HomeMy WebLinkAboutT10N R2E SEC 18/19 LT 26 PART 4T1ON R2E
Sec. 18 & 19
Part 4
Lot 26
#075 - 061 - 26
�. —MAR -03-98 TUE 12726 PM M -W DRILLING
M -W DRILLING, Inc.
P.O. Box 110370 10330 Old Seward Highway
(907)349-8535
AtUCHORAGE, ALASKA 99511
DRIWNG LOO
Well Owner DEXTER ZERNIA
907 3453287
Use of We
P.01
DOMESTIC
Location (address of: Township, Range, Section, if known; or distance main road
TION. R2E, SECTION 18/19, LOT 26, PART 4
GTRDWOOD, ALASKA
Size of casings"Depth of Hole 100 Leet Cased to 100.23 Leet
Static water level..-51—ft. (gb ibelow) land surface. Finish of well (check one) open end ( X );
Screen ( ); Perforated (
3 -
Describe screen or perforation ' N/A''
Well pumping test at 1 n gall8ns # *SaY (minute) for 1 hours with 100% 1(.
of drawdown from static level. •'tr
Date of completion 23 FEBRgARfl1 998"
t't: • i F
r••
i': • :�• WELL LOG
Depth in feet from
ground surface
0 To 2
2 TO 1
_3_TO 37
_3Z__TO_34_
- 3A__TO 7A
70 TO_ 76_
�TO1QQ__
TO
TO
TO
TO
TO
TO
TO
•
CPA -details of formations penetrated, size of material, color and hardness
C}1S_IN9 . STICK UP
pRAVi T.. ? REV, STT.TY
G#2&VL:.SILTY CLAYEY
4c' tIRAVF.T,•, f.RF.Y STT.TY
`rZAVFTI: GREYI;$ JLTY. ('LAYEY
IrlWARRF.ARTNO-prowef'r.1 �?I�OWN, SILT
TRY
WATER BFk'PTP1 "GPAV41 BROWN. ('LEANER
RECEIVED
MAR 101998
Municipality of Anchorage
Dept. Madith 91lumen Sorv&cea
1 —CUSTOMER
MCA COPY
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW970416
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:ZERNIA DEXTER C & MONIKA
OWNER ADDRESS:3500 NORTHPOINT DRIVE
ANCHORAGE, ALASKA 99515
PARCEL ID:07506126
LEGAL DESCRIPTION:
T10N R2E SEC 18/19 LT 26 PART 4
LOT SIZE: 7796 (SQ. FT.)
NUMBER OF BEDROOMS: 1 THIS PERMIT: 1
THIS PERMIT IS FOR THE CONSTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
DATE ISSUED:12/29/97
EXPIRATION DATE:12/29/98
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 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
RECEIVED BY:
ISSUED BY:
DATE: v/r/fr
DATE:12-29-/7
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03/09/98 MON 14:58 FAX 9073448770
MINIM'S DIMOND BLVD
March 9, 1998
Mr. Robert C. Cowan, P. E.
Civil Engineers
17034 North Eagle River Loop
Suite 204
Eagle River, Ak 99577
Ref: Well Abandoment Sec 18/19 T1ON R2E: part 4 140
Abandonment was completed by M W Drilling. Old well casing was
filled with Enviro mix and cement.
Please submit the water sample to the Municipality for
final a.proval.
®001
12/11/1997 15:18 9076941211
S AND S ENGINEERING
PAGE 02
PART 4 OF LOT 26, SECTION
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Municipality of Anchorage
On -Site Water & Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 075-061-26
1. GENERAL INFORMATION
Complete legal description T1 ON, R2E, SECTION 18 & 19; PART 4, LOT 26
Expiration Date: 7-12--7— 1 CO
Location (site address)
Current Property owner(s)
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
120 MY RD *GIRDWOOD, AK
DANIEL & JENNIFER O'NEILL Day phone (909)782-7216
120 MY RD *GIRDWOOD, AK
SHARNEE EPLY Day phone 351 —0473
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
WaiverNariance request for.
N/A
3
TYPE OF WASTEWATER DISPOSAL:
■ Individual On-site
❑ Individual Holding tank
❑ Community On-site
❑ Public Sewer
•
Distance: —
Received by:
COSA to be released to the engineer. unless otherwise requested by the engineer.
Date: We2 9/(G
COSA Fee $ 51)—G
Date of Payment L(/z V1 L
Receipt Number (%S $ 72 0
COSA # C9 SC I G)
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. f 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 GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK, 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
•
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the
guidelines and regulations established by the Municipality 01 Anchorage and industry practices. The reported results describe the
condition of the systems on the dete/s of the evaluation. Separation distances were measured to readilyidentifable features.
Hidden defects or encroachments may exist that were not identified du fing the evacuation. The operational life of ell wells and septic
systems depend on a variety of variables including, but not limited to, soilcondiions, groundwater levels (that may fluctuate during
the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These
conditions can vary, and am outside the control of GEG. Satisfactory test results do not guarantee future performance of the
systems; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system.
GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either ofthe
current systems fail. The content of this reports for the sole benefit of the person/party who retained GEG. Reliance upon the
information prov!dedin this report by any other person or party, including but not limited to subsequent property purchasers. is riot
authorized. In shod, GEG disavows any legal duty to anyone other than the person/party who paid for this repod.
6. DSD SIGNATURE
System #1 Approved for bedrooms.
System #2 Approved for bedrooms.
Disapproved.
Conditional approval for
Phone 337-6179
Date
•
.0 VrifiJTtTJ
.Garness 4r
®C/ '• _®O , CE -7953
�Y\, `1 OF /1/4
bedrooms, with the following stipulatidrEs. O
ON-SITE
WATER AND cn.
WASTEWATER ci,
PROGRAM
Or,
.4/7 -
SER 11GF5
By.
Original Certificate Date: E%" 2 S I b
The Municipality or Anchorage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations 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. ATTCHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
(Rev. 10112/12)
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: T1 ON, R2E, SECTION 18 & 19; PART 4, LOT 26
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A
Date completed 2/23/1998
Total depth 100
Sanitary seal (Y/N) YES
ft Cased to 100.23 ft
FROM WELL LOG
Date of test 2/23/1998
Static water level 55 ft.
Well production 10 g.p.m.
WATER SAMPLE RESULTS:
Coliform ND colonies/100 ml.
Arsenic: ND<5 ug./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Parcel ID: 075-061-26
Well Log (YIN)
YES
Wires properly protected (Y/N) YES
Casing height (above ground)
AT INSPECTION
4/6/2016
63.5 ft,
5.5+ g.p.m.
Nitrate 0.483 mg./L.
Date of sample: 4/6/2016
PUBLIC SEWER
18+ in.
Collected by: GEG. Ltd.
Date installed
Tank size gal Number of Compartments Cleanouts (Y/N)
Depression over tank (Y/N) High water alarm
Foundation cleanout (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2or ft'lbdr System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption - -a ft2 Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in abso $ • field before test in Water added _gal. New depth in.
Elapsed T _ min. Final fluid depth in. Absorption rate >= g.p.d.
ejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN
i
"Pump on" level at in. "Pump of" level : i High water alarm level at
in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots
Absorption field on lot N/A On adjacent lots
Public sewer main 75'+ Public sewer manhole/deanout 100'+
Sewer /septic service line *25'+ Holding tank
Animal containment areas 50'+
100'+
100'+
75'+
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
PUBLIC. SEWER
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIEL ' • OT TO:
Property line Buil. .. .undation Water main
Water service line Surface water Driveway, parking/vehicle storage
C - : rain Wells on adjacent lots
F. COMMENTS
*PER CONVERSATION WITH AWWU FIELD SERVICES ON 4/19/2016, THE PROPERTY LOCATED ON
1503 ALYESKA HIGHWAY (USS 3043, LOT 27) HAS THREE STRUCTURES BUT ONLY TWO
PRIVATE SEWER CONNECTIONS. PER CONVERSATION WITH JAMES JAY CREWDSON, P.E. ON
4/28/2016, ONLY TWO OF THE STRUCTURES ARE ASSUMED BY THE MOA TO BE CONNECTED,
THEREFORE, NEITHER OF THE CONNECTIONS ARE CLASSIFIED AS "COMMUNITY", AND A 25 FOOT
SEPARATION DISTANCE IS ALL THAT WILL BE REQUIRED.
G. ENGINEER'S CERTIFICATION
1 certify that I have determined through field inspections and
review of Municipal records that the above systems am in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date
(Rev.11/05)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/oilsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 075-061-26 COSA#
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
C -,Cid
Expiration Date: / / - CI -11
T1ON, R2E, SECTION 18 & 19; PART 4, LOT 26
120 MY ROAD * GIRDWOOD, AK * 99587
AARON & TOMARA DELAHOUSSAYE Day phone
P.O. BOX 876951 * WASILLA, AK * 99687
C/0 AGENT
Day phone
SHARNEE EPLEY W/ REMAX OF ALYESKA Day phone 783-4217
P.O. BOX 1029 * GIRDWOOD, AK * 99587
Unless,` otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well 1 Individual On-site n
Individual Water Storage ❑ Individual Holding tank ❑
Community Class Well ❑ Community On-site ❑
Public Water System ❑ Public Sewer 1
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 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. l 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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
Date
Gayness:
=If° ago
rOO n° �\a
o��tt(tttrsrrrr�
rr
`2�� •,3 .• yo
J ON-SITE •'• �;
WATER AND ; "=
WASTEWATER
• PROGRAM
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
d .
Jam' •
JJJ�/o ��`
6.S ‘'s
By:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
N t ate Adv soyy
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
(Rev. 11/05)
Original Certificate Date:
s' -I/
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: T1 ON, R2E, SECTION 18 & 19; PART 4, LOT 26 Parcel ID: 075-061-26
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 2/23/1998
Total depth 100 ft.
Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Cased to 100.23 ft.
Casing height (above ground) 18+ in.
FROM WELL LOG AT INSPECTION
Date of test 2/23/1998 7/26/2011
Static water level 55 ft. 64 ft.
Well production 10 g.p.m. 6.3+ g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate 03'14 mg./L. Collected by:
Arsenic: ! v 0 ug./L. Date of sample: 7/26/2011
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal. Number of Compartments
Foundation cleanout (Y/N) Depression over tank (Y/N) -
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2or ft2/bdr • System type
Length ft. Width ft. Gravel below pipe ft
Total depth ft. Eff. absorptio - ea ft2 Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absor• '.n field before test in. Water added gal. New depth in.
Elapsed T a min. Final fluid depth in. Absorption rate >= g.p.d.
y rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
Date installed
Cleanouts (Y/N)
High water alarm
GEG, Ltd.
PUBLIC SEWER
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N
"Pump on" level at in. "Pump off" level - High water alarm level at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A
Absorption field on lot N/A
Public sewer main 75'+
Sewer /septic service line 25'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
100'+
100'+
100'+
N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
PUBLIC SEWER
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIE • • 1 OT TO:
Property line B . • oundation Water main
Water service line Surface water Driveway, parking/vehicle storage
in drain Wells on adjacent lots
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 JEFFREY A. GARNESS
Date til b,
COSA Fee $ l l o
Waiver Fee $
Date of Payment 7 5 / /1 Date of Payment
Receipt Number C� 3-5-
(Rev. 11/05)
Receipt Number
LOT 25
LOT 27
THE PORTION OF LOT 26 SHOWN IN THIS ASBUILT SURVEY
WAS TAKEN FROM THE DESCRIPTION IN BOOK 2651
PAGE 118.
NOTE: THIS DRAWING IS NOT TO BE MODIFIED FOR USE AS A PLOT PLAN WITHOUT THE EXPRESSED WRITTEN CONSENT OF LANTECH.
AS-BUILT
PART 4 OF LOT 26,
US SURVEY 3043, ALASKA
lEGAL DESCRIPTION:
LAND & CONSTRUCTION SURVEYORS-PLANNERS-ENGINEERS
440 West Benson Boulevard, Suite 200 Phone: 562-5291
Anchorage, Alaska 99503 Fax: 561-6626
O,de'ed By. Tomaro Delahoussaye
Septic Standpipe ® Doveman_
Water Well e
Fence-X-X~<i9£§~
Legend:
SURVEY CERTlFlCATlON: LAN TECH tics conducted a physlcol survey of \he
property as shown on this drawing and certifies that the improvements
situated thereon ore within the property linea and nc encroachments exist
other thon noted.
EXClUSIONARY NOTE: It Is the owners' responsibility to determine the
~:~~~~~c:h~:ha~~ ~~:e;;~:~e; ~~";'hneo~~~;~:r'~~'~~i~'.~~n"~~tofU;d"!r
no circumstances should ony dotQ hereon be used for constructlon,
for establishing property Irnes. or for plot-pIon purposes.
Plol: C,;d, 4813 Date, Noy. 7/20D8 O,awn By. cb
Work O,de" 200B-L-184 Fb!Pg, Ref: 2008LJ9 Scale: 1"=40' Checked By. JMZ
Authentisign ID: 487913D4-AF7A-EE11-B004-6045BDED1DA9
US SURVEY 3043
GER HEMLOCKS
CIN OYu
CON3TRURION
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DESIGN
FIELD BOOKS
2.00
TOM N0.
3+00
4.-00 5.00
LOCATION
ELEV.
DATA
CVO
DATA
REV.
DATE
7.00
SASE
TELE.
STAKING
TOPO.
ELEC.
8/21/86
DESCRIPTION
ASB INFO PER CONTRACTORS PRINTS
81
SJ
PROFILE
DESIGN
SAN. SEWER
QUANTITIES
STORM DR
PRELIM. CHECK
CONTRACTOR
BASIS OF THIS DATUM
WATER
FINAL CHECK
BAB
EARTHWORK
INSPECTOR
OTHER FACILITIES
CONSTRUCTION RECORD
VERTICAL DATUM
PLAN CHECK
REVISIONS
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 075-061-26
Certificate of On -Site Systems Approval
Expiration Date: 2- 22 2, 0 Z
Legal description T10N R2E SEC 18/19 LT 26 PART 4
Site address 120 MY RD Girdwood AK
Current property owner(s) LEARY
X The On -site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
Original Certificate Date: 11 /22/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval June 2022
MUNICIPALITY ANCHORAGE
Development Services Department P p Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application °n 14-
1. GENERAL INFORMATION
Parcel I.D. 075-061-26
Complete legal description T10N Range 2E Section 18&19 Lot 26 Part 4
Location (site address) 120 My Road, Girdwood, AK 99587
Current property owner(s) Dan Leary Day phone
2. ON -SITE SYSTEMS SIZED FOR 3 BEDROOMS
3. TYPE OF WATER SUPPLY: ❑® Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank A Community Septic or Public Sewer
5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age N/A - See advisory if steel older than 20 years
\rR�JC��11�IA�J��IrRILTAWAIIn����1�1��_
Waiver request for:
Expedited review requested: O
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On -site staff
to verify the accuracy of the information provided.
COSA Fee $ - ! '� � Waiver Fee $
Date of Payment
COSA# 05c_2_
Date of Payment
Waiver #
COSA Application —June 2022
2/23/1998
0.418
>
Benjamin Schiller, P.E.
(907) 522-7773
Municipality of Alhcliorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orglonsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 016'00 6- 2(v cosA# ( D114
Expiration Date: 7 " .2. 6- 07
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
-Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
T1ON R2E SECTION 18 & 19 PART 4 LOT 26
120 MY ROAD • GIRDWOOD, AK 99587
KIMBERLY NIELSON
120 MY ROAD * GIRDWOOD, AK 99587
Day phone 343-0264
Day phone
ERIN EKER w/DYNAMIC PROPERTIES Day phone 230-7266
3111 "C" STREET * ANCHORAGE, AK 99503
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 1
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
•
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
•
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an Independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also Issues COSAs upon request to homeowners. Certificates of On -Site Systems
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 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. 1 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 Finn GARNESS ENGINEERING GROUP. Ltd.
Address
3701 E. TUDOR ROAD. SUITE 101 * ANCHORAGE. AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, LID. attempted to provide a thorough,
conscientious engineering analysis of the system In accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results doscrlbed the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational fife of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there am no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report Ls for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party Is not authorized, nor will 11 confer any legal right whatsoever.
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
Phone 337-6179
Date it17-3/Of
• ON-SITE •-17^
: WATE
WASTEWATER
bedrooms, with the (flowing stipulations o.• PROGRAM
�! ••••...••1
!.9), It t,l;
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Reort
Other
(Rev. 11p5)
Original Certificate Date• a 6 - 0 7
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 995194650
www.muni.org/onsite
(907 343-7904
OF ON-51TE SYSTEMS APPROVAL CHECKLIST
CERTIFICATE
Legal Description* T1 ON R2E SECTION 18 & 19 PART 4 LOT 26 Parcel ID: 0 75-- 0 6 / 2 %
A. WELL DATA
Well type PRNATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 2/23/1998 Sanitary seal (Y/N) YES
Total depth 100 ft. Cased to 100.23 ft.
Wires properly protected (Y/N)
Casing height (above ground)
FROM WELL LOG AT INSPECTION
Date of test 2/23/1998 4/5/2007
Static water level 55 ft.
Well production 10 g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate o• 2& mg /L
Arsenic: t__ ug /L.
B. SEPTIC/HOLDING TANK DATA
65 ft.
Date of sample: 4/5/2007
7.5 g p m
YES
18+ in
Other bacteria colonies/100 ml.
Collected by:
PUBLIC SEWER
Tank Type/Material Date installed
Tank size gal. Number of Compartments eanouts (Y/N)
Foundation cleanout (Y/N % : • ession over tank (Y/N) _ High water alarm (Y/N)
GEG, Ltd.
pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2or ft2/bdnn)
Length ft.
Total depth ft. Eff. absorption area
System type
Width ft : • :low pipe ft.
ft2 Mon i • • tube Depression over field
Date of adequacy test = - (Pass/Fail) For bedrooms
Fluid depth in absorption field : : st _ in Water added gal New depth in
Elapsed Time: In Final fluid depth in. Absorption rate >= g p d.
ejuvenatlon treatment (past 12 mo.) (Y/N & type) If yes, give date
Date installed
"Pump on" level at in.
Datu
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons Manhole/Access (Y/N
"Pump off' leve - High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
NIA
N/A
75'+
Sewer /septic service line
25'+
Animal containment areas 50'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line Absorption
On adjacent lots
On adjacent Tots
100'+
100'+
Public sewer manhole/deanout 100'+
Holding tank
N/A
Manure/animal excrete storage areas
Water main
ntlots
w
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation
Water service line
r
ran Wells on adjacent lots
F. COMMENTS
100'+
Surface water
Driveway, parking/vehide storage
G. ENGINEER'S CERTIFICATION
I ceMfy that I have determined through field inspections and
review of Municipal records that the above systems am in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date 4%23/4›,-
COSA Fee $ �
Waiver Fee $
Date of Payment 4 ^ 2 2 - 07 Date of Payment
Receipt Number 7) a 0 9 Receipt Number
(Rev. 11/05)
4
J
1 0 'sr/
z
4L££ £8L L06
.1..%'40, t 1 Z T .1HM ws-.;r•-nn .
(opoiN e6ioes eZb:80 LO 4L idy
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I D # 075-061-26 . HAA ri `caennimP,h
1. GENERAL INFORMATION
Complete legal description
Part 4 of Lot 26; Sec 18/19; T1ON; R2E
Location•(site address or directions)
•
Mile 1.3 Alyeska Hwy.
Circiwond. AK
Property owner 'Dexter Zernia Day phone 243-5084
•
Mailing address 3500 Wnrthpoint Drive Anrhnrage, AK 99415
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
1
XXX
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank •
Community on-site
Public sewer xxx
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72423 (Rr,. 1/91) Front MOA 921
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 of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is 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 in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm 5 8 S ENGINEERING
age River Loop Road No. 204 Phone _65 '/—o -R 7 G
Address Ea. le River Ala ka
Engineer's signature
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
By:
Additional Comments
Date 347713/
. •
syb11
* 43.».ROH RT .'cowANJ 44
'1Ili\ CE- E80144 //+f.
bedrooms, with the following stipulations:
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given In paragraph 5 above by an Independent
professional engineer registered In the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-02S (Mv. 1N1) Back MOA 121
Municipality of Anchorage RECEIVE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division - -►en�R 10 1998
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343$44
Municipality of Anchorage
Health Authority Approval Checklist Dept. Health &Human Services
/� 5/01.040l 10?
Legal Description: kr 4 4 r Loi .11v T/Od /2L Parcel I.D.: O" S- D 6 1- 6
A. WELL DMA
Well type ki UAT-
Log present (VM) YEs
Total depth O /
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed PSS. A3, /st7 ! g8
Sanitary seal (VM) YA, 5
N
41-
Cased to `ti 1 Casing height (above ground) Z
Wires properly protected (WN) y65
FROM WELL LOG AT INSPECTION
Date of test FEag 23, /9d l
Static water level sS
Well production // g.p.m.
WATER SAMPLE RESULTS:
Coliform --(7 Nitrate O - 332- -Mill-- Other bacteria
Date of sample: 414 " . /if? Collected by: (1-k &tl
B. SEPTIC/HOLDING TANK DATA A A Corin+04•Y SE.4et2
Date installed Tank size Number of Com
Foundation cleanout (VM)
Date of
ression (WN)
ng Pumper
C. ABSORPTION FIELD DATA /.%/t
Date installed / Soil rating (g.p.dJft2 or ft2/bdrm)
g.p.m.
eanouts (VM)
High water alarm (VM)
Length Width Gravel thickness pipe Total depth
Effective absorption area Monitorin a '- • e present (VM)_ Depression over field (VM)
Date of adequacy test Results (Pass/Fall) For bedrooms
Fluid depth in absorption fore test (in.); Immediatety after_ gal. water added (in.):
Fluid depth (ins) Minutes later: Absorption rate = g.p.d.
Pe -.• .: treatment (past 12 months) (VM) If yes, give date
72-026 (Rev. 3/96)'
D. UFT STATION AVA
Date installed Size in gallons
Manhole/Access (Y/N) Pump on" - "Pump off" level at'
High water alarm level at 'Datum
Cycles to
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic./holding tank on lot /U/il On adjacent lots �JR
Absorption field on lot /lV/t4
i
Public sewer main 79 1
Sewer /septic service line S6, f
On adjacent Tots
Public sewer manhole/cleanout 1/214-
Lift
/2' -
Lift station ,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: ' it JA
Foundation
Water main/service line
i/A
Property line Absorption field
Surface water/drainage Wells
SEPARATION DISTANCE FROM ABSORPTION FIELD
acent Tots
Property line Buil • . . ndation Water main/service line
Surface water Driveway, parking/vehicle storage area
Curtaio .: n Wells on adjacent Tots
F. ENGINEER'S CERTIFICATION
-'�c O qL
I certify that I have determined thnr field inspections and review of Municipal nr�1i the
in conformance with MOA guidelines in effect on this date. f
il
Signature ''n�7C-24m% —
Engineer's Name
g04 t.cr C_
Date 3r 9 I9
1 ROBEPT C. COWAN
RCf 880 !
HAA Fee $ '(Y"),
Waiver Fee $
Date of Payment U - 1.Q -q 1 Date of Payment
Receipt Number n21\ "r) `>•{ (49) Receipt Number
72-026 (Rev. 3/96)'