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HomeMy WebLinkAboutPREUSS #3 BLK 11 LT 6Preuss #3
Lot 6
Block 11
#050-572-29
Municipality of -Anchorage ••:: - ,a
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage. AK 9951M650 Page of
www.ci.anchorage.ak.us (907) 343-7904 I
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: 0q00:3 "T PID Number:
Name: n
t",efe a r- Wastewater System: ❑ New
�. Upgrade .
Address: p
aD07Lan. /ive efcive 9qS ABSORPTION FIELD
Phone: Number of Bedroorre
O Deep Tnxdi $fShabw Trend, O Bed ❑Mound O Other.
LEGAL DESCRIPTION SodRatn¢Tow Depth hm originai pade:
DI Gpiwe �/ Ft.
&pelt: Lot: Subdivision• Depth to pipe bottom from original �. Gravel depth beneath pipe:
Flo -3 Ft.
Township: Range: Section: Fill added above original grade: t � Fl. Gravel Length: 70
Ft.
Well: ❑ NewUpgrade Gare( wadK Fl. " rrwex Distance between bines:
❑ --��' Ft.
as90cabon (Private. A. B. C): Total Depth: Cased to:.. --- Total absorption are: e Mat
Ft. Fl=
Driller. -Date-Druted: Static Water Level: Installer l Date installed:
Yea: Pumn
p Set at CasmgHeigMAbovgGroundFl. 'ef )� aJ1a
GPM Ft.FL TANK
SEPARATION DISTANCES 0 Septic ❑ Herding I•S.T.E.P. ❑ Other.
To Septic Absorption Uft Holding 3ub9dPrivate n paotr:
From Tank Field
Field Station Tank ^SeeweerLine Pre -VII a/,�PIC.S / GS 1304 Gat.
Well I W + ( i /1� % I V O'1' �� O(J � Menet: ^ 1 ee "� or Cariparunents:
Surface Water 11 0 (/ I DG'•� 10/ ) 4-1 �/ LIFT STATION of
Lot Line �F ` 16' 0' I �DO Gal. P
\ \ i 'Pump On' lewd at: •Pump off' level at High water alarm aC
Foundation Tmin � /. S h. a.-1/114 in.
Curtain Oran jaMake a Model Electrical
6}ZrOCpOS RSIn.G�vl
Remrris: J BENCH MARK
��G{ ✓1 t...�q L,crY� ��
London and Desa+pbon:
IL ec
ll r S 7 iZ I li i 0 P! 4, „ Assumes evauon:
/t -s 3 0 0!» 145 Ft.
3/i6fr D,,A . S/°A��EU
a. 3 r o _C
S & S ENGINEERING i .''. ,• • ��
17034 Eagle River Loop Road, No. 204 '' // >- - >_'%/ > • ••»«.•>:•_•.,.ap
Inspections performed by: Dates: 1� 3-.3 —O7 GFS', ' ..'✓�_
2nd q—I _0q till ROBERT G COWAN• r OZ-
Development
Z-Develo ment Services Department ApproZl P���`�• c`"8aol ,.••'���r
i Reviewed and approved by:Date -�
I
PERMIT N0. SW040035 PAGE 2 OF 3
MunicipaUtAof Anchora e
DEPARTMENT OF HETH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Te'l�ephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 6, BLOCK 1 1 , PREUSS S/D ##3 P.I.D. NO.
050-572-29
10' UTILITY EASEMENT
EXISTING
TH#1
TRENCH
MT2PPOLER
MT1
• r
7��RENCH
DV 1 DV2
Q 2 \w
TBM
k J
13/,
A B
Q3Q
EXISTING 3
BEDROOM
HOUSE
LOT 5
LOT
LOT "7
FCO T
STI °
WIGARAGE
H DECK MH
C
3�
3I
SEPTIC h,
�
c AREA
y
LUCAS
AVENUE
SCALE: 1" = 40'
:f: Fri•',. �..,L,�
ROBERT
C. COWAN f
CE
LOT 6
-8801 .'�`•e�
. f
PERMIT NO. SW040035
PAGE 3 OF 3
Municipalit of Anchora e
DEPARTMENT OF HEATH AND HURAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Tel 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 6, BLOCK 11, PREUSS S/D #3 P.I.D. NO. 050-572-29
FINAL GRADE
ST1 MH ,-90.3
NEW
87.3' 1300 GALLON
POLYETHYLENE
SEPTIC TANK
MT2 MT1
MT2 = 101.9'
MT1 = 101.8'
98.5'9: SR DISTRIBUTION PIPE
2" INSULATION
FINAL GRADE
2" INSULATION
MT2 = 95.5' -� "-MTI = 95.5'
NO WATER FOUND
89.0' B.O.H.
N. T. S.
A
B
C
FCO
-
38.5
22.5
ST1
-
47.5'_19.5
MH
-
51.0'17.5
MT
-
42.5
23.0
DV 1
38.5
14.0
-
DV2
39.5
15.0
-
MT1
42.0
25.5
-
MT2
42.0
6',1.0
-
N. T. S.
1
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Permit Number: SW040035
Legal DescriptionIPREUSS#3 BLk�-.1.11T:76-p
Design Engineer: 0003 S & S Engineering
Owner Name: Peter Muller
Owner Address: 20607 Lucas Drive
Eagle River , AK 99577 -
14) ?--1 T)q
aK
Date Issued: Mar 24, 2004
Expiration Date: Mar 24, 2005
Parcel ID: 050-572-29
Site Address: 020607 LUCAS AVE
Lot Size: 22531 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
0 Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy
All construction must be in accordance with:
1. The attached approved design.
❑ Private Well ❑ Water Storage
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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only).
4. From October 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: kA
Issued By: Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(07) 343-7904
�- -ON-SITE SEWERPANEL-i.-PERMIT APPC_IG;%.TiL;;
FOR A SINGLE FAMILY DWELLING
Parcel I.D. �S Z`- Permit Number SW
Property owners)r`�— tA uk �--L- �- Day phone � O I (-, C-�- I
Mailing address (1)
Mailing address (2) Zip Code
Legal description (Lot, Block & Sub'd.) -� pi-eW S -17-3
Legal description (Section, Township & Range) Z��O�� l.l� l K -y /V) U0'
Lot Size as . S�_Acre Sq.Ft. Number of Bedrooms
THIS APPLICATION IS FOR:
Sewer Only ❑ Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening'Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
S & S ENGINEERING
17034 Eagle River Loop Road N0. 204
v__1-_Vt.Ar_ 1a%ka 99577
(Signature of property owner or authorized agent)
Permit Fees: 4h 1190 Waiver Fees:
Date of Payment: -?—s. `-t Date of Payment:
Receipt Number: Receipt Number:
(Rev. 12/00)
S&SN
�in��ninG
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CML ENGINEERS
(907) 694-2979
FAX (907) 694-1211
March 16, 2004
HEALTH AUTHORITY
APPROVALS
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
SEWER&WATER
Anchorage, AK 99519
MAIN EXTENSIONS
REFERENCE: Lot 6; Block 11; Preuss Subdivision 43
SEWER & WATER
INSPECTION
It is requested that you issue a permit to install a new trench to serve the existing
three bedroom dwelling on the referenced property.
ENGINEERING STUDIES
The test holes and percolation tests were performed in April 1990 by Mr. Lou Butera P.E.
AND REPORTS
The test hole logs report finding ground water, but the depth was not recorded. The
original pipe for ground water monitoring was monitored and found to be dry.
WELL INSPECTION
The design is based on the assumption that the test,holes were stopped at the level of the
& FLOW TEST
ground water found. The new system is placed so the bottom of the gravel is 6 feet above
the test hole bottom.
SITED
This lot as well as lots on either side are served by the AWWU Public water system,
therefore contamination of wells is not a critical factor. We do not anticipate any adverse
effects on neighboring wells, septic systems, reserve areas or drainage patterns by the
installation of the proposed trench. The installation of this trench will not prevent any
MAD DESIGN
future development on any of the adjacent properties.
If you require additional information, please contact us.
SOILTEST
Sincerely,
PERCOLATION/!/
7
v r
TEST
Robert C. Cowan, P.E.
RCC/bj j
Enclosure
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUfTE 204 • EAGLE RIVER, ALASKA 99577
DESIGN
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SOILS LOG
— MUNICIPALITY OF ANCHORAGE PERCOLATION
% ,�,• DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST
825 L. Street, Anchorage, Alaska 99601 264.4720
��-- SOILS LOG — PERCOLATION TEST
;1 DATE PERFORMED: Z/,L/f 0
Of
PERFORMED FOR: J�Orrr, r -
LEGAL DESCRIPTION: >` �J-94eXX SLOPE SITE PLAN
P::Pp
12
54,.�sl� Grw✓e/
1"'1�g3
N
-'tr. Os y�� "L
13 4 fir' " cQ'U.•q„o..�.,,s? `�4
does, S
WAS GROUND WATER yES l
ENCOUNTERED? ��.— 0
/P
IF YES, AT WHAT Nit ►..i.r�>Niy E
DEPTH?
Grose Nat Depth to Net
Roedin0 Deta IT me Time Weser Drop
72.000 (61791
I
Saba* 0se.o.• . �t
�b
I%41
�� • ........ ....... o
17
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rl
�' $ = S' �G
�s ��
Q ��l''• ••
N
A
iJ FP.S
�r0i
S
19
LEI
3-8 /6
/6
20
PERCOLATION RATE
$r N (minutes/inch)
FT
TEST RUN BETWEEN
..----�
– FT AND
COMMENTS K efrv41'..,a 6Xq
��"'�
OT ma••/ r d!t rrJ v
d•,t✓.T, G✓ .r dG✓iyc+Y I�•_�•c.ar7` `
PATE:
r^
PERFORMED BY:^,_ /f,04/Pe_CERTIFIEDBY:
72.000 (61791
I
0 SOILS LOG
MUNICIPALITY OF ANCHORAGE
f • } DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
lTEST
826 L. Street, Anchorage, Alaska 99501 264.4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: �orn+� e,r DATE PERFORMED: f/Ae>/so
LEGAL DESCRIPTION: 1-,07,-.1
�K / ,���M I I SLOPE SITE PLAN
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
SAP.,Wy d-/4YG/
w,i� aGC�.is:
17
� �•��..es..�a.''Y�1,1_ as
^0pROFESS�ON;i'O"'
a04oa�n.•s�••
WAS GROUND WATER S
ENCOUNTERED? yEs 0 B. -
P
IF YES, AT WHAT N•t
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
FTI
1-77
20 S H.oa .. J -/..
UPERCOLATION RATE /lJ_(minutes/inch)
TEST RUN BETWEEN FT AND V_ FT
COMMENTS 15A e/iy'. f,. a �h e1/+•.-fr Rti
/y r1-
At �7i� ifarY cr �or 6 rW- 41.f avr ul.✓rv�'' 1-��j are✓�./�"
PERFORMED BY: /e•N ee CERTIFIED BY: r.f.-7 - DATE: -el �
72.008 (6/79)
HEALTH AJf HORITY
APPROVALS
SEWERMATER
WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELLINSPECTION
d FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
S&S1
1 -in epung
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
REFERENCE: Lot 6, Block 11, Preuss Subdivision #3
March 16, 2004
GENERAL:
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
1. The scope of this project includes the installation of a pressurized drainfield
to serve the existing three bedroom residence located on the referenced
property.
2. 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.
3. The contractor shall be responsible for obtaining any necessary
underground utility locates.
4. Unless specifically agreed otherwise, the property owner shall be
responsible for final grading areas subsequently depressed from soil
settling.
5. 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 from the Municipal
Health Department.
SEPTIC TANK INSTALLATION:
1. A septic tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two 4" cleanouts for pumping access.
2. The septic tank shall be sufficiently bedded to prevent settling or shifting of
the tank.
3. 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 6, Block 11, Preuss Subdivision #3
March 16.2004
4. Septic tanks installed with less than 4 ft. of cover shall be insulated.
5. A foundation cleanout shall be installed one to four feet from the building foundation.
6. Final grading over the septic tank shall be such that a positive slope exists away from
the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
1. 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.
2. Once the gravel is installed, the distribution pipe is to be installed level with the holes
faced downward. The distribution piping is to be of PVC (ASTM D3034 or equal).
All joints are to be solvent cemented. Gravel is then to be placed over the distribution
pipe to provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier 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.
4. 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 grade.
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.
5. Backfill over the final gravel layer must not be less than twenty-four (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 formation of a
depression after settling.
MINIMUM MATERIAL SPECIFICATIONS:
Any septic tank proposed for installation must be constructed by a Municipally
approved septic tank manufacturer.
Page 3
Lot 6, Block 11, Preuss Subdivision #3
March 16, 2004
2. The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
Tie 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.
3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco,
or equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi MON, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
passing the #200 sieve.
7. When sand is being used as a filter material, its gradation specifications must conform to
current M.O.A. or D.E.C. requirements, which ever specifications applies.
Page 4
Lot 6, Block 11, Preuss Subdivision #3
March 16, 2004
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the installation of
the wastewater disposal system. These inspections will occur as follows:
1. 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.
2. The second inspection must be conducted after the placement of the silt barrier,
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 construction. If necessary, 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 cavy 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 incident to this project.
CONTRACTOR / INSTALLER
Municipality of Anchorage Page of 2 -
DEPARTMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 0 Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: 9z19Z37 PID Number: o_-0 X12 - al�
Name: �
Wastewater System: ❑ New >I -Upgrade
Address: q �`iS'Y�
Zo CoO �{C,/�S Atlb. �A�P L.6 Qt�k. r,
ABSORPTION FIELD
Phone:_
¢_ 31 S 3
No. of Bedrooms:
3
❑ Deep Trench,'Shallow Trench El Bed D Mound 11 Other
W�n1--)970
LEGAL DESCRIPTION
Soil Rating:
Total Depth from original grade:
O. 8 GPD/Sq. . Ft.
S
Lot: Block: Subdivision: 2
4.
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
1' puss
3. Ff.
1.5 Ft.
Township:
Range:
Section: p
Fill added above original grade:
Gravel length:
1.5r ^"00_%s Ft.
CSZ5 Ft.
WELL: El New ❑Upgrade
Gravel width:
S
Number of lines:
Distance between lines:
Ft.
i
Ft.
si
Cfication (Private, A,B,C):
tU
Total Depth:
Cased To:
Total absorption area:
/
Pipe material: Svc ZkLM- .a
PSC -t c_. ( Q *-Mjr—
Ft.
Ft.
S*P3 SQ. Ft.
Driller: �Vj L4j t 1
"�
Date Drilled:
Static Water Level:
Installer:
Date installed:
Ft.
/�
LIJA4,9G -r _ C0&32.T
/ 2 — g /% Z
Yield:
Pump Set at:
Casing Height Above Ground:
TANK
GPM
Ft.
Ft.
SEPARATION DISTANCES
11 Septic ❑Holding >S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:
Capacity in gallons:
From
Tank
Field
Station
Tank
Sewer Lines
jQ00+AA'_.r-p.m (
Well
�^
��
Material: C
Number of Compartments:
Surface
Water
(E7p i-}-
I olp'-F-
t 00�'fi'
--"
LIFT STATION
Lot
Size in gallons:
Manufacturer:
Line
f Z,
I Z
Z
_
AAocB_ % r_O /LPAXXo SO'
Foundation
"Pump on" level at:
"Pump off' level at:
I
High water alarm at:
1
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Curtain
Pump Make & Model
Electrical Inspections performed by:
Drain
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Remarks:
BENCH MARK
Location and Description:
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Assumed Elevation:
ENGIAAER a
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Inspections performed by: / Dates: 1st
2nd 5 /9 5Z
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Department of Health and Human Services approval
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Reviewed and approved by: t-- �— Date:
72-013 (Rev. 9/91) MOA 25
V1v
Permit No. S 1,/ 172-02-3,7
Page 2' of Z_
Municipalityof Anchorage
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
Legal Description: 1,.>-r 6° 1?)L 11 ulz�s *3 PID No.:
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PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE o o MS
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502 //��
ANCHORAGE, ALASKA 99519-6650 Cl,
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW9202.37
DESIGN ENGINEER:DAVID R. DAYTON, P.E.
OWNER NAME:DORMAIER DOYLE W
OWNER ADDRESS:20607 LUCAS AVE
EAGLE RIVER, AK 99577
PARCEL ID:05057229
LEGAL DESCRIPTION: PREUSS #3 BLK 11 LT 6
LOT SIZE: 22554 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
DATE ISSUED: 8/18/92
EXPIRATION DATE: 8/18/93
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
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 FOLLOWING SPECIAL PROVISIONS.
SPECIAI, PROVISIONS:
THE WELL AND SEPTIC TANK AND SEPTIC SYSTEM UPGRADE MUST BE
IN ACCORDANCE WITH THE APPROVED ENGINEER'S DESIGN DATED
8/11/92. n /1 /
RECEIVED BY:
DATE:
ISSUED BY: .._ __ _ DATE:
D. R. DAYTDN, P.E., R.L.S.
l;RoWxJ 5 Chugiak, Alaska 99567 (907)kx
20210 Donalar St. 696-2417
Design Narrative
Lot 6, Blk 11, Preuss Subd. #3
The design presented is an upgrade system to replace a failed
absorbtion trench.
The new system will be placed on the rear of the lot uphill
from the old system, using a STEP tank and pressurized shallow
trench.
The test holes and percolation tests were performed in April 1990
by Mr. Lou Butera P.E.. The test hole logs report finding ground water
but the depth was not recorded. The original pipe for ground water
monitoring has been monitered weekly for the past month, showing
no ground water.
The design is based on the assumption that the test holes were
stopped at the level of the ground water found. The new system is
placed so the bottom of the gravel is 6 ft. above the test hole
bottom.
This lot as well as lots on either side are served by the AWWD
Public warer system, therefore contamination of wells is not a
critical factor.
The proposed system will have no measurable impact on reserve
space, surface or subsurface, or on drainage.
7
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David R. Dayton
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20210 Donalar St.
Chugiak, Alaska 99567.
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20210 Dangler St.
Chuglak, Alaska 99567
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION � PERCOLATION
A* -.-6-D)
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: DATE PERFORMED: V/S0�`/O
LEGAL DESCRIPTION: 40 7`4 /'rcrex-F
SLOPE SITE PLAN
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WAS GROUND WATER y�P L
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IF YES, AT WHAT Al, t- m.��t+.'er/E
DEPTH?
Reading
Date
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Time
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Drop
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PERCOLATION RATE /O (minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS FX elf �4 P,o" 65 �/�. <!z (fSr/-
NC'f - /Yis r/ i{zV—� �!' �r.-r e. v✓. %, 4.I �gsp. ���rv��^ !^� j t.P�s'r
PERFORMED BY: CERTIFIED BY: DATE:
72.008 (6/79)
i
MUNICIPALITY OF ANCHORAGE
-�-Ig PERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST
825 L. Street, Anchorage, Alaska 99501 264.4720
SOILS LOG — PERCOLATION TEST
/ DATE PERFORMED: yl-- 00 0
PERFORMED FOR: �r�"4 /
LEGAL DESCRIPTION:
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IF YES, AT WHAT
Time
DEPTH?
Drop
SITE PLAN
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IL_—JI PERCOLATION RATE 8/ Zf (minutes/inch)
TEST RUN BETWEEN FT AND FT
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PERFORMED BY: f\ �Pe CERTIFIED BY:
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Time
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PERFORMED BY: f\ �Pe CERTIFIED BY:
72-008 (6/79)
� F GUAM? CR ANCHORAGE ARCA ElMi JGH
IBJ Department of Environmental Quality
d 3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME -V Q �F .14� °C MAILING ADDRESS 110ilY ;/-�° °L/S/PHONE
LOCATION " ---_ LEGAL DESCRIP-I ION _`"'._._`�� /� !� �f'� �S� ✓V'"��� `y
SEPTIC TANK:
DISTANCEQ�f NUMBER OF
FROMWELT_ / �_MANUFACTURER�L�_--MATERIAL_ ✓,Tr'--COMPARTMENTS-
INSIDE LENGTH— INSIDE. WIDTH _—LIQUID DEPTH — LIQUID CAPACITY_ `� ' ,v GALLONS.
SEEPAGE PIT:
NUMBER OF PITS _Y— ..,DIAMETER --OR WIDTFI �i, LENGTH G5DEPTH
LINING MATERIAL CRIB SIZE: DIAMETT�EIJR—DEPTH* DISTANCE FROM: WELL n
TOTAL EFFE
BUILDING FOUNDATION __ , NEAREST LOT LINE_/_y_ . ABSORPTIONCA AREA (WALL AREA) -S
54. FT.
ADDITIONAL ABSORPTION
WELL:
TYPE ___—CONSTRUCTION
BUILDING NEAREST
FOUNDATION LOT LINE
-—
CESSPOOL
APPROVED
DISTANCES:
INSTALLED BY
OTHER SOURCES
NE=AREST
SEWER LINE
DISAPPROVED REMARKS
nPI PE MATERIAL:
4 'Y /Z G
LOT SLOPE:
REMARKS:
DATE
Form No. EO -037
DEPTH
SEPTIC
TANK.
DISTANCE FROM:
SEEPAGE
SYSTEM
DIAGRAM OF SYSTEM I�y� (ciT'
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DEPHRTMENT i HEHLTH HND ENVIRONMENTHL� ]TECTION L�
~ IC', \
2510 E i�DOR RD . HNCHORFGE/ HK. 9�j87
` ` + E. �
, ~ 276~2221
Cfl �IFZ., ������
PERMIT NO. ( 76412 )
/
HPPLICHNT GEORGE 1]0] HTKINSON DR ]�7~2591
LOCAT' ION EAGLE RIVER
LEGAL L6 13,11 PRI -[ESS #] LOT SIZE ]]000 SQIF- RE FEET
TYPE OF SOIL HBSORBTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = ] SOIL RATING (SQ FT/BR) 125
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
������������ ����1r�� �
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFHCE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET)
THERE IS NO SET WIDTH FOR TRENCHE&
THE GRHVEL DEPTH IS THE MINIMUM DEPTH 0F GRAVEL BETWEEN THE OUTFALL PIPE
HND THE BOTTOM OF THE EXCHVHTIONFEET).
�F=l -IL CH IfD 12:9 �������
BACKFILLING OF ANY S9' -STEM WITHOUT FINAL INSPECTION HND RPPROVHL BY THIS
DEPHRT| NT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSHL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 200 FEET FOR H PUBLIC WELL
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]0 DHYS
OF THE WELL COMPLETION.
SPECIFICATIONS HND CONSTRUCTION DIHGRHMS ARE HVHILHBLE TO INSURE PROPER
INSTHLLHTION.
P_'> F:- IFR �lr--D U_ '-e FEE F,::l PF -f C-9 IM IF=
I CERTIFY THAT /
1� I HM FAMILIAR WITH THE REQUIREMENTSFOR 8N -SITE SEWERS HND WELLS AS SET
FORTH BY THE MUNICIPHLIT9 OF ANCHORAGE.
2� I WILL INSTHLL THE SYSTEM IN HCCORDHNCE WITH THE CODES
]� I UNDERSTHND
'THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE EWLHRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDROOMS.
SIGNED:------~--
��PPLICHNT JOHN��GEORGE ~�
60nitowatlon gest _LaE
"One test is worth a thousand opinions"
2204 Cleveland Anchorage, Alaska 99503
Performed For 71 k1iCmc-?6sro1a 1 Date erformed 2 Z
Lenal Descrintion: Lot___&Bloc4:_Subdivision L)C?.SS !S ;j 1-3 f9eu,`f'��
This Form Reports Soils Loq d Percolation Test
Oenth
Feet Soil Characteristics
CQ -s V L-
2—
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7
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Was Ground Water Encountered?A/3
If Yes, At what Depth?
l �� 3j, -6c4 ��GfJV,U
1 �3�c+vv�'l"'7 LDI
IMMrc,�.-'�■�r•
Readinq I Date I Gross Time I Net Time I Depth to H2O
Net Dron
Percolation Rate Minute
Proposed Installation: Seenaoe Pit Drain Field _
Deoth of Inlet Denth To Bottom Of Pit 0 7rench
a —7
Test Performed By 0—t w► VU14L1C, _ Data Certified By:
Date:
b /
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nG£ G1
• '� Municipality of Ancho
On -Site Water and Wastewater Prog AUG 2 7 2015.
(907) 343-7904 Gree m StD'lef rt 's . E r.
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 050-572-29
1. GENERAL INFORMATION
Complete legal description PREUSS #3 BLOCK 11, LOT 6
Expiration Date: 8 –/ � — 1-7—
Corn plate
_
Location (site address) 20607 LUCAS DRIVE, EAGLE RIVER, AK 99577
Current Property owner(s) WILLIAM J. STREUR Day phone
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
20607 LUCAS DRIVE, EAGLE RIVER, AK 99577
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
Individual Well
❑
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual
Holding Tank
❑
Community
❑
Public Sewer
❑
Waiver/Variance request for: Distance:
Received by: 6d � Date:
COSA to be released to the engineer, unlesst e ' e requested by the engineer.
COSA Fee $ 52-&
Date of Payment all J$
Receipt Number olem
COSA# D505 LJto3
Waiver Fee $
Date of Payment
Receipt Number
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 S(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
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 r Oh A
occupants or can ArcTerra guarantee that no unseen v AZ
4. deficiencies or discrepancies exist. / lZ� S��
1A n T T I
6. DSD SIGNATURE ??
�ystem #1 Approved for 3 bedrooms.
System #2 Approved for bedrooms.
Disapproved.
P, KENN]irlf
Me DVF /
'r ��, Alf
'Ls i'w� i
tasroN�' .i
Conditional approval for bedrooms, with the following stipulations:
By: �/
.��i� "L�� A r o�Original Certificate Date:
The Municipality of of Ancorage 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 theprofessional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12.d.
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 11, LOT 6 Parcel ID: 050.572.29
A. WELL DATA —PUBLIC
Well type If A, B, or C provide PWSID #
Date completed Sanitary seal (Y/N) Y
Total depth ft. Cased to _ft.
FROM WELL LOG
Date of test
Static water level ft.
Well production 9.13 -m -
WATER SAMPLE RESULTS:
Coliform —colonies/100 mL Nitrate _mg/L
Arsenic: ug/L Date of sample:
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SEPTICIHDPE
Tank size 1300 gal. Number of Compartments 2
Foundation cleanout (Y/N) Y Depression over tank (YIN) N
Date of
C. ABSORPTION FIELD DATA
_ Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground) _in.
AT INSPECTION
5
Collected by:
Date installed 4/112004
Cleanouts (Y/N) Y
High water alarm (Y/N) Y
Date installed 411/2004 _ Soil rating (g.p.d./ft2 or ft2/bdrm) 0.8 System type SHALLOW TRENCH
Length 70 ft. Width 5 ft. Gravel below pipe 3 ft.
Total depth 5_5 ft. Eff. absorption area 603 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 8/19/2015 Results (Pass/Fall) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth 1 in.
Elapsed Time: 10 min. Final fluid depth 0 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed 411/2004 Size in gallons 1300 Manhole/Access (Y/N) Y
"Pump on" level at 48 in. "Pump off" level at 51.5 in.
Datum TOP OF MAN HOLE Cycles tested 2
E. SEPARATION DISTANCES - PUBLIC WATER
WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
Animal containment areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+
High water alarm level at 44.5 in.
Meets alarm & circuit requirements? Y
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
Absorption field 54
Water main 10'+ Water service line 101+ Surface water 1001+
Wells on adjacent lots 2001+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 104 Water main 104
Water Service line 101+ Surface water. 1001+ Driveway, parkingfvehicle storage 10'+
Curtain drain 50'+ (NONE KNOWN) Wells on adjacent lots 200'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I ceftffy 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.
Engineer's Printed Name KENNETH M. DUFFU$
Date 8125115
COSA canary sheet,-6-15.doc
/��� OF�ALA ',
I' Ko o T/ T4
Municipality. of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-572-29
1. GENERAL INFORMATION
HAA #_ iDL4 D. V
Expiration Date: _;, ± - 1 3 -- [) �.
Complete legal description Lot
6; Block 11;
Preuss Subdivision
#3
Location (site address or directions)
20607 Lucas
Dr. Eagle River,
AK 99577
Current Property owner(s) Peter -Muller Day phone
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Rolf Milton
Day phone
Day phone 694-4994
11940 Business Blvd. Ste. 202 Eagle River,AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup. � � �
.41
2. NUMBER OF BEDROOMS:_
3. _TYPE OF WATER SUPPLY: ,
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
g
Individual Water Storage
El'-
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
Public Sewer
❑
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 samples.)
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 Firm S & S Engineering
Address 17034 N. Eagle River Loop Ste. 204 Eagle
Engineer's Printed Name Robert C. Cowan
Phone,
River, AK 99577
Date /q/0
'�F
..qAlc
��..��'�`l
Qui
694-2979
-e i ROBERT C. COWAN F ell-
S.- DSD SIGNATURE
Approved for 3 bedrooms. `��
s ..,
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments "'��c�ni�►Tcc� _
YYHJ
PROGRAM
JJJJ J�� J,,�,�,�r��
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: Original Certificate'Date: " " f 3-04
(Rev. 01102)
Municipality of Anchorage °E
Development Services;De aetment
i Building Safety Division
On -Site Water.& Wastewater Program S A F E* Y
4700 South Bragaw St.
P.O. Box 196650 'Anchorage, AK 99519=6650
www.ci.anchorage.ak!us
(907) 343-7904. I
HEALTH AUTHORITY APPROVAL�I CHECKLIST
I I
Legal,Description: _�oT l3Lo ctt 1/_ IR✓vsS w 4 .3 Parcel ID: O f° —S7a
I A. WELL DATA, V 13 L.I-C_ L-/ 4--r It 4-
: .
.Well type If k B, or C provide PWSID # : Well Log (Y/N)
R Date completedSanitary seal (Y/N) Wires properly pr d (Y/N)
de th
p ft. Cased to ft. L i' 3 Casi eight (above ground)
Total in.
i
i;itFROM WELL LOG i AT(INSPECTION
f Date of test
1
Static water level ft. i ft.
Well production'
g.p.m: c g.p.m.
WATER SAMPLE R LTS ' `` i €
Coliform colonies/100 m1. Nitrate
m ./l Other bacteria
' colonies/100 .. 9es/100 mL
Ar ic: mg./I. : Date of sample.Collected'by
I I
B. SEPTIC/HOLDING. ,
I � TANK DATA I +
I I
Tank Type/Material ' S7 -h-P )to P f Date installed
Tank'slize 13 o o 1 "gal. Number of Compartments S.
-- Cleanouts (YEN) y,
'i.t,
I. FoundationcleanoutpN) Yts': Depression'overtank (Y/�(j� �'.d High.wateralarm6N) y�
,I li G V �; o
P,
Date'of pumping' =;N'�u/Pumper i tit
;-
`C
ABSORPTION FIELD DATA � !
lri I/ 2 2
Date installed = i Soil rating g.p.d.'/f or ft /bdrm) g System type
' Length �p ft. Width i' I { ill i ft. j Gravel below pipe 3
i
I I I � 7 I, r
Total depth S ft'. Eff' absorption area 'GD 3 ft Monitoring tube ^y �. I Depression over field
2
i
j , Date of adequacy test N 1 Nei w Results l(Pass/Fail) 71 is For bedrooms
I'i I i ,
Fluid depth in absorption field before test rin.
r er added gal. New depth in.
Elapsed Time .min. 'Final f epth ' rn y 3! Absorption rate >_ g.p,d,
F; ;
# I
I I s ,
j Any rejuvenation treatment 12 mo, Y/N & e 11- i i�
( typ )' If yes, give date
I �i
. I•_ ' `; t _ Ijl J it ,� I ',n j 71
''r'•r�rwl•1lN�• ISI I . I 1 3 - _
E.
LIFTSTATION
4/0 / 3
Date installed '� Size in gallons
Manhole/Access'&N)
"Pump on level at h in. "Pump off' level at ` Lin. High water alarm level at �/ Y. S in.
Datum ,T°�' I dF_ MSN �►'�� Cycles tested a
I
Meets alarm & circuit requirements?
; I ,.
y�-S
SEPARATION DISTANCES
SE PA RATION DISTANCES FROM WELL ON LOT TO:
I.I
I
I
k
Septic tank/lift station on lot
1'
On adjacent lots
Abso l ption Ilfield on lot
scent lots
.
t
I t
'leanout
Public sewer manhole/ c
Public sewer main'
'
Sewer /septic se
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
j
Building foundation $ "I" Property line g AbsoIF rptionlfield
I
Water main ; 10 r4- Water service line
10 Surface water
I I�! ° 4 -
Wells on adjacent lots
SEPARATION ('DISTANCE FROM ABSORPTION FIELD
ON LOTTO:
I;
Property, line, - G �' Building foundation?
0 Water main
1 c7' I r
,Ili' I ILIII�i r
Water Service line '/0 -r Surface water I o
.
Driveway, parking7vehicle storage
%� f
I I�NO�at; kNow
Curtain dram' r✓ • Wellson adjacent lots
/A ,IIII � I �I i ,
�.• �', �
I -� ;
'F. COMMENTS
�' Is
I,
,I
I
II ,
} I I
G : ENGINEER'S CERTIFICATION �, �' ,Ii • -z�jt �� �:'`` I''
I�'�� is �..,>� ✓��� ,; I�
certify that I have'determined through field inspections and �,v " ..-'7�.»•.• ........,=:.•i..P�+
review of Municipal records that the above systems are in I ,
!N. s... ..1......�. .,I. •.....
C''
IfIj �nIII' cI'eIJ withMOAHAA guidelsin/e1s�T in efCect on t9hi�s✓date. ^t�e.onm�r 'CR�� .Do<:'I!aG'�+CE!d.c..r. -{i'I .n ' COWAN ,AN �{•�• r��f
8n01
Engineer's Printed Name/w�, i
7 Date D
I
I'
I •I i v'� 1 �� 'I
I I
• s I r
I I
• 1 P
I
1 I I
III 30 !�
+
�i Waiver Fee $ I
1� I
HAA Fee $ '
Dater iflPaymelrit Y `l toy Date of Payment
It
ReceipiltlNumber Receipt Number
'� , . , , .;I I, I' •; , 1 .. I
I!
.'
(Rev:12/01) I y II
> I
I r.
f 1
i I
1
1 6'
•1 i
1'
S
i'
II
of
M
12-17,o,ol
N
7 -
AS -BUILT
I hereby certify 'that I' have -surveyed ,the follo*Ing
described property:1-Ir
Anchorage -Recording Precinct and that the*'
improvements situated thereon Ware Within the .property
lines and
00- do not overlap 'or encroach on the property.'
-Ing, adjacent: thereto, that no improvements on''pro p-`
crty lying adjacent thereto encroach on the premises in
question and that there are no roadways, transmission
lines or other Visible easements on
said property except
nson as,indicated hereon.
^bated at Eagle River, Alaska
7. A
this -12 -- day of
rt ROBERT C.'JOHNSo
Ni N --X& -*- +"
SCALE: Registered Land
Surveyor No.880-LS,'
Box 456, Eagle River, Alaska
Phone 694-2543
U - .4•t
r peck
,,
;;•-� j
- -
N WY.
G
12-17,o,ol
N
7 -
AS -BUILT
I hereby certify 'that I' have -surveyed ,the follo*Ing
described property:1-Ir
Anchorage -Recording Precinct and that the*'
improvements situated thereon Ware Within the .property
lines and
00- do not overlap 'or encroach on the property.'
-Ing, adjacent: thereto, that no improvements on''pro p-`
crty lying adjacent thereto encroach on the premises in
question and that there are no roadways, transmission
lines or other Visible easements on
said property except
nson as,indicated hereon.
^bated at Eagle River, Alaska
7. A
this -12 -- day of
rt ROBERT C.'JOHNSo
Ni N --X& -*- +"
SCALE: Registered Land
Surveyor No.880-LS,'
Box 456, Eagle River, Alaska
Phone 694-2543
MUNICIPALITY OF ANCHORAGE V� w
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. # y5y HAA # F�ViCLCY�73
1. GENERAL INFORMATION
Complete legal description Lot 6, Block 11, Preuss #3 S/D
Location (site address or directions) 20607 Lucas Avenue
Propertyowner VA % All Star Pat Arnett —Dayphone 561-7827
Mailingaddress 2207 E. Tudor, Suite 33, Anchorage, AK 99507
Lending agency Day phone
Mailing address
Agent Day phone
Address _
Unless otherwise requested, NAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. 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 X21
�i
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 furtherverifythat 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 5& 5 ENGINEERING Phone 61 H - a 22 9
17034 Eagle River Loop Road No. 204
Address Engle River Alaska 99542
Engineer's signature
6. DHHS SIGNATURE
✓ Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
0
UITIC
Date
ROBERT C. COWAN - 4?
CE -8801
bedrooms, with the following stipulations:
Date 3 — '7-00
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-M(AW.151) Back MOAK21
Municipality of Anchorage
C*D DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division ti
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
/ Health Authority Approval Checklist
Legal Description: Zor Saf_�fI/CL! /l�_�Lr=L SS 74_Parcel LD.: /2,50 -372 9 _
A. WELL DATA
Well type A �5z /Cl If A, B; or C, attach ADEC letter. ADEC water system number
Log present(Y/N)
Total depth _
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAMPLE RESUL
Coliform
Date of sample:
Date completed
Cased to
FROM WELL LOG
Nitrate
Casing height (above ground)
Wires properly protected (Y/N)
g.p.m.
Collected by:
AT INSPECTION
Other bacteria
B. SEPTIC/HOLDING TANK DATA \ (( //
Date installed q Tank size L7 rJO �' Number of Compartments 2 Cleanouts& 7C
Foundation cleanout(o)///,,,Depression (Yo Ao_ High water alarm (Y/N)
Date of Pumping / l l/lllJ Pumper V 6
C. ABSORPTION FIELD DATA/
Date installed Soil rating (g.p.d./ft2 or ft2/bclrm) Q6 System typeO/�L�L/Gyf
i
Length 8� Width _ _ Gravel thickness below pipe �/ /
a Total depth
Effective absorption area Monitoring Tube presenON)Depression over field (Y/) o
Date of adequacy test Results (Pass/Fail) 4-6S For bedrooms
Fluid depth in absorption field before test (in.); 0-1Z I r
Immediately after 2Vgal. water added (in.): — !U
Fluid depth (ins) Minutes later:_ 20 Absorption rate = `,4 ?) g.p.d.
Peroxide treatment (past 12 months) (Y/N) /ONE- C_11V6NIN If yes, give date
72-026 (Rev. 3/96)'
D. LIFT STATION
Date installed
Manhole/Access 6k
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at* Z "Pump off" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
i
Foundation S Property line
y '-4-
Absorption field 6"+
Water main/service line O < Surface water/drainage (i� �7 Wells on adjacent lots 0/
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line �� Vit" Building foundation /b /'f Water main/service line /0
d?� / y '
Surface water � Driveway, parking/vehicle storage area
Curtain drain ND7UL ��it/d7idit! Wells on adjacent lots MIA -
F. ENGINEER'S CERTIFICATION
/ certify that / have determined thru field inspections and review of Municipal
in conformance wit MOA gXl�
ines in effect on this date.
2
Signature
Engineer's Name (�. Co wAl.)
Date
2/�Lt/0 0
HAA Fee $ 3p-n.c
Date of Payment aI�ct (3D
Receipt Number �,(Pa C
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
ROBERT C. COWANF,+
CE - 8801 %
are
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
F
IUIPALITY of ANCHURAUJ
NMPN1AL ftnylcu iiIVl5li�ry
MAY 22 1997
REcr1V
CERTIFICATE OF HEALTH AUTHORITY - L. U
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. It - Iz _1 % HAA It 4a2
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Day I.Jwne
Mailing address
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup. RECEIVED
2. NUMI3ER OF BEDROOMS:
3. TYPE OF WATER SUPPLY: MAY 22 1997
Municof Anchorge
Individual well D pt.Heath(&HumanServiices
Community well
Public water /
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:
Indivirl-n! nn -sitar.
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(Rml/91( From MOAn21
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 Phone
Address el E�PL' f
Engineer's signature I w< a - L —Date-
6A
ate
6
�hF ♦a':)1 t i'slazi�se qy••t�`
r�` '• Cv8176
6. DHHS SIGNATURE �� `"%r; ......
Approved for E 3 bedrooms.
Disapproved.
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 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.
7244 Re,1l91) Back MOAN21
Municipality of Anchorage MUNICIPALITY Of ANC
DEPARTMENT OF HEALTH & HUMAN SERVICE
IRONMENTAL URVIC
Environmental Services Division env
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-&42 19�
Health Authority Approval Checklist RECEIVED
Legal Description: Lor do <, e / / = ter„s 11./ Parcel I.D.: DSD —,a XZ — -Z
A. WELL DATA
Well type A
Log present(Y/N) Y
Total depth
Sanitary seal (Y/N) _
Date of test _
Static water level
Well production
WATER SAMPLE RESI
Coliform
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed _
_ Cased to
FROM WELL LOG
9—
p.m-Nitrate
Casing height (above
Wires properly
of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
AT
Other bacteria
7 - iDdO /•
Date installed /� _Tank size Number of Compartments z Cleanouts (Y/N)_ Y _
Foundation cleanout (Y/N) _ Y _ Depression (Y/N) A) High water alarm (Y/N) Y
Date of Pumping _ r''�97 Pumper
C. ABSORPTION FIELD DATA
Date installed %�9 _ Soil rating (g.p.d./ft2 or ftz/bdrm) System types
Length _ Y��i Width %f _Gravel thickness below pipe_ / 5 �� Total depth _ ft
Effective absorption area 5 -e -f
2. Monitoring Tube present (Y/N) Y Depression over field (Y/N) _Y _
Date of adequacy test _/ /-v v eYS7 Results (Pass/Fail)Y51 _ For _ _bedrooms
Fluid depth in absorption field before test (in.); /--f Immediately afterY” `gal. water added (in.): �9
Fluid depth _ (ins) Minutes later: /J
Peroxide treatment (past 12 months) (Y/N)
72.026 (Rev. 3/96)"
Absorption rate =E'Y
If yes, give date -
D. LIFT STATION
Date installed
%Y -419x—
Size in gallons
.25 0
Manhole/Access (Y/N) Z "Pump on" level at* "Pump off' level at* yZ
High water alarm level at* *Datum RECEIVED ECEIVED
Cycles tested __?
E. SEPARATION DISTANCES MAY 22 1997
Municipality of Anchorage
SEPARATION DISTANCES FROM WELL ON LOT TO: Dept. Health & Human Services
Septic/holding tank on lot On adjacent lots
Absorption field on lot On adjacent to
Public sewer main Public sewer manhole/cleanout
Sewer / eptic service line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation Property line /,2 F'/- Absorption field
Water main/service line -2.9" y JSurface water/drainage Wells on adjacent lots �00 /.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line /Z
Surface water
Building foundation
Curtain drain L�10101La r'o 1='X15
F. ENGINEER'S CERTIFICATION
�� cf Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots 000 `f
I certify that f have determined thru field inspections and review of Municipal record70t I
in conformance with OA HAA guidelines in effect on this date. i+w. °
to
Signature
Engineer's Name P.
Date h- L2 • °1'1ti ux4.� �1iCa
HAA Fee $ `'e)
Date of Payment �P2��6-,:: r
Receipt Number a�� � Uo?�%
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
4e 0 /-,
are
MUNICIPALITY OF ANCHORAGE
• T DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services •�t
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 l.D.#-a-Q\c+ HAA# 0Q(U1Afnic,l j
1. GENERAL INFORMATION
p 9 P ow- 6- �?a
Complete legal description L�^�- � t i�/�t,L�-�
Location (site address or directions) s oGco"j Luh_ 1xu-- La Av-Mz-, At, `%9577
Property owner Dc) YL -Lm LA01 `�-�rin�ar� Day phone
Mailing address 2-0L�c,-1 l_u-ems No a- /Ei .tz )eaves, A ;e- 41#57'7
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
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 X
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 regulbt;WaRilbgW6gtpQe. the date of this inspection.
20210 Danalar St. phone ' ge,-as-i7
Name of Firm k„-ggS .7
Address
Engineer'
6. D HS SIGNATURE"
Approved for �f" ' al bedrooms.
Disapproved.
Conditional approval for
Additional Comments
M11. nr
V;<j
j c • an.+'.+f
Dlo. 21^Crc � t"
'a
40
.Y
°rROF�ss�oe'�o.�
bedrooms, with the following stipulations:
By: -.-- C! a u a !� Date
1IITIF
The Municipality of Anchorage Department of Health and Human Services ((:)HHS) 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.
7M25(R.V.1/91) Back MOAH21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: oT- Par ill 1211 466{ " Parcel I.D. 0
A. WELL DATA
Well type
Log present(Y/N)_
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
If A, 13, or C, attach ADEC letter. ADEC water system number A•usWU,
Date completed
FROM WELL. LOG
Driller
Casing height
Wires properly protected (Y/N)
AT INSPECTION
MUNICIPALITY OF ANCHORAGE
o INV RONMENTAL SERVICES DIVISION
g.p.m. 6MVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot On adjacent lots
Absorption field on lot
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed Tank size 239D PSL Compartments
Depression (Y/N) 4/
Cleanouts (Y/N)
Foundation cleanout (Y/N)
High water alarm (Y/N) Y Alarm tested (Y/N)
Date of pumping /VCr✓'yYrsrvi Pumper
SEPARATION DISTANCES FROM SEPTIC/H(),!= H Gi TANK TO:
Wel I(s)onlotN��Onadjacent lots" -Foundation
12,1
To property line /Z_ Absorption field -5-2 " Watermaia/service linerVo ;,r -
Surface water/drainageIdem'--
72-026(RCV. 7/91)Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed I9�9 L Manufacturer I+A1t44 ��uw� 1d2t�2uc�
Size in gallons 1 opt '4 Manhole/Access (Y/N) Y
Vent (Y/N)__ "Pump on" level at ¢Z "Pump off' level at aoz`°
High water alarm level At Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO: /
Well on lot 000 On adjacent lots _ ����urface water /00
D. ABSORPTION FIELD DATA
Date installedq Ij�9 Soil rating 0' 9 /'lw System type T2&M10H
r
Length Width Gravel thickness r Total depth
Total absorption area �5-e-.3 Cleanouts present (Y/N)
Depression over field (Y/N)
Results (pass/fail)
Date of adequacy test A&eo �5z5T1z»�
for
Peroxide treatment (past 12 months) (Y/N) dV& If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot Moni1>- On adjacent lots �' Property Ii
To building foundation ;:�5_ To existing or abandoned system on lot lL`
On adjacent lots /V/h+vr6 Cutbank /490 -/- Water main/service line Z '—
Surface water iDr) , /- Driveway, parking/vehicle storage area 7S
Curtain drain /✓vU� /7 NuuJ�
E. ENGINEER'S CERTIFICATION
bedrooms
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature LLwvvi +/// v
y.
Engineer's Name Dwtf) 72, GzJ�3
Date
Dov"d It. Dayton e` k
`(, J� eo NLI. 2205E e°
06
gP.. rssoeaP����A.:
HAA Fee $ / / u Waiver Fee: $ —
Date of Payment -9 -9 Date of Payment
Receipt Number � _o7 Rel / i�03 �% Receipt Number
72-026 IRe, 3/91) Back MOA 21
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF ENVIRONMENTAL QUALITY- Sewer and Water Section
?,ck3cQxFcxdasx�A�1P.t�ex�#seat§c�;3�c4c�cx:2�Z�m2�2�2�x�cx�3
825 "L" Street, Fourth Floor, Anchorage, Ak. 99503 279-2511 Ext. 229
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
1. Type of Inspection: /CMRO _ VA - _ FHA CONY
2. Property Owner: ani/n
Mailing Address:Ate"" ��&0 � E 7/ _ Day Phone
3. Name of Buyer:. J`n �! _ –ve 42
Mailing Address: 'ctpJ)g� __ Day Phone
4. Name of Lending Institution: _ �Pa/i�5 &,2M, 2:44�9V ----
Mailing Address: 3 !? ?_L C �–' _S'ef,�r,9 1' Phone
5. Name of Realtor or Agent:
N1
7.
E
Mailing Address:
Phone
Legal Description: 6 7– _—1 ✓ ze _�l
Location: 4.1 Al AZ e� g_& 5 —�
Type of Facility to be inspected: 2�'& _ No. Bdrms.
Water Supply
Type of Supply: Public Utility
Individual __x
If Individual, number of dwellings presently served
If Individual, depth of well
Sewage Disposal System
Type of System: Public Utility
If Individual, date of installation
EQ -037 (1/74)
Individual (on-site)
MUNICIPALITY OF ANCHORAGE �
D`PA OF HEALTH AND ENVIRONMEN,.,..;_ PROTECTION 9J�
825 L treet, Anchoramn. Alaska 99501 I
J�cfJ� 264-4720 �1� � l�
F8Wednesday
Date Received: January 31, 1978
#1: Time 3:0 #2: Time k��,'] �yyL� #3: Time
Date 2-1Date l _ 77
- j` �-�.i rs , Date
Insp Pr tt Insp A.;•,z`�-�'.- Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIESII
1. Lending Institution Request: Spokane Mortgage Company
Mailing Address: 3201 C Street, Suite 250 Phone:
2. Property Owner: John C. George
Mailing Address: Post Office Box 1474
3. Legal Description: Lot 6 Block 11 Preuss Subdivision #3
4: Single Family Residence: (X)
Multiple Family Residence: ( )
Number of Bedrooms: Two
Number of Bedrooms:
5. Well System: Individual Well (x)) Community/Public System ( )
Permit #
Construction
Depth of Well 405'
'1�
no
Well Log on File ( )
Bacterial Analysis
6. Sewage Disposal System: On-site System (x4
Permit # Installed 1976
7
Public Utility ( )
Installer
Septic Tank Size Zyti Manufacturer
Absorption Area Soils Rate Material
Distances: Well to Septic Tank to Absorption Area
to Sewer Line
to Nearest Lot Line
Nearest Lot line
Absorption Area
Page Two
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 6 Block 11 Preuss Subdivision #3 -
Comments:
Affadavit Attached:/ (/) v Letter Attached: ( )
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Approved:
,� ate
Disapproved: _
Date:
Department Worksheets
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