HomeMy WebLinkAboutROLLING HILLS VIEW ESTATES BLK 4 LT 3 Rolling Hill
View Estates
Block 4
Lot 3
#050- 322-13
Mur~icipality of Anchorage Page ! o!
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: ;~./~"~ ~ ~ PID Number: O-~- Z~2. CZ- ~"'~
Phone: INo. of B~oo m s:
LEGAL DESCRIPTION
Lot: Block: Subdivision:
Township: Range: Section:
WELL: [] New [] Upgrade
Classification (Private, A,B,C): Total Depth: Cased To:
Ft. Ft.
Driller: Date Dr I ed: Static Water Level:
Ft.
Yield:
From
GPM Pump Set at:
Casing Height Above Ground:
Ft. Ft.
SEPARATION DISTANCES
TO Septic Absorption Lift Holding Public/Private
Tank Field Station Tank Sewer Lines
Surface
Line
Foundation
Curtain
Drain
Remarks:
Inspections performed by: %--¢)
Wastewater System: ;, New j~Upgrade
ABSORPTION FIELD
Deep Trench [] Shallow Trench []Bed [] Mound []Other
Soil Rating: It ,,~ Total Depth from tri~inal grade:
GPD/Sq,
Ft.
Depth to pipe bottom from original grade:
Ft
Fill added above original grade: Gravel length:
Gravel width: Number of lines:
Ft. /
Total absorption area: Pipe material:
Date installed: ~I~
Installer: ~t~..-- I I/~' . / [~ ~/' '7
TANK
Gravel depth beneath pipe
7 Ft
~i!¢'Septic [] Holding [] S.T.E.P.
Manufacturer: Capacity in gallons:
Material: ~ ~
LIFT STATION
Size in gallons: Manufacturer:
"Pump on" level at: "Pump off" level at:
~ump Make & Model Electrical Inspections performed by:
BENCH MARK
IHigh water alarm at:
Location and Description:
Dates: 1st ~*/"//'~ l
2nd
Assumed Elevation:
72-013 (Rev 9191) MOA 25
Department of Healt[l~and Hu, mi~n Services approval
Reviewed and approved by ~,~, /~ate //-2 '-
/ /
ENGINEER'S SEAL
'- '~,., <.- ,.., ,
~ENCH ~
ABSORPFION
TOTAL 50 FT
TOTAL I1 FT
COVE~ ~ DEPTH
!
!
\
\
TOBBEN SPURKLAND P.E.
203 W 15TH. AVENUE
ARCH. AK. 9950!
(907) 279-39!6
IOLLING HILLS FIE~, BK 4, LOT 1[
JOAN HAMILTON
19221 UPPER McCRARY ROAD
BENCH MARK:
BOTTOW S/D/ND
& SSIIWFR F( rv,~ T~n~ rnn nn ~-r
SEPtiC SYSTEM AS BUILT
9ATE: ROY, 9, 1997
SHEET: 2/5 SRID.Hl, Y254
PER'MIT # SW970556
Plonltor'
C~ean DuE
Cleon DuE
Sfondord ?tenth ~
Honi~or
£' W/de
$0' Lon9
]/' Deep
7' Sewer roc/~
d' Cover
(: o o
i000 90~ Septic ~onR
ZD 200 FLZTW ?IVE£TER'
Cleonoufs
d, / Co vel"
FLOW D/VERIER
/000 SEPTIC TANK
/V[on/ qcOF'
IE 75.5
SILT
68.2
7,0 £~: of" SPP?iC Rock
ND SCALE
IE 75.3
68. 1
~ENCN NA~/~i BOTIOY S/DING
ASSUMED ELEV, 100,00
TDBBEN SPURKLAND P,E,
203 WlSth Ave
Anchoro, 9e Al< 9950].
P7?-~?lfl
HILLS VIEW ?/( 4. LZ]? ?
JDAAI HAMIL TON
]9£21 UPPE£ HcC£A£Y £DAD
sEPTIC SYSTEM. AS BUILT
DATE, N~ ~
SHEET~ ~/~ 6RI~,
PER~iviI? ii SW97038(~ PIP # 050-3~£-13 RHV$4033,9~/O
PAGE 1 OF 1
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 (UPGRADE) PERMIT
PERMIT NUMBER:SW970386
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:STARR JOAN D
OWNER ADDRESS:19221 MCCRARY RD
EAGLE RIVER, ALASKA 99577
DATE ISSUED:10/31/97
EXPIRATION DATE:10/31/98
PARCEL ID:05032213
LEGAL DESCRIPTION:
ROLLING HILLS VIEW ESTATES BLK
4 LT 3
LOT SIZE: 50312 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD SYSTEM
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 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
RECEIVED BY: ~
ISSUED BY:
DATE:
ROLLING
203 W 15th. Avenue, Suite 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
SEPTIC SYSTEM DESIGN
HILLS VIEW ESTATE, BLOCK 4, LOT 3
19221 UPPER McCRARY ROAD
JOAN HAMILTON
Municipality of Anchorage
Department of Health and Social Servtces
820 1 Street
Anchorage, Alaska 99501
We are submitting an application for the installation of a upgrade septic system for this lot. The submittal consists
of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the
proposed improvements of the lot, of which only the septic system is subject to this permit application, (sheet 2/3),
and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also
enclosed. A grab sample of the soil found in the testhole is submitted for your visual classification. This lot is very
steep with slopes in excess of 45% off McCrary Road. At the suggested location for the replacement trench the
slope is at 30% more or less. The septic system design is based on the following:
No Ground Water or Impervious Layer to 17 ft.
Use Standard Trench
Soil Rating. 1 min/in = 1.2 gal per sq.ft/day
No. of Bedrooms 3
Required Area per Bedroom: 150/1.2 = 125 sq.ft..
Total area required: 3 x 125 = 375 sqft
Testhole depth 17 feet
Bottom Rock At 1t feet
Top Rock At 4 feet
Rock Depth 7 feet
Total Trench Length 375/14 = 26 ft,
Use 30
SYSTEM CONFIGURATION
STANDARD TRENCH
TOTAL LENGTH 30 FT
TOTAL WIDTH 2 FT
TOTAL DEPTH 11 FT
ROCK DEPTH 7 FT
COVER 4 FT
VERIFY CONDITION OF EXISTING SEPTIC TANK
REPLACE IF CORRODED.
The installation of this septic system will not prevent wells from being installed on the adjacent lots.
There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots.
The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface
rtmoffwill not result from this installation.
' ~., '.....~....,. ~ : ~ % /
50 0 50 100 I50 300 ~50 300
SCALE' 1' = lO0 FL
TOBBEN SPURKLAND P.E.
203 W ~5TH. AVENUE
ARCH. AK. 99501
(907) 279-3916
IOLLING HILLS VIEt~, BK 4, LOT 3il
JOAN HAMILTON
19221 UPPER McCRARY ROAD
SEPTIC SYSTEtW DESIGN
DATE: OCT 7, 1997
SHEET: 1/5 OR/D: NW254
PERMIT # ': RHVO4031,PlV6
?
TOTAL LENOT~
I
..." 4~ 05 0 25 50 75 100 125 150
TOBBEN SPUR/(LAND P.E.
205 W 15TH. AVENUE
ANCH. AK. 99501
(907) 279-5915
IOLLING t-/ILLS VIEK BK 4, LOT 3]]
JOAN HAMILTON
19221 UPPER McCRA£Y NOAD
SEPtiC SYSTEM DES/ON
DATE: OCT 7, 1997
SHEET: 2/$ GRIDS!W254
PE,2M/T ii: PI? # OSO 2££-1_3 P, HV04032,?~5
/Vlon/tor
O0' ,'.on9
ol
9ol £epf/c tank
BOO FLEW DIVE£TER
/
/
/ /-'
Cleonout:
klon,'~om
4' CO V~P
/ FLOW DIVENTE£
lO00 SEPTIC TANK
7,0
SCALE
3ENCH MARK,
ASSUMED ELEIX ZO0, O0
T[]]}BEN SPUAKLANr) J :
803 WlSth Ave
Ancho~o9e Ak 9950]
SEPTIC SYSTEM SESIGN
D~TE: ~C~ Z /997
SHEET~ ~/~ GRI~
PE£W/T # £V?7OXXX P~? # O50-,J££-/3 £HV?4033DV6
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2o
COMMENTS
Munici~'ality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
(ENGINEER'S SEAL)
Township, Range, Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth lo Water Aller j
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PE~ '3OLATION RATE ~' ~ (minutes/inch) PERC HOLE DIAMETER
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE· DATE:
MUNICIPA'LITY 0'F ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE EW
MAILING ADDRESS
LOCATION NO. OF BEDROOMS
I w e,, J Absormion area, Dwelling P E~
~ DISTANCE TO: ~'~ j~ ~ ~O*~ /~
~ ~ Manufacturer Material No. of compartments
~ ~ L~tEn gallons IF HOMEMADE: inside I~ Width ~ Liquid depth
. mTA.O TO: / Owe,,,n,
~ Manufacturer /~ Material Liquid capacity in
We~¢ F°~t~n Nearest I°t line ¢ + PE~'~ ~
I DISTANCE TO: ' I~ ' ' I~
: : ~ NOi of ,,~es:wid~ inches
T~taJ le~h~f~lines Distance betwee
Length ~ ~ine Trench
~ : ~ ~__ Total effective absdrp~0 area
B~ P Top of tile to finish grade ~ ¢ Material beneath til~,~ ~ inches ~
Length Width Depth PERMIT NO.
~< ~ Type of crib Crib diameter ~/ ~rib depth Total effective absorption area
~ Well i Bu Id ng foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO,
~ ~ilding foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS ~'~ ~ ~
I'
APPROVED ~ ~f~ ~ E~GI~EEBiN~ DATE LEGAL
~o~ o ~ o ~o~ o ~ o ~o
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~/~$OI LS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
7
8
SLOPE
DATE PERFORMED: ~'- ' I /~ ~c-~O ~
SITE PLAN
11
12'
13--
,~---~..14 -
15-
16
17,
19.-
20-
COMMENTS
PERFORMED BY:
WAS GROUND WATER
=NCOUNTERED?
,~.~, AT WHAT ~
/ ti ~ i
.~ eadi ng Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ,/~ /'~ (minutes/inch)
TEST RUN BETWEEN FT...~_~-- FT
ff-~,
Municipality of Anchorage
Development Services Department
· Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEHS APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D. 050-,322-15
1. GENERAL INFORMATION
Expiration Date: j/-¢/-//
·2.
Complete legal description ROLLING HILLS VIEW ESTATES S/D; BLOCK 4, LOT 3
Location (site address) 19221 MCRARY ROAD * EAGLE RIVER, AK * 99577
Current Property owner(s) J.D. COX
Day phone C/O AGENT
Mailing address 19221 MCRARY ROAD * EAGLE RIVER, AK * 99577
Lending agency
Day phone
Mailing address
Real Estate Agent
D'ETRE OWENS W// KELLER WILLIAMS Day phone 865-6586
... .M.ailingaddress 101 W. BENSON BLVD, #503 * ANCHORAGE, AK * 99503
Unless othetwide requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well · Individual On-site ·
individual Water Storage [] Individual Holding tank []
Community Class Well [] Community On-site []
Public Water System [] 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. Certificates 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.) 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 engineer's work.
4. STATEMENT OFINSPECTION 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 afl appficable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Phone ,357-6179
Address 5701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Date
o
Engineer's Comments:
In conducting this evaluation, GEG, LtD. 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 wells 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.
DSD SIGNATURE
~'"/Approved for 3
Disapproved.
Conditional apprOval for
bedrooms·
".
bedrooms, with the following stipulation~
Attachments: COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
(Rev. 11 ~05)
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: g '-~ c~ ~ / /
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF
Legal Description: ROLLING HILLS VIEW ESTATES S/D; BLOCK
A. WELL DATA *ASSUMED. BEDROCK @ 15'.
Well type PRIVATE If A, B, or C provide PWSID#
Date completed 6/14/1985 Sanitary seal (Y/N) YES
Total depth 85 ft. Cased to *BEDROCK ft.
FROM WELL LOG
Date of test 6/14/1985
Static water level 60 ft.
Well production 5 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi.
Arsenic: ND ug./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Tank size 1000 gal. Number of Compartments 2
Foundation cleanout (Y/N) YES
Date of pumping 8/19/2011
ABSORPTION FIELD DATA
Date installed 1/7-8/1997
Length 30 ft.
ON-SITE SYSTEIVlS APPROVAL CHECKLIST
4, LOT 3 Parcel ID: 050-522-15
Nitrate 7.80 rog.IL.
Date of sample: 5/16/2011
Depression over tank (Y/N) NO
Pumper
~'BELOW EXISTING GRADEJ
Soil rating ~or ft2/bdrm) 1.2
Width 2 ft.
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
8/17/2011
24 .ff.
5.8+ g.p.m.
YES
YES
12+ in.
Collected by: GEG, Ltd.
Date .installed 1/7-8/1997
Cleanouts (Y/N) YES
High water alarm (Y/N) N/A
ONE STOP SERVICES
System type TRENCH
Gravel below pipe 7
Total depth '11.6 .ft. Eft. absorption area 420 ft2 Monitoring tube YES
Date of adequacy test *'8/17/2011 Results (Pass/Fail) PASS
Fluid depth in absorption field before test 0 in.
Elapsed Time: 135 min. Final fluid depth 10
Any rejuvenation treatment (past 12 mo.) (YIN & type)
**HOUSE WAS VACANT AT TIME OF TEST. PRE-SOAKED ON
DOCUMENTED 1985 TRENCH CONNECTED AS RESERVE SITE.
Depression over field__
Water added 815 gal.
in. Absorption rate >=
NONE KNOWN If yes, give date
NO
For ,3 bedrooms
New depth 24 in.
450+ g.p.d.
8/16/11 WITH 2190 GALLONS. NOTE: PREVIOUSLY
RESERVE TRENCH WAS DRY AT TIME OF INSPECTION.
D. LIFT STATION
Date installed
"Pump on" level at
Datum
E.
in.
Size in gallons Manhole/Access ~
"Pump off" leve~ High water alarm level at
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
100'+
Septic tank/lift station on lot
Absorption field on lot 100'+
Public sewer main N/A
Sewer/septic service line 25'4-
Animal containment areas 50'4-
in.
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank N/A
Manure/animal excrete storage areas
100'+
· 97'+/** 100.57'
N/A
100'4-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+
Water main N/A Water service lin"~ :~ 10'+
Wells on adjacent lots 100'4-
Absorption field
Surface wate[
5'+
100'4-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation. 10'+ Water main N/A
Water service lin~t('~r' 10'4- Surface water 100'4- Driveway, parking/vehicle storage
Curtain drain NONE KNOWN Wells on adjacent lots 100'4-
COMMENTS *PER EXISTING WAIVER #WR980005 (DRAINFIELD WELL TO EDGE OF TRENCH CLEANOUT ON
ENGINEER'S CERTIFICATION
10'+
ON L~T,,~Z). *'100.57' FROM EDGE OF
LOT ~r. SHOT W/ TOTAL STATION.
i~q7
~ 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 /-'~) 'ZH~ /II
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Community Development Department
Development Services Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Bo× 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Nitrate Advisory
Certificate of On-Site Systems Approval # 111321
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 4, Lot 3 of
Rolling Hills View Estates subdivision. This inspection revealed a nitrate
concentration of 7.8 milligrams per liter (mg/L) was reported for the
property's well water sample. The Environmental Protection Agency (EPA)
has established a maximum contaminant level (MCL) of 10.0 mg/L for
public drinking water systems. While private wells are not subject to this
regulation, EPA standards are based on existing health information and can
therefore be used to gauge the relative quality of water from private wells.
Please see the attached "Nitrate Fact Sheet" for important information
regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
SGS ReL# 1113880001
Client Name Garness Engineering Group, Ltd Printed Date/Time 08/23/2011 13:47
Project Name/# Rolling View Estates B4, L3 Collected Date/Time 08/16/2011 14:00
Client Sample ID Rolling Hills View Est B4, L3 Received Date/Time 08/17/2011 8:53
Matrix Drinking Water Technical Director Ster)hen C. Ede
PWSID 0
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals by ICP/MS
Arsenic ND 5.00 ug/L EP200.8 C (<10) 08/18/11 08/22/11 NRB
Waters Department
Total Nitrate/Nitrite-N 7.80 0.100 mg/L SM20 4500NO3-F B (<10) 08/19/11 AYC
Microbiology Laboratory
E. Coli Negative I 100mL SM20 9223B A 08/17/11 DLC
Total Coliform Negative I 100mL SM20 9223B A 08/17/11 DLC
I HEREBY CERTIFY THAT I HAVE SURVEYED THE~,/t::~'~,,~/
FOLLOWING DESCRIBED PROPERTY: .~.~~,
INDICA~D. IT IS THE RES~NSIBILI~ OF THE
~ ~ D~ER~INE THE EXISTENCE OF ANY ~RI~ ~"
~1~ DO NOT ~R ON THE RE~D~ ~BDI- ~'~
v~s~o~ PU~. UED~ ~0 CmCU~ST~O~S S~ ~e, ~.... ~.~ ....~,
~ DATA H~EON BE US~ FO. CONS~U~ION ~'~/
OF FENCE LIN~, OR ~R EST~LISHING ~ND- DRAWN= _
ARY LINES. ~/
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage. AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
1..GENERAl' INF6RMATION
Complete legal description
COSA # E) Cl O O I?,
Expiration Date: /¢~- -,2 - O ~
Location (site address) %5~-~4
Current Property owner(s), ~'~
Mailing address '=13¢O- $, C,Jo~,t'z_.~o,-, ,_,c~-..
Lending agency
Day phone 303- 7-.q5- fo~,O0
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Un/ess otherwise requested, COSA will be held by DSD for pickup.
2. NUMBEROF BEDROOMS: ~'
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ~
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. Certificates 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 sample results. (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 engineer's 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 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 fime of installation.
Name of Firm .~'~r~,.~.~ ~n(~m~r'in,, Phone
Engineer's Printed Name L~ ~-~¢~c~ ~ ~ Date.
DSD SIGNATURE
~,/ Approved for
Disapproved.
Conditional approval for
~ C~.~'''' .,,.~ ~,..~ -~
bedrooms. 'l/~Sx 1) ~0~ .~
bedrooms, ~th the follo~ng stipulatio~~
By:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisor~
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Nitrate Advisory
Certificate of On-Site Systems Approval # 090013
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 4, Lot 3 of
Rolling Hills View Estates subdivision. This inspection revealed a nitrate
concentration of 7.69 milligrams per liter (mg/L) was reported for the
property's well water sample. The Environmental Protection Agency (EPA)
has established a maximum contaminant level (MCL) of 10.0 mg/L for
public drinking water systems. While private wells are not subject to this
regulation, EPA standards are based on existing health information and can
therefore be used to gauge the relative quality of water from private wells.
Please see the attached "Nitrate Fact Sheet" for important information
regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
S(;S Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
PWSID 0
Sample Remarks:
1094365001
Spurkland Engineering
Rolling[lillsVicw Estates B4,L3
RollingHillsView Estates B4,L3
Drinking Water
Printed Date/Time
Collected Date/Time
Received Date/Time
Technical Director
09/02/2009 14:24
08/21/2009 13:30
08/21/2009 16:35
StephenCEde
Allowable Prep Analysis
parameter ResulL~ POi. t Jails M~.'t hM Container I[) Limits Date Date hilt
Waters Department
Tolal Nitmtc/Nitdl~'-N 7.69 0.100 mg/L SM20 4500NO3-F A (<10) 08/28/09 R~-r
SG,$ Ret.ti 1094168001
Client Hame Spurkland Engineering Printed Date/Time 08/17/2009 9:55
Project Hame/tl Rolling llills Veiw Est B4,L.3 Collected Date/Time 08/12/2009 16:30
Client Sample ID Rolling Ilills Veiw Est B4,L3 Received Date/Time 08/13/2009 12:40
Matrix Drinking Water Technical Director Stephen C. Ede
Sample Rcmarks:
^llowahlc Prep Analysis
paramclcr Results PQI, Units M ct h~v,l Container ID Limits Date Dale Init
Microbiolo~ Laborator~
Colony Count 0 col/100mL S~t209222[~ A (<200) 0R/13/09 DLC
TotaIColiform 0 col/100mL SM20922211 A (<1) 0R/13/09 DI.C
FccalColiform 0 col/100ml, SM2092221~ A (<1) 08/13/00 DI.C
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
GENERAL INFORMATION
Complete legal, description, ~[.,,.~
Location (site address) ~ ~ ~.'Z~
'Current ProPerty owne~'(§)
'Sailing a~d. ress '
Lending agency
COSA #
Expiration Date:
Lo[' 3
~ Donn~ ~r~.~,~.. Day phone
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unles~ otherwise requested, COSA will 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 []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
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. Certificates 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 lo 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 sample results. (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 engineer's 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 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.
Name of Firm ~..Pu~-~4n~
Address ~,5 ~, t$t~' A¢~
Engineer's Printed Name ~_~,
I
5. DSD SIGNATURE
~ Approved for
Disapproved.
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
OriginalCertificate Date: /- ~ ~ -0 ~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore 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:
A. WELL DATA
Well type ~'iv4
Date comp,eted
Total depth ~'~' fl.
Date of test
Static water level
Well production
If A, B, or C provide PWSID # ~ Well Log (Y/N)
Sanitary seal (Y/N))/ Wires properly protected (Y/N)
Cased to ~ I?~ft. Casing height (above ground)
FROM WELL LOG AT INSPECTION
5 g.p.m. ~,3 g.p.m.
q
in.
WATER SAMPLE RESULTS:
Coliform ~ coloniesll00mL Nitrate "{-,3~ mg/L Other bacteria
Arsenic: ~/[3 ug/L date of sample: 101z'~lot~ Collected by: L4~5
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material ~]~
Tank size J~ gal. Number of Compa~ments
Foundation cleanout (Y/N) ~ Depression over tank {Y/N)
Date of pumping I[~ 0~ Pumper
C. ABSORPTION FIELD DATA
Oateinstalled [1~817~ Soilrating ~orfl~/bdrm)
Length .~ fl. Width ~ ff.
Total depth J ~ ft. Elf. absorption area ~
Date of adequacy test 1l~5/O~ Results (Pass/Fail)
Fluid depth in absorption field before test ~ in. Water added GSOgal.
Elapsed Time: ~ min. Final fluid depth ~5 in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & ~pe) ~o~
colonies/100 mL
Cleanouts (Y/N) '~/
High water alarm (Y/N) A/'
System type 17~?
Gravel below pipe ~ ft.
Depression over field ,'1/'
For '~ bedrooms
New depth ~/,~ in.
~) g.p.d.
If yes, give date '~
D. LIFT STATION
Date installed ~
'Pump on' level,~n.
DatumJ
E. SEPARATION DISTANCES
Size in gallons ~ Manhole/Access (Y/N)
'Pump off leve~..~,~in. High water alarm level at J'
Cycles test,,~ Meets alarm ~ements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot Ice~-
Absorption field on lot 1oo 4-
Public sewer main IooI -I.
Sewer/septic service line [00'+
Animal containment areas IO0~-
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation IO*'~ Property line I o ~
Water main ~O 4- Water service line 10 .~
Wells on adjacent lots ~oot
Absorption field
Surface water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 1,0~+ Building foundation lc) ~
Water Service line {0 + Surface water ,4/, O,
Curtain drain ,4,/, O, Wells on adjacent lots leo ~-
Water main
Driveway. parking/vehicle storage
F. COMMENTS
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 ~..AiZ~ S~v~
COSA Fee $.
Date of Payment
Receipt Number
(Rev. 11/051
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 EImore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Nitrate Advisory
Certificate of On-Site Systems Approval # 090013
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 3, Lot 4 of
Rolling Hills View Estates subdivision. This inspection revealed a nitrate
concentration of 7.34 milligrams per liter (mg/L) was reported for the
property's well water sample. The Environmental Protection Agency (EPA)
has established a maximum contaminant level (MCL) of 10.0 mgtL for
public drinking water systems. While private wells are not subject to this
regulation, EPA standards are based on existing health information and can
therefore be used to gauge the relative quality of water from private wells.
Please see the attached "Nitrate Fact Sheet" for important information
regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
/
/
/
/
I HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALD
FOLLOWING DESCRIBED PROPERTY:
~N~ TO D~ER~INE THE EXISTENCE OF ANY
VISION PLAT. UND~ NO CIRCUMSTANCES S~
~Y DATA H~EON BE US~ FOR CO~STRU~ION
OF FENCE LINES, OR FOR EST~LISHING ~ND- DRAWN=
ARY LINES·
SCS Ref.#
Client Name
Project Name/if
Client Sample ID
Matrtx
PWSID 0
Sample Remarks:
10858440O1
Tobbcn Spurkland P.E.
Rolling Ilills View Estates
Block 4, Lot 3
Drinkin~ Water
Printed Date/Time
Collected Date/Time
Received Date/Time
Technical Director
I 1/17/20O8 11:53
10'27/2008 15:45
I 0/27/2008 16:55
Stephen C. Ede
Arsenic
PQL
Units Method
ug~ EP200.8
Allowable Prep Anal?.is
Container ID Limits Date Date Init
C (<10) 11/03/08 11/12.O8 NRB
To~al Nitmt ',ffNitrite-N
7.34
0.100
mtdL SM20 4500NO3-F B (<10)
1~28~8 SDZ
.141crobtoloq¥ :Imborator~
Colony Count
To~al Coliform
Fecal Coliform.
col 100mL SM209222B A (<200)
col/100mL SM20 9222B A (<l)
co1,'100mL SM20 9222B A (<1)
I 0/27,~g DLC
1027,08 DLC
I 0/27/08 DI.C
Parcel I.D. #
1.
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
GENERAL INFORMATION
Complete legal description
0
location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent ~ ~/~..
Ad dress
Cc~Py ,f:' */. ~ -e.~ ~),~ Day phone
Day. phone
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.
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.
DHHS SIGNATURE
Approved for -/'-/L//~-A~bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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 DH HS does this as a courtesy to pumhasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS 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.
72q)25 (Rev. 1/91) Back MOA#21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
.RFPlf~
1998
825L Street, Room 502, Anchorage, Alaska 99501, (90,7) 3Z$~'-47~tZt
Municipality of Anchorage
Dept. Health & Human Services
Health Authority Approval Checklist
Legal Description:
A. WELL DATA
Well type ~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) y Date completed ~'~ / ~ -~
Total depth ~..~ Cased to ~t~)~'~ c~
Sanitary seal (Y/N) ~'
FROM WELL LOG
Date of test ~/1~//~ ~
Static water level ~
Well production -~ g.p.m.
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
-/
g.p.m.
WATER SAMPLE RESULTS:
Coliform "~
Date of sample: ~/t /
N it rate
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed g ~/
Foundation cleanout (Y/N)
Date of Pumping
Tank size 10~-~.~ Number of Compartments ~ Cleanouts (Y/N). ~/
~'/ Depression (~/N) ~'~ High water alarm (Y/N) ~
Pumper
C. ABSORPTION FIELD DATA
Date installed I~t J'71 ~ '7
Length ,~O Width
Effective absorption area
Date of adequacy test ~ [~'<--~
Fluid depth in absorption field before test (in.);
Fluid depth ~ (ins) Minutes later:
Soil rating (g.p.d./fF or fWbdrm)
Gravel thickness below pipe
Monitoring Tube present (Y/N)
Results (Pass/Fail)
Immediately after
System type
Peroxide treatment (past 12 months) (Y/N)
-7 Total depth t I
Depression over field (Y/N) ~
For ~ bedrooms
'~'gal. wateradded (in.): ~
Absorption rate =
If yes, give date
g.p.d.
72-026 (Rev. 3/96)*
LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at*
"Pump off" level at*
High water alarm level at*
*Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot J ~
Absorption field on lot I ~
Public sewer main /~/~
Sewer/septic service line ~/tP-E~
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDir~ lANK ON LOTTO:
Foundation c~' '7 Property line ~ O
Water main/service line ~.~ 4,
-- Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ,¢_'~ O Building foundation ~
Surface water
Curtain drain
Absorption field ~ (~,~ ~
Wells on adjacent lots
Water main/service line ~ O '~
Driveway, parking/vehicle storage area 79
Wells on adjacent lots ~' /¢-,~}
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and rewew of Municipal records/tl~at',t/~e~above,,syste~ are
in conformance with MOA HAA guidelines in effect on this date.
Signature '--[, ~.~ ~x,~
Engineer's Name - I ~ ~ ~ ~~( ~
HAA Fee $ ~"~('"~{(~,
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev, 3/96)*
0"' '07
S~P-8S-1'~98 ~1:0~ CT~E ESI ANCHI]F~A_QE ....
a~tk CT&E Environmental Services Inc.
CT&E Ref.#
Client Name
Project Name/#
Client Sample iD
Matrix
Ordered By
PWSID
982386012
Tobben Spurkland P,E.
Roiling Hills View 3/4
Drinking Water
Sample Remarks:
Ciier~t. PO#
Printed Date/Time 09/08/98 20:52
Collected Date/Time 09/01/98 09:40
Received Date/Time 09/02/98 12:00
Technical Director: Stephen C, Ede
Released By~_~ ~,~
PQL
Allo~ab[e Prep
Method Lfm]ts Date
AnalysL~
Date Init
Total Caliform a COI/100mL SM18 92928 a9/0~/98 leap
Nitrate-N 3.34 0.100 molL EPA 3gO.0 10 max 09/0~/95 09/0z/gg GCP
Parcel .D. cf
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES ./~
Division of Environmental.Services ~j~
On-Site Services Section ~'z,~ o~
P.O. Box 196650 Anchorage. Alaska 99519-6650 ~ ~.~,~L,~
343-4744 . ~'4,,~,;;~
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent ~/~5 ~-
Address
~_'~ v~ ;|~o~, "~o~ Day phone
Day phone
"~?J 4~'s~.4~, -~-¢~ Dayphone
=
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
ii · ; As certified b'
Seal affixed hereto and as [he validation date shown below
r
DHHS * SIGNATURE '*' ........ :" ';
APproved 1 rooms.
Disapproved. · -
Conditional approval fOr" ':'
%
bedrooms, w~th the following' st~[ '
Additional cOmments
By:
Apl
ions in o,rder to ~atisf)
conduct inspections or analYZe databeforea
Municipality of Anchorage P~ ~, C ~ IV E ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division NOV 10 ~99~
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907).343-4744
Mumcipauty of Anchorage
Oept. Health & Human Services
Health Authority Approval Checklist
~ t LL~
A. WELL DATA
Well type ~ If A, B, or C, attach ADEC letter. ADEC water system number ~I~/V
Log present (Y/N)7 Date completed ~/'L~ l~ ~
Total depth LO ~ Cased to '[~'z~-~ ~-~-~ Casing height (above ground) ,-~
Sanitary seal (Y/N) ~-/ Wires properly Protected (Y/N) ~
FROM WELL LOG AT INSPECTION
Date of test ~/~1~' '01~l~:
Static water level ~ , ~ ~ I
Well production ~ g.p.m. ~, ~ g.p.m.
WATER SAMPLE RESULTS:
Coliform t'~ J
Date of sample:
B. SEPTIC~ ~CLD:~',~C T~.H.v- D.~.~.
Date installed l i/p~ lq '? Tank size
Foundation cleanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Nitrat~ ,~,,~ ff I,~,.~/~ ' Other bacteria
Collected by: ~ -~
Depression (Y/N)
Pumper
Length ~0 Width
Number of Compartments c~ Cleanouts (Y/N) "-/
High water alarm (Y/N) ~ ~
Soil rating (g.p.d./fF e~-t~eflw~) / -
c~' I Gravel thickness below pipe
System type
Total depth
Effective absorption area
Date of adequacy test
Fluid depth in absoytion field before test (in.);
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Monitoring Tube present (Y/N)__~___ Depression over field (Y/N)
Results (Pass/Fail) u'/' For ~" bedrooms
/ Immediately after I,//ggal. water added (in.):
J Absorption rate = J .g.p.d.
J If yes, give date
LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at*
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot J
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
I;2o
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ '7 Property line ,~ Absorption field ~
Water main/service line ~,~ ~ Surface water/drainage I~/,~_ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
50 Building foundation ~ ~/'
Property line
Surface water N.~ ~ v~ ~
Curtain drain ~-10 ~4 -~
ENGINEER'S CERTIFICATION
Water main/service line
Driveway, parking/vehicle storage area "70
Wells on adjacent lots ~. /u-c)
I certify that I have determined thru field inspections and review of Municipal records-that-the above systems are
in conformance with MOA HAA guidelines in effect on this date.
Signature ~.. ~ ' ~
Engineer's Na ~. ,~_~,.~ x
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
~lr~ CT&E Environmental Services Inc.
CT&E Ref.# 976103001
Client Name Tobben Spurkland P.E.
Project Name/# N/A
Client Sample ID Lot3, Blk4, Rolling Hills Est
Matrix Drinking Water
Ordered By
PWSID 0
Sample Remarks:
Client PO#
Printed Date/Time 10/13/97 10:35
Collected Date/Time 10/06/97 00:00
Received Date/Time 10/07/97 08:40
Technical Director: Stephen C. Ede
Released By~~f~l~.[ ~
Parameter Results PQL Units Method
Allowable Prep Analysis
Limits Date Date Init
Nitrate-N 3.49
Total Coliform 0.00
0.100 mg/L EPA 300.0
co[/100mL SM18 9222B
10 max
10/07/97 GCP
10/07/97 TMW