HomeMy WebLinkAboutROEHL LT 3ARoehl
Lot 3A
020-092
-99
%ncv vaivci 10)
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP221009
PID Number: 020-092-99
Dwelling: 9Z Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family
Project: ❑ New 0 Upgrade
Name
Willard Smith
A ORPTION FIELD
❑ D Trench El Wide
Trench E] Bed ❑Mound
Site Address
5445E 172nd Ave
Other
Phone
Number of Bedrooms
Soil RatingTotal
depth from original grade
4
D/SFJ
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original
de Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Roehl
3A
Fill added above original grade
Gr el length
Ft. Ft.
Township Range Section
Gravel width
Ft.
Beds: Number
of Lines
Dist ce between lines
Ft.
SEPARATION DISTANCES
Tol
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between ches
From
Tank
Field
Tank
Line
Ft'
Well
100+
TANK 21 Septic ❑ S.T.E.P.
❑ Holding ❑ Other
Manufacturer
Capacity
Surface WaterI
100+
Greer
1500Gal.
Material
Number of compartments
Lot Line
5+
NA
Plastic
2
Foundation
10+
I
gATION
Manufacturer
Capacity
Remarks
Gal.
Alarm location
Electri lied by
Installer
PIPE MATERIAL House to tank Tank to
D3034 drainfield D3034
Jr's
Drainfield CO/MT
Inspector Arcterra
Consulting
BENCH MARK (Assumed elevation) 100 It
ctionLocation
Inspdeates: Is' 6/3/22
20 6/3/22
and description
3`° 6/6/22
4'"
Roof top corner
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineers Stamp
Conditional Approval:
Date
•''�'"t CF
`•��
� 1
49 m � '�•��
�W f
Septic System
p Y
It�KENNETH UFFUS s
�;
Approv t�
Date _
I� s� CE s +
�1+ f'pTy`�.+e•
Note: this approval does not include well permit requirements.
�41k%k 0�
%ncv vaivci 10)
AS—BUILT SYSTEM DETAILS/SITE PLAN Permit OSP221009
ROEHL LOT 3A PID# 020-092-99
GPRPG� O
DWnNG TROCH
0
3' EILJ1 SECTION UNE
I. A -C=117.7'
B -C=135.1'
N A -D=118,7'
B -D=136,1'
y
A -E=120.4'
o
B -E=137.8'
_
A -F=124.5'
o
B -F=141.7'
Q A-15=127.0'
A
m B-13=144.2'
o
r A -H=128.3'
N
o B -H=145.3' ! a
15M GAL TANG
P 'C
SCALEi NTS
500 GAL
SEPTIC
OF• AZ —
:,<Q� PREPARED FERI
WILLARD & GAIL SMITH
5445 E 172ND AVE
*:4 TH ANCHORAGE, AK
KE 5 .: FIELD BOOKS compuTED:
CE 7 BOUNDAR" N A DRAWN: KSD
STMNc. N A CHECKS)' KMD
6 " f ' • ASBUILT: HOLT .DATE:
'sslat�7/5/2,
DM FILE: GMD: 3337-
AOAD F1'� FILE 'IDB N° 21086
O
EXISTING
BUILDING
711
a 5�
T?Ip 5�5
7�
M14S
l
SCALE, 1' = 40'
SCALE: NTS
I�
W
W
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: OSP221009
Work Type: SepticTank Upgrade
Tax Code Number: 02009299000
Site Legal Address: KOEH (_ L -T 3 A
Site Mailing Address: 5c.j5 F 1'1 Z,ND 'RN E 1 NII�CH
Owner: Smith Willard
Design Engineer: ARC TERRA CONSULTING INC
This permit is for the construction of:
Effective Date:
Expiration Date
��cnt
n"31,11
n
!!.
llLI) 11'tinent
Lot Size in Sq Ft:
Total Bedrooms:
1/20/2022
1/20/2023
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ 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) 343-79.04 (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
Received By: 11 Date: _
Issued By: .t Date: l .2b 0;2.,,
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 020-.092-99
Property owner(s) Willard & Gail Smith
Mailing address 5445 E 172nd Ave. Anchorage, AK
Site address 5445 E 172nd Ave. Anchorage, AK
Legal description (Sub'd., Block & Lot) Roehl Lot 3A
Day phone
Legal description (Township, Range & Section)
Lot Size 90,040 Sq. Ft. Number of Bedrooms _ S
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF)
(w/wo ADU)
Septic Tank
❑x
Upgrade 0
Duplex (D) EJ❑
Holding Tank
❑
Renewal
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
Dea Duffus
(Signature of property owner or authorized agent)
Permit/Rush Fees: � '? '� 5 Waiver Fees:
Date of Payment: 1/20/26;Z2- Date of Payment:
Receipt Number: 06%b l G Receipt Number:
Permit No. O SIoa2 1 009' Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221009, Rebecca Carroll, 01/20/22
1250
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221009, Rebecca Carroll, 01/20/22
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
~ame DISTANCES
--~,~8,,~'(¢,~'" (~J..E')"f,'~ FROM~ SEPTIC ABSORPTION WELL
Address TANK FIELD
·
, FOUNDATION
Township, Range, Section
AS-BUiLT DIAGRAM (Show location of well, septic system, properly lines, foundation,
'~/~ ~U ~ driveway, water bodms, Otc,)
Capacity in gallons ~
~"~2~ ~ /~ ~, .,~'.~
Material No, of Compa~ments
II
II
~TRENCH ~ BED ~ W. DRAIN ~ OTHER
Depth to pipe bottom from Total depth f rom original grade II ~
Fill added above original grade Gravel depth beneath pipe
~ FT ~ FT
Gravellength ~0 ~ Grave/width . 'T ~ F'
Total ~bsorptio. area ~ SQ FT :~ ~ FT
~mbor of li~es 8oil rat,no ~;/~
Installer ~~-S ' ~ Date Insta~d ~
WELLS
~PRIVATE ~ OTHER fldentifv)
Classification (A.B,C) Total DepthFT Ic"~d t° FT
~stailer Date Installed:
Scale: ~ ENGINEER'S SEAL
I~s Pedormed by: , ~ :' , ,: :
I ceflify that this inspmi0n was ped0rmed according t0 all
Municipal and State guidelines in effect 0n this date:
M U N I (.'] I P A L I T Y 0 F A N C H 0 R A G E
Depar, tment o~ Heal{h &. Human Services
8::~!5 L Str~eet, Anchorage, Alaska 9950:1. 345~.~;~7~,{:~
ON-SITE SEWER ~,; SEPTIC TANK &. WELL PERMi'T
Per~m.tt Number ~ 880'10,t
Date I¢'.~...,u~:,.d,~' = - ~.h.)/c,.." ~ "~ ..../8~:.'1
Engineer' Designed
Owner Name: GEORGE [.,LEMANs:,
Ownep Address: ],690() GULDEN/IEW DR.
ANCHORAGE, AK 99516
Day Phc~ne:
...:,4,.~-6~.88
I::'ar~ c:e ]. I d: 0~.'.::'.0-092-78
t,,.,ot I.,.,egal: Subdivision: ROEHL Lot: 4 Block:
Secti;:n: 3 ]"ownship: 11N Range:
t...ot. S:i. ze 40477 (sq, ft,, or acres)
Max Bedr'-ooms: This Permit~ 4 Total Capacity:
SEPTIC TANK: Minimum t{:)t, al septic tank capac:it¥: ].~25~'. ..,. gallons. Each septic
tank must have at least 2 compartments,, Depth to top c)f sept:Lc tank(s) < 4,,0
· ~s insulatir~n over. tank(s)
feet r equ i r' (..,,,. .
WELL: L. og must. be subm:itted tc.~ MunicipaIi'ky of Anchopaqle Depar, tment, of Health
and Hl.l~an ~:' ~-
..~4~ vices within 30 days ¢::~f ~m.;~].l comple~ion.
INSTALL, PER ENGiNE?.ERS DESIGN, A TRENDH TYPE ABSORPTION SYSTEM,,
LENI:i')TH~ 50.0~; GRAVEL. DEPTH: 6.0'; MAXIMUM DEl?TH: :1,(),0~ .,
NOTIFY DHHS PRIOR TI] EACH INSPECTION,, THIS PERMI]' IS ISSUED FOR
A SINGL, E F¢)MILY RES IDENCI!!!: ONI,,..Y AND EXPIRES ON 12/:].";1/88.
]: CERT]:f:'Y THAT::
:1.~ I am ~'amiliar with tl~e requirements for' on-site .~:~ewers and wells as ~;et
~orth by the Municipality of Anchcmage (MOA) and the State o{ Alaska.
~?.,, I will install the system in accordance with all MOA codes and rmgutations,
and in compliance ~,,ith the design criteria of this permit.
3,, I t~ill adher'e to all MOA and State ~)f Alaska requirement~ fer' the set back
distanc:es f'r'om any exist:Lng well~ wastewatep disposal system op public
~ewera¢;~e system on this ~:~ any adjacent or neapby lot.
4. I undepstand that this pepmit is valid (op a ma~timum of' 4 bedr~eoms,, I
(Owner) GEORGE []LEMANS
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
Township, Range, Section: '-T--/I.Z~ ~.~J :a'~ ~
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT ~
DEPTH? p
E
Depth to Water After ~)~ 4
Monitoring? Dale:
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
+W~o /, ~'-zq-~'~ ~¢?-~'? /~ f~I ,~7--,?/~'
PERCOLATION RATE ~*'* ~'""- m~nutes/mcn.~ PERC HOLE DIAMETER
TEST RUN BETWEEN ~ . FT AND +7 FT
~7 0, ~" ~ If',
PERFORMEDBY: /~--5 ,
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
JOB
SHEET NO OF
CALCULATEDBY /z~, /~J/~'~,~//~ DATE
CHECKED BY DATE
SCALE
ALASKA
erlUlRonm6nTAL CONTROL SI RUICtB, InC.
[~nclimmq ~ ~nuironmcntal Studies
SPECIFICATIONS FOR A TRENCH-TYPE WASTEWATER DISPOSAL SYSTEM -
ROEHL SUBDIVISION, LOT 4
1.0 GENERAL
1.!
The drawings, sheets ] through 3, shall be a part af this
specification.
All materials and workmanship shall meet the requirements of
the Municipality of Anchorage, Department of Health & Human
Services (DHHS), the conditions of the perm]t, and all applicable
rules and regulations currently in effect.
All elevations and depths are advisory, and are to be verified
or modified in the field by the engineer or inspecting agency.
1.4
1.5
It is the responsibility of -the owner or installer to adhere to
approved designs for installation, maintain the specified separation
distances, and have the appropriate inspections.
If the installation is not inspected by an AECS engineer, AECS will
not be responsible for the installed system. An engineer at AECS
should be consulted prior to construction to determine the number of
inspections that will be required and to explain what these
inspections will involve.
2.0 SEPTIC TANK
2.1 If there is an existing septic tank, it may be nsed if it meets the
capacity requirement for the residence and the approval of the MOA,
2.2
The septic tank shall be a UPC--Approved two-compartment tank,
constructed of 12-gauge steel with bitumastic coating and set
levet on undisturbed soil. If the Lank is buried at a depth of 4
feet or less, it must be insulated with an overlying layer of 2 inch
burial type polystrene rigid board insulation.
2.3
The septic tank and trench shall be a minimum of 100 feet from any
private well or body of water, 150 feet from Class C wells, and 200
feet from Class A or B wells, unless otherwise specified. Less than
the required separation distance must have prior approval or waiver
by ADEC or MOA.
2.4 The septic tank shall be a minimum of 5 feet from the hotme
foundation, and a minimum of 5 feet from the absorption area.
2.5
Piping shall be fitted with a mechanical watertight ca]der coupling
on the outlet and inlet of the septic tank. Piping shall be 4-inch
solid PVC ASTM D3034 or cast iron, sloped a minimum of 1/4 inch per
lineal foot. If the piping is buried at a depth of 4 feet or less,
must be insulated with an over_lying layer of 2 inch burial type
poiystrene rigid board insulation.
2.6
Cleanouts shall be installed as designated and capped with air--tight
rain caps (Jim caps or equivalent), and exteaded a minimum of 1 foot
above ground level.
2.7
If a lift station is required it shall be a combination lift station
septic tank per Anchorage Tank and Welding, Iuc. design.
Specifications are attached.
3.0 Absorption Area
3.!
The gravel for the trench shall be 0~5 to 2.5 inch, screened rock
with less than 3% passing #200 sieve residual. Ail substitutes must
have prior DHHS approval.
3.2
The bottom and sides of the excavation shall be raked with the
backhoe blade 'to insure that it has not been compacted during
excavation. The bottom elevation shall be level.
3.3
Monitor standpipe(s) shall be placed as shown in the drawings, and
shall be 4 inch rigid PVC ASTM D3034, or cast iron. The section
shown with holes may be 0.5 inch holes drilled on 6--inch centers on
opposing sides of the pipe, or a regular section of perforated sewer
pipe clamped to a solid section with either a no hub coupling or
a solvent joint. A rubber rain cap (Jim cap or equivalent) shai] be
installed over the top of 'the pipe.
3~4
The distribution pipe shall be perforated 4 inch rigid PVC with a
minimum crush strength of ~500 lbs and shall meet the approval of
DHHS for use as drainfield pipe. All distribution pipes shall be
laid level.
3.,5
Trenches ]nay be paralleled, but must have a minimum separation
distance between tile trenches of 10 feet or 2 times the gravel depth
(whichever is greater). 75 feet is the maximum allowed linear length
of any trench.
If the final grade over the trench is less than 4 feet above gravel,
insulation is required, using burial type polystyrene rigid board
insulation. There shall be 1 inch of insulation for every foot of
soil less than the required 4 feet of cover, but there must be at
least 24 inches of soil cover even though insulation is used. The
solid pipe extending from the septic tank to the drainfield shall
also have 4 feet of cover or an equivalent layer of insulation to
prevent freezing of the line.
3.7 If insulation is not necessary, the gravel shall be covered with a
layer of nonwoven Geotextile fabric (such as Mirafai, Fibretex 200
grade, Poly Filter X or equivalent).
4.0 INSPECTIONS
A minimum of 'two inspections are required for the installation of the
trench. The first inspection will be of the open excavation to
assure that the system is installed in the proper soil s'trata,
correct depth and meet minimum specified design parameters.
4.2
The second inspection will be after placement of the gravel, monitor
standpipe and distribution pipe to verify proper installation and
position prior to backfill.
4.3 The inspection of the septic tank installation can be incorporated
with any one of tile above listed inspections.
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
1200 West 33rd Avenue Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
JOB
SHEET.O, / O. ?
CALCULATED BY. DATE
CHECKED BY DATE
SCALE
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
1200 West 33rd Avenue. Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
JOE
SHEET NO
CALCULATED BY
CHECKED BY
SCALE
OF
DATE
DATE
I
j!
0
Date Drilled: 8-12-88
Static Water Level 77
Draw Down N-A feet
WELL LOG
feet
Gallons Per M~nute '
Total Feet of Casi.ng-' 112". _
Type Material Drilled:
0 'feet to 112 Giacial till
1 1 ? f~mt · to bedrock ~
to
encountered 1 gpm at 355 ft. continued on to 370 ft.
to
ta
to
to
to
to
HEFTY DRILLING
3540 AKULA DRIVE
ANCHORAGE, AK 99516
(907) 345-0593
MUNICIPALITY OF A~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
RECEIVED
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMEN'I'AL ENGINEERING DIVISION
925 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE x,~NEW
Alan M. Harala 346-2183 [~UPGRADE
MAI LING ADDRESS
P. 0. Box 10-2063, Anchorage, AK
LEGAL DESCRIPTION
Lot 3, Roehl Subdivision
LOCATION
99510
NOiOFBEDROOMS
5
PERMIT NO.
850544
SectiOn 3~
I Well
DISTANCE TO: 1 ~¢1
Manufacturer
Greet
I
Manufacturer
~S~A~C~ ~o: I]70
No of lines I Eenqth of each ine
]' I 65
Top of tile to finish grade
4f~, +
Length Width
Type of crib Crib diameter
DISTANCE TO:
iClass Depth
P~vate 200 f~.
I J.: ...... Buildinq foundation
DISTANCE TO: 25 f~.
Township llN~ Range 3W
Absorption area
5 ft.
Dwelling
85 ft.
Material
steel
Width
Inside length
Dwelling
Material
Foundation N s
100 ft.+ ~a~e t~t line
Total65 le0qthft, of lines ~-~ench w ~tth
Material beneath tile
60 ~
inches
No. of compartments
2
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMIT NO,
850544
Distance between lines
Total effective absorption area
690 s. f.
Depth
Crib depth Total effective absorption area
Building foundation Nearest lot line
Driller
Syren Bros.
PERMIT NO.
Distance to lot line
60 ft,
ePtic tpnk
50 ft.+
PERMIT NO.
850544
I ffSc~ r p¢i~ n. area(s)
OTHER
PIPE MATERIALS
ASTM D3034 PVC
SOIL TEST RATING
INSTALLER
REMARKS
density burial type styrofoam
APPROVED DATE LEGAL
P,O. SOX 6650
ANCHORAGE, ALASKA 99502-0650
90'7~ 264-4111
TOI~Y KN( MLES
DEPARTMENT OF HEALTH & HUMAN SERVICES
January 10, 1986
TO: Permit Applicant
Subject: Permit # 850544
Lot 3 Roehl Subdivision
A permit issued by this Department for an individual well and/or on-site
sewer system has expired as of December 31, 1985.
Permits are issued on a calendar year basis by authority of Municipal
Ordinance° A new permit must be obtained from this Department for any
well and/or on-site sewer system not installed by the expiration date.
If you have drilled the well, a well log needs to be sent to this
Department for documentation of the installation and to close the permit.
If a private engineer inspected the installation of the on-site sewer system
the original as-built inspection report(three part form) must be sent to
this office for review and approval,and for documentation.
If there are any further questions, please call this office at 264-4720.
Sincerely,
Susan E. Oswalt
Program Manager
On-site Services
SEO/lj w
enc: Copy of Permit
F:'EF:;:I'4 1 T NO .~
DATE [SSLJED:
i}EF:'ARTMEIkT ['IF HIEAL. TH AND ENVIRONMIEN"I~AL PROTE:CTION
8.?."5 L. ,S'TREE:-'T, ANCHCIRAGE, AK 9950 1
~:'.64-4 7::-'.~C)
850544
08/2'7/85
APF::'L t CAN]":
A D D R E S S:
CONTA[]'T F:'HONE
I..,,EGAL DESCRIP:
L.OT SZZE~
MAX BED ROOMS:
ALAN HARALA
P. 0.. B[]X 10-2063
ANCHORAGE, AK 99510
346-2183
StJBD I V I,S I ON: ROEHL
!BE{CT' I ON: 3 'T'OWNSI-I I P ." :1, 1N
:1.. 14A (SQ. F'T. OR ACF?ES)
RANGE ,", 3W
BLOCk;: NA
I...isted below are the c~pt.~on~-:i avail, able to yc)u :Ln designing yOLtP septic:
system,, Choose the option that best {':i.~]s yOLtP site.
DEF:']"I4 TO PIPE BOTTOM (FT.) 4.0 4.0 4.0
GRAVEl... DEP]"H (F']".) 5., 5 O. 5 3.5
T'OTAL DEPTH (FT'.) 9.5 4.5 7.5
GRAVEL. WIDT'H (F:"T.) 2.5 22_. () 5.0
GRAVEL. LENG'rH (FT.) 57.0, 43, 0 68.0
GRAVEL. VOLUMIE (CU. YDS.) 3:L.7 35. 1 50.4
]"ANK SIZE (GALS) 1,500.0 .~.~ 1,500.0 *~ 1,50();0 **
SOIL. R(:YI"ING (SQ.FT. /BR) 125 125 125
· ~-,~ TANI< MUST HAVE AT L. EAST TWO COMPARTME;NTS
I c:er'ti{y that:
:I.. I am familiar' w:i.'!',.h 'f_he recluicemertts £or' on-site seweps and wells as set
£or'th by the Municipality o~' Anchor'age (MOA) and the State o~' Alaska.
2. I w:i. ll ins'Lall t. he sys't:.en~ ~.n accordance wJ.'f..I-'~ all MOA' codes and r'egulatior'~s,
and zn comp].zance with the des:~.gn cr'.i, ten.ta o{' this per'mit.
3. I will adhe~-e to all [~I[)A and State of Alaska r[-::qL.t].nements {'on the set back
d:~stances ~'r'om any ~r,.,':i. stlng well, ~astewatep d:[sl::H-)sa], sys'[.er~ or pLtl]].zc:
seweP, age system on th:i.s or any adjacent of near'by lot.
4. ] und~erstand that this permit is valid £op a ¢l~a),'lf~]Lt£~'i E)~' 5 bedPooms and
any enlargemerrl' w~].], r'ec:tuire an add:i.t:i, ona]. per'mit.
IF: A I....IFT ,C.~rT'AT ]: ON I~,~ INSTAI...LED IN AN AREA COVERED BY ME~A BLIIL..DING CODES,
]"HE:N (1) AN ELEC]"RICAL. F::'ERMIT AND INSF'EC] IDN MLJST BE OBTAINED; (2) AS-BLIIL..TS
W]:L.L IqDT BE AFd='FROVED W:[THOU]' AN EL..ECTRICAL.. INSF:'ECTION REF:'ORT; AND (3) THE
EI'.,,EC'TRICAL WORI,;:: MUST' BE DONE BY A L ICEIxlSED [ELECTRICIAN.
S;. '[ GNIED
~~ ................................................................................. DATE: .........................................
AF:'y'L. :[ CAt~ ~ARAL..A
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L Street, Anchorage, Alaska 99501 2E~ 4720
SOILS LOG - PERCOLATION TEST
[] SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2,
3-
4-
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19,
20
SLOPE
DATE PERFORMED: 7/~'~/~'~''
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SITE PLAN
eft
COMMENTS-~.--"~/'~.,~ b.~'~ ~ ~'-'~' J~J~r~.~.~',~
Reading Date Gross Net Depth to Net
Time Time Water . Drop
S ,'.co /o ,,~, /o ~" / '~
~-; ,~o ~o ~-~ /~ /
~ ~ ~ ~ ~,~ /~ ~" / ~"
PERCOLATION RATE 8, ~ minutes/inch)
TEST RUN BETWEEN /~' FT AND /3 ~'~. ET
!
CERTIFIED BY: ~ ~- .~~--~ DATE:
LOT 3 ~OEtlL SUBDIVIS .;~
Septic system install~ion ~hotos
/85
level, Total excavation is 60~ below
leach line elevation.
2. Leach lin~
~,~as qed drair
lacement upon 60" of
dck.
6 Insulation coverage upon septic
tank
7o Leach field insulation coverage
Leach field insulation coverage
MUNICIPALITY OF ANCHORAGE
MEMORANDUM
DATE:
TO:.
May 15, 1989
Department of Economic Development and Planning
Zoning and Planning Section
FROM:
Department of Health and Human Services
On-site Services Section
SUBJECT: Request for Comments on Subdivisions
May 19, 1989
The Environmental Services Division, On-site Services Section,
of the Department of Health and Human.Services has r~viewed
the following cases and has'these comments:
S-8798: Lots 20, 21 Eaglewood Subdivision %4 - Vacation only
No objection.
S-8802:
Lot 3A Roehl Subdivision
DHHS has a record of a sewer system and well on
each lot. We have no objedtion to the proposed
subdivision, but will require that both wells and
, sewer systems be, maintained in compliance with
Municipal ordinances.
S-8804:
Lot 35B Bella Vista Subdivision %1
This lot has recently issued a Conditional Health
Authority approval which requires either a new well
be drilled or a connection made to public water.
The Conditional is valid until July 1, 1989. We
will require that the Health Authority be satisfied
prior to final plat.
Susan Oswalt
On-site Services
SO/ljw
of O
• Municipality of Anchorage
On -Site Water and Wastewater Program 2 '
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 020-092-99 Expiration Date: -7r ZZ
1. GENERAL INFORMATION
Complete legal description Roehl Lot 3A
Location (site address) 5445 E 172nd Ave. Anchorage AK
Current Property owner(s) Willard & Gail Smith Day phone
Mailing address
Real Estate Agent
5445 E 172"d Ave. Anchorage AK
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
0
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Waiver/Variance request for:
Received by:
4
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual
Holding Tank
❑
Community
❑
Public Sewer
❑
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ � Z am
Date of Payment / —ZC9 ` 0Z
Receipt Number 00-K2 e) 1
COSA # 6 - C_ Z ZJ
Date:
Waiver Fee $ _
Date of Payment
Receipt Number
Waiver #
stance:
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 ARCTERRA CONSULTING, INC. Phone 696-6111
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name _KENNETH M. DUFFUS
Q
Datez/A
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen
Oil 41
encroachments, deficiencies or discrepancies exist.
���� _y
`'11
A:"
>e
* 4- 9 TTH
6. DSD SIGNATURE
?� KENNETH =P'Il
System #1 Approved for ___qbedrooms.
I:I�
System #2 Approved for bedrooms.
rortasto�;•" ,�
Disapproved.\�
Conditional approval for bedrooms, with the following stipulations:
ALIT yn,�r�,_
T F o
0=
Arron 9 T "7
- VICES
Original Certificate Date:_ mi —2�z�
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 blue sheet 10-1a12.doc
Legal Description:
Roehl Lot 3A
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 7/8/85
Total depth 205 ft
Cased to 93 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 11/3/21
Static water level at beginning of test 78.6 ft.
Comments
B. TANK DATA
Age of tank(s) New years
Tank type/material Septic/Plastic
Measured operating fluid level in septic tank New
10 Standpipes/foundation cleanout per record drawing
Date of pumping New Install 6/3/22
D. ABSORPTION FIELD DATA Old Lot 4 System
Which system tested (date installed) 7/18/88
ALL standpipes present per record drawing
Total measured depth from grade 10 ft (max)
Measured depth to pipe invert from grade 4 ft (min)
❑ N/A —pressurized field
New depth 36 in
11 Monitor tubes go to bottom of effective. If not, state Elapsed time 1200 min
depth into effective
Code -required soil cover over field Final fluid depth 2 in
❑ System presoaked Absorption rate 750+ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months)
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
Parcel ID: 020-092-99
Structure served by this system
Well production at time of test 2.5 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes No
Coliform bacteria is Negative
Nitrate mg/L 11 Nitrate less than MRL (ND)
Arsenic ug/L M Arsenic less than MRL (ND)
Collected by Areterra Consulting
Date of Sample 10/19/21
IFT STATION
❑ Requl aintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 11/8/21
Results Q✓ Pass For 4 bedrooms
Fluid depth prior to test 2 in
Water added 750 gal
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 ft Wells on Adjacent Lots:
Water Main > 10'
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No ft
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25'2] Yes
if No ft
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No ft
Neighboring Absorption Fields > 100'
Animal Containment > 50' ® Yes
if No ft
® Yes
if No
ft
Manure/Anima! Excreta Storage > 100'
Community Sewer Main > 75' ®Yes
if No
ft
® Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft 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 distances if less than required)
Building Foundation > 10' 0 Yes if No ft If absorption field is under driveway comment below
Property Line > 10'
® Yes if No ft Wells on Adjacent Lots:
Water Main > 10'
® Yes if No ft Private Wells > 100'
Water Service Line > 10'
® Yes if No ft Community Wells > 200'
Surface Water > 100'
® Yes if No ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
l 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.
COSA Checklist yellow sheet
® Yes if No
® Yes if No
ft
W
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 020-092-99 Expiration Date:
1. GENERAL INFORMATION
Complete legal description Roehl Lot 3A
Location (site address) 5445 E 172nd Ave. Anchorage, AK
x-17 -2-
Current Property owner(s) Willard & Gail Smith Day phone
Mailing address
Real Estate Agent
5445 E 172nd Ave. Anchorage, AK
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
WaiverNariance request for:
Received by:
4
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual
Holding Tank
❑
Community
❑
Public Sewer
❑
COSA to be released to the engineer, unless otherwise requested by the engineer.
Date:
COSA Fee $ ��t/ 2L (J Waiver Fee $
Date of Payment " 2-0 ' 2Z Date of Payment
Receipt Number 0 �K (91 C? Receipt Number
COSA # (9,sc— 221 0 13 Waiver #
istance:
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 ARCTERRA CONSULTING, INC. Phone 696-6111
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577
Engineer's Printed Name KENNETH M. DUTPU_S Date //B%
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. 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 inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future �� o \ \
occupants or can ArcTerra guarantee that no unseen AW
encroachments; Ll..nclas ar-discrepancies exist. OF -41
<ti r
�Y,1- C) T LI*
6. DSD SIGNATURE
System #1 Approved for bedrooms. ` �� T-11.
System #2 Approved for bedrooms. q `, /8 z\���
or•�;ssto•'' ' -�
Disapproved.
Conditional approval for bedrooms, with the following `tt k�pt 66"sPF.q
s ct4dw MOVU
VV T E R -A N.D m
'ATER z�
\ V\J
e
By:._ J� Original Certificate Date:; / 7% 2C'ZZ
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 blue sheet -10-10-12 doc
Legal Description: Roehl Lot 3A Parcel ID: 020-092-99
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 7/8/85
Total depth 205 ft
Cased to 93 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 18+ in.
Date of flow test for COSA 11/3/21
Static water level at beginning of test 78.6 ft.
S Qmmen
B. TANK DATA
Age of tank(s) 35* years
Tank type/material Septic/Steel
Measured operating fluid level in septic tank 49"
Standpipes/foundation cleanout per record drawing
Date of pumping * Conditional COSA requested.
D. ABSORPTION FIELD DATA Old Lot 4 System
Which system tested (date installed) 7/18188
ALL standpipes present per record drawing
Total measured depth from grade 10 ft (max)
Measured depth to pipe invert from grade 4 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:
COSA Checklist yellow sheet
Well production at time of test 2.5 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes M No
Coliform bacteria is Negative
Nitrate mg/L in Nitrate less than MRL (ND)
Arsenic ug/L M Arsenic less than MRL (ND)
Collected by Areterra Consulting
Date of Sample 10/19/21
IFT STATION
ElRequ r aintenance,completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 11/8/21
Results Q Pass For 4 bedrooms
Fluid depth prior to test 2 in
Water added 750 gal
New depth 36 in
Elapsed time 1200 min
Final fluid depth 2 in
Absorption rate 750+ gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
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
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
23 Yes
if No ft
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No ft
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No ft
Neighboring Absorption Fields > 100'
Surface Water > 100'
® Yes
Animal Containment > 50' ® Yes
if No ft
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No
ft
® Yes
if No ft
From Septic/Holding Tank on Lot to: (Please
enter distances if less than required)
Building Foundations > 10' ® Yes
if No
ft
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 --Maim ,._1.0'-- -.__..._._.._-_ _O Yes-
. if No
ft _
_ Community_ e!L---?_2oo'.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 distances if less than required)
Building Foundation '> 10'
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No °"
ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' Yes if No ft
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' ® Yes if No ft
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
/ 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.
COSA Checklist yellow sheet
DocuSign Envelope ID: C40BEBA3-28A6-4EE7-80BC-98D85C5A66BF
ESCROW HOLDBACK AGREEMENT
To: Municipality of Anchorage
Agreement between: Smith and Greenbaum
Property Address: 5445 E 172"d Avenue, Anchorage, AK 99516
File No. 1551344
Amount withheld: $16,228.50
The undersigned parties authorize Stewart Title to escrow funds in the amount of $16,228.50 from the
seller
For the purpose of: Replace Septic Tank
It is the sole responsibility of the undersigned parties to provide invoices to Stewart Title for payment.
Upon receipt and with Municipality approval, Stewart Title shall pay invoices for the above-mentioned
work. In the event parties are requesting to be reimbursed for invoices they paid out of pocket, Stewart
Title will require evidence of paid invoices before any reimbursement is paid. Once work is complete and
invoices paid; any excess funds will be refunded to the seller.
The undersigned parties hereby jointly and severally indemnify and hold Stewart Title harmless from and
against all costs, damages, judgments, attorneys' fees, expenses or obligations of every kind and
descriptions which, in good faith, it may incur or suffer in connection with this escrow holdback.
Dated: lib >'u �4,2 nz2
Bu er:
DocuSigned by: DocuSigned by: _
06KAI an t ,Alan. 5via, atn,t,In,'A.UaM
hd2Bc7&pwnbaum Ns PW8Qfo'Q114Rum
Seller(s):
Willard C Smith Jr. \ / ZN' L. Smith
READ AND APPROVED Y:
Munici ' )�-et ch ge
January 17, 2022
I1CI I ERRA
CONSULTING, INC
20441 Ptarmigan Bid, Eagle River, AK 99577
Office (907) 696-6111, Fax (907) 868-3793
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Conditional COSA - Roehl Lot 3A
The owner has requested we proceed forward to obtain a conditional COSA with
a septic tank upgrade permit to replace the existing 1500 gallon tank that serves
the existing house on the subject lot. The leachfield passed our adequacy on
11/8/21 and field inspection does not show any indication of failure. The
property is served by a private well and there are no wells within 100 feet. The
septic tank will be replaced with a 1500 gallon tank. The house is currently
vacant, and we see no health and safty issues at this time.
The adjacent lots are served by public and private wells more than 100 feet from
the septic system on this lot. There is no surface water within 100' of the
proposed tank. The new system will be outside all protective well radii. We do
not expect there to be any adverse effect on adjacent lots by the development of
this system. If you have any questions, please contact me at 696-6111/ FAX 868-
3793.
Respectfully submitted,
ArcTerra Consulting, Inc.
Kenneth M. Duffi
Attachments: On -Site Sewer Application
Wastewater Absorption System Details/ Site Plan
20441 PTARMIGAN BLVD - EAGLE RIVER, AK 99577-8736 - PH (907) 868-3791 - FAX (907) 868-3793
Septic Tank Advisory
Certificate of On -Site Systems Approval #OSC 221013
Subdivision: Roehl Lot 3A
Starting at 35 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this p"roperty is 20 years old. Typical replacement costs range from $9,000 to $12,000
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of what the metal of a 20 -year-old steel tank MAY look like.
Mailing Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org
'-qELIMINARY PLAT APPLICATION OFFICE U~(~'~
Municipality of Anchorage
DEPARTMENT OF COMMUNITY PLANNING REC'D BY
P.O. BOX 6650 VERIFY OWN:
Anchorage, Alaska 99502-0650
Please fill in the information requested below. Print one letter or number per block. Do not write in the shaded blocks.
0. Case Number (IF KNOWN) 1. Vacation Code
2. New abbreviated legal description (T12N R2W SEC 2 LOT 45 OR SHORT SUB BLK 3 LOTS 34).
3. Existing abbreviateO legal 0oscription (T~ 2~ ~2W SEC 2 COl 45 OB S~O~I SUB BkK 3 kOI 34) full legal on back
pa~e.
4. Petitioner's Name (Last- First)
'~ ~,~1~1~1~1. I~1..101~1~1~1 I I I I I I
I I II I I It I I I
Address [ [ ~ ~ ~ --~k.L ./. ~'-<5 0-C'~ ~:~.
City ~-'~ ~/C~U..-~-.~ State
Phone No. '~-t ~, -[~,~ ~ %~. Bill Me
~ Z 77
Petitioner's Representative
IIitl '
Address ~
Phone No. f~" ° ~f'"~ Bill Me __
6. Petition Area 7. Proposed 8. Existing 9. Traffic 10. Grid Number 11. Zone
Number Number Analysis Zone
Acreage Lots Lots
I
I1 I 111 I I I III IIII
12. Fees '"~'¢'(~ ,~'~t ~' 13.-CommunityCounci, ~e~)l,~'-
B. I hereby certify that (I am) (I have been authorized to act for) the owner of the property described above and that I desire to
subdivide it in conformance with Chapter 21 of the Anchorage Municipal Code of Ordinances. I understand that payment
of the basic subdivision fee is nonrefundable and is to cover the costs associated with processing this application, that it
does not assure approval of the subdivision. I also understand that additional fees may be assessed if the Municipality's
costs to process this application exceed the basic fee. I further understand that assigned hearing dates are tentative and
may be have to postponed by Planning Staff, Platting Board, Planning Commission, or the Assembly dueto administrative
reasons.
S}gnature
'Agents must .provide written proof or authorization.
Date:
C. Please check or fill in the followh,g:
1. Comprehensive Plan -- Land Use Classification
~' Residential
Commercial
Parks/Open Space
Transportation Related
2. Comprehensive Plan -- Land Use Intensity
Special Study
3. Environmental Factors (if any):
a. Wetland
1. Developable
2. Conservation
3. Preservation
Marginal Land
Commercial/Industrial
Public Lands/Institutions
Dwelling Units per Acre
Alpine/Slope Affected
b. Avalanche
c. Floodplain
d. Seismic Zone (Harding/Lawson)
D. Please indicate below if any of these events have occurred in the last three years on the property.
Rezoning Case Number
Subdivision Case Number
Conditional Use Case Number
Zoning Variance Case Number
Enforcement Action For
Building/Land Use Permit For 1~,~,~'~ ~-~2..~'~,,' 0"~ ~"~" ~r ,,~ ~'~,~
Army Corp of Engineers Permit
E. Legal description for advertising.
Alpine/Slope Affected
Industrial
Special Study
F. Checklist Waiver
"- 30 Copies of Plat
Reduced Copy of Plat (8Y~ x 11)
Certificate to Plat
Fee
Topo Map 3 Copies
Soils Report 4 Copies
Aerial Photo
Housing Stock Map
Zoning Map
Water: '
Sewer: x
20-003 Back (4,85j
Private Wells Community Well
Private Septic Community Sys.
Public Utility
Public Utility
' Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 020-092-99
GENERAL INFORMATION
Complete legal description
Location (site address)
COSA # ~, ~D ~---.
Expiration Date:
Lot 3A, Roehl Subdivision
5445 East 72nd Avenue Anchorage, AK 99516
Current Property owner(s) Rick R. Clemens
Mailing address 2230 Mouton Drive Carson City NV 89706
Day phone
Lending agency
Mailing address
Day phone
Real Estate Agent
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: Four (4)
Day phone
TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class ~ Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding Tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (exCept between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of iSsue for properties served by a pdvate or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
DSD ~.~IATURE
~ Approved for ~
Disapproved.
Conditional approval for
bedrooms.
Phone 522-7773
bedrooms, with the following stipulations:
Attachments: COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(Rev. 11105)
X
Arsenic Advi.sory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: / (~ ~ ~,~ 7~//
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site. Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99507
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type Private
Date completed 7/8/85
Total depth 205 ft.
Lot 3A, Roehl Subdivision
If A, B, or C provide PWSID #
Sanitary seal (Y/N) Y
Cased to 93
FROM WELL LOG
7/8/85
Date of test
Static water level
51 ff.
3 g.p.m.
Nitrate N/D mg/L
Date of sample! lO/18/11
Bo
Well production
WATER SAMPLE RESULTS:
Coliform o colonies/10OmL
Arsenic: N/D ug/I
SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel
Number of Compartments Two
Depression over tank (Y/N) ~
Pumper
Tank size 1,5oo gal.
Foundation cleanout (Y/N) Y
Date of pumping No Sludge
C. ABSORPTION FIELD DATA
Date installed 3/1986
Length 65 ft.
Total depth 10 ft.
N
Parcel ID: 020-092-99
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
10/21/2011
68.6 ft.
2.5 g.p.m.
Collected by: MEA
Y
Soil rating (g.p.d./ff~ or ft2/bdrm) 125 SF/BDRM
Width 4 ff.
Eft. absorption area 65o ft2 Monitoring tube
Date installed 3/1986
Cleanouts (Y/N)
High water alarm (Y/N)
Date of adequacy test 10/21/11 Results (Pass/Fail) Pass
Fluid depth in absorption field before test 0 in. Water added 655 gal. New depth
Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 600
Any rejuvenation treatment(past 12 mo.) (YiN & type) N If yes, give date
System type Deep Trench
Gravel below pipe 5
Y Depression over field N
For 4 bedrooms
0
Y
>18 in.
in.
g.p.d.
LIFT STATION
Date installed
."Pump on" level at
Datum
in,
E. SEPARATION DISTANCES
Size in gallons
"Pump off" level at
Cycles tested
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot >100'
Absorption field on lot >100'
Public sewer main N/A
Sewer/septic service line >25'
Animal containment areas >50'
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
On adjacent lots >1oo'
On adjacent lots >lOO'
Public sewer manholelcleanout
Holding tank N/A
Manure/~nimal excrete storage areas
N/A
>100'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation. >5' Property line >5'
Water main N/A Water service line >1o'
Wells on adjacent lots >lOO'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line >1o' Building foundation >1o'
Water Service line >1o' Surface water >1oo'
Curtain drain None Noted Wells on adjacent lots >lOO'
COMMENTS:
Absorption field >5'
Surface water >1oo'
Water main >10'
Driveway, parking/vehicle storage >25'
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.
Date 10/24/2011
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
z~,,,~ o,~¢' N89° 51' 41"W 300.34'
I
~ I~ ~ 6
I-- i~o z
, ~¢"~
3O'
I ~ 3oo.~o' s89~ 55, 17-E ~
EAST 172nd AVENUE
UNDER NO CIRCUMSTANCES SHOULD AN AS-BUILT BE USED FOR CONS~UC~ON OR FOR ESTABLISHING BOUNDARY O~ FENCE LINES.
THE SUR~YOR TAKES RESPONSIBILITY FOR THE INI~AL ~ANSACTION ~LY AND ASSUMES RNANCIAL LIABILITY ONLY FOR ~E COST OF THE SURLY.
LIS~D DISTANCES PREVAIL O~R SCAMNG. REPROOUC~ON MAY CAU~ ERRORS IN SCALE.
~ ~OT ~.~ SURVEY TYPE
~ r~O. *S-aU~LT SYMBOLS
~ FmNAL SmUC~RE AS-BUILT ~ SET REBAR ~ ~ DRAINAGE ~ ASPHALT
~ PLOT PLAN , . AS-BUILT . . . LOT ~R~Y . , , T~OG~HY O F~ND ERBAR C C O WOOD FENCE ~ CONCRETE
~ AS-BUILT . . . NO CORNERS SET ~ RE~RaRCA~ON AS-~ILT . . NO C~N~S ~T ~ ASSUMED ELEV, ~ ~ ~ METAL FENCE ~ WOOD DECK
PLOT PLANS ~ LOT SURVEYS NOTE:
IT IS THE RESPONSIBILITY OF THE ~UILDER OR OWNER, PRIOR TO ONLY ~OSE IMPRO~MENTS ABOVE GROUND AND ~SIBLE ~LL
CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE SHO~. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRI~WAYS
TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DE~RMINE ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW
THE EXIS~NCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PEE~NT SOME IMPEDIMENTS FROM BEING SEEN AND LOCA~D.
WHICH DO NOT APPEAR ON THE RECORDE0 SUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED.
SURVEY CERTIFICATION .~mmm- Prep o red b y
OF Robert E. Johns Jr. & Assoc.
........ · ,
............. , ................. ~ee. Professional Land Surveyors
.............. ~o.1~ m~ ~litiel, ~1 dimm[m~ ho~ ~m~ ~~~ ANCHORAGE. ALASKA 99504
~ ~th s:.le: R~. Lot S.[ Re~.
~o~,~o, ~-.~,~ .......... 1" = 60'
ho~ perf~ on A~t ~y of ~e~.~ Dote Surve~d: Drown b~ Checked b~
.................... , ......... . 10/20/11 REJaMK
~omn oth~im& ¢ O ~ Dote Drown: Grid: W.O.
~~ 21 ~ ./..~ 10/20/11 3337 11-368
RNAL S~UC~RE AS-BUILT ~ % ¢ ~ ~
I, ")(¢t ~. ~"l, ~-, "l~y )~l¢y t"~t m ~ ~e *' ," ~(--~ Legal Description:
........................ ~¢Z**o' .......... , ~[.~' LOT 3A