HomeMy WebLinkAboutBRUIN PARK BLK 4 LT 23Dec 0720 1005a Anchoray Well & Pump Is Z;v I : t.- U f 14. N. ,
Mayor
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Date 4 Issue.
Pump Installer Name:
no St 7Rh ANAL18
AK 99513
P ane: 907-243.0740
MWON2
A pump wwwHation log to Inc DSD whWa 30 &y of,my hyWhulm.
.utcafion. 'File i�
(Kev Ub/U2/1 ti)
Municipality of Anchorage
On-Site Water and Wastewater Section e (907) 343-7904 Page 1 of 3
ON-SITE
WASTEWATER INSPECTION REPORT
Permit Number: OSP201395
PID Number: 016-101-13
Dwelling: FE4 Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New K Upgrade
Name
David and Marci Elvers
ABSORPTION FIELD
❑ Deep Trench Q Wide Trench El Bed EJ Mound
Site Address
11000 Polar Drive
❑ Other
Phone
Number of Bedrooms
Soil Rating
depth from original grade
3
1.2 GPD/SF
JTotal
12.5 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
8.5 Ft.
Gravel depth beneath pipe
4.Ft.
Subdivision
Block Lot
Bruin Park
4 23
Fill added above original grade
0.0 Ft.
Gravel length
50 Ft.
Township Range Section
Gravel width
5.0 Ft.
Beds: Number of Lines
n/a
Distance between lines
n/a Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
500 Ftz
1
n/a Ft.
Well
97'+
118.3
25'+
TANK ❑® Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Existing
Capacity
1000 Gal.
Surface Water
100'+
100'+
Material
Number of compartments
Lot Line
5'+
10'+
NA
Steel
2
Foundation
10'+
10'+
LIFT STATION
Manufacturer
Capacity
Remarks
Gal.
Alarm location
Electrical installed by
PIPE MATERIAL House to tank Tank to 3034
drainfield
Installer
Owner
Drainfield 3034 CO/MT3034
Inspector Pannone Engineering
BENCH MARK (Assumed elevation) 100 ft
Inspection �S,�fl �J�i3 2°4/ CI1Zg1-zo
Location and description
dates: 2""
s� a_�n rq '`h2o E
Nearest Deck Footing
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
kkk
Conditional Approval:
Date
.�� ..... ,q
q;,�P
TH R"
... .. .. ......
Steven R. Panno.)
Septic SysteCE
88�=}�
�. Cin • �`� d
Approved
Date
l.�V ����
Note: this approal does not include well permit requirements.
(Kev Ub/U2/1 ti)
Ilm
WITH DOUBLE CLEAN OUT
VERIFIED IN GOOD CONDITION
EXISTING DRAIN FIELD /
ABANDONED PER CODE
NEW DRAINFIEL
5'W x 50LF x 4'ED x 125T
INSTALLED MT & CO AT EACH EN
• TH-
LOT
'JWINU IItJ AKt S I.0
W
Lij
/ M\\ 0
P
-1 JFK O
<�
`
g
HOUSE
A (E)
B
T1 FCO WELL
T2 WELL
DCO /
C1 /
M1 411/
V /
M 2
/ RESERVE SEPTIC SYSTEM
NO. BEDROOM: 3(450 gpd)
A
B
T1 (E)
42.2
70.5
T2 (E)
48.8
75.1
DCO
52.7
77.5
C1
71.2
87.4
mi
71.7
87.2
C2
115.5
117.1
M2
1 113.6
1 115.5
'JWINU IItJ AKt S I.0
W
Lij
/ M\\ 0
P
-1 JFK O
<�
`
g
HOUSE
A (E)
B
T1 FCO WELL
T2 WELL
DCO /
C1 /
M1 411/
V /
M 2
/ RESERVE SEPTIC SYSTEM
NO. BEDROOM: 3(450 gpd)
—w
w — N ER UNE )
TANK SIZE: 1000g (EXISTING)
LL RADIUS
/ PERC RATE: 3.6 MPI
NEW SEPTIC
SOIL RATING: 1.2 GPD/SF
ABBREVIATIONS
/ AREA RQD: 375 SF
TH
TEST HOLE
SYS. TYPE: 5' WIDE TRENCH 4.0'ED
(P)
PROPOSED
RF: 0.50
(E)
EXISTING
MIN LENGTH: 37.5 LF
CO
CLEAN OUT NO.
DCO
DOUBLE CLEAN OUT
USED:
FC
FOUNDATION CLEANOUT
50LFx5'Wx4.0' E.D., 12.5' TD
FS
FLOW SPLITTER
TOTAL AREA: 500 SF
\
MT
MONITOR TUBE NO.
/TYP
TYPICAL
w w
m m
r 0 r r r
O ¢O wp O
w J ma Q O O W
W Z 2
[> U W ii U 0 U
NOTES: PANNONE ENG SVC, LLC (C.1. 1088) ee�����\\\ REVISIONS DATE
RECORD DRAWING P.O. BOX 1807 PALMER, AK 99645 OF \t I 9/30/2020
PHONE 907 745-8200 FAX 907 745-8201 ,..�P•' SCALE
* 1" = 50'
BRUIN PARK, BLOCK 4, LOT 23 �.... ... P.I.D. NO
016-101-13
DRAWN DRM SD DAVID 1000 POLARVERS DRIVE It :'155
8149 n�/ P OSP20ne
l395
SITE PLAN ANCHORAGE, AK ISHEET
1 2 OF 3
TEST HOLE 1A
1
DATE
UN
TOPSOIL
NET DROP
RATE
(MPI)
2
NO PERC
3
2
4-
3
5-
56
4
6
5
7
6
Sw
SAND WELL
8
GRADED
9
10
11
12
13
14
15
16
17
18
19
BOH
DATE
PERFORMED:
23SEP2020
READING
DATE
NET TIME
WATER
LEVEL
READING
NET DROP
RATE
(MPI)
1
NO PERC
2
3
4
5
6
WAS GROUND WATER
ENCOUNTERED? N
IF YES. AT WHAT
DEPTH? -NA—'
DEPTH TO WATER AFTER
MONITORING? — DRY —
DATE: 30SEP2020
SOIL TEST RESULTS/ANALYSIS
C SEE ORIGINAL PERC TEST
SUPPLEMENTAL TEST HOLE TO
ACCOMMODATE DEPTH
COMMENTS: Test hole excavated by OWNER.
PERFORMED BY: PES. I CERTIFY THAT THIS TEST
WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL
GUIDLINES IN EFFECT ON THE DATE OF THIS TEST.
NOTES: I'ANNONE ENG SVC, LLC (C.I. 1088)
RECORD DRAWING P.O. BOX 1807 PALMER, AK 99645
BRUIN PARK, BLOCK 4, LOT 23 -<
DRAWN DRM DAVID & MARC( ELVERS
SITE PLAN SITE A11000 NC ORAOEAR DRIVE �PPjj'
n 'F�: 'Pa'nnor�e'
CE 8149
REVISIONS
9/29/2020
;CALE
1' = 50'
'A.D. NO
016-101-13
ERMIT NO.
OSP201395
;HEET
3OF3
C3 s�
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:
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SHEET SIZE: 11 " X 17" -
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fid
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (967) 343-7997
http://www,muni.org/onsite
On -Site Wastewater disposal System Permit
Permit Number: OSP201395
Work Type: Septic Upgrade
Tax Code Number: 01610113000
Site Legal Address: BRUIN PARK BLK 4 LT 23 G:2633
Site Mailing Address: 11000 POLAR DR, Anchorage
Owner: ELVERS DAVID B & MARCI L
Design Engineer: PANNONE ENGINEERING SERVICES
This permit is for the construction of:
Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date
o�'i�cnt
Depa 11 t III ell t
9/22/2020
9/22/2021
Lot Size in Sq Ft: 23850
Total Bedrooms: 4
❑ Private Well ❑ Water Storage
All construction shall 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 shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By:
/
Issued By:
Date:``
Date: 91,z�1;20,9 U
MUNICIPALI TY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section —' Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION'
Parcel I.D. 01610113
Property owner(s) Dave Elvers
Mailing address 11000 Polar Dr
Site address 11000 Polar Dr
Legal description (Sub'd., Block & Lot) Bruin Park B4 L2.3
Legal description (Township, Range & Section)
Lot Size
Sq. Ft
APPLICATION IS FOR:
(® all that apply)
Absorption Field [_x]
Septic Tank
yl
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
Day phone
Number of Bedrooms Ll
APPLICATION IS AN
Initial
❑
Upgrade
0
Renewal
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
TYPE OF DWELLING:
Single Family (SF) ❑
(w/wo ADU)
Duplex (D) ❑
Multiple Dwellings ❑
(SF and/or D)
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 authorized agent)
Ia17.7s FZusM
Permit/Rush Fees: 77�. C0�1 - .�J) Waiver Fees:
Date of Payment: � 2
22-20ZD 9 23 VDate of Payment: _
Receipt Number- 09'M56.2 0qyy06 Receipt Number: _
Permit No. 0220 1395 Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201395, Rebecca Carroll, 09/22/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201395, Rebecca Carroll, 09/22/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201395, Rebecca Carroll, 09/22/20
MUNICIPALITY OF ANCHORAGE
Development Services Dwartment Phone- 907-343-7904
Or, -Site VNater &Wastewater Section Pax: 907-343-7997
The On-site Water and Wastewater Section (On-site) may issue an approval for a homeowner
to performwork on an on-site wastewater dispo3a( system to se!ve that individual's owner -
occupied, simgie-family or duplex home if the homeovirier meets and agrees to the follovAng
requirements*
1. The property owner and excavation equipment operator may perform work on rio more
than one owner -installation project in a 12 -month period.
2, Owner's projected active involverrient with the installation:
compete ;nvu;vernew mataiiing 4br leachileld only and ripe tr, smsting tank
3. The narne of the excavation equipment operatol.: david b elvers
4, 11 agree that there will be no monetary corntpensation for installation services rendered.
5. The name of the inspecting engineer- pannone
6. 1 agree to discuss the followir!g items with the inspecting engineer,
a. Permit design criteria and specifications,.
b. Inspection requirements set forth in AMC 15.65.070.
c. Advance notice given to the On-site Wates, & Wastewater Section for all reqwired
municipal inspections (AIAC 15.65.070A).
7, 1 agree to have the project -specific Qn-site Wastewater Disposal Systern Permit available
at the construction site for the duration of all related work.
8, 1 agree that if the systenn is an advanced wastewater treatment system (,N ITS), i will
obtain additional installation instructions and approval from the equipment distributor.
q e
As,owriorofli,egaidesc,,i,ptio,i)_ &2--2
i agree that the information above is true and accurate.
Owner's printed narnse: David Elvers
Owner's signature:
__ Datc- 09/21120
ICA;—
f"I —0-11 li
C
9
A
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME ~j~/ IPHONE
~ DISTANCE TO: ]W"" I Ab'o~Ptio~"r"~ Dwelling
~ ~ Manufacturer~ ~ q~ ~ Material .o. of compartments
kiq. capaciW in ~allons IF HOMfiMAD~ Inside length ~idth liquid depth
~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
~ -- ~ Manufacturer Material Liquid capacity in gallons
= Well Foundation ~[~ Nearest Iot,~ . PERMITNO.
=, DISTANCE ,O: I='
~ ~ ~ No. o, ,,n.~I Length g~lre Total leVel, es Trenches Distance betwee~z
Tot~ ...~
~ Top of tile to finish grade ~ ( Material beneath tile ~ inches ~~narea,
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class i Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PWE ~i ~
REMARKS [ [ ~
APPR~VED~ ~ DATE LEGAL '
72- (Rev. 3/78)
PERM.'[ T NO.
DEPRR]"MENT OF HIEFIL. TH FIND E:.N',,,'IRONPIEN'rRL. PROTECTION
825 '" L. '" 5]'REET., FINC'HORFIC:iE., FIK. 9.950::[.
264-472E~
,_-.~ It'~ .... :.'-=--... ;T. '"IF' ET.. .'.:::~; CE; I1.,.~ EE F;.'. IP E.] IF;;.'. IP-.!I LIE "If'"
7'90529 )
f:!PF'L. I C:F~i'.4T EL.[...:SHORTH EXCR',/FIT I NCi SRR 8C)::.;: 94-L.
LOCF-IT I OIq POL..FIR SI" '
L. EGFIL L.;:.i:]: E:4 8F.:tJ!N F'K S,-"D :L':;T RI;)[:,
TYPE OF SOIL RS$ORSTION SYSTEM I:iT,: TRENCH
MFI::.:;i'MUM NUMBER OF' E:.:EE:,ROOM'E; = ::ii:
"I]..-tE RE[::!U I RE[:, :E; I ZE ':-;ri I L. FE '::;r" ~'P]"I iN ::, ~, =, TE. fl I :i.'3 -
E> tEi~ F" 'T ~-II == :.:it_~ IL~ E: IP..,,I ~2~ "T~ I1-~1 ..... ~:: :~: C:~ lr~: F:it ",,," E I1~ .... t[> Ei..]: IF::" T'
THE LENGTH [:,IMENSIOI'.,I I'.::; 'THE LENGTH (IN r:' E: E T .':, or.:' THE TF..:ENC:H OR DRRtNF:!EL.D.
'THE E:,EF'TH OF 8 TRENCH OF: PI'T .T.~.] THE DI'L:;TlaI'-4CE E:ETHEEN THE E.';URFF~CIE OF THE
GROUN[':, RN[) 'THE BOTTOM OF THE E'?-':CR',?RTION ,::IN FEE-.]''.':,.
THERE .IS NO SET I.,.II.r;,TH FOR TRENCHE':_:;.
THE GRRVEL DEPTH I:E; 'f'HF 1'411'.4:(MI...t1',1 DEPTH OF' GRFI',,,'EL E.'ETHEEI'.,I THE (]fJTFFILL
FINE:, THE BOTTOM OF THE E::',;CRVFITI. ON (:IN FEET).
PEF.':M I 'T FIPF'L I CFINT HR:E; THE RE~;F'(]I'.,12.; 181 L. I "r'¢ TCI I NFORP'I TH ! ::; [:,EF'FIF::Tt,'IENT [:,UR ! 1'.4'G 'T'HE
I NS]]RL. LFIT I O1'.,t .'[ N.:,F E .. T ~ O1'.,15 OF Ftl"i"r' I-,J.I::T'.L[.."2] FIE) .]'FTC EHT TO ].'H I :.5 F'ROPEF.:T"¢ FIt"~.[:' TF"IE::
NUME:ER OF RES I £:'ENC:E¢~;; THFIT THE HELl .... l-,.lI L.L. :{';ER',.,'E.
M I N ! MUM [.', I :F.';Tf:tNCE E:E:'T'I.4EEN Ft I.,.IE:LL F:tI'.,I[:, t::lt",l~'r
:]..AO F:EE'r FOR R PRI'v'FITE HEL. L.~ OR
150 ].'(:) ;:.~E~O FEE]" FROM Ft F'UF.')LIC: !.4ELL. DEPEN[:)IN[]i LIf:'Ot",l 'THE 'I"'T'PE ElF I::'LtE:L. IC I.,.IE[J .....
O'T'HER REC-.!LI I REMEt",I"f'S':; I"lFl"r' RPF'L"r'. SPEC: I F I CFIT ! [)N~; FI I",! [.':' CC)I"~.':.:.';'T'RUE:T 1 ON [::' :[ F, IGRF:IMI.:j !:::~RE
F:I'v'FI I LFIE~LE TO I NSLIRE PROF'ER I I",I'.F.,TRL LFIT ! ON.
I CERTIF"r' 'T'HFIT
:1.: I FIM FFIMILIEIR 1.4!'T'H THE REQL.IIF..:EMEN'TS FOR Of'-,!-%I]"E
F:'Of;.:]"H B'¢ ]"HE MUN I E: ! F'R[_ I T"r' OF' RI",ICHCIRFtGE.
2:.': I t.4II...L. IN::'.'i;'I'FIL[. 'THE $'¢s"rEr,l :IN RCCOR[:,FINCE IqtTH THE CODES.
3:: I UN[:,ERSTF~N[:, 'T'HRT THE ON-SITE SEHER '}.';"r'.'F.,TEM MFI'¢ REQUIRE ENL. FIF. IGE':MIEN'T' IF:' THE
F.:E:F;I[:,EI"4C:E IS REMO[:'ELE[:' TO,~I);',ICL. UDE MORE THRN 3 8EE:'RO()M'.E;.
PERFORMED FOR:
LEGAL DESCRIPTION:
SOILS LOG.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6.65(I, Anchorage, Alaska 99502 276-222~J
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
SLOPE SITE PLAN.
, (d,'~,"~) "
WAS GROUND WATER
ENCOUNTERED?
. ~o~"~ ~,~'~[~ IF YES, AT WHAT
:~.' '~ 3 ~l#e -~'~'~y ~ dS DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
--~ ~ ~JO$~ PERCOLATION RATE ~-- 7 (minutes/inch)
. .:' ./ r I
,;; ?2-O0S (7)~6)' ' ""
, I
DATE:
MUNICIPALITY OF ANC - AGE
teDevelopment Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 016.101-13
1. GENERAL INFORMATION
Complete legal description BRUIN PARK BLOCK 4, LOT 23
Expiration Date: I " C _2 dZ(
Location (site address) 11000 POLAR DRIVE, ANCHORAGE, AK 99516
Current property owner(s) DAVID & MARCI ELVERS
Mailing address
Real estate agent
Day phone
11000 POLAR DRIVE, ANCHORAGE, AK 99516
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Private Well
Water Storage
Community Well
Public Water System
Waiver request for:
3
Day phone
TYPE OF WASTEWATER DISPOSAL:
®
Private Septic
❑
Holding Tank
❑
❑ -
Community
❑
❑
Public Sewer
❑
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ IM U� %- I
Date of Payment
Receipt Number
COSA# ciSCa0i5`�0
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
Distance:
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
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 & Fwrs
6. DSD SIGNATURE
1 System #1 Approved for —13-- bedrooms
System #2 Approved for bedrooms
Disapproved
ate 9/30/2020
r
i g�P Tt-I
. .��.. ....... r�
r� • Curtis Huffman
c9slF,�'9 30/20?0•'F��'���rr�
Conditional approval for bedrooms, with the following stipulations:
s
OF,�Li����
WATER AND uR'
�^ Original Certificate Date: 2OZ D
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
Legal Description: BRUIN PARK BLOCK 4 LOT 23 Parcel ID: 016-101-13
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 4/11/1979
Total depth 154 ft
Cased to 154 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 9/8/2020
Static water level at beginning of test 54 ft.
Well production at time of test 4+ gpm
Comments
B. TANK DATA
Age of tank(s) 6 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 49"
® Standpipes/foundation cleanout per record drawing
Date of pumping 9/8/2020
D. ABSORPTION FIELD DATA* - NEW FIELD
Which system tested (date installed) 9/24/2020
® ALL standpipes present per record drawing
Total measured depth from grade **12.5 ft (max)
Measured depth to pipe invert from grade **8_1 ft (min)
❑ N/A — pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective
Water storage tank volume NA gallons
Well disinfected for coliform test? ❑ Yes ® No
® Coliform bacteria is Negative
Nitrate mg/L ® Nitrate less than MRL (ND)
Arsenic 6.20 ug/L ❑ Arsenic less than MRL (ND)
FWES
Collected by ==.t
Date of Sample 9/8/2020
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _ years
Lift station material
Comments:
Adequacy test date
Results ❑ Pass For _bedrooms
Fluid depth prior to test _ in
Water added _gal
New depth _ in
Elapsed time —min
® Code -required soil cover over field Final fluid depth in
❑ System presoaked Absorption rate _ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test)
Gallons introduced gallons If yes, enter date
Fwcs
Comments/Deficiencies: ORIGINAL FIELD SATURATED. *NEW FIELD PER MOA IR (PES). **MEASURED 10/1/20.
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
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
*97 ft
® Yes
if No
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' ® Yes
if No
® Yes
if No
ft
ft
If septic tank is under driveway comment below
*WAIVER.
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No
ft
® Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
® Yes
if No
ft
Surface Water > 100'
® Yes if No
Property Line > 5'
® Yes
if No
ft
Wells on Adjacent Lots:
® Yes
Absorption Field > 5'
® Yes
if No
ft
Private Wells > 100'
® Yes if No _
Water Main > 10'
® Yes
if No
ft
Community Wells > 200'
® Yes if No _
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'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® 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'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
*WAIVER.
G. ENGINEER'S CERTIFICATION
Aw A
1 certify that I have determined through field inspections and review ���•. •' ���
of Municipal records that the above systems are in conformance •:� 4
with MOA COSA guidelines in effect on this date. �'� • .. • .';
L
.... ......�....
d ' Curtis Huffman
�� �'c<�, •. CE 128991 .• �� i
/sTF�F� .1Q/1/2Q28��
��� WROFESSIONR ,�
ft
ft
ft
ft
ft
ft
ft
ft
APPLIC 'NT FILLS OUT UPPER HAl. .)NLY
Property'Owner ~/_/'f~'~/~ r~ ,~_. ~/~,~/¥'~Oz~/ Phone
MailingA~?ress ~'~ ~ /~ ~, ~, ZlpCode
~u~.r
Address ..;; Zip Code
Address ~?~ ~t~ i~. ~LI//~ ZlpCode
Realty Co. & A~nt Phone
Address Zip Code
LegalDescription ~Or ~ ~ ~ /~ p~ ~~
Type of Resi~nce
~ Single Family
~ Multiple Family No. of Bedroo~
~ Other
Water Supply
Individual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975.
Community For wells drilled prior to that date, give well depth (attach log if available).
~ Public Utility
Sewer Disposal
~ Individual Year Indiv~ual Installed:
Public ~ility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
RECEIVED
( 3 ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
I t D~SAP."OVED
I I CONDmONAL APPROVAL'
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
72-023 (3/82)
' ~ ' DEPARTMEN~'b~HEALT'& ENViRONMENTAL'PROTECTION"" '~-I~-- ' :~" '
:'.-:- ' '_.'/ 82~ gStrset ] Anchorage. Alaska. 99501 ] CN~_RONMENTAL_ ~ ~.,P~OT.~IO
~~~ ' ENVIRONMENTAL ENGINEERING DIVISION AU8 3 8 19Z9
~ - :~ ':- Telephone 264~7=0-
' P ' A 1 D -g T
REQUEST FOR ~PI: ROV,,~,L QF IN :: lVl :: UAL WA" 'ER AND SEWE~F~~
D!RECTtO~: Comp eteall par~s on,page 1. In=omplete'r~will not ~pro;~. Pl~e allow ten (10) days for pr~assing.
i':-Stll~ Bien -- - _ - ~ 344,9138
LINGADDRE8~ ' '- ' ~ - . ..... .
S~Box 1'772 Anchorage, Alaska 99507 -
PMOPEM~Y M~SIDENT (If diffe~ot'f~m above) ' ' ~ · ' PHONE '
~0~ ' .
Cli:~ford gdmondson ~ _ ~ '
~/]161Doe~z~ane-Anehora~e~ Alaska 99507 .
L~NDING IN~T T~ION .... ~ PHONE
L[NOADDRESS ~- ' ~ ' " / ' '
- _4~97 Business Park P.O. ~Box 1200 A~cho~ase, Alaska 99510 -
4;-'"AEraTOR/AGENT ' ' ' ' ' ..... ~ -' ] 'PHONE~
t:":--t0~-B$t~ee~,..Sui~i-_I05 .~chota;e, .Alaska 99503 ~ r ,
Lot:-23- Block ~+ Bruin Park Sub. Addn. ~1
i]STRE~T LOCATION ' ' ........ _-
-Polar Drive
~YPS,OF "~SlDmCE '~ ..... - ' NUMBER OF B~oo'Ms
~ SiN~L~F...i.'y - ~ one "~- F°ur
~ MULTIPLE FA?LY - ~ - ~' ~ Three ' ~ Six
WATER S.UPP LY
- ~ INdiVIDUAL *A~ACH WELL ~OG. A wolt log is reqoired for all wells drilled
~ COMM~ITY mn~sJuno ~07S. For~ll~ drdl~d prior to th~gd~t~,
~ pUBLIC UTI LITY ?pth(attach log if available,)~e~ -well Within the last:~
8~AGE DISPOSAL SYSTEM ' ..... - ' ' ' ' ....
~ INDIVIDUAL/ON SITE** If individual/on-site, give Instal atmn date ~ . · .
THIS SIDE FOR OFFICIALUSE ON-L-%
INsPEcT ON APPOINTI~IENTS- - ' ' .....
TiME ' ~ ' - ' 'TII~I'E!' ~ ~- ' ' ' '~IME
bATE .... ": DATE ' - - . - DATE
,INSpEb-TOB - ~ r!INSPE~:TOi~ "' 'INSPECTOR ..... , ' '
,rDm'EC¥10.S: · · , . ,,, ·
~. TYPE-o~ .~S~D~CE ~ - .UM.ER O~ .~.OO~S -
[] SINGLE FAMILY [] ONE. [::3 THREE [] FIVE []' OTHER
-Iq-MULTiPLEFAMIL.Y lq TW° lq FouR [] SiX
'~ '" 9 -' /pr.Lv " PE"M'T"~SER ............ '
~2; WATER $1:J ' ~ '
.~ [] INDIVIDUAL ~ DEPTH OFWELL
lq COMMUNITY DATE DR I LLED ' ' ~ '
~ [] ~ PUBLICUTILITY
· Connection Verified _ . LOGRECEIVED -
~3;~ 8EWAGEDiSPOSAi~'SySTEM PERMIT I~UMBER '
-r"IlNDI~/1DUAL/ON-SITE D'A,TI~ NS~I'~/~I:LED .... ~ _ _
:F-I PU'BLIC UTI LITY
INSTALLER ~ _
_,~Septic Tankor [] HoldingTank :
~iz~,'- If Tank ishomemade S~IL~ RATIhiG - ' ' ~ '
-~ive dimensions.' , . - . '
-TYPEOF :rANK · - .... , MANUFACTU"RER .
'-TO3:AL~A~S~RPTION AREA :'' ~ ' MATERIAL _~ .r ,
:~ O~ ST~NC Es '' ' ' _-. A,. ISewe; LJrle" ' l'Near'est Lot I'ine
~ _- WE~L TO[ - ' ' r i I r j . - I l
~Abso~ption'Area to~earest Lot Line
~;..c~i~M~s~ ..... _ . _ ' ~ , ' - , ~
'~ ,[~L~PPROVED;FOR~ ~-- BEDROOMS - '
[] CONDITIONAL AppROVAL (letter must aCCom/~ertificate)
[] DISAPPROVED! / ,/ - ~
LEGALDESCRIPTION - · ~ '[ ~ '