HomeMy WebLinkAboutPREUSS #3 BLK 5 LT 6 ! 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 NAME LOCAT,ON DISTANCE TO: /*~ / ~ ~ Liq. capacity in gallons Well Inside length IWidth , J ~O~) O IF HOMEMADE: D,STANOETO: I Dwe'""g n///) 3:;I-- Manufacturer /y/,/~ ' Material ~-o~= I D~STANCE TO:. We, /,/,~ /~__ Fou,dation/,~Z ~Nearest Io~o.~i.a .~ ~. ;~ I No. of hnes ~.1 Lengt~of each line..~---r- Total length ovf lines/ ~ Trenc~b~vi~t h uJ I Length Width Depth ~ I- I Type of crib Crib diameter Crib depth :~' DISTANCE TO: mm -- Well Building foundation Nearest lot line  Class Depth Driller Distance to lot line ~ I DISTANCE TO: Building foundation Sewer line Septic tank /_.O N E [] NEW [] UPGRADE NO. OF BEDROOMS No. of compartments~:~ Liquid depth PERMIT NO. Liquid capacity in gallons PERM'T NO' f$O2'S / Total effe,c~rption area PERMIT~"~. Total effective absorption area PERMIT NO. Absorption area(s) OTHER PIPE MATEI~IA LS SOIL TEsT RATING /6~<~ ,~ INSTALLER REMARK~,~ ~ t~O LAPF~OVB~/ ' DATE LEGAL i'qFI;:.:;:[P!!..,It'1 NI..I!',IE:E~: 01:::' !ii!:l~:!;l)l::i:O0!'q:!ii; ..... ;;!~: 'i'HiE l...F~;l'.,!(;ii-t"l.I [)); ]'!li!!:!'.,tS ;I; O1",I ); :~!; T!'.lli!; ! .lii!:!'-4(~i*l"l-.l ( Z!; i:',! f::'!iil;!i!i;"i' ;:, O!::: "['1...I!}::: Ti;;:!;!!;i',i(iX...i ()!:;;; DP.i:::! ;[ I'.:!!:::' ;[ ~!:;i..D. THE Dli':;I:::'TH CIt:::' I:::i "f'I:;;;~:;I'-,tC:H O1;i: I:::'];T ;IS TI..l!i'~ (}il;;'.C~I..Ii'.,!D I:::II',ID TI--IE ~i',(;Zr'l"'i"(1)H (.)I:= "!"l-..!!i!:; !-!!X:.~',C:I=iVI:=!T;i;(;'~N T H t.i; (i!il:;i:!:;:i',,,'l}!; L. [;:, l!!i; F' "I'H ;[ S '1" H l!il; i'! ;!; I",! )' t"1 I.I!', I:::!i'-,i.D Tl-.ll~i; i:!i:o"rTOt"! 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TEST ~so~ls 'log [] percolation test performed for: '~-~'v,~x~/,~z:> le desc, ,,z~,~--~/~; ~ 4- 5- 6- 8, 9 I0 Il 12 l$ 15 16, 17- 18' 19- depth date, ?~/-?,~' read, ne date a.hme in.time d.fov~aternet dron 20- perc. rate between comments ~/-~,,~z~-~/,~- ~-~ ~ ~ performed by: /~~/~ _ cerhfled OWNER OF LAND ~-,~tc/~ ADDRESS LEGAL DESCRIPTION ,,d?-,~.) ~/~' DATE - Started PERMIT NUMBER (~" ., STATIC LEVEL OF WATER FT. &; t5~,~oC ':J' ~"DRAW DOWN FT. / ~' Ended GALS. PER HR ~4} ~'7-'~t KIND OF CASING G '~ OD by ENVIRON~TAL PF:OTECTION A & L B ILLI G COmPAnY JAN lgTg KIND OF FORMATION: From ,") Ft. to cf~, Ft. (-) ~g'/d (fc~ ~ t)~-~'d From--Ft. to From ~:? Ft. to ~',~Ft. (~.,q'7' -~ g,~/~c~, From__Ft. to}__ From¥,?.'~i Ft. to d>e;~ Ft. ~/~,~.~ ¢-f~od~.d __Ft. to___ From ,~:~d From / "c o From c'~ From_ ? From ,i;??~) Ft. ta ~' '?'7 Ft From ? Y(7 Ft. to ~ P'3~ Ft From Ft. to Ft Ft. to/~JTM Ft 45~f~2~ ~'° ~k~'~'~tt-~ From Ft. to Ft. to · - From _Ft. to~ Ft. to c*,~ Et ~C~'F ~'ff~C ~ ~d0u~ ~om · Ft. to~ ~Ft. to ~ 70 Ft. ~J ~ 6'~ ~-~c ~ff~* d~- ~ From~Ft. to~ C4~f ~-~(~do~ From ~Ft. to_~ From Ft. to__ From Ft. to Ft. From Ft. to From__Ft. to Ft. From Ft. to__ From__Ft. to Ft From Ft. to From Ft. to Ft. From Ft. to From Ft. to Ft. From__Ft. to__ From Ft. to Ft. From__Ft. to From Ft. to Ft. From Ft. to Ft. .Ft. Ft. Ft, Ft. Ft. Ft. Ft. Ft Ft Ft Ft Ft. Ft Ft. Ft. FL MISCL. INFORMATION: /~'. '.~ .? DRILLER'S NAME GES e� Municipality of Anchorage On-Site Water and Wastewater Program K e:IL9 (907) 343-7904 s A T, CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 050-571-29 Expiration Date: Ja .28 .2077 1. GENERAL INFORMATION Complete legal description PREUSS#3 BLOCK 5, LOT 6 Location (site address) 20218 LUCAS AVE., EAGLE RIVER,AK 99577 Current Property owner(s) WILLIAM&MAY SMITH Day phone Mailing address 20218 LUCAS AVE., EAGLE RIVER,AK 99577 Real Estate Agent Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 TYPE OF WASTEWATER DISPOSAL: 4. TYPE OF WATER SUPPLY: Individual Individual Well ® Holding Tank ❑ Individual Water Storage ❑ Community ❑ Community Class _Well ❑ Public Sewer ❑ Public Water System ❑ WaiverNariance request for: Distance: Received by: '` Date:1'/!1 4j COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Ja(D Waiver Fee $ Date of Payment 4/a570- Date of Payment Receipt Number a(ILq I 0 Receipt Number COSA# 6,50'31/415- Waiver# 5. 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 ARCTERRA CONSULTING, INC. Phone 868-3791 Address 20441 PTARMIGAN BLVD.,EAGLE RIVER,AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 4/13/2017 THIS COSA DOCUMENT CANNOT BE USED TO TRANSFER TITLE UNLESS ALL VENDORS(ENGINEERING,SURVEYING,CONTRACTORS,ETC...ASSOCIATED WITH THIS COSA ARE PAID IN FULL AT OR BEFORE CLOSING. Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use. local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen encroachments,deficiencies or discrepancies exist. Or 91 A 6. DSD SIGNATURE p4 4 7't II System #1 Approved for 3 bedrooms. , I I Ar Pi � KENN 1. DU: System #2 Approved for bedrooms. 4 c`r�� /s wr#� Disapproved. , ''°FF»So`�' dor Conditional approval for bedrooms, with the following stipulations: .� OF ANcho - cQ . ON-SIT Np rnc" WATER z o WASTEWATR --- �� pROGR �AE • X44" 'Arr•qpP\I\ (e By: P.diketeA CRAfilYel Original Certificate Date: Ll 28/20 1 '7 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet 7a1a12.doc If more than 1 septic system is on the lot: COSA Checklist# of Structure served by this system _ Certificate of On-Site Systems Approval Checklist Legal Description: PREUSS#3 BLOCK 5, LOT 6 Parcel ID: 050-571-29 A. WELL DATA Well type PRVT If A, B, or C provide PWSID# Well Log (YIN) Y Date completed 114/1979 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Total depth 384,5 ft. Cased to 384 ft. Casing height (above ground) 24+ in. FROM WELL LOG AT INSPECTION Date of test _ 114/1979 _ 4/13/2017 Static water level 349 ft. 347 ft. Well production 10 _ g.p.m. _ 4.7+ _ g.p.m. WATER SAMPLE RESULTS: Coliform(, colonies/100mL Nitrate O.1bS mg/L Arsenic: ug/L Date of sample: 4/13117 Collected by: ARCTERRA B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC I FIBERGLASS Date installed 1011211978 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y___ Foundation cleanout (Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N Date of pumping 411.2/17 Pumper JRs C. ABSORPTION FIELD DATA Date installed 10/12/1978 Soil rating (g.p.d./ft2 or ft2/bdrm) 150 System type DEEP TRENCH Length 62 ft. Width 3 ft. Gravel below pipe 4 _ ft. Total depth 7.4 ft. Eff. absorption area 496 ft2 Monitoring tube Y Depression over field N Date of adequacy test 4113/17_ Results (Pass/Fail) _PASS _ For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth 3 in. Elapsed Time: 15_ min. Final fluid depth 0 in. Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) 14 If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN) "Pump on" level at in. "Pump off level at in. High water alarm level at in. Datum Cycles tested Meets alarm &circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ _ On adjacent lots 100'+ Public sewer main 75'+ Public sewer manhole/cleanout 100'+ Sewer/septic service line 25'+ Holding tank 100'+ Animal containment areas _50'+ Manure/animal excrete storage areas 100'+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ _ Water Service line 10'+ Surface water 1004_ Driveway, parking/vehicle storage 104 Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION t 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. 40. 1 .• �, OF Azo \ Engineer's Printed Name KENNETH M.DUFFUS ,T�" c51 Date 4/13117 ° 4 9 Tt COSA canary sheet_2-6-15.doc f . KENNETH M. Pr �� 1 718 , Air Ilk '111f Carroll, Rebecca M. From: Dea Duffus <dea@arcterra.net> Sent: Thursday,April 27, 2017 2:46 PM To: Carroll, Rebecca M. Cc: Brent Western; urwildchild@hotmail.com Subject: Re: PREUSS#3 BLK 5 LT 6 Becca, I just spoke to the owner who has lived at the property for almost 30 years and he says there has never been a CO at the other end of the line. He is transferring title to his daughter who was raised in the house. Since there is no way of locating the line without great risk of damaging the leachfield and since the line is less than 50' so it could be snaked if a problem arises, will you approve the COSA with the information provided? The Asbuilt survey does accurately show the existing system. Dea Duffus ArcTerra Consulting On Apr 26, 2017, at 11:20 AM, Carroll, Rebecca M. <CarrollRM@ci.anchorage.ak.us> wrote: <Onsite Review Comments.pdf� 1 Cti t t_:.) , ice. : is Z UC. 7.-. 4L 1 (ID 11111 k n o • _ /V639 a s2 'w ,/9e 7s • i+ D Q Ar. eW . \:"1 I ll�V1 r\cik • ` RI V � e ° urr o ' Qi0 06 V • 4-4,..,..r. , 9FS,iO,ENtF ti ,v i per-4au o CO VZ 1 --- - WWLL • N 1 \\\ I 76.- �1p. 1 -PD 14------,..? ,,,oz,- x f.-i1/c/rO•T� fr, • ,S Q ' .-,•49TH 7`� • i' ; ,,� , �j. .. Duane Merk Seward i � LS-5918 0 AS-BUILT To corners set this date EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE I hereby certify that I have performed a Mortagee's in- RECORDED PLAT ARE NOT SHOWN HEREON. spection of the following described property: Un i t No . 3 Prpiiss Siihri_ , Int 6, Rik_ 5 :he information hereon is for the use of lending Anchorage Recording Precinct,Alaska, and that the improve- ments situated thereon are within the property lines and do institutions showing the relationship of existing not overlap or encroach on the property lying adjacent there- structures and platted easements and lot lines. to, - ---- = i -- _= aiit-eheictu It is not to be used for positioning additional > n- and that there are no roadways, transmission lines or other Visible easements on structures or fencelines. said property except 83 indicated hereon. Dated at Anchorage,Alaska 7,0.9...A.../.4.--.'��� .Q�r�s%8/9 ~ t�. Tc '?,y. `5 9 tit"` 19 day 6of 88-4566 19 89 "�`" '=.70 ' -.37 ���� / �/1/''Sd SEWARD & ASSOCIATES LAND SURVEYING J 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 Parcel I.D. # n5(~-571 -?9 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA# ~ ¢;~'~ ~-~ ¢'/\ °~-~ Preuss #3 Lot 6, Block 5 T14N R1W Sectior~:~8 Location (site address or directions) 20218 Lucas Avenue, Eagle River Property owner William & May Smith 20218 Lucas Avenue, Eagle River, AK Mailing address Day phone 99577 694-0490 Terri Corbett/GMAG Lending agency Mailing address 460 N. Tudor Road, Anchoraqe, AE Agent N/A Address Day phone 562-2181 99503 Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water 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 NOTE: X Public sewer 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 DHHS SIGNATURE ' ~" Approved for ~-_~,~) bedrooms. -- Disapproved. 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 tho 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 fur[her 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. Name of Firm Eagle River Entering Services ~ Phone 694-___5195 Address __ P~O. ~ox~~Eag~iv~ 995/7 Engineer's signature ~- . . .~.%, ~_ ~ -~ Conditional approval for _. ~ bedrooms, with the following stipulations: Additional Comments By: . 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 DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state req uirements. 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 & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST * Legal Description: A, WELL DATA Parcel I.D. Well type /,~,E/¢//¢7'~ If A, B, or C, attach ADEC letter. ADEC water system number Logpresent (Y/N) Y'~S Date completed /P,~/O~ O//O~¢/~ Driller Total depth ,.~ ~',Z/, 5 / Cased to -~o~/'/ / Casing height Sanitary seal (Y/N) Y~ -- Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG /O v/v~/Jrt b~/4 g.p.m. MUNiCiPALITY OF ANCHORAGE AT INSPEOTIOI~INviRONMENTAL SERVICES DIVISION .?:~ 2 0 199,~ CEIVED D N ~JV'i314) t,J SEPARATION DISTANCES FROM WELL TO: Septic/ho!ding tank on lot Absorption field on lot Public sewer main Public sewer service line /V/~/ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank 4~ WATER SAMPLE RESULTS: Coliform ~ Nitrate O. ~ ~ /L.- ~ Date of sample: ~/7'/~)~'/~'~ ~ Collected by: Other bacteria B. SEPTIC/HOL-BtNG TANK DATA Date installed Cleanouts (Y/N) )/~'~ ~-~ High water alarm (Y/N) Date of pumping Tank size /000 w Compartments Foundation cleanout (Y/N) ~--~ -'"' Depression (Y/N) Alarm tested (Y/N) ///4 SEPARATION DISTANCES FROM SEPTIC/I ~CLDh~;G TANK TO: Well(s) on lot ¢'/0O/ To property line .~//,) I Surface water/drainage On adjacent lots Absorption field Foundation Water mcln/service line 72-026 (Rev. 3/91 Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level .1~. Meets MOA electrical codes (Y/N) .~..~'~ SEPARATION DISTAf~GE~OM LIFT STATION TO: Well on lot--'?~' On adjacent lots D. ABSORPTION FIELD DATA Date installed [[)/[~,/~ Length ~ ~' / Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Manufacturer M a n h el e/Ac~ce~,s.~,.(Y2~) -- "Pump off" level at Cycles tested Surface water Soil rating / ~0 System type '~'-fg, A/~ ,L/ Gravel thickness .Z~ / '~/ Total depth -- Cleanouts present (Y/N) Date of adequacy test for ~ -- bedrooms ~VI4 If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot C- To building foundation On adjacent lots Surface water /~///) Onadjacentlots ¢'/¢~0 z Propertyline ¢- //~ / To existing or abandoned system on lot /~///:) Cutbank /V/~ Water.-mcJn/service line ¢'/~ ¢ Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature ~'~.-~'" Engineer's Name Date HAA Fee $ / ~(~ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number 72-026 fRev. 3/91) Back MOA 21 MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include Ii)t, block, subdivision, section, township, range) LOT 6; BLOCK 5; Preuss Subdivision ¢_ ~ Location (address or directions) 20218 Lucas Avenue (b) Property owner Alaska Housinq F.¢. - AHFC#65624 Mailing Address 5?0 Ea_*~ _~4~_t,_ Avenue (c) Lending Institution Mailing Address Telephone:(home) 4nchoraqe, Alaska 99503 Telephone Business 56~'- 1900 (d) Real Estate Company and Agent RE/MAX OF EAGLE RIVER ATTN: EVA LOKEN Address 16600 Centerfi~ld Drive Suite 201, Eagle River, Ak. 99577 Telephone 694-4200 (e) Mail the HAA to the following address: (or check here,~ if hold for pick up.) List contact person and day phone number below: 17034 Eagle Ri~er Loop Road NO. 204 Eagle l~iver, Alaska ~9577 2. TYPE OF RESIDENCE Single-Family,~( Number of bedrooms ~ 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DIsPosAL On-siteJ~(X Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my sea[ affixed hereto and as of the validation date shown below, Iverifythat my investigation of th is Health Authority Approval shbws 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. Name of Firm Address Date S & S ENGINEERING 17034 Eagle River Loop Roa~/No. 204 Eagle River, Aleska ~577 Telephone 6. DHHS APPROVAL Approved for ~ bedrooms by Approved ~'~ Disapproved Terms of Conditional Approval Conditional The MunicipalityofAnchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph S above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHSdo not conduct inspections or analyze data before a certificate is issued. The MunicipalityofAnchorageisnot responsible for errors or omissions in the professional engineer's work. 78-025 (Rev, 7/88) Back Page 2 of 2 ~,~.~og ~¢JNICIPALITY OF ANCHORAGE (MOA) ~,~'~ AA ~,~ Health Authority Approval (H ) CHECKUST- FE RU R · . ~ ~. ~, 343-4744 Legal De cr I , .E Well Log Present (Y/N) ~ Date completed ~a~ I~ ~ ~ Yield Total Depth .~_Y¢¢. Cased to ~Depth of Grouting Static Water Level ~ '/1L ~' Casing Height Above Ground Electrical Wiring in Conduit(Y/N) ti/ SEPARATION DISTANCES FROM WELL:, To Septic/Holding Tank on Lot To Nearest Edge of AbsorPtion Field 0ri,Lot To Nearest Public Sewer 'Line To Nearest Sewer Service Line on Lot Water Sample Co ected by Water Sample Test Results Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots . / CO / 't*' /_DO '¢- ; On Adjoining Lots / 00' '/- To Nearest Public Sewer Cleanout/Manhole /L)/J¢I Comments B. SEPTIC/HOLDING TANK DATA Date Installed /O/?'~ Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: T° Water-Supply Well To Property Line / OOO No. of Compartments Air-tight Caps (Y/N) K Foundation Cleanout (Y/N) /' Date Last Pumped /~t)c,' / /-/, /~ ; for Temporary Holding Tank Permit (Y/N) To Building Foundation "~' t To Disposal Field To Water I'~=,~/Service Line '~0 ~ To Stream, Pond, Lake or Major Drainage Course Comments '~"~ ~' ¢'*'~/* £- 'J~gr ¢ t(/' Ir-' ~ ' ' ¢'~A '°~c~ 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Date Installed ,/(3/ ~ ~ Length of Field ~¢ ,2.. Width of Field ~ (¢ ~' _ Depth of Field Gravel Bed Thickness ~-'/U~ Square Feet of Absortion Area '/-JF ~/¢ ¢ Statndpipes Present (Y/N) Depression over Field (Y/N) ~ Date of Last Adequacy Test Results of Last Adequacy Test =~ i~'/'~ ~ ~-¢~C."~¢',~ -- .'~ /~ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well / / (2 To Property Line ,/ 0 To Building Foundation .~ (2 To Existing or Abandoned System on Lot ~/¢t ; On Adjoining Lots / ~oo ' '/-- To Water Main/Service Line '~(2 p To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course /d/~ ~ To Driveway, Parking Area, or Vehicle Storage Area ~0 ~ Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) _ ,~ Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effg~C.g~t~dQ.J;e of th s inspection.. ~, Signed S & S ENGINEERING Company Date of Payment Z-~ ~ Waiver Fee: $ Amount: $ ./~,- ¢ ~ Date of Payment 72-026 (Rev. 7/88)Back Page 2 of 2  CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER PRIVATE WATER SYSTEM Name Mailing Address S & S ENGINEERING Phone No. 17034 Eagle River L~np Eagle River, Alaska 99577 City State Mo. Day Year Zip Code SAMPLE TYPE: )~ Routine Check Sample (for routine sample with lab ref, no, [] Special Purpose ) [] Treated Water [] Untreated Water SAMPLE Time Collected NO. LOCATION ~ I I .~.o-/" ~.~ ~/~C~'~,' ~)FE'O$$-~J~ Collected · . . , 1.~,20 . TO BE COMPLETED BY LABORATORY shows this Water SAMPLE to be: factory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received . Time Received Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* I I Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direcl Count ~'~ Verification: LTB BGB. Final Membrane Filter Results ~ Reported B3~ ria~te Timei TNTC -- Too Numberous To Count OB -- Other Bacteria Collform/10Oml Coliform/lO0ml a.m. p.m. PART I OF 2 REMAINDER TO FOLLOW CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. /~~,k ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID# 92-0040440 Date Report Printed: AUG 18 89 9 t9:26 Collected AUG 15 89 ~ 15:20 h~s. Received AUG 15 89 ~ !6:00 hrs. ?~ase~ved ~ith :kS ~EQUIhZD Req ~ Ordered ~y : Send ~epo~:t~ to: 2) Special ~.l!owable Pazameto~ Tested Reault/U~its ~et ho~ ........................ 2& ........................................................... : ~I~J~4; I;D(0.10) ~'4/1 Sample ROUTINE 3&~fPLZ l{e~rks: SAb~I'LE COLLECTED BY R.J. !~en~ De~ected ~" See Sa~ple Ramark~ Above Not Analyzed L~=Le~s Than, GT-G~eater Than MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRON]~ENTAL REALTH DEPARTMENT OF HF~ALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1o General Information Application Date (a) Legal Descrip~ion~ (include lot, block, subdivision, section, township, range) Location (address or directions~ ~(~ Co"/~- :~ ~ :'~ ( ~ ~'~,. hone - Ilome Business (b) Applicants Name ~ ~ . ~ ,:~ , ~Telep (c) Applicants Address Applicant is (check one) Lending Institution ~--~ ; ~ner/builder ~--~ ; Buyer ~ ; Other ~ (explain); (d) Lending Institution Telephone (e) Address Address (f) Mail the HAA to the following address: 2. Type of Residence Single-Family~ Number of Bedrooms Multi-Family ~--~ Other (describe) Individual Well ~ Community ~ Public ~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite~. Public ~ Community ~ Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [PAge 1 of 2] 5. Engineering Firm Providing ~In_~ectio~ Tests~ Fil.e 8ear_~_~ Data and Information 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 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 regula- tions in effect on the date of this inspection. Name of Firm Address DHEP Approval Approved for~¢~ff~?).bedrooms Approved L~- Disapproved __ Telephone__ Conditional Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONb~NTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL ~;D STATE REQUIRE- MENTSo EMPLOYEES OF DHEP 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. (DHEP SEAL) RR4/ej/Di8 [Page 2 of 2] 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH ALrfHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 WELL DATA Well Classif icat i~/~'~ Well Log P~esent((~ Total Depth ~ ~J~ Cased to Static Water Level .~ ~ Casing Height Above Ground Electrical Wiring in Conduit((Y__~) Separation Distances from Well: To Septic/Holding Tank on Lot O,O" ': If A, B, or C, D.E.C. Approved(Y/N) Date Completed /9 7 ~ YieldS/ ~ ~ F~ Depth of Grouting Pump Set At ~ ~ Sanitary Seal on Casinu((Y~___/.~___ Depression Around Wellhead To Nearest Edge of Absorption Field on Lot/~O ToNea~est Public ~ L~e/ C lean~t/Ma~ole Water S~ple Collected By Water S~le Test ~sults Standpi~ ~g ' __ Ai~-tight Cap¢~) Fou~at ion, Cleanout~) ~p~essio~ Ta~ (~ Date ~st .~d P~ing~aintenan~ Con~act on Holding Ta~ High-Wate~ Ala~ (Y~f/~ Te~ra~y Holdi~ Tank Per~t (Y~) /~ Sep~ation Distan~s f~ ~ptic~olding Tank: / To Water-Supply Well //~ To Property Line /LQ To Water ~ervice Line Course To Building Foundation 7 To Disposal Field c~ / To Stream, Pond, Lake, or Major Drainage Comments Receipt Date Paid: Amount: [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorpti, on St/~ata /~-~ Type of System Design Date Installed /~/'Z ~P Length of Field ~ Z / Width of Field ~ ~ t~ Depth of Field 7 / · Gravel Bed Thickne]s f~ Square Feat of Absorptio~ea ~-~ Standpipes P~sent (~.Y~ / Depression over Field (~ Date of Last Adequacy Test Results of Last Adequacy Test~.~/~ ~/~/~/g~ Z-O ~ ~ Separation Distance from Absorption Field: To Water-Supply Well ///~) g To Property Line /~3 To Building Foundation ~ O r To Existing or Abandoned System on Lot /~ ; On Adjoining Lots To Water ~/Se~vice~ Line ~c~ ~'~F- To Cutbank(if present) ,~z To Stream/Pond/Lake/or Major Drainage Ccurse /~/ To Driveway, Parking Area, or Vehicle Storage Area _~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions ~Ma~hole/Access (Y/N) ~// ~ ~- Vent Pumping Cycles during Adequacy Test. Meets Conn~nts Check Permitted Bedroc~n Rating Against HAA Request I certify that I have checked, verified, or confor~ed to all MOA HAA C~idelines in effect onthe date of this inspection. ~/--~/~ ~ _ ~%~. [Pa~ 2 of 2] -- '~: ~'~9F~%~u~~ 2-15-84 L)ATE RECEIVED " INSPECTION APPOINTMENTS -~ TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR I NSP ECTC~F~ MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE . DEPA.TMENT DP .EA.TR E.V, RONMENTAL  825 L Street - Anchorage, Alaska 99501 i ENVIRONMENTAL SANITATION DIVISION ~,~0V 5 1980 Telephone 264-4720 DIRECTIONS: Complete all parts on page 1. Incon~plete requests will not be processed. Please allow ten (10) days for processing. I PHONE 1. PROPERTY OWNER A1 6 Barbara Hathewso~ MAILING ADDRESS ?. O. :Box 249, ~agle River, Al( 99577 PROPERTY RESIDENT (If different from above) PHONE PHONE 2, BUYER Thomas 6 ~assie Borden MAILING ADDRESS 11631 "B" N2× Ct., Anchorage, A~ 99502 I PHONE 3, LENDING INSTITUTION Alaska Bank of the North MAILING ADDRESS 3301 C Street, Anchorage, AK 99503 I PHONE ~, REALTOR/AGENT A1 Romaszewski, AREA, Inc. Realtors , 694-9555 MAILING ADDRESS P. O. Box 249, Eagle River, A~ 99577 5. LEGAL DESCRIPTION Lot 6 Blk 5 Preuss Sub. ;TREET LOCATION Lucas Street NUMBER OF~BEDROOMS 6. TYPE OF RESIDENCE [] One [] Four [] Other~ I~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [~ Three [] Six 7, WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY *ATTACH WELL LOG. Awell lo§ 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 [~ INDIVIDUAL/ON'SITE** [] PUBLIC UTILITY 1978 YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-O10 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS E~] ONE [] THREE [] FIVE [] TWO [] FOUR [] SiX [] OTHER 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATEINSTALLED INSTALLER []Septic Ti]nl~)r E~] Holding Tank Size: ll~;~) If Tank is homemade SOlLSRATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line Septic/Holding Tank Absorption Area Sewer Line JNearest Lot Line 5. COMMENTS DATE EJ~'~APPR OV ED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (Fetter must accompany certificate) E~] DISAPPROVED 72-010 (Rev. 6/79) MUNICIPALITY OF ANCHORAGE DEPT. ©F i',ZALT;{ & · ¢¢g;::-- i)EPAWFMENT OF HEAl_TH .-2~ ENVH)~ONMENTAL PROTEC'FI~''IRONMENI''qt' F;,.':i~CTION ,~,%,E~4;*.~/),~,~:, ,,:~ ,~ ENVIRONMENTAL ENGINEERING DIVISION REQJ,...q FOR APPROVALOF ND v,DUA!. DIRECTIONS: Complete aH pints on page 1. incomplete requests will not M..M LING ~DDRESS '~:~'~¥~=~-g ~EStDENT (if differen~ ,rom above) 2, BLIY EI~ MAILING ADDRESS ~ 4, REAL~OR/AGENT MAILING ~DRESS 5, ~ EGAL OE$ORIPT|ON TYPE OF RESIDENCE ~ SINGLE FAMILY [~ MULTIPLE FAMILY WATER SUPPLY NUMBER OF BEDROOMS ~] One ~ Four ~_l Other E_] Two ~'] F i va ~ Three ~ S~x ~ INDIVIDUAL" r._q_ COMIv1UNtTY Lc--J PUBtJC UTILITY SEWAGE DISPOSAL SYS'rEfv] INDIVIDUAL/ON-SiTE PUBLIC UTILITY * ATTACH WEt, L LOG. A ,,*,'eli log is required for all wells drilled since Jdne 1975. For wells drilled prior to that date, give well depth ~attaci~ loft if available,) If system, is over two (2) years old an adequacy test is required by this DepartmenL NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITiAT;:[}. '72~)i0(3/78) 2l L I ,,L., ._ ;Y ONI '~i~liEtL '~ i-IVE [' ~ OTI-IER ; I-iP _1: ~ALII ~ t ; [WO . FOul{ ' SiX i SLJPPI..Y PFRMI-I' r,;'.J~,.'~Fi-; ~;,V [)L ; DEPTH Qi ','.,~ I ', ' ................................. . .,' zc:'c ¢'m~fir.,i ...... LOG RLC~:IV-~J ...... L U: SI i-E ~' - ',dA N U FACTO ~ ~ .: