HomeMy WebLinkAboutGLENN VIEW ESTATES WEST PH 2 BLK 2 LT 14Glen View
Estates West 2
Block 2
Lot 14
#051-793-31
Municipality of Anchorage Page 1 of 3
Development Services Department
Building Safety Department
On-Site Water and Wastewater Program. 4700 S. Bragaw St.
P.O. Box 196650 Anchorage. AK 99519-6650
wvw.d.anchorage.ak.us (907)343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number. SW000466 • PID Number. 051-793-31
Name:
Homes by Randall
Wastewater System: New 9 Upgrade
AdernE
P.O. Box 4125 Palmer, AK 99645
ABSORPTION FIELD
wattera eedrowna
Phot:
T.e oSuao,Twd obd avow oOnen
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746-6643 Four (4)
LEGAL DESCRIPTION
So/ Remy:
A5 Gnarl'
Total Depth kom o gnY great
12 n.
bode LOC SWdawdn:
2 14 Glenn View Estates West Phase II
Depth b poi baton Own wgc.M grade:
4 rt.
Gravel depth beneath pp:
8 FL
Towrung: Rang,: Siam
RI .tided Wow oapnal grade:
3 n.
Gravel Length:
84 n.
Well: ® New ❑ Upgrade
Gravel out,
3 R.
wetter o, Ines:
1
Dalen between Innes:
- FL
oa.aiion (Rivas. A.B. C):
Class A
Tot Depth:
n.
Card b:
rt.
TOW .Wwpaon Net
1,344 Pr
PIPS Www:
ASTM D3034 PVC
Darr:
Date Dred:
Sao Ws Levet
FL
In.W,r.
Eagle Mtn. Exc.
Dal. Installed:
11/6/2000
Y,ew:
GPM
Pang sat at:
FI.
Comm
/have Ground:
n.
• TAN K
SEPARATION DISTANCES
El Septic 0 Holding 0 S.T.E.P. 0 Omer:
To
From
Septic
Tank .
Absorption
Field
Lift
station
Holding
Tank
'oar-Private
Sewertrle
Milfl °wr.
Anchorage Tank
Lapaotyn t.+011..
1,250
Wed
>200
>200
N/A
N/A
>100'
Witmer:
Steel
Number a Compartments:
Two
awnnwM.
>100'
>100'
N/A
N/A
LIFT STATION
Lot line
>5'
>10'
N/A
N/A
y..
Gd.
er:
rw.wWoa
>5'
>10'
N/A
N/A
'Ramp m halt.
i,
'Pump ole level M:
h
/MA water MarnM.
M.
Malin Dr.n
None
Noted
Pump Mean a MOOS
Er.rts ll9..ttww t by:.
Rale"':
BENCH MARK
L..abdn and oesonpl w.
Second Story Deck Back of House.
A...aed Ela ncn
100.0 a
,Encnln' eers.Stamp
�OF 4:,
�-
F...
4.
'. r',ie
Inspections performed by: MEA - Dates: 11t 11/6/00
:7*
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49 B / "` ftr
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2nd 11/6/00
03
4l.Sn0.4
;MICHAEL E. ANDERSON
Department of Health and Human Services approval
ed and approved by: o� d t Date: LL'27 01
•:
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' Perna Number SW000466
POLLY CIRCLE
PID No. 051-793-31
77
LOT 15:
(Vacant)
(Vacant.)
PLAN AS -BUILT
SCALE 1" = 30'
OF D
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17.5
32.5
S2
22.0
34.9
C4
30.0
69.9
M1
31.4
70.0
M2
69.5
31.8
C5
70.1
31.8
PLAN AS -BUILT
SCALE 1" = 30'
OF D
•0
°'. MICHAEL E. ANDERSON • 4�
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Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 - Anchorage, AK 99519.6650 - 343.4744
On -Site Wastewater Disposal System or Well Inspection Report
Page 3 of 3
Permit Number SW000466 PID No. 051-79341
•
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93.5
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88.72
oic
,500 Gal 1—
Septic
-Septic TaE 88 60
IC)
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PROFILE AS-BUILTei
r.
= �, • MICHAEL E. ANDERSON•..
1 -10' �'• CE -4381
Permit Number: SW000466
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On -Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
!t (co 0 1:36p,
1 I l L0 0(50 x, 3vaA
Date Issued: Nov 02, 2000
Expiration Date: Nov 02, 2001
Parcel ID: 051-793-31
Legal Description: GLENN VIEW ESTATES WEST PH 2 BLK 2 LT 14
Design Engineer: 0014 Anderson Engineering
Owner Name: Homes by Randall
Owner Address: PO Box 4125
Palmer , AK 99645 -
This permit is for the construction of:
Disposal Field ✓ Septic Tank Holding Tank
Site Address:
Lot Size: 40890 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
Privy
Private Well
Water Storage
All construction must 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 engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 (24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
Annij'A' Date: 11 °96C6
r2ree
Date: // - 2 -OC
• .1.11/4' \. C +.� •-y...q ..,",1,••••'/‘ , , M'!- •
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
October 23, 2000
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject: Lot 2, Block 14, Glenn View West Estates No. 2
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of the subject lot intends to construct a four-bedroom home on the property.
We are therefore applying for a permit to construct a new septic system on the lot to
serve the new home. The attached Site Plan and backup documentation identify the
location and configuration of the new septic system and the parameters used in the
design. It also shows the location of the water service connection to the new house.
The subdivision is served by a community water system and all separation distances
are easily met.
A test hole was placed on the lot at the location shown which indicated silty gravel with
varying percentages of silt. No groundwater or bedrock was encountered in the test
hole nor was any found during the monitoring period. We are therefore proposing to
place a 3' wide deep absorption trench system with 8' of drainfied rock beneath the
distribution pipe. The pipe will be placed at 3.5' below the existing ground surface and
the total depth of the trench will be 11.5'. The length of the trench will be 84'. A
minimum of 3' of cover will be placed over the trench to prevent frost penetration and
possible freezing.
The ground surface on the lot slopes as shown on the attached Site Pian. The area for
the new absorption trench, however, is fairly flat. The new trench will be constructed
parallel to the contours of the surface in conformance with Municipal requirements.
Grading will be accomplished to assure surface drainage is away from the new trench.
If the system is constructed in accordance with our design the following statements
apply:
1. The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future. The subdivision is currently
served by a community water system.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
Lot 2, Block 14, Glenn View West Est. No. 2
October 15, 2000
Page Two
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattem will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
POLLY CIRCLE
7
NOTE: —All 'tots surrounding
This Property Are Currently
Vacant.
49
, n
•
' r
LOT 14, BLOCK 2, GLENN VIEW WEST ESTATES
SUBDIVISION NO. 2
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Four Bedroom Home
Perc. Rate: 40 Min./Inch
Application Rate: .45 GPD/SF
Deep Trench System
1,250 Gallon Septic Tank
8' Drainfield Rock
4 Bedrooms X 150 GPD / .8 GPD/SF = 1,333.3 SF of Absorption Area
1,333.3 SF/16 SF/LF = 83.3 LF Trench Length
Therefore: Construct a New Absorption Trench 84' in Length by 3' Wide With 8' of
Drainfield Rock Beneath the Distribution Lateral. Distribution Lateral to Be Placed 3.5'
Below Existing Ground. Total Depth of Trench to Be 11.5' from Existing Surface. Mound
Over Trench if Necessary to Provided Minimum Cover of 3'.
Natural Backfill
(3' Cover Min
Geotextile Fabric:`
4" ASTM D3034 Perforated
PVC ( Holes Down...
WashedC t Holes Down)•
NOTE:
TYPICAL DEEP TRENCH SECTION
(NO SCALE)
Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 10' Separation From Lot Line.
Minimum 4' Separation From Groundwater.
•00qt •' `••-; •'1 Sk i,'
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4.
•
Municipality of Anchorage
Department of Health & Human Services
825 L Street, Anchorage, AK 99502-0650
SOILS LOG - PERCOLATION TEST
Performed For. Homes by Randall Date Performed: 10/11 Ie
Legal Description: ) nt 2. Rork 14. Glenn View West Fstates Subdivision ;AEtd1(� - �1
SLOPE SITE PLAN A0«'i•-••
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
21
Perc.
Zone
OG/OL
GM
TESTHOLE NO.1
Well
Compacted
Silty
Gravel
Bottom of
Hole
Was Groundwater
Encountered?
If Yes, What Depth?
No
Depth to Water
After Monitoring None
Date:
10/23/00
S
L
0
P
E
See Site Plan
Reading
Date
Gross
Time
Net
Time
Depth To
Water
Net
Drop
1
17 Oct
3:00
1125"
2
3:30
30
12.125"
.875'
3
4:00
30
12.875'
.75'
4
4:30
30 ,
13.625'
.75'
5
5:00
30
14.375"
.75*
Perc. Rate: 40 MinJ nch Perc. Hole Diameter. 6'
Test Run Between 6 Ft. and 7 Ft.
Comments: Percolation Cavity Presoaked Prior to Testing
Performed By: Tim Kimbmugh I, Michael E Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 10/23/00
Municipality of Anchorage
Department of Health & Human Services
825 L Street, Anchorage, AK 99502-0650
SOILS LOG -PERCOLATION TEST
Performed For. Homes by Randall Date Performed:
Legal Description. I nt 2 Block 14 Glenn View West Fstates Subdivision
SLOPE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
21
Perc.
Zone
OG/OL
GM
TESTHOLE NO.2
Well
Compacted
Silty
Gravel
Bottom of
Hole
Was Groundwater
Encountered?
If Yes, What Depth?
Depth to Water
After Monitoring
Date:
No
None
10/23/00
S
L
0
P
E
SITE PLAN
See Site Plan
Reading
Date
Gross
Time
Net
Time
Depth To
Water
Net
Drop
1
17 -Oct
3:10
8.25'
2
3:40
30
9'
.75'
3
4:10
30
9.625'
.625'
4
4:40
30
10.18'
.55'
5
5:10
30
10.73'
.55'
Perc. Rate: 55 Min./Inch Perc. Hole Diameter. 6'
Test Run Between 6 Ft. and 7 Ft.
Comments: Percolation Cavity Presoaked Prior to Testing.
Performed By: Tim Kimhmugh I Michael E Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 10/23/00
MUNICIPALITY OF
Development Services Department
On -Site Water & Wastewater Section
Parcel I.D. 051-793-31
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Complete legal description GLENN VIEW
Phone: 907-343-7904
Fax: 907-343-7907
Expiration Date: 13 11 U�
ESTATES WEST PHASE 2. BLOCK 2. LOT 14
Location (site address) 21305 POLLY CIRCLE, CHUGIAK, AK 99567
Current property owner(s) TIMOTHY & BEATRIZ JOHNSON — Day phone
Mailing address
Real estate agent
2. TYPE OF DWELLING:
1300 INDEPENDENCE PLACE DRIVE APT, HINESVILLE, GA 31313
Z Single Family (w/wo ADU)
F-1 Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
Day phone
4. TYPE OF WATER SUPPLY:
1
TYPE OF WASTEWATER DISPOSAL:
Private Well
El
Private Septic
z
Water Storage
El
Holding Tank
El
Community Well
El
Community
El
Public Water System
z
Public Sewer
El
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA # 0SC:Z1 1 y() 40 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 FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY ANCHORAGE AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 7116/2021
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 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 & FWi:S
6. DSD SIGNATURE
I% System #1 Approved for t bedrooms
System #2 Approved for bedrooms
Disapproved
.41
..... ........
• ' • Curtis Huffman
:. CE 128991 . •��`���
PROF SS10 t`�����NN
Conditional approval for bedrooms, with the following stipulations:
�tlttif(((((,.
�V\ly OF ir(rr
c WATER AND um
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
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Other. -ro�n`R G.op- x
COSA Checklist
Legal Description: GLENN VIEW ESTATES WEST PHASE 2, BLOCK 2, LOT 14 Parcel ID: 051-793-31
If more than 1 septic system on lot: COSA Checklist #
of
Structure served by this system
A. WELL DATA – PUBLIC WATER
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) 21 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 51”
Standpipes/foundation cleanout per record drawing
Date of pumping 7/12/2021
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 11/5/2000
ALL standpipes present per record drawing
Total measured depth from grade 14.5 ft (max)
Measured depth to pipe invert from grade 6.8 ft (min)
N/A – pressurized field
Monitor tubes go to bottom of effective. If not, state
depth into effective 7.8’ INTO THE 8’ ED
Code-required soil cover over field
System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced 2100 gallons
Adequacy test date 7/13/2021
Results Pass For 4 bedrooms
Fluid depth prior to test 52 in
Water added 700 gal
New depth 62 in
Elapsed time 1380 min
Final fluid depth 52 in
Absorption rate 600 gpd
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Comments/Deficiencies: FIELD OPERATING IN THE UPPER HALF OF THE 8’ ED – SIMILAR TO LAST COSA.
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 *5+ 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
F. ENGINEER’S COMMENTS
*PER CODE AT TIME OF INSTALL.
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.
7/19/21
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907‐343‐7904
On‐Site Water and Wastewater Section Fax: 343‐7997
www.muni.org/onsite
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519‐6650 * www.muni.org
Septic Tank Advisory
Certificate of On‐Site Systems Approval # OSC211406
Subdivision: Glenn View Estates West Ph 2 Block:2, Lot: 14
The septic tank for this property is 21 years old. The average life for a steel septic
tank is 20 years. Typical replacement costs range from $7,000 to $11,000.
This advisory must be attached to all copies of the subject Certificate of On‐Site
Systems Approval.
This is an example of what the metal of a 30 year old steel tank MAY look like.
Parcel I.D. 051-793-31
MuniciIuOnly of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
Expiration Date: 6, g
1. GENERAL INFORMATION
Complete legal description Glenn View Estates West Phase 2, Block 2, Lot 14
Location (site address) 21305 Polly Circle Chugiak, AK 99567
Current Property owner(s) Tom & Jill Jordan Day phone 862-0204
Mailing address
21305 Polly Circle Chugiak, AK 99567
Real Estate Agent Day phone
2. TYPE OF DWELLING:
O Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
Four
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual 0
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System l] Public Sewer ❑
WaiverNariance request for: Distance:
Received by:1/tlht %fif/Q/f »1/4"2i y Date: iP/J. J//(O
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ SS2 G2
Date of Payment
aez3)
Receipt Number (9 (D / ti 0 6
CosA # C9 SC 1 62 2 s't
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 Anderson Engineering Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E. Date 6/23/2016
6. DSD SIGNATURE
System #1 Approved for
System #2 Approved for
Disapproved
Conditional approval for
bedrooms
bedrooms
�`�� 00 OF <�S�e'
k 49 "IE 1;.4 3.
verAMICHAELT ANDERSON
%r.CE-4361 g
sPeoieses1O.4". 4:17
bedrooms, with the following stipulations:
?P�\\Y OFAke
O
ON-SITE
WATER AND
ti")
T
WAST EWATER cmz
to PROGRAM
OA. J
�N! SERVO"
ai
By: Original Certificate Date: I( 7-\7- >/C
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 blue sheet S c
If more than 1 septic system is on the lot:
COSA Checklist # of _
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: Glenn View Est. West PH2, Block 2, Lot 14 Parcel ID: 051-793-31
A. WELL DATA - AWWU Water System
Well type If A, B, or C provide PWSID # Well Log (Y/N)
Date completed Sanitary seal (YIN)_ Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 9/30/2000
Tank size 1,250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping 5/23/2016 Pumper Sanitary Pumpers
C. ABSORPTION FIELD DATA
Date installed 11/5/2000 Soil rating (g.p.d./ft2 orft2/bdrm) .45 GPD/SF System type Deep Trench
Length 84 ft. Width 3 ft. Gravel below pipe 8 ft.
Total depth14 ft. Eff. absorption area 1,344 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 6/8/16 Results (Pass/Fail) Pass For 2 bedrooms
Fluid depth in absorption field before test 48 in. Water added 750 gal. New depth 61 in.
Elapsed Time: 1,440 min. Final fluid depth 48 in. Absorption rate >= 600 g p d
N
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at in. "Pump off' level at in.
Datum Cycles tested
E. SEPARATION DISTANCES - AWWU Water System
WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
Animal containment areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation > Property line
Water main > Water service line >10'
Wells on adjacent lots >100'
ABSORPTION FIELD ON LOT TO:
>5'
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
Property line
>10'
Water Service line >10'
Curtain drain None Noted
F. COMMENTS
Building foundation >10'
>100'
Wells on adjacent lots >100'
Surface water
Absorption field >5'
Surface water >100'
Water main >10'
>10'
Driveway, parking/vehicle storage
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.
Engineers Printed Name Michael E. Anderson, P.E.
Date 6/23/2016
COSA brown sheet 10-10-12.doc
fA. MICHAEL E. ANDERSON
4141. CE -4381 /4? .
IT IS THE RESPONSIBILITY OF THE OWNER OR BUILDER
PRIOR TO CONSTRUCTION TO VERIFY PROPOSED BUILDING
GRADE RELATIVE TO FINISHED GRADE AND UTILITY
CONNECTIONS. AND TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS OR RESTRICPIONS WHICH DO NOT
APPEAR ON THE RECORDED SUBDIVISION PLAT.
NOTE:ELEVATIONS ARE ASSUMED DATUM.
AS BU 1 LT
HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
; ARY LINES.
SEWARD & ASSOCIATES LAND SURVEYING 694-08
SCALE:
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DATE:
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Municipality of Anchorage
epartmerh of,Health and;Human:Services:
• Division of Environmental Services •, ;.`
;. On-SiteServices Section 825 V. Street Room 502: ;
P.O Boz' 196650" 'Anchorage, AK:99519-6650 .
www:ci.anchorag e.ak:u s •
(907) 34334744 r
CERTIFICATE OF' F.iEAL•TH'AUTHORITYTAPPROVAL:.
''FORA' SINGLE FAMILY DWELLING
Parcel I.D. 051-793-31
rn
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Expiration Date:-. %f7. .;
1: GENERAL INFORMATION
Complete' legal description Lot 14, Block 2; Glenn Yew Estates West Phase II .
Location (site address or directions) Polly Circle
Current Property owner(s) Homes By Randall . : Day phone 746-6643'
Mailing address . a P.O. Box 4125 •= Palmer, AK 99645
Lending agency Day phone
Mailing address
Real Estate Agent • Day phone
Mailing Address
Unless otherwise requested, HAA will be hold by DHHS for pickup. pm.
picked up by. •
2.NUMBER OF BEDROOMS:. ' 'Four 4 -
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Certificates 'of ,Health
Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional
civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water
supply system. DHHS also issues.HAAs upon request to home owners. Certificates of Health AlithoritY Approval -
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results less than 30 days old. Certificates are valid for one year for properties served by
Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or
omissions in the professional engineer's work.
(Rev.1099) .. ,
•
STATEMENT OF INSPECTION BY ENGINEER,
As certified by my seal affixed hereto' and as of the valdation`date shown below, I verify that, my investigatron�
based'on procedures' outlined 1n,the Health`Authonty:Approval Guidelines for ths'Health Authority•Approval;
application shows that the on-sde wa• terr;supply and/o• r wastewate• r d• isp• osal syste• m'; is •%safe • functional and
,adequate for; the number of bedrooms'and type of structure indicated herein.'1 further verify that based on the
information obtained from the Municipality; of Anchorage files and from my investgation and inspection the ori-',
site water supply and/or, westeweter disposal system is: in compliance with. all app !cable Municipal and State
codes ordinances, and regulations in effect at the time of installation.
•
Name of Firrn Anderson Engineering • Phone c.522-7773+ -
'Address.'P.O,Box240773Anchorage, AK99524
Engineer's Printed Name. 'Michael E.'Anderson, RE . .`Date `' 4124101,
•`oo‘,212).ta
eii
Fr*: 49Th 1;, �i4 0
F MICHA'-E E ANDERSON . M it
6. DHHS SIGNATURE o00'••. CE 4381• ,�••. i'
I/ Approved'for -• ' bedrooms t #4,
40 'Pg0ilss164\- .`'J
Disapproved 6dttt.e.T S' ..
•
Conditional approval for bedrooms, with the following stipulations:
ttt!curwo�y‘Y OF/rJt�rr,�
Additional Comments.
J • ONSITE �.t
WP,TCR,\ND ,• Int:
•
WASTEWATER
PKOGXAM
Attachments:
HAA Checklist X • Maintenance Agreements .
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory • Other
By: ti� 47 ' / Original Certificate Date: 1/ 3 0 - 0 /
Expiration Date:
(Rev.10.99)
%/- - 3 p - O .7 Reissue Date:
•
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 14.Block 2, Glenn View Estates West Phase 0 Parcel ID: 051.79331
A. WEU. DATA
Well type _ If A, B, or C provide PWSID # _ Well Log (Y/N)
Date completed _ Sanitary seal (YIN) _ Wires properly protected (VM)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform cdaniesl100 ml. Nitrate mgJI. Other bacteria colonies/100 mt.
Date of sample: Collected by:
8. SEPT1C/HOLDING TANK DMA
Tank Type/Material Steel Date installed 913012000
Tank size 1,250 gal. Number of Compartments 2 Cleanouts (YIN) y
Foundation deanout (YIN) Y Depression over tank (YM) N High water alarm (VIN) N
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed 111612000 Soil rating (g.p.dJft2 or 1t2/bdrm) .45 GPD/SF
System type Deep Trench
Length 84 ft. Width 3 ft. Gravel below pipe 9 ft.
Total depth 14 ft. Eff. absorption area 1.344 la.ft2 Monitoring tube Y Depression over field N
Date of adequacy test Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption field before test _ in. Water added gal. New depth in.
Elapsed Time: min. Final fluid depth _ in. Absorption rate x g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date WA
D. LIFT STATION
Date installed Size in gallons ManholelAccess (Y/N)
'Pump on" level at in. 'Pump off' level at _ in. High water alarm levet at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanknif station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/deanout
Sewer /septic service line Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >S
Water main WA
Wens on adjacent lots >100'
Property line >5'
Water service line >10'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line >10'
Absorption field >5'
Surface water >100'
Building foundation >10' Water main >10'
Water Service line >10' Surface water >100'
Curtain drain None Noted Wens on adjacent lots >100'
F. COMMENTS
Property is served by a water system owned and operated by AWWU
G. ENGINEER'S CERTIFICATION
Driveway, patting/vehicle storage >25'
I certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Michael E. Anderson. P.E
Date 42412001
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Er:4331 v
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41ktF
HAA Fee $ 3'D O. 0 .o
Date of Payment 14-214-0/
Receipt Number 3 3 fit
(Rev. 12(0O)
Waiver Fee $
Date of Payment
Receipt Number