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COSA Checklist.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No *5+ ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
*5’+ SEPTIC TANK TO FOUNDATION SEPARATION PER CODE AT TIME OF INSTALLATION.
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 6/19/24
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. 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 in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. 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, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
6/19/24
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LI V� U lJ V `CEJ PDi\ L. � TY 0 F /\ ll U C H ®R,/t GE
Development Services Department -343-7904
On -Site Water & Wastewater Section - Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050 304 08
1. GENERAL INFORMATION
Complete legal description
Expiration Date
EAGLE CREST #1 TR A LT 43
Location (site address) 19512 SECOND ST
Current property owner(s) STENDER
Mailing address
Real estate agent
2. TYPE OF DWELLING:
Fx-1 Single Family (w/ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: NONE
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 55v Waiver Fee $
Date of Payment l y Date of Payment
Receipt Number dig 5 3J Receipt Number
COSA# 0SC2ZA35o Waiver#
Distance:
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 C&M ENGINEERING Phone 8545558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 7/11/22
OF Ak.
*: 49 TH •.* I
6. DSD SIGNATURE• •
r.... H .
System #1 Approved for bedrooms rr CHARLES G BALZARINf
System #2 Approved for bedrooms ��`���% CE -13854 , •. ��r�
Disapproved �i1i`��PROFE6s1oNP��r�
Conditional approval for bedrooms, with the following stipulations:
B
Original Certificate Date: —1 "
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
COSA Checklist
Legal Description: EAGLE CREST #1 TRACT A LOT 43 Parcel ID: 050 304 08
If more than 1 septic system on lot: COSA Checklist # 1 of 1 Structure served by this system 1
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 2003
Total depth 290 ft
Cased to 290 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) +18 in.
Date of flow test for COSA 7/8/22
Static water level at beginning of test 252 ft.
Comments
B. TANK DATA
Age of tank(s) 19 years
Tank type/material STEEL SEPTIC
Measured operating fluid level in septic tank 50
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 7/12/22
D. ABSORPTION FIELD DATA TRENCH
Well production at time of test +4.1 apm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ N
❑ Coliform bacteria is Negative
Nitrate 1.08 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by A.LAMSON (C&M Engineering)
Date of Sample 7/7/22
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Which system tested (date installed) 2003
Adequacy test date 7/8122
❑ ALL standpipes present per record drawing
Results ❑✓ Pass For 3 bedrooms
Total measured depth from grade 10 ft (max)
Fluid depth prior to test 0 in
Measured depth to pipe invert from grade 6 ft (min)
Water added 450 gal
❑ N/A — pressurized field
0
New depth in
❑ Monitor tubes go to bottom of effective. If not, state
10
depth into effective
Elapsed time min
❑ Code -required soil cover over field
Final fluid depth 0 in
❑ System presoaked
Absorption rate 450 gpd
(Required if vacant for greater than 30 days prior to
Any rejuvenation treatment (past 12 months) NO
date of test)
Gallons introduced gallons
If yes, enter date NA
Comments/Deficiencies: DEPTH MEASUREMENTS AT WEST SIDE OF FIELD.
COSA Checklist yellow sheet
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'
111 Yes
if No
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100' ❑✓ Yes
if No
ft
Private Sewer/Septic Line > 25' (,( Yes
if No ft
Absorption Field on Lot > 100' M✓ Yes
if No
ft
Holding Tank > 100' R1 Yes
if No ft
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' n✓ Yes
if No ft
Q✓ Yes
if No
ft
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' 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' Q✓ Yes if No ft Surface Water > 100' Q Yes if No ft
Property Line > 5'
111 Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'✓Q
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Main > 10'
IZI Yes
if No
ft
Community Wells > 200' 0 Yes if No ft
Water Service Line > 10'
❑✓ 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'
IZI
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'✓Q
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'✓�
Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
0
Yes
if No
ft
Community Wells > 200' 0 Yes if No ft
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
LANDSCAPING FEATURES OVER LEACHFIELD DO NOT APPEAR TO IMPACT
PERFORMANCE. ALL SEPTIC TUBES ARE CUT CLOSE TO GRADE AND MAY BE HARD.
TO FIND IN WINTER.
G. ENGINEER'S CERTIFICATION
l 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. 7/11/22
COSA Checklist yellow sheet
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TH
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CHARLES G BALZARINd,_ 0
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