HomeMy WebLinkAboutNORTH WOODS PHASE 2 BLK 2 LT 12North Wood
Pha,
lock 2:
Lot 12
051,-821
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 1
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP 211480 PID Number: 051 821 12
Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade
Name
JIMERSON
ABSORPTION FIELD
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
22238 SHADOWY SPRUCE
❑ Other
Phone
Number of Bedrooms
Soil Rating
depth from original grade
3
-- GPD/SF
JTotal
-- Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
-- Ft.
Gravel depth beneath pipe
-- Ft.
Subdivision Block Lot
NORTHWOODS PH2 B2 L12
Fill added above original grade
Ft.
Gravel length
-- Ft.
Township Range Section
Gravel width
-- 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
-- Ft2
--
- Ft.
Well
_
-
-
-
+25
TANK N Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
INFILTRATOR
Capacity
1000 Gal.
Surface Water
+100
_
_
_
Material
Number of compartments
Lot Line
+10
-
-
-
NA
PLASTIC
2
Foundation
+1
LIFT STATION
Manufacturer
Capacity
Remarks old tank disposed of per moa code
-
_ Gal.
Tank Replacement Only
Alarm location
Electrical installed by
Installer
PIPE MATERIAL House to tank 3034 Tank to 3034
drainfield
ARM SERVICES
Drainfield unk Co/MT3034
Inspector Charles Balzarini
BENCH MARK (Assumed elevation) 100 ft
Inspection ection 151 1/12/22 1/13/22
Location and description
2nd
aro 4`h
GARAGE DOOR THRESHOLD
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
-`"®®�
kk
Conditional Approval: Date
'STM.. •:���
,/
�� •CHARLES
Septic System D�
Approved ��flZ�t� Date .21346.-12
�
G BALZARINI
�+� ��`��� . • CE -13854 .. �`��,�'
Note: this does include
•
��1� PROFESSION
approval not well permit requirements.
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CHARLES G BALZARINI
CE-13854
2/2/22
Lot 3
00
Lot 4
WOODEN
FENCE /
/ Lot 12
28,811 S.F.
/ MANHOLE
75' ELECTRIC
/ EASEMENT
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Lot 11
NK /
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61.6'
1111
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48'22"W 258.90' 1"
1 25.0'
Lot 13 15' T&E EASEMENT
I
NOTES:
1) DUE TO SNOW & ICE COVER, THE
GRAVEL DRIVEWAY IS APPROXIMATE.
2) THE LOT IS SERVED BY A COMMUNITY
WATER SYSTEM.
0
V)
PLOT PLAN ___ AS BUILT _x_ SCALE —11 — 50__
GRID __NW 1560—_ Project
No.
Lang & Associates, inc.
11500 Daryl Avenue, Anchorage, Alaska
(907) 522-6476 Phone
99515-3049
(907) 522-4625 FaxF
oQ000p00
A X04
Professional Land Surveyors
ken®langsurvey.com
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jonathan®langsurvey.com
I hereby certify that I have surveyed the following described property:
LOT 12, BLOCK 2, NORTH WOODS SUBDIVISION — PHASE 11 (PLAT No. 82-204)
Anchorage Recording District, Alaska, and that the improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on said property except as Indicated hereon.
Dated this the __` -- Day of �ard�4i} ______, �-�'•L �' at Anchorage, Alaska
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat.
49TH*I
L — 202. •'
0?peSSIONAX- � _
AECC963
MUNICIPALITY OF ANCHORAGE mens
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 ' v
r.
Department
Permit Number: OSP211480
Work Type: SepticTank Upgrade
Tax Code Number: 05182112000
Site Legal Address: NORTH WOODS PHASE 2 BLK 2 LT 12 G:1560
Site Mailing Address: 22238 SHADOWY SPRUCE DR, Chugiak
Owner: JIMERSON MATTHEW D & JESSICA A
Design Engineer: C&M ENGINEERING SERVICES
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date: 11/24/2021
Expiration Date: 11/24/2022
Lot Size in Sq Ft: 28811
Total Bedrooms: 3
❑ 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: _46J
Date:
Date: r Z .202
MUNICIPALITY OF ANCHORAGE
Development Services Department r Phone: 907-343-7904
On -Site Water & Wastewater Section Fax- 907-343=7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051 821 12
Property owner(s) JIMERSON
Mailing address
Site address 22238 SHADOWY SPRUCE
Day phone
Legal description (Sub'd., Block & Lot) NORTHWOODS PHASE 2 BLOCK 2 LOT 12
Legal description (Township, Range & Section)
Lot Size 28,811 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) El
Septic Tank
El
Upgrade
(w/wo ADU)
(D) El
Holding Tank
ElRenewal
ElDuplex
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION
INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
C&M ENGINEERING
(Signature of property owner or authorized agent)
Permit/Rush Fees: 0.2 2 5 Waiver Fees:
Date of Payment: It 2 Date of Payment:
Receipt Number: O 3 3 $ Receipt Number:
Permit No. O S /0,21 t t/(fV Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
C&M ENGINEERING SERVICES
Ph: 907-854-5558
Municipality of Anchorage
Onsite Water & Wastewater Program
4700 Elmore Rd Anchorage, Ak 99507
RE: Proposed Septic System for NORTHWOODS PHASE 2 BLOCK 2 LOT 12
Dear Reviewer,
The above referenced property is currently served by an older septic system with a leaking tank that
needs to be replaced.
The owner wishes to replace the tank at once.
Our review of available documentation and field investigation show that this project will not adversely
impact any nearby Wells, Wastewater disposal systems, replacement disposal sites, or drainage flowing
onto and off of the subject property.
As shown on the plan, the tank will be greater than 10’ from the house foundation.
The tank shall be covered with a minimum of 2” moa approved insulation and 3’ of cover or a minimum of
4’ of cover without insulation.
The repair must be performed by a moa certified installer in accordance with MOA requirements.
Repair of the proposed system will not negatively impact adjacent lots.
Upon completion of the installation, a record drawing will be submitted showing the location of the new
tank, leach field, well, and other applicable features.
Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854-
5558 or by email cgbalzarini@gmail.com with any questions or concerns.
Sincerely,
Charles Balzarini, PE
11/13/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211480, Rebecca Carroll, 11/24/21
CHARLES G BALZARINI
CE-13854R
EGISTEREDPROFE S S IO N ALENGINEER11/20/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211480, Rebecca Carroll, 11/24/21
~'~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME C~'~ IPHONE ~NEW
LOCATION I NO.~EDROOMS
~, DISTANCE TO: W~ ~ ~. AbsorptioT~, Dwelling ~
~ ~ Manufacturer ~ No. of compartments
~ Liq. c~'~alJon, IF HOMEMADE= Inside length Width Liqui th
~ Well Dwelling PERMIT NO.
DISTANCE
TO:
~ Manufacturer Material Liquid capacity in gallons
~ Well Foundation Nearest lot line PERMIT NO.
~ ~ DISTANCE TO:
~ No. of lines Length of each line Total length of lines Trench width Distance between lines
inches
~ ~ Top of tile to finish grade Material beneath tile Total effective absorption area
Q inches
~ Length q q ~ Width ~ ¢ t Oepth .~ ( PERMIT N~
~ ~ Type of cri~ ~ Crib diameter ~ Crib depth~ Total effective absorption area
~ Class ~epth Driller Distanco to lot line Pfi~MIT ~O.
~ DISTA~Cfi TO: BuHdinO foundation Se~er line Septic tank ABsorption area{s)
OTHER
PIPE MATERIALS ~ ~ ~ ~
REMARKS U~ ~
,,,,
72-01:
F'ERr~I T NO.
APPLICANT STEVENS SKAGGS CONST. P, O. BOX P CHUGIAK AK.
LOCATION
LEGAL LOT '12 BLK .~ NORTHWOOD SUB PH# LOT SIZE
TYF'E OF ~nlL ABSORF'TION _,,.~TEM IS
MR',;z, IMUM NUMBER OF E:EDROOMS =
44444 SQJARE FEET
SOIL RATING (S..] FT,,"BR)=~,~'-"-.~
THE REQUIRED SIZE UF THE ~C~L HEE~OE~'TI~OI-~i~_TEM I_.
C, EF'TH= 7 LE~UTH---- --~8~'~] (~RR'~ "~ EL DEPTH-- 5
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFRCE OF THE
GROUND RND THE 80TTOM OF THE EXCRVRTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE
RND THE BOTTOM OF THE EXCRVRTION (IN FEET).
PERMIT APPLICANT HAS THE RE:,FJN_,IBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION IN_,FEL. TION_, OF ANY WELLS ADJACENT TO THIS PROPERTY AN[) THE
II ' * '- )
N_MBER OF RE_-.IEENUE=. THAT THE WELL WILL SERVE.
TI.-~C~ ,:'. ~-'-:'- ) I ~'-,~SPE~]T I ~]N_- ~ RF~2E I~.'EQLi I RE[:,
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEF'RRTMENT WILL BE =,LIBJEL. T TO PROSECUTION.
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
· 100 FEET FOR A PRIVATE WELL OR '150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F'ERi~I I T E;:-~F' I RES [:~ECE~'IBER
I CERTIFY THAT
-I'
i: I AM FAMILIAR WITH THE REC..!UIREMENTS FLR ON-SITE SEWERS AN[:, WELLS AS SET
FORTH BY THE blLINICIPALITY OF ANCHORAGE.
2: I WILL INSTBL~THE SYSTEM IN ~CCORD~NCE WITH THE CODES.
3~: I LtNDERSTRND ~T TH~N-SITE SEWER SYSTEM MAY REQUIRE ENLBR~EMENT IF THE
Russell Oyster
694-2774
Performed for:
O & E EN~,'NEERING & DEVELG,~MENT CO.
Legal Description: ,L-
Depth (feet)
0
9__
10__
11
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
SOIL LOG
Soil Characteristics
Earl Ellis
688-2280
Tel. No
PLOT PLAN
12__
13__
14__
15__
16__
Ground Water Encountered: Yes ~ No__
Proposed Installation: Seepage Pit
Comments:
Performed by:
If yes, what depth
Drain Field. ~
PERC. TEST
APPLICANT FILLS OUT uPPER HAl ONLY
Prop~[ty ~)wner J~ ~'A/ ~ g'~'~ ~-'- Phone .:
Mailing Addre~ ~C]?/ ~ ~ .~.~ ~?~--~ ~ r ZiP Code
Buyer
Address ,~__ Zip
Code
Le'~ing Institution Phone
Address Zip Code
Phone
Realty Co. & A~nt
Address~ Zip Code
Legal Descript~n ~ /~ ~
Street Locati~ ~) ? ~ ~. ~ ~
Type of Resi~nce
~e Family
~ Multiple Family No. of Bedroo~
~ Other
Water Supply
al A~ACH WELL LOG. A wall log is required for all wells drilled since June 1975.
nity For wells drilled prior to that date, give well depth (attach log if available);
~ Public Utility
Se~e~sal
~lndividual Year Indiv~ual Installed: ~ ~
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date (~
Inspector Inspector Inspector Inspector
Field Notes: /&/O ,/~3 ~t J'~ MUNICIPALI~ OF ANCHORAGE
DFPT O~ ','~'LT',~ ~
ENVIRONM;:h M,. ~ .O,ECTION
X<C 1 1982
RECEIVED
( ~) APPROVED BEDROOM8 *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVA~
DATE J ~ -~ ~
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
Well to Tank Septic T~k Size
72-023 (3/82)
MUNICIPALITY OF ANCHORAGE CAS H
Development Services Department p p z� Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051 821 12
1. GENERAL INFORMATION
Expiration Date: D e- C- I � , ), 0 )- J
Complete legal description NORTHWOODS PHASE 2 BLOCK 2 LOT 12
Location (site address) 22238 SHADOWY SPRUCE
Current property owner(s) JIMERSON Day phone
Mailing address
Real estate agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
0
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
El
Public Sewer
❑
Waiver request for: N O N E
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date:
COSA Fee,13 Waiver Fee $
Date of Payment Date of Payment
Receipt Number �3� �`� Receipt Number
COSA # 0 S C a a 1 0 3 2 Waiver #
Distan
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 2/2/22
6. DSD SIGNATURE
-41 System #1 Approved for
System #2 Approved for
Disapproved
Conditional approval for
3 bedrooms
bedrooms
*: 49 TH •.
iCHARLES G BALZARINI
�FG.; • CE -13854 • �`��
/sTFq•••.....••'0
���F�PROfE5S10�P -�
bedrooms, with the following stipulations:
WATER A tv n
By: �?���` ��� Original Certificate Date: a 3 o2�2-Z
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 __________________________________________________________________________________
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
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:
B. TANK DATA
Age of tank(s) years
Tank type/material3ODVWLF
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA ______________________
Which system tested (date installed)
NORTHWOODS PHASE 2 BLOCK 2 LOT 12 051 821 12
11 1
ON PUBLIC WATER
0
Septic
NA
NEW TANK
bed
1982 12/16/21
3
4.5 0
na 450
0
0
0
450
NA
NA
No cleanouts in bed per record drawings.
✔
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.2/22/22
✔✔
✔
✔
✔
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Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DVVELLING
Parcel I.D. 051-821-12
1. GENE~L INFORMATION
Complete legal desCription
cos^# o
~ Expiration Date:
NORTH WOODS: BLOCK 2, LOT 12
Location (site address) 22238 SHADOWY SPRUCE, CHUGIAK, AK 99567
Current Property owner(s) JOHN & JANET SIMPSON
Day phone
Mailing address
Lending agency ~''
POBOX 671563, CHUGIAK, AK 99567
':~ Day phone
Mailing address
Real Estate Agent
LES BAILEY & ASSOC. - KW
Day phone 694-1234
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE.'O~ WA,~'~'R,~UPPLY:
,~i,vid'ual Weli'~ "::;
, ;i, jndividu~i .Water Sto~,ge
~Com~Unity~ClaS~ A_~ Well
Public water System
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site ~]
[] Individual Holding Tank
[] Community On-site
[] Public Sewer
The Municipality Of A~ch°rage 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 sample results. (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 ^ 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, I verity 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 verity 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 ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 12/15/2011
Engineer's Comments: This inveStigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested, The flow
cand absorption rates may change due to subsurface conditions that may not be observed froth the surface,
hanges inland use, Ioc~i soil characteristics, groundwater levels that maY fluctuate during the .year and the
water usage of the family being sewed by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics a nd are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
bedrooms.
DSD SIGNATURE
J~// Approved for
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
~ ,~.,~v-..
WATER
Arsenic Adviso~
Maintenance Agreements
Supplemental Engineers Report
Other
Original Certificate Date:
/
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DVVELLING
Parcel I.D. 051-821-12
1. GENERAL INFORMATION
Complete legal description
COSA# ~:~} ,~ ~'-~ \~\
% Expiration Date: (~- ~_ ff" / L~
NORTH WOODS ~ BLOCK 2, LOT 12
Location (site address) 22238 SHADOWY SPRUCE, CHUGIAK, AK 99567
Current Property owner(s) IOHN & IANET SIMPSON
Day phone
Mailing address
PO BOX 671563, CHUGIAK, AK 99567
Lending agency
Day phone
Mailing address
Real Estate Agent
LES BAILEY & ASSOC. - KW
Day phone 694-1234
Mailing Address
Un/ess otherwise requested, COSA will be held by DSD for pickup.
OF.~DROOMS: 3
,TYPE O?~WA TE~;'~UPP LY:
I nd!ivid6a[ ~11 ' ¢ ?.:
,""i'~id6~['~ter~Storage
' c°'m~bn'itY'Class A We,
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 sample results. (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, 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 ARCTERRA CONSULTING, INC. Phone 868-3792
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 06/01/2011
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The
assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow
and absorption rates may change due to subsurface conditions that may not be observed from the surface,
changes inland use, local soil characteristics, groundwater levels that may fluctuate during the year and the
water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function.satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
DSD SIGNATURE
[//'"' Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
E · ON.SITE
: WASTEWATER
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
(Rev. 11/05)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: NORTH WOODS #2 BLOCK 2, LOT 12
A. WELL DATA
Well type COMMUNITY - A
Date completed
Total depth f.
If A, B, or C provide PWSID # 213001
Sanitary seal (Y/N)
Cased to ft.
FROM WELL LOG
Date of test
'Static water level
Well production
WATER SAMPLE RESULTS:
Coliform colonies/100mL Nitrate
Arsenic: mg/I Date of sample:
B. SEPTIC/HOLDING TANK DATA
mg/L Other bacteria
Collected by:
Parcel ID: 051-821-12
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground) in.
AT INSPECTION
g.p.m.
colonies/100 mL
Fluid depth in absorption field before test [ in. Water added 450 gal. New depth < 0.5
Elapsed Time: 1__ min. Final fluid depth ~ in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date __
Gravel below pipe 0.5 ft. Total depth 43 ff.
Monitoring tube Y Depression over field N__
Results (Pass/Fail) Pass For 3__ bedrooms
in.
Length ~zt ft. Width 36 ff.
Eft. absorption area 158~ ft2
Date of adequacy test 5/31/11
Tank Type/Material Septic/Steel Date installed 12]1982 Tank size 1000 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) N Date of pumping 5/31/11 Pumper IRs
C. ABSORPTION FIELD DATA
Date installed 12/1982 Soil rating (g.p.d./ft~ or ft2/bdrm) 265 System type Bed
LIFT STATION
Date installed Size in gallons
"Pump on" level at in. ~Pump off' level at
Datum Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
Animal containment areas
in.
Manhole/Access (Y/N)
High water alarm level at __.in.
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+
Water main 10'+ Water service line 10'+
Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+
~Water Se. rvice line 10'+ Surface water 100'+
Curtain drain SlY+ (Nene Knewn)
COMMENTS
Absorption field 5'+
Surface water 100'+
Water main 10'+
Driveway, parking/vehicle storage
· Wells on adjacent lots 200'+
10'+
G. ENGINEER'S CERTIFICATION ..~~ .,
i certify that I have determined through #eld inspections and .~ ~,~.'..
~. ...;, .~ ..;..: ·
review of Municipal records that the above systems are in .'..~~~:; ~"~&'
conformance with MOA COSA guidelines in effect on ~his date. !.~
. . '~:.~..... ,:,,.:.:~...~"~ ~ ~ ~.. .~ ..
Engineer's Printed Name KENNETH M, DtTFFUS
COSA Fee $490.00
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
/
L,:,: _. , Block
LOT SURVEY CERTIFICATION
f*E~"~:~I,OP~O t~ fRS ~mpcovements sit,J¢l~ there~ ore ~ffhin t~ prop-
er~.v nes ar,d ~o ~t over~p 0¢ encroocf ~ ~joce~ property and thor no
tmpr,:,.¢emer~s ot~ OdjOOa~f property overlap 0¢ encr~chon the premises
LEGEND.. 0¢-0.~
0 = lr~ pipe an~ rear r~,~emd
e = ~8"x ~" rear ~1 rms survey
Dote
Prepared by: ,9. £, BUTTON '!~
(~07)279-~200 .5/~ ~:' E;'~/;'/b Ave. >~ncho~-oge, ~i~'sk'c~ ~,950/
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
Parcel I.D.
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~/ /~'~ NAA#
1. GENERAL INFORMATION
Complete legal description
Lot 12; Block 2; North
AUG 2 G
Woods Subdivision ~2
Location (site address or directions)
22238 Shadowy Spruce
Chuqiak, AK
Ken Best
'24850 Hammond Court
Dayphone 694-9301
Eagle River, AK 99577
:~ Rroperty owner
-, Mail!n~ address`
',,..Lending agency
t. Mailing address
Day phone
Agent
Address
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
3\,
NOTE:
Individual well
Community well xx×
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
XXX
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
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.
$ & $ ENGINEERING
Nameof Firm l?13:~41~..lel~;ve, L,~epl~,~..i ~,, ~_n4_ Phone ~ c/cf . -~,~ -7 ~
Eagle Ri~ver, Alaska 99577
Address
Engineer's signature ~'~/~-- ?/~'¢~-- Date ~/'~' c. /~'7
DHHS SIGNATURE
X Approved for b
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
The Municipality of Anchorage Department of Health and Human Sen/ices (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 DH HS 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.
724)25 (Rev. 1/91) Back MOA ~21
· Municipality of* Anchorage
DEPARTMENT OF HE~,LTH & HUM/~N SERVICES
EnvirOnmental Services Division
825 L Street, Room 502. Anchorage, Alaska 99501 · (907) ~
Health Authority Approval Checklist
LegalDescription: ~'~" ~'~' ~t~ ~i.~OOD~ ~>l~arceilDi OJ'! ~"~.!
Well type l~k I! A, B, or C, attacbADEC letter. ADECwater system number
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date completed
Cased to Casing height (ab
=-. Wires
FROM WELL LOG
AT INSPECTION
Date of test
Static water level
Well production
WATEF
g.p.m.
g.p.m.
Nitrate
Other bacteria
~le:
B, SEPTIC/HOLDING TANK DATA
Date installed
Foundation clean¢
Date of ~
Collected by:
Tank size: ~,C~o c:) Number of Compartments ~ .Cleanouts (~,) y
Depression (Y(~D ~ High water alarm('YAN')~
Effective absorption area
Date of adequacy test
'2.0 ~ System type ?;;~::)
~ Gravel thickness below pipe ~, ~ ' Total depth ~, ~ ~
Monitoring Tube present~q)~ Depression over field (Y~I~ /~
Results~Fail) }~"~ For ..~ bedrooms
Fluid depth in absorption field before test*(in.); ~) ~ Immediately after~__~ gal,watb~' added (in.i
Fluid depth (ins) Minutes ater ~/D Absorption rate --
Peroxicle treatment (past 12 months)(Y~ Da ~ /~"~J~)If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date inStalled Size in gallons
Manhole/Access (Y/N) "P u m ~ o.~.[~-~'-~
High water alarm level *~-~'-'""'~ *Datum
E. SEPARATION DISTANCES
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Spw~
On adjacent lots
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
FoundatiOn ~- ~Jr Property line lcp ~ ~' Absorption field
Water main/service line ~ O t-l- ~ ~c
Surface water/drainage [o z:) Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line I;3 ~ Building foundation ~ ~ t ~ Water main/service line \ o ~' ¥
Surface water \ O ~ ~,~L. Driveway, parking/vehicle storage area ~'-~ ~ '~
Curtain drain I,.~/,~.~ I/--~c~/~ Wells on adjacent lots ~'~O ! '{-'
ENGINEER'S CERTIFICATION
I certify that l have determined thru field inspections and review of MUnicipal recor~j~ ~-~-.~'~ms are
SignatureinC°nf°rmance withMOA ~~~ ~lAAg~idelineslneffectonthisdate.
Engineer's Name
Date ~/~
HAA Fee $ ~ - ~
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number