 4~ SQ. Ft. ~SI~ ~
Driller: Date Drilled: StaticWater LeVel: Installer:
~ ·
SEPARATION DISTANCES ~ s~pti~ ~S.T.E.~.
TO 'Seplic Absorption 'Lift Holding ~Pdvate Manulacturer:~ % ~allons:
From Ta~k Field Slalion Tank Sewer Lines
~'~t~7 N/A N A' ~/. ~ LIFT STATION
Foundation ~/~ · ~¢ ~/A Pumpon le~t,~water alarm at
Drain
Remarks: ~o~OM oF ~c~ ~S o~,Oe 'BENCH MARK
Location and Description: '
B"~ ~0~ 5~Ob ~ ~'~ IAssumedElevati°n:
¢' ~' O~tes: 1st
Inspections performed by: ~ ~', 2nd '/'/'~
e,ar men of,ea 2an ?man Servi esa,,rova .....
Reviewed and approved by: Date: ~-/~ -~ ~_ ur~,
s~tir2~
7
AD = ~'5 , .
BC = G~-LB''
Bi) =
~_-
PAGE 1 OF 1
MUNICIPALITY OF ANCHOR_AGE
DEPARTMENT OF HEALTH AND HUM/LN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NI3HBER:SW940103
DESIGN ENGINEER:ALASKAWATER & WASTEWATER SERVICES
OWNER NAME:BOWDEN MARTIN A &
OWNER ADDRESS:12800 WELLSFORD CIRCLE
ANCHOP~AGE, AK 99516
DATE ISSUED: 4/29/94
EXPIRATION DATE: 4/29/95
PARCEL ID:09004132
LEGAL DESCRIPTION: US SURVEY 3200 LT 12C
LOT SIZE: 38350 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PEP, MIT 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 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 BY: ~ ~~-~ ~
DATE
Alaska Water & Wastewater Services
"Preserving The Last Frontier"
April 24, 1994
Municipality of Anchorage
Department of Health and Human Services
Division of Environmentai Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Septic System Upgrade for Lot 12o, NE 1/4, Sec 6
TION, RIW, S.M.; Indian, Alaska
To whom it may concern:
Attached is the application, site plan, and design
for the subject septic system upgrade. Comments
the proposed system are as folIows:
drawings
regarding
1. TRENCH DESIGN: As can be seen from reviewing the
attached percolation test results, the soil "perked" at 1.75
minutes/inch at the location proposed for the system. For a
trench system, this corresponds to an application rate of
1.2 gpd/ftz. Since the existing home has 3 bedrooms, the
total design flow is 450 gpd. Based upon this, the minimum
amount of absorption area is 375 ft2. The proposed trench
is 6 feet deep and 37.5 feet long, providing an absorption
area of 450 ft2.
SURFACE WATER: None observed
3. TOPOGRAPHY: The lot slopes downward at a rate of 10~
from north to south. In addition, it slopes downward at a
rate of 8~ from west to east. In short, there are ilo slope
concerns.
4. UTILIZATION OF EXISTING TRENCH AS STANDBY SYSTEM:
Please note that the existing trench is going to remain in
place for future use. An alternator valve will be installed
so that the homeowner can switch back and forth between the
new and existing systems.
5. CONDITION OF EXISTING SEPTIC TANK: The existing tank
was exposed down below the water line (4/16/94) on both
sides. The ends were not physically exposed~ The tank did
not have any holes, and I was unable to poke any
Telephone: (907) 337-6179 · Fax: (907) 338-3246 · 8471 Brookridge Drive · Anchorage, Alaska 99504
holes through the steel with a screw driver. In short, the
tank visually appears to be "OK", however, it is not
possible to determine how much longer it will be
structurally sound.
6. OWNER INSTALLATION: The homeowner intends to install
the new trench himself. Attached is a copy of hie resume'.
He appears to have considerable construction experience. If
you need further information, please contact him directly.
I am unaware of any negative impacts that this installation
would impose on adjacent wells, or septic systems. If you
have any question, please call me a 557-6179.
Sincerely,
JAG/jag
8owdenS. WPS
P.E.,
......~
7
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
g
10
13-
14;
15-
16-
17-
.18-
19-
20-
'~OMMENTS
Munlclpallty ol Anchorage
DEPARTMENT OF HEALTH &HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
soils LOG -- PERCOLATION TEST
LOT
DATE
Township, Range, Section:
Lc
WAS GROUND WATER
ENCOUNTERED?
Gross Net Depth to Net
Reading Date Time Time ~ Water Drop
PERCOLATION RATE / °'7~'' Iminutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ , FT AND ~ ' ~'' FI
72-008 (Rev. 4/85)
'/--~' 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
MAILINGADDRE~ g ~ ~ ~ ~
LEGAL DESCRIPTION
LOCATION ~ ~ ~ / I I ' ' NO, OF BEDROOMS
~ Ma.ufacturorG~ No. of compartments
Liq.~ in gallons IF HOMEMADE: Inside length Width Liquid depth
, ~ Well Dwelling PERMIT NO.
O Z ~ Manufacturer Material Liquid capacity in gallons
_ ~ Top of tile to finish grade Material beneat ti
Depth PERMIT NO.
( ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ WeiJ Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO,
~ foundation Sewer line Septic tank Absorption area(s)
DISTANCE
TO:
OTHER
SOIL TEST RATING
REMARKS
72-01
f-ll...l~'-,i Z C: IL' PRL ~ T~P C"F R~'-,tCHc~RRcT~E
DEPRRTMENT OF HERLTH RND ENVIRONMENTRL PROTEI]:TION
g
PERMIT NO. ( 7904C44 ',
MRRTIN E, IJWDEN
INDIFIN ¢ RF:IND
)FFLI..HNF
LOCRT I ON
LEGRL.
STREET, ANCHORBGE., FIK. 95,50:t
264-47~E~
F'O B_,-, 4-77(~ 99.5C4D
LI2C NE±?4:,e,'-~ T'iC'IN Rill
LOT ~ I ~'.E ?~=A;
_. ..... Ld SQURRE FEET
-I"r'PE OF _-,uIL M6_,uRE, TIuN .~'r-",TEM Iz,. TREHCH
MFIXIMUH i',!Lli'IEEF.. OF E, EERL.Ji'I_, = 3:
'-] ..:,t~. FY,. E,R. -..
::,LIL RFITING ¢"-- ' ' .....
'['HE F. EI:.IJIRED ,..I~-E OF THE SOIL. HE,_,ORFTIuN _,W_,FErt I:S:
[:'EF" TI-~= 5
THE LENGTH DIMENSION IS THE LENGTH (IN FEET)OF THE TRENCH OR DRRINFIEL.[:'.
THE DEPTH OF 8 TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF 7'HE
GROUND FIND THE BOTTOM OF THE EXCRVRTION (IN FEET]:'.
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL~ DEPTH IS 7'HE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRL. L. PIPE
RND TFIE BOTTOM OF THE EXCRVRTION (IN FEET).
SEPT I E: T t-] ~-~ ~-~.'S;. ][ ZE=--- ...... .'1. F'-, Fl ~-':~ L-~ H L_ L. t., ~-.t ....
PERMIT RP"'F'LIC:FINT NHz THE RE:,FuNz, IBILIT¢ TO INFORM THIS [:,EPRRTMENT DLIRING THE
IN_THL. LHTILN IN.-,FEL. TIuN- OF FIN"r' HELL_, FIDJRCENT TO THIS FRLFERT'r RN[:' THE
NUMBER OF RESIDENCE'~ THFI]7 THE WELL HILL _ERIE.
E, HCKFIL. LINb OF RN"r' --,r..,TEM HITHOUT FINRL INSPECTION RND MFFF. 3/RL E,'~ ]HI..,
[EFHF. TMENT WILL E,E :,UE, JEE, T TO F'ROF;EZ:UTICN.
FIINIMUM DISTRNCE BETI4EEN R WELL AND RN¥ ON-SITE SEHRGE DISPOSRL. S'¢STEM IS
±OE~ FEET FOR R PRI"/RTE HELL; OR
:LSE~ TO 200 FEET FROM FI PUBLIC WELL DEPENDING UPON ]'HE T'¢PE OF PLIBLIC HELL.
HELL LOGS RRE REQUIRE[:' RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 2;C~ DR"r'S
OF THE HELL COMPLETION.
OTHER REQUIREMENTS MFl"r' RPPL'¢. · SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE
RVRILRBLE TO INSURE PROPER INSTRLLBTION.
I
1:
FORTH BY THE MUNICIPRL. IT¥ OF 8NCHORRGE.
2: I WILL INSTRLL THE SYSTEM IN BCCORDRNCE W~TH THE CODES.
]~: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MR¥ REQUIRE ENLRRGEMENT IF THE
RESIDENCE I~ REMODELED TO INCLUDE MORE THRN S~ BEDROOMS.
SI GNED: _._~ .......... ~ .................... RPPLICFINT MFIRTIN BOWDEN
I..,_,UE[; E,~ ......... [HT~ ........ 3. 2'
C:ERT I F'¢ THFIT
I RM FFIMILIFIR 14ITH THE EEb!UtREflENT_, FJF, ON-..ITE _,EHEF._, FIN[:, HELt ...... Er
/
?Performed Fo~
Lena1 ~escrJntJon:
Thts Form Renorts
2204 Cleveland Anchorage, Alaska 99503
Marty Bowden Date Performed
Lot~2c Block
Sotls Lon Yes
6-24-78
Subd1v1sion u.s. Survey 3200
Percolation Test_
PeDth
Feet Sot1 Characteristics
2 '
4-- Brown Sandy Gravel
6
8--
10--
12--
14-- Bottom of test hole
16--
18--
20--
SE M~P
' I
Was Oround Water Encountered? No
If Yes, At what Depth?
~ i I I ~- I ! ! I
I I I. L,,,,r . · -I
L_L. a~ ~
I I Fl': ~ ,I
Readtn; Date Grnss Time Net Time Depth to H20 Net oron
Percolation Rate fltnute
Prn.osed XnstallatJon: 'Seenaae Pit Dratn Field :'
Oeoth of Znlet ,.Depth 'To 8ottom Of Pit Or Trench
CfIMff£NTS: 100 sq. Ft. d~aSna_ge area required ~er bedroom.
·
Test Performed By ~ /~;~- Data Certified By~~ n.~.' -
t PCftP/i
MUNICIPALITY OF ANCHORAGE
Development Services Department �
On-Site Water& Wastewater Section - Phone: 907 343-7904
Fax: 907-343-7997
Certificate of On-Site Systems Approval
Parcel I.D. 090-041-57
Expiration Date: _67-2--C7-1?
1. GENERAL INFORMATION
Complete legal description US SURVEY 3200 LOT 12C-1
Location (site address) 132 RAND DRIVE INDIAN AK 99540
Current property owner(s) JASON SMITH&KIMRA WIDMER
Day phone
Mailing address 132 RAND DRIVE INDIAN AK 99540
Real estate agent
— —— -- Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY:
Private Well Private Septic
Water Storage ❑ Holding Tank ❑
Community Well ❑ Community 11]
Public Water System ElPublic Sewer ❑
Waiver request for:
Distance:
Received by:
Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $- ��
Waiver Fee $
Date of Payment ��g
Date of Payment
Receipt Number
p � Receipt Number
COSH# gIp 7a
Waiver#
•
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the 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 ANDERSON CONSTRUCTION&ENGINEERING
Address 4640 SHOSHONI DRIVE ANCHORAGE AK 99516 Phone 345-3377
Engineer's Printed Name MICHAEL N.ANDERSON PE
Date 3/19/2019
NIL
OF 447‘
A . I
/44
6. DSD SIGNATURE j*49 Ti
System #1 Approved for 3 bedrooms / qac IExso�
System #2 Approved for bedrooms `+ N�' 9'e9
'
Disapproved
D63sI014t"'
Conditional approval for bedrooms, with the following stipulations:
,ZY
RAND
WASTEWA
P, • _ _ . ,,
• 'ILVT
ERv\C
Original Certificate Date: 3-2—C, /Or
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval(COSA)based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X
Septic System Advisory Nitrate Advisory
Arsenic Advisory
Well Flow Advisory
Other
cosA Checklist blue sheet
COSA Checklist
Legal Description: US SURVEY 3200 LOT 12C-1
Parcel ID: 090-041-57
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 2.8 gpm
Date drilled 7/22/1980
Water storage tank volume NA gallons
Total depth 236 ft
Well disinfected for coliform test? Yes
Cased to 74 ft
Sanitary seal is functioning correctly Coliform bacteria is Negative
Wires areNitrate 0�mg/L
properly protected
Arsenic ND ug/L Arsenic less than MRL (ND)
Casing height(above ground) 24+ in.
Date of flow test for COSA 2/12/19 Collected by FWCS
Static water level at beginning of test 188 ft Date of Sample 2/12/2019
Comments
B. TANK DATA—3/18/2019 - 1250-gal
Age of tank(s) NEW years C. LIFT STATION -NA
Tank type/material SEPTIC /STEEL Required maintenance completed
Age of lift station years
Measured operating fluid level in septic tank
Lift
Standpipes/foundation cleanout per record drawing station
Date of pumping NEW Comments:
Date material
D. ABSORPTION FIELD DATA—39'L x 3'W x 5.95'ED—1.2 GPD/SF=464 SF
Which system tested (date installed)5/8/1994
ALL standpipes present per record drawing Adequacy test date 2/12 ZO�g
Results
Total measured depth from grade 9.5 ft(max) Pas For 3 bedrooms
Fluid depth prior to test *41 in
Measured depth to pipe invert from grade 5 ft(min)
N/A—pressurized field Water added 460 gal
Monitor tubes go to bottom of effective. If not, state New depth *47 in
depth into effective 5_5 Elapsed time 1400 min
Final fluid depth *40 in
Code-required soil cover over field
System presoaked Absorption rate 450+ gpd
(Required if vacant for greater than 30 days prior to
date of test) Any rejuvenation treatment
Gallons introduced (past 12 months) N
If yes, enter g
Comments/Deficiencies: *Incluudinons tthe missin. 5"+/- ED. S stem o•eran.de intthe •.
u er half of the 5.95' ED.
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'
if No ft Community Sewer Manhole/Cleanout> 100'
Yes if No ft
Neighboring Tank > 100'
,Yes if No ft Private Sewer/Septic Line >25'
Absorption Field on Lot> 100' Yes if No ft
Yes if No ft Holding Tank > 100'
Neighboring Absorption Fields > 100' — Yes if No ft
Animal Containment> 50'
Yes if No ft Yes if No ft
Community Sewer Main > 75' Manure/Animal Excreta Storage > 100'
Yes if No ft
Yes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' Y . if No ft
Surface Water> 100'
Property Line> 5' Yes if No ft
YDS, if No ft Wells on Adjacent Lots:
Absorption Field > 5'
if No ft Private Wells > 100'
Water Main > 10' Yes if No ft
Yds— if No ft Community Wells> 200'
Water Service Line> 10' Yes if No ft
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' )_/gs— if No ft
If absorption field is under driveway comment below
Property Line > 10'
.fie- if No ft Wells on Adjacent Lots:
Water Main > 10' Ye if No
' ft Private Wells > 100' Yes if No ft
Water Service Line > 10'
Yom_ if No ft Community Wells> 200'
Surface Water> 100' Yes if No ft
yes if No ft
F. ENGINEER'S COMMENTS
Of *+
4, 44• *
G. ENGINEER'S CERTIFICATION 0/77
i4
I certify that I have determined through field inspections and review 1 X. rxeCItsetit-
tNs. CF
of Municipal records that the above systems are in conformance 3/19/20].9• }
with MOA COSA guidelines in effect on this date.
Zo
cv
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(N7g 51'pp"ww /25'00,4 6R 3.__.._______
ANCHORAGE RECORDING DISTRICT,ALASKA `
AS-BUILT OF:
REPLAT OF LOT 12 US SURVEY No.3200 O =FND REBAR
LOT 12C PLAT 72-184&96-125
SURVEY CERTIFICATE:I,John L.Schuller.Have conducted a i of A\�>( SCHULLER LAND SURVEYING, LLC
physical survey of this property as shown on this drawing and that the
As. `� . .. 9 1
improvements situated hereon arc within the property lines and no 4`•• s 11'
enchroachments exist other than noted.Under no circumstance should /�Gj�'49TH )•�
any information on this drawing be used for construction of fences. �+ �' ` t ,
structures.improvements,or for establishing boundary lines. S.
EXCLUSION NOTES:It is the owners responsibility to determine L`
the existence of any easements,covenants,or restrictions which ,/,ep, • HN L. SCHULLER.• o/` t,
do not appear on the recorded subdivision plat. t m LS-10408 0 •
MIRK OROEIt tInN9ER; MA acus �,K; 1 @ ••2 y��� 1831 Talkeetna Street
AIAR 20, 2019 II 1' 40' ` dp J.•j :/. a Anchorage, Alaska 99508
19-011-2 wer.Io¢axasrJaaxweot ` fesslonot ��� g
LS 11111 SW4455 190125 \\\ (907) 227-1455 office
\��aa.� (907) 274-4992 fax
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 090-041-.,-'<
1. GENERAL INFORMATION
COSA # 05(', ! \ IqO0
Expiration Date: '~--/:~__.~ J/~
/ ·
Complete legal description U.S. SURVEY 3200, LOT 12C
Location (site address) 132 RAND DRIVE, INDIAN, AK
Current Property owner(s) FEDERAL HOME LOAN MORTG. Day phone
Mailing address 400 NATIONAL WAY, SIMI VALLEY, CA 93065
Lending agenCY ,. .......... .... Day phone
Mailing address
Real Estate Agent BARB"HUNTLEY & ASSOC.
Mailing Address
Day phone 227--,~228
Un/ess otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEO~0'O~:~ .. 3
TYPE OF
individuai. Well'', , ;; ?,. ~:~:;. []
Individual Water Storage"-,', []
Community: Class __ ~ell: []
Public Water S~istem []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a pedod 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 vedfy that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 10/13/11
Engineer's Comments: This investigation was completed in compliance with.ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to sul~urface conditions that may not 'be observed from .the surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the' year and ~the
water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
DSD SIGNATURE
P'/" Approved for ~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
(Rev. 11/05)
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety DiVision
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(9.07) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: U.S. SURVEY 3200, LOT 12C-, !
A. WELL DATA
ParcellD: 090-041-~ ~' 7
Well type P ~RIVATE Ifa, B, or C provide PVVSID # __
Date completed ?/22/1980 San~ry seal (Y/N) Y_
Total depth 236 ft. Cased to 74 (steer) ff.
FROM WELL LOG
7/22/1980
Date of test
Static water level
Well Log (Y/N) _.Y
Wires properly protected* (Y/N) Y
Casing height (above ground). 24+
AT INSPECTION
10/5[2011
164 ft.
in.
Well production 5.0 g.p.m, 3.44 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEC colonies/100mL Nitrate ND mg/L
Arsenic: ND mg/I Date of sample: 10/5/2011 Collected by: A~¢Ten'a'
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 8/6/'1979 Tank size 1000 gal.
Number of Compartments O.K. Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
High water alarm (Y/N) N Date of pumping 10/3/11 Pumper A+
C. ABSORPTION FIELD DATA
Date installed, 5/8/1994 Soil,rating (g.p.d./ft2 or f[2/bdrm) 1,2
Length 39 ft., Width --3 ff. Gravel below pipe $.95 ff.
Eft. absorption area ,4~64;.ft2
Monitoring tube Y
System type TRENCH
Total depth 9._~5 ft. (Measured 10/5/11)
Date of adequacy test 10/5/2011
Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 30 in. Water added 450 gal. New depth 32.4 in.
Elapsed Time: 30 min. Final fluid depth 30 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) Nil yes, give date ---
Depression over field N
LIFT STATION
Date installed
"Pump on" level at __
Datum
in.
E. SEPARATION DISTANCES
Size in gallons
"Pump off" level at ~
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot lo0'+
Absorption field on lot 100'+
Public sewer main 75'+
Sewer/septic service line 25'+
Animal containment areas 50'+
JR.
Water main 10'+
Wells on adjacent lots 100'+
Manhole/Access (Y/N) ,~
High water alarm level at in.
Meets alarm & circuit requirements?
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout 100'+
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation $'+ Property line 5'+ Absorption field 5'+
Water service line 10'+ Surface water 100'+
10o'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 3,0'+ Building foundation 10'+
Water Service line 10'+ Surface water ;tOff+
Curtain drain 50'+ (Noz~e K~town)
COMMENTS
Water main 10'+
Driveway, parking/vehicle storage 10'+
Wells on adjacent lots 100'+
G. ENGINEER'S CERTIFICATION
' ed through fie/d inspections and
review of Municipal records that the above svstems are in " ~"~:,' ~' '.~
-- :~..~.... ~ :, · .. .... .~..~,.
conformance with MOA COSA guidelines in effect on this clete.
Engineer's Printed Name KF. NN~T~ ~Vl. DIJ'I~I~LT$
COSA Fee $490.00 Waiver Fee $
Date of Payment /~ I(~ II/ C~ Date of Payment
Receipt Number (~)~) ~" I(~ '[~ Receipt Number
i.ev. ~/o5)
10' x 10'
TeiscommunTcaUon &
Bectrlc £m~ments
Well
RAND AVENUE
LOT 12A-1
2 STORY
WOO0 FRAME
HOUSE
LOT 12B-1
N
LOT 15
LOT 12D-1
Sepflo
Drain
Fisld
Scale 1"=40'
LOT 12 C-1
I PGEND
· Found 5/8~ Rebor wt~ ~a~t~ Cop
AS BUILT No Corners Set This Date
1. Easements of record, other than thosev~hown on recorded
Plot nO. 96-125, ore not shown hereon.
2. This document is for the exclusive use of the client. This
document is not ~ntended or represented to be sul~able for
reuse by othem. Any reuse by others without the express
consent of domes S. Robor, PLS 6095, will be et their Sole
risk and without liability or legal exposure to sold Surveyor.
3. This document is not Wild without the original signature of
the Registered Profes~Ion~ Land Surveyor.
I hereby certify that I have performed a
Mortgage Location Survey of L~t 12C-1,
U.S. Survey No. ;5200, According to the
official plot thereof, filed under plot number
96-t25, Records of the Anchorage
Recording DiStrict. Third dudk:lol District,
state of Alaska, and that the improvements
shown hereon represent the conditions that
were found on Octobe~ 28, 2011 when the
~urvey was performed. 1his document does
not constitute ~ boundary survey and la
· ubJect to any lnaccuroc~ss that o
subsequent boundary survey may disclose,
Tho InformoUon contained on this drawing
shall not be used to establish any fence,
structure or Other Improvement~
Data:. November 18. 2011
12904 Chops! Drive
Anchorage. Alaska 99516
' ' ' ''' ' MUNICIPALn'YOFANcHoRAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Sen, ices
. On-Site Services Boron
· · P.O. Box 196650 Anchorage, AJaska 99519-6650
· ,: .... (907) 343-4744
· ' ' :'' ' CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILLY DWELLING
Parcel I.D. #
1. GE,NERAL INFORMATION
Complete l~galdesc[ipti0n, u.s. SURVEY'32~O: 'LOT
Location (site address or directions) s~'W~RD HWY. TO INDIAN. Ak. 'TAK'E [Fi='I' AT INDTAN
ROAD. RICHT AT RAND ROAD, SECOND HOUSE ON .RIGHT.
. P. rop. erty owqer CENDA~qT MOBILIS' Day phone' CONTACT ACENT
· ~ Mail!ngaddress 'c./° C~,~R RA~SE'~ w/ DYNAMIC PROPERTIFS ' '- * '" '
· Le.nd!ng agency ~ * , · Day phone
Mailing address
· Agent CI~AIR RAMsEY w/ DYNAMIC PROPERTIES Day phone (907) 261-75,~;~
Address 3111 C STRFET ANCHORAGE. AK 99503
Un/ess otherwise requested, HAA wi//be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well xxx
Community well
Publicwater
NOTE: ff community well system, provide wrftten confirmation from State ADEC attest-.
lng to the legality and status of system. '
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site xxx
Holding Tank
Community on-site
Public sewer
NOTE: ff community wastewater system, provide written confirmation from State ADEC
lng to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21 Computer Version
Note: ,Naska Water and Wastewater Consultants,/nc,. s. ha/I be paid $1,150.00
or prior to, closing for the engineering serWces proWdec].
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 further verify that based on the Information obtained from the Municipality of
Anchorage flies and from my Investigation and
disposal system Is in cemplianca with all Mu~
on the date of this Ins. pection._.
NameofF, rm- ALASKJ~WA~EF~ /~T~W
Address 69.0.1 OEBARh ROA~D,I~
Engineer's $,gnature ~k
system In accordance with ADSC and ~OA DH 'S Guidelines & Regulations. The repert~ results described the
perfomlance of the system underthe cenditiee~ =.ncountered at the Eme of the test. and s¢pamtion distanees
measured to readily Identifiable features. The e ~emtional life of all wells and septic systems depend
on the local soils condition, ground water levels that may fluctuate dudng the year, and the water
usage of the family being sen/ed by the system. These ceeditions are outs/de the control of
.the e~aluator of the system. Satisfacto/y test results do not guarantee future performance
of the system, nor do they guarantee that there are no hidden defects or encroachments.
AWWC, Inc. can therefore not provfde any warramy for future estimate of how long the
system Mil cenb'nue to meet the operational requirements of the ADEC or MOA DHHS.
The content of this report is for the sole benefit of the owner listed above. Any
reliance upon or usa of this report by any other person or parly ls not authorized,
nor v~ll it confer any legal right whatsoever.
6. DHHS SIGNATURE
I,~ Approved for ,~
Disapproved
Conditional approval for
bedrooms
~ection, the on-site water supply and/or wastewatar
~1 and State cedes, ordinances, and regulations In effect
I'ER CONSULTANTS, INC. Phone ~g07) 337-6179
CRAGE. ALASKA 99504
Date /r-~ -/'~=" (:D~--~
~'de a thorough, conscientious engineering ana~y'~is of the
bedrooms, with the following stipulations:
Additional Comments.
The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Health Authority
Approval Certificates based only upon the representations given In paragraph 5 above by an Independent
professional engineer registered In the State of Alaska. The DHHS does this as a courtesy to purohasera of
homes and their lending Institutions tn 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 professicnal engineer's work,
72-025 (Rev. 1/91) Back MOA/121 Computer Version
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental ~endces Division
825 "!." $1met, Rm 602 Anchorage, Alaska 89501 (907) 343-4744
Legal Oesndptton:
A. WELL DATA
Well Type PRIVATI~
Log present (Y/N)
Health Authority Approval Checklist
U.S. SURVEY ,.3200; LOT 12C Parcel I.D.:
If A, B, or C, ~tach ADEC letter. ADEC water system number
YES Date completed 7/22/1980
STF_.EL TO 74 FEET
Total depth 236' Cased to
FROM WELL LOG
Date of test 7/22/1980
PV~ TO 236 FEET Casing height (above ground)
VV1res properly p:ut~ (Y/N)
AT INSPECTION
12/4./2000
Slaflc water Imml 165' 1 §5'
Well production .5.0 g.p.m. 2.95
WATER SAMPLE I~ULT~:
., te 0.6
090-041-52
Date of ~ample: 12/6/2000
SEPTIC/HOLDING TANK DATA
Date installed 8/6/1979 Tank size
1000
Other bacteria
Foundation cleanout (Y/N)
Date of Pumping 12/4./2000
C. ABSORPTION FIELD DATA
Date installed 5/7- 8/1994
A.W.W.C.r INC.
Number ofCompadments U.K. Cleanouts(Y/N)
YES Dapresslon (Y/N) NO
Pumper A+ PUMPING
High water alam~ (Y/N)
Suil rating (~or fl2/txlrm) 1.2
Length 39'
Effective ~mo~pflon area
Date of adequacy te~t
Ruld depth in abso~ptlon field before test On.);
Fluid depth 22.5" (Ins) Minutes inter:.
Peroxide tmalmem (past 12 months) (Y/N)
24"+
YES
g.p.m.
*MEASURED IN MT.
System type TRENCH
~.95 Total depth .8.7'
~ 3'+/- Gravel thickness below pipe
464 SQ.FT. MonltodngTubepmsent(Y/N) Y[.S Depmssinnoverfleld(Y/N) NO
12/4/2000 Results (Pass/Fall) PASSED For 3 Bedrooms
'}" Immndlatoly after 878 gal. water added (in.): 26.5"
30 Absorption mte = 450+
NONE KNOWN If yes, gtve date -
D. UFT STATION
Date installed Size In gallons ~
Manhole/Access (Y/N) ~ "Pump oft" level at*
,--'-~"-- *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO.'
Septlc/~dlng tank on lot 100'+
Abeo~llon field on lot 100'+
Publlo sewer main N/'A
Sewedsepfio ~ervice line 25'+
On adjacent lots 100'+
On adjacent lots 100'+
Publle sewer manhole/cleanout N/A
Lilt stel~n 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+ Property line 5'+ ~rptlon field
Water main/service llne. 10'+ .Surface wateddmlnsge 100'+ .Wells on adjacent lots
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Properly I~e 10'+ Building foundation 10'+
Surface water 100'+ Driveway, paddng/vehlde etorage area
100'+
· Water main/service line. 10'+
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $.
Date of Payment
Receipt Number
MUNICIPALI~ OF AIqCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES.
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
q \/._
Location (site address or directions)
T~.E- LF~P ~ -~NOI/J~J P-o~O
Property owner
Mailing address
Lending agency
Mailing address.
Agent 'g I ~-~----'~ ,~-
Day phone ~'~'-
~c~. A,Y_.
Day phone /,/,/~
~' ~ A,~ ~ ·
Address ~O~DO C~ ~"i"r'dF'.--c-~T )
Day phone ~ Z- ~.~,~4-
Al(-_
Unless otherwise requested, HAA will be held for pickup,
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system. ,,
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(Rev. 1/91) Front MOA#21
5. STATEMENT OF INSPECTION BY EI~IGINE'ER
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 fur[her 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.
Alaska Water & , / ,o --~
NameofFirm W~stew~.teL les ,m ,'Cd' Phone ?o /- ~, / /
84;'..,~roo~ ~/Jr. / //! ,
.,~noh.,/~ 34 / ~ /
Address /'//
EnoineeCs sionature (/ ~-/~ C/Z/ q Date
DHHS SIGNATURF
~' Approved for
bedrooms,
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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 D H HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72~)25 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage /~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Uo"r ~2. ~.3
Legal Description: T ~ o M ~
A. Well Data
Well type
Log present (Y/N) "'( ~ ~
Total depth ~-~'~ ~, !
Sanitary seal (WN) ',1~-.~
/
~'r2--I V,~---- If A, B, or c, attach ADEC letter. ADEC water system number hi
Date completed 7/Z Z-/¢~ Driller
Cased to p,~ r_ mo ,~ ~z, Casing height
Wires properly protected (Y/N) '"/~---'
,MUNICIPALITY OI= ANCHOI~AGP.
ENVIRONMI~NTA~ SERVICES DIVISION
AT INSPECTION
/~'3.5-'
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG
~" g.p.m. Zr- I
U ~u ~.,,~ot.~ rJ O ~J V-4o ~ ,"J ·
; On adjacent lots
; On adjacent lots
SEPARATION DISTANCES FROM WELL TO:
/
Septic/holding tank on lot ) ) ~
· Absorption field:on lot ~ I dc/
Public sewer main
Sewer service line
~iAY 1 2 1994
Public sewer manhole/cleanout
Petroleum tank ~ O ' ±
WATER SAMPLE RESULTS:
Coliform ~)
Date of sample: ~-/~ /
Nitrate o. 5'~ ~, 3/.~
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed ' ¢/~0/"7'~ Tank size
Cleanouts (Y/N) '"/~ ~ ' Foundation cleanout (Y/N) . ~ ~ --% Depression (Y/N) j,J O
High water alarm (Y/N) -N//~- Alarm tested (Y/N)
Date of pumping ~2//_~/~)~/-. Pumper J_%A ,A- C-.._~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot · /10 *-'-
To property line ~ 0 / &
Sudace water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
~-026(3/93)TM CONTINUED ONBACKPAGE
Manufacturer
Size in gallons ~"'""'~, Manho,e/Access (Y/N)
~ Vent(Y/N) ."ID~~ ~at
~~es ~$t~
High water alarm level
Meets MOA electrical ~des (Y/N) ~ ~
~'.~
~ On adjacent lots Sudace water
D. ABSORPTION FIELD DATA
Date installed .~//~'q'-~/~/~'Soilrating(GPD/Ft2) \..'Z. .System type
Length --q ff ' Width ~ / +- Gravel thickness ~'- ~ 5'-' Total depth / O. / -
Total absorption area zl'(o~ F~' Cleanout present (Y/N) ~/~ ~ Depression over field (Y/N)
~'~Date of adequacy test /.//,A Results(pass/fail) /v'/~ for _~ Bedrooms
~ Water level in absorption field before test /"///~'/.4 After test /'/?"~-
{Peroxide treatment (past 12 months) (Y/N) /'-//. ,
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot I [~' / z
To building foundation
On adjacent lots -~ ~
__On adjacent lots
Cutbank
If yes, give date ~,',//~
Surface water /'J//~'
Curtain drain /~,//4~
ilo~ ocO ~'¢zE-..JC..,H Propertyline
To existing or abandon~ system on lot
Water mai~seMce line
Driveway, pa~in~vehiole storage area ~%0 ~
E. ENGINEER'S CERTIFICATION
I ce~'fy that I have checked, verified, or confo~ed to all MOA and HAA guidelines in effect o~. _~. l~t~ this inspection.
Date ~'/"/~ * '"~~~:~
I'IAA Fee $ .~z~-~
Date of Payment
Number
Receipt
Waiver Fee $
Date of Payment
Receipt Number