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PREUSS #3 BLK 6 LT 4
Preuss #3 Block 6 Lot 4 #050-571-25 Municipality of Anchorage On-Site Water and Wastewater Program ° (907) 343-7904 Page / of ON-SITE WASTEWATER INSPECTION REPORT Permit Number: C75-P/1S//S'S6 PID Number: 0SD-57i^7-AZ- Dwelling: 9Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New [Z Upgrade Name: + ABSORPTION FIELD (t/? /re Pd 40,1 Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound Address ❑ Other Phone Number ofBedrooms Soil Rating Total depth from original grade of �( r�of // ` GPD/SF /V Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 3.. 0 Ft. Gravel depth beneath pipe 7, o Ft. Subdiv' on Block Lot tt1 Voil Fill added above origin/al grade f , f- Ft. Gravel length 3 (1 Ft. -°u 6 S +� te 'I Township Range Section Gravel widthBeds: Z. D Ft. Number of Lines Distance between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding sewer Total absorption area Number of trenches Dist. between trenches I From Tank Field Tank Line ,500 �— Ftp I Ft. Well / �V fJ (' X00 1 / 7X f 1 S� TANK Se tic ❑ S.T.E.P. ❑ Holding E] Other p 9 /- Manufactyf rer �1 L Capacity !F n� T o, n k r / Z S D Gal. Surface Water f� 0�,� d 6 Material r Number of compartments Lot Line S �� /0 t f NA Foundation m5�L Irlf./ LIFT STATION Manufacturer Capacity T Curtain Drain (/ytk fvjkl Gal. Remarks W P f /t- I �p e.µ cL 08 ? f Pump on level at Pump off le High water alarm at N(1 h d e-. n. in. in. model Electrical Inspections performed by Installer PIPE MATERIAL House to tank zi VY-( drain k to 3U i y ld n % / Ir 'e Ir S/ A t �� Drainfield V 3q CO/MT ?D ALF Inspector r Mk BENCHMARK (Assumedelevation) Vrj ft � �� Inspection ,i dates:) I 2 / 'r '� Location and description S�nf/' Got�.n CrU✓ITY'-risC �Rl'�. 4" 3" r7 COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL e A Conditional Approval: Date SLP.• ®* ° 49TH*r€ }}-- ..•e. ..•}.•A•..... �9 III MICHAEL N. ANDERSON CEj 946I Approved Date �k% Inspection Report _9-f *.doc Permit No. OSP151158 Page 2 of 2 Municipality of 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: PREUSS #3 BLK 6, LOT 4 PID No.: 050-571-25 MARK B Col 46 a6 TC01 51 ' 32 TCO2 56 40 CO2 / 57 43 CO3 / 58 44 C04 7 70 Cob 43 50 61 63 / C05 I SEPTIC I v I 'MT1 I ENCH AT STAIR LANDING \ CO2 0 CO3 / B � C01 TC01TC'B2— / \ EXISTING' TAI K �UMPED AND CRUSHED - \ 1 \\\ ; SEPTIC \ 1\ \ I ---4 f�SB1�4L�—� ----- \\\=_ N.T.S. 49TH ............. . 0.............................. . 0. .,MICHAEL N. ANDERSON; 0. MICHAEL NorCE 469 On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP151158 Tax Code Number: 05057125000 Work Type: Septic Upgrade Permit Effective Dates: June 04, 2015 to June 03, 2016 Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Subdivision: PREUSS #3 Site Legal Address: PREUSS #3 BILK 6 LT 4 G:0056 Owner/Address: ANDERSON CHRISTOPHER M 10135 LOUIS DRIVE EAGLE RIVER AK 995778760 Site Mailing Address: 10135 LOUIS PL, Eagle River This permit is for the construction of: Y Disposal Field N Septic Tank N Holding Tank Lot Size in Sq Ft: 22922 Total Bedrooms: 4 N Privy N Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received Issued By MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-343- o Development Services Division Fax: 907- a 7--�0 ,, $ On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION ( JUN 0 8 w 5 Parcel I.D. V S 0- j'7/ - Property owner(s) v I S AA Mailing address Site address ! 0 /1 2 ';-\e-\ c(. e v s v rr P �- Day phone of 6 a Legal description (Sub'd., Block & Lot) r•r'_lw 61> (o Legal description (Township, Range & Section) Lot Size _LL q 'L I Sq. Ft. Number of Bedrooms. APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field Initial ❑ Single Family (SF) (w/wo ADU) Septic Tank ❑ Upgrade Duplex (D) ❑ Holding Tank ❑ Rene al ❑ Multiple Dwellings ❑ Privy ❑ s �� y i V (SF and/or D) Private Well ❑ Water Storage ❑ J THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. property owner or Permit/Rush Fees: '5(o9 Date of Payment: Receipt Number: /075300 Permit No. 65P151158 91J)"4° Permit App_:; :L.:c, Waiver Fees: Date of Payment: Receipt Number: Waiver No. June 3, 2015 Municipalities of Anchorage Departments of Health and Human Services P.O. Box 196650 Anchorage, Alaska 99519-6650 Fax 249-7847 Re: New Septic system Legal: Preuss #3, Blk 6, Lot 4 To Whom it may concern: This is a request for a septic permit on the above referenced lot, the old system has failed and needs replacing. A new test hole was excavated in the backyard and found various types of gravels, GM/GM. No water was observed during the excavation or after the 7 day monitoring period. The perc rate was 2 minutes per inch at 5 feet below grade. A deep trench has been designed as a replacement trench. The tank will be checked and replaced if it damaged by corrosion. The lot slopes to the northeast at about 2 percent, see the drawing. This replacement system will not impact any of the neighboring properties due to the lot layout. Please call me if you have any questions. Sincerely Luke Randall, P.E. r I r r r r I I I I PROPERTY LINE ' PREUSS #3 \ BLOCK 6, LOT 3 / r I I WELL I EXISTING HOUSE \ \ I ` I \ t - W PREUSS W PREUSS BLOCK 5, LOT OT 8 � BLOCK fi, LOT 4 I I Ij I I ii EXISTING WELL 100' RADIUS��� Co SEPTIC I I / CO�i i / NEW 1250 TANK PREUSS #3 / BLOCK 6, LOT 9 r OLD TANK TO BE I DECOMMISSIONED PER THE ' PROPERTY LINE W LA I N � � I SEPTIC I I I I PIOUSS 13 I BLOCK 6, LOT 5 _--L-- -_-------_-_I-_-_--- 1 z r \ I / 1 / — D A V I D AVE/ Septic Design Prepared for CHRISTOPHER ANDERSON PREUSS #3, BLOCK 6, LOT 4 Eagle River Alaska Lucas M. Randall, P.E. DATE: 3330 East 41A AVE DRAWN: ANCHORAGE, ALASKA 99507 (480) 540-0390 SCALE: I 11 11 1 I \ \ I \ I \ \ ` I I L _ _ _ _ - 49TH 6/3/2015 LUCAS M. 1� No. CE1 DJR 1"50' •,♦ ''PRcpES DESIGN CRITERIA - 4 BDRM X 150 = 600 GPD SOILS = 600/1.2 = 500 GPD 500 GA/12 = 42' (1) TRENCH 9.0' DEEP 6.0' EFFECTIVE 2.0' WIDE 42' LONG (rH#1) 10 ORG n GM I I/ EXISTING WELL \II BLOCKUSS 6, LOT 8 - 100' RADIUS \\ PREUSS g3 W • i I! �.. BLOCK 5, LOT 7 � 1v � I I i I •� ' PREUS9�3 \ PROPERTY LINE y I BLOCK 6, 2QT 3 / / y PREUSS #3 OCK 6, LOT 4 � rr \\ PREUSS #'3 1 01 WELL ��EPTIC/ ''x\BLbtiIE�,_IOT�. BLOCK 5, LOT 8 — PROPOSED -- DRAINAGE FIELD SEPTIC PROPERTY LINE\\\\D(ISTINGEXISTING HOUSE \ PREUSS $3 'SEPTA \\ BLOCK 5, LOT 9 / PREUSS #3 \ PREUSS #3 BLOCK 6, LOT 5 11 \� BLOCK 6, LOT 10 � KIM 01013 =DAVID AVE - ---- —\ ---—— —— — — Septic Design Prepared for CHRISTOPHER ANDERSON PREUSS #3, BLOCK 6, LOT 4 Eagle River Alaska Lucas A Randall, P.E. DATE: 3330 East 41st AVE DRAWN: ANCHORAGE, ALASKA 99507 (480) 540-0390 SCALE: 49TH 6/3/2015 ♦♦ - ;LUCAS M. RANDAL ♦ S No.E12595 DJR ♦♦1♦♦�r •• W+ 1"=100' FA � � Performed For: Legal Description: Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.ci.anchoraoe ak.us (907) 343-7904 *--'49M ;4 • _ _y ............. .-. r.•. r................ 0� MICHAEL N. ANDERSON : f•. CE -9469 Soils Log - Percolation Test �o ��i'�fa ;,_••••••�.. �i�.®" l .k J t 6 '4 �—"V"D ✓,t r Date Performed: P/ f S70 3 AIS L t. V L- " ' T Township, Range, Section: f�•c/ohtz s G 14115, P 9- WAS GROUND WATER ENCOUNTERED? 14 D S 10- IF YES, AT WHAT DEPTH? L Depth to Water After D 11- /� 1Iw Monitoring? AGS EP �fL� 12- Date: � / l S 13- V�"� A 19 - COMMENTS A f 1-o PERCOLATION RATE r,,-5 (nmtealinch) PERC HOLE DIAMETER Ce TEST RUN BETWEEN IT- FT AND y FT PERFORMED BY: tAN-t I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: / S' Ufa r l� iLO 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 NAME i PFJONE ��� 1:1 UPGRADE MAILING ADDRESS ' S" LEGALPESCRRI--PTION LOCATIONcz i NO. OF BEDROOMS O DISTANCE TO: Absorption area Dwelling PERMIT N��� _Y ~a Q LU Manufacturer n Mated No. of compartme rn Liq. tZ in—gallons IF HOMEMADE: Inside length Width Liquid depth ia z DIST O: Well Dwelling ERMIT NO. = z F Ma facturer I Mater' Liq capacity in Ballo C3 w= DISTANCE TO: Well �'j' !,�/ Foundation ��� Nearest lot line /� PERMIT N0. J W Z F ? cc No. of lines Length of h ink' Total len h of fines ' Trench h inches Distance betwee�p If''n s N f ttF ❑ Top of the to finish grade Material ben h tilq 'S.G.2_ inches Total effec rption area _ C7 Length Width Depth L'o/,b' PERMI O. Q F as w Type of crib C ' ameter Crib depth To off ive absorption area Lu DISTANC 0: Well Building foundation Nearest Io line J J Class Depth Driller Distance t lot line PERM 0. W STANCE TO: Building founclati 4mmrivne Septic tank Absorption area(s) OTHER PIPE MATERIALS SOI LTEST RATING`� FF INSTALLE j REMARKS APPR ED Cly / Q DATE LEGAL 72-013 (Rev -3778) V I | 825 /b` /STREET. ANCHORAGE, AM 99,`~1 264-4720 VxzlY� ,~ L_ F-1 P-14 r_. 0 P-4 ��F-0 ��r__2 r.'l ]r P��mIT NO ( 800464 }:x ./m ,w / �'«` � (__,l, il �^C/\ �`� � - APPLICANT H8RRY H MHCKEY ST RT BOX 1175 8 LOCATION -t LEGAL L4 B6 PRUESS #] LOT SIZE 22922 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT/ )�25 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: ( \ ��Fo_Tlo��i -1 vz_T -TH�- -*;Z* THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIEL[1 THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IW FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION <IN FEET). Gg U I��� �������� ������� ������ �L���0 O����O�� PERMIT APPLICANT 1-11H5 THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. �—� 'T1,1 P3 < ;7-o > I Ir -4 _�-- F="r- I::-. -IF I RD lr-.l _�_. n FZ F=" Re 1= C-1 u 3E F_ -o IE-_ r -p BACKFILLING OF OF HNY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC. WELL ` MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET HND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 3:0 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE' TO INSURE PROPER INSTALLATION. F-o��� ����������� ���������� ��� I CERTIFY THAT 1� I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ' I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLHRGEMENT IF THE ] RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. / ^ � SIGNED: -_-__--__----~-_--~._-~__-__----~~~-~-_-_~ HPPLICANT HARRY H MHCKEY V4.0 ISSUED --- � '___- /� I c" i "ON I �._; C T ION � 48TH AVE. STE. 'C �js1 s —GP— 125 i r iK 4 ANCHORAGE, ALASKA 99503 5.5' _ �__I_ TES"T LAB n AS 248—f333 GRV—SA SW 125 sq f PERFORMED FOR: Harry MacKey —GP— DATE PERFORMED:_9 5 80 LEGAL DESCRIPTION: Lot 4 Block 6 Subdivision Pruess No. 3 THIS FORM REPORTS: INVisual Soils Examination O Percolation Test ACTL-80-1.446 DEPTH SOIL 11rT nw=ccRIPTInN NOTES -- 1.5' Topsoil —GP— 125 — iK 4 sq ft/BR 5.5' SA—GRd 6.5' GRV—SA SW 125 sq f BR - —GP— SA—GRV. 125 sq f BR 18' BOTTOM OF HOLE WAS GROUND WATER ENCOUNTERED NO IF YES, WHAT DEPTH LEGEND — Perc zone �) S — Sample taken Ej — Frozen zone — Water table READING I DATE GROSS TIME PERCOLATION RATE: PROPOSED INSTALLATION C'O'MMENTS Kinney R. xter 3656-EAw R0FE551fl����- NET TIME I DEPTH TO H2O I NET DRAINAGE DRAINAGE REQUIREMENTS: 125 sq. ft,/BR ❑ SEEPAGE PIT IX DRAIN FIELD O OTHER TEST PERFORMED BY: LS _ _DATA CERTIFIED BY:_ Kinney R. Baxter DATE: 9/05/80 `• `i(\�� ���� Q•y iK 4 e0c O aaoe< e¢yypa^sY0aeo0 e.� Kinney R. xter 3656-EAw R0FE551fl����- NET TIME I DEPTH TO H2O I NET DRAINAGE DRAINAGE REQUIREMENTS: 125 sq. ft,/BR ❑ SEEPAGE PIT IX DRAIN FIELD O OTHER TEST PERFORMED BY: LS _ _DATA CERTIFIED BY:_ Kinney R. Baxter DATE: 9/05/80 a 17 i ,r 6. ul �'(}�' / °il rl r`•a 'i _L. jJ Ai/,- / ( .. t..� !, r _�, .7 �'i�//: v - __. .. __.__....,.__��.. _._...,.e__ ..r i4 AN ` /'.� f'" � CJ .n.v tit s c �;�,� ✓ •, � A J 1, . r = ,' , ,. .._ _ -. __�.__..�r.__._.--_.e.. -----------. T __- MUNICIPALITY OF ANCHORAGE M E M O R A N D U M DATE: August 18, 1989 TO: Accounting & Budget FROM: On-site Services, ESD SUBJECT: Request for Refund - Account #2570-9426 Please make arrangements for a refund for the following. A permit application was submitted and after research of the property it was discovered an upgrade permit or an upgrade of the system was not necessary. Thank you. S & S Engineering 17034 Eagle River Loop Road Suite 204 Eagle River, Alaska 99577 Lot 4 Block 6 Preuss Subdivision #3 Amount: $ 90.00 Receipt #21354/7845 4 - Laura J. Montgomery On-site Services cc: File Municipality of Anchorage os— DEPARTMENT OF HEALTH AND HUMAN SERVICES 21354 Environmental Services Division Mdl-1r15 Telephone: 343-4744 -- - - - ON-SITE SERVICES FEE DOCUMENTATION _k7 Date Paid: / Permit Number: Name of Payer: (Name eck) Receipt #: Mailing Address: (Offof o /L/ �f C/ Check #: Legal Description(s): Type of Payment: (Indicate Amount Paid) WAIVERS: Ith Authority: Excavator Permit: Lot Line: tller &Well Permit: Engineer Permit: Well to Tank: Well Permit: Pumper Permit: Well to Field O Sewer Permit: -� Well Driller Permit: Field to Surface Water Copy Request: Tank Manufacturer: Tank to Surface Water (Waste Treatment) 72-034 (Rev. 10/87) � DISTRIBUTION: WHITE—MASTER FILE CANARY—PROGRAM FILE G� o� MUNICIPALITY OF ANCHORAGE c�c� 0 Department of Health & Human Services (�e���c.`�S� On -Site Sewer/Well Permit Application �.—!�� NOTE: Ap�Rr� Kist be field out completely. �LSINGLE FAMILY DWELLING Parcel Identification/Number P wne 7ev1 Day Phone ti7lailing App ress ����0 t 3'r CC''� Legal Desc!"10;R Zip Code 4- P W -PW Oss 3 Lot Size s�Sa. Fc Inspections will be conducted by: �' 3 Number of Bedrooms: 4 �— Approved Engineering Fir Municipality (permit fee inclub@ 9 1 9nV Does your house contain any of the following: Hot Tub, Swimming Pool, Therapy Pool, Jacuzzi, t4OUO3iONd 1V1N3WNONIAN3 or Water Softener Unit? tj 0 If yes, which one? — II-; q"jo 'fd3A 3`JkrZ4 FgNV do AMlVdIJINnW This application is for: Sewer Only Sewer and Well Sewer Upgrade Well Only I certify that the above information is corre6� 1 further certify that this application is being made fora Single Family Dwelling and in accordance with applicable Municipal codes. S S & S ENGINEERING - n 5 17034 Eagle River Loop Road No. 204 1 Pro erty Owner/WeIr Driller Eagle River, Alaska- 95a7d 2 _ r� �/ Fees: —_/J Receipt # 'V / 3 <S i Zi Permit # 79_n19 (Rcv 1WAS) - Y� SCALE MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION AUG 161989 0 m m m S • -� Municipality of Anch ° P 5 2015 z On -Site Water and Wastewater Pr am JUN 2 ^` (907)343-7904 SRF F. TY 2ret®t1en Stuller CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 050-571-25 Expiration Date: " r l 1. GENERAL INFORMATION RUSH(! Complete legal description PREUSS #3 SID BLOCK 6, LOT 4 Location (site address) -10135 LOUIS DR ANCHORAGE, AK 99516 Current Property owner(s) CHRIS ANDERSON Day phone Mailing address Real Estate Agent 10135 LOUIS DR, ANCHORAGE, AK 99516 Day phone 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WAST Individual Well Individual Water Storage Community Class Well Public Water System ® Individual ❑ Holding Tank ❑ Community ❑ Public Sewer I Waiver/Variance request for:- Distance: Received by: /4�2 / i-� Date: W / 2 COSA to be released to the engineer, unless otherwise requested by the engineer.. COSA Fee $/.i0(J Waiver Fee $ Date of Payment tla4 l s Date of Payment Receipt Number gL2zReceipt Number COSA # a 5051309 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 is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE. Engineer's Printed Name MIKE N ANDERSON, PE Date 06/24/15 6. DSD SIG 7System #1 Approved for bedrooms. System #2 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following of- A� 49TH.........; 7s • MICIIA�2 L9.DER50N ; �a .J,•. C -9 69 i 8��p ..........4� WATER AND By:���/ Original Certificate Date: The- icipality f;chorage 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 the professionalengineer's work. - 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSAbluesheet 10-10-12.doC 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 SID BLOCK 6, LOT 4 Parcel ID: 050-571-25 A. WELL DATA Well type Private Date completed 10181980 Total depth 128 ft. Date of test Static water level Well production If A, B, or C provide PWSID # Sanitary seal (Y/N) Y Cased to 128 ft. FROM WELL LOG 101711980 113 ft. 7 g.p.m. WATER SAMPLE RESULTS: Well Log (YIN) Wires properly protected (YIN) Y Casing height (above ground) SEE NOTE AT INSPECTION 4/2212015 ft. g.p.m. Coliform NEG colonies/100 mL Nitrate 10.8 mg/L Arsenic: ND ug/L Date of sample: 411012015 Collected by: Mike Anderson B. SEPTICIHOLDING TANK DATA Tank Type/Material SEPTIC I STEEL Date installed 812112015 Tank size 1250 gal. Number of Compartments 2 Cleanouts (YM) Y Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (YIN) N Date of pumping NEW Pumper NEW C. ABSORPTION.FIELD DATA -1985 SYSTEM TESTED Date installed 12112015 Soil rating (g.p.d./fe or ft2/bdrm)1.2 System type DEEP TRENCH Length. 38 ft. Width 2 ft. Gravel below pipe 7.0 ft. Total depth 11' ff. Eff. absorption area 500+ ft2 Monitoring tube Y Depression over field N Date of adequacy test NEW Results (Pass/Fail) NEW For!L bedrooms Fluid depth ire absorption field before test NEW in. Water added NEW gal. New depth NEW in. Elapsed Time: NEW.. min. Final fluid depth NEW in. Absorption rate >= NEW g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) UNKNOWN If yes, give date D. LIFT STATION Date installed "Pump on" level at in. Datum E. SEPARATION DISTANCES WELL ON LOT TO: Size in gallons Manhole/Access (Y/N) "Pump off' level at in.High water alarm level at Cycles tested Meets alarm & circuit requirements? Septic tank/lift station on lot 1001+ Absorption field on lot 100'+ Public sewer main 751+ Sewer /septic service line 501+ Animal containment areas 1001+ SEPTIC/HOLDING TANK ON LOT TO: in. On adjacent lots 1001+ On adjacent lots 100'+ Public sewer manhole/cleanout 1001+ Holding tank NA Manure/animal excrete storage areas 1001+ Building foundation 51+ Property line 51+ Absorption field 51+ Water main 1004 Water service line 10'+ Surface water 1001+ Wells on adjacent lots 1001+ ABSORPTION FIELD ON LOTTO: Property line 101+ Building foundation 10'+ Water main 101+ Water Service line 10'+ Surface water 1001+ Driveway, parking/vehicle storage 10'+ Curtain drain 501+ (Node Known) ' Wells on adjacent lots 1001+ F. COMMENTS WELL IS PROTECTED BY A MANHOLE IN THE DRIVEWAY WITH BOLTED/GASKET COVER AND DRAIN INSIDE THE MANHOLE G. ENGINEER'S CERTIFICATION 1 certify that t 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 MIKE N. ANDERSON, PE Date 0612412015 COSA canary sheet_2-6-15.doc 907s RESIDENTIAL & COMMERCIAL WATER AND WELL SERVICES 24NR AND EMERGENCY SERVICES AVAILABLE FREE ESTIMATES JO:an N101.1" 11 G630 fn:� 8'" i Rrs�l.o�.�.ye ?lase On 6/24/2015 a well inspection via camera was done by John @ 907 Water Well Services at 10135 Louis Dr. Eagle River, AK. Results show that the total depth of the well was 127 feet, static water level 103 feet, cased to 103+ feet with no breaks, creaks or perferations, pitless at 9 feet, and the casing level is -1.8 feet below grade. If you have any question please feel free to contact us at 1-907-230-1868. Thanks for your business, 7� John Netherton Owner/Operator of 907 Water Well Services . Municipality of Anchorage Community Development Department Development Services Division s;FE,Y On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907)343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 51309 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 6, Lot 4 of Preuss #3 subdivision. This inspection revealed a nitrate concentration of 10.8 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. rxrenao Mwmm-rwas u .. (AM. ) AS l �wc COMM rcxwc catrecr ixCwT &IWNG WTSAIX 9m WtONG SEIRA PFAR HAIfx10 SEMAL% A . i 191.02' S89° 59' OO I w o I l p d z WELL .'• ;p EXISTING I O I —,F HOUSE E Z 783 4,0' 'n I O o 280, JLfr�( e�e 25' I I I S890 59" OTE € i 5 UNDER NO CIRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES. THE SURVEYOR TAKES RESPONSIBIUTY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL LIABIUTY ONLY FORTHECOST OF THE SURVEY, LISTED DISTANCES PREVAIL OVER SCAUNG; REPRODUCTION MAY CAUSE ERRORS IN SCALE. 10T 9UR1£Y SURVEY TYRE SYMBOLS FOUNOAiION AS -BUILT © Attu. STRUONRE AS -BUILT � ww PRW S£7 REBAR- � � DRAINAGE 1 ASPHALT PLOT PLAN , .. LOT SURVEY ... TOFO O FOUND BEHAR g.�....g WOOD FENCE 4 ° CONCRETE o COR MSLT x No. ut U SUL 00 ASSUMED ELEV '� �X--X—X- METAL. FENCE WOOD DECK NOTE: PLOT PLANS & LOT SURVEYS IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER. PRIOR TO ONLY THOSE. IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS, TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. WHICH DO NOT APPEAR ON THE'RECORDED SUBDIVISION PLAT. ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTEO. SURVEY CERTIFICATION't•►tall ��+'`� `^ A , Robert\11� Prepared by O,, E. Johns, Jr. CX, Assoc. PLOT PLAN *d^'h��°kw«� a» ae lel been wa aeevaa careen, ma met l Professional Land Surveyors .caw faw e. e.miuN a of me ix nvnw �J'�F.•je�# i GJ,.•`'- 1700 Drink Drive, ne ek d m man meq a m w ^wNMNoe e..e roeCet, ax am�.iwe RM rwT - Y {1 : - ANCHORAGE, ALASKA 99504 /� Scale:. 1 T` - 4Q' Rea. Let S.F. Rea. Piet He No. FOUNDATION AS -BUILT ,e Y •• •'•'.` r �. ' 1. RWrt E.bM1ea .F.• br&y gIgy qat I A..an .ow I ae taacaeBonmteir ml met ouw r d •.. . , lr...r .. ...IE Date. Surveyed; i'e ` l ) U6/22�15 Drawn by. p Checked bA A au aenngme ana mfem um os euow wren. RO E J / 73� 73 �Y1 „. We 2 ne .n wNmPl4 "i.n ,en 4 - °+ `•:(4 Oete. Drawn: ®6(22/15 Grid: N1N56 W:C. 15-201A FINAL STRUCTURE TIS; -BUILT t R.e.l E as e r t ee, mw r 1- .�°� �' ml, +' i� Leg at Description: . .he�. p..« w A. -_d W et et M. n fey as net en ae e. ,,.•' Sa . ., . tid Lot 4 BLOCK 6 . ,4 ammwn a�u xtamaum m men nreee p a rope ianol .do Qom- an.�i mnrx:>aoraamm.,a mtwwe -. i�ig1Y}\'�d� PR�y I�EUS�+S#3 .Iy The Municipality of Anchorage'Development Services 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. 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 less than 30 days old. (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. Municipality, of Anchorage 0: • -� Development Selvlces bepartnient Building Safety Division �. • On Site Water and Wastewater Program 4700 South Bragaw St s . • a'r r P.O. Box 196650 ;Anchorage, AK 99519 6650 - , :c-, ;-v!Ww.ci.anchoregeak.us , _ (907) 343-7904 CERTIFICATE OF AUTHORITY APPROVAL -HEALTH FOR A;SINGLE FAMILY;DWELLfNG `;' . , Parcel l.D;'050-5-7/-a5 __._. _...: HAA#': Expiration Date: / - 7 - O: '3 ` 1. 'GENERAL INFORMATION ; r r - `Complete legal description P(*49A tGS Cain iS` acC _ „Location (site address or directions) 11'P� n0135 :Current Property owner(s) Day phone Mailing address Lending agency Day phone Mailing address - Real Estate Agent ' Day phone ' Mailing' Address Unless otherwise requested, HAA will be held by DSD for pickup. 2: •NUMBER'OF BEDROOMS: 3. TYPE OF -WATER SUPPLY:..,, _ TYPE OF WASTEWATER DISPOSAL:. Individual Well ° :• [ -individual On-site ' Holding tank � Individual Water Individual Storage � , � ❑ � • - g ❑ .:c : ; — Community Class - - -VNeli : -- ❑ - - - Community On-site -- -.- ---0 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 5 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 less than 30 days old. (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 HealthAuthority Approval Guidefines 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'Wth all applicable Municipal and State codes, ordinances, and regulations In effect at the time of installation. Name of Firm Eaille River En$inee.A4 Services J phone !nq y- 5195 Y.O. Box 773294, Eagle River, AK99577.3294 Address EngineersPrinted Name Curls A.-r,u�e✓c� Date arae-:v-oy OF _ 6 • EN. �S'•�� gf ��9P a -491 5. _ DSD SIGNATURE I r+ ; „Louis A.eutera v FQ0% CE -6736 _ jL Approved for . /� bedrooms Disapproved. Conditional approval for bedrooms, with the following stipulations: YfOF�� ; ON-SITE Additional Comments �A' WATER D �. Note: The well for this properq'•meets existing State and Municipal Cobs. -117 iLQJ r tes present It is iuggcstcd that periodic tosting be performed to insure the �clls•co$ �ylrtaBiliti. Current nitrate concentration is 6.6 m;A. EPA maximum concciitrationli &mg/l. Moro',��.. information on nitrates is available from the On -Site Services Program, at 04: ••' SCf ,Z. .... V1, 11 Gti 11p • . . . _ . I�IJJJ I Attachments: . HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: ����-�/ /CJ. //J CL_1� Original Certificate Date: / D - / %- C 2— (Rev. 12/CO) w Municipality of Anchorage ° • `" Development Services Department Building Safety Division Onsite water & Wastewater Program ti 470D South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchomge.ek.us (907)343-7904 ((�� HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: PruesS * 3, Lr{l Ato Parcel ID: C66-5-71-aS A. WELL DATA Well type aaLb Date completed -nLdgo Total depth Je ft. . If A, B, or C provide PWSID # SIA Sanitary seal (YM) Y Cased to.4-Q--ft. Well Log (Y/N) f Wires property protected (Y/N) Y Casing height (above ground) 1_in. FROM WELL LOG AT INSPECTION Date of test 10 --t - I% O y- u -01 Static water level 113, ft. /00 ft. Well production �, g.p.m. 6 • S g.p.m. WATER SAM E RESULTS: Coliform mlonies1100 ml. Nitrate " , 6 mg.A. Other bacteria coloniesHoO mi. Date of sample: /A -7-a 1. Collected by: E1J k Rin fNS, ••"r B. SEPTICIHOLDING TANK DATA Tank Type/Material S tee/ Date installed A - I () -90 Tank size IQ5Q gal. Number of Compartmentscyi Cleanouts (YM) Y Foundation deanout (YM) I-- Depression over tank (YM) -A)- High water alarm (Y/N) AI Date of pumping Al2S--6} Pumper TR S C. ABSORPTION FIELD DATA Date installedQ_ ISoil rating (g.p.dJW or ft'Abdnn) ( System type -1 YP�i0,4( Length '-Y4 ft. Width 3 ft. Gravel below pipe ft. Total depth Ja- ft. Eff. absorption area 5W ftr Monitoring tube Y Depression over field IJ Date of adequacy test 9 -.2J :7°e'8- Results (Pass/Fail) ,pis For 'i bedrooms Fluid depth in absorption field before test 5 in. Water added to gal. New depth $J in. Elapsed Time:.L min. Final fluid depth 6Y°Z£in. Absorption rate >= 601r9 g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) od 0 If yes, give date — D. LIFT STATION Date installed Size in ga11on3 Manhole/Access (YM) 'Pump on' i _ in. "Pump off level at _ in. High water alarm level at in. D Cycles tested Meets alarm d circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankfitR station on lot M r t On adjacent lots Absorption Held on lot 1001 + On adjacent lots 100 r + Public sewer main A)A Public sewer manhole/deanout NA Sewer /septic service line a5 r } Holding tank IOD 14 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation nZ o1 r Property line 10 r + Absorption field J Water main 101,4- Water service line �b r+ Surface water r + Wells on adjacent lots 104D 1+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10 t+ Building foundation 0 -7 r Water main I O 4. Water Service line )O r t Surfacewater LOO r t Driveway, parkingM"cle storage 50 r t rr Curtain drain Al 1A Wells on adjacent lots Lam_ F. COMMENTS G. ENGINEER'S CERTIFICATION ,!y��}�:••"T I certify that I have determined through field inspections and 491H review of Municipal records that the above systems are in - ------- conformance - ""'conformance with MOA HAA guidelines In effect on this date. Engineer's Printed Name UOU ig A. 2)Xti?*ai • s4ClUtpft�xe Date Al — /i - 01— HAA Fee E `5-75.Waiver Fee E Date of Payment /D // A#1/41 ->d Date of Payment Receipt Number p2 tD's Y y Receipt Number (Rev. 12/10) tR� 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 1. D. # 2sa`1 ` —�� HAA # MS LLLISS 1. GENERAL INFORMATION Complete legal description Lot 4• Block 6; Preuss Subdivision _#_3 Location (site address or directions) 10135 Louis Place Eagle River, AK 99577 Property owner Ken Robinson Day phone 696-2649 Mailing address 10135 Louis Place, Eagle River, AK 99577 Lending agency Day phone Mailing Agent Day phone Aildroo Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual well X 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: 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 S. 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 furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address 17034 Eagle River Eagle River, Alask Engineer's signature No. 204 6. DHHS SIGNATURE !�- Approved for bedrooms. Disapproved. Conditional approval for Additional Comments Phone 1 �y- y bedrooms, with the following stipulations: 411TIC 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 (RaV.1/91) Back MOA W21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L—,�r 4 %"v.- Lo f7y,-L)ss'lo 4-3 Parcel I.D. A. Well Data I Well type 1 ��v F If A, B, or C, attach ADEC letter. ADEC water system number '�6A Log present (R/N) 4 Date completed ID - 7- 2� ° Driller T4ielf cg Total depth /.�6 ' Cased to —Casing height Sanitary seal O/N) Wires properly protected O/N) FROM WELL LOG AT INSPECTION o z Date of test a Static water level ! /3 m o Well flow 70 g.p.m. b. g.p.m. rrIcp a x Pump levell JIG N G) SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /00, 4- ; On adjacent lots s / oo Absorption field on lot loo 14- On adjacent lots / ov ^J/ Public sewer main ''/lam Public sewer manhole/cleanout Sewer service line 25' / 4-- Petroleum tank es 14 - WATER SAMPLE RESULTS: Coliform D Nitrate Z/, S S Other bacteria D Date of sample: 7-/D - 7 %4 Collected by: S � S ,e, J4 B. SEPTIC/HOLDING TANK DATA Date installed 9-10-36 Tank size 40 5-0. Cleanouts (ON) �[�_Foundation cleanout( N) High water alarm (YA d Compartments Z Depression (Y& r� Alarm tested (Y/N) 0 �/ Date of pumping 7- 7- 9"1'( Pumper ,e. (1-60S eoaL SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /oo On adjacent lots deb /f Foundation 2z To property line /15 Absorption field S Water main/service line / a Surface water/drainage to ° 72-026(3=)•Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANVE FROM LIFT STATION TO: Manufacturer Manhole/Access (Y/N) tested I at lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed % - /D 3 a Soil rating (GPD/Ft2) 44- System type Length 3 5" Width 3' Gravel thickness te / Total depth 16 J Total absorption area S0`' 7/ Cleanout present&N) +/ Depression over field (Y69) Date of adequacy test 7-9- 9 �ResultsM9�6l) SASS for 1�z Bedrooms Water level in absorption field before test S7 ' After test SY_ Peroxide treatment (past 12 months) (Ya rf a �F i4,V 0 .J ✓ If yes, give date '-'d- SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /00 ' ¢ On adjacent lots 166 '4- Property line To building foundation .27' To existing or abandoned system on lot On adjacent lots Cutbank JZ- Water main/service line Surface water !oo Driveway, parking/vehicle storage area Curtain drain 1-1 14 E. ENGINEER'S CERTIFICATION S`6 ' � I certify that ! have checked, verified, or conformed t OA and HAA guidelines in effect on tli fc� of this inspeclion. Signature Engineer's Name oar Eagle Rive p R d No, 204 A. a a YY Date �! s: HAA Fee $ �� Waiver Fee $ Date of Payment (�/ f�� t r Date of Payment Receipt Number (Ci l� s ct b Receipt Number 72-026 (3/93)' Back ommsrc ORATO MALYSIS REP~ lc Rcat~ck$: ROH't'INi~ .":, 4 ~rH.E COI.1.F.C TF.D BY h,l~tedDate~ L Re~o,'4ed vd~e i~ t~,.~ 99~ MUNICIPALITY OF ANCHORAGE • T Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D.# ��11 -'11' Q� HAA# k�Ci':L (�'�`� 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Loi' 4, Ma 6- PREUSc 4t18DIVISIO" t5 Location (address or directions) 10135 Louis Ptace (b) Property ownerRob 9 Ro ffq l atioa Telephone: (home) 694-3965 Business Mailing Address 1013; Iniji6 ZPace ..'o � 99577 (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent Address 16600 Centen.ftieed DiLive #201 Eagle Rivea Atasha 99577 Telephone 694- (e) Mail the HAA to the following address: (or check hereA if hold for pick up.) List contact person and day phone number below: 17034 Eagle River Loop Road No. 204 a 2. TYPE OF RESIDENCE Single -Family R( Number of bedrooms 4 3. WATER SUPPLY / Individual Well qX ✓ Community ❑ Public ❑ Note: If community well system, must have written confirmation from•the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL ()n -site Kk ✓Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 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 Telephone Address 17034 Eagle River Loop Road No. 204 ei "99577 Date ..v 6. DHHS APPROVA Approved for drooms(�y Approved Disapprved Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) • Health Authority Approval (HAA) j CHECKLIST -FEBRUARY 1984 343-4744 n Legal Description: A. WELL DATy���� �V ; Well Classification V_ �� �` r If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/ Dple Completed a O Yield `Jt. 0 �Prm Total Depth Cased to. '—Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground 1a �� fi Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) _ SEPARATION DISTANCES FROM WELL Depression Around Wellhead (Y/N) I N To Septic/Holding Tank on Lot 1-60 �t On Adjoining Lots / oa t To Nearest Edge of Absorption Field on Lot ( L>Q t ; On Adjoining Lots / Co ' t To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lotmmpw 2 /4 G Water Sample Collected by "� 5 �NylA1Nul rjDate J U1 r Water Sample Test Results(4/es Comments B. SEPTIC/HOLDING TANK D9,TA Date InstalledSize No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped .31 JUL4 Pumping/Maintenance Contact on File (Y/N) fi1A ; for Holding Tank High -Water Alarm (Y/N) _1—Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well too t To Building Foundation 2 2 - To To Property Line ( O t To Disposal Field & To Water Main/Service Line /0__ To Stream, Pond, Lake or MajorDrainageCourse N r� Comments SN tAtJk ,DUa"-)oca� �H �t� sr�SSObo' DUtm�Dlnf . 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata t 3 - �� IT Type of System Design—i ecPic i/ Date Installed -6b Length of Field 3� Width of Field Depth of Field b Gravel Bed Thickness Square Feet of Absortion Are 'S CC)Statndpipes Present (Y/N) f Depression over Field (Y/N) Date of Last Adequacy Test a )�/u Y3 I Results of Last Adequacy Test J �)Ajl-,fogc oty `f (Sed rcovM SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well Pio f To Property Line b To Building Foundation ~i To Existing or Abandoned System on Lot NIA ; On Adjoining Lots / 00 i To Water Main/Service Line / C f To Cutback (if present) AVO To Stream, Pond, Lake, or Major Drainage Course (fid t To Driveway, Parking Area, or Vehicle Storage Area O f Comments D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump Off' Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments "Check Permitted Bedroom Rating Against HAA Request" I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed'`°'" s Q= S ENGINEERING v A' 4 Company 17034 Eagle Enver Loop Read Ne , ska 99577 r'' �'ineb{{" opal Date Eagle River, Ala MOA No. f'r W............�. I. C J �n'• •Rob"t A. Swdcr :llt Na. 1457.9e y� Receipt No.� Receipt No. of / Date of Payment �f � N Waiver Fee: $ Amount: $ �1,2LI).- itJ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID # 92-0040440 Client Sample ID:L4 B6 PREUSS #3 PWSID :UA Collected JUL 26 89 @ 16:45 hrs. Received JUL 27 89 @ 16:00 hrs. Preserved with :AS REQUIRED ANALYSIS REPORT BY SAMPLE for Work Order # 15310 Date Report Printed: JUL 31 89 @ 19:56 Client Name S & S ENGR Client Acct SNSENGP P.O.# NONE REC"D Req # Ordered By Analysis Completed :JUL 31 89 Send Reports to: Laboratory Supexvis x :STEPHEN_C EDFy 1)S & S ENGR Released By : �C. i.lc� 2) Special Instruct: Chemlab Ref #: 6635 Lab Smpl ID: 3 Parameter Tested --------------------------- NITRATE-N Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY RJS. Matrix: WATER Result/Units Method ------------------------------------------ 2.9 mg/l EPA 353.2 IDD6=====1=Tests Performed=oa==_== __` See Special Instructions Above UA -Unavailable ND- None Detected See Sample Remarks Above NA- Not Analyzed LT=Less Than, GT=Greater Than Allowable Limits 10 1`1,„A 5. LEGAL DESCRIPTION DATE RECEIVED INSPECTION APPOINTMENTS Subdiv. TIME TIME TIME 6. TYPE OF RESIDENCE CI ,-` _ c ti DATE DATE DATE al ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six INSPECTOR INSPECTOR INSPECT R MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH ENVIRONMENTAL PROTECT[ VEi T. OF HEALTH & 825 LStreet - Anchorage, Alaska 99501 ENVIRONMENTAL Pito' -CTION • ENVIRONMENTAL SANITATION DIVISION MAR 2 i1�1 Telephone 264-4720 FF ((��II ���� REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEe1rER`FPA7L ID DIRECTIONS: Complete all parts on page 1. Incomplete requests will not he processed. Please allow ten (10) days for processing. 1. PROPERTYOWNER PHONE 688--2813 Harry A. and Madeline M. Macke ❑ PUBLIC UTILITY MAILING ADDRESS Star Route Box ;" 1175 C1_iugiak2 Alaska 99567 PROPERTY RESIDENT (If different from above) PHONE Bob and Betty Lauer PHONE 2. BUYER Bob and Betty Lauer None MAILING ADDRESS unknown 3. LENDING INSTITUTION PHONE Alaska Pacific Bank MAILING ADDRES �Bui7_der will pick up approval and hand carry ) 4. REALTOR/AGENT PHONE Target Realtors MAILING ADDRESS 1021 West 25th, Anchorage9 A.k. 99501 ®(do not mail approval) 1`1,„A 5. LEGAL DESCRIPTION Lot 4 Blk 6 Pruess Subdiv. STREET LOCATION Louis 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS ❑ One KI Four ❑ Other EX SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY ;❑ INDIVIDUAL* *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM EN INDIVIDUAL/ON-SITE** 1980 YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) ' 1 � V 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ TWO ❑ FOUR ❑ SIX ❑ OTHER 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL T0: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS &--APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must ccom any certificate) ❑ DISAPPROVED DATE BY 72-010 (Rev. 6/79)