HomeMy WebLinkAboutPREUSS #2 BLK 3 LT 5
MUNICIPALITY OF 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 [ '~
IPH°NE
NAME
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
Well Absorption area Dwelling PERMIT NO.
~ ~Z Manufacturer ~ Material~ ~/ No. of comp~ments
iLiq, capacity in gallons Inside length Width Liquid depth
/~ ~ IF HOMEMADE: ,~- ~
~ ~ DISTANCE TQ: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
O Well Foundation / Nearest Io~e ~' PERMIT NO
~ DISTANCE TO: /¢¢ ¢ /¢ ~
No. of lines / Length °' each 'ine~ ~ ' T°ta' 'e~h~ I~es Trench wiOth~,x inches Distance be~2~es
~ ~ ~ Top of tile to finish grade Material beneath tile ~ Total ef rea
~/ Length Width Depth PERMIT NO.
~ Type of crib Crib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
Class ~ Depth Driller Distance to lot line PERMIT NO,
~ DISTANCE TO: Building foundation Sewer line ~ ~ Septic tan~ ¢ AbsorptioQ area(s)
OTHER
PIPE MATERIALS ~ ~,~'~
SOIL~EST RA~G
INSTALLER ~
REMARKS ~ ~e~ /
!~'':~'~ · ~ "~ /~ ~- l~ ·
APPROVED DATE LEGAL /~
72-013 (Rev. 3~78)
() :.::.:i /
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 g Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED EOR: C.4~,~_..P ~:~,-,.
DATE PERFORMED: /~.,~- /S~/ /~.¢~
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16,
17
18
19-
20
COMMENTS
SLOPE
SITE PLAN
WAS GROUND WATER S
ENCOUNTERED? //~O L
O
P
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
/ ~-/,,/,.~- 3:, ~ /o ~,~. ~-'~ '~"
z,'3~ 7 d '- ~ ~
PERCOLATION RATE ~ ~. (minutes/inch)
TEST RUN BETWEEN ~ FT AND '7 FT
PERFOI~MED BY: ,¢~'~ 7~ ~
72-008 (6/79)
GREAI'~R ANCHORAGE AREA BORb~GH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTAN_~E~ ~
FROM WELL /g~0 ~- MANUFACTURER (~"~"~"~ ~ MATERIAL
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH
NUMBER OF ~.~
,.~t'~ ~c~/ COMPARTMENTS
LIQUID CAPACITY/~-~'~ GALLONS.
SEEPAGE'~/"Th. ~/~ ~"~' Ok
/
NUMBER OF PITS __ DIAMETER __
LINING MATERIA CRIB SIZE:
OR WIDTH
DIAMETER
BUILDING FOUNDATION
NEAREST LOT LINE
ADDITIONAL ABSORPTION
LENGTH DEPTH /Y
DISTANCE FROM: WELL
TOTAL EFFECTIVE 7 ,~
ABSORPTION AREA (WALL AREA) SQ. FT.
WELL:
TYPE
BUILDING
FOUNDATION __
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST
LOT LINE
OTHER SOURCES
DISAPPROVED
NEAREST
SEWER LINE
REMARKS
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE
TANK SYSTEM
DISTANCES:
INSTALLED BY:
PIPE MATERIAL:__
LOT SLOPE:
REMARKS: __
DIAGRAM OF SYSTEM
DATE
r4!' ._. I
L. EiCFi"I"
' i ~ '' ~ ........ :I
i'"ii~'~;;;';: ~[ l'ql_l!"l ~ _'i'll ::,~:.t;. ijit:::' ii~::Eii:,I;::(]IL*}I"'i~; =- .~.%,~/.~ ........
THE b:i:!i];i~.. TF'iFi" ':'E; I ;;!:t:{ Eli:: Ir'l'::. ::::,Li~.L l'l~:,.::,U!'*-:r i!Lu'~ :::, 'r .::, p:. r l ~"",;
'THE MENG'i"i.d [::,]'HiiE!'.,!~!.;IOi,! I::5 THE i...ENGTH
'Tb!~.:; DEF'"i'H OF Fi Ti::i;i~-!NCH (]JR I::'ZT IS T'iqE I-;:,i:!~;-i"Ri'-4C:I:~; IE:E'i"b.!Ei~EI'-4 THE Slljt~:F:'FiE:E ()F THE;
6iROl..lt'.41') Fii'.,![) THE( E::()'I"TCii,i CIFr TI...iI::i; i'E',:-:',i;;]F'i~,,,'FIT];Cih4 (ihl F:'EiET).
i"i. II.~;FdE ]; :;ii; NO SET t.,I i [:,TH F'~:~U:;~: 'T'I;;:EIqCHES.
'I'Iiii'! i}il:;;'.Fik,'lEL DiEF:'TH iS THE H:!;i'.4iMI..IH DE!;F:'TH OF i]iii:;Lf.:iVE~J Bi:£Ti4E.r. Ei,~ THE l:;ll...l'l"i::;'i::il..i.. F:'I.F'i!
F:ii',I[) 'i'HEi: E:EFt"'T'EiH i)? 'Y[.-j[~; i;i!;:..;:E:i:::i',,,'l::i"l"
.-- .~,.....: ..... ,,._.,:: ...... -:, .,...,~-.,. .,..¢¢¢.-; .,* ....... / "~'Z' 4'~//?';''~'/ u
E]:THEi:;;: I::I E:I..FiS:~; i OR :i:]' NSF f:tF'F'i;;:O',/IED [::'i....f:ll'4"l" i"'if:l*r' BE ii',iE;TFIL..i_[ED.
H i i',! I i"iUh! I::;, I STFii'.JCE .I:!i;EFI'!.,.IiEF_:N Fi 141EL.I.... FIi'.4i::;, FiN? ()l'~-S i TE Si';b.iFi(:iiE: D
;:U;:)Ei I::tEiffT I::'OF;: F:! F't:;;:I',,,'l::i"i'ii!: !4EL..i... O1:;~: ;;.~OEi FEtE"F F:Cit'-'-~: F.I iC'l...li:ii~i_ '.[ C: i.,.ii:~i_.i ....
I,.iEi...i... L.r)GS RF.:IE I:.;.:1~ii:(;:!1..i]:~4:1!:[[::, i:::li'.,!D l,ilJ?f' [:!~E i.;;:E:TLIF4'.I'4ED 't"C.i THE
OF 'T1...iiE i,.iiEI..L. L~:GHF:'I..tET' :I: O11.
SPEC ]' F:' i C;i::iT ! O1'¢_'~i; t::11'.,!i:) COt',!?i'Fd.tCT i ON [:, ]: FiiJiFi:Fii',i;.:i; Fii:?.E i:::I',/I::i i i....i::tEit...(.:.i
i N:::.;'T'FtL,i ..Fl'i" :[
E GEO'[~..CHNICAL 6r DEVELC..,,'MENI L;u.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
RusseH Oyster
694-2774
Soils ~ Foundations
Performed for: Name:
SOIL LOG.,
¥~% ~. \- ~'~ ~ Tel, No.
Legal Description: \~b-< '~t ~-~'~ ~ '~'/) ~o
Depth {feet)_ Soil Characteristic)
Earl Ellis
688-2280
Land Development
10 ,,.
11 _
13
14
~5
16
Ground Water Encountered: Yes No ~ If yes, what depth~
Proposed Installation: Seepage Pit__Drain Field ~
Comments: ~-~-~' ~,.~j~ ~°~ ~ ~ ~x~ ~ . * ~ ~" ~
Performed by: ~-- ;~-~ Date:
OWNER OF LAND /~' //. &
ADDRESS
LEGAL DESCRIPTION ~ ,- -4'-~ ,/
DATE-Started ;i;i/':~*/'/7 Ended
PERMIT NUMBER : , : ~ ;~
:
DEPTH OF WELL ~ //
STATIC LEVEL OF WATER
DRAW DOWN FT. /
GALS. PER HR
KIND OF CASING
KIND OF FORMATION:
From d) Ft. to /
From / Et. to /~
From 1~.)~ Ft. to ~'
From ~'~ Ft. to "~ ~
From '/':(' Ft. to ..
From ~:r:'! Ft. to. .
From_/~ ~/,~'~'~Ft. to
From ,,?'] d~ Ft. to
From ~d~;t~ Ft. to
From Ft. to
From__Ft. to
Ft. to
__Ft. to__
Ft. to__
__Ft. to
Ft. to
__Ft. to
__ Ft. to
Ft. O 0~,~4~()~ ~'~-4 From
Ft. C~/qff 0~ ~0~ From
Ft. ~" ~ ~d~ From
, . ~,., ~
~'r~ Ft. -~'~Fc)~F'~9 C¢~l-~; From
/~ ~0 Ft. r~, z, ~7~ 7' d ~t:~ From.
,~Q)D Ft. (!&/q~ ~ (~/d~dt~c~ From Et. to
~o~Z .Ft. to
Ft. ~ Fromm. Ft. to~
Ft. From Ft. to.~
From Et. to__Ft.
From Ft. to
From Ft. to Ft
From Ft. to ·
From__Ft. to Ft
From Et. to
From__Et. to Ft.
From Et. to
From Et. to Ft.
From Ft. to
From Et. to Ft
From Et. to
Ft.
Ft
Ft
Ft
Ft
Ft.
Ft.
Ft.
Ft.
Ft
Ft
Ft
Ft
Ft
__.Ft.
__.Ft.
Ft.
MISCL. INFORMATION:
DRILLER'S NAME ' ' "" '
E DRILLiNG-: O
' ' :: ~ - '-':-...~- ~ ~, ;~. ::3:5 :~. -*..;~-::~ -r- .... ., -
-' ...... .:.. ~... .: ~:.. 'C~ '~ :.. 'From - -
~ ~ ~,~ '~_'2'"':'2'. ,:"~::~':~ .-:;' · :, , . ' ...... "-..From
, .~ ~,~.~ . ~ .~%, ..... ~. , - ' -~ ~',~ ~' '% '7 "- ' ~
Yrom. ' ' Ft./O__Ft ' From ~Ft. to _Ft.
~'rom Ft. to -Ft,
:ton{ Ft. to ' Ft
'rom.. Ft. to Ft._
¥
tom Ft. t~ Ft.
.'om. Ft. to. Ft._
.~.m Ft. to Ft.
From Ft. to Ft.
From_ Ft. to~ . Ft.
From .Ft. to_ Ft._
From Ft. to Ft.
From_ Ft. to~ Ft.
From _Ft. tO__Ft.
Fr°m--Ft. to Ft
Parcel I.D. #
GENERAL INFORMATION
complete Jegal description
Preuss #2
~ 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
050-572-21
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES ~ : ·
Lot 5,___Block 3
Location (site address or directions)
10145 Preuss Lane, Eagle River, AK
Property owner Patrick & i~tth Donadio Day phone.
Mailing address 1928 E. Canterbu_~-y Street, Spr±ngfield, MI 65804-7706
Lending agency
Mailing address
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF'BEDROOMS: 4
NBA / Pat Angevine Day phone. 694-5373
P,O, Box 6127, Anchoraqe, AK 99519
Re/Max of Eagle River / Audrey MaSO~ay phone 694-4200
16600 Centerfietd Drive, Eagle River, AK 99577
3. TYPE OF WATER SUPPLY:
Individual well ×
- Community well
'P.. ublic water
NOTE: If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system. ,: '~,"; ~ +)/,/ ,~.
4. ,',"' -~:':"-~, ', ....... ,~'"/,~ ,
NOTE: If community wastewater system, proede written confirmation from State ADEO
' ' attesting to the legality and status ~f system.
72~25 (Rev. 1/91) Front MOA~21
T~YPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Commun ity on-site
Public sewer
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.
694-5195
Name of Firm Eagle River Engineering Services Phone
Address . ~ver, AK 99577
Engineer's signature --~.-/~- '~'~-~ Y Date //1~/'~,¢
DHHS SIGNATURE
~ Approved for
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Cdmments
Date
.. , . i.'~ .... '; -' ~hora~e De-artment of Health and Human Services (OHHS) issues Health Authority
The Munic~paHW q,',~u ~ ~ · · · ve b an independent
'- ' .' , ~,~;~,-i~t~:haSed onlv upon the representabons g~ven m paragraph 5 abo. Y ..... ,,. ....
Aopr, ova.t~,,,-,~.~-~ .... __ ~, ,, ,~.., _~,~.~ooo~,-ourtesvtoourcnaser~u,,,,~,,,~o
professk~riAI engineer registered m the State of Alaska./ne umno uo~o .........
and their lending institutions in order to satisfl/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.
72-025 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage ,/~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A. Well Data
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level1
If A, B, or C, attach ADEC letter. ADEC water system number /,///,2/
Date completed ~/.v ~¢,-.,~.~ Driller
Cased to ~'- ~/~ / Casing height
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
' ....
g.p.m. ~, ~ .g.p.m. ~
SEPARATION DISTANCES FROM WELL TO:
Septic/tzotflmg tank on lot
Absorption field on lot
Public sewer main
Sewer service line --~ ?
; On adjacent lots '~- i/)~ /
; On adjacent lots ¢'/~)~2 /
Public sewer manhole/cleanout /.////,:~L
Petroleum tank /V~'//£
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
O, / ~'/~ ./L
Collected by:
Other bacteria
B. SEPTIC/~ TANK DATA
Date installed ~//~ '~
Cleanouts (Y/N) ,V~/</
High water alarm (Y/N)
Date of pumping
Tank size /~"'~' ~ Compartments
Foundation cleanout (Y/N) Y~ Depression (Y/N)
/t///~ Alarm tested (Y/N) ./(//~
01/~/~ Pumper
SEPARATION DISTANCES FROM SEPTIC/I-I~L-DING TANK TO:
Well(s) on lot 7L/0(~ / On adjacent lots
To property line '-/' /0 Absorption field
Surface water/drainage /"'////~
Foundation ~-~ /
Water m-,~i,/service line '~/~) 1
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION /',///3
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MOA efectrical codes (Y/N)..¢''''~
SEPARATION DIS~ANCE FROM LIFT STATION TO:
Well~nt6~- On adjacent lots
"Pump off" Level at
Cycles tested
D. ABSORPTION FIELD DATA
Date installed ¢~/~5 Soil rating (GPD/Ft2)
Length ~¢ '~' Width '~P"
Total absorption area /~..~(,¢ ~7~ Cleanout present (Y/N)
Date of adequacy test ¢//eL//¢~ Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Surface water
System type
Gravelthickness ~ / Total depth /
~.~ Depression over field (Y/N)
/D/,~ :~' for ~ Bedrooms
After test <¢', 5- / ..4'~.,,~ .~-,.;Y~-..,~ ,,'-
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot //P~) ¢
To building foundation
On adjacent lots 'Y- -'~¢~ /
Surface water /"///~
Curtain drain /~///~
On adjacent lots /-/~0~ / Property line
To existing or abandoned system on lot
Cutbank ./~//~ Water r~d~/service line
Driveway, parking/vehicle storage area /¢ /
E. ENGINEER'S CERTIFICATION
I certi~ that I have checked, verified, or conformed to all MOA and HAA guidelines in effect or~:.the date. of this inspection.
Engineer's Name ~d~b,/.S /~,~f~/¢.~4., ~,
Date
HAA Fee $ ~ .E~'_'.~ ~
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~- - -
LABORATORY ANALYSIS REPORT
CT&~ Ref.~ 95.0067-1
C~$ent 8at~lm ID pREU~ ~2 $/3
D~ID ~ Technical Director 8~N C. ~D~
........................... 01/06/95 CMR
Ni~za~e-N 0,10 ~ ~u/L EPA 353.2 10.
5633 8 Street, Anche~ge, AK 99~18-16~a -- Tel; (907} 56/-~343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA. COEOEADO, FLORIDA. ILLINOIS, MARYLAND, NEW JERSEY. O~IO, UTAH, WES~ VIRGINIA
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
;)1RECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNEPv~.~ ' ~ ~ ~.~----~' P~tONE
2, PHONE
~AILIN~ ADDRESS
3, LENDING INSTITUTION ~~___.~=~ J PHONE
MAILING ADDRESS
4. REALTOR/AGENT ~-~--~'~----~'~"~-'~ J PHONE
MAILING ADDRESS
[] One [] Four [] Other__
~ SINGLE FAMILY [] Two [] Five
[] ~viULTIPLE FAMILY .~ Three [] Six
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available,)
8.
SEWAGE
DISPOSAL
SYSTEM
**If individual/on-site, give installation date
~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTI LITY If system is ~;~er two (2) years old an adequacy test is required
MUST
NOTE: THE INSPECTION FEE ACCOMPANY EAC~ UEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
" [~ATE RECEIVED ' ' ~:
INSPECTION APPOINTMENTS
T,ME T~ME T~ME
DATE DATE
DATE 3- U- ~ ~ U~A 5.
INSPECTOR ~ , INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
~ SINGLE FAMILY ~ ONE ~"THREE ~ FIVE ~ OTHER
~ MULTIPLE FAMILY ~ TWO ~ FOUR ~ SlX
PERMIT ~UMBER
2. WATER SUPPLY
~ INDIVIDUAL DEPTH OF WELL
~ COMMUNITY
DATE DRILLED
~ PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYgTEM PERMIT NUMBE.
~DIVIDUAL/ON -SITE DATE INSTALLED
Connection Verified INSTALLE~
~ptic Tank or ~]Holding Tank
Size: I A ~'~ If Tank is homemade SOILS RATING
give dimensions:
MATERIA~~
TOTAL ABSORPTION AREA
4, DISTANCES Septic/Holding Tank Abso~tion Area Sewer Lin~' ~ Nearest Lot Line
WELL TO:
I
Absorption Area to nearest Let Line
~ APPROVED FOB ~ BEDBOOMS
~ CO~DITIO~Ak AP~OVAk (letter must accompan~ certificate)
DATE BY (Title)
72-010 (Rev. 3/78)