HomeMy WebLinkAboutHANSEN SAND LAKE LT 9C4Onsite File
#012-153-36
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2025-011132-0
S Recording District 301 Anchorage
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THIS COVER SHEET HAS BEEN ADDED TO
THIS DOCUMENT TO PROVIDE SPACE FOR
THE RECORDING DATA. THIS COVER
SHEET APPEARS AS THE FIRST PAGE OF
THE DOCUMENT IN THE OFFICIAL PUBLIC
RECORD.
DO NOT DETACH
Y, /w7y-�-
May 8, 2018
Shared Well Water Agreement
'Ibis Agreement, made and entered into this qday of November by and between
Scott Adamson , who resides at 3731 W 74th Avenue.
^"d'l arc 99502 !street address, city, county, state, zip code), hereinafter
referred to as the "supplying party," and Catamount Properties 2018. LLC , who resides at
3731 W 74th Avenue. Anchorage. AK 99502 (street address, city,
county, state, zip code), hereafter referred to as the "supplied patty:"
WHEREAS, the supplying party is in possession of the property located at
3727 W 74th Avenue, Anchora¢e, AK 99502 (street address, city,
county, state, zip code), which property is hereafter referred to as "Parcel I" and is more fidly
described as follows:
(Put Legal Description of Property Here)
WHEREAS, the supplied party is in possession of the property located at
3731 W 74th Avenue. Anchorage, AK 99502 (street address, city,
county, state, zip code), which property is hereafter referred to as "Pared 2" and is more fully
described as follows:
Hansen Sand Lake L9C4
(Put Legal Description ojProperty Here)
WIlEREAS, the undersigned parties deem it necessary to provide a well system to service the
parcels described hereto, and an Agreement has been reached relative to supplying water from the
well and sharing the cost of supplying said water, and
WHEREAS, there is located a well upon the above described property of supplying party;
together with water distribution facilities, hereinafter referred to as "water distribution system" for
the purpose of supplying water to all properties connected to the said water distribution system; and
WHEREAS, it is the intention and purpose of the undersigned parties that the well and water
distribution system shall be used and operated to provide an adequate supply of water for each of
the properties connected thereto, for the domestic consumption of the occupants of said properties,
and to assure the continuous and satisfactory operation and maintenance of the well and water
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Page 2 of 7
301— 2025— 011132 — 0
distribution system for the benefit of the present and future owners, their heirs, successors and
assigns of the properties connected thereto; and
WHEREAS, the said well is deemed by the parties hereto to be of adequate capacity to supply
a single family dwelling on each of the parcels described herein with water from the well for all
domestic uses of a single family residing thereon; and
WHEREAS, the water from the well has undergone a water quality analysis from the State of
Alaska health authority and has been determined by the authority to supply safe for human
consumption; and
WHEREAS, the parties hereto desire to enter this Agreement for the purpose of reducing to
writing their respective rights and obligations pertaining to said well and water distribution system_
NOW THEREFORE, in consideration of the promises and covenants herein contained, it is
agreed that the well and water distribution system situated on Parcel 1 shall be used by the parties
to this Agreement, as well as by all future owners and occupants of said Parcels 1 and 2, upon the
following terms and conditions:
1. That until this Agreement is terminated, as hereinafter provided, the parties hereto (and their
heirs, successors and assigns, for the exclusive benefit of the respective parcels of said real estate,
and for the exclusive use of the households residing thereon), are hereby granted the right in
common with the other patties to this Agreement, to draw water from the well located on Parcel 1
for domestic use excluding the right to draw water to fill swimming pools of any type.
2. That the owners or residents of the dwellings located on Parcels 2, as of the date of this
Agreement shell:
a. Pay or cause to be paid to the supplying party, an annual fee for this use of the well and
water distribution system in the amount of $ 0.00 on or before the 151e of January each
year, with the exception of this year whereby the amount shall be $ 0,0o and paid on the
execution of this Agreement
b. Pay or cause to be paid promptly, a proportionate share of all expenses for the operation
and maintenance of the well and water distribution system that may become necessary. Each
respective share shall be determined by dividing the amount of each expense by two, it being
understood that the supplying party and the supplied party shall pay an amount equal to one half of
the total of such necessary repair or replacement Shared expenses include the cast of electricity for
pumping, repairs and maintenance on said well and water distribution system
3. That the cost of any removal or replacement of pre-existing site hnprovements on an individual
Page 3 of 7
301-2025-011132-0
parcel necessary for system operation, maintenance, replacement, improvements, inspection or
testing, damaged as a result of repair of the well or water distribution system maintenance will be
home by the owner of the affected parcel, except that costs to reprove and replace common
boundary fencing or walls damaged as a result of repair shall be shared equally between or among
parties so damaged.
4. That each of the parties hereby agrees that they will promptly repair, maintain and replace all
water pipes or mains serving their respective dwellings.
5. That the consent of all parties to pay a proportionate share of costs shall be obtained prior to
embarking upon expenditures for system maintenance, replacement or improvement, except in
emergency situations.
6. That the supplied party shall pay to the supplying party half of the cost of
energy for the operation of the pumping equipment.
7. That it is the agreement of the parties hereto that the payment for energy cost shall be made not
later than the l5 day of each succeeding month during the term of this Agreement In the
event that any such payment remains unpaid for a period of 30 days, the supplying ley may
terminate the supply of water to the supplied party until all arrearages in payment are received by
the supplying party.
8. That each of the parties to this Agreement does hereby grant to the other, his heirs, successors
and assigns, such easements over, across and through the respective parcels as shall be reasonably
necessary for the construction of the well, maintenance of water pipes, pumping equipment, mains,
electrical wiring and conduit consistent with the purposes of this Agreement These easements are
described below, to wit:
(Describe easements, if any)
10. That no party may install landscaping or improvements that will impair the use of said
easements.
11. That each party shall have the right to act to correct an emergency situation and shall have
access to the pertinent parcel in the absence of the other. An emergency situation shall be defined as
�IIIIIIIhIP�i11llIC'�hl�h���'!��'���h'I'III'III'IIIIIB'll'II'lllll'Ilill
Page 4 of 7
301-2025-011132-0
the failure of any shared portion of the system to deliver water upon demand.
12. That only those parcels of real estate hereinabove described and the dwellings located thereon
shall be permitted to receive water from said well and pumping equipment; and each of the parties
hereto does hereby covenant and agree that he/she will not allow or permit other persons, other
than household guests, to take, draw, use or receive water from the well, nor permit other persons
to connect to the pipes or mains serving his/her respective parcel.
13. That in the event the referenced well shall become contaminated and shall no longer supply
water suitable for domestic consumption, or shall no longer supply water adequate for the needs of
all relevant parties, or in the event that another source of water shall become available to the
respective parcels, then the rights and obligations of the parties created by this Agreement shall
cease and temente in accordance with the terms and conditions hereinafter described.
14. That upon the availability of such other source of water, it is contemplated that a reasonable
time shall be allowed to effectuate the necessary connections to the new source.
15. That the respective rights and obligations of the parties shall continue until the parties who wish
to terminate their participation in the Well Agreement have executed and filed a written statement of
termination at the Anchorage Rerorder'c Office (office where deeds in your state are
recorded) of the County of Anchorage and the state of Alaska . Upon
termination of participation in this Agreement, the owner and occupant of each residence which is
terminated from the Agreement shall have no further right to the use of the well. The terminated
parties shall disconnect their respective lateral connection from said well system and shall have no
further obligation to pay or collect for maintenance and related expenses incurred thereafter. The
costs of disomr>ection from the well and water system shall be home by the owner of the pertinent
parcel.
19. That the term of this Agreement shall be perpetual, except as herein limited.
20. That the benefits and burdens of this Agreement shall constitute a covenant running with the
parcels of land herein described and shall be binding upon the heirs, successors in title and assigns
of the parties hereto.
21. Any dispute under this Agreement shall be required to be resolved by binding arbitration of
the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one
arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall
arbitrate said dispute. The arbitration shall be governed by the rules of the American
Arbitration Association then in force and effect.
Witness our signatures this the _ day of 20—
' � I'!Illi IIICICII'll'II'III�III�!IDIIII"I''I III'IICIIGb'f h if lllll�l161
Page 5 of 7
301— 2025— 011132— 0
(Acknowledgment before a notary public, the form of which will vary by state)
I'111141''nil'II'IIIIIIIIIIIIIIII!II!1111''1'9"Illll�nl'II!Illnlll�
Page 6 of 7
301-2025-011132-0
CALIFORNIA CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the Identity of
the Individual who signed the document to which this certificate is attached and not
the truthfulness, accuracy, or validity of that document.
State of California
County of Los Angeles )
On November 23. 2020 before me, J G Nunez
there mw.i I. name and title of the oOKeo
personally appeared Gregory L Geiser
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to
the within instrument and acknowledged to me that hefshe/ehey-executed the same in hisMierAMR,
authorized capacity(les)r and that by hislherfthe)r-signature(s) on the instrument the person(s), or the entity
upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the
State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature
Optional Information
). G. NUN"
a CoMM. !12321139 z
Notary Public •California 0
z Los Angeles County
t Conwn. 6 fres Fah. i I, 202
(Seal)
Although the information In this section Is not required by law, it could prevent fraudulent removal andreattachment of this ack ent to an
unauthorized document antl may prove useful to persons relying on the attached document.
Description of Attached Document
The preceding Certificate of Acknowledgment is attached to a document
titled/for the purpose of
containing pages, and
The signer(s) capacity or authority is/are as:
❑ hKgvidua"
❑ Anon-th-raa
❑ corporate Offcet(s)
Vrothod of Signer Identification
Proved to me on the bash of satisfactory evidence:
Q larnn(S) of 1,1aMlAcauon O 0tedr* wenen(-)
Notarial event is detalled in notary journal on:
Page R Entry R
Notary contact:
❑ Additional Signedd
❑ 5yne(slmumW"(5)
❑ GuardiaNCatser
❑Pan,ters) ttai
ElW
Trustee
❑ Page 7 of 7
!pf nting: 301 —2025— 011132 —0
Narne(a) or Panannl w [ohStieU 5i9nei la MgeseMinO
oCgryrl0lit taD]-301atbarY aOnwY. PO aoaala0a nes AtdnaLM 50111 OS0/. AM Mahn Referved. Ilam NWM riot?", Pleax caaact yaw Aadrodred Renal" to PUrCh" cordes armh ben.
United States of America
State of Alaska r "
THIS IS TO CERTIFY that the foregoing is a full, true and correct
copy of the document as it appears in the records and files of my office.
IN THE WITNESS l%MEM—OF, I have hereunto set my hand
and have affixed my official seal at Anchorage, Alaska,
this — day of
By
Recorder q
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CERTIFICATE: OF APPROPRIATION OF WATER
Certificate No... . .751 ...............
Witux it Men j9p �94rsr ?Preopula that the State of Alaska, pursuant to A,S, 46.15, as amended
and the rules and regulations promulgated thereunder, hereby grants to . J.ames..p.,. Duff.fy .....................
I ... 37,31 ... . ....................................................................
the right to the use of ..... 5.,,00.0 .. gaU.QJR5_W4Ur._per .. Irom the public waters of the State of
Alaska for the purposes of ... donjostic.. use, ..... ... .. ...... ...... I ........................................................
The location of the water source to which 1he W�gtd�:ffght herein granted shall appertain
is- dr,31-10d .....
well in Lot 9-D in re-sd'�ivisxoh of llahseif, Sand Lake Addition,
'7 , .
...... ... ...... SK.J/4--of .. SPI .. 11-4_qff-',� a.", 21...T 11. l*
.. Merd-dian ............ ...............................
and the right to said water shall ba appurtenant that certain tract of real property described as
4rt6n ,
follows:
Lot 9-C in re -subdivision of flan'son Sand Lake Addition,
SW 1/4 of SW 1/4 of See. 2, T. 12N, R. 4W, Seward Meridian.
0 4 6 3 6
3-
-F
Fq, 15 2,117
Beneficial use of water began .......... ......... March 196i 4001�Ess
.............. I .................. ....... I'll ..................................
(UV HaUf HO to 3RAlb the said water right with the appurtenances thereof unto
and........... hils.................heirs and assigns forever, subject to the provisions of A. S. 46.15.140-160.,
lilt Mr.6fitn111l# lfrxrAf the State of -Alaska has caused these presents to be executed by the Director
of the Division of Lands pursuant to A. S. 46.15, as amended, this ................. _rth. ... .............
dayof ... ........ .......... .......... ...................... A.D.
First.American Title
INSURANCE COMPANY
Filed for Record at Request of '
Address..............................................................................................................
Cityand State....................................................................................................
THIS SPACE RESERV �� R RECRR'5�USE
77--017996
eo
Statutory Warranty Deed
rILL P' 1",
P,NCHC�r;I;GF FtE�;
d I S;TR I C:T'
Ari 19 Oa 48'77
REQUESTED BY aCA
ADDRESS 1 7 .a:
R
THE GRANTOR JAMES PATRICK BUFFY, a single man
for and in consideration of ONE ($1.00) DOLLAR and other valuable considerati
in hand paid, conveys and warrants to BETTI RUTH BAKER, as her separate estat
the following described real estate, situated in the (kMg taf State of Alaska
et/„of, the replat of Lot 9A and 9C of the Resubdivision of the Hansen
Lake"Add'itidn according to the recorded Replat thereof, all located within
southwest one-quarter (1/4) of Section 2, Twp.12 N., Range 4W.,S.M., Alask
TOGETHER WITH an undivided one-quarter (1/4) interest in and to the follow
easement appurtenant to said Lot A and Lot 9C:
A permanent easement and right-of-way over, across, through and under Lo
of the Re -Subdivision of Hansen Sand Lake Addition, according to the rec
Replat thereof, all located within the southwest one-quarter (1/4) of Se
2, Twp. 12 N., Range 4 W.,S.M., Alaska, for the purpose of construction,
tenance and repair of water well located on said Lot 9D in which the own
Lot 9C has an undivided one-third (1/3) interest, and for the purpose of
struction, maintenance and repair of water lines leading from said well
said Lot 9C;
TOGETHER WITH a further permanent easemen and right-of-way for purposes of
installing, maintaining and repairing a water line running from the existi
water line crossing and serving structures on Lot 9CG-4 for domestic water
purposes, and the right to extend said water line across said Lot 9C-4 ont
9C-3 to provide domestic water service to Lot 9C-3; and
TOGETHER with an undivided one-quarter (1/4) interest in and to the water
rights appurtenant to Lot 9C in and to the water well located on Lot 9D.
A-'Qt/'�37
uoos3Zr£ '.;c1•. 3��f"
WARRINTY DEED
The grantors, WILLIAM A. BERQUIST and NITA G. BERQUIST,
for and In consldoration of the sum of TEN DOLLARS ($IODD), in hand paid, CONVEY and WARRANT to
JAMES PATRICK DUFFY
----Grantees, the following described real property located In the State of Alaska:
LOT NINE NC" O -C), of the resubdivision of the HANSEN SAND LAKE ADDITION
acoofdingW'tho-recorded -re-plat thereof; all -located within the Southwest one-
quarter (SW 1/4) of Section Two (2), T12N, 114W, S. M., Alaska;
TOGETHER with a permanent easement and right of way over, across, through
and under LOT NINE "D" (9-D) of the re=subdivksionref-HANSEN SAND LAKE
ADDITION, according to the recorded re -plat thereof all located within the south-
west one-quarter (SW 1/4) of Section Two (2), T12N, R4W, S. M., Alaska
for the purpose of construction, maintenance and repair of waterwells, and
pipelines leading to Lot 9-C from the well located on I..ot 9-D in which :Lot 9-C
has one-third (1/3) interest.
�y-027400 _-
O_
REC0RG-IE D= �
TPC—N!11':GE RCC.
0IS7RlCT
DEC 70 5 qa PH 'PH
REUJCSTEU BY ALASKA TITLE GUARANTY COMPANY
ADDEESS
DATED this _. 12th cloy of December � 196--L-
a-y/
STATE OF ALASKA )
) ss:
THIRD JUDICIAL DISTRICT )
THIS IS TO CERTIFY that on the 19th day of December 196__.B_, before me, the undersigned, a
Notary Public for Alaska, personally appeared ._ WILLIAM A. BERQUIST and NITA G. BERQUIST
to me known and known to me to be the Identical individuals mentioned In and who executed the above and Foregoing Warranty Deed
and who each acknowledged to me that they did the some freely and voluntarily for the uses and purposes therein contained.
WITNESS my hand,and'seal the day and year above written.
4UI Ugnrr
t r Notary Public for Alaska
My commiselon expires: 10-17.-69
IRVINE. & MER60N
ATTOnNxVS %T-! `' i L/(•%ir///itJ. F.N-'('%%l"f
506 SIXTH AVENUE _ lt)"I Y. -h
:: r. •�
rs:
15
IRVINE. & MER60N
ATTOnNxVS %T-! `' i L/(•%ir///itJ. F.N-'('%%l"f
506 SIXTH AVENUE _ lt)"I Y. -h
TIl'E GRANTOR
23o .. EJC 9 -a
for and in consideration of
convey and quit claim tp�'-^-
the following described, _real estate, situated in the
State of Alaska:
-✓�--�-� Cj.��--�}--y—rC.% .--v-v'�--P—s (mac.-O--�---4.-2�� ..�-...�--P_Jc�x o-1'�J ,�
-9—
r�o o=��
rz
AilCHill;�.;r REc.
. uisi•;ic'r
im 12 2 s2
/�� is 0 ll Y•
Dated this ;'�'2- day oP�2e`-�'�-`
,/✓✓ ,� �z ,�s�y� 99s'Q3
Signed, Sealed and Delivered in the Presence of -�
_ [ -------------------------------------
.. ------------------------ (SEAL)
------------------
S�f� Pi OF ALA'Sfs
AMERICA,
)r the uses
my hand s
Individual Acknowledgment (Alaska)
I ss.
that on this -•2 �'`�-' 4 c et l� '�/
�--------day of �----- 1rJ'--'
9, a Notary P ie in and for th taL' Alaska, duly commissioned and
d_______ 1_G'CCLC tx�__� _ _—__- i1 -`------------------
person
--_______ _______
person_____ described in and who executed the above and foregoing
edged to me that ------- he------- signed and sealed the same freely and
nd purposes therein mentioned.
d official seal the day and year irythis certificate first above written.
pmfflsi 1 1
THE GRANTOR ����•��) . �� .��G — 4,!*
7 7,
for and in consideration of ; f/.n'�-C!/ .�L�^—�••�•"' ',
convey and quit claim to"�`"'""' �•:�KJ yUU s� / J� /
the following described real estate, situated In the
State of Alaska:
. Cr
tiL) cam- —
f
Rizr.np.nrn- D
zis-.;:e i
JHx 12 2 sz/
Dated this /„ 2 t% y �.,/l. �� `�'•E J a'( %JCGI.(, 44k—
Signed,
SS�v
Signed, Sealed and Delivered in the Presence of - i.��-�-^-'�
(SEAL) V � ----------
-------------------------------------
.---------------------`--------------------
c:, ;1JN�LTRii. S x A,TES OF AMERICA,
Ur `SIPATE'b•Ex ALASKA, ss.
-------------------------------- (SEAL)
Individual Acknowledgment (Alaska)
�••, THIS IS ER'PIFY that on thfs_____��'_'_______day of____ 2;•'cc.t 1cJ.7r�
`'-5hxifo;.e•rn'oth�`c1 I -signed, tt Ngi.�.ry Pub7,is m d for the State'of Alaska, duly commissioned and
.•••h)voS'ii', pc�; olially appeared___,li..l - _L�L________________
to"irrc own to be the person___ described in and who executed the above and foregoing
instrument, and aclmowledged to me that_______he_______ signed and sealed the same freely and
voluntarily for the uses and purposes therein mentioned. '
WITNESS xny hand and official seal the day and year ,i}l this certificate first above written.
(� RECORDING REQUESTED BY I -� bV.iO� `'S�•...L I',}(�};����
n _
/ ' 'J N. �ti^.'L T�;7 �Z%C:%lllA^ iiL';tria
(P � � [ry � � I '1 J
AND WoEN Pt CO.. I,. MAIL TO
M.11t 'AM S o.'N's 10
Namp
SIOe1
Addrev
City 6
Slal< L
REC0R0F0-PL 0
1) 5TRICT
OCT � 1 0 wl P11169
RE(SIpU`_SigEO PY,c ALASKA TITLE GUAS.IN"rY CGIY:PANI
AO II IiFJJ A60VE THIS LINE FOR RECORDER'S USE -
Grain L Deed LAryn I.R.S. S-... ......... ....._..._...__..... Anow
T. nos a le -<>i THIS FORM FURNISHED BY TITLE INSURANCE AND TRUST COMPANY
FOR A VALUABLE CONSIDERATION, receipt.of which is hereby acknowledged,
RAY E. JU11AN and SLTRUT)L;K. JULIAN
bereby GRANT(S) to
James P. Duffy
the/ fell �w
o_4 fing described real properly in the ANCHORAGE RCROUGH
C/ , State of Vgyfjt'l; ll. ALASKA
lot 9 A, Hansen Sand lake Addition, located in the S. W. 1/1+, Section 2, Tavnship
12 N•, Range 4 Pep, S.M.
Ey this agreement let it be undei:stood that Lot 9A has one third interest in
the deep well located an sdjoinin3 lot 913.
Let it also be understood that any and a.11. Eai.ntai"nance pertaining to the
above fnntioned viell or pwnp thereof, one third of the resultin-, expense w"a11
be tix; responsibility of the: caner of F.ot 9 A. _
Dated .._.__
STATE 01' CALTFORNl1 SS.
COUNTY
on—o'. - —_.5.=.. I {m'c me, tha antler
signed, a Notary Puhlic IS and fnr laid Sblio, p.•rymnlly nppearrd
kRr N N L+ IOf
11. Ih. ped n-�_. I.i nvl -�- u!-nl do. l6c l.ithiu
m+1 Ii RaH ;mlakm rr l: I�dtl t !-.1. _<vullrl lL. sine,
1CI'I'Sf �i my I.;n+d .nut :.Ili. wl "A. �
&V L jJuli.an
i
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r ,
`t1 Lj�'s i
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LIP<I c,. r,L>[r 15, 19yu�
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: (907)343-7904
On -Site Water & Wastewater Section Fax: (907)343-7997
Parcel ID 012 -153-36
Certificate of On -Site Systems Approval
OSC251139
Expiration Date: 4/17/2026
Legal description HANSEN SAND LAKE LT 9C4
Site address 3731 W 74TH AVE
Current property owner(s) PEACEFUL PASSING TRUST
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
By:
Comments or conditions:
The well serving Lot 9C4 is located nextdoor on Lot 9D. Prior to the
sale of the forclosed property (Lot 9D) the well pit will need to be
decommissoned and the well brought up to current code.
Original Certificate Date:
5/1/2025
This ertif —ate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
s tem(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage,
bevelopment Service 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 submittal.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory X
Other
111�1111 1� qii 1 11111
Awe
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 012-153-36
Complete legal description HANSEN SAND LAKE LOT 9C4
Location (site address) 3731 W 74TH AVENUE ANCHORAGE, ALASKA 99502
Current property owner(s) PEACEFUL PASSING TRUST
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: FNJ Private Well serving # 2 dwelling units
F1 Other Non-public well as regulated by MOA Fj Water Storage
M Community Well or Public
4. TYPE OF WASTEWATER DISPOSAL: Fj Private Septic ❑ Private Septic serving 2 dwelling units
Fj Holding Tank FM Community Septic or Public Sewer
5. SEPTIC TANK: El Steel E] Plastic F-1 Concrete F -I Fiberglass
Age - See advisory if steel or fiberglass older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS F-1 Bed R Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for: Distance:
Expedited review requested: El
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 $ A�ft. Waiver Fee $
,
4
Date of Payment fDate of Payment
COSH #'e)
_1 -5 C _),4 I 12 � Waiver #
COSA Application—Apr2025.doc
COSA Checklist WELL ONLY.docx
COSA Checklist
Legal Description: HANSEN SAND LAKE LOT 9C4 Parcel ID: 012-153-36
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 UNK Total depth UNK ft
Cased to UNKNOWN ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 4/17/25
Static water level at beginning of test 39’ ft.
Well production at time of test 3.5+ gpm
Water storage tank volume None gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic 10.7 ug/L Arsenic less than MRL (ND)
Collected by Date 4/17/25
Comments Per MOA docs well drilled circa 1969. Well is on adjacent Lot 9D & is below grade in cement structure w/
manhole. A well flow was conducted & the attached 30 scale sketch shows well and sewer manholes.
B. TANK DATA – PUBLIC SEWER
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 - PUBLIC SEWER
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 WELL ONLY.docx
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 FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 04/25/2025
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
04/25/25
SSMH Q
SSMH Q
W 74TH AVE
SSMH Q
MUNICIPALITY
i
DEVELOPMENT SERVICES DEPARTMENT 907-343-7904
On -Site water and wastewater SectionFax: 343-7997
www.muni.org/onsite
Arsenic Advisory
Certificate of On -Site Systems Approval # OSC251139
Subdivision: Hansen Sand Lake, Block: , Lot: 9C4
A water sample revealed an arsenic concentration of 10.7 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can'therefore be used to gauge the relative quality of water
from private wells. information on arsenic is available from the On -Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
1"=20'
LOT 9C3
N89°55"30"E /2.tU
0
SSMH O
W 74TH AVE
ANCHORAGE RECORDING DISTRICT, ALASKA
AS -BUILT OF:
HANSEN SAND LAKE ADDITION
LOT 9C4 PLAT 70-131
SURVEY CERTIFICATE: I, John L. Schuller, Have conducted a
physical survey of this property as shown on this drawing and that the
improvements situated hereon are within the property lines and no
enchroachments exist other than noted. Under no circumstance shoull
any information on this drawing be used for construction of fences,
structures, improvements, or for establishing boundary lines.
EXCLUSION NOTES: It is the owners responsibility to determine
the existence of any easements, covenants, or restrictions which
do not appear on the recorded subdivision plat.
WORK ORDER NUMBER: DATE: SCALE: E—MAIL.
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