HomeMy WebLinkAboutDEER HORN BLK 2 LT 4r Horn
Block 2
Lot 4
#051-042-83
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water end Wastewater Program, 4700 Elmore St.
P.O. Box 196650 Anchorage. AK 99519-6650 Page of
www.ci.anchorage.ak,us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM ANOIOR WELL INSPECTION REPOI~T
Permit Number: r? q (~0 ~.~'"' PID Number:
"'"' WastewaterSystem: [] New ~[Upgrade
'~"' ?.'Z. O51 I)e,,- P~,,-k ~rc\~ ABSORPTION FIELD
phon~ '~..~t~. q~,~j~ .umb~efeedr~s...~ r'lOe~pTrer,~ r'lSba,o~,Tr~n~ r'tBed
LEGAL DESCRIPTION
SEPARATION DISTANCES ~septic [] Holding [] S.T.E.P. [] Other.
¥
"'""~" BENCH MARK
Development Services Department Approva--i---- ~ ~.-5'~1_._~ ~... j'^..9°
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¢OMMUNIT)' WATER, WELLS >> 200'
~BANDONED EXISTING .... ' '
IJ SEPTIC TANK IINSTALLED DOUBLE CLEANOUTb'I
I NTTSSrELTALLEO NEW !000 GALt
SEPTIC
INSTALLED £DUBLE
CLEANOUTS --
%
1000
~ALLDN SEPTIC
3.0' FEET COVER
P5 0 P5 50 7§ 100
SCALE, 1' = 50 FL
p-IN. INSULATION
CONNECTED TO
]/EXISTING PIPING
O£bIO~ ~IARK ~01~0~ ~/Olb!~ #Lr ~ ~ORtl£1
SPURKLAND ENGINEERING
203 W 15TN. AVENUE
ANCN. AK. 99501
(907) 279-$9~
DEER HORN BLOCK 3 LOT 4
SUE DAVIS
22051 DEER PARK CIRCLE, CNUGMK, AK 99567
J J SEPTIC SYSTEM ASBUILT
DATE: JUNE 15, 2009
SHEET:II1 GRID: NV/ 1558
PERMIT # SMODOOXX PID # BEERHORNB2L 4flI. flVG
MUNICIPALITY OF ANCHORAGE
Development Services Depadment
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 9951g-6650
(907) 343-7904
/1:3o
ON-Sri'E WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Jun 11, 2009
Expiration Date: Jun 11, 2010
Permit Number: SW090085
Legal Description: DEER HORN BLK 2 LT 4
Design Engineer: 0007 SPURKLAND ENGINEERING
Owner Name: SUE DAVIS
Owner Address: 22051 DEER PARK CIRCLE
CHUGIAK, AK 99567-
Parcel ID: 051-042-83
Site Address: 022051 DEER PARK CIR
Lot Size: 0 SQ, FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. Ail 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 engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, Alaska 99507
www. muni.org/onsite
(907) 343-7904
ON-SITE SEWER/~VELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Property owner(s)
Mailing address
Site address
Legal description (Sub'd., Block & Lot) Deer
Legal description (Township, Range & Section)
Lot Size Sq. Ft.
i~loch.
Day phone
Zip Code
Zip Code
Number of Bedrooms
THIS APPLICATION IS FOR (~;~ all that apply): THIS APPLICATION IS AN:
Absorption Field [] Initial []
Septic Tank ~' Upgrade ~
Holding Tank [] Renewal []
Privy []
Private Well []
Water Storage []
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number:
(Rev. 11105)
Waiver Fees:
Date of Payment:
Receipt Number;.
Environmental Consulting and Design
Municipality o£Anchomge
Development Services Depa~ment
Building Services Division
On-she Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
I
June 8, 2009
Subject:
SEPTIC TANK PERMIT APPLICATION
DEER HORN BLOCK 2 LOT 4
Ladies and Gentlemen:
We are submilling an application lo upgrade the septic tank for this lot. The existing septic tank serving the
above referenced propeay appears to be leaking. The submittal consists of one (I) drawing showing the
present improvements on the lot and the proposed improvements of the lot, of which only the septic tank is
subject to this permit application.
There are no wells within one hundred feet ofthe proposed replacement site. The installation ofthis septic
tank will not prevent wells and septic systems from being installed on Ihe adjacent lots. There are no
developed or natural surface / sub surface drainage courses within 100 feet of the proposed septic tank
location. The proposed septic tank will not change the general slope ofthe area. Ponding and/or
concentration of surface runoffwill not result from this installation.
Ifyou have any questions or are in need of additional information please contact me at 279-3916.
Sincerely,
203 West 15'a Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (907) 276-6013, SpurklandEng~gci.net
ii ii COt~WUNITY WATER, WELLS >> 200'
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INSTALL DBU3LE ~
Cl. EA~~ ..
4 FEET COVER
.. CONNECTED TO
· ~EXISTING PIPING
I000 6ALLBN SEPIIC
SCALE, l' = 50 FT.
'ANK
SPURKLAND ENGINEERING
203 W 15TO. AVENUE
ANCO. Al(. 99501
(9OX) 2x9-.~916
DEER HORN BLOCK 3 LOT 4
SUE DAVIS
22051 DEER PARK CIRCLE, cOUGIIOC AK 99567
SEPTIC SYSTE/~ DESIGN
DATE: JUNE 8, 2009
SHEET:III GRID: NV/ 1558
PERMIT # svogooxx PID # DEERHORNBPL4DI. DWG
Environmental Consulting and Deslgn
Single Family On-site Wastewater Disposal System
Construction and Material Specifications
Subject Property: Deer Horn Block 2 Lot 4
Date: 3une 8, 2009
General:
e
e
5.
6,
7.
The owner shall contract with a contractor to perform the work outlined in these
spedfications and plans in accordance with the attached MOA permit. There is not
contractual arrangement between the contractor and the Engineer. The Engineer shall
be the owner's representative and will inspect the work to document the contractors
activities. Final acceptance of the contractors work rests with the owner and the MOA.
The scope of the work includes the installation of a new :t000 gallon septic tank. The
location of the drain field is shown on the attached site plan drawings. All components of
the proposed septic system must be constructed a minimum of 100 feet from any surface
water or water wells In the area. A minimum of 4 feet of earthen cover is required over
the septic tank. Zf less than 4 feet of cover is available, 2-1nch thick, 40 psi, direct bury
board foam shall be installed directly over the septic tank and all installed piping.
Construction shall be in accordance with the approved site plan and design drawings and
any special provisions noted on the Hunicipal well and/or septic permit. All materials,
components, workmanship and construction practices shall comply with the Hunicipality
of Anchorage's latest ordinances regarding wells and septic systems, as well as HOA,
Development Services Department, On-site Water and Wastewater Program (DSD)
policies.
The contractor is responsible for obtaining all underground utility locates, layout of the
proposed system, and verifying and maintaining all required separation distances to lot
lines, surface water, wells, steep slopes, etc.
The property owner shall be responsible for final grading any depressions formed from
settlement of backfill material. The property owner is also responsible for vegetation of
all areas disturbed by septic system installation activities.
Contractors installing wastewater disposal systems must be certified to do so by the HOA
DSD, On-site Water Wastewater Program. Property owners installing their own systems
must receive advanced approval from HOA DSD pdor to system installation activities.
The contractor shall ensure that ALL materials being used are in compliance with the
most current guidelines established by the Hunicipality of Anchorage. Refer to
"Standards and Specifications for Component Parts and Haterials Used in the
Construction of On-site Wastewater Disposal Systems", Dated December 2000, as
provided by MOA DSD, On-site Water and Wastewater Program.
203 West 15th Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland~gci.net
Environmental Consulting and Design
SepUc Tank ZnstallaUon:
1. A new septic tank, of the size spedfied in the design drawings, shall be procured from a
qualified manufacture/supplier if the existing septic tank is found to be defective.
ConstnJction shall Indude two 4" diameter deanouts for pumping access.
2. The burial rating of the tank shall be adequate for the actual burial depth encountered.
3. The tank shall be level and suffidently bedded to prevent set+Jing of shifting of the tank.
4. All standpipes on the tank shall extend a minimum of 12inches above the final grade.
5. Tanks installed with less than 4 feet of cover shall be insulated.
6. The sewer service line from the house to the tank shall have a minimum slope of 2%
unless pdor approval is obtained from the engineer.
7. The inlet and outlet lines from the tank shall be bedded In drain rock or the soil shall be
suffidentJy compacted to prevent future settlement of the soil.
8. Septic tank inlets, outlets and deanouts shall be fitted with water tight couplings.
9. A deanout shall be installed I to 4 feet from the foundation.
10. Post tank deanouts shall be installed per MOA requirements. Does not apply to
pressurized lines.
11. In areas with high ground water, the septic tank shall be sufficiently anchored to resist
buoyancy forces when there is not adequate soil cover to resist uplift force. The
contractor shall refer to the engineer for direction regarding this matter.
12. The tank backfill shall be graded suffidentJy to ensure positive drainage away from the
tank.
1:3. Ail holding tank and lift stations shall have an audible and visible alarm inside the
residence being served.
].4. All lift stations shall be wired in compliance with all HOA guidelines and the Uniform
Electrical Code. A municipal electrical permit and inspections must be obtained where
required by the MOA.
15. The contractor shall verify that the septic tank/lift station is a minimum of 100 feet from
any residential water well, 150' from any dass 'C' well and 200 feet from any community
water wells. Additional separation distances must also be maintained.
:t6. The contractor shall remove or abandon the existing tank in compliance with the Unform
Plumbing Code.
~nspections:
A minimum of one inspection is required by the Municipality of Anchorage. These
inspections must be conducted under the supervision of a Professional Engineer licensed
to practice in the State of Alaska.
2. The septic tank may be set in place, but may not be backfilled.
3. The contractor shall provide a legible copy of all field notes relating to system layout and
construction to the engineer for the use in preparing the record drawings.
4. The contractor shall coordinate all Inspections with the Engineer. A minimum of 24 hours
notice is required pdor to the start of construction. If necessary, a preconstruction
meeting will be held on-site.
203 West 15tb Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland~gci.net
MUNICIPALITY OF ANCHORAGE
l e ~ 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
.EGAL DESCRIPTIO~
LOCATION NO. OF BEDROOMS
~O ~ DISTANCE ~O: Well ~ Dwelling PERMIT NO.
-- ~ ~ ~ Inches.
~ ~ ~ ~ Top of tile to finish grade ~ Material beneath tile Total eff~&w~bsor~n
~ Well ~ Building f~ndetion Nearest lot line
~ DISTANCE TO:
DISTANCE TO:
OTHER
MUN I I~ I PAL I TY OF ANCHORAGE.
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 9c~501~
264-4720
ON--SITE SEWER PERMIT
PERMIT NO: 840582
DATE ISSUED: 07/1&/84
APPLICANT: C/O S & S ENG'G LIFESTYLE IND
ADDRESS: SRB 19&X
EAGLE RIVER~ AK 99577
CONTACT PHONE:
LEGAL DESCRIP:
LOT SIZE:
MAX BEDROOMS:
SUBDIVISION:' DEERHORN LOT: 4
SECTION: 4 TOWNSHIP: 15N RANGE: 1W
89580 (SQ.FT. OR ACRES)
BLOCK:
Listed below ape the options' available to you in designing youp septic
system. Choose the option that best fits youp site.
DEPTH TO PiPe BOTTOM (FT.) 4.0
GRAVEL DEPTH .(FT.) 2.0
TOTAL DEPTH '(FT.) 6.Q
GRAVEL WIDTH (FT.) 2.5
GRAVEL LENGTH (FT.) 85.0 **
GRAVEL VOLUME (CU.YDS.) 19.2
TANK SIZE (GALS)' 1,000.0 **
SOIL RATING (SQ.FT.'/BR) 110
BED W. DRAI N
4.5 4.0
o.5
5.0 5.0
51.0 58.0
18.5 16. 1
1,000.0 ** 1,000.0 **
'110 110
** GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH)
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
I ceptify that:
1. I am familiar with the requirements fop on-site seweps and wells as set
fopth by the Municipality of Anchopage (MOA) and the. State of Alaska.
2. I will install the system in accopdance with all MOA ~odes and regulationa~
and in compliance with the design cpiteria of this permit.
5. I will adhepe to all MOA and State of Alaska requirements fop.the set ~ack
distances from any existing well, wastewater disposal system op public
sewepage system on this op any adjacent op nearby lot.
4. I und'epstand that this pepmit is valid fop a maximum of 5 bedrooms and
any enlapgement will require an additional pepmit. .
IF A
LIFT STATION
(1) AN ELECTR
IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
AND (5) THE
THEN CTR~[~m~f. PERMI'
WILL NOT BE APP~J~ED~WITHOUT AN ELECTRICAL INSPECTION REPORT;
ELECTRICAL BY A LICENSED ELECTRICIAN.
SIGNED ~
APPLICANT: S & S ENG'G LIFESTYLE IND
,EGALDESCR,PT,O ,/--q
F/Il
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
~ J- DATE PERFORMED:
SLOPE SITE PLAN
8
9
10
11
~IUNICIPALITy OF
DEFT. OF HEALTH &
ENVIRONMENTAL
WAS GROUND WATER
13-
14-
15
16
17
20-
COMMENTS
PERFORMED
72-008 (6/79)
SOILS LOG
PERCOLATION
TEST
P
E
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN . FTAND FT
minules/inch)
ENGINEERS, INC.
7123 OLD SEWARD H'WY.
ANCHORAGE, ALASKA 99503
549 -6,561
SOILS LOG I'ERCOLATION I'ES1
I
2
3
4
5
6
7
8
g
10
II
12
I,$
IS
18
Ig
20
.,
PEflCOLAT~
TEST'RL TWEEN . FT ANO
__ FT
_ CEnTI;iEO 0',': D~t"E:
Certificate of On -Site Systems Approval
W_ - I
Complete legal description Deer Horn B2 L4
Expiration Date:
Location (site address) 22051 Deer Park Circle Chugia-k, AK 99567
Current property owner(s) Jessica Arasmith
Mailing address
Real estate agent
I- Same
2. TYPE OF DWELLING:
nx Single Family (w1wo ADU)
171 Duplex
El Multiple Dwellings (Single Family and/or Duplex)
1.4
3. NUMBER OF BEDROOMS: W
Day phone
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
Fxl
Water Storage
❑
Holding Tank
❑
Community Well
ED
Community
❑
Public Water System
n
Public Sewer
Waiver reque Distance:
Received by: Date: A�
COSA to be released to t e gineer, unless otherwise requested by the engineer.
COSA Fee 5D.D'D
Date of Payment Woa C)
Receipt Number
COSA# OSG,� O
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
.A ..
01OX
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.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA
COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time
of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on
the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not
guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot
provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole
benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly
recommends buyers hire their own engineer to evaluate this report.
Name of Firm Pannone Engineering Services
Address P.O. Box 1807 Palmer, AK 99645
Engineer's Printed Name Steven R. Pannone P.E.
6. DSD SIGNATURE
./ System #1 Approved for -3 bedrooms
By:
System #2 Approved for bedrooms
Disapproved
Phone (907) 745-8200
Date
rC� OF ALq�t!
••Steven �•�'onncme•
CE 8149
�tlll���?OfE5S10NP��C�
cl 1
Conditional approval for bedrooms, with the following stipulations:
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 X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: Deer Horn B2 L4
If more than 1 septic system on lot: COSA Checklist # 1 of 1
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 ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Comments
B. TANK DATA
Age of tank(s) 11 years
Tank type/material "P""""
Measured operating fluid level in septic tank
FEC Standpipes/foundation cleanout per record drawing
Date of pumping 3/23/2020
11{ MUT
Parcel ID: 051-042-83
Structure served by this system 1
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ 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 completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA Wide Trench
Which system tested (date installed) 1984 Adequacy test date 312312020
_..._ _.-___ .____ ®-- standpipes preseYit per"record drawing Results ❑✓ Pass For 3 bedrooms
Total measured depth from grade 5.5 ft (max) Fluid depth prior to test 0 in
Measured depth to pipe invert from grade 4.5 ft (min) Water added 500 gal
❑ N/A —pressurized field New depth 0 in
Al Monitor tubes go to bottom of effective. If not, state
depth into effective Elapsed time 80 min
ME Code -required soil cover over field
FE -1 System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced 2000 gallons
Comments/Deficiencies:
COSA Checklist yellow sheet
Final fluid depth 0 in
Absorption rate '450 gpd
Any rejuvenation treatment (past 12 months) no
If yes, enter date
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
E3 Yes
if No 5.0*
Community Sewer Manhole/Cleanout > 100'
❑ Yes
if No
ft
F Yes
if No fi
Neighboring Tank > 100' ❑ Yes
if No
ft
Private Sewer/Septic Line > 25' ❑ Yes
if No ft
Absorption Field on Lot > 100' ❑ Yes
if No
ft
Holding Tank > 100' ❑ Yes
if No ft
Neighboring Absorption Fields > 100'
Water Service Line > 10'
❑✓ Yes
Animal Containment > 50' ❑ Yes
if No ft
❑ Yes
if No
ft
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ❑Yes
—
if No
ft
r] Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
E3 Yes
if No 5.0*
ft Surface Water > 100'
Yes if No ft
Property Line > 5'
® Yes
if No
ft Wells on Adjacent Lots:
if No
Absorption Field > 5'
M Yes
if No
ft Private Wells > 100'
Q Yes if No ft
Water Main > 10'✓[]
Yes
if No
ft Community Wells > 200'
Yes if No ft
Water Service Line > 10'
❑✓ Yes
if No
ft If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
121
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'
IZI
Yes
if No
ft
Private Wells > 100' P/1 Yes if No ft
Water Service Line > 10'
0✓
Yes
if No
ft
Community Wells > 200' [✓ Yes if No ft
Surface Water > 100'
✓0
Yes
if No
ft
_F. ENGINEER'S COMMENTS
*Tank to house foundation distance was code compliant at time of installation.
G. ENGINEER'S CERTIFICATION
l certify that 1 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.
7E,d�3z--6
COSA Checklist yellow sheet
OF A/-,,
PC •
49 T a
Steven R annone i
-CE 8149 Q s
,,
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O51- o~Z- 8~
1, GENERAL INFoRmATioN
Complete legal descriPtion
:~.°cation (site address)
~Urrent Prope~y owner¢)
Mailing address.
Lending agency
Mailing address
Expiration Date:
Day phone
Day phone
Real Estate Agent
Mailing Address., i'":,
Un/ess 'othen4,ise requested, COSA wi//be held by DSD for pickup.
NUMBER O'F BEDROOMs:
TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class ~ Well []
Public Water System
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site
Public Sewer
[]
.D
[]
The Municipality of Anchorage Development Services Department (DSD) issues Cedificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners, certificates of On-Site Systems APproval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for propedies served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions 'in the professional engineer's wOrk.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I 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(ara) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm
Address
Engineer's Printed Name
DSD SIGNATURE
'/ Approved for 3
Disapproved.
Conditional approval for
Phone
Date
5't
V,
bedrooms. ~
bedrooms, with the following stipulatiOns:
By:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(Rev, 11/05)
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
:f-fl--i/
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 EImore Road
P.O. Box 196650
Anchorage, AK 99519-6650 '
www.muni.org/onsite
(907) 343~7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: P~-~F-- ~eg~ ~lk ?_ ~.o'~ L~
WELL DATA ~ubl;c I'}zo
Well type - IfA, B, or C provide PWSID #~
Parcel ID: 051-OHZ- g3
Well Log (Y/N) --
Date completed -- Sanitary seal (Y/N) --
Total depth -- ft. Cased to -- ft.
Wires properly protected (Y/N) --
Casing height (above ground) -- in.
Date of test
FROM WELL LOG
AT INSPECTION
Static water level "-" ft.
Well production ~ g.p.m.
g.p.m.
WATER SAMPLE RESULTS:
Coliform -- colonies/100 mL Nitrate -- mg/L
Collected by:
Arsenic: ---- ug/L date of sample:
B. SEPTIC/HOLDING TANK DATA
TankType/Material S-~¢¢/ ]/}¢~.~oca~/~,
Tank size ~000 gal. Number of Compartments
Foundation cleanout (Y/N) ~ Depression over tank (Y/N) ../V'
Date of pumping ~ ~/l~/ll Pumper ~J~5
ABSORPTION FIELD DATA
Date installed ~r/Z~l/~H Soil rating (g.p.d./ff~ or~)
Length ~ ft. Width 5 ff.
Total depth 5.% % Eft. absorption area 330 ft2 Monitoring tube.
Date of adequacy test ;~c~ll Results (Pass/Fail) ~:~'
Fluid depth in absorption field before test /~ in. Water added ~0,5. gal.
Elapsed Time: -- min. Final fluid depth ~ in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (YIN & type)
Date installed
Cleanouts (Y/N)
High water alarm (Y/N) /V/
System type ,_%. )1o
Gravel below pipe { ft.
Depression over field
For ~ bedrooms
New depth ,E~ in,
/l'~O .g.p.d.
If yes, give date
:E.
LIFT STATION
Date installed
"Pump on" level at ,,,,"~n.
Datum .J
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot ~
Public sewer main ~
Sewer/septic service line ~
Animal containment areas --
,,~Size in gallons ,,,-~anhole/Access (Y/N)
"Pump offf level at.~ High water alarm level at J in.
Cycles tested/~~' · Meets alarm & circ~ents?
On adjacent lots --
On adjacent lots ~
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line 5 ~- Absorption field
Water main '~ 5 ~-
Water service line ~v,.5 a Jr'
Surface water
Wells on adjacent lots
i
oo'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line J0 ~'/' Building foundation J0' +
Water Service line ~-5 ~ Surface water ~00'+ ~/V,0~.
Curtain drain 50'~' (,~/. Wells on adjacent lots "ZOO -I-
F. COMMENTS
Water main Z5 [~
Driveway, parking/vehicle storage
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name
Date ~l~o/,I
COSAFee $ q~o --
Date of Payment C~I ~ [//
Receipt Number OC~!, I L[ '~--~
(Rev. 4/10)
Waiver Fee $
Date of Payment
Receipt Number
AS-BUILT
I hereby certify that I have surveyed the following described
property: /--~'?' ~:"' ~'"" :"
Anchorage Recording Pred.n~t, Alaska, and that the imp_rove-
ments situated thereon are g ithin the l~rope_rty lines and do not
overlap or encroach on the property lying adj"cent thereto, that
no improvements on property lying adjacerit thereto encroach
on the Premises in question and that there are no roadways,
transmission lines or other visible easements on said property
except as indicated hereon.
Dated at E~agle River, Alaska
!,.. ?t-'~-. " ' '
day of -"~'~_ i ~. ~ 19 '::' '
this2 ~ .... ' . ROBERT C. JOHNSON '~'¥~'~'d
SCALE,: , Registered Land SurveyorL~ uo'."8 0-LS
1" = ~G Box 77-0456, Eagle River, Alaska. 99577
Phone (907) 694-2543
Municipality of Anchorage
Dovolopment Services Dopartment
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www,muni,org/onsite
(9O7) 343-79O4
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. ,O5~1-0,~2-~.Z,
1. GENERAL INFORMA,'rl0N
~Complete.leg.al de~criptioq ~ee~
lr. ocat!on (site address) .' "l.~.o5 I
Current Property ownei(~i
Mailing a.ddress t
COSA# ~Olq~"
Expiration Date:,
~e [~)~v[~ Dayphone "2-qq-clb3~
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: '~
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class __ Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site [~
Individual Holding Tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Depadment (DSD) issues Cedificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Cedificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a pdvate or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I 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 Stare'codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm S~-~,~
, / ./
Address '2o~ c~, Ist~' Ave.
Engineer's Printed Name
DSD SIGNATURE
~ Approved for
Disapproved.
bedrooms.
Phone
Conditional approval for
bedrooms, with the following stipulations:
ON-SITE
.,... .. in:
.~, :. WASTEWATER : =
..... ..
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~, ~ ~ 0 ---- 0 ~J
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Street
· P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:. [~L,~,¢ ~,,., I~l~h ?_ Lo{-
A. WELLDATA. p~,%~[,
Well type '-" IfA, B, er C provide PW~ID
Date completed '-' Sanitary seal (Y/N)
Total depth ff. Cased to -- .fi.
FROM WELL LOG
Date of test
Parcel ID: 0 ~'1 ' O H'. ;Z' ;~ 3
Well Log (Y/N) ~
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
Static water level ~ ft.
ft*
Well production ~ g p.m.
gp.m.
De
WATER SAMPLE RESULTS:
Coliform '" colonies/100 mL Nitrate -- mg/L Other bacteria
Arsenic: ~' ug/L date of sample: -- Collected by:.
SEPTIC/HoLDING TANK DATA
Tanksize leco gal. Number of Compartments '7..
Foundation cleanout (Y/N) ~ ' Depression over tank (Y/N)
Date of pumping ,A/~,u Pumper
ABSORPTION FIELD DATA
Date installed, ~'~['ZH ! f~t~_. So?rating. (g.p.d.lft~ or ~[~
Length ~ (5 ft. ' Width ~ ft.
Total depth 57~ ft.' · ' Eft. absorption area ~O ft~: Monitoring tube
Date of adequacy test $~'1 o~ Results(Pass/Fail)
Fluid depth in ;bsorption field before test ~.. in. Water added (~50 gal.
Elapsed Time:.~ rain. Final fluid depth ~ in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (YIN & type)
"-- colonies/100 mL
Date Installed
Cleanouts (Y/N)
High water alarm (Y/N) ~
System type i .~ ~lo~ 'Tr-¢nc.~
Gravel below pipe ~ ' ft.
· Depression over field /V~
For "~ bedrooms
Newdepth~ in.
~ g.p.d.
~ ~o~ If yes, give date ~
D. LIFT STATION
Date installed ~
'Pump on" le~.
Datum ~
SEPARATION DISTANCES
...,Manhole/Access (Y/N)
Size in gallons ~ High water alarm leve~.~-"~
'Pump off" level at
Cycles test~.,~'~ Meets ala~.~iC'-cuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
Animal containment areas
On adiacent lots ' "
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation .~ I Property line -~ I-I" Absorption field ~ 14'
Water main ~ 2 ~ t Water service line ~' 251 Surface water ~ O,
Wells on adjacent lots "Z. O0 ~ ..1--
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line I o I + Building foundation
I
Water Service line ~ ?..5 Surface water A~,O
Curtain drain N'~ O, Wells on adjacent lots
Water main '7' 2. 5 I
Driveway, parking/vehicle storage
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I ce/lify that I have determined through field inspections end
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name [.~,~-S
COSA Fee $, '~'~'~ ~
Date of Payment ~,/Z'~[~1
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
0 S ~ ~'~ Receipt Number
AS-BUILT
I hereby certdy that [ have surveyed the Iollowing described
Anchorage Recordin$ Pr,.cinct, Alaska, and that the improve-'
ments situated thereon are within the property lines and do not
(n,'erlap or encroach ol~. the property,iyi'ng adjacent thereto, that
lm Improvements on property lying adlacent th~'reto encroach
¢~ the premises in questmn 'and that there are no roadways,
transmission Lines or other ~,isible easement~ on said property,
e~c~pl as indicated hereom
Dated at Eagle River, Ala, ska .
this fr-. Z:L dayot [\Z-'"* ~' / ~9~,'~, '
SCALE; I Registered 'Lan.d.,~urveyor No. 8~.0-LS
1" - ,~ [k.~x 77-04.56, Eagle River, Alaska 99577
. ' l~mne {907) 694-2543.
HUNI¢IPALITY OF ANCHORAGE
DIVISION OF ENVIRONMI!iNTAL HEALTH
DEPAP, THEI~ OF HEALTH AND ENVIRO~IF-NTAL PROTECTION
APPLICATION FOR HEALTH Ab~HORITY APPROVAL CEKTIFICATE
.general Information Application Date ~~
,al Le,al es#ip, nFnclude lot. , ock. subdivision..ac,to,. ,o sh p.
Location (address or directions)
(b) Applicants Name~/F~' IT~f/~-A~ /M/O Telephone -tlome Business
Applicants Address
(c) Applicant is (check one) Lending Ins~itution ~--~ i Owner/builder ~
Buyer ~-~ i Other ~ (explain)i
(d) Lendin§ Institu~ion Telephone
Address
(e)
(f)
Real Esta:e Co, & Agent
Address
Telephone..
Mail the HAA ~o the following address:
T~pe of Residence
Siugle-Family.~J
Number of Bedrooms
Multi-Family
Other (describe)
Water Supply
Imdividual Well~"
Community
Public.~'~.
Note: If community ~ell system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Sewage Disposal ,.~
Onsite~ Public ~--~ Community ~ Holding Tank ~--~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
5. En~ineerin~ Fir~ Providin~ Inspections} Tests} File Search~ Data and Information
As certified by my seal affixed hereto and as of the validation date shown bel6w, I
verify that my investigation of this ~ealth Authority Approval shows that the on-site
~ater supply and/or wast.water 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 o~-site ~ater supply and/or wnstewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm ~ . . r.,~.,x~=.~ ,.,~ Telephone
Approved ~ D~sapprove~
Te~s of Conditional Approval
CAUTION
rile MUNICIPALITY OF ~NCHORAGE DEPARIM. ENT OF I~ALTH ~ND ENVIROh,"~Eh~AL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON TEE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY ~N INDEPENDENT PROFESSIO~%L ENGIh~ER REGISTERED
IN TttE STATE- OF ALASKA. TEE ~EP DOES THIS AS A COURTESY TO PUl{CHASERS OF HOMES
TEEI~ LENDING INSTITUTIONS IN ORDE~ TO SATISFY CERTAIN FEDEP~ AND STATE KEQUIRE-
ME5~S. ~HPLOYEES OF ~{EP DO NOT CONDUCT INSPECTIO~ OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
O~ OMISSIONS IN T~ PROFESSIO~%L ENGINEER'S WORK.
(DHEP SEAL)
ER4/eJ/D18
[Page 2 of 2]
7-19-84
A. ~ELL ~TA
Well Classification
Well Log P~esent (Y/N)
Total Dept~. Cased to
Static ~ater fe~l
Casing Height Abo~ Ground
Electrical ~iring in Conduit (Y/N)
Separation Distaness from Well:
To Septic/Holding Ta~k on Lot ~ ~
If A, B, cr C, D.E.C. Approved(Y/N)
Date C~leted Yield
Depth of Groutirg
Pump Set At
Senita~y Seal on Casing (Y/N)
Depression A~ound Wellhead (Y/N)
; On Adjoining Lots
To Nearest Edge of Absc~ption Field on Lot ~ ~- ; On Adjoining Lots
'TO Nearest' Public Sewer Line
Watef'sa~ie 'Collected By
Water Sample Test Results'
To Nearest Public Sew~
To Nearest Sewer Servioe Line on Lot
; Date
SEPTIC/~ TANK DATA
Date Instal~ ~/~'///~ '~ Size N~D. cf C~ar tmon, ts
Holding Ta~ High-~te, ~a~ (Y~/~ ~ra~y ~ldi~ Tank ~t (Y~/~
~ati~ Distan~s ~ ~ptic~lding Ta~:
To ~ter-Su~ly ~11 ~ ~ To ~ildi~ F~n~ti~
To ~rty Li~ /O ~ To Dis~al Field
To ~ter ~i~vi~ Li~ ~ ~ ~~, ~, ~e, ~ ~jor ~ai~a~
C~
Receipt ~
Date Paid
Amount:
[Page 1 of 2] 2-15-84
C. ABSORPTION FIESD [I~TA
Soils Rating in Absorption Strata Type of System Design
Date Irmtalled ~ ~____~~__~W Length of Field
Width of Field___~(~)/ ~! Depth cf Field
.ravel Bed Thickr,~ss
Depression over Field (~ Date of Lest Adequacy Test
Results of Last Adequacy Test ~ ~-~
Separation Distance frcm Abso£ption Field:
To Wate Supply 2-(3_0 To omrty Lin ..
To Building .-cundation /~_~ F To Existing or Abandoned System ca
Lot~J ~ ; On Adjoining Lots
To ~ater Main/Service Line ~--O ~ To Cutback(if p=esent)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, c~ Vehicle Stc~age Area ~ /-
D. LIFT STATION
Date Irmtalled
Size in Gallo~s
"Pump On" Level a~
High Water Alarm [svel at
Tested for
Electrical Codes(Y/N)
M~ets 5~DA
** Check Permitted Bedroom Rating AGai~.~t HAA Bequest **
certify that/k'~ checke, d, verified, or oonfo~,~d to all MOA HAA Guidelir~s in effect
on the date.(~E th~r~. ~.%
2-15-84