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H & H LT 2
H&H Lot 2 #050-731-57 C A.di4m at &( Rus N MUNICIPALITY OF ANCHORAGE Development Services Department �, Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-731-57 1. GENERAL INFORMATION Expiration Date: _2— / — Z ©Z.3 Complete legal description H & H LOT 2 Location (site address) 25724 IMPERIAL DR, EAGLE RIVER AK Current property owner(s) Mailing address Real estate agent LISA MURCHISON SAME 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Private Septic F] Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ �3 `7 Waiver Fee $ Date of Payment / o / a y/ a'?' Date of Payment Receipt Number _ 0 d L(733 Receipt Number, COSA # Q 5 C a a 15-/ 9 - 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 MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 10-22-22 6. DSD SIGNATURE - • • .. < , • + r ........ System #1 Approved for bedrooms ; ' • - - ..... , , , „ ,} i 'A4ICHAEL N. i�DLRSG\ , System #2 Approved for bedrooms = c - 9 9 i Disapproved Conditional approval for M, bedrooms, with the following stipulatiotis���ti.� J .a 13 ��-- Original Certificate Date: — Z 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 engineers work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet Legal Description: H & H LOT 2 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 5/30/03 Total depth 191 ft Cased to 191 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 30 in. Date of flow test for COSA 9/28122 Static water level at beginning of test 40 ft. Comments B. TANK DATA Age of tank(s) 5124113 years Tank type/mat erial Measured operating fluid level in septic tank 48 ❑ Standpipes/foundation cleanout per record drawing Date of pumping 9/28/22 D. ABSORPTION FIELD DATA conditional cosa Which system tested (date installed) ❑ ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A —pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced 0 gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 050-731-57 Structure served by this system Well production at time of test 5+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ N ❑ Coliform bacteria is Negative Nitrate 2.34 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 9128!22 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date Results E3Pass For bedrooms Fluid depth prior to test 0 in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Yes if No Community Sewer Manhole/Cleanout > 100' 0✓ Yes if No ft E] Yes if No ft Neighboring Tank > 100' ✓V Yes if No ft Private Sewer/Septic Line > 25'M Yes if No ft Absorption Field on Lot > 100' ✓] Yes if No ft Holding Tank > 100' ❑f Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment? 50' Q✓ Yes if No ft P1 Yes if No ft if No ft Manure/Animal Excreta Storage > 100' —Z✓ Community Sewer Main > 75' 0 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' Q Yes if No ft Surface Water > 100' Yes if No ft Property Line > 5'✓Q Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' Yes if No ft Private Wells > 100' Q Yes if No ft Water Main > 10' Yes if No ft Community Wells > 200' Yes if No ft Water Service Line > 10' 0 Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' Yes if No ft If absorption field is under driveway comment below Property Line > 10' Q Yes if No ft Wells on Adjacent Lots: Water Main > 10' Yes if No ft Private Wells > 100' Q Yes if No ft Water Service Line > 10' 0 Yes if No ft Community Wells > 200' Yes if No ft Surface Water > 100' Q Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION / certify that ! have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet Oct. 31, 2022 Municipalities of Anchorage On -Site Water and Waste Water Section 4700 Elmore Rd Anchorage, Alaska Phone 343-7904 Re: New septic field permit w/ conditional COSA Legal: H &HLT 2 To whom it may concern: This is a request for a conditional COSA on the above referenced lot. The granting of this conditional will not impact any of the neighbors or this single-family home. The existing septic system and well are working well with no issues for public safety concerns. The only reason for the Conditional COSA is to close the loan application and winter weather conditions. Money will be escrowed (see the letter) per the MOA requirements. Two bids have been provided for the reserve amount. No money will be paid -out till the MOA signs -off on the final COSA. Please call me if you have any issues concerning this request. Sincerely /, Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 it eP' zl? O X33 N� dla u oz w Hum Fm u > F- F -z o z - z z , zw "W Lj nzzw < z a > - = o wo tj Jx�- Wu� > w�wz <woo<. W "Q OI Q> wn MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP221442 Work Type: Septic Upgrade Tax Code Number: 05073157000 Site Legal Address: H & H LT 2 G:0363 Site Mailing Address: 25724 IMPERIAL DR, Eagle River Owner: MURCHISON LISA R Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: Effective Date: Expiration Date Lot Size in Sq Ft Total Bedrooms: t�`n"r o o S�. v Department 11/1/2022 11/1/2023 55192 ❑ 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 i fir: _ ��5ur�l fiv /%i k e- /t% A0&"G"::4 Issued By: Date: Date: 0/0 2 c � Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 050-731-57 Property owner(s) LISA MURCHISON Mailing address 25724 IMPERIAL DR, EAGLE RIVER AK Site address SAME Day phone Legal description (Sub'd., Block & Lot) H & H LOT 2 Legal description (Township, Range & Section) Lot Size 55192 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® att that apply) Absorption Field 0 Initial ❑ Single Family (SF) (w/wo ADU) Septic Tank ElUpgrade Q Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: q5g . UU Waiver Fees: Date of Payment: to 41 ,2 'Z Date of Payment: Receipt Number: it oZ Receipt Number: _Permit No. 0 S a �ZI LIV Waiver No. GADevelopment Services\Bui[ding Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc Oct. 22, 2022 Municipalities of Anchorage On-Site Water and Waste Water Section 4700 Elmore Rd Anchorage, Alaska Phone 343-7904 Re: New leach field permit Legal: H & H LT 2 To whom it may concern: This is a request for a septic permit on the above referenced lot. The existing trench has failed the adequacy test and needs replacement. We are proposing to replace the field in the same location. The septic tank is plastic and therefore good for the new COSA, but due to the slope (over 4:1) west of the field, we have decided to install the new trench in the same location. New cleanouts and monitoring tubes will be installed and 10 feet will be maintained from the north property line. No cut banks exist within 50 feet of the proposed site. This new system will not impact any of the surrounding neighbors, see the attached site plan. Sincerely Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221442, Deb Wockenfuss, 11/01/22 SEPTIC FIELD SECTION DESIGN CRITERIA: REBUILT EXISTING TRENCH 7.0' EFFECTIVE 3 BDRM X 150 = 450 GPD SOILS = 450/0.8 = 563 SQ FT REQ'D 563/2(7) = 41', 2.0' WIDE 41' LONG (1) TRENCH 11.4' DEEP 1.0'2.0' -11.4' -4.4 MOUND OVER FILTER FABRIC SEWER ROCK 3,3( GRADE 1"=200' PROPERTY LINE EXISTING DRAINAGE FIELD7.0'EXISTING WELL 100' RADIUS SCALE: DJRDRAWN: DATE: H & H, LOT 2 Eagle River, Alaska LISA MURCHISON 10/22/2022 -EAG LE R IVER ROAD - -WHITE SPRUCE DRIVE- -I M P E R I A L D R I V E - EXISTING HOUSE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221442, Deb Wockenfuss, 11/01/22 1"=50' EXISTING HOUSE REBUILD EXISTING ABSORPTION FIELD WITH CO AND MT TYP. EXISTING WELL 100' RADIUS WELL PROPERTY LINE H&H, LOT 1 SCALE: DJRDRAWN: DATE: H & H, LOT 2 Eagle River, Alaska LISA MURCHISON 10/22/2022 EXISTING PLASTIC SEPTIC TANK TO REMAIN EXISTING SHED EXISTING RETAINING WALL DRI V E W A Y H&H, LOT 2 H&H, LOT 4 H&H, LOT 3 -EAG LE R IVER ROAD - -I M P E R I A L D R I V E - CO CO MT DCO SLOPES GREATERTHAN 3:1,WAIVE R REQUESTED Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221442, Deb Wockenfuss, 11/01/22 1"=20' DRAIN PIPE 4.4' BELOW GRADE, TO MATCH EXISTING EXISTING STEEP SLOPE, 100%, HEAVILY FORESTED SHOULDER OF STEEP SLOPE TYP. EXISTING TRENCH INSTALLED IN THE SAME LOCATION WITH A STEEP SLOPE PROVISIONS PER THE 15.65.210.B.1.V. EXCEPTION 35.0' EXISTING GRADE 2.5'SCALE: DJRDRAWN: DATE: H & H, LOT 2 Eagle River, Alaska LISA MURCHISON 10/22/2022 32.0'4.4'35' SLOPE INTERSECTION WITH NO DAYLIGHTING OVER THE PAST 20 YRS 46% SLOPE LINE 2.5" ABOVE PIPE INVERT Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221442, Deb Wockenfuss, 11/01/22 CO: 49 TH S ✓�. fid SHANE A. HOLT G Q LS -6914 y�o0 s sions� WOOD REI WALL AS -BUIL T SURVEY I" = 40' \\ NO CORNERS SET DY15 DATE \ I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY OF THE FOLLOWING DESCRIBED PROPERTY LOT 2 H & H SUB. ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN NOTED. DATED AT ANCHORAGE,ALASKA THIS _18 TH DAY OF _OCTOBER , 2022 HOLTLANDSURVEYING 9309GROVERDRIVE GE,AK 99507 15660 227 64 223.86113 3750GCI NET S/NGLEFgM/L y y0(� E 9spy9�r \\ •WELL 56 LOT 3 SEE NOTENO. 4 (PLAT2000 30) LOT 4 L=30.0 R=5001 <D 15' TELE & ELEC ESM7 /NOTE' REFER TO DOCUMENT RECORDED ATSN2003-0451=EGARDLNG INGRESS/EGRESSAFFECTING LOTS 1,2,3 THEEASEMENT DOES NOTHAVEANYMEASUREMENTS RE ATED TO THEPROPER7YLINES AND THEREFORE THE EASEMENT IS NOT SHOWN HEREON THE INFORMATION HEREON IS FOR THE USE OF ENDING INSTITUTIONS SPECIFIGAIT Y TO SHOWANY CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS, AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS OR FENCELINES. EASEMENTS OF RECORD, OTHER THAN THOSEAPPEARING ON THE RECORD PLAT, ARE NOT SHOWN HEREON (UNLESS INDICATED) NOTEFENCELINES THAT MA YAPPEAR ON THIS DRAWING ARENOT TO BE USED TO DETERMNE PROPERTYLINES OR POSITIONADDITIONAL IMPROVEMENTS ANYPA IIING SHOWN HEREON MA YBEAPPROXIMA TEDUE TO EXCESSNESNOWAND/OR ICE Municipality of Anchorage J;vDevelopment Services Department : Building Safety Division Onsite Water and Wastewater Program, 4700 S. Bragaw St. P.O. Box 196650 Anchorage, AK 9951M650 Page I of www.ci.enchorage.ok.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: 60 030 13 K PID Number. 050-731--57 Name. n CQ r l Wastewater System: K9 New ❑ Upgrade -s o a I),-, --it9 215-06 ABSORPTION FIELD Phone3� 7 Number of Bedroanr _ y g Deep Trench d Snetbw Trench I] Bed 13 Mound 0 0tner. LEGAL DESCRIPTION Sal Rating � Q D. Total Depot from original grade: O p ,p= t, Block: Lot: Subdivision: H ' I Depth to pipe batom ham odginat pad Gravel depth beneath pipe: -7Ff 4 IFIi FI. Township Range, section: Fill added above original grade: 4F �s � Gravel Length: Fl. FI. Well: ®New E] Upgrade Cravalvddth: Number of fines I Oislencs between linea: Fl. FL CtgTsiGutbn (Pdvau, 0. e, C): Total Depth:Q Cased to, s� Total absorption wall' ''/-) PI * matanet: `i�7(� Q W P I 1 FI. 101 O.. J Fl. FI= J ..J0 J! U'O Driller. w) — W ba f r."AO G Dale Drilled S— 30 0 3 Static: water Levet /�a 0, )1 FL InstaMn:� � ( ee ! t"Ci i vi Date Installed: 5--a — t�3 Yield Pump Set at: /K Casing Height Above Ground. TANK GPM V Ft. i- S f FL SEPARATION DISTANCES N Septic ❑ Holding O S.T.E.P. O Other. To Septic Absorption Lift Holding PubndPdvat Manufacturer, . n r capaoly I �Q From Tank Field Station Tank Sewer Una / P/yi / e/ %'/ S Gat. Well as ` 1 1 L1 �� ��— �5 I.� twat /L j�� J't�' Num er of Comps l rents' 1 F 0000 Surface water 160\+W IF LIFT STATION Lot Line 66' , � ,3 , Size. Manufacturer Gal Foundation ( 5S% 'Pump an' Nvel at. levet al Hgh water alxm al: J�S In In Pump Make d el Electrical Inspections performed b)r Curtain Drain Ovie �`jCN n Remarks BENCH MARK Location and Deswpbon: r3� rr� lh 0 A s l a f N G e !r %I Assumed Eleveaon; 0 1X FL s�'.�L Oi= s5/ids ,.•e eeee•, �~�1,t y� f �1r •• L; S d= S ENGINEERING u 17034 Eagle River Loop Road, No. 404 of ae�_o3 Inspections performed by. Dates: 1 S- Alook f. `/ 7� •- • ••. ,„..••,:••.Eagle ...'f� River, : a 2"d-a�-�3 Development S ices Department Approval r!„C� tOBERT G COWAN % Reviewed and approved by: Date: 10/3 o CE .8801 w c;��`�'�� tit (Rev IJUO) �• /� _. ..,Js^� PERMIT No. SW030136 PACE 2 OF 3 Municipalit of Anchorage DEPARTMENT OF HEATH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 •Anchorage, Alaska 99519-6650 • Telephone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 2, H&H S/D P.I.D. NO. 050-731-57 \ LOT 1 LOT 4 \ 0 CO2 MT TH#2 • DBL1 k OBL2 °NEW O, 14' MIN. \�;� TMiT • STI 00 HDPE 10EPTICALLON TANK t' y TH#lA \ FCO 3 v \ TQM A h C,p41,E< Oq��fw4y \ 9 PROPOSED DRIVEWAY \ V�� EASEMENT FOR LOT 3�\ SCALE: 1 ' 50' A. ` fj IN ROBERT C. COWAN • i`�C Ops +• CE -8601 �� LOT 3 t< <:• '`' �'� s PERMIT NO. SW030136 PAGE 3 OF 3 Municipalit of Anchora e DEPARTMENT OF HEATH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • TeWL hone: 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL LOT 2, H&H S/D P.I.O. No. 050-731-57 ST1 ST2 96.9' FINAL GRADE 2" INSULATION NEW 93 2' 1000 GALLON POLYETHYLENE 92.9' SEPTIC TANK M8.54 FCO 0 ST1 5 CO1=94.5' ST2 5 TMT a02=95.1' DBL15 DBL2 40.0 45.5 C01 53.5 58.0,- 0O2 94.0 95.0r - JM T1 88.0 89.5 FINAL GRADE C01=90.1' SR CO2=90.3' N. T. S. ,�titE©;:syje 1 ix��,.,..«..,,• .. s MT1=82.9' %C'e ' "'•7+� i_ NO WATER FOUND ' •••�• nf� R06ERT C. COWAN 76.9 B.O.H. c,• CE -8801 KI M -W Drilling, .Inc. JUL 0 3 RECO ♦ P.O. Box 110378 ♦ Anchorage, AK 99511 ♦907-345-4000 ♦ 907-345-3287 Fox* Job No.: 03-137 Project No.: N/A Permit No. SW030136 Groundwater Well As -Built & Loz ♦ Well Owner.. Carl Remley & Patricia ♦Legal Description: I I & II Subdivisior Construction ♦ Use of Well. Domestic ♦ Yale Depth: 191' ♦Casing Size. 6" ♦Cased To: 190.5' ♦)tlaterlak A 53 Steel *DrillMethod. Air Rotary Perf. ♦ Well Completion- Open end X Screen Perforated _ Alethod: ♦Screen/Perforation description: None ♦Grout Notes: (1) Sack- No. 8 bentonite granules ♦ Notes: ♦ Well Development. Method: Air surge Notes: ♦Static water level (SILL) 160.21' (above) (below) top of casing (TOQ. ♦ {fell yield test at 5+ gallons per minute (GPM)/gallons frer Jeekr (FPl/) for I /yours with 100% of drawdown (DD) from static level (SWL). ♦Alethod: Airlift ♦ Date of completion: 30 May 2003 ♦ Pump Install.- Well nstall.Well Loe Depth in feet from to orcasin . Details or formations penetrated, size of material color and hardness. 0 TO 2.7 Casing stickup 2.7 TO 45 Boulders: cobble gavel 45 TO 178 Gravelly sand: damp; with dry sil!y gravel layers 178 TO 191 Water bearing ravel TO TO TO TO TO TO TO TO TO 4-► — _ TO -.-.n,,G ,;, Wit;%-��a;.�..s•� TO r' j TO TO 7wW-1_Certified-Contracto Certificate No's. 814 & 973 S zP 3 Ca) //:Oo MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT Initial Permit Number: SW030136 Legal Description: H & H SUBDIVISION Design Engineer: 0003 S & S Engineering Owner Name: PETER C. & SHEILA T. WILLIS Owner Address: NHN IMPERIAL DRIVE EAGLE RIVER, AK 99567 - ,ax- Date Issued: May 19, 2003 Expiration Date: May 18, 2004 Parcel ID: 050-731-57 Site Address: NHN IMPERIAL DRIVE Lot Size: 55192 SO. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: F✓ Disposal Field ❑✓ Septic Tank ❑ Holding Tank Privy ❑✓ Private Well Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: ,yW2 Date: s`1/ 9 A 3 Z%' 7�/ a. Y?�C� _ Date: f 17/0 3 Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Zr Parcel I.D. 0:570— 731 —3-7 Permit Number SWO30/34 Property owner(s) UIRX k4.CA1t\j Day phone Z• As hI- Mailing address (1) 3 5 5 D c O ki D R - ''k% C: Mailing address (2) frk%4,!!�. .A N&Voy Legal description (Lot, Block & Sub'd.) Z„ R )A Legal description (Section, Township & Range) Lot Size�'S', / 92 Acre q.Ft. THIS APPLICATION IS FOR: Zip Code "k9 5 a B Number of Bedrooms 3 Sewer Only ❑ Well Only ❑ Sewer and Well Water Storage ❑ Sewer Upgrade ❑ THIS PROPERTY CONTAINS: Hot Tub ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. 1 & S ENGINEERING W712- 1J4rA, 17034 Eagle River Loop Road No. 204 Eaglo River, Alaska 99577 (Signature of property owner or authorized agent) Permit Fees: I 5 SO • o Waiver Fees: Date of Payment: S` / S' to 3 Date of Payment: Receipt Number: 03 S o S- $ Receipt Number: (Rev. 12100) ROBERT C. COWAN, P.E. ROBERTA. SHAFER, PE. CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 May 6, 2003 HEALTHAULHORITY APPROMS MUNICIPALITY OF ANCHORAGE TEST Development Services Department STRUCTURAL& P.O. Box 196650 SEWER&WATER Anchorage, AK. 99519 MAIN EXTENSIONS REFERENCE: Lot 2, H & H Subdivision SEWER&WATER ' INSPECTION It is requested that you issue a permit to install a well & septic system to serve the proposed three bedroom dwelling on the referenced property. ENGINEERING STUDIES A test hole was excavated and a percolation test was performed. The approximate location ANDREPORTS of the test hole is located on the attached site plan. At the time of excavation 4/16/03 water was not found. After seven days of ground water monitoring the test hole was found to be d'y. WELLINSPECTION &FLOW TEST We do not anticipate any adverse effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent SITE PLANS properties. If you requir�addit' al information, please contact us. ROAD DESIGN Sincerely, SOIL TEST / ;Rob A. safer, P.E. PERCOLATION TEST nclosure STRUCTURAL& MECHANICAL INSPECTIONS ONSITE I WASTEWATER DISPOS&SYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577 SITE PLAN DESIGN 1" = 60' O SCAT F spry � Tn 4 mg0 Op� u 30 p�f- H fY Inrr>n ~O X Z�� a.go m=r z r 0 '�' yam. 111 o�oAr' �ij A Ln � Qyo yyy / r�i •moo E C i ��o �. N1py �� ro =VI r,a W `a� rev' •o \l bl O / -,Ln q zz--4 � oo �o7 �. 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Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.d.anchoraae.ak.us (907)343-7904 Soiloer g - Percolation Test Performed For; ^7 ) J1 o'% G Date Pfc ZLegal Description: L / f i /'7 S �7 Township, Range, Section: 2- 3- 4- 6- 7- 12- -3-46-7- 12- } 13- 14- y 3- 14 -Y , 15- 16- 17- 18- 1 COMMENTS SA4 6—M OHM WAS GROUND WATER Dale Gross Time Net Time ENCOUNTERED? 1. S IF YES, AT WHAT DEPTH? L Depth to Water After D Monitoring? �� G I E Date: Z v� Reading Dale Gross Time Net Time Depth to Water Net Drop �� G I �, / � r � L• 4 t/ /Zito -- /�l / -2 PERCOLATION RATE Z7! (L' IminutesAnchl """ ��l��,PERC HOLE DIAMETER TEST RUN BETWEEN LjL FT AND y� FT PERFORMED BY: `✓y i1YI) PERFORMED IN ACCORDANCE WITH ALL STATE AND CERTIFY THAT THIS TESD y 'ns EFFECT ON THIS DATE. DATE; 1 d 03 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www. ci. a nchoraae.ak.us yam. e*s 907 343-7904 l ) /a ./` / oils L5g - Percolation Test Performed For: r % Date erfc Legal Description:/,2 /T -*, i S Township, Range, Section: Depth 2- 3- " 4- 5- (el 6- 7- 8- 9- 10- -9-10- 0s 11- . 12- v (� 13- 4 14- 15- U 16- r" 17- , 18- 19- 20 COMMENTS 6- i1 or S A/1 (5i -M P). 0' H PERFORMED BY: if I_ PERFORMED IN ACCORDANCE f� N WAS GROUND WATER ) ENCOUNTERED? A. V IF YES, AT WHAT DEPTH? � Depth to Water After nn ./ Monitoring? �/ox Date: -! /�j sne clan T Reading Date Gross Time Net Time Depth to Water Net Drop Z,. e :' !3 0 A- - 12.3 f4 3a ' os' .3,) �*, f " Z '' PERCOLATION RATE iminutesAmK) PERC HOLE DIAMETER TEST RUN BETWEEN k5- FT ,A'* t , Ft ALL STATE AND 2 CERTIFY THAT THIS TEST WA IN EFFECT ON THIS DATE. DATE: y/ 0�5��3 EAGLE RIVER ROAD 0 0 N 370104"W 14"W 228.00' 10' BUFFER LANDSCAPE EASEMENT om mo c0 rn 0 N N mm v �� my - an m N � m 4: w D 2 (fl C z U N N CP rri o O r D r" N ctt C7 N O N O°l�p m p cp O z 77.9' man �•9e w m 1 N fv C✓ yS\X� 11 9,1\1SM� Z'� �ddd 1 \ \ 7 \ 1 Q \ I n 1 f 1 I - -_1----I ---__--.-----------------:. mI 3Naa -RAeea MAIM 25' DRIVEWAY EASEMENT C m �-- N 38002'50"W 231.88' (M) ro = m N 38°04'02"W 231.87' (R) Om m D n y =o m v o o c °vc z �N flo I r- a < b m 7 . ° ° O f' �N -Z+ m3 �e�so0 -7 'ca��N O w w z 0 O ca my 0:3 n zcr wa0o°roa < � am� o to 3 = D A W 4 m ert rt 3 ~' ? �•'- '` l :01 AV �.• . i T ••� � O N v N c-,3 Vic° p Ar �A .Q% o r- mITIo m D as nN�3P«f°rno 000 1 v\ • r N m < •`�/ D w r n 3 3 N G C O �p .•+ - .__+ 4-.0A / m D m N a G p �' 47 N N = C V O w,' d CL 0 cm p Om o=3v � m a = Q .O.- m N O z al I I < °. 1 < A .p at* f N J J co to 3 Municipality of Anchorage �• „� On-Site Water and Wastewater Program t _ (907) 343-7904 Lai i' sr.< < CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 050-731-57 Expiration Date: ic(--2 -k 1. GENERAL INFORMATION Complete legal description H&H Lot 2 Location (site address) 25724 Imperial Drive,Eagle River, AK Current Property owner(s) Erickson Day phone 250-0811 Mailing address same Real Estate Agent Owner Day phon 908117 72 ` 2. TYPE OF DWELLING: " ti0'�� �_ i_ - ® Single Family (w/wo ADU) • <" CO 111 Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) bpi �1 11066 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class C Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Received by: Date: c' 2 O/I et COSA to be released to the engineer,un ess otherwise requested by the engineer. COSA Fee $ 5 Date: Date of Payment 61,114/i3 Date of Payment Receipt Number 032—C15D Receipt Number COSA# aSC 1g1 aW 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. Name of Firm NorthRim Engineering Phone 694-7028 Address PO Box 770724,Eagle River Engineer's Printed Name Steve Eng Date 6/14/18 6. DSD SIGNATURE y' o 4,1 System #1 Approved for 3 bedrooms. A.. • g W. Lng System #2 Approved for >; ;3 bedrooms. :; `• 662- Disapproved. Ø'"/" „,• • Conditional approval for bedrooms, with the following stipuratf'oris� - ON-SITE Wp,IER AND z: Wi\STEWER o PROGRAM' ),0°d� r,c_9\1\C�` . Original Certificate Date: The Municipality of Anchorage Devlopment Services Division(DSD)Issues Certificates of On-Site Systems Approval(COSA)based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: • COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Pkdvisory Well Flow Advisory Other COSA blue sheet 9-1-12.doc ' • . • If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system Certificate of On Site Systems Approval Checklist Legal Description: /V 14/71 Z or a Parcel ID:0.5-6 7 31 S 7 A. WELL DATA Well type / If A, B, or C provide PWSID# Well Log (Y/N) y Date completed 5/36/0 3 Sanitary seal (YIN) Wires properly protected (Y/N) yTotal depth/7/ ft. Cased to / / ft. ( Casing height(above ground) 3G, in. FROM WELL LOG AT INSECTION Date of test. 513603 5136 h i Static water level /(Q, Z ft. / 53. -s ft. Well production 5± g.p.m. 5 g.p.m. WATER SAMPLE RESULTS: Coliform J colonies/100 mL Nitrate 2, G-Smg/L Arsenic Nn ug/L Date of sample: 5. s-?°/1 Collected by: AlA)//'h- B. SEPTIC/HOLDING TANK DATA ! Tank Type/Material STC/r/1 A f e Date installed �/2Al2 Tank size /6'80 gal. Number of Compartments Z Cleanouts(Y/N) Foundation cleanout(YIN) Y Depression over tank (YIN) /,/ High water alarm (Y/N) /✓ Date of pumping 573( /l 4P. Pumper S441 C. ABSORPTION FIELD DATA Date installed S .Zy/o3 Soil rating (g.p.d./ft2 or ft2/bdrm) t1.. r1 System type -te.r� Length 1.(( ft. Width 3 ft. Gravel below pipe 7 ft. Total depth 1/ ft. Eff. absorption area 571f ft2 Monitoring tube '�/ _ Depression over field Al Date of adequacy test 3 7r Results (Pass/Fail) I For 3 bedrooms Fluid depth in absorption field before test 74 in. Water added -/ `?cO' gal. New depth 4Z in. Elapsed Time: / 0 min. Final fluid depth 76 in. Absorption rate >= /ISO g.p.d. Any rejuvenation treatment(past 12 mo.) (Y/N &type) VA/fe-- If yes, give date D. LIFT STATION N4 Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot /tO <" On adjacent lots /0 G /t" Absorption field on lot /0 6 IT` On adjacent lots /c � - Public sewer main /0 Q It Public sewer manhole/cleanout . /40 (tSewer/septic service line Z S (F Holding tank ADO (74- Animal FAnimal containment areas So '- Manure/animal excrete storage areas Al C cT SEPTIC/HOLDING TANK ON LOT TO: r Building foundation /� -t' Property line �Q f Absorption field s Water main /0 rf Water service line /4 f Surface water /00 Wells on adjacent lots /c26 ABSORPTION FIELD ON LOT TO: Property line / „ r"" Building foundation /D Water main /D (t Water Service line /40 !I" Surface water /O0 (" Driveway, parking/vehicle storage /G 4. Curtain drain 1/NK Wells on adjacent lots /D4 F. COMMENTS z #Q 7f P.cS'ro.ze 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 COSA guidelines in effect on this date. 'r4tk:`T`_° 4: 8s Engineer's Print d Name Date b 4// I r • COSA yellow sheet_2-6-15.doc 50 Ic I fropi 8221 DEL STREET 1: ANCHORAGE, ALASKA 99502 BASIS 240.23' (R) PH0tIE 243-4890 N 52°49'56"E 240.32' (M) ( 1 1 ' 0 1 1 0 I s 1 1 7/3/03 AS BUILT 58-47 ' 4/30/03 PLOT PLAN 58-47 t 4. PVC SEPTIC 10 I ' STD-PIPES (TYP) a) 1 1 DATE ��+�%t�' FLU. BK. 0 I ••� Of "�S* i 1 w •02: ' ..*!4.4• • 0 I Sp491B �' .W ,l\ .*'0 z 11.i , I W '40 i4�i/f�Ll/.M I - U) 1 >- c0 • a 1 I C0 f „"• D. Fleming .•7 0 I M +� 1 yo I > ro f. ,,� LS-5773 .� Ar CV T� 1 Fc N ♦ ti ••. .'•h r Li i 127.1' I a 4 1 4, ••.......• e • "1.- ai :°0 cn 'J � i(� a 3 Iii p`Ofessiono�I' 11 z r o TA a. ,n ta o J 1 N- Q 0 Z $ NOTES; Easements not appearing on record subdivision N- ixi r" w I 68.9' Ito CO CO to ro plat ore not shown unless description of easement is z ? ; 2 -,-1/, zb•` , z z provided by client. It is the responsibility of the owner m bo I g or builder, prior to construction, to verify proposed p I 1 building grade relative to finish grade and utilities - I 1,ti ' connections, and to determine the existence of any Igs 1 easements, covenants, or restrictions which do not 1 ' � appear on the recorded subdivision plot. 0 0 Well 1 Elevations based on assumed datum unless otherwise 1 SET 5'8" REBARS PROPOSED DRIVEWAY ESMT. 1 indicated, and bearings and distances are record data. FOR USE BY LOT 3 _ I- -- I 1 I r i CLIENT: 1 CHORD CARL RAMLEY I I N 6O°I8'D9'E r .--' 1 29.55'(HOLD REC) I _ //c-. kik. R=300 0LEGAL DESCRIPTION N 52°49'56"E 214.57' •(HOLD REC.) LOT 2, H 8 N SUBDIVISION 50 3 t�enrnl n+ - — — • Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 s • : E r . Certificate of On -Site Systems Approval Parcel I.D. 050-731-57 Expiration Date: 1 -22 3 1. GENERAL INFORMATION Complete legal description H & H LOT 2 Location (site address) 25724 IMPERIAL DR, EAGLE RIVER AK 99577 Current Property owner(s) CARL REMLEY Day phone 632-7075 Mailing address SAME 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 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual IN Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request Received by: ,' ?0 �LALAV - Date: :1 2 l COSA to be released the ehglineer, unless othemise requested by the engineer. COSA Fee $ ��0 .� pp Waiver Fee $ Date of Payment i� i �J C1 �v Date of Payment Receipt Number Oi`f�Li� Receipt Number COSA 4 y` C_13) I t 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. Name of Firm SPURKLAND ENGINEERING Address 203 W. 15TH AVE. STE. 202A, ANCHORAGE, AK 99501 Engineer's Printed Name LARS SPURKLAND Phone 279-3916 Date $/13/13 OF. At -s31 S�? yft, 6. DSD SIGNATURE ,TH ;. ! System #1 Approved for bedrooms / f l •, •• v; , . System #2 Approved for bedrooms sPIJRKLAND, /1150 Disapproved 1 P �FAFD� Conditional approval for bedrooms, with the following st%(@�:_�p By: 1L, t Original Certificate Date: S - 13 The M nici ity f A orage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSAbl.e.heet r - .- c If more than I septic system is on the lot: COSA Checklist # 1 of 1 Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: H & H Lot 2 A. WELL DATA Well type PRIVATE Date completed 5/30/03 Total depth 191 ft. Date of test If A, B, or C provide PWSID # Sanitary seal (YIN) Y Cased to 190.8 ft FROM WELL LOG 5/30/03 Parcel ID -050-371-57 Well Log (Y/N) Y Wires properly protected (YIN) Y Casing height (above ground) 24+ in. AT INSPECTION 8/9/13 Static water level 160.2 ft 152 ft Well production 5+ gpm 5.6 9 -P.M. WATER SAMPLE RESULTS Coliform NEG colonies/100 mL Nitrate 1.98 mg/L Arsenic ND ug/L Date of sample: 8/6/13 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/HDPE Tank size 1000 gal. Number of Compartments 2 Foundation cleanout (Y/N) Y Depression over tank (YIN) N Date of pumping 8/7/13 Pumper JR'S PUMPING Collected by: ANSON MOXNESS Date installed 5/24/03 Cleanouts(Y/N) Y High water alarm (Y/N) N/A C. ABSORPTION FIELD DATA Date installed 5/24/03 Soil rating (g.p.d./ft? or ftZ/bdrm) 0.8 System type TRENCH Length 41 ft. Width 3 ft. Gravel below pipe 7 ft. Total depth 11 ft. Eff. absorption area 574 fl? Monitoring tube Y Depression over field N Date of adequacy test 8/9/13 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 63 in. Water added 450 gal. New depth 77.5 in. Elapsed Time: 240 min. Final fluid depth 74 in. Absorption rate >= 450 9 p d Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at _ Datum Size in gallons — in. "Pump off' level at _ E. SEPARATION DISTANCES WELL ON LOT TO Cycles tested Manhole/Access (YIN) in. High water alarm level at- Meets alarm & circuit requirements? _ Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100+ On adjacent lots 100+ Public sewer main NIA Public sewer manhole/cleanout N/A Sewer/septic service line 25+ Holding tank N/A t Animal containment areas *Q- > 100: jLb. Manure/animal excrete storage areas N.O. > IUV L.S. SEPTIC/HOLDING TANK ON LOT TO Building foundation 5+ Property line 5+ Absorption field 51+ Water main NIA Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain N.O. Wells on adjacent lots 100'+ F. COMMENTS 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 COSA guidelines in effect on this date. Engineer's Printed Name Date COSA brown sheet_10-IG-12.doc ..�4�OF•Atgst�l �P {7 1� I �49T / 9 SPURKLAN0:4ci UnJ•, 115pp0� 11 1`�PRt�FE$SoNP�� Municipality of Anchorage o • Development Services Department �•' �'`'� Building Safety Division On -Site Water and Wastewater Program ' t 4700 South Bragaw St.- P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us ' (907) 343-7904 CERTIFICATE OF HEALTH AUPIORiTYAPPROVAL' F dk A SINGLE F=AMILY DWELLING Parcel I.D. • 050-731-57 HAA#_ 3b LAQ -Expiration Date:D- 1. GENERAL INFORMATION Complete legal description Lot 2: H-& H ' Subdi vi s i on Location (site'address or directions) - Nd TmnPri n 1 Dr_ F-4 Current Property owner(s) Carl Remley Day phone 632-4847 Mailing address Lending agency Mailing address Real Estate Agent 355 Dona Dr. #9 Anchorage, AK 99508 Mailing Address Unless othenvise.iequested, NAA will be held by DSD for pickup. NUMBER OF BEDROOMS: .3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage ❑ Community Class . Well ❑ Public Water System ❑ Day phone Day phone TYPE OF WASTEWATER DISPOSAL: Individual On-site R Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered In the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of Issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. a. 5. J STATEMENT OF INSPECTION 13Y ENGINEER As certified by my seal affixed hereto and as of the validation date`shown below, I: verify that my investigation, :;�='[•fJ?,?,^. based on procedures outlined in the Health Authority Approval Guidelines for (his application, shows that the site water supply and/or wastewaterdisposal system is(are) safe,;functional and adequate for the number of bedrooms and type of structure indicated herein: I further venfy that based on the information obtained from the ... Municipality of Anchorage files and from my investigation;and }ins-.pection; the on•sit' .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:.. •.f 1 Y'a ,1 ,'wry i1 tJameofFirm_S_&�it{�iiF'_fg4_�979 ^t . Address 17034 N Eagle -River' `L`ooy'§te:''L> �i` aQle.':R3ver.; -AK •995 .7 ,...- r.,. �j�D3 Engineer's Printed Name Robert C'. Gnw n ''' `t`}'`"' ``• Date .• •>,: f.�.'• '.1: `'!' �' f :, ,.`11 ..it S,...:Y.n�(.. IryrJ.%•• . •,'r •-.�,1... ..l.i ,'r l4i. �Jt :'�•�.'i�f{:/•.•f1.F-.f {..�• .�l 4�l .fv eta i r •..,-:- ..i1'7•Fr.. f.••,f-Lff•ff•� ' ' �' l` .'r'.'.:••'6f ••�.�'••'.w,.l ir; tsar:.•}y °'1.- . f>.t •1!s�.. .. :�: .'I.•..y,«': ,r:.7 G�.. .'II''n �'�f �dEifT� 6wAN •:f QI�� •: DSDSIGNATURE ;;.,;; :;'', r'';�;,��f°fti-: • r, ;; Approvedfor. 3 bedrooms. ' Disapproved. M1tV x :: • if r f.'•:f n.: y . .. A.v1fr - Conditional approval for - ••' =,.bedrooms; with the following 'stipulations: '• "'"'. ::' . f•1f: '�!:±� yI f Y'j. r! ( •'r�' •;, r' 1(ttttY 6. ; :j;:,.,, :;'.. ;;' :,r':2:°'{';� 2-: ;: /1�f•.' •..� ::;. Additional Comments. a"vATERA ,. ,� •' . ��;,, ,• : ••':urec•rFWATER .. F ° :". r; •�. - • �;y,i •fir. `.' PROGRAM • ; [' . ,• f . :. ` F, yw.. DF- . V\ Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory' Supplemental Engineer's Report Well Flow Advisory Other By: Original Certificate Date: /0-3-03 (Rev. 011172) Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.enchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lo 1- -i; 144 �-) S' -:;> Parcel ID: ems -73%'-6? A. WELL DATA Well type j!�e If A, B. or C provide PWSID # = Date completed 530 / 03 Sanitary seal (Y/N) Total depth -1-ILfL Cased to 4 fL FROM WELL LOG Date of test Q3 Static water level Well production 5 -a 9•p•m- WATER SAMPLE RESULTS: Well Log (Y/N) y Wires properly protected (YIN) Casing height (above ground) /B in. AT INSPECTION Coliform O colonies/100 ml. Nitrate x.77 mg./l. Arsenic: mg.n. Date of sample:0.3 8'-7`��/�z3 B. SEPTICIHOLDING TANK DATA Tank Type/Material ;ePl7L I /-f Tank size IOVO gal. Number of Compartments Other bacteria 0 colonies/100 ml. Collected by: :5 S &..vG ^ve-LW2iA/4— Date installed '-; Z 0..1 Cleanodts (YIN) % Foundation cleanout (YIN) y Depression over tank (YM) AJ High water alarm (Y/N) '0J Date of pumping A/ &tW Pumper C. ABSORPTION FIELD DATA Date installed S 12Q X 03 Soil rating (g.p.dlfe or ft /bdnn) o pj System type & %2 ewc M Length 41 �� ft. Width 3 ft. Gravel below pipe 4-- ft. Total depth R Eff. absorption area S -74f Monitoring tube �` _ Depression over field �✓ Date of adequacy test I'le/Results (Pass/Fail) '4945-<, For 3 bedrooms Fiuid depth in absorption ld before test _ in. Water added_ gal. / New depth_ in. E?apsed Time: _ m n. Final fluid depth _ in. Abscrptio /rte >= c.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) /V If yes, cive date D. LIFT STATION Date installed N "Pump on" level at Z i1. Datum E. SEPARATION DISTANCES Size in gallons "Pump ofr level at _ in. Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift.006n on lot / LV %+- Absorption field on lot / 00 'r Public sewer mail A/ // A 7'-- S r /septic service fine ZS 1 X Manhole/Access (Y/N) High water alarm level at Meets alar & circuit requirements? On adjacent lots _ I / Od for - On adjacent lots _ / 012 ' -r- Public Public sewer manhole/cleanout A//-4 Holding tank - 4 SEPARATION DISTANCES FROM SEPTIC/1-100ING TANK ON LOT TO: Building foundation r'r Property line S Absorption field I r Water main /i Z A Water service line l r� surface water Wells on adjacent lots too ,•r" f� SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10 � -r Building foundation , Water main Water Service line j •f Surface water i (' Driveway, parking/vehicle storage Curtain drain tio.ad Wells on adjacent lots F. COMMENTS ~c G. ENGINEE .............. '1S R'S CERTIFICATION I certify that I have detemdned through field inspections and ;% Y`'= r • `.T; review of Municipal records that the above systems are in ;;` ' `' ' "•� • '• conformance with MOA HAA guidelines in effect on this date. _ •,Z �. I C; ROBC . Ca w,4, J AWAN,>. j�c, Engineer's Printed Name Date lo -3t C40 ..__•::;r % t,d ,\� HAA Fee S 3 -7df . vQ Waiver Fee S _ Date of Payment c7/3 0103 Date of Payment Receipt Number n H a y`f Z / Receipt Number. (Rev. 12101)