HomeMy WebLinkAboutSOUTHFORK BLK 5 LT 1Onsite File
Southfork
Block 5
Lot 1
#078-031-08
The berm shown on OSP211484 shall
remain in place or the septic system will
be deemed out of compliance due to
proximity to surface water.
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: PID Number: 078-031-08
Dwelling: X Single Family (SF) 0 with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade
Name
Danny & Carol Crow
ABSORPTION FIELD
El Deep Trench El Wide Trench El Bed El Mound
Site Address
1421 South Creek Rd.
❑ Other
Phone
907-250-3154
Number of Bedrooms
3
Soil Rating
Existing
Total depth from original grade
GPD/SF
Ft.
LEGAL DESCRIPTION
to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Southfork 5 1
Fill added above origin de
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number o ' es
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. betw trenches
From
Tank
Field
Tank
Line
Ft2
Well
>100r
N/A
N/A
N/A
>25
TANK ❑� Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Greer
Capacity
1250 Gal.
Surface Water
41'
N/A
N/A
N/A
Material
Steel
Number of compartments
2
Lot Line
>5'
N/A
N/A
N/A
NA
Foundation
>1o,
N/A
N/A
N/A
LIFT STATION
Nar,ufacturer
Capacity
Remarks Tank installed in 2011 without permit or inspections
Gal.
Alarm location
installed by
Installer
PIPE MATERIAL House to tank D3034 drainfield Tank to
D3034
Owner Installation
Drainfield Existing CO/MTD3034
Inspector
BENCH MARK (Assumed elevation) 100 ft
Inspection 15, 10/11/11
Location and description
dates: 2nd
Threshold of back door
3rd 4m
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Approval: axxtu Date I 13aoa1
P��sConditional
.
&_rm +D be Cov1S-6-L/,c-k_J b I� 15 Z,ozz.
Q'�'
®� An
..........
Septic System
% Benjam,,5chiller %
Approve Date
�••. /
F� CE 12592
'slF • , 11/23/21 , . •*,e
k)l F, PROFESSIONP��®�
Note: this approval does not include wee permit requirements.
0�
Benjamin Schiller
CE 12592R
E
GISTEREDPROFE S S I O N A LENGINEER1"=50'
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
PERMIT # OSP______PID # 078-031-08
SOUTHFORK, BLOCK 5 LOT 1
A B
SV1 22.6
SV2 30.2
AB
16.0
23.2
FEET
0 50 100
BERM DETAIL 3-BDRM HOMEGARAGE
EXISTING WELLS w/
100' RADII
EXISTING BED
NEW MT
1250-GAL SEPTIC TANK
SV1
SV2
PLAN AS-BUILT
25' CREEK
MAINTENANCE
EASEMENT
10' T&E EASEMENT
2CO1 20.514.6
2CO2 35.328.0
2CO1
2CO2
CREEK MEANDER LINE
BUILD BERM TO
PROVIDE 100'
OVERLAND TRAVEL
BEFORE REACHING
CREEK
REMOVE ALL ORGANICS
FROM UNDER BERM
PRIOR TO BUILDING
1'
NTS
2'
IN-SITU SOIL
12/13/21
PROFILE AS-BUILT
(NO SCALE)
1250 GAL
SEPTIC TANK
Benjamin Schiller
CE 12592
R
E
GISTEREDPROFE S S I O N A LENGINEERNovember 23, 2021
PERMIT # OSP______PID # 078-031-08
SOUTHFORK, BLOCK 5 LOT 1
91.8
87.7
92.4
95.9COSV
91.4SV2" INSULATION
Hiland Excavation LLC
--Po-box-7-72752----_. _.
Eagle River, AK 99577 US
hilandexcavation@gmaii.com
INVOICE
BILL TO
Alisa Parrent
DATE ACTIVITY
06/16/2022 Services
DESCRIPTION
Remove old septic tank and dispose of,
dig 1 00'trench per engineer design in
order to provide overland travel.
BALANCE DUE
Page 1 of 1
s
HIL/;I�iLJ RR
EXC/&V/&T10N
fOR ALL TO UR DIRT WORK H E USM11L541419
INVOICE
1035
DATE
06/18/2022
TERMS
Due on receipt
DUE DATE
06/18/2022
QTY
RATE AMOUNT
1
2,200.00 2,200.00
$2,200.00
25'
CREEK
MA
INTENANCE
EASEMENTEDGE OF PAVEMENTLOT 5
10' TEL. & ELEC. EASEMENTLot 1, Block 5
Southfork Subdivision
98,900 Sq. Ft. +/-
1421 South Creek Road
2 Story Wood Frame House
with Attached 2 Car Garage &
1 Story Wood Frame Art Studio
N85° 03' 39"W 219.
9
9
'N20° 38
'
55"W
149
.78
'N25° 03
'
54"W
29
.78
'
N89° 54' 22"E 20.08'10' UTILITY EASEMENT3
0
'
R
.
O
.
W
.
W
TE
N0° 06' 18"W 565.83'20.320.3SS
DETAIL "A"
SCALE 1" = 25'
NORTH EDGE SOUTH FORK EAGLE RIVER
LOCATED 10-28-2021℄ SOUTH CREEK ROADART
STUDIO
13.0
9
6
.
5
1
1
2
.
4 DIRT
DR
IVEWAY 199.3L=95.81R=319.42CULVERT6.1
81.5
50.2SS
SS
S
SSN36° 31' 26"E 367.60'41.956.2
40.1 100' WELL RADIUS36.1
46.9
44.4
40.220.3
14.312.913.06.0
6.0
6.2
24.1 20.124.1
20.12.3
1.0
2ND STORY
KICKOUT
G
E CONC
R
E
T
E
BOLLA
R
D
1.0
WOOD
RAMP
WOOD
DECK
TYP.
6.1
PROFESSIONAL SEAL
Date:Frontier Surveys, LLC Project No:
650 W. 58th Ave. Suite E Anchorage, Alaska 99518
As-Built Survey of:
www.frontiersurveys.com
Frontier Surveys, LLC
I, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or
under my direct supervision on
Plat:Grid:Ordered By:
907.460.1686 - info@frontiersurveys.com
This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and
conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any
inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the
existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances
should this document be used for construction or for establishing a boundary or fence line.
November 18th, 2021.
Legend:
Scale 1" = 70'
Electric MeterE
Lot 1, Block 5 Southfork Subdivision
General Notes:
1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws.
2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey.
3. All measurements/setbacks are to the visual/apparent building footprint.
4. All dimensions to property lines are plus/minus 0.1ft.
Alisa Parrent
21-861 Rev. 4 12/01/2021
82-121 1059
E Elec. Pedestal Tel. Pedestal
STA T E O F ALA
S
K
A49 TH
ROYEVRUSDNALLANOISSEFORP
DERE
T
S
IGER Pierre M. Stragier
NO. LS-9812
12/10/2021
T
Wood DeckGGas Meter SepticS
Water WellWMetal Post
STREAM
MEANDER LINES
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: OSP211484
Work Type: SepticTank Upgrade
Tax Code Number: 07803108000
Site Legal Address: SOUTHFORK BLK 5 LT 1 G:1059
Site Mailing Address: 1421 SOUTH CREEK RD, Eagle River
Owner: CROW DANNY L & CAROL S
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
Effective Date
Expiration Date:
11�cnt-
♦o
n
L)ei)artine.nt
Lot Size in Sq Ft:
Total Bedrooms:
12/13/2021
12/13/2022
•S•11
❑ 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
Special Provisions: "This permit is to document a septic tank that was installed without a permit.
Received By: Date:
Issued By: Date: % '2 % 3 -2
3
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 078-031-08
Property owner(s) Danny & Carol Crow
Mailing address PO Box 2126, Seward, AK 99664
Site address 1421 South Creek Rd
Day phone 907-250-3154
Legal description (Sub'd., Block & Lot) SOuthfork, Block 5 Lot 1
Legal description (Township, Range & Section)
Lot Size 98,900 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) ❑x
Septic Tank
INUpgrade
❑X
(w/wo AD U)
Holding Tank
El
Renewal❑
(D) ElRenewal
Privy
❑
Multiple Dwellings ❑
(SF and/or D)
Private Well
❑
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.
t,g
(Signature of property owner or authorized agent)
Permit/Rush Fees: 'M 2 � 5 Waiver Fees:
Date of Payment: 11 002021 Date of Payment:
Receipt Number: Receipt Number:
Permit No. 0 S 1 Waiver No.
Permit App_'- ::-.,:c
MUNICIPALITY OF ANCHORAGE
of DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
*0
825 L Street - Anchorage, Alaska 99501 Telephone 264.4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION
REPORT
NAME
PHONE
Eig4EW
_ '
LVel— Z71ZI
❑ UPGRADE
MAILING ADDRESS
?3ox JS- - t9-6- el Lf K- �
_ �� J
LEGAL DESCRIPTION
Z_e) / DSL G S Sv �&7 Aj
LOCATION
NO. OF BEDROOMS
Wellh
Absorption area
Dwelling
PERMIT NO.
U Y
DISTANCE TO:
N
f
13
FZ
W�
Manufacturer
2
Material
No. of compartments
Z
��
rn
Liq. capacity in gallons
IF HOMEMADE:
Inside length
«.- -
Width
Liquid depth _
J
0 YDISTANCE
TO:
Well
Dwelling
PERMIT NO.
JV`Z
= z F
Manufacturer
Material
Liquid capacity in gallons
D
Well
Foundation
Nearest lot line
PERMIT NO.
w=
DISTANCE TO:
J LL z
No. of lines
Length of each line
tal length of lines
Trench width
Distance between lines
F Z w
inches
Top finish
Material beneath tile
Total effective absorption area
cF
of tile to grade
p
inches
LU
Length /
Z J
Width -7
3
Depths /
6 S J UAI'D I 10 DY 2
PERMIT NO.
E) lL`�
Q a.'
Type of crib
Crib diameter
Crib depth
Tot effective absorption area
W
to
WellAll
Buildin ¢ruti?i ation
Nearest lot line
/
DISTANCE TO:
I
Class
Depth
QrjjllEr/ I
Distance to lot line
PERMIT NO.
J
J fj
LU
Building foundation
Sewer line
Septic tank
Absorption area(s)
DISTANCE TO:
OTHER
PIPE MATERIALS
y�
SOILTESTRATING
qq
INSTALLER
sem.F -K.
REMARKS
m
J.
,s n
Pu.
A.Sha§,r
APP ED DATE LEGAL
�'
a`
72-643.,(Rev. 3178)
����I #:� I I— F=4 P I _T 2-ru CH F=- ����F_-1 F:� ID��
^ `
DEPARTMENT � HEALTH AND ENVIRONMENTAL :OTECTION
` 825 i/ STREET' ANCHORAGE, HK. "'-c1
^^' 264-4720
- L -j F- L_ L_ ��� I 'TE7 &-I E7 F�-? ���F;-co It -1 1 -r*
PERMIT NO. ( 8]0412 )
APPLICANT DANNY L CROW 1675 BLUE SPRUCE LANE 688-I528
LOCATION
LEGAL LOT 1 BLK 5 SOUTH FORK SUB LOT SIZE 999999 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: BRHINFIELD
MHXIMDM NUMBER OF BEDROOMS = ] SOIL RATING (SQ FT/BR)= 140
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
�D V:- F, -F H �� -t !ffa:E�ft aD Fen %0 F:- I ���-11 "� �
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
-F " FE �Fi! E: P -A #:� " ��I E"m _F " I f 3
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
���UlF-'1—=E-9 �F::�r-jK ��12:E-= -1 �F::§L-1 CffP-J!S`
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
�i.-A co
pA,= F::4 F:R::. ��E7
�FE C-! U I R. -'F= C-
BHCKFILLING OF
HNY
SYSTEM WITHOUT FINAL INSPECTION AND
APPROVAL BY THIS
DEPARTMENT WILL
BE
SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]0 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
�FEE �11-1 TL -IF ���I Fm� F=!E. C -o 1—= 9--- E� lr-1 ED EE FZ �-1L� ����-:-:*
I CERTIFY THAT
I. I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2� I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
]� I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ]' BEDROOMS.
i .'1
SI
ISSUED
V4.0
MUNICIPALITY OF ANCHORAGE
Department f Health and Environmenta- Protection
825 Street, Anchorage, AK. � 9501
264-4720 <
Permit #�# # # HANDWRITTEN PERMIT
n r�Et-E- IGR ON-SITE SEWER PERMIT
Applicant: .0Mailing Address:
Location: Pho/-e Number:
Legal Description: Lot Size:
Type of Soil Absorption System Is:
Trench: Drainfield: Seepage Bed: A Holding Tank:
Maximum Number of Bedrooms: Soil Rating(sq.ft/br) 1125 -
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH GRAVEL DEPTH 6o1 J WIDTH �0 I
°d it
The length dimension is the length(in feet) of the treAch �or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(H ) TANK SIZE = tU`0 GALLONS # #
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * TWO(2) INSPECTIONS ARE REQUIRED # # #
Backfilling of any system without final inspection.and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
# * * PERMIT EXPIRES DECEMBER 31, 1 9 3 3
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlar e ent if
the esidenc is remodeled to include more that be ooms.
Signed: Issued by:
A plicant h�
Date:
SWP/024(1/81)
t'
✓, SOILS LOG -
MUNICIPALITY OF ANCHORAGE
`� ac DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMED FORM �CW%CCJ� t DATE PERFORMED: Qr )_-3z
LEGAL DESCRIPTION: 6uuil t�Gr-K nIJ3 . oc- S LCAT1y
t ( SLOPE —� SITE PLAN
r_2
3
a
_4
5 ^
6-
8 8
9-
10
11
12
13
14-
15-
16-
17
4151617
18
19
20
COMMEN
WAS GROUND WATER S
ENCOUNTERED? L
O
P
IF YES, AT WHAT /7' E
DEPTH? / i
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
TEST RUN BETWEEN
PERFORMED BY: C0kC FCjZL,3n().a bm<-�(� CERTIFIED BY:
72-008 (6/79)
FT AND
(minutes/inch)
-- FT
DATE:— 6"—
PERFORMED FOR:
LEGAL DESCRIPTION:_
DEPTH
(FEET)
1 I Flv�i-
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
SOI LS LOG Y
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
V, L C
Bi
M 16M � O cl Z /Z- // to
C� '711 v e- -y CjA wj -
cI rll. +
DATE PERFORMED:
G.� t l
PE SITE PLAN
WAS GROUND WATER j / SLev, /111
ENCOUNTERED? /l�,0 L
O
P
IF YES, AT WHAT E
DEPTH?
i
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
TEST RUN BETWEEN
PERFORMED BY: A4AcrAKLANAe CERTIFIED BY:
72-008 (6/79)
(minutes/inch)
FT AND FT
DATE: „)�
4
f
f�( SOILS LOG
MUNICIPALITY OF ANCHORAGE
+.� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: /. V'sl0-+(.1T�I DATE PERFORMED:_ C
LEGAL DESCRIPTION:_ �c7:it✓�- ir�w�C, IJ K J I.O l I 4►
pt- / SLOPE SITE PLAN
2
3
4-
5-
6 56
7
9
10-
11
12
13-
14-
15-
16-
17
314151617
18-
19-
20-
COMMENTS
81920
COMMENTS
1 f o -VI
Ai f.9
WAS GROUND WATER/'
S
ENCOUNTERED?
7� C'7L
Depth to
Water
O
P
IF YES, AT WHAT
E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
TEST RUN BETWEEN
PERFORMED BY: /WC- rA&}/0' CERTIFIED BY:
72-008 (6/79)
FT AND
(minutes/inch)
— FT
DATE: — 'ti J-
DRILLER'S NAME
PVUMUPDA TY OFHcc=ORAG
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. 078-031-08 Expiration Date: Iy�3 , 2b 22
1. GENERAL INFORMATION
Complete legal description Southfork, Block 5 Lot 1
Location (site address) 1421 South Creek Rd
Current property owner(s) Danny & Carol Crow Day phone
Mailing address PO Box 2126, Seward, Alaska 99664
Real estate agent Alisa Parrent pay phone (907)250-3154
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:
Private Well
Private Septic
❑Q
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee CLQ + Z %0 Waiver Fee $
Date of Payment 2 l 2 i Date of Payment
Receipt Number C��6 2 �(� �' 053 Receipt Number
COSA# 03G21 Waiver#
Distance:
---5—S-T-ST-T-OF-INSPECTION-B-Y-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
Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller, P.E. (M.J.)
6. DSD SIGNATURE
System #1 Approved for 3
System #2 Approved_for
Disapproved
Conditional approval for 3
bedrooms
bedrooms
Phone (907) 522-7773
Date 11/2/21
*�49 TH
,G\l • * /
.-
Benjarq*rvSchiller
1E1/2/2192
E! 292 •F��'�,�'r/
PROFE00 .�
bedrooms, with the following stipulations:
'* Berm To be ConS�yc4 d , a& skow n a?i en j i ne e r' S S i
VVHI tK ANU
By: Original Certificate Date: 120120-m
2
The Municipality of Anchorage Development Se ices 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
COSA Checklist blue sheet
COSA Checklist yellow sheet
COSA Checklist
Legal Description: Parcel ID:
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)
Date drilled
Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test?Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date of Sample
Comments __________________________________________________________________________________
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA ______________________
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 gallons
Adequacy test date
Results Pass For bedrooms
Fluid depth prior to test 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
Comments/Deficiencies:
*
Note: Tank is not originial and was installed without a permit. Resolution pending
Southfork Sub, Block 5 Lot 1 078-031-08
■8.5+
May 1984
60
60 ■
0.260■
■■
16 Forge Engineering
11/1/21
19
10/13/21
10
Septic/Steel
49
■
JR's Septic 6/21/21
Absorption Bed
5/29/1983 11/1/21
■3
2.95*0
2.65*1436
3
■
200
0.3 1
1440
*Depth measurements closely match original inspection report. Change in grade explains any discrepencies.
✔
COSA Checklist yellow sheet
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 ft
Neighboring Tank > 100’Yes if No ft
Absorption Field on Lot > 100’Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’Yes if No ft
Holding Tank > 100’Yes if No ft
Animal Containment > 50’Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
From Septic/Holding Tank on Lot to:(Please enter distances if less than required)
Building Foundations > 10’Yes if No ft
Property Line > 5’Yes if No ft
Absorption Field > 5’Yes if No ft
Water Main > 10’Yes if No ft
Water Service Line > 10’Yes if No ft
Surface Water > 100’Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’Yes if No ft
Community Wells > 200’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
Property Line > 10’Yes if No ft
Water Main > 10’Yes if No ft
Water Service Line > 10’Yes if No ft
Surface Water > 100’Yes if No ft
If absorption field is under driveway comment below
Wells on Adjacent Lots:
Private Wells > 100’Yes if No ft
Community Wells > 200’Yes if No ft
F. ENGINEER’S 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.
11/2/21
✔✔
✔
✔
✔
✔
✔
✔
✔✔
35*
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
35*
*Minor runoff from nearby creek. Resolution pending
✔
December 10, 2021
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Southfork Block 5 Lot 1, 1421 South Creek Rd
Conditional COSA request
Dear On-Site Services Engineer:
The owner of the above lot is in the process of selling the property and has a closing date coming
up very soon. Unfortunately, over the years, the stream has changed locations and has created a
situation where it is within 100’ of the septic tank, which was replaced without documentation a
few years ago.
We are proposing building a berm to channel water overland in a path greater than 100’ before it
reaches the stream. With the frozen ground and snow, it will not be feasible to build this berm
before spring. Therefore, we are asking for a conditional COSA to allow for the sale of the home,
with the work to be done no later than May 15, 2022.
We have received three bids from contractors, and have placed 150% of the highest bid in
escrow, to be released upon completion of the work.
Thank you for considering this request,
Benjamin Schiller, PE
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date �f'•'�---A
(a) Legal Description (include lot, block,,subdivision, sect_�on, township, range)
Locat on (address or direcxions)
(b) Applicants Telephone - Home Business
Applicants Address
)2c, %S r t-1 J _ /�, c�_.<: �u�, � ,� s> ,/)�c Yule 1 �
(c) Applicant is (check one) Lending Institution ; Owner/builder ;
Buyer � ; Other � (explain);
(d) Lending Institution.., _f r 1- /'xez z' Telephone `9 V
L
Address
(e) Real Estate Co. & Agent -h Ir
Address
Telephone 777
(f) A the HAA to the following &d dress:
/.,
2. Type of Residence
Single -Family Multi --Family Other (describe)
Number of Bedrooms
3. [dater Supply
Individual 47e11 Community Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite Public 1=1 Community � FIolding Tank
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page I of 2]
5. Engineering Firm Providing.Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is 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 ow -site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm Telephone
Address
Date
L7_
(ENGINEER SEAL)
6. DHEP Approval
Approved for bedrooms By
Approved �.-�'� Disapproved
Terms of Conditional Approval
CAUTION
Conditional
Sh®iar 4
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR. LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MU14ICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 21
7-19-84
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE (MOA) DEPT. OF HEALTH &
ENVIRON,MENTA.L PROTECTION
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984 OCT I ' INA
A. WELL DATA C11ED
B.
Well Classification (1GC If A, B, or C, D.E.C. Approved(Y/N)
jCCe�
Well Log Present (Y Date Completed J� Yield 52,
Total Depth 4 ! Cased to Depth of Grouting --
Static Water Level 30 Pump Set At C,�
Casing Height Above Ground i2- 11 �- _ Sanitary Seal on Casing (Y )
Electrical Wiring in Conduit (Y Depression Around Wellhead (] )
Separation Distances from Well:
To Septic/Hol4irng Tank on Lot /d L3 / On Adjoining Lots 6eN 06
To Nearest Edge of Absorption Field on Lot 116 ; on Adjoining Lotst-CMDF cJ
To Nearest Public Sewer Lie To Nearest Public Sewer
Cleanout/Manhole N Line
r To !Nearest Sewer Service Line on Lot `0
Water Sample Collected By _5 ), 5 �`2�) Gbe� /t bt g Date' / � ��
Water Sample Test Results
Comments A-) Z9 ^J F
SEPTICS TANK DATA
Date Installed S Z ) 3 Size IZ20 L) No. of Ccanpartments
Standpipes (Y Air -tight Caps/
Depression over Tank (YA2 Date Last`
Pumping/Maintenance Contract on File
Holding Tank High -Water Alarm (Y),
Foundation Cleanou,6�
pumped
for
Temporary Holding Tank Permit (Y/N) a
Separation Distances from SepticTank:
To Water -Supply Nb ll 103 f To Building Foundation /n YL
To Property Line /0 To Disposal Field
r
To Water Main/Service Line XO -71- To Stream, Pond, Lake, cr Major Drainage
Course
Comments /Vo
4c ---L# �;u�-)co-1
(Page 1 of 21
2a15-84
C. ABSORPTION FIELD DATA
Soils Rating in Abs�tion trata �� 61 Type of System Design
CY
Date Installed �� ngth of Field
z
Width of Field / '2j Depth.of Field
Gravel Bed Thickness
Square Feet of Absorption Area% 7 //_ Standpipes Present (Y d)
Depression over Field Date of Last Adequacy
Results of Last Adequacy Tbst <2 L-.-)
Separation Distance from Absorption Field:
To Water -Supply Well To Property Lire h
To Building Foundation 25— f To Existing or Abandoned System on
Lot /U //� On Adjoining Lots cJ_
--T
To Water */Service Line �L% To Cutbank(if /present)
To Stream/Pond/Lake/or Major Drainage Course A% l
To Driveway, Parking Area, or Vehicle Storage Area
Comments ti
D• LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Access (YM)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at Vent (YM)
Tested for Cycles during Adequacy Test. Meets MOA
Electrical Codes(Y/N) tAj 2 t
Comments
** Check Permitted Bedroom Rating Against HAA'Request **
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed SRI) 196)S Date5ffu;.•, •••;o�wn�: 34
dv t. (� 4 9. f ,�:
Company Ipki. ii*2970 MOA No. .
KB1/d5/s
[Page 2 of 21
;,4 r ........ra
%Abort A. 3hok%r ; 1`u•
No. 1457-E
ode
^�'`o.... •.••app. ono
2-15-84