HomeMy WebLinkAboutPREUSS #4 BLK 7 LT 64A q
*0' 90 *101 a v ILAS.,
Municipality of Anchorage Page / of Z
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
sig/g�
Permit Number: y 0/5�_1 PID Number: 0.50 - -5_Z ^ 4n __
Name:
stewater System: 9New ❑ Upgrade
/lti
Address:
��
ABSORPTION FIELD
rX�DeepTrench
TSD /30 7 /dG�
Phone:
No. of Bedrooms
❑Shallow Trench ❑Bed ❑Mound ❑Other
LEGAL DESCRIPTION
Soil Rating: D ,/C
Total Depth from original grade:
5".J GPD/S . Ft.
Lo
Lot: Block: Subdivision:
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
7.
Ft.
Ft.
Township:
Range:
Section:
Fill added above original grade:
Gravel length//:
Varl(S ,I — Ft.
e27lU+G/JC Ft.
WELL: ❑New ❑ Upgrade
Gravel width:
2 Ft.
Number of lines: Distance between lines:
2 /D h Ft.
u6�G
Classification (Private, A,B,C): Total Depth: C ed To:
Total absorption area: rr11
I
Pipe material: Fg/D
D 30
Ft.
LD SQ. Ft.
Driller:
Date Dri
Static Water Level:
Installer:
CGC C&n,5 A
Date installed:
71f 7
Ft.
Yield:
Pump Set at:
Casing Height Above Ground:
I�
TANK
GPM
Ft.
Ft.
SEPARATION
DISTANCES
Septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacttrer, ���
Capacity in gallons:
/9 O
From
Tank
Field
Station
Tank
Sewer Lines
/�
'
Material:
rj
Number of Compartments: 2
Well-
TGU/
Surface
f
/DO
LIFT STATION
Water
/ao
f
Lot
/
f
/
/0 4
Size in gallons:
Manufact er:
Line
/0
"Pump on" level at:
"Pump off' level at:
High water alarm a
Foundation
S �
/� .�-
Curtain
/�
r
Pump Make del
Electrical Inspection performed by:
Drain
/00
/DO f
BENCH MARK
Remarks:
Location and Description:
.5
L ��
Assumed Elevation:
ENGINEER'S SEAL
®F'"�e
����°
®deo �9
® a °ae
Inspections performed by: Dates: 1s#Poa
9TH
®°°® °°• • 006
2n
Health and Human Services a
�°®ennCE 116 5Department
�F °°,
of
,c °°. ���
°p° Gam./ �
�f
'/ "`' e ' V
��®��FESS1
Reviewed and approved by: e Date:
72-013 (Rev. 9/91) MOA 25
AS -BUILT SYSTEM DETAILS/SITE PLAN Permit SW970154
PREUSS SUBDIVSIUN #4, LHT 6, BLLICK 7 PID#050 572 40
MAIN WATER LINE
KN ❑ ---------------------------
Lucas Avenue
PRI Y S EM a
A -C=31,5' B L �{ % I MT H
B_C_6 6• C TRENCH 2 CU
A -D=23.45'
FIELD BOOKS
L ❑ T 1
B
-D=12.28'
DRAWN:
A
-E=16.45'
CHECKED:
B
-E=26.92'
DATE:
A
-F=24.5'
SEPTIC
B
-F=28.65'
OB Nn:
A
-G=72.1'
B
-G=72.4'
A
-H=21.7'
B
-H=44.3'
A
-I=70.3'
13-I=78.4'
SCALE: 1"
w
v, CLEANOUT
Z
S ILO
1250 GAL
SEPTIC
o TANK
i�� of AL4"�
#01*4 TH�I
/ KENNETH M. D � /
` �Cn CE -7116 cya
1� w
lk
PROFESS1010
O C❑
IMT TRENCH 1 F C
I
1H #97-2
1250 S.T.
BLK 7
L❑T 6
CLEANOUT
BLK 7
S
----------F
WATER LINE :
BM
T T E
4 BDRM SFR
R -SERVE SY
O
TH
7
FINISHED GRADE
FILTER FABRIC, 2INSULATION
FILTER
TRENCH 1
SEWER ROCK
50'
FINISHED GRADE
2' INSULATION
TRENCH 2
SEWER RUCK
PREPARED FOR:
MICHAEL QUINN CONSTRUCTION
P.U. BUX 772641
EAGLE RIVER, ALASKA 99577
FIELD BOOKS
COMPUTED:
BOUNDARY: SEWARD
DRAWN:
KMD
STAKING: SEWARD
CHECKED:
KMD
ASBUILT: SEWARD
DATE:
11/5/9
DWG. FILE:
GRID:
NW056
ACRD FILE: 97006.DWG
OB Nn:
97006
I
I
M j
I
I
I
MONITOR TUBE CLEANUUT
2
EL=97,10
1
EL=87
VARIES
..--_ 05'
-- 1
96.14
TO
C_8_89�, j
MONITUR TUBE N R CLEANDUT
SCALE: NTS
VARIES
I
0,51
T
T,•
82.14 BUD
LLsI\I LU-) ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW970154
DESIGN ENGINEER:KND ENGINEERING
OWNER NAME:LEE DINAH
OWNER ADDRESS:20444 LUCAS AVE
EAGLE RIVER, ALASKA 99577
PARCEL ID:05057240
LEGAL DESCRIPTION:
PREUSS #4 BLK 7 LT 6
LOT SIZE: 19600 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
DATE ISSUED: 6/26/97
EXPIRATION DATE: 6/26/98
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 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY: DATE:
ISSUED BY: vUVN DATE: (p 2 4� /
"LQ.r1C��
KND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
1/FAX (907)696-8111
June 4, 1997
Municipality of Anchorage
Dept. of Health & Human Services
On -Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519-6650
Subject: Lot 6, Block 7, Preuss Subdivision Addn #4 - Septic Permit
Gentlemen:
Following a request from the owner regarding the proposed development of the
referenced property, we dug two testholes for the proposed system and replacement
field. The results of those tests are attached. The lot will be served by public water.
The system will be placed on the southern portion of the lot. As indicated on the
site plan there is sufficient grade to maintain a gravity system. A 1250 gallon tank
will be installed in anticipation of a 4 bedroom house being constructed. There is
also sufficient area and grade to maintain a replacement gravity fed field.
As indicated by the site plan drainage arrows, natural drainage is away from this site
and will be maintained after construction. There is no surface water within 100' of
the proposed installation. There are no known curtain drains within 50' of the
proposed installation. No wells exist within 100' of the proposed installation. The
system has been placed outside a 50' setback from any slope that exceeds 25%.
Additional re -grading of the site is anticipated in connection with the construction
of the house and driveway. Development of this lot should have no adverse effect
on development of adjacent lots.
If you have any questions, please contact me at 696-6111/FAX 696-8111.
Respectfully submitted,
1Kl1��1' D Engineering
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
JUN 05 1997
Kenneth M. Duffus, P.E. RECEIVED
attachments: On -Site Well and Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
K14D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
11/FAX (907)696-8111
June 26, 1997
Municipality of Anchorage
Dept. of Health & Human Services
On -Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519-6650
Subject: Lot 6, Block 7, Preuss Subdivision Addn #4 - Septic Permit
Gentlemen:
Following a request from the owner regarding the proposed development of the
referenced property, we have relocated the system to preserve more of the
vegetation.
The system will now be placed on the northern portion of the lot. The system has
been lengthened to accommodate the soils encountered in this location has noted in
test hole #2 of the previously submitted permit request. This design change should
have no adverse effect on development of adjacent lots.
If you have any questions, please contact me at 696-6111/FAX 696-8111.
Respectfully submitted,
X14 DD Engineering
Duffus, P.E.
attachments:
Wastewater Absorption System Details/Site Plan
WASTEWATER DISP❑SAL SYSTEM/SITE PLAN
PREUSS SUBDIVSION #4, LOT 6, BLOCK 7
Public Water
PubLic Water
Public Water
PubUc Water
PubUc Water
Public Wate
BLK 11..-- _
... , BLK 11
BLK 11
BLK 11
BLK 11
BLK
LOT. IA
LOT 2A
LOT 3
LOT 4
LUT 5
LOT
SEPTIC
SEPTIC
LOT 2
BLK8
0
---
_
SEPTIC
SEPTIC
WELL
SEPTIC
LOT
6
ERVE SY
MAIN WATER LINE
---------------------
Lucas Avenue
TH
BLK 7
LOT 1 SEPTIC
SEPTIC
c
BLK 7
d LOT 2
J
c
N WELL
i
3
BLK 7
LOT
I
BLK 7
—_—_—_T
___—_
SEPTIC(13L
PROPOSED
WATER
LIME
a_
9
BLK 8
BLK 8
iEL=97.10
EE=100.00
SEP IC
LOT 2
BLK8
0
WELL
WELL
LOT
6
ERVE SY
BLK 8
L 8
L T 8
LOT 3
L 8
WELL
SEPTIC
TH
-1I
_- SEPTIC - PubOc Water
NO SEPTIC SYSTEMS WITHIN 200' OF
PROPOSED WELL, EXCEPT AS NOTED.
NO PRIVATE OR PUBLIC WELLS WITHIN 200' OF
PROPOSED SYSTEM EXCEPT AS NOTED.
OFAL�\1
.� 1
/* 49TH*,
/ ...... /
KEN m-
US /
CE -7116 a'
2
Aw
d 'b'OFESSIO'0P
0
WELL
0
WELL
DESIGN CRITERIA
1. 4 BEDROOMS X 150 GAL./DAY/BEDROOM = 600 GPD
2. SOILS RATINGi 32 MIN./INCH = APPL. RATE 0.45 GPD/SF
3. 600 GPD/0.45 GPD/SF = 1334 SE
4. 1334 SE /(2' x 7') = 95.3'L
5. MIN. DESIGN SIZE - 2 TRENCH - 47.7' LUNG x 2' WIDE x 7.0' DEEP
6. DEPTH OF GRAVEL BELOW PIPE IS 7.0'.
7. TOTAL DEPTH OF SYSTEM IS 8.0' FROM ORIGINAL GRADE.
N❑TES:
1. TIE INTO TRENCH AT ENDPOINT.
2. USE 1250 GALLON SEPTIC TANK. INSULATE TANK IF <4' COVER.
3. INSULATE TRENCHES WITH 2' HD BURIAL FOAM IF <3' COVER.
4. CONTRACTOR WILL ENSURE MAXIMUM 27 SLOPE INTO SEPTIC TANK.
5. INSTALL ZEBCO SPLITTER ❑R EQUAL
FOR:
MICHAEL QUINN CONSTRUCTION
P.D. BUX 772641
EAGLE RIVER, ALASKA 99577
KND ENGINEERING
20441 PTARMIGAN BLVD
EAGLE RIVER, AK, 99577
(907)696-6111/Fax (907)696-8111
DATE: 6/4/97 rev. 6/25/97 DRAWING t4
SCALE: V = 100' 97006-S1
SEPTIC(13L
dVACANT
a_
BLK 8
BLK 8
SEP IC
LOT 2
LOT 7
0dl
WELL
C:
0I
BLK 7
7
BLK 8
L 8
L T 8
LOT 3
L 8
WELL
NO SEPTIC SYSTEMS WITHIN 200' OF
PROPOSED WELL, EXCEPT AS NOTED.
NO PRIVATE OR PUBLIC WELLS WITHIN 200' OF
PROPOSED SYSTEM EXCEPT AS NOTED.
OFAL�\1
.� 1
/* 49TH*,
/ ...... /
KEN m-
US /
CE -7116 a'
2
Aw
d 'b'OFESSIO'0P
0
WELL
0
WELL
DESIGN CRITERIA
1. 4 BEDROOMS X 150 GAL./DAY/BEDROOM = 600 GPD
2. SOILS RATINGi 32 MIN./INCH = APPL. RATE 0.45 GPD/SF
3. 600 GPD/0.45 GPD/SF = 1334 SE
4. 1334 SE /(2' x 7') = 95.3'L
5. MIN. DESIGN SIZE - 2 TRENCH - 47.7' LUNG x 2' WIDE x 7.0' DEEP
6. DEPTH OF GRAVEL BELOW PIPE IS 7.0'.
7. TOTAL DEPTH OF SYSTEM IS 8.0' FROM ORIGINAL GRADE.
N❑TES:
1. TIE INTO TRENCH AT ENDPOINT.
2. USE 1250 GALLON SEPTIC TANK. INSULATE TANK IF <4' COVER.
3. INSULATE TRENCHES WITH 2' HD BURIAL FOAM IF <3' COVER.
4. CONTRACTOR WILL ENSURE MAXIMUM 27 SLOPE INTO SEPTIC TANK.
5. INSTALL ZEBCO SPLITTER ❑R EQUAL
FOR:
MICHAEL QUINN CONSTRUCTION
P.D. BUX 772641
EAGLE RIVER, ALASKA 99577
KND ENGINEERING
20441 PTARMIGAN BLVD
EAGLE RIVER, AK, 99577
(907)696-6111/Fax (907)696-8111
DATE: 6/4/97 rev. 6/25/97 DRAWING t4
SCALE: V = 100' 97006-S1
t �r
Municipality of Anchorage
DEPARTMENT OF HEALTH R HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: /C�LLP�/C_iG�LVLLG( C4f & ska(. -! 1�DATE PERF
LEGAL DESCRIPTION: Township, Range, Section:
%EGGS$ a
DEPTH_ �r ' SLS SITE PLAN
or `� G I I I
1 tr��/sh
2
3
he- Z. LGG�rG/)
4
5 4M /'-ow`?
6
7
F3
41
10WAS GROUND ENCOUNTERED? ENCOUNTERED?
11 SL
IF YES, AT WHAT O
12 DEPTH? P
E
Depth to Water After
13 Monitoring? T Date: 3 2
14
15-
16-
17
5 1617
1e
19
Reading Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
d - -
z'v
7
2-: u'
1/9
r
3
2,10
20 L-1
PERCOLATION RATE .3 0?1 (mmulesimyc/h) PsERC HOLE DIAMETER 40
TEST RUN BETWEEN 315 FT AND ' ' "' FT
COMMENTS
9f
PERFORMED BY , ' I �n�� �u j4z(S CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WI1 H ALL STATE ND MUNICIP A�IDELINES IN EFFECT ON THIS DATE. DATE
7? 008 (Re, 4!851
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
T 825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: &),, SPL G,L�•LA l�/i/QJ ('D'9P/SSC/l LL L/D/% DATE PER
LEGAL DESCRIPTION: '! Township, Range, Section:
DE P7FI SLOPE SITE PLAN
(FE T I I I I I -
F,
N
67&,,-
Z 0,-,q I'IPAI
3
4 G /Vj ,Pe<l�s1 !3rDw.�
5 r,'D �6/,,s / L�
6-
7
7
8
9
10
11
12
13
14 � 1 ejo'111
15
16
17
18
19
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
S
L
O
P
E
Depth to Water Afte `
Monitoring? Dale: L
meDepth
®�Gross
to
0
Water ..
no WEVALEW-i
20 ll PERCOLATION RATE —1la Immules/nnch) PERC HOLE DIAMETER V
TEST RUN BETWEEN 3' 5 FT AND F1
COMMENTS
PERFORMED BY � �CIGUIDELINES
I 1/��%��`l L7 T[ GERI IFY THAI HIS EST WAS PERFORMED IN
ACCORDANCE WITH ALL STA E AND MUIN EFFECT ON THIS DATE DATE _
72-008 (Rev 4,85r
Municipality of Anchorage 0-
Development
O-Development Services Department Z'
Building Safety Division
/ On -Site Water and Wastewater Program a
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-600"50
wvnv.ci.anchorage.ak.us
(907) 343-7904
_ CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 05-0'S-1 a— `/ 0 1iAA#`)SQk5,Q
Expiration Date: z O O �{-
1. GENERAL INFORMATION
Complete legal description Lot 6; Block 7; Preuss Subdivision #4
Location (site address or directions) 20444 Lucas Ave EaEleRiver_
Current Property owner(s) Doug Askerman Day phone 694-4900
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
same
Day phone
at Roordn _-__ Dayphonc__2a9-3u_fi__
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:'
Individual Well
Individual Water Storage
Community Class Well
Public Water System
4
'24, ?l,e/a 3
TYPE OF WASTEWATER DISPOSAL:
❑ Individual On-site U
❑ Individual Holding tank ❑
❑ Community On-site ❑
TJX Public Sewer 0
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 -by an.independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 sarriples.)
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 Health Authority 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 Finn S & S Engineeri-ng p11U1)e • 694-2979
Address 17034 N. Eagle River Loop Ste. 204 Eagle River, AK 99577
Engineer's Printed Name Robert C. Cowan Dater d SA3
..Y..:._._..._ ................... ..
5. DSD SIGNATUREr ROBERT C. COWAN
CE -8801
Approved for ^LIL bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date: %- C7.3
(Rev. 01102)
F. ....._...._._._...._ .............
Municipality of Anchorage
• "' Development Services Department
Building Safety Division
Onsite Water & Wastewater Program.
4700 South Bragaw St
P.O. Box 196850 Anchorage, AK 995195650
www.d.anchorage.ek.us
(907) 343.7904
HEALTH AUTHO
QRITY APPROVAgL_ CHECKLIST
Legal Description: f/SLOGI:, ' �"�Et[r5 5�7 �� Parcel ID:t7�t%— 2 ^�
A. WELL DATA Puu�
Well type It A. B, orC provide PWSID Well Log (YM) _ f
Date completed _
Total depth ft.
Date of test
Static water level
Well production
WATER sAMP RESULTS:
Coliform colonies/10
Arsenic: mg.A.
S�iitary seal (YIN)
//Cased to ft
WELL LOG
8.
g.p.m.
MI. Nitrate mg.A.
Date at. mple.
B. SEPTICIHOLDING TANK DATA
height
in. .
AT INSPECTION
9 -p.m.
Othe bacteria colonies/100 ml.
Coll d by:
Tank TypelMa'661�1; , T �/L Date installed
Tank gal. Number of Compartments i Cieanouts (YM) '+!
Foundation cleanout(YIN)Depression over tank (YM) A/ High water alarm (Y/N) ^�
Date of pumping Pumper Q/t2 j
C. ABSORPTION FIELD DATA
Date instafledIT'T"-1 Soil rating (g.p.dAt2 or ftz/bdrm)� System type t��
Length ` r R Width ft Gravel below pipe ft.
Total depth 2&6 ftp Eff. absorption erea4�Wfe Monitoring tube y Depression over field
Date of adequacy test 10 3 Results (Pass/Fail) ;@go For 4 bedrooms
Fluid depth in absorption field before test &_,;-In. Water added -"al. New depth fin.
Elapsed Time: /� min. Final fluid depth .k in. Absorption rate >_ 4M g.p.d.
_ / A-V tia/Gt$fArl5v4a'
Any rejuvenation treatment (past 12 mo.) (YIN & type) N If yes, give date
0
D. LIFT STATION
Date installed _
'Pump on" level at
Datum
�A' Size in gallons
in. "Pump off level at _ in.
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic serviceline
Manhole/Access (YIN)
High water alarm level at in.
Meets alarm & circuit requirements?
1446Ldc
On adjacent 6
On adjacent b
Public sewer
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOJ.DKG TANK ON LOT TO:
Building foundation S f Property line S 0_ 'Absorption field
Water main / 0 Water service line / 4- Surface water /OO �r
i
Wells on adjacent lots
SEPARATION DISTAN E FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation / r% 4- Water main I D l r -
Water Service line 0 /4- Surface water 100 /i- Driveway, parking/vehicle storage
Curtain drain /y0A/P]�A-10 /A1 Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that /have determined through field inspections and i•• ..... ..««.:¢.'�
review of Municipal records that the above systems are in d •• • ....,.�.. ;i
conformance with MOA HAA guidelines in effect on this date. �+j�Iq��g�H,uy •%z
Engineer's Printed Name a Q-2� `-d�✓��4rc I�BOi f;IJ +f
Date 7 a- 8 �D J ��4•' 'ja 1'%, :'
HAA Fee $ 3 7S/ - e o Waiver Fee $
Date of Payment 7 r 'l 9/03 Date of Payment
Receipt Number 0 3 9 a a 9 Receipt Number
(Rev. 12/01)
lu cys .ova
.. Pry[• �'
• a e
�\ I • SSS �-72
Z l
ZS
an
CV\I
ASBUILT SEWARD S ASSOCIATES LAND URVEYING 694-0829
I HEREBY CERTIFY -THAT I HAVE SURVEYED THE SCALEt-ten, 4♦♦��%Me
FOLLOWING DESCRIBED PROPERTY: !+�,OF At OR
�t'ETi1S sGB�/�virHo• ycor� �•f; > DATE=
AND THAT NO ENCROACHMENTS EXI§T EXCEPT AS ,o%/s,; .•"' r 1
INDICATED. IT IS THE RESPONSIBILITY OF THE iZ-'N
OWNER TO DETERMINE THE EXISTENCE OF ANY GRID= . r � • • • 6
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB` LS
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND- DRAWN: �'��� ......
ARY LINES.
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MUNICIPALITY OF ANCHORAGE
® M DEPARTMENT OF HEALTH & HUMAN SERVICES
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
Parcel 1. D. # 050-572--1710
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HAA # t� QS it )14
1. GENERAL INFORMATION /
Complete legal description Lot (o
Location (site address or directions) N// Al L esGas 1e% • 4
/farl��oi/"ICLG�
Propertyowner Day phone
Mailing address Fd6o itlAlk y:
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
X
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: 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
//e"ss zl�Y' 37/4,
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 of this Health Authority Approval application shows that the ort -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 furtherverify 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 KND Engineering Phone
Address Eagle River, AK 99577.87
Engineer's si
6. DHHS SIGNATURE �.
`, Approved for �ou►� bedrooms.
Disapproved.
Conditional approval for
Additional Comments
By:
C.
ItfTln
Date— I' S
bedrooms, with the following stipulations:
Date —`/./3 q
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 orderto satisfy 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
..,,,,e,�WALI 1 Y OF ANS 11U"n,6
NVIRONMENTAL SERVICES DIVISI
Municipality of Anchorage NOVO 6 1997
OU* DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907 yl E
Health Authority Approval Checklist
Legal Description: / BUSS ! � 0 7 Lo /4, Parcel I.D.: 050 – 572 – -//0
A. WELL DATA
Well type
Log present (Y/N)
Total depth ---Z
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform Nitrate
Date of sample:
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to
FRnne WF1 i i Or,
Casing height (above gi
Wires properly protected (N
AT INSPECTION
g.p.m.
Other bacteria
�Colle ed by:
g.p.m.
B. SEPTIC/HOLDING TANK DATA
`11
Date installed 9 Tank size /25D Number of Compartments 2 Cleanouts (Y/N)
Foundation cleanout (Y/N) Y Depression (Y/N) Al High water alarm (Y/N)
Date of Pumping
Pumper
A114
C. ABSORPTION FIELD DAT
Date installed 7 Soil rating (g.p.d./ft2 or ft2/bdrm) `1.5 System type Qee2 �i fir�G�i
Length J D cci Width a P.Q Gravel thickness below pipe 7. / Total depth VAY-iecS
Effective absorption area /y2D Monitoring Tube present (Y/N)--Y— Depression over field (Y/N) /I
Date of adequacy test
Results (Pass/Fail)
Fluid depth in absorption field before test (in.);
Fluid depth (ins) Minutes later:_
Peroxide t atment (past 12 months) (Y/N) _7z
72-026 (Rev. 3/96)"
For
iediately after_ gal. water added
Absorption rate =
If yes, give date
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
On adjacent Ic
Absorption field on lot
On adjacent to
Public sewer main
Public sewer manhc
Sewer /septic service line
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
"Pump off" level at*
Foundation S / Property line /D Absorption field 1U f
Water main/service line 25 f Surface water/drainage /UD Wells on adjacent lots /OD
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /0
Surface water / 00 --
Curtain drain
F. ENGINEER'S CERTIFICATION
Building foundation /D Water main/service; line ZS
Driveway, parking/vehicle storage area
Wells on adjacent lots
I certify that / have determined thru field inspections and review of Municipal records
in conformance with MOA NAA guidelines in effect on this date.
Signature
Engineer's Name r! S
Date
HAA Fee $ Cid ' Waiver Fee $
Date of Payment ��1 Date of Payment
Receipt Number (O �Receipt Number
72-026 (Rev. 3/96)*
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