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Home My WebLink AboutT12N R3W SEC 29 PARCEL 5 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. 018-161-06 COSA# 03C [a1�A3+ 1. GENERAL INFORMATION Expiration Date: 9 _ : ) II — >i.2— Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address T12N, R3W, SEC 29, PARCEL 5 13926 LAKE OTIS PKWY *ANCHORAGE, AK 99516 LEILA NELSON Day phone 345-2578 13926 LAKE OTIS PKWY *ANCHORAGE, AK 99516 Day phone BETH SIMPSON W/ KELLER WILLIAMS Day phone 865-6556 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer E The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 1 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 GARNESS ENGINEERING GROUP, Ltd. Phone Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DS, D/SIGNATURE V Approved for :3 bedrooms. Disapproved. Conditional approval for bedrooms, with the following Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory 337-6179 Date Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other ON-SITE WATER AND WASTEWATER PROGRAM by: �I Original Certificate Date:�— (Rev. t1/O5J Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519.6650 www.cl.anchorage.ak.us (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: T1 2N, R3W, SEC 29, PARCEL 5 Parcel ID: A. WELL DATA *PER AAROW PUMP AND WELL SERVICES (SEE ATTACHED) 018-161-06 Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) NO Date completed UNKNOWN Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth *96 ft. Cased to *50+ ft. Casing height (above ground) 12+ in. FROM WELL LOG Date of test NO WELL LOG Static water level ft. Well production g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Arsenic: mug./L. B. SEPTICIHOLDING TANK DATA Tank Type/Material Tank size gal. Foundation cleanout (Y/N) Date of C. ABSORPTION FIELD DATA Nitrate 4.18 mg./L. Date of sample: 4/25/12 Number of Compartments Pumper AT INSPECTION 2/25/12 73 4.81 g.p.m. Collected by: GEG. Ltd. PUBLIC SEWER Date installed High water alarm (Y/N) Date installed Soil rating (g.p.d./ftor ft2/bdrm)_ System type Length ft. Width ft. Gravel below pi ft, Total depth ft. Eff. absorption area_ ft2 Monitoring tube Depression over field_ Date of adequacy test Results (P I For bedrooms Fluid depth in absorption field before to _ in. Water added Elapsed Time: — ra1 . Final fluid depth _ in. treatment (past 12 mo.) (Y/N & type) — gal. New depth _in. Absorption rate >= g.p.d. If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN "Pump on" level at in. "Pump ofP level at_i . High 'water level at Cycles tested Meets alar & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A On adjacent lots 100'+ Absorption field on lot N/A On adjacent lots 100'+ Public sewer main Sewer /septic service line 25'+ Animal containment areas 50'+ Public sewer manhole/cleanout 100'+ Holding tank N/A Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption Water main Water service line Surface Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION Property line Water service line / Surface water Wells on adjacent lots F. COMMENTS TO: Water main Driveway, parking/vehicle storage G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in"""' "" " """• """" confoimance with MOA COSA guidelines in effect on this date. f. a. ......ss;:... Engineer's Printed Name JEFFREY A. GARNESS Q� 9 Es79 3 m� Date b`Zorfz O�� b{ Dov ro f es'7"r, COSA Fee $ :7y(4-0 Date of Payment Receipt Number tRW.11/05) Waiver Fee $ Date of Payment Receipt Number AAROW PUMP. & WEU SERVICE, LLC P.O. Box 110496 Anchorage, AK 99511 Office: (907) 346-9355 • Fax (907) 333-8976 Eagle River: (907) 622-9335 CUSTOMER L JOB SITE Z6244 ZSL PHYNCE No. 9440 J INVOICE DAT WELL DEPTH SWL 7n CHLORINATED PUMP DEPTH SA�LESR R ON `JP_RRIICE. Uq ITY DESCRIPTION - '1` AMOUNT _Z � f LABOR HOURS RATE AMOUNT TOTAL MATERIAL TOTAI,LABOR WORK ORDERED BY DATE COMP. TOTAL LABOR PAY THIS AMOUNT Thank You SIGNATURE (I Hereby Acknowledge the Satisfactory Completion of the Above Described Work and agree that if above work is not paid for in 90 days I agree to allow Aarow Pump & Well Service, L.L.C. the right to remove unpaid for equipment and charge for labor already performed & labor to remove unpaid for equipment.) TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS. r: WLW W L9 • I PasTM�s°0--------- DEARMOUN ROAD-- �-1U -----J 5 .,e, f/ T1exN=oRMAnoN HEREON xsFa+TI¢ VSE oF�Noxw Iwnrvrzo SHANEA. HOLT u�0 tMPLICis 9ETx MSS WSWVCi E$ AND MATTED LOTUWS NDT i0 BE VSEO Fd PORTSGMNS ADDITIONAL STRVCTUREYIM±RP L"9;4EnSENRNT50FREMTCATNE4TW.NT4g5E AR:N60NTh8 RFCG �4 te9clon0\I'Ao� NJ✓TLgfF1.KELiIk'S THAT M4DY1 A.D OMA, WR MASIMEN'JT TO ��`J�`Jppoc V¢CiERTYttPESgl PWC.IApptnON TWAW MEMS ANv]AVIIK. SHOWN VGRECNMAv &' A4Po10%INATE Otf M E%[ESSIIT N i INDICATE NORTH STREET r t e /t k t �r SEWER SERVICE LINE SKETCH SHOW LOCATION OF CONTROL MANHOLESICLEANOUTS ALLEY SIZE MAIN: 3q_'_ TYPE MAIN: D r f CONNECT DEPTH AT MAIN .13— CONNECT DEPTH AT Prop. Line CONNECT LOCATION: /f9 N COMMENTS:__ 0 L,F._�x�rn st7�} tfv INSPECTED BY: DATE: -- SUBDIVISION: cc cc O A- W cc z 0 U w IL z Z_ x w 3 w fn SEWER SERVICE LI SHOW LOCATION OF CONTROL SIZE MAIN: TYPE MAIN: CONNECT LOCATION: COMMENTS: LOT: CONNECT DEPTH INSPECTED BY: .....%{/Ss _ _.— DATE: _/v MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~'),\C~ \/~-,\ -('%.~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner ~-~'¢__Xr~cb¢ P,n¢/~y Telephone: (home) Business Mailing Address % R~ ~6~ ~o¢ (c) Lending Institution ~ ~¢~ ~/~ ~o~ Telephone Mailing Address ~ff~-[ ~/~ ~ ~ /~/~ ~ (d) Real Estate Company and Agent ~ ~m~ ~ ~¢~ Telephone ~7- (e) Mail the HAA to the following address: (or check here ID, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family [] Number of bedrooms 3. WATER SUPPLY Individual Well I~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025(Rev 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein, I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection, Telephone 6, DHHS APPROVAL Approved for '-'-~__ bedrooms b Uato &../ / / Approved Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 DH HS 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. 72-025 (Rev 7/881 8ack Page 2 of 2 Well Classification p¢'~ u'~ ~-~ Well Log Present (Y/N) ~/ Date Completed MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: If A, B, C, D.E.C. Approved (Y/N) Yield 7, / w Total Depth :~ ?/' Static Water Level Casing Height Above Ground %0" Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: Cased to ~/'__ Depth of Grouting ___N, ~, Pump Set At ~ 7(' Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) iV To Septic/Holding Tank on Lot /~, ,4,. ~. ?~xb/,c ~"~<71; On Adjoining Lots /~1, To Nearest Edge of Absorption Field on Lot F/. 6. __; On Adjoining Lots /~' To Nearest Public Sewer Line ~_/5'~ To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ._ ~' ~¢ Water Sample Collected by __~--f:: I'-/ ; Date 1(.'/1~'./~ WaterSampleTest Results ~C~ /~r,~c/z2~",2. ~ ~;~ co 6.~,**~ Comments ~'/~¢'lfl¢ci ccan/~ ~ c~ro,O ~ /¢'(~ ~ ~ N//~ B, SEPTIC/HOLDING TANK DATA~ Date Installed Size _____ No. of Compartments Standpipes (Y/N) Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments ~pm, f'l~c.¢ con~t¢' Cf-coo lea Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field 72-026 (Rev. 7/88) Fronl Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments [_p~ ~, l,'c ~C~.r.~, e/"] Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) D, LIFT STATION A/ //)- Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA gg,J,~re~,$r~gffect on the date of this inspection. Signed ~~ ~ ~ ~%~" ....... Company ~(~ ~o~(~{ %~c~ ~ffi .................. ~.'-.~ Engineer's Seal Date O~;~ /7 /¢~¢ MOA No. ~ - ¢~ ¢ Receipt No. ~./~ f Receipt No Date of Payment -' ,/~' -~/ Waiver Fee: $ Amount: $ .~ ~2 Date of ~ay~ont 72-028 (Rev 7/88)Back Page 2 of 2