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HomeMy WebLinkAboutSAMUELSON LT 6Samuelson Lot 6 #051-091-44 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 NAME /Rp�`EPORT P/Z7..S,.3 �- r _ ❑ UPGRADE MAILING ADDRE -,, LEGAL DESCWTION LOCATION NO. OF BEDROOMS�37 Well Absorp ion gfea4 DISTANCE TO: Dwellin j�� o PERMIT ` U Y Ma nal No. of compartments ' J a Q / Manufacturer d e e/ �-- W H rn Li c t �}ons Inside length 9 yt G IF HOMEMADE: Width Liquid depth q P ' Well - Dwelling PERMIT NO. D Z J O Z Q DISTANCE TO: Y Material Liquid capacity in gallons 2 H Manufacturer ❑ Well Foundation Nearest lot line PERMIT NO. J= DISTANCE TO: Lu UL z No. of lines Length of ewht in - Total length of lines Trench width inches Distance between Ines _ ~ Z R F £(w Top of tile to finish grade Material beneath the inches Total effective absorption area 0 w Length 2. O Width `Z Depth -� / PER N2l �/ " C7 Q U Type of crib iaEYec--- Crib dpl Crib deptha. Total effective abc®ypio�.�re - -7" C J Lu W y DISTANCE TO: Well / W Building �ndatio�_4 �fJ Nearest lot li e p Class Depth Driller Distance to lot line PERMIT NO. J J Lu Building foundation Sewer line Septic tank Absorption area(s) DISTANCE TO: OTHER G, PIPE MATERIALS /f SOIL TEST RATING 17�T_ INSTALLER /7 �f R MARKS_ �.9 L L+a Do4�Oc Pu+^.s/ ei G 4 �AL ` P�'e - AWOV7DAg'�5-I E L ar.'iNK waracallem�cm:4i �•�0 Et.1 T A=- T F:l A=AA nC 1�-F-,�_'eF_1=Bf-iE DEPARTMENT OF HEALTH AND EFdVIRONMENTAL PROTECTION 825 :•L: STREET: ANCHORAGE: AK. 99501 264-4720 A_A h -.i -- -• T —r "=• 1-•-1 E 1•:' F E F -:C 1'•l T T PERMIT NO. 821096 } IPPL I CANT R. B. WOODS i iC:AT I ON .EGAL LG SAMUEL' .Ota S/D PO BOX 90 EAGLE RIttER 99577 sKlv,gt 5 Q�, d •YPE OF SOIL ABSORPTION 'SYSTEM I S : IAXIMUM NUMBER OF BEDROOMS = = SOIL RATING (SQ FT/ESR)= -HE RE:UIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: �loCYr' li� 6ElU&u lot"-- THE LENGTH DIMENSION IS THE LENGTH (IN FEET) F THE TRENCH OF: DF'AIPdFIELC:. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM iM OF THE EXCAVATION (IN FEET). -r 1-1 E V4 T C' _r " T _�­ !ffs . ASA ASA A_A E THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL F'IF'E AND THE BOTTOM OF THE EXCAVATION(IFd FEET). /' Vim; a((�- 694-`255 LOT SIZE 95999 SQUARE FEET F? E CAR U T F --l' E C ° E �''r T A; -r i=i C .t t = T ` E = � t=e A� 9=11_ 1_ C •! _• :'ERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS, DEPARTMENT DURING THE iNSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE gUMBER OF RESIDENCES THAT THE WELL WILL SERVE. BACKFILLING OF DEPARTMENT WILL < p^ >~ A_: _I T A=A C .1'= 1=1 �' E F;? E A ! 1_I T .:.F=. C:° AN'r 'SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS. BE SUBJECT TO i PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY Ori -=.ITE SEWAGE DIS•POS,AL SYSTEM I- 1.00 FEET FOR A PRIVATE WELL OR 1.50 TO 200 FEET FROM A PUBLIC: WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE _EWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS. ARE AVAILABLE TO INSURE IRE PROPER INSTALLATION. F EI*_M T _..r E; F' T 1-;'E=. E-aEA_:EM0E1;_ -1 e -,="v: - I CERTIFY THAT 1.: I AM FAMILIAR WITH THE REQUIREMENTS FOR CF -SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY � �F ANCHORAGE. : I WILL INSTALL THE SYSTEM IFd ACCORDANCE WITH THE CODES. I UNDERSTAND THAT THE ON-SITE '=EWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO IF CLf iC?E MORE THAN 3 BEDROOMS. i Sgt 4`r.'_�( !C T _ AF' CANT R� B. I.JC IOC: S 'K2 3 I SS � QED SOILS LOG P / MUNICIPALITY OF ANCHORAGE ❑ PERCOLATION �..e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: SLOPE DEPTH (FEET) 1 �'l �2 3 � U 4 5 6 G / 7 a 9- DATE PERFORMED: cl //) SITE PLAN 10- J - Net Depth to WAS GROUND WATER '/ _. S �'J L 11 Date ENCOUNTERED? O 12/ Water P E IF YES, AT WHAT FI DEPTH? 13 OF At, `49 15- 16- 5 16 =' 'r3 17 CL Robert A. Sh r� 18 '`S No. 1457- 19- 20- COMMENTS 457-19 20 COMMENTS PERFORMED BY: 1n nn° 16,701 PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT CERTIFI DA -k- Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT CERTIFI DA -k- ra ii r-4 1 C- T ` ..a=1 F _ g —r •— C, F=' F=l r -J a=- (P' F=Y 1:3 E - DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION•d 825 "L' STREET, ANCHORAGE., AK;. 99501 264-4720 L4 L_ FEE F r-1 I i PERMIT NO. 8''ii.35 APPLICANT WAYNE COUSINEAW LOCATION LEGAL LE SAMUELSON•d Po BOX 27'9 CHUGIAK 99567 688-3999 LCAT SIZE 999999 SQUARE FEET MINIMUM DI_TAN•dCE BETWEEN A WELL AND ANY ON—SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR ick? TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MIN•dIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE I_• 25 FEET AND TO A CCiMMUNITY SE14ER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO IN•dSURE PROPER INSTALLATION. F=� E—= F;3! M I —r• E—=L4 po I F;;o F=-.r•��-�r���� ! 3- -::L �_�=_� I CERTIFY THAT is I AM FAMILIAR WITH THE REQUIREMENTS FOR ON•d--'=ITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. : I WILL -INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. APP L CANT WAYN•dE COUSINdEAS ISSUED B4'_L T� _<� ' JC�1��=-------DATE---��-=—���— 'v4. 0 Dri t t I g"T, [ -by DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2759 OWNER OF LAND f 0 «' 1 ADDRESS jfi>- , x 7,` f tom_ f , DEPTH OF WELL STATIC LEVEL OF WATER FT. r.. LEGAL DESCRIPTION � ��'''�"'�' DRAW DOWN FT. DATE - Started t / , : `' Ended V# .), PERMIT NUMBER KIND OF FORMATION: From Ft. to Ft Ft. to z� Ft. � ��p ANOHORAGE Ft. toMUN�O�� ?�,, r 1 ' . From G` ''r c_r j10P1 Ft. to � ! Ft t' `a From Ft. to—Ft. Ft. to _11'p Ft. _. e From From -' �-' Ft. to r} Ft. s f .' st / Ft. to From -, Ft. to --L- ' Ft. / ' U "" - Ft. From Ft. to Ft. r From Ft. to—Ft.— o Ft. From t From%< -,J. Ft. to —LLi' Ft. From Ft. to Ft. From Ft. From Ft. From d Ft. to - V_ Ft t Ft GALS. PER HR fj KIND OF CASING From Ft. to Ft. From Ft. to Ft. From Ft. to -Ft From Ft. to Ft From � ��p ANOHORAGE Ft. toMUN�O�� ?�,, r 1 ' . From—Ft. From G` ''r c_r j10P1 From Ft. to ESI From Ft. toFt,1` From Ft. to—Ft. From Ft. to Ft. From - Ft. to__ From Ft. to Ft. - From—Ft. to Ft From Ft. to Ft. om . 0- From—Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to—Ft. From Ft. to Ft. From - Ft. to Ft. From - - Ft. to Ft. From Ft. to Ft From -- Ft. to Ft. From Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: DRILLER'S NAME f t ! Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-09144 1. GENERAL INFORMATION Expiration Date: 1/-,-2 -7::-/-3 Complete legal description Samuelson Lot 6 Location (site address) 21233 Valley Ave, Chugiak, AK Current Property owner(s) Castillo, Tom Day phone 244-1930 Mailing address same Real Estate Agent Cindy Wilson, RE/MAX Day phone 244-1930 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class C Well Public Water System 3 TYPE OF WASTEWATER DISPOSAL: ® Individual ❑ Holding Tank ❑ ❑ Community ❑ ❑ Public Sewer ❑ Received by: % � Date 2 COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 00, Date: Date of Payment &/A3113 Receipt Number r JLJ(( COSA #_ Q561314-115 Date of Payment Receipt Num 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 NorthRim Engineering Phone 694-7028 Address PO Box 770724, Ea¢le River Engineer's Printed Name Steve Eng Date 8L=Q11 OF Al, �etqh y °• e•• NN 6. DSD SIGNATUREse�:®s• --AZ System #1 Approved for bedrooms.•°•••° Steve. W. Eng J < System #2 Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following By_ Original Certificate Date: ©"c2 -7`/-3 The nicipalof Anchorage Devlopment 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 professional engineer's work. 7. ATTACHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory COSA blue sheet 9-1-12 doc X Nitrate Advisory Arsenic Advisory Other 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: oT 6 Parcel ID:451 A. WELL DATA Well type 1— If A, B, or C provide PWSID # Well Log (Y/N) Date completed VIZP2 Sanitary seal (Y/N) Wires properly protected (Y/N) Total depth 66.25 ft. Cased to y o,*ft. Casing height (above ground) /2 in. FROM WELL LOG AT INSPECTION Date of test 00a �fiz�l3 Static waterlevel 33 ft. Z ft. Well production 7 9 -p.m. 8 g.p.m. WATER SAMPLE RESULTS: Coliform O colonies/100 mL Nitrate Z- iZ mg/L Arsenic ug/L Dateofsample: Collectedby: B. SEPTIC/HOLDING TANK DATA Tank Type/Material S77=,54rL Tank size CJD 0 . gal. Number of Compartments 2— Foundation Foundation cleanout (Y/N) k Depression over tank (Y/N) Al Date of pumping Pumper 12. J C. ABSORPTION FIELD DATA Date installed le / c•O. Cleanouts (Y/N) High water alarm (YIN) A/ Date installed o�ZSoil rating (g.p.d./ftz or fe/bdrm) 061 System type S .a( Length 20 ft. Width 23 ft. Gravel below pipe G. ft. Total depth Z i ft. Eff. absorption area �fe Monitoring tube 4-- Depression over field A Date of adequacy test 0"/10/15 Results (Pass/Fail) Axs- For 3 bedrooms Fluid depth in absorption field before test (3 in. Water added Z'/SG gal. New depth iJ in. Elapsed Time: 3 0 min. Final fluid depth 0 in. Absorption rate >= 0 g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) i/o✓!( If yes, give date D. LIFT STATION N/4 Date installed Size in gallons Manhole/Access (YIN) "Pump ono level at in. "Pump off" level at in. High water alarm level at Datum . Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOTTO: i Septic tank/lift station on lot / 00 Absorption field on lot /0 0 /r- Public YPublic sewer main A/4 Sewer /septic service line �� r Animal containment areas Jr 0 SEPTICIHOLDING TANK ON LOT TO On adjacent lots (00 On adjacent lots .40 0 r>: Public sewer manhole/cleanout 14114 Holding tank AIA Manure/animal excrete storage areas 1001+ Building foundation S '+ Property line /D f Absorption field S,4 - Water main A/A Water service line _/O '* Surface water /0 0 'tWells on adjacent lots ABSORPTION FIELD ON LOT TO: in. r Property line /d f Building foundation E 0 t Water main N,4 Water Service line /0 'f Surface water /a 0 i -f Driveway, parking/vehicle storage /o't Curtain drain (g/,�- Wells on adjacent lots /Od F. COMMENTS G. ENGINEER'S CERTIFICATION I certify 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 STELE Date /7,/ t3 COSA brown sheet_10-10-12.doc MUNICIPALITY ORANCHORAGE • DEPARTMENT OF HEALTH & HUMAN -SERVICES M� 1 Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEATH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # HAA # 1. GENERAL INFORMATION Complete legal description Lot 6; Samue23an Subdivizion; Location (site address or directions) 21233 Va,22ey Avenue Property owner MaA Ujn R Bonchan.dt Day phone 561-1591 688-4232 Mailing address HC 78 Bax 2655 Chugiak, Ata.6 za 99567 Lending agency Lynn Pope CITY MORTGAGE Day phone (viainng auuress Agent Day phone Address - Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 �d 3. TYPE OF WATER SUPPLY: Individual well XX 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 XX 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. 2 0 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 S & S ENGINEERING Address 17034 Eagle River Loop Road NM go :a le R1vw, Alaska 99577 Engineer's signature Date- DHHS SIGNATURE Approved, for _2 bedrooms. Disapproved. Conditional approval for Additional Comments N Rq{q tt Y C �A 1� ° 0 oe •Jq•.O cu. q w :D °:: FGvL" J. S•rir Ffi:lr P•F R.:,t/ � �•• 6821 °° G� p OFESSN'P� bedrooms, with the following stipulations: Date l 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 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.1/91) Back MOAN21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: "-r- LP o , ss o tL ' o Parcel I.D. (!2 ( / �9Z y A. WELL DATA t � A Well type '�R-Nd)Crt: If A, B, or C, attach ADEC letter. ADEC water system number Log presentON) --� Date completed /�ti Driller. Total depth U U' , Cased to '.'!:;7c� Casing height )�- Sanitary seal (9N) Wires properly protected &I) / FROM WELL LOG AT INSPECTION CZ Date of test Static water level 33` n Z D En 0 Well flow 1. >� g.p.m. S.S r'r'1 g.p. C En < o Z Pump level UIL y1L- t'n o p SEPARATION DISTANCES FROM WELL TO: y rn 0 Septic/holding tank on lot ao' ; On adjacent lots Absorption field on lot \00 k ; On adjacent lots � Public sewer manhole/cleanout lA Public sewer main ,.r Sewer service line 2`� Petroleum tank 2S WATER SAMPLE RESULTS: Coliform 0 Low%AceO Ax� Nitrate �D Other bacteria N�o�� l\ - 4 -�► I Collected by: Date of sample: ��^ k'�'`� 1 S & S ENGINEERING17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 B. SEPTIC/HOLDING TANK DATA Date installed i t7 - I Co -S'7- ti Tank size 1 b'pCi Compartments 2 Cleanouts&N) Foundation cleanout &N) — Depression (Yt 4 High water alarm (Y& Alarm tested (Y/N) Date of pumping �� �� 1 Pumper S� LAS P noL_ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 1 a Z> On adjacent lots 1 aD tk Foundation 1k �k To property line IV ` Absorption field Water main/service line 10 Surface water/drainage 1.1 G(LDckl• I.- CONTINUED ON BACK PAGE 72-026 (Rev. 7/91). Front C. LIFT STATION Date installed Size in gallons " Vent(Y/N) High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/NL. Meets MO=DISTANCE Y/N) SEPARATOM LIFT STATION TO: on lot On adjacent lots D. ABSORPTION FIELD DATA "Pump off" level at Cycles tested Surface water Date installed — t L, — 62 Soil rating �o� �i�rU System type Length Zo Width 23 Gravel thickness Total depth Z Total absorption area Cleanouts present &N) Depression over field (Y/@ Date of adequacy test Results as ail) IPASS for Tkl(Zr-_� C13 bedrooms Peroxide treatment (past 12 months) (Y& r(o+JE 14.4aWe/ If yes, give date *.5 e, r le, +--. SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lotcue t On adjacent lots c>& ->t Y Property line ( o ( k To building foundation D t To existing or abandoned system on lot On adjacent lots 30 � } Cutbank '')Ar Water main/service line Surface water c> o t+ Driveway, parking/vehicle storage area S Curtain drain E. ENGINEER'S CERTIFICATION i certify that l have checked, verified, or conformed to all MOA and HAA guidelines in effect on.the date of'this inspection. - S & S ENGINEERING �u Signature 17034 Eagle River Loop Road Jqp z ' ° tiagle River, Alaska 99577 Engineer's Name • • ° ° ° ' ' ' ° ° 1 s ,,� _ — q , O� ��°° sH Date /�1.� l°,• 9821 RF�PROFESSIO�P� HAA Fee $ d� Waiver Fee: $ . Date of Payment Date of Payment Receipt Number Receipt Number 72-026 (Rev. 3/91) Back MOA 21 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANALYSIS REPORT BY SAMPLE for WORKordex# 39994 Date Report Printed: NOV 7 91 @ 08:12 Client Sample ID:L6 SAMUELSON S/D PWSID :UA Collected NOV 4 91 @ 12:10 hrs. Received NOV 5 91 @ 14:10 his. Preserved with :AS REQUIRED Client Name :S & S ENGINEERING Client Acct :SNSENGP BPO # PO # NONE RECEIVED Req # Ordered By :R. SHAFER Send Reports to: Analysis Completed :NOV 6 91 1)S & S ENGINEERING Laboratory Supervisor : T NEN C. EEDDDE 2) Released By J� % G lz ............................................................ Chemlab Ref #: 915958 Lab Smpl ID: 1 Matrix: WATER Parameter Tested Result Units Method ------------------------------------------------------------ ND(0.10)�/1 EPA 353.2 NITRATE -N Sample ROUTINE SAMPLE COLLECTED BY: RAY. Remarks: 1 Tests Performed See Special Instructions Above UA -Unavailable ND- None Detected See Sample Remarks Above NA. Not Analyzed LT -Less Than, GT -Greater Than Allowable Limits ��NSGS Member of the SGS Group (Societd Generale de Surveillance) 10 APPLIC'NT FILLS OUT UPPER HA( ONLY Property Owner w!4 y N[ Co o-5 /" Co d �. Zip Code Mailing Address 1 Buyer w fn . f)-) LJ IZ ! Lj U t_j AA R Ali Address PC- ,4- /> G-%'� I / Zip Code L -/=i -" Lending Institution (` Zip Code Address 1��Azi 1z Realty Co. & Agent -rQ .D /4'� S / Zip Code Address v Legal Description G Q ! / / -5 O f\J s (J Q -- Street Location I C IZ Type of Residence -J;],-�hgle Family _ ❑ Multiple Family No. of Bedrooms ❑ Other Phone Phone Phone Water Supply �? ATTACH WELL LOG. A well log Is required for all wells drilled since June 1975. individual - X I i�,.�- L.( nL• For wells drilled prior to that date, give well depth (attach log if available). ❑ Community ❑ Public Utility Sewer Disposal (7 r iIndividual �5�� I �� 10' 1 IC- )� �'? Year I Connected toPublicU ility: ❑ Public Utility _ ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Date . Date Inspector Inspector Field Notes: (3 APPROVED BEDROOMS ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' DATE B _ Soils Rating Date Sewer Installed We A) -__ 61 i . We ]2023 (3182) Time Date Inspector I To Absorption Area I to Tank 'CONDITIONS OF APPROVAL Time Ca-,\ 9'\i4 P Date l\ - I -IQ CN-�S Inspector MUNICIPALITY OF ANCHORAGE DFGT. or ;"-'iT;! % ENVIRoidr.t_(r,;A._ ;.,V.-'CTION l V 3 v; RECEIVED Well Log Received Septic Tank Size /