HomeMy WebLinkAboutSLEEPY HOLLOW #1 BLK 2 LT 3Sleepy Hollow
F Aff
AAAffn3j
Block 2
Lot 3
#051-501-14
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP141242 PID Number: 051-501-14
Dwelling: 0 Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New N Upgrade
Name:
John E. Fritz
ABSORPTION FIELD
❑0 Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
P.O. Box 670310 Chugiak, AK 99567
F1 Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
357-9394
4
.6 GPD/SF
14 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
7 Ft.7
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Sleepy Hollow #1 2 3
Fill added above original grade
0-1 - Ft.
Gravel length
74 Ft.
Township Range Section
Gravel width
3 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
1,036 _ Fe
1
Ft.
Well
>100'
>100'
>100'
NA
>25'
TANK [:1 Septic ® S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Greer
Capacity
1,250 Gat.
Surface Water
>100'
>100'
>100'
NA
Material
Steel
Number of compartments
TWO
Lot Line
>5'
>10'
>5'
NA
NA
Foundation
>5'
>10'
>5'
NA
LIFT STATION
Manufacturer
Capacity
Gal.
Curtain Drain
None
Noted
I
I
Remarks Existing Septic Tank Decommissioned
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
in Accordance with Municipal Code. Existing
Absorption Trench Abandoned in Place.
Pump make and model
Electrical Inspections performed by
to
PIPE MATERIAL House to tank D3034 T D3034
InstaInstallerdrainnfieldld
Green Construction
Draintield D3034 CO/MT
Inspector A. Harala
BENCH MARK (Assumed elevation) 100.0 ft
Inspection
1' 10/21/14 10/21/14
Location and description
2.d
dates:
3' 10/22/14 am
Lower Level Finished Floor.
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL is
'.Inv ww,'
'•
Conditional Approval: Date
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Approved Date%,I--/ /
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Inspection Report_9-1-12.doC
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Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number: OSP141242
PID No. 051-501-14
x
No Groundwater
10-21-14
PROFILE AS -BUILT
No Scale
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
4700 BRAGAW STREET ANCHORAGE, AK 99519-6650
DEPTH
(feet)
I-
2
3
4
5
6
7
8�
9
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION: LOT 3, BLOCK 2 SLEEPY HOLLOW No. I
PERFORMED FOR: JOHN EE117
DATE: 10/14/14 PROJECT No.:
PARCEL ID#: TECHNICIAN: A HARALA
TEST HOLE A
OB/OG
d SILTY GRAVEL
GM/ML
.Q
A
SITE PLAN
SEE SITE PLAN
WAS GROUND WATER ENCOUNTERED? No
'01 O IF YES @ WHAT DEPTH? 7c'
DEPTH OF WATER AFTER MONITORING: ONGOING 5%
11 DATE OF MONITORING:
I
1
1
BOH @ 20.5'
DATE
READING
GROSS TIME
(MINUTES}
NET TIME
(MINUTES)(INCHES)
DEPTH TO
W
NET DROP
(INCHES)
TEST HOLE PRESOAKED PRIOR TO TESTING:
10-21
1
9:14
0.63'
2
9.44
30
2.00"
1.37"
3
9:45
0.50"
4
10:15
30
1.75"
1.25"
5
10:16
0.50"
6
10:46
30
1.75"
1.25"
PERCOLATION RATE: 24 j"N/INCR) PERC. HOLE DIA. 6! INCHES)
TEST RUN BETWEEN: _LOFT. and—EO—FT.
COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST.
TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE: 12/11/14
On -Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number:
OSP141242
Tax Code Number:
05150114000
Work Type:
Septic Upgrade
Permit Effective Dates: July 22, 2014 to July 22, 2015
Design Engineer:
ANDERSON ENGINEERING
Subdivision:
SLEEPY HOLLOW #1
Site Legal Address: SLEEPY HOLLOW #1 BLK 2 LT 3 GA 160
Owner/Address: FRITZ JOHN E
PO BOX 670310 CHUGIAK AK 995670310
Site Mailing Address: 23745 SLEEPY CIR, Chugiak
This permit is for the construction of:
Y Disposal Field N Septic Tank N Holding Tank
Lot Size in Sq Ft: 70500
Total Bedrooms: 3
N Privy N Private Well N Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater
Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80).
3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Special Provisions: PRIOR TO CONSTRUCTION: A new testhole shall be completed to verify the
permitted design. Any required changes to the design shall be approved prior to construction.
Results shall be submitted with the final inspection report.
Special Provisions: NOTICE: The existing 1984 drainfield shall not be used for future COSA
approvals.
Received
Issued By
By: Date:
MUNICIPALITY OF
Community Development Department
Development Services Division
On -Site Water & Wastewater Program
ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 051-501-14
Property owner(s) John Fritz Day phone
Mailing address P.O. Box 670310 Chugiak, AK 99567
Site address 23745 Sleepy Circle Chugiak, AK 99567
Legal description (Sub'd., Block & Lot) Sleepy Hollow #1, Block 2, Lot 3
Legal description (Township, Range & Section)
Lot Size 70,500 Sq. Ft. Number of Bedrooms Four (4)
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑X
Initial ❑ Single Family (SF) ❑X
(w/wo ADU)
Septic Tank
❑
Upgrade ❑x
Duplex (D) ❑
Holding Tank
❑
Renewal F-1Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Dis tance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
property owner or authorized agent)
Permit/Rush Fees: Waiver Fees:
Date of Payment: �y Date of Payment:
Receipt Number: 0 jla C16 �7 Receipt Number:
Permit No. la!�01 '7 107 40_ Waiver No.
Permit App_.:. :L.,:c.
CGS
October 16, 2014
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 Elmore Road
Anchorage, AK 99519-6650
Subject: Lot 3, Block 2, Sleepy Hollow #1 Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The absorption system on the subject lot has failed and must be replaced prior to the
issuance of a COSA. We are therefore requesting a permit be issued for the upgrade
of the septic system to accommodate the four-bedroom home on the lot. The attached
Site Plan and backup documentation identify the location and configuration of the
existing and proposed septic system. The existing septic tank will be decommissioned
in accordance with Municipal Code and a new tank 1,250 gallon septic tank will be
placed. The existing absorption trench will be left intact and tied to the new system with
a flow diverter valve. A note will be added to the certified as built that only the new
trench can be tested for future COSAs. Also identified on the plans are the locations of
the existing well on this and adjacent lots and adjacent septic systems. No conflicts
exist between the proposed septic system and the wells on this or adjacent lots.
Drainage arrows are shown indicating the current drainage patterns. The drainage
patterns will be maintained after construction.
The test hole placed on the lot when the initial system was constructed indicated Silty
Gravel (GM) in the absorption zone of the trench. The percolation rate was determined
to be 28 minutes per inch. We have designed the new trench with an application rate
of .6 gallons per date per square foot. We are proposing to place a 72' long trench by
3' wide with a 7' effective depth. The total depth of the system will be 13' with the
distribution line at 6' below the existing surface. A test hole was placed to 20.5' with no
groundwater present. The groundwater monitored for a minimum of 7 days. We do not
anticipate the presence of groundwater based on the test hole placed on this and the
adjacent lot. If conditions are found other than those anticipated work will stop and a
change order will be drafted and submitted for approval.
coj
Lot 3, Block 2, Sleepy Hollow #1
October 16, 2014
Page Two
The ground surface on the lot slopes to the southeast in the area of the absorption
trench. The trench will be placed parallel to the contours of the ground as much as
possible and in conformance with design criteria. A minimum of 100' will be maintained
between all components of the septic system and the proposed well and from any
surface water in the area.
If the system is constructed in accordance with our design the following statements
apply:
1. The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
xl Ems,
Michael E. Anderson, P.E.
Attachments
.49th
MICHAEL E. ANDERSON
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LOT 3, BLOCK 2, SLEEPY HOLLOW #1 SUBDIVISION
DESIGN FACTORS: SYSTEM REQUIREMENTS
Four Bedroom Home 5' Wide Trench System
Perc. Rate: 16-30 Min./Inch Verify Existing 1,000 Gallon Septic Tank
Application Rate: .6 GPD/SF 7' Drainfield Rock
4 Bedrooms' 150 GPD/Bedroom = 600 SF Absorption Area
600 SF/.6 GPD/SF/14 SF/LF = 71.4 LF Trench Length
THEREFORE: Construct an Absorption Trench 72'x T Wide x 7' Effective Depth . Flowline
Elevation to be 5.5' Below Existing Ground. Total Depth Expected to be 12.5' Below Existing
Ground. Place 3' Cover Over Absorption Trench and 4' Cover Over Septic Tank. In lieu of Fill Place
2" Insulation and 2' of Cover. Verify the Structural Integrity of the Existing 1,000 Gallon Septic Tank.
Replace if Necessary. Place Flow Diverter Valve and Connect Existing Trench'for Future Use.
5'
TYPICAL DEEP TRENCH SECTIO"'
NOTE:
(NO SCALE)
Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 4' Separation From Groundwater.
Minimum 100' Separation From Private Wells in the Area.
Minimum 1 00'Separation From Surface Water or Streams,
DEPTH
(feet)
1-
2
3
4 -
5-
6-
7-
9 -
10 -
II
14
15
16
17
18
19
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
4700 BRAGAW STREET ANCHORAGE, AK 99519-6650
I SOILS LOG - PERCOLATION TEST I
LEGAL DESCRIPTION: LOT 3, BLOCK 2, SLEEPY HOLLOW NO. I
PERFORMED FOR: JOHN FRITZ
DATE: 10/14/14 PROJECT No.:
PARCEL ID#: TECHNICIAN: S. G ILBERT
d
°
d
TEST HOLE 1
OB/OG
SILTY GRAVEL
GM/ML
d SM
SLOPE
WAS GROUND WATER ENCOUNTERED? No
( 5%
@1F YES WHAT
S
DEPTH OF WATER AFTER MON
L
NET TIME
(MINUTES)
DEPTH ro
WATER
(INCHES)
DATE OF MO
SITE PLAN
SEE SITE PLAN k
ig
9
DEPTH?
ITORfNG: ONGOING �
NITORING:
( 5%
[DATEREADINGING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DEPTH ro
WATER
(INCHES)
NET DROP
(INCHES)
TEST HOLE PRESOAKED PRIOR TO TESTING:
10-14
1
2:10
3.25"
2
2:40
30
4.31"
1.06"
3
2:41
3.13"
4
3:11
30
4.19"
1.06"
5
3:12
3.00"
6
3:42
30
4.06"
1.06"
PERCOLATION RATE: 28 (MIN/INCH) PERC. HOLE DIA. 6„ (INCHES)
TEST RUN BETWEEN: 60 FT. and 7_0 FT.
COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST.
TEST PERFORMED BY ANDERSON ENGINEERING. 1, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE: 10/15/15
Municlpallty of Anchorage / R
DEPARTMENT OF HEALTH & HUMAN SERVICES ;•/.Ir
825 " L' Street, Anchorage, Alaska 99502-0650 N
SOILS LOG — PERCOLATION TEST i
i�
PERFORMED FOR: Cjo
/ ? ,,t,, DATE P
LEGAL DESCRIPTION: ! 3 L{,r, p1u414L1�ownship, Range, Section:
IDEPdH i� SLOPE
6xi A. SNOOK ' W
tow 1417.1• 4Z•
00RDfES•1Qy�, /
D`AlA
elI lelkl r
SIT7P LAN--�
�3
E€Ta
11
0/
t'
DEPTH?
'9
'q
13 -
r
/� !
go #001 rc - — 40 /2
14-
2
3
1. e,/r�o
-
y`r�
Gi P'
gate:
Reading
4
: 6
/
Net
Depth to Net _
17 �
J
.:oo.ean Awa
/
6-Af — l R0 �Igx
-qe. :
3 13 d
LI
14574" f ''�QEi+'y''�
-1
7
227gh
,.
'0010
3 n Y 0
`! a
,� p r,
I
9
b
10
-
WAS GROUND WATER
ENCOUNTERED?
6xi A. SNOOK ' W
tow 1417.1• 4Z•
00RDfES•1Qy�, /
D`AlA
elI lelkl r
SIT7P LAN--�
�3
11
0/
t'
DEPTH?
12-
'q
13 -
r
/� !
go #001 rc - — 40 /2
14-
Depth to Water Atter
Moritoriee?
15
gate:
Reading
Date
Gross
Net
Depth to Net _
17 �
J
.:oo.ean Awa
Time
Water Drop
-qe. :
3 13 d
LI
14574" f ''�QEi+'y''�
-1
---
227gh
6xi A. SNOOK ' W
tow 1417.1• 4Z•
00RDfES•1Qy�, /
D`AlA
elI lelkl r
SIT7P LAN--�
�3
20 PERCOLATION RATE AsZ_,- (minutes inch) PERG HOLE DIAMETER rti�
TEST RUN BETWEEN .._ FT AND - FT
COMMENTS G!hSD5GJAL C.
1. - S .WGUr6CRfry
S rrais�
PERFORMED BY: 'ittVfR-Ait+
ACCORDANCE WITH ALL STATE AND MUNICIPAL
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
ON THIS DATE. DATE: _ .
S
IF YES, AT WHAT
L
O
DEPTH?
E
Depth to Water Atter
Moritoriee?
�)
gate:
Reading
Date
Gross
Net
Depth to Net _
Time
Time
Water Drop
/ 0
3 13 d
-1
---
227gh
,.
'0010
3 n Y 0
,� p r,
I
b
20 PERCOLATION RATE AsZ_,- (minutes inch) PERG HOLE DIAMETER rti�
TEST RUN BETWEEN .._ FT AND - FT
COMMENTS G!hSD5GJAL C.
1. - S .WGUr6CRfry
S rrais�
PERFORMED BY: 'ittVfR-Ait+
ACCORDANCE WITH ALL STATE AND MUNICIPAL
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
ON THIS DATE. DATE: _ .
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 " L' Street, Anchorage, Alaska 99502, Telephone 264-4720
ON—SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Na'neP�—
,�
DISTANCES —
FROM
SEPTIC
TANK
ABSORPTION
FIELD
WELL
Address
4::'. ,,c,
Phones) Permit No. No. of Bedrooms
WELL
��
r
Q
LOT LINE
LEGAL DESCBIPTIDN
-
Lol Block Subdivision
�7=_2��jLx
Township, Range, Section
T 1 W
TANKS
FOUNDATION
--
A5DIAGRAM )Show location of well, septic system, property hoes, foundation,
driveway,eway, water bodies, etc.)
♦ p
SEPTIC ❑ HOLDING
M6ulocturerCapacity
in gallons
TYPE OF SYSTEM
TRENCH ❑ BED ❑ W. DRAIN ❑ OTHER
Depth to pipe bottom from Total depth from original grade
original grade Z5 FT 19 FT
Fill added above original grade / Gravel depth beneath pipe 1
(5::)'— FT FT
Gravel length ( Gravel width /
'J2 FT Z- rs FT
Total absorption area ^ /I Distance between lines
�cJ Sp FT �A FT
Number of "nes Soil rating Pipe material
qI G11�sQ FT h'1 1'�.C�
Installer I Vit1 L Dote Installed
)
WELLS
�RIVATE ❑ OTHER (Identiiv)
Classification (A,B,C) Total Depth Cased to
FT FT
Installer I Date Installed:
REMARKS:
S 81 S ENGINEKKnvv
uI RIcenly1_T04
qo
Municipal �0�161e�b19@A'I��hlon in7da�ie --��
Health Department Approval:
72-013 (3/85)
I
Inspections Performs Iy:
Oe 04440 . K
Date:
according to all
A•„ . pan, A. aht-Na'�,..
No. I rl).1 r
MUNICIPALITY OF ANCHOR0UE
Department of Health & Human Services
825 L Street, Anchorage, Alaska 99501 343
ON`SITE SENER & WFLL PERMIT
0
Permit Number: 890047 ��\d'�/lvl(/~l
Date Issued: 04/11/89 Engineer Designed
Owner Name: JOHN E. FRITZ Day Phone:
nwner Address: PD BOX 67031O 338-420o
CMUGlAK, AK 99567
Parcel Id: 051-501-14
Lot Legal: Subdivision: SLEEPY HOLLOW #1 Lots 3 Blacks 2
Section: 5 Townships 15N Range: Ito
Lot Size 70500 (sq,1t" or acres)
Max Bedrooms: This Permit: 3 Total Capaci!yx 3
SEPTIC TANK: Minimum total septic tank capacity: 1,000 gallons. Each sepLic
tank musthave at least 2 compartments. Depth to top of septic tank(B) < 4"0
feet requires insulation over tank(s),
WELL: Log must he submitted to Municipality of Anchorage Department of Health
and Human Services within 30 days of well completion.
INSTALL PER ENGINEERS ATTACHED DESIGN. NOTIFY DHH8 PRIOR TO
EACH INSPECTION BY THE ENGINEER. VARTFY GROUND WATFR SHPARATION.
NOTE: WEIGHT LIMITS ARE IN EFFECT FOR ROADS. [HIS PERMIT IS
ISSUED FOR THE PLANNED THREE BEDROOM SINGLE FAMILY DWELLING ONLY
AND EXPIRES 12/31/89,
I CERTIFY THAT:
1" I am familiar with the requirements for nn -site sewers and wells as set
forth by the Municipality of Anchorage (MOA) and the State of Alaska"
2" I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
3. I will adhere to all MOA and State of Alaska requirements for the not back
distances from any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot"
4^ I understand that this permit is valid for a maximum of 3 bedrooms. I
also understand that the capacity of the total system is 3 bedrooms and
any enlargement will require an additional permit"
Signed:/' DATE:
'
^ �'"�~
(Dwner) JOHN E` FR
Issued By: DATE:
rz�-~---------------.... ... .... ^... .... ...... --^--�....... -�r����`--T~-'-
F- SEAL)
Munlcipallty of Anchorage ,mac
DEPARTMENT OF HEALTH R HUMAN SERVICES �'•' �•` �•�
825 "L" Street, Anchorage, Alaska 99502-0650 � • J'�►
SOILS LOG — PERCOLATION TEST �', in i��F�
PERFORMED FOR: /�? DATE PERFO'R�/I�
LEGAL DESCRIPTION: ! J 2 LEaw ff riwL.jownship, Range, Section: �,�'N ��'/�t/ I'
1
2
3
4
5
6
7
s
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
cs'w/l%/Ic�D
61v — l qo �/e2
WAS GROUND WATER �J i�
ENCOUNTERED? _ ///
IF YES, AT WHAT
�% DEPTH?
90 /7a H9 A Y� l�jO to M nttarinp7to arAter., Date:
C.
3
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net _
Drop
—
2-
U41iJ
_
'f
4
7: o o
3:51
to'.
to
�3 �'
_�Fa"
9 a
u7G'r
01
(O r.
r�
7• r.
11PERCOLATION RATE— (minutes/inch) PRC HOLE DIAMETER 6 _
TEST RUN BETWEEN __ FT AND --Sr—ZFT
PERFORMED BY: _1.UW4 pnt ,AVSPM7— I -�" . CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDE:LI UI EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
It>
DOC Co. dOa
SULLIVAN WATER WELLS
P.O. BOX 870272, CHUOIAK, ALASKA 99567 - TELEPHONE 6882759
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OWNER OF LAND /i/%) FQl r2
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ADDRESS /0 8A"'
LEGAL DESCRIPTION $ LiCK 0 %T469e 04LO CU
DATE - Started `� 6 �� Ended
PERMIT NUMBER S Q -C)C_VA
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KIND OF CASING 'c'$ c)
KIND OF FORMATION:
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K MtOIPAtN Of ANQIORAGE
MISCL. INFORMATION: ii A -f /u6
r M /�L C
DEPT, OF HEALTH &
9WIAONMENTAL PROTECTION
'! 6
MAY 0 .i 1989
RECEIVED
DRILLER'SNAME LJJ;! � yc- ----
MUNICIPALITY OF ANCHORAGE
Development Services Department f
Phone: 907-343-7904
On -Site Water & Wastewater Section
Certificate of On -Site Systems Approval
Parcel I.D. 051-501-14
1. GENERAL INFORMATION
Expiration Date: 2 �Z `{ bZZ
Complete legal description SLEEPY HOLLOW #1 BLOCK 2, LOT 3
Location (site address) 23745 SLEEPY CIRCLE, CHUGIAK, AK 99567
Current property owner(s) JARROD & CASEY ANN ROMINSKE Day phone
Mailing address
Real estate agent
PO BOX 671370, CHUGIAK AK 99567
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
4
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:
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date:
COSA Fee $ 5 5 0 Waiver Fee $ _
Date of Payment/ 16 A I Date of Payment
Receipt Number 116 % 31 Receipt Number
COSA # D S G z 1 16 —7 a 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) iri-compliance with alF applicable Municipahand 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 FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 11/15/2021
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to r+�111
these various and dynamic characteristics and are outside the control of the evaluator of the l
well and septic system. Therefore, any estimate of how long a system will function satisfactory ��P• • • . •
for current or future occupants or guarantee that no unseen encroachments, deficiencies or fig•' '.9 `r
discrepancies exist can be given by First Water Consulting & FWCS . *' 7H •'*
6. DSD SIGNATURE
Curtis Huffman
System #1 Approved for `� bedrooms CE 128991
System #2 Approved for bedrooms `l,F�PROFESSIONA
Disapproved
Conditional approval for bedrooms, with the following stipulations:
ON-SITE �
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)))))))))111
By: Original Certificate Date: I A
The Municipality of Anchor a 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 X Other
COSA Checklist
Legal Description: SLEEPY HOLLOW #1 BLOCK 2, LOT 3 Parcel ID: 051-501-14
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 4/26/1989
Total depth 400 ft
Cased to 96.4 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 24+ in.
Date of flow test for COSA 9/30/2021
Static water level at beginning of test 116 ft.
Well production at time of test 0.31 gpm
Water storage tank volume 300 gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 6.59 mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date of Sample 11/4/2021
Comments __________________________________________________________________________________
B. TANK DATA
Age of tank(s) 7 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 50”
Standpipes/foundation cleanout per record drawing
Date of pumping 9/29/2021
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 10/21/2014
ALL standpipes present per record drawing
Total measured depth from grade *14.7 ft (max)
Measured depth to pipe invert from grade *7.3 ft (min)
N/A – pressurized field
Monitor tubes go to bottom of effective. If not, state
depth into effective 7’+ OF THE 7’ED
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 9/30/2021
Results Pass For 4 bedrooms
Fluid depth prior to test 26 in
Water added 600 gal
New depth 37 in
Elapsed time 1380 min
Final fluid depth 25 in
Absorption rate 600 gpd
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Comments/Deficiencies: *AT MT & CO
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
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.
11/22/21
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
Well Water Advisory
Certificate of On-Site Systems Approval # OSC211672
Subdivision: Sleepy Hollow #1, Block: 2, Lot: 3
This well’s productivity was determined to be .31 gallons per minute. The minimum
well productivity required under (AMC 15.55) for a 4-bedroom residence is .41
gallons per minute or 150 gallons per day per bedroom. Although the well
production does not meet this requirement, additional water storage has been
provided.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
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 # OSC211672
Subdivision: Sleepy Hollow #1, Block: 2, Lot: 3
A water sample revealed a nitrate concentration of 6.59 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.
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
Parcel I.D. 051-501-14
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Expiration Date: j(_3cq_/ f
Sleepy Hollow #1, Block 2, Lot 3
23745 Sleepy Circle, Chugiak, AK
Current property owner(s)
Mailing address
Real estate agent
Samuel & Brittany Busch Lindquist Day phone 907-406-0959
25343 Homestead Road, Chugiak, AK 99567
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: Four
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
El
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 $ 656 Waiver Fee $
Date of PaymentLgL1 Date of Payment
Receipt Number Receipt Number
COSA # osed13,80 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 Forge Engineering Phone 907-522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503
Engineer's Printed Name Michael E. Anderson, P.E. Date 8/14/19
6. DSD SIGNATURE
XSystem #1 Approved for <I bedrooms
M
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
`�illEEiilt°,
Original Certificate Date: D G
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
Legal Description: Sleepy Hollow #1, Block 2, Lot 3 .
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 4/26/89
Total depth 400 ft
Cased to 96.4 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) '24 in.
Date of flow test for COSA 8/6/19
Static water level at beginning of test 118 ft.
Comments
B. TANK DATA
Age of tank(s) 5 years
Tank type/material Septic / Steel
Measured operating fluid level in septic tank 51
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 8/19/19
D. ABSORPTION FIELD DATA DEEP TRENCH
Which system tested (date installed) 10/21/14
❑ ALL standpipes present per record drawing
Total measured depth from grade 14.7 ft (max)
Measured depth to pipe invert from grade 5.9 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
Comments/Deficiencies: -System remained in use during test period.
COSA Checklist yellow sheet
Parcel ID: 051-501-14
Structure served by this system
Well production at time of test 0.35 gpm
Water storage tank volume 300 gallons
Well disinfected for coliform test? ❑ Yes ❑ Nc
❑ Coliform bacteria is Negative
Nitrate 7.09 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by FORGE ENGINEERING
Date of Sample 8/6/19
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 8/13/19
Results F✓ Pass For 4 bedrooms
Fluid depth prior to test 16 in
Water added 1450 gal
New depth 37 in
Elapsed time 1440 min
Final fluid depth 28 in
Absorption rate '600 gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
No
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'
F/ Yes
if No
Community Sewer Manhole/Cleanout > 100'
✓0 Yes
if No
ft
Q Yes
if No ft
Neighboring Tank > 100' 0 Yes
if No
ft
Private Sewer/Septic Line > 25' F-/1 Yes
if No ft
Absorption Field on Lot > 100' FV -1 Yes
if No
ft
Holding Tank > 100' FV� Yes
if No ft
Neighboring Absorption Fields > 100'
if No
ft
Animal Containment > 50' El Yes
if No ft
Yes
if No
ft
ft
If septic tank is under driveway comment below
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' P/1 Yes
if No
ft
0 Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
F/ Yes
if No
ft
Surface Water > 100'
®✓ Yes if No ft
Property Line > 5'✓0
Yes
if No
ft
Wells on Adjacent Lots:
Wells on Adjacent Lots:
Absorption Field > 5'
❑✓ Yes
if No
ft
Private Wells > 100'
✓� Yes if No ft
Water Main > 10'
ED Yes
if No
ft
Community Wells > 200'
F71 Yes if No ft
Water Service Line > 10'
F71 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'
21
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'✓Q
Yes
if No
ft
Private Wells > 100' R✓ Yes if No ft
Water Service Line > 10'
0
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100'
✓1
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION OF'� L�
I certify that 1 have determined through field inspections and review�'\P.•'`
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date. �'• �'
to . r....... ..4a .........kry...a i.3a.o
to
�saassa°aslalaaaaaaa.aasitaie40Pff��i""t����b.•.•4.(aiAa �sy
A N4ICHAEL E. ANDERSON e • LL
L
No. CE -4381
8/14/1
aepcSS����
COSA Checklist yellow sheet i j� "..........
�_ FL
Well Water advisory
Certificate of On -Site Systems Approval # OSC191380
Subdivision: Sleepy Hollow #1, Block: 2, Lot: 3
This well's productivity was determined to be .35 gallons per minute. The minimum
well productivity required under (AMC 15.55) for a 4 -bedroom residence is .41
gallons per minute or 150 gallons per day per bedroom.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Nitrate Advisory
Certificate of On -Site Systems Approval # osc191380
Subdivision: Sleepy Hollow #1 B2 L3
A water sample revealed a nitrate concentration of 7.09 milligrams per liter
(mg/Q. 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. 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.
Parcel I.D. 051-501-14
Municipality of Anchorage
On -Site Water and Wastewater Program =` k
(907)343-7904
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Expiration Date: 7 /
Complete legal description Sleepy Hollow #1, Block 2, Lot 3
Location (site address) 23745 Sleepy Circle Chugiak, AK 99567
Current Property owner(s) John E. Fritz Day phone
Mailing address 1209 F Street Anchorage, AK 99501
Real Estate Agent
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: Four
Day phone
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well 1XI Individual 111
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
Waiver/Variance request for: Distance:.
Received by:e!�( l /x. Date:
COSA to be released"t engineer, unless otherwise requested by the engineer.
COSA Fee $ 26�6.yU Waiver Fee $
Date of Payment 12-// ff/�q Date of Payment
Receipt Number 00266 � Receipt Number
COSA# 05 G Ili 16 tih Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Anderson Engineering Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E. : Date 4/2
a►���aOF eq4-
F ea 4s.0
AW `! �l®
W* *e 9 H f*/) 40
G. DSD SIGNATURE ed.a*.........c ................g
System #1 Approved for bedrooms �� l MICHAEL F ANDERSON
CE -4381
System #2 Approved for bedrooms
Disapproved i0J"A
6'S
Conditional approval for bedrooms, with the following stipulations:
By: LAI, Original Certificate Date: (Z
The Municipality of Ancho He 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 blue sheet r -
N more than 4 septic system is on the lot:
COSA Checklist # ---of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: Sleepy Hollow #1, Block 2, Lot 3 Parcel ID, 051-501-14
A. WELL DATA
well type Private
Date completed 4/26/89
Total depth 420—oft-
Date
00ft.
Date of test
Static water level
Well production
If A, B, or C provide PWSID #
_ Sanitary seal (YIN) Y
Cased to 96.3 ft
FROM WELL LOG
4/89
WATER SAMPLE RESULTS:
108 ft,
20 g.p.m.
Coliform 0 colonies/100 mL Nitrate 3.47 mgt
Arsenic N/D ug/L Data of sample: 10116/14
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Tank size 1,250 gal. Number of Compartments 2
Foundation cleanout (YM) Y
Date of Pumping New Const.
C. ABSORPTION FIELD DATA
Well Log (YIN) Y
Wires properly protected (YIN) Y
Casing height (above ground) >12 in.
AT INSPECTION.
10116/14
94.3 ft.
3.9 9.p -m.
for recer�'F�ia-I�bv�
N� �-a-ks �Nl
Col�'Forn.
Collected by: a ngrg.
Date installed 10/21/14
Depression over tank (Y/N) N
Pumper
Clearrouts (Y/N)
Y
High water alarm (YIN) N
Date installed 7112/13 Soil rating (g.p.d.lfO or felbdrm) .6 GPD/SF System type Deep Trench
Length 74 ft. Width 3 ft. Gravel below pipe 7 ft.
Total depth 15 ft. Eff. absorption area _1, 036 ftp Monitoring tube Y Depression over field N
Date of adequacy test New Const. Results (passlFail) For —bedrooms
Fluid depth in absorption field before test in. water added gal. New depth in.
Elapsed Time: - min. Final fluid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YM)
°Pump on" tevel at in. "Pump off' level at in. High water alarm level at in.
Datum
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tankilift station on lot
Absorption field on lot
Public sewer main
Cycles tested
>100'
>loot
N/A
Sewer /septic service line
Animal containment areas
>25'
>50'
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
>100,
>100'
Public sewer manhoielcleanout NIA
Holding tank N/A
Manure/animal excrete storage areas >100'
SEPTICIHOLDING TANK ON LOT TO:
'field >5'
Building foundation >� Property line >5' Absorption
mA/alwr main >10' _. _. _._. Water service line >10 Surface water >
Wells on adjacent lots > 100'
ABSORPTION FIELD ON LOT TO:
Propertyline >10' Building foundation >10'
Water Service line >10' Surface water >100'
None Noted >100'
Curtain drain Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that I have determined through held inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Michael E. Andersoni P.E.
12/11!14
COSA brown sheet I O-1 o-12.doe
Water main N/A
Driveway, parkingivehide storage >10'
JM 6. AND19MON
..CE-4sar
• Municipality of Anchorage
On -Site Water and Wastewater Program
(907)343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 051-501-14
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Expiration Date:
Sleepy Hollow #1, Block 2, Lot 3
3-31-/,6-
23745 Sleepy Circle Chugiak, AK 99567
Current Property owner(s) John E. Fritz Day phone
Mailing address
Real Estate Agent
1209 F Street Anchorage, AK 99501
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: Four
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
El
WaiverNariance request for:
Received lay: ( � ' .L2 Date: `
COSA to be releas to a engineer, unless otherwise requested by the engineer.
COSA Fee $ oZ loS.6t) Waiver Fee $ _
Date of Payment l 2� I K 11 q ("-y Date of Payment
Receipt Number 0blolpGt Receipt Number
COSA # 05U q 1 15 Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Anderson Engineering Phone
Address P.O. Box 240773 Anchorage, AK 99524
522-7773
Engineer's Printed Name Michael E. Anderson, P.E. 12/11/14
l
S*a 49�
6. DSD SIGNATURE
/ �rNNMr� w
V System #1 Approved for bedrooms MXWM L AND&SM
* 6 'CE -4381
System #2 Approved for bedrooms i♦�l
Disapproved �QfE55 0 -�.®®
Conditional approval for bedrooms, with the following
By: V Original Certificate Date: [,Q--3 1 -/�
The- i ' o cborage Development Services Division (DSD) issues Certificates of Onsite Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered In the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue shaet r :.i e
If more than 1 septic system is on the lot:
COSA Checklist # _of
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: Sleepy Hollow #1, Block 2, Lot 3
Parcel ID: 051-501-14
A. WELL DATA
Well type Private If A, B, or C provide PWSID # Well Log (Y/N) Y
Date completed 4/26/89
Sanitary seal (Y/N) Y
Wires properly protected (YM)
Y
Total depth 400 ft
Cased to 96'3 ft.
Casing height (above ground)
> 12 in.
Date of test
Static water level
Well production
FROM WELL LOG
4/89
WATER SAMPLE RESULTS
108 ft,
20
AT INSPECTION
10/16/14
94.3 ft.
3.9
g.p.m.
Coliform 0 colonies/100 mL Nitrate 3.47 mg/L
Arsenic N/D ug/L Date of sample: 10/16/14 Collected by: Anderson Engrg.
B. SEPTICIHOLDING TANK DATA
Tank Type/Material Septic/Steel
Tank size 1,250 gal. Number of Compartments 2
Foundation cleanout (YIN) Y Depression over tank (Y/N) N
Date of pumping New Const. Pumper
C. ABSORPTION FIELD DATA
Dateinstalled 10/21/14
Cleanouts (Y/N)
Y
High water alarm (Y/N) N
7/12/13 a ' 6 GPD/SF Deep Trench
Date installed Soil rating (g.p.d.fft or If lbdrm} System type
Length 74 ft. Width 3 ft. Gravel below pipe 7 ft.
Total depth 15 ft. Eff. absorption area 1,136 fe Monitoring tube Y Depression over field N
Date of adequacy test New Const. Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption field before test in. Water added gal. New depth in.
Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed
°Pump on" level at in.
Datum
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot _
N/A
Public sewer main
Size in gallons Manhole/Access (YIN)
"Pump off' level at in. High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
>100'
>100'
Sewer /septic service line >25'
>50'
On adjacent lots >100'
on adjacent lots >100'
Public sewer manholelcteanout N/A
Holding tank N/A
Manure/animal excrete storage areas >100'
Animal containment areas
SEPTICIHOLDING TANK ON LOT TO:
Building foundation >51 Property line >5' Absorption field !=-
Water main >10' Water service line >10' Surface water >100'
Wells on adjacent lots > 100'
ABSORPTION FIELD ON LOT TO:
ProP arty line >10' Building foundation >10' Water main N/A
Water Service line > 10 Surface water
' >100' Driveway, parkinglvehide storage >10
Curtain drain
None Noted Wells on adjiacent lots >100'
F. 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.
Engineer's Printed Name Michael E. Anderson, P.E.
_._ 12/11/14
COSA brown sheet 70.70-72.doc
MR E. ANDIIti M
a-4.381 Y
I�
r
+i
t
LOT 2
S 81'55'10-E
J00.00'
10' UTILITY EASEMENT \
t1
1 / h
/ 6.0'x11.8' Co
LOT 3 COVERED ENTRY
' 70,500 s.f.
i WELL
1 R= 100'
PROTECTIVE RADIUS o 1t,
2 STORY . ENCBALCC
`IRE 42D71
0
a \
12.2'x 10.2•
r SHED
r
r N 81'55'10
r
r ' LOT 4
i
2.0' CANT
1.0' CANT
F
;It
PLOT PLAN _ AS BUILT X SCALE 1' - 50' GRID NW 1160 Project No. 14-198
LOT 6
Lang & Associates, Inc. 11500 Daryl Avenue, Anchorage, Alaska 99515-3048
907 522-6476 Phone
Registered Land Surveyors 907) 522-4625 Fax
kenOtongsurvey.com / jonathanOlangsurveycom A`�•..•• ••., qs
I hereby certify that I have surveyed the following described property:
LOT 3, BLOCK 2,SLEEPY HOLLOW ji (PLAT 73-84) �: 49 y*
Anchorage Recording District, Alaska, and that the improvements situated thereon aro ............. ... ..........
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.. ... .. .. ... ... ••,
promises and that there are no roadways, transmission lines or other visible tFi
easements on sold properly except as indicated hereon.
1%((4
Dated this the Day of at Anchorage, Alaska t-520$.•' g
if 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.
• MUNICIPALITY OF ANCHORAGE Aida
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 l.D.# HAA# 0li:�o9ll'A 9' 6
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
LOT 3: BLOCK 2: SLEEPY HOLLOW Ni
Location (address or directions)
3745 Steeou C.ikcte
(b) Property owner John Fkitz Telephone: (home) 688-1088 Business
Mailing Address P.O.Box 670310 Chugiak, Ak. 99567
c Lending Institution Ke Bank o{, A2a6fza 564-0349
() g Telephone _—
A ue e�ct, ti�.cdent
Mailing Address 101Dies# Benson S.taeet, Anchorage Ataska
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here, if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
97034Eag(0 River Loop Road No. 204
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family IZx Number of bedrooms
3. WATER SUPPLY
Individual Well [�X 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 1XX Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. ries) 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 thatmy investigation of tnis
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.
Name of Firm
Address
Date
Telephone ef7ls17
y & 5 N v- ERING
_ ..._ River Loop Road No. 204
Eagle River,
6. DHHS APPROVAL
Approved for 3 bedrooms by
Approved � X":_ Disapproved Conditional
Terms of Conditional Approval
CAUTION
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 DHHS 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. 7/88) Back Page 2 of 2
u u MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
�
D
rd,urr�aPALrrr or- n,.a io,.A4ue�-4744
f'NVIriONrAcN rAL SERVICES DIVISICE)6gal Description: «:(C�
A. WELL DATA / [
Well Classification —_c If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) j� Date Completed Yield -C
Total Depth-41_co-_ Cased to Depth of Grouting
Static Water Level 108 Pump Set At ll�
Casing Height Above Ground _1-02 Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) ►�
SEPARATION DISTANCES FROM WELL
To Septic/Holding Tank on Lot On Adjoining Lots (00 f -
r ,
To Nearest Edge of Absorption Field on Lot _ / ; On Adjoining Lots (oo
To Nearest Public Sewer Line --A*—To Nearest Public Sewer Cleanout/Manhole T
r
To Nearest Sewer Service Line on Lot -_ (-
Water Sample Collected by e = 5QJ�,LLL)�__ Date_ 5 E3 7
Water Sample Test Results v - .I
S�-,J' i ✓} Ada
Comments
B. SEPTIC/1-1101-DING TANK DATA
Date Installed"ISize (QdD_ydLNo. of Compartments
Standpipes (Y/N) L Air -tight Caps (Y/N)
Depression over Tank (Y/N) -1`�
�_—Foundation Cleanout
Date Last Pumped
Pumping/Maintenance Contact on File (Y/N) AqO ; for —
Holding Tank High -Water Alarm (Y/N) -�/A Temporary Holding Tank Permit (Y/N) _-4A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well I 0� ' To Building Foundation
To Property Line I t2 To Disposal Field
To Water Main/Service Line
r
To Stream, Pond, Lake or Major Drainage Course too 1� _
Comments
72-028 (Rev. 7/88) From Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 0/8R Type of System Design
Date Installed (o - 8 8 1 Length of Field -7 a /
Width of Field o? . S / Depth of Fieldgl
r
Gravel Bed Thickness 41
Square Feet of Absortion Area Statndpipes Present (Y/N) /
Depression over Field (Y/N) Date of Last Adequacy Test N �✓k
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD
To Water -Supply Well 105, To Property Line 10 ±
To Building Foundation /4S- / To Existing or Abandoned System on
Lot fi./Aa ; On Adjoining Lots .30,+
To Water Main/Service Line / t7 t To Cutback (if present) A).11i
To Stream, Pond, Lake, or Major Drainage Course /00,t
To Driveway, Parking Area, or Vehicle Storage Area ao
r
Comments
D. LIFT STATION
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)
**Check Permitted Bedroom Rating Against HAA Request**
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines
inspection.
Signed 9, & 5 klquiNEE.RING
17034 Cagle River Loop ROOM No, 204
Company 9 FPWAr Alaska 99577
Date /7i p4 ��
MOA No. C� /� AbO ?�
nl
Receipt No. N '
Date of Payment �a ✓�� G I
w
Amount: $
Receipt No.
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
lNdate of this
ysri A. Lhai�'
�, 1M157�
Seal