HomeMy WebLinkAboutPREUSS #3 BLK 11 LT 9 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
~y ~ Wastewater System: u New ~pgrade
Address:
Phone:~_~/~ INo. of Sedro~ms: ~DeepTrench D Shallow Trench ~Bed DMound POther
Total Depth from original grade:
Township: Range: Section: Fill added above original grade: Gravel length:
W.l.. ~/' ~ Gravelwidth: Numberoflines: IBista,cebetwee~lines:
Classification (Private, A,B,C): Total Depth: ~ Cased TO: Total absorption area: Pipe material: ~
Driller: ~ate Drilled: StaticWater Level: Installer: Date installed:
Yield: ~mp Set at: I Casing Height Above Ground:
~EPARATION DISTANCES ~s~pt~ ~ Holding U S.T.E.P.
TO Septic AbsorpSon Lif~ Holding 3ublic/Privat~ Manufacturer: Capscilyin gallons:
Lot
Foundation /~ ~ff~ ~ ~ ~ "~mp on" lavol at: ~o lat: High water alarm at:
Drain ~
Remarks: ~.~ ~/ ~~ '~.~ ~ BENCH MARK
Location and Description:
Assumed Elevation:
Inspections performed bY: ~''~ '~ ~~ Dates:21~ ¢,/,~ ~..
Department of Health and Human Services approval '~ ~',~,. .........
72-013 (Rev. 9/91) MOA 25
Permi~ No. 4
SWg?OI '15 Page 2 of
Municipality of Anchorage
DEPARTMENT OF HEAl_TH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P,O, Box 196650" Anchorage, Alaska 99519 6650. Telephone 545 4744
On-Site Wastewater Disposal Syslem and/or Well Inspection Report
Legal Bescriptipn: LOT 9, BLOCK 11, PREUSS SUBDIVISION ADDITION //I
No.: 050 572 26
72 013 A (2/91) MOA 25
Permit No. 4
SW970175 Page _.__5._ ......... of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SP~RVIOE8
ENVIRONMENTAl~ 8ERVIOE8 DIVISION
P.0. Box 196650 · Anchorage, Alaska 99519 6650° Telephone 545-4744
On--Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: LOT 9, BLOCK I1 PREUSS SUBDIVISION ADDITION /t5
P/D No.: 050 572 26
Z
O
E~
72 013 A (2/9/) MOA 25
Permit No.
Legal Description:
SW970175 Poge 4 of 4
blunicipaliLy of Anchorage
DEPARTMENT OF HEAl_TH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchoroge, Alaska 99519 6650° Telephone ,;45 4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LO'l 9, BLOCK 11 PREUSS SUBDIVISION ADDITION #3 PI[) No.: 050 572 26
,9'6 ,9
ENGINEER'S SEAL
72 0/5 A (2/91) MOA 25
PAGE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW970175
DESIGN ENGINEER:DOUGLAS T. KENLEY, P.E.
OWNER N~_ME:HUGHES JEFFREY H &
OWNER ADDRESS:20727 LUCAS AVE
EAGLE RIVER, ALASKA 99577
DATE ISSUED: 7/08/97
EXPIRATION DATE:
PARCEL ID:05057226
LEGAL DESCRIPTION:
PREUSS #3 BLK 11 LT 9
LOT SIZE: 22392 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION 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 (18/LAC80).
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.
1 OF
7108/98
1
SPECIAL PROVISIONS
c.iv D B
DATE:
DATE:
Dottgla$ T. Kettley, PI~ 9960~ Pttffltt Drive, l'altttel', /llttska 99645 (907} 746.1076
June24, 1997
Mr. Jim Cross
Municipality of Anchorage
Health & Human Services
On-site Services
Re:
Upgrade of septic system from present tin'ce-bedroom to a four-bedroom
Lot 9, Block 11, Preuss Subdivision
Owner: Ms Leslie Wenderoff
Mr. Cross:
This letter is to request approval to upgrade a three-bedroom septic system to a four-bedroom system, on
the above-referenced property. The Owner of the property is selling and the buyer wishes to upgrade the
existing fail system with a new (4) bedroom capacity system.
The original system for the property was a documented crib. The area where the system is to be installed
has a slope of approximately 10% slope. The area that has been selected for the upgrade system is tight.
The system has been positioned between the existing crib that will be abandoned, and the comer of the
prope~W. A minimum setback has been achieved from the property lines and the crib. A test pit was dug
on the property to a depth of 16-feet. A soils log is attached to this submittal for your review. Soils were
generally found to be sandy, silty gravel with a pemolation rate of just under 15 minutes per inch.
Thank you for your review. Please call the above telephone number or 243~5372 if you should have any
questions~
Sincerely,
Douglas T. Kenley, PE
CE #8t76
/
/UCA8 AVENUE
LESLIE WENDEROFF RESIDENCE
20727 LUCAS AVENUE
Lot 9 Block 11 Preuss .3 Subdivision
Eagle River Alaska, Alaaka
4'-0'
lAIN.
To
LESLIE WENDEROFF RESIDENCE
20727 LUCAS AVENUE
Lot 9 Block 11Preuss t3 Subdivision
Eagte River Alaska, Alaska
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502~0650
SOILS LOG -- PEFICOLATION TEST
1
2
3
4
5
6
7
8
9-
10-
11
13-
DATE PERFORM
Township, Range, Section:
WAS G.OUND WATER
ENCOUNTERED?
SLOPE SITE PLAN
15-
16-
17-
18-
19-
20-
S
L
iF YES, AT WHAT O
DEPTH? p
E
Depth Io Water After
Monitoring? Dole:.
Readin§ Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE f,--~ (m~nutes/~ncht PERC HOLE DIAMETER
. . /~ -- '~ TEST RUN BETWEEN (P __ F/TT AND ~ F'~-- ~7-~
' , ..... '> .:"M ,(. x
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EF~ECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
Municipality of Anchorage
DEPARTMENT OF I-IEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TESI'
LEGAL DESCRIPTION: ?-~'~'
Township, Range, Section:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Oepth 10 Water After,
Monitoring? x'~z'~'~)~
Date:
Reading Date Gross Net Depth to Net
Time Time p~ Water Drop
PERCOLATION RATE __
TEST RUN BETWEEN
(mmuteshnch) PERC HOLE DIAMETER __
'~ FTAND ~ ' ~'" FT
PERFORMED BY: ~2~'~ r ~~ I
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
?2-008 (Rev. 4/85)
CERTIFY THAT THiS TEST WAS PERFORMED IN
DATE:
!~) MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
~"AM E PHONE
LEGAL DESCRIPTION
LOCATION NO. OF ~ROOMS
~ ~ ~ Man~fact~re~ Material Eiquid capacity
~ ~ ~ inches
~ ~Y~" o crib . Crib diameter~ Crib depth Total effective ab;!erp~n
, Class Depth Driller Distance to Io, lind PE~I~.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
SOIL
TEST
RATING
REMARKS
....... t _.I I ;1: :!~:
Il.iF}; l;i'.l~)]i:!l.t;fl RI:!i) i:i!, ]] ii!'.~il OF I11E ,::;i 1 r l F:tl:i::i!;()l;i:l::' f ]!] O1'-,! :"- ::" "::"
llil::i: ! !]:t'.,!(i'lll [:, :l: l,li!:l',t'::; ]: Ol',l :l:!i; tllh: IJi:::l',l(:!if'H ,:;:I:N I::'1!:~!:1'::, QI: Fill:!:
IIIiil [;,FiI::'!'II OF: F:i -ll;i:!::NCH O1:;i'. I:::']:!' ]:::il; Till:i: t::, )] 'i~'l'F!l',lClii: BE'I !,II: :! :N fi.It:!: i!:;t, ll';i:t::'l:':!(i!:: (.11::' Fl.IIi:
GI:i:(:iI. It'-,!Ii) t:::1t'..1[::, 'i'llll !:i:()l i'OH O1::: i'!.11!: !!:i:-:;CF:fv't:::IT :( (::IN ,:::!:t'.,I
Tl.ll::i:t:;i:li :i::il; I',!O Sli:l !,.t:I. DTII I::(::II;: l'i;~'.!il'.,l(::lll(?::i;.
t'1!t': p:il:;i:I'l'v'!::! t)Ii1:::'1'II :1: !i; '1!111 H :I~ I'..! :l: HI. I1',1 I)l::i:l:::"t"H (iIF (31:;i:F:IV[i:i 15',!::i t"i,tlE(3'.,! t'! Il'i: Ol.l'lI:-i:::ll !.. F:' :!i P!i:
l':'ll'.,ll) 'IHI}: i~',OT'fOH (:iF:' TI.It~!: I!:;:.::Cl:fv'l::t'r:!:(i:ll'.,! ,;::i]!'.,I
F:'l:(l:;;ff,'l]'l .. "r'l .I . I, I Ill::f:i; i'IIE] [.i ,t ..I,I.:,..I,.1t.I I "10 ): I',!1:: 01;;'.!"1 1!'I I)!3:::'l::ll;;'.l'!"lli]Nt' DlJl';i:]:!',l(!i
]li!',!'!]i;il:'ll.l.l::l'l']!iON .!11 1 1: ! . 1. (]~F: FIl",h" I,tEiI I ':::; FII,"l::n"til]i",!f' I '~ t~ . F'l:;~'.Ol::;'lil:;~i !'? l::ff,!i> '!1I!:]
NI.It"tt!:I;R I])1: I;i:I]:!i;;l][]:,l:]t'-,ll]il;t~ili; !'Hr::li FI.I!:; f,.tl!!]!l 1,t;i]11 .:,::.,: I
:;I.: ]ti I:Ii',1 l:::'1:::11',1 ii] 1 ]( i:::IF: I,! i[ I't.t TI i~ii F]:l:iil].!kl ]!; Iq'F!iHEI'.,tT'.:i; I::'OI;i: ON..'.ii; i( I Ii ;:;151!,Ii}.(f,i:S I::II'.,!D !,IE.I i !:!;
i::o1:;i'.i'!I [i','.d I1..11( t',iI.tI'..!)]CiilF'r::IL.)i'I'.d O1::'
;:I: ;I !,!~iI1. ;iit'..!~i;ti:it.t. Flll?] 'i!;'.d'.ii;lfi]H ]!i!'.,! i::iCF?(}!;i'.!3,!:::iI'..!CIi:' !.,!]li tll Flllli]
i;i:; i] !.il'.,ll)!ii]!;i'.?fl::ll'.,!() t'1.It:::!'I '1'tlt~] ()bl-.~;ii.T!!. '.i:;l!il,tEI;i: ::!;'./:;'!'F:;I',I Hl:::l'.d I:,:1:!)]:!I..t]]!.;i~i;
Fi:E;S ;i] Dl:il N C !(
PERFORMED FOR:
LEGAL DESCRIPTION:
§
12
13
15
17
18
19
20
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 8*SE0, Anchorage, Alaska 99§02 '27E~~,22'[
SOILS LOG - PERCOLATION TEST
DATE PERFORMED:
COMMENTS
WAS GROUND WATER
IF YES, AT WHAT
DEPTH?
[O '
[~] SOILS LOG
[] PERCOLATION
TEST
WALLACE ENGINEERrNG CO.'
48~ [ANNA CIRCLE O 333-4787
ANCHORAQE,. ALASKA 99504
Reading Date Gross Net Depth to - ' Net ,
Time Time Water Drop
72-008 (7/76)
DATE:
This well is producing _ gallons rater per hour. Set pump
DRILLING
SR BOX 668, BOGARD RD,
PALMER, ALASKA 99645
TELEPHONE 745-4071
INVOICE
Lot__ BIk, _Sub
WELL LOG
__ feet.
INVOICE NO
DATE
YOUR P. O, NUMBE~
TERMS
SALESMAN
ne ...... 2~e _--
'~2s' ~s--- _-
PLEASE PAY FROM THIS iNVOICE ..~ toot AMOUNT
EXCAVATION
ROBERT A. Sl4AFER
WORK
Apri 1 5,
1983
CIVIL ENGINEER
694-2979
Totem Realty
ATTENTION: Debby Wise
P.O. Box 911
Eagle River, Alaska 99577
Dear Ms. Wise,
Reference: Lot 97 Block 11: Pruess Subdivision ~3
A sewer system adequacy test was performed on the system located
on the referenced property, as you requested. The septic tank was
verified to have a capacity 1000 gallons. After the clean out
was located the tank was pumped. The seepage pit was charged with
1100 gallons of fresh water and after a period of 24 hours, approximately
886 gallons had percolated out of the cr~b.
It can be concluded from this test; that the waste water disposal
system serving the three bedroom residence located on this property
is currently functioning adequate].y. However, the system cannot be
guaranteed against subsequent failures.
If we.~m~ay be of fur.~-her
×'~' =]~ // service, please do not
S ~cerel~y
Pepa~men~ o~ Hea~h aha ~nv~onmen~aZ
hesitate to call.
SR6 196X EAGLE RIVER, ALASKA
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. dS"'o -
1. GENERAL INFORMATION
Complete legal description /-u ~-
Locati'~n (site'address or directions)
HAA#
Expiration Date:
Current Property owner(s),
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: ~
Day phone
Day phone
Day phone
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ~
Individual Holding tank []
Community On-site []
Public Sewer [--~
The Municipality of Anchorage Development Se,vices Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Cedificates 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 hcmeowners. Certificates of Health Authority Approval are
valid fcr 90 days from the date of issue for propedies served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Cedificates 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 /'z'(i ¢ ~ -C//X[
Address ~ ~ 0 4 / ~ ~ ~ ~n , ,,~,~.
Engineer's Printed Name
DSD SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
Phone
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
wv~.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Well type ~,4,~ {t~ If A, B, or C provide PWSID #
Date completed __ ~ _Wlre. s p.rop, e.r~/, protected (Y/N).
Total depth Cased to. ff. '. ·: Casing height (above ground)
Date of test
Static water level
Well production
FROM WELL LOG. ' . ~
D~lS~mple: '
B. SEPTIC/HOLDING TANK DATA
Nitrate mg./I.
Collected by:
Foundation cleanout {Y/N) ~
Tank TyPe/Material ,~7-.~ c [, -- ~ ~,~aw~g
Tanksize I'ZT0 'gal.. Number of Compartments ~
Depression over tank (Y/N) ~
Pumper ~ ~
Date installed ~
Cleanouts (Y/N) /v'
High water alarm (Y/N) /~,~J~
/-
System type ~- ~'-~ e- Jo.
Grovel below pipe ~ O ft.
Depression over field t~
For~ bedrooms
New depth '~ ~in.
Absorption rate >= ' /.~o.O 3( g.p.d.
if yes, give date
Other bacteria
colonies/100 mi.
Date Installed *'7/~'~/'P ~ Soil rating (g.p.d./ft~ or ~/bdrm) ~3~, ~
Length. (,e '~ ft. Width 'Z.,~) ft.
Total depth ~1, t ft. Eft. absorption area '7~'(~ft= Monitoring tube
Date of adequacy test ~ Result~ (Pass/Fail) Pp ~,
Fluid depth In absorption field before test /~ in. Water added
Elapsed Time:/ ~ZOmin. Final fluid depth /~ in.
Any rejuvenation treatment (past 12 mo,) (Y/N & type)
D. LIFT STATION
Date installed Size in gallons ~
"Pump on" level at '~ High water alarm level at
Datum ,~ Cycles tested Meets alarm & cimuit requirements?
E. SEPARATION DISTANCES
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
~hole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTICII'I~B~E~} TANK ON LOT TO:
Absorption field
Surface water
On adjacent lots
Building foundation ~¢ .~ Propert~ line ~'~ I.~_
Water main ~'o; ,~ Water service line "Z, ~ ~t/---
Wells on adjacent lots .~~/~1~--- ~ 0! '/'''-
/0¢
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /0 I'-/'-
Water Service line
Curtain drain ~ ~ ~,¢ n
Building foundation "Z.
Surface water /o¢/ry, Driveway. pafldn~vehicle storage
Wails on adjacent lots ~~
/o
F. COMMENTS
G. ENGINEER'S CERTIRCATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA I-L4A guidelines in effect on this date.
Date '~'/~/~ ~'
HAA Fee S
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
LOT <~ BLOCK
ANCHORAGE RECORDING DISTRICT ', · ·
· ri lOSE SI IOWN ON TI I1-: RECOItDEI) PL^T.
ARE NOT.SHOWN HEP, EON. ;
I
BRASS CA ' MONUMENT
IRON PIPE : ! '
0 REBARCORNEI(FOUND
r'l IIUB AND'I'^CK'
: I
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.# .O,~ O-- ~"7~ -~.~
1. GENERAL INFORMATION
Complete legal description ~,ot 9 ~
Block 11~ Preuss #3 S/D
Location [site address or directions) 20727 Lucas Avenue
P. ropertyowner Ba~ba[a Gr:~mes . ' Day phone
¢ '~,~ ,,.. ,~... .... .,., :.
~ailing~dd~:esJ:.20727...Lucas Avenue~ Eagle River~ AK 99577
..' Day phone
~alhg agency '""
Ma[hng address
694-6434
"'. Prudentih'l. Vista/Jacqueline Polis
A,~ ,~.,-~ue,,,'%. .
Address~,'41 B Street, Anchorage, AK 9950'3
-Day phone
250-2055
. Unless otherwise requested, HAA will be held for pickup.
2, NUMBER OF BEDROOMS:
3, TYPE OF WATER SUPPLY:
Individual well
Community well
PuNic water ,~ x
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of sys~m.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
XXX
Community on-site
Public sewer
NOTE: If community wastewater systern, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-o25(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 suppty
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 dispoeal system is in compliance with all Munici aal and State codes,
ordinances, and_regulations in effect on the date of this inspection.
Name of Firm s & S £NGINEERING Phone
17034 Eagle River Loop Road No. 204
Address Ei~gla River: AIn~b~,
Engineer's signature -,~ .~ ~. ~ Date ~'/',~ /~/~
DHHS SIGNATURE
L// 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 AU6 'j,~
DFPARTMENT OF HEALTH & HUMAN SERVICES
' ,, MUNICIPALITY
Environmental Services Division r'NVII~O'"'~I,,I .......
825 L Street, Room 502 · Anchorage, Alaska 99501 (907) 343-4J44
Health Authority Approval Checklist
Legal Description:
A. WELL DATA
Well type [.~/~/-~/'~
Log present (¥/~)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAM,~z'I E~SU LTS:
Coliform ~
Dot o~f sample:
If A. B. or C, attach ADEC letter. ADEC t{~lmber
Date completed ~
Cased to ~asing height (above ground)
FROM WELL LO/G/'//
Wires properly protected (Y/N)
AT INSPECTION
g.p.m, g.p.m.
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~-7//'~//(~Z Tanksize /'~-ST-)('~NumberofOompartments Z,
Foundation cleanout~¢,) F~ Depression (~ ~0 . High water alarm (Y/N)
Date of Pumpih~; ';"~¢ . Pumper *~ ~
· /
C. ABSORPTION FIELD DATA
Date installed ~2~/¢~ _Soilrating~r~)~,~ Systemtype
Length ~¢ '//& Width ¢ Gravelthickness below pipe. ¢ Total depth_ ¢¢ /
Effective absorption area ¢5¢~ MonitoringTubepresen¢¢~/¢~ Depressionoverfield(~.~O
Date of adequacy test ~//] / ¢ ¢ __ ResuIt~I)_~'¢% For /¢,_¢,~ bedrooms
Fluid depth in absorption field before test (in.); Z / Immediately a~er~¢gal, water added (in.):
Fluid depth _'~/// (ins) Minutes later:. ¢% Absorption rate = ¢¢¢ ¢ g.p.d.
Peroxide treatment (past 12 months) (Y/N) /~ ~- ~g ~WIf yes. give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed ~.l
Manhole/Access (Y/N)
High water alarm level at*
Cycles t~t~ .~~
//~- Size ~ns~
,~~jm p~'~ve[ at*
*Datum
E. SEPARATION DISTANCES
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot '~Z.J/¢.?C,.~~..~Q~-
Absorption field on lot On adjacent lots
Public sewer m~,.~ ~ Public sewer manhole/cleanout
Se. wer.~,,/sep~service line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~/'/- Properly line ,~- /~- Absorption field
Water main/service line ?-~- ~- Surface water/drainage /00 ~/ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /~ /
Surface water
Curtain drain ,,~/OA/,~ /~'/V o ~J ~J
Building foundation / C) /?'- Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots /k/ /~
/
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal reco~ ~ystems are
in conformance with MO. A~HA,~ g,uidelin,~ in effect on this date. ~.~ ~',~'; ...... :; ~.~
S~gnature 7~~. ~
Eng neet s Name f( ~¢~ ~'~ ~ - ~ ~ ~'~'- ~ ,.~_~.t( ~
' ' k
t t, '~!'~_,'
HAA Fee $.
Date of Payment
Receipt Number
Waiver Fee $
Date ef Payment
Receipt Number
72-026 (Rev. 3/96)*
MUNICIPALITY OF ANCHORAGE ~
DEPARTMENT OF HEALTH & HUMAN SERVICES A4~I'~"~"~"~"~"~"~"~"~"~Ty ~.
D v s on of Env ronmental Services 6NW/~ ~,t. ANCHo,~A,G~
On-Site Services Section ~j~A~ ,S~ViC~,S DiVkSiON
P,O. Box196650 Anchorage, Alaska 99519-6650 JUL. ~Pz~ 1997
343-4744
CERTIFICATE OF HEALTH AUTHORITY RECEIVED
APPROVAL FOR A SINGLE FAMILY DWELLING
GENFRAL INFORMATION
Complete legal description
Location (site address or directions) ,~,¢2'.~? z~/~,,.¢~//~,~. ~-.~_~',4¢_,~.,~.-,~j
Property owner -/~'~--¢'~:-~*' '*-/~'~'-~¢
Day phone
Mailing address
Lending agency
Mailing address
Day phone
Agent Day phone
Address
Unless otherwise requested, HAA will be held f,o.£ oic.k,~p.
NUMBER OF BEDROOMS:
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 WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(Rev. 1/91) Front MOA
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 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
Address
Engineer's signature
Phone ;¢¢'~/~/~' ?~'
DHHS SIGNATURE
_X
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.
72q)25 (R6v, 1t91) B~ck MOA
MUNICIPALITY OF ANCHORAGE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN sE~b~T^LsERwcEs DiVIsiON
Environmental 8e~ices Division
825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) ~-~7~4~ ~997
RECEIVED
Health Authority Approw~l Checklist
Legal Descripti0n: _Zoo-, ~ ~'.c~'//~ .~'~-~'~-.s
A. WELL DATA
Well type -~¢'-',¢"~-/~- IfA, 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
Coliform
Dat~sample:
Date completed
Cased to
FROM WELL LOG
Casing height (above gr~gnd~_
Wires properly p~.ot ceded (Y/N)
AT INSPECTION
/ g.p,m, g.p.m.
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed 7/5g//q 2' Tank size //_,.¢T¢ ~'4ZNumber of Compartments ,~- Cleanouts (Y/N)
Foundation cleanout (Y/N) __ )/ . Depression (Y/N) 4J High water alarm (YfN) = x//~ __
Date of Pumping ~'My~-'~'~-~/ Pumper
C. ABSORPTION FIELD DATA
Date installed '~/97,/4~? Soilradng (g.p.d,/ft2orfl2/bdrm) ~- ~ _Systemtypc 7-~,~,~',~e,'¢'
Length ~.¢ / Width -~ / Gravel thickness below pipe ~ / Total depth.
Effective absorption area Monitoring ~ube present~ ~ _ Depression over field ~
Date of adequa~ test ~x ~/ Results &ass~ail) For ~ bedrooms
Fluid depth iu absorption field before test (in.);
Fluid depth (ins.) Minu.t.~ Jatcr:
~ra~ide-rrYa~tiiient (past 12 months) (Y/N)
Ignmediately afteL ..... ~e~r added (in.):
Absorption rate = g,p.d,
ffyes, give date
D. Lllfl' STATION
Date installed
Manhole/Access (YfN)
"Pump on" level at*
High water alarm level at*
*Datum
Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LO'~ TO:
Septic/holding tank on lot
Absorption field on lot -
Public scwerjnain
Sewer/septic service line
Size in gallons
"Pump off' level
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ./~9 '* Properly line .~ to ~ Absorption field
Water main/sen, ice line .5'-~'~-z'7 Surfacewater/drainage /'~'~r? Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation ~'?, .F' / Property Line / ~ / Water main/service line -~'-~' '~.~'~/.
Surface water
Curtain drain
Driveway, parking/vehicle storage area
Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
I certify that 1 have determined thrufield inspections and review of Municipal records
in conformance with MOA ff3A guiffelines in effect on this date.
Engineer's Name ~.~'~.~o~' ~,-
Date "~7' '~ c( ~
HAA Fee $ ~0 · cO
Receipt Number _-z~/// ¢~..aff
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
1. Property Owner
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
Environmental Sanitation Division ~0[~ ~ ~ ~ ~/~ ~
825 L Street · Anchorage, Alaska 99501 · TelephoBo 26
CERTIFICATE OF INSPECTION APR 2 5 1983
SEWER AND WATER FACILITIES
"MUMIP. Jn21ih~" n~ ~,,^~
Mailing Address
"Dept. of Heaf~h &
EtMr0nmenlaf Protection"
2. Legal Description
3. Type of Dwelling
[] Single Family
[] Multiple Family
Title
Date
5. Sewage Disposal
Individual
Public Utility /~
APPROVA~_FJ~ /// J . ~
¢
W~thout Departmental Seal ~¢~'~, ,¢
APPLICANT FILL.S OUT LOWER HALF ONLY
Property Owner ~7,~,~¢
Mailing Address ~5
Address ~ ¢,
Phone
Lending Institution
Address ~'~D
Address
Phone
Type of Residence
F~' Single Family
[] Multiple Pamlly No. of Bedrooms
[] Other
Water Supply E~ Individual
[3 Commnnity
(3 Public Utility
ATTACH WELl. LOG. A well log Is reguired for all wells drilled since June
1975. For wells drilled prior to that date, give well depth (attach log if
available.)
Sewage Disposal Eg' Individual
[3 Public Utility
[] Holding Tank
Year Individual Installed: ?~
When Connected to Public Utility:
EXCAVATION
ROBERT A. SIIAFER
WORK CIVIL ENGINEER
694-2979
April 5, 1983
Totem Realty
ATTENTION: Debby wise
P.O. Box 911
Eagle River, Alaska 99577
Dear Ms. Wise,
Reference: Lot 9~ Block 11; Pruess subdivision ~3
A sewer system adequacy test was performed on the system located
on the referenced property, as you requested. The septic tank was
verified to have a capacity 1000 gallons. After the clean out
was located the tank was pumped. The seepage pit was charged with
1100 gallons of fresh water and after a period of 24 hours, approximately
886 gallo~s had percolated out of the cr~b.
It can be concluded from this test that the waste water disposal
system serving the three bedroom residence located on this property
is currently functioning adequately. However, the system cannot be
guaranteed against subsequent failures.
If we may be of fur,~her
Sincere~v/,?
cc: Municipality of Anchorage
Department of Health and Environmental Protection
service, please do not hesitate to call.
~R8 19GX EAGLE RIVER, ALASKA
0
0
0
0
0
0
0
LU
MUNICIPALITY OF ANCF ORAGE MUNICIPALITY OF ANCHORAGE
__) DEPARTMENT O1= HEALTH & ENVIRONMENTAL PRDTECTJON DEPT. OF
825 L Street - Anchorage, Ala!~ka 99E01 ENV RONMENT,.,. ,~. dK;TION
ENVIRONMENTAL FNGINEERING DIVISION
Telephone 264-4720
DIRECTIONS: Commete air parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing,
1, PROPERTY OWNER
Paul Myers (Builder)
PHONE
694-2~80
MAILING ADDRESS
Box 351 0hugiak, Alaska 99567 -
PROPERTY RESIDENT II/different from above] PHONE
NHL~i LuaaB R~. Eagle River, Alaska 99577 694-2271
2. BUYER PHONE
Peter H. Rensema 694-2271
MAILING ADDRESS
PSC 1 Elmendorf AFB, Alaska 99506
3. LENDING INSTITUTION Pi- ONE
MAILING ADDRESS {~
44~9 Business Park Blvd Anchorage, Alaska 99503
4, REALTOR/AGENT I PHONE
Alaska~ Real E~tate I 274-26311
MAI kl NG ADDR ESS
319 Gamble Anehorage~ Al.aska 99501
B. LEOAI. DESCRIPTION
Lot 9, Blk 11, Preuss s/d //3
STREET LOCATION
NttN Iueas Rd. Eagle River, Alaska 99577
6. 'rYPE OF RESIDENCE '~IUMBER OF BEDROOMS
[] One [] ~our
[] SINGLE FAMILY
[] Two [] Five
[] MU L'rlPLE FAMILY [] Three [] Six
[] Other _
7. WATER SUPPLY
[] INDIVI DUAL* ~ ATTACH WELL LOG. A well log s required for all wells drilled
[] COMMUNITY since June 1975, For wells drilled prior to that date, give wel
[] PUBLIC UTI LITY aesth lattach log if available. I
S, SEWAGE DkclPOSAL SYSTEM
E~] INDIVI DUAL/ON-SITE'* "f individual/on-site, give installation date New - I C]~, .
If system s over two (2) veers old an adequacy test is required
[] PUBLIC UTI LITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST REFORE PROCESSING CAN RE INITIA'rED.
72~)10(3/7E)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
~ SINGLE FAMILY [] ONE '~ THREE [] FIVE [] OTHER
[] M U'I~TI P LE 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
-E~]IN DIVIDUAL/ON -SITE DATE INSTALLED
IS]PUBLIC UTILITY
Connection Verified
INSTALLER
l~E~Septic Tank or [] Holding Tank
Size: /~)C)~/~'). If Tank is homemade ! SOILC'RATING
give dimensions: /~,.~
TYPE OF TANK MANUFACTURER
4. DISTANCESwELL TO: Septic/Holdin~ Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
--*,PROVED FOR .EDROOMS ,/)
[] CONDITIONAL APPROVAL {letter must acc~n~n¥ certificato)
SAPPROVE //
LEGAL DESCRIPTION
72-010 (Rev, 3/78)
/./ ~,__:S~.~,~_.%, ANCHORAGE, ALASKA 99502
March 6, 1979
Paul Myers
]Box 351
Chugiak, Alaska 99567
Subject: Lot 9 Block ].1 Preuss Subdivision #3
Approval for your individual sewer and water facilities
will not be granted until the following items have been
completed:
(1) A well log is submitted to this department.
(2) The water analysis report delivered to this office
from Chem Lab, 5633 B Street, for our review.
As soon as we have received the above items, we will
be able to grant full approval and send notice to the
lending institution.
If there are any further questions, please contact this
office at 264-4720.
Sincerely,
Robert C. Pratt, R.S.
Associate Specialist
RCP/ljw
cc: Lomas and Nettleton Company
4449 Business Park Boulevard
99503