HomeMy WebLinkAboutABBOTT CO-HOUSING TR AOnsite FileAbbaott Co=
Mummpality of Anchorage
.on-site Water and WasteWater program . · ·
· ': "'"' ' ' CERTIFICATE OF ON,SITE SYSTEMS APPROVAL
:GENERAL INFORMATION
Day phone
' 3. NUMBEROFBEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well- .
Individual Water Storage
· gommunity Class Well
· Public Water System
' .'.-.r~ M~ltiple Dwellings (Single Family and/or Duplex) ·
'3
TYPE OF WASTEWATER DISPOSAL:
.COSA to be released to the engineer, unless otherwfse requested by the'engineer.
Individual []
Holding Tank []
Community []
- Publio sewer. · ~' ·
COSA Fee $
Date of Payment
Receipt Number
COSA #
qqo
Waiver'Fee '$
Da{e of Payment
Receipt NUmber
Waiver#
' STATEMENT OF INSPEC~ON BY ENGINEER' : ' ' · :' '"" '
.... · As:~ed by my seal.affix;ed hereto and as· of the validation date shoWn, below, I verity that my lnveStigati(~n,
.." ::". :.'~ :"-;t~ased .6ri'prOCedures o~ided Iff the. Certificate 'of On,Site Syst0ms Appre. val Guidelides for .thls application ·
· - .:: '. :i':/.s[mws that tho on-~;~te"water Supply and/o~; ~astewater di.~posal 'system is (are) ~;a~e, functional and adequate.
' . .' i ' :: fei~ the ndmber of bedrboms ahd ~pe of structure nd cared herein I further ~,erify that based on the information
:' ·: ". pbta[ned from the Muniqi~[i~j o.f Anch0mge files and fro.m my investigatipn'and inspectiqn the on-site water
· .' ' ·:.supply and/or waste;water dis,coSal system .is(am) in. compliance with all applicable Municipal and State codes,.
· ".ordinances, and regulations in effect at the time of installation.
. Address. 15~13i ,~CdO
..... t · .Engineer's Printed Name
;'" ' '.". i.' :'... SYstem #1'Approved for "'~ bedrooms.
· :'.~'i' .i ' ' " '. System f/~APpr0ve~.for bedrooms.
.:. .. ........ . .. ~. Disapproved, ...
....' · Conditiqnal approVal for
__. bedrOOms, with'the following stipulationS:
up'on the represen[alJons given in paragraph 5 by an independent professional, civil enginee~ registered in the State of ~,la~ka. The
Munldp~lJty of Anchorage is not responsible for errors or omissions In the professional engineer's wo~'
ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
X
· Nitrate Advisory
Arsenic Advisory
Other
: '' If more th:;n l'septic system is on the lot:
-: . cosA checklist # ' of
Structure served by.lhis system __
Certificate of On-Site Systems ApprOval Checklist
.... LegalDescription. ~o'F c~7
'?~' . .A. WELL DATA
· " . .; · Well type
~.'. ' ' Date completed
.TOtal depthS:;'/lO fL
'. ...' Date of test
"Static Water level
...... .:. ~ .. ~ 'Well production
WATER 8AMPLE RESULTS:
IfA, B, orC provide PWSID #,
Sanitary seal (Y/N)
Cased:toT 5o lt..
FROM.WELL LOG
.Coliform...
-.: SEP C,NOLD,.G T%'DATA
' .... TankType/Material
:. Foundation eleanout (Y/N) -
. Date of pumping
Number of Compartments
Depression over tank (Y/N)
Pumper,
· wel~ LOg (y/N)
Wires properly protected (Y/N)
Casing height (above ground)
'AT INSPECTION
35- ff.
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
· C. ABSORPTION FIELD DATA
Date installed·
Length ft.
Total depth, It.
Date of adequacy test
· Fluid depth in'absorption field before test in.
Elapsed Time: min. Final fluid depth
Any rejuvenation ~'eatment (past 12 mo.) (Y/N & [ype)
Soil rating (g.p.d./lt~ or ~/bdrm)
Width
Eft. absorption area __.fl~ .Monitoring tube
Results (Pass/Fail)
Water added '
· System type .
Gravel below pipe ff.
Depression over field,
For bedrooms
· gal. - New depth. ' in.
' Absorption rate >=' g.p.d.
If yes, g!ve date .
in.
D. LIFTSTA¥10N ~
Date installed
'Pump on' level at
Datum
Size in gallons
in. 'Pump oW level at
Cycles tested
in,
Manb31e/Accese (Y/N) .'
High water alarm level at
Meets alarm &'circuit requirements?
in.
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
- Public sewer main ~.~O
Sewer/septic service line
Anima! containment areas
SEPTIC/HOLDING TANK ON LOT TO:
S' Building foundation
water main
,.Wells on adjacen{ lots -
Property line
Wat~ service line
-.;ABSORI~TION FIELD ON ~OT TO:
Property line Building foundation
Water SeP,,ice line Surface water
Curtain drain. Wells on adjacent lots
On adjacent lots
On adJacent lots
Public sewer manhole/eleanout
Holding tank
Manure/animal excrete storage areas ~/OO
Absorption field.
Surface water
Water main
D~eway, parkingNehicie storage
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I ceY~ify that I have determined through .field inspections and
review of Municipal records that ~he above systems are in
conformance With MOA COSA guidelines in effect on this date.
Engineer's Printed Name C
Date
COSA brown sheeL10-10-12,doc