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HomeMy WebLinkAboutSHANE LEE ESTATES BLK 1 LT 5Shane Lee Estates Block 1 Lot 5 #014-061-61 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. ITJ a GV r;1 rl m • nt pc s.! eM M uv'.f r C? C H Vr vx N W W W W W N k+ W M es of Cl LS Q i rll p-{ f� w r+: Ci Cii cj r4 r -i of U)i rC rt y d @ N: p f r4 WW cli r7 O H A W A r;1 m • nt pc s.! uv'.f E4 C H Vr W W W W T_ -Y-P-0 Cl F-7 P -A C- 9- F�' Fz��� ` DEPARTMENT uF HEALTH AND ENVIRONMENTAL .'ROTECTION ~ 825 'L' STREET, ANCHORAGE, HK. 99501 279-2511 PERMIT NO. HPPLICHNT EDWIN RINNER 8]10 WELLSLEY CT 44~41]1 LOCHTION LEGHL L5 B.I. LOT SIZE 8000 SQUARE FEET MINIMUM DISTANCE BETWEEN H WELL AND PN -r' ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE'. WELL OR 2@0 FEET FOR A PUBLIC WELL WELL LOGS ARE REQUIRED AND MUS -IT BE RETURNED TO THE DEPARTMENT WITHIN ]0 DAYS OF THE WELL COMPLETION. SPECIFICHTIQNS AND CONSTRUCTION DIAGRAMS FIRE AVAILABLE TO INSURE PROPER INSTHLLHTION. �LEE �9-11 1 -Y' V F� 1-. 1 E -M P- C�� ���� ����� ����� I ���� I CERTIFY THAT 1: I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE 5EWERS AND WELLS AS SET FORTH BY THE MUNICIPHLITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. v HPPLa-.- EDWIN RINNER I cS|]ED BY MUNICIPALITY OF ANCHORAGE 0 Development Services Department P p Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 014-061-61-000 Expiration Date: 8/2/2023 Legal description SHANE LEE ESTATES BLK 1 LT 5 Site address 6710 TIFFANY TER Anchorage AK 99507 Current property owner(s) GILBERT JEFFREY & JOY REVOCLIVING TRUST X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: Original Certificate Date: 5/2/2023 '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 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 Application 1. GENERAL INFORMATION Parcel I.D. 014-061-61 Complete legal description Shane Lee Estates Block 1 Lot 5 Location (site address) 6710 Tiffany Terrace, Anchorage, AK Current property owner(s) Jeffery & Joy Gilbert Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank 0 Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ 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. COSA Fee $ / Waiver Fee $ Date of Payment Z �l �Z3 Date of Payment COSA # SSG?_3� I (2 Waiver # COSA Application—June 2022 Legal Description: COSA Checklist Shane Lee Estates Block 1 Lot 5 Parcel ID: 014-061-61 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ✓❑ Well log is filed with Onsite (or attached) Date drilled 1/19/78 Total depth 57 ft Cased to 57 ft ./❑ Sanitary seal is functioning correctly © Wires are properly protected Casing height (above ground) 47 in. Date of flow test for COSA 4/25/23 Static water level at beginning of test 27 ft. Comments K DATA Measured operatingul a tic tank Date of pumping ❑ Required maintenance completed, if AWWTS Comments: . BORPTION FIELD DATA Which s m tested (date installed) ❑ ALL standpip resent per record drawing Total measured depth fro rade ft (max) Measured depth to pipe invert fro rade ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑ 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 3.8 qpm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ❑✓ No ✓❑ Coliform bacteria is Negative Nitrate 0.429 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L © Arsenic less than MRL (ND) Collected by Arcterra Consulting Date 4/19/23 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station ma Comments Adequacy test date Results ❑ Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in orption rate gpd FIELD DTUS — POST RECOVERY Effective dept r record drawings) Effective depth used In Effective depth remaining n in E. SEPARATION DISTANCES From Private Well on Lot to: iP".ease enter distances If less than required sir If i;cmmunity well on lot) Septic Tank/Lift Station on Lot > 100 Community Sewer Manhole/Cleanout > 100 [] Yes if No NA ft © Yes if No ft Neighboring Tank > 100 Q Yes if No ft Private Sewer/Septic Line > 25' Q Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No NA ft Holding Tank > 100'✓❑ Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ❑✓ Yes if No ft Yes if No ft ManurerAnima Excreta Storage > 100' Community Sewer Main > 75 ✓❑ Yes if Na ft ❑✓ Yes if No ft ❑ NiA - Served by Community Well ,not on lot) or Public Water SepticlHolding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundation❑Yes if No ft Surface Water ? 100' [:]Yes if No ft Tank to Property Line > 5' ❑ Yes ft Wells on Adjacent Lots: Field to Property Line > 10' ❑ Yes if No ft ate Wells > 100' ❑ Yes if No ft Water Main > 10' [] Yes if No ft Community We _ ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft If tank or fied is under driveway commen F, ENGINEER'S COMMENTS 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 invest gation 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 Natne of f=irm Areterra Conso Phone (907)-696-6111 _ — Engineer's Printed Name Kenneth Duffus Date l•.nginccr's Comments: This in+-cstigation ++as contpleied in compliance ++ith ADEC and N10A regulations. Clic asscssawnI or the condition of [lie %I ell and septic applies an 1% u, the conditions as of the dac tested. The non• and al►sarption rates may change due to subsurface eonditinn% that nia+ nut he nhwr+ed arum the surrate, changes ininod use.locui suit chornrleri.micc, gratindit tiler levels That may nuctuatedueiag Ilte +e+tr Air and the water nsage of the fancily bei ag sor+ed br Ilse st'stent. I•he aperaIimra I life of all well and septic ` it Tk5 systems are suhjeci to Ihese s oriaus and d+namie characierislies and tare nutside the enntral of the c+nluator or tits well and septic system. Therefore, Arc terra can not gi+c arty' estimate of hnss long a sysiem will functiurt satisfactory for current or ruture occupants or run Are i•crra guaruntae that no unseen : encroachments, deficiencies or discrepancies exist. iSEtt�:` II K51 kl off COSA Checklist June 2022 t , M� E S';i l ��I Municipality of Anchorage e f �-•� Development Services Department�,{I�_� Building Safety Division On -Site Water 8 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. Qty -- 0 6161 ' 4 / COSA# 09 0 q 1. GENERAL INFORMATION Expiration Date: 9-/0-09 Complete legal description Location (site address) Current Property owners) Mailing address Lending agency Mailing address Real Estate Agent Mailing address SHANE LEE ESTATES: BLOCK 01, LOT 05 6710 TIFFANY TERRACE *ANCHORAGE. AK JOYCE LEHMAN Day phone 344-8881 6710 TIFFANY TERRACE 'ANCHORAGE. AK Day phone JUDY ROSENBERG Day phone Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well 0 Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ 762-6800 TYPE OF WASTEWATER DISPOSAL: Individual On-site ❑ Individual Holding tank ❑ Community On-site ❑ Public Sewer 0 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site 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 riles 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 Finn GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date fS Ce) Engineers Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines 8 Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIIGGNATURE Approved for - ' bedrooms. Disapproved. i �. EUjc�-7 ' e`i n � Conditional approval for bedrooms, with the fllowing stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Y OFgN QP . 0 ON-SITE •:�Gis WATERAND ; m- WASTEWATER PROGRAM IA gy; -0 Original Certificate Date: — 9 (R". 11/05) 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 (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SHANE LEE ESTATES; BLOCK 01, LOT 05 Parcel ID: rl /I/ A. WELL DATA •ASSUMED BASED ON SURROUNDING WELL LOGS. SEE ATTACHED. Well type PRNATE If A. B, or C provide PWSID# N A Well Log (YIN) YES Date completed 1/19/1978 Sanitary seal (YIN) YES Wires properly protected (YIN) YES Total depth 57 ft. Cased to 40'+ ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 1/19/1978 5/5/09 Static water level 16 ft. 27 ft. Well production 12 g.p,m. 3.6 - g.p,m. WATER SAMPLE RESULTS: ColiformA �l� colonies/100 ml. Nitrat�•a2 mg./L. Other bacteria 0 colonies/100 ml. Arsenic: reaug./L Date of sample: 5/5/09 Collected by: GEG Ltd. B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Tank Type/Material Date installed Tank size gal. Number of Compartments _ Cleanouts (YIN) _ Foundation cleanout (Y/N) _ Depression over tank (Y/N) _ High water alarm Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed - Soil rating (g.p.d./Wor ft'/bdrSystem type Length ft. Width ft. Gravel below pipe ft. Total depth ft. Eff. absorption a_ ft' Monitoring tube_ Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absor field before test _ in. Water added _gal. New depth _in. Elapsed Ti _ min. Final fluid depth in. Absorption rate >= g.p.d. Anr rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access(YIN) "Pump on" level at in. "Pump off level High water alarm level at in. Datum Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot NSA On adjacent lots 100'+ Absorption field on lot NSA On adjacent lots 100'+ Public sewer main 75'+ Public sewer manhole/cleanout 100'+ Sewer /septic service line 25'+ Holding tank Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Building foundation Property line Absorption field Water main Wells on adjacent lots Water service line Surface SEPARATION DISTANCE FROM ABSORPTION FIEL OT TO: Property line Buil ' undation Water main Water service line Surface water Driveway, parking/vehicle storage Wells on adjacent lots 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. f e A. or ss.-* Engineer's Printed Name JEFFREY A. GARNESS �Q4�, ' / C — 3 ei Date 01 P. COSA Fee S q q 0 Waiver Fee $ Date of Payment Date of Payment Receipt Number I Receipt Number (Rev 11105) A-- ®i I V' _ �bVb]]jO�� pM1�. tl1 h� �pFF75Ft•��a qq y�U.'4 •JH�I�i1�!•„C �' H�.O6 �M~��• r N _ � yuraaIs N so.N .Z.09N 100 o w I w w I � w n •L.I I t 0.09 $ 101 !90 fN • p 1 Page Two Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Comments: Lot 5 Block 1 Shane Lee Estates Subdivision Affadavit Attached: ( ) Letter Attached: ( ) Approved \ r Date: � Disapproved: Date: Department Worksheet: 1 IL6I -AV 1VNOILVN831N1 803 lON 009C w,0.4 sci IJ - 7..1 64L-094y�� eL6i Od0 ilyyr gn-0 V1-9 vag) —03la 30MA00 30NVHnSN1 ON A93AIl30 ltlIQ130 .•••... �Pv�lnba+ea}o�1xe) ""•��•����.��.•�.� .•�." AlNO 33SS3NOOV Ol U3AI130 P09 959 .............. S30IA83S .... • • quo aassaippe 01 6i wo4M u1 sM04S 'Z' 1d1303H �5S 91 slog Due a3eP " Pa..... P 01 lJam ap 411 NB013 aassaI0�� X59 "— �IaP a3eP Pue wo4M ........... p J lop 1V M1160tl HOl 5301Atl35 'IVNOIldO - S331 "0'd 3000 'ON ONtl 13391S_ 31tl0110 HNtlW1SOd (ale;sod snld) ;50£-11VW (131�11213� HOA ld1333 - 5 MUNICIPALITY OF ANCHORAG,G� �e DEPARTML OF HEALTH AND ENVIRONMEK L PROTECTION 825 L Street, AnchoraaP, Alaska 99501 264-4720 Date Received: February 14, 1978 #1: Time 9:30 a.m. #2: Time #3: Time Date 2-16-78 Thursday Date Date Insp Pratt Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: Alaska National Bank of the North Mailing Address: 3301 C Street, Calais II Phone: 278-4581 2. Property Owner: Sebring Builders Phone: 344-3069 Mailing Address: Star Route A Box 1540C 99507 3. Legal Description: Lot 5 Block 1 Shane Lee Estates Subdivision 4: Single Family Residence: (x) Multiple Family Residence:.( ) Number of Bedrooms: Number of Bedrooms: 5. Well System: Individual Well (x) Community/Public System ( ) Permit # ` ) 1 I S ` Depth of Well �S� , Well Log on File i ) Construction � F�a� Bacterial Analysis IACACIMLA 6. Sewage Disposal System: On-site System ( ) Public Utility (x) Permit # Installed Installer Septic Tank Size Manufacturer Absorption Area Soils Rate Material 7., Distances: Well to Septic Tank to Absorption Area to Sewer Line Nearest Lot line Absorption Area to Nearest Lot Line MUNICIPALITY OF ANCHORA(_ Department of Health and Environmental Protection *.equest 825 L Street, Anchorage, Alaska 99501 264-4720 for Approval of Individual Sewer and Water Facilities 1. 2. 3. Property Owner: Mailing Address: Name of Buyer: Mailing Address: Lending Institution: Mailing Address: Phone: Phone: Phone: 4. Realtor/Agent: Mailing Address: Phone: 5. .91 Legal Description: Street Location: cs� �jC�/JGi Single Family Residence: Multiple Family Residence: Number of Bedrooms: ( ) Number of Bedrooms: rY' - 7. Water Supply: *Individual Well (ublic/Community System ( ) If Individual Well, well depth If Community System, name of system 8. Sewage Disposal System: *bn-site System If On-site System, date of installation: ( ) Public System pl� *NOTE: A well log is required on ALL wells drilled since 6/75. **If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fae or $25_00 must accompany each request before processing can be initiated. 3/77