HomeMy WebLinkAboutT12N R3W SEC 15 LTS 142 N100' & LT 143 N100'•
s
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191315 PID Number: 015-484-21
Dwelling: ❑■ Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ❑t Upgrade
Name:
Joseph & Marie Lastufka
ABSORPTION FIELD
❑ Deep Trench ❑Q Shallow Trench ❑ Bed ❑ Mound
Address
P.O. Box 110052 Anchorage, AK 99511
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
227-1243
3
1.2 GPD/SF
6.8 Ft.
LEGAL DESCRIPTION
Depth to pipe4Rvert from original grade
2.8 Ft.
Gravel depth beneath pipe
4.0 Ft.
Subdivision Block Lot
142/143 N 100
Fill added above original grade
0.7 Ft.
Gravel length
38
Township Range Section
12N 3W 15
Gravel width
5 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
380 Ft2
1
Ft.
Well
>100'
>100'
N/A
N/A
>25'
TANK R] Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Greer Tank
Capacity
11,000 Gal.
Surface Water
>100'
>100'
N/A
N/A
Material
Number of compartments
Lot Line
>5'
>10'
N/A
N/A
Plastic
2
NA
Foundation
>10'
>10'
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
None
Noted
Gal.
Remarks Tank is insulated.
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
Existing tank and crib filled and abandoned
In place per MOA code.
Pump make and model
Electrical Inspections performed by
Installer
PIPE MATERIAL House to tank D3034 Tank to
drainfield D3034
Isaac's Excavating Services
Drainfield D3034 CO/MT 3034
Inspector J. Mlllette / J. Williams
BENCH MARK (Assumed elevation) 100 ft
Inspdecct sn 15' 8/12/19 8/14/19
Location and description
2nd
3`d 4'h
Asphalt @ base of carport center support column.
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
Conditional Approval:
®® OF q ®+
"''C:qS®®♦®♦
Date
��P"'
.• .�
J d
s �' 49th =� 0
m
.....::...... .... ........ ... ..�.....
..................�......' :::..: `.. o
.
MICHAEL E. ANDERSON g Qjg
®♦��J,'o� No. CE -4381 7*_m
♦♦®�,!pF.,,. 3/3/20
ApprovedDate
,,.•���®0
P11 ROFESS\O'N�®®®
inspecuon mepori_a- i- i t.aoc
T12N R3W SEC 15, LOT 142 N100'& LOT 143 //
PERMIT # OSP191315
PID # 015-484-21
I
LOT U4
I
I
Du rNI CINI RCJCRV/11 IVIV
FOR R.O.W. & UTILITIES
I
I
LT 113 LOT 112
I EDGE OF ROAD
I
ALTERNATE SITE
EXISTING WELLS
L? L
O,S,�yo B
>10
LOTS 142 + 143 FCO =C1,20TH10SHED
1,000 GALLON GREER
I PLASTIC SEPTIC TANK
W/ 20" MANWAY
I
I
ZIMMERMAN SUBDIVISION
LOT I
EXISTING WELL
l -i- RING
PLAN AS -BUILT
0 50 100
FEET
V=50'
0,
38'LONG x 5'W)DE x 4'
EFFECTIVE DE TH
ABSORPTION TRENCH
A B C
FCO
12.1
19.7
MH1
34.5
40.2
SV1
38.4
44.8
2CO
40.8
47.4
C01
45.8
52.1
MT1
49.7
56.4
CO2
84.1
94.6
MT2
79.2
81.7
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
Tl 2N R3W SEC 15, LOT 142 N 100'& LOT 143 N 100'
PERMIT # OSP 191315
92.1
1* *..P
�;
PID # 015-484-21
95.6 FINISH GRADE
OUB /- 94.9 ORIGINAL GRADE
DRAINFIELD ROCK
�- 88.1
38'
78.9
NO GROUNDWATER 7/9/18
PROFILE AS -BUILT
(NO SCALE)
'INSULATION
88.1
92.1
"�,;.•
49th
MICHAEL E. ANDERSON
N0. CE -4381
••�'' 11/26/19
Lot 114
Lot 113
WELL
100 PROTEOiNE RPOIUS
1 132.4'
N100' Lots 142 & 143
o \ 32,991 S.F.
o ROOFTOP
Lot 141 12.2'x15.2' SHED DECK
w/ 4'x6' RAMP 6.2'x8.0' COVERED DECK
WEST 329.90'
Lot 1
C
M
M ;1
0
M
PLOT PLAN ___ AS BUILT —X— SCALE _ 1= __ 40__ GRID _ SW 2536_— Project No.
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates i n c , (907) 522-6476 Phone ooOOp O
(907) 522-4625 Fax o� Q
Professional Land Surveyors kenOlongsurvey.com o � �F :q.�gO44
ionothanOlanasurvev.com O S
I hereby certify that I have surveyed the following described property:
NORTH 100' OF LOTS 142 & 143, SECTION 15, T12N, R3W, SEWARD MERIDIAN, ALASKA
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 ore no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
Dated this The __Q__ Day of ___hi�'>=�5 _—_____,_bU__, 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.
491H*q) y�(
KENN H NC .o
LS -5202.''
n a Nuc
uQn�aFfSSI0NA1- �o
AECC963
\ 50' PATENT RESERVATION
FOR R.O.W. & UTILITIES
Lot 112
\
EDGE OFIROAD
EAST329.92'
24.7'
- ASPHALT DRIVEWAY
PDQ
C
�1466'
24.7
2 STORY o
RESIDENCE
SEPTIC'
'" PIPES
I
40.7•
/ , i
\'MANHOLE
;q
2.4' CANT
o
n
CHAIN—LINK FENCE
WEST 329.90'
Lot 1
C
M
M ;1
0
M
PLOT PLAN ___ AS BUILT —X— SCALE _ 1= __ 40__ GRID _ SW 2536_— Project No.
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates i n c , (907) 522-6476 Phone ooOOp O
(907) 522-4625 Fax o� Q
Professional Land Surveyors kenOlongsurvey.com o � �F :q.�gO44
ionothanOlanasurvev.com O S
I hereby certify that I have surveyed the following described property:
NORTH 100' OF LOTS 142 & 143, SECTION 15, T12N, R3W, SEWARD MERIDIAN, ALASKA
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 ore no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
Dated this The __Q__ Day of ___hi�'>=�5 _—_____,_bU__, 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.
491H*q) y�(
KENN H NC .o
LS -5202.''
n a Nuc
uQn�aFfSSI0NA1- �o
AECC963
5((7i(7.
MUNICIPALITY OF ANCHORAGE
� �-- o, c n t
On-Site Water&Wastewater Program \o
•
PO Box 196650 4700 Elmore Road a"
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.orgtonsite !"
De partlnenr
`NCNOR"G0
On-Site Wastewater Disposal System Permit
Permit Number: OSP191315 Effective Date: 7/29/2019
Work Type: Septic Upgrade Expiration Date: 7/28/2020
Tax Code Number: 01548421000
Site Legal Address: '72/U R3W f--/cc 15 t.-t9 /yz A) /001 and Ly3 A) Ivo
Site Mailing Address: 10300 OW
Owner: LASTUFKA JOSEPH J & MARIE V Lot Size in Sq Ft:
Design Engineer: FORGE ENGINEERING Total Bedrooms: 3
This permit is for the construction of:
El Disposal Field El Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 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
\YY
Received By: pg-Ilttit., 8 Date:
��
Issued By: Date: Alf/
eikhAiS
MUNICIPALITY OF ANCHORAGE
I i
Community Development Department \ ' Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On-Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 015-484-21
Property owner(s) Joseph and Marie Lastufka Day phone 227-1243
Mailing address P.O. Box 110052 Anchorage, AK 99511
Site address 10300 Our Road Anchorage, AK
Legal description (Sub'd., Block & Lot) T12N R3W SEC 15 Lots 142 N100' and 143 N100'
Legal description (Township, Range & Section)
Lot Size 28,000 Sq. Ft. Number of Bedrooms Three (3)
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(SI all that apply)
Absorption Field ❑x Initial ❑ Single Family (SF) n
(w/wo ADU)
Septic Tank [ Upgrade n Duplex (D) U
Holding Tank ❑ Renewal ❑
Multiple Dwellings n
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE/WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
a(.. t.9---1
(Signature of property owner or authorized agent)
Permit/Rush Fees: 596 Waiver Fees:
Date of Payment: 7-7x3/6 Date of Payment: _
Receipt Number: 033gt D Receipt Number:
Permit No. 05P/91.315 Waiver No.
Permit App_.-
PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
July 26, 2019
MOA Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: T12N R3W Section 15, Lot 142 N100’ & Lot 143 North 100’ – 10300 Our Road
Septic System Design
Dear On-Site Services Engineer:
The existing septic system on the subject lot has failed and must be replaced. We are submitting
this permit application for the construction of a new septic system to serve the 3-bedroom home
on the lot. The attached site plan identifies the location of the home and the existing well and septic
system and the proposed septic location and alternate site. No conflicts exist between this proposed
system and any other well or septic system on this lot or adjacent lots.
The ground surface on the lot slopes to the west, at an approximate 10% slope. There are no slopes
steeper than 25% within 50’ down slope of the proposed absorption trenches. Drainage arrows are
shown on the site plan showing the grade and direction of flow. Storm water drainage will not
impact this septic system. The new trench will be constructed parallel to the slope as much as
possible. Test holes on the lot and in the subdivision indicate silty sand with very few fines. The
absorption rate of effluent is faster than 1 minute per inch. The laboratory gradation is attached
which indicates the material is a silty sand.
Wells on this and adjacent lots are shown. The new system will be a minimum of 100’ from all
wells and surface water, and more than 5’ away from the septic tank. The alternate site is located
more than 16’ away.
Please refer to the attached test hole logs, soils lab analysis, plan and profile sheets for the septic
design. If this design is followed, there will be no adverse impacts to adjacent properties.
Sincerely,
Michael E. Anderson, P.E.
7/26/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191315, Deb Wockenfuss, 07/29/19
x xALTERNATE SITE
TH1
10050 0
FEET
1"=50'
38' LONG x 5' WIDE x 4' EFFECTIVE
DEPTH ABSORPTION TRENCH
NOTE:
NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE
PROPOSED SEPTIC SYSTEM
ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC
SYSTEMS.
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
MT
T12N R3W SEC 15, LOT 142 N100' & LOT 143 N100'OUR ROAD7/26/19
3-BDRM HOME
CHAIN LINK FENCE
EDGE OF ROAD
SHED
50' PATENT RESERVATION
FOR R.O.W. & UTILITIES
EXISTING WELL
CO
CO
2CO
2CO MH
SV
DECOMMISSION EXISTING SEPTIC
TANK PER MOA CODE. PUMP,
CRUSH AND BACKFILL
ABSORPTION CRIB.
1,000 GALLON SEPTIC
TANK w/20" MANWAY
1
0
%10%10%
EXISTING WELL
EXISTING WELL
>10'
>10'
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191315, Deb Wockenfuss, 07/29/19
T12N R3W SEC 15, LOT 142 N100' & LOT 143 N100'
DESIGN FACTORS: SYSTEM REQUIREMENTS:
450 GPD PEAK FLOW
PERK RATE: .63 MIN/IN
APPLICATION RATE: 1.2 GPD/SF
5' WIDE TRENCH SYSTEM
1,000-GALLON SEPTIC TANK
TYPICAL TRENCH SECTION
(NO SCALE)
4" PERFORATED PVC (HOLES DOWN)
DRAINFIELD ROCK
5'
6"
6"
3.5'
4'
NOTES:
1. GRADE AREA OVER TRENCH TO DRAIN AWAY
2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2'
WITH 2" OF INSULATION
3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER
THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY
BOTTOM OF TRENCH: 8' BELOW GRADE
FLOW LINE ELEVATION: 4' BELOW GRADE
TOP OF TRENCH: .5' ABOVE GRADE
450 GPD / 1.2 GPD/SF /5' WIDE * .5 RED. FACTOR= 37.5 LF TRENCH REQUIRED (38 LF SPECIFIED)
7/22/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191315, Deb Wockenfuss, 07/29/19
LEGAL DESCRIPTION:
PERFORMED FOR:
DATE:
PARCEL ID#:
SOILS LOG AND PERCOLATION TEST
TECHNICIAN:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
DEPTH
(feet)
PROJECT No.:
TEST HOLE 1
SLOPE
SLOPE
SITE PLAN
See Site Plan
DATE READING GROSS TIME
(minutes)
NET TIME
(minutes)
DEPTH to
WATER NET DROP
TEST HOLE PRESOAKED PRIOR TO TESTING:
PERC. HOLE DIA. (INCHES)PERCOLATION RATE: (MIN/INCH)
TEST RUN BETWEEN: FT. and FT.
COMMENTS:
(inches)(inches)
T12N R3W SEC 15 (10300 OUR ROAD)
6/19/19
L. Tidwell
DATE OF MONITORING:
WAS GROUND WATER ENCOUNTERED?
DEPTH OF WATER AFTER MONITORING:
IF YES @ WHAT DEPTH?
NO
-
7/9/18
0.63 6
5 6
015-484-21
CLIENT
3:01
6/19
1
2
3
4
5
6
2:51 112 - 118 63:09
3:12
3:20
3:25
3:29
OVERBURDEN
SM
None
Professional Engineers Stamp:
7/22/19
2:23 112 - 118 6
3:21 112 - 118 6
3:01 112 - 118 6
3:42 112 - 118 6
3:46 112 - 118 6
SAND WITH SILT
SEE LABORATORY ANALYSIS.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191315, Deb Wockenfuss, 07/29/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191315, Deb Wockenfuss, 07/29/19
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MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Water System Permit
Permit Number: OSP201075
Work Type: Well Upgrade
Effective Date
Expiration Date
Tax Code Number: 01548421000
Site Legal Address: % 11,) K' -;W Sec. 15 Lofi5 XYZ. A)10# aal fy3 kioo'
Site Mailing Address:
Owner: LASTUFKA JOSEPH J & MARIE V
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy
o�t�cnt S
U �
C n
Department
Lot Size in Sq Ft:
Total Bedrooms:
4/29/2020
4/29/2021
Q 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 uncle onstructi n during fre we e
shall be either: k
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freeziS
Special Provisions:
To close this permit please submit:
1. Well Log
2. Pump Install Log
3. Water sample results
4. Well Decommissioning Log
Received By:
3
Date:
Issued By: ��.�- Date:V/
0 2o
GR' I'ER ANCHORAGE AREA IBOROU
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION /xJ~ O J~-'~/'~J ~) U J~ "~, L[_-G AL DESCRIPT 0 N I'~' 7~2./~'" '~ 3 ~-~ ~C /~ ~[J,/O0I
SEPTIC TANK: ' ...... ~ ~ Z~ ~ ~'/~X
DISTANCE FROM weLl ~ ~MATERIAL r /
LIQUID CAPACIfY ~ GALLONS. INSIDE LENGTH ~ ~,~ INSIDE WIDTH ~ ~ _DEPIH~,LIQDID ~ ~-
SEEPAGE SYSTEM:
NUMBER OF PITS
LINING MATERIAL
NEAREST LOT LINE
TILE DRAIN FIELD:
SEEPAGE PIT:
.OUTSIDE DIAMETER
OR WIDTH
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
LENGTH .... DEPTH
, BUILDING FOUNDATION ',:~,~ t
DISTANCE FROM WELl
FOUNDA11ON
· NEAREST LOT LINE
TOTAL LENGTH
, OE LINES
NUMBER OF LINES
DISTANCE BETWEEN LINES
TRENCH WIDTH
IN. TOTAL EFFECTIVE
ABSORPTION AREA
SQ. Fl. LENGTH OF EACH
DEPfH: TOP OF TILE TO FINISH GRADE
DEPTH OF FILTER MATERIAL BENEATH TILE
IN. ABOVE TILE
WELL: TYPEZ~)t"-I lie ~ , DEPTH '~ 9'
LOT LINE /O! NEAREST ~'7 ' SEPTIC
, SEWER LINE , TANK.
DISTANCE FROM //4~/. / WATER
,BUILDING FOUNDATION -- __SAMPLE ~/~' . NEAREST
SEEPAGe / OTHER
., SYSTEM ~ CESSPOOl '--- ., SOURCES
DIAGRAM DE SYSfEM
DIS1ANCES:
,J
DAle
APPROVED___
Certificate of On -Site Systems Approval
Parcel I.D. 015-484-21 Expiration Date:, Cc,.+,
I
1. GENERAL INFORMATION V4\00 , ��
Complete legal description T1 2N R3W Section 15 Lots 142"%k &l 43 N100'
Location (site address) 10300 Our Road Anchorage, AK
Current property owner(s) Marie Lastufka Day phone (907) 250-4325
Mailing address
Real estate agent
P.O. Box 110052, Anchorage, AK 99511
2. TYPE OF DWELLING:
Fmil Single Family (w/wo ADU)
F71 Duplex
❑ Multiple Dwellings (Single Famiry and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Fmil
Private Septic
limil
Water Storage
D
Holding Tank
1771
Community Well
0
Community
7
Public Water System
7
Public Sewer
1771
Waiver request for: Distance:
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 Phone (907) 522-7773
Address 1399 W 34th Ave Suite 101, Anchorage, AK 99503
Engineer's Printed Name Michael E. Anderson Date 7/6/2020
6. DSD/ SIGNATURE
System #1 Approved for
System #2 Approved for
Disapproved
Conditional approval for
3 bedrooms
bedrooms
10 F ..............�I- �1 ���
`• 49th •�
..............................................
MICHAEL E. ANDERSON t� �
h�'••.,, 7/6/20 •••r�r�a®
bedrooms, with the following stipulations:
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By: LJJOriginal Certificate Date: 7� �� �� o
r
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 X
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 __________________________________________________________________________________
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA ______________________
Which system tested (date installed)
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:
T12N R3W SEC 15 LOT 142 & LOT 143 N100' 015-484-21
3.8
1969*None
49*
Unknown
6.95
>12 Forge Engineering
7/1/20
31
7/2/20
Well information found in MOA records.
<1
Septic/Plastic
49
New Construction 8/14/19.
5' Wide Trench
8/14/19 New Construction
7.5
3.5
NA
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.
7/7/20
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✔
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Septic tank and absorption system constructed 8/14/19.
✔
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904
On‐Site Water and Wastewater Section Fax: 343‐7997
www.muni.org/onsite
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Nitrate Advisory
Certificate of On‐Site Systems Approval # OSC201315
Subdivision: T12N R3W, Section: 15, Lot: 142 N100' & Lot 143 N100'
A water sample revealed a nitrate concentration of 6.95 milligrams per liter (mg/L).
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/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. Since nitrates are known to slowly increase, we recommend
you monitor the water quality. Please see the attached “Nitrate Fact Sheet” for
important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On‐Site
Systems Approval.
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate
is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as “blue baby” disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a medi a with a strong affinity for negatively charged
ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several “wet chemical” methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive “screening test”, and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
Lot 114
Lot 113
WELL
100 PROTEOiNE RPOIUS
1 132.4'
N100' Lots 142 & 143
o \ 32,991 S.F.
o ROOFTOP
Lot 141 12.2'x15.2' SHED DECK
w/ 4'x6' RAMP 6.2'x8.0' COVERED DECK
WEST 329.90'
Lot 1
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PLOT PLAN ___ AS BUILT —X— SCALE _ 1= __ 40__ GRID _ SW 2536_— Project No.
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates i n c , (907) 522-6476 Phone ooOOp O
(907) 522-4625 Fax o� Q
Professional Land Surveyors kenOlongsurvey.com o � �F :q.�gO44
ionothanOlanasurvev.com O S
I hereby certify that I have surveyed the following described property:
NORTH 100' OF LOTS 142 & 143, SECTION 15, T12N, R3W, SEWARD MERIDIAN, ALASKA
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 ore no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
Dated this The __Q__ Day of ___hi�'>=�5 _—_____,_bU__, 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.
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AECC963
\ 50' PATENT RESERVATION
FOR R.O.W. & UTILITIES
Lot 112
\
EDGE OFIROAD
EAST329.92'
24.7'
- ASPHALT DRIVEWAY
PDQ
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�1466'
24.7
2 STORY o
RESIDENCE
SEPTIC'
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CHAIN—LINK FENCE
WEST 329.90'
Lot 1
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PLOT PLAN ___ AS BUILT —X— SCALE _ 1= __ 40__ GRID _ SW 2536_— Project No.
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates i n c , (907) 522-6476 Phone ooOOp O
(907) 522-4625 Fax o� Q
Professional Land Surveyors kenOlongsurvey.com o � �F :q.�gO44
ionothanOlanasurvev.com O S
I hereby certify that I have surveyed the following described property:
NORTH 100' OF LOTS 142 & 143, SECTION 15, T12N, R3W, SEWARD MERIDIAN, ALASKA
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 ore no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
Dated this The __Q__ Day of ___hi�'>=�5 _—_____,_bU__, 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.
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AECC963
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.---TO BE COMPLETED llY FHA
INSURING OFFICE MORTGAGEE SERIAL NO.
MORTGAGOR OR SPONSOR P~ROPERTY ADDRESS :,~O't~.~h
UBDiVISION NAME ~'-(~,O~ ~j i~,~p ~ ~%'t~) ~h~.~Sg D '~']'oD~,~ ~ ~,D~'JL~[~LOCK NO. LOT NO,
/
TOTAL NUMgERI
[] New installation
C.n attic or other arel~ be made Into
additional bedrooms?
(If Yes, how manyf)
WATER SUPPLY BY:
[~] Public system
SEWAGE DISPOSAL BYt
~[~ Public system
-] Community system
Community system
Individual
Individual
SYSTEM DESIGNED FOR
9. [] Yes [] No
PART II.inTO BE COMPL[¥ED BY HEAl. TH DEPARTMENT
HEALItt DEPARTMENT INSPECTOR'S SKETCH
It is the opinion of the [] State [] County I~] Local Department of Health that this individual water-supply systern
U] is [] is not satisfactory asa domestic water supply for the subject property,
It is the opinion of the [] State [] County ~'[~] Local Department of Health that this individual sewage-disposal sys-
tem with proper maintenance:
1~] Can be expected to function satisfactorily, and [-] Cannot be expected to function satisfactorily
is not likely to create an insanitary condition
DATE J SIGNATURE /' / / fi
Hnv
196g
U~e of the ~bove grid for Health Depe~rtment Intpactor's sketch as well a~ u~e of the back of this form Is at the option of the
health fluthorlty.
PART III.--IFOR USE OF FHA OFF~CE
TO THE CHIEF UNDERWRITER~
I have reviewed the foregoing and the pertinent FHA CotnpliaDce Inspection Report, and recommend that the
Individual water-supply system he considered ~--'] acceptable [~1 blot Acceptable
Sewage disposal be considered [] Acceptable [] Not Acceptable.
DATE
flIALYH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
CHIEF ARCHITECT
DEPUFY FOR CH'EF ARCHIT'!CT
REPORT OF INSPECTIONwlNDIVIDUAL SEWAGE-DISPOSAL SYSTF~!
Distance from well,__
Total liquid capacity.
Inside length,_
Distance from: Well
Inside diameter,
feet. Material
feet. Jnside width,
Number of compartments
gallons. Capacity inlet compartment
feet. Lkluid depth,__ __feet.
gallons.
feet; foundation, feet; nearest lot line at [] front, [] side, [] rear,_
feet. Depth, feet. Liquid capacity, gallons. Lining material
SECONDARY TREATMIENT consists of [] Tile disposal field [] Seepage pits. Other
Distance from: Well..
Total length of tile lines.
Trench width,
Length of each line,..
feet; foundation, feet; nearest lot line at [] front. [] side, [] rear,
feet. Number of lines, Distance between lines,
inches. Total effective absorption area in bottom of trenches, feet. Depth, top of tile to finish grade,
Type of filter material: [] Gravel [] Broken stone. Other
Depth of filter material beneath tile.~ ___.inches. Depth of filter material over tile.
Seepage Pits:
Number of pits ..... Outside diameter, feet, Depth,
Distance from: Well, feet; building foundation,.
square feet.
inches.
feet. Lining material
feet; nearest lot line at [] front, [] side, [] rear,.
[] Local Health Authority.
Inspected by-
__ inches.
REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM
Distance to nearest public water main, feet. Size of main, inches.
lndivklual wells [] arc [] are not customary in neighborhood.
Give most recent record of failure of wells in immediate vicimty to furnish adequate supply of water_
Properties in neighborh~x~d [] are [] are not being developed with both individual water-supply and sewage-disposal systems.
Lot size: feet wide. feet deep. Dwelling set back from front property line, feet.
Individual water supply from: [] Drilled well. [] Driven well. [] Dug well. [] Bored well.
Distance of well from:
Building foundation,
cast iron sewer, feet; tile sewer,
seepage pit. feet; cesspool,
Well construction:
Diameter, inches. Total depth1 feet. Type of casin&
Approximate depth to pumping level of water in well, feet. Approximate yield,
Sealed watertight to depth of feet.
Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill.
Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Yes. [] No.
Pump: [] Shallow well. [] Deep well. Length of drop pipe,, feet Pump capacity,
la)cared in: [] Basement. [] Pumproom off basement. [] Pumpbouse above ground. [] Pump pit.
Pumproom properly drained: [] Yes. [] No. Pump mounting watertight: [] Yes. [] No.
Type of storage: [] Pressure. [] Gravity. Capacity, gallons.
Has bacteriological examination of water been made? [] Yes. [] No. If answer is "yes," give date
Quality of water [] is [] is not satisfactory for human consumption.
Installation [] does [] does not comply with approved exhibits, if any.
Inspection made by: [] State. [] County. [] Lcxal Health Authority.
Inspected by
Date of inspection 19
fret; nearest lot line at [] front, [] side, [] rear.
feet; septic tank._ feet; disposal field,
feet; other sources o£ possible pollution, ~'eet.
Depth of casing,
gallons per minute.
19
gallons per minute.
feet;
feet.
MORTGAGL
, oPOI{ANE
ALA~,KA BIIANCH
523 ~. EIGHTH AVENUE ROOM
ANCHORAGE, ALASKA 99501
272-7443
May 14, 1969
CAAB Itealth Depa:rtment
327 Eagle Street
Anchorage, Alaska 99501
Attn: Mr. Roger Strickland
Re: Anderson~Cera]d & Barbara
Dear Mr. Str:i. ckland:
In accordance with our phone conversation this morning on the
Health Department approval for Mr. and Mrs. Gerald Anderson~ we
enclose a 2573 form.
If you would pi.ease complete this and forward to the I.'IIA
office, P. O. Box 480, we can then receive our clear final for
processing on this case.
Thank you for your help.
encls
Sincerely~
Mrs. Lorraine Cate
Mareh 28~ 1969
Hr. Robert llickman
Federal llousing Administration
P, O, Box uA]O
Aaoho~age, Alaska 99501
SUBJECT: Sewage System Serving
Home of Gerald W. Andsl~son ~
See, 15, Ti~N, R3W,
Dea~, Mr. Ht,~kman~
Personnel of the Grmater Anchorage Area Borough ltealth Department
have made a recent inspe~t~on of the sub,eot sewage system.
Our investtl~attons have shown tha't the present system consists of
a conorste block cesspool looated 110 feet from the dr].lled w~l]..
Mr. Anderson can meet our ~ewage disposal facilities ~equ[remonts
with the in.'~tallatloa of a 750 gallon s~ptic tank plaeed in the
liY, e to the cesspool and at least 50 feet from the existing well.
Money put in esorow for this censtruetion~ ~hieh cannot be accomplished
until the sprini,; thaw, would e~pedfte 'l:he loan approw~l,
DAVID R. L, DUNCAN, M,
Medical Director
BY:
San it arian
DBll/sr~'
~EQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILIFIES
(Fill out in TriDli~¢~te)
- /. ) . ..~. /
re uestJn, a rova /' / /~ "': ' '~" '
~ar~ of propez,~y, owner
Water Analysls:
a, Bacte~.~a ]
b. Detergent
We]~ data: ,/-~
b. Depth ~/d/7
c. Casing Size
d. Distance from well to closest existing or proposed:
1, Sewer, line
2. Septic tank
3. Seepage Area
U, Cesspool'
5. Property Line
houses, barn~ lrazna[e ditch, etc.
Sewage disposal system.
a. Age of system__ ~[.,,
b. Septic tank capacity in
c. Name of septic tank manufactu~
Other sources of p sslble contamlnetlon~ i,e. ~ creeks~ lakes,
].. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type__
1. Oistsnce to property llne to house foundation .
Percolatlon~ Test ~eults
f. Percolation Test performed by
Use the reverse .side of this form to show diagram. Diagram should include
the foJ]owing ~nformation: pDoperty lines4.well location, house location,
~'~c tank location, disposal area ].ocation, location of percolation test,
a~,d dJrection of ground slope,
The ~'~'~-i~,n on this form is true and correct 'to the best of my knowledge,
/ ,
$~Fnature of Applicant Date Signed
T..O_BE FILLED OUT BY HEALTI! DEPAP. T~ENT PERSOHNEL
~The above descrqbed saeitary facilities are hereby epproved subject_to the
roi lowing cond¢~'lo~ns_~:
~'The above described sanitary facilities are disapproved for the followinK
Approval is valid for one year followJnK the date of approval.
CPJ: cw