HomeMy WebLinkAboutBEAR PARK LT 10Municipality of Anchorage Page of a
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
Permit Number: 5aC7 o3y8 PID Number: 05 -
Name:
/Aee
Wastewater System: ';;.New ❑ Upgrade
o C.
Address:
• C qg�b�
ABSORPTION FIELD
at q lit
Phone: No. of Be
G � 1513 L
ooms:
Deep Trench ❑Shallow Trench ❑Bed ❑Mound ❑Other
LEGAL DESCRIPTION
Soil Rating:
0-'R
Total Depth from original grad
GPD/S. Ft.
�7
Lot: Block: Subdivisio
) 0 —
Depth to pipe bottom from cor�iginal grade:
-IT
Gravel depth ben Ih pipe
G 6
1
Ft.
. Ft.
Township: :/
�
Range:
�—
Section:
Fill added above original grade:
r-19
Gravel length: ['
ID / 53
Ft.
Ft.
WELL•New ❑Upgrade
Gravel width: �t /
Numberofilnes:
Distancefe�5p line
0( Ft.
Class l anon (Private, A,B,C):
Total De the
/ 6
Cased To:
IG
Total absorption area: T64)
¢tCA 1 r/ S
Pipe material:
Ft.
Ft.
Igo I! SG. Ft.
Ori lt.D'ate��
III
91
Static WaQfer Level:
Installer: /f�
c0
Date installed:
V
I
O Ft.
Yield: Pump Set at: I
ioo N
Casing Height Abyve Ground:
/ f
TANK
GPM miwAl Ft.
Ft.
SEPARATION
DISTANCES
XSeptic ❑Holding ❑S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufactures
� 6
Capacity in gallons
From
Tank
Field
Station
Tank
Sewer Lines
GE��
11
Well
a�f
1v+V r'I
ary
asrF
Material: ST�E.L
d
Number of Compayants:
Orgl
Surfac
Watere
lob tl
100
LIFT STATION
Lot1
l0
Size in gallons:
Manufacturer:
Line
9
/oil
Foundation
C 14to
J
r rr
I
"Pump on" level at:
"P off' level at:
High water alarm at:
Curtain
a7
-`
Pump Make &
Electrical Inspections performed by:
Drain
/-
Remarks:
BENCH MARK
Location and Description:
Cass rd n✓rnod
Assumed Elevation: %w
T♦
a .4
y
Inspections performed by:$&S9"1NE"1" __ `gates: 1st low -SS
17054 MI& River Cdepkelat N0. A04 2nd-
nd
Eagle River, Alaska 99gii
N
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CE -88Q1
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Department of Health and Human Services approval
-
Reviewed and approved by:Date:'E ' / It
72-013 (Rev. 9/91) MOA 25
c
PERMIT NO. SW950348 PAGE 2 OF 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERWCES
ENVIRONMENTAL SERVICES DWISION
P.D. Box 196650 • Anchorage, Alaska 99519-6650 ® Telephone; 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 10, BEAR PARK SUBDIVISION P.I.D. No. 051-042-74
TRANS. LINE
EASEMENT
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/ 98.7' n
II II FINAL GRADES i
NEW
1250 GAL93.5C01 = 98.8'
R.T. ' MT `CO2 = 98.9'
= 93.3'
= 93.3'
MT1 = 86.7'-/MT2 = 87.8'
MT CO3 = 98.9'
n C04 = 98.8'
NO WATER FOUND
80.7' B.O.H.
WELL
—NEW 1250 GAL.
SEPTIC TANK
EW TRENCHES
SCALE 1" = 40'
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PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM PERMIT
PERMIT NUMBER:SW960098 DATE ISSUED: 6/04/96
DESIGN ENGINEER:S & S ENGINEERING EXPIRATION DATE: 6/04/97
OWNER NAME:RANKIN GORDON E &
OWNER ADDRESS:21533 ROCK PTARMIGAN
EAGLE RIVER, ALASKA 99567
PARCEL ID:05104274
LEGAL DESCRIPTION:
`BEAR PARK LT '10
LOT SIZE: 48477 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE .FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY
ISSUED BY
DATE: �'-J ?6
—
DATE:- 49, _7 - /b
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW950348
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:RANKIN GORDON E &
OWNER ADDRESS:22616 URSA MAJOR CR.
CHUGIAK, AK 99567
PARCEL ID:05104274
LEGAL DESCRIPTION:
BEAR PARK LT 10
LOT SIZE: 47477 (SQ. FT.) .
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
DATE ISSUED:10/18/95
EXPIRATION DATE:10/18/96
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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED
ISSUED
DATE:
DATE• Q//� G'
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW930421
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:RANKIN GORDON E &
OWNER ADDRESS:1776 FOREST PARK DRIVE
ANCHORAGE, AK 99517
PARCEL ID:05104274
LEGAL DESCRIPTION: BEAR PARK LT 10
LOT SIZE: 48477 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
DATE ISSUED:10/07/93
EXPIRATION DATE:10/07/94
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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED B
ISSUED BY:
DATE:
DATE:
September 25, 1993
HEALTHAUTHORITY unicipality of Anchorage
APPROVALS [DEPARTMENT OF HEALTH AND HUMAN SERVICES
25 'L' Street
.O. Box 196650
nchoraqe, Alaska 99519-6650
SEWER & WATER
MAIN EXTENSIONS
Bear Park Subdivision, Lot 10
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
SEWER &WATER
INSPECTION
Request you issue a permit to drill a well and install a
septic system to serve the proposed four bedroom house on the
referenced property.
ENGINEERING STUDIES
AND REPORTS Test holes were excavated and
percolation tests performed.
The approximate location of the test holes are located on the
attached site plan. The monitoring tubes within the test
holes have been checked and found to be dry.
WELL INSPECTION
& FLOW TEST
This property has enough area for a future septic upgrade
which can be seen on the attached site plan. We do not
anticipate any adverse effects on neighboring properties by
SITE PLANS the installation of the proposed septic system.
If you have any questions, or require additional information
for your review, please contact us.
ROAD DESIGN
j2fShafe�rP.E.
SOILTEST
(/BRAS/LSU/lsu
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
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Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: 9.'� L4'f'e-' DATE PER
LEGAL DESCRIPTION: ��'[' �O (�¢-9KR rDc$1�— Township Range Section:
SLOPE SITE PLAN
14-
15
4 15
16-
17
18-
19-
20-
COMMENTS
81920COMMENTS
WAS GROUND WATER `
ENCOUNTERED? N
S
L
IF VES, AT WHAT 0
DEPTH? P
E
Depth to Water ``After ``� __
Monitoring? � Date: -'LS -`l5
Reading
Date Gross Net
Time Time
Depth to
Water
Net
Drop
S
a� c'o
ya,y> • 30 �--
z 3
v
g•.ao � µ.a
�°
�'
3
�.5� •^
3 s'
'tea'
D
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
PERFORMED BY: S& S ENGINEERING I CERTIFY THAT THIS TEST WAS PERFORMED IN
17034 Eagle River Loo RoadNo. 204 4^-b
ACCORDANCE Wlb*M�FEAOQ"( 915ML GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85) ��
'i
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG - PERCOLATION TEST
PERFORMED FOR:
7� �Jx Y�I`� DATE
LEGAL DESCRIPTION:`\--&( 1 D GiTiO���A�L Township, Range, Section:
!?TJ% 6fZ SLOPE SITE PLAN
6
G j
7
0
8 '
6
9 >.
T.
10 0
11
�e
u
12-
13-
14
213 14
i
15 '
16
17
18-
19-
20-
COMMENTS
81920
COMMENTS
WAS WATER
ENCOUNTERED?
�
S
IF YES, AT WHAT LO j
DEPTH? P
E
Depth to Waterer\ o
Monitoring? '� Date:
Reading
Date Gross Net
Time Time
Depth to
Water
Net
Drop
PERCOLATION RATE A (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN 4 FT AND FT
PERFORMED BY: 17024 y nuie River Loop Road No.204 CERTIFY THAT THIS TEST WAS PERFORMED IN
F le River Alaska 99577
ACCORDANCE WITFelkrCL STAT AND MUNICIPAL GUIDELINES IN EFFECT ON HIS DATE. DATE:
72-008(Rev. 4/85) -
•
•- Municipality of Anchorage °`'' ' .g&`
On-Site Water and Wastewater Program ri:Li 111
(907) 343-7904 SA < <,Y
Certificate of On-Site Systems Approval
Parcel I.D. 051 -042-74 Expiration Date:
1. GENERAL INFORMATION
Complete legal description Lot 10 , Bear Park Subdivision
Location (site address) 22616 Ursa Major Circle, Chugiak, AK 99567
Current Property owner(s) Bridgette Evermann Day phone(907) 301-8971
Mailing address 22616 Ursa Major Circle, Chugiak, AK 996-67
Real Estate Agent Keira Dreher/Keller Will. Day phone(907) 529-4660
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
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:
472
Received by: Date: Zet
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ Waiver Fee $
Date of Payment g )21t 1"1 Uk 131 Date of Payment
Receipt Number //�� 0166 12- Receipt Number
v
COSA# 5 5/9 Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Pinard Engineering Phone §907) 232-1347
Address PO Box 871347 Wasilla, Alaska 99687
Engineer's Printed Name Paul E. Pinard Date 8/17/17
`
EOF ��._
6. DSD SIGNATURE �� % �f3
•
System#1 Approved for4( ?� . .
Y pP bedrooms e �4:....., .
System#2 Approved for bedrooms rr':Peds E. Pinard ��`
•� CE -4793 .` ��a
Disapproved �`fi�'F•�••• ..••"'• 04
�
Conditional approval for bedrooms, with the following stipulatidnsri', ;II
.,r
� f
ON-611 E 1;
<vniv/TcR ANn
r WASTEWATER
=, PROGRAM
•
t.
171
By' Original Certificate Date: g"Z3 7
The Municipality of Anchorage Development Services Division (050) 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 engineers work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other e. • �;
COSA blue sheei i '. c
• n
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems . pprovaD Checklist
Legal Description: Lot 10, Bear Park Subdivision Parcel ID: 051 -042-74
A. WELL DATA
Well type Pvt If A, B, or C provide PWSID# NA Well Log (Y/N) Y
Date completed 7/11 /96 Sanitary seal (YIN) Y Wires properly protected (Y/N) Y
Total depth 1 63 ft. Cased to 163 ft. Casing height (above ground) 1 8+ in.
FROM WELL LOG AT INSPECTION
Date of test. 7/11/96 8/10/17
Static water level 8 ft. 21 . 6 ft,
Well production 100 Estimated g.p.m. 4.0 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate ND mg/L
Arsenic ND ug/L Date of sample: 8/3/17 Collected by: Pinard Engineering
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 10/26/95
Tank size 1250 gal. Number of Compartments 2 Cleanouts (YIN) Y
Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (Y/N) N
Date of pumping 8/16/17 Pumper JRs Pumping
C. ABSORPTION FIELD DATA
Date installed 10/26/95 Soil rating (g.p.d./ft2Ix#2XIMIcrla) o•8 System type Deep Trench
Length 15 & 53 ft. Width 2 . 5 ft. Gravel below pipe 6 & 6. 5 ft.
Total depth 9 . 5 ft. Eff. absorption area 869 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 8/10/17 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 0 in. Water added 720 gal. New depth 0 in.
Elapsed Time: 180 min. Final fluid depth 0 in. Absorption rate >= 600+ g p d
Any rejuvenation treatment(past 12 mo.) (Y/N & type) None Known If yes, give date
.
D. LIFT STATION NA
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 1001+ On adjacent lots 100 ' +
Absorption field on lot _ 100 '+ On adjacent lots 1001 +
Public sewer main NA Public sewer manhole/cleanout .NA
Sewer/septic service line 25 ' + Holding tank 100' +
Animal containment areas 1001 + Manure/animal excrete storage areas 1 00'+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5 ' + Property line 5'+ Absorption field 51 +
Water main NA Water service line 10'+ Surface water 1001 +
Wells on adjacent lots 1001 +
ABSORPTION FIELD ON LOT TO:
Property line 10' + Building foundation 101 + Water main NA
Water Service line 10 1+ Surface water 100'+ Driveway, parking/vehicle storage 10 I+
Curtain drain None Known Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION 2/ffifi��l�.
IIjP��OF AI
Itft
I certify that 1 have determined through field inspections and I 'C ; ..�..
review of Municipal records that the above systems are in %S �; 1
conformance with MOA COSA guidelines in effect on this date. * k..4 : 1'
Engineer's Printed Name Paul E. Pinard ' \ „ 4 ---E---
• Paul E. Pinard ;`w V
Date 8/17/17 `s: ;a``11
.hi .. CE -4793 . .
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zPROFESSI��.u..&,
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COSA yellow sheet_2-6-15.doc
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RONALD R. MITCHELL
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4044 �1 Ow'�roresslonal��1�
Rev,sek-/�c�C�cS�s/c-.y. .9-/3./. llmi*uwr+r
NO CORNERS SET THIS DATE SCALE: 1” = 50' AS—BUILT SURVEY
AS—BUILT SURVEY OF : EXCLUSION NOTES: It is the owners responsibility to
LOT 10 determine the existence of any easements,
covenants, or restrictions which do not appear on
BEAR PARK SUBDIVISION (84-163) the recorded subdivision plot. NOTE: Under no
LOCATED WITHIN: circumstances should any data hereon be used for
construction or for establishing property lines.
SECTION 4, TOWNSHIP 15 N, RANGE 1 W, S.M., ALASKA
SURVEY CERTIFICATION: I have conducted a physical
RONALD R. MITCHELL survey of this property as shown on this drawing
P. 0. BOX 141884 and determined that the Improvements situated
thereon are within the property lines and no
Anchorage, AK. 99514-1884 encroachments exist other than as noted.
(907) 229-1424 LEGEND: FND
WATER WELL (1fi/�
ORDERED BY: DRAW BY: PUTT NUMBER: RECORDING DISTRICT: `
MILKMAN RRM 84-163 ANCHORAGE SEPTIC SYSTEM e
RRM JOB/: O►ECCED BY: GRID NUMBER: BOROUGH:
BEAR PARK RRM NW 1558 ANCHORAGE ELECTRICAL ,E)
DATE: FlELD BOOK/PAGE: SURVEY DATE: FIELD CREW: SHED NO FOUNDATION SNF
09/02/13 _ 09/02/13 RRM
� t B
•, r.... Municipality of Anchorage
46 - On-Site Water and Wastewater Program
(907) 343-7904
Certificate of On-Site Systems Approval
Parcel I.D. 051-042-74 Expiration Date: 1 ' I -3 -13
1. GENERAL INFORMATION
Complete legal description Lot 10, Bear Park Subdivision
Location (site address) 22616 Ursa Major Circle
Current Property owner(s) Ron Carr Day phone (907) 688-3751
Mailing address 22616 Ursa Major Circle, Chugiak, Alaska 99567
Real Estate Agent Mike Schwartz@Keller Williams Day phone (907) 351-4228
2. TYPE OF DWELLING:
• Single Family (wfwo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Q Individual [X]
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: Al"---s===1-------re a (�a Date: C
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ _ p4.�0 ' Waiver Fee $
Date of Payment 0 17J�I b_ ( 2 I Date of Payment
Receipt Number Receipt Number
COSA# b14 4 + Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Pinard Engineering Phone (907) 357-3647
Address PO Box 871347 Wasilla, Alaska 99687
mar,.,.,.
Paul E. Pinard, P.E. `°��1 ' ^
Engineers Printed Name D , `.- _ Y a c .
gle
fyc ; FFP . 2 ret
AC:(711111C
n e a a c r
6. DSD SIGNATURE face ,'4,ne,,seeeecc ®crar.ror5 .
1.7. System #1 Approved for " bedrooms V N-' G . �� o d r
e
AV
System #2 Approved for bedrooms r;t- ,c c oo0;41, tip
yr- ".r ..
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Conditional approval for bedrooms, with the following stipulations:
takk(�tP`'\-cY(OF(( t ifr�
2 ON-SITE p
- WATER AND
_
WASTEWATER o
fo PRO(RAM ;
NN
J�J/nod ScR�1�,.G-c- ��
By: a/ i(/ l (-- Original Certificate Date: I - 1 3 -/3
The 'unic.ality oVCchorage Development Services Division (DSO) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sneer_..: - -
• If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: Lot 10, Bear Park Parcel ID: 051-042-74
A. WELL DATA
Well type Pvt If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 7/11/96 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 163 ft Cased to 163 ft. Casing height (above ground) 18+ in
FROM WELL LOG AT INSPECTION
Date of test 7/11/96 8/11/13
Static water level 8 ft. 18.8 ft.
Well production 100 Estimated g.p.m. 4.0 g p m
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate ND mg/L
Arsenic ND ug/L Date of sample: 8/5/1 3 Collected by. Pinard Engineering
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 10/26/95
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N)
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 8/15/13 Pumper JRs Pumping
C. ABSORPTION FIELD DATA
Date installed 10/26/95 Soil rating (g.p.d./ft' or ft2/bdrm) 0.8 gpd/sf System type Deep Trench
Length 15 & 53 ftWidth 2.5 ft. Gravel below pipe 6 & 6.5 ft
Total depth 9 5 ft. Eff. absorption area 869 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 8/11/13 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test 0 in Water added 720 gal. New depth 0 in
Elapsed Time: 1 80 min. Final fluid depth 0 in. Absorption rate >= 600+ g.p.d.
None Known
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes. give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot 1001÷ On adjacent lots 100 +
Absorption field on lot 100'+ On adjacent lots 100 +
Public sewer main NA Public sewer manhole/cleanout NA
Sewer/septic service line 25'+ Holding tank NA
Animal containment areas 100'+ Manure/animal excrete storage areas 1001+
SEPTIC/HOLDING TANK ON LOT TO.
Building foundation 5'+ Property line 5+ Absorption field 5'+
Water main NA Water service line 101+01+ Surface water 100'+
Wells on adjacent lots 100 +
ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 1��+ Water main NA
101+ 100'+
Water Service line Surface water Driveway. parking/vehicle storage 1 +
Curtain drain None Known Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
ia
I certify that I have determined through field inspections and M • �•T" '
review of Municipal records that the above systems are in ' � •i ,
conformance with MOA COSA guidelines in effect on this date. rs, 9 H �'� <Fa
Paul E. Pinard, P.E. `iii���/
Engineer's Printed Namee•• ' o.oeo a.•••••.*. rit
Date 8/23/13 t. E. d
• '�@qqyye
N
A
COSA brown sheet 10-10-12.doc