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Home My WebLink AboutKASILOF 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 c=_0m=o Cl)CD I I A ��3a s . • . SJ' # I cciDzMo D=° nm I r- = I °m 0 0 0 I Mo0,z°� � D h Q N Cp M MO I I ZN z z m; p AO do • �� M mo o --1 CO00 6�V W ZZ a CD I 09 �va��s�/ oZ v < 3 CP wo (D W p CD v �. a F U1 4 o CD Q° 0 w .� o o � � 4 0 W M : 11 Cl)CD A ��3a s . • . SJ' # 00o Cao o r— = I . .'• o' �•�x t� 0 0 °0. O • (S • h Q N Cp /U) 00 00 00 G ^ ° I AO do • • o • �C7� yOR: CO00 ZZ a CD 11 `�� W v < 3 CP wo CD 9, (D n (.� �O N �(D O R �Qa j vv �� _`°�0o m m v ao a) M m°'mmoMCD 3 N CD N (D i N (AD O 7 3p 0 0 y 0 N (n CD C CDo F 7 3 O p Q v p 8 7 > (n O O m (1 (p T N d v n p j (om vv a o3o D (D o °p 11) o _ (D (D . (D N p N D y 3� 3 m vv r UT D c C) 0 R (D Q N - cn ID o U) cn N d OO 3 N O O CD CD CD Q o o70 � D i v M S� m (D r (7 z O 0 O X z M X M O D M V `� a "s ......... O, �o / / 00 :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 :1+•`^Ic 4, s A -9th_ e MICHAEL E. ANDERSON '^ No. CE -4381 a Z° 20: D I I 8484X cn � n f- I om=Z y I o I =0 0�f 1 0)I M�zo 7' I -r ox I �2N mo-zIn I zz=o o m 0 o I 0�va�OD al I C Z CTI O - � m a c t d a'0 0 ' o Cil°m -P CP � S I A MW MW 0 ., T 0 cr► r o'or a� • ;9 O �. m Cfl f F' CTf CL ^ ® n S . �® y =1 ® p O D N T— O • • �l -L1 r CL CD ANW 00 AMW i YaR • %� ��' W y A m wCD ZY s y° N m m C 3 D m O rn ID0 o o fl.o N (D �X °vv� Fl 0 5.0<* > �p4 rn m°7 mm�f0 D O2° tom rn � 3°mm�mCCD =coZ CD coo m a Q mai O� N 0 N A v O n— / i(D CO Q3 Z 0 v m N v d o o° 0 CD O CL aK:7ff- ° � �� n m 0 V� / c° m m °– 0, 'O m O / O O o -.0 3° �� y �m o z m D w m m= m o� 3 x x-03 mN I D my m=Er*v ZrQ CO D- CL C x CD v fn = D C = (.D 0 CL -i o -i 9. v -i m > -�j y (D !R CD = m 2 occn ��-0m -ov Dco 0o cn 0 SR � � m .p O o N� �'0 ID riaL D 00 CD CL N m >C m 5Z�m to o CD -> n cn o n 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 '~tJO,~ s,JeeU!SUe leUO!SSejoJd @ql u! suo!ss!Luo Jo sJoJJ@ JOj elq!suodseJ lou s! el~eJOqOUV jo ,~l!lgdp!unl~ eq/ 'p@nss! s! e~eo!j!]a@o e eJojeq elep eZ/~leUe JO suo!~,oedsu! ~onpuoo ~ou op SHHG jo see/~Old~U3 'slueu~eJ!nbeJ e~e~s pue leJepe~ u!e~aeo ,~siles o~ Jep~o u! suoRn~!~su! 6u!puel J!@ql pue seLuoq JO sJeseqo~nd oh,~se~noo e se s!q~ seop SHHO @qJ. 'e>lSeW jo ele~S eq~ u! peJels!6ej Jeeu!6ue leUO!SSejoJd ~,uepuedepu! ue /,q e^oqe 9 qdeJbeJed u! ue^!8 suo!~e~ueseJdeJ eq~ uodn ,~lUO peseq se~,eo!j!MeO le^oJddV ~Hoq~n¥ q~leeH senssf (SHHG) seoFues ueLunH pue q~leeH jo lueuJpedeQ e6eJoqouv jo ,~!ledp!unlA! eqJ. s~ueLuuuoo leuo!~!ppv :suo!~elnd!~s bu!~OllO~ eq~ q~,!~ 'swooJpeq Jo~ leAoJdde leuoB!puoo 'peAo~ddes!G 'SLUOOJpeq ~ JOJ pe^oJddv ~-- :at:ln.L~fNIDIS SHHO .~--~. e~n~euS!s s,Jeeu!Su3 '9 ~6I§-~69 eUOqdSeOTA~OS bUT~OeUTbU~ ze^T~ sseJppv wJL-I jo eweN · uoRoedsu! s!q~ jo e~ep eq~ uo ~oej~e u! suoi~eln6eJ pue 'seoueu!p~o 'sepoo e~e~S pue led!o!unv~ lie q~!~ eoue!ldwoo u! s! Lue~s/~s lesods!p ~e~e~e~se~ ~o/pue Xlddns ~e~e~ e~!s-uo eq~ 'uo!~oedsu! pue uo!],elS!~SeAUj/~Lu LuoJ~ pue sel!J eSeJoqouv jo ,~!led!o!un!/~ eq~ u~o~j peu!e~qo uoReLuJoju! eq~ uo peseq ~eq~/~¢pe^ ~eq~nj I 'u!e~eq pe~eo!pu! e~n~on4s ¢o ed~ pue sLuoo~peq jo ~equunu eq~ Jo~ e~enbepe pue leUO!~ounj 'e~es s! Lue~s/~s leSOds!p ~e~e~e~se~ ~o/pue ,~lddns ~e~e~ e~ls-uo eq~, ~eq~ s~oqs uo!~O!ldde I~^oJddv/~poq~n¥ q~leeH s!q~ jo uoi~el~!~se^u! /~u ~eq~ ,~J!~e^ I '~oleq u/~oqs e~ep uo!~ep!le^ eq~ ~o sa pue o~eJeq pex!jje lees/,w/~q Pe!j!~eo sV 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