HomeMy WebLinkAboutMEADOW RIDGE ESTATES BLK 2 LT 3Onsite File
Meadow Ridge
Estates
Block 2
Lot 3
#051-461-19
Municipality of Anchorage
On-Site Water and Wastewater Section ° (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP201060 PID Number: 051-461-19
Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑ Upgrade
Name
Patrick Domitrovich
ABSORPTION FIELD
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
21045 Meadow Lake Dr
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
907 390 0845
1 3
0.8 GPD/SF
9.54 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
6.87 Ft.
Gravel depth beneath pipe
2.67 Ft.
Subdivision Block Lot
MEADOW RIDGE ESTATES 2 3
Fill added above original grade
0.5 Ft.
Gravel length
30'+ 40' Ft.
Township Range Section
Gravel width
5 Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
I Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
564.5 F0
2 -
13 Ft.
Well
NA
NA
NA
NA
NA
TANK X Septic [IS.T.E.P. F-1Holding [:1Other
Manufacturer
Anchorage (installed 2016)
Capacity
1250 Gal.
Surface Water
I > 100'
> 100'
NA
NA
Material
Number of compartments
I
Lot Line
1>10'
> 10'
NA
NA
NA
steel
2
Foundation
>10'
>10'
NA
NA
LIFT STATION
Manufacturer
Capacity /
Remarks septic tank and 30' length x 32" ED
Gal.
trench constructed in 2016.
Alam, location
Electrical installed by
Tank to
PIPE MATERIAL House to tank D3034 drainfield D3034
Installer
QRS Septic
Drainfield D3034 CO/MTD3034
Inspector Curtis Townsend
BENCH MARK (Assumed elevation) 100 ft
Inspdection 1m 4/21/2020 4/24/2020
Location and description
2nd
3d 4/27/20i 4'h 4/29/20
side door threshhold
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval: Date®P'����
�Aek°v�d
ti .
°Curtis L d '
O
�� Date 5 2nd;
��FC�p,F No. CE
Septic System.
Approved Date Date 5 (aD�U
��l �FDPROFESS10t��
Note.: this approval does not include well permit requirements.
�����?�
kRCV VV, VG, 10)
NEIGHBORING SEPTIC
IS 1' FROM PROPERTY
Q / LINE, WR920075
2 � I
21% / 1'
1250 GAL SEPTIC / ypMR WATER LINE ENTERS I
TAN INSTALLED 016: Cp$ E BM HOUSE AT THIS POINT
0' L x 5' W 32" 50/50 SPLITTER VALVE
FENCH C H INS ALL CO 4 D TH
RE \ ADDITIONAL 40' L x 5' W x
/2016
0
C T \ 32" EFFECTIVE DEPTH /
SHED.. TRENCH WAS CONSTRUCTED/
2�% \APRIL 2020
T /
CO3 3 30 1 FENCE j \
10 40/
NEIGHBORING SEPTIC �
IS>10'FROM /
PROPERTY LINE
SCOPE OF WORK
1. 1250 GALLON STEEL SEPTIC TANK INSTALLED 2016.
2. 30' L x 5' W x 32" EFFECTIVE DEPTH TRENCH
INSTALLED 2016.
3. AN ADDITIONAL LENGTH OF 40' x 32" EFFECTIVE
DEPTH TRENCH WAS CONSTRUCTED IN APRIL 2020. / /
MAXIMUM DEPTH OF EXCAVATION WAS 10'. /THIS LOT AND ALL NEIGHBORING
4. ALL CONSTRUCTION WAS IN ACCORDANCE WITH ALL / / LOTS ARE SERVED BY A
REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL / COMMUNITY WATER SYSTEM AND
CODE CHAPTERS 15.55 AND 15.65. i THERE ARE NO WELLS WITHIN
100' OF THE SEPTIC SYSTEM
SWING TIES ON PAGE 2
Septic As Built Drawings Prepared for ...+�
**�1k■ �mi
++
PATRICK DOMITROVICH �.
10,p�,...•••••••.��Qs�i*�
21045 Meadow Lake Dr Chugiak, Alaska 99567 �,.•� '' !#
MEADOW RIDGE ESTATES BLOCK 2 LOT 39T-" : •
0SP201060 ;................ t
................:.....,0.............�......................•
EK�UTNA ENGINEERING, LLC DATE: 5/8/2020 .CURTIS TOWN i
19162 MOUNTAIN ROAD DRAWN: CLT �� 0' No. E 1904 :ff
CHUCIAK, ALASKA 99567 = ' •�1 •'fir,.......
(907) 355-9820 PDA 051-461-79 SHEET 120F03 '+++��++•••
H
a
z
ORGANICS JOB
SILTY SAND WITH �sm
GRAVEL AND
FRACTURED ROCK
NEW 4D' x 5' x 32" �'
LFFECTIVE DEPTH TRENCH
INSTALLED 2020
MARK
Z
�
-
F-
zF-
F -0
_j
_j
�a
0
U
U
mz
Z
Zl¢iJF
33'-9"
Q0
J
aCJ
27'-4"
;s
H 0
O
J
LL C) r
n_
C��_�
�_
—Q -C,-
,9�.
H
a
z
ORGANICS JOB
SILTY SAND WITH �sm
GRAVEL AND
FRACTURED ROCK
NEW 4D' x 5' x 32" �'
LFFECTIVE DEPTH TRENCH
INSTALLED 2020
MARK
A
B
SV1
20'-5"
27'-1
"
SV2
24'-2"
33'-9"
CO1
27'-4"
39'-6"
CO2
50'-4"
67'-2„
CO3
53'-0"
51'_0„
C04
32'-9"
22'-10"
SWING TIE B TO OUTSIDE
OF CANTILEVER
EXISTING 30' x 5' x 32"
EFFECTIVE DEPTH TRENCH
INSTALLED 2016
Lci
EXISTING 3D' x 5' x 32"
EFFECTIVE DEPTH TRENCH
INSTALLED 2016
AREA BETWEEN TRENCHES WAS
EXCAVATED AND BACKFILLED AND
COMPACTED
ORGANICS
SILTY SAND WITH
GRAVEL AND
FRACTURED ROCK
GROUNDWATER WAS NOT
PRESENT 4/13/2020
Septic As Built Drawings Prepared for .,
PATRICK DOMITROVICH OF q���
���,
21045 Meadow Lake Dr Chugiak, Alaska 99567
MEADOW RIDGE ESTATES BLOCK 2 LOT 3'. 49T" �= �0
OSP201060
............ ...
........"""' "'"".. . ..
'
EKLUTNA ENGINEERING, LLC ,�........... '�. S ................... ..'
DATE: 5/11/2020 � CU TIS TOwNSEND;r
19162 MOUNTAIN ROAD DRAWN: CLT •�'��':,� No. C 11 04
CHUGIAK, ALASKA 99567SCALE: 1112" = 1' * + f . 14
�U•���"^"�"'�-��
(907) 355-9820 PID: 051-461-19 SHEET 3 OF 3 +� ,����
0,
�10' UTILITY EASEMENT
Lot 2
00 635
^h0
ry� 1.1'x1.4'
CANT
"C
3�Lot 3
,8• 2.0'x26.2' CANT 28,489 S.F. /
O iL
.RETAINING 11 4.0'x12.2'
WALLS DEC
� \ DECK
�b
SEPTIC PIPES
/ a /..
O� `\
SHED" 5 J `CHAIN-LINK FENCE vA r
/ H 6.5'x6.7' SHED
S�, ^
q 0
Lot 4 /' 0
ao V
RETAINING WALL �
10' UTILITY EASEMENT / 0 /
NOTE: LOT IS SERVED BY A COMMUNITY WATER SYSTEM. /
PLOT PLAN ___ AS BUILT _x_ SCALE __1"_=4a-_ GRID _ NW 1362-- Project No.
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates, inc. (907) 522-6476 Phone 00000p��
(907) 522-4625 Fax oF q X04
Professional Land Surveyors ken*langsurvey.com
y jonothanAlangsurvey.com OpP gs04o
I h `OTy3Certify BLOCKh2 (MEADOW surveyed
E ESTATESfollowing
SUBDIVISIONdescribed
(PLAToNorn72-261) 0° 49?H ����
Anchorage Recording District, Alaska, and that the improvements situated thereon are 0" ""' "' . . . .
within the property lines and do not encroach onto the property adjacent thereto, that
no improvements on the property lying adjacent thereto encroach on the surveyed �'�'KENNET.. . .. .....0
premises and that there are no roadways, transmission lines or other visible O��, % :• �
easements on said property except as Indicated hereon. 'Lt'Y11J p
Dated this the — Day Day of ___LLLI ` at Anchorage, Alaska 0�4�F�p 'LS -5
404RaFfS--
202
SIONA� �o
It is the responsibility of the owner to determine the existence of any easements, O40�0N00
covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963
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: OSP201060
Work Type: Septic Upgrade
Tax Code Number: 05146119000
Site Legal Address: MEADOW RIDGE ESTATES BLK 2 LT 3 G:1362
Site Mailing Address: 21045 MEADOW LAKE DR, Chugiak
Owner: DOMITROVICH PATRICK F
Design Engineer: EKLUTNA ENGINEERING, LLC*
This permit is for the construction of:
q -2—Z — Z U
�1»cnr
.S:
Ucpurtmcnt
Effective Date: 4/17/2020
Expiration Date: 4/17/2021
Lot Size in Sq Ft: 28489
Total Bedrooms: 3
Q 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
e3xe_O_Qa ; V�, US,
bq-IWQeA 'Jo1 �0 +Te.taic_( -+- (\e0
eve b Z p ov�� m ac (dam Pu�)' ✓ C Lt) hozb
Received By: Date: _
Issued By: jwaa. (�Uwv Date: y/17 1 0
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201060, Rebecca Carroll, 04/17/20
— Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIA 4C
OSP201060, Rebecca Carroll, 04, 7/,
NEIGHBORING SEPTIC
/ IS 1' FROM PROPERTY
Z LINE, WR920075
hof 2
O
21% 3 /
3
1250 GAL SEPTICHpyE WATER LINE ENTERS
TAN INSTALLED 016 .' .x L -4i
COs HOUSE AT THIS POINT
I0' L x 5' W 32" / 50/50 SPLITTER VALVE / 3
FFECTIVF D TH O
'TRENCH VINS ALL CO CONSTRUCT AN ADDITIONAL
I 2016 % 5' _ 40' L x 5` W x 32" /
/ �. /
SHED .. EFFECTIVE DEPTH TRENCH. / __k �
/
MT T� ��2
0, 30 r— FEN�E
CO 1 AREA
30%
OEa
NEIGHBORING SEPTIC
IS > 10' FROM /
PROPERTY LINE
SCOPE OF WORK Qj
1. 1250 GALLON STEEL SEPTIC TANK INSTALLED 2016
WITHOUT THE BENEFIT OF A PERMIT.
2. 30' L x 5' W x 32" EFFECTIVE DEPTH TRENCH � �
INSTALLED 2016 WITHOUT THE BENEFIT OF A PERMIT.
3. BASED ON PERCOLATION TEST PERFORMED APRIL
2020, AN ADDITIONAL LENGTH OF 40' x 32" /THIS LOT AND ALL NEIGHBORING
EFFECTIVE DEPTH TRENCH NEEDS TO BE / LOTS ARE SERVED BY A
CONSTRUCTED. MAXIMUM DEPTH OF EXCAVATION TO / / COMMUNITY WATER SYSTEM AND
BE 10'. r THERE ARE NO WELLS WITHIN
4. ALL CONSTRUCTION TO BE IN ACCORDANCE WITH ALL 100' OF THE SEPTIC SYSTEM
REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL
CODE CHAPTERS 15.55 AND 15.65.
Septic Permit Drawings Prepered for
PATRICK DOMITROVICH p. 4k .DF DF 44 kilt
21045 Meadow Lake Dr Chugiak, Alaska 99567 d 9°0�
MEADOW RIDGE ESTATES BLOCK 2 LOT 3 `°�" �o
OSP201060 �' ,.....................
.
a
�..,. .............................*. ,0
EKL UTNA ENGINEERING, LLC DATE: 4/17/2020=;CURTIS TOWNSENDi �,�
a DRAWN: CLT �d No. CE 11904 ::'��'AY
19162 MOUNTAIN ROAD 0
CHUGIAK, ALASKA 99567
(907) 35;;-9820 SCALE: 1" = 40'
PID: 051-461-19 SHEET 1 OF
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201060, Rebecca Carroll, 04/17/20
Double foundation clean outs at the house foundation.
Close up of double foundation cleanouts.
Inlet line into septic tank. Tank was placed to avoid large rocks discovered while excavating.
Upstream end of tank visible.
Excavated hole where tank was placed. Tank was placed to avoid large rocks near foundation.
1250 gallon steel tank manufactured by Anchorage Tank is visible in the photo. Also visible is the septic
rock that was placed in the new 30& wide trench.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAI LI NCzAD DR ESS
LEGAL DESCRIPTION
LOCATIO~
I DISTANCE TO:
Absorption
, ,.,. y
__ J J¢~¢~ I IF HOMEMADE: Inside length
Dwelling
IWell
DISTANCE TO:
PHONE
8'?
Dwelling
MateriagT~, e
W dth
Manufacturer
Length
Type of crib
Class
DISTANCE TO: ' Well,/~ A
No. of lines Length of each li0e
Top o'f tilYto finish grade ~,~i'~ ~,~ 2i
NO. OFBEDROOMS.~
PERMIT NO.
No. of compartments
Liquid depth
Width
PERMIT NO.
Material Liquid capacity in gallons
Foundation /'~ '~' Nearest lot line,~,.~,.~ PERMIT NO~ ~ Z~
Total. I.~engt~s
Trench width
· ~ inches
Material beneath tile
Depth
inches
Sewer line
~ NEW
[] UPGRADI=-
Distance between ,ine~ .~
Total effective absorp~To~ area
PERMIT NO.
Crib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
Depth Driller Distance to lot line PERMIT NO.
DISTANCE TO: Building foundation Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
INSTALLER
REMARKS
Z' ¢lbll t '
,,j
~ '~ - "~ ~ ' ' ~' ~ V
APPROVED ~ p,0~ESSi0~y~ DATE
LEGAL
z r3
72-013 (Rev. 3/78)
F'ERHIT' NO.
DEPFII';TTHENT ~. I../I:~:FIL. TH FINE:, Ehl',,,' ~ RONI"tEI'.,tTFi[ OTECT I 01'.,I
S25 "'1.. '" !~';TI?IZE:T., RNCHOI:.~'.FIGE.,F. II-:::. 9950:J.
2,5,4-472E'~
':: Lz',}'--":Oq.d;Z"..':,
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LO~F:IT]:Ed'-,I II",IiSTFIL. L ::L~Z~O'" I:'ROH H:[GH HFITER ON LFIk:E
LEGFff... 1_3 ?,3 I"IEFIE:,Ckt,.IF.: l [:,Gl!.: [:Z:gTFITES LFFt"
kq F::E:
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:5OIL RI::IT:[I'.,II:i ':::~;Q t::'T,-."EIR)= ::LS,cZ~
I"/FIX]:HUH NI.JHBER OF E~E£:,F.:O0t"I~; ,:= 3
THE L_ENEi]"H [:,II"IEi'.,I$IOI'.4 IS THE: LENGTH ,.'ZII'.,I FE:ET::, OF THE TREI"4C:H 01;:: DRFIIt'-,II::'IEL[:,.
THE [>EF'TH OF FI TRENE:H OR F'IT ]:?~ THE [:,I'.-Z, TFtNCE E:ETHEEN 'THE': '_-7, URFFIC:E OF THE
GROUNI.-:, FIN[> THE BOTTOH OF' ]"HE IEXCFt',,,'FIT I O1",t ,:: l I",! FEET
"I"HER[Z.. I:5 I'.,!0 L:.;IET klI[:,TH FOR TREi'.,IC:FIE:5.
THE GI:4:I::I',,,'EL [:,EPTH 1' S THE I'1 :[ i'.,I I HIjH [:,EF'TFI OF' GF.:R",,'EL BEI'[,.IEEN '1'HE OU]"F'FILI_ F:'I I::'E
I::lhtD THE E',O]'TOH OF THE EXCI::I'v'FI]"]:ON ,:; I1'.,I FEET::,.
PEF::H I T FIPPL I CFtI'.,IT HI::IS THE RESF'Ed'.,I:51L:: I L I"F'.r' TO I NFOF:H TH 1:5 I::,EF'RF.:THEi'.,I"I~ [:,l...ll:~ ]: l'.,ll'3 THE
]: NE;'I'FILLI::t"I' ]: ON Ii'.,I:~I::'ECTILqI'.,t:.~; FF:' IZll'.,l'.r' I.,.IELL. 2; FIDJFICEI",IT 'TO "FHZ% FF:UJFEI:.-[~ FI~",I[::, THE
NUHE:IZR OF' ,q'.E:~;:[[:'ENCEff; THFFF 'T'HE I.'.llEL. I... I.,.IILL.. :E;ER',,,'E':.
E:RCI.:::I::iLLINC. i OF FtN'T' :q.,"r".E:;TEH HITHOU]" FII",IFIL IN2;F'IECTION Fli'.,ll::, HF'PF:.- -~ .... ,HI.. E:"r' 'THI:5
[:'EPFtRTME]",H- [4 ]; LL. ~.~:E '~";I_IE J'E: 'I" TO F'ROSECUT :[ ON.
H II",tlI%IH [:'I:~.;TI::INCE E:E'I"!4EEI",I FI .[']ELL FIND FII",I"," r'II'.,I-SITE 2;EHFII3E I::,IE;F'iDSF~L E;"r'STEH
::I..(']E'~ FEET FOR FI F'RI',,,'FITIE [,.IELL. OR ±SE~ TO 2Eu.Z~ FEET FROH FI I:::'UE~LIC [,]lEl_[... DEF'EI",I[:,IIqG
UPON 1"HE T","F'E nF PUE',LIC HELl._.
H:[NIHUr,1 [:,t?.,TFINCE FROH FI F'F.'I',,,'F~TE HEL. L. TAR F'F.:I',/FITE :~';EI.,.IER L. IhlE I'.'.:; 25 FEET Ffi'.,II:>
']"0 I..-.I C:OHHL.INIT"r' '.:.;E[,.IER LINE I':L:; 75 FEET.
OTHER I:~:'.EC!I...Itl;"..'EHEt'.,IT:5 I'"IF':t'T' F:IF'F'L.'T'. :SF'EC::IFICFI]"ION2"; FINE:, CCII",t'.'STRUCTIOI'.,I I)IFtIC]RFIHS FIRE
I::I ',,,' FI I I_F:IE:L[:Z TO I I",IL-Z,I..IF.':E F'F.:OF'ER I I",I?.',TI::IL LR'T I L-IN.
Z[ CER"I" l F:"T' THFIT
:i.' :[ FIH F'I::IHIL.~FIR [,.II'I"H THE RE6:!UIF,::EH[:Zi'.,ITff; I':"E[R E[I'.,I-.-E;ITE ':7, EklEF.:2"; FINE:, ,t,.IELL. L:; Fl'.".".; '-'-";ET
F'Cff~:TH B'T' THE HI_II",I:[CtPFIL. tl'"r' OF' FIi',IE:HEIRFtGE.
:"~:: ): HILL. ZN:.".7, TRL. L THE :E;'9~.";TEH ]:1",1 F:ICCOF::DFII",ICE kI:t:TH THE
3' :i: UI",t[:'EI:~::STI::II",IE:' ]'HFIT THE Ed"4"'":~;TTE :'SE!-'.IEI;:": .'Sr'..~;TEH I'"lF:l"r' F.:EC!UIRE EI",ILFIF.:GEHENT IF ]"HE
F.:EL'5, Z [:'ENE:E :[ ~:EI"IEff::'E'LE3EL "i"E~ INCL. LIDE HORE THRhl 3: BEE:'F.:OEd"/:5.
fflI::'F'L. ICRHT FIL. L. FI[~I'~',LI):LE:ER:~.';'" --
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
5
6
7
8
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
PERFORMED BY:
72-008 (6/79)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
SLOPE
WAS GROUND WATER ?Z'') 0 SL
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN . FT AND ~"/~T
, -/~. //////
(minutes/inch)
DATE/
MUNICIPALITY OF ANCHORAGE
Development Services Department
Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 051-461-19
1. GENERAL INFORMATION
Expiration Date: ffAqdQ09
Complete legal description MEADOW RIDGE ESTATES BLK 2 LT 3
Location (site address) 21045 Meadow Lake Drive Chugiak AK 99567
Current property owner(s) PATRICK DOMITROVICH Day phone
Mailing address 21045 Meadow Lake Drive Chugiak AK 99567
Real estate agent Ristine Casagranda
2. TYPE OF DWELLING:
0 Single Family ( wo ADU
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone (907)362-2299
3. NUMBER OF BEDROOMS:
3
i
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
[]
Water Storage
❑
Holding Tank,
❑
Community Well
❑x
Community 1
❑
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 $ go _ 0 16.00 Waiver Fee $
Date of Payment Sf l /go ;2d Date of Payment
Receipt Number - () (?o�to40 - Receipt Number
COSA #15 Waiver Waiver #
COVID-19
?5% DISCOUNT APPLIED i'
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* 6n 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 thetime of installation. i acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Eklutna Engineering, LLC
Phone 907.355.9820
Address 19162 Mountain Rd Chugiak AK 99567
Engineer's Printed Name Curtis Townsend, PE Date 4/30/2020
6. DSD SIGNATURE
y/ System #1 Approved for 3 bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
o.
®N -SITE •
ER AN M
WASTE oIA �-:
PROCf,AM
i
By:- Original Certificate Date: 5 La
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.
t
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: MEADOW RIDGE ESTATES BLK 2 LT 3
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above } in.
Date of flow or COSA
St water level at beginning of test ft.
Comments served by community well
B. TANK DATA
Age of tank(s) 4 years
Tank type/material septic Steel
Measured operating fluid level in septic tank 49,
■❑ Standpipes/foundation cleanout per record drawing
Date of pumping 5May2020
D. ABSORPTION FIELD DATA
Parcel ID: 051-461-19
Structure served by this system
Well production at time st gpm
Water Stora volume gallons
W isinfected for coliform test? ❑ Yes ❑ Nc
❑ Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by
Date of Sample
C. LIFT STATION
❑ Required maintenance com
Age of lift station y
Lift station material
Comment
Which system tested (date installed) 2016 Adequacy test date 41W2020
■❑ ALL standpipes present per record drawing Results ❑✓ Pass For 3 bedrooms
Total measured depth from grade 8.5 ft (max) Fluid depth prior to test 0 in
Measured depth to pipe invert from grade 5.80 ft (min) Water added 825 gal
❑ N/A — pressurized field
New depth 0 in
❑■ Monitor tubes go to bottom of effective. If not, state 415
depth into effective Elapsed time min
❑E Code -required soil cover over field Final fluid depth 0 in
System presoaked
07Absorption rate ' 450 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) no
date of test)
Gallons introduced 2000 gallons If yes, enter date
Comments/Deficiencies: trench constructed in 2016 was tested for adequacy. Additional 40' length of trench was constructed April 2020.
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
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
Property Line > 5'
No ft
Neighboring Tank > 100' ❑ Yes
if No
ft
Private Sewer/ Ine > 25' ❑ Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No
ft
ing Tank? 100' ❑ Yes
if No ft
Neighboring Absorption Fields > 100'
❑✓ Yes if No ft
Water Main > 10'
Animal Containment > 50' ❑ Yes
if No ft
es
if No
ft
Yes if No it
Water Service Line > 10'
❑✓
Yes
if No
Manure/Animal Excreta Storage > 100'
If septic tank is under driveway comment below
COMM URi er 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 it
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'
0
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. _��� X e_1 ffE,ERBS
��P :4Cq���¢
R
....
�-A, Date. l
40..
0 . .A • FE5510NP�'�
COSA Checklist yellow sheet
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 051-461-19 HAA#
1. GENERAL INFORMATION
Complete legal description Meadow Ridge Estates, Lot 3, Block 2
T15N R1W Section 11
Location (site address or directions)
21045 Meadow Lake Drive
Property owner Brian & Lynn Hattos Day phone 688-6518
HC 79, Box 6227, Chugiak, AK 99567
Mailing address
Lending agency N/A
Mailing address
Day phone
Agent Roll Milton/Heritage Real Estate Day phone
Address 18550 Eagle River Eoad, Eagle River, AK 99577
694-4994
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 ~v
TYPE OF WATER SUPPLY:
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:
X 'N
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA fi21
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 of this Health Authority Approval application shows that the on-site water supply
and/orwastewater disposal system is 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 in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
694-5195
99577
Phone
Name of Firm Eagle River Engineering Services
Address P.O. Box 773294. Eagle Rvier, Ak
Engineer's signature ?.L~--. ~4~--~ ~->>
DHHS SIGNATURE
'2~ Approved for '/'"/,~,"~9 bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By:
The Municipality et Anchorage Department of Healtt~ and Human Services (DHH$) issues Health Aulhodty
Approval C;ertifieates ba~ed only upon the representations given in paragraph ~ above by an independent
p~ole$$ional enginee~ registered in the Slate et Alaska, The DHH$ does lhi$ as a ¢ou rlesy to purchasers of homes
and thei~ lending institutions in order to sati$l¥ certain federal and slate ~equirements. Employees of DHH$ do not
conduct inspe¢lion$ o~ analyze data betore a certificate is issued. The Municipality of Anchorage i$ not
responsible for errors or emissions in the professional engineer's wo~k.
724)25 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /4r/¢;'4~('d /Z/./~E' ECT~5 Parcel I.D. 051¢ ~/¢/?
Well type ~¢~¢/~ If A, B, or C, attach ADEC letter. ADEC water sys(em number
present (Y/N) Date completed Driller
Total de
Cased to Casing height
Sanitary seal
Wires properly protected (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
AT INSPECTION
MU,~.~C")A' ITY r'F ~',F'r'HORAGE
ENVIkGNMENT/L LER~ IC~S ~)IVISION
'¢'.'i5.d. ~ 1993
RECEIVED
; On lots
; On adj,
Public sewer main
Sewer service line
Public sewer
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
Collected by:
B. SEPTIC/~21 TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Other bacteria
Tank size // OOO
_Foundation cleanout (Y/N) Y -
/"//'~' Alarm tested (Y/N)
0.~/"~9 ¢/~._,~ Pumper ~.~-/2/~
SEPARATION DISTANCES FROM SEPTIC/I:~.:cJ=E~G TANK TO:
Well(s) on lot /V//~
To property line ,~ '~ ~
Compartments ~ J
Depression (Y/N) /~¢/
.
Surface water/drainage
On adjacent lots '/' ~,' [,)f~ j Foundation
Absorption field
/D'
Water main/service line ¢'/O
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)_.~,,--
SEPARATION DIS_..T_.A-N~ FROM LIFT STATION TO:
~ On adjacent lots
Manufacturer ~. ":'
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Soil rating
Width ~' /<~
/SD 'f' ./,'~ ~ System type
Gravel thickness {~ ~' '~
Total depth
Cleanouts present (Y/N) y
Date of adequacy test¢)~//~ c//c/_~
for -';~ --
Peroxide treatment (past 12 months) (Y~_~ /Vi,4
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /',/
To building foundation //
On adjacent lots
Surface water
Property line .~/ /
To existing or abandoned system on lot ,/¥//~
Cutbank 'Z/'O / Water main/service line ¢- /,O/
Driveway, parking/vehicle storage area /D /
Curtain drain /'/¢/')~ ,~/~,P,'~/'V'7"
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the dote of this inspection.
, ~-. ~ r" ~ ~ ,'~:~
Engineer's Name
Date
HAA Fee $ /
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA
Waiver Fee: $
Date of Payment
Receipt Number
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ~--"~)\ -L~\LC~ \ -- \O\ NAA#
GENERAL INFORMATION
Complete legal description
Meadow Ridge Estates ~1, Lot 3, Block 2
T15N R1W Sec.ll
Location (site address or directions) 21045 Me~i. dow Lake Drive
Property owner
Mailing address
Lending agency
Mailing address
AHFC
520 E. 34th Avenue, Anchoraqe, AK
N/A
Day phone 561-1900
99503
Day phone
Agent
Address
Roll Milton/Heritage Real Estate Day phone 694-4994
18550 Eagle River Rd., Eagle River, AK 99577
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
x
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
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 02t
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Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIS'r
Legal Description: J~-R~Id I~II;¥_~E~:¢'~. ZDT" ~ ,~.,~ ~ Parcel I.D.
-'l"/ 5,,u ,~ l ld 5 ~ . / ]
A. WELL DATA
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Well type IfA, B, orC, attach ADEC letter. ADEC water system number
Log-p"'Yesent (Y/N) Date completed Driller
Total depthS'"'%_ Cased to_ __ Casing height
Sanitary seal (Y/N)~'-.,. Wires properly protected (Y/N)
'~0 MYNICIPALiTY OF
i'." M WELL LOG AT IN S PEOL:~,/~JNMENTAL SERVICEsANCHORAGEDivisION
Date of te'§t '~ ""!3t 0]99][
Static water level '~~ ~ i~?pEm~ V~D
,,~,.p.m. . . .
Nitrate
~acent lots
; On adjacont~
Public sewer manhole/cleanbu,~
Petroleum tank %
Other bact
Collected by:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Public sewer service line
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping ~/'"~,,
Tank size //~¢z~¢ Compartments
Foundation cleanout (Y/N) )/ Depression (Y/N)
Alarm tested (Y/N) /¢/'¢
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /*///)
To property line '~?
Surface water/drainage
On adjacent lots )~ ~¢¢ ~ Foundation /¢)"
Absorption field ?~ ce~-d Water main/service line /~
72-026 (Rev. 3/91) Front MOA21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
%1~i (wY~e)r alarm level "Pu m p on" level ~...~.~.
Meets MOA electrical~__
SEPARATI~NCE FROM LIFT STATION TO:
Wel~n adjacent lots
D. ABSORPTION FIELD DATA
Manufacturer ~
Manhole~
~ "Pump off" level at
Cycles tested
Surface water
Date installed
Length ,,"~-~' ~-
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Soil rating /50 /'~//~,~
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
for
Width
System type
Total depth
bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~./,~1
To building foundation
On adjacent lots
Surface water
Curtain drain
,// /
On adjacent lots ¢' ~)~ / Propertyline ~'
To existing or abandoned system on lot
Cutbank /¢'¢ / Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
Signature
Engineer's Name
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in eff~(.ott,the~.date, of this inspection.
,r~''~ '' ' ~i~" '''~'
HAAFee$ /?~
Date of Payment
72~026 (Rev. 3/91) Bsck MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
A
Eagle River Engineering Services
11940 Business Blvd, Suite /~205
'P.O, Box 773294
Eagle River, Ak. 99577
694-5195
Fax 694-3297
Legal:
Owner: ,~ H,~
Date: aZ~/~f
Type of test:
[] Well Flow Test [] Septic 'fast Only [] Well & Septic Test rq Other:
Meter Monitor Well Tank GPM
Time Reading Level Level Level
lO, y?
1.2: 3~
PSI
Remarks
DEPT. OF ENVIRONMENTAL CONSERVATION
WALTER J. HICKEL, GOVERNOR
ANCHORAGE DISTRICT OFFICE
3601 "C" STREET, SUITE 322
ANCHORAGE, ALASKA 99503
563-6775
September 6, 1991
FOR: Eagle River Engineering
PWSID 211431
My review of the records on file in this office reviews that the Dawn Water Company Class
"A" Public Water System, is in compliance with the routine coliform bacteria samples
requirements listed in ]"able C, and with the inorganic sampling listed in Table B of 18 AAC
80.200.
Keven K. Kleweno
Lead Engineer
~ primed on recycled paper I) y O.D.
Property Owner
Mailing Address
Buyer
APPLi,? "NT FILLS OUT UPPER HA' 'ONLY
Phon~ (' ~
Address
Lending Institution
Address
Realty Co. & Agent
Zip Code
Zip Code
Phone
Address
Legal Description
Street Location
Ty p~.cf Residence
_~:_~- Single Family
[': Mulliple Eamily No. of Bedrooms
~ Other
Water Supply
t~R"'Com m unity
__.~, Public Utility -Y~'? '-/
Sewer Disposal
~:~ Individual
~ Public Utility
~ 14olding Tank
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
For wells drilled prior to that date, give well depth (attach log if available).
Year Individual Installed: \~! ~:'~-/ '-;~'> __
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
[)ate
Inspector
F:ield Notes:
Date
Inspector
APPROVED BEDROOMS
DISAPPROVED
CON Dll'IONAL APPBOVAL'
Date
Inspe2tor
Time
Date
lrlspeotor
MUNICIPALITY OF ANCHORAGE
[~;:~ ~ 'f& ENVIRONM2NI'AL PROTFCTION
t~O Ci':'*~t"'""'~'~'.- ,:,FP
RECEI _
'CONDITIONS OF APPROVAL
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well to Tank ~'J¢' ¢¢'
Well Log Received
Septic Ta~k Size ~ ~a~
