HomeMy WebLinkAboutPOTTER HIGHLANDS PH 2 BLK 2 LT 7Onsite File Potter Highlands Ph 2 Block 2 Lot 7 #020-281-67 Municipality of Anchorage On -Site Water and Wastewater Section e (907) 343-7904 Page 1 of 2 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211005 PID Number: 020-281-67 Dwelling: 0 Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑Q New ❑ Upgrade Name Visser Construction LLC ABSORPTION FIELD ❑ Deep Trench 0 Wide Trench ❑ Bed ❑ Mound Site Address 5968 Potter Valley Road ❑Other Phone Number of Bedrooms Soil Rating Total depth from original grade 4 5 GPD/SF 2.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 1.5 Ft. Gravel depth beneath pipe 0.5 Subdivision Block Lot Potter Highlands PH 2 2 7 Ft. Fill added above original grade Gravel length Township Range Section 1.5 Ft. 35 Ft. Gravel width 5 Beds: Number of Lines N/A Distance between lines N/A 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 175 Ft2 1 N/A Ft. Well 101.7 128.8 NA NA 25'+ TANK pQ Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Surface Water 100'+ 100'+ NA NA GREER / Advantex 1500 Gal. Material Number of compartments Lot Line 10'+ 10'+ NA NA NA HDPE 2 Foundation 10'+ 10'+ NA NA LIFT STATION Manufacturer Capacity Remarks Orenco 500 Gal. Alarm location Outside House Electrical installed by Wiring Up AK Electric LLC Installer PIPE MATERIAL House to tank 3034 Tank to 3034 drainfield BTH Construction Drainfield 3034 cO/MT3034 Inspector Pannone Engineering BENCH MARK (Assumed elevation) 100 ft Inspeection im 9/27/21 2nd 9/28/21 Location and description 3`d 9/30/21 41" Bottom of Siding / SW Corner of House ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date �� OF A�,4 kk G? '•e TH .... Steven R. Pannone Septic System �, . CE 8149 Approved Dated 2 I 0� Note: this approval es not include well permit requirements. rRAn�im�au� PRIMARY/ RESERVE SEPTIC SYSTEM NO. BEDROOM: 4(600 gpd) TANK SIZE: 1500g ADVANTEX W/ AX20 POD PERC RATE: 10 MPI SOIL RATING: 5 GPD/SF AREA RQD: 120 SF SYS. TYPE: WIDE TRENCH 0.5'ED MIN LENGTH: 24 LF USE: 35LFx5'Wx0.5' E.D., 2.0' TD TOTAL AREA: 175 SF MT MONITOR TUBE NO. TMT TANK MONITOR TUBE TYP TYPICAL R.I. RIGID INSULATION /$CAt -/ 00 00 04 00 APPROXIMATE LOCATION OF FOUNDATION DRAIN OUTFALL T2 (NOT SURFACE WATER) / T' \ Q A�o 0. I J / C1 FCO -o- 1-N M1� / H-91 r*t o NEW 'm rn M2 TMT 48R \ � .-''"" � C/) � � / B HOU / WELL �P) / / K / � / J C2 TH\-zm D INSTALLED 1500g ADVANTEX W/ AX20 POD / / p INSTALLED FOUNDATION CLEAN OUT / m INSTALLED POST TANK CLEAN OUT / / / T- � PER MANUFACTURERS RECOMMENDATION / m� / NEW PRIMARY DRAIN FIELD / RESERVE DRAIN FIELD (P) 35LF x5'W x 0.5'ED x 2.0'TD INSTALLED CLEAN OUT AND J / o MONITOR TUBE AT EACH END C NOTES: PANNONE EMG SVCLLC (C.', 1088) 11/REVISIONS DATE PAE RECORD DRAWING PHONE . BOX71807 0 LfFX AR, (907)AK 9745-8201 = ��:4 P�� of AC�S�y'', SCA E22/2021 sic 1" = 50' POTTER HIGHLANDS PHASE II, BLOCK 2, LOT 7 - P.I.D. NO DRAWN DRM POTTER CREEK DEVELOPMENT LLC Steven R. Pannone 020-281-67 POTTER VALLEY ROAD CE -8149 PERMIT N0. OSP211005 SITE PIAN ANCHORAGE, AKS SHEET 'tt......., 2 OF 3 A B FC 17.2 SS NEW SEPTIC T1 38.9 42.2 T2 42.7 44.8 TMT 38.3 37.9 DCO 0.0 0.0 Cl 69.8 59.2 mi 67.5 56.6 C2 93.0 68.2 M2 94.7 70.4 MT MONITOR TUBE NO. TMT TANK MONITOR TUBE TYP TYPICAL R.I. RIGID INSULATION /$CAt -/ 00 00 04 00 APPROXIMATE LOCATION OF FOUNDATION DRAIN OUTFALL T2 (NOT SURFACE WATER) / T' \ Q A�o 0. I J / C1 FCO -o- 1-N M1� / H-91 r*t o NEW 'm rn M2 TMT 48R \ � .-''"" � C/) � � / B HOU / WELL �P) / / K / � / J C2 TH\-zm D INSTALLED 1500g ADVANTEX W/ AX20 POD / / p INSTALLED FOUNDATION CLEAN OUT / m INSTALLED POST TANK CLEAN OUT / / / T- � PER MANUFACTURERS RECOMMENDATION / m� / NEW PRIMARY DRAIN FIELD / RESERVE DRAIN FIELD (P) 35LF x5'W x 0.5'ED x 2.0'TD INSTALLED CLEAN OUT AND J / o MONITOR TUBE AT EACH END C NOTES: PANNONE EMG SVCLLC (C.', 1088) 11/REVISIONS DATE PAE RECORD DRAWING PHONE . BOX71807 0 LfFX AR, (907)AK 9745-8201 = ��:4 P�� of AC�S�y'', SCA E22/2021 sic 1" = 50' POTTER HIGHLANDS PHASE II, BLOCK 2, LOT 7 - P.I.D. NO DRAWN DRM POTTER CREEK DEVELOPMENT LLC Steven R. Pannone 020-281-67 POTTER VALLEY ROAD CE -8149 PERMIT N0. OSP211005 SITE PIAN ANCHORAGE, AKS SHEET 'tt......., 2 OF 3 WATER LINE / W WELL RADIUS SS NEW SEPTIC ABBREVIATIONS TH TEST HOLE (P) PROPOSED (E) EXISTING CO CLEAN OUT NO. FC FOUNDATION CLEANOUT FS FLOW SPLITTER MT MONITOR TUBE NO. TMT TANK MONITOR TUBE TYP TYPICAL R.I. RIGID INSULATION /$CAt -/ 00 00 04 00 APPROXIMATE LOCATION OF FOUNDATION DRAIN OUTFALL T2 (NOT SURFACE WATER) / T' \ Q A�o 0. I J / C1 FCO -o- 1-N M1� / H-91 r*t o NEW 'm rn M2 TMT 48R \ � .-''"" � C/) � � / B HOU / WELL �P) / / K / � / J C2 TH\-zm D INSTALLED 1500g ADVANTEX W/ AX20 POD / / p INSTALLED FOUNDATION CLEAN OUT / m INSTALLED POST TANK CLEAN OUT / / / T- � PER MANUFACTURERS RECOMMENDATION / m� / NEW PRIMARY DRAIN FIELD / RESERVE DRAIN FIELD (P) 35LF x5'W x 0.5'ED x 2.0'TD INSTALLED CLEAN OUT AND J / o MONITOR TUBE AT EACH END C NOTES: PANNONE EMG SVCLLC (C.', 1088) 11/REVISIONS DATE PAE RECORD DRAWING PHONE . BOX71807 0 LfFX AR, (907)AK 9745-8201 = ��:4 P�� of AC�S�y'', SCA E22/2021 sic 1" = 50' POTTER HIGHLANDS PHASE II, BLOCK 2, LOT 7 - P.I.D. NO DRAWN DRM POTTER CREEK DEVELOPMENT LLC Steven R. Pannone 020-281-67 POTTER VALLEY ROAD CE -8149 PERMIT N0. OSP211005 SITE PIAN ANCHORAGE, AKS SHEET 'tt......., 2 OF 3 z�-- oZD Qo NEW z a 4BR HOUSE 0-i BOTTOM SIDING: 100.0 1 C) Of m w w (n w m w m Of 5.1 �D �� POD o RIGID INSULATION o faAX20 w z INSTALLED OVER z w v FIELD 0 nn FG 86.9 = OG 85.4 83.9- EB -83.9 OR(86.4) 83.4/ FIELD (35LF) \83.4 SM(85.4) GM/ W © 78.9 �_ SM (1/15/2021) BOH: 76.4 NOTES: PANNONE ENG SVC, LLC P.O. BOX 102954 ANCHORAGE, (C.i. 1088) Al< 99510 " """", REVISIONS DATE 22/2021 RECORD DRAWING PE 907) 272-8 HON218 FAX 907) 272--8211 SCALE POTTER HIGHLANDS PHASE II, BLOCK 2, LOT 7 POTTER CREEK DEVELOPMENT LLC POTTER VALLEY ROAD �� ���, Stevan Ponnana - %� CE -8149 - P.I.D. NO oto -2a1 -s7 DRAWN DRM PERMIT NO. OSP211005 SHEET SOIL LOG ANCHORAGE, AK I?,, nCF OF 3 R DOC CO dba BILL Sc COLE ULLIVAN WATER WELLS P.O. Box 670269, Chugiak, AK 99567 688-2759 OWNER OF LAND: Visser Construction Bore Hole Data ADDRESS: Depth LEGAL DESCRIPTION Potter Highlands Ph 2 Block 2 Lot 7 From To DATE: 3-4-21 0 2 PERMIT NUMBER: OSP211005 DATE OF ISSUE: 2-10-21 TAX IDENTIFICATION NUMBER 02028167000 2 4 Is well located at approved permit location: ®Yes ❑No 4 1 20 Method of Drilling: ®air rotary ❑cable tool 20 34 34 36 Depth of Well: 320' Casing Type: Steel Wall thickness .250 inches 36 108 Diameter: 6 inches, depth 44 feet 108 128 Liner type Static Water Level: 30 feet 128 139 Recovery Rate 5 ® gpm ❑ gph 139 j 149 Method of Testing Air Well Intake Opening Type: ❑ open end ®open hole 149 220 220 234 ❑ Screened Start feet Stopped 234 320 ❑ Perforations Start feet Stopped Grout Type: Bentonite Volume: 250 lbs Depth: from 2 feet, to 42 feet Well Disinfected Upon Completion: ®yes ❑ no Method of Disinfection: Chlorine 50 PPM Comments: Shallow Bedrock Surface Seal installed per MOA code Casing Stickup Overburden Silty Sand & Gravel Bedrock Gray Hard Fractured Bedrock Bedrock Gray Bedrock Brown Bedrock Gray Bedrock Brown Bedrock Gray 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. Well Drilling Permit Number: SW Parcel Identification Number: www.sullivanwaterwells.com Pump Installation OSP211005 Date of Issue 2-10-21 02028167000 Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. U F - Lot 8 5' DEVELOPMENT SETBACK 10' T&E EASEMENT III a m M Oma:• 5 N•ygo00 M m Ln co n N OO'. O%: :Z 0 �Q :" •0 000 0 44p�S : Edo Z o O O O 0 N O OO O acs c '0 a Q L O ° ° a E m o m m O1 c o > 06 ro TN NL+y�jL L mC 7 't co m ° 10 Y ZZO m C0+>N Qc 10-2, I I 0_ ° ClN m 0° N qH O r— °NNC O c 7•-°�C.00 ° O0.0InNN O 0._'o 0� o.-...°« a"m ° o w q in m t o K NOO c c QN CO C ', 9 V' �v0O w 0 aW m d0 m 0� C m< m c c m o d 2> a O c n m �a0 R� m U L of aLmoO o O ._ moL t:EEL,6' c N c y. o m m o 3>« ccm �� .. o o° n o Q o Ea J N L w�+ao U W ) m y C '0CL 0 ° Vl t U).L.. 00030 C m Z 0 O s 0 0 XI • U 0 2 p c 0 wl C CD— ,0 O g x Q 9 c 0 r O L O . J >WLp O.Oi O �; mv% O m •r m a Q Lpaoc+m°� > 0 o= { _ Y� m° rUoO cot m N aa m Z 0 ma: '0. noo a �`~ rn o�°mc « me 0 Qf_E amm �o moocE—E v c L =0 .0 =0 « —m> D_ J a" _ Q3c0.0 C -O MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program POBox 18O85O 4rOOElmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 #n -Site Water & Wastewater System Permit Permit Number: DSP211805 Effective Date: Work Type: VVeUSeotic}nKial Expiration Date: Tax Code Number: 02028167008 Site Legal Address: POTTER HIGHLANDS PH2BLK 2 L 7 G:3838 Site Mailing Address: 50G8POTTER VALLEY RD, Anchorage Owner: POTTER CREEK DEVELOPMENT LLC Lot Size in Sq Ft: Design Engineer: PANNONEENGINEERING SERVICES Total Bedrooms: This permit hsfor the construction of: 2/10/2021 2/10/2022 Disposal Field Septic Tank - [] Holding Tank [] Privy Private Well [] Water Storage All construction shall beinaccordance with: 1. The attached approved design. 2. All requirements specified inAnchorage Municipal code Chapters 15.55 and15.G5and the State ufAlaska Wastewater Disposal Regulations (18V\C72)and Drinking Water Regulations (18AAC8�U) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development t Services Department per AMC 15.G5.Provide notification bvcalling (y07)343-7984( '. 4. From October 15toApril 15. asubsurface soil absorption system under construction during freezing weather shall beeither: - a. Opened and Closed nnthe same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: Date: 11 MUNUPALITY OF ANCHORAGE Community Development Departments Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 020-281-67 Property owner(s) Potter Creek Development LLC Day phone Mailing address 561 E 36th Ave, Ste 200, Anchorage, AK 99503 Site address NSN Potter Valley Road Legal description (Sub'd., Block & Lot) Potter Highlands Phase 2, Block 2, Lot 7 Legal description (Township, Range & Section) Lot Size 168,402 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑X Initial ❑X Single Family (SF) ❑x Septic Tank ❑X Upgrade F]Duplex (w/wo ADU) (D) ❑ Holding Tank El Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑X Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with l Cd applicable Municipu:)Q- Q � (Signature of property owner or authorized agent) Permit/Rush Fees: a.0 Waiver Fees: Date of Payment: o? 012 1 Date of Payment: Receipt Number: 02 1 1 1 G Receipt Number: Permit No. 05r)- 11605 Waiver No. Permit App_:- : :—'.,:c ; Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211005, Deb Wockenfuss, 02/10/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211005, Deb Wockenfuss, 02/10/21 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211005, Deb Wockenfuss, 02/10/21 MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and entered into as of this 5-4'h Day of� of 20 21 , by and between herein the "OWNER," and the Mimicipality of Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as (Do G t40111L )a4x located at (legal description) A 4fer � 1-� h10,n (! Ph Z 81 L, 7 Ij 2. Maintenance, Repairs and Alterations. (Owner is required to read, understand and initial each section) -.S Throughout the term of this Agreement, the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. �� It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This includes an annual maintenance fee (typically $400 to $600). kS Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. �J Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. 05/18/2018) Page 1 of 3 Owner acknowledges that the Municipality may request records of maintenance and repairs from the manufacturer's representative or maintenance provider. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS. The Municipality will give at least 24-hour notice. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the constriction, maintenance and repair of the Owner's AWWTS. '[ Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed system, or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7. Severability. Any provisions of this Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev. 05/18/2018) Page 2 of 3 OWNER: By: (signature) Date: t� 2 lr/c�— �vrspn (print name) STATE OF ALASKA ) ss. THIRD JUDICIAL DISTRICT ) The foregoing instrument was acknowledged before me this day of 20dti1 , by OTARY PUBLIC FOR AL My Commission expires: I STATE OF ALASKA NOTARY PUBLIC Natalie Trayersvmyre Aly Commission Expires March T, 2021 MUNICIPALITY: By: (signature) (print name) Date: Z 1 2 Title: (rev. 05/18/2018) Page 3 of 3 A -d l/ Development Services Department \ i Phone. 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 02028167 1. GENERAL INFORMATION Expiration Date:.3z/ /ZZ Complete legal description Potter Highlands Ph2 B2 L7 Location (site address) 5968 Potter Valley Rd Current property owner(s) Mailing address Real estate agent 2. TYPE OF DWELLING: Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic ❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Dista Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Date of Payment Receipt Number 03.67.5G COSA # 0-5C, 2. 11693 Date: Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. 6. DSD SIGNATURE Phone (907) 745-8200 Date Okk 49 TH X System #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved "Steven �. Pcnnona 7 �••. CE 81419 P F��• Conditional approval for bedrooms, with the following stipulations: - ATER r JmZ- PROGEAM . BY: Original Certificate Date: The Municipality of Anchage 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 Legal Description: Potter Highlands Ph2 B2 L7 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 3-4-21 Total depth 320 ft Cased to 44 ft FOR Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 18+ in. Date of flow test for COSA new Static water level at beginning of test 30 ft. Comments B. TANK DATA Age of tank(s) "`""12"1' years Tank type/material ""Pt` &�e'x Measured operating fluid level in septic tank new ❑ Standpipes/foundation cleanout per record drawing Date of pumping new D. ABSORPTION FIELD DATA wide trench Which system tested (date installed) 9/28/21 ❑ ALL standpipes present per record drawing Total measured depth from grade 3.5 eft (max) Measured depth to pipe invert from grade ft (min) r N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective Parcel ID: 02028167 Structure served by this system 1 Well production at time of test 5 Qpm Water storage tank volume na gallons Well disinfected for coliform test? ❑ Yes ®✓ No ❑ Coliform bacteria is Negative Nitrate .94 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by Sullivan's Date of Sample 119`21 C. LIFT STATION ❑ Required maintenance completed Age of lift station 9/28/21 years Lift station material HDPE Comments: A Ayc" -t— 5V,5 Adequacy test date new Results 0 Pass For 4 bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min ❑ Code -required soil cover over field Final fluid depth in ❑ System presoaked Absorption rate gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) _ date of test) If yes, enter date Gallons introduced --—gallons Comments/Deficiencies: r`� ,,�� LT 5 7�Ns e9 C -i"'"C _2o•ti'U�D"i�o�le9 c COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' L,�J Yes Community Sewer Manhole/Cleanout > 100' Q Yes if No ft ❑✓ Yes if No ft Neighboring Tank > 100' M Yes if No ft Private Sewer/Septic Line > 25' F✓ Yes if No ft Absorption Field on Lot > 100' F,71 Yes if No ft Holding Tank > 100' R✓ Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' E✓ Yes if No ft M Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' F/� Yes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 0 Yes if No ft Surface Water > 100' ®✓ Yes if No ft Property Line > 5' L,�J Yes if No ft Wells on Adjacent Lots.- ots:Absorption AbsorptionField > 5' ❑✓ Yes if No ft Private Wells > 100' ® Yes if No. Water Main > 10' 0 Yes if No ft Community Wells > 200' n Yes if No. Water Service Line > 10' 0 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' 0 Yes if No ft If absorption field is under driveway comment below Property Line > 10' F-11 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' M 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. 2 If t2 -c> I COSA Checklist yellow sheet OF A( 49 TN .. tUven R. Pannone •, . CE 814-Q J ft ft ft ft MUNICIPALITY OF ANCHORAGE ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE ANIS REPAIR AGREEMENT THIS MAINTENANCE AND REPAIR AGREEMENT, herein the "AGREEMENT" made and entered into as of this 16th Day of November Tra Dinkins of 20 21 , by and between herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY", in accordance with Anchorage Municipal Code (AMC) 15.65.365. In consideration of the mutual covenants contained herein, the parties to this Agreement agree as follows: I. Advanced Wastewater Treatment Systems. The Municipality grants permission to the Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as located at (legal description) Lot 7 Block 2 Potter Hiahlands 2. Maintenance, Repairs and Alterations. Owner is required to read, understand and initial each section) c hroughout the term of this Agreement, the Owner shall enter into a service agreement with an AWWTS service and maintenance provider approved by the Municipality or the manufacturer's representative. The AWWTS shall be maintained in a satisfactory condition capable of performing as designed and producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. It shall be the responsibility of the Owner during the term of this Agreement to pay for all repair(s), maintenance, adjustment(s), replacement costs, and inspection costs. This —~includes an annual maintenance fee (typically $400 to $600). �<: --- 'Owner agrees that only maintenance and repair personnel approved by the Municipality or the manufacturer's representative will inspect and make any necessary maintenance, repairs or permitted alterations to the system. Owner acknowledges that regular maintenance of an AWWTS reduces the potential failure of the system, which could include sewage backup and costly repairs or drainfield replacement. (rev. 05/18/2018) Page I of 3 ,19�Owner acknowledges that the Municipality may request records of maintenance and epairs from the manufacturer's representative or maintenance provider. Owner acknowledges that the fine for failing to maintain and repair an AWWTS may be assessed in accordance with AMC 14.60.030. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS. The Municipality will give at least 24-hour notice. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. Owner agrees that the AWWTS installation and maintenance requirements as provided by the AWWTS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the Owner's AWWTS. Owner agrees to maintain remote monitoring of the AWWTS as required by the AWWTS approval. 3. Term. The term of this Agreement shall begin on the date of approval by the Municipality to operate the installed systern, or upon transfer of title, and shall continue while the AWWTS is operational or until title is transferred. 4. Nonwaiver. The failure of the Municipality at any time to enforce a provision of this Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Agreement or any part hereof, or the right of the Municipality thereafter to enforce every provision hereof. 5. Amendment. This Agreement shall only be amended by authorized representatives of the Owner and Municipality. Any attempt to amend this agreement by either an unauthorized representative or unauthorized means shall be void. 6. Jurisdiction: Choice of Law. Any civil action arising from this Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Agreement. 7. Severability. Any provisions of this Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Agreement. (rev. 05/18/2018) Page 2 of 3 OWNER: �.� (signature) Date: \ \ BY: 7 �f lC� ' (print name) STATE OF ALASKA Ov7�jh;, ) c D lf,n OF ) ss. T-144RB'--��I.OIALDIS--R-I-C-7 ) The foregoing instrument was acknowledged before me this Jlf_�`day of 20 �L. by -Fr6l -t,11 f1 5 NOTARY PUB 61t FOR AIA- -A iVy.0 n 6h OFFICIAL STAMP JOCIE M SANDS My Commission expires: jIt l6f � , A�,a NOTARY PUBLIC -OREGON COMMISSION NO. 1014541 MY COMMISSION EXPIRES JULY 14, 2025 IViU'41CIPALITY: By. (signature) (print name) (rev. 05/18/2018) Date: MIA 7 Title: Page 3 of 3