HomeMy WebLinkAboutPROSPECT HEIGHTS #5 BLK 2 LT 6Prospect
Heights #5
Block 2
Lot 6
#015-135-14
Municipality of Anchorage Page of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: °I-1o1Ic,1 PID Number: 015 -'135 —1
Name: h
''K Pe-ra(z rl Geour AT-rill:M%Y-e B "
Wastewater System: ❑ New ❑ Upgrade
Address:# ANcH.t INK.ABSORPTION
Sr,l-ra
FIELD
3-87-o LAY -V- oris �PLOI. lay soa
Phone: _ I I
No, of Brooms:
O Deep Trench L)(Shallow Trench 0 Bed 0 Mound 0 Other
LEGAL DESCRIPTION
Soil Rating:
'Z
Total Depth from original grade:
%1
- GPD/Sq. . Ft.
Lot: Block: 6 Subdivision:
2 I' cSPEGC HGA #5
Depth to pipe bottom from original grade:
r Ft.
Gravel depth beneath pipe
41 Ft.
Township:
Range:
--�-
Section:
Fill added above or pal grade:
��
Gravel length: t
--'
Ft.
.5D Ft.
WELL: ®New ❑Upgrade
'
Gravel width: Si
Number of lines:
l
Distance between lines:
Ft.
Ft.
Classification (Private, A,B,C):
Total Depth:
'S(-5
Cased To:
Total absorption area: _L
Pipe material:
PKI -JA. -Ta
Ft.
115 Ft.
ter' 00 So. Ft.
AST: 03e34 FS►o
Driller:
ALPIAE C)Rtt-Ll4G
Date Drilled:
'�-29-��
Static Water Level:
102 Ft.
Installer: /
KOCKID 'I• -< PK.C,
Date installed: —y
/'Z�'97
Yield:
Pump Set at:.
/
Casing HeightAbove Ground:
TANK
2 GPM
Q r ft Ft.
mac, Ft.
SEPARATION
DISTANCES
19 Septic 0 Holding 0 S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:
_rAPM
Capacity in gallons:
From
Tank
Field
Station
Tank
Sewer Lines
acRoP,04GE
Iz6o
Welh
lo014
fool'
_
�5ti
Material:
ST E1—
Number of Compartments:
Z
SurfaceLIFT
1*
+
STATION
Water
lcm
100
Lot
-"
'—
Size in gallons:
Manufacturer:
Line
101.1-
lata.
Foundation+
"Pump on" level at: "P "level at:
High water alarm at:
51
idtt
Curtain
ottE
k�10
!J
Pump Mak del
I Electrical Inspections performed by:
Drain
BENCH MARK
Remarks:
Location and Description:
TaP of cMv CLOSE
n n
o Po1Ar
Assumed Elevation:
IO O . OFt
}M
••..N••
•iw•• L ; 11
1
A .. •.�, NJ
•
.�&$�fdVIN�@RIid3 �/—�T�(-97
Inspections performed by: 1St
l+.w a..a• •,Hssu:rn.c
17034 Eagle OD
Eagle River, Alaska 49577 2nd
9
.
ROBERT C. COWAN �Q
3�d S -13-91
CE -8801
°�t�l
Department of Health and Human Services approval
PP
� C �� q' 77
Reviewed and approved by: a- Date: z'
72-013 (Rev. 9/91) MOA 25
plapp NO.SW970161
PAGE 2 or 2
DEPARTMENT TH ANDhHURXN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
INGAI LOT 6, BLOCK 2, PROSPECT HEIGHTS NO. 5 P.I.D. N0. 015-135-14
/ NEW 1250 GAL.
SEPTIC TANK
CO' oslz
/I MT1/o/ 08L
ALT. SITE-----___.� ♦ srz STI A
o / TH / FCO
O
/
411 <// JPO �Pl
% {1 8c02y B �O�Q ��J O��`��' WELL
3ZS
----
gra .Z ? 91J
6 $ `►f _e.. NEW TRENCH
Orb -i yo �N3 S �
'd-3 L2 4+) 4 N__:
M r 1 G., 7 S'/
SCALE 1" = 40'
ST1 ST2 C01
99.2' MT1 CO2 "M__9
FINAL GRADE A'c��.
96.7'11,ccO.' = 96.9'
.Y .. •..M .N.......
NEW
S20 GAL
T14. SR COl = 88.3'...
CO2 = 88.5' ?+ ROBERT C. COWAN l Q,
`P�fs4 CE -8801
MT1 = 84.3'AL
N
NO WATER FOUND �c �Pjl ' ,�. 'g
73.3' B.O.H.a�.
From : ALPINE DRILL 907 345 0202 Nov.12.1997 04:33 AM Pei
LOCATION OF WELL
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
DIVISION OF MINING & WATER MGMT
WATER WELL RECORD
BPR suaDI I810N
LOT
BLOCK SECTION OTRs
SECTION TOWNSHIP
RANGE MERIDIAN
t
Ji'
4�
a N
❑ E
❑S
0W
LOCATION/SKETCH:
WE WNER:
DEPTHS MEASURED FROM:❑casing top ❑ground surface
WELL DEPTH: DATE OF COMPLETION
Depth of hole: 7 (t
BOREHOLE DATA: Depth
Depth of casino; 4Z_A�1— It J, 7 /
Materiel Type and Color From To
w
DEPTH TO STATIC WATER LEVEL -
V e, ft below$ Mop of casing 0 ground surface
..
f
(ry
Date: '? 1`q1
METH00 OF DRILLING: "p -air rotary 0 cable tool
At
❑ other
n
USE OF WELL; W2omastic ❑ irrigation ❑ monitor
El public supply 0 other
//
�(f+
CASING -STICK •U It. Diam: In, to ft
Casing type:.In. tot
0or
-k
/
WELL INTAKE OPENING TYPE: I-) open end 0 screened
U Z
D perforated /, open hole
Depths of openings: to It
SCREEN TYPE: Diam: in.
Slot/Mesh Size: Length; It
GRAVEL PACK TYPE:
Volume usod: Depth to top: _...-. -
GROUT TYPE: me: ory
Depth: from It to _ It
DEVELOPMENT METHOD;
Duration:
NOV TT _1991
PU PlN!g LEVEL AND YIELD:
It after 2— hrs pumping W' gpm
Dept. Health & Human
DervlcOS
PUMP INTAKE DEPTH: _ It Horsepower:
WELL DISINFECTED UPON COMPLETION? R YES 0 NO
CONTRACTOR INFORMATION:
REMARKS:
PLEASE MAIL WHITE COPY Or LOG TO:
DNR/DIVISION OF MINING 94 WATER MGMT
360a C 6t, Sujte 800
Anchorage, Ak 99503-5935
Ph14A717A9-961Q 1�nA
/'2 p/t--- c oer
/0-D pm
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW970161
DESIGN ENGINEERS & S ENGINEERING
OWNER NAME:PARK KEVIN B & JANET K
OWNER ADDRESS:10101 SCHUSS RD
ANCHORAGE, ALASKA 99516
PARCEL ID:01513514
LEGAL DESCRIPTION:
PROSPECT HEIGHTS #5 BLK 2 LT 6
LOT SIZE: 100104 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
71;u' /R7
PAGE 1 OF 1
DATE ISSUED: 7/01/97
EXPIRATION DATE: 7/01/98
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: DATE: 7-Z-
��
HEALTH AUTHORITY
APPROVALS
SEWER& WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELLINSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
June 9, 1997
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 6, Block 2 Prospect Heights No. 5
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
Request you issue a permit to install a septic system to
serve the proposed four bedroom house on the referenced
property.
A test hole was excavated and a percolation test performed.
The approximate location of the test hole is located on the
attached site plan.
The monitoring tube within the test hole has been checked
and found to be dry.
This property has enough area for a future septic upgrade
which can be seen on the attached site plan.
We do not anticipate any adverse effects on neighboring
wells, septic systems or drainage patterns by the
installation of the proposed septic system.
If you require additional information, please contact us.
Sincerely,
1/&Z
Robert C. Cowan, P.E.
RCC/mg
Enclosure
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
60'
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NO WELLS/SEPTIC
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Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: PSI bC,V C
LEGAL DESCRIPTION: Lo T 13LoC K
o�PTH� PAOJF/cc7 148t(—t4 rt
1
L
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS 31
0A(-i1Nt G s
S P
GW/5W
( .'O- �
r
�6 ROBERT C. COWAN hC
DATE PERFORMED:
Township, Range, Section:
S' SLOPE SITE PLAN
SAn+�
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT L
O
DEPTH? p
E
I N cA jnJ n"t, Depth to Water After/
Monitoring? �Ry Date: 5 /a7 6 7
SAN✓
wt7-H Depth to
1) w -r# ==MM Water
PERCOLATION RATE _
TEST RUN BETWEEN
O rnnem CO LL✓z C7 f.6 a
(minutes/inch) PERC HOLE DIAMETER
FT AND FT
l(' ' o /7'
PERFORMED BY: 8{ S ENGINEERING CERTIFY THAT THIS TEST WAS PERFORMED IN
17034 Eagle River oop Ifia o.264
ACCORDANCE&OW R"T4kjFjsjaE99WCIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: r a-7
72-008 (Rev. 4/85)
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3/4"
1/2"
3/8"
Vo. 4
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Development Services Department {
p P =' Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-135-14-000
Expiration Date: 8/24/2023
Legal description PROSPECT HEIGHTS #5 BLK 2 LT 6
Site address 10101 SCHUSS DR Anchorage AK 99507
Current property owner(s) LANGLAND MARC & SANDRA L
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
Original Certificate Date: 5/24/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory X
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approva"une 2022
COSA Checklist.docx
COSA Checklist
Legal Description: PROSPECT HEIGHTS #5 BLOCK 2, LOT 6 Parcel ID: 015-135-14
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA
Well log is filed with Onsite (or attached)
Date drilled 7/29/1997 Total depth 365 ft
Cased to 115 ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) 24+ in.
Date of flow test for COSA 5/5/2023
Static water level at beginning of test 160 ft.
Well production at time of test 0.8 gpm
Water storage tank volume NA gallons per client.
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate 1.83 mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by Date 5/1/2023
Comments SEE MOA WATER WELL ADVISORY.
B. TANK DATA
Measured operating fluid level in septic tank 48”
Date of pumping 5/5/2023
Required maintenance completed, if AWWTS
Comments: SEE MOA TANK ADVISORY
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 8/13/1997
ALL standpipes present per record drawing
Total measured depth from grade 11.6 ft (max)
Measured depth to pipe invert from grade 8.1 ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes (MT) go to bottom of effective. (ED)
If not, state depth into effective 3.5’ of 4’ ED
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 5/5/2023
Results Pass
Fluid depth prior to test 1 in (fluid & sludge)
Water added 650 gal
New fluid depth 3 in
Elapsed time 1140 min
Final fluid depth 1 in
Absorption rate 600 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 48 in (MOA 4’ ED)
Effective depth used 7 in (Missing ED + Final Fluid Depth)
Effective depth (ED) remaining 41 in
Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots &
appears approximately 0.5’ ED is missing.
COSA Checklist.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 5/11/2023
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. 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 in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. 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, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
5/11/23
�N 00.08'43"W r5e��-
15.76' RETAINING WALL
Loi
WOODEN
GRAVEL
ACCESS EASEMENT
(Doc. No. 1997-035460-0)
1 PLANTER
i Lot 7
\WELL
14.3'x16.4'I
CABIN \
Lot 6
100,104 S.F. L _ /
J
ROOF OVERHANG /
F VpQ� �1
Lot 4
631
/
1
I
IEDGE OF PRIVATE LAKE
1
\
0 10 25 50 100
SCALE: 1"=50'
10' T&E EASEMENT
Lot 3
r,
PER PLAT NOTE:
OWNERS OF LOTS 3, 4, 6, 7 & 8, BLOCK 2, SHALL HAVE COMMON ACCESS
TO THE ENTIRE LAKE SURFACE WITHIN THIS SUBDIVISION. THE COMMON
ACCESS EASEMENT SHALL EXTEND TO THE SHORELINE OF THE LAKE.
PLOT PLAN _ AS BUILT x_ SCALE 1 50 GRID _ SW 2540_ Project No.
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang &7 522-6476 Phone
Associates, inc. k90enOlangsurvey.com
Professional Land Surveyors jonothanOlongsurvey.com ?t OF At l
trovisOlangsurvey.com
I hereby certify that I have surveyed the following described property:
LOT 6, BLOCK 2, PROSPECT HEIGHTS SUBDIVISION — ADDN. No. 5 (PLAT No. 82-313)
Anchorage Recording District, Alaska, and that the improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no Improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
Dated this the __i4K� _ Day of ___,1.02 at Anchorage, Alaska
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat.
49TH *1
• .....
y KENNETH G. LANG , Q
0.5202
IIl�:R5.�2SQ-123PaQy i
State of Alaska AECC963
/
3S0 /
/
10'
T&E EASEM EN
PIPES_
SEPOTIC
^�
CNCRETE
WALKWAY
J
�
I
I
�N 00.08'43"W r5e��-
15.76' RETAINING WALL
Loi
WOODEN
GRAVEL
ACCESS EASEMENT
(Doc. No. 1997-035460-0)
1 PLANTER
i Lot 7
\WELL
14.3'x16.4'I
CABIN \
Lot 6
100,104 S.F. L _ /
J
ROOF OVERHANG /
F VpQ� �1
Lot 4
631
/
1
I
IEDGE OF PRIVATE LAKE
1
\
0 10 25 50 100
SCALE: 1"=50'
10' T&E EASEMENT
Lot 3
r,
PER PLAT NOTE:
OWNERS OF LOTS 3, 4, 6, 7 & 8, BLOCK 2, SHALL HAVE COMMON ACCESS
TO THE ENTIRE LAKE SURFACE WITHIN THIS SUBDIVISION. THE COMMON
ACCESS EASEMENT SHALL EXTEND TO THE SHORELINE OF THE LAKE.
PLOT PLAN _ AS BUILT x_ SCALE 1 50 GRID _ SW 2540_ Project No.
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang &7 522-6476 Phone
Associates, inc. k90enOlangsurvey.com
Professional Land Surveyors jonothanOlongsurvey.com ?t OF At l
trovisOlangsurvey.com
I hereby certify that I have surveyed the following described property:
LOT 6, BLOCK 2, PROSPECT HEIGHTS SUBDIVISION — ADDN. No. 5 (PLAT No. 82-313)
Anchorage Recording District, Alaska, and that the improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no Improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
Dated this the __i4K� _ Day of ___,1.02 at Anchorage, Alaska
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat.
49TH *1
• .....
y KENNETH G. LANG , Q
0.5202
IIl�:R5.�2SQ-123PaQy i
State of Alaska AECC963
Well Water Advisory
Certificate of On -Site Systems Approval # OSC231128
Subdivision: Prospect Heights, Block: 2, Lot: 6
This well's productivity was determined to be 0.8 gallons per minute. The minimum
well productivity required under (AMC 15.55) for a 4 -bedroom residence is 0.41
gallons per minute or 150 gallons per day per bedroom. Although the subject well
currently exceeds this minimum requirement, the production capacity can
fluctuate and may be insufficient to meet your needs.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
Mailing Address P O Box X96650 *Anchorage, Alaska 99519 6650 *www muni org
DEVELOPMENT SERVICES DEPARTMENT c
On -Site Water and Wastewater Section
www.muni.org/onsite
Septic Tank Advisory
Certificate of On -Site Systems Approval # OSC231128
Subdivision: Prospect Heights #5 Block:2, Lot: 6
907-343-7904
Fax: 343-7997
The septic tank for this property is 26 years old. The average life of an asphalt
coated steel septic tank is 20 years. Typical replacement costs are $10,000 or more,
not including engineering, surveying or MOA permitting fees.
This advisory must be attached to all copies of the subject Certificate of On -Site
Systems Approval.
This is an example of what the metal of a 30 year old steel tank MAY look like.
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# O1 - i36 — I HAA#
1.
2.
3.
GENERAL INFORMATION
Complete legal description Lot 6; Block 2; Prospect Heights 15
Location (site address or directions)
NHN Schuess Drive
Property owner The Petersen Group Day phone
562-1170
Mailing address 3820 Lake Otis Pkwv. Suite 204 Anchorage, AK 99508
Lending agency
Mailing address
Day phone
Agent Mike Backus/ Petersen Group Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XXX
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 XXX
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
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 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 c r e €bIGIN€EKING Phone __e� ay - -7 `I
Address
17034 Earle River Loop Road No. 204
Engineer's signature
6. DHHS SIGNATURE _
Approved for ��<% bedrooms.
Disapproved.
Conditional approval for
Additional Comments
By:
Date / / 1 2.1'q V
ROBERT C. COWAN
Cc -8801 A
bedrooms, with the following stipulations:
Date (' l4'%$
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 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. 1/81) Back MOA #21
4RONMENTAL SERVICES DIViSIc..
Municipality of Anchorage 1A1 111111&
DEPARTMENT OF HEALTH & HUMAN SERVICES R C 1 V E
Environmental Services Division C
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: L-0 T 6 13 1--0 c cc I Parcel I.D.: 0
Pio s r,i rl rL I G.1-/ v f It '�-
A. WELL DATA
Well type E' 1\14 7 (L
Log present (9/N) \/ C S
Total depth I 1� S
Sanitary seal e/N) 'Y ri S
Date of test %
Static water level
Well production
If A, B, or C, attach ADEC letter. ADEC water system number l
Date completed 7 / D- 9 / `I 7
i
Cased to / / Casing height (above ground)
FROM WELL LOG
/a E{/917
WATER SAMPLE RESULTS:
Coliform
to 4
O Nitrate
Wires properly protected O/N)
AT INSPECTION
Y4 S
g.p.m. / g.p.m.
a,, j5 -It
Other bacteria 0
Date of sample: 1 `i i `/ Collected by: S & S ENGINEERING
17034 Eagle River Loop Road No. 204
B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99577
Date installed 7 /,j -f ( JJ`/ 7 Tank size ),I ' a Number of Compartments A Cleanouts(LWN) $'6-J
Foundation cleanout &N) �7 f S Depression (Y/, ^' 0 High water alarm (YQN a Q
Date of Pumping '`� `N� ^� Pumper
C. ABSORPTION FIELD DATA
Date installed
Length
r Width
Soil rating g.p.d./ftor ft2/bdrm) System types✓� L a1
r
Gravel thickness below pipe 1 Total depth
Effective absorption area S-00 9 Monitoring Tube present (&N) Y f -(Depression over field (Y& PO
Date of adequacy test N//+ — y' h v Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test (in.);
Fluid depth
Peroxide treatment
72-026 (Rev. 3/96)'
(ins) Minutes
(Y/N)
redia ly-aftsf� gal. water added (in.): _
Absorption rate = g.p.d.
If yes, give date
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N)
"Pump on" level a' ,,Pump off' level at'
High water alarm level at' *Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: ;
too U
Septic/holding tank on lot t On adjacent lots
/ c On adjacent lots
O0 -k
Absorption field on lot
Public sewer main t) Public sewer manhole/cleanout f
Sewer /septic service line
5- 4 Lift station p.)( �
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ;ON LOTTO:
Foundation IT i f Property line �� f Absorption field
Water main/service line 10 4 Surface water/drainage IUO 4 Wells on adjacent lots
iUU -�
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: ,
� /0 -f- lU �
t o Building foundation Water main/service line
Property line �
Surface water l 0 U t Driveway, parking/vehicle storage area
3O
Curtain drain N Q i� Wells on adjacent lots
/dd f
F. ENGINEER'S CERTIFICATION
q °
w of Municipal rec�' ms are
I certify that I have determined thru field inspections and revieons xhXtire abbv�g
in conformance with M H.V ui lines in effect on this date.
S ♦ae' i.eH<
Signature .
4 ril'v f 0 u�.v' a1 Fr'f . .. P.OBERT C. •COWAN...a
Engineer's Name / fs Cr
Date
HAA Fee $ bo Waiver Fee $
Date of Payment
I Date of Payment
Receipt Number
681) Receipt Number
72-026 (Rev. 3/96)'°