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HomeMy WebLinkAboutSHADOWBROOK LT 4hadowbrook Lot 4 #015-492-05 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211314 PID Number: 015-492-05 Dwelling: ❑ Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 9 Upgrade Name David & Mary Matekovich ABSORPTION FIELD ❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 6201 Bubbling Brook Circle, Anchorage, AK 99516 ❑ Other Phone Num ber of Bedrooms Soil Rating Total depth from original grade (907) 865-6445 3 Existing GPDISF Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade Ft. Gravel depth beneath pipe Ft. Subdivision Block Lot Shadowbrook 4 Fill added above original grade Ft. Gravel length Ft. Township Range Section Gravel width Ft. Beds: Number of Lines 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 Ft2 Ft. Well >100' N/A N/A N/A >25' TANK F21 Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Capacity Greer 1000 Gal. Surface Water >10o, N/A N/A N/A Material Plastic Number of compartments 2 Lot Line >5' NiA N/A N/A NA Foundation *6' N/A N/A N/A LIFT STATION turer Capacity Gal. Remarks Tank is insulated *See tank profile Alarm location installed by PIPE MATERIAL House to tank D3034 Tank to D3034 drainfield Installer JR's Septic Drainfield Existing CO/MTD3034 Inspector L. Tidwell BENCH MARK (Assumed elevation) 100 ft Inspection�S, 8/19/21 Location and description nd dates: 2 a tn Bottom of Siding 34 ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date 49 r Schiller . e® '���`��' Septic SystemBenjarri C�J��( Approved Date.Cs�2aAw i292 • ��FO Dri, I FEESSt4NPL�' RO Note: this approval does not include well permit requirements. (Nev uo/uziia) Benjamin Schiller CE 12592R E GISTEREDPROFE S S I O N A LENGINEER1"=50' CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND PERMIT # OSP211314 PID # 015-492-05 SHADOWBROOK SUB, LOT 4 A B FCO 5.6 MH 15.9 SV 17.4 A B 2CO 17.5 CO 19.8 7.6 8.8 13.1 14.7 27.2 FEET 0 50 100 FCO BUBBLING August 24, 2021 3-BDRM HOME 10' T&E EASEMENT BROOK CIRCLE 12.5' CREEK MAINT. EASEMENT STREAM THREAD MEANDER LINE 37.5' PUBLIC USE & CREEK MAINT EASEMENT NEW 1000-GAL SEPTIC TANK w/ 20" MANWAY 2CO EXISTING TANK REMOVED & DISPOSED OF EXISTING FIELD TO REMAIN IN SERVICE EXISTING WELL 100' WELL RADIUS EXISTING WELL DETERMINED WETLANDS LIMITS MH SV CO PLAN AS-BUILT PROFILE AS-BUILT (NO SCALE) 95.9 91.7 96.6 100.3FCOMH SV1000 GAL SEPTIC TANK 2CO95.7 Benjamin Schiller CE 12592 R E GISTEREDPROFE S S I O N A LENGINEERAugust 24, 2021 PERMIT # OSP211314 PID # 015-492-05 SHADOWBROOK SUB, LOT 4 2" INSULATION Benjamin Schiller CE 12592R E GISTEREDPROFE S S I O N A LENGINEERPERMIT # OSP211314 PID # 015-492-05 SHADOWBROOK SUB, LOT 4 August 3, 20211"=3' FOUNDATION TO TANK SLOPE PROFILE 6.0' 3.7' 100.0 (BENCHMARK) 93.5 I N F L U E N C E L I N E 1 1 FEET 0 3 6 91.7 N0° 04' 20"E 329.35' REC.S45° 03' 26"E 416.49' REC.N89° 58' 09"W 280.60' REC.S45° 03' 26"E 415.16' MEAS.N0° 09' 28"E 328.23' MEAS.N89° 56' 14"W 279.93' MEAS.LOT 5LOT 6LOT 8LOT 7LOT 6LOT 3LOT 2LOT 1UNSUBDIVIDEDLOT 2LOT 3LOT 4LOT 1Lot 4Shadowbrook Subdivision53,462 Sq. Ft. +/-6201 Bubbling Brook Circle2 Story Wood Frame HouseWith Attached 2 Car Garage10' TEL & ELEC. EASEMENTTEMB SSSSSSEDGE OF GRAVEL46.3 4 0 . 8 2 8 . 8 72.9 50' RADIUSSHED8.4 12.3L=39.25R=50.00 MEAS.LUND SUBDIVISION10' TEL & ELEC. EASEMENT12.5' CREEK MAIN. ESMT.10' TEL & ELEC. EASEMENT12.5' CREEK MAINT. ESMT.BIRCH ROAD ESTATES SUBDIVISIONL=39.19R=50.00 REC.W100' WELL RADIUS2ND STORYWOOD DECKWOODDECK2ND STORYKICKOUTSTREAM THREAD MEANDERLINE PER PLAT #81-322CENTER LINE OF STREAMSURVEYED 8/25/21CONCRETEPADWOODDECK2ND STORYKICKOUT37.5' PUBLIC USE & CREEKMAINT. ESMT.127.1PAVED DRIVEWAY℄ BUBBLING BROOK CIRCLEESCSSSSS17.226.313.025.78.140.23.912.51.611.7SCPREPARED BY:FRONTIER SURVEYS, LLC650 W. 58th AVE. SUITE E, ANCHORAGE, AK 99518907-460-1686DRAWN BY: CHECKED BY: DATE: SCALE:DRAWING ID: SHEET 1 of 11. Excepting for gross negligence, the liability for this survey shall notexceed the cost of preparing this survey. Dimensions to property linesare plus/minus 0.1ft.2. This document is created by Frontier Surveys for the purpose of anas-built for Christina Gomez, only.3. This document is based on Plat No. 81-322, Anchorage RecordingDistrict.4. All lot corners have been located and marked.General Notes DisclaimerLegend1. This survey complies with the ASPLS Mortgage Location Standards. The survey represents visibleimprovements and conditions at the time of the survey. This document does not constitute a boundarysurvey and is subject to any inaccuracies that a subsequent boundary survey may reveal. It is theresponsibility of the Owner to determine the existence of any easements, covenants, or restrictionwhich do no appear on the record plat. Under no circumstances should this document be used forconstruction or for establishing a boundary or fence line.PS1" = 50ft08/26/202121-633JSScale 1" = 50'A PLOT PLAN OFLOT 4SHADOWBROOK SUBDIVISION6201 BUBBLING BROOK CIRCLECONTAINING: 53,462 Sq. Ft. +/- (RECORD)RECORD PLAT: 81-322 ANCHORAGE RECORDING DISTRICTETElectric MeterElec. PedestalTel. PedestalFound Alum. CapFound RebarSCSeptic CoverTelephone PoleLight PoleOver Head UtilitiesChain Link FenceS T A TEOFALASKA49THROYEVR U SDNALLANOISSEFORPDERETSIGERPierre M. StragierNO. LS-981208/26/2021GGas MeterSSepticDETAIL "A"SCALE 1" = 30'EWater WellWGGE 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 Wastewater Disposal System Permit Permit Number: OSP211314 Work Type: SepticTank Upgrade Tax Code Number: 01549205000 Site Legal Address: SHADOWBROOK LT 4 G:2638 Site Mailing Address: 6201 BUBBLING BROOK CIR, Anchorage Owner: MATEKOVICH DAVID C & MARY Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date: Expiration Date: Lot Size in Sq Ft: Total Bedrooms: C Di- tinent 8/4/2021 8/4/2022 53462 Disposal Field 0 Septic Tank Holding Tank Privy Private Well Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: Prior to construction, locate the end of the field in order to ensure 5' separation from tank to field. Install a cleanout at the beginning of the trench. Received By: Issued By: Date: Date: Z MUNICIPALITY F Kid { Community Development Department Development Services Division On -Site Water & Wastewater Program Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWER/WELL PERMIT APPLICATION Parcel 1. D. 015-492-05 Property owner(s) David & Mary Matekovich Day phone (907) 865-6445 Mailina address 6201 Bubbling Brook Circle, Anchorage, AK 99516 Site address Same Legal description (Sub'd., Block & Lot) Shadowbrook Sub, Lot 4 Legal description (Township, Range & Section) Lot Size 53,462 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank IN Upgrade ❑X (D) F-1 Holding Tank ElRenewal ElDuplex Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ 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 apolicable Municioal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 422 Waiver Fees: Date of Payment:�1Z/ Date of Payment: Receipt Number: OT502D Receipt Number: Permit No. 0-5)02-115 Waiver No. Permit App_::- : :-'.,:c July 27, 2021 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 7/27/21 Subject: Shadowbrook Sub, Lot 4 - 6201 Bubbling Brook Cir Septic tank design Dear On-Site Services Engineer: The owners of the above lot are intending to sell their home and the existing septic tank is well beyond its 30-year life expectancy. Therefore, we are submitting this permit application for its replacement. Wells on this and adjacent lots are shown. The new tank will be a minimum of 100’ from all wells and surface water. No septic system on this lot or adjacent lots will have any effect on the proposed septic tank location. The tank will be at least 10’ away from the foundation and 5’ away from the existing septic trench. Please refer to the attached plan for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211314, Deb Wockenfuss, 08/04/21 Benjamin Schiller CE 12592R EGISTEREDPROFES S I O N ALENGINEER 1"=50' CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND SHADOWBROOK, LOT 4 FEET 0 50 100 NOTE: NO SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS. BUBBLING August 3, 2021 3-BDRM HOME 10' T&E EASEMENT BROOK CIRCLE 12.5' CREEK MAINT. EASEMENT STREAM THREAD MEANDER LINE 37.5' PUBLIC USE & CREEK MAINT EASEMENT NEW 1000-GAL SEPTIC TANK w/ 20" MANWAY MAINTAIN 10' MIN FROM ALL PARTS OF FOUNDATION 2CO DECOMMISSION EXISTING TANK PER UPC INSTALL CLEANOUT AT BEGINNING OF TRENCH EXISTING FIELD TO REMAIN IN SERVICE EXISTING WELL 100' WELL RADIUS EXISTING WELL DETERMINED WETLANDS LIMITS Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211314, Deb Wockenfuss, 08/04/21 72-013 (Rev. 3/78) (--J MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION *0 0* 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE NEW � ❑ UPGRADE MAILING ADD LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS DISTANCE Well�w Abso pticr area Dwelling PERMIT NO. U Y TO: /®61 _ CL G Manufacturer Material No. o ompartments W F. N Liq. cypa itt ' allons -� Inside length Widt Liquid depth IF HOMEMADE: DISTANCE TO: Well Dwelling PERMIT NO. J<=Z Oz F Manufacturer Material Liquid capacity in gallons w= DISTANCE TO: Well ��r Foundo o ! Nearest lip e �L PERMIT NO. J u.2 z No. o lines _ Length o e, rline Total en tj2pF lines Trenck�vj th Distanc b t en lines F- Z W (/ �J t�('J inches Top tile to finish Mater beneath Total F• of grade, ' al tile '�j eff� �ab Tv, area � O inches Length Width Depth PERMIT NO. LU 0 Q I- Type of crib Crib diameter Crib depth Total effective absorption area aFL W LU y DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to lot line PERMIT NO. J W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS / ' L i SOIL TEST RATING IV 97 INSTALLER REMARKS G 9 74 rL eelA e l j Ae e,-r oma'. Shd&0,J d ou iro,, �� --- T1% 91 PPRO DATE LEGAL 72-013 (Rev. 3/78) (--J MUNICIPALITY OF ANCHORAGE 0 �l Depa`rtment r--', Health and Environmental"`rotection j 825 L Street, Anchorage, AK. �,y501 264-4720 # # # Permit # HANDWRITTEN PERMIT # WELL AND/O -SITE SEWER PERMIT Applicant :�,��'c�A `�,�i/✓' Mailing Address: Location: / Pone GNumber :�� Legal Description_: p�_,C Y44c/o 6o-- �vx� Lot Size: Type of Soil Absorption System Is: Trench: _ Drainfield: _ Seepage Bed: Holding Tank: 11 P -e3 Maximum Number of Bedrooms: Soil Rating(sq.ft/br); `� The Required Size of the Soil Absorption System Is DEPTH LENGTH �� [ GRAVEL DEPTH X WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE _ ��� �) GALLONS # Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. # # # TWO(2) INSPECTIONS ARE REQUIRED # # # Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet 'for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. .Specifications and construction diagrams are available to insure proper installation. # # # PERMIT EXPIRES DECEMBER 31, 1 9 3 3 I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement.if the esi ence Zisreod d to include more that )bedrooms. ._ Signed: Issued by: Appli an > Date: 6 C�_ 5 swp/024(1/91) I. //��// �� LSX1- c/OH/�voOsE PR OJ ECT Sub. CLIENTT. Schultz W 0 0960 SHEET TEST HOLE NO. Three ELEV. TOP OF HOLE 6880 DATE 8-21-81 OF 0 0 11 Forest Duff & Organics, Pt 2 2 Moist, Brown, Silty Sandy Gravel GM 3 3 ,— --- Some Cabbies 4 4 5 5 Test = 30 min/inch :�.Colation 6 6 �"D 7 7 8 8 9 9 10 10 — 1 11 Moist, Grey Silty Sandy Gravel, GM 12 12 13 13 14 14 15 15 - 16 Bottom of hole 16 No water Table 17 17 18 18 19 1 0 A 19 ,mss ��5� R�P9A9 i'Y L1� @t 2021 0C r e *� 20 . 21j:§_ 22 22- 23 23 23 4 f� ��: Z4 24 �25 25 UNWIN s SCHEBEN ® KORYNTA e HUETTL _ —2515 Vimir"1�1 4 A STREET ANCHORAGE, AK. Sa503 276-4245 `1. ^ WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES A Division of Geologicol & Geophysicol Surveys LOCATION OF WELL (Please complete either la, Ib or Ic.) Drilling Permit No. _ A.D.L. No. T0:11 Borough Subdivision Lot Block Ib. I/p gtrs. Section No. Town a hip N 171 Range E ❑ Meridian ,i ,ti6t=4.51 sLJ a, —0 f— _Ota S ❑ W ❑ f t '2 t+ Ic. DISTANCE AND DIRECTION ,ROM ROAD INTERSECTIONS I :C1 3. OWNER OF WELL: A s Yr t � l lL. C[fe - i l ! /•w'. % !,E* " Address: t} ! i .• v�: " ,ti s�./ 1 r f , Street Address and Area of Well Location 2. WELL LOG Feet BelowSurface 4. WEL Lr.DEPTH: (final) 5. GATE OF COMPLETION •`s Material Type lop Bottom `( `i it. 'F_j 6, Coble tool 0 Rotary Driven Du ❑ Auger ❑ Jetted ❑ Bored ❑ Other; - + �..,• ,,...• `1 i` - z. ..-, _+--.", _- f � $;f wz 7. USE: Q Domestic ❑ Public Supply ❑ Industry ❑ Irrigation ❑ Recharge ❑ commerical ❑ Test Wel ❑ Other: e/ Fj ''fes?•%,=^--c.�-:..{/ _�:.a -Sr € � r" ` %i x<� -, -„r; /` - r2z.. ` S. CASING: ❑ Threpded'a❑', Welded diam ?l`. in. to -L.2 ft. Depth Weight Ibs./ft. diom. in. to ft. Depth Stickup ft. 9. FINISH OF WELL. Type: [,'.:'-- '->"i ;!s Diameter;'`�t Slot/mesh Size: Length: Set between ft. and ft. Backfilling Gravel pack e,F p €% It 10 ! /.d7�.�j ,�,. 10. STATIC WATER LEVELEVEL:�% ft. 1`' 1 i .`. - Date ❑ Above or P Below IanQp surface r° } - ) ... . Equipment used: r i ,•�`` �`} II . PUMPING LEVEL below land surface and YIELD ft. after �_... hrs. pumping ;(€/ g.p.m. ft. after hrs. pumping g.p.m. 12.GROUTING Well Grouted: ❑ Yes ; ❑ No Material: ❑ Neat Cement ❑ Other: - 13. PUMP; (if available) HP"��t Length of Drop Pipe ft. capacity g.p.m. ❑ Subm. Jet ❑ Centrifical ❑ Other 14. REMARKS: 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Wafer Temperature ❑ F ❑ C _° This wefljl was dri llie,d; under 'my juri dlctio. and this report is true to the best of my knowledge and belief; ff `A—'t { t f!f Registered Busi ne ssf Name ' Contract License Number 1,) ':� Address; I r,,A� �i :i r i. 2 4K j r, , / _. Date: -” Signed: l,l..ti.. anyr' / /..-[%: t. a orf •': f �., --. J7 Authorized ,1114epresentative Form 02-WWR (11/81) Copy Distribution: WHITE - State DGGS, PINK -Driller, CANARY- Customer MUNICIPALITY OF ANCHORAGE t Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 015-492-05 1. GENERAL INFORMATION Expiration Date: N oy ), 7, a 0 � 1 Complete legal description Shadowbrook Sub, Lot 4 Location (site address) 6201 Bubbling Brook Circle Current property owner(s) David & Mary Matekovich Day phone (907)830-2903 Mailing address 6201 Bubbling Brook Cir, Anchorage, AK 99516 Real estate agent Christina Gamez 2. TYPE OF DWELLING: ❑ Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone (907)865-6445 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Q Private Septic 0 Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ is SO Date of Payment g'6 ;zD,21 u Receipt Number 0 19 7 7 J COSA # DSC 2.1 /S l g 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering Phone (907) 522-7773 Address 1399 W. 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Benjamin Schiller, P.E. 6. DSD SIGNATURE System #1 Approved for 3 System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms Date 8/24/21 caF !gC'q�1�� TH . , .fes Benjarr-nSchiller • CE 125928/24/21 kF9F� pROFESSIONP.���� bedrooms, with the following stipulations: . , I i I f I I f t / , . 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 yellow sheet COSA Checklist Legal Description: Parcel ID: If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test?Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample Comments __________________________________________________________________________________ B. TANK DATA Age of tank(s) years Tank type/material Measured operating fluid level in septic tank Standpipes/foundation cleanout per record drawing Date of pumping C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA ______________________ Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field 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 Adequacy test date Results Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: Shadowbrook Sub, Lot 4 015-492-05 ■4.8 11/19/83 187 187 ■ ■ 29 Forge Engineering 7/26/21 121.8 7/15/21 <1 Septic/Plastic New ■ Installed on 8/19/21 Deep Trench 11/30/83 7/26/21 ■3 8.6 18 n/a* 603 30 ■ 1440 5.6 17 >450 *Only trench pipe is a CO/MT sump ✔ 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’ 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 From Septic/Holding Tank on Lot to:(Please enter distances if less than required) Building Foundations > 10’Yes if No ft Property Line > 5’Yes if No ft Absorption Field > 5’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 septic tank is under driveway comment below From Absorption Field on Lot to:(Please enter distances if less than required) Building Foundation > 10’Yes if No ft 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 If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’Yes if No ft Community Wells > 200’Yes if No ft F. ENGINEER’S COMMENTS G. ENGINEER’S CERTIFICATION I 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. 8/24/21 ✔✔ ✔ ✔ ✔ ✔ ✔ ✔✔ *6 ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ *See tank profile drawing. ✔ Y.� • Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 51 Ell Certificate of On -Site Systems Approval Parcel I.D. 015-492-05 Expiration Date: 9-9- 1 2 1. GENERAL INFORMATION Complete legal description SHADOW BROOK LOT 4 Location (site address) 6201 BUBBLING BROOK CIR. Current Property owner(s) MARIE FRIED Day phone 748-6381 Mailing address Real Estate Agent Day phone 2. TYPE OF DWELLING: n Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Fx I Individual Fx] Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: NONE Distance: Received by: / 1 Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ +16 Date of Payment Receipt Number COSA# 05L 1.3103 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. Name of Firm SPURKLAND ENGINEERING Address 203 W. 25TH AVE.,STE.202A, ANCHORAGE, AK 99501 Engineer's Printed Name LARS SPURKLAND 6. DSD SIGNATURE I/ System #1 Approved for _3 bedrooms Phone 279-3916 Date System #2 Approved for bedrooms; -✓,e t� ` Disapproved Conditional approval for bedrooms, with the following stipulations: L a P Original Certificate Date: 1J� The unici lity A orage Development Services Division (DSD) issues Certificates of Onsite 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. ATTACHMENTS: COSA Checklist X Septic System Advisory Well Flow Advisory COSA blueshee[ r n ., Nitrate Advisory Arsenic Advisory Other By: az Original Certificate Date: 1J� The unici lity A orage Development Services Division (DSD) issues Certificates of Onsite 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. ATTACHMENTS: COSA Checklist X Septic System Advisory Well Flow Advisory COSA blueshee[ r n ., Nitrate Advisory Arsenic Advisory Other If more than 1 septic system is on the lot: COSA Checklist # 1 of 1 Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: SHADOW BROOK LOT 4 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID # Date completed 11/19/83 Sanitary seal (YIN) Y Total depth 187 ft. Cased to 187 ft. FROM WELL LOG Date of test 11/19/83 Static water level 117 Well production 10 WATER SAMPLE RESULTS Parcel ID: 015-492-05 Well Log (Y/N) Y Wires properly protected (Y/N) Y Casing height (above ground) >12 in. AT INSPECTION 2113/13 ft. 117 ft. g.p.m. 5.3 g.p.m. Coliform NEG colonies/100 mL Nitrate ND mg/L Arsenic ND ug/L Date of sample: 4/17 &4/25113 Collected by: ANSON MOXNESS B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Date installed 11/30/83 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (YIN) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 2/24/2012 Pumper ISAAC'S PUMPING SERVICE C. ABSORPTION FIELD DATA Date installed 11/30/83 Soil rating (g.p.d./ftz or ft2/bdrm) 287 System type DEEP TRENCI Length 40 ft. Width 36 ft. Gravel below pipe 8.5 ft. Total depth 75* ft. Eff. absorption area 867 fe Monitoring tube Y* Depression over field N Date of adequacy test 2/13/13 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test <54' in. Water added 610 gal. New depth 61 in. Elapsed Time: 300 min. Final fluid depth <54 in. Absorption rate >= 600 g p d Any rejuvenation treatment (past 12 mo.) (Y/N & type) NO If yes, give date _ D. LIFT STATION Date installed "Pump on" level at — in. Datum E. SEPARATION DISTANCES WELL ON LOT TO: Size in gallons "Pump off"level at Cycles tested Septic tank/lift station on lot >100, Absorption field on lot >100' Public sewer main NA Sewer /septic service line >25 Animal containment areas >50, in. Manhole/Access (YIN) High water alarm level at Meets alarm & circuit requirements? On adjacent lots >100, On adjacent lots >100, Public sewer manhole/cleanout NA Holding tank NA Manurelanimal excrete storage areas >100, SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5 Property line >10, Water main >10 Water service line >10' Wells on adjacent lots >100' ABSORPTION FIELD ON LOT TO: Property line >10 Building foundation >10' Water Service line >10 Surface water >100, >50'(N.O.) >100, Curtain drain Wells on adjacent lots Absorption field >5 Surface water >100, Water main >10' Driveway, parkingtvehicle storage 3 F. COMMENTS 'MONITOR TUBE BLOCKED AT A DEPTH OF 8.75' BELOW GROUND SURFACE. G. ENGINEER'S CERTIFICATION O F. I certify that I have determined through field inspections and y • review of Municipal records that the above systems are in i Gj conformance with MOA COSA guidelines in effect on this date. [} T LARS SPURKAND Engineer's Printed Name 0 . ..1 Date 10/16/12 ��! �. _S . SP COSA brown sheet -1 0-10-1 2.doc in. N s \ Meande �Lene z \ 3Z5'Pub/ic Uae � Zc Creek iLloinf. r00 wlo $GALE rz-40' a Recerfifr''ed April ZZ, /996 ado deck, 5anroam,#707110-eK cont. j�:•49T�+ �•. _„_, . -... �a. \ 6R f LESLIE L RATTS N I HEREBY CERTIFY THAT AN ACCURATE SURVEY Of THE FOLLOWING SCRIBED PROPERTY- LOT SHd404PW45R00K SUB. •AREO FOR, WAS MADE ON March 4 /984, AND THAT THE SChreck CO, BIdrS, IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND DO NOT OVERLAP OR ENCROACH AS 8U I LT T�/i�V THE PROPERTY LYING ADJACENT THERETO AND THAT n j `,J� NO IMPROVEMENTS LYING ADJACENT THERETO ENCROACH CR FILE NO. 8_ N ON THE PREMISES IN QUESTION AND THAT THERE ARE BRI0Z�D,3B •'n\-//�''��`�1'�v' N� A NO ROADWAYS, TRANSMISSION LINES OR OTHER VISIBLE & lAYES CEMENTS ON SAID PROPERTY EXCEPT AS SHOWN - 4 -460 Jose NO. &6 % p .�..�• w.,a,.,... ANCHORAGE, ALASKA, THIS&a DAY OF %%arch � IGBa 5. Engineering Firm Providing Inspections, Tests, Data and Information I certify that I have ehacked, verified, or conformd to all WA MA Guidelines effect on the date of. this inspection. f Apprmved for � �ApprUye3 `. C in r• I MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) j i CHECKLIST - FEBRUARY 1984 i i Lot 4 Shadow Brook Subdivision A. YL.L DATA •-� I ii Well Classification If A, B, cr C, D.E.C. Approved(Y/N) N14 Well Log Present (Y/N) i� Date Completed //-/9-£ Yield Wwm Total Depth /c9`7 FFeef Cased to le71eel- Depth of Grouting N/A Static Water Level 1/7 -Fee k Pump Set At Casing Height Above Ground 113 Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N) (� Separation Distances frau Well: To Septic/Holding Tank on Lot JD0 �eJ + On Adjoining Lots oG �f4v_+ To Nearest Edge of Absorption Field on Lot 118 ice[ ; On Adjoining Lots 100 -fee+ 4r To Nearest Public Sewer►.i Line To Nearest Public Sewer Cleanout/Manhole N I N - To Nearest Sewer Service Line on Lot AIA u Water Sample Collected By /A6E Date 3- Water Sample Test Results Cam ents B. SEPTI OLDING TANK DATA SEPTIC /HOLDING Installed /%30•`83 Size %&700 gal No. of Canpartments Z Standpipes (Y/N) I Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) Al Date Last Pumped Ne -w SSS �e�► Pumping/Maintenance Contract on File (Y/N) A ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (YIN) Al Separation Distances lfro¢rt�Septic/Hclding Tank: To Water -Supply Well AV To Building Foundation qe�?e i To Property Line 0500 -fie To Disposal Field 2/ _dee I/ MaA To Water'Main/Service Line To Stream, Pond, Lake, cr Major Drainage Course Comments [Page 1 of 21 2-15-84 C. ABSORPTION FIELD DATA z Soils Rating in Absorption Strata Z8'7 --P bdro, Type of System Design Date Installed //-30- &3 Length of Field 4o{'e Width of Field 36 ivi, Depth of Field e S Gravel Bed Thickness.` Square Feet of Absorption Area ;280}L Standpipes Present (YfN) Depression over Field (Y/N) /If Date of Last Adequacy Test Results of Last Adequacy 'lest Separation Distance from Absorption Field: To Water -Supply Well //L5' -le -e /- To Property Line Z0 f To Building Foundation 33 To Existing or Abandoned System on 'Lot &X- ; On Adjoining Lots To Water Main/Service Line /(/�To Cutbank(if present) To Stream/Pond/Lake/or Major Drainage Course > /10'ree.A To Driveway, Parking Area, or Vehicle Storage Area /0 .�ee•� Contents lily �e SyS,/Erw is lacs,'// /.S -ror+n. cc'dlee/ D. LIFT STATION IV14 "0 y 4o 1,. SI -�oce st /o �;'-�r���c l� . �hs�ec-jro c� '�� v r•. S'hu�yl Date Installed Dirmnsions Size in Gallons "Pump On" Level at Manhole/Access (YM) "Pump Off" Level at High Water Alarm Level at Vent (YM) Tested for Pumping Cycles during Adequacy 'lest. Meets MDA Electrical Codes(Y/N) Comments -- ** Check Permitted Bedroam Mating Against HAA Request ** I certify that I have checked, verified, or, conformed to all MOA HAA Guidelines in effect on the 'date of this inspection. OF eat %I, Signedl C � Date /%^vc� O i✓x+� n� Cc apany - e<%��s,�¢ E1v;vo11vV1eh4ci 6Jro MOA No. 03 -oz — n �3 S"ervr"CES �� ° � � � • OQBCOOY /, ,,�06.9 KBl/as/s d °. e °.°. l ?4;;.e 6.��� �m al( t.roy C. Reid, Jr. e w� ©�� �% O�No. 2251-E'° [Page 2 Of 2] 04 tn Jbokv3 2-15-84