HomeMy WebLinkAboutROOSEVELT PARK BLK 13 LTS 4 & 5Roosevelt Pork
lock 13
010- 202-32
Municipality of Anchorage =¢
V
On -Site Water and Wastewater Program a
(907) 343-7904 s A r E T Y
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 010-202-32
Expiration Date: �Jic o� C7 a
1. GENERAL INFORMATION
Complete legal description Roosevelt Park Blk 13 Lots 4&5 _
Location (site address) 4201 Taft -St / 2106 Jefferson Ave _
Current Property owner(s) Glenda Bach_ Day phone _
Mailing address 4201 Taft St. Anchorage, AK 99517
Real Estate Agent
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
_ Day phone
3. NUMBER OF BEDROOMS:
03
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY:
Individual
❑
Individual Well
®
Holding Tank
❑
Individual Water Storage
❑
Community
❑
Community Class _ Well
❑
Public Sewer
Public Water System
❑
WaiverNariance request for: Distance:
Received by: _ Date:
COSA to be released to the engineer, unless otherwise requested by.the engineer.
COSA Fee $ 280.00
Date of Payment
Receipt Number 0y
COSA # _C_S C 21 I_I _q tj.
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.
Name of Firm ARCTERRA_CONSULTING, INC. Phone 696-6111
Address 20441 PTARMIGAN_ BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M.�DUFFUS Date 4/2Q1-21_____________
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition
of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface
conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen AW
encroachments, deficiencies or discrepancies exist.
� f
6. DSD SIGNATURE 0
/ KENNETH t, '017- _'S
V System #1 Approved for -3 bedrooms. #4 l'
System #2 Approved for bedrooms.
Disapproved. ��-
Conditional approval for
By: Ali
_wA—_
- - . __. __. _
bedrooms, with the following stipulations:
�:ik4F ( r,16-,
0� Q go
G� r
i\f�e =
PROGF�M-
— � 1
T SES_ ,,6.
Original Certificate Date:_V_3/aO � i
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 blue sheet -10-10-12 doc
Legal Description:
COSA Checklist
Roosevelt Park Block 13 Lot 4 & 5
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 1950
Total depth 74+* ft
Cased to 74* ft
❑■ Sanitary seal is functioning correctly
L Wires are properly protected
Casing height (above ground) 21 in.
Date of flow test for COSA 4/8/21
Static water level at beginning of test 30 ft.
Comments * Information based on previous COSA
TANK DATA
Age of t years
Tank type/materia C/Steel
Measured operating fluid leve tic
❑ Standpipes/foundation cleanout per
Date of pumping
tank
drawing
BSORPTION FIELD DATA
Which s tested (date installed)
❑ ALL standpipes nt per record drawing
Total measured depth from g h (max)
Measured depth to pipe invert from gra ft (min)
F1 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: 010-202-32
Structure served by this system
Well production at time of test 3 gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes 0 Ne
Coliform bacteria is Negative
Nitrate mg/L [■I Nitrate less than MRL (ND)
Arsenic 62.4ug/L ❑ Arsenic less than MRL (ND)
Collected by Arcterra Consulting
Date of Sample 4/8/21
STATION
❑ Requl aintf
Age of lift station
Lift station material
Comments:
nce completed
vears
Adequacy test date
Results ❑ Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
lapsed time min
Fina epth —i n
Absorption rate gpd
Any rejuvenation treatme st 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'
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No NA
ft
[0 Yes
if No ft
Neighboring Tank > 100'
❑ Yes
if No NA
ft
Private Sewer/Septic Line > 25' Yes
if No ft
Absorption Field on Lot > 100'
❑ Yes
if No NA
ft
Holding Tank > 100' ❑ Yes
if No NA ft
Neighboring Absorption Fields
> 100'
Animal Containment > 50' ® Yes
if No ft
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75'
® Yes
if No
ft
® Yes
if No ft
epticlHolding Tank on Lot to: (Please enter
distances if less than required)
Building Founda e _
❑ Yes
if No
ft
Surface Water > 100' ❑ Yes
if No ft
Property Line > 5'
❑ e
ft
Wells on Adjacent Lots.
Absorption Field > 5'
❑ Yes
if No
ft
Private Wells > 100' ❑ Yes
if No ft
Water Main > 10'
❑ Yes
if No
ft
Commune > 200' ❑ Yes
if No ft
Water Service Line > 10'
❑ Yes
if No
ft
If septic tank is under driveway c
below
bsorption Field on Lot to: (Please enter distances if
less than required)
Building Foundateo
❑ Yes
if No
ft
If absorption field is under driveway comment
below
Property Line > 10'
❑ e
ft
Wells on Adjacent Lots:
Water Main > 10'
❑ Yes
if No
ft
Private Wells > 100' ❑ Yes
if No ft
Water Service Line > 10'
❑ Yes
if No
ft
Commuel e > 200' ❑ Yes
if No ft
Surface Water > 100'
❑ Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION +f, �q/
1 certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance with R f 49 gi
MOA COSA guidelines in effect on this date.
KENNETH 14"D
I mss, CE 711
,TA�R��r����
COSA Checklist yellow sheet
1
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904
On‐Site Water and Wastewater Section Fax: 343‐7997
www.muni.org/onsite
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Arsenic Advisory
Certificate of On‐Site Systems Approval # OSC211194
Subdivision: Roosevelt Park, Block: 13, Lot: 4&5
A water sample revealed an arsenic concentration of 62.4 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. Information on arsenic is available from the On‐Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343‐7904.
This advisory must be attached to all copies of the subject Certificate of On‐Site
Systems Approval.
Municipality of Anchorage
Development SerVices Department
Building Safety Division
On-Site Water & Wastewater Program
47.0.0 B~agaw_ Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE
FOR A
Parcel i.D. 010-202--,p5"' ~_
1. GENERAL INFORMATION
OF ON-SITE SYSTEHS APPROVAL
SINGLE FAHILY
DWELLING
Expiration Date:
Complete'legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
ROOSEVELT PARK S/D, BLOCK 15, LOT
4201 TAFT DRIVE *ANCHORAGE, AK 99517
GEORGE & DEBORAH MOORE Day phone
DRIVE *ANCHORAGE, AK 99517
Day phone
4201 TAFT
4&5
244-3486
Day phone
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
'3~ TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well · Individual On-site []
Individual Water Storage [] Individual Holding tank []
Community Class Well [] Community On-site []
Public Water System [] Public Sewer ·
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water 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 engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
LIi [lie VclIIUO[HJll
As ce~fieo by my sea~ amxeo h~u and as ,~,~,,v, I
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 t,~e Municipality of Anchorage Nes 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.
NameOfFirm GARNESS ENGINEERING GROUP, Ltd. Phone 557-6179
Address 5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & 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 life of all wells and
septic systems depend on the local soils condition, groundwater 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 the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. 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 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.
DSD SIGNATURE
'~,J Approved for 3
Disapproved.
Conditional approval for
bedrooms.
-.. · PROGRAM
bedrooms, with the following stipulations: ~, ~2~'.. ."
· Jjj)))) ) ) )" , ~ '-,'
ON-SITE '. ~
WATER AND . m:
WASTEWATER
Attachments: COSA Checklist
Septic System Advisory
Well Flow Advisory
(Rev. 11/05)
A, se, ,ic Advisory.,
Maintenance Agreements
Supplemental Engineer's Report
utr~er.
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 ON-SITE SYSTEMS APPROVAL
CHECKLIST.
Legal Description: ROOSEVELT PARK S/D; BLOCK 13, LOT 4 & 5 Parcel ID: 010-202-,,e5'~'~
WELL DATA
Well type PRIVATE
Date completed ~ 1950
Totaldepth *74+ .ff,
*PER AAROW PUMP AND WELL INSPECTION, ON FILE @ MOA.
If A, B, or C provide PWSlD# N/A Well Log (Y/N),
Sanitary seal (Y/N) YES Wires properly protected (Y/N)
Cased to *74 ft. Casing height (above ground)
NO
YES
12+ in.
Date of test '
Static water level
Well production
FROM WELL LOG AT INSPECTION
10/11//2010
,,~~/ff. 24 ff.
g.p.m. 3.16 .g.p.m.
C=
WATER SAMPLE RESULTS:
Coliform (~ colonies/100 mi.
Arsenic: (o'~, ~ ug./L.
SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal.
Foundation cleanout (Y/N) ~
Date of pumping
ABSORPTION FIELD DATA
Date installed "
Length ft.
Total depth ft.
Nitrate I~JO mg./L. Other bacteria (~ colonies/100 mi.
Date of sample: 10//11//2010 Collected by:
GEG Ltd.
JPUBLIC SEWERJ
Date installed
Number of Compartments __ Cleanouts (Y/N)
Depression over tank (Y/N) ~ High wate~
Pumper
Soil rating (g.p.d./ft2or ft~em type
. Width ..--"' ff. Gravel below pipe .ft.
Eft. a ft Momtonng tube Depression over field~
/ Results (Pass/Fail)
Date of adequacy test
Fluid depth in~ before test in.
Ela~,~Jm'~:_ min.. Final fluid depth
A~y rejuvenation treatment (past 12 mo.) (Y/N & type)
Water added ~ gal.
in. Absorption rate >=
If yes, give date
For,__bedrooms
New depth in.
g.p.d.
D. LIFT STATION
Date installed
"Pump on" level at
in.
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons Manhole/Access ~ __
"Pump off" level__a~. High water alarm level at
Cycles tested. Meets alarm & circuit requirements?
NOTE: WELL DRILLED Prior TO 1983
On adjacent lots N/A
On adjacent lots N/A
Public sewer manhole/cleanout
Holding tank N/A
Manure/animal excrete storage areas
Septic tank/lift station on lot N/A
Absorption field on lot N/A
Public sewer main 50'+
Sewer/septic service line 25'+
Animal containment areas 50'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: P U B LIC
Building foundation Property line Absorption field
Water main Water service line. Surface water
50'+
100'+
SEWER
Wells
on adjacent lots ~
S EPAP, A T, ON DIST AN CE FR OM ABSORPT~TO:
Property line .... ~ndation Water main
Water service line / Surface water Driveway, parking/vehicle storage
Wells on adjacent lots.
COMMENTS
.in.
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.
Engineer's Printed Name JEFFREY A. GARNESS
Date JOIl~ /1~
COSA Fee $ ~
Date of Payment
Receipt Number
(Rev. 11/C5)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.rnuni.org/onsite
(907) 343-7904
Arsenic Advisory
Certificate of On-Site Systems Approval # 101260
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 13, Lot
4&5 of Roosevelt Park Subdivision. This inspection revealed an arsenic
concentration of 67.8 micrograms per liter (ug/L) for the property's well
water sample. The Environmental Protection Agency (EPA) has established
a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Information on
arsenic is available from the On-Site Water and Wastewater Program
website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
SGS Ref.# 1105485001
Client Name Gamess Engineering Group, Ltd Printed Date/Time 10/14/2010 16:16
Project Name/# Roosevelt Park B13, L4&5 Collected Date/Time 10/11/2010 15:10
Client Sample ID Roosevelt Park B13,L4&5 Received Date/Time 10/11/2010 15:43
Matrix Drinking Water Technical Director Stel~hen C. Ede
Saml~le Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals b~ ICP/MS
Arsenic
67.8 * 5.00 ug/L EP200.8 C (<10)
10/12/10 10/13/10 NRB
Waters Department
Total Nitrate/Nitrite-N
ND 0.100 mg/L SM204500NO3-F B (<10) 10/12/10 AYC
Microbiolo~ Laborator~
E. Coli
Total Coliform
Negative I 100mL SM20 9223B A 10/11/10 DLC
Negative 1 100mL SM209223B A 10/I1/10 DLC
Anchorage Recording District, Alaska
L_OT SURVEY CERTIFICATION
! berel~ eels'Ifa, ~a~ II~eve ~e~ed ~ ~o~t~ eh~a ~ ~eo~bed '
Dates~. /}30' . ~ o~-0~-~
~.'
"
~e ~lat of rlQ~d
LEGEND
~ast or Alumin~ ca, ed monument r~covsred
0 Ir~ pipe en~or rebar recovered.
2~2 ~ub ~ tack ~ec~red
~8"x~, rebar let this survey
~ Fence Li~e (Ap~ox. L~ation)
Prepored by:
Property of:
Municipality o.f Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 0 1 0 -' ~ O ;:~ -. O ~ COSA #
Expiration Date:
t. GENERAL INFORMATION
Complete legal description tot 5; 8~:k 13; Roosevelt Park Subd~visioin
Location (site address) 4201 Taft Ih'. N'~Kgage, AK
Current Property owner(s) .,~abe,e T~to Trust
Day phone 248-3884
Mailing address
- Lending agency
Day phone
Mailing address
Real Estate Agent
Debt)ie Moore
Day phone 244-.3488
Mailing Address
Unless otherwise requested. COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
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 []
The Munidpality of Anchorage Development Sewices 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 betweer~ 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. (Ce~flcates 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 vedfy 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 wastawater disposal system is (are) safe, functional and adequate
· for the number of bedrooms and type of structure indicated herein· I further vedfy 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 s & s Engineering
Address 15861 $. Birchwood Loop Rd. Chugiak. AK 99567
Engineer's Printed Name Robe~A. Sharer
5. DSD SIGNATURE
f Approved for ~
Disapproved.
Conditional approval for
Phone 694-2979
bedrooms.
· .
bedrooms, with the following shp;~a~h~.
By:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
~:::::~ Odginal Certificate Date: ~ - I ,~- ,0 cj
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 EImore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.orgtonsite
(907) 343-7904
Arsenic Advisory,
Certificate of On-Site Systems Approval # 080260
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 13, Lot 5 of
Roosevelt Park Subdivision. This inspection revealed an arsenic
concentration of 64.7 micrograms per liter (ug/L) for the property's well
water sample. The Environmental Protection Agency (EPA) has established
a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Information on
arsenic is available from the On-Site Water and Wastewater Program
website (www.muni.orWonsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
SGS Ref.# 1092352001
Client Name S & S Engineedng
Project NameJ#/~'~-L-4:BI3,Roosevelt Park S/D
Client Sample ID,~T~'4..~4~313,Roosevelt Park S/D
NlatHx Drinking Water
Printed Date/Time
Collected Date~flme
Received Date'Time
Tethnical Director
06/12/2009 10:58
06/02/2009 12:00
06/02/2009 12:27
Stephen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results POL Units Method Container ID Limita Date Date Init
Arsenic
64.7 * 5.00 ug/L EP200.8 C (<10)
06/08/69 06111/09 NRB
Wa ~.~:s Depa rl:.m~nt:
Total Niwate./Ni~te-N
ND 0.100 mg/L SM204$00NO3-F B (<10~ 06/10/09 LCE
l, ti. etobioloc/~ I. abot'a tot~
Colony Count 0
Total Coliform 0
Fecal Coliform 0
col/100mL SM20 9222B A (<200)
col/100mL SM20 9222B A (<1)
col/100mL SM20 9222B A (<1)
06/02/09 DLC
06/02/09 DLC
06/02/O9. DLC
2of4
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 EImore Road
· P.O. Box 196650
Anchorage, AK 99507
www.muni.org/onsite
· (907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
ParcelI.D. OlD-
1. GENERAL'INFORMATION
., Complete legal description Lot 5; Block 13; Roosevel{ Park S/D
Location (site address) 4201Talt Drive, Anchorage Ak.
COSA#0
Expiration Date.
Current Property owner(s) Annabelle Tito Trust
Mailing address
Day phone 248-3884
Lending agency
Mailing address
Day phone
Real Estate Agent
Mailing Address
Unless othe~vise requested, COSA' will be held by DSD for pickup.
NUMBER OF BEDROOMS: 3
Day phone
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 []
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 numb.er:.of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained front,the Municipality of Anchorage files and from my investigation and Inspection, the on-site water
supply~arJd/gr ~astewater disposal system is(are) in compliance with all applicable Municipal~J~d S~.te codes
ordina~c~sl and regulations in effect at the time of installation.
Phone 694-2979
Name of Firm s & s Engineering
/-
/
5. DSD SIG, j'~IATURE
~ Approved for
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Atta¢l~ents:
COSA Checklist
Septic.Sy. stem Advisory
Well Fl~.w Advisory
Nitra{e Advisory
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 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.orglonsite
(907) 343-7904
' ,CERTIF. ICATE ON-SITE .SdY EMS APPr AL CHECKLIST
Legal Description: ~---~T 5 ! "~..~ I ~ ~/~C~ ~ Parcel ID: O / O --
A. WELL~
Well ~pe ,~ V~- If A, B, or C provide PWSID ~ -- Wail Log ~ ~
Datecompleted~' J Sanita~seal~) ~ Wires properly protected~)
Total depth ~ ff. Cased to ',~ff ~ I ' Cas ng he ght (above ground)
Date of test ~/~ ~ 10 ~
Static water level / ~/I ff.
Well production ~, / g.p.m.
ft.
g.p.m.
WATER SAMPLE RESULTS:
Coliform O colonies/100 mL Nitrate ,/~/b mg/L
Arsenic:-~,t] ug/L dateofsample:'l[tTa-1/~o~
B. SEPTiC/HOLDING TANK DATA~'~"~OF'...~I
Tank Type/Material
Tank size __ gal,
Foundati~)6 clea~o~Jt (Y/N)
Date of pumping . '
Number of Compartments
Depression over tank (Y/N)
Pumper
Other bacteda ~ coloniesll00 mL
Co lected
Date Installed
Cleanou~
er al!rm (Y/N)
Date installed' '. ' '. _ ' Soil rating (g.p.d./~2/bdrm) __ System type
Ler~gth ' ff. ' ' ~ ..,_~~ ft. Gravel below pipe
Total'~le~i~:: ~f~." E~f~tion area ~ Monitoring tube Depression over field
Date of adequacy test / Results (Pass/Fail) For
Fluid depth~n field before test in. '
Elapse~. me: __ min. Final fluid depth
.,,,,,~'~ rejuvenation treatment (past 12 mo.) (YIN & type)
bedrooms
Water added gal. New depth in.
in. Absorption rate >= .g.p.d.
If yes, give date
D. LIFT STATION t~/~t "'-~OBLIC
~ate installed. Size in gaIIons
Pump on level ~ w ta er a~vel a.t .~ in.
Da.~...~ Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main '"~'
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
Animal containment areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ~..)/~
Building foundation Property line Absorption field~
Water main Water service line Surface wat~'~'''~
Wells on adjacent lots
SEPA~TION DISTANCE FROM ABSORPTION
line B~ion Water main
Prope~
Water Se~ice line ~ Sudace water DHveway, parkingNehicle storage
C~ WeIIs on adjacent lots
F. COMMENTS
G. ENGINEER S CERTIFICATION , .~ ~ ~/~/-
I ce~i~ that I have dete~ined though field inspections eno ~-~' ~ .~ u
rewew' of Munich. ~al recess ~he .... above s~stems a~ in ~
confo~ance with MOA COS~gu~lme~ ink.this ~tb. ~/~
Engineers Printed Name ~/] ~/2~[ / ! I ~ ' "~ / ~
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 EImore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Arsenic Advisory
Certificate of On-Site Systems Approval # 080260
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 13, Lot 5 of
Roosevelt Park Subdivision. This inspection revealed an arsenic
concentration of 73.9 micrograms per liter (ug/L) for the property's well
water sample. The Environmental Protection Agency (EPA) has established
a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Information on
arsenic is available from the On-Site Water and Wastewater Program
website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
SGS Ref,#
Client Name
Project Name/#
Client Sample ID
1083502001
S & S £nglnccring
LS,B3 Roosevelt Park S/D
LS,B3 Roo~evcll Park S/D
Drinking Water
Ail Date~/Time~ are AlasLa Standard Time
Printed Date~l'ime 08,~)1/2008 9:16
Collected Date/Time 07/17/2008 14:00
Received Date/Time 07/17/2008 14:20
Technical Director Stephen C. Ede
P%VSID 0
Sample Remark:
AIIo~ble Prep Analysis
Parametar Results POL Units Method Container ID Limits Dale I~le Init
.~etals bg ICP/Ma
Arsenic
73.9 * 5.00
ugtl. EP200.8 C (<10) 07/18/08 07/21/08 NRB
Waters Department
Total Nitrale/Nitrile.N
ND 0.100 mg/L SM20 4500NO3-F B (<10) 07/30/08 JDZ
Mi. crobiol cu~r~, Laboratorlr
Colony Count 80
Total Col/form 0
Fecal Coliform 0
col/100mL SM20 9222B A (<200)
col/100mL SM20 9222B A (<1)
col/I 0Oral SM20 9222B A (<l)
07/17/08 DLC
07/17/08 DLC
07/17/08 DLC
07/2{/2008 10:39 FA~ 9075525449 Alaska Pump & Supply ~00!
Aarow Pump & Well Service, LLC
P.o. Box 110495
Anchorage, AK 99511
Office: (907) 340-9355 · Fax (907) 833-8975
Eagle River: (907) 6~2-9335
No 08095
CUSTOMER JOB SITE
r
~BO~ HOURS ~ATE AMOU~ TOTAL MATE"IAL
TOTAL~O~ ~ ~ ~
~RK ~DER~O 8Y~ DA~ COMP. TOTAL
~R
Thank You
SIGNATURE
(I He~el~y Aclo3owledge the Satisfactory Complefio~ of the A/~ve Des~'~ed Work and agree ~ if above wo~'k is roi paid for ir, 90 days I agree to a~10w ,~'ow
Pump & Well Service, LLC, ~e ~jht to remove unpaid lot equipment and charge for laJ3or already performed & la/3or to remove unpaid l~x equipment.)
TERMS: ACCOUNT~ PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE.
SFRV1CE CHARGE AT RATE OF 1 ..~/~ PER MONTH W1LL BE CHARGED ON OVERDUE ACCOUNTS.