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HomeMy WebLinkAboutCHUGACH PARK ESTATES BLK 2 LT 15Chugach Park Estates Lot 1.5 Block 2 #051-481-10 Municipality of Anchorage On -Site Water and Wastewater Section - (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211364 PID Number: 051-481-10 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade Name LAUREL DERKSEN ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 19265 SULLINS DR, CHUGIAK AK ❑ other Phone ber of Bedrooms Soil Rating Total depth from original grade =3u GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot CHUGACH PART EST. BLK 2, LOT 15 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 I Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line Ft2 Ft. Well 100'+ 50+.x. TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer GREER TANK Capacity 1000 Gal. Surface Water 100'+ Material Number of compartments Lot Line 10'+ NA STEEL 2 Foundation + LIFT STATION Manufacturer Capacity Remarks TANK DECOM. PER UPC Gal. �� ©t*,r. Sd l Pry"` fil hI�'l Z t' -+t ri •F cs rc Alarm location Electrical installed by t� PIPE MATERIAL House to tank 3034Tank to 3034 drainfieid Installer DENALI Drainfield COIMT3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 100 ft Inspection 1m 4!2/19 Location and description 2 nd TOP OF CONCRETE SLAB 3'a 4in ON-SITE WATER AND WASTEWATER SECTION APPROVAL En ' e;a_' -,�'eae ..Stamp ' s 01: �. Conditional Approval: Date '' • �'�� A •'•;�' W1�;••' *.:49— •• MICHAEL Septic System r N. ANDERSCN•; �^ f ++ cE 949 �}����•. Approver L.. Datej-27'–Z( �ro�7.C.�.'c`-._.� • ,�.Yf-tel+ Note: this approval does not include well permit requirements. . 1 . • tliXX��E`�'`-=-i trcev voruzr 10) Permit No. OSP211364 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: CHUGACH PART EST. BILK 2 LT 15 MARK A B FCO 5 15 TC01 10 10 TCO2 18 10 CO2 20 11 CO3 21 11 BENCH, TOP OF ASBUILT_ SCALE: T"-= a In PID No.: 051-481-10 NEW 1000 GALLON STEEL T9NK /) 20; DRAINAGE EASEMENT CO2 10' UTILITY EASEMENT OF Aff Ar 49 TH ' ��� eas aoo.11W........ GALLON 94.3 STEEL TANK 9�';MICHAEL •N. ANDERSON.-mr No. CE 9469 Ar ®® .,8-26-21 SEPTIC SECTION N.T.S. � O , V) Z � ± UTILITY EAS wENT a Duc c STATE PARK / Q L- 0 o . � lv� § V) 0 '0 : 00 V) V� Q 86¢ o/ E o 0 C -i k■� - �0. k / EkC7 f \ k- \ ,2v / ?1%§{0 0 E k -)m . � 23\ 0,5.E0 i2° _o �k£ k % 0 \ } =J..§ � 0 \ \/\\c rr he / e � !Ir- am ! sco .0 \ k g)! MUNICIPALITY OF ANCHORAGE Ru5H X_ Development Services Department �, Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-481-10 Property owner(s) LAUREL DERKSEN Day phone Mailing address 19202 MCCRARY RD CHUGIAK, AK Site address 19 265 SL Jk Iyt s Ur Legal description (Sub'd., Block & Lot) CHUGACH PARK ESTATES BLK 2 LT 15 Legal description (Township, Range & Section) Lot Size 55,962 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 (w/wo ADU) Septic Tank El Upgrade El Duplex (D) F-1 Holding Tank F-1 Renewal El 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. (Signature of property owner or authorized agent) Permit/Rush Fees: 6 Date of Payment: S 26 ;w 1 Receipt Number: Od ( 3Dr7 Permit No. 0-e-�'P2 I -t 6 4 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc NAME (~-.~ 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 LOCATION MAILING ADDRESS Well ! Absorption areaA /~. DISTANCE TO: I /a0 4 I Z(~ Manufacturer _~ [Liq. capacity in gallons ~ ............. ~ Inside length DISTANCE TO' Well ,//I Dwelling ~ell ~ IFoundation __ ~, DISTANCE TO: I /DO * I /0 No. of lines ~ ~ Lengt~h~n~ I Total Io~f I~ Top of tile to fi~jh~ra~ I M~e~ial ber~ tiJe. Length -- Width ~ ] Depth Type of crib Crib diameter /~ Crib depth DISTANCE TO' Well ~ Building foundation ~Class Depth Driller DISTANCE TO: ~n~;o/~r ~er line KNEW [] UPGRADE IDwelling "7 ~ IMateria~..~ ~. ~ Width NO. OF BEDROOMS No. of compartments Liquid depth PERMIT NO. Material Liquid capacity in gallons Nearest lot line ~.- / Trench~dth [( <..)~ inches 72~ inches PERMIT NO. ~ ' ~, Distance between lines ~//il~ To tale ffe4;.~/~on area PERM T ~0. Total effective absorption area Nearest lot line Distance to lot line Septic tank PERMIT NO. JAbsorpt on area(s) OTHER PIPE MATERIALS SOl L TEST RATING / INSTALLER ~ llY, R EMAR KS 72-0.~3/(R ev. ~/78) DATE LEGAl_ I' H. 69-1-2079 I hereby certify that I have sum)eyed the followi~ng described not ov~p ~ e~n on ~e ~o~ty l~ a~jaeent ~ to, ~at no ~ve~?s on ~o~y .l~g a~a~nt t~to ~eh on the pre--es in question-and ~t ~ are no r~dway~ ~m~ion lines ~ ~r v~ble ~~ on said p~ ~t ~ indica~ h~n.. Dat~ at ~g~ River, Ala~a ROBOT C. JOHN~N 1" = ~ t ~x 456, ~gle Riv~, A~ P~e (~) NovemDer lb, Charles S. ~assara Box 596 Girdwood, Alaska 99587 Sub3ect: Lot 15, Block 2, Chugiak Park Road Approval for the individual sewer and water facilities cannot De ~3ranted until tile followinG items have been completed: A well log suDmitted to this office for our files and review. ~)~- o T~e engineer's as-builts, which have Deen suDmitteG to tills office, are not within the parameters of t]~e on-site installation permit issued Dy this department. The discrepancies will need to ~ correcte~ De~ore thais ~ ~-~ department can accept the ~UD~it~ed~ ~B~ine~'as-Dui'~lts,~ ~' ~ Yfle unused well must be properly abanGoned. ~0~ o~ ~~ Piea~no th~s Department for a reinspec[ion when the noted discrepancies have ~en corrected. Ir t~%ere are any ~urtner questions, please call t~%is otrice at z~4-472O. ~incerely, Cory Willis, R.$. Actin9 Sewer & Water Program Manager CW35/e3/E1 " C, EF'RF.:TMENT OF HERLTH FtND EH',,.' I F.:F~NMENTR~q~I:':C. ITECT I ON ' 825 '" L'" STREET., ANCHOF.:RGE., RE. La_. ,. ';.'64-4720 i-4ibb Rf-,i[:, C! [4 -- '~--% T Ti "~-~EL,.IEF: F'ER["'I l' T PERMIT f.401. ,:: :-Z,'.~04.~:5 ) RF'F'L I CRNT SRSSRF.:Ft CONSTF:LICT 1 ON F'O E;O',,-': 596 131RD~]OI-I[:, R~::: ~._q..587 7E~--'.:-2~.'1 ? LOCRTION LOT SIZE qqqqs'~ $6¢JRF.'.E FEET LEGRL L~.5 B2 CHUGIRK PRRK ESTRTES T'-r'F'E OF SOIL RBSnRF'TION '-,¢=,TEf' IS' [)F.:RINFIELE:' -' ,il ~.: SOIL RRTING ,:"=,,6! FT,--"E:F.:)= ~.50 MH,,':,Ifl-M NUME:E~.: OF E:EDR'.OOMS = '- THE RE6'_IIRE[:' SIZE OF THE SOIL RBSOF.:PTION S'eSTEM IS' _~, mS ~: R'-..' E L [)EP TH= --'~' [:,iF'TH= ,-"~- bil--.im2 T i = --- ~: THE LENOTH DIMENSION IS THE LENGTH ,'IN FEET::' OF THE TRENOH OF.'. DF.:RINFIELE:'. THE DEPTH OF R TRENCH OF.: PIT IS THE D ISTRNC:E BETH[EH THE SURFFtCE OF THE 6['CUND RNE:, THE E:OTT¢IM OF THE E::4CFt',/RTION (IN FEET::'. T H i T F-: E f-.i U--: H 1.-1 I [:' T H I S 5. ,-S-I E~ ¢_.4 F i i T. THE OUTFRLL F'IPE THE ~F..H,,,EL DEPTH IS THE MINIMUM C, EF'TH OF L3~R'¢EL BETWEEN FtN[.', THE E:f-ITTOM I-IF THE EXCR'¢FtTION ':: IN FEET::,. F~-: i ~;! Ij I F: E [:, S i F' T I i'-': T R f-.i ~=:: S I Z i = -1 E4 i-.-_-I I--":'l ~-'~ R b b ~'"~ I%1 S F'EF.:M I T RPF'L I F:RNT HRS THE F.'.ESPONS I E: I L I T'¢ TO I NFOF.'.M TH I S DEPFtRTblENT [:,LIE: I N6 THE INSTRLLRTION INSPECTIONS OF RNY WELLS RD..TRCENT TO THIS PROF'EF.:TY RNC, THE HUME:iF.'. ¢'~F F.'.ESI[:,ENC:ES THRT THE WELL 14tLL SERVE TL4L~ ,:: 2 ::, I i"-~SF'EL-:T I ~-'~l"-,IS RRB Rit~LI I BRCKFILLING OF Rt'4Y SYSTEM WITHOUT FINRL INSPEC:TION RND RF'PROVRL E:Y THIc [:,EF'FtF.:TMENT [41LL BE SUE:.$EC:T TO PR¢'ISE¢':I_IT I ON. HINIMUM [:,ISTRNCE BET[4EEN R WELL FtN[:, RNY IDN-SITE SEWRGE - · 100 FEET FOE: R PR I',/FtTE WELL ¢~F.: t50 TO 2ilO FEET FRl'lf'l R PUBLIC: WELL DEPENDING LIPON THE TYPE OF PUBLIC WELL. I'IlNIf'IUM [:,ISTRNCE FF.:OM R F'F.:I',,,'RTE WELL TO Ft F'RIVRTE SEWER LINE IS ';-'5 FEET RN[:, TO R COMMLINIT"r' SEWER LINE IS 75 FEET. ~4ELL LC,SS RF.:E E:EC!UIRE[:' RN[-" MUST E:E RETURNED TO THE [:,EPRF.:TMENT WITHIN 3:0 [:,R'¢S OF THE WELL COMPLETION. ¢~THEF.: RE6..!U I F.:EMENTS r,IR'~' RF'F'L'¢. SPEC I F I iZ:RT I OHS RND CONSTF.:U¢:T I ON D I R6RRMS RF.:E RVRILRBLE TO INSUF.:E F'F.'.OF'EF.: INSTFtLLRTION. i'il~-:l-1 I T E::-::F' I F:ES C, iu-:ir,li:i~: '":~:: t.. 1~--" :E:.-~=-: I CERTIF'¢ THFIT i' I ~M F~MILI~I~'. WITH THE I;'.E6!UIREMENTS FOR ON-SITE SEWERS ~ND WELLS RS SET FORTH 8'¢ THE MUNICIF'~LITY OF BNCHOR~GE. 2' I WILL INST~LL THE S¥STEH IN ~CCOR[:,BNCE WITH THE C:O[:,ES. 2~' I UN[:,ERSTBND THBT THE ON-SITE SEWER S'¢STEM MR'¢ RE6]UIRE ENLBRGEMENT IF THE SIS :: ........ z ~F,F'L l CRNT _ SRSSRRR CC'N~T~:UCT ":'N ~_~ ' './4. 0 SOl LS LOG PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 --'--~ 4 12 17 18 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST Reberl A. 5haler No. 1457-E 20 COMMENTS WAS GROUND WATER ENCOUNTERED? PERFORMED BY: 8 & ~ E:,IGINEERING 72-008 (6/79) -- SI ~E 0 P E DATE PERFORMED: [] PERCOLATION TEST SITE PLAN IF YES, AT WHAT ~*-L i~j ~ ~. DEPTH? ~ Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN FT AND CERTIFI ED~~--~_~v (minutes/inch) ~ FT // MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVl RONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG [] PERCOLATION TEST PERFO.MED POR: F~.AN~ VA l u. DATE PERFORMED: LEGAL DESCRIPTION: 1 2 8 9 e. ~ uo~.4cH P^ ~- F, o r~-,~ i~7 ~,"- SLOPE 11 12 13 14 15 16 17 18 19 20 WAS GROUND WATER 0 P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) COMMENTS TEST RUN BETWEEN v f 1.50 ~/b,/-rm. CERTIFIED BY: AND -- FT 72-008 (6/79) APPLIC"NT FILLS OUT UPPER HAl ONLY Proper~ Owner Phone Mailing Address ~'~/~.~/'/...-L~_.~' ,~"',/'~.~/.~-/'~/~U'~ ,~ ~"~' ~'~/t"2 ~4~4.~l~Zip Code (~q Address Zip Code Lending Institution Phone ~ Zip Code Address . ,t Realty Co. & Agent Phone Address Zip Code Legal Description ~.~:)/-- ,/,._~-' ,.~-' 2-- Street Location ~ i~/~1~ ~ ~.-/~-'C'~ ~ ~ · Typ_e o?~bidence ~ Single Family tJ Multiple Family No. of Bedrooms~ [] Other Water Supply .,~lndividual ,~~ ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. "'[] Community For wells drilled prior to that date, give well depth (attach log if available). [] Public Utility Sewe.r Disposal ,/,<~ Individual Year Individual Installed: 'E~ Public Utility When Connected to Public Utility: [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Inspector Inspector Inspector Inspector ,,~ .,.,, J ~ ~ MUNICIPALITY OF ANCHO~GE DEPT. OF H~2.LTIt ~NVIRONM~NTAL ( ) CONDITIONAL APPROVAL* DATE Soils Rating Date ~wer Installed Well To Absorption Area ~ ,~ ~' Well Log Received 72-023 (3182) UNICIPA IT OF ANCHORAGE Dene llop-nent'S%ervices a �epar,t!nen in-_-, '£ 907-34'2-''904 P 1 f�ltr \?rS�e<lc"j( Se:t!)j0rl-.,[ t ax: 907-34.3_ SC�'j • 1_, r' Parcel I.D. 051-481-10 Certificate of On -Site Systems Approval Expiration Date: 11- �7—,Z--( 1. GENERAL INFORMATION Complete legal description CHUGACH PARK ESTATES BLK 2 LT 15 Location (site address) 19265 SULLINS DR, CHUGIAK, AK Current property owner(s) LARUEL DERKSEN Day phone Mailing address SAME Real estate agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic Z Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Waiver Fee $ Date of Payment /0 2 Receipt Number OI 302. COSA # 05(a 1 1 -1 6 7 Date of Payment Receipt Number Waiver # 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 MIKE N ANDERSON, P.E. Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. 6. DSD SIGNATURE System #1 Approved for 3 System #2 Approved for Disapproved Conditional approval for Phone 727-8864 Date 8-9-21 `!1r... OF i * 49TH '; J bedrooms /..... �! -;F0 MICHAEL N. ANDERSCN bedrooms C 9 69 � f ....- k �P,Ro EsS10# - bedrooms, with the following stipula`or�C4 of WATER AND m WAST`�v\'ATER o �JJJiJ FNT SEPN By: '^' Original Certificate Date: g��7� 2.1 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 sliest i of WATER AND m WAST`�v\'ATER o �JJJiJ FNT SEPN By: '^' Original Certificate Date: g��7� 2.1 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 sliest Legal Description: CHUGACH PARK ESTATES BLK 2 LT 15 If more than 4 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 1011983 Total depth 280 ft Cased to 40'+ ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 30"+ in. Date of flow test for COSA 7123121 Static water level at beginning of test 190 ft Comments B. TANK DATA Age of tank(s) 2019 years Tank type/material SopfC51..1 Measured operating fluid level in septic tank 48° ❑ Standpipes/foundation cleanout per record drawing Date of pumping tank replaced due to 11/30/18 earthquake(emergency) D. ABSORPTION FIELD DATA Which system tested (date installed) 6/1/83 ❑ ALL standpipes present per record drawing Total measured depth from grade 10.4 ft (max) Measured depth to pipe invert from grade 4.4 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 0 gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 051-481-10 Structure served by this system Well production at time of test 2+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 1.97 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 7/23/21 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 7/23121 Results QPass For 3 bedrooms Fluid depth prior to test 0 in Water added 500+ gal New depth 0 in Elapsed time 1440 min Final fluid depth 0 in Absorption rate 500+ gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private well on Lot to: (Please enter distances if less than required or if community well) ❑ Yes Septic Tank/Lift Station on Lot > 100' Q Yes if No ft Community Sewer Manhole/Cleanout > 100' 91 Yes if No ft Neighboring Tank > 100' Yes Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No ft Absorption Field on Lot > 100' [V Yes if No ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' �✓ Yes if No ft Animal Containment > 50' Q Yes if No ft Community Sewer Main > 75' []✓ Yes if No ft Manure/Animal Excreta Storage > 100' Q Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No *5 ft Surface Water > 100' [✓ Yes if No ft Property Line > 5' ED Yes if No ft Wells on Adjacent Lots: Water Main > 10' Absorption Field > 5' ✓Q Yes if No ft Private Wells > 100' 0 Yes if No ft Water Main > 10' 0 Yes if No ft Community Wells > 200' R� Yes if No ft Water Service Line > 10' [D 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' F71 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' Q Yes if No ft F. ENGINEER'S COMMENTS septic tank was replaced after the Nov. 30 2018 earthquake collapsed the tank no permit was obtained, photos provided. *5 SEPARATION, TANK NOT IN CONFLICT W/ FOUNDATION BEARING G. ENGINEER'S CERTIFICATION _ q� OF. At I certify that / have determined through field inspections and review v '•,•� � of Municipal records that the above systems are in conformance with fr : ,� 9 t ti .7 r� MOA COSA guidelines in effect on this date. /. . ��.q fl tNG1 ... • • r • • . !J ,i;':.' ... ......... � •• MICHAEL N. ANDERSON ; Or �YCE 94A9 Z" '9Z L COSA Checklist yellow sheet i� PRQFESSIT"A-r MUNICIPALITYOF ANCHORAGE Devellopment 'Services DE'partinn?fif t �''I � Pl"onco • 907:je1+2.,'ir�(ii�• `�n- mite V\later & `.� laste.f�laler . e(, -I ion r_ f0^- 7 9 ? Parcel I.D. 051-481-10 Certificate of On -Site Systems Approval Expiration Date: I I— 2,7—,Zt 1. GENERAL INFORMATION Complete legal description CHUGACH PARK ESTATES BLK 2 LT 15 Location (site address) 19265 SULLINS DR, CHUGIAK, AK Current property owner(s) LARUEL DERKSEN Mailing address SAME Real estate agent 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ❑ Private Septic Fx� Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 550 Waiver Fee $ Date of Payment/012 >' Receipt Number 01n 302 COSA # o5ca 11 q6 7 Date of Payment Receipt Number Waiver # 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 MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 8-5-21 OF 100, / • 49TH •fir �l 6. DSD SIGNATURE �...'..,.. ••••••,,,,,� System #1 Approved for 3 bedrooms '� • • •. • • • • • •pi �j vO •• MICHAEL N. ANDERSON System #2 Approved for bedrooms f �= • c 9 69 Disapproved �a�``,�'� •q/ I. •'�'�`O�� Conditional approval for bedrooms, with the following stipulatior�������.=` Flea S c V A -e 1 0" LkAu k -_Q t"Lld at, . r V vVA4� OFIAI R AND �o WAST' v\!ATER oz^ -� rr _1 FRO( RAM JJJI��F�SERv\G���`. BY Original Certificate Date: 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 Legal Description: CHUGACH PARK ESTATES BLK 2 LT 15 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 10!1883 Total depth 280 ft Cased to 40'+ ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 30°+ in. Date of flow test for COSA 7/23/21 Static water level at beginning of test 190 ft. Comments B. TANK DATA Age of tank(s) "2019 years Tank type/material A° Measured operating fluid level in septic tank 48" ❑ Standpipes/foundation cleanout per record drawing Date of pumping *tank replaced due to 11/30/18 earthquake(emergency) D. ABSORPTION FIELD DATA Which system tested (date installed) 6/1/83 ❑ ALL standpipes present per record drawing Total measured depth from grade 10.4 ft (max) Measured depth to pipe invert from grade 4.4 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 0 gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 051-481-10 Structure served by this system Well production at time of test 2+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 1.97 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 7123/21 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 7123121 Results [Z Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 500+ gal New depth 0 in Elapsed time 1440 min Final fluid depth 0 in Absorption rate 500+ gpd Any rejuvenation treatment (past 12 months) If yes, enter date 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 *8 Community Sewer Manhole/Cleanout > 100' �]✓ Yes if No ft M Yes if No ft Neighboring Tank > 100' 21 Yes if No ft Private Sewer/Septic Line > 25' F,7/ Yes if No ft Absorption Field on Lot > 100' 1✓ Yes if No ft Holding Tank > 100' [] Yes if No ft Neighboring Absorption Fields > 100' Water Main > 10' 0 Animal Containment > 50' P/1 Yes if No ft 21 Yes if No ft Water Service Line > 10' [D Yes if No ft Manure/Animal Excreta Storage > 100'Z comment below Community Sewer Main > 75' 21 Yes if No ft Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No *8 ft Surface Water > 100' [Q Yes if No ft Property Line > 5' []✓ Yes if No ft Wells on Adjacent Lots: Water Main > 10'✓Q Absorption Field > 5' Yes Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10' 0 Yes if No ft Community Wells > 200'✓71 Yes if No ft Water Service Line > 10' [D 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'✓Q Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Service Line > 10' 0 Yes if No ft Community Wells > 200' Q Yes if No ft Surface Water > 100' Q Yes if No ft F. ENGINEER'S COMMENTS septic tank was replaced after the Nov. 30 2018 earthquake collapsed the tank no permit was obtained, photos provided. *8 SEPARATION, TANK NOT IN CONFLICT W/ FOUNDATION BEARING G. ENGINEER'S CERTIFICATION � OF salq�lt ,gyp••'' • `S'.f-1t l certify that l have determined through field inspections and review ,® '�.•� ' .y of Municipal records that the above systems are in conformance with : 49TH t' MOA COSA guidelines in effect on this date. .. j �,•• MiCHAEL N. ANDERSON ; 4 CE 94 9 COSA Checklist yellow sheet td P OFFSStO��-r i 3p0, / O �O ins IITII ITY FASFMFNT—J rWllnAru CTATr PAP{( U to o� 'A ®� VVI ® C3 '� J V) _ < O Old VVI' C: 0 �L- CL E N p o v a vtoID P� OM :��a': Z�� v) C m U C Ac Z+v CO M U to o� 'A ®� VVI ® C3 '� J V) _ < O Old VVI' C: 0 �L- CL E N p o v a vtoID ai N Q U m v) C m U C Ac Z+v CO M C r- O C H+OID v p 2'83 mV CO E aiL m= > .00 0 � ®NOm E nD�LQ G�C4 n#-- �o m s 0Z�O-CM m OH O O O cy= v ® 61 O e-. W O y U L � Q �• ,~' �� •ems � W .0 Q C y- 7 .� O O M Am U mdYO O v C `e- �=< C •°_ N O H C_i A -L�c a=` c c v v o = q 0� 'CU[�vcOi�m Op 0 +. N M=m •e. UE 4- h c m •>,�O0 a 030 ._� J U O 06 m C 'o O' . tL' O 'v m V) U ti) m p m A m •- 01 L- 000 Nf 0 0 J 0 t U a N 0 .«- — Q �i�- C O Municipality of Anchorage Depa~ment of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 1. Current Property owner(s) Mailing address Lending agency Expiration Date: GENERAL INFORMATION' Complete legal descr pt on: '"Chugach' Park Estates Block 2, Lot 15 Lo~tion (site address or directions) 19265 Sullis Drive, Chugiak, AK 99567 Dave Johnson Day phone 688-2330 · ' 19265 Sullis Drivb, Chugiak, AK 99567 '- :". "~ '" Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:. 2. NUMBEROF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: '~ [] Individual On-site :- ' [] ~- L [] individual Holding tank __ [] 7i" [] community On-site :: BI .'~: [] Public Sewer -- ' [] The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Cedificates of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority 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 tess than 30 days old. 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. (Rev. 11/99) 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 Health Authority Approval Guidelines for 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 applicable Municipal and State cooes, ordinances, ana regulations in effect at the time of installation. Name of Firm KNn Fnoin~.~_rln0 Address ~na4,1 pfnrmio~n RIvH F~__.I~ River. AK _q_qR77 Engineer's Printed Name DHHS SIGNATURE J-"'" Approved for Disapproved, bedrooms. Phone Conditional approval for Date _q/d_q/no oedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory By:. ~~,/' /..C/. Expiration Date: (Rev. 11~9) X Maintenance Agreements Supplemental Engineer% Report Other Original Certificate Date: c~ _ ..~.~ ~ _ ~p O Reissue Date:. Municipality of Anchorage $£P Department of Health and Human Services Division of Environme,n,,t,a,I Services .... .M._UNICIPALITY OF ANCHORA.~3~ on-Site Services Section 825 L Street RooA~J~NMENTAL SERVICES DJVI$10N P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. WELL DATA Well type private Date completed 10/t983 Total depth 280 ft Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi Date of sample: 9/14/2000 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Steel Chugach Park Estates Block 2, Lot 15 If A, B, or C provide PWSID Sanitary seal Cased to 40+ FROM WELL LOG 10/'1/'1983 6O ff 10 g.p.m Parcel I.D.: 051-48%10 Well Log y Wires properly protected .Casing height (above ground). 22 in. AT INSPECTION 615/2000 192 2.6 g.p.m Nitrate 0.703 mg/I Other bacteria 0 colonies/100 mi Collected by: KND Enclineertng Date installed 6/'1/1983 Tank size Cleanouts y Foundation cleanout y Date of pumping 9/18/2000 Pumper Sanitary Pumping C. ABSORPTION FIELD DATA Date installed G////?~ Soil rating (g.p.d./ff2 or ft2/bdrm) '113 Length 38 ff Width 1.5 ft Total depth 1Oft Date of adequacy test 1000 gal Number of Compartments_2 Depression over tank n_ High water alarm na System type ~£E? 7£E,'JCH Gravel below pipe 6 ff Effective absorption area 450 it2 Monitoring tube ¥ Depression over field n~ ¢~P¢~) Results(Pass/Fail) pass For3bedrooms Fluid depth in absorption field before test 5~0 in Water added450 gal. Elapsed Time: 90 min Final fluid depth 5~0 in Any rejuvenation treatment (past 12 mo.) (YIN & type) n (Rev. 11/99) New depth5~2 in. Absorption rate >= 450 g.p.d. if yes, give date D. LIFT STATION ~' Pump on" level at in"Pum ' at in High water alarm level at in Datum Cycles tested Meets alarm & circuit requirements'~ SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main ~0'+ Sewer/septic service line 'inn,+ On adjacentlots 100'+ On adjacent lots tnn'+ Public sewer manhole/cleanout Holding tank 100'+ Property line 10'+ Water Service line ~.~'+ Cudain drain ,Inn,+ F, COMMENTS SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 7' Water main 100'+ Drainage 100'+ Wells on adjacent lots tnn,+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation 10'+ Surface water 'inn'+ Wells on adjacent lots 'inn'+ HAA Fee $ Date of Payment Receipt Number (Rev. 11/99) Property line 10'+ Absorption field 'in,+ Water service line 2.~'+ Surface water 'inn'+ Water main 1nh'+ Driveway, parking/vehicle storage ~[0~+ , G. ENGINEER S CERTIFICATION I codify that I have determined through fi~ld/~spect/bns and review of Municipa/ records that the above systems are in ~ conformance with MOA HAA guide/ines in effect on thzs dat~~R'S , Engineers Printed Name K*nnnfh M n,,ff~s ~ ' '~, Waiver ~/'¢ /~ .. Date of Payment a~/7~ C~/ .eaeipt Number 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. # 051-481-10 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Chugach Park Estates, Lot 15, Block 2 T15N R1W Section 15 Location (site address or directions) 19265 Sullins Drive, Chugiak Property owner Alt-~_r~- R. Tohin: Jr. Day phone msg 694-5195 Mailing address P.O. Box 100126, A~chorage, AK 99510 Lending agency N/A Day phone Mailing address Agent Joe Perrozzi/Target Realty Day phon.e' Address P.O. Box. 774627, Eaqle River, AK 99577 ~, Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 ~ 694-2388 TYPE OF WATER SUPPLY: Individual well x Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site X Holding tank Community on-site Public sewer NOTE: 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*t21 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, *Exception: Well located ordinances, and regulations in effect on the date of this inspection, in public ROW drilled for _this property is not p~o~_~sabandoned- Name of Firm Eaqle River Engineering ~erv~ces Phone - Address P_O_ _~ox 773?94. W. agl~ River, AK 99577 Engineer's signature ~~ DHHS SIGNATURE ~. Approvbd for ~ DisapProved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (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 DHHS 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. 72q325 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lo-/' A. WELL DATA Well type ,~/21V/I~., If A, B, or C, attach ADEC letter. Log present (Y/N) Total depth Sanitary seal (Y/N) ~1~ Parcel I.D. Date completed Cased to ~- ~'~" Wires properly protected (Y/N) ADEC water system number ~//~ ID~ ~ ~ Driller ..~,4¥ .J/tJ i l..I...l.,4,4,'l.~ Casing height ,D./" FROM WELL LOG Date.of test /0/ Static water level Well flow Pump level g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/I-~t~la~ tank on lot Absorption field on lot Public sewer main F~tbftc'sewer service line AT INSPECTION i I g.p.r~ ~o ~ o~ ; On adjacent lots ; On adjacent lots Y-/=~" Public sewer manhole/cleanout Petroleum tank /t/~...~ ~,~.,~,.~- WATER SAMPLE RESULTS: Coliform Nitrate Date of sample: ~ _~/Z.Z/ Collected by: Other bacteria B. SEPTIC/I,.I~I~i~ItflG TANK DATA Date installed D~/~--~ Cleanouts (Y/N) Tank size ./, DO~) Foundation cleanout (Y/N) High water alarm (Y/N) Date of pumping SEPARATION DISTANCES FROM SEPTIC/~G TANK TO: Well(s) on lot ~.O.o/' On adjacent lots To property line /5" Absorption field ~' ' ~-~- Surface water/drainage Compartments Depression (Y/N) Alarm tested (Y/N) Foundation ~ Waterma~/service line 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons "pump on" level at Vent (Y/N) High water alarm level J-~'~t · Meets MOA electric~~IX SEPARATION~)JSq'ANCE FROM LIFT STATION TO: Well oj3A15t On adjacent lots D. ABSORPTION FIELD DATA Date installed (~)(.~/ Length --~ ~' / Width Total absorption' area ~-~5~ ~Z~ Depression over field (Y/N) / Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Manufacturer` J . "Pump off" level at Cycles tested Surface water Soil rating / / ,-~ _~',/Z~ .~ Gravel thickness ~.~/ System type Total depth Cleanouts present (Y/N) Date of adequacy test for If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~'/o~ ~ To building foundation ~' ~s On adjacent lots ~- 3.) / Surface water ~'/~ ' On adjacent lots "-/'~'~ t Property line ?/· To existing or abandoned system on lot Cutbank '"/,,~ Water. mere/service line ~/~" Driveway, parking/vehicle storage area ~'/= Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name Date HAA Fee $ ///7 ~) Date of Payment 7--~'~ ~ ~~_~ ~_~.~ Receipt Number ',~._~ o1~ _~' ~ 72-026 (Rev, 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number Louis Butera, P.E. Registered Civil Engineer July 31, 1992 Robbie Robinson Municipality of Anchorage Dept. of Health & Human Services 825 L Street Anchorage, AK 999502 Re: Chugach Park, Lot 15, Block 2 PID# 051-481-10 Dear Mr. Robinson: We have inspected the well abandonment of the well located in Sullins Drive, which was drilled to serve the above referenced property, and have found it to have been performed to Municipality standards (attached). If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. P.O. Box 773294 · Eagle River, Alaska 99577 · Telephone (907) 694-5195 · Fax (907) 694-3297