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HomeMy WebLinkAboutPENNINGTON PARK BLK 1 LT 7APennington Pork Block I Lot 7A #020-181 - 56 MuniCipality of Anchorage Development Services Department Building Safety Division OmSite Water and Wastewater Program, 4700 S. Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 Page j of' www. ci.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: '~ (/JO JO ~ ~ ~' PID Number: O~O Z, / ~ 1- ~ ...... Na~,:~;~ ~/[~ WastewaterSystem: ~.New ~Upgrade ~': [7~00 ~pa~ ~. ~n~ ~~[ ~' ABSORPTION FIELD Phone:~ 2 ~__ ~g?~ Number ol Bed ...... ~ DOeepTren~Shali~Trench DEed ~Mound ~Othe,: LEGAL DESCR'PT~ON' SoilRating: ~'q~gDIF,' To,lDep~fro~originalgrade: ~FL Subdivision: . . Township: Range; ' S~'--: ' Fill added above odgina[ grade: < ~.Tt. Gravel Length: ,. Well: D New D Upgrade ~.,,~d~: ~ Ft. Number of lines:~ Distan~ be~eenli .... Ft. . Yield: ~ [ ~ Pump Set at: Geeing He~gh[ A~ve SEPARATION DISTANCES ~ septic D Holding ~S.T.E.P. ~ Other: ~ Septic Absorption Lift Holding Publi~Pdvat, ~:act.rer; ~ GaL Ta~k Field Statio~ Tank S~r Li~e , ~r ~ ~ ~ Num~ of Cempa~ments: F~ndation '7' I1' 9, /~ 'Pump~'leveik2 in. 'Pumpo, levelat: ~ in. Highwateralarm~ in. ""~"~': BENCH MARK InsPections pedormed Dy:.., ........ .,..,.. ~ Dates: Development~Se~ices Depa.ment Approval PERMIT NO. SW010396 PAGE 3 OF 3 Hunicip. aLi-l:-.~y __ .of Anchor'aee DEPARTMENT OF HEALTHAND HUM'AN SERVICES ENVIRONMENTAL SERVICES DIVISION P,D, Box 196650 IAncho~age, Alaska 99519-6650eTetephone~ 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT L:~CA~, LOT 7A, BLOCK 1, PENNINGTON PARK S/D P.I.D. NO. 020--181-56 ST1 ST2 /89.5' FINAL H 2" INSULATION 87'~'~ I OALLON 'S~."E.~:I ~87.o' MT3 MT4 102.6'--~ 100.4'--~ ivlT3 = 93.5'-~ IH~102'3' 99'8'--k ,//-FINAL GRADE .... .,... ]]_ ~..,,~_~2" INS ULATI 0N'-.,...,~ S~ DISTRIBUTION PIPE ~MT4 = 93.4' ~' MT1 = 89.9'~' MT1 MT2 //--98.9' "~ 96.9' ~'X-MT2 = 89.9' A B C FCO 25.5' 15.0' - ST1 28.0' 14.0' - ST2 35.5' 10.5' - MH .57.0' 10.0' - MT1 - 54.5' 16.5' IMT2 - 32.0' 40.0' MT3 - 70.5' 56.0' IMT4 - 51.5' 47.5' NO WATER FOUND 83.9' B.0.H. Municipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 R/ck Mystrom htr p://www.ci.anchorage.ak, us Mayor Permit Number: #SW 010396 Date of Issue: 9-26-01 Parcel Identification- Niimbe~'..' 020-18%66 Date Started: 6-19-02 Date Completed: 6-20-02 Is well located at approved Permit location? [] Yes [] No Legal Description: Pennington Park BIk 1 Lt 7A Property Owner Name & Address: Mike Allen 17600 Spain D#ve Anchorage, Alaska 99516 Borehole Data: Depth (ft) Method of Drilling [] air rotary [] cable tool Soil Type, Thickness & Water Strata From To Casing type: steel stick-up 0 2 organics and silt 2 4 gravelly silt 4 58 sandy silty gravel H20 3gpm 58 61 silt 61 67 gravelly silt 67 81 weathered bedrock 81 9 7 bedrock ~ 97 207 Wall Thickness: ,250 inches ~Diameter: _6 inches Depth: 100 feet Liner Type: ~ Diameter: __ inches Depth: __ feet Casing stickup above ground: 2 feet Static water level (from ground level): 45 feet Pumping level: 207 feet after 2 hours pumping 4 gpm Recovery Rate: 4 gpm ~ Method of Testing: airlift : ~ , ~ ~ ~: ~ ~ '~ ,i: Well Intake Opening Type: [] Open End [] Open Hole [] Screened Start ~ feet Stopped ~ feet [] Perforations Start~ feet Stopped feet Grout Type: Bentonite granules Volume: 1 bg Depth: Start 0 feet Stopped - feet Pump: Intake Depth ~ feet Pump size hp Brand Name ~ Well Disinfected Upon Completion? [~ Yes [] No Method of Disinfection: chlotfne tablets Comments: Well Driller: Alpine Ddlling & Enterprises PO Box 110496 Anchorage Alaska 99511 Attention: The well driller shall provide a well log to the property owner within 30 days of comPletion and the property Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-8650 www. ci.a nchorage.ak.us (907) 343~7904 Soils Log - Percolation Test Performed For: h') I~ :~.~., /¢~ 1,. L. ~.,/~J Legal Description: Slope 7- 8- 9- 12- 15- 17~ 18- 19- 20- COMMENTS Site Plan WAS GROUNDWATER ENCOUNTERED? S IF YES, AT WHAT DEPTH? O Depth to Water After ~ p Monitoring? E Date: Reading Date Gross Time Net Time Depth to Water Net Drop 3 0 3 o ,~,,,~ /o ~/~" G" '3'0 .-- ~" ~. PERCOLATION RATE ~:~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN 9 FT AND ~ FT PERFORMED By$& $ ENGINEERING J ~/~ · - .............. I ~"~_INESI-N"EFFECT<N CERTIFYTHATTHtSTESTWAS PERFORMED IN ~~~~ ~IC PAL GU DELINES N EF EC O THIS DATE. DATE: E~le RDer, Alaska ~5~ MUNICIPALITY OF ANCHORAGE Development Services Department On-Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM ! WATER SUPPLY PERMIT Initial Date Issued: Sep 26, 2001 Expiration Date: Sep 26, 2002 Permit Number: SW010396 Legal Description: _ - - Design Engineer: 0003 S & S Engineering Owner Name: Lori Jo Oswald Owner Address: PO Box 4083 Palmer, AK 99645- Parcel ID: 020-181-56 Site Address: Lot Size: 41937 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: ~ Disposal Field [] SepticTank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must 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 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. Received By: Issued By: Date: ¢/Z~ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE SEWER/VVELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. Permit Number SWOI~ ,~ ~'~' Property owner(s) /...O~'; Mailing address (1) ~ O ~O3( Mailing address (2> Legal description (Lot, Block Day phone 7~'-- 567~ Legal description (Section, Township & Range) Lot Size ~ Acres~ q l ~l za 7 THIS APPLICATION IS FOR: Sewer Only Sewer and Well Sewer Upgrade THIS PROPERTY CONTAINS: Hot Tub Swimming Pool Therapy Pool Number of Bedrooms Well Only [] Water Storage [] Jacuzzi [] Water Softening Unit [] 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. $ & S ENGI~.'E~RING ~2 ~ '7034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 (Signature of property owner or authorized agent) Permit Fees: Date of Payment: Receipt Number: (Rev. 12/00} Waiver Fees: Date of Payment: ~C>"~- ~eceipt Number: ROBERT C. COWAN, P.E. September 13, 2001 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 SEWER&WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL fNSPECTION & FLOWTEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCI'URAL & MECHANICAL INSPECTIONS ONSITE WA~TEWATER DISPC~AL SYSTEM DESIGN MUNICIPALITY OF ANCHORAGE Development Services Department P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 7A, Block 1, Pennington Park S/D It is requested that you issue a permit to install a well and a septic system to serve the proposed three bedroom dwelling on the referenced property. A test hole was excavated and a percolation test was performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation 8/29/01, water was not found. After monitoring, no ground water was found. We do not anticipate any adverse"effects on neighboring wells, septic systems, reserve areas or drainage patterns by the installation of the proposed septic system. The construction of this system will not prevent any future development on any of the adjacent properties. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/bjj Enclosure 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 SCALE ~, r~ ~1>~ ~''''~ II ~ 21> "'r- DESIGN 0 ,] 10' UTILITY EASEMENT PROPOSED 4 BEDROOM HOUSE ALT. SITE SITE-PLAN 0 qbbb © m m z oo 0 L I Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bmgaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Soils Log - Percolation Test Performed For: Legal Description: 5- 6- 7- 8- 9- 11- 12- 13- 14- 16- 18- 19- 20- COMMENTS Slope ~"~ ~ '~ .,,, ........ ~Township, Range, Section: Site Plan WAS GROUND WATER ENCOUNTERED? ~ O S IF YES, AT WHAT DEPTH? ~ L O Depth to Water After p Monitoring? )"~/& )/ E Reading I Date Gross Time Net TimeDepth to Water Net Drop ..~. ~..-, ..- ~o ~o ,,,.,.~,-'/~" ~-/~" ~,~ ~ ¢ ~"~ o ~ ~ ~/~" ~/~" PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ / AFT AND ~ / .~-~ FT P E R F O R M E D I N AC C~ I~[~.~'q~ ~V ~ ~'L ~'.,~,~.~.~.E' -~'D'~ U ~AL/~ 01 [~ E L'l N E S N EFFECT ON THIS DATE DATE' ,-agre ~lver, A[asKa-Y~'~/~ ' ROBERT C, COWAN, P,E. HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER&WATER INSPECTION ENGfNEERING STUDIES ANO REPOR?S WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECH.aNICAL INSPECTIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Lot 7A, Block 1, Pennington Park Subdivision September 13, 2001 GENERAL: The scope of this project includes the installation of a 1000 gallon minimum H.D.P.E. septic tank, a lift station, and a pressurized drainfield to serve the proposed three bedroom residence located on the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Mtmicipal Wastewater Disposal Regulations. The contractor shall b'~ responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 17034 NORTH EAGLE RIVER LOOP ° SUITE 204 ° EAGLE RIVER, ALASKA 99577 Page 2 Lot 7A, Block 1, Pennington Park Subdivision September 13, 2001 o All standpipes on the septic tank shall extend a minimum of 12 inches above fmal grade. Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (riffled-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. Page 3 Lot ?A, Block t, Pennington Park Subdivision September t 3, 200t MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipal approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). o A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill° All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. o When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements, which ever requirement applies. INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: Page 4 Lot 7A, Block I, Pennington Park Subdivision September 13, 200t The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre- construction meeting will take place on-site. The inspecfmg engineer will not coordinate, direct or control in any way the contractors activities° The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project° CONTRACTOR / INSTALLER ® Municipality of Anchorage r .a On -Site Water and Wastewater Program (907) 343-7904 5 f E T Y Certificate of On -Site Systems Approval Parcel I.D. 020-181-56 1. GENERAL INFORMATION: Expiration Date: q .-Z -2- Complete legal description PENNINGTON PARK; BLOCK 1 LOT 7A Location (site address) 17250 Mariiane Street `Anchorage 99516 Current Property owner(s) Justin Doll Day phone 748-5746 Mailing address Real Estate Agent 2. TYPE OF DWELLING: © Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class_Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver/Variance request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ S50 Date of Payment 5 a 90 1� 1 Receipt Number 0(0 3 COSA # 0-`5G 21 I ZI? 7 Waiver Fee $ Date of Payment Receipt Number 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. Name of Firm: Garness Engineering Group,'Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507 / Engineer's Printed Name: Jeffrey A. Garness Date. Vii'.)%/ Z` In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and Q0000p�� industry practices. The reported results describe the condition of the system/s on the date/s of the Separation distances to identifiable features. Hidden defects or ` G of A evaluation. were measured readily encroachments may exist that were not identified during the evaluation. The operational life of all wells C� j // and septic systems depend upon a variety of variables, including but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and "'""" "' """" "" are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well GEG makes no representation whether an alternative well or septic system �..• • • • • • . • • • • • • '.J fry . Gorn s.: ��A or septic system. can be installed on the property in the event either of the current systems fail to perform adequately in �, v�9. '. C)— 79 �c the future. The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person orE 'nor ea party (including subsequent property purchasers) is not authorized, will it confer any legal rightsio�� whatsoever. #AECC884 D�IGNATURE System #1 Approved for � bedrooms System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms, with the foll Q`\1Y tOF AAjC6,/,i i ON-SITEm WATER AND _ lec Sta&n? WATER z PROGRAM 11 1-11 By:V%11 Original Certificate Date: ,," Zr 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 Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other LO COSA Checklist Legal Description: PENNINGTON PARK; BLOCK 1, LOT 7A If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA 0 Well log is filed with Onsite (or attached) Date drilled 6/20/02 Total depth 207 ft Cased to 100 ft 0 Sanitary seal is functioning correctly ® Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA 5/13/21 Static water level at beginning of test 56.4 ft. Comments B. TANK DATA Age of tank(s) 19 years Tank type/material SIMSTEEI Measured operating fluid level in septic tank 50" ❑ Standpipes/foundation cleanout per record drawing Date of pumping 4/21/21 D. ABSORPTION FIELD DATA Parcel ID: 020-181-56 Structure served by this system Well production at time of test 4.3+ gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes 0 No Al Coliform bacteria is Negative Nitrate mg/L 0 Nitrate less than MRL (ND) Arsenic ug/L W Arsenic less than MRL (ND) Collected by GEG, LTD. Date of Sample 5/13/21 C. LIFT STATION W Required maintenance completed Age of lift station 19 years Lift station material STEEL Comments: FCO IS LOCATED INSIDE HOME (SEE PHOTO) Which system tested (date installed) 5/24/02 Adequacy test date 5/13/21 0 ALL standpipes present per record drawing Results F_71 Pass For 3 bedrooms Total measured depth from grade 9.66 ft (max) Fluid depth prior to test 32 in Measured depth to pipe invert from grade ft (min) Water added *607 gal 0 N/A — pressurized field 46 New depth in Monitor tubes go to bottom of effective. If not, state 120 depth into effective Elapsed time min Al Code -required soil cover over field Final fluid depth 40 in System presoaked Absorption rate 450+ gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) NONE date of test) Gallons introduced N/A gallons If yes, enter date N/A Comments/Deficiencies: `TESTED EAST TRENCH ONLY- WEST TRENCH HAD 55"-60" UPON ARRIVAL 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' 0 Yes Community Sewer Manhole/Cleanout > 100' ❑✓ Yes if No ft Q Yes if No Neighboring Tank > 100' M Yes if No ft Private Sewer/Septic Line > 25'✓M Yes if No Absorption Field on Lot > 100' ❑✓ Yes if No ft Holding Tank > 100' ❑✓ Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' 0 Yes if No F,71 Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' F71 Yes if No ft 0 Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No *5+ ft Surface Water > 100' ft ft ft ft ft Q Yes if No ft Property Line > 5' 0 Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' F71 Yes if No ft ** Private Wells > 100' ❑ Yes if No _ Water Main > 10' 0 Yes if No ft Community Wells > 200' ✓❑ Yes if No _ Water Service Line > 10' Fv� 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' [Z] Yes if No ft If absorption field is under driveway comment below Property Line > 10' FV7I Yes if No ft Wells on Adjacent Lots: ** Water Main > 10' ✓Cj Yes if No ft Private Wells > 100' ❑ Yes if No Water Service Line > 10' 0 Yes , if No ft Community Wells > 200' Yes if No Surface Water > 100' P-1 Yes if No ft F. ENGINEER'S COMMENTS *MET CODE AT TIME OF INSTALL **COULD NOT PHYSICALLY CONFIRM BECAUSE WELL ON LOT 6A (TO SOUTH) IS REPORTED TO BE INSIDE THE DWELLING PER 5/24/02 INSPECTION REPORT. G. ENGINEER'S CERTIFICATION 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. n . .:.... } g /............... ....... y A. Gar ess.- COSA Checklist yellow sheet 400 Pro f essi°°°oma ME 884 ft ft ft ft NUNICIPALITY OF ANCHORAGE Development Service: Department i\ - � ` Phone: 901-3,,...-7904 ?n -Site V)ater & Was: water Section Fax: 907.0," 79.91 f Lift Station/Pump Vault Maintenance Lig Street Address `12`�Zc� pi-ono Legal Desi. _ PID _ 3_Q ank: Sludge level 7'inc les Pumping: required 4e_s ilo •Punic, basket cleanec ye� nQ •C,ontrol floats cleane: •0-aer2tion satisfactor; A!,_LM_$_Ya1Q_rM •Purnpina completed ,xyl_,�_,_,_, -Effluent filter cleaned Leo moo_ -Proper float settings confirmed �G� 04 -Dedicated electrical arra circuit ;.�L -Audible and visual alarm inside dwelling •;;larrn system operat .n isa�iamctornot satisfart� Uanhoie 1a _._ Greund water intrusic i at riser .o tank connection,g n4 ( rJLir'; iVat'�r ijr;trusic ? around pipe ef-:etratlons ves `.' •V1/eer, hole. functional' `•/<' nn 1. .._ -Manhole lid: Func=i >nal �L Insulated ;��_L2 Properly Secured 4�1 .All manufacturer regru red inspections and maintenance completed yes no -ika-1-MMOM Technician -r ti Date of maintenancey.?�_' ,24 nPaTly Date Signatu a�tl��� s����-��sr�t3�..'��tct�araglras►��src���`����s5� �-+► ��� o "�. , .. s