HomeMy WebLinkAboutHENKINS BLK 1 LT 6H
nkins
Block I
Lot 5
#051-292-20
Parcel I.D.
Municipality of Anchorage
On-Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
051-292-21,051-292-20
ExpirationDate: / 'r~ l- /
GENERAL INFORMATION
Complete legal description Henkins Block 1 Lot 6 ~' Z.,~,¢..¢
Location (site address) 16143 &16127 Old Glenn Hwy, Eagle River, AK
Current Property owner(s) Smith, Max~aret
Mailing address same
Real Estate Agent Susan Bickman
Day phone 240-0385
Day phone 240-0385
2. TYPE OF DWELLING: [] Single Family (w/woADU)
[] Duplex
[] Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class __C Well
Public Water System
Received by: ::--.
COSA to be released to the engineer, unless otherwise requested by the engineer.
TYPE OF WASTEWATER DISPOSAL:
Individual []
Holding Tank []
Community []
Public Sewer []
Date:
COSA Fee $
Date of Payment
Receipt Number
COSA #
Date:
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 NorthRim Engineering
Address PO Box 770724, Eagle River
Engineer's Printed Name Stev~ Eng
6. DSD SIGNATURE
V'/ System #1 Approved for
System #2 Approved for
Disapproved,
Conditional approval for
.-~ bedrooms.
Phone 694-7028
Date
bedrooms, with the following
WATER AND ¢'~
~. t"~ r ~ x',,.' ....... ....~ ~.
My: !/.,~-/?// ~ { /~../. ~1 ~ [ Original Certificate Date: }
The Municipality of Anchorage Devlopment 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
Septic System Advisory
Well Flow Advisory
COSA blue sheet_0-1-12 doc
X
Nitrate Advisory
Arsenic Advisory
Other
. If more than 1 septic system is on the lot:
· COSA Checklist # of
Structure served by this system ~
Certificate of On-Site Systems ApprOVal Checklist
Legal Description: /-~/~.k,~-~ ~
A. WELL DATA
Well type p If A, B, or C provide PWSID #
Date completed. (//f,/?~ Sanitary seal (Y/N) ~
Total depth .~'5~. Cased to. 5~ ft'~. --
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform (~ colonies/lO0 mL
Arsenic .0. ~g'~ ug/L
051- 2P.~'2t
Parcel ID: 0 ~'1 -29Z-~o
g.p.m.
Nitrate
Date of sample: ~
Well Log (Y/N) ~
Wires properly protected (Y/N) ~
· Casing height (above ground) ,;'Y~:~ in.
AT INSPECTION
ft.
g.p.m.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material,..~ -~f::27~"~ c.;,/,,~" 75P_ ~_ I
Tanksize //~OO. gal. Num~rofCom~ents ~
Foundation cleanout ~/N) ~ Depression over tank ~/N) ~
Date of pumping ,~ ~ Pumper ~/~3
Date installed 5"/o~/?.~'
Cleanouts (Y/N) y
High water alarm (Y/N)
ABSORPTION FIELD DATA
Date installed ,_~/(~..Y Soil rating (g.p.d./ft! or ft'lbdrm) /.
Length /-t// ft. Width ~ ft.
Total depth ~. ~' ft. Eft. absorption area 3 7..5'~ Monitoring tUbe .
Date of adequacy test ~'/,..~0//~.~ Results (Pass/Fail)
Fluid depth in absorption field before test Z/-/ in. Water added /---/',.~"0
Elapsed Time: o/~ min. in.
Final fluid depth.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
System type ~,P.~.o~
Gravel beloW pipe '-~- 7 ft.
7 Depression over field ,Ax/
For ..~ bedrooms
gal.' New depth. ._.P'O in.
AbsorPtion rate >L-_ /-?/.,4-d g.p.d.
If yes, give date
LIFT STATION
Date installed.
"Pump on" level at
Datum
Size in gallons
in. "Pump oft" level at
Cycles tested
Manhole/Access (YIN).
in. High water alarm level at in.
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot ,/'~'
Public sewer main ,/~
Sewer/septic service line 2 5' ~-
Animal containment areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation. ,~'
Water main / ~
Wells on adjacent lets ,/O~
ABSORPTION FIELD ON ~OT TO:
Property line //~ '~'
Water Service line
Curtain drain
On adjacent lots ./~/~'
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal ex(~rete StOrage areas /Z~ ~'~ '
Property line /~ ~-
Water service line /g~' ~'
Absorption field
Surface water
Building foundation / ~ ~-
Surface water /~(3 ~
Wells on adjacent lots /~'~' ~'
Water main /¢? f/c
Driveway, parking/vehicle storage '-~ ~
F. 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.
Engineer's Printed Name
Date
COSA brown sheeLt 0-10-12.doc
,