HomeMy WebLinkAboutPOLLOCK HOMESTEAD BLK A LT 6Onsite File Pollock Homestead Block A Lot 6 #017-112-53 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP 191507 PID Number: 017-112-53 Dwelling: 9 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑■ New ❑ Upgrade Name TARAS ILNITSKIY ABSORPTION FIELD ❑ Deep Trench ■❑ Wide Trench ❑ Bed ❑ Mound Site Address 15339 Pollock Dr, Anch, AK ❑ Other Phone Number of Bedrooms Soil Rating depth from original grade 4 0.8 GPD/SF JTotal 5.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 2.0 Ft. Gravel depth beneath pipe 3.0 Ft. S division �[ �,,q Block Lot 7-0 T I C, `�'"" ""'� Pr / Fill added above original grade 2+ Ft. Gravel length 89 Ft. _ Township Range Section Gravel width 5.0 Ft. Beds: Number of Lines 0 Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trenches From Tank Field Tank Line 750+ FF 1 Ft. Well 1001+ 1001+ 50'+ TANK X Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity GREER TANK 1250 Gal. Surface Water 1001+ 100'+ Material Number of compartments Lot Line 10'+ 10'+ NA PLASTIC 2 Foundation 10'+ 10' i LIFT STATION Manufacturer Capacity 1 Remarks Gal. Alarm location Electrical installed by Installer PIPE MATERIAL House to tank 3034Tank to 3034 drainfield MIKE N ANDERSON, P.E. Drainfield 3034 CO/MT 3034 Inspector MIKE N ANDERSON, P.E. BENCH MARK (Assumed elevation) 104.8 ft Inspdection 1s` 11-29-19 n 11-29-19 Location and description 2 GARAGE SLAB 3rd 4,h ON-SITE WATER AND WASTEWATER SECTION APPROVAL En ineer's Stamp Conditional Approval: Date •�'°�°° •o � ��.•' �''���-,� °•'off ��: �+ A Q T Iii 4: , p p p p p. p p.. p p p E 1 o p.° p p. p. p b b 0 �•• MICHAEL N. ANDLR5CN°,•`� ¢ •, CE- 469 �..� Septic System pp DateZ 0 it •��� � 0P p , Note: this approval does not include well permit requirements. ���, kkp��®®��,4 (RCv Va/VL/ 16) Permit No. OSP191507 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: POLLOCK HOMESTEAD, BLK A, LOT 6 MARK A B C� C01 110', 15 CO2 24 6 TC01 2010 TCO2 16 14' 1 CO3 16 0 C04 17 1MT1 ( i C05 35 8 I 62 \ ( C06 62 43 I / 1 WELL V i \ /\\ X X DWELL \ DRI\ CO \ GALLO \ \v / \ \ /CE)3 / 1 / H�,, X X I PID No.: 017-112-53 I' \ I f BENPH, GARAGE/ SLAB j NAY PLASTIC TANK // \ I � � / i i I WELL \ ASBUILT SCA! -E- - 5fl' cot CO2TC01 c0 C04 cos (� C05 ®®®`®®®% N l C. q� ®®®® FINISH CRAOE ® %. /� •.•� ®® INSOtAiiON ® "J • /' FILTER FABRIC .0 ORO ®M ' `,(`/\//[/`V7 • ®® — s Y 49TH 0 9 1,150 n m. •••••• GALLON 1 985 98 OM •• ® P(ASPC 0 TANK .. ....... ..... . .. .. . . ••• .. 94 0. •;MICHAEL N. ANDERSON -® ®®-, No. CE 9469 .�� 2-28-19 SEPTIC SECTION 86 ®®m®44Ec�c�\p®®® N.T.S. WATER 084, NGV 2 19 I TH�2 \ L\, \ j 1 1 ! / / / 1 WELL V i \ /\\ X X DWELL \ DRI\ CO \ GALLO \ \v / \ \ /CE)3 / 1 / H�,, X X I PID No.: 017-112-53 I' \ I f BENPH, GARAGE/ SLAB j NAY PLASTIC TANK // \ I � � / i i I WELL \ ASBUILT SCA! -E- - 5fl' cot CO2TC01 c0 C04 cos (� C05 ®®®`®®®% N l C. q� ®®®® FINISH CRAOE ® %. /� •.•� ®® INSOtAiiON ® "J • /' FILTER FABRIC .0 ORO ®M ' `,(`/\//[/`V7 • ®® — s Y 49TH 0 9 1,150 n m. •••••• GALLON 1 985 98 OM •• ® P(ASPC 0 TANK .. ....... ..... . .. .. . . ••• .. 94 0. •;MICHAEL N. ANDERSON -® ®®-, No. CE 9469 .�� 2-28-19 SEPTIC SECTION 86 ®®m®44Ec�c�\p®®® N.T.S. WATER 084, NGV 2 19 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 Water & Wastewater System Permit Permit Number: OSP191507 Work Type: WellSeptic Renewal Tax Code Number: 01711253000 Site Legal Address: POLLOCK HOMESTEAD BLK A LT 6 G:3137 Site Mailing Address: 15339 POLLOCK DR, Anchorage Owner: ILNITSKIY TARAS & IRINA Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING This permit is for the construction of: Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: ►giro/iy [.,k s0H �inerlr S C� U Department 11/14/2019 11/1312020 21361 Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy Q Private Well ❑ Water Storage 4 All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: An additional percolation test shall be completed prior to construction of the drainfield, so > > that entire proposed primary and alternate drainfields are within the 30 ft radius of a percolation test. If results require a design change, construction shall stop pending On-site review and approval of a change order. Please submit results with the inspection report. Received By: Ak Issued By: Date: 1 Date: 1 1 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 017-112-53 Property owner(s) Taras llnitskiy Day phone Mailing address 6421 Andover Circle, Anchorage, AK 99516 Site address 15339 Pollock Dr, Anchorage, AK Legal description (Sub'd., Block & Lot) Pollock Homestead Block A Lot 6 Legal description (Township, Range & Section) Lot Size 21,361 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field 0 Initial ❑ Single Family (SF) El AD U) Septic Tank El Upgrade El(w/wo Duplex (D) ElHolding Tank ElRenewal 0 Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well 0 Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: `1 i 1 Receipt Number: _t I 1 MQ (Uux— Permit No. o sp 1 °115 O I Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc MUNICIPALITY OF ANCHORAGE menr On-Site Water&Wastewater Program \0 p,, 'ab" , PO Box 196650 4700 Elmore Road ` Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 r http://www.muni.org/onsite �.. ` cpartment �hc,,ORpGE On-Site Water & Wastewater System Permit Permit Number: OSP181359 Effective Date: 10/10/2018 Work Type: WellSeptic Initial Expiration Date: 10/10/2019 Tax Code Number: 01711253000 Site Legal Address: POLLOCK HOMESTEAD BLK A LT 6 G:3137 Site Mailing Address: Owner: SIMON MARION Z TRUSTEE OF Lot Size in Sq Ft: 21361 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 4 This permit is for the construction of: El Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy 0 Private Well 0 Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: An additional percolation test shall be completed prior to construction of the drainfield, so that entire proposed primary and alternate drainfields are within the 30 ft radius of a percolation test. If results require a design change, construction shall stop pending On-site review and approval of a change order. Please submit results with the inspection report. Received By: M.44 Date: ! S e/ Issued By: lCkt ,"_.A Cllltlt- Date: 10 To 16 MUNICIPALITY OF ANCHORAG ,, Development Services Department • j Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 017-112-53 Property owner(s) TARAS ILNITSKY Day phone Mailing address Site address Legal description (Sub'd., Block & Lot) POLLOCK HOMESTEAD BLK A LT 6 Legal description (Township, Range & Section) Lot Size 21,361 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field 0 Initial ❑ Single Family (SF) ❑ (w/wo ADU) Septic Tank Upgrade ❑ Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multi• - !we ;- ❑ Privy ❑ ti _nd/or D Private Well ® RUSH Water Storage ❑ a OCT U 9 [Ulii THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: - .'. I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. MA-4 (Signature of property owner or authorized agent) Permit/Rush Fees: has` .yo Waiver Fees: Date of Payment: /0 /q/117 Date of Payment: Receipt Number: /NA.? t. Receipt Number: Permit No. OSP/11359 Waiver No. G:1Development Services\Building SafetylOn Site Water and Wastewater\Forms\Client Forms\Permit Application.doc G� A Nov. 21 , 2019 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: Well and Septic Pen -nit plus lot line waiver CHANGE ORDER Legal: POLLOCK HOMESTEAD BLK A LT 6 To Whom it may concern: This is a request for a change order on the above septic permit for the referenced lot. Nothing has changed except the well has been installed and shown correctly on the site plan and the new test hole showed water at 11 feet. The perc rate was 7.5 minutes per inch which matches test hole #1. This higher water table caused the design to be altered to a 5 -wide w/ 3 feet of effective depth. Per the On-site code the high water reading was raised to 10 feet which allowed the bottom of the system to be installed no more than 6 feet. We have designed the system to be no deeper than 5 feet. For the secondary system a note has been added that the original field will be rebuilt which the best option. The surrounding properties will not be impacted by this new well and septic permit. Please call me if you have any questions. Sincerely `ly� Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 Nov. 11 , 2019 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: Well and Septic Permit plus lot line waiver PERMIT RENEWAL Legal: POLLOCK HOMESTEAD BLK A LT 6 d l'-� - To Whom it may concern: 12,-53 This is a request for a septic permit renewal on the above referenced lot. Nothing has changed except the well has been installed and shown correctly on the site plan and a new plastic tank has been referenced per the MOA On -Site code changes. The surrounding properties will not be impacted by this new well and septic pen -nit. Please call me if you have any questions. Sincerely P&4 - Michael & - Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 asP IaIso"i- tt[r31(°+ 0- Uo06 Oct. 9,2018 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: Well and Septic Permit plus lot line waiver Legal: POLLOCK HOMESTEAD BLK A LT 6 To Whom it may concern: This is a request for a well and septic permit on the above referenced lot. A new test hole was excavated and found silty gravels(GM)and no water after the 7 day monitoring period. The perc rate was 6 minutes per inch. The lot slopes 5to 10 percent toward the southwest corner of the lot,see the site plan, but the area at the septic is a slight depression or flat. A simple trench has been designed and a secondary test hole will be done prior to the installation of the system due to the length of the new system. The surrounding properties will not be impacted by this new well and septic permit. Please call me if you have any questions. Sincerely,/( Michael N. Anderson, P.E. 4661 Natrona Anch, Ak 99516 Ph 727-8864 CO 1 DESIGN CRITERIA: MOUND OVER (TH#1) (TH#2) o GRADE 4 BDRM X 150 = 600 GPD 0.5 ORG FILL SOILS = 600/0.8 = 750 GPD FILTER FABRIC 750 GA/5 * 0.58 = 87' GM 2.0 -2.0 4.0"0 PIPE (1) TRENCH GM -5.0 SEWER ROCK 5.0' DEEP I 5.01 3.0' EFFECTIVE 5.0' WIDE 87' LONG 18 14 NO WATER OCT 2018 WATER @ 11NOV 2019 SEPTIC FIELD SECTION \\ II \\ II II 0 0 I I _-- ==_I F---_,= I I I PROP , 1 1 / /� �� I \•� ERTY LINE ui > I I PROPOSED HOUSE ( T _\ C, 3:I PROPOSED01 m I I DRAINAGE FIELD II o — — w – \� RABBIT/ �ZC, EEKFtOAD ` \\ EXISTING 100 WELL RADIUS Septic Design Prepared for TARAS ILNITSKY POLLCOK HOMESTEAD, BLOCK A, LOT 6 Anchorage, Alaska Michael N. Anderson, P.E. DATE: 4601 NATRONA AVE DRAWN: ANCHORAGE, ALASKA 99516 (907) 727-8864 / FAX: (907) 345-1391 SCALE: DF 44 10 �. •�♦ AV 49��THf �� :,r ............................................ . 11/8/2019 / ".MICHAEL N. ANDERSON.- Ar ♦♦♦♦%'•. No. E 9469 AV DJR V=200' ♦♦♦�s • SSS ��� SE41C / POLLOCK HOMESTEAD BLOCK A, LOT 2 SECONDARY SYSTEM TO BE REMOVE AND REPLACE PRIMARY \ \ \ POLLOCK HOMESTEAD \ I BLOCK A, LOT 1 \ 1 11 \ 1 i 1 PROPOSE HOUSE i 'r bFz o tt \ \\ DC f 1� i PROPERTY LINE 4-5% Al li i i\ { i `\ POLLOCK HOMESTEAD \ BLOCK B, LOT 10 i \ � t i 1\ 1 i S PTIC POL CK HOMESTEAD i OCK B,'t OT 11 I EPTIC EXISTING WELL W / 100' RADIUS / PROPERTY LINE / 1 1 4-5% I I WELL — PROPOSED 1250 GALLON PLASTIC SEPTIC TANK W/ 20" RISFR 2' CONTOURS \\ f \.r -RABBIT GREEK ROAD- Lam* Septic Design Prepared for TARAS ILNITSKY POLLCOK HOMESTEAD, BLOCK A, LOT 6 Anchorage, Alaska Michael N. Anderson, P.E. DATE: 11/8/2019 4601 NATRONA AVE DRAWN: DJR ANCHORAGE, ALASKA 99516 (907) 727-8864 / FAX: (907) 345-1391 SCALE: 1 "=50' SEPTIC 1 I I I / 1 I / 1 i I / POLLOCK HOMESTEAD } BLOCK A, LOT 5 1 /z i \ 1 i 1 PROPOSE HOUSE i 'r bFz o tt \ \\ DC f 1� i PROPERTY LINE 4-5% Al li i i\ { i `\ POLLOCK HOMESTEAD \ BLOCK B, LOT 10 i \ � t i 1\ 1 i S PTIC POL CK HOMESTEAD i OCK B,'t OT 11 I EPTIC EXISTING WELL W / 100' RADIUS / PROPERTY LINE / 1 1 4-5% I I WELL — PROPOSED 1250 GALLON PLASTIC SEPTIC TANK W/ 20" RISFR 2' CONTOURS \\ f \.r -RABBIT GREEK ROAD- Lam* Septic Design Prepared for TARAS ILNITSKY POLLCOK HOMESTEAD, BLOCK A, LOT 6 Anchorage, Alaska Michael N. Anderson, P.E. DATE: 11/8/2019 4601 NATRONA AVE DRAWN: DJR ANCHORAGE, ALASKA 99516 (907) 727-8864 / FAX: (907) 345-1391 SCALE: 1 "=50' Municipality of Anchorage Development Services Department On -Site Water and Wastewater Section 4700 Elmore St. P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Soils Log - Percolation Test ;ee 000ee oo °00000 00000 eoo r' ? MICHAEL N. ANDEI:SON CE - 9469 fd �� (A f1 O " • � �I� .rte Performed For: T` Uy 4 lz Date Performed: Legal Description: Pp/ 1uZ k'V W 41 CA' A Township, Range, Section: _ Slope ^ir + (O 3- 4- 5- 6- 7- 8- 9- 10- 11- 12- 13- 14, 15- 16- 17- 18- 19- 20 - COMMENTS g/ / //( WAS GROUND WATER Date Gross Time ENCOUNTERED? y Net Drop it .N r s IF YES, AT WHAT DEPTH? (3 , L Depth to Water After 0 P Monitoring? � E Date: ZZ -11 Ill Site Plan Reading Date Gross Time Net Time Depth to Water Net Drop it .N r /dam,'1 '( / s PERCOLATION RATE �t (minutes/inch) PERC HOLE DIAMETER �P TEST RUN BETWEEN FT AND 7_FT PERFORMED BY: L"_m 4 L I CERTIFY THAT THIS TEST WII PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: -L Municipality of Anchorage .\(c(IN � �NkL) Development Services Department• 4•P••' .;-i•;r1-t On-Site Water and Wastewater Section ..'?.• •e. �,/ (40 c-belie 4700 Elmore St. •,�9 Y N /, P.O. Box 196650 Anchorage,AK 99519-6650 f" www.muni.orq/onsite / i'l• ' r, (907)343-7904 �• •• \�_ .v,„,',..MICHAEL N. ANDLRSON..,� r �P ,• CE-9469 Soils Log - Percolation Test �I/6, • '•�� Performed For: Toro h t {',i(tiDate Perform`d i `\��\ /� g p pi S . 4 Township,Range,Section: Legal Description: Pal v?� �Vr L. p, g 12 A Lv(- (I Slope Site Plan rN4f4 / Depth (Feet) 0 1- 2- �� ‘7'e- ---'v 3- �'� 17/ 4 C ci aPi 4- 5- C.-77s/1 6- 7- 8- WAS GROUND WATER 9- 7- ENCOUNTERED? �'�� s u 10 �/ IF YES,AT WHAT DEPTH? L Depth to Water After /� 11 U.1/ Monitoring? Oil t1 E 12- L 1--\i 1 Date• r 13- /07/0 ,v P vie Mhj 14- Reading Date Gross Time Net Time Depth to Water Net Drop 15- /c/-04 /0 nil o rr�(p 16- �/ /r ( hAo 17- G /� ( ti(o 18---- ( )Ha ' 60 if / '`ry n 1.1 tt 19- �i G (o 20- (0 1 'A, PERCOLATION RATE (Aft (minuiestoch) PERC HOLE DIAMETER 1.0 TEST RUN BETWEEN 7i• FT AND 3 FT COMMENTS PERFORMED BY: fit.-('Qi,/-, I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ' .0 k N 89'58'25" E 139.00 ��525 •WELL r r -cm 131>- r op �._.. • N N 25.0 g 25.20 S . n3- '-*rte- '�-�5.o0r 9.00%1ci 6 r4 I W nt hi cr) - > W ° CO I > oo - M ` I ' w _ Zin �.00 - t O ei " - 0SIO +1 WE"A in 13.00 /f • 1.0 V aW dq wo a 1'0 \,,,Z W Q s OW 4.1 zOa 10.88 CD / ›. H II O o -t4 Cr O a cnA z z _1 E-+ —I 00 mos/ SEPTIC O k ---.‘,....... 0- 25 N 86'41 21 E 139.23 Nt>� - CD ci un 0 Q u) CREEDr _RDAD RABBIT _ _ Bobby F. Burnett GRAPHIC SCALE: 1 Inch = 30 Feet 2941 arriage Drive Anchorage, Alaska 99507 I (907) 350-5541 15 0 15 30 60 ��� ,1k Date Scale Legal Description �" OF \ 10/4/2018 1" = 30' Lot 6 BLOCK A r � . • 4,..s- Grid /cS . ' •.� SW 3137 PLOT PLAN POLLOCK HOMESTEAD SUBDIVISION *.. . %\ * ; Drawn by Field Book PLAT # 69-76 BFB 411111111112,- I hereby certify that the property described hereon has been surveyed BOBBY / by me, or at my direction, and that the improvements situated thereon F.F. BUBU RNET] are within the property lines and do not overlap or encroach on the property lying adjacent thereto unless otherwise shown. That no 4 A, _q'.l c .. ,ems Al improvements on the property lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission ,` FS ' lines or other easements on said property except as shown. \ SSIONAL``_-411p. 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 1. D. 017-112-53 Expiration Date: 3-31 _ ZQ Z CD 1. GENERAL INFORMATION Complete legal description POLLOCK HOMESTEAD BLK A LT 6 Location (site address) 15339 Pollock Dr, Anch, AK Current property owner(s) Mailing address TARAS I LN ITSKIY Day phone 6421 ANDOVER CIR, ANCH AK Real estate agent Day phone 2. TYPE OF DWELLING: 3 G 6 7 F, 0 Single Family (w/wo ADU) ❑ Duplex Q� ❑ Multiple Dwellings (Single Family and/or Duplex) 64 , 1Q19 3. NUMBER OF BEDROOMS: 4 I �a E 8 Eti 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER � AL: Private Well El Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. Date: COSA Fee $ Iao Waiver Fee $ Date of Payment 1213110 Date of Payment Receipt Number 4t 11106' Receipt Number COSA # o�nC. jQ j(012 Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE ANCH AK Engineer's Printed Name MIKE N ANDERSON, P.E. Date 12-28-19 ' G `1, P 6. DSD SIGNATURE os .`t°eA9T-1 —� System #1 Approved for 4 bedrooms ' " ° ° " ° ° ` ` ° e ° ° ' ° �eO .oee°eao°..00a eoo �� System #2 Approved for bedrooms ,0° MICHAEL N. AI<Cf RSCtJ Disapproved. CE -9 Conditional approval for bedrooms, with the following stipulakeksiipe �G�PALIT�ox , ®s o'V i t_x) F 0. By: 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 COSA Checklist Legal Description: POLLOCK HOMESTEAD BLK A LT 6 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 10/17"6 Total depth 400 ft Cased to 64 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 24+ in. Date of flow test for COSA NEW Static water level at beginning of test 52 ft. Comments B. TANK DATA Age of tank(s) NEW years Tank type/material PLASTIC Measured operating fluid level in septic tank NEW ❑ Standpipes/foundation cleanout per record drawing Date of pumping NEW D. ABSORPTION FIELD DATA NEW SYSTEM Which system tested (date installed) 11/16119 ❑ ALL standpipes present per record drawing Total measured depth from grade 7.0 ft (max) Measured depth to pipe invert from grade 4.0 ft (min) ❑ N/A — pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Code -required soil cover over field ❑ System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 017-112-53 Structure served by this system Well production at time of test 1.1 gpm Water storage tank volume 300 gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑M Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by MNA Date of Sample 12/17/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date NEW Results ❑✓ Pass For 4 bedrooms Fluid depth prior to test NEW in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) UN 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 > 10 ' L!�J Yes Community Sewer Manhole/Cleanot� t > 100' j�Yes if No ft ©'Yes if No Neighboring Tank > 100' 2' es if No ft Private Sewer/Septic Line > 25' [EY s if No Absorption Field on Lot > 100' E?' es if No ft Holding Tank > 100' /s if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' VYes if No LUXes if No ft Community Sewer Main > 75' Yes if No ft Manure/Animal Excreta Storage Ves if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q Yes if No ft Surface Water > 100' ft ft ft ft ft El Yes if No ft Property Line > 5' L!�J Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 21 Yes if No ft Private Wells > 100' 0 Yes if No Water Main > 10' 21 Yes if No ft Community Wells > 200' 0 Yes if No Water Service Line > 10' El 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' Q Yes if No ft If absorption field is under driveway comment below Property Line > 10' Q Yes if No ft Wells on Adjacent Lots: Water Main > 10' 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' 0 Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION l certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet V ° A a C A MICHAEL N. ANDI-Ro r E- ft ft ft ft Certified Drilling Log P DOC CO dba BILL S. COLE ULLIVAN WATER WELLS P.O. Box 670269, Chugiak, AK 99567 688-2759 OWNER OF LAND: Taras Ilnitskiy ADDRESS: LEGAL DESCRIPTION Pollock Homestead Block A Lot 6 DATE: 10-17-18 PERMIT NUMBER: OSP181359 DATE OF ISSUE: 10-10- 18 TAX IDENTIFICATION NUMBER 01711253000 Is well located at approved permit location: ®Yes ❑No Method of Drilling: ®air rotary ❑cable tool Depth of Well: 400' Casing Type: Steel Wall thickness .250 inches Diameter: 6 inches, depth 64 feet Liner type Static Water Level: feet Recovery Rate 15 ❑ gpm ® gph Method of Testing Air Well Intake Opening Type: ❑ open end ®open hole ❑ Screened Start feet Stopped ❑ Perforations Start feet Stopped Grout Type: Bentonite Volume: 50 lbs Depth: from 2 feet, to 42 feet Well Disinfected Upon Completion: ®yes ❑ no Method of Disinfection: Chlorine 50 PPM Comments: 15 GPH before Hvdrofrack Bore Hole Data Depth From To 0 2 2 4 4 27 27 31 31 33 33 44 44 89 89 129 129 220 220 264 264 372 372 381 381 400 Casing Stickup Overburden Tight Silty Sand & Gravel Clay & Gravel Wet Silty Sand & Gravel w/ Clay Tight Sand & Gravel w/ Clay Bedrock Broken Bedrock Gray Bedrock Green Hard Bedrock Gray Bedrock Green Hard Bedrock Gray w/ Quartz 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. Development Services Department` Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: OPS 191507 Date of Issue: ,11 -14 -19 Parcel Identification Number: 017_11253 Legal Description Block Lot POLLOCK HOMESTEAD A 6 Pump Installation Date: 08 -09 -2019 IPump Intake Depth Below Top of Well Casing: 395 IPump Manufacturer's Name: Pentek I Pump Model: 2N FL72-5-P4 Property Owner Name & Address: TARAS ILNITSKIY feet Pump Size: 3/4 hp Pitless Adapter Burial Depth: 10 feet Pitless Adapter Manufacturer's Name: MARTINSON B-10XLF Pitless Adapter Installer: MIKE ANDERSON, PE. Well Disinfected Upon Completion? ❑ Yes ❑ No Method of Disinfection: CLORINE TABLETS I Comments: IPump Installer Name: Ta ra s 11 n its ki ICompany: self Mailing Address: 15339 Pollock City. Anchorage state: AK Zip: 99516 Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. O Ln O N 89. '2 „ E 139.00 0 2! I\ Z I � w � ' I I I RABBIT REEK - -C - w Q BobbF. Burnett 2941 'Carriage Drive I 0 I 6' WOODEN FENCE N N • WELL W I Anchorage, Alaska 99507 (907) 350-5541 H I I I 25.20 25.0 '—ASPHA.T.::.. � I .:.. O I a I \ W DlRIVEW. Y.:... .,.. L\\LJ O Q CO I� \ o V) Cfl I L0 I 6.0 [V 7.00 w 0 n 0 0 0N � I zo L(')ro I N N o CJ O 00 I 0a0 N O / I v I O p (QUI Z I 100' WELL RADI J LLI b I OIW QI W I I Fes- I 6' WOODEN FENCE JI � I 2 I OI I 139.23 O Ln O 0 � I RABBIT REEK - -C - _ROAD BobbF. Burnett 2941 'Carriage Drive GRAPHIC SCALE:1 Inch = 30 Feet Anchorage, Alaska 99507 (907) 350-5541 15 0 15 30 60 _qhh.'%h�l Aft \ ate Scale Legal Description AQr�' 1/3/2020 1" = 30' Lot 6 BLOCK A ' ��� 1 SW 3137 AS -BUILT POLLOCK HOMESTEAD SUBDIVISION raven by Field Book PLAT # 69-76 49 . BFB ASB2019 1 / I hereby certify that the property described hereon has been surveyed , BOBBY F. BURNETT / by me, or at my direction, and that the improvements situated thereon in -5464 are within the property lines and do not overlap or encroach on the property lying adjacent thereto unless otherwise shown. That no 1 '� Z3 ^ 5 Of improvements on the property lying adjacent thereto encroach on the \ P' - premises in question and that there are no roadways, transmission \�'�'SSIONAL l'AW lines or other easements on said property except as shown. ``_f /