HomeMy WebLinkAboutDONAHO HOMESTEAD #1 BLK 2 LT 3BDonahoe
Homestead #1
Block 2
Lot 3B
#050-211-83
Municipality of Anchorage Page —j—of
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
Permit Number: 7SWU316 PID Number: 050 -A -CS
Name: &AAecsm
Wastewater System: New ❑ Upgrade
Addres � �K��
�r- 4t 9
ABSORPTION FIELD
Phone: (C l
No. of Bedpgoms:
y
Deep Trench El Shallow Trench ❑ Bed 11 Mound ❑ Other
LEGAL DESCRIPTION
Soil Rating:
Os (o
Total Depth from original grade:
49
GPD/S . Ft
Lot: Block: Jn� A,Subdivision: j� / rt
313 a
Depth to pipe bottom from original grade:
1
Gravel depth beneath pipe
5-1
1 ti✓A if
3Ft.
Ft.
Township: _,
Range: _
Section:
�—
Fill added above original grade:
ve
Gralength: too 1
�
" � Ft.
Z -rG T%L Ft.
WELL'�jb�� ❑ New ❑ Upgrad
Gravel width: ^'� �
a
Number of lines:
an lines:
ij
Ft.
Ft.
Classification (Private, A,B,C): Total D
Cased To:
Total absorption area:
Pi ee material:
.' Ft.
dtoll i
Ft.
how Q. F
SIM
Driller: Date Drilled:
Static Water Level:
Installer;
Date installed:
Ft.
Yield:
Pump Set at:
Casing Height Above Ground:
TANK
GPM
Ft.
Ft.
SEPARATION DISTANCES
XSeptic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lin
Holding
Public/Private
Manuf ct rer:
Capacit in 11 s:
in
From
Tank
Field
Station
Tank
Sewer Lines
f'
p
Welh
sf,,0,
O(.(J
��
^ ��
OL
Material: eG'
Numbe f Compartments:
Watere
)od+-
104
—"
—'
LIFT STATION
Lot
,,.�
Size in gallons:
Manufacturer:
Line
�1 >�
�Ci+-
J
�"
��
Foundation
151
1+
�'
"Pump on" level at: P?11" level at:
High water alarm at:
Curtain
/�®�
�W
Pump M odel
Electrical Inspections performed by:
Drain
Remarks:
BENCH MARK
Location and Description: J
Assumed Elevation:y�
W
S & S ENGINEERING .0Inspections
a,
performed by: 1S
a,r
Ea le River, Alaska 99577 2nd 1
t'' ^% ROBERT C. COWAN r
3rd Z�t
Department of He Ith an u Services approva
CE - 8801 ,i.�d fr
r a'•.,
,. ^\
Reviewed and approved by Date:
72-013 (Rev. 9/91) MOA 25
Permit No. SW960310
Page 2 of 2
Municipality of Anchorage
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
Legal Description:
LOT 3B, BLOCK 2, DONAHO HOMESTEAD #1
PID No.: 050-211-83
72-013 A (Rev. 9/91) MOA 25
q
B
15'UTIL.
ESMT.
2.0'
------
--------
-------
-----18.0'
6.5'
tO
6.0'
I
-b-i
FL TF 32.0'
4.0'
ALT.
SITE
N
D
L2 33.5'
5.5'
C01
37.5'
5.5'
A TI
1#2
C
_01
2 58.0'
0.0'
57.5'
9.5'
-
I
T03
50.0'
7.5'
C
4 67.5'
6.0'
WATER
LINE
4
66.5'
[-M---2
4.5'
DRM
i w
F_/_WA
FDD
NOSE
ST1
'E-
I
NEW 1
50 GAL.
10' MN.
o
DBL1 COi
DBL2
NEW TRE
CHES
MT1
-
CO2~
_
�Q
MT2
'003
C04
_
I
4�
I
(t
EY BOX
INSTALLED FLOW SPLITTE
OT EXTENDED ABOVE GR
DE)
CITATION
STR
ET
ST 1
ST2
C01 = 97.2'
CO2 = 95.6'
CO3
coo
94.8'
93.4'
s7.t
FINAL
RADE C01
CO3
SCALE
1" = 40'
CO2 MT1
C04
MT2
91.5' 1250
AL
91.3'
S.T.,.........,�
••
CO3 = 90.8'
C04 = 90.8'
cot=
CO
90.9'
= 90.6' R
.1`���•••� �� "'. a+��t
fx �} .," _....1 '•�_ .�
ROBERT C. COWAN
�r+��G�J�"•tae. CE' SF3O�
NO WAT• FOUND
`•.��i✓
"�.
79.7' B.O.H.
��:'�„ °b•
..
72-013 A (Rev. 9/91) MOA 25
M64 ropy
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW960310
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:GREGG GUNNARSON
OWNER ADDRESS:P.O. BOX. 771504
EAGLE RIVER, AK. 99577
PARCEL ID:05021183
LEGAL DESCRIPTION:
DONAHO HOMESTEAD #1 BLK 2 LT 3B
LOT SIZE: 25999 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
aofvN
aAd
ZIVC stioup>w
/0Al&
DATE ISSUED: 9/24/96
EXPIRATION DATE: 9/24/97
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 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
TO ENSURE EQUAL DISTRIBUTION OF EFFLUENT
TRENCHES A FLOW SPLITTER/DIVIDER MUST BE
DOWNSTREAM
RECEIVED B
ISSUED BY:
BETWEEN
INSTALLED
DATE:
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
S &S1
;IneeR1nq
DMVER, J
LASKA /
August 27, 1996
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
REFERENCE: Lot 3B, Block 2, Donaho Homestead, Addn #1
Request you issue a permit to install a septic system to
serve the proposed four bedroom house on the referenced
property.
Test holes were excavated and percolation tests performed.
The approximate location of the test holes are located on
the attached site plan.
At the time of excavation, no water was encountered in test
holes and after seven day ground water monitoring, the
monitoring tubes were found to be dry.
This property has enough area for a future septic upgrade
which can be seen on the attached site plan.
This property is served by a Community Water System.
We do not anticipate any adverse effects on neighboring
wells, septic systems or drainage patterns by the
installation of the proposed septic system.
If you require additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E.
RCC/gk
Enclosure
MICipEA✓IRONM
Otr
E&74RyO�GE
SFp VICES
DIVISION
04 1996
RrCFI
VSD
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
1" - 50' SITE PLAN DESIGN
SCALE
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10
e Municipality of Anchorage : 4 9 T H
DEPARTMENT OF HEALTH & HUMAN SERVICES • • • • . • • : • •.�
825 "L" Street, Anchorage, Alaska 99502-0650 /• • • • • • /
SOILS LOG — PERCOLATION TEST d01 �,'• I, Ek J.
:, .gFER,P.E. •�,i000
PERFORMED FOR: 6 c2L,'1(�_lxilkJ DATE PERFORM �t�111�� '•M�
LEGAL DESCRIPTION: L,5:>V 7.- Township, Range, Section: Vj %GL
CPTH _ n L AIA Ae 4,1—/ &--, 1 SLOPE SITE PLAN
15-
16-
17
(RIEET)
IJV" I �y r ✓ .V i
12-
1/0
Mt�
2
3
14-
14
r
�•
4
5
6
of
C
8
. %-
:6�1
9-
10
10-
dµ'
WAS GROUND WAT
.4
ENCOUNTERED?
15-
16-
17
me
12-
1/0
Mt�
3
13-
14-
14
151617
81920 18-
19-
20
COMMENTS
S
IF YES, AT WHAT L
O
DEPTH?
P
E
Depth to Water Alter -
Monitoring?
erMonitoring? Date:
®®
me
Depth
•
..
Mt�
PERCOLATION RATE -b (minutes/inch) PERC HOLE DIAMETER 7
TEST RUN BETWEEN % FT AND (a FT
s A S ENGINEERING
PERFORMED BY:ver I . CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WIT STXfE'AIVD"AfPJAWRL GUIDELINES IN EFFECT 91N THIS DATE. DATE: 13- Iq
72-008 (Rev. 4/85)
e Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG - PERCOLATION TEST
� 4 9,
I• e4` ' .
%�
� 1 If
PERFORMED FOR: (- L-2--216 I%=>. 1 fes+ DATE PERFORM
LEGAL
DESCRIPTION:
Depth
•
...
(6EPJT
2
3
4-
5 5
o
8
9
10
11
12
r�
13
14
15-
16-
17
51617
18
19-
20
COMMENTS
Township, Ranqe, Section:
WAS GROUND WAl
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SLOPE
Depth to Water AA —I3-9
Monitoring? ��_ Date:
t
A-iJ
SITE
PERCOLATION RATE 1,C)(minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND 6 FT
PERFORMED BY: 'yjfZO34 Ragle RiNer Leen Read No A94 CERTIFY THAT THIS TEST WAS PERFORMED IN
77
ACCORDANCE WITH TtIVAiTE�QNO MUNICIP L GUIDELINES IN EFFECT ON THIS DATE. DATE: ^ 13— W
72-008 (Rev. 4/85)
Depth
•
...
PERCOLATION RATE 1,C)(minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND 6 FT
PERFORMED BY: 'yjfZO34 Ragle RiNer Leen Read No A94 CERTIFY THAT THIS TEST WAS PERFORMED IN
77
ACCORDANCE WITH TtIVAiTE�QNO MUNICIP L GUIDELINES IN EFFECT ON THIS DATE. DATE: ^ 13— W
72-008 (Rev. 4/85)
S &A ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
pneeRlnG CM -SITE WASTEWATER DISPOSAL 5YISTEM
EAGLE CIVIL ENGINEERS
�A�A CONSTRUCTION PRACTICES
and FAX(907)694 -1211
%/ MATERIAL SPECIFICATIONS
REFERENCE: Lot 3B, Block 2, Donaho Homestead, Addn. #1
HEALTH AUTHORITY
August 27, 1996
APPROVALS
GENERAL:
SEWER & WATER
MAIN EXTENSIONS
1. The scope of this project includes the installation of
a 1250 gallon septic tank and a leachfield trench to
serve the proposed four bedroom residence located on
the referenced property.
SEWER & WATER
INSPECTION
2. Construction shall be in accordance with the approved
site plan and design drawings, Municipal permit with
any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal
ENGINEERING STUDIES
Regulations.
AND REPORTS
3. The contractor shall be responsible for obtaining any
necessary underground utility locates.
WELL INSPECTION
4. Unless specifically agreed otherwise, the property
&FLOW TEST
owner shall be responsible for final grading areas
subsequently depressed from soil settling.
5. Contractors installing wastewater disposal systems
SITE PLANS
must be certified by the Municipal Health Department
for system installations. Owners installing their own
systems must also receive prior approval from the
Municipal Health Department.
ROAD DESIGN
EPTIC TANK INSTALLATION:
SOIL TEST
1. A septic tank is to be constructed by a certified
septic tank manufacturer. Construction shall include
two 4" cleanouts for pumping access.
PERCOLATION
2. The septic tank shall be sufficiently bedded to
TEST
prevent settling or shifting of the tank.
3. All standpipes on the septic tank shall extend a
minimum of 12 inches above final grade.
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
Page Two
Lot 3B, Block 2, Donaho Homestead, Addn #1
August 27, 1996
4. Septic tanks installed with less than 4 ft. of cover shall
be insulated.
5. A foundation cleanout shall be installed one to four feet
from the building foundation. In the line between the tank
and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic
tank). These cleanouts shall be located on undisturbed
soil not more than 10 ft. from the tank. The first
cleanout, in line, shall be to clean toward the leachfield.
The second cleanout shall be to clean toward the septic
tank.
6. Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
1. Excavate the proposed trench to the dimensions shown on the
design. The bottom of the excavation shall be within 2
inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed -up) before
gravel (sewer rock) placement.
2. Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier must be installed between the final gravel
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
4. Monitor tubes shall be of four (4) inch diameter,
installed approximately in the locations shown on the
design, and extend a minimum of 12 inches above final
grade. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is
equivalent to the effective depth of the gravel as noted on
the design.
Page Three
Lot 3B, Block 2., Donaho Homestead, Addn #1
August 27, 1996
5. Backfill over the final gravel layer must not be less than
twenty-four (24) inches. Insulation must be installed when
the backfill depth is less than thirty-six (36) inches.
The finish grade over the trench must be mounded to prevent
the formation of a depression after settling.
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Type of Pipe Perforated Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be
approved by the inspecting engineer.
3. Insulation shall be at least 2" thick extruded direct
burial_ polystyrene (Dow Chemical Company Styrofoam HI or
equal).
4. Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N,
or equal) must be installed between the final leachfield
gravel layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the #200 sieve.
7. When sand is being used as a filter material, its gradation
specifications must conform to current M.O.A. or D.E.C.
requirements.
Page Four
Lot 3B, Block 2, Donaho Homestead, Addn #1
August 27, 1996
INSPECTIONS:
Typically there will be a minimum of three (3) inspections
required during the installation of the wastewater disposal
system. These inspections will occur as follows:
I. The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel. A septic tank
may be set in place, but may not be backfilled before
this inspection.
2. The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
3. The final inspection is to occur upon final grading of
the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at least 24 hours prior
to the start of construction. If necessary, a pre -construction
meeting will take place on-site. The inspecting engineer will
not coordinate, direct or control in any way the contractors
activities.
The owner shall contract with the contractor to perform the work
outlined in these specifications and plans and in accordance
with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S
Engineering. S & S Engineering shall be the owner's
representative and will inspect the work as stated above to
document the contractors activities. Final acceptance of the
contractors work rests with the owner and the M.O.A.
Page Five
Lot 3B, Block 2, Donaho Homestead, Addn #1
August 27, 1996
S & S Engineering shall have no liability to the owner or to
others for acts or omissions of the contractor or any other
persons performing work on this project or the failure of the
contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer
will not be responsible for the construction means, methods,
techniques, sequence, procedures or the safety precautions
incident to this project.
CONTRACTOR/INSTALLER
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
Sip
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-911-93 COSA# Cl1. GENERAL INFORMATION Expiration Date: If — 0 1
Complete legal description
DONAHOE HOMESTEAD N 1:
LOT 38,
BLOCK 2
Community Class Well
❑
Public Water System
Location (site address)
19339 CITATION ROAD* EAGLE
RIVER AK,
99577
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
GREGG do JACKIE GUNNARSON Day phone
P.O. BOX 90982• ANCHORAGE AK. 99509
Day phone
762-3158
BARBARA CRITTENDEN W/ PRUDENTIAL Day phone 689-1802
16635 CENTERFIELD DRIVE, ANCHORAGE AK, 99577
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
❑
Individual Water Storage
❑
Community Class Well
❑
Public Water System
0
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
a
Individual Holding tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certifitates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems
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 samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) C6rtificates are valid for one year for properties served by Clads A or B wells or a public water system.
The Municipality of Anchorage is not respopsible 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, 1 verity 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 optained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site.watei 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
GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 •E. TUDOR ROAD, SUITE 101 ' ANCHORAGE, AK 99507
Engineer's Printed Name
JEFFREY A. GARNESS, P.E. Date 1 D d
Engineer's Comments:
In conducting this evaluation, GEG, LID. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily Identifiable features. The operational life of all weps and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG. LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report Is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
S. DSD SIGNATURE
Approved for 4 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the fllowing stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
—L.�- Arsenic Advisory
Maintenance Agreements
Supplemental Engineers Reort
Nitrate Advisory Other
By:lzl''
(R".11105)
Original Certificate Date:
PROGRAM
Municipality of Anchorage
• '� Development Services Department =�
Building Safety Division
On -Site Water d Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:. _____ DONAHO HOMESTEAD #1; LOT 3B, BLOCK 2 Parcel ID: 03�o'2�>'' S�
A. WELL DATA • PUBLIC WATER
Well type If A, B, or C provide PWSID# _ Well Log (Y/N)
Date completed Sanitary seal (Y/N)_ Wires properly protected (Y/N1
Total depth ft. Cased to ft. Casing height (ab round) in.
FROM WEL;—g.p.m.
AT I CTION
Date of test
Static water level
Well production g.p.m.
WATER SAMPLE RES
Coliform colonies/100 ml. Nitrate mg./L. Other bacteria colonies/100 ml.
Arsemug./L. Date of sample: Collected by:
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL Date installed 10/5/1996
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping 5/7/2008 pumper JR'S PUMPING
C. ABSORPTION FIELD DATA EEow EXISTING GRADE NORTH TRENCH/SOUTH TRENCH
Date installed 10/5/1996 Soil rating .p.d. or ft'/bdrm) 0_6 System type DEEP TRENCH
Length 100' (2050') ft. Width 2.5/2.5 ft. Gravel below pipe 5/5 ft.
•9.75/
Total depth •8.6 ft. Eff. absorption area 1000 ft= Monitoring tube YES Depression over field NO
Date of adequacy test 0 *5/13/2008 . Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 30/21 In. Water added 9100 gal. New depth 46 33 in.
Elapsed Time: 120 min. Final fluid depth 44/31 In. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date —
"WATER INTRODUCED THROUGH DOUBLE CLEANOUTS AFTER TANK.
D. LIFT STATION
Date installed Size in gallons Manhole/Access
"Pump on" level at in. "Pump off' I�at �r High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
PUBLIC WATER
Septic tank/lift station on lot On adjacent
,Absorption field on lot On adjacent lots
Public sewer main
Sewer /septic service
areas
manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
5'+
Property line
5'+
Absorption field
5'+
Water main
10'+
Water service line
•10'+
Surface water
100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water service line '10'+ Surface water 100'+ Driveway, parking/vehicle storage 3'
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
"PER S&S INSPECTION REPORT.
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date 5/&lc>13
COSA Fee U- 00
Date of Payment t1D 28�1�
Receipt Number , -4;dO
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
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