HomeMy WebLinkAboutSPENARD HEIGHTS ADDITION LT 20A-1H
Sp
nard
ights Addn
Lot 20A- 1
#012-053-45
Mark Begich
Mayor
bevelopmcn? Services bepaCment
Building Sefel~/ bivision
On-Site Wa>rer & Wasl'ewater P~ogram
4700 Elmore Ro~d
P,O. Box 1~6650
Anchorage, AK ~507
w~,mu~i,or~/o~Jte
Pump Installation Log
Well Drilling Permit Number: SW
Date of Issue:
Parcel Identification Number:
Legal Description
rpump Installation Date: {o -'b' ,5
Property Owner Name & Address:
Pump Intake Depth Below Top of Well Casing: 03 ~, feet
Pump Manufacturer's Name: ~E.0J'~c:t<~'l'
Pump Model:
Pump Size ~'/~] hp
Pitless Adapter Burial Depth: ! ~ feet
' Pitless Adapter Manufacturer's Name: /
Pi~less Adapter Installer:
Well Disinfected Upon Completion'.> es ~ No
Method of Disinfection: ~.t41o RI
Comments:
Pump Installer Name:
Attention: Tt~e pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
MUNICIPALITY OF ANCHORAGE
Development Services Department a Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 012 053 45
1. GENERAL INFORMATION
Expiration Date: _fie C �, 0,2 0
Complete legal description SPENARD HEIGHTS ADD LOT 20R-1
Location (site address) 6045 BLACKBERRY
Current property owner(s) SMITH
Day phone
Mailing address
Real estate agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)�
❑ Duplex t
❑ .Multiple Dwellings (Single Family and/or Duplex) �
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
❑
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
N
Waiver request for: NONE
Distance:
Received by:
Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 3 � lO LCO
Waiver Fee $
Date of Payment % 3 a Z O
Date of Payment
Receipt Number 0 / 5% �a�
Receipt Number
COSA # O S C� Q 1 `A' S 0
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation.
Name of Firm C&M ENGINEERING Phone 8545558
Address 20182 TULWAR
Engineer's Printed Name CHARLES BALZARINI Date 8/28/2020
Nk
°F a/,�s���
'49 TH
6. DSD SIGNATURE
d .� .. .
System #1 Approved for � bedrooms r
t;HARLES G BALZARI111
System #2 Approved for bedrooms �$��F���.. CE -13854
Disapproved ���pROFESSVAW
Conditional approval for bedrooms, with the following stipulations:
OFA*"'
c' vn ori
—E)N SITE n. :
\NATER AND
WAST o
PROGRAM '�
k
By: Original Certificate Date: o2�v�G
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
COSA Checklist blue sheet
COSA Checklist yellow sheet
COSA Checklist
Legal Description: Parcel ID:
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date of Sample
Comments __________________________________________________________________________________
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA ______________________
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field
Monitor tubes go to bottom of effective. If not, state
depth into effective
Code-required soil cover over field
System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Adequacy test date
Results Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
Comments/Deficiencies:
SPENARD HTS ADDITION LOT 20A-1 012 053 45
11 1
4.1
UNK NA
UNK
UNK
5.373
+12 C.Balzarini
8/28/20
83
8/19/20
**pump intake measured at approximately 225' below top of casing. +/- 142'of water storage inside casing.
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
From Septic/Holding Tank on Lot to:(Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Property Line > 5’ Yes if No ft
Absorption Field > 5’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10’ Yes if No ft
Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
If absorption field is under driveway comment below
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
F. ENGINEER’S COMMENTS
G. ENGINEER’S CERTIFICATION
I certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.8/30/20
✔
✔
✔
✔
✔
✔✔
well only, no septic
** Pump intake level was measured with an acoustic well probe and is relative to top of casing.
The measured pump level varies slightly from the reported 212' and should be considered approximate.
✔
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