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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
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0 �•• MICHAEL N. ANDLR5CN°,•`�
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Septic System
pp DateZ
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Note: this approval does not include well permit requirements.
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(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
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( i
C05
35
8
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62
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I
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WELL
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PID No.: 017-112-53
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BENPH, GARAGE/ SLAB j
NAY
PLASTIC TANK // \
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\
ASBUILT
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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
\
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\
j
1
1
!
/
/
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WELL
V
i \
/\\ X X DWELL
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\ \v /
\ \ /CE)3 /
1 /
H�,, X X
I
PID No.: 017-112-53
I' \
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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
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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 ,
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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.
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(907) 350-5541
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GRAPHIC SCALE:1
Inch = 30 Feet
Anchorage, Alaska 99507
(907) 350-5541
15 0 15
30 60
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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 /