HomeMy WebLinkAboutCREST VIEW BLK A LT 6ACrestview
Block A
Lot 6A
#010-231-20
MUNICIPALITY OF ANCHORAGE
:11' 4-.-'
Development Services Department `"'4
p p--'� Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 010-231 -20
1. GENERAL INFORMATION
Expiration Date: J r zZ -22-
Complete
22
Complete legal description Crest View Block A Lot 6A
Location (Site address) 4420 Van Buren St, Anchorage, AK- 99517
Current property owner(s) Sherrie Ace Day phone
Mailing address 37310 Ansel Dr, Soldotna, AK 99669
Real estate agent
-- . Larry- Imm
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 2
Day phone (907)229-8999-
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑■
Private Septic
❑
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑m
Waiver request for: Distan
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date:
COSA Fee $ a Waiver Fee $
Date of Payment -�g 2-0 ZZ
Receipt Number (91(19-s
COSA# OS c a a 1 a 53
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering (M.J.) Phone (907) 522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller, P.E. Date 2/14/22
4 o A'q�l1i
6. DSD SIGNATURE "'
System #1 Approved for 2 bedrooms B�enjlarri(rv5chiller
CE 12592
System #2 Approved for bedrooms ,�isfF�FO2/14iZ2
PROF
Disapproved ll ROFESS1oN
Conditional approval for bedrooms, with the following stipulations:
l�llll((((l(/frr
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By: Original Certificate Date: 2 -zZ -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
Legal Description: Crest View Block A Lot 6A Parcel ID: 010-231-20
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) Well production at time of test 4 gpm
Date drilled c.1958 Water storage tank volume gallons
Total depth Approx 185 ft Well disinfected for coliform test? ❑ Yes ❑ No
Cased to 40+ ft ❑ Coliform bacteria is Negative
®❑ Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND)
Fol Wires are properly protected Arsenic 32.3 ug/L ❑ Arsenic less than MRL (ND)
Casing height (above ground) 18+ in. Collected by Forge Engineering
Date of flow test for COSA 2/8/22 Date of Sample 02/01/22
Static water level at beginning of test 17 ft.
Comments Well located inside house, 1976 approval on file. No well log, some data pulled from previous COSA.
K DATA
Age of tan years
Tank type/material
Measured operating fluid level i tic
❑ Standpipes/foundation cleanout per
Date of pumping
tank
drawing
T STATION
❑ Require aintenance completed
Age of lift station ears
Lift station material
Comments:
SORPTION FIELD DATA
Which sys ested (date installed)
Adequacy test date
❑ ALL standpipes p t per record drawing
Results ❑Pass For bedrooms
Total measured depth from gra ft (max)
Fluid depth prior to test in
Measured depth to pipe invert from gra ft (min)
Water added gal
❑ N/A — pressurized field
New depth in
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
apsed time min
❑ Code -required soil cover over field
Final I epth in
❑ System presoaked
Absorption rate gpd
(Required if vacant for greater than 30 days prior to
Any rejuvenation treatmen t 12 months)
date of test)
Gallons introduced gallons
If yes, enter date
Comments/Deficiencies:
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' NSA Community Sewer Manhole/Cleanout > 100'
❑ Yes if No ft ❑ Yes if No >50*ft
Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' 71 Yes if No ft
Absorption Field on Lot > 100' ❑ Yes if No NSA ft Holding Tank > 100' ❑✓ Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' ❑✓ Yes if No ft
M Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑Yes if No >50 ft g 0 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
Surface Water > 100' ❑ Yes if No ft
Property Line > 5'
❑ Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
❑ Yes
if No
ft
Private Wells > 100' ❑ Yes if No ft
Water_Main.>_ 10' _ _
❑ Yes
if No
ft .
Community Wells > 200' ❑ Yes if No ft
Water Service Line > 10'
❑ 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 If absorption field is under driveway comment below
Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots:
Water Main > 10' ❑ Yes if No ft Private Wells >100'
_ ®Yes if No ft
Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft
Surface Water > 100' ❑ Yes if No _ ft
F. ENGINEER'S COMMENTS
*Well and public sewer both installed prior to 1983.
G. ENGINEER'S CERTIFICATION
I certify that l 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.
COSA Checklist yellow sheet
*..,o
; TH ••
Benjarrt chiller
�'<"�; •. CE 12592 •���
2/1
4/22
����F��'OPROFESSOW �®�
www.muni.org/onsite
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC221053
Subdivision: Crest View, Block A, Lot 6A
A water sample revealed -a-n arsenic concentration of 32.3 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
�, `r Ma�lirg Address P Q Box 196650 * ,Anchorage, Alaska 99519 6650 *www muni org
i
Scale 1" = 30'
Frontier Surveys, LLC Project No: 22-059
Date: 2/15/2022
Ordered By: Larry Imm I Plat: 72-276 1 Grid: 1828 [
W. 44TH AVE.
(PLATTED)
-
S89° 58'00"E 29.66
— _ 70'u7
-�1L. ESrr7T.'�-
LOT 4
5 \ \
Lot 6A, Block ALOT 4A
\ Nw \ \ \
/ + Crestview Subdivision
14,122 Sq. Ft. +/- BASEMENTACCESS
/ 4420 Van Buren Street \ M \ \ \ \
ltt Story Wood Frame Duplex w/Basement 6g oy \
0.6 :
/9 SHED
'6 + D.B.W.
` I��iS `'`-" ,\ \'� :. fid• \\
1 \+ + \
F
y Electric Meter/Outside Power
Gas Meter ® Deck
(S; Sewer C.O. Concrete
\_ :....
t!�. s-7 L +
d'
+ 10'x30' ` / y6 ✓ �'^�
CEA ESMT
{ A
EDGE OF
\ PAVEMENT
ro, Telephone Pole -au-
-.�- Fence D.B.W. Daylight Basement Window NOTE: LOCATION OF wATER
Fire Hydrant ()V WELL IS APPROXIMATE.
General Notes: 0 1$ 30 60
1. This document is created for the purpose of a single property transaction and is subject to Federal Copyright Laws.
2. Excepting for gross negligence, the liability for this survey shall not exceed the cost of preparing this survey. SCoI e In Feet
3. All measurements/setbacks are to the visualtapparent building footprint.
4. All dimensions to property lines are plus/minus 0.1ft.
This survey complies with the ASPLS Mortgage Location Standards. The survey represents visible improvements and
,�•� conditions at the time of the survey. This document does not constitute a boundary survey and is subject to any
�rG OF,�-n�� inaccuracies that a subsequent boundary survey may reveal. It is the responsibility of the Owner to determine the
•
V- existence of any easements, covenants, or restriction which do no appear on the record plat. Under no circumstances
-``w.'n• • • • ?�
should this document be used for construction or for establishing a boundary or fence line.
• `� ®���
As -Built Survey UP
Lot 6A, Block A Crestview Subdivision
9 ; Pierre f St r . er 1, Pierre Stragier, hereby certify that this Mortgage Inspection Survey was performed by me, or
• No. L.S. - 9 12 i�� under my direct supervision on February 9th, 2022.
� lF9FOpR�.ESSIONPIY..... I .Nti
%S� Frontier Surveys, LLC ONTIER®�650 W. 58th Ave. Suite E Anchorage, Alaska 99518Ag�R
rveys• •,
907.460.1686 - info@frontiersurveys.com
PROFESSIONAL SEAL www.frontiersurveys.com
MAINTENANCE AGREEMENT Dj�tricl'
Block A
The undersigned owners of Lots 6 and 7/F Crestview Subdivision,
their successors' and assigns, accept all respQnsibility for maintenance of
the service connect approved for construction to serve said lots.. This -
serv-Lte-connection extends from Lot 7 through Lot 6 to the lateral located
north of 44th Avenue.
IN WITNESS 11HEREOF, we have hereunto set our
hand and seal this 26 day oust 1971
Owner 6f Lot
STATE OF ALASKA
THIRD JUDICIAL DISTRICT) ss:
Owner of Lot 6
BEFORE ME, the undersigned, a Notary Public in and for Alaska,
duly commissioned and sworn as such, this day personally appeared
Frank F. Frohlich and Gerald A. Michael
to me known and know to be the persons described in and who executed tile
above instrument and they acknowledged to me that theyi'.'-;'
signed and sealed the same freely and voluntarily for the uses and-,,.pur-P'0�0s'
therein mentioned.
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NOTARY PUBLIC IN AND FOR THE'S TATE. - -QF
!,ALASKA
My commission expires:
• 77 -NCHORAGE REE.
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vvATER& WASTEWATER UTILITY
3000 ARCTIC BOULEVARD
PHONE277--M22
CONNECT PERMIT
DATE OFAPPLICATION_
SCHEDULED COMPLETION DATE
/nImGLEFxM|LY
O mUOl'DvvELL|wG
wn.APTa______
_
cow��RC�L
LOT�f���� BLOCK uO INDUSTRIAL
'
SUBDIVISION
')GRID DRAWING No.
TAX CODE C-)LD—L23IL-�L
BUILDING ADDRESS -
MAIL ADDRESS _f'ru` +44
(License & Bond required)
0 Paid previously
0 ON PROPERTY ONLY
0 Main extension agreement
A|NTAP—TO PROPERTY L! Subdivision uSubdivision agreoment
'mM0A OExtended connect agreement
U MAIN TAP &ON PROPERTY CONNECT O Pending—AMOUNTS
0&00A or Sta1e RO*%! RieqmlredV |
CONNECTION SIZE
INSPECTION_-___
PERMIT —
ns|MBUn8|aLE
NUMBER
(Please Print)
_____FEE s
_-___DEPOSIT $
LJ PAID 0 CASH
INSPECTED BY:
TOTAL $ n DATE:
cL/
-��_~��u
MAIL ADDR.
I HAVE READ THE CONDITIONS AND REGULATIONS ON THE REVERSE SIDE OF THIS PERMIT AND AGREE TO
COMPLY WITH THEM,
PERMITTEE SIGNATURE
POST IN A CONSPICUOUS PLACE AT THE J 0_13 SITE
80-019 (10182) AMU CUSTOFAER SERVICE
w
w
MUNICIPALITY OF ANCHORAGE
WATER & WASTEWATER UTILITY
3000 ARCTIC BLVD.
PHONE: (907)564-2762
WASTEWATER
CONNECT PERMIT 99 - 3480
DATE OF APPLICATION 08/16/1999
SCHEDULED COMPLETION DATE 12/31/1999
BLOCK/LOT/TRACT BLK A LT 7 `Xj SINGLE FAMILY
SU61VISION CREST VIEW I MULTI -DWELLING No. APTS
L..
TAX COD � 1023121 GRID 1828. AS -BUILT COMMERCIAL
STREET ADDRESS 4430 VAN BUREN ST
OWNER FROHLICH DOROTHY A PHONE
MAIL ADDRESS 4430 VAN BUREN ST ANCHORAGE, AK 99517
CONTRACTOR -*UNKNOWN-- - -
_--.--. _ ASSESSMENTS
(XI Repair Existing Service
I Main Line Extension
1 On Property Only
�_
I City Tap
-
X) Have Been Levied
Hydrant Only
(
150' or Longer
To Be Levied
Main Tap - To Property Line Only
Comments:
j Main Tap & On Property Connect
Row No
Disconnect
R & R - Main Tap Only
iOwner IStaff
CONNECT SIZE 6 "
ISSUED cfickes
INSPECTION FEE
$ 0.00
PAID ;CASH
PERMIT FEE
$ _ 35.00
! CHECK #
$ 0.00
j OTHER
DEPOSIT
$ 0.00
INSPECTED BY
REIMBURSABLE
TOTAL
$ 35.00
NUMBER 0000000287
DATE
REMARKS
THE SERVICE WAS BROKEN CONTRACTOR WORKING FOR PLUBLIC WORKS 7-30-99. SERVICE WAS REPAIRED.
THEN
WAS RE -LOCATED 8-14-99 (BILL TYRELL)
PERMITTEE (Please Print) PHONE
MAIL ADDRESS ,
SIGNATURE
POST IN A_PON P CUOUS PLACE AT THE JOB SITE
a AWWU INSPECTOR original
J
DATE SCHEDULED 'I L22 ThE -"k M SPECTOR
SUBDIVISION CREST VIEW BLOCKILOT RACJ.BLK A LT 7
INDICATE NORTH
F/O M Cd r5 G, 7 /f
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SIZE MAIN: 2 6� ,�
TYPE MAIN: Cr P
DEPT AT MAIN: N I O r
AT PROP. LINE:
CONNECT LOCATION:
COMMENTS:
A G GI -)v D
AJfio
.7> N4
INSPECTED BY: by s 'r
w.�I
l�'r'Ir
.�r
DATE:
•
,.-,
.�r
-- POST IN A CONSPICUOUS PLACE-" . 0 51.2 6
SEWER CONNECTION APPLICATION & PERMIT
GREATER ANCHORAGE AREA BOROUGH
2207 MC RAE ROAD, ANCHORAGE, ALASKA 99503 S. S. A.
BOOK PACE ILB a SUS N ,:y G LO BLOC
CONNECTION STREET ADDRESS `..,iv ,? t .r. •..
CITY STATE ZIP CODE rrtu- RIP• LAT. IMP. DIST. NO.
o�ST ::2
PROPERTY,PWTJ ER NAME
1 I I� I"�'1��I' �t`'1' I I tW'I •I 11•-1,�• I I I I I I I I i I I I I
PROPERTY OWNER ADDRESS _
CITY 4 i STATE ZIP CODE PHOT E•NO�COIDAY DATE
yf Y
h10O DAY R
-1-L I- It, 1
RES. r<PT,. NO.UNITS - ✓ CONNECTION INFORMATION
SIZ EINCH�C REF.
CONNECT, "FO TRUNK CONNECT .TO LAT. .• +�' `
YES❑ NO YESE NO 11
CONNECTION ,L{JOCATION 1
i:✓ /_���, ;.;� Ate.4-9
- ,
SERVICE STATUS _ .._.��•
TRUNK SERVICE PROVIDED. BY (AGENCY):
LATERAL ASSMT.: TR NK. ASSMT.: CONNECTION,F- #E:.
DATE PAID_ r�TE PAID AMOUNT PAIDY --
CONNECTION F£E D BY CONNECT FEE RECEIVED BY: D�
5--&M-AGENCY CONNECT AGENT AMOUNT DEPOSIT DATE"DEPOSIT
rY.i'�.. a MO. DAY YR
PAYER NAME - - -
1I I l l l l' I I l I I_L1 III 1 1 1 1 1 1 I I I I III I I I I I �i I L I i I
PAYER ADDRESS
LILLI__lI I I J_1 1 I LL I I f-LLL LL1_LL(�LLLL1_l_L LL I L
CITY - - STATE ZIP COD -
BASIC PREM.. TYPE BILL CODE BILL INDICATOR FILE 1
BILLING AGENT. _....:. "'- ""R:4TE`CODE'-'•"." ...". :`.. .,. ACCT. Na.- ..: ..'_.
CUSTOMER BILLING"NOTICE - - BILLING DATE
DATE FWD.
CORRECTED BILLING ADDRESS
CORRECTED BILLING ADDRESS ..
COMMENTS -
MAI JENAi t : r p
11
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"AjrE ,Anka+ �.
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received July 21, 1976
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF 1016. S0-
INDIVIDUAL
SEWER & WATER FACILITIES
FOR
V.A.
1. Approv 1 requested by: Coast Mortgage Company
Mailing A ess: Post Office Box 1200 Phone: 279-0665
2. Property Owner.
Merle Shultz Phone: 277-5759
Mailing Address: 2111 West 44th Court
3. Legal Description: Lot 6A Block A Crestview Subdivision
4. Location: 2111 West 44th Court
5. Type of fac i 1 i ty to be inspected Single Family No. of bedrooms 3
6. Well Data: Individual
A. Type
C. Construction
B. Depth
D. Bacterial Analysis
7. Sewage Disposal System: public Utility
A. Installed "B. Installer
C. Septic Tank: 1. Size
."A
l
a .
E. Disposal Field: Total length of lines
8. Distances:
2. Manufacturer
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" Street, Anchorage, Alaska 99503 - 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection: CMRO VA xx FHA
2. Property Owner:
CONV
Mailing Address: 71 11 Nest -44th Court, Anchorage Day Phone 277-- 5759
3. Name of Buyer: Michael G. Stoudt
His: Work
Mailing Address: 305 East 13th, Anchorage Day Phone 862-0212
4. Name of Lending Institution: Coast Mortgage Co.
Mailing Address: P. 0. Box 1200, Anchorage, Ak 99510 Phone 279-0665
5. Name of Realtor or Agent: none
Mailing Address: Phone
6. Legal Description: Lot 6A, Block A, CAS -vi Pw Sn Anrhnr APs Ak
Location: 2,111 Wact 44th Cnurt, Anrhnrngo, A1r Q9503
7. Type of Facility to be inspected: private water supply No. Bdrms. 3
8. Water Supply
Type of Supply: Public Utility Individual xxx
If Individual, number of dwellings presently served one
If Individual, depth of well
9. Sewage Disposal System
Type of System: Public Utility __N Individual (on-site)
If Individual, date of installation
EQ -037 (1/74)
Poge 2 of two pages - Re st for Approval of Individual ._ er & Water Facilities
Leg' rl Description T,n, 6A Block A Crestview s bdiyi s;_on
Comments
Approved Disapproved Date 7
Approval;Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED Date
EQ -034 (1/74)
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GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received //-1 3 /71
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
V•
1. Approval requested by:
Mailing Address: "1'9D y' Phone:
2. Property Owner: Phone: 77
Mailing Address: // YL
3. Legal Description: At -/-
4.
-/-4. Location: 'a-/// 'w �.
5. Type of facility to be inspected No. of bedrooms
6. Well Data:
A. Type — LxJ� v� B. Depth
0-0
C.
C. Construction (p�-'��� D. Bacterial Analysis
a-
7. Sewage Disposal System:G��-�
A. Installed B. Installer
C. Septic Tank: 1. Size 2. Manufacturer
D. Seepage Pit: 1. Absorption Area 2. Material
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank Absorption area Sewer Lines ,
Nearest lot line Other contamination
B. Foundation to septic tank Absorption area
C. Absorption area to nearest lot line
EQ -034 (1/74) Page 1 of two pages
,-gage 2 of two pages - Ret est for Approval of Individual -_,er & Water Facilities -
Legal Description
Comments
Approved V �, Ti � Disapproved Date
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
EQ -034 (1/74)
Date
rg i 1 12, 1973
..r Tuns
;1 La Vionto Orive
t 31c1Ci'af.1i~, ti1z15�.d c,t�ryX?
:ouli ject: r+at r Supoly Servi n l Crestview Vi l l ugr a/u
Ltear ;1r. Sni slur:
c;Q1.sj,uni y well scrvicin,- �,<:: S�b;}�'c% sU�'�'1VisiGli iaS
—n apprc•veL; this u >aarti-enrr. T!ie subject well will
ca to be approve, i ` i t is to service; Ole iiol. c:s i r3 �iirr
sui`jLci: subdivision. Arran eE ents 1:rUst be ti:u.de by yuu ur
v our !hoirie oviners' association to contact i'r. i ci fi tri ckl ajr . y
t; fin itariuii, to review your rrubler: .
If fou ii<,vc any questions, please, feel fres: to cull °r. Stri Klanu
:sincerely,
kubert C. Pratt
EirM ronir,ental Control yiffi cer III
js
RECEIPT FOR CERTIFIED MAIL -30S (plus postage
SENT TO POSTMARK
OR DATE
STREET AND N0.
00
N P.O., STATE AND ZIP CODE
CV
OPTIONAL SERVICES FOR ADDITIONAL FEES
RETURN t, shows to whom aed date delivered 15¢
RECEIPT With delivery to addressee only ............ 650
2. Shows to whom, date and where delivered .. 354
SERVICES With delivery to addressee only ............ 854
DELIVER TO ADDRESSEE ONLY ..................................................... 50!
O SPECIAL DELIVERY (extra fes require4Q ....................................
z PS Form3800 NO INSURANCE COVERAGE PROVIDED— (See other side)
Apr. 1971 NOT FOR INTERNATIONAL MAIL
, GPO ; 1972 0 - 4ee-749
0
Municipality of
On -Site Water and Wast
(907) 343-7
CERTIFICATE OF ON-SITE
Parcell.D. 010-231-20
1. GENERAL INFORMATION
Complete legal description CRESTVIEW BLOCK A,LOT 6A
Expiration Date: /0 .-/ 0
Location (site address) 4420 VAN BUREN STREET, ANCHORAGE AK 99517
Current Property owner(s) SHERRIE ACE FAMILY REV. TRUST Day phone
Mailing address
Real Estate Agent
4420 VAN BUREN STREET ANCHORAGE, AK 99517
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
2
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual
❑
Individual Water Storage
❑
Holding Tank
❑
Community Class _ Well
❑
Community
❑
Public Water System
❑
Public Sewer
WaiverNariance request for: Distance:
Date: 7—/J -/,5
COSA to be released to the engineer, unless
COSA Fee $ 52& - Waiver Fee $
Date of Payment '41$115
Receipt Number GM03 d
COSA #_ 65051245
Date of Payment
Receipt Number _
Waiver #
5. STATEMENT OF INSPEC N BYENGINEER
As certified by my seal affixe ere re
a d 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 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 7/4115
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 unseen / OF ALA
encroachments, deficiencies or discrepancies exist. �r� ,!
00, 9THId k+
6. DSD SIGNATURE
V System #1 Approved for 19bedrooms. P.xnele Al. nye'
7 16 /
System #2 Approved for bedrooms. 1 a°o 7 6' 7 i
Disapproved.
Conditional approval for bedrooms, with the following stipulations;,t(((U(((0lN,
=:g %AfaTER AND
oy: of Original Certificate Date: / i
The Mdniof-alitdel orage 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.
ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12AM
If more than 1 septic system is on the lot:
. COSA Checklist # of
Rtructure served by this system ,
Certificate of On -Site Systems Approval Checklist
Legal Description: CREST VIEW BLOCK A. LOT 6A Parcel ID: 010-231.20
A. WELL DATA*
Well type PRVT If A, B, or C provide PWSID # _
Date completed CIRCA 1958 Sanitary seal (Y/N) y
Total depth 185 apnrox ft. Cased to 40+ ft.
FROM WELL LOG
Date of test
Static water level
Well production
ft.
g.p.m.
WATER SAMPLE RESULTS:
Coliformcolonies/100 mL Nitrate 0.10 mg/L
Arsenii t ug/L Date of sample: 6129/2015
B. SEPTIC/HOLDING TANK DATA - PUBLIC SEWER
Well Log (Y/N) N
Wires properly protected (Y/N) Y
Casing height (above ground) 24+ in.
AT INSPECTION
6129/2015
19 ft.
3+ 9.p -m.
Collected by: ARCTERRA
Tank Type/Material Date installed
Tank size _ gal. Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N) Depression over tank (Y/N) High water alarm (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ffz or l�/bdrm) _ System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption area ft Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) _ For bedrooms
Fluid depth in absorption field before test in. Water added al. New depth_ in.
Elapsed Time: _min. Final fluid depth _ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) _
If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at _ in.
Datum
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot NA
Absorption field on lot NA
Public sewer main 75'+
Size in gallons
"Pump off" level at _ in.
Cycles tested
Sewer /septic service line 251+
Animal containment areas 50'+
SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation Property line
Water main Water service line _
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO: PUBLIC SEWER
Property line Building foundation _
Water Service line Surface water
Curtain drain Wells on adjacent lots
F. COMMENTS
Manhole/Access (Y/N)
High water alarm level
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manholelcleanout 100'+
Holding tank
Manure/animal excrete storage areas 1001+
Absorption
Surface water
Water main
Driveway, parking/vehicle storage
*PER MOA RECORD DOCUMENTS -1976 MOA APPROVED WELL INSIDE HOUSE I
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through field inspections and review of
Municipal records that the above systems are in conformance with MOA
COSA guidelines in effect on this date.
Engineer's Printed Name KENNETH M. DUFFUS
Date 07/0412015
COSA canary sheet_2.6-15.doc
Aw OF Al,
JH_
7 1I DUF8
SIOIIPS' .1I
in.
Municipality of Anchorage
Community Development Department
Development Services Division s a E'.
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
Arsenic Advisory
Certificate of On -Site Systems Approval # 151345
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block A, Lot 6A
of Crest View Subdivision. This inspection revealed an arsenic
concentration of 34.8 micrograms per liter (ug/L) for the property's well
water sample. The Environmental Protection Agency (EPA) has established
a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Information on
arsenic is available from the On -Site Water and Wastewater Program
website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
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