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HomeMy WebLinkAboutRAVEN MOUNTAIN ESTATES #1 BLK 3 LT 4Raven Mountain Estates #1 Block 3 Lot 4 #076 - 031 - 20 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: OSP131341 Tax Code Number: 07603120000 Work Type; Well Permit Effective Dates: September 18, 2013 to September 18, 2014 Design Engineer: ANDERSON ENGINEERING Subdivision: RAVEN MOUNTAIN ESTATES #1 Site LegalAddress; RAVEN MOUNTAIN ESTATES #1 BLK 3 LT 4 G:4018 Owner/Address: NORWOOD STEVE PO BOX 993 GIRDWOOD AK 995870993 Site Mailing Address: 220 GOLD CLAIM DR, Girdwood Lot Size in Sq Ft; 33680 Total Bedrooms: 2 This permit is for the construction of: N Disposal Field N Septic Tank 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. Date: MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division On-Site Water & Wastewater Program Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWER/WELL PERMIT APPLICATION Property owner(s) Mailing address Site address r~o~O Parcel I.D. 0¢~'- 03l - 20 Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) LotSize ~, ~0 Sq. Ft. Number of Bedrooms Day phone APPLICATION IS FOR: APPLICATION IS AN: ((~ all that apply) Absorption Field [] Initial [~ Septic Tank [] Upgrade [] Holding Tank [] Renewal ~ Privy [] Private Well 'E~ Water storage [] TYPE OF DWELLING: Single Family (SF) (w/wo ADU) Duplex (D) Multiple Dwellings (SF and/or D) THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or adthorized agent) Permit/Rush Fees: Date of Payment: Receipt Number: Permit No. Waiver Fees: Date of Payment: Receipt Number: Waiver No. Permit App_;* :, ', 2.dc = Municipality of Anchorage 4 =°` "° ® Development Services Department ,; Building Safety Division �� sT. On -Site Water and Wastewater Program, 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 Page of www,cl.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: OSP111159 PID Number. 076-031-20 Name: Steve Norwood Wastewater System: ❑✓ New ❑ Upgrade: Address: P.O. Box 993 Girdwood, AK 99587 ABSORPTION FIELD Phone: Number of Bedrooms: 2 ❑ Deep Trench q Shallow Trench 14 Bed 13 Mound Q Other. LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: Bfock: Lot: Subdivision: 3 4 Raven Mtn. Est. #1 7 GPD/F? Da th to p pipe 1 Ort m original grade: 13.1 Ft. Graver depth beneath pipe: Township: Range: Section: Ft. Fill added above original grade: •$ FL Gravel Length: 0 Ft. 35 Ft. Well: ❑ New ❑ Upgrade Gravalwidth Numberoflines: Distance betweengres: Classification (Private, A, B, C): Total Depth Cased to: Propose 15 Ft. Total absorption area: 3 5 Ft. I Pipe Material: FI FL 525 Fe ASTM D3034 PVC Driller. Date Drilled: Static Water Level: Installer. Date installed: Ft PCN, Inc. 8122-2512011 Yield: Pump Set at Casing Height Above Ground: GPM Ft. FL TANK SEPARATION DISTANCES ® Septic © Holding ❑ S.T.E.P' ❑ Other: To Septic Absorption Lift Holding ubiiclPrivata Manufacture, Capacity: From Tank Field Station Tank Sewer tine Anchorage Tank 1,000 Gal. welt N/A N/A N/A N/A >25' Material: Siee! NumberofCom rtmerrLs: Numb'two rof pa -7 surtamWater >100' >100, >100' NIA LIFT STATION Lot Line >6 >10'. >5' N/A Sze: Manufacturer. Gal. Foundation >5' >10' >5' N/A /V1 Pump on° level at: Pump cif" level at: High water alarm at: in. im in. durtain Drain (Mone Noted Pump Make & Model Electrical inspections performed by: Remarks: Well Not in Place as of This Date. BENCH MARK Location and Descriptton: Top of Retaining Wall. West End of House. Assumed Elevation: 100.0 Ft. ,�luiine s5t�mp Inspections performed by: MPS Dates: 1at 8/23/2011 0t ••e •••�5���� 2nd 8/24, 2812011 m �Q:�• Arfi�, Development Services Department Approval •�=y ; �� * �• Conditional Approval pate: 60 *• •••• "•�` sN 0 woo* •s•� i�it t Y,�/A�a) ®Cat }�AM+y+� fie \fir B 4381 e.`\� a� ed and approved by: Date: �� �tJ� j + � *'tOrisslov;o' LOT 5 VACANT i Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 Permit Number: OSP 111159 Page 2 of 3 PID No, 076-031-20 A [ S Existing m 57.0' 5s.4' Well S2 72.7' 61.4' C4 52.7' 73.3' C5 111.5'99.3' M184.8' 72.6' ,~,o,.s. co.~ Block 5 x, / \/ A / \ / ! LOT /4 \ LEGEND: CO - Cleanout % /" SV - SepUc Vent FCO - Foundation Cleanout ~ .' TH - Tes( Hole '~MT - Monitor Tube SCALE 1 ' : 40' Pr&ced"'X \ / LOT 3 VACANT I..~.~.~ ~t MIC~L ~. ANDERSON Municipality of Anchorage DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 On-Site Wastewater Disposal System or Well Inspection Report Permit Number: OSP111159 Page 3 of 3 PID No. 076-031-20 Finished /~ 96.7 1 000 Gallon ~ Sept c Tank 98.0 97.1 Finished Grade / Odginal Ground Geotextile Fabdc 97.9 --' · ~-- 87.1 Drainfield Rock 87.1 2' Coarse Sand ~ 81.1 8/23n 1 87.9 35' (Bed Length) PROFILE AS-BUILT No ScaPe Pipe Not ! ~._~~~~~qsNT~C ............ .................. ...................... ~.... " ~ Proposed Well Su~eying · Engineering S'~ C~TW[CAT[ON: 9ENIAC has co~md 2525 Gambell Street, Suite 200, Anchorage, Alaska 99503 ~p~ysic~lsuwcyofthis pmp~as s~o~o~is O Test Hole Tele: (907) 563-3835 Fax: (907) 563-3817 d~w[~ ~d that ~ ~pmwm~ situated thc~coa arc " ' wit~thcp~op~[~ess~d~o~oac~c~tscxJst ~ Fnd, 1" Gel, Pipe ~ot 4~ ~[OCE ~ ~aVCD ~OUDt~JD ~StatCS U~t EXCLUS[O~ NO~: It is ~c' o';a~ rcspo~'~b~tJty ~ Fnd. Su~ey Mom No. ], G~tdwood. Alaska to ~ ~. ~i,~.~ or~ ~.~, co~.t~, .......................... or ms~cti~s which do not appear on ~e mco~ed Jaly2Z 2011 1 ~t~6~ ,sent¢c~eeiteam~com subdivision plat. NOTE: Under no c~ms~nces l 1-5762 ~'~'j~ '~:a~H a~aS~lS :~' ~x ........ forSn°uld any dam hgeon be useathe establishing ofpmp~ lin~.f°r ~e co=~cfionor II IIIIIIIIIII IIIIIIIII I Permit Number: Tax Code Number: Work Type: Permit Effective Dates: Design Engineer: Subdivision: Site Legal Address: Owner/Address: Site Mailing Address: On-Site Water & Wastewater 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 OSP111159 07603120000 WellSeptic Initial July 27, 2011 to ANDERSON ENGINEERING RAVEN MOUNTAIN ESTATES #1 July 26, 2012 RAVEN MOUNTAIN ESTATES #1 BLK 3 LT 4 G:4018 NORWOOD STEVE PO BOX 993 GIRDWOOD AK 995870993 220 GOLD CLAIM DR, Girdwood Lot Size in Sq Ft: Total Bedrooms: 33680 2 This permit is for the construction of: Y Disposal Field Y Septic Tank N Holding Tank N Privy Y Private Well N Water Storage Ali 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 Ddnking Water Regulations (18AAC80). 3. The wastewater code requires inspections dudng 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: 25% or steeper slopes within 50 feet of the downhill side of the drainfield shall be removed (flattened). A cross-section shall be submitted with the final inspection report verifying the 50 foot separation. Special Provisions: Prior to construction; a second test hole shall be completed to verify the soils for the alternate drainfield site. If the test results do not support the proposed alternate drainfield design, an approved change order shall be issued prior to construction. Test results shall be submitted with the final inspection report. Received By: ~'~-~ ' · [Date: Date: '~,//~...~,/~// ! MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division On-Site Water & Wastewater Program Mayor Dan Sullivan Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWERRVELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel i.D. DT~,-- Property owner(s) Mailing address '~.O, ~. Day phone Site address ~-~O ~--~O ~7.~.,~4~,4 Legal description (Sub'd., Block & Lot) ~__A~E'I,,J Legal description (Township, Range & Section) Lot Size ~ ~ ~O 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. (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number: Permit No. 0%~0 Waiver Fees: Date of Payment: Receipt Number: Waiver No. G:\Building\On Site\Forms\Client Forms\Permit App_010411,doc (Rev. 1/11 ) ANDERSON ENGINEERING: : I I I $22-7773 677~776:6 (F~)I July 11,2011 Municipality of Anchorage Development Services Department On-Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Su~e~: Lot 4, Block 3, Raven Mountain Estates Unit No. 1 Well and Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The owner of the subject lot intends to construct a new well and septic system to serve the existing two-bedroom home on the property. We are therefore requesting a permit be issued for the construction of a new well and septic system to accommodate the home. The attached Site Plan and backup documentation identify the location and configuration of the proposed well and septic system along with the alternate site. No existing wells or septic systems are closer than 100' from the proposed well or septic system. The house location is at the end of an existing road with development only to the northeast. Drainage arrows are shown on the site plan showing the grade and direction of flow on the lot. The drainage pattern will not be changed as a result of this project. The test hole placed on the lot in the area of the absorption trench and alternate site indicated fill material to nearly 3' underlain by clean gap graded gravel below (GP). The percolation rate of the soil was determined to be less than 1 minute per inch. No groundwater was found during the placement of the test hole and none was noted during the monitoring period. A 2' sand filter will be required to slow the percolation rate of the septic effluent. An application rate of .7 gallons per day per square foot was used in the design of the absorption system. We are proposing to place a new 1,000- gallon septic tank and a 30' long by 15' wide absorption bed to treat and dispose of the effluent generated in the house. The elevation of the distribution line in the absorption trench will be 4.0' below the surface and the total depth will be 6.5' which includes the depth of the filter sand. A minimum of 3' of fill or 2" of insulation and 2' of fill will be placed over the absorption trench and 4' over the septic tank. The ground surface on the lot in the area of the absorption trench slopes to the west at Lot 4, Block 3, Raven Mountain Estates No. 1 July 11, 2011 Page Two a grade approximating 5%. The edge of the fill is nearly 40' from the edge of the new bed. The slope at that point is approximately 25%, but increases at approximately 50' from the edge of the bed. The new bed will be constructed parallel with the contours of the slope as much as possible in conformance with Municipal requirements. The new septic system will be constructed a minimum of 100' from all wells and any surface water and 10' from the proposed and existing water services in the area. If the system is constructed in accordance with our design the following statements apply: The system, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on reserve space, either sur[ace or subsurface, on any lots located in the area. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, Michael E. Anderson, P.E. AEachmen~ · 49th ~=' ~'"'"'~'"'""#'""~'F~'"'~ ~ ~- MICHAEL E. ANDERSON LOT 5 VACANT Septic Area ¥'~, 1,009 gallon~ SeptJc~Ta n k / 4 / / CO Two Bedroom House LEGEND: \ CO - Cleanout SV - Septic Vent FCO - Foundation Cleanout TH - Test Hole i '/~MT - Monitor Tube "~ SITE P~N SCALE 1" = 40' Existing Well VACANT LOT 4, BLOCK 3, RAVEN MOUNTAIN ESTATES UNIT NO. 1 DESIGN FACTORS: SYSTEM REQUIREMENTS: 2 Bedroom Home Shallow Bed System Pero. Rate: <1 Min./Inch 1,000 Gallon Septic Tank Application Rate: .7 GPD/SF 2' Sand Liner 2 Bedrooms X150 SF/Bedroom/.7 GPDlSF(Application Rate) = 428.6 SF Absorption Area 428.6 SFI15 LF (Width) = 28.57 LF Bed Length THEREFORE: Construct a 30' Long x '15' Wide Shallow Bed as Shown Below. Place Distribution Piping at 4.0' Below Original Ground Surface, Place 2' Sand Filter Atop GP Layer. Provide 3' Cover Over Bed and 4' Cover Over Septic Tank. Existing Ground 3,5' Revegetate Top of Bed ~To ~ Grade to Drain Existing Ground Prevent Erosion Geotextile Fabric O O O Drainfield Rock ~ 4" PVC 2' Sand Liner (See Specification) Underlying GP 2.5' 5' 5' 2.5' NOTE: TYPICAL BED SECTION (NO SCALE) Grade Area Surrounding Bed to Drain Away. Minimum 6' Separation From Bedrock. Minimum 4' Separation From Groundwater, Minimum100' Separation From Wells in the Area. Minimum 100' Separation From Surface Water or Streams. Minimum 10' Separation From Water Service Line. Z m k.-- m,,~z Z © 0 Z 4700 MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT BRAGAW STREET ANCHORAGE, AK 99519-6650 SOILS LOG - PERCOLATION TEST ] LEGAL DESCRIPTION: PERFORMED FOR: DATE: 8/25/2011 PARCEL ID#: LOT 4, BLOCK 3, RAVEN MOUNTAIN EST. NO. I STEVE NORWOOD PROJECT No.: TECHNICIAN: D:P~ I TEST HOLE 1 [ (f~t) 1 SLOPE 2I 3 5 PEAT, ROOTS, STUMPS OTHER DEBRIS 6 0B/OG ? 8 9 WAS GROUND WATER ENCOUNTEKED? NO IF YES ~ WItAT DEP'~Ht__ DEPTH OF WATER AFTER MONITORING: NONE 11 DATE OF MONITORING:. 8/28/2o, 2O ANDERSON GRAVEL WITH SILT GM SITE PLAN SEE SITE PLAN 4% DATE READING GR, OSS TIi'JE ,NET TIM,EI IN,ET DRO, P TEST HOLE PRESOAKED PRIOR TO TESTING: PERCOLATION RATE: TEST RUN BETWEEN: (MIN/rNCH) PERC. HOLE DIA. FT. and FT. i~c~S) COIV~VIENTS: TEST HOLE TO VERIFY ABSENCE OF BEDROCK. TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS DATE: 11/~/2010 4700 DEPTH 1 2 3 4-- 5 6-- 7-- 8-- 9-- 11 20 MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT BRAGAW STREET ANCHORAGE, AK SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: PERFORMED FOR: DATE: 8/2Z./2011 PARCEL ID#: LOT &, BLOCK 5, RAVEN ~IOUNTAIN EST. NO. [ STEVE NORWOOD PROJECT No.: TECHNICIAN:. ~1. ANDERSON PEAT, ROOTS, STUMPS OTHER DEBRIS WAS GROUND WATER ENCOUNTERED? -- IF YES ~ W~IAT DEFI~%__ DEPTH OF WATER AFTER MONITORING: DATE OF MONITORI/q~ OB/0G DATE 8/24 SLOPE NO GRAVEL WITH SILT GN SITE PLAN SEE SITE PLAN GROSS TINE NET TIMEI DwE/~RT° INET DROP READING (MINUTES) (MINUTES) (INCHES) (INCHES) TEST HOLE PRESOAKED PRIOR TO TESTING'. 4:45/4:55 10 6.5/DRY 6.5 4:56/5:06 10 6.5/DRY 6.5 5:07/5:17 10 6,5/DRY 6.5 5:18/5:28 IO 6.5/DRY 6.5 5:29/5:39 10 6.5/DRY 6.5 5:40/5:50 l0 6.5/DRY 6.5 PERCOLATION RATE: 1.5 (MIN/INCH) PERC. HOLE DIA. 6 TEST RUN BETWEEN: 10 FT. and II FT. COlvI~NTS: TEST HOLE PRE SOAKED PRIOR TO TEST. TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MLrNICIPLE GUIDELINES IN EFFECT ON THIS DATE: 8/25/2011 MUMCPA UTYOF-'-' HCHOR„GE Development Services DepartmentPhone: 907-343-7904 On -Site Water & Wastewater Section --' Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 076 03 120 1. GENERAL INFORMATION Expiration Date: p 1 15 1W � A Complete legal description RAVEN MOUNTAIN ESTATES#1 BLOCK 3 LOT 4 Location (site address) 220 GOLD CLAIM DRIVE Current property owner(s) NORWOOD Mailing address Real estate agent 2. TYPE OF DWELLING: Single Family (w/ADU) [� Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone Day phone 3. NUMBER OF BEDROOMS: 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 Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ .5 50 Date of Payment / �yA—, I Receipt Number COSA # Z) 16 q 9 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 C&M ENGINEERING Phone 8545558 Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI Date 11/2/21 �� A/ -,law low TH Sll� 6. DSD SIGNATURE •• ..•• •�•••• r System #1 Approved for bedrooms r� • • Z:HARLES G BA RN • j System #2 Approved for bedrooms63'•. CE -13854 ••�� • ��� Disapproved �ll1FOPROFEss1oNP���= Conditional approval for bedrooms, with the following stipulations: See (neer' C�o rvirY1e/t f oh /aS� � 0E 0C'i��-. yoAM srr-Fn g WATER AND rn rr� WAST`=V"ATER z J O JJJ0, -�m � By: Original Certificate Date: 5 1,20.1 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 yellow sheet COSA Checklist Legal Description: Parcel ID: If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample Comments __________________________________________________________________________________ C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) 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 Adequacy test date Results Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: B.TANK DATA Age of tank(s) years Tank type/material6WHHO Measured operating fluid level in septic tank Standpipes/foundation cleanout per record drawing Date of pumping D.ABSORPTION FIELD DATA ______________________ Which system tested (date installed) RAVEN MOUNTAIN ESTATES#1 BLOCK 3 LOT 4 076 031 20 11 1 +3 09/23/2013 1200 97 90 1.26 +24 C.Balzarini 10/28/21 79** 11/10/2021 Pump log not available. ** From well log, it was not possible to measure the static water level. 10 Septic 50 10/19/21 bed 2011 10/28/21 2 9 0.25 8 300 1 15 0 300 NA NA North MT has some minor debris. Does not impact function of system. ✔ 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’ 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 From Septic/Holding Tank on Lot to:(Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Property Line > 5’ Yes if No ft Absorption Field > 5’ 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 septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10’ Yes if No ft 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 If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft F. ENGINEER’S COMMENTS 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.11/06/21 ✔✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ This is an off the grid home. The well is powered by generator. The water storage tank, waterline, and sewer lines may freeze if not properly drained or kept heated. The buyer should familiarize themselves with the operation of the water/sewer system. ✔ AMW OF.q\11l �,•� •e �,•, L-176 l �f•SS11 .NI P 0 20 40 US SURVEY V0.01, FEET NOTES ' -All dimensions shown are grid bearings and ground distances, Record boundaries are per Plat No. 66-161. -49th Star has conducted a physical survey of the property and all details shown on this Asbuilt Survey are correct. Under no circumstances should any data hereon be used for construction or for establishment of property lines. -It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. AS BUILT SURVEY Lot 4, Block 3, Raven Mountain Estates, Unit 1, Girdwood, AK LEGEND ® Septic Cleanout O Well 49th Star Surveying U_%' PO Box 738 Girdwood, AK 99587 (907)891-6111 Jeremy@49thStarSurveying.com W.O. 2144 1 DATE: 11/11/21 SCALE: 1 "=40'