Loading...
HomeMy WebLinkAboutMOSSFLOWER HILLS LT 1Onsite File Mossflower Hills Lot 1 PID# 015-141-78 Formerly T12N R3W SEC 22 LT 15 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report ~m~: ~ e ~¢.¢ ~-~ /~ Wastewater System: D New ~Upgrade Address: No. of Bedrooms: Phone: ~ ~ -- ~ ~/ ~ ~ Deep Trench ~ Shallow Trench DBed ~Mound DOther LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: Lot: Block: Subdiv~ion: Depth to pipe bottom from original grade: Grovel depth beneath pipe Township: ~ Range: Section: Fill added above original grade: Gravel length: ~7/~T D New D Upgrade Gravelwidth: ~ Ft, Numbe[ of lines:( lOist~ncebstweenlines:~ Ft WELL: C~assificabon IPrivate, A,B,C): Total Depth: Cased TO: Total absorption area: Pipe material: F-~[ Oriller: Date Orilled: Static Water Loyal: Installer: Da~e installed: Yield GPM Pump Set St: Ft. Casin9 Height Above Gr0und:Fh TAN K SEPARATION DISTANCES s Septic U Holding ~ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank SewerL[nes ~CA¢¢¢¢¢ ~4 ~ ) ~ Material: ¢ Number of Compadments: W~e~ ~, > ~., - - LIFT STATION - Lot Size in gagons: ~ Manufacturer: Foundation i[¢' ,O~, - "Pu~P °n"level at: I "Pu~P °ff"level at: I High water alarm at: Cu~ainDrain _ _ -- Pump Make & Model Electrical Inspections pedormed by: Remarks: BENCH MARK Loc~tion and Description: ~ ¢ Assumed Elevation: Inspections performed by: Flok~/ %¢c4 5~ Dates: 1st ~/~/99 ' ' ,?. Department of Health and Human Se~ices approval , ., 72~JI 3 (Rev 9191 ) MOA 25 PERMIT NO: SW990211 PID NO: 015-141-05 R 100' ",PAGE 2 OF 2 / NEW 1000 GAL. SEPTIC TANK ~G~ SWING TIES: ,,, .oM: co.."A" co.."." TO: " C.O. "F" §4' ,, - ' ' NEW 43' LONG C.C. "G" 89' 72' - ......... - SOIL ABS. TRENCH-- C.O. "H" 89' 51' W. 5.0' EFF. GVL. S.T.C.C. "1" '139' 113' PLAN VIEW r S.T.C.O."J" 118.5' 14S' SCALE: 1" = 50' DBL. C.C. "K" 122' 149' TR. C.O, "L" 110' 143' t~, ' '":' ''¢ TR. M.T. "M" 148.5' 174' 1000 GALLON SEPTIC TANK 86.7' PROFILE VIEW NOT TO SCALE BOTTOM OF TRENCH ELEV. 81.1'~ BOT. T.H. #1 M.T. ELEV. 73.7' DRY 8/3/99--~ LOT 15, SEC. 22, T12N, R3W, S.M. SEPTIC SYSTEM UPGRADE AS-BUILT INSPECTION REPORT FLATTOP TECItNICAL SERVICES 14530 ECHO STREET I ANCHORAGE, ALASKA 99516 SCALE: AS NOTED DRAWN BY TFM SEPTEMBER, 1999 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box '196650, Anchorage, AK 995'19-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Jul 2I, 1999 Expiration Date: Jul 20, 2000 Permit Number: SW990211 Legal Description: T12N R3W SEC 22 LT 15 Design Engineer: 0019 Flattop Technical Services Owner Name: Eugene Roguzka Owner Address: 4320 O'MALLEY ROAD ANCHORAGE, AK 99516-1505 Parcel ID: 015-141-05 Site Address: 004320 OMALLEY RD Lot Size: 193050 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] SepticTank [] Holding Tank [] 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. ~::d~. ~':i'-'~ , Receive Issued By: Date: Date: CIVIL & ENVIRONMENTAL ENGINEERING * ENERGY CONSERVATION & ANALYSIS THEODORE F. MOORE, P.E. 14530 ECHO ST. PH: (907) 345-1355 ANCHORAGE, ALASKA 99516 July 8, 1999 M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: The purpose of this letter is to provide the required design narrative in support of our application for a permit to construct new wastewater disposal facilities for an existing 3-bedroom residence on Government Lot 15, Section 22, T12N, R3W, S.M., located at 4320 O'Malley Road. Soils logs, perc test results, a site plan, design drawings and specifications are enclosed for your review. The proposed system will be constructed in the vicinity of test hole #1. As can be seen from the soil log, the native material below 1 foot is a slightly silty gravelly sand with a measured pert rate of less than one minute per inch. Because the native material is sand, no additional sand filter should be necessary. Using the soil application rate of 1.2 gpd/sq, ft. specified in the wastewater ordinance for soils with perc rates between 1 and 5 minutes per inch, this 3-bedroom residence requires a total absorption area of(3 x 150)/1.2 -- 375 square feet. The proposed 40-foot long trench design with an effective gravel depth of 5 feet has a total absorption area of 400 square feet. The topography of the lot in the area of the proposed construction slopes down towards the south and east at 0 - 10%. The proposed project will have no significant impact on present or future water supply and wastewater disposal systems serving adjacent properties, nor will it have any significant impact on reserved space-surface and subsurface, or on drainage. Please give me a call at 345-1355 if you have any questions on this submittal. Sincerely, Ted Moore, P.E. O'MALLEY ROAD ~- TAYLOR S/D LU LOT 15, SECTION 22, ~ Tt2N, R3W, S.M. r ~ /¢~....'-TRACT"C" / N 1/2, LOT 14 ,' I WELL WELL ~ , / ~ / ~ / INSTALL '~ / ¢ ~r 'NSTA~M INSTALL EXISTING _/ ........ ' ~ 8EPTIO TANK SOUTH 1/2, LOT 14, CONSTRUCT 40' LONG SOIL ADS. T~NCH ~ SEC. 22, T12N, R3W, S.M. W. 5.0' EFFECTIVE DEPTH SEWER GRAVEL LOT 18 (VACANT) LOT 19 (VACANT) .... ' "' LOT 15, SEC. 22, TI2N, R3W, S.M. -' ;.~ ~':~ SEPTIC SYSTEM UPG~DE : :,; i. 14530 ECHO STREET DRAWN BY TFM h ' , ,', ANCHO~G~,ALA8~99516 JULY, 1999 .' ~. , , · ~ NOTE: THIS IS NOT A SURVEYED P~T. ' ~ ?. [ ... ~ "*'i" ALL LOCATIONS SHOWN ARE APPROXIMATE. 4" DIA. D-3034 WASTE LINES FROM HOUSE 1000 GALLQN SEPTIC TANK "A" ~ DOUBLE C.O. ~" ~ 4"DIA. F-810PERFPIPE c.o.-~., ........... _-:::: ::::-----~- __ ~: :_______, ____:: _- _- - PLAN VIEW SCALE: t" = 10' - 0" 40' LONG SOIL ABSORPTION TRENCH WITH 5' GRAVEL BELOW DIST. PIPE BETWEEN 3.5 & 8.5 B.G.L CLEANOUT MONITOR TUBE MOUND BACKFILL 6" 3 1 GROUND FILTER FABRIC F~810 PERF. PIPE 1/2"-2 1/2" SEWER GRAVEL BOTTOM OF EXCAVATION SECTION "A" - "A" SCALE: 1" = 5' - 0" LOT 15, SEC. 22, T12N, R3W, S.M. SEPTIC SYSTEM DESIGN PLAN AND CROSS-SECTION FLATTOP TECHNICAL SERVICES 14530 ECHO STREET ANCHORAGE, AK, 99516 SCALE: AS SHOWN DRAWN BY: TFM JULy, 1999 Flattop Technical Services 14530 Echo Street, Anchorage, AK 99516 Phone (907) 345-1355 Government Lot 15, Section 22, T12N, R3W, S.M. 4320 O'Malley Road Wastewater disposal system installation Specifications 1.0 General: 1.1 The scope of the project consists of abandoning an existing 1000 gallon septic tank and installing a new 1000 gallon septic tank which discharges into a new 40' long soil absorption trench containing a total of 5.5 feet of sewer gravel. 1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor deviations from these drawings may be allowed or required by the engineer conducting the inspections. All construction procedures and material specifications shall conform with Municipal and State requirements. All separation distances shall be in conformance with Municipal requirements, unless specifically waived. 1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work around any buried utilities. 1.4 The contractor shall provide adequate cover material and rough grading over all system components to ensure that proper drainage is achieved after settlement and that there are no residual depressions. Insofar as possible the contractor shall minimize damage to trees and existing lawn areas. 1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after the soil is compacted, as well as placement of topsoil and reseeding all areas disturbed by the construction. 2.0 Septic Tank: 2.1 The existing septic tank must be properly abandoned by thoroughly pumping, removing the top and backfilling with soil. 2.2 The new 1000 gallon, 2 compartment septic tank shall be Municipally approved and shall be set level on undisturbed soil. Each compartment shall be equipped with a watertight manhole cover and a 4" cleanout. If the tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial type, rigid insulation. 2.3 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The waste lines from the residence to the septic tank shall have a minimum slope of 1/4'" per foot, and the waste line between the tank and the soil absorption system shall have a minimum slope of 1/8" per foot. Cleanouts on each line shall be installed within 5 feet of the building foundation, and at 75' intervals thereafter. Portions of waste lines passing under plowed driveways shall be insulated with 4" of rigid, burial type insulation. A double cleanout shall be installed within 5 feet downstream of the septic tank. 3.0 Soil absorption system: 3.1 The soil absorption system shall be constructed by excavating a 40' long trench in the location shown on the site plan to a total depth of 8.5 feet below ground level. The long axis of the trench shall be parallel to a natural contour of the ground. 3.2 The bottom of the excavation shall be level. Any compacted or smeared surfaces shall be raked to allow proper infiltration. 3.3 A total of 5.5 feet of approved sewer gravel shall be placed in the bottom of the excavation with the perforated distribution pipes laid level such that the pipe inverts are no less than 5.0 feet above the bottom of the sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing the #200 sieve. 3.4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on the design drawings. The portion of the monitor tube extending through the sewer gravel shall be perforated. 3.5 Approved filter fabric shall be placed over the entire top surface of the sewer gravel. A minimum of 2 feet of soil covet' is to be placed over the filter fabric. If the soil cover thickness is less than 3 feet, two inches of rigid, burial type insulation is to be placed over the entire top surface of the gravel, in addition to the filter fabric. 3.6 The top surface of the cover material shall be raised a minimum of 6 inches higher than the surrounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill slopes shall be no steeper than 3:1. 3.7 Unless specifically agreed otherwise the homeowner shall be responsible for arranging to have the site finish graded after the backfill material has stabilized, and for placement of adequate topsoil and seed to promote rapid revegetation of all areas disturbed by the construction. 4.0 Inspections: 4.1 A minimum of 4 engineering inspections will be required during the course of the project: (1) initial stakeout with the contractor to establish the location of the system and to discuss the plans, specifications and construction procedures, (2) after the native material has been excavated to expose the infiltrative surface to ensure that it is level and at the right elevation, and conforms with the soil test information, (3) after the sewer gravel is in place and the distribution pipes have been laid and connected up to the septic tank, but prior to placement of insulation or filter fabric, and (4) after rough backfill and grading is complete. The septic tank requires one inspection after it is set level and the piping connected, but prior to backfill. This inspection may be incorporated with any of the above inspections. 4.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in advance to ensure the availability of the engineer. TEST HOLE LEGAL DESCRIPTION: DATE PERFORMED: PERFORMED FOR: FLATTOP TECHNICAL SERVICES 14530 ECHO ST. ANCHORAGE, ALASKA 99516 SOILS LOG -- PERCOLATION TEST Lot 15, Section 22, T12N, R3W, S.M. June 10, 1999 EuRene Roguszka DEPTH (feet) 3 4 13 COMMENTS: Pt. SM Sandyloam SP/GP Slightly silty gravelly sand Cleaner at north end of T.H. Sidewalls unstable below 10' SLOPE io% SITE PLAN SEPTIC Depth to Groundwaler Date No gr_oundwater 6/10/99 M.T. dry 6/17/99 ~ 0% 5% Dale Reading Clock Net Time Percometer Net Drop Time (minutes) Reading (inches) 6/10 12" Presoak 11:31 27 3/8 Perc hole dry 11:32 1 17 3/8 10+ Resoak 11:33:40 28 Perc hole dry 11:34:40 1 18 1/2 10+ Resoak 11:35:40 28 Perc hope dry 11:36:40 1 19 10+ PERCOLATION RATE <<1 (minutes/inch) PERC HOLE DIAMETER 12 TEST RUN BE'iANEEN 5.5 FTAND 6.0 FT No sand filter should be necessary since the material in which the perc test was done is already sand. PERFORMED BY FLA1TOP TECHNICAL SERVICES, I_,~,..~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~/~'/~.~ t Acj4' tX2 C Development Services Department On -Site Water &Wastewater Section Certificate of On -Site Systems Approval Parcel I. D. 015-141-05 1. GENERAL INFORMATION Complete legal description Location (site address) Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: 11-P-1-20 T12N R3W SEC 22 LOT 15 4320 O'Malley Road, Anchorage, AK 99507 Current property owner(s) Kent Family Trust Day phone Mailing address Real estate agent Nip` Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 907-250-6716 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Fx_1 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 $ Co VD Cal Waiver Fee $ Date of Payment " 2 O Date of Payment Receipt Number ' Receipt Number COSA # 09 C 2.01 LAO f/ 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 Triad Engineering, LLC Phone 907-720-6128 Address 1300 E 68th Ave, Suite 210, Anchorage, AK 99518 Engineer's Printed Name Grant Mathews, P.E. Date 8/27/20 7 OF. A��S,N •• i 49 TH * *I 6. DSD SIGNATURE AiHEWS System #1 Approved for bedrooms �� '�,��++�rw. 444 Y Pp CE 135444 System #2 Approved for bedroomsOHM Disapproved Conditional approval for bedrooms, with the following stipulations: g WATER AND m WASTEV%`ATER oz OGRAM 1 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 Legal Description: T12N R3W SEC 22 LOT 15 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 7121171 Deepened 10/91/85 Total depth 260 ft Cased to 260 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 21 in. Date of flow test for COSA 8/24/20 Static water level at beginning of test 206 ft. Comments B. TANK DATA Age of tank(s) 21 years Tank type/material Steel Measured operating fluid level in septic tank 4.2' ❑ Standpipes/foundation cleanout per record drawing Date of pumping 8/26/20 D. ABSORPTION FIELD DATA Which system tested (date installed) 8/3/99 ❑ ALL standpipes present per record drawing Total measured depth from grade 9.6 ft (max) Measured depth to pipe invert from grade 4.6 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 Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 015-141-05 Structure served by this system Well production at time of test 8.3 gpm Water storage tank volume' gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate 1.85 mg/L Nitrate less than MRL (ND) Arsenic 1.01 ug/L 0 Arsenic less than MRL (ND) Collected by Grant Mathews Date of Sample 7/21/20 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 8/24/20 Results R Pass For 3 bedrooms Fluid depth prior to test 0 in Water added 1000 gal New depth 12 in Elapsed time 60 min Final fluid depth 0 in Absorption rate '450 gpd Any rejuvenation treatment (past 12 months) If yes, enter date lore 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 Community Sewer Manhole/Cleanout > 100' Q✓ Yes if No ft Q Yes if No ft Neighboring Tank > 100' Yes if No ft Private Sewer/Septic Line > 25' Yes if No ft Absorption Field on Lot > 100' Q Yes if No ft Holding Tank > 100' Yes if No ft Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50'✓[] Yes if No ft ❑✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' F,71 Yes if No ft [71 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' 121 Yes if No ft Surface Water > 100' Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' F/� Yes if No ft Private Wells > 100'C]✓ Yes if No Water Main > 10' ✓0 Yes if No ft Community Wells > 200' 0 Yes if No Water Service Line > 10' F✓ 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' [Z] Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10' Q Yes if No ft Private Wells > 100' Yes if No Water Service Line > 10' Yes if No ft Community Wells > 200' 0 Yes if No Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS Standpipe for C.O. from garage bathroom is located underneath shed decking. Structure is on temporary foundation and could be relocated for access if the need arises. G. ENGINEER'S CERTIFICATION OF. ALgli I certify that I have determined through field inspections and review A�P� of Municipal records that the above systems are in conformance with * "4�c TH MOA COSH guidelines in effect on this date. • • �... .. . r.f� ...... ,G N MATHEWS CE 135444 ff����ie� ROFESSIO P�� � COSA Checklist yellow sheet ft ft ft ft LEGENDBLM Lot 15T12N, R3W Section 22, S.M.8/26/2020Feet60300 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ~(~'"- (VI-d2 ~'- HAA# 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owr~er r Mailing address Lending agency. Day phone ~'~' - /~ ay Day phone. Mailing address Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: Individual well ~ Community well , Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front MOA#21 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 of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is 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 in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm. ~/~ ¢-/-~,? '7-~c4,~ ~ ~,~ / £~-~.-¢. Phone 5' ~,~'-- i-~.~'.~-- Address Engineer's signature ~ THEODORE F. MOORE DHHS SIGNATURE J'/'"' Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to pu mhasere of hemes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. RECEIVED ·. OCT 08 1999 Mumclpality of Anchorage /~\ c~^m'¥ o~ ^NCH~ DEPARTMENT OF HEALTH & HUMAN SERV~[(~'?iIJENTALSERV[CE$~,,w,~,,,uv, Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: A. WELL DATA Well type ?~' ~ ~' ~/-~- Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed '7/Afl/'7 I.., '~ '",~ "? '"~--'~ /¢/9 / ~5- Cased to ~' Casing height (above ground) 2 /" ~',~-f Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION g.p,m. ~', ~ 'f- g.p,m. Oolleoted by: Date of test Static water level Well production WATER SAMPLE RESULTS: Coiiform ~ dc, [¢~,¢_r //c,o~,X Nitrate Date of sample: Id)/,5"/) ¢ B. SEPTIC/HOLDING TANK DATA Date installed Other bacteria Foundation cleanout (Y/N) Date of Pumping A/./~. C. ABSORPTION FIELD DATA Date installed ~'/.? Length '¥.~' Width ~/.?/9,~ Tank size ~ Number of Compartments ~ Cleanouts (Y/N). Depression (Y/N) High water alarm (Y/N) /V, Pumper /V. ,~. Soil rating (g.p.d./ft~ or fF/bdrm) ~ System type -$-' Gravel thickness below pipe ~", ~ Effective absorption area ~/.70 ~' Monitoring Tube present (Y/N) ¥ Date of adequacy test N. ~. ( ~ '~(~') Results (Pass/Fail) PCJ'~ Fluid depth in absorption field before test (in.); C) Fluid depth (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) /X/ Immediately after Absorption rate = "~ ¥~'o If yes, give date N, ,~,. Total depth ~. d' ' Depression over field (Y/N) __ For gal. water added (in.): g.p.d. bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION J"/' '~' Date installed Manhole/Access (Y/N) High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main /,,,'. A. Sewer/septic service line '~. Size in gallons "Pump on" level at* "Pump off" level at* On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Date of Payment Receipt Number HAAFee $ '~ C.,~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation I t ,~ ' Property tine ~ ~ ' Absorption field Water main/service line ~> ~o ' Surface water/drainage ~' ~'o~' Wells on adjacent lots ~ I o~ ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Prope~ line ~5-' Building foundation. I O ~' Water main/se~ice line ~ ~o ' Sudace water ~ ~ o¢, Driveway, parking/vehicle storage area ~ ~ ' Cu~ain drain l~ ~ ~ ~ ~ ~ Wells on adjacent lots ~ ~ ~ ~ ' F. ENGINEER'S CERTIFICATION I ceRi~ that I have determined thru field inspections and review of Municipal records that the abo~¢ ~ystems are in conformance with MOA H~ guidelines in effect on this date. Date ¢C~~¢¢ ~ OCT-O?-g9 17:17 FRO~-CTE ENVIROi'I~ENTAL zt~m, CT&E Environmental ~eevices me. T-?OZ POZ/04 F-ZTZ CT&E Ref,# Client Naxae Projec~ Name/t/ Client Sample ID Matrix Ordered By PWSID Sample Remarka: 995453002 Client P(M PXe-Pa~d Coils/NO3 Flattop Technic.d Sty l~'inted ~te/Time 10107/99 16: l l N/~ Coll~t~ Dale~ime 10/0~/99 14:30 L 15 ~c 22 T12N R3W R~iv~ ~/Time 10/05/99 15:55 Dfi~g Wa~r T~i~ D~or: Stephen C. Ede 0 Released B 0 co[/lOOmk $#18 922~5 10/05/99 JP~ 1.19 0.500 m~/k EPA 500.0 10 max 10/05/09 10/05199 SCL MESSAGE goad DAT~ 7-27-72 G3:eater Ancho Area Borough, Depto of Environm( The llpguszka's have applied for a foster home l%¢Dn~3q and. ha~ a private deep wa%10 l'~ould a representative of you~' agency please collect a REPLY ) ntal Oual:tt¥ Bou.t. xy us o~ ~he results? Directions for iqile g~ 0'Hal].ey Road, South side, ~:irst Jriveway east qf O~l. lg!l. ey / Abhogg L~op Ir~gel:~ecgion ( ag---red~,a~eol) Follox.~ cr [veway in about Thank you fo~; yom: coopol~ggion · SIGNED PINK COPIES WITH CARBON INTACT. SIGNEO I. WRITE REPLY. 2, DETACH STUB, KEEP PINK COPY. RETURN WHITE COPY TO SENDER. !,hr]ql!ES'r FOP APn ~OVAL OF INgIV:fDUA!. ~;!!;¢~EP & ¢~AT[U-I FACII. IT!~]h; F OR FOSTERHOME Numbe~ of Bedrooms:~.. ................................. ~. 7{ell Data: A. Tv~ "/2,', I/_~~. C. Construct~ on ;~,,'o~;e .~, D. 7. Sewage g~sgosal C. SepB&c Tank: D. Seepage Pit Disposa] F~eld; A. Well To; Sept;~c Tank_,./~z/~ ......... , Absorption ff~/'~ Nearest' Lot line.~_~ ......... , Of. her ' . Tank ~ ",. AbSorotio~ C. Absorotion A~'ea t;o blea~:e~ii; Lot; f. ine.,...~. ,_.~ Request for Apgrova~ of ]' ,!dural Sewer & ~N~ter F:~Jc~li. ti~, P~.ge Two ,,%p?,-'ova7 ~oJ!d for One Y,~ar }::o:~ Date ~'~ Greater Ancbor~cm Area '~orou~h, Deroc~:~nor~[:, .-: "~:~,~,~'~ 'c '~,nial .... Quality / I certify that the infermat}on contained in this request for approval to be a true and accurate repz'eserd:at_~or~ of ~:he (;u~ie¢:L ,ce:roY' arm '>~ahe~_-fac".]Tt~es located at;: Signed !)ate Au g u s t" · ), 1972 Virginia Stewart State ¢)f Alaska Depar. tment of Health & Social 527 East 4th Avenue Anchorage, Alaska 99501 Services Subject: On-Site sewer & water inspection, T12N, R3W, S.H. Lot 15, section 22 Dear Hrs. Stewart: At your request all o;1-stte sewer and water iilspectton was performed on the above subject lot owned by Hr. & Mrs. Eugene Roguska. The sewer and water system is disapproved for the followin§ reaSOllS: 1) No septic tank. Sewer system consists of two log cesspools only. 2) Individual well distance requirement from well sewer system not met. A water satisfactory. to sample was obtained and the analysis was shown to be If we can be of to contact us. any further assistance, please do not tiesltate Sincerely, C.S.t.lcKechnte Environmental Control Officer MESSAGE Greater Ancho Area Borough, Depto of Environme REPLY ) mtal Ouality R~:_ Evg~B~ & Su~s~ Roguszl~a .... The Rpguszka's have applied for a foster home license_ ~!d ha~e pri~a~D~p ~llo ~Q~ld a representative of your agency please collect a water__~ple z~r. ~naly.~%~ ~nd ~n~p~c~ ~he w~ll and notify us of the results? Directions for Mile ~ O'Malley Road~ South side, first drivewa east ~~1) Follow driveway in about A~ f~at to ~nd. Tha~ phone nn~= is 344-1352 ___Thank yau~ fo~yo~ cooporation Virginia Stewart .......... Social &~orkar III SIGNED SIGNED 1. KEEP YELLOW COPY. 2. SEND V~ E AND PINK COPIES WITH CARBON INTACT. I. WRITE REPLY. 2. DETACH STUB, KEEP PINK COPY. RETURN WHITE COPY TO SENDER. Fha, 02.006 . J GR~ATE R AI~.,,HORA ~: .... BOROuG?! Department of unv~o~menta] Qu~h..5 3500 Tudo~ ~oad, Ancho~age~ Alaska 995~7 2'/9-8686 Date Received 8-1 -72 REQUEST FOR AR~;ROVAL OF INDTVIDUAL SE~I[~R & YVATER FACILITtES FO~ FOSTERHOME Approval Requeste_d By:__ Add~es~:_ DPp-~~ S~l SErvers ,-,,one: ~ Phone ~ 344-1353 Prooertv ~ner :_~~~a Location:_ mi 1 ~~ road Type of Facility to be Inspect. ed: 6. '~/el] Data: A. T~e . C. Construction~,:,~P~L~,~'~U~ ~-- 7. Sewage Dlsaosal o~stem: C. Septic Tank: 1. D. Seepage Pit ~3].. Disposal Fie'ld: B. Deoth ~.jZ 2-/ D, ~ac r ] An Total Length of Lines__z~/_~ Distances: A. Well To: Septic Tank_/~/~ . Absorotion Area //~ . Sewer Lines /~ ~ . ~ea~e~ Lot ~.inaZ~ . Ot~,~r ~o~a~ina~ion/~.~ ..... . Foundation to Seotic Tank_/g~/~.. Absorption Area to Neare,..~ Lot Line_~ · Request for Approva~f ~ _~a~e Two -· ~- 9~ Comments: Aporoved Disapproved Date Ap~rova~ .a,~d for One Year F~-o~ Date S?~ned Greater Anchorage Area Borouqb Derartment of Env!~on~ental Quality D2rAG[-,'t~ OF SYSTE]'~ /-,iI I certify that the information contalned in this request for approval to be a true and accurate representation of the subiect sewe~' and water facilities located at: Signed Date August 5, 1972 Virginia Stewart Slate of Alaska D~pa~tment of Health & Social 527 East 4th Avenue Anchorage, Alaska 99501 Services Subject: On-site sewer & water inspection, T12N, R31~, S.)i. Lot 15, section 22 Dear Hrs. Stewart: At your request an on-site sewer and water inspection was performed on the above subject lot owned by Mr. & Mrs. Eugene Roguska. The sewer and water system is disapproved for the following re~so~s: l) No septic tank. Sewer system consists of two lo9 cesspools only. 2) Individual well distance requiren~ent from well to sewer syste~ ~ot met. A water sample was obtained and the analysis was shown to be satisfactory. If we can be of any further assistance, please do to contact us. not hesitate Sincerely, C.S. 14cKechnie Environmental Control Officer mb