HomeMy WebLinkAboutKASILOF HILLS BLK 1 LT 5AOnsite File
#015-161-57
Mar 31 22 11:09p Anchorage Well & Pump Ser
9072430742 p.1
MUNICIPALITY OF ANCHORAGE
Development Services Departmentt
Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number:
Parcel Identification Number: 015 161 57
Date of Issue•
Legal Description Block Lot Property Owner Name & Address:
COAR, MATTHEW & JENNIFER
KASILOF HILLS 1 5A 10980 STROGANOF DRIVE
ANCHORAGE, AK 99507
Pump Installation Date: 03 _ 30 - 2022
Pump Intake Depth Below Top of Well Casing: 190
Pump Manufacturer's Name: RED JACKET
PumpModel: 8S16
Pump Size: .75
Pitless Adapter Burial Depth: 10 feet
Pitless Adapter Manufacturer's Name: MARTINSON
Pitless Adapter Installer:
Well Disinfected Upon Completion?Yes ElNo
Method of Disinfection: PELLETS
Comments:
feet
Pump Installer Name: _
ANCHORAGE WELL & PUMP SERVICE
Company: 7640 KING STREET
ANCHORAGE, AK 99518
Mailing Address: 907-243-0740
City: State: Zip:
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pmnp installation.
Municipality of Anchorage
On-Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191393 PID Number: 015-161-57
Dwelling: Fmil Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ❑ Upgrade
Name:
Charles and Delores Weiler
ABSORPTION FIELD
❑Deep Trench ❑Shallow Trench F71 Bed ❑Mound
Address
10980 Stroganoff Dr, Anchorage, AK
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
307-251-4985
3
Existing Trench GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Kasilof Hills 1 5A
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
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ft
Ft.
Well
>100'
NA
N/A
N/A
>25
TANK ❑p Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Greer
Capacity
11,000 Gal.
Surface water
>100'
NA
N/A
N/A
Material
Number of compartments
Lot Line
>5'
NA
N/A
N/A
Plastic
2
NA
Foundation
>10'
NA
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
None
Noted
Gal.
Remarks Tank only replaced under this permit.
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
Pump make and model
Electrical Inspections performed by
Installer
PIPE MATERIAL House to tank D3034 Tank to
drainfield D3034
Denali Excavating
Drainfield Existlnq CO/MT
Inspector J. Williams
BENCH MARK (Assumed elevation) 100 ft
Inspection 15 10/1 /19 ntl
Location and description
da,32
r 4th
Bottom of siding
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
®SOF q °�
Conditional Approval: Date
��P�°•°"'°•°°.��jS���
49th `•®��
io
® ass. A anus ...... ao .... .... .......
® a"ai7a'.a.�aaseoeoswraanana. ....nen.......
MICHAEL E. ANDERSON
No, CE-4381 •°
ApprovedDate�O
10/4/19 ,..•``°c`�C'
°•.,, .........
%ior"ROFESSI
inspection mepori—,d- i-IZ.aoc
�
����K8lTff(���1�1��� �Y[l�O1��1A1_�7
PERMIT ,,~^~^^ .~^."°'~^ . /�^,,"." .". ^^'
/
/
EXISTING WELL |
BLOCK 8, LOT 2A
�
\
& \
| \
NEW 1.oonGALLON SEPTIC
\ TANK W/20" MANWAY'
_____\__ ------- --
LOT 6A
/
�
—r
lwG ABSORPTIONTRENCH \ ` LOT /
LOT 4A", Y
EXISTINGAELL
\ \
\
\
\
� ~~
A B
MH 16.5 45.7
01)
SV 1.3 49-
2CO 245 1 497
U 50 100
bm no imm FEET
LEGEND
CO-CLEANUUT
2CO-DOUBLE CLEANOUT
FCO ' FOUNDATION CLEAN(
FS'FLOW SPLITTER VALVE
MH'MANHOLE
MT'MONITORING TUBE
8V - SEPTIC VENT
TH'TEST HOLE
KASILOF HILLS. BLOCK 1. LOT 5A
PERMIT # OSP191393
[ N Gi H E .1I--
PID # 015-161-57
(NO SCALE)
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:i/www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP191393
Work Type: SepticTank Upgrade
Tax Code Number: 0".516157000
Site Legal Address: KASILOF HILLS BLK 1 LT 5A G-2641:
Site Mailing Address: 10980 STROGANOF DR, Anchorage
Owner: WEILER CHARLES D & DOLORES G
Design Engineer: FORGE ENGINEERING
This, permit is for the construction of:
❑ Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy
Effective Date
Expiration Date
tl�Crtt
n
� 7
71 epartmeut
915/2019
9/4/2020
Lot Size in Sq Ft: 26927
Total Bedrooms: 3
❑ 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 (24/74
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:
Issued By:�
Date:
Date: j J
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 015-161-57
Property owner(s) Charles & Delores Weiler Day phone 307-251-4985
Mailing address 10980 Stroganoff Drive Anchorage, AK 99516
Site address Same
Legal description (Sub'd., Block & Lot) Kasilof Hills, Block 1, Lot 5A
Legal description (Township, Range & Section)
Lot Size 26,927 Sq. Ft. Number of Bedrooms Three
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑ Initial ❑
Single Family (SF) ❑X
(w/wo ADU)
Septic Tank
❑x Upgrade 0
Duplex (D) ElHolding
Tank
❑ Renewal ElMultiple
Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION
INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that
this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: aC gE Waiver Fees:
Date of Payment: g��' /7 Date of Payment:
Receipt Number: Q�'�8�p Receipt Number:
Permit No. Waiver No.
Permit App_.;-:• ,'.mac
PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
September 4, 2019
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Kasilof Hills, Block 1, Lot 5A – 10980 Stroganof Drive
Septic System Design and Permit Application
Dear On-Site Services Engineer:
The septic tank on the subject lot has exceeded its useful life and must be replaced before a COSA
can be issued on the property. The attached site plan identifies the location of the home and the
proposed and existing septic tank location. The existing well on the lot is also shown. No conflicts
exist between this proposed system and any other well or septic system, whether on this lot or
adjacent lots.
The new septic tank will be a minimum of 100’ from all private wells and surface water and more
than 10’ from the house foundation and 5’ from deck/stair supports.
Please refer to the attached plan sheet for the septic design. If this design is followed, there will be
no adverse impacts to adjacent properties.
Sincerely,
Michael E. Anderson, PE
9/4/19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191393, Rebecca Carroll, 09/05/19
// // // // // //
// // // // // // // //CL //10050 0
FEET
1"=50'
3-BDRM HOME
NOTE:
NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE
PROPOSED SEPTIC SYSTEM
ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC
SYSTEMS.
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
CO
KASILOF HILLS, BLOCK 1, LOT 5A
9/4/19
SHED
20' WALKWAY
10'
UTILITY EASEMENTSTROGANOF DRIVE
EXISTING WELL
EXISTING WELL
EXISTING WELL
EXISTING ABSORPTION
TRENCH
DECOMMISSION EXISTING
SEPTIC TANK PER MOA CODE.
1,000 GALLON SEPTIC
TANK w/20" MANWAY
CO
SV
MH
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191393, Rebecca Carroll, 09/05/19
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:Y`S
~:~GREA,,,~ iR ANCHORAGE AREA BORr 'GH
/~ ~'<?] Department of Environmental Quality
~ 3330 C Street
Anchorage, Alaska 99503
,d,Cf/ 7'o : &~c'.)/ /)~'T,~ ~,,,~
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAMF~,o,,-i-~~,;:' MAILING ADDRESS ~."2~-~,F---2-~ --'-~,u -, ./r / i f, PHON~ ~'~
LOCATION LEGAL
SEPTIC TANK:
DmTANCE
FROM WELL
INSIDE LENGTH
MANU FACTU R E ~t/NO~ l/
INSIDE WIDTH
<,.+ / NUMBER OE
MATERIAL ~ COMPARTMENTS
LIQUID DEPTH LIQUID CAPAC TY/~O GALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WELLN(27~'/1/ FOUNDATION__2~)/'J"-'? __ _NEARESt LOT LINE i~ ;~' 'oFTOTALLINEsLENGTH~'~" __ ,
NtJMBER OF LINES / DISTANCE BETWEEN LINES ___~/~ TRENCH WIDTH~ IN. TOTAL EFFECTIVE
ABSORPTION AREA :~,'} ~ SQ. FT. LENGTH OF EACH LI"E / /F ~A
~,'ff/~.~/:'~'~/.~U~<:'~:~THOFFILTER ~
DEPTH; TOP OF TILE TO FINIS~GRADE MATERIAL BENEATH TILE IN. ABOVE TILE IN.
BLJILDING
FOUNDATION__
CESSPOOL
APPROVED
___CONSTRUCT,ON
NEAREST
LOT LINE
, OTHER SOURCES
DISAPPROVED____
NEAREST
SEWER LINE
DEPTH
SEPTIC SEEPAGE
, TANK SYSTEM
.REMARKS _
DISTANCE FROM:
DISTANCES:
I
SEWER LINE DEPTH: /~/
PIPE MATERIAL:
LOT SLOPE~
DIAGRAM OF SYSTEM
/,,/,,T
/~y
G.A.A.B. J
Form E(A-032
GRE ,'ER ANCFIORAGE AREA B¢ DUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY ": ~ /,~ PERMIT NO .....
TELEPHONE 274-4561 ·
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT' '~-'~"~
NAME OF aPPUCANT ~/~/~/~
INSTALLATION LOCATION
INSTALLATION OF: SEPTIC TANK SEEPAGE Pit , DRAIN FIELD
TYPE ANDS,=OFFAD'L'TYTO BE SERVED
, OTHER
NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TE~l'
COMPLETION DATE ANTICIPATED --
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF' ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL. QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPT'° TANK s,zE U*U t,PE "
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEEPAGE PIT '~/~ / /(~ /
-/ - DRAIN FIELD
, SEEPAGe Pit , DRAIN FIELD /~ I
w~. to s~PtlC TANK //)L) /
. ., SEEPAGE Pit ~ /
DRAIN FIELD / ., ALSO CONSIDER AREA WELLS.
WATER main to SEPTIC taNK /~ ~ , SEEPAGE Pit [~ ~
DRAIN FIELD /~ ~
SEPtiC TANK, ~/~t seepage Pit //~/~ ' , DRAIN FIELD ~ /
TO RIVER, LAKE, STREAM.
CAST IRON INTO AND OUT OF SEPTIC TANK A~D INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE Pit
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDing INSTALLATION.
OR
LICENSED D ESIG~IER
DIAGRAM OF .~YSTEM
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
FORM NO. EO-016
CONSULTANTS, INC.
249 EAST 51ST AVENUE P.O. BOX §087 ° ANCHORAGE. ALAD!(A 99503 TELEPHONE D07-27D.O4D3 TELEX 0g0.35419
June 23, 1975
Rappe Excavating
8001 Arctic Blvd
Anchorage, Alaska
99501
RE: Test Hole and Soil Log Report for Sanitary System
Lot 5A, Block 1, Kisloff Hills subdivision
Dear Mr. Rappe:
R & ~,t No. 562084
We are submitting herewith the test boring results and our comments regard-
ing soil conditions encountered at the subject site. This investigation
was performed in accordance with your request of June 23, 1975, and those
procedures outlined in a letter dated December 19, i974r by Mr. Rolf Strick-
land of the Greater Anchorage Area Borough Department of Environmental
Quality.
A single test hole was put down within the Lot 5A area for the purpose of
defining general subsurface soil conditions for the proposed sanitary sys-
tem. Excavation was accomplished with a tractor-mounted backhoe and the
test hole was extended to a total depth of 11.0 feet below ground surface.
The final log prepared for the test hole bas been included in Drawing A-01.
Ground water was not encountered in the test hole.
We appreciate being given this opportunity to be of service to you. Should
you have any questions with regard to the above, please do not hesitate to
contact us.
Very truly yours,
R & M CONSULTANT~q, INC.
JWR/WE D/j a
xc: GAAB
TH-1
6-23-75
ORGANICS
SILT, SO}I SAND
SANDY G RA~JEL
TRACE SILT
OCCASIONAL COBBLE
(c~w)
11.0'
NO WATER TABLE
Lot represents
Lot 5A Block 1
Kisloff Hills
Subdivision
R Consultdnfs Inc.
./L nNC,OR*O~ ,Am~A,~S ALASKA .¢u~ EnU
~-~ Excavating
Lo[ of Test Hole
~ra~e, Alaska
. =3 ['~b [CHKO e¥ .... 'D TPr~oJ. No 562084 lowe ~;o. A-01
6-23-75 I$CAL~ 1" ' IOWN
'~" ~' 4040 "B" STREET,
t ANCHORAGE, ALASKA
99503
PHONE: 907-279-2581
February 4, 1975
W.O. #7951
Hal Graser Realty
401 East 36th Avenue
Anchorage, Alaska
99503
Attention:
Mr. Bill Foster
Subject:
Soil Analysis
Lot 5A, Blk 1, Kasilof Hills
Gentlemen:
Transmitted herewith are the results of the subsurface investi-
gation performed on the above property on February 1, 1975.
Exploration consisted of 1-16 foot test hole drilled by Denali
Drilling Inc. employing Nodwell mounted, ~obJ_iLe B~.50 drill,
fitted with an 8" hollow stem, continous flight auger. A
grab sample was taken at five feet, by pulling the auger
out of the test hole and removing the sample from the flights
of the auger from near the bit. Standard penetration samples
were 'taken at 10' and 15' These samples were taken with
2'~ O.D. split spoon sampler advanced into the soJ_l by the
action of a 140 lb. hammer free falling 30". The blows required
to drive the sampler each 6" increment are recorded on the
logs. The blows required to drive the sampler 12" is, by
definition, the standard penetration. The soils were visually
classified in the field in accordance with sheets 3 through
5, following the text. This field classification was verified
by visual review and mechanical analyses of the samples in
the laboratory. The compilation of the field and laboratory
analyses is contained on the test hole log and grain size
distribution curves, which follow immediately after the text.
Test Hole No. 2
Depth in Feet
From To
SOIL DESCRIPTION
0 0.6
0.6 16.0
16.0 16.5
F-4, brown Peat, Pt.
F-.2, brown Silty Gravelly Sand, Damp, medium
density, SM.
F-4, brown Silt, stiff, damp, PL-, ML.
~ -.~. DRII..LING, Inc.
(907) 274-461]
ANCHORAGE, ALASKA 99509
DRILLING LOG
Well Owner : i,,,, :; ;,:i _(~-% ~.~Sfi~ Use of Well
Location (address of: Township, Range, Section, if known; or distance main road.
Size of casing. ~ .Depth of Hole ;2':5 feet Cased to !~ · feet
Static water level ~' ft. (above) (below) land surface. Finish of well (check one) open end
Screen ( ); Per:[orated ( ).
Describe screen or perforation
Well pumping test at ' gallons per
of drawdown from static level.
(minute) for ~ hours with
Date of completion
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
);
ft.
TO
TO
_TO
TO
_TO
_TO
_TO
_TO
_TO
TO
__.TO.
TO.
.TO.
TO ::;
2 --STATE
MUMUPAU7Y OF
Development Services Department
On -Site Water & Wastewater Section
Parcel I.D. 015-161-57
AHcHmAeE
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
� z7
Phone: 907-343-7904
Fax: 907-343-7997
Expiration Date: 1—' _:2-0 Z 0
Complete legal description Kasilof Hills, Block 1, Lot 5A
Location (site address) 10980 Stroganof Drive Anchorage, AK
Current property owner(s) Charles & Dolores Weiler Day phone 307-251-4985
Mailing address 10980 Strogonof Drive, Anchorage, AK 99507
Real estate agent
2. TYPE OF DWELLING:
2 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Z
Private Septic
0
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 $ 6n Waiver Fee $
Date of Payment 161 q I Ig Date of Payment
Receipt Number 06-a5&o Receipt Number
COSA # V 5Cl' 6LI-9 1 Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering Phone 907-522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503
Engineer's Printed Name Michael E. Anderson, P.E. Date 10/4/19
6. DSD SIGNATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
By: Original Certificate Date:
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
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
X Nitrate Advisory
Arsenic Advisory
Other
Legal Description: Kasilof Hills, Block 1, Lot 5A
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 7/12/1975
Total depth 255 ft
Cased to 41.8 ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) '24 in.
Date of flow test for COSA 7/30/19
Static water level at beginning of test 71.5 ft
Comments
B. TANK DATA
Age of tank(s) 10""9 years
Tank type/material Septic / Plastic
Measured operating fluid level in septic tank New
❑ Standpipes/foundation cleanout per record drawing
Date of pumping New Construction - 10/1/19.
D. ABSORPTION FIELD DATA Deep Trench
Which system tested (date installed) 8/29/75
❑ ALL standpipes present per record drawing
Total measured depth from grade 9.1* ft (max)
Measured depth to pipe invert from grade 3.8* 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 N/A gallons
Comments/Deficiencies:
Parcel ID: 015-161-57
Structure served by this system
Well production at time of test 4.8 gpm
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate 1.24 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by Forge Engineering
Date of Sample 10/3/19
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 7/30/19
Results [D Pass For 3 bedrooms
Fluid depth prior to test 1.5 in
Water added 559 gal
New depth 3 in
Elapsed time 1440 min
Final fluid depth 1.5 in
Absorption rate '450 gpd
Any rejuvenation treatment (past 12 months) None
If yes, enter date
*Slight grade difference between monitor tubes and flow line accounts for additional effective depth.
Trench is historically recorded in MOA files to be 4' effective.
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'
✓Q
Yes
Community Sewer Manhole/Cleanout > 100'
Q Yes
if No
ft
M Yes
if No ft
Neighboring Tank > 100' 0✓ 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' 0 Yes
if No ft
Neighboring Absorption Fields > 100'
✓� Yes if No ft
Water Main > 10'✓0
Animal Containment > 50' Q Yes
if No ft
F✓ Yes
if No
ft
dQ Yes if No ft
Water Service Line > 10'
P�
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway comment below
Community Sewer Main > 75' 21 Yes
if No
ft
2✓ Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
✓Q
Yes
if No
ft
Surface Water > 100'
®✓ Yes if No ft
Property Line > 5'
Q✓
Yes
if No
ft
Wells on Adjacent Lots:
✓0
Absorption Field > 5'
P/
Yes
if No
ft
Private Wells > 100'
✓� Yes if No ft
Water Main > 10'✓0
ft
Yes
if No
ft
Community Wells > 200'
dQ Yes if No ft
Water Service Line > 10'
P�
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'
[D
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
F✓
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
✓0
Yes
if No
ft
Private Wells > 100' ®✓ Yes if No ft
Water Service Line > 10'
0✓
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
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
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
KasilofI Hills, Lot 5A, Block 1
Location(siteaddressordirections)
1Q980 Stroganoff Drive, Anchorage
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Charles Weiler Day phone2?4-6667
10980 Stroganoff Dr., Anchorage, AK 99516
City Mortqage/Warren Gossett Day phone563-0700
P.O. Box 92810, Anchorage, AK 99509-2810
N/A
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WA'I'ER SUPPLY:
x
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 {Rev. 1/91) Fronl MOA ~f21
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EI~I3NIIDNEI Aa NOIJ. O:MSNI JO .I.N:I~IJ.¥J.S
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
If A, B, or C, attach ADEC letter.
Legal Description:
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Parcel I.D.
Date completed
Cased to Z//, ~'
Wires properly protected (Y/N)
ADEC water system number
0'~/Z/¢ ~ Driller ~/t¢.
casing height -~ ~ '"'
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG AT INSPt"CTION
~'~ g.p.m. ~, 5~
SEPARATION DISTANCES FROM WELL TO:
Septic/b~;~. tank on lot /-//~"
Absorption field on lot /~'-' '
Public sewer main /~//¢
+eub~ sewer service line ¢- ~,,-')- ~- '
; On adjacent lots /'.'¢"¢"
; On adjacent lots '/,'¢ ,* ~'
Public sewer manhole/cleanout /V//¢
Petroleum tank /*'-~-"~ --'~/~,,-~ '~ ;~ ""/-
WATER SAMPLE RESULTS:
Coliform __(~ Nitrate
Date of sample: ¢ ¢/*~/~,~
/v/(~// Other bacteria
/
Collected by:
B. SEPTIC/J,tetC.4.t,~$ TANK DATA
Date installed ¢) ~/~ ~?/'~ ~ Tank size /
Cleanouts (Y/N) ~'~--~ Foundation cleanout (Y/N)
High water alarm (Y/N)
Date of pumping
Compartments
Depression (Y/N)
Alarm tested (Y/N) /,///I
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line -/-/o
Surface water/drainage
//4
On adjacent lots P/~
Absorption field
Foundation
Water main/service line
72-026 (Rev. 3/91) Fronl MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level N _~/~~
Meets MOA electrical codes (Y/
SEPARATION D~I.S..TAIq~E FROM LIFT STATION TO:
Well.oral'et On adjacent lots
Manufacturer ~
Manho~
"Pump off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ¢
Length Z¢~ / Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail) ,~/~ ~ ~
Peroxide treatment (past 12 months) (Y/N)
Soil rating
System type
Totaldepth ¢¢,,2 /
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
for
(.,//¢K/VOk¢/../ If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Weal on lot /' .;¢ '~ '
To building foundation
On adjacent lots t
Surface water
On adjacent lots /-/¢ ~ Property line
To existing or abandoned system on lot ,A//~
Water main/service line f-/o '
Driveway, parking/vehicle storage area '¢'/¢ '
Cutbank ,~/'.4
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on, the date of this inspection
Engineer's Name
Date ///'2/¢~
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number