HomeMy WebLinkAboutSIEFKER TR 7Sief ker
Tract 7
#015-281-24
�CREA, cR ANCHORAGE AREA BM-iGH
Department of Environmental Quality
��
999^ 3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
/_9
NAME/ MAILING ADDRESS— PHONEO
LOCATION-�_��rC/t!,_J ' ` LEGAL DESCRIPTION
SEPTIC TANK: �
DISTANCE Z Ct,1C�^ , to t�
FROM WELL _3 0 _f- MANUFACTURER.
INSIDE LENGTH INSIDE WIDTH
NUMBER OF
MATERIAL_ COMPARTMENTS
LIQUID DEPTH_ LIQUID CAPACITY_ !`o.e) MG LLONS.
SEEPAGE RtT-: �j/5.5� f1 a �( �Jv '' rL Q f
V ) r
NUMBER OF PITS DIAMETER OR WIDTH ? LENGTIo, DEP 1-1 /
LINING MATERIAL CRIB SIZE: DIAMETER__DEPTHy DISTANCE FROM:
TOTAL EFFECTIVE
BUILDING FOUNDATION_, NEAREST LOT LINE 7� t. ABSORPTION,AVEA (WALL Pjo
ADDITIONAL ABSORPTION
WELL
TYPE
BUILDING
FOUNDATION
_CONSTRUCTION
NEAREST
LOT LINE
CESSPOOL OTHER SOURCES
APPROVED DISAPPROVED
DISTANCES:
INSTALLED BY: 1 - (�f_ U
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form No. EQ -031
NEAREST
SEWER LINE
REMA
DEPTH _-
SEPTIC
TANK
DIAGRAM OF SYSTEM
IV
WELL
A) `�'� (% SQ. FT.
__ DISTANCE FROM:
SEEPAGE
SYSTEM
DATE
APPROVED
G.A.A.B.
(AL)
GREATER ANCHORAGE AREA BOROUGH ��3 �_�'/�
o� OIl • DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO.
II JI t 3330 "C" STREET ANCHORAGE, ALASKA 99503
L F TELEPHONE 274-4561
Y x
e`
SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT
NAME OF APPLICANT -
�Y/[/"'� -- G`2-<. �' --- MAILING ADDRESS
i'�� r X? V 17
PH(
INSTALLATION LOCATION
LEGAL DESCRIPTION ( d n -
INSTALLATION OF: SEPTIC TANK
J Gu' � 0.1'Jt^ ' I, -
( SEEPAGE PIT -,DRAIN
FIELD
OTHER
TYPE AND SIZE OF FACILITY TO BE SERVED
�y q
FINANCED THROUGHTO BE INSTALLED BY
7 —
SOIL TEST RESULTS �U2O �( P L J �l\i�7 NOTE: THIS PERMIT IS NOT VALID V14TIJOUT SOIL TEST
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK SIZE
TYPE
MINIMUM DISTANCES, REQUIREMENTS / )✓
FOUNDATION TO SEPTIC TANK �
FOUNDATION TO SEEPAGE PIT
SEPTIC TANK TO SEEPAGE PIT WALL
DRAIN FIELD
SEPTIC TANK SEEPAGE PIT , DRAIN FIELD
TO NEAREST LOT LINE. I
WELL TO SEPTIC TANK
DRAIN FIELD
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
0
SEPTIC TANK, SEEPAGE PIT
TO RIVER, LAKE, STREAM.
SEEPAGE AREA SIZE
SEEPAGE PIT �_O
ALSO CONSIDER AREA WELLS.
SEEPAGE PIT
DRAIN FIELD
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REG L-A NS REGARDING INSTALLATION.
G.A.A.B.
OR
LICENSED DESIGNER
TYPE
DIAGRAM OF SYSTEM
1 CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDI
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE,
� 7 ,
DATE APPLICANT'S SIGNATURE
1
FORM NO. EQ -01 6 /
,. z8•.6.® D THAT TH OVE
0/
�j
i
I �
I
�
I �
I
I
r
I
C"C�tI kl-
l
J
1 CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDI
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE,
� 7 ,
DATE APPLICANT'S SIGNATURE
1
FORM NO. EQ -01 6 /
,. z8•.6.® D THAT TH OVE
0/
�j
i
GAAB-"D' GR TER ANCHORAGE AREA BOROI 'i
DErARTMENT OF ENVIRONMENTAL QUALII Y
3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
_MAILING
�sy
NAMEA3'�GLj' �' ✓O/� S—ADDRESSX1—T���s_`—_—PHONE-
LOCATION
cl::DTTr TAKIV.
DISTANCE FROM WELLJ_�
LIQUID CAPACITYGALLONS.
SEEPAGE SYSTEM
NUMBER OF PITS
LEGAL DESCRIPTI
TERIAL� NUMBER OF
/��T�7-� ___.COMPARTMENTS �
/moi/ F�✓�//✓! /f ; ��l� //i =1
QUID
INSIDE LENGTH '--- INSIDE WIDTH_ � -- DEPTH__`='-
SEEPAGE PIT:
OUTSIDE DIAMETER OR WIDTH_ f LENGTH_DEPTH
LINING MATERIALS GAG- Cj��J' �J�. DISTANCE FROM WELL_Z,;� % ,BUILDING FOUNDATIONII
i
NEAREST LOT LINE Z�� > %4/j/ TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)—
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINE _ DISTANCE BETWEEN LINES
ABSORP-PON AREA
SQ. FT. LENGTH OF EACH LINE
NEAREST LOT LINE
TRENCH WIDTH
FT.
TOTAL LENGTH
OF LINES
IN. TOTAL EFFECTIVE
DEPTH: TOP OF TILE TO FINISH GRADE_._ DEPTH OF FILTER MATERIAL BENEATH TILE__IN, ABOVE TILE
WELL:DISTANCE FROM i WATER
-- TYPE Com!%l-l_G _, DEPTH G�z BUILDING FOUNDATION,.------ SAMPLE NEAREST
LOT LINE NEAREST`� SEPTIC �' / SEEPAGE i r_ OTHER
SEWER LINE TANK ��-
SYSTEM__�� , CESSPOOL- SOURCES --
DISTANCES:
DIAGRAM OF SYSTEM
N
DATE �!?/G/G�� APPROVED_'_-e;.C�__—_
G.A.A.B.
GREA I ER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. / -Y'I7
3500 TUDOR ROAD POUCH 6.650
ANCHORAGE, ALASKA 99502
SJ V TELEPHONE 279-8686
SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMITZ/zz
NAME OF APPLICANTMAILING ADDRESS
� PHONE
INSTALLATION LOCATION `"//(e,, /' / m °"`� /�C/
LEGAL DESCRIPTION �V —FS'
=I r"F����l�✓ &/r
INSTALLATION OF: SEPTIC TANK C'� SEEPAGE PIT DRAIN FIELD OTHER ,
TYPE AND SIZE OF FACILITY TO BE SERVED
JJn�—
FINANCED THROUGH TO BE INSTALLED BY
SOIL TEST RESULTS NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL /BBE SUBJECT TOv PROSECUTION.
SEPTIC TANK SIZE �^ �� TYPE /\ �1�.,' Ce��&L'/tE�EPAGE AREA SIZE
TYPE
MINIMUM DISTANCES, REQUIREMENTS DIAGRAM OF SYSTEM
FOUNDATION TO SEPTIC TANK
Vyr
FOUNDATION TO SEEPAGE PIT � DRAIN FIELD (
`>
SEPTIC TANK TO SEEPAGE PIT WALL ,
SEPTIC TANK SEEPAGE PIT `^'•L.� DRAIN FIELD
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK SEEPAGE PIT
DRAIN FIELD ALSO CONSIDER AREA WELLS.
WATER MAIN TO SEPTIC TANK /l SEEPAGE PIT
DRAIN FIELD
SEPTIC TANK, SEEPAGE PIT , DRAIN FIELD
TO RIVER, LAKE, STREAM.
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
- HEALTH AUTHORITY
OR
LICENSED DESIGNER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
DATE APPLICANT'S SIGNATURE
�- �,
GREAT' -R ANCHURAGE AREA BOROUGH
DEPPPT I TN P IN "i iF !L CAI S r,
3500 TUDOR ROAD
ANCHORAGE, P LASKA 99502
Performed For Bill Jones Date Performed
Legal Descrip�EionLOt-7 Block Subdivision Siefker
This Form Reports Soils Tie 1 -a -Ci 'on -T-P S —t
Depth
Feet Soil Characteristics
T—Brown silty fine sand (SM)
2—
Gray sand3-
4—.
6 Gray fine sand
7-
81
9--
10—
(Sw)
(SP)
Was Ground Water Encountered? no
If Yes, At What Depth?
Reading
Date
I
II
Reading
Date
Gross Time jyet Tillie Depth to H20 Net Drop
Proposed InstaMa�ion: Seepage Pit Drain Field
Depth Of Inlet ------Depth —T6 —Bottom Of Pit Or Trench
COMMENTS:
170 square feet per bedroom of dr required.
e_q 1
_q�red
re—sT7e—rTOrme -TTy--R—E--Car Tii-sle---Tai—t '-T-e-r-t iT�ipT-Ty :
NATIONAL TESTING SERVICES, INC. Date:
8e-Pt€=b(-x 23o 7.977
O7 590
William milt lt.
Star ROUta A Box 1554P
Anchorar;�, Wasim 99507
6iY11j,�H3Ct® f ]"T. Xnira11:iol-I
A Permit :issued k -)y t1li.s d(Nl.)artil�nt for W,
all itX1[t/cjr oil -site
seller illstal_latiOyl 01, Lot 7 Siefter subtly visaion Y1cts e�l7ir;�ti
:aizaco the: issue, ao'tfa OXCechds one (1) Year.
In the event yoYt st-.ijj l>],aaa to i.nstaI.1 the aaell and/or on-sito
.saevier rj.VstOj-o, e`a XIOW l7OXPlit is d"E?[(iti:C ed, The origi tj Soil.
test May be used to ohl:uin a Current, porglita
xf t1a€1 17p_ll ba -q be -011 €1a-i.17.ra�3, a Yve:l:l 10cf 8110"Id be sent to.
tlai,s rlo`1F':`tTf (!nt tO d0cmul-,Ont t1le instill :la't. ton cl€tie .
�f
YOU have any c tY E3$ i,c;rli€, ] c�gu]'c1i a(f t11c) above 1,mitter, please,
do
4720 -lot 1108itat0 to collta c+ Of
41ais ic() iTtMedixtely at 264—
Sincerely,
Sanitarian
J iND/l j 1a
. L :I J AHY flow TO KA FP--II us ER:
SAO: -2201.
1 WC 115 �10 ob waS
I f 'I I 11-'-' F'! F1 C! I
j. TY Iq
1 WC 115 �10 ob waS
'.'ATEH WELL DRILLERS LOG DO NOT FILL IN
Drilling Co. USGS No.
Driller�azZ Area
Well Owner /!,.��g,�/ tse of well
Location address ; Township, Range, & section, if known; or distance from main
road
141
casing �, Depth of hole Po y-' feet Cased to �j"S/' feet
Static water level' feet (above)(below) land surface. Finish of well (check
one) Open end ; Screen ( ); Perforated ( ).
Describe screen or perforations
Well pumping test at -- /,/ —gallons per ho
_ feet of drawdown from static
Remarks
Well 3o
Depth in feet from Give details of formations penetrated, size of material, color,
r— ground surface and hardness.
O to 417
to
to
to
to
to
to
to
to
to
to
to
to
to
to
to
gT�CNO[iGf a,tl II i ��
N
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
%Lo„nL.QY,, 3330 "C” Street, Anchorage, Alaska 99503 274-4561
Ott
Date Received March 1, 1976
Time of Inspection-�
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Conv.
1. Approval requested by: First National Bank of Anchorage
Mailing Address: post Office Box 4-2090 Phone: 2741521 x 39
2. Property Owner: Billy R. & Agnes Y. .TonesPhone; � Ll�Cn262sc Y
Mailing Address: Star Route A Box 1549M, 99507
3. Legal Description; Tract 7 Siefker Subdivision
4. Location: C:ange Street
5. Type of facility to be inspected Single Family
6. Well Data: Individual
A. Type/z/—)
C. Construction gaLL-14
7. Sewage Disposal System::
A. Installed
C. Septic Tank: 1. Size
B. Depth
No. of bedrooms
i
M
D. Bacterial Analysis
B. Installer
2. Manufacturer
D. Seepage Pit: 1. Absorption Area 2. Material
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank , Absorption area Sewer Lines
Nearest lot line Other contamination
B. Foundation to septic tank Absorption area
C. Absorption area to nearest lot line
EQ -034 (1/74) Page 1 of two
pages
Page 2 of two pages -• Re it for Approval of Individual ,r & Water Facilities
Legal Description Tract.7 Siefker Subdivision
Comments
Approvedt/Jdn�l�(/, „�..(°2. Disapproved Date i
— Approval Valid for. one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
i cerci I LrlaL LnC I n I ur'Il la L I ur I Gun La Irwu I LrlIS L TUI' dPPr'u VaI Lu uC a Lr "UC CmU
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
EQ -034 (1/74)
Date
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" Street, Anchorage, Alaska 99503 — 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
MUNICIpAI,ITY OF %Q-I0IMor'-_
DEpt. OF fIFA. LIII %
1NVIItON,,91Nmn, I'f0TECTI()tq
I. Type of Inspection: CMRO VA FHA CONV X
2, �� — Interim/Long Term ') �' 0 - 1� 8 Vic.
Mailing Address: SRA Box 1549 M Anchorage 99507 Day Phone me—&°N` L-uLc)2D_9
3. Name of Buyer: ___Billy R. & Agnes Y. Jones
Mailing Address: SRA Box 1549 M Day Phone
4 Name of Lending Institution: First National Bank of Anchorage
Mailing Address: P.O. 4-2090 Phone 274-1521 ext. 39
5. Name of Realtor or Agent: none
Mailing Address:
G. Legal Description: Tract 7 Siefker
Location: _-q_ Can_ggSt. Anchorage, AK
Phone none
7. Type of Facility to be inspected: -house -LW1('_No. Bdrms. 3
3. Water Supply
Type of Supply: Public Utility Individual
If Individual, number of dwellings presently served
If Individual, depth of well
9. Sewage Disposal System
Type of System: Public Utility
If Individual, date of installation
EQ -037 (1/74)
Individual (on-site)
mare, 31t 1976
r
Firat National.`
t .
Post Offleo Osx iz`2090
aSWd5` Q : 3/ aot f !.}.Lafhew
r a'. gg �.a
. 1Lk� pro;
'�r4`ty 4 9 x In k'�,.k�xY"{'.4t.1ii>�1, L s&'�t? .''`! 3°4t .1 '�# '4 tory
bacteriological. -Arnt ,yo1gr r7bAl, S3C"Lser Ayst/!'Ib ,f,�l�'r Y1�4`i3��4A
&�, ,' } ,: C#�l area :`.fi:k { kf b.,P ,�. z"}�' `ikT: :"-� ,�1 ✓fP i:I) T)c?/ `{:7i"JZ1 'F� .+: ?7I5!": [�.`,'.
211 seer li m«yn4:ry tzonci,, atteio;Svei tv tho K res i >�, f3oeglayr Pit 7:)y
Jane 30, 1976 suffl.c.,
"4t«4 4 mull ' he me-?rix'a tpo �"!� i •x +ta (�,`; }
lovel than the crt) i2 ",
\1
i
Los JK,n �,Ucllllolt °
CO Billy Jonem.
2.
N
4.
5
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" St., Anchorage, Alaska 99503 - 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER R WATER FACILITIES
Type of Inspection: CMRO
Property Owner: Y7_
Mailing Addres
Name of Buyer:
Mailing Address:
Name of Lending Institution:
Mailing Address: lv -
Name of Realtor or Agent:
W11
FHA
Day Phone
Day -Phone
Phone --
C 0 N V I- -i
s,G•.
Mailing Address: Phone
6. Legal Description:
Location:
7. Type of Facility to be inspected: No. Bdrms. _
8. Water Supply
Type of Supply: Public Utility Individual
If Individual, number of dwellings presently served_
,i
If Individual, depth of well
9. Sewage Disposal System
Type of System: Public Utility Individual (on-site)
If Individual, date of installation �����—
EQ -037 (1/74)
Page 2 of two pages - Re
Legal Description
st for Approval of Individual er & Water Facilities
Approved
Disapproved
Date ��/�) ;�
Approval.Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
• ,CrL.IIy L-naL wie-Inrorma7cion contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
EQ -034 (1/74)
Date
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received
Time of Inspection
s -
Date of Inspection
REQUEST FOR APPROVAL OF
1 INDIVIDUAL SEWER & WATER FACILITIES
FOR
1. Approval requested by:
Mailing Address: _ S. ij. �!j r - i.5 `� j� Phone
2. Property Owner:
C
Mailing Address:
Legal Description:
4. Location:
5.
6.
�• ._- � � a `tJ � Grp-,f�. r�
Type of facility to be inspected
Well Data:
A. Type. l �.
C. Construction
7. Sewage Disposal System:
A. Installed
C. Septic Tank: 1. Size
Phone:
jz/s/- Zz':j
No. of bedrooms
B. Depth
D. Bacterial Analysis
B. Installer
2. Manufacturer
D. Seepage Pit: 1. Absorption Area 2. Material
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank , Absorption area Sewer Lines
Nearest lot line , Other contamination
B. Foundation to septic tank , Absorption area
C. Absorption area to nearest lot line
EQ -034 (1/74) Page 1 of two
pages
EV 5;OR GER II;IFD MAIL -1004 (pills ,..5t_ago)
i SENT 'f0
P {RK
0.. .,ATE
I:
STREET AND N0.—
t CX) P.O., STATE AND ZIP CODE --
I
OPT_IGNA SFRVICE_5 FOR ADDITIONAL FEE$
RFJURN 1. SIIDVS to Win or nnrl data de -11—Y d
[[�� Witll deliver to addressee only 65�
9iune U 17 IEf.£IPT Y
1 I SiRVICES 2• Shows to whom, date and w0ere Jelwered .. 35V
With delivery to addresonly ....... 85e
n _ DELIVER TO ADDRESSEE -ONLY see - -S - -- —
I SPI CIAL DCLIVERY (extra foe roquiraJ) SOt
f-0 PS Iarm
P 1971 3000 NO INSURANCE COVERAGE PROVIUEO_
I
NOT FOR INTERNATIONAL MAN. See other 0;743
+r CPO :1972 O - 400-793
Mr. Billy it. jotips
SHA Box 1549 -int
Anchorage, %K 99507
SUBJECT: Sevier and water approval for Lot I Siefker Subdivision,
Year Sir:
The 50140r system serving the subject lot was inspected and
approved by this department on Sept a-mLter ICI,, 1 J7Y 4
The well serving the subject let -is pr(,?SeI1tly in a €31 t- arta
cannot be approved at this time. Also, giro wattor sample
dP4WY} had a 001iform bacteria count of Z.2/10[t cc which Is
also unable to approve,
Be, fore 2PPrOyfll coon be �)ranted the well casing trrill teed to be
brought 12 i►iches above ground level and the Vit fi l 1p psi th
impervious sail. There moist: t,(! a Sanitary seal an the head
Of t*TQ W011 casing. Enclosed is the procedure you gonl<.9
follow to chlorinate your well. ,After the well it; r lafiAirsute^(t
tura will resample, and if the Construction of the VG11 is sat-
isfactory.. and the bacteria count Of the nater is zero, then
><O will drive our approval.
1f ,you Piave ally (luestions cOacerniny this matter, P1 as) call
mO at 274-4561 Oxtension 137.
Sincerely,
Robert C. Pratt
Covironmental Control officer
RO/sr
Enclosure
cc. 1st UtlOgal Bank of Anoorage
G�
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program 5 E t r
4700 Elmore 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. 2411 —2f4 COSA# �CJ` aOS
Expiration Date:
9. GENERAL INFORMATION- /
Complete legal description _ t SI
Location (site address) Z Dom(( e r g P 5
%Jn s P, . L ly —mist
Current Property .owner(s) Gi' a Vv Day phone
Mailing address
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS; 3
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL'
Individual Well Individual On-site
Individual Water Storage ❑ Individual Holding Tank ❑
Community Class Well ❑ Community On-site ❑
Public Water System ❑ Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a 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.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seat affixed hereto and as of the validation date shown below, f verify that my.investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the onsite water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and We 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 Mirk tom( /1r pr .vim f0, P . Phone '3 4;;—
Address 4 (r fa ( (A �c
Engineer's Printed Name PA IA Date & 1711 Iz—
oma;°J
/ . . ....
5. DSD � c :MICHACEE%N9ANDERSON :�,4�
SIGNATURE
_ Approved for 2 bedrooms./.���
Disapproved;
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X Arsenic Advisory
Maintenanoe.Ag reements
Supplemental Engineer's Report
Other .
By: Original Certificate Date: Cay _ /3 J2 ---
/Rev 11105)
Municipality of Anchorage
• "� Development Services Department°
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SY
I STEMS APPROVAL CHECKLIST
Legal Description: S / a t- �Lz� 4"u C 7 ? Parcel ID:
A. WELL DATA
Well type -Qrkv w If A, B, or C provide PWSID # Well Log (Y/N) --
Date completed W(03 Sanitary seal (Y/N)Wires properly protected (Y/N)_
Total depth -LI-L-ft. Cased to ft. Casing height (above ground) n.
FROM WELL LOG AT INSPECTION
Date of test Z (._1!4 2
Static water level 2 S ft. Z `% ft.
Well production i g.p.m. 7Z f- g.p.m.
WATER SAMPLE RESULTS:
Coliform �colonies/100 mL Nitrate !j�_1img/L Collected by: � 11 ti L �'^ � s g
Arsenic: � ug/L date of sample: �3�y
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material CO Ln ry t te— l r�r ` Date installed
Tank size / �5 D gal. Number of Compartments wm4&Y#wvr Cleanouts (Y/N) Y
rv,aw t SP d te—
Foundation cleanout (YIN) _ Depression over tank (YM) 2_4 High water alarm (Y/N,)
Date of pumping 15-L i -z-- Pumper /4 u0v �_ d fti2 c (U a ri..
C. ABSORPTION FIELD DATA
v,,(,,&
�
Date installed q /U Soil rating (g.p.d./ft2ftzlbdr fe�0 System type Cj( ',' y'-'rkr �.
Length Iq ft. Width /` f ft. Gravel below pipe
Total depth A— ft. Eff. absorption area 31W Monitoring tube Depression over field,
Date of adequacy test Results (Pass/Fail) ,r. S S For 3 bedrooms
Fluid depth in absorption field before test 3L in. Water added 400 al. New depth in.
Elapsed Time: 1N, min. Final fluid depth 30 in. Absorption rate >= ASO f` g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) v7 u w rl If yes, give date /
D. UFT STATION
Date installed
"Pump on" level at _ in.
E. SEPARATION DISTANCES
Size in
Cycles tested
at in.
(YM)
High water alarm level at in.
Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:`/�I
Septic tankAiil chin on lot 'YD wa, via " On adjacent lots / rJ 0
Absorption field on lot !u 0 t �-
Public sewer main do h a-
t
Sewer /septic service line S 0 'i*
Animal containment areas /00'i
On adjacent lots lot) 1 4 -
Public sewer manhole/cleanout 1`4014e�
Holding tank 6b'n [W J40Nr�
Manure/animal excrete storage areas /00
r�
SEPARATION DISTANCES FROM SEPTIC/htOLMG TANK ON LOT TO:
Building foundation `Z- 0 1 Property line Z0
r -4- Absorption field -Z,,)
{ {
Water main t--( Id, Water service line 6J'+ Surfacewater 100 1
Wells on adjacent lots / u O 4 -
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 201. k Building foundation S Dr a' Water main /t9 D)
Water Service line NO � � Surface water too Driveway, parkirglvehide storage 70 r �
Curtain drain U" k4,0Ly ✓t Wells on adjacent lots lyr/t .l
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that t 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 hilt"r1X( 4 d el5o.//
Date
2
COSA Fee $ i0
Date of Payment:—
Receipt Number
(Rev. 4110)
Waiver Fee $
Date of Payment
Receipt Number
. :49LH*
A..... 4 ..'!'Ko 00
,% MICHRETBAMPOERSCN ;,`�00
s CE -94 9
Municipality of Anchorage a
Community Development Department
Development Services Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
Nitrate Advisory
Certificate of On -Site Systems Approval # 121205
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
of Siefker Tract 7 subdivision. This inspection revealed a nitrate
concentration of 7.59 milligrams per liter (mg/L) was reported for the
property's well water sample. The Environmental Protection Agency (EPA)
has established a maximum contaminant level (MCL) of 10.0 mg/L for
public drinking water systems. While private wells are not subject to this
regulation, EPA standards are based on existing health information and can
therefore be used to gauge the relative quality of water from private wells.
Please see the attached "Nitrate Fact Sheet" for important information
regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
SGS
SGS Ref.#
1121936001
Client Name
Mike N. Anderson, P.E.
Project Name/#
12041 Cange St
Client Sample ID
12041 Cange St
Matrix
Drinking Water
Sample Remarks:
Printed Date/Time
06/06/2012 15:44
Collected Date/Time
05/31/2012 14:30
Received Date/Time
05/31/2012 15:00
Technical Director
Stephen C. Ede
Allowable Prep Analysis
Parameter Results LOQ Units Method Container I Limits Date Date Init
Metals by ICP/MS
Arsenic ND 5.00
Waters Department
Total Nitrate/Nitrite-N 7.59 0.100
Microbiology Laboratory
E. Coli Negative 1
'Ibtal Coliform Negative 1
ug/L
EP200.8
C
(Q0)
06/01/12 06/04/12
NRB
mg/L
SM214500NO3-P
B
(<Io)
06/04/12
AYC
I00mL SM219223B A
100mL SM219223B A
05/31/12 DLC
05/31/12 DLC
2 of
t
LIJ
LTJ
CD
Z
U
50 `
PLAT NO. P-286
SIEFKER SUBDIVISION
TRACT 7
46,200 S.F.
N 90000'00"E 280.00'
REVISED 6/13/2012 ADDED CLEANOUT
AS -13U I LT
167.3'
GASTALDI LAND
PROPERTY DEPICTED ABOVE AND THAT NO
SURVEYING, LLC
ENCROACHMENTS EXIST EXCEPT AS INDICATED.
If IS THE RESPONSIBILITY OF THE OWNER TO
JEFF A. GASTALDI, R.L.S.
DETERMINE THE EXISTENCE OF ANY EASEMENTS,
2000 E. DOWLING RD., SUITE 8
N
N SHEDAWNING
ri
PHONE 248-5454
UNDER NO CIRCUMSTANCES SHOULD ANY DATA
GRID
DATE
20.0'
2735
5/24/2012
24.0'
X'X'X
ANCHORAGE RECORDING DISTRICT, ALASKA
TX�x o
FENCE j
n STORAGE
CLEANOUT-.•
(APX) _
O(IS77NG
X
CLE4NOUT • NG
j
x
SEPTIC 2.0' COV,
x
CONC
VENT ENTRY
L—X (
o
0
DECK P,9.4•
J
o
n
weu
10.01
o
3
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s.�
3
M
p
Iv
M
O
O
0
O
e
Z
O
Z
SHED u
4.0'
GRAVEI.ORNE
REVISED 6/13/2012 ADDED CLEANOUT
AS -13U I LT
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
GASTALDI LAND
PROPERTY DEPICTED ABOVE AND THAT NO
SURVEYING, LLC
ENCROACHMENTS EXIST EXCEPT AS INDICATED.
If IS THE RESPONSIBILITY OF THE OWNER TO
JEFF A. GASTALDI, R.L.S.
DETERMINE THE EXISTENCE OF ANY EASEMENTS,
2000 E. DOWLING RD., SUITE 8
COVENANTS OR RESTRICTIONS WHICH DO NOT
ANCHORAGE, ALASKA 99507
APPS ON THE RECORDED SUBDIVISION PLAT.
PHONE 248-5454
UNDER NO CIRCUMSTANCES SHOULD ANY DATA
GRID
DATE
HEREON BE USED FOR CONSTRUCTION OR FOR
2735
5/24/2012
ESTABLISHING BOUNDARY OR FENCE LINES.
ANCHORAGE RECORDING DISTRICT, ALASKA
F.B. JOB NO.
SSTR7 NOTE: NO CORNERS SET THIS DATE.
1 11=30'