HomeMy WebLinkAboutHILLSIDE NORTH ADDN #9 LT 6Hillside North
#9
Lot 6
#041-032-09
Municipality of Anchorage Page t of 3
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw, Street
P.O. Box 196650 Anchorage, AK 99519-W5o
www.cl.anchorage.ak.us (907) 3437904
OWSITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number. SWM041 PID Number. 041-032.09
R.n•:
Gr o Motyka Wastewater System: New
Adwwa
P.O. Box 90846 Anch., AK 99509
ABSORPTION FIELD
• wrow a e•meae.:
333.9977 Four 4
Deep Trench
LEGAL DESCRIPTION
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6 Hillside North Addn. 9
4 Fl.
8 FL
T-Y*W Rw" sworn:
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1-2.5 Ft.
67 Fl.
Well: New
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Private
84 184
1,072 Fe
ASTM 3034 PVC
PJI•r
Dw• Dn Stwn Www L• ,
Alpine
5123104 54 FL
AMAQ Corporation
6117.20104
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8
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1
Cary Ao Grana
>2
TANK
GPM
Fl.
Ft
SEPARATION DISTANCES
0 Septic ❑ Holding 0 S.T.E.P. I] Other.
To
Septic
Absorption
Lift
Holding
From
Tank
Field
Station
Tank
sewerune
Anchorage Tank
1,250
wr
>100'
>100'
WA
NIA
>25'Steel
Two (2)
srn.o•ww
>100'
>100'
WA
WA
LIFT STATION — NONE ON LOT
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>5'
>10,
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>10'
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BENCH MARK
Back Deck Southeast Comer.
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Engineer's Stamp
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0:49th � `�"
Inspections performed by: MEA Dates: 1'L 8/12104
0
A
2 nd8/12104
: fi,MICHAEL E. ANDERSON 4yy,
Department of Health and Human Services approval
•• s No. CE -4381 f �%
Date:cZ'/6-0�
♦♦♦•h�fEssa::`�•
mRevi�wedandapprovedby:
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT Page 2 of 3
4700 South Bragaw Street Anchorage, AK 99519-0655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number. SWO40041 I'll', ; PID No. 041-032-09
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Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number. SWO40041
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PID No. 041-032-09
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PROFILE AS -BUILT
scale: V • 1P
Mayor
Municipality of Anchorage
Department of Health and Human Services
84'L' Street
P.O. Box 190650 Anchorage, Alaska 99519-6650
hnp:#*ww.ci.anchonga ak.ua
Permit Number. #SW 040041 Date of Issue: 4-1.04 Parcel Identification Number -041-03
Date Started: 5-23-04 Date Completed: 5-23-04 Is well located at approved permit location? ® Ya El No
halal Description: Hillside North Add/tb7 # 9 Subdhrision Lot 6
Property Owner Name & Address: Gregory Motyka
PO Box 90846
Anchornae. Alaska 99509.0846
Borehole Data:
Soil Type, Mietm m & Water Strata
Depth (ft)
From To
Method of Drilling 1Z air rotary ❑ cable tool
Casing type: , tpj
Stick up
0 ..
.2 _
Wall Thickness: 10 inches .
gravelly sbt
2
59
Diameter. ¢ inches' Depth:11 feet
silly sandy gravel wet
59
62
Liner Type:
gravelly sdt
S*
sandy gravelly silt
grsvelly sandy silt H2O
62
67
67
'76'
67
73
76
84
Diameter: inches Depth: feet
Casing stickup above ground: Z feet
Static water level (froth ground level): '�4 feet
Pumping level:ifeet after
Z hours pumping I gpn
Recovery Rate: $ gpm
Method of Testing: $klid
Well Intake Opening Type:
® Open End ❑ Open Hole
❑ Screened Start feet Stopped feet
❑ Perforations Start feet Stopped feet
Grout Type: hentonite it 8 Volume: Lhg
Depth: Start 9 feet Stopped 9 fat
Pump: Intake Depth feet
-
Pump size hp Brand Name
Well Disinfected Upon Completion? ® Yes Q No
Method of Dhinfection: chlorine tablets
Comments:
Well Driller. Alpine Drilling 6 Enterprises
PO Box 110496
Anchorage Alaska 99511
Attention: The well driller shall provide a well log to the property owner within 30 days of completion and the property
MUNICIPALITY OF ANCHORAGE
Development Services Department
Onsite Water 6 Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519.6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM / WATER SUPPLY PERMIT
Initial
Permit Number: SW040041
Date Issued: Apr 01, 2004
Expiration Date: Apr 01, 2005
Parcel ID: 041-032-09
Legal Description: ;HILLSIDE NORTH ADDN #9 sUBDIVISION LOT 6
Design Engineer: 0014 Anderson Engineering Site Address: NHN HAVEN CIRCLE
Owner Name: GREGORY MOTYKA Lot Size: 99655 SQ. FT.
Owner Address: PO BOX 90846 Total Bedrooms: 5 Permit Bedrooms: 5
ANCHORAGE. AK 99509-0846
This permit Is for the construction of:
❑✓ Disposal Field Q Septic Tank ❑ 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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 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
Issued
Date: 0 4
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 041—OR-07 Permit Number SW 0 5004/
Property owner(s) Gregory Motyka Day phone 333.9977
Mailing address (1) P.O. Box 90846 Anchorage, AK 99509
SITE
Mailing address (2)MHN 14J9VEN C/RCLF Zip Code `/9507
Legal description (Lot, Block & Sub'd.) Lot 6. Hillside North Subdivision, Addition No. 9
Legal description (Section, Township & Range)
Lot Size 996 SS Acres q.Ft. Number of Bedrooms Five (5)
THIS APPLICATION IS FOR:
Sewer Only ❑ Well Only ❑
Sewer and Well ® Water Storage ❑
Sewer Upgrade ❑
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit Fees: !P3215 — Waiver Fees:
Date of Payment: Date of Payment:
Receipt Number: `i N ZO Receipt Number:
(Rev. 12100)
C} iQ/p 51V2/42
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 FAX
March 29, 2004
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 6, Hillside North Subdivision Addition No. 9
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 6, Hillside North Subdivision Addition No. 9 intends to construct a five -
bedroom home on the lot. We are therefore requesting a permit be issued for the
construction of a new well and septic system to serve the new home. The attached Site
Plan and backup documentation identify the location and configuration of the proposed
well, septic system and alternate site. There is currently no development on lots
adjacent to this lot and no conflicts exist between the well and septic system proposed
for this lot and those on adjacent properties. Contour lines with representative surface
slopes are shown on the Site Plan. The drainage pattern will be maintained after
development of this lot is complete.
Test holes placed on the lot in the area of the new absorption trench indicated silty
sand with gravel and some cobbles to 12" in diameter. The accepting soils were tested
and found to have percolation rates ranging from 16 to 18 minutes per inch. No
groundwater was found during excavation and none was noted during the monitoring
period. We are therefore proposing to place a new 1,500 -gallon septic tank along with a
80' long by 3' wide by 8' effective depth absorption trench to collect and treat the
sewage generated in the house. The bottom of the trench will be 11' below the surface.
A minimum of 3' of cover will be placed atop the trench and 4' atop the new septic tank.
The ground surface on the lot slopes at grades up to 15% from east to west as shown
on the Site Plan. The absorption trench will be constructed parallel with the slope of the
ground surface as much as possible in conformance with Municipal requirements. The
new septic system will be constructed a minimum of 100' from the well proposed for the
lot and on adjacent lots. It will also be constructed a minimum of 100' from any surface
Lot 6, Hillside North Subdivision Addn. No. 9
March 29, 2004
Page Two
water in the area.
If the system is constructed in accordance with our design the following statements
apply:
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.
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.
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 pattern will be maintained.
Sincerely, 0-t-,
Michael E. Anderson, P.E.
Attachments
'4749 th )FK
MICHAEL E. ANDERSON
E No. CE -4381 ,0
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LOT 6, HILLSIDE NORTH
SUBDIVISION, ADDITION NO. 9
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Five Bedroom House 5' Wide Trench System
Perc. Rate: 16 Min./Inch 1,500 Gallon Septic Tank
Application Rate: .6 GPD/SF 8' Drainfield Rock
5 Bedrooms X 150 GPD/.6 GPD/SF (Application Rate) = 1,250 SF Absorption Area
1,250 SF/16 SF/ LF = 78.1 LF Trench Length
THEREFORE: Construct a 80' Long x 3' Wide x 8' Effective Depth Absorption Trench.
Flow Line Elevation in Trench to be 3' Below Original Ground Surface. Total Depth to be
11' Below Existing Ground. Provide 4' Cover Over Septic Tank and 3' Cover Over
Absorption Trench.
Natural
Backfill
2'6"
Geotextile
Fabric
6" t 4" Perforated
t PVC (Holes Down)
810" 1 I— Drainfield Rock
F 3 4
TYPICAL DEEP TRENCH SECTION •••.,�,
(NO SCALE) E •�
NOTE: Grade Area Over Trench to Drain Away. 49m
Minimum 6' Separation From Bedrock. �._.; .....
Minimum 4'Separation
om
Minimum 100' Separations FromrSurf ce
Minimum 100' SepaWater or Streams. �. �k.,. Na CE4ml LE. ration From Wells in the Area. YiC IiNOER
VeTec•h Engineering Technical `.
P.O. Box 873141 Wasillo, Alaska 99687-3141
Phone: 907-357-6304 Fax: 907-357-6305
I SOILS LOG - PERCOLATION TEST I
LEGAL DESCRIPTION- LOT 6, HILLSIDE NORTH ADD#9 S/D i •,
DATE: R 3/100 04 AMAO EXCAPROJECT No M0410 VATINGfell j�0.
PR``O`FE`SS%
PARCEL ID,11. TECHNICIAN: T.L.KIMBROUGH Prolee`Q 01L
DEPnI TEST HOLE # 1 Type of Test: E Percolation ❑ Visual
(f"t)
1 OB/OG
2
3
4
6
BROWNISH -GRAY SILTY -SANDS
W/GRAVELS SOME COBBLES TO 12"
8 MEDIUM COMPACTION
MED MOIST
9
10
15
16
17
18
19
::F
SITE PLAN
THIO � It
TH2o
SEE FUTURE ASBUILT
CIOo/ 0% C50%
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
WATERF
(INCHES) I
NET DROP
(INCHES)
3/10/04
TEST HOLE PRESOAKED PRIOR TO TESTING:
1
10:25
8.0'
CHARGE
2
10:55
30
6.0"
2'
3
10:55
8.5"
RECHARGE
4
11:25
30
6.625"
1.875'
5
11:25
8.0"
RECHARGE
6
11:55
1 30
6.125'
1 1.875'
PERCOLATION RATE•• 16 (MIN/INCH) FERC. HOLE DIA. 6 fINCI1ES)
TEST RUN BETWEEN. FT. and 5_5 FT.
WAS GROUND WATER ENCOUNTERED? NO IF YES Q WHAT DEM19
DEPTH OF WATER AFTER MONITORING: NONE DATE OF MONITORING: $ ��
COMMENTS: NO IMPERMEABLES ENCOUNTERED
TEST PERFORMED BY VETECH ENGINEERING TECHNICAL SERVICE. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE-
VeTeah Engineering
P.O. Box 873141 Wasillc
Phone: 907-357-6304
DEPn I
(rat)
2
n
Technical S
Alaska 99687-3141
Fax: 907-357-6305
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION- LOT 6. HILLSIDE NORTH ADD#9_S/D
PERFORMED FOR- AMAO EXCAVATING
DATE: 3/10/04 PROJECT No • M0410
PARCEL ID/j• TECHNICIAN: T.L.KIMBROUGH
OB/OG
TEST HOLE #2
6
BROWNISH -GRAY SILTY -SANDS
W/GRAVELS SOME COBBLES TO 12'
8 MEDIUM COMPACTION
MED MOIST
9
11
me
17
E
Type of Test: ® Percolation ❑ Visual
SITE PLAN
THIO- 1-0
n a
TH2o '5 11
SEE FUTURE ASBUILT
o
. not 0% =
1 7!nd
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DW TERF
(INCHES)
NET DROP
I (INCHES)
3/10/04
TEST HOLE PRESOAKED PRIOR TO TESTING:
1
10:35
10.0"
CHARGE
2
11:05
30
8.125'
1.875'
3
11:05
10.0"
RECHARGE
4
11:35
30
8.25"
1.75'
5
11:35
10.0"
RECHARGE
6
1 12:05
1 30
1 8.25'
1 1.75"
PERCOLATION RATE• 17.1 (MIN/INCH) FERC. HOLE DIA. 6 (INCHES)
TEST RUN BETWEEN:: 4_5 FT. and 5_5 FT.
WAS GROUND WATER ENCOUNTERED? NO IF YES @ WHAT DEPTH?
DEPTH OF WATER AFTER MONITORING: NONE DATE OF MONITORING: 3 Z
COMMENTS: NO IMPERMEABLES ENCOUNTERED
TEST PERFORMED BY VETECII ENGINEERING TECHNICAL SERVICE. 1, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE:
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 6, HILLSIDE NORTH SUBDIVISION, ADDN. NO. 9
GENERAL:
1. The scope of this project includes the procurement and placement of a new
1,500 -gallon septic tank at the location shown on the Site Plan. Work also
includes the construction of a new 80' long X 3' wide X 8' effective depth
absorption trench at the location also shown on the Site Plan. The
distribution line in the trench will be placed at 3' below the existing ground
surface. Total depth of the trench will be 11' below the existing ground
surface. The new absorption trench must be placed a minimum of 100' from
the well on this and adjacent lots. A minimum of 10' must separate the
trench from the lot line.
2. Construction shall be in accordance with the approved site plan, design
drawings, Municipal Permit with any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal Regulations.
3. The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the location
of all lot lines. The Contractor must also verify the location of wells in the
area and assure that the separation distances are met.
4. Unless specifically agreed otherwise, the contractor shall be responsible for
final grading areas subsequently depressed from soil settling. Property
owner shall be responsible for revegetation of affected areas unless
specifically agreed otherwise.
5. Contractors installing wastewater disposal systems must be certified by the
Municipal Department of Health and Human Services for system installations.
Owners installing their own systems must receive prior approval from
D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
A new 1,500 -gallon septic tank must be procured from an approved source
and installed at the location shown.
2. A septic tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two 4" cleanouts for pumping access.
3. The septic tank shall be sufficiently bedded to prevent settling or shifting of
the tank.
Lot 6, Hillside North Subdivision No. 9
March 29, 2004
Page 2 of 3
4. All standpipes on the septic tank shall extend a minimum of 12 inches above
final grade.
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial
insulation.
6. A foundation cleanout shall be installed one to four feet from the building
foundation. Two cieanouts are required between the tank and the drainfield.
7. Final grading over the tank shall be such that a positive slope exists away
from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown on the design.
The bottom of the trench shall be within 2" of level.
2. Distribution piping must be placed level with perforations down atop a level
bed of drainfield rock. Rock should then be placed over the pipe to provide a
minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between the drainfield rock
and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the locations shown on
the design. The portion below ground must be perforated.
5. Contractor shall verify the septic tank and drainfield are a minimum 100' away
from any private water wells in the area, 150' from a Class "C" Well or 200'
from any community well.
6. Direct bury insulation must be placed over the distribution system if less than
3' of backfill depth is available. Finish grade over the trench must be
mounded to prevent settlement or depressions.
7. Grade area surrounding the absorption trench to drain away.
8. A minimum 2' of accepting soil is required below the drainfield rock for a 5'
wide trench. Contractor shall verify this condition prior to placement of the
rock. All pockets of unacceptable materials must be removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a municipally approved septic tank
manufacturer.
Lot 6, Hillside North Subdivision No. 9
March 29, 2004
Page 3 of 3
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and
solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662
or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow
Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Fernco, or equal).
5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing the
#200 sieve.
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These inspections
must be conducted under the supervision of a professional engineer registered
in the State of Alaska. The first inspection must be conducted after the
excavation of trenches, beds or pits and before the installation of any gravel. A
septic tank may be set in place, but may not be backfilled.
The second inspection must be conducted after the placement of the geotextile
fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No
backfill should be in place at the time of inspection.
Contractor shall provide a copy of all field survey layout and construction notes
for use in preparing the certified as -built of the completed system.
jar -W
Municipality of Anchorage
Development Services Department
Building Safety Division
Onsite Water and Wastewater Program
4700 South Bragaw St
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FORA SINGLE FAMILY DWELLING
Parcel I.D. 041032.09
1. GENERAL INFORMATION
HAA# D5 o�z
Expiration Date: 0
Complete legal description Lot 6 Hillside North Subdivision, Addition No. 9
Location (site address or directions) 9660 Haven Circle Anchorage AK 99516
Current Property owner(s) Gregory Motvka Day phone 333-9977
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
P.O. Box 90846 Anchorage AK 99509 —
Unless otherwise requested, HAA wDl be held by DSD for pickup.
2. NUMBER OF BEDROOMS
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
Four 4
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
®
Individual On-site
19
❑
Individual Holding tank
❑
❑
Community On-site
❑
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) 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) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority 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 may be reissued for a period of up to one year with
valid water samples.) 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 engineers
work.
4. 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 Health Authority 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 2/9/2005
S. DSD SIGNATURE
✓ Approved for ---q— bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: (Lc.1�. / �o �// Original Certificate Date: d
Municipality of Anchorage e
• Development Services Department
Building Safety Division "
Onsite Water 6 Wastewater Program s "
4700 South Bragaw SL
P.O. Box 196850 Anchorage, AK 99519-6650
www.cl.anchorege.ak.us
(907) 3437904
HEALTH AUTHORITY APPROVAL CHECKLIST
� _ . � . .1 .Il . •u•� � :dui- • � • � - _ � � g �r
A. WELL DATA
Well type Privets If A, B, or C provide PWSID s _
Date completed Sanitary seal (YIN)!
Total depth _R -R. Cased to A4 ft
FROM WELL LOG
Data of lest S23RQ4� —
Static water level S4 ft.
Well production 8 9 -P.M.
WATER SAMPLE RESULTS
Weil Log (YIN)
Wires property protected (YAV) Y
Casing height (above ground) 24 in.
AT INSPECTION
ft
9.p.m.
Coliform J_coloniesl100 mi. Nitrate 1.68 mg.A. Other bacteria __L ookmies1100 ml.
B. SEPTICIHOLDING TANK DATA
Tank Type/Material See00020
Tank sits 1250 gal. Number of Compartments j
Foundation cleanout (YIN) Y Depression over tank (YIN) y
Cleanouts (YIN) Y
High water alarm (YAV) N
Date of pumping Pumper New Constnrction
C. ABSORPTION FIELD DATA
Date installed 618R004 Sob rating (9-p.d.fie or fe/bdrm) .6 GPDMF System type Dee° Trench
Length 67 R Width 3.3 fL Gravel below pipe 8 ft.
Total depth 13-15 fL Eft. absorption area 1.072 fe Monitoring tube Y Depression over field N
Date of adequacy test Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption ftek1 before test _ In. Water added_ gat. New depth_ in.
Elapsed Time: _ min. Final fluid depth _ in. Absorption rate >= 9 p -d.
Any rejuvenation treatment (past 12 mo.) (YIN fL type) N If yes, give date
D. UFT STATION
Date installed Sae in gallons
'Pump on' level at _ in. 'Pump ofP level at _ in.
Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tanknift station on lot >1W
Absorption field on lot >JW
Public sewer main WA
Manhole/Access (Y/N)
High water alarm level at in.
Meets alarm & circuit requirements?
On adjacent W _MW
On adjacent lots >1W
Public sewer manhakdcleanout WA
Sewer /septic service fine >25' Holding tank WA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >S Properly line >_,Er Absorption field >S
Water main WA Water service line MO* Surface water >IV
Wells on adjacent kits MW
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line >10, Building foundation _ >10, Water main >10'
Water Service line >10' Surface water >1W Driveway, parking/vehicle storage 5,25'
Curtain drain None Noted Wells on adjacent lots MW
F. COMMENTS
G. ENGINEERS
I certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in _ t
conformance With MOA HAA guidelines in effect on this date.
L rObMEL E MaQSW
Engineer's Printed Name Michael E. Anderson. P.E. `, No, CE -,3m ;'%
Date 2191 =5 v.�j
�ee1.• /iN.....
HAA Fee $ �7 V/ 7S �vs N Waiver Fee $ _
Date of Payment 2 �� psO S Date of Payment
Receipt Number f'9 3� ocP t,, � Receipt Number,
lrtev. 12M)
I
■■■ 2-14-05: 6:05PM:
SGS Ref. #:
Client Name:
Project Name:
Client Sample ID:
Matrix:
PWSID
Sample Remarks:
1050674
Anderson Engineering
Hillside North, #9, Lot 6
Hillside North, #9, Lot 6
Drinking Water
:907 56,5301
CT&E Environmental Services
200 W. Potter Drive
Anchorage, AK 99518
Tel: (907) 562-2343
Fax: (907) 561-5301
All datesttimes are Alaska Standard Time
Printed Date/Time:
02/14/05 16:50
Collected Date/Time:
02/09/05 10:25
Received Date/Time:
02/09/05 10:52
Technical Director
Stephen Ed
1.00 mg/kg EPA 300.0 10.00
02/10/05
Released Byr—•/"
mx
Allowable Prep Analysis
Parameter Results PQL Units Method Limits Date Date Init
Bacteria
20B, w/o coli
9222B
02/09/05
02/11/05
do
Nitrate
1.68
1.00 mg/kg EPA 300.0 10.00
02/10/05
02/10/05
mx
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2001-176
HILLSIDE NORTH SUED., ADDN. NO. 9
LOT 6
99.656 S.F.
HAVEN CIRCLE
s�or mown [sur.
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