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HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 1 LT 3Campbell Heights Block 1 Lot 3B #014-071-74 t)F Trj STATE OF ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION rtfy INVENTORY AND SOURCE REGISTRATION FORM FOR CLASS "C" PUBLIC WATER SYSTEM PUBLIC WATER SYSTEM NAME AND LOCATION: System Name: Lot 3B Block 1 Campbell Heights Class C Well and Water System Legal Description of Property: Lot 313Block 1 Campbell Heights Subdivision Number of People Served Daily: 10 (Proposed Max.) Number of Service Connections: 1 (Proposed) Owner's Name: ARC of Anchorage Mailing Address: 2211 Arca Drive Anchorage AK 99508 Phone: 277-6677 Fax: 272-2161 Email: mvanhaneghanpthearcof anchorage.org ITEMS REQUIRED FOR REGISTRATION: Check box if complete. Provide written explanation if not complete. ❑ $75.00 registration fee as required by 18 AAC 80.1910(c)(3). Make checks payable to "State of Alaska". © Results of nitrate and Coliform water samples taken within the last 6 months, indicating those contaminants do not exceed the MCL set in 18 AAC 80.300. Attach reports from certified laboratory. © All source water protection requirements of 18 AAC 80.015 listed on page 4 have been met. © All minimum separation distance requirements of 18 AAC 80.020 listed on page 4 have been met. © All cross -connection requirements of 18 AAC 80.025 listed on page 4 have been met. WATER SOURCE: Applies to all systems Circle Yes or No. Yes No Well depth is less than 30 feet to the first opening for water collection. 18 AAC 80.200 (i) Yes No Well is located less than 50 horizontal feet to a surface water source. 18 AAC 80.200 (i) Yes No Source uses an infiltration gallery, spring, rain catchment, or surface water. 18 AAC 80.200 (i) Yes No Source requires treatment to meet required MCUs set in 18 AAC 80.300. If answer is "Yes" to any of the above, then water treatment must be provided and the items on page 5 under PUBLIC WATER SYSTEM SOURCE TREATMENT must be.addressed. If all answers are "No" continue to page 4. Page 3 of 8 (revised December 2011) For Depar:rent Use Only The in.'ormation in this registration form has been reviewed and is complete. The following Public Water System Identification number (PWSID) is assigned to this system: (Signature of Drinking Water Program staff) SOURCE WATER PROTECTION REQUIREMENTS - 18 AAC 80.015: Applies to wells only Please initial each line to indicate the requirement is met Yes The well casing is provided with a suitable well cap or sanitary seal. Yes The well is not in a pit, and the casing extends a minimum of one foot above ground level or well house floor. Yes The well casing is grouted with a watertight cement grout, sealing clay, bentonite, or an equivalent material. The we] I must have at least 10 feet of continuous grouting within the first 20 feet below ground surface or another method approved by the Department. es The well is adequately protected against flooding. Yes For at least 10 feet in all directions, the ground surface around the well is sloped or contoured to drain water away from the well. Yes Before use, a newly constructed or reworked well has been flushed of sediment and disinfected. Yes Copy of the well log is attached. Well log requirements are found at 18 AAC 80.210(h) and can be downloaded from the web site at http:/iwww.navinaps.alaska.eov/welts . MINIMUM SEPARATION DISTANCE REQUIREMENTS - 18 AAC 80.020: Applies to all water systems Please initial each line to indicate the requirement is met Yes Source is located a minimum of 150 feet from a wastewater treatment works, wastewater disposal system, pit privy, sewer manhole, lift -station, or sewer cleanout YES Source is located a minimum of 100 feet from a community sewer line, holding tank, or other potential source of contamination including sanitary landfill, domestic animal and agriculture waste and industrial discharge lines. YES Source is located a minimum of 75 feet from a private sewer line, petroleum lines, and drinking water treatment wastes. YES A letter from DEC granting the necessary waiver(s) needs to be attached if a system does not meet the requirements of 18 AAC 80.020. Page 4 of 8 (revised December 2011) CROSS -CONNECTION REQUIREMENTS - 18 AAC 80.025: Please initial to indicate the requirement is met. Applies to all water systems Yes This water system is not connected directly or indirectly, to any unapproved water system, sewer, drain, conduit, pool, storage reservoir, plumbing fixture, glycol loop, or other device that contains, or might contain, wastewater or other substances of unknown or unsafe quality that might be capable of contaminating the water supply through backflow (loss of pressure), without an approved backflow prevention device or assembly. BUSINESS INFORMATION Type of Business Residential Housing Will business be open on a seasonal basis? eX NO e YES If YES dates from Food or ice preparation or food service? X NO YES Applies to all water systems to CERTIFICATION: I certify that the above statements are true and accurate to the best of my knowledge and this system is operated in compliance with 18 AAC 80, Drinking Water Regulations. (Signature SOURCE WATER TREATMENT: This section must be completed if any "Yes" answer was given to questions under WATER SOURCE on page 3. Please initial each line to indicate the requirement is met The water treatment is designed to meet current public health standards. Current regulations require 99.9 percent removal and inactivation of Giardia lambia cysts, 99 percent removal of Cryptosporidium and the required level of treated water turbidity. (1.49 NTU for alternate systems and 0.3 NTU for conventional and direct systems) The water treatment is designed to consistently meet the applicable MCL's set in 18 AAC 80.300. Specific design plans and calculations for this water system have been completed by a professional engineer and are attached with this registration form. The person responsible for operating this water system holds applicable certification from the DEC/Operator Training and Certification Program, and understands how to operate the system as designed. CERTIFICATION OF COMPLIANCE WITH SOURCE WATER TREATMENT REQUIREMENTS: I certify that this water system is operated in compliance with 18 AAC 80, Drinking Water Regulations. (Signature (Signature of Engineer) Page 5 of 8 (Date) (Date) (revised December 2011) THE STATE of ALASKA April 12, 2013 GOVERNOR SEAN PARNELL Mt. Michael Anderson, P.E. Anderson Engineering P.O. Box 240773 Anchorage, AK 99524 Re: Campbell Heights S/D, Block 1, Lot 3B Class "C" Public Water System Separation Distance Waiver Deas Mr. Anderson: Department of Environmental Conservation DIVISION OF ENVIRONMENTAL HEALTH Drinking Water Program 555 Cordova Street Anchorage, Alaska 99507 Main: 907.269.7623 Fax: 907.269.7650 Jessica.cahill®alaska.gov File: Campbell Heights S/D, Block 1, Lot 3B PWSID: To be issued upon Registration On April 10, 2013 this office received your Class "C" Public Water System separation distance waiver request for a proposed well serving a three bedroom group home to be located at Campbell Heights Subdivision, Block 1, Lot 3B. This well will be located 48' from the 4" private sewer line serving the house on the nearest lot to the east The purpose of this letter is to grant the separation distance waiver for this Class "C" Public Water System, identified by PWSID (to be issued upon Registration), between the proposed well and the existing sewer service to the east. System Information Your submittal indicates that although sewer service is available, no water main reaches the property. The well will be located a minimum of 150' from sewer manholes and 100' from the sewer main located at the north end of the lot. The well serving this group home will be drilled to a depth of approximately 110', penetrating confining layers of dense blue clay. The well will be serving a resident population of six occupants and four transient employees. Based on an evaluation of the available information, the potential for contamination due to the lesser separation distance between the public well and sewer line does not appear to be significant. A separation distance waiver between the well and sewer line is granted in accordance with the provisions for the State's Drinking Water Regulations, 18 AAC 80. After completion of construction of this Class "C" water system, a nitrate sample result, negative coliform sample result and a site plan and well log showing the water system as it was actually built shall be submitted along with your Class C Registration request. A PWSID for the Class C System will be issued at that time, 130412 -Campbell Heights SD, Block 1, Lot 3B _WA.docx Page 1 of 2 Mr. Michael Anderson, P.E. April 12, 2013 For the continued health and safety of the water system's users, it is strongly recommended that the system be routinely inspected and tested. While there is no ongoing state requirement for inspections, visual inspection of the well and surrounding area (within approximately 200 feet) will help identify potential risks to the system. There is also no requirement for ongoing drinking watet sampling. But, periodic sampling for nitrate/nitrite and total coliform (recommended at least annually) will help identify drinking water issues that may otherwise go unnoticed. Waiver Limitations Any changes, constructed or natural, that affect the conditions to which the waiver and was granted will void the waiver. This approval does not imply the granting of additional authorizations, not obligate any federal, state, or local regulatory body to grant required authorizations. This is not an approval of omissions or oversights by this office or noncompliance with any applicable regulation. The Department's approval of this separation distance waiver does not guarantee correctness of the functional design or waive the owner's responsibility for continued compliance with State regulations. Appeal Process Any person who disagrees with this decision may request an adjudicatory hearing in accordance with 18 AAC 15.195- 18 AAC 15.340 or an informal review by the Division Director in accordance with 18 AAC 15.185. Informal review requests must be delivered to the Acting Division Director, Elaine Busse Floyd, 555 Cordova St., Anchorage, Alaska 99501, within 15 days of receipt of this decision. Adjudicatory hearing requests must be delivered to the Commissioner of the Department of Environmental Conservation, Larry Hartig, 410 Willoughby Avenue, Suite 303, Juneau, Alaska 99801, within 30 days of this decision. If a hearing is not requested within 30 days, the right to appeal is waived. More information on the Department's administrative appeals process can be found at the following website: htttn://www dec state ak uslcommish/Revie 'dance htm. If you have any questions regarding this plan review please do not hesitate to contact me. Sincerely, Jessica D. Cahill Environmental Program Technician Cc.: Wes Clubb Crown Pointe Homes PO Box 112313 Anchorage, AK 99511 130412_Campbell Heights SD, Block 1, Lot 3B _WA.docx Page 2 of 2 PLAT N0. 2009-92 CAMPBELL HEIGHTS SUBDIVISION LOT 3B, BLOCK 1 20,362 S.F. - 67TH AVE. s / 9 S_ s 8" DIP Sewer Main N s �\ \\ j \ / •c. osxc \\ ------\ 00 J \\ / w wn w \ n� pI I ___� I I Ir 34' 1 I. n �48' i Class CWell 1 1 N 89'55'22"E 105.96' 11\ z \ I / Q I w / Ezisling Building \ \�\Existing Building / \ I \ z I d----�� I 13.5' T. & E. ESMT. SLOPE ESMT. N 89'59'23"E 125.97' M UTILITY PLAN GRID N0. 2035 E. 68TH AVE. SCALE 1" = 40' SGS SGS Ref.# 1134491001 Client Name Anderson Engineering Project Name/# 4095 E. 68th Ave Client Sample ID 4095 E. 68th Ave Nlatrix Drinking Water Printed Date/time Collected Date/Time Received Date/Time Technical Director 09/25/2013 15:06 09/16/2013 11:25 09/16/2013 11:33 Stephen C. Ede 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) 09/19/13 09/24/13 HKS Waters Department Total Nitrate/Nitrite-N 0.163 0.100 mg/L SM21 4500NO3-F B (<10) 09/16/13 AYC Microbiology Laboratory E. Coli Negative 1 100mL SM21 92238 A 09/16/13 SDP Total Coliform Negative I 100ml- SM21 9223B A 09/16/13 SDP O O 0 a 3 i7 n 0 0 z PLAT NO. 2009-92 CAMPBELL HEIGHTS SUBDIVISION LOT 3B, BLOCK 1 14,834 S.F. EAST 67TH AVENUE Ln N N 89'55'22"E 105.95' m GRAVEL DR. v N x 24.0' 20.9 3 U 15.3' 0 0 O V N od N O v 4.7' COVERED ENTRY 10.0' ri e M g EXISTING BUILDING 20.0' 20.9' 16.7' M 12.0' � o DECK O 15.3' WELL AS -BUILT GASTALDI LAND SURVEYING, LLC JEFF A. GASTALDI, R.L.S. 2000 E. DOWLING RD., SUITE 8 ANCHORAGE, ALASKA 99507 PHONE 248-5454 GRID DATE SW2035 9/3/2013 F.B. JOB NO. 13-03 CHS3131 N 89'55'22"E 105.96' I HEREBY CERTIFY THAT I HAVE SURVEYED THE PROPERTY DEPICTED ABOVE AND THAT NO ENCROACHMENTS EXIST EXCEPT AS INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. UNDER NO CIRCUMSTANCES SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES. ANCHORAGE RECORDING DISTRICT, ALASKA NOTE: NO CORNERS SET THIS DATE. O O 0 a 3 r a 0 0 z 1 "=20' N • 0 f I 5. LEGAL DESCRIPTION MUNICI 3 -6s CA MUNICIPALITY OF ANCHORAGE DEPT. OF IzAL ,� DEPARTMENT DEPARTMENT OF HEALTH &ENVIRONMENTAL PROTECTIOGNVIRONMENTAL 'A 825 L Street - Anchorage, Alaska 99501 • JAN 8 19/9 rr ENVIRONMENTAL ENGINEERING DIVISION Lcc{ Telephone 264-4720 RECEIVE w REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES W' INDIVIDUAL- DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (101 days for processing. ❑ COMMUNITY 1. PROPERTYOVVNER (� y A. PHONE —7 8. SEWAGE DISPOSAL SYSTEM 7o�/4 1-7 ❑ INDIVIDUAL/ON-SITE** MAILING DDRESS - c� /t A If system is over two (2) years old an adequacy test is required PROPERTY RESIDENT (If different from above) PHONE by this Department. %'AMC 72 01013 "31 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION PHONE MAILING ADDRESS 4. REALTOR/AGENT PHONE _ BASS fZE-7-� t MAILING ADDRESS 5. LEGAL DESCRIPTION 3 -6s CA AI rS s 'D STREET LOCATION Cc) �. 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS SINGLE FAMILY ❑ One ❑ Four ❑ Other Two ❑ Five ❑ MULTIPLE FAMILY yN;r ' ❑ Three ❑ Six 7. WATER SUPPLY W' INDIVIDUAL- * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM ❑ INDIVIDUAL/ON-SITE** **If individual/on-site, give installation date If system is over two (2) years old an adequacy test is required 151/ PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72 01013 "31 THIS SIDE FOR OFFICIAL USE ONLY r INSPECTION APPOINTMENTS DATE RECEIVED _ , TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE ❑ SINGLEFAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON-SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holding Tank - Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS V,—APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate( ❑ DISAPPROVED DATE BY (Title) LEGAL DESCRIPTION - 72-010 (Rev. 3/78) to