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Municipality of Anchorage Page of
DEPARTMENT OF HEALTH AND. HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 0 Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: 5L 910045 PID Number: 0$/OS3/.1
Name: M M d- M ConrreA STI M 4
Wastewater System: New 0 Upgrade
Address:
P.O, go,� 1-70q-,15 CNUGrA1�, AK -
ABSORPTION FIELD
Phone: / /Z 3-7
No. of Bedrooms:,
f Deep Trench ❑ Shallow Trench ❑Bed ❑Mound C3 Other
LEGAL DESCRIPTION
Soil Rating:
/•0
Total Depth from original grade: ,
61 To /0
GPD/So. Ft.
-
Lor Block: Subdivision:
13 / SAMA$old l5srA-T'ES
Depth to pipe bbnem from original grade:
2.S Tv µ.0 Ft.
Gravel depth beneath pipe .
69 Ft.
Township:
Range:
Section:
Fill added above original grade:
S
Gravel length: SO Ft.
- Ft.
WELL: KNew 0 Upgrade
Gravel width:
3
Number of lines:
Distance between lines
Ft.
Ft.
Classification (Private. A,B,C):
Total Depth:Casad
To:
Total absorption area:
1000
Pi a material:
srm 303
�1VAI—C
Ft.
Ft.
SO. Ft.
/'1
Driller.
5L)LLIvAN W ATaz W=LS
Daterilled:
B 96
Static Water Level:
t SZ .3 Ft.
Installer.
IH M,1-
Date ins Iled:
977'- 9 /o
Yield:
Pump Set at: I
Casing Heignt Above Ground:
TANK
8 GPM
I Ft.
L Ft.
SEPARATION
DISTANCES
0eptic ❑Holding ❑S.T.E.P.
To
septic
Absorption
Lia
Holding
PublfaPrivats
Man facturer. ��
CNG2ALE •ArJ M.
Capacity in gallons:
ZS�
From
Tank
Field
Station
Tank
Sewer Linea
^1
I
Material:
5T_E'EL
Number of Compartments:
O
Well
>100,
>/00
N A
N/p
>50`
yj
Surfac
LIFT STATION
Water
>/00{
>/Do'
VIA
NIA
>/00`
Lot/J
t
Size in gallons: Manufacturer.
L ne
> /0
il0
�A
/J Q
50'
"Pump on" level at' "Pump off' level at: High water alarm at:
Foundations'
��O'
Q
A
—
Curtain
/AU/JE
Orl
LGT
Pump Make & Model
Electrical Inspections performed by:
Drain
BENCH MARK
Remarks:
Location and Description: ` ,ELL ACAD
Assumed Elevation: /OD Ft
ENC�JNF ,REAL
W64 a >�
�ry �
-
�9
e
S� �.eY
01%j Dates: 1st
inspections performed by: 144D05
2nd 91.
e..o .ea e..eeoe�o�.o�o.oe,F,
�gA 9m^ litich'C.I,E. Anderson
)�
ti e4a A�1 ' A
Department of Heal h and H In,tices approval
Q t't s}
,
Reviewed and approved by: `'` ate:
72-013 (Re . 9/91) MOA 25
1 _ I
Permit No. 5 w g L oZ33 Page 2' of 3
Municipality of Anchorage r r'
DEPARTMENT OF HEALTH AND HUMAN SERVICES rti
ENVIRONMENTAL SERVICES DIVISION
rsa _.
Permit No. s 4j q L O[ ,3 3 Page of 3
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
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SULLIVAN WATER WELLS
P.O. BOX 670272,CHUOIAK,ALASKA M567 • TELEPHONE8t1E•2TGO !
OWNER OF LAND / // ��r7 _ DEPTH OF WCLL /S
ADDRESS STATIC LEVEL OF WATER FT- ► 3 c�
LEGAL DmSCRIPTION L r' f P4/YI{7�nr 1 t^$ •i DRAW DOWN FT. --
DATE •Started Ended �{ G GALS. PER HR
PERMIT NUMBER KIND OF CASING h
KIND OF FORMATION:
From—Ft. to -s -2n.
(— ,J,S" Aj�f %'�G- r' � From
' . Ft. to Ft.
Fromm _Ft. to Ft.,
hUr~�i3 r? �F •� "� From Ft. to
Ft.,
From. ••4 to-SY—Ft.
2,Lf4, 1 +Ra tA: f From
Ft. to
Ft.
,_Vt.
7
�ZFt.
✓4'^j'd 5 6&,A Jj. L From
J1.10
Ft•
FrOM4 -.-Ft. to_p�..-.Ft.
— r-- -------- From Ft. to --
Ft
From. _Fl.
1.1.. lal From
Ft. to
Ft.
Jr L_
Ft. to
Ft.
_From
From—LID—Fl. to_L*�k_Ft.^ S.4fo4,0, 4 4 AL% L__ ' � f From
Ft. to
Ft, _
/[f�•t
From:•L� 3 Ft, to,15LLFt
4^j O 64 *Q,,: L.4 u. From,_...,. -Ft. to
Ft.
++.J_
From ht. to Ft.
From
Ft. to
Ft. i
From Ft. to Pt.
From.
Ft. to—Ft.._...
From Ft. toFt.,
From
Ft.to
Ft. j
From Ft. to -Ft,
From
Ft. to -Ft.
From Ft. to .. Ft.
From
Ft. to
Ft.
From Ft. toL___' Ft,
Fiom
Ft. to
Ft,
From Ft. to Ft.
Fiom
.. Ft. to
Ft.
><+rom Ft: to ' :_ Ft,
_ From
Ft
``I►SISCL;IN ORMATIONf a\\rjj
tl Sm
l
NOV 2.. 1996
Municipality of ArCrIorage
Dept. Health & i-luman Services
FRUI MMM CONTRACTING PHONE NO. : 6881238 Dec. 07 1996 03:33PM P1
MM&M. CONTRACTING INC.
P. O. BOX 670495
C:IIUGIAK, ,A,K, 99567
Phone: 688-1236 Fax. 680-1238
Decombor 61 1996
Mr. Mikc Anderson
Anderson Enginewing
P. O, Box 240773
Anchorage, Ak. 99524
Re: Lot 13 Block X Sampson Iistates
Dear Mr. Anderson:
Test Hole No. 2 shown was mislocated on the drawings. 'fest 11010 No, 2 is in the middle
of the seplic trench 5' to th0 side as por dosign.
I spoke k► Mr. Williams turd appreciate his efforts in correcting this minor error.
Sincerely, .
pawl Myers
Superintendent
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW960223
DESIGN ENGINEER:KND ENGINEERING
OWNER NAME:M M & M CONTRACTING INC
OWNER ADDRESS:P.O. BOX 670495
CHUGIAK, ALASKA 99567
PARCEL ID:05105361
LEGAL DESCRIPTION:
SAMPSON ESTATES BLK 1 LT 13
LOT SIZE: 71249 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
Lo ?)D�f-n
DATE ISSUED: 7/30/96
EXPIRATION DATE: 7/30/97
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 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.
SPECIAL PROVISIONS:
RECEIVED B
ISSUED BY:
DATE:-
DATE:
ATE:DATE• 7 ,_ /
Municipality of Anchorage
Department of Health and Human. Services
825 "L" Street
Rick Mystrom, P.O. Box 196650 Anchorage, Alaska 99519-6650
Mayor
343-4744
August 1, 1995
M M & M Contracting, Inc.
PO Box 670495
Chugiak, Alaska 99567
Subject: Lot 13 Block 1 Sampson Estates Subdivision
Permit #SW940270, PID #051-053-61
The subject permit, issued August 1, 1994 by this office for a
single family well and/or on-site wastewater system, has
expired as of August 1, 1995.
A new permit must be obtained from this office for a well
and/or on-site wastewater system NOT installed by the
expiration date.
If you have drilled the well, a well log must be sent to
this office for documentation of the installation and to
close the permit.
If a licensed Professional Engineer has inspected the
installation of the on-site wastewater system, the original
as -built inspection report must be sent to this office for
review, approval and documentation. All inspection reports
must be submitted within 30 days of construction completion.
When applying for a new permit, the fees are: $320.00 for an
on-site wastewater permit; $120.00 for a well permit and
$440.00 for a combined on-site wastewater and well permit.
If you have any questions, please call this office at 343-4744.
S' cerely,
V
ames Cross, P.E.
Program Manager
On-site Services
enc: Copy of Permit
cc: KND Engineering
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PAGE 1 OF 1
g, a 3 p,,,,
PERMIT NUMBER:SW940270 DATE ISSUED: 8/01/94
DESIGN ENGINEER:KND ENGINEERING EXPIRATION DATE: 8/01/95
OWNER NAME:M M & M CONTRACTING INC
OWNER ADDRESS:P.O. BOX 670495
CHUGIAK, ALASKA 99567-0495
PARCEL ID:05105361
LEGAL DESCRIPTION: SAMPSON ESTATES BLK 1 LT 13
LOT SIZE: 71249 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 (24 HOURS) .
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.
SPECIAL PROVISIONS:
RECEIVED BY: LL4 - w- Ou� DATE: ey- � -9'�
ISSUED BY: / % zm a _/14� DATE: 9 - /_ 1�14
ND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER. AK 99577-8736
/FAX (907)696-8111
June 4,1994
On -Site Services
DHHS
825 L Street
Anchorage, AK 99501
Dear Sirs:
REF: Lot 13, Block 1, Sampson Estates Subdivision
Attached is our request for an on-site well and sewer permit for the above lot.
As shown on the site plan, there are no conflicts with existing on-site well, sewer systems or
with potential reserve areas. In addition, there are no public wells within 200' of the property.
This lot is generally flat north to south with a 1%- 2% slope running north and east. There is
adequate area directly east and south of the test hole locations on the lot to install both an
original and a replacement system. The natural slope will provide positive drainage away
from the proposed installation site. There is no surface water within 100 feet of any portion of
the proposed installation.
We performed two soils tests in the proposed absorption area, and conducted three
percolation tests on this property. The design we are submitting is based on a weighted
average of the soils conditions encountered(4 min./inch).
Thank you for your consideration of this request. If there are any questions, please call me at
696-6111 or leave a message at 694-2359.
Sincerely,
1e�6 ///�/, AVAe16ka___-'
Kenneth M. Duffus, P.E.
KND Engineering
Attachments: On -Site Well and Sewer Application
Wastewater Absorption System Details
Site Plan
Soils Log/Percolation Test(s)
SITE PLAN
WASTEWATER ABS❑RPTI❑N SYSTEM
LOT 13, BLOCK 1, SAMPSON ESTATES
S
"90 00
gMASO�
SRI
VACANT �'F
M�
C�
S
36q.
PRWELL/ I
3
o
4 0
99•
N PP�ED
9 BD.M
1SED
2
C.O.
. S.T. M.T.
C.D. ' . C.0
C.O. .0. 9u
.T 2
M.
D
�. D
SEPTIC T.R#1 ,yyoo
AREA
30 0
SEPTIC
WELL AREA
0
18
VACANT
16
SEPTIC
A4
4
1
o WELL
0 WELL
SEPTIC
AREA
o�FAL�\O
LOT SIZE: 71249 SE
*_49TH*
KENNETH DUFF
7116 -CE . 44j PREPARED FOR: KND ENGINEERING
lOA% llw oi® M M & M CONTRACTING 22041 PTARMIGAN DR
Ilk P, 0. BOX 670485 EAGLE RIVER, AK, 99577
CHUGIAK, ALASKA 99567 694-2359
688-1236 DATE: 5-26-94 DRAWING #
SCALE: 1' = 100' 94 -SI -0506
A
DESIGN DETAILS
WASTEWATER ABS❑RPTI❑N SYSTEM
LOT 13, BLOCK 1, SAMPSON ESTATES
� � W
0
w � ¢ a a o�
x2' HD INSULATION OVER ENTIRE FIELD & ALL PIPES W/ LESS THAN 4' COVER
xx FILTER FABRIC OVER ENTIRE FIELD
50'TRENCH
rI
Aw;�4
�49TH*
` - KENNETH DS /
7116 -CE
�SSIDNAL
T
5' MIN. I cn
H
z
DESIGN CRITERIA:
BOTTOM OF TRENCH 9.0'
PROPOSED
FRAME
HOUSE
4 BEDROOMS X 150 GPD/BEDROOM = 600 GPD
SOIL RATING: WEIGHTED AVER. 4 MIN/IN = USE 1.0 GPD/SF
600 GPD / 1.0 GPD/SF= 600 SF ABS. AREA
DEEP TRENCH DESIGN WITH 600 SF
600SF / (2)(6) = 50' TRENCH
DESIGN MINIMUM SIZE 3'W X 6'D X 50' LONG
6' MAXIMUM DEPTH OF GRAVEL
2" HD INSULATION REQUIRED OVER FIELD & PIPES IF < 4'COVER
INSTALL 1250 GALLON SEPTIC TANK. INSULATION
REQUIRED IF BURIAL DEPTH < 41.
'IPE
PREPARED FOR: KND ENGINEERING
M M & M CONTRACTING 22041 PTARMIGAN DR
P. ❑. BOX 670485 EAGLE RIVER, AK, 99577
CHUGIAK, ALASKA 99567 694-2359
688-1236 DATE: 5-24-94 DRAWING #
NOT TO SCALE 94—S2-0506
N
Municipality of Anchorage
DEPARTMENT OF HEALTH R HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: 14110 Contracting _ DATE PE
LEGAL DESCRIPTION: Lotl3,B1 kl , Sampson Est Township, Range, Section: NE 1/4 Sec -3 T15N R1W
SLOPE SITE PLAN
DEPTH
(FEET) Organic
1 Silty Loam
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Silty Sand, Loose
w/ lenses of sand <4"
Perc
Elev (No sand lenses)
Silty Sand, loose
WAS GROUND WATER
ENCOUNTERED? No
s
L
IF YES, AT WHAT 0
DEPTH? P
Dense Sandy E
Silt Depth to Water After
Monitoring? none_ Date: 5/31 /94
Perc <120 "/"
Reading Date Gross-
Time
Net
Time
Depth to
Water
Net
Drop
0 5121/9 14-52
3 3/8"
-
15:02
10
min
3 15/16
9/16
15:12
10
min
4 7/1611
1 2"
3 15:22
10
min
5"
9/1611
15.32
10
min
5 1/211
1 2"
5 15:42
10
min
6"
11211
20 � g��
PERCOLATION RATE 20 — (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN 5 FT AND 6 FT
COMMENTS Test Hole #1 Hole presoaked prior to testing
PERFORMED BY: KMD I Kenneth Duffus CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 5/21Z94
72-008 (Rev. 4/85)
OF A
1v®'ppp�°p000p�
�P��' o °oo -G v
• : Municipality of Anchorage Asa °ooh E
DEPARTMENT OF HEALTH 8& HUMAN SERVICES ^��`IP� g
825 "L" Street, Anchorage, Alaska 99502-0650 pnio o.oc.o.. 009 00 �p9p
SOILS LOG — PERCOLATION TEST Q.< oowoaoc0000a o oow oo
1AA Kenneth M. uffus a Lam,
PERFORMED FOR: MM Contracting DATE PERFOR",---Ogcray 4n 4v
—rrr0t- L 55ry ®-
LEGAL DESCRIPTION: -1 otl 33,61 k1, Sampson Estjownship, Range, Section: NE 1 /4 Sec 3 TI 5N Rl W
DEPTH SLOPE SITE PLAN
(FEET) Organic
1 Loom
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Perc Elev #1
Gravelly Sand
w/ Trace of Silt
Perc Elev #2
Sand
ROM
MEBe
MEIN
MEMO
EEME
OMEN
WAS GROUND WATER NO
ENCOUNTERED?
S
L
IF YES, AT WHAT 0
DEPTH? P
E
Sandy Silt Depth to Water After
Monitoring? None Date: 5/31/94
n
Reading
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
5/21/94 16:00
-
4"
-
1
16:10
10
min
9 1/8"
2
6:
min
-
3
16:
min
4
16-19
Tmin
-
5
16:21
2
min
7 3/16"
1"
16:23
2
min
8 3 16"
1"
AD
WATER
20 811
PERCOLATION RATE 2 (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN 3 FT AND —4 FT
COMMENTS Hole presoaked prior to testing
Perc Test #1 This Hole (#2)
PERFORMED BY: KMD I Kenneth Duffus CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
�oOF Aig
PERFORMED FOR: MMRM contl2aGting DATE
LEGAL DESCRIPTION: Lot 1 3 Bl k1 Sampson Est Township, Range, Section: NE 1/4 Sec 3 T1 5N Rl W
DEPTH SLOPE - SITE PLAN
(FEET) I I I I I
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Perc Test #2
e
WAS GROUND WATER NO
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? P
E
Depth to Water After
Manitoring? None Date: 5/31/94
Reading
Date Gross
Time
oo° eao 000a
WDUUS-
Depth to
Water
�� Kenneth M.
o ,W
PERFORMED FOR: MMRM contl2aGting DATE
LEGAL DESCRIPTION: Lot 1 3 Bl k1 Sampson Est Township, Range, Section: NE 1/4 Sec 3 T1 5N Rl W
DEPTH SLOPE - SITE PLAN
(FEET) I I I I I
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Perc Test #2
e
WAS GROUND WATER NO
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? P
E
Depth to Water After
Manitoring? None Date: 5/31/94
Reading
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
9
5/21/94 16:00
-
3"
-
1
16:12
12
min
4 9/1611
1 9/1611
2
16:16
4
min
5 1/811
9/16"
3
16:20
4
min
5 5/811
1 2"
16:24
4
min
3 112- 44
1/211
5
16:30
6
min
4 3/411
3/4"
AD
WATER
20
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER 811
TEST RUN BETWEEN FT AND —8 FT
COMMENTS Hole presoaked prior t0 test
Perc Test #2 only, Test Hole #2
PERFORMED BY: KMD I Kenneth Duffus CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 5/21/94
72-008 (Rev. 4/85)
Parcel I.D. #
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
05105361 HAA#��Inln���
1. GENERAL INFORMATION
Complete legal description _
Lot 13, Block 1 Sampson Estates
Location (site address or directions)
Sampson Drive/North Peters Creek
Property owner MM&M Contracting Day phone 688-1236
Mailing address P' 0. Box 670495 Chugiak, AK 99557
Lending agency Day phone
Mailing address
Agent Day phone
A riri race
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: Four (4 )
3. TYPE OF WATER SUPPLY:
Individual well xxxxxx
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 xxxxxx
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I 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
Anderson Engineering
Phone
Address P.O.
Box 240773
Anchorage,
AK 99524
Engineer's signature
_qq-d
(LI
Date
6. DHHS SIGNATURE
X Approved for 4 bedrooms.
Disapproved.
Conditional approval for
Additional Comments
By:
563 7155
11/20/96
bedrooms, with the following stipulations:
Date /2 bP_. cclIK—
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 courtesyto 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. 1191) Back MOA 021
1
bedrooms, with the following stipulations:
Date /2 bP_. cclIK—
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 courtesyto 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. 1191) Back MOA 021
-�� Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICE E C I V E Q
Environmental Services Division a
825 L Street, Room 502 • Anchorage, Alaska 99501 * (907) 3404-A4 1996
Municipality of Anchorag$
Health Authority Approval Checklist Dept. Health & Human Services
Legal Description: t-" J3�f X4, f, ,S&sAP50M GWA'ZS Parcel I.D.:
A. WELL DATA
Well type P121Vk_rV If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) i Date completed���
/5Z ` r
Total depth � � Cased to
Sanitary seal (Y/N) Y
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform
/5�z : Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Nitrate 1'e"5 103/L- Other bacteria
Date of sample: I'Ll 9/91, Collected by: A AAj0112504
B. SEPTIC/HOLDING TANK K DATA
Date installed q! 1(/96 Tank size 44- Number of Compartments � Cleanouts (Y/N) Y
Foundation cleanout (Y/N) _� Depression (Y/N) /J High water alarm (Y/N)
Date of Pumping t%/GW Pumper �)'J: "A4J Cr/0 4
R
C. ABSORPTION FIELD DATA
Date installed (7191gn, Soil rating (g.p.d./ft2 or ft2/bdrm) A System type Din -7—WvJcN
Length Width Gravel thickness below pipe Total depth 9 Qty %o
Effective absorption area 40 F%/ Z -Monitoring Tube present (Y/N)--Y-- Depression over field (Y/N) Aj
Date of adequacy test NGW 6055' Results (Pass/Fail) PA SS For 4 bedrooms
Fluid depth in absorption field before test (in.); Immediately after gal. water added (in.):
Fluid depth (ins) Minutes later: Absorption rate = g.p.d.
Peroxide treatment (past 12 months) (YIN) If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at* _
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot 1 /6
Absorption field on lot
Public sewer main
Sewer /septic service line
Or
On adjacent lots
On adjacent lots
"Pump off" level at*
>10f)
IN
r LA'S Public sewer manhole/cleanout /A LGA
5
> V r Lift station /UO"ir fir-► Ler
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
y�
Foundation ) 5 Property line 7 /0 Absorption field >
s f r
Water main/service line > To Surface water/drainage > /00 Wells on adjacent lots > /OO
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 5/0 Building foundation ?/G Water main/service line
Surface water ! ? /00 Driveway, parking/vehicle storage area
N
Curtain drain eal c; Gi.1 Eel- Wells on adjacent lots >/Ob,
F. ENGINEER'S CERTIFICATION
! certify that l have determined thru field inspections and review of Municipal recor4,
in conformance with MOA HAA guidelines in effect on this date. AAs;;
ter, .>
'
j �+
SignatureZ�� �" ;
ll. "I
Engineer's Name 4(4 -MCL � Aq 0 �Q"� � t
M
Date /1111/,16 .01
HAA Fee $ ?-m 0) Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Date of Payment
Receipt Number
the aboGezystems are
e
1 I
11/22/96 13:14 ME ESI ANCHORAGE 5635389
CME Environmental Services Inc.
CT&Lr Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
Parameter
Nitrate -N
Total Coliform
966194001
Anderson Engineering
L13 B1 Sampson Estates
LII B1 SampsonlistateS
Drinldng Water
NO. 567 1702
Client PO#
Printed Date/Time ll/21/96 17:06
Collected DatePrime 11/19/96 16:00
Received Date/Time 11/20/96 08:10
Technical Director: Stephen C. hide
Released By w C L�C�
ALLowable Prep Analysis
Results POL Unita Method Limit8 Date Date snit
1.65 0.100 me/L SM18 4500-NO3F 10 max 11/20/96 EMB
0 col/100mL SM1B 92226 11/20/96 TAV
11/22/96
13:16 ME ESI RNCHORRGE � 5635389
NO. 568 1701
CT&E Environmental Services Inc.
Laboratory Division r�.r��ir�i�ri�rs./.rriits-.►.i�.rlr�f/.riiiii���rri«i��
Drinkincr 200 w. i'ottzr Drive Water Report for Total Coliform Bacteria Anchorage, AK 99518-1605
READ INSTRIICTIONSONREYERSESIDEBEFORE COLLECTMGSAd1PLE Tel: (907) 562-2343
Fax: (907) 561.5301
MUST B6 COMPLETED BY WATtR SU'FPLMR TO BE COtvIPLETED BY LABOILkTORY
Analysis shoes this Water SA;viPLE to be:
O PiJ'P,LIC WATER SYSTEM I.D. Satisiactor!
to PRIVATE WATERSYSTEiVI a (fnsadsfactory
❑ SendRaruf[S ❑ SendJnvoite
wue arnan , unr�vmwny ,vane �onu.r.
aa, y.norr
on. ume<r
Maung nand.
rN
❑ Sample over 30 hours old, results may
be unreliable
❑ Sample too long in transit; sample should
not be over 43 hours old et examtltation
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received 11) 2,0
Time Received
'T
Sand Results ❑ Send Jnvaiet
amv.ny Wane
Maung A=05
aw. Io
�a
SA?YfPL£ DATE: t ! 9®
Month Day Year
SAMPLE TYPE:
XRoutine
❑ Repeat Sample (for routine sample
with lab ref, no.�,�-^)
❑ Special Purpose
SA;IMPLE LOCATION
10-1
In
O --Treated-Water
❑ Untreated Nater
Time Collected
Collected By
ffe. film
Date Time:
Client notified or unsatisfactory results:
Phoned Spoke with Fixed
Date: Time:
13ACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-MUG Result: Total Colifor " E tali
Membrane Filter: Direct Count O W ()k 110Colonies/l00 ml
rvrC Ca..!
Verification: LTB B COLiFTR�t
f!8 •lhhu Bacreia
Fecal Coliform Confirmation
` G
Final i4tatnhrane Filter Results Coliform/100 ml
f V} ih tj 2I X16 Time hrs
Reported By �-7'a Date
Comments PART 3f
I
Member of the SGS Group(5oci4t6G6Mdrafede Surveillance)
cN\l1 C1.1.... c..... ...�. ...nn ..� •. nCVe PAr run ovn M name 11 i.vn-C ... vv, .. .. .......�..... .. ......... .. �..... n.. ..
p lvsis Began
r 'i'�
.1Ra1yt(cal Ivfethod:
i- Membrane Filter
r
❑ MMO-�tT1G
r
Number oti colonies/ 100 ml.
Result* Analyst -
/1� 13
61 g4,
42U
inch Fbks Jun C3
Fixed
Date Time:
Client notified or unsatisfactory results:
Phoned Spoke with Fixed
Date: Time:
13ACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-MUG Result: Total Colifor " E tali
Membrane Filter: Direct Count O W ()k 110Colonies/l00 ml
rvrC Ca..!
Verification: LTB B COLiFTR�t
f!8 •lhhu Bacreia
Fecal Coliform Confirmation
` G
Final i4tatnhrane Filter Results Coliform/100 ml
f V} ih tj 2I X16 Time hrs
Reported By �-7'a Date
Comments PART 3f
I
Member of the SGS Group(5oci4t6G6Mdrafede Surveillance)
cN\l1 C1.1.... c..... ...�. ...nn ..� •. nCVe PAr run ovn M name 11 i.vn-C ... vv, .. .. .......�..... .. ......... .. �..... n.. ..
t
ME 4vironmental
Services Inc.
Laboratory Division ��rii►.vim-ii�r.Dior��wrr�r�'.►iiirw���ir��ir�i-�ioirr,
Drinking Water Analysis Report for Total Coliform Bacteria ter orive
A0chorage, AK 99518.1605
READINS7'RUCT10tYSWREYER.S$SIDEBEF0MCOLLECTIN'GSAAfFLE Tel: (907) 562.2343
Fax: (907) 561-5301
BE
(3 PUBLIC WATER SYSTEM I.D. N
❑ PRIVATE WATERSYSTEPA
W
❑ Send Rualtr ❑ Send Invoice
ea. urao<r
ane. umeer
AINMI A"m
Lim un
tJ Send Resultr 0 Smd Invoice
pepanr nd,s 1, unnan,e
PD
&ow. Z�1O 7713
"" A°°t A g95z�
h �
,1 w
FeR
SAMPLE DATS: L L.1D '
Month Day
SAMPLE TYPE:
Routine
O Repeat Sample (for routine sample
with lab ref. no. )
0 Special Purpose
SAMPLE LOCATION
M
year
Treated Water
a Untreated Water
Time Collected
Collected By
Lo*' !3 Btoc tc..l POO PM A4
Meme Mni
TO13FCQVtFLh1h1)13Y LADUM IQS%T
Analysis shows this Water SAMPLE to be:
0 Satisfactory
O Unsatisfactory
o Sample over 30 hours old, results may
be unreliable
o Sample too long in transit: sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample via Spec i delivery M i1.
Date Received
7�
Time Received G
Analysis Began
Analytical Method:Membrane Filter
MMO-MUO
• Number ofcole. -s/100m1.
Result" Alyst
08 Mrd
86.6397 F o
Aneh • Fbls Jun ❑
Fried
Date: Time:
Client notified of unsatisfactory' results:
❑ ❑
Phoned Spoke with Fated
Data: rime:
BACTERIOLOGICAL WATER ANALYSIS RECORD
11b10 -MUG Result: Total Coliform I E Coli
Membrane Filter: Direel Count L.3�lr C Ionies/1 0 mt
Verification: LTH BGB COLIFIRb4 t
Fecal Coliform Confirmation
Final Membra
Reported By
Comments: r
B
V Coliform/100 ml
.� I ' -_
' ime _j l hrs
IIA - nrAw Aednie
tO1 �S Member of the SGS Group (Socidid G6n6eale de Surveillance)
_ �.•
Z00 GGI.*ON 68£S£95 f 39Fi80H0Nti IS3 3813 S£ <3i 96/91/ZT