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On-Site Water System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSPl11316
Tax Code Number: 05010117000
Work Type: Well Initial
Permit Effective Dates: October 28, 2011
Design Engineer:
Subdivision: W G PIPPEL
to October27, 2012
Site Legal Address: W G PIPPEL BLK 3 LT 4 G:0251
Owner/Address: FEDERAL NATIONAL MORTGAGE
ASSOCIATION 400 COUNTRYWIDE WAY SV-35 SIMI VALLEY CA 930656298
Site Mailing Address: 16563 FARM AVE, Eagle River
Lot Size in Sq Ft: 24360
Total Bedrooms: 3
This permit is for the construction of:
N Disposal Field N SepticTank N Holding Tank N Privy Y Private Well N 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Special Provisions:
1. The existing septic system is to be decommissioned prior to drilling the new well.
2. The connection to public sewer must be complete prior to drilling the new well.
3. The existing well is to be decommissioned prior to final approval.
Received By~~
Issued By: ?t~'~ ~~
MUNICIPALITY OF ANCHORAGE
Community Development Department
Development Services Division
On-Site Water & Wastewater Program
Phone:907-343~7904
Fax:907-343-7997
Mayor Dan Sullivan
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. ~ .DCJ-- Jt._~,-i-"{
Property owner(s) ~ E'C'~ Day phone
Ma,,ng address i ~-r$ ~-~.~. ~ ,~ ~ ~ a~
Legal description (Sub'd., Block & Lot) ~ ~(~1 ~'~ ~ ~/ '~(~'~
Legal description (Township, Range & Section)
Lot Size Sq. Ft. Number of Bedrooms
THIS APPLICATION IS FOR:
([] all that apply)
'Absorption Field
Septic Tank
Holding Tank
Privy
Private Well
Water Storage
THIS APPLICATION IS AN:
Initial ~]
Upgrade []
Renewal []
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
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.
.sign~.tt~ of p~op"erty owne~ or authorized agent)
Permit/Rush Fees: ..,i~00 - / "¢~?~~
~¢o - Waiver Fees:
Date of Payment: .. ).C7.) ~,"7 i II Date of Payment:
Receipt Number: ~ ~"'~ ~-(-~- Receipt Number:
Permit No. (~i~ ¢ ~\\ '~ '~ i,~ Waiver No.
G:\Building\On Site\Forms\Client Forms\Permit App_010411 .doc (Rev. 1/11)
EAST 116.00
ONE STORY'
SINGLE, FAMILy
F_.BAME HOUSE
" ' ..... [_....l WEST !16.00
FARM A VENUE
34.6
THE INf:ORMAI'ZON HEREON IS FOR THE USE OF LEND]:NG ];NS'I'ZTUTION5 5PEC~I~CALLY TO SHOW ANY
CONFL];CT5 BETWEEN EX'J;5'I'ZNG STRUCTURE5 AND PLATTED LOT LINE5 AND/OR EASEMENTS; AND 3;5
NOT TO BE USED FOR POSITIONING ADDIT'J;ONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES.
EASEMENT5 Of: RECORD, OTHER THAN THOSE APPEARTNG ON THE RECORD PLAT, ARE NOT SHOWN
HEREON ( UNLE55 INDICATED)
NOTE: FENCELINES THAT MAY APPEAR ON THIs DRAWING ARE NOT TO BE USED TO DETERMNE
PROPERTY LINE5 OR POSII-ION ADDITIONAL IMPROVEMENTS.
ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE 5NOW AND/OR ICE.
]
I
I
I
I
AS-BUILT SURVEY 1" = 20'
NO CORNERS SET THIS DATE
----~'~MANHOLE
I HEREBY CERTIFY THAT I HAVE PERFORNED A SURVEY
OF THE FOLLOWING DESCR[BED PROPERTY
LOT 4~ BLOCK 3~ WG PIPPEL SUB.
ANCHORAGE RECORDING DISTRICT~ ALASKA, AND THAT THE
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
EXIST OTHER THAN NOTED.
DATED AT ANCHORAGEjALASKA THIS
__OCTOBER ~ 2811.
11740, FB 145-10
_26TH__ DAY OF
HOLT LAND 5UI~.VEYING
600 HIGHVIEW DRIVE
ANCHORAGE,AK 99515
345-5513
p.O. B k-"O~(6650
ANCHORAGE. ALASKA 99502-0850
(907) 264-4111
DEPARTMENT OF HEALTH & HUMAN SERVICES
January 10, 1986
TO: Permit Applicant
Subject: Permit # 850500
Lot 4 Block 3 Walter G. Pipple Subdivision
A permit issued by this Department for an individual well and/or on-site
sewer system has expired as of December 31, 1985.
Permits are issued on a calendar year basis by authority of Municipal
Ordinance. A new permit must be obtained from this Department for any
well and/or on-site sewer system not installed by t~e expiration date.
If you have drilled the well, a well log needs to be sent to this
Department for documentation of the installation and to close the permit.
If a private engineer inspected the installation of the on-site sewer system
the original as-built inspection report(three part form) must be sent to
this office for review and approval,and for documentation.
If there are any further questions, please call this office at 264-4720.
Sincerely,
Susan E. Oswalt
Program Manager
On-site Services
SEO/ljw
enc: Copy of Permit
DEF'PR'rMENT OF: HEALTH AND ENVIRONMENTA[: F'ROTECTION _
825 .~ STREET, ANCHORAGE, A~: 9950:[
,::64' 47=: )
PERM I T NO ." 85()5(: :'
DATE ISSUED: U8 / 1..:./8~
APPLICANT: ORRIN J. IVIE
ADDRESS: P.O. 80X 770151
EAGL. E RIVER~ AK 99577
LEGAL DESCRIP: SUBDIVISION: W~LTER G. ]P]]PEL LO]"~ 4
SECTION: 1 TOWNSHIF': 14N RANGE~ 2W
LOT SIZE: 39575 (SQ.FT. OR ACRES)
BLOCI',.. :~
]' certify that:
1. I am ~'amilia~- with the requirements for on-site sewers and wells as set
[or'th by the Municipality of Anchorage (MOA) and the State of Alaska.
2. I ~ill instal], the system zn actor, dance with all MOA .--odes and rec~ulations~
and ~.n compliance with the design criteria of this permit.
5~ I will adhere to all MOA and State o~' Alaska ~,equirements ;'or the set back
distances Crom any existing well, wastewatep disposal s'/stem or public
sewerage system on this or any adjacent of nearby lot.
APF'LICAN]-: OR~I~J. IVIE
Municipality of Anchorage
Development Services Department
Building Safety Division
On~Site Water & Wastewater Program
4700 EImore Road
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak, us
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-101-17
1. GENERAL INFORMATION
COSA# 0 5;
Expiration Date:
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
WG PIPPEL; BLOCK 5~ LOT 14
16565 FARM AVENUE *EAGLE RIVER~ AK 99577
RAYMOND MILLER Day phone
16565 FARM AVENUE *EAGLE RIVER, AK 99577
Day phone
551-2727
Day phone
Unlessothen/v~e ~queste~ COSA w~beheldbyDSD ~rp~k~.
2. NUMBER OFBEDROOMS: 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 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
As certified by my seal affixed herelo and as of the validation date shown below, I verify that my
investigation, based on procedures outlined in the Certificate of On-Site Systems ApproF/al 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 GO the
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal syst¢m is(sre) in compliance with all appficable Municipal
and State codes, ordinances, and regulations in effect at the time of instaJlation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Phone 337-6179
Address 5701E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. OARNESS, P.E.
Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide e fhorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system unde: the conditions encountered at the flme of the test, and separation
d/stances 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 se~/ed 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 gearantee 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 benefi! of the owner listed above. Any reliance upon or use of this report by any
other person or pady is not authorized, nor will it confer any legal right whatsoever.
5. DSD SIGNATURE
~ Approved for ~3 bedrooms.
Disapproved.
Conditional approval for
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate 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 EImore Road
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type PRIVATE
Date completed
Total depth 4-0
WG PIPPEL; BLOCK 5, LOT 4-
UNK
*PER AAROW PUMP &: WELL SERVICES.
(SEE A'Fi-ACH ED)
IfA, B, orC provide PWSID~ N/A
Sanitary seal (Y/N). YES
Cased to 40 ft.
Parcel ID: 050-101-17
**PER SPURKLAND ENGINEERING
Well Log (Y/N) NO
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
Date of test
Static water level
Well production
FROM WELL LOG
NO WELL LOG
~ g.p.m.
AT INSPECTION
*'9/22/11
34.5 ft.
5 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi.
Arsenic: ND ug./L.
Nitrate 0.391 mg./L. Collected by: SPURKLAND ENGINEERING
Date of sample: 9/22/11
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size __gal.
Foundation cleanout (Y/N) __
Date installed
Number of Compartments __ Cleanouts (Y/N) ~
Depression over tank (Y/N) __ High water alarm~)'/
Pumper .
Soil rating (g.p.d./ft2or ft~em type
Width J ft, Grovel below pipe ft.
Date of pumping
C. ABSORPTION FIELD DATA
Date installed
Length ft.
Total depth ft, Eft. absorptio~.a~ ft2 Monitoring tube Depression over field
Date of adequacy test / Results (Pass/Fail)
Fluid depth in. before test in.
For__bedroOms
Water added gal. New depth in.
in. Absorption rate >= g.p.d.
if yes, give date
THE PROPERTY HAS BEEN CONNECTED TO PUBLIC SEWER.
D. LIFT STATION
Date installed Size in gallons ~ ~~
"Pump on" level at ~ High water alarm level at in.
Datum ~
~ Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lotN/A
Absorpton field on lot N/A
Public sewer main ~' 75'~
Sewer/septic service line 25'+
Animal containment areas 50'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout 100'+
Holding tank
Manure/animal excreta storage areas 100%
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Property line
PUBLIC SEWER
Absorption field
Water main Water service line. Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTI~O~
Property line __ __ __~ndation. Water main
Water service line / Surface water dveway, parkingNehicle storage
Cu~n~a~-n Wells on adjacent lots
F. COMMENTS ~ ~ k)~-~,~, t~Jo~O ~,JF-._~..D
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 Pdnted I~ame JEFFREY A. GARNESS
Date
COSA Fee $
Data of Payment
Receipt Number
(Rev. 11/o5)
Waiver Fee $
Date of Payment
Receipt Number
GARNESS ENGINEERING GROUP, Ltd.
CONSULTANTS & Gt~NERAL CONTRACTORS
June 5, 2012
Municipality of Anchorage
Development Service Department
On-Site Water & Wastewater Program
4700 Elmore Rd.
P.O. Box 196650,
Anchorage, Ak 99519-6650
(907) 343-7904
Ref: Release of Conditional COSA; WG Pippel; Block 3, Lot 14:
To whom it may concern:
A conditional COSA was approved by your department for the referenced property. The new owner was
required to drill a new well on property and connect to public sewer. The owner (Raymond Miller) had
the new well drilled but it proved to be non-viable. Raymond decided to have the newly drilled well
abandoned (performed by Sullivan Water Wells May 2012) and document the old well (performed by
Aarow Pump & Well Services April 2012). The home was connected to public sewer (AWWU). We now
are requesting issuance of a conditional COSA. Documentation of the abandoned well, old well
inspection data, and public sewer connection are atxached to tiffs letter.
please contact us at 337-6179. Thank you for your assistance.
(~rn.e~.E., M.S.
d
370I E. Tudor Road, Suite 101 * Anchorage, AK 99507-1259
Ph: (907) 337-6/79 * Fax: (907) 338-3246 * Website: www.garnessengineering.com
('UOUU ) 0~'60~ Hi,ON
(UUOOSU ) 00'0~ ~lUON
>- o
LU --~
o
Aarow Pump & Well Service, LLC
P.O. Box 110496
Anchorage, AK 99511
office: (907) 346-9355 · Fax (907) 333-8976
Eagle River: (907) 622-9335
No. 9352
CUSTOMER JOB SITE
'~UA~Y DESCRIPTIO~ , : - ; PRICE AMOU~
:BOR HOURS : RATE AMOUNT TOTAL MATERIAL :
TOTA~LABOR ~ .
WOR~ORDERED BY BATE OOMR ~BoRTOTAL,
ThankYou -.~"% / /
(I Hereby Acknowledge the S%afi~Jactory Completion of the Above Described Work and agree that if above work is not paid for in 90 days I agree to allow Aarow
Pump & Well Service, LLC, the right to remove unpaid for equipment and charge for labor already performed & labor to remove unpaid for equipment.)
TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE.
SERVICE CHARGE AT RATE OF 1.5~ PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS.
Jun 01 12 08:52a Sullivan Water Wells 907 688 2759 p,2
Municipality of Anchorage
Community Development Department
On-Site Water and Wastewater Program
4700 Elmore St. · P.O. Box 196650 Anchorage, AK 99519-6650 o http:I/www,muni,org/onsite. (907) 343-7904
Legal Address:
Subdivision
T
IName:
Well Decommissioning
,, Block '~ Lot H
R Section Lot
On-site Water & Wastew~ter Program cedili~d cantracter performing the well decommissioning:
Methodofdecommissionlng: AMC 15.55.060L1 a, [] b. [] c.~
Location: Use the space below to previde a drawing of the property showing the following items;
Nodh arrow
Decommissioned w~lt,
Other water wells on the property,
· Two separate swin§qie d Istances for each well shown on the drawi ng,
Nole: The s~tng-tie distance~ shell be maas ured I¥om either permanent structures or the property comers.
Environmental Consulting and Design
RESIDENTIAL WELL INSPECTION
LEGAL:
OWNER:
LOCATION:
WG Pippel Block 3 Lot 4
FNMA
16563 Farm Ave., Eagle River, AK 99577
TYPE OF WELL:
WELL LOG AVAILABLE:
INSTALLATION REQUIREMENTS MET:
WAIVERS GRANTED:
WELL YIELD FROM WELL LOG:
WELL YIELD FROM TEST:
Private, Single Family Residence
No
No
None
Unknown (GPM)
5 GPM
DATE OF INSPECTION: September 22, 2011
TEST PROCEDURE: The well was pumped at a rate of 5 to 7.5GPM while the draw down was monitored with
a water level indicator. At the beginning of the test water level was found at 34.5 feet below the top of the casing.
The well was pumped for 86 minutes. The water level stabilized at 38 feet while 450gallons was drawn from the
;yell. After the water was shut off, the water level recovered to 35 feet below the top of case within 5 minutes.
TEST FOR TOTAL COLIFORM, NITRATE NITROGEN, AND ARSENIC: A water sample was collected
on September 22~'~, 2011 and is being analyzed for arsenic, bacteria, and n trate.
RESULTS: Pending
Total Coliform Neg Total Nitrate-N ND mg/I
Arsenic ND ug/l. Max. allowable Total Coliform PA,
Total Nitrate-N 10 mg/l, Arsenic advisory issued if above 10 ug/1 ND- None Detected
When Nitrate levels are above 5 mg/l the Onsite Water and Wastewater Program issues a Nitrate advisory.
TEST RESULTS: This well will meets the minimum operational requirements of the Municipality of
Anchorage. A pump must be installed so thatthe house has a working water supply.
The Municipal requirement for well flow is 150 gallons ofwatar per bedroom per day. This we/1 exceeds this
requirement. The assessment of the condition of the well applies only to the conditions as of the day tested. The flow
rate may change due to subsurface conditions that may not be obse~wed fi'om the surface, and changes in the land use
and other factors that may impact the aquifer feeding the well.
203 West 15th Avenue Suite 202, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland~gei.net
DATE SCHEDULED 12f31/20t' TIME I2:00 am INSPECTOR
SUBDIVISION W G PIPPEL BLOCK/LOT/TRACT BLK 3 / LT 4
INDICATE NORTH
Mumclpal,ty of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 EImore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEHS APPROVAL
FOB A SINGLE FAMILY DWELLING
050-101-17 COSA# O~'~0''' t ~
1. GENERAL INFORMATION Expiration Date: ~
Parcel hD,
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
WG PIPPEL; BLOCK 5, LOT. /4 ! .
16565 FARM AVENUE *EAGLE RIVER, AK 99577
RAYMOND MILLER
Day phone
16563 FARM AVENUE *EAGLE RIVER, AK 99577
351-2727
Day phone _
Mailing address
Real Estate Agent
Day phone
Mailing address
Unless otherwise requested, COSA w#l be held by DSO for pickup.
2. NUMBER OF BEDROOMS: 5
TYPE OF WATER SUPPLY:
* Individual Well ·
Individual Water Storage []
Community Class Well []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Water System [] * Public Sewer ·
· SEE COMMENTS CONCERNING THE EXISTING WELL AND SEPTIC SYSTEM ON BROWN SHEET.
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.
· k
The Municipality of Anchorage is not responsible for errors or omissions in the professional eng neet s wor .
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 Anchorege files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with afl applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Phone
Date
337-6179
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering anatysis 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, greundwater 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 e valuator 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 them[ore not previde
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.
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
(Rev, 11105)
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 Read
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEHS APPROVAL CHECKLIST
Legal Description: WE; PIPPEL; BLOCK 5, LOT 4 Parcel ID: 050-101-17
THERE IS NO DOCUMENTATION ON THE EXISTING WELL SERVING THE PROPERTY AND
A. WELL DATA WAS DETERMINED TO BE NON VIABLE TO CONTINUE TO SERVE THE PROPERTY. A
Well type
Date completed
Total depth ft.
Date of test
Static water level
WATER SAMPLE RESULTS:
WELL PERMIT HAS BEEN ISSUED TO DRILL A NEW WELL (0SPl11316).
If A, B, or C provide PWSID# __ Well Log (Y/N)
Sanitary seal (Y/N) Wires properly
Cased to .ft. Casing?jght'~above ground) in.
FROM WELL LO~PECTION
.g.p.m. g.p.m.
Coliform 0 colonies/1 O0 mi.
Arsenic: ND ug./L.
B. SEPTIC/HOLDING TANK DATA
Nitrate 0..591 mg./L.
Date of sample: 9/22/11
Collected by: SPURKLAND ENGINEERING
WATER SAMPLES WERE PULLED
FROM THE EXISTING WELL.
Tank Type/Material
Tank size__ gal.
Foundation cleanout (Y/N) __
Date installed
Number of Compartments Cleanouts (Y/N) J
Depression over tank (Y/N) __ H gh wate~
Pumper
Soil rating (g.p.d./ft~or ft~em type
Width / ft. Gravel below pipe ft.
Eft. abso ft Momtonng tube Depression over field__
/ Results (Pass/Fail) For__.bedrooms
Fluid depth in ~before test in.
Elap~__ mira Final fluid depth
...~rty'rejuvenation treatment (past 12 mo.) (YIN & type)
Date of pumping
C. ABSORPTION FIELD DATA
Date installed
Length .ft
Total depth ft.
Date of adequacy test
Water added __ gal. New depth in.
__ in. Absorption rate >= g.p.d.
If yes, give date
THE EXISTING SEPTIC SYSTEM SERVING THE PROPERTY IS UNKNOWN AND THE HOMEOWNER IS
PROPOSING TO CONNECT TO PUBLIC SEWER.
D. LIFT STATION
Date installed Size in gallons ~ ~
.Pump on. lev~.. ~g~l~rm l.evel at in.
~ ~ Cycl~ tested. Meets alarm & cimuit mquirements~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot-
Public sewer main
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Sewer/septic service line Holding tank ~
Animal containment areas. Manure/animal e~torage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TAN~-OT TO:
Building foundation Property line J Absorption field
Water main Wat~
Surface
wate[
Wells on adjacent lots ~
SEPARATION DISTAN~ ABSORPTION FIELD ON LOT TO:
Property line J Building foundation Water main
Surface water Driveway, parking/vehicle storage
Wells on adjacent lots
F. COMMENTS
~,[~,,,~) WELL TO BE DRILLED AND PUBLIC SEWER CONNECTION TO BE DONE AT A LATER DATE.
OF
G.E.G,.EE.'SCE.T,F'CAT'O" .......
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 Pdnted Name JEFFREY A, GARNESS
Date ,°/3//,,
COSA Fee $ ~ ~ 0 '~'
Date of Payment //0 / 3~ / ])
Receipt Number (~0 ,~0,..~.~
(Rev. 11/~)
Waiver Fee $
Date of Payment
Receipt Number
] First American
First American TiUe Insurance Company
3035 C Street
Anchorage~ AK 99503
Phn- (907)561-1844 (800)770-0510
Fax- (907)561-1948
Re:
First American Title Insurance Company
Escrow Officer: Ann Barndt
16563 Farm Avenue~ Eagle RiveG AK 99577
Anchorage County
APN: 050-101-17
Date: November 01~ 2011
File No.: 0201-1749113 (AB)
Estimated Closing Date:
HOLD FUNDS AGREEMENT
Buyer: Raymond L. Miller and Teresita S, Miller
OTHER:
First American Title Insurance Company is instructed to hold the sum of $7500.00 in escrow after closing
for the following purpose:
Final COSA approval from the Municipallity of
Anchorage Onsite Dept.
7500.00
Funds will be held in a non-interest bearing account for a term of no longer than ]uly 1, 2012. If Buyer does not
have Final COSA Approval from the MOA by said date, the funds held will be released to Northern Utilities for
completion.
BUYER:
The Party responsible for submission ofwritten instructions as to the disbursement of funds is: Buyer
Escrow Holder will continue to hold the funds in the above referenced file until:
1. Funds are released pursuant to these instructions
In the event that funds remain in escrow for any reason more than 90 days after the close of escrow, or if escrow
has not closed 90 days after the estimated closing date set forth in the existing escrow instructions to Escrow
Holder ("Dormancy Period"), Escrow Holder will make reasonable efforts to notify the parties regarding same. If
funds remain in escrow beyond the Dormancy Period, a monthly "funds held fee" of $25.00 shall accrue for each
month or fraction of a month thereafter that the funds, or any portion thereof, remain in escrow. Escrow Holder
is instructed to deduct the monthly funds held fee directly from the funds held in escrow on a monthly or other
periodic basis (i.e. quarterly, semi-annually, etc.). The parties agree to pay these sums to compensate Escrow
Holder for administering, monitoring, accounting, reminders and other notifications and processing of the funds
so held in accordance with this provision.
Page 1 of 2
First American -title Insurance Company File No.: 0201-1749113 (AB)
Date: November 01, 2011
BUYER(S):
READ AND APPROVED BY:
Northern Utilities
Date
Page 2of 2
UTILITY SERVICES
Estimate And
Authorization
Box 233368 Auchorage, AK 99523 Tel. 907-222-4084 Fax 907-346-1169
To: Raymond Miller Date: 10/17/2011
18735 Fish Ave
Eagle River, Alaska
995477
Job Description:
Sewer line connection from AWWU stub out to Connection point in Crawl space. Support and re-bedding of MTA sub-
station panels. 16563 Farm Ave. Eagle River, Alaska
Labor Estimate
2 man Crew 2.5 days @ $1400/day $3500.00
Equipment
Cat 303.5
Vacuum Excavator
Mob and de-mob
20 hr @ $65.00 per hour
3 hr @ $150.00 per hour
$1300.00
$450.00
$300.00
Materials
70' 4" pvc and Misc Fittings
Awwu Permit
$400.00
$162.00
Mark up
Total
This estimate is for completing the job as described
above. It is based on our evaluation and does not
include material price increases or additional labor
and materials which may be required should un-
foreseen problems or adverse weather conditions
arise after the work has begun.
Estimated By:
Authorized By:
Date:
$6112.00
David Kranich