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HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 3 LT 12Onsite File Y �k � t x g .F � x r MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section 6,Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 014-072-09 Expiration Date: % I -3d - 1. GENERAL INFORMATION Complete legal description Campbell Heights Sub, Block 3 Lot 12 Location (site address) 3825 E 67th Ave, Anchorage, AK 99507 Current property owner(s) Mike Barry Day phone (907) 223-1614 Mailing address 1713 W 7th Apt #11, Frederick, MD 21702 Real estate agent Valerie Whitmore 2. TYPE OF DWELLING: ❑■ Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone (907)223-1125 3. NUMBER OF BEDROOMS: 1 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Q Private Septic ❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer Q Waiver request for: Distan Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ 2, 90 Waiver Fee $ Date of Payment 5h -!5Z I Date of Payment Receipt Number 00156 0 Receipt Number COSA # 05 C Z 1 113 12 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 Forge Engineering Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller, P.E. Date 8/11/21 6. DSD_ SIGNATURE gel System #1 Approved for System #2 Approved for Disapproved Conditional approval for C00 Ll D 14 Pero c yl I1 V-4 1-4-e i I 1 TH 9— i * *d ..r:.I ........ bedrooms Benjam(n Schiller bedrooms ���%/22 Fq 8191 PROFESSO .� bedrooms, with the following Drr stipulations: ywS a kAAoff •e 61_� JPct�� i C (7, 1,_i _2 q r �o"\-DIY OF' ,���i. By: Original Certificate Date: < 1-3c r 2/ 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 Septic System Advisory Well Flow Advisory COSA Checklist blue sheet X Nitrate Advisory Arsenic Advisory Other ON-SITE WATER AND J� ST PROGF;AM By: Original Certificate Date: < 1-3c r 2/ 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 Septic System Advisory Well Flow Advisory COSA Checklist blue sheet X Nitrate Advisory Arsenic Advisory Other COSA Checklist Legal Description: Campbell Heights Sub, Block 3 Lot 12 Parcel ID: 014-072-09 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA ❑ Well log is filed with Onsite (or attached) Well production at time of test 3.0 gpm Date drilled *unknown Water storage tank volume gallons Total depth **24 ft Well disinfected for coliform test? ❑ Yes ❑ Nc Cased to **24 ft ❑ Coliform bacteria is Negative W Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND) Q Wires are properly protected Arsenic ug/L ❑ Arsenic less than MRL (ND) Casing height (above ground) 12 in. Collected by Forge Engineering Date of flow test for COSA $/2/21 Date of Sample $/4/21 Static water level at beginning of test 11-6 ft. Comments *No well log or muni records. **Engineering verified depth at 24ft. TANK DATA Age of to years Tank type/materia Measured operating fluid leve E ❑ Standpipes/foundation cleanout Date of pumping tank drawing BSORPTION FIELD DATA Which sys tested (date installed) ❑ ALL standpipes nt per record drawing Total measured depth from gr ft (max) Measured depth to pipe invert from gra 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 gallons Comments/Deficiencies: COSA Checklist yellow sheet IFT STATION ❑ Requl aintenance completed Age of lift station years Lift station material Comments: Adequacy test date Results ❑ Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final epth in Absorption rate gpd Any rejuvenation treatmen t 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' n/a Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft [❑/ Yes if No ft Neighboring Tank > 100' F✓ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No ft n/a Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ❑✓ Yes if No ft ❑✓ Yes if No. ft >50 Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑ Yes if No ft ❑✓ Yes if No ft e tic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations _ ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft Property Line > 5' ❑ Yes ft Wells on Adjacent Lots: Absorption Field > 5' ❑ Yes if No ft ivate Wells > 100' ❑ Yes if No ft Water Main > 10' ❑ Yes if No ft Community V e . _ 0' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft If septic tank is under driveway comme I'w �-••` t sorption Field on Lot to: (Please enter distances if less than required) Building Foundation _ Yes ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes ft Wells on Adjacent Lots: Water Main > 10' if No ft Private Wells > 100' ❑Yes if No ft Water Service Line > 10' El if No ft Communi > 200' ❑Yes if No ft Surface Water > 100' F-1 Yes if No ft F. ENGINEER'S COMMENTS *Home was built in 1963, code required 50' separation for private wells G. ENGINEER'S CERTIFICATION 1 certify that 1 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 coTH •' V Benjarr ry'Schiller .4 j �� •. • CE 12592 • �`� v+ �'s1<c 8/11/21 , •'�C�� ����� PRO" FESSIONS'° -- ---- ------ - 12- IsOill L) C- cl P E R TY C,"w L, i{ MUNICIPALITY OF ANCHORAGE WASTEWATER CONNECT PERMIT oo - 5463 Of WATER & WASTEWATER UTILITY DATE OF APPLICATION 09/29/2000 3000 ARCTIC BLVD. SCHEDULED COMPLETION DATE 12/31/2000 PHONE: (907)564-2762 BLOCK/LOT/TRACT BLK _ 3 LT 12 k SINGLE FAMILY SUBDIVISION CAMPBELL HEIGHTS 'MULTI -DWELLING No. APTS COMMERCIAL TAX CODE 1407209 GRID 2034 AS -BUILT STREET ADDRESS 3825 E 67TH AVE OWNER HOKE DIANE MARIE PHONE MAIL ADDRESS 3102548TH AVENUE SOUTHWEST FEDERAL WAY, WA 980230000 CONTRACTOR DENALI SEWER AND DRAIN ASSESSMENTS Repair Existing Service Main Line Extension X On Property Only City Tap _.. X Have Been Levied Hydrant Only 50` or Longer To Be Levied Main Tap - To Property Line Only Comments: Main Tap & On Property Connect Row No. Disconnect R & R -'Main Tap Only Owner Staff CONNECT SIZE 4 " ISSUED sparr INSPECTION FEE $ 104.00 'PAID CASH PERMIT FEE $ 35.00 CHECK'# $ 0.00 --OTHER DEPOSIT $ 0,00 INSPECTED BY REIMBURSABLE TOTAL $ 139.00jLo/,LG$ NUMBER DATE /0 15 1yV KEMARKS PERMITTEE (Please Print) PHON MAIL ADDRESS �--,, x� .� SIGNATURE =� POST IN A CONSPICUOUS PLACE AT THE JOB SITE AWWU INSPECTOR Original DATE SCHEDULED TIME INSPECTOR SUBDIVISION CAMPBELL HEIGHTS BLOCK/LOTITRACT BLK 3 LT 12 INDICATE NORTH ti ni~ cy e t ra 0 r � w ti i SIZE MAIN: TYPE MAIN: DEPT AT MAIN: AT PROP. 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