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HomeMy WebLinkAboutBLUE SKIES ESTATES #3 LT 1B-1Onsite File A 10 Blu,m&e bKies Es M-Uft a T Ate :Nk s Pa t # t UO4'1 Municipality of Anchorage Page . DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: $1,4,, ¢)c~ C:~ ~'7' PIDNumber: ~:~"Z.! -or! Name: ~1 ~ ~ ~c~ Wastewater System: ~New. D Upgrade too~ ~. ~ ~, ~c~ ~/ ABSORPTION FIELD Phone~ '~ ~ ~ Deep Trench D Shallow Trench ~Bed ~Mound ~Other LEGAL DESCRIPTION Township; I Range. I Section: Fill Idded above original grade: Gravel langth: WELL: ~ New ~ Upgrade G*a~e~: ~ ~ Num~e~°f""':l ~"~ ~, ~. TANK SEPARATION DISTANCES as,~c o Holding O S.T.E.P. we. I1~' I~ -- >=~/ ~/ w=~., >~' >~' - ' ' LIFT STATION ~.~ Line ~O' ~' - -- Remarks: Ov~ ~ t~//,~ BENCH MARK ENGINE~R'~ SEAL ~a~,~*/~.~o~ ~ ~'~c~, ~-~1~ ~I~ ~,~'-~ ........ '~ .,~ Inspections performed by:.. ~~c~¢ Dates: 1st ~//~/~ ~ ~' ~ '~ Department of Health and Human Servmes approval ,,,: ~ cE-~ .. d and approved b t; '":'~ ' ...... PERMIT NO: SW990254 PAGE 2 OF 3 PID NO: 021-011-29 85' LONG SOIL ABS. TRENCH WITH 4.0' EFFo SEWER GRAVEL SWING TIES: FROM: COR."A" COR."B" TO: S.T.C.O "C" 42' 34' ,' S.T.C.O. "D" 50' 40.5' DBL. C.O. "E" 54' 44' TR. C.O. "F" 67.5' 74.5' TR. M.T. "G" 65' 62' TR. M.T. "H" 81.5' ," 61° TR. C.O. "1" 83' ,' ! U;,ELOT1B SKIES ESTATES LOT lA (VACANT) 1250 GALLON SEPTIC TANK LOT 2 (VACANT) 4Cc~ LOT1B, BLUE SKIES ESTATES SEPTIC SYSTEM INSTALLATION AS-BUILT INSP. REPORT - PLAN VIEW FLATTOP TECI [NICAL SERVICES 14530 ECtlO STREET ANCl IORAGE, ALASKA 99516 SCALE: 1' = 30' DRAWN BY ?FM OCTOBER, 2000 PERMIT NO: SW990254 PAGE 3 OF 3 PID NO: 021-011-29 4'+ SOIL COVER 2' SOIL COVEI~ -- 99.6' INV. 99.3' 2'RIG1 SEWER INV. g8.7' ' BOT. TRENCH ELEV. (5.0' B.G.L.) BOT. T.H. fi3 (11.0' B.G.L.) WATER {~ 10.0' B.G.L 9/7/00 LOTIB, BLUE SKIES ESTATES SEPTIC SYSTEM INSTALLATION AS-BUILT INSP. REPORT - CROSS-SECTION FLA'FroP TECI INICAL SERVICES 14530 ECllO STREET ANCI IOP. AGE, ALASKA 99516 NOT TO SCALE DRAWN BY TFM OCTOBER, 2000 JTESTHOLE#3 J LEGALDE$CRIPTION: DATE PERFORMED: PERFORMED FOR: DEPTH (f~) 1' 2- $- 4- 11 12- 13- 14- FLATTOP TECHNICAL SERVICES 14530 ECHO ST. ANCHORAGE, ALASKA 99516 SOILS LOG -- PERCOLATION TEST SLOPE Lot 1 B, Blue Skies Estates June 19, 2000 Hal and Cathy Schneider Pt. SM Silty loam GPIGM Somewhat si/ty sandy gravel Loose, dry Material similar to T.H. #! GM/ML Silty gravel GPIGM Silty gravel Angular rock fragments Hard digging below 10' B.H. Bedrock ;% Depth to Groundwater Date W_a~er se~eps ~. 10' 6119/00 Water ~ 10' 9/~100 o, SITE PLAN T.H. #3 T.H. SEPTIC TANK NEW 85' LONG __ SOIL ABS. TRENCH Date Reading Ck)ck Net Time Percometer Net D~'op Time (minutes) Reading (inches) 20- PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN F'rAND FT COMMENTS: Test hole dug to assess continuity of soils in TH #1~ allowing t~ench extension to east. PERFORMED BY FLATTOP TECHNICAL SERVICES. I ~""~'..,,.~ ~ CERTIFY THAT'THIS TEST WAS PERFORMED IN ACCORDANCEWITHALLSTATEANDMUNICIPALGUIDEMNESiNEFFECTONTHiSDATE. DATE: . _/¢~'/~' /ZO~/ From : I:I..PII'E I:RILL ~g? 345 gD~2 : Municipality.of Anchorage Department of Health and Human Services 825 'L' St¢~Ct P.O. Box106050 Anchorage, AJaska 99519-6050 Mayor Permit Number: ;/$W 990254 Date orlt~ue: 8- -99 . Date Started: f0-4-99_ Date Completed: 10-,~99 Legal De~crlpOen: Property Owner Name & Addrc~: Borchole Daf. t: Soil ']~,c. 'lhi~n~s & Water Strata stick-up 0 2 gravelly S/It 2 14 bedrock 14 247 RECEIVED OCT 24 2000 Municipality of Anchorage Dept. Health & Human Services plue Skies E,ff #2 LC 1 ~ · Hal & Cathy Scneider 1008 West 16 Ave Anchorage, Ak 99501 Depth (fi) I"mm '1'o Purccl ldcutir.:.tiun N.u. mber:~ Is well located at approved p,:tmit location? ~ Ym n No Method of Drilling 1~} air rotary f-I cable tool Casing type: ,steel Wull Thlckne~: .250 inches Diameter: _6 inche~ Depth: 20 fcct l,incr Type: l)iamctcr: .inches D~th: feet Casing stickup above ground: ~ feet Static water level (from ground level): ~? feet Pumping Icvel:24Z feet after _2 hours pumping 3.5 gpm Recovery Rate: 35 gpm Method of T~flng: airlift Well Intake Opening Type: [] ()pen }-:nd I~ Open Hole [] Set.ned $1art, feet Stopped, [~] Perforations Start. feet Stopped Grout Type.: ben/on#¢ # ~ Volume: 1 Depth: Stun p f~ Stopped 20 Pump: Intake Depth feet Pump size hp Brand Name Well Disiukcted Upon Completion'/[] Yt~ [] No 'Method of Disinfection: Comments: Wall Drillar: Alpine Drilling & Enterprisesl P.O. Box 11049~ · Anchorage AK 9951f Alteatioa: Thc well driller shall provide a well log to thc properly owner within 30 days ofcomplctlon and the property MUNICIPALR'Y OF ANCHORA GE Depadment of Health and Human Sen/ices On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM I WATER SUPPLY PERMIT Initial Date Issued: Aug 05, 1999 Expiration Date: Aug 04, 2000 Permit Number:. SW990254 Legal Description: BLUE SKIES ESTATES #2 LT lB Design Engineer:. 0019 Flattop Technical Services Owner Name: Hal & Cathy Schneider Owner Address: 1008 West 16 Avenue Anchorage, AK 99501- ParcellD: 021-011-29 Site Address: Lot Size: 188179 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit Is for the construction of: [] Disposal Field [] 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 DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either. A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Issued By: ~ Date: ~ Date: ~:~ -- -~-' ?~;~ FLATTOP 'TECHNICAL' SERVICES ClY1L & ENVIRONMENTAL ENGiNEERiNG., ENERGY CONSERVAIION & ANALYSIS TllEODORE F. MOORE, P.E. 14530 ECIIO ST. Pti: (907) 345-1355 ,CNCllORAGE, ALASKA 99516 July 27, 1999 M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: The purpose of this letter is to provide the required design narrative in support of our application for a permit to construct water supply and wastewater disposal facilities on Lot lB, Blue Skies Estates, located on Glen Alps Road. Soils logs, perc test results, a site plan, design drawings and specifications are enclosed for your review. The proposed system will be constructed in the vicinity of test hole # 1. As can be seen from the soil log, the native material between 1 and 6 feet below ground level is a somewhat silty sandy gravel with a measured pete rate of I minute per inch. Using the soil application rate of 1.2 gpd/sq, fL specified in the wastewater ordinance, the proposed 4-bedroom residence requires a total absorption area of(4 x 150)/1.2 = 500 square feet. The proposed 50 foot long trench design with 5 feet ofsewer gravel has a total absorption area orS00 square feet. The topography of the lot in the area of the proposed construction slopes down towards the north- northwest at approximately 15%. The proposed project will have no significant impact on present or future water supply and wastewater disposal systems serving adjacent properties, nor will it have any significant impact on reserved space-surface and subsurface, or on drainage. Please give me a call at 345-1355 if you have any questions on this submittal. Sincerely, Ted Moore, P.E. GLEN ALPS ROAD LOT IA (VACANT) LOT lB CONSTRUCT 50' LONG SOIL ASS. TRENCH WITH 5.0' GVL BELOW PIPE / / SITE FOR SIMILAR / RE.LTR NOH \,5:,,V .... ~. .'~.--'~ F INSTALL S&S .~ 15",t,~ ' '..~"~_ 1250 GALLON T.H. ~' T~H~ ~TIC T~K T.H. "! ''' ~ ''-.. i LOT2 ~2 ~ ·, ' ' ~ . (VAC~T) /' ~ ",oo' PROP. ' WELL LOT lB, BLUE SKIES ESTATES WELL AND SEPTIC SYSTEM SITE PLAN FLATTOP TECI INICAL SERVICES 1 INCH = 100 FEET 14530 ECllO STREET DRAWN BY TFM A~CI IOP~,OE, ALASKA ~)~ 16 JULY, 1999 NOTE: THIS IS NOT A SURVEYED PLAT. ALL LOCATIONS SHOWN ARE APPROXIMATE. CONSTRUCT 50' LONG SOIL ~BSORPTION TRENCH ~ "A" . W 5 0 GRAVEL BELOW P PE ~ / M T · ' ~ ~ 50// '° , PLAN VIEW SCALE: 1" = 10' ~ASTM F-810 PERF PIPE DOUBLE C.O. INSTALL 1250 GALLON SEPTIC TANK 4" DI~ ASTM D-3034 WASTE LINE FROM HOUSE / CLEANOUT MONITOR TUBE ' / 2 FEET SOIL COVER ER FABRIC ~-- 4" D~A. F-8'I0 PERF P~PE ~ lr~-2 1/Z'GRAVEL BOTFOM OF EXCAVATION SECTION "A" - "A" SCALE: 1" = 5' LOT lB, BLUE SKIES ESTATES SEPTIC SYSTEM DESIGN PLAN AND CI~OSS-SECTION FLATTOPTECIINICALSERVICES 14530 ECIIOS'fREET ANCIIOP, AGE, AK, 99516 SCALE:ASStlOWN DP, AWNBY:TFM .~JLY, 1999 FLATTOP TECHNICAL SERVICES - ~ ~ .' .:',~ ~ ~',~'..' A . ~' · 14530 ECHO ST. ~ 2~OTH ~ ~ ~ i ~CHO~GE, A~S~ 99516 ~.,..... .... ~-.. ~ SO LS -* PE.CO T[ON EST LEGAL DESCRI~ON: Lot lB, B~ue Skies Estates PERFORMED FOR: Hal & Ca~ SchneiOr SLOPE S~ P~N DE~ ~ ~ (f~t) ~ SM S~loam 2- GM/SM Sil~ gravel Depth to Groundwater Date ._.~N o_gr o~u n~dw_ a_ t e r 7113199 10- 11- Crock Net Time Percometer Net Drop Date Reading l~me (minutes) Reading (inches) 18- 19- 20- PERCOLATION RATE (minutetJinch) PERC HOLE DIAMETER TESTRUN BETWEEN __ FTAND FT COMMENTS: No molf~tor~tybe install~d,_~e__d_r_o;:kJ_qo sh_aI~w for ¢onventional_sy~_tem, PERFORMED BY FLATFOP TECHNICAL SERWCES, I...~' ~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: --~' / ~-- ~ / ~ Munlclpallly ol Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 'L' S[reet, ^nchorage. Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 4 5 6 ? 8 9 t0- 12 13 14 15 18 19 20 DATE pEFIFORM! 1 ownship. Range, Seclion: SLOPE SITE PLAN L/ WAS GROUND WATER J~J 0 ENCOUNTERED? IF YES, AT WHAT -- 0 DEPTHt , P E O,~th lo Wit,r A~t,, ~l/io/q~ '' I HOoII0f I/Ig? L~P,. ¥ Dale: PERCOLATION RATE [ '/' I (mmuteS~mch! PERC HOLE DIAMEIER 1EST RUNBETWE[:N .~__ FTAND _ '~) F1 COMMENTS ACCORDANCE ~A~ ~lPAL GUIDELINES iN EFFECT ON I HiS DA1 E. 72.~ (Rev. JTESTHOLE# 1_ J LEGAL DESCRIPTION: Lot IBB~ue Skies Estates FLATTOP TECHNICAL SERVICES 14530 ECHO ST. ANCHORAGE, ALASKA 99516 SOILS LOG -- PERCOLATION TEST DATE PERFORMED: July 13, 1999 PERFORMED FOR: Hal.._& Cathy Schneider DEPTH ~ Pt. (feet) SM Silty loam 1 GPIGM Somewhat silty sandy gravel Loose, dry SLOPE SITE PLAN 6 7- 13 14- 15- 19- 20- GM/ML Silt/Gravel Dense, damp B.H.(nctbedrock) Depth to Groundwater Date .._N o_gr_o_un_dwet e r ?113/9_9 Wat_er (~ 11-0' 7r)1/~9 Clock Net Time Percometer Net Drop D~te Reading Time (minutes) Reading (1riches) ~7113 Add wate_r &~_s. tar~ 3:06 2 3_~L4 #1 3Ll2 4 18_3/8 4 718 Add w___ater 3L1_2:_35 1~3_3/8 ~ 3:16:35 4 18 118 5 1/4 Add water 3:17~.~5 ~3_318 #3 ~l:"~1:15 4 18 3116 5 3/16 PERCOLATION RATE 1 (minutes/Inch) PERC HOLE DIAMETER 8" TEST RUN BETWEEN ~ FT AND ~l.~ FT COMMENTS: $i~znifican~.r._ain collecfin~g ~_~_ga~ally~ackfilled-[qst hole may_account for water in rnonitor tube, PERFORMED BY FLAI'roP TECHNICAL SERVICES. I ~"'-,~ ~ CERTIFY THATTHIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. 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 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. ,O?..t - c)l I -- :2 ~. . GENERAL INFORMATION Complete legal description LOcation (site address) I Expiration Date: Current Property owner(s) H,,ct Day phone 3' ~'~ .Mailing address ttt~-t. ~. _q~'._ A-,~c~o,-~,, ~ 9')c'a,~ Lending agency Day phone Mailing address Real Estate Agent _,o ~.~,~ ~b~y Day phone Mailing Address Unless otherWise requested, COSA will be held by DSD for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well [] Individual Water Storage [] Community Class ~ Well [] Public Water System [] ta l' ctal-6 e~ that;clan e~,nt et'' 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:l 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. Address Engineer's Printed Name DSD SIGNATURE ~ Approved for ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Attachments: COSA Checklist Septic System Advisory Well .Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: (Rev. 11105) 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 FORA SINGLE FAMILY DWELLING ~ Parcel I.D. O,z. t - Ot I - 3 2.. GENERAL INFORMATION Complete legal description LOcation (site address) COSA# © '7:) ¢___.~ Expiration Date: Current Property owner(s) Mailing address Lending agency Day phone Mailing address Real Estate Agent Mailing Address Unless otherwise requested, COSA wi// be held by DSD for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class ~ Public Water System Well [] [] TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding Tank [] Community On-site [] Pubiic Sewer [] L 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 ¸5. As certified by my seal affixed hereto and as of the validation date shown below, I verify that my. investigation, based on precedures outlined in the Certificate of On-Site Systems Appreval 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 bedreoms 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. NameofFirm ~'(~/--/,,~, 7'e,-/~,~ ,~,! _~e,',~,'c~. Phone Address ~'~ ~- ~o ~/ ~o~ ~ Engineer's Printed Name. ~~o~ ~. ~ ~ Date 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 By: Original Certificate Date:.. S - 1 (Rev. 11/05) 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) Current Property owner(s) Mailing address COSA# (~., Expiration Date: Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, COSA w/l/be held by DSD for pickup. 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 Depadment (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. (Cedificates 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 vedfy 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 F'l~f/-~r,~ '7"'~J~n Address I ~/&-Z~' --,~'¢/~ Engineer's Printed Name DSD SIGNATURE Approved for LC' Disapproved. Conditional approval for ~ ¢ ~,-,¢,~..,, Phone '3' 4-'< ~, ~w~,~, Date 7/ bedrooms, with the following stipulations: By: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: (Rev, 11/05) 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 ~>vt' IfA, B, or C provide PWSlD #~ Date completed lO/b"~/ q~ Total depth ~. q 7 ff. Date of test Static water level Well production WATER SAMPLE RESULTS: Sanitary seal (Y/N) Casedto ~_~ ft. FROM WELL LOG Coliform ~ colonies/100 mL Nitrate ~ :~?&"mg/L Arsenic: ~. ~,"' ug/L date of sample: .7/tq !/~, SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size I 'Z,,5'~ gal. Number of.Compartments Foundation cleanout (Y/N) Date of pumping .. ~' Pumper. ~g Z l -Olt IJ. ,,~. Well Log (Y/N) ~ Wires properly protected (Y/N) casing height (above ground) AT INSPECTION 7/ I · O g.p.m. Other bacteria Collected by: "- 'colonies/100 mL Date installed Cleanouts (Y/N) High water alarm (Y/N) · C. ABSORPTION FIELD DATA Date installed ~'/2.1/~'~ Soil rating (g.p.d./~ or ~/bdrm). I, ~- ~'-P--~System type Length ~" ft. Width '~' ft. · Total depth '7 ft. Eft. absorption area/L~:~ft~ Monitoring tube . Date of adequacy test 7 / I ~ / ~// Results (Pass/Fail) ~ Fluid depth in absorption field before test ~ in. Water added_~gal. Elapsed Time: I ~'1 1 min. Final fluid depth ~ in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type). ~J Gravel ·below pipe ~'/, O ft. Depression over field ~ For ~ bedrooms New depth J ~,¥in. g.p.d. .If yes, give date D. LIFT STATION Date installed Size in gallons "Pump on" level at Datum Cycles tested E. SEPARATION DISTANCES in. Manhole/Access (Y/N) -High water alarm level at Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot J Public sewer main Sewer/septic service line Animal containment areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: On adjacent.lots "~ I ~'~, ' On adjacent lots Public sewer manhole/cleanout Holding tank I~- Manure/animal excrete storage areas' in. Building foundation '~. 7 ~ Property line ~.~' ' Absorption field Water main /V. ~1.. water service line "~ t ~,~ Surface water 'Wells on adjacent lots _'~ IO~,' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Water Service line Curtain drain COMMENTS Building foundation ~/' Z. ~ Water main Surface water '~, l~.a~' ' Driveway, parking/vehicle storage Wells on adjacent lots "~ I~,~,, 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 COSA Fee $ Date of Payment Receipt Number (Rev. 11/05) 00_s" o Oo- Waiver Fee $ Date of Payment Receipt Number i35 SB3NBOD ON :3.LON 'G.:I ~!O ,k,ldVONI"IOG IN~L~NOO ~O3 0~c~9 ~8 OHS ~JQC~H~IO ON !~N~ ('IDOl~DO~ 31..LL NO ~ ,,~v' ,30 3Oi'~1X3 31,.LL 3NIl~Dq:mr:q] "]t-LL .40 ,MJglEIlSROd~I ~ SI II .Ld3OX3 .LSIX3 ~J. 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