HomeMy WebLinkAboutMANN BLK 3 LT 1BMann
lock
Lot i
020-041
-06
Mark Beg,ch
Mayor
Deve!opmtn't $:ervices Depart'merit
~'-~, ~ z Division
4700 ~regow Street
?.O, ~ox L96650
wv,,w.mun J,o rq/"o nsf to
(~07} 343-7904
Well Drilling Permit Number: SW
Parcel Identification Number:
Pump Installation Log
¢)
Legal Description
'Pump Installation Date: -7/'7/
L'IR
Property Owner Name & Address:
Pump Intake Depth Below Top of Well Casing: 2"Z7_. feet
Pump Manufacturer's Name: /~6J dc~c/(e .~
Pump Model: ~A/5 i~) V ~
Pump Size ~/L/ hp
Pitless Adapter Burial Depth: [~ feet
Pitless Adapter Manufacturer's Name: ~ ~'~ ~S~
Pitless Adapter Installer:
Well Disinfected Upon Completion?~Yes ~ No
Method of Disinfection:
clz
Comments:
Pump Installer Name:
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Municipality of Anchorage Page I of
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: 5t,¢~00~8 PID Number: ,¢~ [~;
Name: 3oHf'J. CO0'['~gES Wastewater System: ~ New D Upgrade
Address:
I[~G ~I~bERN~S b~lvE,~c~ ~5/ ABSORPTION FIELD
NO. o~Bedrooms:
Phone:~_ ~ ~ DeepTrench ~ Shallow~rcnch_D Bed B Mound ~Other
L E G A L D E S C R I PTI O N so, Rating: I, 2 GPD/Sq. FI. Total Depth from2,origin~l~, grade:
Lot: Block: Subdivision: Depth to pipe boltom Irom original grade: Gravel deplh beneath pipe
J 6 3 H4~ 2.0 ~t. O,~
Township: ~1 ~ Range: 3 ~ Section:~ Fill added above originall grade: Ft. Gravel length: '~ ~ Ft.
Number of lines; B~stance belween lines:
WELL: ~ New ~ Upgrade Gravel width: ~ Ft. I I ~ Ft.
Classification (Privale, A.B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Ft. Ft. ~ SO. Ft. ~"¢ERF
Ft. ~IEL~oN
Yield: GPM Pump Set at: FL Casing Height Above Ground:FL TAN K
SEPARATION DISTANCES ~s~.tic u ~o~di,g u S.~.E.~.
TO Septic Absorption Lig Holding ~ublic/Priva~e Manulaclurer: Capacity in gallops:
From Tank Field Station Tank S .... Lines A~C~oRA~ TANK
Well ~ IO¢ ~ O~ ¢ ~ ~ I O~/ Material: ~T~ & Number of Compartments:
Surface ¢
Water >JOO >/~o __ -- >/~o' LIFT STATION
Lot ~ j Size in gallons: Manufacturer:
Line ~0 ~ ~ -- ~O /
Foundation ~1 ~ i ~ ~ ~ "Pump on' level at: "Pump olf' level at: High water alarm at:
Curtain ~ ~ ~ ~ ~ Pump Make & Model Eleclrical Inspections performed by:
Drain
Remarks: ~v;~ ~(~ ?¢ BENCHMARK
/ Location and Description:
~nro ~ ~rm',~ , ~ I,n& ToP OF F~NbAT/O~ No~T~E5~
Assumed Elevalion:j OO, O
145~0 ~
,nspections performed by: FLATTOP ~" 5'¢65 Dates:lst G/E/~5 ~;;~9~
~ _ 2nd ~/~/q~ ~'"'"" ......... '~'"~
o, es a.?,/
e ,ewe a oved
72-013 (Rev. 9/91) MOA 25
Flattop Techn~ca! ~ervice~
Permit No. ~ ~ c~5OO~'S ]4530 Echo Street Page 2 of '~
;[r~choraqe, Alc~slcc~ 995]8
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: /.,o'r I B, ISI, I~ ~ ~ M.,~NN 5ID PID No.:
/
1"=30 '
Iooo (~/ta
5'£PT~c 'rANk
C ,0," b"
A
ToP oF F'OU~'IDAT~O~(
B' HOUSE
'0 /
(.:
ENGINEER'S SEAL
72-013 A (Rev 9/91) MOA 25
:Flattop TechnfcaI Services
14530 Echo Street
Permit No.5~':/&oO 8:~ Anchorage, Alaska 995]R Page 3 of 3
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LegalDescription: ).oT I B~ I~,LI<3/ I'4.,~I~N ~/D PIDNo.:
~5
VEP. TICAL SCAL[ : I"'=~
Ro HOR~Zo~4T,~L. $CAL~
~3,0t
Bo.~
ENGINEER'S SEAL
· THEODORE F. ~OORE
72-013 A (Rev. 9/91) MOA 25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE
1 OF
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW930088
DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES
OWNER NAME:COOMBES JOHN C & JOAN L
OWNER ADDRESS:il765 WILDERNESS DR.
ANCHORAGE, AK 99516
DATE ISSUED: 5/07/93
EXPIRATION DATE: 5/07/94
PARCEL ID:02004106
LEGAL DESCRIPTION: MANN BLK 3 LT lB
LOT SIZE: 44961 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / 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 (iSAACS0).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 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:
WR 930023 DATED 5/0~/93/C~RANTSJ)~OT LINE~I~VER FOR THE
ORIGINAL AND R~P~E~CE~ABS~P~?IQN F IEL~/6J/
~EIVED BY [ ~///~7~/~,-~- //~ ~/ DATE:
Tom Fink,
Mayor
uni ipal ty of ncLo a ¢
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
May 10, 1993
Ted Moore, P.E.
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
Subject: Waiver Request for Lot lB Block 3 Mann Subdivision
Waiver Request #WR930023, PID #020-041-06, Permit # SW930088
Dear Mr. Moore:
Your request for waiver of the required 10 foot separation
between a septic system and a lot line has been approved.
waived distance is 2 feet from the south property line.
The
This approval applies to the existing septic system lot line
separation only. Any future upgrade to the septic system will
require all separations be met or another approval from this
department.
....
Civil Engineer
On-site Services
RWR/ljm
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR~ WR930023 PID~ 020-041-06
Date Received: May 6, 1993
HA# Permit
Legal Description: Lot lB Block 3 Mann Subdivision
Engineer: Ted Moore, P.E.~ Flattop Technical Services
14530 Echo Street, Anchoraqe, Alaska 99516
Applicant: John/Joan Coombes
Waiver Requested: Lot line waiver - 2 feet of south property line
Criteria: 1. Geology: Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
Special Conditions:
3. Other:
Waiver is Granted: Waiver ~s NOT Granted:
List Conditions or Re'so'ns for above:
Date:
Name of Reviewer
Rec #: 24656/7754 Amount: $ 70.00 Date Paid: May 6, 1993
THEODORE F. MOORE, P.E.
PH: (907) 345-1355
CIVIL & EN¥1RONMENTAI. ENGINEERING * ENERGY CONSERVATION & 324ALYSIS
May 5, 1993 14530 ECHO ST.
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sirs:
MAY 6 1993
Munic~pal:ty o~ An6llQra~3~
Dept. Health & tflltman S~'
The purpose of this letter is to provide the required design nan'ative in support of our application for a
permit to construct wastewater disposal facilities on Lot lB, Block 3, Mann S/D, located at 16236
Elizabeth St. Soils logs, perc test results, a site plan, design ch'awings and specifications m'e enclosed for
your review. We are also requesting a lot line waiver allowing construction of the ch'ainfield within 2 feet
of the south property line to take advantage of the particularly favorable soils in that area. Granting of this
waiver will have no significant impact on the ability to upgrade the existing septic system on Lot 4A at
such time as an upgrade is needed.
The proposed system will be constructed in the vicinity of test holes #1 and #3. As can be seen fi'om
the soil log for test hole #1, the native material between 2 feet and 5 feet below ground level is a clean well
graded gravel with a measured percolation rate faster than one minute per inch. This material is ideal for
accepting septic tank effluent, and no sand filter should be necessat7 because them is more than 2 feet of
unsaturated underlying material with a measured perc rate'of 10 minutes per inch. The gravel material at
a comparable depth in test hole #3 is somewhat siltier and has a measured perc rate of 5 minutes per inch.
While this material is also suitable, we are requesting the lot line waiver in order to allow maximum
utilization of the i~eal material encountered in test hole #1. Om' design is based on a soil application rate
of(1.2 gpd/sq, ft, -.The proposed 3 bedroom residence requires a total absorption area of (3 x 150)/1.2 =
375'~qu~u'e feet The proposed 5 foot wide by 75 foot long drainfield design has a total absorption at'ea of
375 square feet. A location for a comparably sized replacement rh'ainfield is also shown on the site plan.
The topography of the lot slopes down to the WNW at 40% above the site of the proposed
drainfield(s) which are on a bench sloping down at 10%. Just west of the proposed ch'ainfield site(s) the
land (h'ops down. a few feet to a poorly (h'ained area. See log for test hole #2.
The proposed project will have no significant impact on present or future water supply and wastewater
disposal systems serving adjacent properties, nor will it have any impact on reserved space/surface and
subsurface, or on ch'ainage.
Please give me a call at 345-1355 if you have any questions on this submittal.
Sincerely,
Ted Moore, P.E.
%OgT~R ~P6-E. o~=
PLA N VIEk/
iii_.- IOl-O''
:~,,
SECTION "A-A"
· ,THEODORE F, MOORE ..
;,~ ~ CE - 3589 i
LOT It3., 13L. Ic 3, PIAN N
WASTEt, c',4T'EtR DISk 5 yST.
PLAN ~ X-SECTION
DA, T~ :
Flattop Technical Service~
14530 Echo Street
Anchorage, Alaska 995!
Flattop Technical Services
14530 Echo Street, Anchorage, AK99516
Phone (907) 345-1355
Lot lB, Block 3, Mann S/D
16236 Elizabeth Street
Wastewater disposal system installation
Specifications
1.0 General:
1.1 The scope of the project consists of installation of a 1000 gallon septic tank followed by a 5 foot
wide by 75 foot long shallow soil absorption drainfield.
1.2 Construction shall be as depicted on the approved site plan and design ch'awings. Minor
deviations from these drawings may be allowed or required by the engineer conducting the inspections.
All construction procedures and material specifications shall conform with Municipal and State
requirements. All separation distances shall be in confonnm~ce with Municipal requirements, unless
specifically waived.
1.3 The contractor shall be responsible to obtain auy necessary utility locates, and to work around any
bm'ied utilities.
1.4 The contractor shall provide adequate cover material and rough grading over all system
components to ensure that proper drainage is achieved after settlement and that there are no residual
depressions. Insofar as possible the contractor shall minimize damage to trees.
1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after
the soil is compacted, as well as placement of topsoil and reseeding all areas disturbed by the construction.
1.6 Prior to the start of construction, the homeowner shall m~'ange for a land surveyor to locate the
NE and SE lot corners and to mm'k 50 feet of the south property line in the vicinity of the proposed
drainfield at 10 foot intervals.
2.0 Septic Tank:
2.1 The septic tank shall be a 1000 gallon Municipally approved tank and shall be set level on
undisturbed soil. Each compartment shall be equipped with a watertight manhole cover and a 4" cleanout.
If the tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial type, rigid
insulation.
2.2 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The
waste line from the residence to the septic tank shall have a minimum slope of 1/4'" per foot, and the waste
line between the tank and the soil absorption system shall have a mhfimum slope of 1/8" per foot. A
cleanout shall be installed within 5 feet of the building foundation, and a double cleanout shall be installed
within 5 feet downstream of the septic tank.
3.0 Soil absorption system:
3.1 The 75 foot long soil absorption ch'ainfield shall be constructed along the natural contour of the
slope by excavating a 5 foot wide trench to a depth of 2.5 feet below the original ground level in the
vicinity of test hole #1.
3.2 The bottom of the excavation shall be level. If excavation to the specified depth does not
penetrate into the gravel stratum at any portion of the drainfield, then the contractor shall excavate
additional material as necessary to expose the top of the gravel stratum. In this case, the bottom of the
drainfield shall be built back up to the design grade by placement of com'se sand.
3.3 A total of 1.0 feet of approved sewer gravel shall be placed in the bottom of the excavation with
the perforated distribution pipe laid level such that the pipe invert is no less than 6 inches above the bottom
of the sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing the
#200 sieve.
3.4 The three monitor tubes and all cleanout pipes shall be of 4" diameter and installed in the locations
shown on the design di'awings. The portion of the monitor tubes extending through the sewer gravel shall
be perforated.
3.5 Approved filter fabric shall be placed over the entire top surface of the sewer gravel. A minimum
of 2 feet of soil cover is to be placed over the filter fabric. If the soil cover thickness is less than 3 feet,
two inches of rigid, burial type insulation is to be placed over the entire top surface of the gravel, in
addition to the filter fabric.
3.6 The top surface of the cover material shall be raised a minimum of 6 inches higher than the
surrounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill
slopes shall be no steeper than 3:1.
3.7 The owner shall be responsible for making sure that all areas disturbed by the consu'uction are
covered with 4 inches of topsoil and seeded with an approved grass seed to promote rapid revegetation.
4.0 Inspections:
4.1 A total of 4 engineering inspections will be required dm'ing the course of the project: (1) initial
stakeout with the contractor to establish the location of the system and to discuss the plans, specifications
and construction procedures, (2) after the native material has been excavated to expose the infiltrative
surface to ensure that it is level and at the right elevation, and conforms with the soil test information, (3)
after the sewer gravel is in place and the distribution pipes have been laid and connected up to the septic
tank, but prior to placement of insulation or filter fabric, and (4) after final backfill and grading is
complete. The septic tank requires one inspection after it is set level and the piping connected, but prior to
backfill. This inspection may be incorporated with any of the above inspections.
4.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently fa' in
advance to ensm'e the availability of the engineer.
Flal[op Techniccd Services
14530 ~cho Sfreef
~inc~or~9'e, Al~sl~cr
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:/.,,O~ I~1~! ~'//'~ ~?,~ /~{)/~ "~(-0 Township, Range, Section:
SITE PLAN
1
2
3
4
5
6
7
8
9
10
11
12
13
14
SLOPE
WAS GROUND WATER
ENCOUNTERED?
$ e e?..r
16
,,,) 19
20-
~.~. S
IF YES, ATWHAT L
DEPTH? ~,~ _ ~ ~/ pO
Deplh to Water After
hlonlloring? ~"h'~
Reading Date Gross Net Depth to Nat
Time Time ~:/11 je) Water Drop
9~o Z:q7 a~Vz - Z7
PERCOLAIlON RA1E 1{9 (m~nutestmch) PERC HOLE DIAMETER
m IY. ¢ .4. TEST RUN ~ETWEEN ~' ~ FT AND ~,5-'
COMMENTS ~ ~C ~ GO~ ~C~ b~. ~,~' ~ ~.7~' ~, Pe~C ~ol~ ~Cc~
PERFORMED BY: ~{~o · - EST WAS PERFORMED IN
~ /4O~bl~a I ~PcI I -{ ~ /~x CERTIFY THAT THIST
ACCORDANCE WITH ALL ST~TE AND MUNICIPAL GUIDELINES IN EFFECT ON THiS DATE. DATE:
72-008 (Rev. 4/85)
F/c~fop Technical Services
14530 Echo Streef
.~nchorage, Ai~s]ca 99,qle
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
,~ .......... ,, __-.~..-...~,'
'~ .................. t ~1
DATE PERFORMED:
LEGAL DESCRIPTION: ~.,¢~ I ~! ~/~%",,~! /¥/~?1~ ~('-~0 Township, Range. Section:
1
2
3
4
5
6
7
8
9
10
11
12
13
14'
15
16
17
COMMENTS
SLOPE
WAS GROUND WATER
ENCOUNTERED?
SITE PLAN
S
IF YES, AT WHAT L
DEPTH? O, ~',5- ~ 0
P
Deplh Io Waler After , ~
Monitoring? O. ~S ~ Date: . ¢i//,~'o/'93
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLAFION RAJ E tmmutes/mch) PERC NOLE DIAMETER
TEST RUN BETWEEN __ FT AND __ FT
y~,ff--ca.61z. ~,r ro~.~t-r~cl-e'o,~ o£ ~o;I ~o~l, k'o~, ~7~,~.
PERFORMED BY; F:'/'~P[I:~/.~ "~.~C~t'f¢Cmel .~e,,'¢4' j ,'~"..,~¢~"~.'~.._ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL ST,~TE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE· DATE:
72-008 (Rev, 4/85)
Flattop Technlccd Services
14530 Echo Street
Anchorage, Alaska
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: A~"/" I 11~/ ~/~',,'~, /~/~/1/~ --,~//,.~ Township. Range, Section:
pt-
SITE PLAN
10
11
12
13
14
15
16
17
~8
~:)ll 9
'TTH.
COMMENTS T,~ ~-,~
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH? ~'
Depth to Water Alter
Monitoring? ~'"(' ~A/-. DaLe:
Reading Date Gross Net Depth to Net
Time Time (-/"/~' o ) Water Drop
~ ~ S:/ff:oo ~ ~ ~ '/z ~11[
PERCOLATION I{^] E ~ (r]lulules/~nch) PERO HOLE DIAMETER
TEST RUN BETWEEN ,,~,~-,~' FTAND z/. ~ FT
~f ~ro~ ¢~,,~ ¢ l~v,a /z o,~ ~.r 7:It, -1=I'1
PERFORMEDOY: ~[~*~. '~'.~C~I'IIC~[ ~'~¢.[ I ~"~--~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DATE: '-~/,.~
72-008 (Rev. 4185)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Township, R~ange, Section:
SLdPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Oeplh t0 Water Alter
Monitoring? Date:
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
~ ~'.~ ~,1~ ~',
PERCOLATION RATE ~-- {minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN __ FI AND __FI
COMMENTS
PERFORMED BY: $ & $ ENGINEERING I ~" (~/'~ '"~ CERTIFY THAT THIS TEST
WAS
PERFORMED
IN
17034 Eagle River Loop Road No. 204
ACCORDANCE WITH ~T~¢,~I~UIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: ~ ~:~ '~'L..-~-. ~
Township, Range, Section:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2o
COMMENTS
SLOPE
WAS GROUND WATER
ENCOUNTERED?
DEPTH? pO
Deplh 10 Waler Aller
Monitoring? . Dale:
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
4 ~,. ~j~ ,-- ~ ~' ' iv_'
PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN '~ FT AND__~ FT
PERFORMED BY: $ & $ ENGINEERING I ~~ ~/'%~
¥7~J'4~op Road No. 204 ..... .V. ....
ACCORDANCE WITH AI~[i~j~[~[J,D~I~I~r~LIIDELINES IN EFFECT UN IHI,5 U~,~.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. m uni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
GENERAL INFORMATION
Complete legal description
Location (site address)
Expiration Date: / / ' ,-~' ,/O
L.c.,/' t tx', EIocte ~'. l"l~n n
Current Property owner(s)
Mailing address
Lending agency
Day phone
Day phone
,.
Mailing address
Real Estate Agent
Mailing Address
Day phone
Unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: ..~
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class __
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] Individual Holding Tank []
[] Community On-site []
[] Public Sewer []
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 sample results. (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. 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 I~'l,¢,/-J~ '"~¢4~',¢~,J
Address I~I~0 1.~-c4~
Engineer's Printed Name
DSD SIGNATURE
~-./ Approved for .~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
By:
(Rev. 11105)
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~4~ "- ~ - //'~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
t~ft.
Well type ~//~' IfA, B, or C provide PWSID #__
Date completed ,~J__ll /~"~ sanitary seal (Y/N)
Total depth 'Z ¥ ~' ft. Cased to __
g.p.m.
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform O ' colonies/100 mL
Arsenic: ,~. ,~- ug/L
Nitrate ~'.,~'9 mg/L
date of sample: 7/1"//
Well Log (Y/N) ¥'
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
3'/19 /
t3 ft.
0".,.4' '/' g.p.m.
Depression over tank (Y/N)
Pumper r'~c
Other bacteria ---- colonies/100 mL
Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material 5'~! ~c / .~'F'~ ~ !
Tank size I0o~ gal. Number of Compartments__
Foundation cleanout (Y/N) ' Y'
Date of pumping ~' / tO / tQ
C, ABSORPTION FIELD DATA
Date installed ~'/z,'/~._~ Soil rating (g.p.d./ft2 or ft2/bdrm) ~z
Length '7,5'- ft. Width ,~' ft.
Total depth~',,,~' ft. Eft. absorption area$'z,¢' ft~ Monitoring tube
Date of adequacy test ~ / t~ ,,/~ ~o- Results (Pass/Fail)
Date installed
Cleanouts (Y/N)
High water alarm (Y/N) ~. ~,.
Fluid depth in absorption field before test ~ in. Water added ~ gal.
Elapsed Time:~-/3 min. Final fluid depth ~ in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~
System type ~"- ~,~.-,,~-/-~-
Gravel below pipe t~.~' ft.
Depression over field
For ~ bedrooms
New depth t ,~"' in.
¥,~O g.p.d.
If yes, give date /~,
D. LIFT STATION ~J. ~,.
Date installed
"Pump on" level at __ in.
Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons
"Pump off" level at~
Cycles tested
SePtic tank/lift station on lot I o'7 '
Absorption field on lot I
Public sewer main
Sewer/septic service line ~, ~-~"
Animal containment areas
in.
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout ~. ,~,
Holding tank ~v.
/~/. ~. Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation '~J'~ / Property line ~"~° Absorption field ~ '
Water main lv.~ water service line ~ ~,~ ° Surface water -> t~,~,
Wells on adjacent lots ~ ~ '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~' ~ Building foundation ~' Water main
Water Se~ice line ~ ~ ' Su~ace water ~ ~ ' Driveway, parking/vehicle storage
Curtain drain ~ ~ Wells on adjacenf~i0ts ~ ~
F. COMMENTS ~'
I ce~i~ that I have datelined through field inspections and
review of Municipal records that the above systems are in
confo~ance with MOA COSA guidelines in effect on this date.
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
SGS Ref.# 110344700~ ~ - //~
Client Name Flatto~T~chnical Srv. Printed Date/Time 07/23/2010 9:05
Project Name/# Lot 1 Blk 3 Mann S/D Collected Date/Time 07/14/2010 14:40
Client Sample ID Lot 1 Blk 3 Mann S/D Received Date/Time 07/14/2010 15:00
Matrix Drinking Water Technical Director Stel~hen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic ND 5.00 ug/L EP200.8 C (<10) 07/16/10 07/21/10 NRB
Waters Department
Total Nitrate/Nitrite-N
3.69 0.100 mg/L SM20 4500NO3-F A (<10) 07/15/10 AYC
Microbiolo~ Laboratory
E. Coli
Total Coliform
Negative 1 100mL SM20 9223B A 07/14/10 DLC
Negative 1 100mL SM20 9223B A 07/14/10 DLC
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