HomeMy WebLinkAboutT15N R2W SEC 25 LT 53 S2T15N R2W
SEC 25
Lot 53 52
#051 � 281 05
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Certified Drilling Log
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;41►ULLIILL VAIN WELLS
P.O. Box 670269, Chugiak, AK 99567 688-2759
OWNER OF LAND: Kenneth Desjarlais
ADDRESS: 16011 Shims St. Eagle River, AK 99577
Bore Hole
Data
Depth
From
To
LEGAL DESCRIPTION T15N R2W Sec 25 Lot 53
DATE: 11-2-22
0
2
Casing Stickup
PERMIT NUMBER: OSP221163 DATE OF ISSUE: 6-3-22
TAX IDENTIFICATION NUMBER 05128105000
Is well located at approved permit location: ®Yes [—]No
Method of Drilling: ®air rotary Elcable tool
Depth of Well: 220'
Casing Type: Steel Wall thickness .250 inches
Diameter: 6 inches, depth 65 feet
Liner type 160' of 4.5" PVC Liner
Static Water Level: 33' feet
Recovery Rate 1.5 ® gpm gph
Method of Testing Air
Well Intake Opening Type: open end ®open hole
Screened Start feet Stopped
Perforations Start feet Stopped
Grout Type: Bentonite Volume: 50 Ibs
Depth: from 2 feet, to 42 feet
Well Disinfected Upon Completion: ®yes ❑ no
Method of Disinfection: Chlorine 50 PPM
Comments:
2
4
Overburden
4
21
Silty Sand & Gravel
21
23
Wet Sand & Gravel
23
39
Tight Silty Sand & Gravel w/ Clay
39
44
Tight Silty Sand & Gravel Wet
44
59
Tight Silty Sand &Gravel w/Clay
59
110
Shale
110
122
Sandstone
122
128
Coal
128
151
Sandstone
151
220
Broken Bedrock
Drillers Name: Cole Sullivan
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority.
Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation.
Matsu Borough: Department of Environmental Conservation.
10 L L
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PO B 6 -`,U2,C3 "h uo, -c A K 5
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I- ump h;,-, sita-11.2"Vion Lo-s
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7
Pump inst*,302`1-,�,for, Date:
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W-ulk-, vlo� V\
,3,,r ', sl no- Suif'-Jar-.� VlVa-er
n n " ne & `,qd C-, "'rec,
WATER QUALITY TESTING
Colifbrm -Col/lOOmL
Nitrates 1v 0 - mg/L
Arseric ,v 0 - ug/L
6 C-0 11
/ -,? / 2�0- -3
tten,ffi n: T"he n,,-,=p sai in H :�qr
ovide purne, t-12� �r,, ioto, t+,,e 1 SD, 3, 0, riays oi. pumip
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 Water System Permit
Permit Number: OSP221163 Effective Date:
Work Type: Well Upgrade Expiration Date
Tax Code Number: 05128105000
Site Legal Address: T1 5N R2W SEC 25 LT 53 S2 G:0753
Site Mailing Address: 16011 SHIMS ST, Eagle River
Owner: DESJARLAIS KENNETH &
Design Engineer:
This permit is for the construction of:
❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy
cnt
De, partment
6/3/2022
6/3/2023
Lot Size in Sq Ft: 54450
Total Bedrooms: 3
Q Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions:
1. The site plan shows the driveway for the proposed shop will be over the tank and possibly the field. Per
the wastewater code, the driveway shall not be over the septic system. The building design will have to
be changed so that the shop door is removed and the driveway adjusted.
2. To close this permit please submit:
1. Well Log
2. Pump Install Log
3. Water sample results
4. Well Decommissioning Log
Received B)
Issued By:
Date: L 3
Date: 49Z31:0-7
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. V4-744 Q 051— 2.4bI -O6
Property owner(s) �iP_J phone
Mailing address 601( A'Cs Sf� Egde- jbxe✓
Site address SaVyLQ.
Legal description (Sub'd., Block & Lot) l2. L.Of SP.chto a5. —1—IT-5
Legal description (Township, Range & Section) �� 2 s • Ni • Pr�
Lot Size Sq. Ft. Number of Bedrooms
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption. Field ❑ Initial ❑
Single Family (SF) 19
(w/wo ADU)
Septic Tank ❑ Upgrade ❑
Duplex (p) ❑
Holding Tank ❑ Renewal
Multiple Dwellings ❑
Privy ❑
(SF and/or D)
Private Well
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that
this is in accordance with
applicable Municipal Codes.
(Signature of property owner(o f authorized agent)
Permit/Rush Fees: $2-Z-6 Waiver Fees:
Date of Payment: SrZ6/zZ Date of Payment:
Receipt Number: 277/07 Receipt Number:
Permit No. 0SP?,2_I (r Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
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Development Services Department
Building Safety Division
On -Site Water A Wastewater Program
;V
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
Mark Begich www.muni.org/onsite
mayor (907) 343-7904
Pump Installation Log
Well Drilling Permit Number: Date of Issue:
Parcel Identification Number:
Legal Description Block Lot Property Owner Name & Address:
(�,:)Lw Sec ) P&r'spr) lvokqrn�Cr-
11boj1rbA_&5) AChOOlak Ak7?SPTr3Sj,*,
_avOkr-nu< /'s /7,2d An same X Arm, wAge
Pump Installation Date: o4- - o,6 -1-Ae, furb)p Galas inslal-.1-epl)
Pump Intake Depth Below Top of Well Casing: S3 feet
Pump Manufacturer's Name &e, oe".L Rzyn p
Pump Model: /PFO 08 /3 N-I�47'o�"1%0)e`>
Pump Size hp
Pitless Adapter Burial Depth: feet
Pitless Adapter Manufacturer's Name: &,ZA
Pitless Adapter Installer: A41A
I O&) 3lvfrr�
55#10) $ PS
Well Disinfected Upon Completion? Yes 0 No
Method of Disinfection:
Comments: The ou)*r7e+ does 1-2&WI-I'lle
AAe Puyhp efjas In5laZZa. 77�e,,
In Ahe, 4:>W-eS_S OV- �C-inq -SCIZd-
Pump Installer Name:
A63 o t [a v m
Company:
Mailing Address:
City: ,1�001r, OYO_ State: zip:
/�e " 4017
et6 'r-5
Attention: The pump installer shall provide a pump installation log to DSD within 30 days of pump installation.
'MUNICIPALITY OF ANCHORAGE
Heal and Environmental Protect in
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
264-4720
INSPECTION REPORT ON -SITE SEWAGE DISPOSAL SYSTEM
NAME _ _— - � — MAILING ADDRESS A_AA 4 F� PHONE •�Q� " r
LOCATION _ � LEGAL DESCRIPTION S`C= 1S 0 ®` �
SEPTIC TANK:
Wow I DUAL DISTANCE NUMBER OF 1*4FROM W L L L —_ M A N U F AC T U R E R CO _ MATF_RIAL COMPARTMENTS _
INSIDE LENGTH-- _ INSIDE WIDTH-- LIQUID DEPTH __ LIQUID CAPACITY17's GALLONS.
TILE DRAIN FIELD:
t TOTAL LENGTH
DISTAP,ICE FROM �NCLL 17AFOUNDATION 40 .__NEAREST LOT LINE___--_ OF LINE S
# of Lines __. _____— DISTANCE BETWEEN LINES __TRF_NCH WIDTH J_ IN. TOTAL EFFECTIVE
ABSORPTION AREA FT. LENGTH OF EACH LINE
t ei DEPTH OF FILTER
OEPTI I; TOP OF 'TILE l-O FINISH GRADE MATERIAL BENEATH TILE _C42IN. ABOVE TILE--A—IN.
SEEPAGE PIT-.
DV'METER--OR WIDTH_ LENGTH_—, DEPTH
Log Crib Rings Crib Size:DI/-\METER__—DEPTH DISTANCE FROM: WELL
- TOTAL EFFECTIVE
BUILDING FOUNDATION—, NEAREST LOT LINE ABSORPTION AREA (WALL AREA) SQ. FT.
Well
Class: \ Depth:
Well Distance To: Lot Line
Bldg: Sewer Line: i too
Pipe Materials:
# of Bedrooms:
Installer: ! L_ —t oru &cay.
Remarks:
C,t
�
I
E
��__-
Ll
�-�--
ell-
_
--
' i
00
I,
DATE)��°-!A7L3 APPROVED �_13�
m Rw rns x n v. sm 3: -v kwA K13 F=_ FA FA cl wA C3 FRI 1FA, �E
- - ----
DEPHRTMENT OF /EHLTH AND ENYIRONMENTHL PP''TECTION~
' '
825 L,TREET, HNCHORHGE, AK. 995L �r '^
` ��'�—� \ 0/ O
264-4720 ,~'� «�-`
�FEE �k.. lot chi Kly 1:1 P-A--- 53 1: 0- FEE 02 EE! ki EE 171 10%7 FT? 1-1 1 -F -____
PERMIT NO. ( 77936 )
lPPLICHNT 4110 DEBHRR ]]7-1200
-QCHTION HNDREW STREET
-EGHL - 1.53 SEC 25 T15N R2W LOT SIZE 108000 SQUARE FEET
FYPE OF SOIL HBSORBTION SYSTEM IS: TRENCH
A
1HXIMUM NUMBER OF BEDROOMS = IF 5OIL RATING (SO FT/BR)= 85
�
[HE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
/
�EH: Fil -y- F-1== flLCot t_�������= �� ������ �����= �
THE LENGTH DIMEN5I004 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 HND 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 OUTFHLL PIPE
HND THE BOTTQM OF THE EXCAVATION (IN FEET).
Fit FEE (OR I -A 1 ���"_D,:ll Fo� 1- 1: (1: �ll,'��.'�, I FEE ���P,4:!�E,,
��P:Z_`-u'EE F" L. FA hA 0- (To _111Z L"fi P-01
I PHCKHQE PLHNT MHY BE INSTALLED AT THE PERMITTEE'S OPTION SUBJECT TO THE
7OLLOWIWG CONDITIONS:
1 EITHER H CLASS I OR 11 NSF APPROVED PLANT MAY BE INSTALLED.
2. H CON TINUOUS MHINTENHNCE HGREla MENT IS REQUIRED. IF H MHINTENHNCE
AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED TO ENLARGE THE SOIL
HBSORPTION SYSTEM HND/OR YOU MHY BE SUBJECT TO PROSECUTION.
________________________________________
-7- 1,1 C3 �Z.-:- 1 P-05 F=? FEE: ol: 0- 1 0:1005 o"I FT ETZ Fz ERI loq k-A I Fit ETE ED.
3HCKFILLINQ OF ANY SYSTEM WITHOUT FINAL INSPECTION FINE, HPPROYHL BY THIS
�EPHRTMENT WILL BE SUBJECT TO PROSECUTION,
1IWIMUM DISTHNCE BETWEEN H WELL FIND HMY OM -SITE SEWAGE DISPOSAL SYSTEM IS
'00 FEET FOR H PRIVATE WELL OR 200 FEET FOR H PUBLIC WELL
Li LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN TO DAY!--,;
)F THE WELL COMPLETION.
)THER REQQIREMENTS MHY APPLY, SPECIFICATIONS AND CONSTRUCTION DIHGRHMS HRE
lVHILHBLE TO INSURE PROPER INSTALLATION.
OW FEE No! 1-1 3: 0- FEZ �w" 1: EEE`iE-.,;; E��`Z FR 0: flL fl. too -31�
[ CERTIFY THAT
L: I HM FHMILIHR WITH THE REQUIREMENTS FOR ON -SITE SEWERS AND WELLS AS SET
"ORTH BY THE MUNICIPHLITIT' OF HNCHORHGE
l: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
|: I UNDERSTAND THAT THE OM -SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
VESIDENCE IS REMODELED TO INCLUDE MORE THAN It BEDROOMS.
5IGWED:___
HP�LICHNT JOE THOMPSON/
�2/l'/
�
h�11-114,7-0,1,1
0 & E GEO'� CHNICAL Et DEVELuMENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russel! Oyster Earl Ellis
694-2774 SOIL LOG 688-2280
Soils Et Foundations Land Development
7/—
Performed for: Name:
Tel. No.
Mailing Address:-�� _L/& L L"r /V 2,,Y- d;Al(- /-/0,0
Legal Description:
Depth (feet)
0
1 — -7- - ---� 2 _
3-
4
5-
6-
7— -- - -4 7�"/' S- /
9.-
10-
11-
12-
13
4�
1 / )43 1-17—
15
Ground Water Encountered: Yes No k--" If yes, what depth_
Proposed Installation: Seepage PitDrain Field
Comments:
Performed by: -41
Date:
0
Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 051-281-05-000
1. GENERAL INFORMATION
Complete legal description
USHfif
s�
o-�
n
Expiration Date: - t '
1/4
T15N, R2W, SEC 25, Lot 53 S2
Location (site address) 16011 Shims St
Current Property owner(s) Jessica & Jeremiah Jennings Day phone
Mailing address
Real Estate Agent
16011 Shims St. Eagle River, AK 99577
Jason Trouts
Day phone
717-9485
2. TYPE OF DWELLING:
Single Family (w/wo ADU) y� ^
❑ Duplex SUBMITT
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
3 JUN 10 2014
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
0
Individual
0
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Pilhlir. Water Svctem
❑
Piihlir gP%Aiar
❑
WaiverNariance request for:
Received by: � �f "�_ Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Release to Vanessa Melarvie
COSA Fee $ 52(+/ 315-.0 �S�
Date of Payment (, [/0.h
Receipt Number
COSA# 0/Qq 1-2-6-D
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
S. 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 Alaska Rim Engineering, Inc.
Address 9131 E Frontage Rd. Palmer, AK 99645
Engineer's Printed Name Charles A. Leet, PE
6. DSD SIGNATURE
System #1 Approved for
System #2 Approved for
Disapproved
Conditional approval for
Phone 745-0222
Date 6/10/14
®®� OF F,( x911,
*�P49TH �•1..,.•��4yo6P
— bedrooms
_ bedrooms Charles A.0eer
CE1s.
�i�ett0 PRSa
bedrooms, with the following stip' llb�fs: r
BY �� ' Original Certificate Date: 62
Th uni nchorage 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.
ATTACHMENTS:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
COSAbluesheet r . c
Nitrate Advisory
Arsenic Advisory _
Other ', f ---!•
If more than 1 septic system is on the lot:
COSA Checklist # _of _
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description:
T1 5N, R2W, SEC 25, Lot 53 S2
A. WELL DATA
Well type Private
Date completed 1977
Total depth 40+ ft.
If A. B, or C provide PWSID # N/A
Sanitary seal (Y/N) Y
Cased to 40+ ft.
FROM WELL LOG
Date of test No well log
Static water level ft.
Well production g.p.m.
WATER SAMPLE RESULTS
Parcel ID: 051-281-05-000
Well Log (Y/N) NO
Wires properly protected (Y/N) Y
Casing height (above ground) 23 in.
AT INSPECTION
6/5/14
24.4 ft.
2 a 06 g.p.m.
Coliform ND colonies/100 mL Nitrate 1.3 mg/L
Arsenic ND ug/L Date of sample: 5/20/14 Collected by:
B. SEPTICIHOLDING TANK DATA
Tank Type/Material Concrete
Brandon Jones
Date installed 10/15/77
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N)
Date of pumping 5/20/14 Pumper JR's Septic Pumping
N/A
C. ABSORPTION FIELD DATA
Date installed 10/15/77 Soil rating (g.p.d./ft' or ftz/bdrm) 85 ft2/bdrm System type Trench
Length 28 ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth 10 ft. Eff. absorption area 336 ftz Monitoring tube Y— Depression over field N
Date of adequacy test 6/5/14 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 489.7 gal. New depth 0 in.
Elapsed Time: 240 min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NO If yes, give date
D. LIFT STATION
Date installed N/A
"Pump on" level at N/A in.
Datum N/A
E. SEPARATION DISTANCES
WELL ON LOTTO:
Size in gallons N/A
"Pump off"level at N/A
Cycles tested N/A
Septic tank/lift station on lot 100'+
Absorption field on lot 100'+
Public sewer main
Sewer /septic service line 25'+
Animal containment areas >50'
Manhole/Access (Y/N) N/A
in. High water alarm level at N/A in.
Meets alarm & circuit requirements? N/A
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout > 100'
Holding tank25 ' A
Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5' Property line 5'+
Water main 10'+ Water service line 10'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+
Water Service line 10'+
Curtain drain NONE KNOWN
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Surface water 100'+
Wells on adjacent lots 100'+
Absorption field 5'+
Surface water 100'+
Water main
+
Driveway, parking/vehicle storage 110'+
I certify that I have determined through field inspections and ``egohe�e'eti
review of Municipal records that the above systems are in ���,; F A�fl�,f:p
conformance with MOA COSA guidelines in effect on this date.
m uj T 9 i
Engineer's Printed Name �����1 -> E� . L✓C,QA *� 491—"
Date
S Ism: iolc W
C� '. Charles A. Last
J'p CE10480 • ci.�
COSA brown sheet 10-10-12.doc
Municipality of Anchorage
Development Services Department
Building Safety Division c s A . E..
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
Water Well Advisory
Certificate of On -Site Systems Approval (COSA) # 141250
During a recent COSA on-site inspection and test of the potable water
supply well on Block , Lot 53 S2 of T15N R2W Section 25
subdivision, the well's productivity was determined to be 0.8 gallons per
minute. The minimum well productivity required by this Department (AMC
15.55) for a 3 -bedroom residence is 0.3 gallons per minute. Although the
subject well currently exceeds this minimum requirement, all parties
concerned are advised that the production capacity of the well may fluctuate.
Restriction of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
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Municipality of Anchorage
Development Services Department:
Building Safety Division '•
\_ On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 19 1231
Anchorage, AK 99519519 -6650
� p
www.muni.org/ons to
(907) 343-7904 (Q
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O5 COSA# nQ�
1. GENERAL INFORMATION
Expiration Date:
Complete legal description TISN, R2W SECTION 25 LOT 53 SOUTH 2
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
16011 SHIMS STREET ' EAGLE RIVER AK 99577
LILLIAN PERSON Day phone 688-3678
24120 RAMBLER ROAD • CHUGIAK AK 99567
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
Day phone
Day phone
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
0
❑
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 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. l further verify that based on the
information obtained from the Municipality ofAnchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with at/ applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm 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 ?Ob
Engineers Comments:
In conducting this evaluation, GEG, LID. 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 fife of all wells and
septic systems depend on the local soils condition, groundwater levels that may
tiuctuato during the year, and the water usage of the family being served by the system.
Those 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 enoroachmonts. 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 benorit 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
V Approved for 3 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the flowing stipulations:
o'er
WATER D •; fn=
--WASTEYYATER : =
PROGRAM
Attachments:
COSA Checklist
Arsenic Advisory
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineers Reort
Nitrate Advisory Other
By'—�� �'�� /—lJ-�(
OOriginal Certificate Date:
tel/ d
fpr IIml
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program
4700 Bragew Street
P.O. Box 168850
Anchorage, AK 99519 -MM
www.muni.org/onsite
(907) 3437904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: T15N R2W SECTION 25. LOT _53 S2. Parcel ID: D S/
A WELL DATA 'PER SURROUNDING WELL LOGS NO INDICATION OF BEDROCK
OR PERFORATIONS IN CASING SHALLOWER THAN 40 FEET.
Well type PRIMATE If A, B, or C provide PWSID# N/A
Date completed —1977 Sanitary seal (Y/N) YES
Total depth 40+ ft. Cased to •40+ ft.
FROM WELL LOG
Date of test
Static water levelft-
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform a colonies/100 mi. Nitrate 0.576LmgJL.
Well Log (Y/N) NO
Wires properly protected (YM) YES
Casing height (above ground) 12+ in.
AT INSPECTION
5/19/2006
30 ft.
2.57 g.p.m.
other bacteria _n colonies/100 mi.
Arsenio NO ug,n„ Data of sample: 5/18/2006 Collected by: GEG, Ltd.
B. SEPTICIHOLDING TANK DATA
TankType/Mated8l CONCRETE Date installed 10/15/1977
2 Ciesnouts M YES
Tank size 1250 gat. Number of Compartments _ (Y )
Foundation cleanoul (Y/N) YES Depression over tank (Y/N) NO High water alar (Y/N) N/A
Date of pumping 12/5/2005 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA
Date Installed 10/ta/t977 Soil rating (g.p.d./ft'oriq§j�D 85 System type TRENCH
Length 28 ft. Width 3 ft. Gravel below pipe 6 ft.
Total depth *9.17 ft. Eff. absorption area 336 fe Monitoring tube YES Depression over field NO
Date of adequacy test 5/19/2006 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth In absorption field before test 3 in. Water added 529 gal. New depth 8 in.
Elapsed Time: 23 min. Final fluid depth 3 In. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N 8 typo) NONE KNOWN If yes, give date —
MONITORING TUBE ONLY EXTENDS APPROX. 5 FEET INTO DRAINROCK.
D. LIFT STATION
Date installed Size in gallons Manhole/Access _
"Pump on" level at _in. "Pumpofa High water alarm level at
Cydes tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAiQ station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+
Public sewer main N/A
Sewer /septic service line 25'+
On adjacent kms 100'+
Public sewer manhole/deanout N/A
Holding tank N/A
Animal containment areas 50'+ Manurelanimal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
10'+
Building foundation
10'+
Water main _ N/A
Water service line
10'+
Surface water
100'+
Driveway, parldnglvehide storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I cerdly that I have determined through held inspections and t
review of Municipal records that the above systems are in F-
Engineers
conformance with MOA COSA guidelines in effect on this
date. ........
Print Name JEFFREY A. GARNESSeas.Date le t 2J4G0�c�
COSA Fee Ste'g3o. U c,
Date of Payment (,,, /u G
Receipt Number
(Rw. 11/0) U r4
Waiver Fee $
Date of Payment
Receipt Number
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