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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$O2'S /
Total effe,c~rption area
PERMIT~"~.
Total effective absorption area
PERMIT NO.
Absorption area(s)
OTHER
PIPE MATEI~IA LS
SOIL TEsT RATING /6~<~ ,~
INSTALLER
REMARK~,~ ~ t~O
LAPF~OVB~/ '
DATE LEGAL
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(}il;;'.C~I..Ii'.,!D I:::II',ID TI--IE ~i',(;Zr'l"'i"(1)H (.)I:= "!"l-..!!i!:; !-!!X:.~',C:I=iVI:=!T;i;(;'~N
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I:;;ES ;~ I;Z:'!~;!q(Z;:!!E ;i;~ I:;;'.!!i;!"I(;IDI~;L. EI~ TO
:!!:; ]: ~;!ii',! .. .~ ..........................................
M.D.G. ENGINEERING
SOILS LOG ' PERC. TEST
~so~ls 'log
[] percolation test
performed for: '~-~'v,~x~/,~z:>
le desc, ,,z~,~--~/~; ~
4-
5-
6-
8,
9
I0
Il
12
l$
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
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~Ft. to ~ 70 Ft. ~J ~ 6'~ ~-~c ~ff~* d~- ~ From~Ft. to~
C4~f ~-~(~do~ From ~Ft. to_~
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From Ft. to Ft. From Ft. to
From__Ft. to Ft. From Ft. to__
From__Ft. to Ft From Ft. to
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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�
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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 ~ ~ .: