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Floorplans on this page are shown for reference only and represent the existing room
configuration and approximate dimensions of the existing area.
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and bedrooms are relocated into the new space.
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MUNICIPAIJ'(Y OF ANCHORAGE
DEPARTMENT OF I IEAI.TII& ENVIRONMENTAI. PROfECTiON
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAl_ SYSTEM AND/OR WELl. INSPECTIQN REPORT
NAME
NEW
MAiLiNG ADDRESS~!;0''
I~UPGRADE
LEGAL DESCRIPTION
LOCATION
[ ' /~O ~ IF HOMEMADE: /width
.J ~ / ~
~o. ofl,/~ No. oflines j~Lengtl~ofeaci~e~ ~' Totaltength~hnes
'-~ ].~[[,~,tofh~ishgrad~ ¢~ M~terial beneath tile
~ ....
inches
NO. OF BEDROOMS
PERMIT
PERMIT NO.
PERMIT NO.
PERMIT NO. ·
OTHER
PIPE MATERIALS
SOIl_ TEST RATING
INSTALLER
~EMARKS
APPROVED
DATE LEGAL
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PERFORMED FOR:__
LEGAL DESCRIPTION:
SOILS LOG
MUNICIPALITY OF ANCHOFI\~I~L~I?ALr~
DEPARTMENT OF HEALTH AND ENVlRONME[~ P, RO~EG'~'I.
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TES1
LoT
· SLOPE
PERCOLATION
TEST
SITE PLAN
1
2
3
4
5
6
7
8
9
10
11
13
14
15
16-
17-
18
19
20
COMMENTS
~25-E
1971
WAS GROUND WATER
ENCOUNTERED? N 0
S
iF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE _ /60/
TEST RUN BETWEEN FT AND -- FT
PERFORMED BY:.
72-008 (6179)
EPiAJS
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On-Site Systems Approval 1
Parcel I.D. 018-191-10 Expiration Date: `- 1
1. GENERAL INFORMATION
Complete legal description T12N R3W SEC 33 LOT 10 REM
Location (site address) 3230 DE ARMOUN ROAD,ANCHORAGE,AK 99516
Current property owner(s) MICHAEL&SARAH REILLY Day phone
Mailing address 3230 DE ARMOUN ROAD,ANCHORAGE,AK 99516
Real estate agent _ Day phone
2. TYPE OF DWELLING:
❑ Single Family (w/wo ADU)
❑ Duplex
E Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Private Well ® Private Septic
Water Storage ❑ Holding Tank ❑
Community Well ❑ Community ❑
Public Water System ❑ Public Sewer [[
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 5ag �� Date of Payment
Receipt Number 6,3t//On Receipt Number
COSA# 0 5 e 9/1(43 Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On-Site staff may visit the site to verify the information submitted.
Name of Firm ANDERSON CONSTRUCTION&ENGINEERING Phone 345-3377
Address 4640 SHOSHONI DRIVE,ANCHORAGE,AK 99516
Engineer's Printed Name MICHAEL N.ANDERSON,PE Date 5/22/2019
oFl/t/tioo, 4.,4.
* :•49 "6. DSD SIGNATURE / i1
System #1 Approved for J bedrooms 111 No. N.
CB 0469 4N.
69 .•�'�
System #2 Approved for bedrooms 1t /22/.1.9.. '/
Disapproved \���i
Conditional approval for bedrooms, with the following stipulations:
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1�VICES \��`5���
By: k (-vv. Original Certificate Date: 6.- S / -w' l
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA)based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: T12N R3W SEC 33 LOT 10 REM Parcel ID: 018-191-10
If more than 1 septic system on lot: COSA Checklist# of_ Structure served by this system
A. WELL DATA
f� Well log is filed with Onsite (or attached) Well production at time of test 5+ gpm
Date drilled 1971 Water storage tank volume NA gallons
Total depth *65+ ft Well disinfected for coliform test? ❑ Yes ® No
Cased to *40+ ft ® Coliform bacteria is Negative
Z Sanitary seal is functioning correctly Nitrate N D _ mg/L ❑ Nitrate less than MRL (ND)
Z Wires are properly protected Arsenic ND ug/L ❑ Arsenic less than MRL (ND)
Casing height (above ground) 12+ in. Collected by FWCS
Date of flow test for COSA 5/16/2019 Date of Sample 5/17/2019
Static water level at beginning of test 44 ft.
Comments *Based on acoustic readings & MOA record docs.
B. TANK DATA—8/20/2009 - 1500-gal C. LIFT STATION - NA
Age of tank(s) 10 years ❑ Required maintenance completed
Tank type/material SEPTIC /STEEL Age of lift station years
Measured operating fluid level in septic tank 49.5" Lift station material
® Standpipes/foundation cleanout per record drawing Comments:
Date of pumping 5/15/2019
D. ABSORPTION FIELD DATA— 105'L x 2'W x 6'ED — 0.6 GPD/SF = 1260 SF
Which system tested (date installed) 8/21/2009 Adequacy test date 5/16/2019
® *ALL standpipes present per record drawing Results El Pass For 5 bedrooms
Total measured depth from grade 13 ft (max) Fluid depth prior to test 16 in
Measured depth to pipe invert from grade 7 ft(min) Water added 950 gal
❑ N/A— pressurized field
New depth 31 in
® Monitor tubes go to bottom of effective. If not, state Elapsed time 1320 min
depth into effective
Z Code-required soil cover over field Final fluid depth 15 in
® System presoaked Absorption rate 750 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test)
Gallons introduced 1500 gallons If yes, enter date
Comments/Deficiencies: *Original '82 system only visible standpipe was a cleanout and lateral was full of liquid.
Presoaked 2009 system and switched diverter to 2009 field. MT will need to be found or installed in '82 field if to be
tested in the future.
COSA Checklist.docx
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' Community Sewer Manhole/Cleanout> 100'
Z Yes if No _ft ® Yes if No ft
Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' Z Yes if No ft
Absorption Field on Lot > 100' ® Yes if No ft Holding Tank > 100' ® Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' ® Yes if No ft
® Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® 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 ft Wells on Adjacent Lots:
Property Line > 5' ® Yes if No ft Private Wells > 100' ® Yes if No ft
Absorption Field > 5' ® Yes if No ft
Water Main > 10' ® Yes if No ft
Community Wells > 200' ® Yes if No ft
Water Service Line > 10' ® Yes if No ft
If septic tank is under driveway comment below
Surface Water > 100' ® Yes if No ft
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' Z Yes if No ft If absorption field is under driveway comment below
Property Line > 10' ® Yes if No _ft Wells on Adjacent Lots:
Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No _ft
Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft
Surface Water> 100' ® Yes if No ft
F. ENGINEER'S COMMENTS
41P-. , AT
G. ENGINEER'S CERTIFICATION ;:(s.....,(S...... . . �s'
I certify that I have determined through field inspections and review I*�49 TH/\ * r
of Municipal records that the above systems are in conformance /
with MOA COSA guidelines in effect on this date. I
r
MICHAEL N. ANDERSON.
. No. CE 9469 4v /
COSA Checklist.docx 15/22/l9 4
A4OFESSIOt=
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. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
I"'~ \ ~t~ -- ~c~. \~ \1~ HAA# ~.
GENERAL INFORMATION
Complete legal description
Location (site add'ress or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Day phone
Day phone
Day phone
Address
Unless otherwise requested, HAA will be heJd for pickup. ' ....
NUMBER OF BEDROOMS: ..~' ",4 '
3, 'TYPE OF WATER SUPPLY:
Individual well
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
Holding tank
Community on-site
Public sewer
NOTE:
,X
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system,
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Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LO-i-' ID -~Q ~;~,TI2N~t¢/ Parcel I.D.
A. WELL DATA
Well type ~ ~.S,
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
b,,/ Date completed
I ~L.~ Cased to I 50
ADEC water system number
Driller
Casing height
Wires properly protected (Y/N)
Date of test
Static water level
FROM WELL LOG
AT INSPECTION MUNICIPALITY OF ANCHORAGE
SIP '1 7 99t
Well flow
Pump level
g.p.m.
L EIVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Public sewer service line
WATER SAMPLE RE~'5'M~TS:
Coliform '"% _ Nitrate
Date of sample:
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Collected by:
Other bacteria
El. SEPTIC/HOLDING TANK DATA
Date installed (¢/,~1] ocz- Tank size /.~ ¢~'~
Cleanouts (Y/N) ~ Foundation cleanout (Y/N) ~
High water alarm (Y/N) ~/~
Date of pumping ~/1~/~ I
t'¢ Depression (Y/N)
Alarm tested (Y/N)
Compartments
SEPARATION DIS'rANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To propertyline_
Surface water/drainage
On adjacent lots >/t.~'~-~ _Foundation
Absorption field ~Water main/serwce line
h//A
72-0261Rev. 3/91) F¢ont MOA21 CONTINUED ON BACK PAGE
C. LIFT STATION ~J/.z~"
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length ~ Width_
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Soil rating /-'~ System type
Gravel thickness ~' Total depth
Cleanouts present (Y/N)
Date of adequacy test
for ~r-'~ bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot //.~ On adjacent lots ,~ /¢..~¢2
Property line
To building foundation
On adjacent lots
Surface water
Curtain drain
To existing or abandoned system on lot t'///~
Cutbank ~'-///'/:k- Water main/service line
Driveway, parking/vehicle storage area ')
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in ef(e.cton the date of this inspection,
Engineer's Name
Date
HAA Fee $ ,///,,,2,,~.
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
205 NEST I511h AVENUE SUITE
ANCHORAGE, ALASKA 99502-7904
(907) 279-79t&
RESIDENTIAL WELL INSPECTION
LEGAL: [.crt. 10,~ Sectiorl 33 T12N,) R3W
LOCAT I ON:
3230 DeArmc:)un Road
OWNER: Bruce Ayer
TYPE OF WELL: Pr:i. vat:e.~ SJ. ngle I::'amily
WELL LOG AVAILABLE:
No
INSTALI_ATION REQIJIREMENTS MET:Yes
WELL YIELD FROM WELL LOG:
PUMP YIELD FROM TEST:
5.5 Gal ].c)ns per M:i.r'lu't:.e
DATE OF INSPECTION:
Sep'l:.,. 3~ 1991
TEST PROCEDURE: Well was pumped at a cons'LarrY, rate while 't:he
probe. Ak the bec. l:i. nn:i.r-,g fD'f t'.he test water level was fOLU"td at 3.6
· f:eet bet f::lw top o't: cas:i, ng. At: a pumpirlg rat. e of ,5.5 gal ] OhS per
m:il'tU'L:e the wa'l:(,)r ].ev6)], dr(:)pped tc:) 57 .t:eet. a.f't:er ~¢ hours [:)~ pt..mil:)
:i.i~:],, A '~:ol:a]. c:)F 750 ga:l, lf:]ns were pumped,,
The rocc:)very ~as mc)ni't.'.ored for 75 m:i. nut. es, ~}LU'Jl](] '(:hJ.s 'U.~.f~e '~.h(a
TEST FOR E.COLi AND TOTAL NITROGEN: Water was '[:es'l:.ed -For E.Cc)l:i.
E,,Co] :i 0,, Total Ni'Erc)(Je[~ ND (Non(z, DetecEecl)
Max,, a].]c)wab].e Total. Nitl"ogen 1() m(;~/].,
TEST RESULTS: Thi s ~.~el ] ine~etc, 'Lhe r'eqLt:i, r emelrLs o',r' the
t~lt..u):[ c:i. pal :i. I:.y o'f:
TGIS WELL .W_ILI_ PRODUCE MORE THAN 3 GALLONS PER MINUTE FOR MORE
T_HAN F_OUR HOURS
,::/ss~:.~sm(,;,nL o'F bl'lr~ condit:i.c}r~ o-F the ~e].]. app].ies c:)r'~].y to 'l/.l~e
c:or~d:it:i.(::)rts as (::)f the day tes~tod. The 'f].c)w rate may clqange duct
203 WES'[ 15VH, AVENUE SUITE 20&
ANCHORAGE, ALASKA 9V502-Jq04
(907) 279-3~16
SEPTIC SYSTEM ADEQUACY TEST
LEGAL:
I...o~: 10 Sect:i. on 33 TJ2n R3W
LOCATION:
3230 DeArmoun Road
OWNER:
Bruce A y ~:,r
RESIDENCE:
S:J. ngle F'ami]y~ 5 Bedrooms
WELL:
F::'r':i. vate~ On Site
SEPTIC SYSTEM:
F:'RSM MLIIqIC:PAL RECORDS: 5 Bedroom System
]'ANK~ Grce~r Steol 1500 Gal. Two Cc~mparts.
ABSORF:'] I ON SYS]EM:
ABSCIRPTION ARI:::A: 756 Sq. Ft,,
SO ]: I. RAF I NG ',', :1. 5C)
I NSTALJ...A-I' I [JN DA']'I: ~ 6/2:1/82
DATE OF LAST PUMPING: Anch.. []ess F'ool Sept. 10, 1991
DATE OF TEST:
Sept. ember :i3~ J. 99:1.
]'EST PROCEDURE: Sys'E<?m was :i. nspected and measured. 'Tank was
· ~ound with 4 Feet o'~ cover and with a ].iquid level o'~ :1.5 :i.n(:::hes.
Tr e~:ch (:..]. can OLd: was zl. 5 ~:eeE deep and dr"y. 'l"r'er'~ch mc>n:i. I::or 'Eul:)e
was 9.,5 'F(z,,eE de)el:) with 47 inches o'f water,,
:1.280 gal. ] ohs (:~-~ c] c~an watc.~r was adcied ~c:} Ehe b.r'c:er~czlq whJ. ] e Ehe
water lc)vels in the I:ank and the monitor rude W~::re morl:Ltor-ed. The)
wa~:c,.)r ]eve]. :i.n t:he ['.alfl<: d:i.d not. change~ whJ].e 'Eke l(...)ve]. :in the
· For 5 I"~our's,. DLH"J.I"H;) Lb:is k~me 'El'it:, water' lev(Il :i.n El'to.i, mc]n:i.l:or' Izub[e
dr'opped 5 :[l'~C:hes.~ :Lr~dic:at:Lng {:hat :~R:t() ga:l.:l, ons o.f wal::el" had [:)e:en
TEST RESULT:
Department
the Health and Soo:iai. Services
'l':he Mun i c i pa:L :i. ty oF Ai](::hoi"Ar.:jt:~.
NOTE The operational :l.:i.-Fe o'f ail septic sysEems:> depends Ol't the
:L oc:al sol ]. (:(:3i'~(::1 :i. {::i. 01'~ :: ~ gl~'(]l.{ll CJWTI'{: E2r 1 e,.)vc~ ]. E~ th&v{] fllay .[ ].
estimate o'f how lc)rig th:is system wi:t:L ~l:rlC:]:iOI] sak:i.s;Eactor-Y 'f:or
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 8 STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
ANAEYSIS REPORT BY SAMPLE for WORRorder$ 37882
Date Report Printed: REP 7 91 @ 11:56
FAX: (907) 561-5301
Client Sample ID:3230 DE ARffOUN RD.
PWSID :UA
Collected REP 3 91 @ 13:06 hrs.
Received REP 4 91 ~ Il:SO hrs.
Preserved with :AS REQUIRED
Client Name :TOBBEN SPURKEAND,
Client Acct :TORRENS
Req ~
Ordered By :TOBBEN SPURKLAND
Analysis Completed :REP 6 91 Send Reports to:
Laboratory Supervisoi :~T_gP~tEN C. I)TOBBEN SPURKLAND, P.E.
Released By : ~~ E~___~_/ 2)
Chemlab Ref ~: 914565 Lab Srapl ID: I ~atrlx: WATER
Allo}lable
Parameter Tested Result Unit~ Method Eimits
NITRATE-N ND(O.IO) ms/1 EPA 353.2 10
Sample ROUTINE SAHPLE C0[J. ECTED BY: STUART.
Remarks:
I Testa Performed ' See Special Instructions Above UA=Unavailable
ND= None Detected "See Sample Remarks Above
}IA; }lot Analyzed ET=Less Than, GT=Greater Than
~G-~ Member of the SGS Group (SockRt* G~n~rale de Surveillance)
/ tt[~ALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAl. SYSTEM
~ARY I.~.YO I~ CO~PL~?~ BY ~IA
~chorage ,
/
.__j~!cl~0~'_~g~_ A]-~i?..~ The l~irs t National Bank of [I 11-011427-203
t.~oa~Aoo~ o~ s~o~so~ ........................ ~o~f~d~
Bruce E. Ayer Jr. & Julia K. Ayer j~eA~mun Rd. Anchorage 99502
Sec~ 33, T12N., R3W., SM / 10
15
I.l Public system ~ Community system ~ Individual' 5 [(Ti Yes [~ No
,,o o,,i,~o, of t~,e [] S,~t~ Iii Co,,~, El ~ocal Department of Health that this individual water-supply system
]~j] is nor satisfactory asa domestic water supply for d,e subject prol~rly.
C,,n he expected to function satisfactorily, mM [] Onnot be expected to function satisfactorily
not likely to create an insanitm~ condition
6/b/72 .... Env~ :
GREATER ANCHOF~G~ AReA BOROUGH
Department of ~.kw'Jrenmental qtality
3500 Tuc]or Road, hnc'orage~, Alaska 99507 279~8686
Type of Facility to be
Number of Bedrooms: ~"
Seepage Pit: ]. Size ~ t;~', 2.
Disposal F~e]d; Total Length of Lines
Distances:
A, We]]. To:
Soptic Tank ............ , Absorpi;ton Area~_~_~___, Sewer Lines
, Nearest I,ot l.lne _~-~'? , Other Contamination /~
Foundation to Septic Tank %0' ~> Absorptien Area ~d) ---~.
Absorption Area to Nearest Lot Line ~ ~ ~
Request for Approval of L ~vfdual Sower & tNatey Fact].it;t6
Page Two
Aoorove ~sapproved Dar
/ ~p~rova] Valid for One Year l~rom Da%e Signed
~r A~ago Area Borouf~h, Department" of ~nv:i. ronmenfial Qualify
DIAGNAM Ot: SYSTEM
:[ cerf, iCy ~ha~ fihe informa~;~on conf, ained in ~his reques'c far approval 'co be a t;rue
arid accurate represe¥~at~on of the subject sewer and water ¢aci].tf, ies