HomeMy WebLinkAboutPREUSS #1 BLK 3 LT 1
Municipality of Anchorage Page I 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: ~ ~'t')°lC~oo0 <~ PID Number: O~'O--
N~: ~ ~&v~-~ Wastewater System: D New ~ Upgrade
~No, of Bedrooms: ~ ~ Deep Trench ~ Shallow Trench D Bed D Mound ~ Other
LEGAL DESCRIPTION Soil Rating: 0. ~ GPD/Sq. Ft. Total Deptb from original grad~
SubdivBion: Depth to pipe bottom from original gr~e: Gravel depth beneath pipe ~ Ft.
Township: Range: Section: Fill added above original grade:0 Ft. Gravel length: ~ Ft.
WELL: D New D Upgr~ Gravel width: ~ Ft. Number of fines:~ Distance~betwe~ lines:Ft.
Classification (Private, A,B,C): ~ Cased To: Total absorption are~: Pipe material:
Driller: Date Drilled: StaticWater Level: Installer: ,
To Septic Absorption Lia Holding Public/Private Manufacturer: Capacity in gallons:
Weter [~ ~0'~ LIFT STATION
Lot SO' ~1' Size i. gallons: I Manufacturer: ~
Line
Fou.datioR l ~, ~' , "Pump on" level a~ level at: [ High water alarm at:
Remarks: ~,~T,~C ~r~/,~ ~¢~ BENCHMARK
Location and Description:
Assumed Elevation: 1
17034 Eagle River Loop noad, N~' 1st E"~-~ ~
Inspections performed by: ~aals mvsr~ ~a~ka ~ : ~,....~
Department of Health and Human ~erwces approvm , <>, -, ,,'
Reviewed and approved by ~, ~ Date:/~"/~??
7g-013 (Rev. 9/91) MOA 25
PERMIT NO. SW990008 PkOE 2 Or 5
Municip. atik o~' Anchor-~ae
DEPARTMENT OF HEALTHAND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P,[3, Box 196650 ~Anchorage, A~aska 995i9-66505Te~ephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEq^L LOT 1, BLOCK ,3, PREUSS #1 P.I.D. NO. 050-572-17
LOT 2
.... EXISTING I
.<
~ I ~
~ ~. I~. '~ /
~o
g?('
~-~.,~,,~,,,~ ........
EAC~E RIVER ROA~
~. ~,,.. .'~
PERMIT NO. SW990008 PAaE 5 OF 3
Municip. aUt of .A,n~ h.o.p 9 9,e'
DEPARTHENT OF HEALTH ANU HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
, p,n, Box 196650 ~_Anchorage, Alaska 99519-6650·Te(ephone~ 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 1, BLOCK 3, PREUSS #1 P,I.D. NO. 050-572-17
ST1 ST2
99.3'
NEW
1000 GAL
SEPTIC
TANK
FINAL GRADE
~,,/INSULATION
A B
DBL1 15.5' 27.0'
DBL2 15.5' 28.0'
ST1 17.0' 52.5'
ST2 21,0' 59.0'
DBL3 23.0' 41.5'
DBL4 23,5' 42.5'
C01 25.5' 45.0'
MT1 27.0' 47,0'
C02 84.5' 109,0r
MT2 85.0' 109.0r
MT2
CO1
C02
MT2.- .- .. MT1 ICO1 = 99.3'
AL GRADE
l II '-"-l-I.-l.dCO~.= 95,3'
./~s~..% ic0£ = 95 3'
92.1' 'MT1 = 92.0'
·
~6,&"WATER FOUND
86.0' B.O.H.
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Slreet, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Feb 04, 1999
Expiration Date: Feb 04, 2000
Permit Number: SW990008
Legal Description: PREUSS#1 BLK 3 LT 1
Design Engineer: 0003 S & S Engineering
Owner Name: ED GRAVES
Owner Address: 10023 PREUSS LANE
EAGLE RIVER , AK 99577-8774
Parcel ID: 050-572-17
Site Address: 010023 PREUSS LN
Lot Size: 28136 SQ, FT,
Total Bedrooms; 3 Permit Bedrooms: 3
This permit is for the construction of:
~ Disposal Field [¢~ Septic Tank iii Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must be in accordance with:
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
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From Octoher 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day,
B, Covered, sealed, and heated to prevent freezing.
Received By: ~ Date:
Issued By: Date:
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER&WATER
INSPECTION
ENGINEERING STUDIES
ANO REPORTS
WELL INSPECTION
& FLOWTEST
ROAO DESIGN
SOILEEST
PERCOLATION
TEST
STRUCTURA~ &
MECHAN[CA_
INSPECTIONS
ONSITE
WASTEWATER
DISPOSALS¥STEM
DESIGN
RF:¢EIVED
ROBERT O. COWAN, RE.
ROBERT A. SHAFER, RE.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 1, Block 3, Preuss #1 Subdivison
Request you issue a permit to install a septic system to serve the three bedroom
dwelling on the referenced property
A test hole was excavated and percolation test perfoiTned. The approximate location of
the test hole is located on the attached site plan.
At the time of excavation 11/9/98 water was found at 14.5'. After seven days of ground
water monitoring the monitoring tube had water at 14.5'.
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
areas or drainage patterns by the installation of the proposed septic system. The
construction of this system will not prevent any future development on any of the
adjacent properties.
If you require additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E.
RCC/rdp
Enclosure
17034 NORTH EAGLE RIVER LOOP · SUITE 204 o EAGLE RIVER, ALASKA 99577
1"=40'
DESIGN I
DETAIL
~mmm
oo 0 ~
PREUSS LANE
BRDRo
o~
II o II ~
m
0
Z
PERFORMED FOR:.
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TES'r
1
2
3
4
5
6
7
8
9
10
11
13-
14-
15-
16
17
18
19
20
SLOPE SITE PLAN
WASGROUND WATER
ENCOUNTERED?
IF YES, Al' WHAT
DEPTH?
S
L
O
P
E
Depth Io Water Alter
Monitor[nD?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~ J (mmutes/~nch) PERC HOLE DIAMETER __
TEST RUN BETWEEN __ FT AND FT
COMMENTS
PERFORMED BY: i~034 E, ag[~ ~,,~ ~v ........... 4
ACCORDANCE WI~B~rE~AL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
Municipality o! Anchorage.
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
17-
18-
19-
20-
(ir
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
j L
DEPTH;'IF YES' A/ WHAT J/,/ /.~ pO
Deplh Io Water Afler /~,~/ /I//6/~
Monitoring? Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
30 ')O ,~,,, c'i '/,r" ~ 'It"
c~O ~0 ~,~ q '/~-" ~ '1~"
PERCOLATION RATE ~ '~' (minutes;inch) PERC HOLE DIAMETER
TEST RUN SETW.EN 5- '/;~_ ,T^ND ¢o %. FT
PERFORMED BY:
ACCORDANCE W~T~AL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
SEWER&WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
ANDREPORTS
WELL iNSPECTiON
&FLOWTEST
ROAD DESIGN
SOlLTESP
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
imee m
/
ROBERT C. COWAN. RE,
ROBERT A, SHAFER, RE.
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
CIVIL ENGINEFRS
(907) 694-2979
FAX (907) 694-1211
REFERENCE: Lot I, Block 3, Preuss Subdivision
November 24, 1998
GENERAL:
The scope of this project includes the installation of a 1000 gallon septic tank and
leachfield trench for the existing three bedroom house located on the referenced
property.
Construction shall be in accordance with the approved site plan and design drawings,
Municipal permit with any special provisions or conditions, and all applicable State and
Municipal Wastewater Disposal Regulations.
The contractor shall be responsible for obtaining any necessary underground utility
locates.
Unless specifically agreed otherwise, the property owner shall be responsible for final
grading areas subsequently depTessed from soil settling.
Contractors installing wastewater disposal systems must be certified by the Municipal
Health Department for system installations. Owners installing their own systems must
also receive prior approval ft'om the Municipal Health Department.
SEPTIC TANK INSTALLATION:
A septic tank is to be constructed by a certified septic tank manufacturer. Construction
shall include two 4" cleanouts for pumping access.
The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank.
All standpipes on the septic tank shall extend a minimum of 12 inches above final
grade.
17034 NORTH EAGLE RIVER LOOP * SUITE 204 " EAGLE RIVER, ALASKA 99577
Page 2
Lot 1, Block 3, Preuss S/D
Nov. 24, 1998
4. Septic tanks installed with less than 4 ft. of cover shall be insulated.
A foundation cleanout shall be installed one to four feet from the building foundation.
In the line between the tank and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic tank). These cleanouts shall
be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in
line, shall be to clean toward the leachfield. The second cleanout shall be to clean
toward the septic tank.
Final grading over the septic tank shall be such that a positive slope exists away from
the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The bottom of
the excavation shall be within 2 inches of level. If the sidewalls of the excavation
become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock)
placement.
Once the gravel is installed, the distribution pipe is to be installed level with the
perforations faced downward. Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
A silt bmTier must be installed between the final gravel layer and the native soil backfill.
Ensure the silt barrier covers the entire gravel surface before placing backfill.
Monitor tubes shall be of four (4) inch diameter, installed approximately in the
locations shown on the design, and extend a minimum of 12 inches above final gn'ade.
The portion of the monitoring tube extending through the gravel shall be perforated
from the bottom of the trench to the invert of the distribution pipe. This is equivalent to
the effective depth of the gravel as noted on the design.
Backfill over the final gravel layer must not be less than twenty-fonr (24) inches.
Insulation must be installed when the backfill depth is less than thirty-six (36) inches.
The finish grade over the trench must be mounded to prevent the fmrnation of a
depression after settling.
Page 3
Lot 1, Block 3, Preuss S/D
Nov. 24, 1998
MINIMUM MATERIAL SPECIFICATIONS:
Any septic tank proposed for installation must be constructed by a Municipal approved
septic tank lnanufacturer.
The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
T_.ype of Pipe Perforated Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be approved by the inspecting
engineer.
Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco,
or equal).
A permeable nontoxic silt ban'ier (Typar 3401, Mirafi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
passing the #200 sieve.
When sand is being used as a filter material, its gradation specifications must confm~
to current M.O.A. or D.E.C. requirements, which ever requirement applies.
INSPECTIONS:
Typically there will be a minimum of tlu'ee (3) inspections required during the installation of
the wastewater disposal system. These inspections will occur as follows:
Page 4
Lot 1, Block 3, Preuss S/D
Nov. 24, 1998
The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any gravel. A septic tank may be
set in place, but may not be backfilled before this inspection.
The second inspection must be conducted after the placement of the silt bamer,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting
engineer is to be contacted at least 24 hours prior to the start of constntction. If necessmy, a
pre-construction meeting will take place on-site. The inspecting engineer will not coordinate,
direct or control in any way the contractors activities.
The owner shall contract with the contractor to perform the work outlined in these
specifications and plans and in accordance with the attached M.O.A. permit. There will be no
contractual arrangement existing between the contractor and S & S Engineering. S & S
Engineering shall be the owner's representative and will inspect the work as stated above to
document the contractors activities. Final acceptance of the contractors work rests with the
owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor
to carry out the work in accordance with these construction documents. S & S Engineering's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incidem to this project.
CONTRACTOR/INSTALLER
NAME
MUNICIPALITY OF ANCHORAGE"
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVlRONME'NI'AL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL DESCRIPTION
DISTANCE TO: '~ [ O O
Manufacturer
DISTANCE TO:
IF HOMEMADE:
Ne. of lines
Top of tile to finish grade
Length
Type of crib
DIST~CE TO:
C~ass Depth
IAbsorption area~
Inside length
DISTANCE TO;
Total length of lin,
Material beneath tile
Depth
meter
fou,~dation Sewer line
'est lot line
o lot line
tank
Liquid depth
PERMIT NO.
allons
NO,
OTHER
PE MATERIALS
NSTALLER
~EMARKS
APPROVED
DATE
LEGAL
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rc:,= I::'1', I:?~.'~ (~'i .......... I::,l:::lT[ii: .......
0 8- E GEO',
Russell Oyster
694-2774
Soils ~ Foundations
Performed fro':
_:CHNICAL Et DEVELL ?MENT
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
S0Z___L LO__A
Maillng Address:__~%.~.~.,_~
Legal Description: Z.~,,-/..~.__~.~ ~> ~-~-~_.~
Depth (feet) Sol1 Charactertst,lc~
CO.
Earl Ellis
688-2280
Land Development
Ts1. NO..._~_¢~- ~.6 3?
Ground Water Encountered: Yes / No__~
Proposed Installation: Seepage Pit____ Drain Field
Comments :_,,__,~.,-
If yes, what depth
Perfomled by:
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. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION .
Complete legal description ~;~7- // ~;;~Cd'.~- ~., '~,~-C/¢5 '¢~ ]
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailin. g address
~---/~. ~/"-'~.,'~ ~"~-¢' Day phone
Day phone
Agent
Address
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
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-Q25(Rev, 1/91) Front MOA*21
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
S & S ENGINEERING
Address
Eagle River, Alaska995?7
Engineer's signature
Phone
Date
DHHS SIGNATURE
/,/"" Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
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.
Municipality of Anchorage JUL 0 i 1999
DEPARTMEN-F OF HEALTH & HUMAN oEP~[~LrrY
Fnvironmental Services DJvJsJon~NVIRONMENTALSERV~CF-S
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
A. WI~-;LL DATA
Wall type ~!
Log present (Y/N)
Total depth ,~ '~,-~ /
Sanitary seal (Y/N). ?(~,S
Health Authority Approval Checklist
- // ~[-J<'.;~,, ~.Z-,~L-/~5':~L- / ParcelI.D.:
IfA, B, or C, attach ADEC letter. ADEC water system number
D ate corn plat e d(/C/C/P/¢--¢ ~')
Cased to '~)///~-./'/~,..~¢~¢>asing height (above ground)
Wires properly protected (Y/N) _
Date of test
Static water level
Well production
FROM WELL LOG
AT INSPECTION
g.p.m. ~' ~ g.p.m.
WATER SAMPLE RESULTS:
Coliform
Date of sample:- ~E/~- /
B. SEPTIC/HOLDING TANK DATA
Date installed ~/~/~
Foundation cleanout (Y/N)
Date of Pumping
Nitrate ~ - g ~'- ~ Other bacteria
Collected by: ./~- ~--~z~/'~~
Tank size /~("~('~ Number of Compartments ~E_ . Cleanouts, (Y/N)_~.~'~
/~--( __ Depression (Y/N) /V ~) High water alarm (Y/N) ~//~
Pumper.
C. ABSORPTION FIELD DATA
Date installed
Length
.Width
Effective absorption area ~-¢ ¢ d Monitoring Tube present (Y/N)/,L~ Depression over field (Y/N) __.
Date of adequacy test A/E:-?~//-.//~d-/C~.~Results (Pass/Fail)
/
Fluid depth in absorption field before test (in.);
Fluid depth (ins) Minu.~tes-d~ e'er:
Peroxide treatme~m~nths) (Y/N)
~--~lmmed~ately after gal, water added (in,):
Absorption rate = .g,p,d.
If yes, give date
.bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION
Date instal[ed
Manhole/Access (WN)
High water alarm level at*
Cycles tested
Size in gallons
"Pump on" level at* ~el at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot /~)
Public sewer main ./k/
Sewer/septic service line
On adjacent lots ./~_2/_.)/~-
On adjacent lots //ICP~ /'~-
Public sewer manhole/cleanout
Lift station A///~-
/
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation /4 / Property line or-~:~ / Absorption field
Water main/service line /0 /7A Surface water/dra nage,//34¢~Z- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 4? / t Building foundation ~- -¢ / Water main/service line
Surface water //-)~ '/- Driveway, parking/vehicle storage area
Wells on adjacent lots
Curtain drain .A/O~/
I certify that I have determined thru field inspections, and.review of Municipal recor_a~lCa'~,Ch~,,,, .: ab~:~es~ ... -,~'~, are
in conformance with~OA HAA guidelipes m effect on this date. ~ ~/ ~ ",~. ~
Date ,~. 4~,~ ............... ,~%.
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
JUN'25'OO )4:37 FROX{'CTE ENVIRONMENTAL
X~[~ CT&E EnvironmenlalServiceslnc,
T-1~7 P02/03 F-615
992933001
S & S l/ngin¢¢ring
Lot I Bik 3 Preuss
Lot 1 gilt 3 Preuss
Drinl~g WaTer
Client POg
Ih'lined Date/Time 06/25/99 12:37
Coll..led Dale/Time 06/22199 l 1: lO
R~eived Da[e/Time 06/22/99 11 :oeo
Technical Director: Stephen C. Ede
0.729
O,SOO F~/~
$H18 9~8 0b/22/09 i~p
EPA 500,0 1o F~ 06/~2/99 a6/2~/99 SCL
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
1. GENERAL INFORMATION
Complete legal description
Lot I~ Block 3i Preuss Subdivision
Location (site address or directions) 10023 Preuss Lane
Property owner
Mailing address
Lending agency
Mailing address
EvanS ~ Edward & Patri~ia
Day~rJn; 0~'.o
Day phone
& Andhorage, Alaska
Day phone
Agent
Address
Jean Locke DON McKENZIE REAL ESTATE
13135 01d Glenn Highway #100
Eagle. Rive% Alaska 99571
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
Day phone 694-9055
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWA'rER 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
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 flies 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
Engineer's signature
17034 Eagle River Loop Eoa({ Ne.
Phone
Date
_~ SIGNATURE
Approved for
Disapproved.
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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 federar 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.
724)25 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~. ~-~"¢ ~ ~¢~¢~ '~ ~~ Parcel i.D.
A. WELL DATA
Well type
Log present (Y/,~¢~
Total depth
Sanitary seag~N)
If A, B, or C, attach ADEC letter. ADEC water system number '---
Date completed ~---~/----~'~, I~"7'~ Driller
Cased to ,~'c;:) ~ Jo' Casing height \''7~ Jr-
Wires properly protecteddCi~¢N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG AT INSPECTION
°
o
g.p.m. "~, ~O g.l~.
; On adjacent lots \ ~
; On adjacent lots \
Public sewer manhole/cleanout hi
Petroleum tank
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot \ ~ L..~¢
Absorption field on lot \ ~1 ~
Public sewer main t'~ j]~
Sewer service line ~-~-~" '~
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample:
I ¢m~(/~ ~ Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed L¢-~"I-'~ Tank size \'~--~-E:) ~" Compartments
Cleanouts4:(~N) "'¢ Foundation cleanout (YZ:~- ~'~ Depression (Y/:~,
High water alarm (Y/N) '-- Alarm tested (Y/N)
Date of pumping \ ~.~ [ t.~--~ "~L.-- ~ Pumper ~ ¢.~_~ /i~,,.j ~.~¢,~ ,...~,~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~.,4:;;~ t,¥. On adjacent lots
To property line t, c;~I J¢ ~'~Absorptionfield
Surface water/drainage \ (:::;~-~[ ~
Foundation
Water main/service line
72-026 (Rev 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed L~, ~ ~-I
Length ~'L~' Width
Total absorption area
Depression over field (Y~[C~P /,4'
R e s u It s,~l~i~;~fa i I)
Peroxide treatment (past 12 months) (Y(~
Soil rating [ ~¢:::}c::::~///¢.-.-.-.-.-.-.-.-.¢- System type "'~'~--,-~-"'~-~
Gravel thickness Total depth ~
Cleanouts presentd~C;;~N) ~
Date of adequacy test t ~ -"Z- \ - ~'7.-
for
~--'/'JO V~//''/If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot \ 4::~=~ --P
To building foundation
On adjacent lots
Surface water
On adjacent lots
\ Oc:~t'J¢ Property line
To existing/or abandoned system on
Cutbank ~ /A~ Water main/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 ~
o! this inspection.
Signature
Engineer's Name
Date
S & S ENGINEERING
17034 Ea~le River Loop Road
Eagle River, Alaska
Date of Payment
72-026 (Rev. 3/91) Back MOA21
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO,
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX:(907)56%5301
ANALYSIS NESULTS fez INVOICE t 59588
Chemlab Roi.# 92.5696 Sample ~ 3 Natrix: WATER
Client Sample ID
P~SID
Collected
P~eserved with
LI 83 ?REUSE S/D Client Name :S ~ S ENGINEERING
UA Client Acct :$NSENG?
OCT 13 92 8 10:25 hfs. BPO# :
OCT 13 92 ~ 14:50 hrs. Neq~ :
AS REQUIRED Ozdered By :
PO~ :NONE RECEIVED
Analysie Completed : OCT 14 92
Labo~atozy Supe~¥1;oz, :~TEPNEN C. NDE
Released By : ~ d ~
Sand Reports to:
I)S & S ENGINEERING
Parameter Results Units Method Allowable Limits
NITRATE-N O.ll mg/1 8PA 353.2/300.0
Sample ROUTINE SAMPLE COLLECTED BY: R.3.S.
i Tests Performed * 3o0 Special Instructions Above UA-Unavailable
ND- None Dete~ted "See Sample Remarks Above
Nh- Not Analyzed LT-Less Than, GT-G~eater Than
~$~,'~S Member o, the SGS G,'oup (Soei~t~ G~n~rale de Surveillance)
MUNICIPALITY OF ANCHORAGE DEiq'.
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720 E C E I V E D
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND 8EWER FACILITIES
PROPERTY OWNER
2, BUYER
4. REALTOR/AGENT d~.'~ PHONE
~. TYPI~i OF RESIDENCE NUMBER OF BEDROOMS
[] One [] Four
[~"~SI NG LE FAMILY [] T~w~9o [] Five
[] MULTIPLE FAMILY ~J=]~ ree E~ Six
[] Other
7, WATER SUPPLY
E]~'d~DIVI DUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC LJTI LITY depth (attach log if available,) ~)/~. )2~/:l-- 'Z-~"-,~'
8, SEWAGE DISPOSAL SYSTEM
E]~.--'~NDiVlDUAL/ON.SiTE,~ '~lfindividual/on-sita, give installation date /~44.~ '2~.'
If system is over two (2) years old an adequacy test is required
[] PUBLIC UTI LITY by this Department,
NOTF.'. THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
! DATE RECEIVED
I NSPECTI ON APPOI NTM ENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR I NSP ECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[~ iNDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
Connection Verified
INSTALLER
[~SepticTank or [~]HoldingTank
Size: )o'~-~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER ~)~
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwEEL TO: Septic/Holding]0~) Tank Absorptionl ~(~Area Sewor LineII Noarest Lot Line
Absorption Area to nearest Lot Line
B. COMMENTS
[~'~APPROV ED FO R ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
~larch 9, 1970
Mr, I)avid Usher
3516 Tarwatcr
^nchoragg, ^laska 99504
Lis}mr
A review ef the files for the subject area shows that a
satisfacto~T individual sower and water systera can bo
located on the mBject lot.
Public se~r and ~mter are not available to this area.
Since'mly,
CLIFFORD P. ,1UI)KINS,
Administrative DireCt:or
RRS:rn
BY:
Envirem~ent~l Health Supervisor