HomeMy WebLinkAboutRABBIT CREEK VIEW & HEIGHTS BLK 8H LT 3AOnsite File
Rabbit Creek
View & Heights
Block 8H
Lot 3A
#020-571-38
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON -SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP231268
PID Number: 020-571-38
Dwelling: ❑® Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: A New ❑ Upgrade
Name
Dmitry Vakulich
ABSORPTION FIELD
❑ Deep Trench❑ Wide Trench ❑ Bed ❑ Mound
Site Address
8100 Byron Drive
❑ Other
Phone
Number of Bedrooms
Soil Rating
depth from original grade
3
5.0 GPD/SF
JTotal
+2.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
+2.5 Ft.
Gravel depth beneath pipe
0.5 Ft.
Subdivision
Block Lot
Rabbit Creek View & Heights
8H 3A
Fill added above original grade
5.0 Ft.
Gravel length
20 Ft.
Township Range Section
Gravel width
5.0 Ft
Beds: Number of Lines
n/a
Distance between lines
n/a Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist, between trenches
From
Tank
Field
Tank
Line
100 Ft2
1
n/a Ft.
Well
50'+
50'+
50'+
NA
25'+
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ®❑ Other
Manufacturer
Anch. Tank
Capacity
1500 Gal.
Surface Water
50'+
50'+
50'+
NA
Material
Number of compartments
Lot Line
5'+
5'+
5'+
NA
NA
Steel
2
Foundation
10'+
10,
5'+
NA
LIFT STATION
Manufacturer
Capacity
Remarks AWWTS
Orenco
250 Gal.
*ABS ASTM D2661
Alarm location
House
Electrical installed by
L&S Services
Installer
PIPE MATERIAL House to tank *ABS Tank to
drainfield Pvccsoo oR19
Northern Excavation & Construction
Drainfield PVC csoo oR,a CO/MT 3034
Inspector PES
BENCH MARK (Assumed elevation) 105.3 ft
Inspdectio im 09/25/23
09/25/23
Location and description
3`d 09/26/23
2nd
41h 09/27/23
See Site Plan, Top of flashing on West House Wail
ON -SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
��O�F®�A�(� .
Date
.w,��,
0
.......
.......
�� Steven R. Pannone
d
Septic System
L
1$ �`��s E 814
Approved
Date
o
.W
/'ROFESS\00 �
Note: this approval does not include well permit requiremen .
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NOTES: PANNONE ENG SVC LLC (C.1. 1088) REVISIONS DATE
RECORD DRAWINGS P.O. BOX 1807 PALER, AK 99645 �S OF• 01/31/2024
PHONE (907) 745-8200 FAX (907 745-8201 tt`'" SCALE
AiiIM :* 1" = 50`
DRAW= sic RABBIT CREEK VIEW & HEIGHTS BLOCK 8H LOT 3A P.I.D. NO
CHECKED ACP DMITRY VAKULICH ••„, a,n„ 020-571-38
CE 8149 PERMIT N0.
SITE: 8100 BYRON DRIVE ?024.04.1? OS 2'
SITE PLAN ANCHORAGE, AK 99516 SHEET
2 OF 2
#MUNICIPALITY
OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT', 907-343-7904
On -Site Water and Wastewater Section ,� Fax: 343-7997
www.muni.org/onsite
CHANGE ORDER
PERMIT # OSP231268
PID 020-571-38
SUBD Rabbit Creek View & Heights TRACT BLOCK 8H LOT 3A
CONTACT PERSON Steven R. Pannone PHONE (907)745-8200 FAX (907)745-8201
PLEASE GIVE A DESCRIPTION OF THE CHANGE Well Griller placed well in different location than shown
on plan.
sRP
CUSTOMER SIGNATURE Date:
4111171124
• •
On -Site
Reviewer:
Comments
Issued
(date)
Review
Time
(hours)
0
APPROVED (date) �! 2 zY TOTAL HOURS
HOURLY RATE $145
TOTAL TO BE PAID
DATE PAID
RECEIPT #
0 DOC CO dba
B,« & �oLE TER WELLS;ola- ULLIVAN WA
VPP.O. Box 670269, Chugiak, AK 99567 688-2759
www.suilivanwaterwells.com
Pump Installation Log
Well Drilling Permit Number: SW �1�jY �j�?_� Date of lssue
Parcel Identification Number: ()NL5 axp
Legal Description Property Owner Name & Address
Q(;�;1f 0I t cY-0� V ► d ��
Pump Installation Date: 1 L) j a - Z3
`Pump Intake Depth Below Top of Well Casing: 7 0
Pump manufacturer's Name:
Pump Model: Il=R-D'S
Pump Size: V1,
Pitless Adapter Burial Depth:
Pitless Adapter installer: �-&-1
Disinfected upon Completion? ® yes ❑ no
Method of Disinfection: Chlorine 50 PPM
IComments: Pitless Manufacturer: ml 1
Pump Installers Name: Sullivan Water Wells
feet
hp
feet
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Certified Drilling Log
OWNER OF LAND: Dmitry Vakulich
ADDRESS: 8100 Byron Dr. Anchorage, AK 99516
LEGAL DESCRIPTION RABBIT CREEK VIEW & HEIGHTS BLK
8H LT3A
DATE: 9/15/23
PERMIT NUMBER: OSP231268 DATE OF ISSUE: 8/31/23
TAX IDENTIFICATION NUMBER 02057138000
Is well located at approved permit location: Yes No
Method of Drilling: air rotary cable tool
Depth of Well: 104’
Casing Type: Steel Wall thickness .250 inches
Diameter: 6 inches, depth 104 feet
Liner type
Static Water Level: Flowing feet
Recovery Rate 2 gpm gph
Method of Testing Air
Well Intake Opening Type: open end open hole
Screened Start feet Stopped
Perforations Start 70 feet Stopped 82
Grout Type: Bentonite Volume: 50 lbs.
Depth: from 2 feet, to 42 feet
Well Disinfected Upon Completion: yes no
Method of Disinfection: Chlorine 50 PPM
Comments:
Bore Hole Data
Depth
From To
0 2 Casing Stickup
2 6 Overburden
6 26 Tight silty sand and gravel with clay
26 49 Hardpan
49 71 Hardpan with clay
71 73 Bleeding hardpan
72 79 Hardpan
79 80 Bleeding hardpan
80 103 Hardpan
103 104 Bedrock
Drillers Name: Cole Sullivan
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority.
Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation.
MatSu Borough: Department of Environmental Conservation.
MUNICIPALITY OF ANCHORAGE
gent
On -Site Water & Wastewater Program �o
PO Box 196650 4700 Elmore Road a
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 Q f
hftp://www.muni.org/onsite
Department
On -Site Water & Wastewater System Permit
Permit Number: OSP231268 Effective Date: 8/31/2023
Work Type: WellSeptic Renewal Expiration Date: 8/30/2024
Tax Code Number: 02057138000
Site Legal Address: RABBIT CREEK VIEW & HEIGHTS BLK 8H LT3A G:3340
Site Mailing Address: 8100 Byron DR, Anchorage
Owner: VAKULICH DIMITRY Lot Size in Sq Ft: 40885
Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 3
This permit is for the construction of:
Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Q 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
Special Provisions:
• The proposed fields are not within 30 ft of a test hole. A test hole is required prior to installation of the
absorption field to verify minimum 3 ft separation to impermeables and verify percolation rate of the
accepting soil. If results require a design change, construction shall stop pending approval of a change
order. Please submit results with the inspection report (or change order, if required).
15suPrI to p� S
Issued By:
Date:
Date: g Z
MUNICIPALITY OF
o
Community Development Department''
Development Services Division
On -Site Water & Wastewater Program
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 020-571-38
Property owner(s) Dmitry VakUliCh
Mailing address
Site address NSN Byron Drive
Day phone
Legal description (Sub'd., Block & Lot) Rabbit Creek View & Heights Block 8H Lot 3A
Legal description (Township, Range & Section)
Lot Size 48,885 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑X
Initial ❑
Single Family (SF) ❑X
AD U)
Septic Tank
FX]Upgrade
El(w/wo
Duplex
El
(D)
Holding Tank
EJRenewal
❑x
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑X
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
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:
Date of Payment: S
Receipt Number: -�'s /�(s
Permit No.
Permit App_'- : . -..:c
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
Pannone Engineering Services LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail: steve@panengak.com
Mailing: P.O. Box 1807, Palmer, AK 99645-1807
Telephone: (907) 745-8200 FAX: (907) 745-8201
DATE 8/16/23
Subject: Expired On-Site Water and Wastewater Permit
Permit Renewal Request
Permit Number: OSP221264
Legal Description: RCVH B8H L3A
This is a request to renew the permit for the above mentioned lot. All site conditions remain the same.
The construction still will not affect the health, safety, or development of the surrounding lots.
Sincerely,
SRP
Steven R. Pannone, PE, F. ASCE
Owner/Civil Engineer
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231268, Deb Wockenfuss, 08/31/23
MUNICIPALITY OF ANCHORAGE
On -Site Woter& Wastewater Program
poBox 1a865u 4rOoElmore Road
Anchorage, Alaska ses1ymoso po um Fax: (907) 343-7997
On -Site Water & Wastewater System Permit
Permit Number: O8P22 2G4 Effective Date: 7/28/2022
Work Type: VVeUSmptic|nitio| Expiration Date: 7/28/2023
Tax Code Number: 02057138000
Site Legal Address: RABBIT CREEK VIEW & HEIGHTS BLK 8HLT3A G:3340
Site Mailing Address: 81OOByron DR, Anchorage
Owner: DEGENSTE|NNBL Lot Size inSqFt: 40885
Design Engineer: P4NNONEENGINEERING SERVICES Total Bedrooms: 3
This permit is for the construction of:
�Disposal Field Septic Tank El Holding Tank OPhvy . �Private Well OWater Storage
All construction shall beinaccordance with:
1. The attached approved design.
2. All requirements specifiedi Anchorage Municipal codChapters 15,55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (1 8AAC72) and Drinking Water Regulations (I 8AAC80)
— The wastewater code requires "inspections during the "installation. ///e engineer shall notify the Development
Services Department per AMC 15.65.Provide notification bcalling (907) 343-7904
(24/7). 4. From October 15toApril 15. osubsurface soil absorption system undorconetruoUonduhngheezingweather
shall beeither:
o. Opened and Closed unthe same day, or
b. Covered, sealed, and heated boprevent freezing
Special Provisions: The proposed fields are not within 30 ft of a test hole. A test hole is required prior to
installation of the absorption field to verify minimum 3 ft separation to impermeables and verify percolation rate of
the accepting soil. If results require a design change, construction shall stop pending approval of a change
order. Please submit results with the inspection report (or change order, if required).
Received B
Issued By:
�A Date:
MUNICIPALITY OF ANCHORAGE
Community Development Department;- Phone. 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 020-571-38
Property owner(s) Dmitry Vakulich
Mailing address
Site address NSN Byron Drive
Day phone
Legal description (Sub'd., Block & Lot) Rabbit Creek View & Heights Block 8H Lot 3A
Legal description (Township, Range & Section)
Lot Size 40,885 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
-APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑X
InitialX❑ Single Family (SF) ❑X
Septic Tank ❑X
(w/wo AD U)
Upgrade r -]Duplex
❑
(D) ElRenewalTank
Renewal El
Multiple Dwellings ❑
Privy ❑
(SF and/or D)
Private Well ❑X
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE / 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: S a 0 Waiver Fees:
Date of Payment: 'fib y;w a Date of Payment:
Receipt Number: 0(023` G Receipt Number:
Permit No. Waiver No.
Permit App_-'- : ,-..:c
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221264, Rebecca Carroll, 07/28/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221264, Rebecca Carroll, 07/28/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221264, Rebecca Carroll, 07/28/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221264, Rebecca Carroll, 07/28/22
33770 Ib UP
RESISTING FORCES (weight of soil & tank)
Volume of Manholes ft3
Volume of Soil ft'
1600 Ib DOWN
NET FORCE ON TANK
32170 Ib
(Volume of Soil over Tank minus Volume of Manholes)
ADDITIONAL BALLAST REQUIRED
Tank Bouyancy Check
PANNONE ENGINEERING SERVICES. LLC
Job Name: Rabbit Creek View & Heights Block BH Lot 3A
Subject: Bouyancy Check
Job Number: 2022.07.11
Originator: uC Checker: SRP
Septic Tank
ASSUMPTIONS
SITE PARAMETERS
1. No angle of repose on backfill material
Weight of Water
62.4 Ib/ft'
2. 110 Ib/ft' backfill material
3. Tank is empty
Weight of Soil (submerged)
110.0 Ib/ft'
— - -
Buoyancy Control:
Tank Bury Depth
o.o ft
1. No soil weight was considered for
buoyancy check. Tank is assumed to fully
Submerged (Worst case).
TANK DIMENSIONS
Diameter
105.0
in
2. Buoyancy will be controlled with a
Diameter
8.75
ft
concrete collar per Orenco specifications.
Radius
4.38 ft
3. Net up force of 32170 Ib
Length
=9ft
32170 Ib 221.8 f t3
145jb
Area
60.13 IT
s
222f t3 * 27fe3 == 8.22 yd'
Volurrie
541.19 ft
4. A minimum of 8.3 yd3 of concrete shall be
Weight
1600 �lb
placed around the spring of the tank as
shown in the attached detail and per Orenco
Manholes
ves
Specifications.
Percentage of Tank in Groundwater
BOUYANT FORCES (weight of the displaced water)
33770 Ib UP
RESISTING FORCES (weight of soil & tank)
Volume of Manholes ft3
Volume of Soil ft'
1600 Ib DOWN
NET FORCE ON TANK
32170 Ib
(Volume of Soil over Tank minus Volume of Manholes)
ADDITIONAL BALLAST REQUIRED
Pump Vault Souyancy Check
RANNONE ENGINEERING SERVICES. LLC
Job Name: Rabbit Creek View & Heights Block BH Lot 3A
Subject: Bouyancy Check
Job Number: 2022.07.11
Originator: UC Checker: SRP
Pump Vault
®�
ASSUMPTIONS
SITE PARAMETERS
1. No angle of repose on backfill material
Weight of Water
62.4 Ib/ft'
2. 1101b/ft3 backfill material
3. Vault is empty
Weight of Soil (submerged)
110.0 Ib/ft'
- - -
Buoyancy Control:
Tank Bury Depth
�ft
1. No soil weight was considered for
buoyancy check. Pump Vault is assumed to
fully submerged (worst case).
Pump Vault Dimensions
Diameter
24.0 in
2. Buoyancy will be controlled with a
Diameter
12.00 Ift
concrete collar per Orenco specifications.
Radius
1.0o ft
3. Net up force of 1568 lb
Height
�ft
156816== 10.8ft3
145T
Area
3.14 ft2
10.8ft3 *'Y`r== 0.4yd3
' Volume
25.13 ft}
z7fr3
4. A minimum of 0.5 yd' of concrete shall be
Weight
�lb
placed around the pump valut as shown in
the attached detail and per Orenco
Manholes
Yes
Specifications.
Percentage of Tank in Groundwater
100%
BOUYANT FORCES (weight of the displaced water)
1568 Ib UP
RESISTING FORCES (weight of soil & tank)
Volume of Manholes
ft3
Volume of Soil
ft3
(Volume of Soil over Tank minus Volume of Manholes)
�lb DOWN
NET FORCE ON TANK
ADDITIONAL BALLAST REQUIRED
1568 Ib
MUNICIPALITY OF ANCHORAGE
ADVANCED WASTEWATER TREATMENT SYSTEM
MAINTENANCE AND REPAIR AGREEMENT
THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and
entered into as of this % % Day of t / L of 20 2 V,'by and between
01 , herein the "OWNER," and the Municipality of
Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code
(AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this
Agreement agree as follows:
1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the
Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS),
described as
Advantex
located at (legal description) Rabbit Creek View & Heights L3A B8H
2. Maintenance, Repairs and Alterations.
(Owner is required to read, understand and initial each section)
f Throughout the term of this Agreement, the Owner shall enter into a service agreement
with an AWWTS service and maintenance provider approved by the Municipality or the
manufacturer's representative. The AWWTS shall be maintained in a satisfactory
condition capable of performing as designed and producing treated septic effluent in
accordance with the equipment's approval for operation in the Municipality.
-It shall be the responsibility of the Owner during the term of this Agreement to pay for all
repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This
includes an annual maintenance fee (typically $400 to $600).
Owner agrees that only maintenance and repair personnel approved by the Municipality
or the manufacturer's representative will inspect and make any necessary maintenance,
lypairs or permitted alterations to the system.
Owner acknowledges that regular maintenance of an AWWTS reduces the potential
failure of the system, which could include sewage backup and costly repairs or drainfield
replacement.
(rev. 05/ 18/2018) Page l of 3
Owner acknowledges that the Municipality may request records of maintenance and
repairs from the manufacturer's representative or maintenance provider.
Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be
/ assessed in accordance with AMC 14.60.030.
/Owner agrees to grant the Municipality reasonable access to test and inspect the
AWWTS. The Municipality will give at least 24-hour notice.
Owner agrees that any sale or transfer of title of the property will not occur without a new
Certificate of On -Site Systems Approval.
/,2/� Owner agrees that the AWWTS installation and maintenance requirements as provided
by the AWWTS vendor/installer and approved by the Municipality are the governing
guidelines for the construction, maintenance and repair of the Owner's AWWTS.
r Owner agrees to maintain remote monitoring of the AWWTS as required by the
AWWTS approval.
3. Term. The term of this Agreement shall begin on the date of approval by the
Municipality to operate the installed system, or upon transfer of title, and shall continue
while the AWWTS is operational or until title is transferred.
4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this
Agreement shall in no way constitute a waiver of the provisions, nor in any way affect
the validity of the Agreement or any part hereof, or the right of the Municipality
thereafter to enforce every provision hereof.
5. Amendment. This Agreement shall only be amended by authorized representatives of
the Owner and Municipality. Any attempt to amend this agreement by either an
unauthorized representative or unauthorized means shall be void.
6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be
brought in the Superior Court for the Third Judicial District of the State of Alaska at
Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the
parties under this Agreement.
7. Severability. Any provisions of this Agreement decreed invalid by a court of competent
jurisdiction shall not invalidate the remaining provisions of the Agreement.
(rev. 05/ 18/2018) Page 2 of 3
Parcel I.D. 020-571-38
Certificate of On -Site Systems Approval
Expiration Date:
3/8/2025
Legal description RABBIT CREEK VIEW & HEIGHTS BLK 8H LT3A
Site address 8100 BYRON DR
Current property owner(s) HOME RENEWAL COMPANY LLC
X The On -site system(s) is/are approved for 4 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
:AP
Original Certificate Date: 9/12/2024
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval —June 2022
1. GENERAL INFORMATION
Parcel I.D. 020-571-38
Complete legal description RABBIT CREEK VIEW & HEIGHTS BLK 8H LT3A
Location (site address) 8100 BYRON DR ANCH AK
Current property owner(s) HOME RENEWAL CO. LLC, Day phone
2. ON -SITE SYSTEMS SIZED FOR 4 BEDROOMS
3. TYPE OF WATER SUPPLY: X Private Well El Private Well serving 2 dwelling units
El Private Well serving 3+ dwelling units El Community Well or Public
[I Water Storage
4. TYPE OF WASTEWATER DISPOSAL: X Private Septic 0 Private Septic serving 2 dwelling units
R Holding Tank El Community Septic or Public Sewer
5. SEPTIC TANK: X Steel F] Plastic El Concrete ❑ Fiberglass
Age NEW - See advisory if steel older than 20 years
6. ABSORPTION FIELD: F-01 AWWTS E] Bed F-1 Deep Trench ❑ Wide Trench 0 Seepage Pit
Waiver request for:
Expedited review requested: OR
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On -site staff
to verify the accuracy of the information provided.
"7
COSA Fee Waiver Fee $
Date of Payment 70 Z-V Date of Payment
COSA # 51 C '?
z 9 Waiver #
COSA Applicationjune 2022
COSA Checklist
Legal Description: RABBIT CREEK VIEW & HEIGHTS BLK 8H LT3A Parcel ID: 020-571-38
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA
0 Well log is filed with Onsite (or attached)
Date drilled 9/15/23 Total depth 104 ft
Cased to 104 ft
❑� Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 3/8/24
Static water level at beginning of test ft.
Comments * FLOWING, PACKER INSTALLED
B. TANK DATA
Measured operating fluid level in septic tank 'NEW
Date of pumping NEW
X Required maintenance completed, if AWWiS
Comments: * PRE-SET LEVELS W/ ADVANTEX
D. ABSORPTION FIELD DATA
Which system tested (date installed) NEW
❑N ALL standpipes present per record drawing
Total measured depth from grade 2.0 ft (max)
Measured depth to pipe invert from grade ft (min)
N N/A — pressurized field.
❑E Per record drawings, field is insulated.
0 Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) _
If yes, enter date
Comments/Deficiencies:
COSA Checklist June 2022
Well production at time of test 2+ gpm
Water storage tank volume 0 gallons
Well disinfected for coliform test? ❑ Yes N No
N Coliform bacteria is Negative
Nitrate mg/L 0 Nitrate less than MRL (ND)
Arsenic ug/L 0 Arsenic less than MRL (ND)
Collected by
Date 3/8124
MNA
C. LIFT STATION
M Required maintenance completed
Age of lift station NEW years
Lift station material STEEL
Comments:
Adequacy test date NEW
Results [j]Pass
Fluid depth prior to test _ in
Water added _ gal
New fluid depth _ in
Elapsed time _ min
Final fluid depth _in
Absorption rate _ gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 6 in
Effective depth used 0 in
Effective depth remaining 6 in
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100' *50 Community Sewer Manhole/Cleanout > 100'
ElYes if No _ ft [E Yes if No _ ft
Neighboring Tank > 100' 0 Yes if No _ ft Private Sewer/Septic Line > 25' Q Yes if No _ ft
Absorption Field on Lot > 100' ❑� Yes if No _ ft Holding Tank > 100' QYes if No _ ft
Neighboring Absorption Fields > 100' Animal Containment > 50' R Yes if No _ ft
❑i Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑s Yes if No _ ft �]i Yes if No _ ft
❑ N/A — Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
Q Yes
if No
_ ft
Surface Water > 100'
Yes if No _ ft
Tank to Property Line > 5'
Q Yes
if No
_ ft
Wells on Adjacent Lots:
Field to Property Line > 10'
Yes
if No
_ ft
Private Wells > 100'
0 Yes if No _ ft
Water Main > 10'
Yes
if No
_ ft
Community Wells > 200'
Yes if No _ ft
Water Service Line > 10'
Yes
if No
_ ft
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
* ADVANTEX SYSTEM, 50' WELL RADIUS
G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines, indicates that the on -site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm miloC N_AeAevcoei
P_OF
Phone 727-8864
Engineer's Printed Name
Date '{ rf 7I
.tNl Y• 1 1`,
I ..••..• •• . •.
•IY YIYYYi.
O I •• MICHAEL N. ANDEB&4f4 :
U-9469 Y•;..,;i
e
COSA Checklist —June 2022
OWNER:
By'--.----��_-_-__— __.—{.signature) Date: .---_.__.y/�`
(print name)
STATE OF ALASKA )
ss.
THIRD JUDICIAL DISTRICT )
The foregoing instrument was acknowledged before me this l day of
2024, by Tv ^ r .__L .__ Gi ..v 4 Y'Y\-- - -
STATE OF ALASKA
car NOTARY PUBLIC °'
__ __--a...____ _.
NOTARY P BLIC FOR ALASKA Jenie R. Sta, Maria
My Commission expires: S - - � ~`1' my cormtsdW ms�f-� �o�-
MUNICIPALITY:
By: (signature)
/� `n S' 1-Y-) (print name)
Date: 2
Title: C-1
t� L-
(rev. 05/18/201 S) Page 3 of 3