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HomeMy WebLinkAboutSLEEPY HOLLOW #2 BLK 2 LT 13Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201042 PID Number: 051-501-24 Dwelling: F Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 9 Upgrade Name JOE & LAUREN WILLERT ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 18843 MOUNTAIN RD CHUGIAK AK ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot SLEEPY HOLLOW #2 BLK 2 LT 13 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Lift Station Tank Line Fl? Ft. Well 100'+ 50'x., �J TANK [9 Septic ❑ S.T.E.P. [I Holding El Other Manufacturer Capacity ANCH TANK/GREER 1000 Gal. Surface Water 100'+ Material Number of compartments Lot Line 10'+ NA PLASTIC 2 Foundation *8'-I- LIFT STATION Manufacturer Capacity Gal. Remarks * NO CONFLICT W/ FOUNDATION Alarm location Electrical installed by PIPE MATERIAL House to tank 3034 drainfield Tank to 3034 Installer MIKE N ANDERSON, P.E. Drainfield 3034 CO/MT3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK Assumed elevation) 100 ft Inspection 3/21/20 Location and description 2 nd GARAGE SLAB 3° ON-SITE WATER AND WASTEWATER SECTION APPROVAL ,tarp 'ter t ' �� e�. C p 4�� e O• O e O Conditional Approval: Date". • . r eooSo.e 000 ve.osov•.e�`.7 e o o e e o v•• v ........... • MICHAEL N. ANDLRSCN Septic System Approve �'_ Date) 2 b CE-9 . • P • e `(.� CaT ���®o®s , Note: this approval does not include well permit requirements. -X- (Kev Ub/U2/16) Permit No. OSP201042 Page 2 of 2 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: SLEEPY HOLLOW ¢#2 BILK 2 LT 13 PID No.: 051-501-24 MARK A C01 C01 5 42 TC01 10 TCO213 i 50 CO2 5 48 CO 15 47 BENCH AT GARAGE DOOR / 1 I i I I t 1 \Y, col col 1.000 CALLON PLASTIC TANK NEW SEP C TANK CD2 TCO1 SEPTIC SECTION N.T.S. J)UALt: l =nU rcot CO3 TCO2 1 1 flit .. OF. 44�54 °®® AV ® AF 49 TH .•' MICHAEL N. ANDERSON;® No. CE 9469.•. ,3-25-20AV C01 i i i BENCH AT GARAGE DOOR / 1 I i I I t 1 \Y, col col 1.000 CALLON PLASTIC TANK NEW SEP C TANK CD2 TCO1 SEPTIC SECTION N.T.S. J)UALt: l =nU rcot CO3 TCO2 1 1 flit .. OF. 44�54 °®® AV ® AF 49 TH .•' MICHAEL N. ANDERSON;® No. CE 9469.•. ,3-25-20AV CIPALI MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP201042 Work Type: SepticTank Upgrade Tax Code Number: 05150124000 Site Legal Address: SLEEPY HOLLOW #2 BLK 2 LT 13 G:1160 Site Mailing Address: 18843 MOUNTAIN RD, Chugiak Owner: WILLERT LAUREN E Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Effective Date: Expiration Date: Lot Size in Sq Ft Total Bedrooms: �»>c.nt c °� `S`: y v 3/18/2020 3/18/2021 35956 ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: The Pump Install Log is to be submitted prior to Inspection Report approval. Received By: Date: Issued By: �„��� Date: v 3 PAUMCIPALITY � F , HORAGE Development Services Department Phone:907-343-7904 On -Site Water & Wastewater Section -- Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-501-24 Property owner(s) LAUREN WILLERT Mailing address 18843 MOUNTAIN RD. CHUGIAK AK Site address SAME Day phone 750-6841 Legal description (Sub'd., Block & Lot) SLEEPY HOLLOW #2, BLK 2, LOT 13 Legal description (Township, Range & Section) Lot Size 35,956 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) El Septic Tank 0 Upgrade FI (w/wo ADU) Duplex (D) ❑ Holding Tank ElRenewal ❑ Multiple Dwellings Privy ❑ (SF and/or D) Private -Well ❑ Water Storage ❑ ti3 � ' 1 THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: a s 4� Distance: I certify that the above information is correct. I further certify that thi�`ts'14ordane applicable Municipal Codes. 8 G 9 5 (Signature of property owner or authorized agent) Permit/Rush Fees: O&D Waiver Fees: Date of Payment: �314910k) PO Receipt Number: C Y- I I tq,4" Permit No. 65 Pim t 6 4a Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc May 16, 2020 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New septic tank permit Legal: Sleepy Hallow #2, Blk 2, Lot 13 To Whom it may concern: This is a request for a septic tank permit on the above referenced lot. This tank replacement will not impact any of the neighbors or encroach on any wells, septic or open water issues. Sincerely &A— Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 tmrcirlll 199 6 7 �— — — — — — -- 4 VACANT Lor / \ , 1 \ 18.7 VACANT LOT \ '• II 10 y/ 5�«°,«, VACANT LOT S0\\ 7 4DIUS i 14 °� \ sernc 1 \ + �I ,/ PACPo5C0 ^� 1 SEPTIC ` \ SYSTEM 1 SEPTIC/ + \ / 9-0 I 0\'pho— I+ELL SEPTIC1 \gyp 1 / % j RADIUS/ z SEPTIC DESIGN PREPARED FOR LARRY HETLET LOT 9, BLOCK 2 ;'�,r;:•'`t�� SLEEPY HOLLOW SUBDIVISION, NO. 1 "'•° �`l':'��'" �' PREPARED BY. • •' ' MICHAEL N. ANDERSON, P.E. d../`:. ...,....�: ... •c'• WCI•IA. I. N. AN110SON ' 14-250 N. GOLDENVIEW DRIVE •~'' rI (907) 345-3377 / FAX (907) 345-1391 Q `;^, SCALE: 1 "=100'� :��.`� 3 a� �� • , •�`�R, DATE: 3/31/98 h k ! � : t m 'aa �lJ MdC-iAEL N. ANDERSCN eQ r a �., C 9169 on(' • y° @ 3jtr�� u�Y4,ii��C ASBUILT ��, �c_ �% �C �j t A) l 4-o OLA sc - . 5l +C)-trTv.r Q I HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY - ROPERTY-TNOEhlaC �\ AT NO EhlaACHM�NTS 65S DCCEPT AS b INDICATED. IT IS THE RESPONS1131LITY OF THE Q OWNER TO DETERMINE THE M(IStENCE OF ANY V EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI_ iY4iioct� VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB: ANY DATA HEREON BE USED FOR CON`-ITRUCTION h OF FENCE LINES, OR FOR ESTABLISHING, BOUND- ! � : t m 'aa �lJ MdC-iAEL N. ANDERSCN eQ r a �., C 9169 on(' • y° @ 3jtr�� u�Y4,ii��C ASBUILT ��, �c_ �% �C �j t A) l 4-o OLA sc - . 5l +C)-trTv.r Q I HEREBY CERTIFY THAT I HAVE SURVEYED THE FOLLOWING DESCRIBED PROPERTY - ROPERTY-TNOEhlaC SCALE` / AT NO EhlaACHM�NTS 65S DCCEPT AS OATt�d INDICATED. IT IS THE RESPONS1131LITY OF THE OWNER TO DETERMINE THE M(IStENCE OF ANY GRID: EASEMENTS, COVENANTS, OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDI_ iY4iioct� VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB: ANY DATA HEREON BE USED FOR CON`-ITRUCTION OF FENCE LINES, OR FOR ESTABLISHING, BOUND- ARY LINES. at Vi OF At Ar op Ginn. Mtrk 3.w. f LS - 8 F IE N Ii: I_. I I=' Ii: I::;~ H :[ '1' .,I)l I:' ()[',~ ] .t I)ll ]: I:::IEt::CI' :[ I:::'Y :1,,, :1: am F: :t: I".hq hi C', E SCALE OWNER OF LAND ADDRESS LEGAL DESCRIPTI DATE. - Started — PERMIT NUMBER (�rrttffitrb Brittinglwg b, DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 • TELEPHONE 688.2759 Ended KIND OF FORMATION: Ft. to Ft. From Ft. to From Ft. to Ft. -. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. _ From_ Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. NF Ft. to Ft. to Ft. to Ft. MUNICIPAUTYOF ANCH&�GE Ft.DF�. ET,IRONMENTAL PROTECTION Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to—Ft.-- o Ft. _From From—Ft. Ft. to—Ft.— o Ft.FromFt. From—Ft. to Ft. From Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: DEPTH OF WELL STATIC LEVEL OF WATER FT DRAW DOWN FT. GALS. PER HR KIND OF CASING Froin—. Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. _. From Ft. to Ft. From Ft. to Ft. From From From Ft. to Ft. to Ft. to Ft. MUNICIPAUTYOF ANCH&�GE Ft.DF�. ET,IRONMENTAL PROTECTION Ft. From Ft. to Ft. _MA_R 1A 1989 From Ft. to Ft Q7 r' r t \ / C 11 DRILLER'S NAME MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 I_ Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTION REPORT NAME MAILING ADDRESS LEGAL DESCRIPTION LOCATION DISTANCE TO: Manufacturer Liq, ca DISTANCE TO: Manufacturer DISTANCE TO: No. of lines ~ £ Length PHONE ~ ~NEW j~VV-~ []UPGRADE 13' ~ 2 _5'L~v Absoretionaroa~ t Materia~r~ IF HOMEMADE: Inside lengt, l~ Well ~/~ Dwelling Well ~ Foundation Length of each~ /~ Total length Material beneath tile Depth NO. OFBEDROOMS ~ No. of compartments Liquid depth PERMIT NO. Material Liquid capacity in gallons .ENM,T NO. 8z Distance between Ii Total effective are8 PERMIT NO. Type of crib Crib diameter Well DISTANCE TO: Depth DISTANCE TO: Building foundation Crib depth Total effective abSolption area Building foundation Nearest lot line Driller Distance to lot line Sewel line Septic tank OTHER PIPE MATERIALS SOl L TEST RATING / ~.~. INSTALLER REMARKS ~ ]~ // V¢~;~ ~ ~ ,; .~,~ PERMIT NO. DEPRRTMENT L NERLTH RND ENVlRONMENTRL . OTECTION 825 "1_" STREET., RNCHORRGE., MK. 9950i 264-4?20 CN~",I---S I T~=] SE[dER F"ERf"l ][ T' ( 82:t014 ) RF'PLICRNT LOCRTION L. EGRL HRROLD D GROSS I_i~ B2 SLEEPY HOLLOW ~44~ BOBBIE CIR LOT SIZE ~44'-5364 999999 SQLIRRE FEET TYPE OF SOIL RBSORPTION SYSTEM IS: DRRINFIELD MRXIMUM NUMBER OF BEDROOMS SOIL RRTING (SQ F'T?BR)= t25 THE REQUIRED SIZE OF THE SOIL RB'-';ORF'TION SYSTEM IS: THE LENGTH DIMENSION IS THE LENGTH (IN FEE]') OF THE TRENCH OR DRRINFIELD. THE DEPTH OF FI TRENCH OR PIT IS '[HE DISTRNCE BETWEEN THE SI..IRFFICE OF THE GROUND RND THE BOTTOM OF THE E.~dCR',.,'RTION (IN FEE:]'). 'T'~-IE Tf~.'E~-.IOl-~ ~-.I I [)TF'~ I :5 5. (.~ENle-~J FEET. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRMEL BETWEEN THE OUTFRLL PIF'E FIND THE BOTTOM OF THE E~-~CRVRTION (IN FEET). PERMIT RPPLICRNT FIRS THE RESPONSIBILITY TO INFORM THIS [-',EPRRTblENT DURING THE INSTRLLRTION INSPECTIONS OF RNY WELLS RDJRC:ENT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. ....... -r i....~ ci ,{ 2 ) I N;~];PfEF:T I C~t-4..~-_; FIRE RIE~---!LI I RE[:, BRCKFILLING OF: RNY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DI2-]TRNCE BETWEEN R WELL RND RNY ON-,SITE SEWRGE I)ISPOSRL SVSTEM IS d.00 FEET FOR Fi PRIVR'FE 14ELL OR i50 TO 200 FEEl' FROM FI PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC I.dELL. MINIMUM DISTRNCE FROM R PRIVRTE WELL TO FI F'RIVRTE SEWER LINE IS 25 FEET BF,ID TO R COMMUNITY SEWER LINE IS '75 FEET. OTHER REG!UIREMENTS MRY RPPLV. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE R',,,'RILRBLE TO INSURE PROF'ER INSTRLLRTION. I ±: FORTH BY THE MUNICIF'RLITY OF RNCHORRGE, 2: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. 3: I UNI)EF.:STRND THRT THE ON-SITE SEWER SYSTEM MRY RECdUIRE ENLRRGEMENT IF THE RESIDENCE I~EM0[:,~LED T~.LIDE bl0RE THRN Z< E:EDROmZmMS. .............. CERTIFY THRT I RH FRMILIRR WITH TIdE REK!UIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET CONSTRUCTION TEST LAB :::'ERFORME D FOR: LEGAL DESCRIPTION: "/'HIS FORM REPORI'S: Harold Gross Lc~ .13 Block :DVisuol Soils Exominofio~ 18 ~) W 48TH AVE STE 'C' ANCHORAGE, ALASKA 99503 248-1:533 DATE PERFORMED: 10/30/81 Subdivision D Percolation Test DEPTH SOIL =EET DESCRIPTION NOTES Sandy Silt - ML 2' ., Silty Sand - SM 4' Sandy Gravel - GP 14' 0 Z ,,','AS GROUND WATER ENCOUNTERED ?':' YES, WHAT DEPTH _EGEND :% -- Perc zone "~ S - Sample loken = -- Frozen zone '~' -- V¢o~er 1able BOTTOM OF HOLE x': :', I ~ < ,% ~,O /.: ' , ', · ;k ~'. i · ''": . :': ":EST PERFORMED BY: :-E RCOI_ATION RATE: · ~ ROPOSED INSTALLATION COM, MENTS: Kevin Braun DRAINAGE REOUIREMENT$: 12.5 S~/be~=oo~,~_~'~ OTHER ""~ L~:.""' IL D SEEPAGE PIT D DRAIN FIELD D DATA CERTIFIED BY: %% ...~ y,~', .......... .:~- -:EADING DATE GROSS TIME NET TIME DEPTH TO H20 NET DRAINAGE GENERAL SITE SLOPE APPLIf' NT FRILLS OUT UPPER HA! :ONLY Buyer Address Zip Code Lending Institution ~,/ /~ ~ ~ ~ Z~ ~ /~ C -' ~;" ~ 0~'~ /~ Z~ )2 C2~ Phone Address ~ % ~ Zip Code Type of Residence ,~ Single Family ~ Multiple Family No. of Bedrooms - .. Water Supply ~ Individual /'' A~ACH WELL LOG. A well Icg is required for all wells drilled sinco June 1975. ~ Community -; ? For wells drilled prior to that date, give woll depth (attach Icg if available). ~ Year Indlvfd.al Installed: Od: Public When Connecte¢ to Public Utilily: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Date Date Date Date Inspector Inspector Inspector Field Notes: Inspe3tor (~ APPROVED BEDROOMS ( ) DISAPPROVED ) CONDITIONAL APPROVAL' 'CONDITIONS OF APPROVAL MUNICIPALITY OF ANCHORAGE DEPT, OF Hf!ALTH ~: ENVIRONMENTAL PROTEC liON ~ ' 98o RECEIVED Soils Rating Date Sewer Inslalled Well To Absorption Area Well to Tank Well Log Received Septic Tm~k Size MUNICIPALITY OF ANCHORAGE ANW Development Services Department Phone: (907)343-7904 On -Site Water & Wastewater Section Fax: (907)343-7997 Certificate of On -Site Systems Approval OSC241492 Parcel ID 051 -501-24 Expiration Date: Legal description SLEEPY HOLLOW #2 BLK 2 LT 13 Site address 18843 MOUNTAIN RD Current property owner(s) ROSS BENJAMIN ANGUS X The On-site system(s) is/are approved for 3 bedrooms By; Conditional approval for bedrooms, with the following stipulations: Comments or conditions: No comments Original Certificate Date: 12/9/2024 This e�ficate of On -Site Systems Approval (COSA) is intended to demonstrate the subject sy em(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, revelopment Service Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's submittal. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other 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 Application 1. GENERAL INFORMATION Parcel I.D. 05150124000 Complete legal description SLEEPY HOLLOW#2 BLOCK 2 LOT 13 Location (site address) 18843 MOUNTAIN Current property owner(s) ROSS 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ■❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑■ Plastic ❑ Concrete ❑ Fiberglass Age 4 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench ❑■ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. t � COSA Fee $ ) S L' Date of Payment /Z6 /z -�l COSA # C9 -S `/ / 9 � "Z Waiver Fee $ Date of Payment Waiver # COSA Application—June 2022 COSA Checklist_June 2022 COSA Checklist Legal Description: Parcel ID: If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date Comments __________________________________________________________________________________ B. TANK DATA Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist_June 2022 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) 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 N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to 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 Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F.ENGINEER’S COMMENTS G.CERTIFICATION & 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm Phone Engineer’s Printed Name Date C&M ENGINEERING CHARLES BALZARINI, PE 11/22/24 EPIANs RUS14 MUNICIPALITY OF ANCHORAGE waoo� 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. 051-501-24 1. GENERAL INFORMATION Expiration Date: (� -2Z - 2-©z0 Complete legal description SLEEPY HOLLOW #2 BLK 2 LT 13 Location (site address) 18843 MOUNTAIN RD CHUGIAK AK Current property owner(s) JOE & LAUREN WILLERT Day phone Mailing address SAME Real estate agent Day phone 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic Fx7l 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 $ gBd Waiver Fee $ Date of Payment 3/ae/aUgo Receipt Number 0'R &r16 COSA# (3SC_2G/1aa Date of Payment Receipt Number Waiver # 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 MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 3-25 °"•ti's r �4Y?4 �`>' °•�°°�•° °•••••.•_•°`� 6. DSD SIGNATURE �� 11" System #1 Approved for 3 bedrooms _ ...> a : _;.: ....,•.. � __, MICHAELN: -94 System #2 Approved for bedrooms j) Disapproved q aa/ t p,'fl Conditional approval for bedrooms, with the following stipulations: s QWTY or r�ir \�i COSA Checklist Legal Description: SLEEPY HOLLOW #2 BLK 2 LT 13 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA Al Well log is filed with Onsite (or attached) Date drilled 4,115/89 Total depth 400 ft Cased to 20'* ft W Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18"+ in. Date of flow test for COSA 3/16/20 Static water level at beginning of test 18.5 ft. Comments * FROM MOA FILES B. TANK DATA Age of tank(s) NEW years Tank type/material. PLASTIC bee, -*,- Measured operating fluid level in septic tank NEW V Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA Parcel ID: 051-501-24 Structure served by this system Well production at time of test 1+ gpm Water storage tank volume 0 gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 1.23 mg/L LI Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 3/16/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Which system tested (date installed) 10/20/82 Adequacy test date 3/16/20 ❑® ALL standpipes present per record drawing Results ❑✓ Pass For 3 bedrooms Total measured depth from grade 10.2 ft (max) Fluid depth prior to test 0 in Measured depth to pipe invert from grade 6.7 ft (min) Water added 500+ gal ❑ N/A — pressurized field 12 New depth in ❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 1440 min depth into effective ❑ Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 500+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) _ Gallons introduced 0 gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ❑ Yes if No 8* Community Sewer Manhole/Cleanout > 100' ❑✓ Yes if No ft [7 Yes if No Neighboring Tank > 100' F/ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No Absorption Field on Lot > 100' 0✓ Yes if No ft Holding Tank > 100' Yes if No Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' Yes if No 0✓ Yes if No ft _ If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' [✓ Yes if No ft [71 Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No 8* ft Surface Water > 100' F Yes if No _ Property Line > 5' 1✓ Yes if No ft Wells on Adjacent Lots: Wells on Adjacent Lots: Absorption Field > 5' 2 Yes if No ft Private Wells > 100' [DYes if No _ Water Main > 10' ✓0 Yes if No ft Community Wells > 200' ✓] Yes if No. Water Service Line > 10' M 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) ft ft ft ft ft ft ft ft Building Foundation > 10' 2✓ Yes if No ft If absorption field is under driveway comment below Property Line > 10' P/1 Yes if No ft Wells on Adjacent Lots: Water Main > 10' F71 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' ✓V Yes if No ft F. ENGINEER'S COMMENTS * TANK IS OUTSIDE OF THE FOUNDADTION BEARING AREA G. ENGINEER'S CERTIFICATION l certify that l 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. COSA Checklist yellow sheet n I" • c ewe o'a ./ � eN. Ae e o . • :e e • MICHAEL NeM•RSONe F �r� CE -9469 -mr t/ � 42.0 1 Cant Use Ho °se H ou (� 2 St NyT S ;' can V 1 CHICK C40P 59.7 00 co l� t� v g c �\ y 7 O F Y� ••,pW 'a '0 p\.t4`4 :R �WUFUHO if m •d' O U y .� �.+ MV 0 °,xv A� aid O O2. v S WF' LO.G'OyD,ym m w [�=K'd O „ o �b � Q1 d If� W .Ly iU+ pf"j d a O 0 0 m OM M RI 00 z �O�U w Cr to �cl �w O E'd m O AFi °� OW zclr. s yy 0) 42 v v c, > a o Oav $.s,R vO n C', CO � O z O p U L4 O.N O CO N ^ W Z) co Q NO Q 0 i Ui pa � c = U O Q) - r >- U Z a 0 w Q O CO N �o O O vra C O � BO �y cho N cc 44 tbo w� o A y 0 C) N r M q O brr �+ m ^+{cli + -'� cd m ;.W kcD j MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 13; Block 2; Sleepy Hollow Subdivision ¢2 Location (address or directions) NHN Mountain Road (b) Property owner AHFC Telephone: (home) Mailing Address AHFC ¢54401 ~O(~, F~ (c) Lending Institution GMAC Telephone Mailing Address Business (d)Real Estate Company and Agent JACK WHITE COMPANY/Lori Crowder Address 10928 Eagle River Road, Eagle River, Alaska 99577 Telephone 694-5500 (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 ENGINEERING/694-2979 17034 Eagle Rive4 Lrmp Road¢ Sa~¢. 204 Eagle R~'u¢.~; Ala~ 99577 2. TYPE OF RESIDENCE Single-Family ~ Number of bedrooms _ 3 3. WATER SUPPLY Individual Well [] 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 EX Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 ~ Jo E @6ed le^o~ddv leUO!~!puoo jo swJeJ. leUO!l!puoo peAoJddeB!CI -.~ pe^oJdd¥ 'l¥^ol:ldcr¢ SHH(~ '9 euoqdele± sseJppv ~ MUNICIPALITY OF ANCHORAGF (MOA) ~ MU~,1,1,1,1,1,1,1,1,1,~_'¢~ OF ANCH~CI~t:Jth Authority Approval (HAA) ENVlR~& SERVICES ~'JI~ICLIST - FEBRUARY 1984 343-4744 MAR ! 3 ]989 Legal Description: ~ ~"~ RECEIVED A, WELL DATA Well Classification Well Log Present (~i~4) ___'7/ Date Completed Total Depth~ Cased toCc:~ W Depth of Grout*ng Pump Set At Sanitary Seal on Casing ¢~N) Static Water Level Casing Height Above Ground Electrical Wiring in Conduit ¢~N) If A, B, C, D.E.C. Approved (Y/N) ',/P~ Yield ~::~'C:) ~---~l¢~'Jf~ ¥ Depression Around Wellhead (Y/~]~ SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot /¢;:;tz~'~''~ To Nearest Edge of Absorption Field qn Lot \ c:~::~ '~ To Nearest Public Sewer Line ~/'~' To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot __ ~ ~ Water Sample Collected by ~--'~ ~ It-~¢~;;:~i~ ; Date Water Sample Test Results ~'~t¢~-( -- ~ Comments .~-~/~ ~ l~k~ -~::) .~_~-~-¢)_ ;On Adjoining Lots ___[ c-~c~'i4- ; On Adjoining Lots _ ~ ~:~l + B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes ¢¢~N) ~-// Air-tight CapsCN) _ Depression over Tank (Y/~(~ Pumping/Maintenance Contact on File (Y/[~ / Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line ~ ~-~ To Stream, Pond~ Lake or Major Drainage Course Comments No. of Compartments '(' Foundation Cleanout ~N) _ t.(. Date Last Pumped ~. /J~ ; for / 'Temporary Holding Tank Permit (Y/N). ¢/~. To Building Foundation To Disposal Field 72-026 (Rev 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y~i) Results of Last Adequacy Test Type of System Design Length of Field ~'~ I Depth of Field \~ Gravel Bed Thickness '~ '~ "22 '/E~c;> ~/~' Statndpipes Present2[~i~N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well \ To Building Foundation Lot ~/¢~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Y To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) Comments Date Installed Dimensions ,,S~vel°ns I at High Water Alar~ Tested for ~ Meets MOA Electrical Codes (Y/N) Comments Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Company Date MOA No. S & S ENGINEERING 17034 Eagle Rl~er Loop Road No. 204 Receipt No. ('~S-- ~.-/O~ Date of Payment Amount: $ 72-026 (Rev. 7/88) Receipt Waiver Fee: $ Date of Payment Page 2 of 2