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