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Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP171321
PID Number: 051-511-17
Dwelling: ❑■ Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑■ New ❑ Upgrade
Name
PAUL DOUTHIT & SARAH HURKETT
ABSORPTION FIELD
❑
El Deep Trench Wide Trench E:1 Bed ❑ Mound
Site Address
NHN MOUNTAIN CIRCLE
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
1.2 GPD/SF
8.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
4.5 Ft.
Gravel depth beneath pipe
3.5 Ft.
Subdivision
Block Lot
Sleepy Hollow #2
2 24
Fill added above original grade
Gravel length
Township Range
Section
0.0 Ft.
41 Ft.
Gravel width
5.0
Beds: Number of Lines
Distance between lines
SEPARATION
DISTANCES
Ft.
Ft.
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
379.6 Ft2
1
n/a Ft.
Well
100'+
99.3*
NA
NA
25'+
TANK XSeptic ElS.T.E.P. [:1 Holding El Other
Manufacturer
Anchroage Tank
Capacity
1000 Gal.
Surface Water
100'+
1001+
NA
NA
Material
Number of compartments
Lot Line
51+
10'+
NA
NA
NA
Steel
2
Foundation
--
-- I
NA
NA
LIFT STATION
Manufacturer
Capacity
Remarks No foundation present
Gal.
*Waiver request attached
Alarm location
Electrical installed by
Installer
PIPE MATERIAL House to tank 3034 Tank to
drainfield 3034
Redstone Builders
Drainfield 3034 CO/MT3034
Inspector Pannone Engineering
BENCH MARK (Assumed elevation) 1008.0 ft
Inspdection vt 8/21/18
8/21/18
Location and description
2nd
3rd 8/22/18
41^ 8/22/18
Top of Well Casing
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
Date
.,.,
.... .. .......
anriope
CE 8149
Septic Syste
Approved_Z
Dat
2°
Note this approval does not include well permit require en
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"r` 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:/lwww.muni.org/onsite
1 rhartmcnt
9hakaR
On-Site Water & Wastewater System Permit
Permit Number: OSP171321 Effective Date: 10/23/2017
Work Type: WellSeptic Initial Expiration Date: 10/23/2018
Tax Code Number: 05151117000
Site Legal Address: SLEEPY HOLLOW#2 BLK 2 LT 24 G:1060
Site Mailing Address:
Owner: DOUTHIT PAUL L & Lot Size in Sq Ft: 66153
Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 3
This permit is for the construction of:
El Disposal Field Septic Tank ❑ Holding Tank ❑ Privy Q 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
AA
Received B • �.�11.0 I will _ — tA_ Date: —
Issued By: ' �. n Date: 10/2 3 D 1
MUNICIPALITY OF ANCHORAGE
"71:
Community Development DepartmentPhone: 907-343-7904
Development Services Division Fax: 907-3997:j,\
On-Site Water& Wastewater Program \\�
ON-SITE SEWERNVELL PERMIT APPLICATION c OCT 1 3
00144%
051-511-17 e
Parcell.D.
j
Property owner(s) PAUL DOUTHIT & SARAH HURKETT Day phone
Mailing address 16921 FOOTHILL AVE, EAGLE RIVER, AK 99577
Site address NHN MOUNTAIN CIR, CHUGIAK, AK 99567
Legal description (Sub'd., Block& Lot) SLEEPY HOLLOW#2 B2 L24
Legal description (Township, Range & Section)
Lot Size 66,153 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
IZ all that apply)
Absorption Field LI Initial ❑x Single Family (SF) ❑X
(w/wo ADU)
Septic Tank ❑X Upgrade ❑ Duplex (D) ❑
Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 7 z'1 Waiver Fees:
Date of Payment: lot(3 i i i Date of Payment:
Receipt Number: 0 ?-3196i Receipt Number:
Permit No. csoi x32 1 Waiver No.
Permit App_ - :: .c
DESIGN PARAMETERS \
\ /! 2
F
PRIMARY SEPTIC SYSTEM
NO. BEDROOM: 3(450 gpd) / i 4011. 7111111*
TANK SIZE: 10009 0 )---7/..--7
/ /PER �� ���
RATE: 1.1 MPI M /M 4 k AZ
SOIL RATING: 1.2 GPD/5F / �' � _
AREA RQD: 375 SF \IV
/ / '
REDUCTION FACTOR: 0.54 'A / / / �J / ��
ADJUSTED ABSORPTION AREA: 202.5 /,„7- /3 `1 ..
ISYS. TYPE: WIDE TRENCH 3.5'ED / / TRUE/NORTH P SCALE 1•- s '
MIN LENGTH: 41,0 LF ,020 , , -\\// -
N / , / /
UE' \ 7 7
41 LFx5.0'Wx3.5' E,D., 8.0' TD V / / / �'
TOTAL AREA: 205 SF , - / / / ya / ' • /
,o1sl / z. , /
W W
NATER LINE /
WE'�t RADIUS f / / G\�
. \ 7 --
,, X \ 1
—ss —ss — NEW SEPTI / / ' WELL (P)/ 1
w / . 1 1
/ INSTALL 1000G SEPTIC TANK(P)
7N V 7 � / / W/ FC BEFORE & DCO AFTER TANK /
i /
Ii / ,D,D • / 24 \
'� DRIVEWAY
/ / / 1
/ --
/ 1
/ c_, 4 /
Y y, - 59.9 1
'/ ® ti 1 \
r-t ,' / 77.6/ /
N 7 �Y ' I N
/ '�1 ( 3B R , I
7 ` _/ / SFD(P) / /
•
/ o XVI / \ / /
f 10051 dpi 0 10.0 /
---- / \
' j 00.9 INSTALL ABSORPTION FIELD P
41LFx5.0 Wx3.5 E.D.,8.0 T.D. • \
/ � W/ MIs & COs AT ENDS OF FIELD
1 / / v /
�/
-/ 79.6 /
110001 /:/ /
/
RESERVE FIELD (NIC) / M
41LFx5.0'Wx3.5'E.D.,8.0 T.O. / ' M \
W/ MTs & COs AT ENDS OF FIELD /
"� / / ABBREVIATIONS
\ TH TEST HOLE
\
1 (P) PROPOSED
I 11 / (E) EXISTING
-Gy w _-----7I'oosl7 • CO CLEAN OUT NO.
r 1 / MT MONITOR TUBE NO.
�' / Y . TYP TYPICAL
/ /
NOTES: PANNONE ENG SVC, LLC oF� Date 10/13/2017
FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 �P'.•"'
PHONE (907) 272-8218 FAX (907) 272-8211 *:� �` ••* Scale1 = 50' _
SLEEPY HOLLOW #2 B2 L24 ; •"' P.I.D. NO
SITE ADDRESS: NHN MOUNTAIN CIRCL ' ••tlaMOf1 A. Qnf1011e 'PERMIT
7
MIT NNO.0.
DRAWN JRL PAUL DOUTHIT & SARAH HURKETT CE 8149
16921 FOOTHILL AVE `'" OSP171321
�Ev:1o/23/201fr
:�'•••. •••� Sheet
SITE PLAN EAGLE RIVER, AK 99577 ''A9 1 OF 3
I '
TEST HOLE 1 SOILS LOG — PERCOLATION TEST
SLOPE EU SrTE PLAT' 2
OR TOPSOIL / DRIVEWAY
1 ....-
,.../7,• __ / / / \
LT BROWN / / /
2 SM/ML ORANGE SANDY \
SILT / r
/
3 z �ioiol \ ��
BRAWN / V /
SM/ML ORANGE SANDY 44-'
�,,
4 SILT w/COBBLES /M`/ \ / // W
5 � 11ioiol-. /
/ If / 3BR 8
6 GM/SM GRAVEL IW/ LAND OBBLES , ` / // SFD(P)/
7
TEST j /
HOLE /
8 'LT BROWN /GRAY
SM ML SANDYSILT W/ / /
9
SM/MLES / / /
10 i
/ /
/
11 \/. I� /
12 SANDY SILT W/ -. • /000]
SM COBBLES
13
WAS GROUND WATER SLOPE
14 ENCOUNTERED? N
15 TH
IF YES, AT WHAT
16 DEPTH? -NA-'
BOH
DATE PERFORMED: 010CT17 DEPTH TO WATER AFTER
MONITORING? - DRY -
DATE: 120CT2017
WATER RATE SOIL TEST RESULTS/ANALYSIS
READING DATE NET TIME LEVEL NET DROP (MPI) • PERCOLATION RATE 1.1 (mfnlinch)
READING (Hydrologic Soils Group: HSG A)
1 010CT17 5.900" • PERC HOLE DIAMETER 6"
2 2.633 MIN 11.900" 6.0" 0.44
• TEST RUN BETWEEN 5 FT AND 6 FT.
• TEST RUN FOR OVER AN HOUR, LAST
3 5.900" THREE READINGS PROVIDED.
4 4.750 MIN 11.900" 6.0" 0.79
5 5.900"
6 5.333 MIM 11.900" 6.0" 0.89
5.900"
6.500 MIN 11.900" 6.0" 1.08
5.900"
6.750 MIN 11.900" 6.0" 1.13
5.900"
6.833 MIN 11.900" 6.0" 1.14
COMMENTS:Test hole excavated by HOMEOWNER.
PERFORMED BY:Joseph Lawendowski. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE
AND MUNICIPAL GUIDLINES IN EFFECT
�ON�THE DATEOF THIS TEST.
r
NOTES: PANNONE ENG SYC, LLC '"' Date
FOR CONSTRUCTION 10/13/2017
P.O. BOX 102954 ANCHORAGE, AK 99510 �'�••'• .
PHONE (907) 272-8218 FAX (907) 272-8211 •• �1, 'y Seale
*14G� .� .•* NTS
SLEEPY HOLLOW #2 B2 L24 ; " ••tL" , P.I.D. NO
SITE ADDRESS: NHN MOUNTAIN CIRCLE os1-511 17
— --- •`�ee 'I�. b�norle PERMIT NO.
DRAWN 1 JRL PAUL DOUTHIT & SARAH HURKETT ". CE 8149 :ti:, OSP171321
16921 FOOTHILL AVE v:10/23/2_'••.
Sheet
SOILS LOGS EAGLE RIVER, AK 99577 ''A '__ 2 OF 3
Pannone Engineering Services LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail:steve@panengak.com
23 October 2017
Subject: SLEEPY HOLLOW#2 B2 L24
Septic System Install Permit Request
Design Narrative
This is a design narrative for a permit to install an initial septic system and well to be issued for this property.The
proposed system will serve a proposed three-bedroom(3BR)house.Currently the lot is undeveloped. The surrounding
lots are served by private wells. The proposed system will not be within 100'of the proposed well on the subject property
nor within 100'of any wells on the surrounding lots.
I. Soils:One test hole was performed on this lot by PES in October of 2017,and groundwater was monitored for at least
seven days.Ground water was not observed at a depth of 15.0' below the surface in the test hole monitor tube after the
7-day monitoring period. Bedrock was not encountered in the test hole. Based on the results of the percolation tests and
overall soils appearance an application rate of 1.2 gallons/day/square feet was used for a conventional system in the area
of the test hole.
2. Soil Absorption System Design.
a. See Sheet 1 of the design package.
3. Surface Water:There is no surface water within 100 feet of the proposed septic tank and drain field.The proposed
drain field will maintain at least 100 feet from all surface water.
4. Topography:The proposed system sits in the low ground of the property. The ground to the southeast of the
proposed system slopes up to the property line at 5%-10%±.The ground to the northwest of the proposed system slopes
up at 20%-25%to the road. There are no steep slopes within 50'of the proposed system.
The proposed installation will not affect the future development of the surrounding or existing lots.There are no wells
within 100 feet of the proposed septic location.
If you have any questions or concerns, please contact me at 272-8218.
Mailing: P.O. Box 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF
ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF
ON—SITE WASTEWATER DISPOSAL SYSTEMS AND AND IN ACCORDANCE WITH AMC 15.65 AND 15.55.
2. SCOPE OF WORK: INSTALL NEW 1000g SEPTIC TANK, AND SOIL ABSORPTION'SYSTEM. INSTALL WELL
3. GROUNDWATER WAS NOT ENCOUNTERED TO A DEPTH OF 16 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL
TEST HOLE. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 16 FEET BELOW
EXISTING GRADE NOTIFY THE ENGINEER IMMEDIATELY.
4. THE CONTRACTOR (BOTH WELL AND SEPTIC SYSTEM CONTRACTORS) SHALL HAVE ANY WELL LOCATION AND SEPTIC
LOCATION STAKED AND ANY LOT LINE AND WELL RADIUS SHOWN ON THE PLAN WITHIN 30 FEET OF THE PROPOSED
SYSTEM STAKED BY A REGISTERED LAND SURVEYOR BEFORE STARTING THE WORK.
5. THE CONTRACTOR IS RESPONSIBLE FOR ALL R.O.W. AND OTHER REQUIRED PERMITS, OTHER THAN THE ATTACHED.
6. THE CONTRACTOR SHALL CALL FOR LOCATING OF ALL BURIED UTILITIES.
7. THE CONTRACTOR SHALL PROVIDE 24 HOUR NOTICE TO THE ENGINEER PRIOR TO START OF WORK. ALL SURVEYING
AND LOCATES SHALL BE IN PLACE PRIOR TO NOTIFYING THE ENGINEER.
8. THE CONTRACTOR SHALL NOTIFY THE ENGINEER OF ANY DISCREPANCY BETWEEN THE APPROVED DRAWINGS AND SITE
CONDITIONS/LIMITATIONS POTENTIALLY CAUSING THE NEED TO MODIFY THE DESIGN.
9. AT THE COMPLETION OF THE WORK, THE CONTRACTOR SHALL SUBMIT RED—LINE AS—BUILT DRAWINGS TO THE
ENGINEER. THE RED—LINES SHALL INCLUDE PIPE LENGTHS, ORIGINAL GROUND ELEVATIONS, PIPE ELEVATIONS, AND
TANK ELEVATIONS.
10. THE CONTRACTOR SHALL PROVIDE PHOTOGRAPHS OF THE SYSTEM INSTALLATION TO INCLUDE BOTTOM OF EXCAVATION,
TOP OF PIPE WITH CLEAN—OUTS AND MONITOR TUBES INSTALLED, INSTALLED TANK AND FINAL GRADING.
11. THE CONTRACTOR PROVIDED DATA (UPON WHICH THIS RECORD DRAWING IS BASED) APPEARS TO REPRESENT THE
PROJECT AS CONSTRUCTED. THIS DATA IN CONJUNCTION WITH THE PERIODIC FIELD OBSERVATIONS BY THE ENGINEER
(OR HIS DESIGNEE) AS REQUIRED BY AMC 15.65 DOES NOT GUARANTEE THAT THERE ARE NO HIDDEN DEFECTS BY THE
CONTRACTOR.
12. THE CONTRACTOR SHALL SIGN THE FOLLOWING:
I CERTIFY THAT ALL WORK WAS PERFORMED IN ACCORDANCE WITH THE APPEND PERMIT, AND ANY AND ALL CHANGE
ORDERS, AND THAT THE AS—BUILT REDLINES ARE TRUE AND ACCURATE REPRESENTATION OF THE PROJECT AS
CONSTRUCTED.
CONTRACTOR:
BY: . TITLE:
DATE:
NOTES: PANNONE ENG SVC, LLC A . �,,A�l """ Dote
FOR CONSTRUCTION _ P.O. BOX 102954 ANCHORAGE, AK 99510 �'(�.••• 10/13/2017
PHONE (907) 272-8218 FAX (907) 272-8211 . �_ Scole
*x'49j t .* NTS
SLEEPY HOLLOW #2 B2 L24 Art:- P.I.D. NO
SITE ADDRESS: NHN MOUNTAIN CIRCLE �� �v 0RMIT N —17
..��even�. �anno�e PERMIT N0.
DRAWN JRL PAUL DOUTHIT & SARAH HURKETT . •. CE 8149
16921 FOOTHILL AVE ;.10/23/201w' OSP171321
DESIGN NOTES EAGLE RIVER, AK 99577 Sheet
` 3 OF 3
Pannone Engineering Services LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail: steve@panengak.com
Mailing: P.O. Box 1807 Palmer, AK 99645
Telephone: (907) 745 8200 FAX: (907) 745 8201
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road
P. O. Box 196650
Anchorage, Alaska 99519
Subject: Sleepy Hollow #2 B2 L24
Drain Field to well on lot Waiver.
Ladies and Gentlemen:
We are requesting a separation distance waiver for an existing drain field to the existing well on the subject lot. The
existing well heads lie at a higher elevation than the drain field so it is not likely that effluent would travel toward the
well head. The distance from the existing well to drain field is 99.3 feet.
Sleepy Hollow #2 B2 L24 Drain Field to Well:
Distance from sewer system bottom to groundwater 8.18
Soil sorption below sewage system 3.27
Soil permeability below the system 1.47
Water table gradient 2.00
Horizontal separation 2.96
Total Points 17.88
The sum of the above values could equate to the following conditions: “Almost sure to be free from any form of
contamination from household sewage”. In my opinion, this waiver request meets the above criteria for approval and
likely does not constitute a risk to health. I hope the above information will assist you in determining that the waiver
should be granted.
If you have any questions or concerns, please contact me at 907 745 8200.
Sincerely,
Steven R. Pannone, P.E., F. ASCE
Owner/Civil Engineer
June 7, 2023
Municipality of Anchorage S
__. _% Ur. �rn•tment
P.O. Box 196650 e 4700 Elmore Road
Anchorage, Alaska 99519-6650 s (907) 343-7904 ® Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Division
On -Site Water and Wastewater Program
* * * * VARIANCE/WAIVER REVIEW * * * *
Waiver#: OSV231031 COSA#:OSC231189 Permit#:OSP171321
PID#: 051-511-17
Legal Description: SLEEPY HOLLOW #2 BLK 2 LT 24
Engineer: Pannone Engineering Services
Your request for a waiver of the required 100 feet horizontal separation from the absorption field
to the property line has been approved. The approved separation distance is 99.0 feet.
This waiver approval applies to the existing absorption field only. Any future upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
............................................... ■ ............................. ■ 1
Waiver is Granted: X Waiver is not Granted:
Date: Approved by: 9,40-10,Gj�
Name of Reviewer
**** VARIAN C E/WAIVER REVIEW ****
OWNER OF LAND: Paul Douthit
ADDRESS:
LEGAL DESCRIPTION Sleepy Hollow #2 Block 2 Lot 24
DATE: 4-26-18
PERMIT OSP171321 DATE OF ISSUE: 10/23/17
NUMBER:
TAX IDENTIFICATION 05151117000
NUMBER
Is well located at approved permit location: ®Yes ❑No
Method of Drilling: ®air rotary ❑cable tool
Depth of Well: 540'
Casing Type: Steel Wall thickness .250 inches
Diameter: 6 inches, depth 4.18 feet
Liner type
Static Water Level: 424 feet
Recovery Rate 4 ® gpm ❑ gph
Method of Testing Air
Well Intake Opening Type: ❑ open end ®open hole
❑ Screened Start feet Stopped
El Perforations Start feet Stopped
Grout Type: Bentonite Volume: 50 lbs
Depth: from 2 feet, to 0 feet
Well Disinfected Upon Completion: ®yes ❑ no
Method of Disinfection: Chlorine 50 PPM
Comments:
Bore Hole Data
Depth
From
To
0
2
Casing Stickup
2
4
Fill
4
6
Overburden
6
45
Silty Sand & Gravel
45
47
Sand
47
99
Silty Sand & Gravel w/ Boulders
99
108
Sand & Silt
108
159
Silty Sand & Gravel w/ Cobbles
159
165
Wet Sand & Gravel
165
210
Hardpan
210
225
Damp Tight Sand & Gravel
225
230
Hardpan
230
240
Wet Sand & Gravel
240
260
Hardpan
260
265
Loose Damp Sand & Gravel
265
305
Clay & Silt w/ Gravel
305
410
Hardpan w/ Boulders
410
425
Bedrock Gray
425
484
Bedrock Green Hard
484
498
Bedrock Yellow Fractures (45 GPH)
498
529
Bedrock Green w/ Quartz
529
535
Bedrock Yellow (3.25 GPM)
535
540
Bedrock Gray
Drillers Name: Cole Sullivan
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority.
Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation.
Matsu Borough: Department of Environmental Conservation.
Well Drilling Permit Number: SW OSP171321 Date of Issue 10-23-17
Parcel Identification Number: 05151117000
Legal Description
Sleepy Hollow #2 Block 2 Lot 24
Pump Installation Date: 6-20-19
Pump Intake Depth Below Top of Well Casing:
Pump manufacturer's Name: Grundfos
Pump Model: 5SQE15-450
Pump Size: 1.5
Pitless Adapter Burial Depth: 10
Pitless Adapter Installer: Redstone
Disinfected Upon Completion? ® yes
Method of Disinfection: Chlorine 50 PPM
Comments: Pitless Manufacturer: Martinson
11 Pump Installers Name: Sullivan Water Wells
Property Owner Name & Address
Paul Douthit
510 feet
E
feet
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
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. 051-511-17-000
Expiration Date: 9/15/2023
Legal description SLEEPY HOLLOW #2 BLK 2 LT 24
Site address 23838 MOUNTAIN CIR Chugiak AK 99567
Current property owner(s) DOUTHIT PAUL L &HURKETT SARAH J
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
Original Certificate Date: 6/15/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval June 2022
MUNICIPALITY OF ANCHORAGE
Development Services Department p P `,l Phone: 907-343-7904
On -Site Water & Wastewater Section r i „Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 05151117
Complete legal description Sleepy Hollow #2 B2 L24
Location (site address) NHN Mountain Circle
Current property owner(s) Paul DOuthit Day phone
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: 0 Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: 0 Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 5 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑ Deep Trench FE -1 Wide Trench ❑ Seepage Pit
Waiver request for: well to septic waiver
Expedited review requested: ❑
Distance: 99.3
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ Sp Waiver Fee $
Date of Payment Date of Payment
COSA # 0 S C Waiver # 05`V2_7_2)1031
COSA Application—June 2022
COSA Checklist_June 2022
COSA Checklist
Legal Description: Parcel ID:
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
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.
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
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank
Date of pumping
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed)
ALL standpipes present per record drawing
Total measured depth from grade ft (max)
Measured depth to pipe invert from grade ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes go to bottom of effective.
If not, state depth into effective
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Adequacy test date
Results Pass
Fluid depth prior to test in
Water added gal
New fluid depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) in
Effective depth used in
Effective depth remaining in
Comments/Deficiencies:
COSA Checklist_June 2022
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F.ENGINEER’S COMMENTS
G.CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm Phone
Engineer’s Printed Name Date