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Home My WebLink AboutT12N R3W SEC 15 LT 141ATI ZN R3W · 15 Lot 14 l,a, #015-484-20 Drilling Permil Mumb~r: SW D~ie of Issue: __ piilesa Adaptor Burial Depth: feet Adapter ~VIanufacmrar:~ [Vame: ~'~/0,,,_. pit[es~ Adnpt~r Installer: ~etbod of Disi~z:ectioa: Commonm: Pump Lu~tatler Nme: The pump/nsta[Ier zha[I provide ~ pump installation leg to tlm DSD w~tbi~ 30 days of pump install~iom.. Municipality of Anchorage Page I el DEPARTMENT OF HEALTH AND HUMAN SERVICFS ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ,~vV-./ e~O J~ PID Number: O/S- ~ - Nam* ~U ~5~¢ ~'T[~ V ~N Wastewater System: ~ew O Upgrade Address: N~t t~ I~H~ ABSORPTION FIELD Phone: No. of B~rooms: ~eep Trench B Shallow Trench ~ Bed Q Mound O Other L. EGAL DESCR I PTION Soil Raft.g; Total Depth fro~ origi.al grade: Lei: 8lock: Subdiv~ion: 3epth to pipe bottom from original grade: Gravel depth beneath pipe Townshi,:,.~ IRange:~ ~/ ISoction: ) ~ Filladdedaboveoriginalgrade:¢ -- .~ Ft. Gravellength: ~O Ft. Number of lines: I D~stance belween lines; WELL: Q New ~ Upgrade Gravelwidth: ~ Ft. II '~ Classification (Private. A.B.C): Total Depth: Cased To: Total absorption area~ Pipe material: Drlller~,~2,,' DateOdlled: S,aticWa,,rL,v,,: Installer: Da,e,ns,ailed: ¢ 1¢ SEPARATION DISTANCES ~eptic n Holding ~ S.T.E.P. From TAnk FWtd Station 'r~nk Sewe¢ Lines ~ w,,. ~o I~o~ ~/A ~ >~ ST~ Surface w.t~ ~ ,~ ~ ¢~ LIFT STATION Lot I , ¢ Size in gallons: I Manufacturer: Line ~5 5~) _I , -- Curtain r~ 0 ~ ~ Pump Make & Model Drain ..-... Remarks: BENCH MARK ENGINEER'8 SEAL -- .~ · Inspections performed by: ~W,¢~ Dates: lst_~/¢~ Reviewed and approved by:/}_~J ~~,(,~--. Date'S. ~' ~. 72 013 (Rev 9/91) MOA 25 ~jiI_I J5 ~ 25 N 50 75 I00 £CALD I' = 50 ET, ~T~ Well I ~ ~ ONG I ~ 1000 GAL SEPTIC TANK I BENCH WAlK A S~llNO tiES: AC 97 FT B£~ 71 BPI 82,5 ABI BE 104 I I TOBBEN SPURKLAND P.E. I I 205 W 15TH, AVENUE ANCH. Al<, 99501 907~ 279-5916 LOT 141 SEC 15 T12N R3F STEVE HULSEY 48i! E 104fH BENCHMARK, fOP EOUNDAflOH ~%fflIWFR ~,£Y, io0. o0 SEPTIC SYSTEM AS BUILT DATE: OCE 29, 1996 SHEET: 2/5 GRID: 2558 £'landm-d l:enche:: ¥? ,ri' / / 4' Plin Cover' To al< I£ 88.6 S']L r ELEV. 83.2 ,5 PI. of' &'erotic f¢oct< / All3 £CALE 8J.J I£ 88 IE 88.76 I000 oooL :ep'[/c tank BENCH MA£K, TOP FOUNDAtiON ASSUNLP ~: l£ , lOO, O~ TOBJ~EN SPU~KLAN~ PE. LOT 141, ~03 \415'.h Ave Anchoroge Ak 99501 , / SEC. 15, T12A, ST£V£ HUL$£'~ 4811 E I04TH. AVE SEPTIC SYSTEM AS BUILT DAFE: ~ ~ CPI P /z9 ,P / ::'- l ~ PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW960148 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:HULSEY STEVEN M & GENEVA OWNER ADDRESS:4811 E. 104TH ANCHORAGE, AK 99516 PARCEL ID:015484~,~-%~ DATE ISSUED: 6/25/96 EXPIRATION DATE: 6/25/97 LEGAL DESCRIPTION: T12N R3W SEC ].5 LT LOT SIZE: 32200 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHE[) 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 (iSAACS0) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: DATE DATE T.SPURKLAND P.E. 203 W. 15th. AVE. SIJITE 203 ANCHORAGE, ALASKA 99501 (907) 2'79-3916 Fax (907)-276-6013 Municipality of Anchorage Division of Enviromnental Health Department of Health and Social Se~wices 820 1 Street Anchorage, Alaska 99501 Subject: Septic System Permit Lot 141 Sec. 15, T12N, R3W Gentlemen; June 3, 1996 We are applying for a septic system permit for this lot. A well and a septic system were installed in the1970's. ThesepticsystemappearstobeintheroadRightofWay. The present structure on the lot is not a residence, but the owner intends to convert it to a two or three bedroom house. The existing septic system will be abandoned. Yours T. Spurkl&h.d P.E. 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LO'r 141 SEC. 15, T12N, R3W STEVE HULSEY No Ground Water or hnpervious Layer to 15 ft. Use Standard Trench Soil Rating. 1 rain/in use 1.2 galper sq.fl/day No. of Bedrooms ,,~1 Required Area p~Bedroom: 150/1.2 = 125 sq.ft.. Total area required: 3 x 125 = 375 sq. ft. Fiaish Floor Elevation 100.00 Ground Elevation at Absorption Field 89 Top of rock 85 TestholeTotal Depth 15' Elev. of bottom 4 feet of cover 74 Bottom trench elevation Rock depth 5 ft. Length of trench 375 / 10 = 37.5 ft. SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 40 FT TOTAL WIDTH 2 FT TOTAL DEPTH 9 FT ROCK DEPTH 5 FT COVER 4 FT SEPTIC TANK 1000 GAL 80 ABANDON SYSTEM SERVING EXISTING STRUCTUR The installation of this septic system will not prevent wells fi'om be installed on the adjacent lots. There are no developed or natnral surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result fi'om this installation. Munlclpallty of Anchorage DEPARTMENT OF HEAL'TH & HUMAN SERVICES 825 'L" Stree[, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST '-E~A'-OESCRIPT,ON:J~07-- I q l 4- 5 6 7 8 9 10 11 13- 14- 15- 16- 17- 18- 19~ 20- COMMENt'S Township, Range, Section: WAS GROUND WATER ENCOUNTERED? T~t'..t, R ~ ¢,', AEc._ SLOPE SITE PLAN IF YES, ATWHAT DEPTH? Gross Net Depth to Net Cieading Date Time Time Water Drop _¢o 5'/.,¢l,f~ I1.--.¢¢ .-- -- ~ t~ ~o ~ IO'1~ I '/'~ o.~ r,~ q ~1~'_ ~ ~1~, ~ o~ ~ q D° PERCOLA'rlON RATE _ __ (m~nul,~/inch) PERC HOLE DIAMETER ACCORDANCE WFrH Ali. STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THiS DATE, 72-008 (Rev. 4/85) CERTIFY 3'HAT THIS TEST WAS PERFORMED IN [ T 148~) L II5 ,9EB,4f? N LB/- I14 I LOT I13 ~0 IOO S£A££: VACANT ~V r~ c~ , ~ ~ 98: T. l L~T 142 I ',S ~ v TOBBEN SPURKLAND P.E. [ 205 W 15TH, AVENUE I ANCH, AK, 99501 /~Q7~ 279-3916 LOT 141 SI'.C 15 TI2N £3tY SEPTIC SYSTEM DESIGN STEVE HULSEY DATE: 6/5/96 48~ E I04TH SHEET: 1/$ GRID: 2558 N ~...~.~ ......................... ~ ~ ............. , ZL'ALE, 1" = 58 FF. I I [ ~ lb II 9j FEET~ ~ 5 s~ I1~ OF ROCK -~ ~ 1000 GAL SEPTIC TANK CLEAN OUT ~ ~ell > Well EXI3I. o'4" C.O. ~ P'P' ABANDON WHATEVE~ IT I~ TOBBEN SPURKLAND P.E. I 203 W 15TH, AVENUE ANCH. AK. 99501 LOT 141 SEC 15 T12N £3fF STEVE HULSEY 48~1 E I04TH BENCH MARK. FINISH FLOOR I I SEPTIC SYSTEM D~qlGN DATE: 6/5/96 SHEET: 2/$ GRID: 2556 S fondorct T~enche~; £' 48' Lan9 '9' .Oeep 5' Set,er' rock 4' Cover Monilor Cleon lOB0 9ol .~epfi. lank REPLACEMENT TRENCH HL1 SCALE Monii~or 3' Co,er 4' M,?~ Cavern Yank M/r'o Pi 140 5 £~ of' SepHc f~oct~ ? NtT ££'ALE lO00 9ol, sepfl'c tan/< BEIV£H MA£K. F/WISH FLOOR ASSUMED LLE~ lO0, O0 TBBBEN SPURKLAND P.E, I 20S ¥/15th Ave I Anch°rcge Ak 99501 La7?-3?lfl LOT 141, S£C, 15, T12N, STEVE HULSEY 45~U E 104TH. AVE fl3 W I SEPIIE SYSTEM DESIGN I D^TE, 6/05/96 SIqEET: ~ GRID: ~53~ (~R~,TER ANCftORA~E AREA BOROU ;H HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 2,2-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANC[: PROM WELL__ ,~,~ /~" LIQUID CAPACITY ~/(;) ~ADDRESS~/)/~ ~~ r-- MA[ERIAL ~~COMPAR[MEN[sNUMBER Of GALLO~S. I~SIDE LENGTH I~SIDE WIDT~ DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS LINING MATERIAl NEAREST LOT LINE ~ 0 o:-%.5 DISTANCE FROM WELl //'~ / ~ BUILDING FOUNI)ATION'~ ~_~2 ~-.) / 7z'~' TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ,-~'~./'/-"'~'~---- SQ. TILE DRAIN FIELD: DISTANCE FROM WELL //~ ~, , TOTAL LENGTH / IN/~B FOUNDATION NEAREST L~T LINE .... OF LINES__ , AT~EA__ S .~-T. ~H LINE ____ ~..~~ DEPTH: TOP OF rILE TO FINISH GRADE DEPTIt OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE WELL: T y p E ~..~//_Z.,~:.,~ DEPTH LOT LINE /~ / g;'~' NEAREST /~,~ ~' SEPTIC , SEWER LINE ., TANK DISTANCE FROM ~ x'~ WATER , BUILDING FOUNDATION.~/ SAMPLE ,/f~'/~ , NEAREST / OTHER c~Z') (t SEEPAGE .,/,Z,~,~ ~-. CESSPOOL '/ SOURCES___ , SYSTEM , , DIAGRAM Of: SYSI,EM DISTANCES: GRE.ATEF 327 Eagle St. 4, NCHORAGE AREA ttEALTH DEPARTMENT Anchorage, Alaska 99501 9ROUGH 279-2511 SEWAGE DISPOSAt, SYSTEM - APPLICAI'ION & PERMIT NAME OF APPUCANT~/!d't RESIDENCE Al)DRESS LEGAL OESCRIPTION APPLICATION TO INSTALL: SEPTIC TANK TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH PERCOLATION TEST RESULTS__.. MAILING ADDRESS ' PHONE NO, LOCATION OF INSTALLATIONj~, ,_.o: / ¢. Idl SEEPAGE PIT. ~ ,DRAIN FIELD ,OTHER ., '.~ 2 ANTICIPATED DATE OF COMPLETION / BELOW TO BE FILLED OUT BY HEALTH DEPAR'rMENT _ TO BE INSTALLED THIS IS TO SERVE AS-- /~qt{>, '[])('r' , PERIVIIT TO INSTALL A DISTANCES: AS DESCRIBED BELOW. S ZE OF,,iUNITTO BE SERVED_._ · SEPTIC TANK SIZE ~z/O00 .TYP'E <%:~-~ F SEEPAGE AREA DIAGRAM OF ~YSTEM that I am familiar with the requirements of Greater Anchorage ~r~,a Borough Ordinance No. 28~8 and tJaat the above described system is in accordance wit l said code %REATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT 327 EAGLE STREET ANCHORAGE, ALASKA §9§01 CASF; ii Legal Description: Lot~lock . o~d~v~.s~on This Fo~m Repo,*ts a: S~"Log Depth ~.et Soil. Chapacteristics Location Sketch Was Gmound Watez, Encountered?~/~/~¢. ....... ~%~0/ If Yes, At What Depth Reading Date G~oss Time Net Time Depth To H20 Net Dr'op Proposed Instal'l'~o~--': See~a,.e Pit ~ · D.e.p~jh Of Inlet_~ _Depth To Bottom Of Pit Or 'r~,enc~ Test Performed By:~~ Data Oeptified By:~a~_. UMCIP UTY OF ANCHORAGE c kn Development Services Department T Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015-484-20 Expiration Date: tV O V 3 d 0o2 Ar 1. GENERAL INFORMATION Complete legal description T12N R3W SEC 15 LOT 141A Location (site address) 4821 E 104TH AVENUE, ANCHORAGE, AK 99507 Current property owner(s) CHRISTOPHER ELKEN Day phone Mailing address 4821 E 104TH AVENUE, ANCHORAGE, AK 99507 Real estate agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ ^ Waiver Fee $ Date of Payment � a 3 020 Date of Payment Receipt Number 3 a 5 Receipt Number COSA # _�SG21� y 2 \ 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY ANCHORAGE AK 99516 Engineer's Printed Name CURTIS HUFFMAN PE Date 7/19/2021 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 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 & fWfS . 6. DSD SIGNATURE V System #1 Approved for 3 System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms 19 TH .'...: Curtis Huffman CE 128991 Aw�,� ��FD PROf ESSI4NP�'.,� bedrooms, with the following stipulations: 2 By: 12dLOriginal Certificate Date: ,3/,V_0 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 0ther 7'"_J0, COSA Checklist Legal Description: T12N R3W SEC 15 LOT 141A Parcel ID: 015-484-20 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 252+ ft Cased to UNKNOWN ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA 7/15/2021 Static water level at beginning of test 244 ft. Well production at time of test 5.1 gpm Water storage tank volume NA gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 4.21 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample 7/15/2021 Comments __________________________________________________________________________________ B. TANK DATA Age of tank(s) 25 years Tank type/material SEPTIC / STEEL Measured operating fluid level in septic tank 48” Standpipes/foundation cleanout per record drawing Date of pumping 7/15/2021 C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 9/12/1996 ALL standpipes present per record drawing Total measured depth from grade 10.3 ft (max) Measured depth to pipe invert from grade 4.6 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 7/15/2021 Results Pass For 3 bedrooms Fluid depth prior to test 29 in Water added 510 gal New depth 41 in Elapsed time 1440 min Final fluid depth 27 in Absorption rate 450 gpd Any rejuvenation treatment (past 12 months) N If yes, enter date Comments/Deficiencies: *ELEVATIONS TAKEN SHOW 5.4’ ED. 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 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. 7/27/21 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 Septic Tank Advisory Certificate of On‐Site Systems Approval # OSC211421 Subdivision: T12N R3W Section:15, Lot: 141A The septic tank for this property is 25 years old. The average life for a steel septic tank is 20 years. Typical replacement costs range from $7,000 to $11,000. This advisory must be attached to all copies of the subject Certificate of On‐Site Systems Approval. This is an example of what the metal of a 30 year old steel tank MAY look like. Municipality of Anchorage On-Site Water and Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 015-484-20 Expiration Date: 1. GENERAL INFORMATION Complete legal description T12N R3W SEC 15 LOT 141A Location (site address) 4821 E 104TH, ANCHORAGE, AK 99507 Current Property owner(s) KERNEY PEART & GENEVA BUPUY Mailing address Real Estate Agent Day phone PMB 2548 3705 ARCTIC BLVD., ANCHORAGE, AK 99503 Day phone TYPE OF DWELLING: [] Single Family (w/wo ADU) [] 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 Well Public Water System Waiver/Variance request for: [] [] [] [] TYPE OF WASTEWATER DISPOSAL: Individual [] Holding Tank [] Community [] Public Sewer [] Distance: Received by: COSA to be released to the engineer, ineer. Date: COSA Fee $ Date of Payment Receipt Number COSA Cf 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 868-3791 Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 12/15/14 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 charectedstics 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 safisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments, deficiencies or discrepancies exist. DSD SIGNATURE ~ System #1 Approved for . System #2 Approved fOr __ Disapproved. C~nditional approval for bedrooms. bedrooms. bedrooms, with the following stipulations: B,:~~~ ~(,, ,--~ ( Original Ce,ificate Date: / ~' ~ ~ /~ The ~~mge Development So.ices Division (DSD) ,ssues Cediflcates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent pro~ssional dwil engineer registered in the State of Alas~. ~e Municipali~ of Anchorage is not responsible for errors or omissions in the professional engineers woA. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory 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: T12N R3W SEC 15 LOT 141A A. WELL DATA Well type PRVT Date completed Total depth ft. IfA, B, or C provide PWSID # __ Sanitary seal (Y/N)_Y Cased to ft. FROM WELL LOG Parcel ID: 015-484-20 Date of test Static water level Well production g.p.m. Well Log (Y/N) ~/ Wires properly protected (Y/N) _Y Casing height (above ground) 24+ AT INSPECTION 11/2512014 252 ft. 5.6 g.p.m. WATER SAMPLE RESULTS: Coliform NEG colonies/lO0 mL Nitrate 3,97 mglL Arsenic: ND ug/L Date of sample: 11/25/2014 Collected by: ARCTERRA B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1000 gal. Foundation cleanout (Y/N) Y Date of pumping 11125114 Number of Compartments _2 Depression over tank (Y/N) _N Pumper ONE STOP Date installed 9/12/96 Cleanouts (Y/N) Y High wateralarm (Y/N) N C. ABSORPTION FIELD DATA Date installed 9/1211996 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 Length 40 ff. Width 2 ft. Total depth 10.25' ff. (Measured 11/25/14) Eft. absorption area 400 ft2 Monitoring tube Y Date of adequacy test 1112512014 Results (Pass/Fail) PASS Fluid depth in absorption field before test 2~4 in. Elapsed Time: 1440 min. Final fluid depth 2~ in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N System type DEEP TRENCH Gravel below pipe 5 Water added 560 gal. Absorption rate >= 450+ If yes, give date Depression over field _N For _3 bedrooms New depth 35 in. ~ g.p.d: D. LIFT STATION Date installed "Pump on" level at __ in. Datum Size in gallons "Pump off' level at__in. Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main 75'+ Sewer/septic service line 25'+ Animal containment areas 50'+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line $'+ Water main 10'+ Water service line 10'+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line I0'+ Building foundation 10'+ Water Service line 10'+ Surface water 100'+ Curtain drain $0'+ {NONE KNOWN) Wells on adjacent lots 100'+ F. COMMENTS Manhole/Access (Y/N) High water alarm level at Meets alarm & cimuit requirements? in. On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout 100'+ Holding tank 100'+ Manure/animal excrete storage areas '100'+ Absorption field 5'+ Surface water 100'+ Water main 10'+ Driveway, parking/vehicle storage 10'+ G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name KENNETH M. DUFFUS Date 12115114 COSA brown shee~_10-10.12.doc z N 00~05'27"W 500.15' cx 133.4' o o N 00°05'14"W 300,16' m ~.1,.~ __.__ _~ _ ___~_"'~. '~ / DEPT. O; MUNICIPALITY OF ANCHORAGE ~NVIRONk'J NTAL nCTtON DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99B01 MAR 2 8 ENVIRONMENTAL EN~INEERI NG DIVISlO~ REQUEST FOR APPROVAL C)F INDIVIDUAL WATER AND SI:WER FACILITIES )IRECTIONS: Complete all par'~s on page 1. Incomplete requests will not be urocessed. Please mJow ten (10) aavs for processing, 1. PROPERTY OWNER -- , P,H?N E MAi LING ADdReSS PHONE PHONE PHONE PFIONE B. LEGAL DESCRIPTION STREET LOCATION ~ ~¢ ~ ~ / / 6. TYPE OF RESIDENCE ~ NUMBER OF BEDROOMS ~ ~ One ~ Pour ~] Other_ ~ ~ Two ~ Five SINGLE FAMILY ~ MULTIPLE FAMILY ~ Three ~ Six 7. WATER SUPPLY ~ INDIVIDUAL* ' ATTACH WELL LOG. Awell log is reqmred for weJJ$ drilled [] COMMUNITY since June 1975. For we! s clriJled prior tu that date, give well [] PUBLIC UTI LITY oeoth (attach log if available.] 8.- sr~WAI~E DISPOSAL SYSTEM 1~ N DIVI DUA L/ON-SI'f'E** "1 f individual/on-site, give instgllat[on dat~ /~V~'· If system is over two (2) years ma an adequacy test is rec JJred ~ PUBIJC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFOP E PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR I NSP ECTOR I NSPECTO R DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] sINGLE FAMILY [] ONE [] THREE E~ FIVE [] oTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX 2. WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVE[:) 3. SEWAGE DISPOSAl. SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY C~,~ Connection Verified INSTALLER []Septic Tank or [~]Ho]ding Tank Size: /~}~)~ If Tank is homemade SOILS RATING ~ive dimensions: - I TYPE OF TANK MANUFACTURER-- ,'-.~. (,A~,, ~._t,~,~?.; TOTAL ABSORPTION AREA MATERIAL (~\ 4. DISTANCE8 Septic/Holding Tank Absorption Area 8ewer Line I Nearest Lot Line WELLTO: Absorption Area to nearest Lot Line 5, COMMENT8 [] APPROVED FOR BEDROOMS ~CCONDITI ONA L APPROVAL(letter must accompany certificate) 72-010 (Rev, 3/78)