HomeMy WebLinkAboutGREENBROOK BLK 2 LT 21Cnbr'ook
Block 2
Lot
#017-023-88
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP181195 PID Number: 017-023-88
Dwelling: X Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: FO -1 New ❑ Upgrade
Name:
FEDERICO LABASTIDA
ABSORPTION FIELD
0 Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
4
1.2 GPD/SF
10 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
5 Ft.5
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
GREENBROOK BLK 2 LT 21C
Fill added above original grade
0.5 Ft.
Gravel length
50 Ft.
Township Range Section
Gravel width
2.0 Ft.
Beds: Number of Lines
Distance between lines
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 Ft z
1.0
Ft.
Well
14
*NA
*NA
50'+
TANK ❑ Septic ❑9 S.T.E.P. ❑ Holding ❑ Other
Manufacturer
ANCH TANK
Capacity
1500 Gal.
Surface water
�a
1001+
100'+
Material
Number of compartments
Lot Line
**5
10'+
STEEL
2.0
NA
Foundation
r0
10'+
10'+
LIFT STATION
Manufacturer
Capacity
Curtain Drain
U td
UN
UN
ANCH TANK
1500 Gal.
Remarks * COMM WATER,
Pump on level at
30
Pump off level at
24
High water alarm at
36
** LOT LINE WAIVER REQUESTED
in.
in.
in
EXTRA FILL INSTALLED
Pump make and model
PF -20
Electrical Inspections performed by
R17-1608
Installer
PIPE MATERIAL House to tank 3034 Tank to
drainfield 3034
MIKE ANDERSON
Drainfield 3034 CO/MT 3034
Inspector MIKE ANDERSON, P. E.
BENCHMARK (Assumed elevation) 97.2 ft
Inspectes: Xtion51 9-11-18 9-11-18
Location and description
Znd
3m 4th
GARAGE SLAB
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
�r=eCS'fita p
Conditional Approval: Date�ao
• y ,4
9
o e e s eo o e o 0 0 0 o e o p e o ,fn
'a
• o 0 o e v a o 0 0 o e v e e• e o e o c r}
%�� • MICHAEL N. AND_ •e-
CE 94 9 • ..�'�.
Approved
,'('�`��� Date 1 $ I
uisNecuUn rcepo1L_a-1-1t.aoc
P.O. Box 196650 0 4700 Elmore Road
Anchorage, Alaska 99519-6650 0 (907) 343-7904 o Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Department
On -Site Water and Wastewater Section
Waiver#: OSV181104 COSA#: Permit#:OSP181195
PID#: 017-023-88
Legal Description: Greenbrook Block 2 Lot 21 G
Engineer: Mike N. Anderson
Applicant: Federico Labastida
Your request for a waiver of the required 10 feet horizontal separation from the absorption field
to the property line has been approved. The approved separation distance is 5.0 feet.
This waiver approval applies to the existing absorption field only, Any future upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
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Waiver is Granted: X Waiver is not Granted:
Date: G -, 8, Approved by:
Name of Reviewer
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Dec 28, 2018
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: Lot Line Waiver
Legal: Greenbrook Blk 2, Lot 21 C
To Whom it may concern:
This is a request for a lot line waiver of 5 feet on the above referenced lot. The system was
installed and the better soils were found closer to the north property line therefore it was moved
slightly.
This waiver will not impact any of the neighboring properties due to the lot layout. Please call me
if you have any questions.
Sincerely N/k
Michael N. Anderson, P.E.
4661 Natrona Ave.
Anch, Ak 99516
Ph 727-8864
Permit No. OSP181195 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: GREENBROOK S/D BLK 2, LOT 21C PID No.: 017-023-88
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P±L MUNICIPALITY OF ANCHORAGE
% On-Site Water&Wastewater Program
, PO Box 196650 4700 Elmore Road ��.
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
• y.. http://www.muni.org/onsite — r
111$ it
I)cpartnit•nt
On-Site Wastewater Disposal System Permit
Permit Number: OSP181195 Effective Date: 7/17/2018
Work Type: Septic Renewal Expiration Date: 7/17/2019
Tax Code Number: 01702388000
Site Legal Address: GREENBROOK BLK 2 LT 21C G:2839
Site Mailing Address: 12914 ALGARIN CIR, Anchorage
Owner: LABASTIDA FEDERICO DE LA TORRE Lot Size in Sq Ft: 118696
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
El Disposal Field 0 Septic Tank ❑ Holding Tank 0 Privy ❑ 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: Date:
7 / ? I
Issued By: � aim", Date:
'etc
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
�5
g78g �j
ON-SITE SEPTIC/WELL PERMIT APPLICATION Q �
r
,�"�7
JUL_ 11 2018
Parcel I.D.
017-023-88 c. Z
Property owner(s) Federico Labastida Day phone ``4 hc,
11741 Gander St, Anchorage, b s L 9 5
AK 99516
Mailing address
Site address 12914 Algarin Circle
Legal description (Sub'd., Block & Lot) Greenbrook BIk 2 Lt 21C
Legal description (Township, Range & Section)
Lot Size 118,696 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field Ei Initial ❑
Single Family (SF) 0
(w/wo ADU)
Septic Tank E Upgrade ❑ Duplex (D) ❑
Holding Tank ❑ Renewal 0 Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the .bove information is correct. I further certify that this is in accordance with
applicable Mun' ipal Codes.
(Sign.'ure of property owner or authorized agent)
Permit/Rush Fees: te 1 U Waiver Fees:
Date of Payment: 1 I 1\` \ C-\\cck**t°561 Date of Payment:
Receipt Number: a a 7 111 Receipt Number:
Permit No. 0 Sp 1 g r I C Waiver No.
G:1Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
!'° a
July 9, 2018
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: Renewed Permit
Legal: Greenbrook Blk 2. Lot 21C
To Whom it may concern:
This is a request for a renewed septic permit on the above referenced lot. Nothing has changed
from the original approved permit we just need more time to install the system.
This renewed permit will not impact any of the neighboring properties due to the lot layout.
Please call me if you have any questions.
Sincerely
Michael N. Anderson, P.E.
4661 Natrona Ave.
Anch, Ak 99516
Ph 727-8864
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP171118
Work Type: Septic Renewal
Tax Code Number: 01702388000
Site Legal Address: GREENBROOK BLK 2 LT 21C G:2839
Site Mailing Address: 12914 ALGARIN CIR, Anchorage
Owner: LABASTIDA FEDERICO DE LA TORRE
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING
This permit is for the construction of:
Effective Date:
Expiration Date
Lot Size in Sq Ft
Total Bedrooms:
7/7/2017
7/7/2018
118696
Q Disposal Field Q Septic Tank ❑ Holding Tank. ❑ Privy ❑ 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: !/J7/( 7
Date: 7
+
20
MUMCPAUT1 Y OF ANCHORAGE
Community Development Department f Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWERMIELL PERMIT APPLICATION
Parcel I. D. e2t
Property owner(s) jr -v r rte a Day phone
Mailing address
Site address
Legal description (Sub'd., Block & Lot) G rou6- F7 Z `,y�
Legal description (Township, Range & Section)
Lot Size J/$' (o Sq. Ft. Number of Bedrooms
APPLICATION IS FOR:
(® all that apply)
Absorption Field
Septic Tank
X
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
APPLICATION IS AN:
Initial
Upgrade
❑
Renewal
fX
THIS APPLICATION INCLUDES A VARIANC
TYPE OF DWELLING:
Single Family (SF)
(w/wo ADU)
Duplex (D)
6 g g �o Multiple Dwellings
rJUN
)201?
(SFand/or D)
3
!IVER REQ SrT FOR:
h
Z
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:reAewj Waiver Fees:
Date of Payment: Date of Payment:
Receipt Number: —
Permit No.
Permit App_9-1-12.doc
Receipt Number:
Waiver No.
Am
1
Permit Number:
Tax Code Number:
Work Type:
Permit Effective Dates:
Design Engineer:
Subdivision:
Site Legal Address:
Owner/Address:
Site Marling Address:
On-Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 995'~9-6650
Telephone: (907) 343-7904
OSP151392
01702388000
Septic Initial
March 23, 2016 to March 23, 2017
ANDERSON CONSTRUCTION & ENGli~
GREENBROOK
GREENBROOKBLK 2LT 21C G:2839
LABASTIDA FEDERICO DE LA TORRE
11741 GANDER ST ANCHORAGE AK 995160000
Lot Size in Sq Fi:
Total Bedrooms:
118696
4
This permit is for the construction of:
Y Disposal Field Y Septic Tank
N Holding Tank N Privy N Private Well
N Water Storage
All construction must be in accordance with: 1. The attached approved design.
2, AFl requirements specified in Anchorage Municipal code Chapters 15.55 and '/5.65 and the State of Alaska Wastewater
Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80).
3. The wasteweter code requires inspections during the installation. The engineer must notify the Development Services
Depar[ment 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 subsun~ace 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.
Issued By:
Municipality of Anchorage
P.O. Box 196650 · 4700 Elmore Road
Anchoraqe, Alaska 99519-6650 · (907) 343-7904 · Fax (907) 343-7997
http://www.m u ni.orq/O nsite
Development Services Division
On-Site Water and Wastewater Proqram
'epartment
**** VARIANCE/WAIVER REVIEW ****
Waiven~: OSV151158 COSA#: Permit#: OSP151392
PID#: 017-023-88
Legal Description: Greenbrook, Block 2, Lot 2tC
Engineer: Mike N. Anderson
Applicant: Federico da la Torre Labastida
Your request for a waiver of the required 50 feet horizontal separation from the absorption field
to the 25% or greater slope has been approved. The approved separation distance is 20.0 feet.
This waiver approval applies to the proposed absorption field only. Any future upgrade to the
on-site wastewater disposal system will require all separation distances be met or mrother
approval from this department.
[] The affected adjacent property owner(s) have been given a 7 day notice regarding tiffs
waiver.
[] Notarized letter(s) of non-objection have been received from the owner(s) of the affected
adjacent property.
[] Adjacent properties are not affected by this waiver.
Waiver is Granted: X Waiver is not Granted:
Date: g/t~//~ Approved ~.~'~
{ f { ~ Name of Reviewer
I UNICIPALITY OF
Community Development Depadment
Development Services Division
On-Site Water & Wastewater Program
ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel LD,
Property owner(s)
Day phone
Mailing address
Site address
Legal description (Sub'd,, Block & Lot) ~_,,~ ~tO¢ ~
Legal description (Township, Range & Section)
Lot Size 1 I z¢ ~. ~ ~ Sq. Ft. Number of Bedrooms
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
([~ all that apply)
Absorption Field E~ Initial [~ Single Family (SF)
(w/wo 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:
~t¢~ ~ ~f/¥-~t~( '1~o ~'1~13~...~ Distance:
I certify that the above information is correct. I fudher 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. O$
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
March 23, 2016
Municipality of Anchorage
Development Services Departments
On -Site Water- & Waste Water Program
P.O. Box 196650
Anchorage, Alaska 99519-6650
Fax 249-7847
Re: New septic pen -nit plus slope waiver
Legal: Greenbrook Blk 2, Lot 21 C
To Whom it may concern:
10r
This is a request for a new septic pennit plus a *'slope waiver on the above referenced lot. A new
test hole was completed and found sandy gravel (GM/GW) for the entire depth with no water
observed during the excavation or after the 7 day monitoring period. The pere rate was 2 minutes
per inch. The new design will be a 4 bedroom system with a deep trench and 5 feet of effective
depth, see site plan.
The lot slopes to the southwest at about 10 to 15 percent with a slope greater than 25 percent down
slope from the site , see the drawing. Due to the wet lands, steep slopes and utility easement we
will need a waiver for installing the proposed trench parallel to the slope and less than 50 feet frorn
a steep slope, see cross section. As can be seen in the section additional fill will be added to flatten
the slope to less than 25 percent within 50 feet of the leach field.
This new system will not impact any of the neighboring properties due to the lot layout. Please
call me if you have any questions.
Sincerely
Michael N. Anderson, P.E.
4661 Natrona Ave.
Anch, Ak 99516
Ph 727-8864
Cv0M `% %.r-rne �? .
_11
DESIGN CRITERIA:
BDRM X 150 = 600 GPD
SOILS •ii ii GP1
ii i = 50
(1) TRENCH
10.0' DEEP
5.0'
WIDE
i LONG
r GREEN BROOK
II
BLOCK 2, LOT2$9-
IIk
FILTER FABRIC
(TH#1) GRADE 1.25'0 PIPE
10 ORG
GM/GW —5.0
—10 DRAIN ROCK
12V
I
LOT SERVED BY,
ROBIN HILLS #3 COMM WATER
BLOCK 3, LOT 6
I
--- I PROPERTY LINE
10 T&E
EASEMENT
i
f f
I I
I � f
PROPOSED 4
BEDROOM HOUSE
� I
LOT SERVED BY
COMM WATER
\-EXISTING WELL RADIUS
N1,
�I/
COMM. WELL MORE-/
1ITHAN 200' AWAY
IIII
IIII
II I GREEN BROOK
111 I I BLOCK 2, LOT t
SECONDARY r
DRAINFIELD
r PROPOSED PRIMARY
DRAINFIELD
i I I ROADWAY BUILT ON
EASEMENT
I � III
I I I VACANT
I I SII I i
-- ALGARIN CIRCLE
APPROX LOCATION OF
WET LANDS BOUNDRY
Septic Design Prepared for
FEDERfCO da la TaRRE LABASTIDA ��
GREENBROOK BLOCK 2, LOT 21 C �
Anchorage, Alaska ;iff : 49TH ,.
S1 DWG ................................ 0
........... .............
MichaelN. Anderson,. • DATE: 3/21/2016 cMICNAEL N. ANDERSON
4661 NATRONA AVE. DR#�%% No. C 9469
,/t, '.�
AWN: DJR � f�
AV
ANCHORAGE, ALASKA 99516 � ��
(907) 727-8864 / FAX: (907) 345-1391 SCALE: 1 "=100'
PROPOSED 4 DTEWAY I I
BEDROOM HOUSE I I
I
i I I
4 i I I
I
Septic Design Prepared for
�F
FEDERICO da la TORRE LABASTIDA
A
GREENBROOK BLOCK 2, LOT 21C #
49 TN A�
Anchorage, Alaska S2 DWG •••• .
® �...............................................
aeAnderson,P.E. DATE: 3/21/2016 t�� :MICHAEL N. ANDERSON;®
4661 NATRONA AVE. 0 NoE 469 AV
V
DRAWN: DJR �® �AV
ANCHORAGE, ALASKA 99516 ./'..•
SCALE: 1 "=30' SS\
(907) 727-8864 / FAX: (907) 345-1391 �����
I i
l
I I
i I
I I I i t
I I I I I
I I I i i
°
REGISTERED SURVEYOR IS
/
REQUIRED TO STAKE ALL
I
EASEMENTS AND PROPERTY
/
LINES PRIOR TO INSTALLATION
`
OF THE SYSTEM
I I
APPROXIMATE LOCATION
OF WET LANDS, NO
OPEN WATER
I W I I
j I
( cn Cn I I
ADDITIONAL FILL
•D.{
`�
REQUIRED FOR SEPTIC
I
CONDARY
AREA, SEE SECTION
TRENCH Wj
CUT
` ICLASS
���\ �►
III SYSTEM
,
I
APPLICATION RATE
OF 2 GPD/SF,
30 X 5' EFF.
TYP. I
APPROXIMATE 8-10'
\`
ELEVATION CHANGE,
``-- - I
COMMUNITYLOCATION
WELL KEVIN
SLOPE GREATER THAN
I
\
25%
A
I
10 SEPARATION FROM
\ i I
RESERVE SEPTIC AREA
LAT
\ I I
I I
��
\ • i I
i i
NEW 1500 GALLON
.
\ I
I I
STEP TANK
I
19T
�.,
DC
i
I I
k
PROPOSED 4 DTEWAY I I
BEDROOM HOUSE I I
I
i I I
4 i I I
I
Septic Design Prepared for
�F
FEDERICO da la TORRE LABASTIDA
A
GREENBROOK BLOCK 2, LOT 21C #
49 TN A�
Anchorage, Alaska S2 DWG •••• .
® �...............................................
aeAnderson,P.E. DATE: 3/21/2016 t�� :MICHAEL N. ANDERSON;®
4661 NATRONA AVE. 0 NoE 469 AV
V
DRAWN: DJR �® �AV
ANCHORAGE, ALASKA 99516 ./'..•
SCALE: 1 "=30' SS\
(907) 727-8864 / FAX: (907) 345-1391 �����
~0~
/ 35.0' ~ ~ EXISTIN~ GRADE
, I
.~~ /~ SLOPE INTERSECTION 2.5' ABOVE
/ INVERT
SLOPE OVER 25~, TO BE~
FILLED 50 FEET ~IN. ~.
OF
SC~f: ~ :--20' DEPIH
F~D~ICO da la TORR[ I_ABAS-I-IDA ~,>
,5% ... ..~ _
GREENBROOK BLOCK 2, LOT 21C
Anchorage, Alaska s3 DWG ~"~.9;',""~ .......................... "'""~
....f'./~ .............................. ,,
Michael
N.
Ad
P.E.
~.~ MICHAEL N. ANDERSON/~
4661 NATRONA AVE. DRAWN: D JR
ANCHORAGE, ALASKA 99~ 16
(90?) 727-8864/FAX: (90?) 345-1391 SCALE: NOT TO SCALE
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Srte Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507
v¢,~' ci arlchora_g~ ~a ~. u s
(907) 343-7904
Performed For:
Legal Description:
5-
6-
7-
8-
9-
15-
18-
19-
20-
Soils Log - Percolation Test
COMMENTS
Slope
I ~-- , Date Performed:
Township, Range, Section;
Site Plan
WAS GROUND WATER
ENCOUNTERED? ~
S
F YES, AT WHAT DEPTHa L
O
Depth to Water After p
Monitoring? ~ E
Reading Date Gross Time Net Time Depth to Water Net Drop
~ 1. /.5- ~'O~.n ~/t
PERCOLATION RATE "'~ (minutes/inch) PERC HOLE OIAMETER
TEST.UN.ET / .T AND 'T
PERFORMED BY: ~\I~/t~./~ t I CERTIFY THAT THIS TEST AS
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE: ~' ~ I/~/V~Y/~-,
•
•-dc. Municipality of Anchorage /
On-Site Water and Wastewater Program z':iii!E
(907) 343-7904 SAFETY
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 017-023-88 Expiration Date: NC 381 e. 0 f 9
1. GENERAL INFORMATION
Complete legal description _GREENBROOK BLK 2, LOT 21C
Location (site address) _12914 ALGARIN CIR, ANCH, AK
Current Property owner(s) _FEDERICO LABASTIDA -- Day phone
Mailing address _SAME
Real Estate Agent Day phone
1 0` 's
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2. TYPE OF DWELLING: � \s
® Single Family (w/wo ADU) ��� � °?
❑ Duplex ��
❑ Multiple Dwellings (Single Family and/or Duplex) o :.).'"
Niet
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class A Well ® Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by. ,irmwtasil_ • __,AA Date: Z
COSA to be released to the engineer, unless othervd requested by the engineer.
COSA Fee $ C I I 646 Waiver Fee $
Date of Payment 12124 8 Date of Payment
Receipt Number
r Che-CV-4 Receipt Number
COSH# O S CJ 10i J'. S 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 MIKE N ANDERSON,P.E. Phone 727-8864
Address 4661 NATRONA AVE.
Engineer's Printed Name MIKE N ANDERSON,PE Date 12/28/18
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6. DSD SIGNATURE
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System #1 Approved for
Y pP -f bedrooms. •
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System #2 Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
, v u Y
, ON-SITE Gam,
s WATER AND
WASTEWATEK
PROGRAM
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4 By: t �VtZ Original Certificate : � ��C 7S
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 blue sheet 10.10-12.doc
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: GREENBROOK BLK 2, LOT 21C Parcel ID: 017-023-88
A. WELL DATA
Well type A If A, B, or C provide PWSID#210346 Well Log (Y/N)
Date completed Sanitary seal (Y/N)_ Wires properly protected (Y/N)_
Total depth _ft. Cased to_ft. Casing height(above ground)
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic: ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEEL/5-re P Date installed 9-11-18
Tank size 1500 gal. Number of Compartments 2 Cleanouts (Y/N)Y
Foundation cleanout(Y/N)Y Depression over tank (Y/N) N High water alarm (Y/N) Y
Date of pumping NEW Pumper NEW
C. ABSORPTION FIELD DATA—1985 SYSTEM TESTED
Date installed 9-11-18 Soil rating (GPD/SF) 1.2 System type DEEP TRENCH
Length 50 ft. Width 2.0 ft. Gravel below pipe 5.0 ft.
Total depth 10.0 ft. Eff. absorption area 500 ft2 Monitoring tube Y Depression over field N
Date of adequacy test NEW Results (Pass/Fail) NEW-PASS For 4 bedrooms
Fluid depth in absorption field before test in. Water added gal. new depth in.
Elapsed Time:_min. Final fluid depth _in. Absorption rate >= g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) N If yes, give date
•
D. LIFT STATION
Date installed 9-11-18 Size in gallons 1500 Manhole/Access (YIN) Y
"Pump on" level at 36 in. "Pump off" level at 24 in. High water alarm level at 40 in.
Datum BOTTOM Cycles tested NEW Meets alarm &circuit requirements? Y
E. SEPARATION DISTANCES
WELL ON LOT TO: COMM. WATER
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10'+ Property line 10'+ Absorption field 10'+
Water main 75'+ Water service line 25'+ Surface water 100'+
Wells on adjacent lots 100'+
ABSORPTION FIELD ON LOT TO:
Property line *5.04 Building foundation 10'+ Water main 75'+
Water Service line 20'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(None Known) Wells on adjacent lots 100'+
F. COMMENTS OF `alit
*SEE LOT LINE WAIVER �r ::••
49TH , .•;i7 �i
G. ENGINEER'S CERTIFICATION
15,1••MICHAEL N. AND[RSCN ,.-:
I certify that I have determined through field inspections and �t s• CE 94159/ . •
review of Municipal records that the above systems are in � e^F•t•2�t4//: •
conformance with MOA COSA guidelines in effect on this date. i1�f7;ufEz; ,;..�
Engineer's Printed Name MIKE N. ANDERSON. PE
Date 1212812018
COSA canary sheet_2-6-15.doc