HomeMy WebLinkAboutSCIMITAR #2 BLK 3 LT 20Scimitar #2
Block 3
Lot 20
#051-132-58
.;� Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program, 4700 Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6550 Page / of 3
www.ci.anchorage ak.us (907) 343.7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number. Lcoo PID Number: 5 / //32'-54
Name
o
Wastewater System: XNew El Upgrade
n
Aayress
/U7 S G S'P O 7
ABSORPTION FIELD
N,+nLer of Beba.na�
s
P�DsaP Tr«r/t O SNllpn Trsron D Bao D MauM Q pnyr
LEGAL DESCRIPTION
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47 FI.
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Data lnatL�//�/� �]
Y412 Pura s« rCivrp 1MT Aw Grarry
Z8
� 3e
TANK
I
GPM FI. ^_
SEPARATION DISTANCES
Pteptic ❑ Holding ❑ S.T.E P. ❑ Other.
To
Septic
Absorption
Lift
Holding
ubIWPnvate
°01.wA
aw tv
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Station
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BENCH MARK
S ��
Location ane Dewaaon
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A.%o� Fr;
/d
Inspections performed b A INK J6,013 - Dates: 1r % / 2 �7
P P y: O r c.tia.
Engin�'0 � �1t
«,
2nd-2/1-3/0-7��P�•
••.«..a•.a4��ir
Development Department
P P Approval
pry: �� '•;9
,� fS.�.Ll ? 0
0.Conditional
Approval Date:
Ma•••a• •• ••
d '
.t
r ; S!evan W. Eno..
•�;`�
�d J•J, :•• PF 46456 V:"
�^F rare.
Reviewed and approved by: / �� ate: Cr
(Rev 04 b),
C ,. •; <}'r
�atCyatbaF'v
[Neighbor
Water Well
Drill d ,
Wat r Well
5 BERM
Home,,,'
RECORD DW7MEASUREMENTS
SCIMITAR #2 S/D
BLOCK 3 LOT 20
._
1 40'
RECORD
PO Sox 770724 it (•s,..'••• •
Eagle River, Alaska 99377 ••.• a-�m°gi : •'�
907.694.7028 ®
DRAWING
A
e:
4/25/08
FCO
25
4
ST C01
STCO2
25
29
15
25
DCO
35
32
co 1
44
29
CO 2/MT
93
89
Site
TH2
Double CO's
500 Gallon Septic
v
Slope < 10%
Septic System Construction
Does Not Preclude Adjoining
Lots From Sanitation
Improvements.
X16 ,
NORTHRIM
ENGINEERING ''49
SCIMITAR #2 S/D
BLOCK 3 LOT 20
._
1 40'
RECORD
PO Sox 770724 it (•s,..'••• •
Eagle River, Alaska 99377 ••.• a-�m°gi : •'�
907.694.7028 ®
DRAWING
SEPTIC SYSTEM
e:
4/25/08
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SOILS LOG - PERCOLATION TEST
Date Performed: 9/11/07
Performed For: Troy Davis (Tim)
Legal Description: Scimitar #2 Subdivision, Block 3, Lot 20
DEPTH
(FEET)
1 -
2 -
3 -
4-
5-
6 -
7 -
8 -
9 -
10 -
11 -
12 -
13 -
14 -
15 -
16 -
17 -
18 -
19 -
20 -
21 -
Organic TH2 Location See Attached Design
GP
Sandy Gravel
w/ Low Silt
Groundwater? No
Depth --
Water Depth
After Monitorinn.NonP nn+Pi
#
Date
Gross Time
Net Time
Depth
lNet Drop
1
9/11
0
--
4'
--
2
9/11
10
10 mir,
9'
5'
3
9/11
40
--
4'
--
4
9/11
50
10 mirl.
9'
5'
5
9/11
80
--
1 4'
--
6
9/11
90
10 mid.
9'
5'
Percolation Rate 2 min./inch Perc Hole Diameter 6'
Test Run Between 4' and 5'
Commentsi
Performed By Northpim Fng, I CERTIFY THAT THIS TEST WAS
Performed in Accordance with All State/Municipal Guidelines in Effect
ON THIS DATE. DATE, 9/11/07
�'++WAU
OF
NORTHRIM E
ENGINEERING * "49m ` •
TESTHOLE LOG
T. H. 2
PO Box 770724 .
Eogls Rive , Alaska 99377 ' •, vo;
907.694.7028 ......
•"
GE❑TECHNICAL-.
9/11/07 12
DE:
FP31 : FFati M : Apr. 28 2W9 11:41PH Pl
Development Services Department
Building Safety Division
ra "` On -Site Water d Wastewater Program •'•• s`
` 4700 Bra9aw Street =
P.O. Box 196650
tfark epM Ancbero9e, AK 997196650 a• 'r'
Atary L�++x.A.+•Lery*M, 1e
(90?) so -1'904 F.'x 3 v3 - 71l'7
Pump Installation Log
Well Drilling Permit Number: SW-PLOII -073/
I
Parse! Identification Number:—
1073 U/,4xy SC/,r"/TAR !},
Pump Installation Date: a .- 7—,P 17
Date or Issue: ,12 9/o g
rperty Ow aer sau & Addrtsu
J"Rey PRY/5 9e^,F%s
/07.r GyE6,r S7 STs'• /s7
/dAS/6,(N ; 4 y y 6s't'
Pamp Intake Dcptb Bsloss Top of Well Casing: fat a 8 (o r
i t �
Pump lfaoufactarer's Name. G O v 6 OS
Pumpllodch 7 SB /V
Pump Size / by
r 0
PidessAdapter Burial Depth: /Y 1 feet
Pidess Adapter hfanufacturrr's Name: /3 / 0 ?(- C .4 Mf SfLL
PsuessAdapter Insulter: f/SgNO
ts'eU Disinfected Upon Comp1etiont7,Yes [3,N0
Afetbod oMsioleetloat C L.#R iiae TAOI <7-S
Commeats:
Pomp Insurer Name: CangwnyN'sme Ov,C11"o/z �/i^Ig i l./tiL
1lleilingAM-err A9
Ciry AK zir
1.i,9S/GL,st� /f�C yy G r y
Aruction: The pvsp lrcullcr shall provide a p::rcp installation log to the DSD within 30 days of pump installation.
Apr 15 08 02:33p
TROY DAVIS HOMES
15073579395 p,1
Certitieborf aing `-Log
by
ox co. d:.
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 09587 -TELEPHONE 688-2759
OWNER OF LAND:: ;: `+ "f S It's ✓ti C S
ADDRESS:
LEGAL DESCRIPTION:
P/i- _2 E47 a C1
i
DATE
PERM.T NLIMSB R: f:: J r £ Date of issue=- r — _I3
TAX ICENTIFICATION NUMBER: QT1 -3A_
Is well located at apptoyed permit locaboo? ] Yes i] No
Method of Drillinc: G-0 rotary 7 cable tool
Depth of well: `- 'a C
Casing Type Lyall Thickness ��' inches
Diameter Inches, depth feet
Liner Type: -Z
Casing Stickup Above Ground -IQ feet
Static Water Level: F feet
Recover Rate: gpm
Method of Testing:` , 1; --
Well Intake Open ng Type: O open end 6,crp n hole
Zi Screened: Start feet Stopped feet
O Perforations Start feet Stopped feet
Grout Type'l • _ i _ Vclume
Depttx from % feet, to feet
NkII Disinfected Upon Completion? trSes 7 No
Method of Disinfectinn: �L .:•.. `iU i �• ��
Comments:
I
Driller's Name __C n � �= S ..f � � • �"^•
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.
C`�rJ r•._
L_
S�
iLR/''- t7Kr�C�
.mac ;rS
Sr..�.�rs — I f 3rd: e•�
I
Driller's Name __C n � �= S ..f � � • �"^•
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.
MUNICIPALITY OF ANCHOR4GE
Development Services Department
On -Site Water d Wastewater Program J/ �j I aj)
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519.6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT
Initial
Permit Number: SW070168
Legal Description: SCIMITAR #2 BLOCK 3 LOT 20
Design Engineer: 0838 NORTH RIM ENGINEERING
Owner Name: TROY DAVID
Owner Address: 1075 CHECK STREET #207
WASILLA , AK 99654 -
Date Issued: Jul 19, 2007
Expiration Date: Jul 18, 2008
Parcel ID: 051-132-58
Site Address: NHN TOLWAR DRIVE
Lot Size: 43326 SO, FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit Is for the construction of:
0 Disposal Field E✓ Septic Tank Ej Holding Tank F] Privy Q Private Well E] 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.
9-31-07
I11 IO"I r
Received
Issued By.
II1'I1 Ca. 11 -cel WCliv:'1_s -t` MOvZ_ weiX -/. / '✓/ wCsY
Cev*ftyp IV -t, �C7Cf /nt-45SA9•- 4V[/L SYe' ✓L p YXcA
Jct
new/ %N. loo+fio,•. new /
Pes,J4 C'44 jcD 506,Trc7 11 +0
Date: --7/.2
Date: i IY
Municipality of Anchorage
❑
- :—Development Servlpe!,Department-
❑
Building Safety Division
•; '�'"
On -Site Water and Wastewater Program
❑
4700 Bragaw Street
P.O. Box 196650
❑
Anchorage, AK 99519-6650
www.muni.orglonsite
(907)343-7904
ON-SITE SEPTIC/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 6S/- /3A- 5R
Propert
Mailing
y owners) Da hone z S-7 9's 97
• / y p
address Zip Code 9 S�
Site address g l -,w -ML AjAQ-ff Zip Code
Legal description (Sub'd, Block & Lot)
Legal description (Township, Section & Range)
Lot Size '-/3. ,3 Sq. Ft.
THIS APPLICATION IS FOR (®all that apply):
Absorption Field
❑
Septic Tank
❑
Holding Tank
❑
Privy
❑
Private Well
Water Storage
❑
Number of Bedrooms 4
THIS APPLICATION IS AN:
Initial
❑
Upgrade
❑
Renewal
❑
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.
/ A 9
(Signature of property owner or aL*ihorized agent)
Permit/Rush Fees:
Waiver Fees:
Date of Payment: '4h & I D y. Date of Payment:
Receipt Number: I!M5_8 Receipt Number:
(Rev. 11/05)
ab
all
.
.�TVLr
rb T
Wn-INEERING
NorthRim Engineering
PO Box 770724
Eagle River, AK 99577
907.694-7028
July 13, 2007
MOA On -Site Water & Wastewater Program
4700 Bragaw St
Anchorage, AK 99519
RE: Scimitar #2 S/D, Block 3, Lot 20
A lot is being developed. Excellent soil was found. The design is based on this test hole.
Private water wells serve the subdivision.
The neighboring lots are mostly developed. No conflicts exist to other on -lot systems.
This site should not negatively impact any of the other area lots. The lot slopes to the
north & is less than 10%.
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
`-9ttve Eng, PE, PH
Design Enclosures
`f
1 ZGIZGWERING Scimitar #2 S/D, Block 3, Lot 20
SPECIFICATIONS & DESIGN GIJIDF,LINF.S
Wastewater System Sizing: This is a new 4 -bedroom, single family home. This is an
older subdivision and most of the neighboring lots are developed. These lots are large and
are served by private water wells. No adverse impacts are expected from development.
No conflicts to the other lots will take place by this septic system and water well
construction. The easements are located on the drawing and are not encroached upon. Soil
tests revealed sandy gravel soil with low silt. An application rate of 1.2 GPD/FT2 with 0.5
reduction factor for utilizing a 5' wide trench. Trench Length = 500 FT=/5'x .5 reduction
factor = 50'; 1 line @ 50'. No bedrock was encountered or groundwater 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, 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 1" 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 V 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 %= inch to 2 %: 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.
9 Insulation board to be extruded direct burial polystyrene (Dow Styrofoam III/equal)
Septic System Construction
Does Not Preclude Adjoining
Lots From Sanitation
Improvements.
TH M'T' 1 Rerve Site
,_—Alosorp Ion Trench
\ \Double C.O.'s \
1250 Gallon Septic Tan
Slope < 10% F.C.O.
New
4 BDRM
Home
Driveway
M
Proposed
Water Wel
DESIGN NO
1. Total De
of Trench is 8'.
es South.
er Service Line minimum 2% slope.
3. Test Hole Log Attached.
4. Lots Served by Private Water Wells.
1• = ao
�.°F
NORTHRIM ''
SCIMITAR #2 S/D
ENGINEERING *.�s ��
BLOCK 3 LOT 20
PLAN
PO &am 770722. :: ;; o.. ;::
LAYOUT
Eagle RlH . Alaska 99377 •. a-ws
907.694.7028 ......SEPTIC
SYSTEM`7MV07
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S❑ILS LOG - PERC❑LATI❑N TEST
Date Performed: 3/9/07
Performed For: Troy Davis (Tim)
Legal Description: Scimitar #2 Subdivision, Block 3, Lot 20
DEPTH
(FEET)
Organic
GP
Sandy Gravel
w/ Low Silt
T.H. Location: See Attached Design
Groundwater? No
Depth --
Water Depth
Ar+or Mnnitnrinn.NnnP Date: 3/28/07 & 5/15/07
#
Date
Gross Time
Net Time
2
Net Drop
3 -
3/9
0
--
7'
--
2
r:
5 -
2 Min
7 -•
1'
3
3/9
8 -
--
8'
--
9
3/9
10
2 Min
9'
1'
11 _
;:....N ;...
64
--
13 -
'••
14 -
3/9
15 -
2 min
16 -
1'
17 -
18 -
19 -
20 -
21 -
Organic
GP
Sandy Gravel
w/ Low Silt
T.H. Location: See Attached Design
Groundwater? No
Depth --
Water Depth
Ar+or Mnnitnrinn.NnnP Date: 3/28/07 & 5/15/07
#
Date
Gross Time
Net Time
Depth
Net Drop
1
3/9
0
--
7'
--
2
3/9
2
2 Min
8'
1'
3
3/9
32
--
8'
--
4
3/9
1 34
2 Min
9'
1'
5
3/9
64
--
8'
--
6
3/9
66
2 min
9'
1'
Percolation Rate 2 min./inch Perc Hole Diameter 6'
Test Run Between 4' and 5'
Comments, PrPsnaked
Performed By NnrthRim Fng, I C
Performed in Accordance with All
ON THIS DATE. DATE: 5/15/07
_ CERTIFY THAT THIS TEST WAS
State/Municipal Guidelines in Effect
NORTHRIM:~P�iem ; *
ENGINEERING •• ......••
TESTH❑LE LOG
T. H. L
PO Box 770724a........
Cagle Rl~. Alaska 99377 •. arr�.;'�
907.694.7026 •••..
GE❑TECHNICAL
•� T.
7/13/07 1
DE:
MUNICIPALITY OF ANCHORAGE
Development Services Department p p Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051-132-58
1. GENERAL INFORMATION
Expiration Date: / r/ t- 2 0 Z Z
Complete legal description Scimitar #2 Sub, Block 3 Lot 20
Location (site address) 20394 TUlwar Dr, Chugiak, AK 99567
Current property owner(s) Griffin Rowdy C & Laura M Day phone 907)632-7353
Mailing address PO Box 770075, Eagle River, AK 99577
Real estate agent Brandi Sullivan
2. TYPE OF DWELLING:
Q Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone (907)232-9504
3. NUMBER OF BEDROOMS:
5
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
9
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550
Date of Payment
Receipt Number OgD17ID
COSA# 5c21158(-,
Date:
Waiver Fee $
Date of Payment
Receipt Number
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 Forge Engineering Phone (907) 522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller, P.E. Date 9/22/21
:9� 1
TH
/ •� .
6. DSD SIGNATURE • • • •-
System #1 Approved for 5 bedrooms eenjamr ,nvSchiller
System #2 Approved for bedrooms��`��� •• CE 12592 •'��,: � l 9/22/21 ' •v���
Disapproved ,l�iF�PRO FE sl64,1
Conditional approval for bedrooms, with the following stipulations:
OF AjV6(
WATER AND
o WAST'_V` o
M
NT
1�
Original Certificate Date:
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: Scimitar Sub, #2 Block 3 Lot 20
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑Q Well log is filed with Onsite (or attached)
Date drilled 7/19/07
Total depth 300 ft
Cased to 100 ft
Fm_1 Sanitary seal is functioning correctly
Fm] Wires are properly protected
Casing height (above ground) 26 in.
Date of flow test for COSA 9/20/21
Static water level at beginning of test 196 ft.
Comments
B. TANK DATA
Age of tank(s) 14 years
Tank type/material Septic/Steel
Measured operating fluid level in septic tank 50
[JE -1 Standpipes/foundation cleanout per record drawing
Date of pumping Sanitary Pumpers 10/6/21
D. ABSORPTION FIELD DATA Deep Trench
Which system tested (date installed) 9/13/07
R ALL standpipes present per record drawing
Total measured depth from grade 9.4 ft (max)
Measured depth to pipe invert from grade 4.9 ft (min)
❑ N/A — pressurized field
0 Monitor tubes go to bottom of effective. If not, state
depth into effective
Fil 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: All stand pipes present per inspection report.
COSA Checklist yellow sheet
Parcel ID: 051-132-58
Structure served by this system
Well production at time of test 5.3 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ N
[i0_1 Coliform bacteria is Negative
Nitrate mg/L Q Nitrate less than MRL (ND)
Arsenic ug/L®❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date of Sample 9/15/21
STATION
❑ Requir aintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 9/20/21
Results Q Pass For 5 bedrooms
Fluid depth prior to test 18 in
Water added 919 gal
New depth 22 in
Elapsed time 1440 min
Final fluid depth 17 in
Absorption rate >750 gpd
Any rejuvenation treatment (past 12 months)
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'
p
Yes
Community Sewer Manhole/Cleanout > 100'
r, Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100' Yes
if No
ft
Private Sewer/Septic Line > 25' M Yes
if No ft
Absorption Field on Lot > 100' 0✓ Yes
if No
ft
Holding Tank > 100' 1✓ Yes
if No ft
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' ❑✓ Yes
if No ft
M Yes
if No
ft
if No
ft
F. ENGINEER'S COMMENTS
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' E✓ Yes
if No
ft
0✓ Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' F71 Yes if No ft Surface Water > 100' ❑✓ Yes if No ft
Property Line > 5'
p
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
❑✓
Yes
if No
ft
Private Wells > 100' Yes if No
Water Main > 10'_ .
El
Yes
if No
ft
Community Wells > 200'✓Q 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'
E✓
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'
Yes
if No
ft
Private Wells > 100' Yes if No
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' 0✓ Yes if No
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 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
- 4�!ko
*: 49 ,M +
Benjarr5chiller
CE 12592 • c�`v�s
�flF • , 9/22/21 • • '�C�
PROFESSI4 VAMW
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Municipality of Anchorage
Development Services Department
°ate ii
Building Safety Safe Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
RASH*
(907) 343-7904
' CERTIFICATE OF ON-SITE SYSTEMS APPROVAL v "•�
FOR A SINGLE FAMILY DWELLING
Parcel l.D.05/-t?2- 59 COSA#_�
1. GENERAL INFORMATION ExpirationDate:
Complefe legal description SCr.°,l IQ✓9.
R/ook
Location (site address)
Current Property owners) _ T2a y t�1 AV/ f Day phone S 7- 93 9y
Mailing address /OiS nll6i!.ST st/a 7
Lending agency Day phone
Mailing address
Real Estate Agent -� r�_�sr•r„n Day phone 6 ZZ- -?24V
Mailing Address—20t,¢yG rt r E.¢r4F ✓2rvER
Unless otherwise requested, COSA will be held by DSD for pickup
2. NUMBER OF BEDROOMS: 5
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual Water Storage
�]
Individual On-site
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
supper system. DSD also issues COSAs upon request tobomeowners Certificates-of-On-Site-SystemsApproval
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 furiher verify that based on the information
obtained from a Municipality of Anchorage files and from my Investigation and inspection, the on-site water
supply a from
disposal system is(are) in compliance with all applicable Municipal and State codes,
o�r�iR regulations In effect at the time of installation. I��
Name of Firm A 0 T N Eng �� q• Phone -45"W—
Address
Engineer's Printed Name ?5';V6'
5. DSD SIGNATURE
_Z" Approved for _5 bedrooms.
Date Z" e
pp .
T /
i:ere� Yl. E.1 r
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
WATER AND R
Additional Comments --- n—T-
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
(R". 11105)
Original Certificate
Municipality of Anchorage
(' Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: 's—'10a I f �� 1 F B/oc i< 3 L 0 7� .00 Parcel ID:
�J S/ 132 - SIP
A. WELL DATA
Well type
Date completed l4e/6 7
Total depth 300 ft.
Date of test
Static water level
If A. B, or C provide PWSID # _
Sanitary seal (Y/N)
Cased to /0O ft.
FROM WELL LOG
VY10 7
201
ft.
Well production 7 g.p.m,
WATER SAMPLE RESULTS:
Coliform ,—colonies/100 mL Nitrate mg/L
Arsenic: 6.26tmgA Date of sample: 411,P10r
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material rj ,nen v. a e e/
Tank size $00 gal. Number of Compartments
Foundation cleanout (Y/N) 4 Depression over tank (Y/N) /t!'
Date of pumping &feoJ Pumper
Well Log (Y/N) �,
Wires properly protected (Y/N)
Casing height (above ground) in.
AT INSPECTION
Al EuJ
ft.
Other bacteria Q colonies/100 mL
y: dg/ie.
Collected br� , En o
Date installed !�//3/CZ
Cleanouts (Y/N) Z
High water alarm (YIN) '
C. ABSORPTION FIELD DATA
Date installed t3/9 7 Soil rating (g.p.d-M2 or*6&,) 2 System type 7';F,6 tJC./f
Length 67 ft. Width _'S ft. Gravel below pipe " !y ft.
Total depth —f— ft. Eff. absorption area 470ftz Monitoring lube * Depression over field Al
Date of adequacy test N(5i 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. Absorption rate >= g.p,d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date
D. LIFT STATION IVA4
Date installed Size in gallons Manhole/Access (Y/N)
'Pump on' level at in. 'Pump off" level at _ i . High water alarm Iv at in.
Datum Cycles tested Meets alarm 8 uit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
r
Septic tank/lift station on lot 10 r f On adjacent lots 1l
r
Absorption field on lot 16o,-,- On adjacent lots /04 't -
Public
Public sewer main /1/A Public sewer manhole/cleanout IV14
Sewer /septic service line Al rI' Holding tank "//fl
Animal containment areas ,00 r,& Manure/animal excrete storage areas /D d r—
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
r
Building foundation �r7 �f Propertyline $Q r Absorption field �O
Water main //i S` Water service line A0 �t Surface water / �O
Wells on adjacent lots 0/ 0 r 'f
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Z0 `� Building foundation 2O �� Water main /0 rf,
Water Service line /0 rr Surface water X40 rr Driveway, parking/vehicle storage 50 x'06
Curtain drain — Wells on adjacent lots 166 fi
F. COMMENTS
ti
Ar
G. ENGINEER'S CERTIFICATION •••. ; `i n`2
I cern that I have determined through field inspections and o'*:•
h v �c1-t
review of Municipal records that the above systems are in r.,,• 'Y•
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name sTE�lE EnIG 4�1��� ; sr::oo'w. tis -1
d tf�\•.• PF 62:6 �, �; „�
Date Lai-S/l rQ� n,'•.,�. :'.moo
�1�1,7 •1.1` •\�`RV
.:A^n
COSA Fee $ 5 5Q g Waiver Fee $
Date of Payment 14 atD Date of Payment
Receipt Number �u 15(� Receipt Number
(Rev. 11/05)
30.00
C ra
LOT 20 BLOCK 3 HAS \
43,328 SQ.FT. OF AREA
30.00
NA(i 9WWW 19n A
V9014 WPIL
1
CURVE TABLE
CURVE I DELTA I RADIUS I LENGTH ^0
Cl 1 1 70.00 ,3
.8
A
m�
2
2
1n
FOR: Troy Davis Homes Date
LanAfark
Grad "
sngaoeerlag a surreytag. lar.
1261
9330 Vanguard Drive, Suite 203
Anchorage, Aleeka 99507
19071 562-6050
Drawn D y
CEF/DL\I
30 on
-11200
I" = 50 Lot 20 -Block 3
280073 SCIMITAR
Field Book SUBDIVISION
227 UNIT NO. 2
1 hereby certify that the properly described hereon has been surveyed
by me, or at my direction, and that the Improvements situated thereon
are within the properly lines and do not overlap or encroach on the
property lying adjacent thereto unless otherwise shown. That no
Improvements on the properly lying adjacent thereto encroach on the
premises in question and that there are no roadways, transmission
lines or other easements on said property except as shown.
It is the responsibility of the owner or builder, prior to construction,
to verify proposed building grade relative to finish grade and utility
connections and to determine the existence of any easements, covenants,
or restrictions which do not appear on the recorded subdivision plat.
Listed distances prevail over scaling.
Reproduction may cause distortion.
14,
�P��•oF.gCso
'�s��i
CHARLES E. FORBES o
�•. LS -7526 • 'ici10 .ce
.....••••p!b �