HomeMy WebLinkAboutTHE TABLELANDS BLK 9 LT 1The Tabl
lands
Block 9
Lot !
#05! -74! -56
Municipality of Anchorage...:f.!;~.'"' :.:~::~ :.,
Development Services Department !"" ~
Building Sa fety Division I~_ i~'~~'
On-Site Water and Wastewater Program. 4700 Bragaw St. ~
P.O. Box 196650 Anchorage. AK 99519-6650 Page /~ of
www. ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELl. INSPECTION REPORT
Permit Number: .~_~,~(:~ ~'O t,./4/'2. PID Number:
~,~:~.y~,O/~.~,,.~l, w- ,_~ot,~,.J' WastewaterSystem: .~New E]Upgrade
LEGAL DESCRIPTION s~,a,~ ~----~ G,n~e .~' F,.
SEPARATION DISTANCES ~ept,c D Holding D S.T.E.P. D Othen
Tank Field Station Tank S~r l,ne ~ /~ ~0
s~w.. /~ ~ '~/00 '~ _ _ ~ / LIFT STATION
V
"~" BENCH MARK
Inspectionspedormed, by:~/~ ~r Dates: 1a
O ve,o, e., .,oes ,,rova,
Reviewed and approved by: ~~ ~ ~~ate: ~-I~-O~
F,C.O, 44
S.T. C,D.I 43 12
S.T,C.O,2 36 19
D.c,rl, 30,5 26
C.O, I 12.5 63
C.O, 2 59.6 15
M.T. 54 13,5
DESIGN NOTES:
1. Total Depth of Trench is 3'.
Remove organic layer.
2. Sewer Service Line
3. Trench is Minimum 10'
4. Lots Served by Public
to Meet Minimum Bulol
round If frozen.
n 2% slope.
Lot Line.
System.
Septic System Construction
9oes Not Preclude Adjoining
Lots From Sanitation
Improvements.
~epth.
LDT 2
Sepi;Ic
Are~
Added Perk Holes Prior To Constructl(
Reserve Site
Absorption Trench
1250 Gallon Septic Tank
907.694, 7028
TABLELANDS S/D
LOT 1, BLBCK 9
D.C,O.
4 Bdrn
Home
~/~ter Key
I' = 50'
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! E~!.,~I~NEERING
SOILS
LBO - PERCOLATION TEST
Dcute Per?orMed: 12/7/05
Per?orMed For: Sudsbury & Sons
LeQot Description: Lot 1, Brock 9
DEPTH
(FEET)
~ Brgonlc
:.,...-...;
3
4 ""'" ;' L? w/GroveL
9-
10-
11-
18-
13-
14 -
15 -
16-
17 -
18-
19 -
80 -
21 -
Stope < 5%
Groundwater? No
Depth
l/ater Depth
AFter Honltorin9, None Date~
DoFte Gross Time Net TIMe Dep't;h Ne't Drop
12/7 0 -- 6, --
12/7 20 20 Min. 12' 6'
18/7 30 -- 6, --
12/7 50 20 Min. 12' 6'
12/7 60 -- 6, --
18/7 BO 20 min. ! 12' 6'
Percotatlon Rate 3.5 Min./Inch Perc Hote Diameter .6'
Test Run Between 3' and 4'
Comments~ Pr ¢,-.'~nokFd
PerFormed B y ~2,c-'b~J~:~.~ 9. I~ CERTIFY
PerFormed in Accordonce wi'th Att S--~o'te/I,4unlcipot
BN THIS DATE. DATE, 12/7/05
THAT THIS TEST WAS
Guidetines In E??ec't
THE TABLELANl)S S/l)
GEBTECHNICAL T,H, 2'
LOT 12'
:BLOCK 4
MUNICIPALITY OF ANCHORAGE
Development Sen/ices Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7~04
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Dec 02, 2005
Expiration Date: Dec 02, 2006
Permit Number: SW050442
Legal Description: THE TABLELANDS BLOCK 9 LOT 1
Design Engineer: 0838 North Rim Engineering
Owner Name: SUDSBURY'S & SONS
Owner Address: 10928 EAGLE RIVE ROAD #122
EAGLE RIVE, AK 99577-
Parcel ID: 051-741-56
Site Address: 22114 OBERG ROAD
Lot Size: 74096 SQ. Fr.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must 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 engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing,
5. The folIowing special provisions.
a.) An additional lest hole and percolation test shall be conducted at time of construction in the location shown on the
site plan. The engineer shall submit the soil log-percolation test results with the Inspection Report.
Date:~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
Permit Number SW
Mailing address ,/0~{;~/'~
Site address l q
Legal description (Lot, Block & Sub'd
Legal description (Section, Township & Range)
Lot Size ~/'¢1 ~ ~ Acre~
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
'~aP--Zip Code
Zip Code
Number of Bedrooms
Day phone ~'~'- [~'(~
??3'?7
Well Only []
Water Storage []
Jacuzzi []
Water Softening Unit []
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
Date of Payment:
Receipt Number:
(Rev, 09/04)
(Signature of property owneri~authori?ed agent)
· waiver Fees:
)ZIDI JO6 Date of Payment:
Uq~)~- .,,. Receipt Number:
!.NEERING
NodhRim Engineering
17237 I~ear Paw Chcle
Eagle River, AK 99577
907-694-7028
December 1, 2005
MOA On-Site Water & Wastewater Program
Julie Makela, P.E.
4700 Bragaw St
Anchorage, AK 99519
RE: The Tablelands, Block 9, Lot 1
A lot is being developed. The soil test from the subdivision is being used; the percolation
rate is very good. Additional percolation tests will be completed at the field prior to
construction to verify the soil. I spoke with you concerning this property a few weeks
back. No groundwater was present in the existing monitor tube. A very conservative
design has been completed, similar to the neighboring lot.
The neighboring lots are mostly developed. This site should not negatively impact any of
the other area lots. The only neighbor development is lot 2; septic system is located as
drawn on drawing !. A greenbelt and road are the boundaries for the majority of the lot.
The lot slope is relatively flat, but drops offto the greenbelt.
Please review the wastewater system design for the single family home. I have included
design plans & specs, design guidelines, & soil tests. If there is need for additional
information or clarification please give me a call.
Sincerely, . ~..
Steve Eng, PE, P}I~
Design Enclosures
I~EERING
Tablelands S/D, Lot I, Block 9
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: This is a new 4-bedroom, single family home. Some of the
neighboring lots are not yet developed. The soil test from the subdivision will be used for
design; this had an excellent perk rate & no groundwater. Additional soil tests will be
completed prior to construction. A shallow, conventional septic is being proposed. This
lot is over 1 acre in size and no adverse impacts are expected from development. The
neighboring lots are similar. The lots are served by a public water system. No conflicts
to the other lots will take place by this septic system construction. The easements are
located on the drawing and are not encroached upon. Soil tests revealed sandy soil with
Iow silt. An application rate of 1.2 GPD/FT~ with 0.64 reduction factor for utilizing a 5'
wide trench. Trench Length = 600 FTV5'x 0.64 reduction factor = 64'; I line (~ 64'. No
bedrock was encountered.
Specification Requlrements: All components and work must comply with the Municipality
of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and
Wastewater Regulations.
· Two compartment, 1250 gallon septic tank. Watertight couplings on inlet & outlet.
· 5' minimum between the tank and bed. 10' to property lines.
· 3' of cover or insulation is required for trench; an equivalent of I" insulation for each foot
soil cover.
· Tank & solid pipe must be set on well compacted, stable soil.
· 4 inch diameter cleanouts with airtight caps are required I' to 4' from foundation wall, prior
to any 90 degree bend in 4 inch line, in each tank compartment, and two adjacent opposing
cleanouts between the tank and the absorption field, not more than 10' from the tank
positioned to provide cleanout access towards the tank and towards the absorption field.
· All cleanouts must extend to at least ground level.
· in solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
· Trench to be placed level, minimum of 4' to groundwater, 6' to bedrock from drain-rock.
· Drain rock to be ½ inch to 2 ½ inch screened. Drain rock to be distributed uniformly
throughout the trench.
· Perforated pipe to be installed level with perforations down.
· Silt barrier (filter fabric) to be installed above the drain rock.
· Smeared trench sides must be raked or scarified before drain rock placement.
· Backfill over drain rock must not be less than 36".
· The finish grade must be mounded to promote drainage over the trench.
· Insulation must be placed over any pipe installed under driveways or parking areas.
· Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS
ASTM D2661,
· Sewer Service Line is minimum 2% slope.
· Septic Tank to be pumped every two years or when required.
· Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI or equal)
DESIGN NOTES:
1. Totel Depth of Trench is
Remove orgonic Ioyer.
2. Sewer Service Line ' '
,3. Trench is Minimum 10'
4, Lots Served by Public
ound to Meet Minimum
round if frozen.
2% slope.
Lot Line.
System.
LDT 2
Septic
Are~
Added Perk Holes Prior To Con.~
Reserve
Absorp'clon Trench~
1250 Gcllon Septic
4 ~drm
Home
! NORTHRIM
ENGINEERING
907.694. 7028
O~ERG RD
W~er Key tloxj
1' = 50' i
TABLELANDS S/D REVISED
LAYBUT
LOT 1, BLOCK 9 ~'~e/1/05 t~o_'F 3
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Municipality of Anchorage
Development Services Department
Building Safety Division
On. Sile Water and Wastewater Program
4700 South Bragaw SL
P.O. Box 195650 Anchorage, AK 99519-6550
(907) 343-7904
Soils Log - Percolation Test
Da!e Pedorrned:
Slow
°--
5- ~ ~--.t,,t s ~
6-
· ,,{ENGINEER'S SEAL)
10 - IF YES, AT WHAT DEPTH? 0
' 13.
Reading Date Gross Time Net Time Depth Jo Wa[et Nel Droo
1~-
20-
PERC~TION ~TE ~ ~ (~e~} PERC M~E DI~ETER
PERFORMED i~Y. '~ "..~=>. I t"--'~ ,.~ o CERTIFY THAT THIS TEST WAS
PERFORMED ~N ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEUNES IN EFFECT ON THIS DATE. DATE: ~-~
MEMO
Steve Eng, PE, PH
17237 Bear Paw Circle, Eagle River AK 99577
(907) 694-7028 tel
(907) 694-7026 fax
NorthRimEng@aol.com
Date: 12/1105
To: Julle Makela, PE
MOA On-Site Program
Subject: The Tablelands Block 9 Lot 1, Revised Design
Number of Pages: 5
Julie,
Based on our conversations today, please accept the revised conventional design. We anticipate
on performing additional test holes/percolation tests to verify the soil prior to construction.
Thanks-Steve
!~NEERING
Tablelands S/D, Lot !, Block 9
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: This is a new 4-bedroom, single family home. Some of the
neighboring lots are not yet developed. The soil test from the subdivision will be used for
design; this had an excellent perk rate & no groundwater. However a S.T.E.P system is
proposed from conversations with your office, manufactured by Anchorage Tank &
Welding. This lot is over 1 acre in size and no adverse impacts are expected from
development. The neighboring lots are similar. The lots are served by a public water
system. No conflicts to the other lots will take place by this septic system construction.
The easements are located on the drawing and are not encroached upon. Soil tests
revealed sandy soil with Iow silt. An application rate of 1.2 GPD/FT: with 0.78 reduction
factor for utilizing a 5' wide trench. Trench Length = 600 FT~/5'x .78 reduction factor =
78'; I line I~ 78'. No bedrock was encountered.
Specification Requirements: All components and work must comply with the Municipality
of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and
Wastewater Regulations.
· Two compartment, i 500 gallon S.T.E.P. tank, conforming to Anchorage Tank &
WeldingJOrenco Systems Specifications, allowing gravity-flow from outlet.
· Watertight couplings on inlet & outlet
· 5' minimum between the tank and bed. ! 0' to property lines.
· 2' of cover is required for trench + i inch insulation board.
· Tank & solid pipe must be set on well compacted, stable soil
· 4 inch diameter cleanouts with airtight caps are required ! to 4 feet from foundation wall,
prior to any 90 degree bend in 4 inch line.
· All cleanouts must extend to at least ground level
· Trench to be placed level, minimum of 4' to groundwater, 6' to bedrock from drain-rock
· Drain rock to be ½ inch to 2 ½ inch screened. Drain rock to be distributed uniformly
throughout the trench.
· Distribution pipe shall be 1.25" Schedule 40 PVC w/1/8" orifices ~ 27" on center.
· Force main shall be 1.25" Schedule 40 PVC, conforming to Anchorage Tank &
Welding/Orenco Systems specifications. Force main burial to be 4' minimum.
· Silt barrier (filter fabric) to be installed above the drain rock
· Smeared trench sides must be raked or scarified before drain rock placement
· Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS
ASTM D2661, PVC Schedule 40.
· Sewer Sctwice Line is minimum 2% slope
· Septic Tank to be pumped every two years or when required
· Insulation board shall be extruded direct burial polystyrene (Dow Styrofoam HI or equal)
· Maintain minimum 10' separation between water line & wastcwater system.
DESIGN NOTES:
1. Total Depth of Trench is 2'.
Remove organic layer.
2. Sewer Service Line ' '
3. Trench is Minimum 10'
4. Lots Served by Public
~und to Meet Minimum
round if frozen.
n 2% slope.
Lot Line.
System, /
Septic System Construction
Does Not Preclude Adjoining
Lots FrOM S(~nlt(~tlon
IMprovements.
,epth.
LOT 8
~ep~lc
Are~
Added Perk Hotes Prior To (
~Absorptlon Trench
Slte
1500 Gallon STEP
E'OSemen t ~ ~
4 Ddrm
HOMe
Key Box/
1' = 50~
SYSTEH
ILAYFIUT
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11/30/05 I1 oF 3
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MUMUPAUTY OF ANCHORAGE
i Q�
`_"'_"._'" - -• -- "--- � '-gi r --..,-.-.---.vim.,--_. ._..__ _ .---�---1-.�-.,
Development Services Department , '-: Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 051-741-56
Certificate of On -Site Systems Approval
Expiration Date: `/ ^ 2� -Z�Z
1. GENERAL INFORMATION
Complete legal description THE TABLELANDS BLK 9 LT 1
Location (site address) 22114 Oberg Rd Chugiak
Current property owner(s) LAFFERTY ROBERT & NUKE KEAFANNY
Mailing address PO Box 671710 Chugiak
Real estate agent
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
F] Duplex
~ -�
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
Day phone
AK 99567
Day phone_
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well ❑ Private Septic 0
Water Storage ❑ Holding Tank ❑
Community Well ❑ Community ❑
Public Water System El Public Sewer ❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550 Waiver Fee $
Date of Payment _ (4 — Zq Z2 Date of Payment
Receipt Number d1-7 Receipt Number
COSA# 05C22-117-�> Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Eklutna Engineering, LLC Phone 907.406.1058
Address 19162 Mountain Rd Chugiak AK 99567
Engineer's Printed Name Curtis Townsend, PE Date /� /-z- "z Z
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
QF
�:491H '�¢d
6. DSD SIGNATURE
�••••••••� -
a' ' W
.114 System #1 Approved for
bedrooms i c� sL. qo, -STAMP
�•- Date ` Z S ? u i,.Zv%
System #2 Approved for
bedrooms ��F��s� .No.CE11904
�DRO o
Disapproved
hESSI.'1"
Conditional approval for
bedrooms, with the following stipulations:
((((
OF AN K--
�e
y WP1ER P ER o^
V� P L h N"'
R
By:
Original Certificate Date: 5�,3� Z dZ Z
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: THE TABLELANDS BLK 9 LT 1
If more than I septic system on lot: COSA Checklist # of
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�evel
SA
Static eginningof test ft.
Comments
B. TANK DATA
Age of tank(s) 17 years
Tank type/material septic steel
Measured operating fluid level in septic tank 50
❑ Standpipes/foundation cleanout per record drawing
Date of pumping May 24, 2021
D. ABSORPTION FIELD DATA
Which system tested (date installed) 2005
❑ ALi- standpipes present per record drawing
Total measured depth from grade 6.1 ft (max)
Measured depth to pipe invert from grade 3.6 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
Parcel ID: 051-741-56
Structure served by this system
Well production at time of test gpm
Water storage tank me gallons
;Well disi ed for coliform test? ❑ Yes ❑ No
oliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by
Date of Sample
C. LIFT STATION
❑ Required maintenance t
Age of lift station y
Lift station material
Comment
Adequacy test date 41211!2022
Results 2] Pass For 4 bedrooms
Fluid depth prior to test 13 in
Water added 853 gal
New depth 19 in
Elapsed time 1440 min
Final fluid depth 13 in
Absorption rate '600 gpd
Any rejuvenation treatment (past 12 months) no
If yes, enter date
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
❑ Yes if No ft
Neighboring Tank > 100' ❑ Yes if No ft Private Sewer/ qpt-ic-Cin-e > 25' ❑ Yes if No ft
Absorption Field on Lot > 100' ❑ Yes if No ft ,, --ro ding Tank > 100' ❑ Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' ❑ Yes if No ft
'.---[j es if No ft
Manure/Animal Excreta Storage > 100'
COMMuni ewer ❑ Yes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' F✓ Yes if No ft Surface Water > 100'
ft
Main > 75' ❑Yes if No ft
Property Line > 5'
0
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
�
Yes
if No
ft
Private Wells > 100' ✓0 Yes if No
Water. Main_>._.10'.__ _-
71
Yes
if No
ft
Community Wells >_.200.' � Yes if No.
Water Service Line > 10'
E]
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' ✓1 Yes if No ft If absorption field is under driveway comment below
Property Line > 10'
0
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
✓1
Yes
if No
ft
Private Wells > 100' Yes if No
Water Service Line > 10'
[✓
Yes
if No
ft
Community Wells > 200' �✓ Yes if No
Surface Water > 100'
✓l
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
/ certify that / have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
COSA Checklist yellow sheet
�3GINEER°S
:^ ..........
Pdo. CL i 150 •'c A
� Yes if No ft
I
0
ft
ft
ft
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and 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. o5z-74~-56
GENERAL INFORMATION
Complete legal description The Tablelands, Block 9, Lot :[
Location (site address) 22:[~4, Oberg Road, Chugiak
Expiration Date:
Current Property owner(s) John Eckstein 8, Pamela Perrenoud
Mailing address
Day phone
Lending agency
Mailing address
Day phone
Real Estate Agent
Mailing Address
Day phone
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. T~PE OF WATER SUPPLY:
.... : .Individual Well
;.
Individual Water Sto~'age
Community Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] Individual Holding Tank [--]
[] Community On-site
[] 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 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.
Name of Firm Pannone Engineering Services, LLC Phone 272-82~.8
Address P.O. Box 100217, Anchorage, AK 99510
Engineer's Printed Name Steven R. Pannone, P.E. Date 1/2_7/2o1_1
Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & Regulations. The reported results describe 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 soil condition, ground water
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 this system. All systems eventually fail and
satisfactory test results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. PES can therefore not provide any warranty for future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the 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 SIGNATURE
~ Approved for ~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
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 rON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: The Tablelands, Block 9, Lot z
A. WELL DATA
ParcellD: on~-7&a.56
Well type .Public
Date completed ~
Total depth ft.
FROM WELL LOG
Static water level ~ ft.
Well production
WATER SAMPLE RESULTS:
Coliform colonies/100 mL
Arsenic: ~ ug/I
B. SEPTIC/HOLDING TANK DATA
IfA, B, or C provide PWSID # ~
Sanitary seal (Y/N) __
Cased to ft.
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
¸in.
·
g.p.m.
_Nit.rate. mg/L O th~ __ colonies/lO0 mL
Date of sample: Collected by: ... ~
Tank Type/Material
Tank size =25o gal,
Foundation cleanout (Y/N) Y
Date of pumping ',l:~,;l~,o~=.
Anchorage Tank ! Steel
Number of Compartments 2_
Depression over tank (Y/N) N.
Pumper JRs Pumping
Date installed aahlaoon
Cleanouts (Y/N) Y
High water alarm (Y/N) N
C. ABSORPTION FIELD DATA
Date installed ~171~oo~ Soil rating (g.p.d./~ or ft2/bdrm) =.= System type .Wide'Trench
Length 65 ff. Width ~i ft. Gravel below pipe ~.~i fi.
Total depth 5 ff. Eft. absorption area 5o8 fi2 Monitoring tube _Y DePression over field _N
Date of adequacy test ~.l~/Ao~.~ .Results (Pass/Fail) Pass For .~ bedrooms
Fluid depth in absorption field before test lO in. Water added,6oo gal. New depths_5 in.
Elapsed Time: ~2o min. Final fluid depth 10 in. Absorption rate >= 6oo g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION ~'
~Date _ ~ize in gallons : Manhole/Access (Y/N)
"Pump on" level at in'~ater alarm level at
Datum Cycles tested Meets a~
in.
E. SEPARATION DISTANCES
DISTANCES FROM WELL ON LOT TO:
Septic tank/lift ~~_
Absorption field on lot ' ~
Public sewer main
Sewer/septic service line
Animal containment areas
On adjacent lots
On adjacent lots
~ean°uHolding tank ~,.
Manure/animal excrete storage a~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~.o+
Water main ~.o+
Property line ~.o+
Water service line 25+
Absorption field 5+
Surface water ~.oo+
Wells on adjacent lots [oo+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~.o+
Water Service line
Curtain drain..5o+
25+
Building foundation ~o+
Surface water ~.oo+
Wells on adjacent lots ~.oo+
Water main
Driveway, parking/vehicle storage ~o+
F. COMMENTS
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.
Engineer's Printed Name
Date
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Steven R. Pannone~ P.E.
'~12712m.~.
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
Anchorage, AK 00510-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
cos^#
Expiration Date:
1. GENERAL INFORMATION
Complete legal description 7~", .~' 7--,,4/~'/.. -------------------~_,4~'~LI'
Location (site address) ,22/[~' ~)~,~.,,~"
Current Property owner(s) .~'
Mailing address ./L~ 9.~ d
Lending agency
Lo?'- /
Day phone ~' ?~' -/'~'/0
Day phone
Mailing address
Real Estate Agent
Dayphone
2. NUMBER OF BEDROOMS:
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site
Public Sewer
'l'he Municipality of Anchorage Development Sen/ices 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 sen/ed 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 sen/ed 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 sen/ed 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 seal affixed hereto and as of the validation date shown below, I ver'~ 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.
EngineeFs P~nted Name. ~ ~
bedrooms.
$. DSD SIGNATURE
. ~'~ Approved for ~
Disapproved,
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
./~~ Original Cedificate Date:
6
Municipality of Anchorage
Development Services Department
Building ~afety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anch<xage, AK 99519-6650
www. muni.oeg/onalte
(907) 343-7g04
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Deacription:7"/~" '~',~RLF_L,4~_A.r ~LOCfC 9 Zar' /
Well type If ^,/~r C provide PWSID if __
Date completed ///Sanitary seal (Y/N) _
Total depth fl. / Cased to ft.
. //DROM WELL LOG
Date of test / __ __
Static water kn~Y ~ __ ft.
Well predu~n __ __ g.p.m.
WATER/~IPt. E RESULTS:
Colifo~ .coionies/100 mL Nitrate
~c: mg~
Wires
(Y/N)
[above ground)
Jn.
fto
g.p.m.
Other becter~
Collected by:.
colonios/100 mL
B. SEPI'IIC/I'IOLDING TANK DATA
Tank size /~--~,~"O 'gal.. Number of Compartments
Fo~ndation'clean°ut (Y/N) ~ Depression over tank (Y/N)
Date of p~mping /~/c",..~ Pumper
C. ABSORPTION FIELD DATA
Date ins~lled ~,,~3tl rating (g,p.d./ff2 or*lil~l~ll~m) ~ ~
Length' ~' :~" ft.-" Width ~ ft.
Date installad //~-/~'/~ ~'
High water alarm (Y/N) /tV/
Total daptl~ .~'"' fl?
Date of adequacy test
System type ~
Gravel below pipe ~--~'..--<'- fl.
Eft. absoq3tion erea.~C-~ ft2 Monitoring tube._~ Dapmssion over field ~
/A,f/~"~ Results (Pass/Fail) For __ bedrooms
Fluid depth in absorption field before test__ in. Water added gal. New depth in.
Elapsed Time: __ min. Final fluid depth in. Absoq3tion rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date instelled
'Pump on' level at __
Datum
/~ze in gallons
In./ "Pump off' level at __
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station/~t
Absorption field on//ha(__
Public sewer/~afn
Sewer I~tl~ service line.
Anim~mtainment areas
in.
Manhote/.~e~s (Y/N)
H~J~'dter alarm leve/at
. ~eets alan~ & circuit requirements?
On adja~ lots
On d/jacent lots
/l~blic sewer manhole/cleanout /
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
in.
Building foundation ,~" ~
Water main //l~' '-P'
Wells oft adjacent lots .,~04:~ ~,~
Pm~e~,ne 5'4 '~.
Water senace line f 0 '~'
Surface water ,,/~ ~' "~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO'
Propertyline /4 If. Buildingfoundation/~' ,v.- Watermain ,/'~:~' /4-
Water Service line /~(~' Surface water /~:7~'/'P D~,eway, pad<ing/vehiclestorage~--~'O/+-
Curtain drain '~' Wells on adjacent lots ~__.C)O' '~
F. COMMENTS
o. E.O'.EE.'S CERT,.CATIO.
I certify that I have determined through field inspectkms and
conformance with MOA COSA guidelines in effect on this date
· .
Engineer s Printed Name ~'~,/~'
Date E//.~-/0~'
COSAF,, $. ~'q-6~ ~' /-'/_V. ~ W~erFee$
Set, P, ent/ /aa Da,, o, Pa ,n,
Receipt Number ~g/'~ ~ Receipt Number
(Rev. 11/05)
ASBUILT
I HEREBY CERTIFY .THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS
INDICA]~.O. IT IS THE RESPONSIBILITY OF THE
OWNE~ TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS~ OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES.
Si~.~ARD
SCALE:
DATE: .~ .
GRID:
DRAWN~
ASSOCIATES LAND SURVEYING
-,¢..' A
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