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\ MUNICIPALITY OF ANCHORAGE
® 1 DEPARTMENT OF HEALTH & ENVIRONMENTAL_ PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
82.5 L Street - Anchorage, Alaska 99501 Telephone 2.04-4720
ON-SITE SEWAGE DISPOSAL- SYSTEM AND/OR WELL INSPECTION REPORT
NAME
N E
e� ���-%S %.J ��/`7 �I
❑ UPGWRADE
_
MAILING ADDRESS -- -
LEGAL DESCRIPTI N
4 �� j SGS dk) =r CflI�� ' c °
LOCATION
NO. OF BEDROOMS
Well // Absorption a a Dwellin _
DISTANCE TO: �) 'i �• PER J1)T N9 ly.�
1-Z Manufacturer
w Q �y.� �� Mates a , No. of comp rtments---�
N Liq. cap c yy gaIlons Inside length
/C.�U IF HOMEMADE g Width Liquid depth
O X DISTANCE TO: Well Dwelling PERMIT NO.
Z
2''b Manufacturer --- -- -
��< Material Liquid capacity in gallons
!!!!!
Well Foundati
•J -- DISTANCE TO: '� !.T f�, Nearest I fB lin ,�T PE ?PT. Q
LL
w No. of lines / Length o c11 t� Total tor� th of r� Trench w h
Lu �•-� ?7v J�`� Distance h tweenJ•i i�g f
F- 4 - inches
-� --- _7
re N Top�9f;til�toiFinish grade Material beneath rile �j �� Total effective absorption area
C] •�-� e_' U '' inches
-
Length Width Depth �� PER MITN O. -
w
(7
4 F Type of crib Crib d' eter
w F �� Crib depth Total effective absorption area
uj
—
Well Building foundation Nearest lot —line
Cn DISTANCE TO:
DISTANCE
Class Dept> f,{)riller
_j
w
^' DISTANCE TO: Building foundation Sewer line
!
,. T
-
Septic
Dis nto
tank
la
t/
`---
PERMIT
Absorption
NO.
_
area
(s)
OTHER
PIPE MATERIALS
��
SOI L TEST RATI NG
/2�
INSTALLER -
REMARKS
OF
a [
c Robert A. Shafg 4
A
A T10v DATE
//I:'R,
LEGAL
ALAR
P_ T., 'Y P-4 1C.", p_ - I : I
PA R.TPI EN T HEALTH Fit -1f) 825 EI`JV1RONI1F.IlITAL I' EC T I
,�,]"REET., FINCf-IORFII3f:.. AK,
2 6 4 -1
C:11 P -J ....... . US'.' X - T" E- ":3 EE 1.4 F-1, F.P. J_*;.-.. g-" 6 0. _.F.
APF L. I ("A NT P'O,:;;_5 Po B"." EF."
LEGAL_. LA". .191.-A ':3CHF'OE_[`-E'_R S,/rj EA -E -IT LOT 1-14".71E f,
TYF"ET Ol", IS: TFENCH
MAXIPILIII F. OF E:F.DR F
R.ATINC
I .. ", A F. -T :1. 2 0
TFIF RE"QUIREE,
I EhIGTH
OF' THE
FjP,_;;OR.f:',T-Iot.4
CIF' THE OF.' F,`RFIINF`IELC
'---'.'YSTE[1I
DEF"TH
CIF' A TRUMI-I
OR PITIS T11E r,'1ISTFIIljCJ-:
P^••,% P:�,
1-4
— e.-"
E��, I_-
THE
I EhIGTH
DIMENSior.,I
Is THE L. F -IN GTH j,"IN FT,,YI-)
CIF' THE OF.' F,`RFIINF`IELC
THEI
DEF"TH
CIF' A TRUMI-I
OR PITIS T11E r,'1ISTFIIljCJ-:
F-El"IdEPli THE 'SURFACIE OF. Ti.*.:
13ROUND
All -If.",
THL" F31CIT"I'01"I
OF= TI --IE"
FEED.
THE FE
1':�-• NC)
IlLIDTI-I
FOR TRENCHES.
.1 N E A/
GRAVI-I.-
E.-EPTH I -S THE MINIMUM I') F: Vrf -I of,GRAVEI
BF'-TI-IEEIlI THE OUTI"ALL PIPE
AtID
THE-,". 130"I'T'01"I
OF THE
E::-,'CA%.T"1TICiN '.'IN
_V IF P-4
I"El""delIT APF"L I T TFIE NS IBI L I T TO ItlIFORPI THP,-; T"CPARTMENT DUF-'.'IJ`JG U -4F7.
F
If;:-
Arir,, 1 -j -'
IE
I"JUMBER Ur" wo-
L. WILL
A WE'LL FIND AlllY ON--5.jjj-" :.-
4:1411.,11H DI.-, C. 'I I- _ Y..
"'PCISF l_. _;TFJ,I
FEET F'OP.., A PRIVATE' WELL CIR J_'_J0 TO ;-_P0L1,I FEET F'ROi;I A
UPOP-4 THE TYPI" OF FIJELIC WELL,
MINIMUM DU;TFINCE FF,'Otel A F'I--?TVATF--. WELL TO A PRV,,�FITF,' -.iJ WER' LINE 13 21.FFJ_',.-.T 9 4.')
TO A COMMUNITY ' F"I,IF':R LJI`-IE IS 75 FEET.
OTFIF'R RE(,.X.IIREP1EIl4TS-- FIAY APPLY. ANI. 1.1 A F r7E
WeT'jILABLE TC.1 Ill-ISURE PRIDPER 1N`3TALL.ATION.
I CERTIF"i, TI. -IAT
I FIN F-19MILIFIR WITH
. ... ......
;2
Fr'.:-.;TEP1
F";::: E
WITHOUT FINAL.T
OPI-SITE SEWER -En' AND
RTJ -1 Tm-
DEFIF"IRTMENT WILL
BE '`;U[::-.YECT'
Pd ND
1`0 r.."ROSECUTION, 1 T I OP14 FI
N:C L.L. Mi -,TALL
THE M IN ACCORE)FItICE
A WE'LL FIND AlllY ON--5.jjj-" :.-
4:1411.,11H DI.-, C. 'I I- _ Y..
"'PCISF l_. _;TFJ,I
FEET F'OP.., A PRIVATE' WELL CIR J_'_J0 TO ;-_P0L1,I FEET F'ROi;I A
UPOP-4 THE TYPI" OF FIJELIC WELL,
MINIMUM DU;TFINCE FF,'Otel A F'I--?TVATF--. WELL TO A PRV,,�FITF,' -.iJ WER' LINE 13 21.FFJ_',.-.T 9 4.')
TO A COMMUNITY ' F"I,IF':R LJI`-IE IS 75 FEET.
OTFIF'R RE(,.X.IIREP1EIl4TS-- FIAY APPLY. ANI. 1.1 A F r7E
WeT'jILABLE TC.1 Ill-ISURE PRIDPER 1N`3TALL.ATION.
I CERTIF"i, TI. -IAT
I FIN F-19MILIFIR WITH
THE REQI_IIRENEIl.IJ"S
F.'OF;,
OPI-SITE SEWER -En' AND
RTJ -1 Tm-
OF ANCHOF.1AI_ir.,:.
N:C L.L. Mi -,TALL
THE M IN ACCORE)FItICE
WITH I'l-IL."
THAT
THE" SEWER
MAY I EC!UIk!.E
I.) E N CE I
F_: I_ E:C, j* (j I N C L. U I') E. M 0 RE
TH Ff N
C Ef) F., 0
.1 N E A/
.......
FIPPL I C"FINT
la i, y, CONZ-7-
❑ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
!` 825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: ---C
OR:_-) �Lli-_ ' RU C -T .L (}{'V �O, DATE PERFORMED: - Gl `Cl
L.,(
LEGAL DESCRIPTION: ) I � `I Sh VOL?Cle.t Frit (L-ly,,.y _
T pEy-I SLOPE �� SITE PLAN
1 ,� CSM - yid}7 Sandy ��)fc-VeA L I (I L"
2
3
tint `
4
5
6
7
9 -,
10
11
12
13 � �r
14 ,y
15
16 '
17
18
19
20
COMM
91rc\ve1 -
0A
�zp �/13K
WAS GROUND WATERS
L
ENCOUNTERED?
O
P
IF YES, AT WHAT E
DEPTH?
-
�13iN ds Ov-
bkkd" C")%(,-,V)K'
Y`ncAtv;�(A ,
J
vT,Robert A. S ier
®'��Fy@�. No. 1457-E + 9i
3
Reading
Date
W
Net
Time
LE
Net
Drop
WAS GROUND WATERS
L
ENCOUNTERED?
O
P
IF YES, AT WHAT E
DEPTH?
-
�13iN ds Ov-
bkkd" C")%(,-,V)K'
Y`ncAtv;�(A ,
J
vT,Robert A. S ier
®'��Fy@�. No. 1457-E + 9i
3
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
rln
20rr
Lo
(� {n n
/
T'0
xy
RoFFSSIONALV�Np PERCOLATION RATE ____L �'/ /_(minutes/inch)
TEST RUN BETWEEN .° FT AND �(a FT
PERFORMED BY
72-008 (6/79)
CERTIFIED B
DATE: a(.acl r. --)CQ 86;,
MINIMUM DISTHNCE BETWEEN H WELL HND RNY ON~SITE SENHGE DISPOSHL SYSTEM TS
100 FEET FOR H PRIYHTE WELL OR 158 TO 200 FEET FROM H PUBLIC NELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTHNCE FROM H PRIYHTE WELL TO H PRIVHTE SENER LINE IS 25 FEET HHD
TO H COMMUNITY SEWEY LINE IS 75 FEET.
WELL LOGS HRE REQUIRED HND MUST BE RETURNED TO THE DEPHRTMENT WITHIN 30 DHYS
OF THE
WELL COMPLETION.
OTHER REQUIREMENTS MY HPPLYSPECIFlCHTIONS AND CONSTRUCTION DIHGRHMS HRE
HVHILHBLE TO INSURE PROPER INSTALLATION.
07 Fin Q two 1: - v ��TO" �C,E91 � to: 1 A PEN K in? 12 A SW TA so,
I CERTIFY THHT
i� I RM FHMILIHR WITH THE REQUIREMENTS FOR ON~SITE SEWERS HND WELLS HS SET
FORTH BY TH£ MUMICIPHLITY OF HNCHORHGE
2� Al: NILL INSTHLL THE SYSTEM IN HCCORDHNCE WITH THE CODES
SIGNED�.
HPPLICHNT CLHY NEWMAN
MUNICIPALITY ()F ANCH(
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CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
PUBLIC WATER SYSTEM
APPROVAL TO CONSTRUCT
Plans for the construction of_'rI)j, `' n;
public water system located
in
Alaska, submitted in accordance with 18 AAC 80.100
by
,
have been reviewed and are
E1. approved.
❑ conditionally approved (see attached conditions).
f f i
_ -
DATE
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Change (contract order no. Approved by Date
or descriptive reference)
The "APPROVAL TO OPERATE" section must be completed before any water is made available to
the public.
APPROVAL TO OPERATE
The construction of the / , i ., r 1 r public
water system was completed on ! (date). The system is hereby
granted interim approval to operate for 90 days following the completion date.
TITLE DATE
As -built plans submitted during the interim approval period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system is hereby granted
final, approval to operate.
"eY - - TITLE
DATE
Ea"'p,w
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL f
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date 7 ^ jr4- cs/*
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
L— o ( L (I A (JL lL (o S lr fts i
Location (address or directions)
/a q3 / 4 . i,L7/,:GC
(b) Property Owner 1"o"`r^/L- Telephone: Home _ Business
Mailing Address
(c) Lending Institution �^-A�4' L 1'AOR_IraACPC: Telephone SioZ - L/0(
Mailing Address 4T-rn(: L7^A Ati( /c (r.r Ln
(d) Real Estate Company and Agent
Address rte• ). '3O% -z8Y9
Telephone C9 ya
(e) Mail the HAA to the following address: or: Check here ❑, if hold for pick up.
List contact person and day phone number below.
5 & 5 ENGI14CCrtuw
'17934 Eagle giver Loop Road No. 204
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family
Number of Bedrooms
3. WATER SUPPLY
13
Individual Well ❑ Community ❑ Public 2_1�
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DIS OSAL
Onsite LK Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 tRev 8/86) Front
5. ENGINEERING FIRM PROVIDINU INSPECTIONS, TESTS, FILE SEARCH, DA i'A AND INFORMATION
1.1
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 _5 & S Telephone
Address 17034 Eagle River Loop Road No. 204
Date
Eagle Inver, Alaska 99577
DHHS APPROVAL
Approved for 4-tilw1o. C' bedrooms by e Date
Approved Disapproved Conditional
Terms of Conditional Approval
CAUTION
.• 4!♦IJvvi,4p♦ee of p14 i4 ti.0 MI
♦ alzv,.,+
�!1� �!4 .y''•'C �i.y
� �,a +t0!'i:;T•`,'+�%`.'ter �,
77 -
The
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.
Page 2 of 2
. 72-025 (Rev 81861 Back
B. SEPTIC/HOLDING TANK DATA
Date Installed Size /Caoe� - No. of Compartments _!
Standpipes r Y�) _ Air -tight Caps6N) Foundation Cleanout6N)
Depression over Tank (Y69 Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) A for ^_11A
Holding Tank High -Water Alarm (Y/N) A Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well _/So 4 To Building Foundation
To Property Line 10V To Disposal Field
'1014
To Water Main/Service Line
Course
To Stream, Pond, Lake, or Major Drainage
Comments fit J2 '5
C_e55?ooc_ ; �n"Pi&t,c- Sr )cE37 - pu
Page 1 of 2
72-026 fRev 8'86) Front
MUNICIPALITY OF ANCHORAGE (MOA)
MUNICIPALITY OF ANCHORAGE
HEALTH AUTHORITY APPROVAL (HAA)
ENVIRONMENTAL SERVICES DIVISION
CHECKLIST - FEBRUARY 1984
264-4744
JUL ? t� 1���
Legal Description: _bra7 4 i3ci� (o
A. WELL DRE CEI`/ED
Well Classification C_ If A, B, C, D.E.C. Approved by
Well Log Present (Y/N)
Date Completed Yield
Total Depth _ Cased to
Depth of Grouting
Static Water Level
Pump Set At _
Casing Height Above Ground
Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
;On Adjoining Lots
To Nearest Edge of Absorption Field
i
on Lot />D On Adjoining Lots
To Nearest Public Sewer Line _
To Nearest Public Sewer
Cleanout/Manhole
To Nearest Sewer Service Line on Lot Z S
_
Water Sample Collected by S�LFuIC�i .l Date
Water Sample Test Results
i5r,i�a�/ZY
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed Size /Caoe� - No. of Compartments _!
Standpipes r Y�) _ Air -tight Caps6N) Foundation Cleanout6N)
Depression over Tank (Y69 Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) A for ^_11A
Holding Tank High -Water Alarm (Y/N) A Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well _/So 4 To Building Foundation
To Property Line 10V To Disposal Field
'1014
To Water Main/Service Line
Course
To Stream, Pond, Lake, or Major Drainage
Comments fit J2 '5
C_e55?ooc_ ; �n"Pi&t,c- Sr )cE37 - pu
Page 1 of 2
72-026 fRev 8'86) Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata % 7 O/�J2 Type of System Design
Date Installed 3� -�� Length of Field 30
Width of Field 3 t' Depth of Field / Z
Gravel Bed Thickness
Square Feet of Absorption Area X1630 f Standpipes Presen�/N)
Depression over Field (YCNP Date of Last Adequacy Test
Results of Last Adequacy Test -/ 3�, E/L
Separation Distance from Absorption Field:
To Water -Supply Well �_ f
To Building Foundation
Lot
1-J/P
I
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments —
D. LIFT STATION
Date Installed .
i
To Property Line b �-/
To Existing or Abandoned System on
On Adjoining Lots
3v a
To Cutbank (if present)
4
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
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Sigrrt I%-�tsv�Mjttate 22-
15" PlV'!„aaPRadNo.20
ComMOA No. p
`y
'. a+�+`•
Receipt No. d () / %
Date of Payment )d
Amount: $
Page 2 of 2
72-026 (Rev 8'86) Bark
1 tty T� �f- C. •� P E C1-
h? R
ta,brol A. �a-r, M
U, r•�. t r;.:
STEVE COWPER, GOVERNOR
NO IF, M. OF ENVAKONWENFT RN a I (rONSwInva'a III ON Telephone; (907)
Address:
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 49501
DATE: Y
PWS I.D.# ( /;.3>
To Whom it May Concern:
274-2533
According to records on file in this office the
C
I I �-ZFj Water System is in compliance with the State Drinking
Water Regulations
Sincerely,
Ay,
Time
APPLIC NT
FILLS OUT UPPER HAI ONLY
Property Owner .�.
Time
Phone
_ _ ,., _
Mailing Address, '
.:'p; i i"---
�. - Zip Code
Buyer
Date 0
Address r
Inspector
` Zip Code -
Lending Institution
Phone
Address
- - - Zip Code
Realty Co. & Agent
Phone
Address
;`
- Zip Code - '- -
Legal Description
Street Location ".
QQ �'x
(v���i
Type of Residence
NG7 Single Family
, IT I Q.
DrDT C- :1,
Multiple Family
No. of Bedrooms
ENVIR,, 1,':r,..V ..U,--'-nON
O Other
Water Supply
Individual _
-
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
0. Community
For wells drilled prior to that date, give well depth (attach log if available).
E Public Utility
Sewer Disposal
Individual
E Public Utility
BY: Ella
Year Individual Installed: -
When Connected to Public Utility:
E Holding Tank
Soils Rating
Dale Sewer Installed
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
�DL,k`V4 (A
Date
Date
Date
Date 0
Inspector
Inspector
Inspector
Inspector
jj
Field Notes: - /lI/41h
QQ �'x
(v���i
MUNICIPALITY OF ANCHORAGE
, IT I Q.
DrDT C- :1,
ENVIR,, 1,':r,..V ..U,--'-nON
. �1! .4 Nn'?
REC IMP
( 4<APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
DATE `p42 `
BY: Ella
Soils Rating
Dale Sewer Installed
Well To Absorption Area
Well Log Received
Well to Tank
Septic Tank Size �¢'�7
z 023 pw)
CHEMICAL & GL LOGICAL LABORATORIES %-,F ALASKA, INC.
TELEPHONE (907)-279.4014 ANCHORAGE INDUSTRIAL CENTER
274.3364 5633 B Street
�F �6
iaeoRArnRiea Drinking Water Analysis Report for 'notal Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY
WATER SYSTEM:
SAMPLE TYPE:
❑ Routine
❑ Check Sample (for routine sample
with lab ref. no. t ❑ Treated Water
❑ Special Purpose ❑ Untreated Water
SAMPLE Time Collected
NO. LOCATION Collected By
L
4
5
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Analysis shows this Water SAMPLE to be:
Satisfactory
❑ Unsatisfactory
❑ Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Received
Time Received
Analytical Method:
❑ Fermentation Tube
❑ Membrane Filter
Lab Ref. No.
Result` Analyst
ti
I.D. NO.
Water System Name
EE
Lv�
Phone No.
•if
L--�
EE e
Mailing Address
ml. or No. of Positive portions.
ell
City
Statee� Zip Code
Q
jj
SAMPLE DATE:
lJ—J
Mo.
Day
Year
SAMPLE TYPE:
❑ Routine
❑ Check Sample (for routine sample
with lab ref. no. t ❑ Treated Water
❑ Special Purpose ❑ Untreated Water
SAMPLE Time Collected
NO. LOCATION Collected By
L
4
5
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Analysis shows this Water SAMPLE to be:
Satisfactory
❑ Unsatisfactory
❑ Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Received
Time Received
Analytical Method:
❑ Fermentation Tube
❑ Membrane Filter
Lab Ref. No.
Result` Analyst
EE _
-�
EE
Lv�
m _
L--�
EE e
+Noof colonies/ 100
ml. or No. of Positive portions.
06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1978
Date Collected
Date Received
Time Received
Source _
a. m.
nm- 1 ah Nn
EMB Broth 24 hours: _Broth 48 hours:
Multiple Tube Report: 10ml Tubes Positive/Total 10ml Portions
Membrane Filter: Direct Count Collform/looml
Verification: LTB BGB_ _
Final Membrane Filter Results - - Coliform/100ml
Reported By - Data _ -
p.m.
to
TARK t Y
qnA r et -rue
AS -BUILT
I hereby, certify that I have verveed�jhfollowing., deacritied .
DroperlY:,�� _
EimJ,f 2 tcF`M,
Anchorage RecordInd Precinct, Alaska, and that the lniprove-.
:' iC -•`� : - tnents situated thereon are within the property linea and do
.�^' • ,;.>..:.. �. ' r'� '.` not overlap or encroach an the property lying adjacent there- .
to, that no Improvements on property lying adjacent•thereto
encroach on the:premhes Lti question and that there are no
roadways, trananilssion lines -or other visible easements on
'..: �. �N K..np,..• «. ,1� 'y said property except as Indicated hereon. -
<rF; s;�-;a:: »: •«'
Dated at Eagle Itricr.'Alaskn`
C.
•fwp.(L. J•, �neGr. trQ i .., �t 7_�' day Cf 'eJ✓ilk I9 i
r• � .• Gu.:r,y .' ROBERT. C.- JOHNSON�(
�U �. , . :'� •
SCALE: �. ResisteredlandSurveYo{N0. ✓�-I•.5
•�° l i ;'� `.i,." �•.�'� �;✓i . .. I" �. i 0 :, .. -.r; .Box 438, Ea61e River, Alaska .
i �; •.r - . r.. _ Fhonc (907) 094-2541