HomeMy WebLinkAboutNORTON PARK #1 BLK 2 LT 7MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
~UNICIPALITY OF ANCHORAGE
Hea_ and Environmental Protec )n
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
279-2511, x 224, 225
SEPTIC TA[,IK:
FROM WLLL //~_E) ~_. _ r-.1Af,;UF/',E1 UR[;~R _ __ ;.,'aTERIAL ..... COMPARTMEIqTS
tNSi!)t{ L EIiGi~H ..... INSIf)E ',',/IDltl . . . LIQUID DEPTH ..... t_lQLJl[) CAPACITY/,c~c~iALLONS.
/ z TO-I-AL LENGTH,¢~ ~, /
DIST/qIC[ FROM VVELL J~[.__FOU2~OATION ~_/~ .... NEAREST LO-I LINE__ ~ ...... OF LINE
¢ o~ %~nes .l ..... D,SrANC~: BmWE~:~ ur,Es ~/~ .....'rr~c~,icH WIDTkI~.~ IN. TOTAL EFFECTIVE
DEr'tit OF FILTER
D[iPI~. TC:F Oi 1ILL !0 f-t;,iJ51t GRAI)E ...... MA-I'ERI&I. BENEA-iH 'FILE .... IN ABOVE -rILE __IN,
.m :P~,Q[L PIT:
DI,,,ME'FER ...... 03,' WIDTH ...... t~.E [',,i G 1't t ..... DEP-I-t I
Log Crib Rings
13Ui LDINC; FOU!!DATION
Crib Size: DI,%ME-I'ER ___DEPI tl ...... DISTANCE FROM: WEI.L
-I'O I'.n.t. EFFECTIVE
NEARES1 LO[ LINE .... /',,[~5QRPTION AREA (WALL. AREA)
SQ. FT.
Class: _.t.~-'- Depth: .............
Well Distance To: Lot ]Line .
Bldg: Sewer Line: : : ~- ............ . '
!I of Bedrooms:
.... :8:8D
::, ~., l l:.l'l iii'3:
'::;(11~:?ii:!',' I I'., '" ...........
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.i: N :E;T A L..i.~I:::IT :[ O M.
GREA,cR ANCHORAGE AREA BORk,.GH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON'SITE SEWAGE DI~PC)SAL. SYSTEM
LOCATION LEGAL DESCRIPltON I -~ 7 / ~
FROM WELL MANUFACIURER MATERIAL _
INSIDE LENGTH
INSIDE WIDYH L IQUID DEPTH
LI qu JO CAPACITY .Z'~-5?) GALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WELL
FOUNDATION NEAREST LOT LINE
TOTAL LENGTH
OF LINES
NUMBER OF LINES
DISTANCE BETWEEN LINES
TRENCII WIDTH ..... IN. TOTAL EFFECTIVE
ABSORPTION AREA
DEPTH: TOP OF TILE TO FINISbl GRADE
WELL:
TYPE ~)K~//~ '~'~ ¢ . CONSTRUCTION
SQ. F'F. t_ENGTH OF EACd LINE
DEP1H OF' FILTER
MATERIAL BENEATH TILE _ IN. ABOVE TILE
IN.
DEPTH
DISTANCE FROM:
BUILDING NEAREST NEAREST
FOUNDATION LOT LINE _____ SEWER LINE
SEPTIC SEEPAGE
TANK _ _, SYSTEM._
CESSPOOL OlNER SOURCES
APPROVED DISAPPROVED_
DISTANCES:
REMARKS .
DIAGRAM OF SYSTEM
INSTALLED BY:
SEWEB LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form EQ-O32
D,',-r ZfAPP"OVED
/.w,~/¢ -
GREA. .R ANCHORAGE AREA BOR JGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE~ ALASKA 99B03
TELEPHONE 274-4§6I
SEWAGE DISPOSAL SYSTEM --- APPLICATION AND PERMIT
PERMIT NO.
INSTALLATION OF:
MAILING ADDRESS ~')U X PHONE¢-'
TYPe AND SIZE OF FACILITY TO BE SERVED .
~ 0--~ ~¢(J NOTE: THIS PERMIT IS NOT VALID wrrHOUT SOIL TEST
SOIL TEST RESULTS
FINAL INSPECTION: ~4 FLOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANR
POUNDATJON TO seEPAGE PIT
SEPTIC TANK TO SEEPAGE Pit WALL
SEPTIC TANK .,SEEPAGE PIT
TO NEAREST LOT LINE.
WELL TO SEPTIC ~ANK
DRAIN FIELD
WATER MAIN tO SEPTIC TANK
., DRAIN FIELD
SEEPAGE PIT
ALSO CONSIDER AREA WELLS.
__.. SEEPAGE PIT
_, DRAIN FIELD
CAST IRON iNTO AND OUT Of SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
G~AVEL I~ACKFILL
DIAGRAM OF SYSTEM
I
. . L.~ ~. , , , ~ .; .. +- .~ ~-.',.-
.... ¢~ -,4. '. / ~] . , '2)~-~,tc~;-,-
/~'I% L?'k l: ~ f /?/-~- ' ' ·
r* ~ '
,/ LICEN$1~D DESIGNER . _ ' ..... :. L .
., /:- '7£ ^PP,,CANTSS,GNATUR X/t '
7"
LQ-016(3-7B)
COIqSIJLTING GEOLOGIST
BOX 476-M, STAR ROUTE A · ANCHORAGE, ALASKA 99507 ' PHONE 344-707{
SOILS LOG
:Performed for ~---~--~'~ ~ff
Soil Descriotion
-.16--
-18-
-20-
Total Depth
~ ? What depth
How determined~
Was groundwater encountered
Depth to bedrock ~0~
--- ?
Respectfully submitted
Gary F. Player
Consulting Geologist
MUN I C I PAL t TY OF ANCHORAO':
OF HEALTH AilO ENVIRONMI:!,
L ~hl?eet:~ Anchorage~ A]_as]i.a
Insp Willis
Da~e Received:
ri) j.!tle
D a h e
]: IIS [)
PROT[~CTION
9950]_
August 29, 1977
3: ':['J me
Date
Insp
t. fs6UE,~] J L~ API?R. OVAL OF INDiV]DUAr, SEWER AND WAI~'~R FACII,Iq"IP, S
l.
Lending InsLihution Rcguesl:: First Federal Savings & Lonn % James D. Fish
Hai!it~g Address: 813 West Northern Lights Blvd. Phone: 274-6561
ProperLy Owne-c:
Mailing 2'u!drc. ss:
Jack W./Ar]ene Carr Phone
Star Route A Box 186-C 99507
Lot 7 Block 2 Norton Park Subdivision
SJng.i,e Fam'i_].y Reside. nc(~; (x)
Mu].t~ l).le Fam'[]..¥ Res:[denee: ( )
Numbe}: of Bedrooms;: Two
Nulaber of Bedrooi~l.q:
5, Well Sy:;l:e;u: :!:l~(l:ivJdua] Wcul'l. (~: CommunJ. i:y/Publ.i_c System ( )
6.
7
Fermi t
Dephh o:ff Well
Well Log on File ( )
Bac'herial Aha.l_.ysJs
..... I:= ...... FiysLera: On.-s'[te System (x) Pub].:[c Utili[ty ( )
PermJ. t ~ Jnst_, Lied 1977 ins[-.al].er
Abso:cpt.ion Area -t ~00 ,-' "~ ~
.................... oO.L .... Rnte Mat:erial
....................... Absorption Area
MUNICIPALITY OF ANCHORAGL
Department of Health and Environmental ProtectiOn
825 L Street, Anchorage, Alaska 99501 .
t~equest for Approval of Individual Sewer and Water Facili'tiL~
Property Owner: _k3~C~ /~). ~ .~.~ le~e ~
Mailing Address: ~n~ ~X /}~-~ ~C~}/~e Phone:
Lending Institution:~~ ~~/ ~'~ ~ /~
Mailing Address: ~/~ /~ ~A~ [~,'4~ Phone:
Realtor/Agent:
Mailing Address:
Legal Description:
Street Location:
Single Family Residence: ~4) Number of Bedrooms:
Multiple Family Residence: ( ) Number of Bedrooms:
Water Supply: *Individual Well ~) Public/Community System ( )
If Individual Well, well depth
If Community System, name of system
8. Sewage Disposal System: On-site System
If On-site System, date of installation:
Public System
_ Iq77
*NOTE: A well log is required on ALL wells drilled since 6/75.
3/77
Page Two
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 7 Block 2 Norton Park Subdivision
Comments:
Affadavit Attached:
Approved: --~
DJ_sapproved:
Letter Attached: ( )
Date:
Date:
Department Worksheet:
06-1220(a) Rev. 1973
DATE
Ab DEPARTMENT OF HEALTH AND SOCIAL ,~ 'ES
DIVISION OF PUBLIC HEALTH
INDIVIHUAL AND SEMI-PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
Lab No.
OFFICE
INDIVIDUAL []
NAME
SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS TO
ADDRESS
CITY
ADDRESS
OF SOURCEi
-- ZIP CODE
-
COMPLETE THIS SECTION
ONLY IF WATER IS AN INDIVIDUAL SUPPLY
SAMPLE COLLECTED BY ' '[ :
DATE COLLECTED TIME COLLECTED
Sal~lpJe Collected Prom [] Kitchen Tap [] Bathroom Tap [] Basement Tap
[] Other (List)
Well- [] Dug [] Driven [] Drilled [] Bored
SOURCE: [] Spring [] Cistern [] Other____
Dug Well or Cislern Constru~llon
Walls--[] Wood [] Concrete [] Metal [] Tile Brick or
Top -- [] Wood [] Concrete [] Metal [] Open Top~ Concrete
LOCATION: [] In Basemenl [] Basement Offset [] Under House
[]rn Yard [] Other
Building Bewer Seplic
DISTANCE TO: or Other Drainage Pipe__ __ Feet. Tank. --Feet.
Tile Seepage Cess-
Field Feet. Pti _ Feel. Pool Feet. Privy .... Feet.
Other Possible
Sources of Contaminallon
MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile [] Fibre [] Asbeslos
[] Plastic Joint Material - Type Cement
GENERAL: Does Water Become Muddy or Discolored? [] Yes [] No
When?
Diameter of Well Depth Feet.
Well Casing
Malerlal -- Diameter Depth
Length of Waler Depth
Drop Pipe From Bottom __ Feet.
Offset in In UlilJfy
PUMP LOCATION: [] In Well [] Basement [] ill Basemenl [] Room
On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION: Illness Suspected?
Nevi Source of Supply? [] Yes [] No
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
Analysis shows lhls Water SAMPLE td be:
[] Satisfactory
[] UnsalJsfaclory
[] Questionable
~] Sample too long ;n lranslt; sample should not be over 4B
hours old at examinatJon to indicate reliable results. Please
send new sample.
[] Bottle broken [n transit, please send new sample.
SANITARIAN'S REMARKS
[] Yes [] No
Repairs to System? [] Yes [] No Signature
Rev,06'12201973(b) BACTERIOLOGICAL WATER ANALYSIS RECORD
:tose Broth 10cc : 10cc 10cc 10cc 10cc 1.0cc 1.0cc
24 Hours
48 Hours
IlJant Green
24 Hours --
48 Hours --
EMB AGAR
Laclose Brolh, 24 hrs. 48 hrs. Gram's stain
Coliform Density (Most probable No. per 100cc)
MF Results
Reported by ' ! Date p.m.
This analysis indicates Coliform Organisms lo he: Absent
Present
."UNNICWALITY OF
pq
A
Development Services Department - s
On -Site Water & Wastewater Section
Parcel I.D. 016.211-46
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Phone: 907-343-7904
Fax: 907-343-7997
Expiration Date: 12 —. z-0
Complete legal description NORTON PARK #1 BLOCK 2 LOT 7
Location (site address) 400 WEST 121ST AVENUE ANCHORAGE AK 99515
Current property owner(s) PAUL & AMY SARAFIN Day phone
Mailing address-- 121 AVENUE; ANCHORAGE, AK
Real estate agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
3
Date of Payment 9/Z Z/?0 F'-0
Date of Payment
4. TYPE OF WATER SUPPLY:
Receipt Number
TYPE OF WASTEWATER
DISPOSAL:
Private Well
®
Private Septic
❑
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
Waiver request for.
Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ ( 0 (cm I �^ ��
Waiver Fee $
Date of Payment 9/Z Z/?0 F'-0
Date of Payment
Receipt Number SI zaC'
Receipt Number
COSA # 0 SC.)- 0 15 1 I
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 FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 9/1912020
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 +It
these various and dynamic characteristics and are outside the control of the evaluator of the m • • • • 1"1
-- - - well and septic-system.Therefore,-any estimate -of how long -a system will function satisfactory���•
for current or future occupants or guarantee that no unseen encroachments, deficiencies or a q••• '•9
discrepancies exist can be given by First Water Consulting & FItiCS . % *• -49 7H ••*
6. DSD SIGNATURE �� • :• • Curtis Huffman
System #1 Approved for
-3-- bedrooms �����s••. CE 128991
/ stem #2 Approved for bedrooms }I�, ROF
S 5S �P��r
Y Pp kt\�
Disapproved
Conditional approval for bedrooms, with the following stipulations:
�M WATER r TER o
By.;,—�-., Original Certificate Date: ` r 2-� - 26
The Municipality of Anchorage 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 engineers work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist
Legal Description: NORTON PARK #1 BLOCK 2, LOT 7 Parcel ID: 016-211-46
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 *PRIOR TO 1977
Total depth *55+ ft
Cased to *UNK ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 9/16/2020
Water storage tank volume NA gallons
Well disinfected for coliform test? ® Yes ❑ No
® Coliform bacteria is Negative
Nitrate mg/L ® Nitrate less than MRL (ND)
Arsenic 5.97 ug/L0 Arsenic less than MRL (ND)
Collected by FMCS
Static water level at beginning of test 27 ft. Date of Sample 9/16/2020 & 9/23120
Well production at time of test 4 gpm
Comments *PER MOA DOCS. TOTAL DRAW DOWN TO 49' FROM TOC PER 9/16/2020 INSPECTION.
'ANK DATA - NA
Age of tank(s) _ years
Tank tvoe/material
Measured operating fluid level in septic tank
❑
Stand pipes/foundati\cleanout per record drawing
Date of pumping
D. ABSORPTION FIELD DATA - NA
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
❑ 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:
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date
Results ❑ Pass For bedrooms
Fluid depth prior to test in
Wate,added gal
New depth"-,. in
Elapsed time ai
Final fluid depth in �\
Absorption rate gpd
Any rejuvenation treatment (past 1
If yes, enter date
onths)
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
Community Sewer Manhole/Cleanout > 100'
® Yes
❑ Yes
if No
NA ft
[-]Yes
if No
*50+ ft
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ❑ Yes
if No
*25 ft
Absorption Field on Lot > 100' ❑ Yes
if No
NA ft
Holding Tank > 100' ® Yes
if No
ft
Neighboring Absorption Fields > 100'
Animal Containment > 50' ® Yes
if No
ft
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑ Yes
if No
*47' ft
® Yes
if No
ft
FroSeptic/Holding Tank on Lot to: (Please enter distances if less than required)
Building F oundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No ft
Property Line >> 5 ® Yes if No ft Wells on Adjacent Lots:
Absorption Field > 5' Yes if No ft Private Wells > 100' ® Yes if No ft
Water Main > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft
Water Service Line > 10' ® Yes if No-- ft If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distant
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
F. ENGINEER'S COMMENTS
*PER MOA DOCS (2015 & 2018 COSAs....
G. ENGINEER'S CERTIFICATION
than required)
If absorption field is under driveway comment below
Wells on Aajacent Lots:
Private Wellsls 100 ® Yes if No _ ft
Community Wells > 200 Yes if No
l certify that / 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.
bf-
P'11
.. ............:.i
Curtis Huffman
�F`•• CE 128991 •`�%
of • 9128/2Q2e •c`����
�i
tpROFESSIOO,��-��-�
Municipality of Anchorage •
r. On-Site Water and Wastewater Program
:id c_ (907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 016-211-46 Expiration Date: -7 -E-- /R
1. GENERAL INFORMATION
Complete legal description Norton Park #1 Block 2 Lot 7
Location (site address) 400 W 121st Ave
Current Property owner(s) Smith Day phone 244-1930
Mailing address Same
Real Estate Agent Cindy Wilson Day phone 2— s = II q 6...
b \7
`b ,--_:-.0.1.r..'
2. TYPE OF DWELLING: a APR G o 'Ciili3
® Single Family (w/wo ADU)
❑ Duplex a.
❑ Multiple Dwellings (Single Family and/or Duplex) !l �,"
ul 6 8 Lg
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual ❑
Individual Water Storage ❑ Holding Tank ❑
Community Class C Well ❑ Community ❑
Public Water System ❑ Public Sewer
Received by: f Date: 5(7//('
COSA to be released to the engineer,unless herwise requested by the engineer.
COSA Fee $ 220 Date:
Date of Payment tf-a '11' Date of Payment
Receipt Number ba-3(0'1D Receipt Number
COSA# 04J Ck$l 1 IO 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 NorthRim Engineering Phone 694-7028
Address PO Box 770724,Eagle River
Engineer's Printed Name Steve Eng Date 4/25/2018 •.-,..
-.V 9,T oe- 's1)
.. of
6. DSD SIGNATURE
)(' System #1 Approved for 3 bedrooms.
System #2 Approved for bedrooms. `r 94-,:SyliV:e-6 a ��
Disapproved. )
•
Conditional approval for bedrooms, with the following stipulations:
)
Q,, OF r✓yG
ON-SITE �, ,, .
MATER AND
WASTEWATER o
. - pROGRA
By: /i/ 110
Original Certificate Date: 5 "3 '
The Municipality of Anchorage Devlopment 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 Advi olry' --'0
Septic System Advisory Arsenic AlivispW:,
:, j
Well Flow Advisory Other .
COSA blue sheet_9-1-12.doc :t' ; r `�;`�
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of tin-Site Systems Approval Checklist
Legal Description: /V6C fOrter 1 / 5 L 7 Parcel ID: O/ 62114/C
A. WELL DATA
Well type P If A, B, or C provide PWSID# Well Log (Y/N) A)
Date completed Friocro 77Sanitary seal (Y/N) y Wires properly protected (Y/N)
Total depth �,''.5 ft. Cased to CA&ft. Casing height(above ground) re in.
(.KOA `Jt)
FROM WELL LOG AT INSPECTION
Date of test (//1/IC L /27
Static water level a//ie ft. 22. 5. ft.
Well production at/K g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform Pl colonies/100 mL Nitrate 0,2C
mg/L
Arsenic (0.3 O ug/L Date of sample: 1 Z f' /2 Collected by: 1\./ 1 t v>/L.
B. SEPTIC/HOLDING TANK DATA PLJ6Ll c. S e,,.JFe
Tank Type/Material Date installed
Tank size gal. Number of Compartments Cleanouts (Y/N)
Foundation cleanout(YIN) Depression over tank (Y/N) High water alarm (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption area ft2 Monitoring tube Depression over field
Date of adequacy test •
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 ,flit
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot /V4 On adjacent lots /OO '+-
Absorption field on lot A/A On adjacent lots /00 ,4.
717'
Public sewer main Lf 7 f Public sewer manhole/cleanout SCS +
Sewer/septic service line 2 5 + Holding tank /O O "f"
Animal containment areas 50 jer Manure/animal excrete storage areas /OO f
SEPTIC/HOLDING TANK ON LOT TO: NA
Building foundation Property line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO: AJ4
Property line Building foundation Water main
Water Service line Surface water Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS
A7410.4 F- '-6
G. ENGINEER'S CERTIFICATION
of A L
I certify that I have determined through field inspections and -°'-`ri�°<•�° '4�`
review of Municipal records that the above systems are in F ;;'.•'' N.7510%
conformance with MOA COSA guidelines in effect on this date. ' ( roE, \* j
Engineer's Printed Name �7-6/E t J G
Date1/2 , :..,. , :, rix 141
•
COSA yellow sheet 2-6-15.doc