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HomeMy WebLinkAboutKASILOF HILLS BLK 4 LT 19Onsite File #015-131-13 (�N�UJ N RBUliZ­6� �J Municipality of Anchorage JAN 2 6 2029 On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP201397 PID Number: 015-131-13 Dwelling: Q Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑■ JUpgrade Name Austin & Regena Joy ABSORPTION FIELD ❑ Deep Trench El Wide Trench El Bed El Mound Site Address 10741 Rezanof Circle Anchorage, AK 99516 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade (907)250-1850 Four (4) Existing GPD/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Kasilof Hills 4 19 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 Ft2 Ft. Well >100' N/A N/A N/A >25 TANK N Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Greer Capacity 1,250 Gal. Surface Water >1 N/A N/A N/A Material Number of compartments Lot Line >5' N/A N/A N/A NA Plastic 1 Foundation >1 Q' N/A N/A N/A LIFT STATION Manufacturer N/A Capacity Gal. Remarks Septic Tank only placed under this permit. Alarm location Electrical installed by PIPE MATERIAL House to tank D3034 Tank to drainfield D3034 Installer Alaska General Industries (Jay Joy) Drainfield N/A CO/MTD3034 Inspector Luke Tidwell BENCH MARK (Assumed elevation) 100 ft Inspection n 1st 10/22/20 Location and description 2 nd 3rd 4th Bottom of Siding on West side of house. ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp OF q ®®�® ... "'�q ®®® Conditional Approval: Date ' 49th =®®® ................................................ Q --N' %A'% MICHAEL E. ANDERSON Septic System �: N CE -4381 ZZ'AV Approved Date ®��0 p 01/0/2..... Note: this approval does not include well permit requirements. 44tty, ESS\6�'% (Kev uwuzii 6) PERMI����[N/T�������M1��� �|Fl�O1�_1�1_1� T `,��~^' =-"'^^"' ' '�^`,"'" '^^' '" \ \ / \ / \ \ ' \ / \ \ \ / / LOT 18 -- ---- --- \ \ ` LOT Ex|SOwG*oO0nPTK]NSYSTEM 1�oR|vEVVAYEaSE�ENTFOR TnnEwm|w|wss |CE / LOT�8.e�O�n� / / BOOK 141z.PAGE sn-oo / \ LOT 19 / DECOMMISSIONED EXISTING SEPTIC \ CO TANK PER U.P.C. ` ' 1,250 GALLON TANK w/20" mmmvwA,. LOT 20 z s\'- EXISTING GRINDER PUMP BEDR, O� LIFT STATION. OME 10'UTILITY EASEMENT EXISTING WELL _ / / / \. \ / MOOSE RUN LOT 4 / A 8 LEGEND K–����8,W PLAN AS -BUILT MH 44.25 5 .0CO – 2C0 CLEANOUT – DOUBLE CLEANOUT sv 43.75 60.0 2CO 44.2 63.8 FCO – FOUNDATION CLEANOUT 0 50 O FS – FLOW SPLITTER VALVE FEET MH – MANHOLE MT – MONITORING TUBE l`'=50' SV – SEPTIC VENT TH – TEST HOLE � PERMIT # OSP201397 EN GINEEN ING PID # 015-131-13 (NO SCALE) 1 U't. 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M v L v N c ca I— 0 OE Z a „L L X „ L l :3ZIS J33HS w c Ca 00 N o a aEi° v s 0 -CL >C >+� E 0 00O.0 _-W L-vi0c N O N °cccvo.3 c v 3 p 0 "-0°v0p�N 0 O` o -v°°°cos vc=yococ o O U .0 3 N N� +� v s 4- o 0-0 OC a'' O 'D L t °'•°.,00� o5 T °0) N 0vcc 0 1-1NT>E� O 0 N ° Z>, �p0ccvn N v �-' 0000 ° L- r ° 0 +' r 4-1 t m `v°+'� oc v - T V) c t O C C y >+ �C 0�ccycE Q ami JO or' E°-�'o'oQE°v o _ rnc� �' U 0 a Ic 3'v� � Q — aci — -W 0 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: OSP201397 Work Type: SepticTank Upgrade Tax Code Number: 01513113000 Site Legal Address: KASILOF HILLS BLK 4 LT 19 G:2541 Site Mailing Address: 10741 REZANOF CIR, Anchorage Owner: JOY AUSTIN J & REGENA S Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft Total Bedrooms: c ` f I�ehartment 9/30/2020 9/30/2021 34441 ❑ 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) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: Date: Date: &// Z 0 4 Parcel I.D. 015-131-13 Property owner(s) Austin & Regena Joy Mailing address P.O. Box 111073 Anchorage, AK 99511 Site address 10741 Rezanof Circle Anchorage, AK Day phone 250-1850 Legal description (Sub'd., Block & Lot) Kasilof Hills, Block 4, Lot 19 Legal description (Township, Range & Section) Lot Size 34,441 Sq. Ft. Number of Bedrooms Four (4) APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑x (w/wo ADU) Septic Tank 19Upgrade FKDuplex (D) ElHolding Tank ❑ Renewal ❑ Multiple 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: - i O , � 5 I -) 61) Waiver Fees: Date of Payment: 7122-1Oo2-0 Receipt Number: oo( Zqb Permit No. 0 S P 2d 1 S9 9 Permit App__- : . �..:c Date of Payment: Receipt Number: Waiver No. PO BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) September 21, 2020 MOA Development Services Department On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Subject: Kasilof Hills, Block 4, Lot 19 – 10741 Rezanof Circle Septic System Design Dear On-Site Services Engineer: The septic tank on the subject property has passed its useful life and must be replaced. We are submitting this application for a permit to construct a new septic tank. The attached site plan identifies the location of the home and the proposed and existing septic tank sites. No conflicts exist between this proposed tank location and any other well or septic system, whether on this lot or adjacent lots. The new septic tank will be placed near the same location as the existing tank. Storm water drainage will not impact this site. Wells on this and adjacent lots are shown. The new tank will be a minimum of 100’ from all wells and surface water, and more than 5’ away from the absorption trench system. No surface water is within 100’. 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, P.E. 9/21/20 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201397, Deb Wockenfuss, 10/01/20 1"=50' 1,250 GALLON SEPTIC TANK w/20" MANWAY. 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 2CO KASILOF HILLS, BLOCK 4 LOT 19 REZANOF CIRCLE9/30/20 FEET 0 50 100 10' UTILITY EASEMENT 10' DRIVEWAY EASEMENT FOR LOT 18, BLOCK 4 BOOK 1412, PAGE 65-66 EXISTING GRINDER PUMP LIFT STATION. DECOMMISSION EXISTING SEPTIC TANK PER U.P.C. SV MH EXISTING ABSORPTION SYSTEM TO REMAIN IN SERVICE. EXISTING WELL THREE BEDROOM HOME NOTE: GRINDER PUMP MUST BE LOCATED INSIDE THE HOUSE FOUNDATION. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP201397, Deb Wockenfuss, 10/01/20 bevelopment Services bepartment .... Building Safety bivision On -Site Water & Wastewater Program 4700 Elmore Road ' P.O. Box 196650 Anchorage, AK 99507 s a F E T Y Mark Begich www.muni.org/onsite Mayor (907) 343-7904 Well Log Permit Number: OSP191298 Date of Issue: 7-16-19 Date Started: 8-12-19 Date Completed: 8-15-19 Is well located at approved permit location`? U Yes U No Legal Description: Kasilof Hills b1k4 lot19 G:2541 Property Owner Name & Address: Joy Austin J & Regena S Attention: The well driller shall provide a well log to DSD within 30 days of completion. Borehole Data: Soil Type, Thickness & Water Strata Depth From (ft) To Method of Drilling Ex) air rotary U cable tool Casing type: steel Wall Thickness: .250 inches Diameter: 6 inches Depth: 49' feet Liner Type: Diameter: inches Depth: feet Casing stickup above ground: 2 feet stickup 0 2 overburden 2 6 bedrock 6 296 Static water level (from ground level): 14 feet Pumping level: feet after hours pumping gpm Recovery Rate: 2.5 gpm Method of Testing. airlift Well Intake Opening Type: n Open End n Open Hole ❑ Screened Start feet Stopped feet n Perforations Start feet Stopped feet Grout Type: Bentonite Volumegranules Depth: 20' Start 0 feet Stopped 20 feet Pump: Intake Depth 270 feet Pump size .75 hp Brand Name Grundfos SQE Well Disinfected Upon Completion? Yes [] No Method of Disinfection: chlorine tablets Comments: Oversized drilled, cased and grouted per muni code. Well Driller Hefty Drilling, Inc. 3540 Akula Dr. Anchorage, AK 99516 Water Sample Results: Arsenic: N� Nitrates: AQ Total Coliform Bacteria: I'l U Other Bacteria: ug/L mg/L colonies/100mL col/100mL 8'I25'ZI Attention: The well driller shall provide a well log to DSD within 30 days of completion. � g sa eIlf bivisio,� G� Q on-si-d°e VVQ` er G: Was i BVIG I P -P 1POOH' Ay ,� oma. a,ro 4700 Elmore Road ` c P.O. Bo:: 196650 Mark Begich Anchorage, AK 99507 Mayor rirww.muni.orq/onsite (907) 343-7904 Pump Installation Log Well Drilling Permit Numbers, -aWf � j; q6 Date of Issue: %4//lq Parcel Identification Number: " Legal DescriptionVC,5110-k 1� i � � � Property Owner Name &�A�d/dress:� e s arc 91k q 1 nk'1 11 Pump Installation Date: 8-31- I -I Pump Intake Depth Below Top of Well Casing: 2-7u feet Pump Manufacturer's Name: Pump Model: ) S Pump Size iT � hp I Pitless Adapter Burial Depth: / D feet Pitless Adapter Manufacturer's Name: Caws to 6-10 7 Pitless Adapter Installer: Well Disinfected Upon Completion? Yes n No Method of Disinfection: Com, l� to Comments: Pump Installer Name: )�-Vii,y VC1 Eftr� IDri!!Uig, Zru. P.O. Box112130 Aahorgg4 AK995U Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. ",c,pAL,TyO MUNICIPALITY HA On-Site Water LIT&WOFastewaterANCProgramORGE PO Box 196650 4700 Elmore Road ST r. Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 �� f, http://www.muni.org/onsite -* 9 NCwpRAGE Department On-Site Water System Permit Permit Number: OSP191298 Effective Date: 7/16/2019 Work Type: Well Initial Expiration Date: 7/15/2020 Tax Code Number: 01513113000 Site Legal Address: KASILOF HILLS BLK 4 LT 19 G:2541 Site Mailing Address: 10741 Rezanof CIR, Anchorage Owner: JOY AUSTIN J & REGENA S Lot Size in Sq Ft: 34441 Design Engineer: Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy EI Private Well 0 Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: 1. This permit proposes to drill the well in the location proposed under the 1986 Well & Septic permit. 2. Contractor shall flag 10 foot Utility Easement along south property line prior to drilling the well. 3. To close out this permit, please submit the following: a) Well log b) Pump install log c) Water sample results for total coliform, nitrates and arsenic. Received By: /114 ) _,AL4‘ Date: 7 Issued By: /gibe-6(a6.0_./aeliDate: 7 16 MUNICIPALITY OF ANCHORAGE • Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. WAS- 131- Property owner(s) r -- ZF---je r Day phone 71S-0-/ S Mailing address -0 ' I \ c7-3L . Site address )a- 9 l 9 Legal description (Sub'd., Block & Lot) KPf3i LC FP )J (/5 `7 to-f- ) Legal description (Township, Range & Section) '- 12A) / /2\ '3 7 t - Z_ Lot Size ,,• cC-c7 Sq. Ft. Number of Bedrooms cj APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial Single Family (SF) (w/wo ADU) Septic Tank ❑ Upgrade ❑ Duplex (p) ❑ 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. .41D gill P. (Signa ure of propert ow aut rized agent) Permit/Rush Fees: 9 2,09-S•UO Waiver Fees: Date of Payment: 1041 Date of Payment: Receipt Number: Ngo 0(O&J Receipt Number: Permit No. 0 Sp taq.s Waiver No. G:IDevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc owner or l • MUNICIPALITY OF ANCHORAGE DE. I-TMENT OF HEALTH AND HUMAN SER\ ,cS • Environmental Health Division 825"L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name— DISTANCES i 6-2T� /'l"'f''1° "pTO SEPTIC ABSORPTION Address FROM TANK FIELD WELL 0(� , �!/l��2/liL hc /il 1� WELL \�Itom- '���tiL- pnonets) Permit No. No.of drooms �,1.- l T. y • .. tJ 6/-- 2293 'ala 00'4• 1- , _ LEGAL DESCRIPTION LOT LINE .40.,S--- .p j lO �-^ � Lot Stock Subd+v ion ' 1_ rail yJ d, �%G J 1J0, l GI Y/S�I u_or I'-1�S . FOUNDATION �" Township.Range.Section Il D 1 1 ti.l 1--\--01--1 ti eR 5\ r -2--L-- AS-BUILT DIAGRAM Show location of well.septic system.property Ines.foundation. — I Z N . ) i__ /J ) /-� dnvev:ay.water bodies.etc.) __ — TANKS ■■_■ , 11_1111 .....,SEPTIC ❑ HOLDING L ■ I' ■i ■ Capacity in gallons 1.:, �;! �' t.S:,nuraClur C• V Y J _,,,,,I�,E tL �2.S o Matcrrii No.of C�o7nipartments I(l_I TYPE3 il OF SYSTEM ■ _ `� ` l , � W. DRAIN ❑ OTHER ,L _ ff . [� TRENCH `� BED ...r _ 111M7,4_60 ■ Depth to pipe button,from - -----1- 1.,depth from original grade I Mr' fl '4 ■ original glade /I�t FT .. AV 1 ' 1 �-✓tUFTI i ■ ■, _ r Frit added above ongu,ai grade Gravel depth beneath pipe I ___ IS O'0 FT 1 'D.FT ■ ■ ■■■ q 1 Gravrl•long:h Gravel width I-)J`�,D FT, St D FT ■■ ■ ■ ■1�I■ l otaf absorption area q•�l=, 1 D stance between tines i ■, ■■ 1;i 1 i Qj'�.1 SQ FT ZOt O FT ■ t t�■■ I I-- t o.► , Number of hoes 50,1 rating I hrpe material I • 2 I , 1 SQ FT c_ /S'ci I M 17 D ^� n,c;;t;:er Date installed WELLS ir� — II■■ ■ PRIVATE n OTHER (Identify) -� Classification IA.l3.Cr 'Total Depths Cased to ;ry ME 11111 a . us St> REMARKS: 111 i • _ , S 17 s , %/t) ■■ ■ ■ 1111-111. �,/ Seale: 1 yp .ENGI•IJEEJt'S SEAL: CA-1Ar '4- • ,<' _ ,'a-1� GP"---- �/ Ce-,1245 Inspections Performed by. __.12 ...1p . .._Pir..f_L/\ \ ,I , _ csr)5. L.375)--CQ )/A—S Date. iz ,. ..4_.' !_ - 411_,, . q2 'J 1 -4 ,/:._ . , IsVz 7 certily that this inspection was performed according to all �: t �.,:. ; ,;:- I :.:.:• /17s cft1 999577 Municipal and State guidelines in cited on this dale: _ Z. ---- / g - g C ____ Health Department Approval: - zie, Dale: _ 7.)_rw,:Z,aai MUNICIPALITY OF ANCHORAGE DE, ATMENT OF HEALTH AND HUMAN SER~ .ES Environmental Health Division 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT TANKS SEPTIC [] HOLDING TYPE OF SYSTEM [] TRENCH ~'] BED .,~ W. DRAIN [] OTHER .z~ FT Fdl added above ougmal grade . O,o FT ~ ',0 FT 1,0 FT Nun bm ol hnes ] SOd rabng ~l&pe material WELLS ~PRIVATE ~] OTHER fldenUfv) _ FT] Cased to FT REMARKS: -ro .._Foot, WELL LOT LINE FOUNDATION DISTANCES SEPTIC TANK ! ABSORPTION FIELD WELL AS-BUILT DIAGRAM tSbow location of well. septic system property hnes foundStlOl~, Inspections Ferfommed by. Dale ~.i:'~ ! ; :;:,' ~ ...... cedily lhat this inspection was pedormed according Io all I t;i~¢~ :, ~' '~,:;!*, /',~.:fcn ~,~9r3~]' Municipal and Stale guidelines in ellncl on lids dale: SUBJECT: ~ 0 '7-' C~ ,4PUTATION SHEET DATE_: SHEE"T BY CI<D OF / ,.'~ ~ 0 '-/riff-, /_.1,~ SU~CT: ~ / ~ 0 ~ C. 4PUTATION SHEET DA'[E: SHEEI' BY CKD OF 7¥:- PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST /¢111 1 2 3 4 5 6 7 8 9 10 I1 12 13 14 15 16- 17 18 19 2O Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? ,~"'~ /2.,~ ,' ~ ~..,,,,; SITE/PLAN S L IF YES, AT WHAT O DEPTH? p E Deplh t0 Water Ariel _ ,, tfloniloring? /~9 ,~ ,_ Date: ~'' --/,~~ 8' g Reading Date Gross Net Depth to Net Time Time Water Drop I z-(, ~ ~_~, /lA.Co/-~ z ', Ia :ac? ac ~,~,'~ /~=" /" > ,, ,0 ,, // ,' ~ ,, /~ ~o ~ lo ., /~" /~//~,, PERCOLATION RATE //~'''"- (m,nutes/,nch} P[:RC HOLE DIAMETER TEST RUN BETWEEN ,,~ f' ~ / FT AND _ FT / COMMENTS ./'J~d)/L/["~"-~,P~Z~//I,r~- r~ /~ ~ ~ ~ PERFORMED BY: &~) ~ 5'5x E;xd': '";',er, ~l~r;!~n ~¢~11' ~/ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELI~EFFECT ON THiS DATE. DATE: ~'~ /~ ~ ~ 72-008 (Rev. 4185) Development Services Department± Phone: 907-343-7904 On -Site Water & Wastewater Section - Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel 1. 015-131-13 1. GENERAL INFORMATION Expiration -Date w 7 - Complete legal description Kasilof Hills Sub, Block 4 Lot 19 Location (site address) 10741 Rezanof Cir Currentert ro s Austin & Regena JO (907)250-1850 p p y owner(s)Austin Day phone Mailing address Real estate agent PO Box 111073, Anchorage, AK 99511 2. TYPE OF DWELLING: 0 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 0 Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ '550 Waiver Fee $ Date of Payment oc0 Date of Payment Receipt Number © 3 y 3 Receipt Number COSA# a SC a 11 59 5 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 1 -01 -Anchorage, -AK -99503 Engineer's Printed Name Benjamin Schiller, P.E. Date 9/20/21 6. DSD SIGNATURE System #1 Approved for 3 System #2 Approved for Disapproved Conditional approval for .....k4b, , 49 �'.•' TH� :911 Ord bedrooms Benia*jSchiller bedrooms �slFq. , 9 20 21 • �`� PpROFESS10Na� bedrooms, with the following stipulations: \S"" PFAU P4041 C, G� A P7) �. Original Certificate Date: 10-7-2 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 Checklist blue sheet COSA Checklist Legal Description: Kasilof Hills Sub, Block 4 Lot 19 Parcel ID: 015-131-13 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA M Well log is filed with Onsite (or attached) Well production at time of test 2.5 gpm Date drilled 8/15/19* Water storage tank volume N/A gallons _._ Total depth 296 _ft -Well disinfected for coliform -test? - ❑ Yes ❑ No- Cased o Cased to 49 ft ®❑ Coliform bacteria is Negative W Sanitary seal is functioning correctly Nitrate mg/L 0 Nitrate less than MRL (ND) ❑® Wires are properly protected Arsenic ug/L 0 Arsenic less than MRL (ND) Casing height (above ground) 24 in. Collected by Forge Engineering Date of flow test for COSA New* Date of Sample 9/20/21 Static water level at beginning of test 14 ft. Comments Project has extended just past 2 years from new well drilling. **Samples pending B. TANK DATA Age of tank(s) <1 years Tank type/material Septic / Plastic Measured operating fluid level in septic tank N/A R Standpipes/foundation cleanout per record drawing Date of pumping Installed on 10/22/20 D. ABSORPTION FIELD DATA Shallow Trench FT STATION ❑ Require aintenance completed Age of lift station ears Lift station material Comments: Which system tested (date installed) 2/18/86 Adequacy test date 9/15/21 W ALL standpipes present per record drawing Results [] Pass For 4 bedrooms Total measured depth from grade 4.8 i "0 ft (max) Fluid depth prior to test 0 / 0 in Measured depth to pipe invert from grade N/A- ft (min) Water added 708 gal ❑ N/A — pressurized field 0 / 3 New depth In 0 Monitor tubes go to bottom of effective. If not, state Elapsed time 1440 min depth into effective RECode-requiredsoil cover over field 0 / 0 Final fluid depth In ❑ System presoaked Absorption rate >600 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: *No cleanouts were included in the original installation. COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) 0✓ Septic Tank/Lift Station on Lot > 100' if No ft Community Sewer Manhole/Cleanout > 100' 0 Yes if No ft ✓0 Yes if No ft M Yes if No ft Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' 0✓ Yes if No ft Absorption Field on Lot > 100' ✓0 Yes if No ft Holding Tank > 100' [7 Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' 0✓ Yes if No ft Yes if No ft --if-No ft Yes ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' 0✓ Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0✓ Yes if No ft Surface Water > 100' 0 Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: ✓0 Absorption Field > 5' ✓0 Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Main > 10'✓0 ft Yes if No ft Community Wells > 200'✓Q Yes if No ft Water Service Line > 10' 0✓ 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' E✓ Yes if No ft If absorption field is under driveway comment below Property Line > 10' F71 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 1 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 �ffj,• ;f7 I • Benjarr�n Schiller ��j�FG� •. 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