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HomeMy WebLinkAboutT12N R3W SEC 25 NW4NE4NW4NW4 LESS S150'TI 2N R3W NW4 NE4 NW4 NW4 Less 5150' #017-421 - 11 Municipality of Anchorage On -Site Water and Wastewater Program • (907) 343-7904 Page/ of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: 6544 1q( % (OY PID Number: U` (7 — L(Z (—/ f Dwelling: �9 Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: A New ❑ Upgrade Name: ( ABSORPTION FIELD ®-Deep Trench ❑Shallow Trench El Bed ❑Mound Address ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade VA -0 GPDlSF /0 0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 710 Ft. Gravel depth beneath pipe OJ' • O Ft. Subdivision Block Lot Fill added above original gradeII Z,( , FL Gravel length (� /� qq 4••.'[ / 7- Ft. Township Range Section 1/7-44 R3 AJ Gravel width 7,0 Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES L -e "0/ tcz p t To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 04"w 4( Ft' I` -- Ft. Well/v0 rIL f(/v 14 -HA Alk S d t TANK Septic ElS.T.E.P. [:1 Holding ❑ Other Manufacturetr I /'�l^P A Capacity / Gal. Surface Water I. VC, t- too,/- Material Number of compartments Lot LineNA �� , Me IL t Foundation (01 1p t� LIFT STATION Manufacturer Capacity Curtain Drain JJO H G7 Gal. Remarks Pump on level at Pump off le n. High water alarm at L Pump make model Electrical Inspections performed by Installer Tankto PIPE MATERIAL House to tank 'ij y ' Ifd a nfield 303x{ ^t P/6 A ay 0, Stir I� p r E . Drainfield 7# 3" COfMT -50JL( Inspector rTt h t der alar IP, �.. BENCHMARK (Assumed elevation) /U 31 / f ft Inspection •, dales: 1 !1 2"" r/ l /{' Location and description t L1 �at''�Sv l�(6a 3'" 41n COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL ve®®ksk OF Conditional Approval: Date 9TH d /•..... .... , I. . .. ..... A •• MICHAELL N. AN'DLRSON C 69 dPdtl�O Approved Ni(r Date I I1bPVUL1VII RCpVIl_tl-1- L.11llli Permit No. OSP141368 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: T12N, R3W, SEC 25, NW4,NE4,NW4,NW4, S150 PID No.: 017-421-11 ---MARK. ' /A 8 i c TC01 / 22 : 48 78 37, C05/ 40 -- 32 DECK'OVERHANG. I, THJI A. COQ\ \ \ I • \ \ / BENCH, GARAGE OTC01 �� 'MT . "C01 DECK OVERHANG Co TC WELL � I l / / / / / i SyaL,e\..,S,'hwrt��t �� ,.� SHED Aa tati-wwv,� / SEPTIC AREA ASBUILT / SCALE: 1'"= 0' 1 J rEco r<m r*col `Trn' rcoz �co3 rcon r.T cos ` ` I 100 ORG EaftTc I.WO CPLL[N SIEfL 1PN( / I DECK'OVERHANG. I, THJI A. COQ\ \ \ I • \ \ / BENCH, GARAGE OTC01 �� 'MT . "C01 DECK OVERHANG Co TC WELL � I l / / / / / i SyaL,e\..,S,'hwrt��t �� ,.� SHED Aa tati-wwv,� / SEPTIC AREA ASBUILT / SCALE: 1'"= 0' 1 J rEco r<m r*col `Trn' rcoz �co3 rcon r.T cos ` ` I 100 ORG EaftTc I.WO CPLL[N SIEfL 1PN( T0:3451391 P.2/2 EirMing, Inc. STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES DIVISION OF MINING, LAND At WATER tt:rtat 1W.•�� 'i]r'tiltn� aiutrFump Srrvi:.� WATER WELL LCX'. 'Amhoafy e' Alaska .(ao;) 44S-05tV Drilling SuaW:0$122,j1= Completed: City/Borough: Subdivision: I BLOCFK71 LOT Property Owner Nam & Address: Kira Ze2el 7121 a Way hoarge Drage, AK 99516 Anorage Meridien Township 12N Range 3W Section 25 '/+oft/+of %+OP �/s BOREIIOLE DATA(f In top of 9aStr)g)[3tepth Drillingmathod: (X) Air rotary, ( ) Cable too], Other Material: Type, Color & wetness I ftM I To well use: ( ) Public supply, (X) Domestic, Other stickup 0 2 Depth of hole: 4 _ fl; Casing stfekup: 2 ft Casing type jW1 Thickness. .254 inches Casing diameter. 6 inches Casing depth: 80 ft overburden 2 4 Liner type: Diameter: _Troches Depth: _ ft Static water (from top of cashtg): 56 R on09 /_6 slit & gravel 4 80 Pumping level & yield: _ feet after ,• hours at — gpm Recovery rate: 1 gpm, Method of testing: 8lrllft bedrock 80 420.] 20 Devaloptnem method: airlift Duration:1 ♦Tour Well intake opening type: ( ) Open and. (X ) Open hole, Other _ Screened; Start: it, Stopped ft Screen type., Slot/mesh sizer Perforated; Start: ft, Stopped. it Start: ft, Stopped: ft Note: Grouttype:__Volume .-----� Depth; from ground e—ugh 8 > to 24 ft Pump intake depth: Pump size: hp. Brand name: Was well disinfected upon completion? (X) Yes. ( ) No Method of disinfeotion:.calclul:ILF.I !^+bILIr1BRl.. ColiformnCA CO i0OmL Driller commentstdisclaimcts:...........................................................,. ............................................................................................................. Arsenic,,Un _ ................................................................................................. ...................................................................»..,..... w,........................... Welldriller name:........ ° . VX ........................................................... Company name: .... !16ftPg@!!gl. M ......................................... Mailing address; ..3540,Aku18.Df, .............................. .,.6 City: AnchoraV State: AK Zip 91516 Phone number : ( 907) 0593 f8X345-4740 Drillers signature. Alaska state law requites that a copy of this well log be scot Department of Natural Resources within 45 days; f'm are atx notable. (AK statutes 38.05.020, 38.05.035, 41.08.020, 46.15.020 and AK regulations 11 AAC 93.140), DNR! Division of Mining,Lend and Water, 550 W 7th Ave-— Sate 424 Anchorage, AK 99501-&%2 Phone (907)269.8639 and fax 19071269-8947 Within the City of Aachoragr,/ft is required that a copy of the well log be sent to the appropriate city office within 60 days and that another copy of the well log be sent to the welt/property owner within 30 days. Permit Number. OSP141369 Date of Issue: Se t 19 2014 Parcel Identification Number: Is well located at approved permit location? (X) Yes or ( ) No MW -2-2016 08:298 FROM: M:3451391 P. 1/2 be�t J$erAm b�epoO"WAt ""' ft Safety Int" On-site WQtet' d Wutewuiw hvgmm 4700 Elmore Road i' P.D. Box 1%690 Mark 8ogkh Anchorap, AK 99907 s w e t r bfayar MaymWAwAft (907) 343.7304 Pump Installation Log Well Drilling Permit Number: sw W 1M f 368 Date of issue: Parcel Identification Number: ' Lega-1 �DescMpfloa Property Owner Name & fd r J� &3w GGr Pump Installation Date: 4l- f S Pump Intake Depth Below Top of Well Caslog:8 jo feet Pump Manufacturer's Name: IA6 } ro' Pump Medel: I �f 75 f +-n 2! fog. 2w. Pump Sha ! by Wdess Adapter Bartel Depth: /J feet Pitkas Adapter Manufacturer's Name: 6-10 Pidess Adapter Installer.. Jin0 5."1 Well Disinfected Upon Completion I Yes n No MelhodofDisinfection: C.kip/i'1t: Name: 03;�Mu7 k47 Attentlan: The pump installer shall provide a pump installation log to the DSD within 30 dogs of pump installation o o c9 a = , C) m M o ma m 0 333=om=m CL a s 0 m? -«p ��_� O u y o m m m z\o Am r 'o i'ma =a.3O t4.�' m n z ,_ ms m O ym�_ m m m S' m a a � " j�� I^� •� IQ 7C 7S' 0m ;u�o a o N f> �0-0 0- m n D m sma moa \m S� n p m Q Dly*�A3 C? O y o m Z a 'o 3 a `<� m fl- (i x os, CL�• m ap C am 5= rn awaaaz m f 3 y u3 m D• � M CL � i C _• m s3 sD~'a S m m a _yS 06' o 0 �mm � ® II x .=3 >> o m'O D y o a cn e'1 m mm- 0 - a' ��O3 -cit' a iv 3 =a c 14,4 0 m m O o m m ;;m O a S u .�...�. p a° S m' O_O O NN14 A C 0 a m O O 3 I I ca s°gam =ac �' AW •c m m •� o a S o rn A D N 0 y `{ a n a w M m m 3 S O m C= S m C •*1 '° m a N W A v n m m m m S x 0, D o rtN •m m O � m O D o.• s o o °m S, 14 O m 000000/4/44 .. t1 y z QOp'a n z Vo Q m #41;±7 D po : :- Ul de N 1 �f 'N �s�• OOOSyO •. Q 0 4w N 1p T: �OQ� N DOODO��Ov cn M M 0 a 1 oY YAa i 6LL M.." L0.00 I o CAR AN M V)V° 10.0" M C) m M o .01 PORT £6M 3„9£,L0.00 S o Wo \ Mo I / /zic NO1S1Aiaans &-77c#Y3n&LS C Z On -Site Water & Wastewater System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP141368 Tax Code Number: 01742111000 Work Type: WellSeptic Initial Permit Effective Dates: September 19, 2014 to September 19, 2015 Design Engineer: ANDERSON CONSTRUCTION & ENG'G Subdivision: T12N R3W SEC 25 Site Legal Address: T12N R3W SEC 25 NW4NE4NW4NW4 LESS S150' G:2840 Owner/Address: ZERKEL KIRA 7121 HILLSIDE WAY ANCHORAGE AK 995163753 Site Mailing Address: Lot Size in Sq Ft: 59400 Total Bedrooms: 4 3 This permit is for the construction of: Y Disposal Field Y Septic Tank N Holding Tank N Privy Y Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received Issued By. (11316 COQ( Chaj, TrOM q JePR'k,5l "t�, 7. MUNICIPALITY OF ANCHORAGE Community Developmen't Department Development Services Division On-Site Water & Wastewater Program Phone: 907-343-7904 Fax: 907-343~7997 ON-SITE SEWER/WELL PERMIT APPLICATION Parcer I.D. Property owner(s) Mailing address Site address SUBMITTAL SEP D 2 2014 Day phone Gretchen Stu!!er Legal description (Sub'd., Block & Lot) Tf'~/q Legal description (Township, Range & Section) LotSize ~'~ c~( O0 Sq. Ft. Number of Bedrooms APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: ([~] all that apply) Absorption Field [~ Initial ,~ Single Family (SF) (w/we ADU) Septic Tank ,~ Upgrade [] Duplex (D) Holding Tank [] Renewal [] Multiple Dwellings Privy [] (SF and/or D) Private Well [] Water Storage [] THIS APPLICATION INCLUDES A VARIANCE ! WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number: Permit No. Date of Payment: Receipt Number: Michael N. Anderson, P.E. Civil/Structural Engineering & Construction 4661 Natrona Avenue Anchorage, Alaska 99516 Phone 345-3377 Fax 345-1391 Aug28,2014 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Legal: Proposed new well and septic T12N, R3W, Sec 25, NW4, NE4, NW4, NW4, LESS SOUTH 150' To Whom it may concern: This is a request for a septic and well permit on the above referenced lot. A test hole was excavated which showed silty gravel (GM) for the entire depth. The peru rate found to be 24 minutes per inch with no water observed dtaSng excavation, or after the 7 day waiting period. A deep trench with 8 feet of effective has been designed for the primary and secondary trench due to the soils. The lot slopes to the west at about 8 to I 0 percent with no slopes greater than 25 percent with lO0~feet ~tEe s,~t-/~-m,~. This new system will not impact any of the neighboring properties due to the large lot sizes and'~ good soils. Please call me if you have any questions. Sincergly ,~ ~'~ O~.t sa ~: 0.4,,, Michael~N. Anderson, P.E. P-~*2r~ ~-r "e OJ~ DESIGN CRITERIA- MOUND OVER (TH#1) 3 BDRM X 150 = 450 GPD GRADE SOILS = 450/0.6 = 750 GPD 1 — ORG FILTER FABRIC 7500 GA/1 6 = 47GM -2.0 4'0 PIPE (1) TRENCH SEWER ROCK 10.0' DEEP 8.01 EFFECTIVE _10.0 2.0' WIDE 47' LONG SEPTIC FIELD SECTIO It, t f b /WELL, t; I PEqGP4N/H/FE1GHTS/ SU%TSM (UNSET 0 1 /'SUF S 2 1 y h WA SUN ET d6L1D,i1NDY 0 TL HEIGHTS ... ..... LOT/I LOT/4 TOT "(11 W LL P El ,WELL X XI ZZZ PROPERTY LINE / U ­i� f�l K nP A P�m :��IK7V 8 -U- 77" �7 ROPED )USE Z" -7 EP11 L I PROPOSED STRUEMPLEff DRAINAGE FIELD PROPERTY LINE WELL V SEPTIC - v v f )t 1`12K R*Sir;25 NWOE4#4NW4 S(5G' t qTRUtER /SEPTIC" t I VELL I LOT:2MPL: v Jt( EN ISriNG WELL 100' RADIUS F_ Z Septic Design Prepared for KIRA ZERKEL OF T1 2N, RM, SEC 25, NW4NE4NW4NW4 LESS S150' 150- 4 4 K, .................. y Anchorage, Anchorage, Alaska Ar 49TH : .. ..... .......................... Michael N. Anderson, P.E. ................. .......... J *-.MICHAEL DATE: 8/25/2014 ♦ N. Al' 4601 NATRONA AVE ANCHORAGE, ALASKA 99516 DRAWN: DJR No. E 9 69 (907) 345-3377 / FAX: (907) 345-1391 SCALE: 1 '=100' I ~ ..."" '"~ i .: ' "~ !i i i ' / ~., ' :--':"x ?. / · //' / / ,, ~ I . .,..,' /SU$1TNA SUNSET ! / , / / \ / / /SUSITUA,8ONSET / I ', >- I j Lo,,; .,,, ...j:,_/,,.,.., ,: / ?,., /,,.: ,: .~,, I I .-. ............. :5' / / 1--.,_./I /',~ ,/ ,./ / / .A -:'"" ',, / .> ..... ,/ ,:" ,'1i /"'// :-'" .."' :: '--..-~. % ~' / k. ,,' I/ / <"'-.:', : ~.. ..-q I W I ," ' ! ' '.{.D,.i::."./': I - ./1-"'1'-' I / \ / ........ " ~. ...... _.: .......... . ...... r .::.l-::'.;~::'.'vl ...> ...... ~ : ..... I I I / :" // ..-"' ..."'-- .-'"' -..-~'-'/. ~:-'"t-: ..:,., ;.:i:"'?~ /-- EXISqN~ 1,250 CALLON ..... /' / ..'"' /' /~' //~'~,./~' I~'L..:'i~ ; SEPTIC TANK TO REI~AIN d--u.~/ ..... :__/__:/ .... /- -- -- ?:-- -- --. / -- ~-- --.~ k-'~'-: /-- ' --: -- -- -~ -~ ,/ / / / / / /" // / .'~',:':{",~ / / / ,' .~ ~o' U~L~ E~SE~ENT / /_T~_~! / / ~ ~'?".. / / / / / q -I-: ~ / / ~r .,>'/ ,=w : ::.::~:::: q / t tELL mO~US I I: I ~ / /" / /,'/ ,~ i.4 j, ~:.::~.~: ':..~ / ~ : ~ -- -- ~ · / .., ~.,..: · .::'.. / ./ ._. ~, co.,o,,s-~.~_ :~'i/,: t.:".,.,,::.:~:..:,:..,:,~, _L.:_ / --: ~jl / /', x/ I ~o7x-'' /' ":' / ?~:: ,~5, / / / - , ...... ~ i / / /, / ::::m / / / .-~-~.~j ~: :.....-, / ', :- ::.. / / ,, ,.,/ /: / / / G //? '"' ,~ , ,i .:.:' / / ;~: . / ; ,, ; i / I / / / .-..// ~-... / / / L~,,-~------mL.=-~- / / PROPERLY LINE / // / /~ / ..--/ / / '~.... .-:, ,,~ lx ~/.i/ / Y ,.;) / /.5'~ / / ~, /.-"7 / / .,' I I/I ? i / ? /', ? / :/'j: / / / ,,' / / I l/ . i ~ / / ~i ~ ^/ :' / / / / : ,' . ~ /,, :-"'~ , , . / /'--/ . .:>.. .- . / / , , ,' i ,' / " / ; "~ .... ,'," / " / I 4 /' ,/~ i ,' : / /// // / / ,, :/ :,,,,, ~... / / ,' ;~ : , : ,, , SepU¢ Design Prepared for T12N, R3W, SEC 25, NW4NE4NW4NW4 LESS 8150' .,~ ?' ..~l-~.. Anchorage, Alaska ~' ~'? 4~ m_ ~ ~.....~ ........... ,~ ...................... .~......~ '~'~1,;~.. No. CE 9469 46Ol NATRONA AVE DRAWN: D.JR ANCHORAGE, ALASKA ~51 ~ 8- 9- 10- 11- 12- 13- 14- 15- 16- 17- 18- 19- 20~ Pedormed For: Municipality of Anchorage · Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Road P,O. Box 196650 Anchorage, AK 99507 www. cL a nchoraqe.ak.us (907) 343-7904 Soils Log - Percolation Test LegalDescription: ~'/~,/~ J~'k,3 1- 2- 3- 4- 5- COMMENTS 2...',.;:.'7:....,' '......,, Township, Range, Section: Site Plan WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? L O Depth to Water After p Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER TESTRUN BETWEEN~FT AND ~'~ FT PERFORMED BY: /~. ,AJ~L., I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THiS DATE. DATE: Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99619-6650 ~ Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: r..~-~ q~(~...-7C2 PID Number: 01~ ~/ N~: ~C~O ~ L~ O ~ Wastewater System: ~ New ~grade AddresS: I~0 T~% ~¢~i~I ABSORPTION FIELD Phone: INo. of B~oms: ~epTrench d Shallow Trench ~Bed BMound BOther Total Depth from original grade: LEGAL DESCRIPTION S°ilRaP"g: ~¢~ OPD/Sq. Ft. Lot: 8lock: Subdivi,fon: Oeplh to pipe bottom from original grade: Gravel depth benealh pipe Township:l ~ ~l IRange:s~ ISeotion~ ~ Fill aOOed above origmal grade: Gravollength: WELL: ~ New B Upgrade O~a¥¢~idth: ~ R. / Ft. Classification {Private. A.B.C): Total Depth: Cased To: Tola{ absorplion area:.~ Pipe material: Yield: GPM IPump Set ah FL Icasing HeigM Ab°ye Ground:FL TANK SEPARATION DISTANCES ~ptic ~ biolding E] S.T.E.P. TO Septic Absorption Pitt Ho,~ng Public/Pdval( Manufacturer: Capaci y in gallons: W~, I10 /7¢ ~ 't0 Maleriah ¢ 'r¢~ Number of Com~ments; W~t~r ,~-- ~W .. LIFT STATION Foundation .~ ~ "Pump on" level at: I "Pump o,," ,eve, at: [ High waler alarm at: Remarks: BENCH MARK Assumed Elevation: Department of H~ th and ervices approval ~,4, ¢~ ..... Reviewed and approved bi': ~ Date: I/~ ~ . .,~r~,-x*, BC 24.5 AD 85 BD 97 I AE 98 BE 119 Well Well 25 -- 0 25 50-- 75 --lOg- 125 1 £CALD 1" 50 TOBBEN SPURKLAND P.E. 205 W 15TH. AVENUE ANCH. AK. 99501 (907) ;279-~91~ LEON HICKOK TUNKS [URN SEPTIC SYSTEM AS BUILT DATE: NOK 2~ 1995 SHEET: 2/$ GRID: 2840 Standard ?-rench~ 2' ~/ide 50' Lan9 18' Deep 5' Sewer rock 5' CarPI' ,.~ ~, ]250 ool Sepbc tank ~ ~ M/FOF/ 140 INK EL. ~ qNK EL. 72.6 ND SCALE 9 6~: 1250 ~oI. septic tank ~£NCH MARK. Betray SIDINO ASSUMED ELE~ TOBBEN SPURKLAND P.E. ~03 WiDth Ave Anchopage Ak 99501 S//2, SE1/4,NEJ/4, N~/1/4, SEC 25, ?Z2N £3~/ LEON HICKOK TURKS TURN SEPTIC SYSTEM AS BUILT DATE: NO~ £~ I995 SHEET~ 3/3 GRID: 2840 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF 1 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW950278 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:HICKOK LEON E OWNER ADDRESS:12540 TURKS TURN ST ANCHORAGE, ALASKA 99516 DATE ISSUED: 9/15/95 EXPIRATION DATE: 9/15/96 PARCEL ID:01742117 LEGAL DESCRIPTION: T12N R3W SEC 25 S2SE4NE4NW4NW4 LOT SIZE: 54450 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80) . 3. THE 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: DATE: 203 W 15th. Avenue, Suite 203 ANCHORAOE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN S1/2,SE1/4,NE1/E,NW1/4,NW1/4 SEC. 25, T12N R3W LEON HICKOK No Ground Water or Impervioug Layer to 16 fi. Use Standard Trench Soil Rating. 2 min/in - 1.2 gai/sq.ft.day No. of Bedrooms 4 Required Area per Bedroom: 150/1.2 - 125 sq.ft.. Total area required: 125 x4 = 500 sq. ft. Testhole Total Depth 16 fl Less 6 10 Rock Depth 5 Length of Trench 500 / 10 -- 50 Ft. SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 50 ft. TOTAL WIDTH 2 TOTAL DEPTH 10 ROCK DEPTH 5 COVER 5 SEPTIC TANK 1250 gal Abandon existing tank and trench The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural 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. pg.1 SCALE: 1' = 100 FT. £50 300 SEPTIC SYSTEM DESIGN DATE: AUGUST 16, 1995 SHEET: 1/3 GRID: 2840 OBBEN SPURKLAND P.E. 20,3 W 15TH, AVENUE LEOM fllCKOK ANCH. AK. 99501 TURKS rUleR Trench ~ ® #1 #B Well Rep[oce I Well N SPURKLAND Well ~5 -- ~ 25 --St~ 75 - Iflg- SCALE: 1' 125 TOBBEN SPURKLAND P.E. 205 W 15TH, AVENUE ANCH. AK. 99501 (907~ 279-3916 l /e, szi/4, vm/4,mr /4, v /4, szv LEON HICKOK TURKS 1-URN SEPTIC SYSTEM DESIGN DATE: AUGUS[ 1~ 1995 SHEET: 2/$ GRID: 2840 3' V/de 50' L on9 10' Deep 5' Sewer rock 5' Cover © © ]~50 9ol Septlo tonk SCALE C~eanouts 4" 3' Cover Monlt~or Mir'o Pi ]40 5 £~. o£ Sept. lc ~ock ND SCALE 1250 gal septic ~onk BENCH MAR/~ ASSUMED ELEV, 100,00 TD~EN SPURKLAND P,E, 203 ~15%h Ave Anchorcge Ak 99501 Si/~,SE]/4,NEi/4,NV]/4,SEC 2~ TI£N R3V LE[TN HICEDK TURKS TURN SEPTIC SYSTEM DESIGN SNEET~ 3/3 GRID:2840 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SLOPE SITE PLAN WAS G.OUND wA'r R 10 ENCOUNTERED? iF YES. AT WHAT DEPTH? Depth to Water Afler~ 13- Mor~itorino? ~ Date: U Gross Net Depth to Net Reading Date Time Time Water Drop ~ ~o ~ 14- 17- 18- 19- 20- PERCOLATION RATE /p ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN /t.~-- FTAND ~7 FT COMMENTS ~ERFORMED BY: ~ I ~'~ ~ CERTIFY THA~.~H~I~TEST WAS PERFORMED iN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON TH~S DATE. : · · - ~ 72-008 (Rev. 4/85) PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 1 2 3 4 5 6 7 8 9 I0 11 13- 14- 15 16 17 18 19 2O SLOPE SITE PLAN WAS GROUND WATER E I ENCOUNTERED? J~ ~ S iF YES, AT WHAT OL DEPTH? p. Depth to Water Aflerl ~ ,~. -- Moniloring? ~ Dale: "~/?-~///¢~J Gross Net Depth to Net Reading Date Time Time Water Drop I< PERCOLATION RATE . (mJn~es/inc~ PERC HOLE DIAMETER ~ l~ ~ TEST RUN BETWEEN ~ FTAND ~ FT COMMENTS I~ERFORMED BY; ~'~ (~ I F ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) CERTIFY THAT THIS TEST WAS PERFORMED IN DEPARTIVIENT OF HEALTH ~ ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVmSION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LOCATION -- TO: I ~ b Inside length Width J Liquid depth J~O ~ IF HOME'DE: O z ~ Manufacturer Material Liquid capacitv in gallons ~ ~ ~ No. of lines / LengJh ~. ~, Total length of lines Trel~wjdth Dis~e~ Length Width Depth ~ Type of crib Crib diameter Crib depth Total .f fective absorpj ~ ~~ ~ ~ DISTANCE TO: Well Building foundation Nearest lot line OTHER PIPE MATERIALS SOl L T EST RATING APPROVED DATE U. A, RECEIVED 72-013 (Rev. 3/78) FIF>PL. i LOCFI 1' I LEON E. HiCKOK I"UF:K'E; '['URN F::L;2 N,q:::ii:!4 S. :SRI::! "F'~"F:'E OF SOIL. F~8:~;O!:;~:[:~r['ION '}.:;'.~.'STEH I:.:!;: TRENCH t'IF:t',:-','!HLIH I'..!LIM[?~ER OF' DEC, ROOMS = ]: {]'tE F'.[E(i:!U ! RED S ]: 2'.E C{F' TI-.IE SCI i L FI[:?:E;OI:;~:I::'T ~ ON 5:'-P~]"EP'I I '='!!;: 'THE LENG'FH D, IF!E]"]':S]Oh! I'-S TI-II/ LENGTH < IN FEET) OF THE TRENCFI OI;?. DRF:II NF'!EL.E). THE [)IEF'TH OF F~ TRENCH OR F'IT Z~ THE E)I~;'FF~NCE E',EI'tqEEN THE SI..IRFFICE OF: "F!.IE: 6iF?.OUF,![) FIND T'HE BOTTOM OF THE E::'::CA"/f:~T~ON '::ii",l F!EET>. THERE ~'.S NO SET k!]:D'TH P'OR TRENCHES. 'FHE GRFI'¥'EL [)EPTH Z~5 THE ["ltHI["!U["'! E)EPFH C[F GRI:i"/EL DET].'.!F~:EN THE OLII't::'FIL.L FtI"~[:, I'HE [?,OTTOH I:]F THE: I:E',:-::CFIYFFI-IOI",! ':: ]:N F'EF?.HIT F~PF'[.iCFIt",Fr HFrJ5 THE F:.'ESPONSiE~IL..]:]'Y TO !NFORH TH!S; DE~:PFtR"['I','IE!'.,FI E:,UR!N6i THE Ii"~:S't]:::IL.L.FF['ICtH IN'_'SF'Ei:C:TICIN~ OF FIN"? kIL::LLS; FI[).IF:ICEIqT TO THIS PF?.OF:'EF}.T"~" I::lF, If)TI"!E ['.~P..IME~ER O1:::' RE:!SI[:,ENCE::T'. THFFF TFIE: !4ELL. !,.IZL.L [!iIFICKF:' ! LL I NG OF FiN? S'~":-~;TE!'"I P.! :1: TI~IOLKI'' F I !",lFIt.. ! NSP[ECT ! Of',! FII",!D F:!F'F:'I:;~'.O'v'I::IL. B"~" T!-I t :S DEPFIF;:T!"iENT !4IL..L E:E :i~;LIEk!ECT TO PRO'J~;I~CCUTtOF,!. t'"i ! f",! i MUH D ! S'TFfIqC:E 8ETP]EEIq Ft I.'.![.:]...L FltqE:, FINY ON""5; i TE ~;E!,.ff:]GE :[J;~3 F'[EE"i' FOR I:::f F'RI',,~FF['E 14ELL.~ :L'.]~:) TO 2C~C~ FEET FROM f::[ F:'LI[:?,L.!C I.qEL.L. !}EF:'EN[)ZNG UPON THE T'T'PE OF PI..IDI.IC O]l~lfZF?. R[EE)U i REP'i[ENT:~]; h'lf~"~' F~F:'F'L"?. :~F'EC I F: l C[aT! Oi',IS~; (:II"4[) C:Oh~::?TRLICT 113iq [) ! F:IG!:E:FIPitS (:iRE F?,,,'FIILFIE~L!~E TO IN:SURE F'ROF'ER CERTtF"r' THf¥1" ]: FIH l:::'Fff'!i L. I f:tl:,~: 1.'.I ! TH THE RE6:]U i REMENTS; FOR OP,P-S i TE l FOI';?.fH Ei:'-,-' THE HLINICIF'F:tL.i'[".~" Cfi:: ;:.:'.: ! FIIL..L IN:ii~TFIL. L THF:: ~PT'~S"t'EP! IN I::~C:CCd~:[:,FI~'~C:E PI/TH THE :J:: i L!F,!E:,ER~F'I'F[ND THFIT THE ON-:SITE ~SE!,.!ER ~5'-,"2:T!EM i'"lFt"r' REC~LIIt::~:E E?qL.F:IRGEMIEI",!T IF TILE. [?.E~:~;IE:,[Ef',IC:E:: !~:~ REI"I(:)E:,ELE[) TO IIqC:[.U[:,E MORE TI-IF:IN ]~: I-'Ip['LII.,I"-!I'~, I._I-LI~-,! E., HiL.I,,uF,, 825 "L" STREET ANCHORAGE, ALASKA 99501 (907) 264-4111 GEORGE M. SULLIVAN, MAYO[~ DEPARTMENT OF HEALTH ANO ENVIRONMENTAL PROTECTION January 9, 1980 R & M Consultants, Inc. Post Office Box 6087 Anchorage, Alaska 99502 Attention: William Robertson Subject: T12N R3W Section 25 S½ NE¼ NE¼ NW¼, Permit #7'90270 Clabo Construction Company - As-builts and Installation Documentation of On-site Sewer Systems Your submittal of an on-site sewer system installation report has been received. Noted in your comments was the gravel backfill requirement being deleted due to existing soil conditions. The department, in the future, request the gravel requirement not be waivered since it is mandated by ordinance and actual authority for waiver does not exist, even for departmental personnel. Additionally, the system may work well under circumstances you noted, however, screened gravel backfill no doubt would increase chances of sewer system life. Soils rated GW were used as backfill until 1975, however, sewer systems were fDund to fail in close proximity to dispersal pipes, therefore, the screen gravel requirement is retained in these as a safety factor. Mr. Robertson January 9, 1980 Page Two This department will accept the inspection report as submitted, however, adequacy testing will be required for resale of the property. It is also this department's position that absorption field life will not be shortened due to washed gravel not being used' per your field comments and professional descretion. Again, please note the screened/washed gravel requirement may not be deleted in the future. If there are any further questions, please contact this office at 264-4720. Sincerely, Les N. Buchholz, R.S. Senior Environmental Specialist LNB/ljw cc: Clabo Construction Company post Office Box 3-4056 99501 825 "L" S/-R EE]' ANCItORAGE, ALASKA g9501 (907) 264-4111 December 31, 1979 Leon E. Hickok Star Route A Box 2390-K Anchorage, Alaska 99507 Permit ~ 790270 Subject: T12N R3W Section 24 S~ SE¼ NE¼ NW¼ NW¼ A permit issued by this department for well and/or sewer system has expired. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a well 10g should be sent to 'this departmen~ to document the installation date. if an enginee~ has inspected the installation of the on-site sewer system, please have them send us the as-builts for our files. If there are any further questions, please contact this office at 264-4720. Sincerely, Les N. Buchholz, R.S. Senior Environmental Speci~-~s~ LNB/ljw enc: Copy of Permit June 6, 1979 R&M No. 950022 The Drilling Company P.O. Box 8717 Anchorage, Alaska SUbject: Soil Investigation for Sanitary Sewer System, Leon Hickok Property, S~ SE~ NE!~ NW!~ NWZ4, Section 25, T12N, R3W, Sewar'd Meridian, Alaska Gentlemen: At your request of June 6, 1979, we conducted a subsurface soils investi- gation at the proposed location of the sanitary sewer system on the subject lot. The investigation complied with those procedures required by the Municipality of Anchorage Department of Health and Environmental Protec- tion. This investigation, which was accomplished on June 6, 1979~ consisted of a test hole excavated to a depth of 15 feet below the existing ground surface. The test 'hole was sited according to your instructions and its location is shown in attached Drawing A-01; Excavation was accomplished with a back- hoe. and all material excavated was continuously monitored by an experienced engineering geologist. Because of coarse granular materials, the contractor may experience slough- ing and caving of the absorption trench after excavation. The soils encountered in the excavation are shown in the test hole log in Drawing A-01. This log displays specific conditions encountered at the test June 6, 1979 The Drilling Company Page The soils encountered in the excavation are shown in the test hole log in Drawing A-01. This log displays specific conditions encountered at the test location. However, subsurface conditions may vary in other parts of the lot without any apparent surficial evidence of the change. Groundwater was not encountered and bedrock was not encountered. At the time the hole was excavated seasonal frost was not present and permafrost was not encoun- tered. Based on the visual classification of the soil and the requirements set forth by the Muncipality of Anchorage, a percolation test was not necessary within the test hole on the subject lot, We appreciated this opportunity to be of service to you. Please contact us if you have any questions concerning this letter or if we can be of additional service. Very truly yours, R&M CONSULTANTS, INC. Ernest R. Rahaim Staff Geologist GS: E R R/dj/ATS I-G Seni Geologist BORING NUMBERTp 1 Date Completed: 6-6-79 SOIL DESCRIPTION SILTY SAND w/SOME GRAVEL, SM 1' GRAVELLY SAND w/TRACE SILT, SW SANDY GRAVEL, GW LOCATION SKETCH No Scale 300' NOTE: DISTANCES SHOWN ARE APPROXIMATE AND HAVE NOT SEEN MEASURED 8Y SURVEYING METHODS. EXPLANATION "'~' .~ ORGANIC MATERIAL LitHe Visible Ice O:10' Vx -- ~:,9 ..l)'_.A.B. ~--,C£ D£SCR, P T/ON TYPICAL SOILS LOG ) ~.a-AFT£RBORING SAMPLER TYPE SYMBOLS 1 SOIL SYMBOLS S% SE¼. NE¼ NW¼ NW¼; Sec 25, T12N, R3W PROJ. Na 95002 Time i " Time ~ne Date Date Date Inspector Inspector Inspector Comments \ ~ ~..22~.~ ~ ~~ Date Sewer Installed Permit No. Septic Tank Size ' ~ ~ Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property Owner ~O~ E, ~/~/~O ~ Phone Buyer Address Realty Co. & Agent Phone Address Typ~pf Residence ~ Single Family ~ Multiple Family No. of Bedrooms ~ ~ Other Wet. Supply ~ Individual A~ACH WELL LOG. A well log is required for ali wells drilled since June Q Community 1975. For we[is drilled .prior to that date, give well depth (attach log if ~ Public Utilit~ available.) Sew~e Disposal ~ Individual Year Individual Installed: ~ Public Utility When Connected to Public Utility: ~ Holding Tank i~ ~E: ~E !N~TIO~ FEE MUBT ACCOMPARY EACWREQUEST BEFORE PROCESSING ~AN BE INITIATED. CHEMICAL & G~ ,LOGICAL LABORATORIES ,~£ ALASKA, INC. TELEPHONE (g07)-279,4014 ANCHORAGE INDUSTRIAL CENTER 274-3364 5633 B Street Drinking Water Analysis Report for Total ColifOrm Bacteria TO SE COMPLETED BY WATER SUPPLIER WATER SYSTEM: Water System Name Mailing Address Phone No, .:'--<-.+' ~..4 Mo. Day Year Zip Co~e SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. 2 I 4 I I LOCATION t Time Collected Collected By TO :BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: :~ 'Satisfactory [] Unsatisfactory [] Samole [oo long n transit; samole should not be over 48 hours ola a[ examination [o indmate reliable results. Please send new sample. Date Received Tir~e Received Analytical Method: [] Fermentation Tube ~;.Membrane .Filter Lab Ref. No. Result* Analyst .i/,: ',;".::> :. j ~ READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICALWATER ANALYSIS RECORD Presumptive ).0mi 10mi 10mi /0mi :t0ml ).,Omi 0.1mi 24 Hours January 9, ~980 _, .-~Page 'l¥/o ~~x ~,-~ment will acceDt the inspection report as ~' po~t]~-~3]a~bsorpt~on field life will not be shortened A~tn,~>ea~e note the screened/washed gravel requirement :~U ~: be ~E.ed in the future. ~ ~?/!L'~' ~rEher questions, please contact this office at 264-4720. · / Sincerely, March 15, 1982 Mr. Leon E. Hickok SP~-%. Box 23~0-K Anchorage, A~[ 99507 Subject: S¥2 SE]/4 NE~4 Nwl/4 NW~ Sec 25 T 12 N R 3 W Approval for the individual sewer and water facilities cannot be granted until the following items have been completed: ~~u~%~c. al wires to the well head are in vl~latzon of the ~unicipality of Anchorage codes and must be encased in conduit. wa~er analysis report need~ to be submitted to this ffice from the Chem Lab, 5633 B Street, for our review. septic tank pumped with a receipt submitted to this departmen%. l_~adequacy test needs to be performed on the existing caching area. This test %~il]. determine if the system is adequate according to National Standards. A listing of private firms performing the test is enclosed. This report needs to be submitted to this office for our review. Please notify this department for a reinspection when -~J'le noted, discrepancies have been corrected. If there are any further questions, please call this office at 264-~.720. Sincerely, Robert C. Pratt Associate Environmental Speclalist ISAACS ?Ui¥~P~NG SERVICE (Norm Tibbetts, Owner) 6218 Q.uinhagak Street ANCNORAGE, ALASKA 99507 Phone 344-0114 )49 sTANLEY BRUST & ASSOCIATES Engineers - Planners - Surveyors 6361 Neilson Way, Suite 110 Anchorage, Alaska 99502 (907) 279-4151 EPTIC SYSTEM ADEQUACY REPORT ,JOB NO, DATE OF REPORT DATE OF TEST ~"~/~. ~.,~t~ ,,--~,~ "~"" LEGAL DESCRIPTION' ALASKA PERFORMED FOR: J REQUESTED BY: ~HONE NO. TYPE OF SYSTEM ' [~ SEPTIC TANK - SIZE __,/~ GALLONS [] CRiB OR SEEPAGE PIT ~ LEACH FIELD NUMBER OF BEDROOMS SEPTIC TANK WAS PUMPED D YES ABSORPTION RATE: AVERAGE 24 HOURS .4~'*fi GALLONS. SURGE RATE] _ ~/'~ GALLONS IN_ ,///~ MINUTES. ~ STANLEY BRUST & ASSOCIATES Engineers - Planners - Surveyors 6361 Neilson Way, Suite I10 Anchorage, Alaska 99502 (907) 279-4151 S E,?"T I C SYVF E M ADEQUACY REPORT DATE OF REPORT DATE OF TEST LEGAL DESCRIPTION ' ?-- /> - SECT ION , , T N ~ B -? W , S M. , ALASKA PERFORMED FOR: / REQUESTED BY: TYPE OF SYSTEM ' TANK - SIZE .__L,_~S,~.T.___/,,'t-,,r~ GAL. LONS CRIB OR SEEPAGE PIT LEACH FIELD SEPTIC NUMBER OF BEDROOMS SEPTIC TANK WAS PU!,~PED 0 YES ~o ABSORPTION RATE: AVERAGE 24 HOUR$--4~,L~'~----GAI-LONS- SURGE RATE: /~/'~ GALLONS IN _~---~.-- M!NUTES. NOTES OBSERVATIONS' TEST PERFORMED BY: ~- REPORI PREPAFED BY: ~ APPRO~D BY: .......... MUHMPAUTY OF AHCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I. D. 0 17-421 -11 -000 Expiration Date: 11/9/2023 Legal description T12N R3W SEC 25 NW4NE4NW4NW4 LESS S150' Site address 7674 UPPER HUFFMAN RD Anchorage AK 99516 Current property owner(s) ZERKEL KIRA 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: 8/9/2023 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 Absorption Field Advisory Tank Age Advisory Other X Well Flow Advisory__ Nitrate Advisory Arsenic Advisory COSA Approval June 2022 ��1�UHMPA UTY OF A HCHORAGE Development Services Department On -Site Water & Wastewater Section Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I. D. 017-421-11 Complete legal description T12N R3W SEC 25 NW4NE4NW4NW4 LESS S150' Location (site address) 7674 UPPER HUFFMAN RD, ANCH AK Current property owner(s) ZERKEL 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 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. TY_P_E_OF WASTEWATER DISPOSAL: ®❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel Q Plastic ❑ Concrete ❑ Fiberglass Age 9 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑® Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: �r. 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 $ ?) C' Waiver Fee $ a Date of Payment Date of Payment COSA # 0S L 2/ J 2 Waiver # COSA Application—June 2022 COSA Checklist Legal Description: T12N R3W SEC 25 NW4NE4NW4NW4 LESS S150' parcel ID: 017-421-11 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _ A. WELL DATA X Well log is filed with Onsite (or attached) Date drilled 9/26/14 Total depth 420 ft Cased to S0 ft ❑� Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 24 in. Date of flow test for COSA 7/18/23 Static water level at beginning of test 56 ft. Comments B. TANK DATA Measured operating fluid level in septic tank 48 Date of pumping 7/27/23 ❑ Required maintenance completed, if AWWTS Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) 11/4/14 Q ALL standpipes present per record drawing Total measured depth from grade 12 ft (max) Measured depth to pipe invert from grade 4 ft (min) ❑ N/A — pressurized field. ❑ Per record drawings, field is insulated. ❑� Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) _ If yes, enter date Comments/Deficiencies: COSA Checklist June 2022 Well production at time of test 1+ gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes H No H Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by MINA Date 7/18/23 C. LIFT STATION ❑ Required maintenance completed Age of lift station _ years Lift station material Comments: Adequacy test date 7/18/23 Results Q Pass Fluid depth prior to test 12 in Water added 450 gal New fluid depth 21 in Elapsed time 1440 min Final fluid depth 12 in Absorption rate 450 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 96 in Effective depth used 12 in Effective depth remaining 84 in E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' ❑� Yes if No _ ft Neighboring Tank > 100' no Yes if No ft Absorption Field on Lot > 100' ❑� Yes if No ft Neighboring Absorption Fields > 100' ❑e Yes if No _ ft Community Sewer Main > 75' 0 Yes if No _ ft Community Sewer Manhole/Cleanout> 100' ❑ti Yes if No _ ft Private Sewer/Septic Line > 25' Q Yes if No _ ft Holding Tank > 100'❑ Yes if No _ ft Animal Containment > 50' Qi Yes if No _ ft Manure/Animal Excreta Storage > 100' Q Yes if No _ ft ❑ N/A — Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' F Yes if No ft Surface Water > 100' ❑� Yes if No _ ft Tank to Property Line > 5' Field to Property Line > 10' Water Main > 10' Water Service Line > 10' F. ENGINEER'S COMMENTS QYes ifNo_ft ❑� Yes if No _ ft Yes if No _ ft 0 Yes if No _ ft Wells on Adjacent Lots: Private Wells > 100' Community Wells > 200' ❑' Yes if No ft g Yes if No _ ft If tank or field is under driveway comment below G. CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Finn P111 -C4 4CLE"40N A+I�'G. Engineer's Printed Name *,Ppt' COSA Checklist June 2022 Phone 727-8864 Date Y L� 4 «s...rr.. r. ......... r /! A • MICHAEL N. AN'U;HSCN •`�-,^' �� fir'• ��t17 '�,.••�;v �'