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HomeMy WebLinkAboutSAMPSON ESTATES BLK 4 LT 23On -Site Water and/or Wastewater 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: OSP151248 Tax Code Number: 05182213000 Work Type: SepticTank Upgrade Permit Effective Dates: August 05, 2015 to August 04, 2016 Design Engineer: NORTH RIM ENGINEERING Subdivision: SAMPSON ESTATES Site Legal Address: SAMPSON ESTATES BLK 4 LT 23 G:1560 Owner/Address: LESTER ROBERT B & ARDETH M 23827 GOLIATH DR CHUGIAK AK 995675505 Site Mailing Address: 23827 GOLIATH DR, Chugiak Lot Size in Sq Ft: 41956 Total Bedrooms: 3 This permit is for the construction of: N Disposal Field Y Septic Tank N Holding Tank 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 B Issued By: Y Date: Date: Q S S MUNICIPALITY OF Community Development Department Development Services Division (e*D� On -Site Water & Wastewater Program Phone: 907-343-7904 Fax: 907-343-7997 ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. oS/' kZZ- /3 Property owner(s) Rosa ' - a s h r Day phone 027 - 74' Mailing address Z3 Site address Zo me_ Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) Lot Size 44 ?5C Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (0 all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) Septic Tank Upgrade Upgrade (w/wo ADU) Holding Tank ❑ Renewal ❑ Duplex (D) ❑ Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ Water Storage ❑ 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. (Signature of property ow r or authorized agent) Permit/Rush Fees: cXI 5 Waiver Fees: _ Date of Payment: 112611 IS 14 Date of Payment: Receipt Number: $3816 1� Receipt Number: Permit No. OSP1512,gf Waiver No. Permit App_9-1-12.doc �IC;2TNi I� ENGINEERING MEMO Steve Eng, PE, PH (907) 694-7028 tel northrimeng@aol.com Date: 7/27/15 Number of Pages: 4 To: MOA On -Site Services Subject: Sampson Estates, Block 4 Lot 23 Septic Tank Failure The subject septic tank has failed, causing the pumper to pump rocks. Please expedite a permit so the tank can be replaced. The tank baffles appear broken along with general tank failure. The existing absorption beds are operating OK.. If there is need for additional information or clarification please give me a call. Thanks-Stzv_ I TPML- ENGINEERING Sampson Estates, Block 4 Lot 23 SPECIFICATIONS & DESIGN GUIDELINES Wastewater System Sizing: This is an existing 3 -bedroom, single family home. Most of the neighboring lots are developed. The current septic tank has failed- the beds are still useable. These lots are large and are served by private water wells. No adverse impacts are expected from tank replacement. No easements are present on the lot. Specification Requirements: All components and work must comply with the Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and Wastewater Regulations. • Two compartment, 1000 gallon septic tank. Watertight couplings on inlet & outlet. • 5' minimum between the tank and bed. 10' to property lines. 4' of cover or insulation is required for tank; an equivalent of 1" insulation for 1 ' foot soil cover. Minimum of 2' soil with insulation. • Tank & solid pipe must be set on well compacted, stable soil. 4 inch diameter cleanouts with airtight caps are required F to 4' from foundation wall, prior to any 90 degree bend in 4 inch line, in each tank compartment, and two adjacent opposing cleanouts between the tank and the absorption field, not more than 10' from the tank positioned to provide cleanout access towards the tank and towards the absorption field. All cleanouts must extend to at least ground level. • In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron. • Insulation must be placed over any pipe installed under driveways or parking areas. • Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789, ABS ASTM D2661, • Sewer Service Line is minimum 2% slope. Septic Tank to be pumped every two years or when required. • Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal) s^ Steven W. Eng '. vE Bas • .� .�:•. DESIGN NOTES: 1. Existing Beds Remain In Place. 2. Sewer Service Line minimum 2% slope. \ 3. Replace Septic Tank/Decommission Old Tank Per UPC. Wells 4. Lots Served by Private Water Wells. 5. No Conflicts Within 200'. EX�Stln9 ged 3% Svope Septic N OR THRI M ENGINEERING PO Box 770724 Eagle River, Alaska 99577 907. 694. 7028 Replace Tank w/ New 1000 Gallon Septic Tank w/DC❑'s ExVstVn9 Bed 3 BdrM 5 Svope Decommission Old Septic Tank PER UPC d 100-/ Q o Existing I Well GoUath Drive SAMPSON ESTATES BLOCK 4 LOT 23 WASTEWATER DESIGN REPLACE SEPTIC TANK Septic 1' = 40' PLAN LAYOUT /27/15 12 of 3 Ln z Oj pq 06 Y L d F- u U a m N N 3 Ol W m 3 O c- d d N U O) L N O O. O 0 IA a v 0) O (A N X w 0 F- C, _ a N Y N L +, d L N o0) C5 d L S 0- U LJ i CD ¢ 0 O N J L 0 6 +' d 0 >U N L- W O) s U +' N -_ C5 X X w U E N u U L N p O) d O > O d L O U S U U L O oY N ou O- O U U C5 O T CL } N L (U O O_ sv Uvi L Y 75 0 N + O 3 £ p f + 6 W Xl 0 0-E d p — v NC� u +' a L u m s U oOvC-a4- 30 LO 4 V) L J O '6 Q.6 L- OiU aU ND O)Y j "' U O C L O SLLJ V) L L O L 4- F -- O C5 �H O 0 O z NNFI W U L i L O z ad 3t41 N3 O -U v,DLO vinvi3va�A w fa .-4 N M V' of �6 I-� 0 W Q W z O Q Y Z Q U W 0 M 0 I� u m a e u Nl- J w s` io U QT' J �u pq \ n a Z W 2 W U Q J CL W z Q n o00 h T O 0 N � a � IOW xe m �?0 ZWa Lu -- MUNICIPALITY OF ANCHORAGE DE. ITMENT OF HEALTH AND HUMAN SER'k Z -S Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES t AddressTO SEPTIC ABSORPTION WELL 13 1�11ef/ / 11 3 FROM TANK / FIELD / Phone(s) . Permit No. No. of Bedrooms WELL r / LEGAL DESCRIPTION LOT LINE, -- Lot Block Subdivision _ Z� -3o9t% NaAo 55�r, FOUNDATION f �� Township, Range, Section AS -BUILT DIAGRAM (Show location of well, septic system, property lines, foundation, driveway, water bodies, etc.) TANKS SEPTIC�j �� f ❑ HOLDING�r Manufacturer Capacity in gallons /f nc Material No. of Compartments TYPE OF SYSTEM ❑ TRENCH P!Q BED ❑ W. DRAIN ❑ OTHER Depth to pipe bottom from Total depth from original grade original grade FT FT Fill added above original grade Gravel depth beneath pipe FT FT Gravel length ��– FT Gravel width FT Total absorption area Distance between lines r SO FT1 5, (a FT Number of Imes Soil rating Pipe material 61 176 SO FT /''9/0 Installer Date Installed WELLS PRIVATE ❑ OTHER Odentifv) Classification (A,B,C) Total Depth Cased to 4'v*D FT 7�_O FT Installer Date Installed: 7� 1j1z_L/*f5 pier �i 7�l9-8 REMARKS:���` 2 l Stt6m-1-vie ze-� a ekl5l"A )5u) LG• I Gn-° r A')f�_ _ Municipal and Stale guidelines in effect on this dl Health Department Approval: 72-013 (3/85) 61 In�ctions Performed by; i Date: certily that this inspection was performed according to all n ENGINEER'S SEAL °^ ` PERMIT NO: DATE ISSUED: I H -6 � - q - . --� "M H��� g-j� ������������� an. GRAVEL / DEPARTMENT OF HEALTH AND ENVIRONMENTAL ADDRESS: 1200 14"33 AVE SUITE B PROTECTION GRAVEL 825 L STREET, ANCHORAGE, AK 99501 SRAVEL ANCHORAGE� (FT.) 264--472O 870129 06/11)87 1P��1Jv 1q; m x~r 6�./ APPLICANT: TO PlFIE FANNE MAE MAKE an. GRAVEL / AECS TOTAL DEPTH (FT.) ADDRESS: 1200 14"33 AVE SUITE B GRAVEL WIDTH SRAVEL ANCHORAGE� (FT.) GRAVEL AK 99503 YDS.) TANK SlZE CLjEll" TACT PHONE: 561~5040 80IL RATING MAN FT,MR) LEGAL DESCRIS": SUBDIVISION: SAMP�ON EST. LOT: 23 BLOCK: 4 SECTION: 3 TOWNSHIP: 15N RANGE: 1thil LUT SIZE: 4090O (Eli. 13T OR ACRES) MAX BEDROOMS: 3 Listed below are the options available to you in designing ;mur septic system. Choose the option that best fits your site. DEPTH TO PlFIE 80 MAKE an. GRAVEL DEPTH (FT.> TOTAL DEPTH (FT.) GRAVEL WIDTH SRAVEL LENGTH (FT.) GRAVEL VOLUME (CU. YDS.) TANK SlZE (SALS) 80IL RATING MAN FT,MR) ** TANK MUST HAVE AT LEAST TWO COMPARTM�NTS ' I certi�y that: 1" I am familiar with the requirements {or on-site sewers and wells as set ForLh by the Monicipality oF Anchorage (MOA) �nd the State oAlaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design oi' this permit. 3. I will adhere tp all MOA and State CIF Alaska requirements {or the set back distances from any existing welli wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. �. I understand that this permit is valid for a maximum o! 3 bedrooms and any enlargeme:t will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BOILDING CODES� THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS^BUILTS WILL NOT 8E APPROVED WITHOUT AN ELECTRICAL INSPECTIUN REPORT; AND (3) THE ELECTRICAL N, SIG�ED : --- ~ ����= APPLICANT: / ISSUED BY DATE: e Municipality of Anchorage A G DEPARTMENT OF HEALTH & HUMAN SERVICES j„ 825 "L" Street, Anchorage, Alaska 99502-0650 110� SOILS LOG — PERCOLATION TEST^ PERFORMED FOR: '"L DATE LEGAL DESCRIPTION:"/ Z3 Oi4ldc'g 3/f, DEPTH (FEET) 7 90, 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Oh 5i4.7-/ S�Wb� bQ/irfe� WAS GROUND WATER ENCOUNTERED? / S IF YES, AT WHAT L DEPTH? /Q. S O P E Depth to Water After 64—,71Monitoring? -7, 8 Date: Reading Date Gross Time Net Time Depth to Water Net Drop /O - g7 o93S- voS 30 .M 67 – . ¢o -2-7 y /oo5'-1e,33' 30 Alm] e/3 .Z`/ 3• /o3S- /lai jo h/ , LSP- . , z I� v PERCOLATION RATE �' (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN j" S FT AND 91 FT COMMENTS 50/t //o/ r3D�11 aJf 3 o //�. C'EE?dfHE�ID ?3ED }iEZ7bi✓ /.57"%754A. PERFORMED BY: /%ECS A JzE,) I u `E . �'—� CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) 1141nGRY�� t v1 N `� I N,bTd o.S i b�^ vvr� X:39' �� s6a e; i>15u E $�9 •r z, �' ,�ae� uPb�& Y'v o 11� , ., ()F At �P c�. lo•••• - Y� .�...• . _ � QEIDI JR. ' ,��2251 c J profess.• � o s � , . , t 1. of A4- .lr1�Q••• �_ ?. '�"roV.� - - t 1:J 1 o• ,.eu..Naa taus^'. /� � _- J, ,lames !Carl Dowling : S;,,W o�•••......!•�a0 - .. _ ; � ...•- ._ � • '7_ , :.• qty �. I I., Q PAUfESSIONA�� -W, �Q�//IH�!s. /Q�e OD $ I �' . R_ H3a 5 85 5J3 I ' "I . N' rr {SIJ '/� '� � �� � 1 1 f 1 .• ' '.I 1 { I 2 It is the responsibility of the: owner to d�tersrrlihe' ; 1 EASEMENTS OF RECORD, I HER THAN the existence of any easements,' covenants4.,!or;re�' THOSE. SHOWN ON THE RECORDED ; stri;ct}ons. which'do not: appear on,'!the, recor e sub= PLAT, ARE NOT: SHOWN HEREON: ; l division plat .Under no: circumstances should`ar�y. data hereon. be used for construction' or;for estap lish'ing;boundary or fence lines The' suYveyor ta;te�J 1 A BUILT responsLb� 7. ty for the:tniti jE >�ansaction�:pri�y LOT SURVEY CERTIFICATIOf� IRONPIPEP ."oH�MEHr •.. STEEL PIN 17 SURVEY HUB s TACK LOT 3 BLOCK ��'/�? �'So�'/FSTATF_.S' • ���/-/O'7: _ _ , . �� SP � ANCHORAGE RECORDING DISTRICT REVISIONS DATE BY PREPARED BY: DOWLING •6h; ASSOCIATES' ..Resid'encs aE:+: a'� .r '804 EAST '15th Ave:-5uie 2 ; .. ;, "t. ` of ANCHORAGE, ALASKA.• 9950'1 DATE: 2 �f%uq /S 35f aY: R scA% y'_ '5�_' w U��-ao2 / _ .F.B, S��i� .�2 DRID�Gr�.LT> 72-013%RW.3/78) V 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 PH/ONE NEW -Sjey� S/G49cIC JJ�� G `D'8–Z831 ❑UPGRADE MAILING ADDRESS RO.13L),4 670/990 ctiky, AK 99s67 LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS 3 Well Absorption area Dwelling PERMIT NO. DISTANCE TO: (Op' 04070L, U y wzz Manufacturer Material s' ^ ' 2 No. of compartments Z F tT I N Liq. capacity in gallons 00 C) IF HOMEMADE: Inside length -- Width Liquid depth — _j0z DISTANCE TO: Well N Dwelling _ PERMIT NO. 02< Manufacturer Material _ Liquid capacity in gallons _ w= DISTANCE TO: Well r Foundation Nearest lot line PERMIT NO. .W.I CL Z No. of lines 7 Length of a line Total length of lines Trewekwidth Distance between lines r F., Z W J I r -'II'IG'�1e5 ccH Top of tile to finish grade / � Material beneath tile (v Total effective absorption area _ p 7 inches , % Length Width — Depth _ PERMIT NO. w t7 a H w °- Type of crib _ Crib diameter — Crib depth Total effective absorption area y DISTANCE TO: Well Building foundation Nearest lot line Class Depth Driller Distance to lot line PERMIT NO. J )�7r, V4+e W DISTANCE TO: Building foundation Sewer line N ig Septic tank ice Absorption area(s) /to, OTHER -+ PIPE MATERIALS SOIL TEST RATING IqL) 0 1Adr'Vj INSTALLER �I:u S Cons+-roc-hcr� REMARKS - /1 -kl mDr/�• O OAD 2 yr 1414 _4- vjZ j Z APPRO E DATE LEGAL prG� 72-013%RW.3/78) V 0 PERFORMED ;d SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION p PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST DATE PERFORMED: - — I LEGAL DESCRIPTION: Gross Time 1-0-1 :L Depth to Water Fr 15- SLOPE 5; iv L9, 1 0.453 0..32- VII I 0L i06-3 ff-T 0. zv 16- 5-.05 2 - a C C r :5 V4A 6atic 6(a �t i E. 'to-, J. Corwin 18 3 CE -5203 4` 19- 'i 0F E S r -k 5- ahs graven 6- 7 - 9-1 10- 11 WAS GROUND WATERS No ENCOUNTERED? L 0 12 - P E IF YES, AT WHAT DEPTH? 13- 14- Date Gross Time Net Time Depth to Water Not Drop 15- 5; iv L9, 1 0.453 0..32- /-fz, 0 i06-3 ff-T 0. zv 16- 5-.05 17-0. 0.5Z0.24 0.26 'to-, J. Corwin 18 - CE -5203 19- 'i 0F E S r -k ,)n J PERCOLATION RATE (minutes/inch) TPqT P1 IN PF=TkA1rF:h1 FT ANIn FT SITE PLAN Reading Date Gross Time Net Time Depth to Water Not Drop 'Zo 5; iv L9, 1 0.453 0..32- /-fz, 0 i06-3 0.2,7 0. zv 5-.05 /0 0.5Z0.24 0.26 COMMENTS PERFORMED BY: 72-008 (6/79) TE: /- t (-(I -(- 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 -S42Ve �S�G4 qq�� 9✓ PHONE �$3/ NEW ❑UPGRADE MAILING ADDRESS RO, BoX G70G90 C-�kJc .r�lc- AK `-7567 LEGAL DESCRIPTION -5 c: r�psan Si b. glrsc�c [o� Z3 LOCATION NO. OF BEDROOMS U Well Absorption area DISTANCE TO: Dwelling PERMIT NO. Y H F Manufacturer /, Material S, ^ ' No, of compartments Liq. capacity in gallons (000 IF HOMEMADE: Inside length Width Liquid depth q_ 0 v_ B Z DISTANCE TO: Well �/ - Dwelling _ PERMIT NO. = Z H Manufacturer .� Material _ Liquid capacity in gallons _ w = DISTANCE TO: Well I I O I Foundation t Nearest lot l`iine,> PERMIT NO. lat�,b �U�ei J LL z No. of lines Length line of each 3(v� Total length of lines Trenel width Distance between lines / aaw = f. Top of the to finish grade - tf3'-inctres Material beneath the V f Total effective absorptio area O inches w Length Width — Depth _ PERMIT NO. C7 a Type of crib Crib diameter — Crib depth Total effective absorption area m W W m DISTANCE TO: Well _s Building foundation g Nearest lot line J Class p,,,va,, Depth Driller Distance to lot line PERMIT NO. w DISTANCE TO: Building foundation Sewer line ry Septic tank Absorption area(s) 1 (U f OTHER 2� p PIPE MATERIALS }STM �U3q SOI L TEST RATING lqo 01 INSTALLER C 1� REMARKS //11 41 rn o D �_ l s fi` y . l a sor b �i� J, APPRO E � DATE LEGAL / /l��L 1,1 4,3 72-013'(Rg. 3/78) V � ^ ^ 1 _F`V' C3F-- ` DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 � � C3P4~~!E3 I-��� `�� `���� F-�EEF="It-1 :1 -IF PERMIT NO: 840706 DATE ISSUED: '08 0/84 ` � APPLICANT: SKAGG8 CONSTRUCTION' ADDRESS: P.O. BOX 670690 CHUGIAKr AK 99567 ~' � CONTACT PHONE: 688 ... 2831 LEGAL DESCRIP: SUBDIVISION,, SAMPSON . ' LOT: 23 BLOCK: 4 SECTION-. 3 TOWNSHIP: 15NRANGE: 1W LOT SIZE: 41956 (SQ.FT. OR ACRES) MAX BEDROOMS: 3 ` Listed below are the options available to you in designing your septic. system. Choose the option that best fits your site. � DEPTH TO PIPE BOTTOM (FT.) GRAVEL DEPTH (FT.) TOTAL DEPTH (FT.)�� ` GRAVEL WIDTH .<FT. } ^ lip, GRAVEL LENGTH (FT.)���� .-�e TANK SIZE (GALS), SOIL RAT IN6 (SQ.FT. /BR) - . ** TANK MUST'HAVE AT LEAST TWO COMPARTMENTS I certify that, 1" I am familiar with the requirements for on-site sewers an' wells as- `t forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. I will install the system in accordance with all MOA -codes r and � lati egu ons, and in compliance with the design criteria of' this permit. 3. I will adhere to all MOA and State 04' requirements fortbe set back distances from any existing well, wastewater disposal system or, public sewerage system on this or any adjacent or nearby lot. 4. I understand that this permit is valid for a maximum of 3 bedrooms and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED MOA BUILDING CODE S9 THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS­BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND � (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN" I � � u,�u DATE: �_ APPLICANT SKAG CTION o ISSUED BY DATE: ^/ ~ �� vJyn r MUNICIPALITY OF ANCHORAGE • yc DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED LEGAL DESCRIPTION: (J},7 /`fir -�✓ �ji�rj��j[}�� Pr SLOPE 01, 2 0 o e F u o �tnf,�t'kQ� (✓?�Q,I/C1. ����� 3 fd 4` o� 5 aN srl 5/�s��y ��acv�f 6- 7 8 9 10 SOILS LOG jA PERCOLATION TEST DATE PERFORMED: •7��/ ~Y SITE PLAN 11 B}'tES WAS GROUND WATER S ENCOUNTERED? NO L /a O 12 P IF YES, AT WHAT E 13 DEPTH? 14 A/� a 15- 0.--r 16 �' ��° `.. fuc J. Corwin 18�r! . CE -5230 19- rpt- ci, =rte b Reading Date Gross Time Net Time Depth to Water Net Drop +k-0 VI/At 4, 3 4-.53 /0 (),51 0. Z3 O, 32- 142,0 4. s' 15! CA5.06O. /0 0e9j27 0.40 /© aim 0.28 0.2 20 PERCOLATION RATE (B, 94 (mirvtes/inch) n TESTRUNBETWEEN ` FT AND 45 FT COMM PERFORMED BY: 72-008 (6/79) 17'JAJ/ Aw *Ll 411 %1� CERTIFIED DATE:. /T [ 'Ldf' I U) N 00 IM., I z 0 O a): 4J: LU > 4-1: W C: 0,4 LLI C/) X 0 Em LQ 4J: U A 44 w to: 0): LL 4J: 44: 0 o%o: 0 0: : CN: 0 z 0 O a): 4J: 4-1: W C: co: LQ 4J: A 44 w to: 0): uE 4J: 44: 0 o%o: EQ: 0: : CN: 0: w w > w 04U C4 -ft LL, V�- 0 z 0 O z 0 W C: LQ w w V�- 0 . . . . . . . . . . . . 0 0 00 0 0 0 0 00 0 4J Qt � a) (0 (3) ra C4 1-1 Qx rd 64 rd CL r6. rcE r 4 r(3 r4 rd rd Q): of vi cv ori ai of d rq Iql. 1;11. LO Ul r` H cq 0 0 0 0 0 0 0 0 0 0 0 0 Lq 0- 0: CIJ: rq Lr) Ln N 1-1i 0 0 0 0 0 0 LL. z 0 MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES M}i Division of Environmental Services = On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # C)� l - � - X HAA # �a nC;t --ICt-Ica 1. GENERAL INFORMATION Complete legal description Lot 23; Block 4; Sampson Estates Subdivision Location (site address or directions) 23827 Goliath Drive, Chugiak, Alaska Property owner Phillip Schuler Day phone 688-0798 hm Mailing address P.O. Box 671751, Chugiak, Alaska 995b27-6093 or 552-2519 wk Lending agency Day phone Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well xxx Community well Public water Day phone 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 xxx 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 H21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ,<cxr 1Jt-t_- • 4- 9 P Parcell.D. A. WELL DATA Well typeIf A, B, or C, attach ADEC letter. ADEC water system number Log present&VN) Date completed Driller 1 L LA S Total depth Cased to ZA_o Casing height Sanitary sealdVN) y Wires properly protectedQ3ON) m FROM WELL LOG AT INSPECTION c Date of test -% Static water level '7 0 c Well flow �,55^ m g,p, 4.4 j 4- o m . 11 9-P.M.91-1 n z Pump level L) tA �- '� i oc rn SEPARATION DISTANCES FROM WELL TO: p m r 2 Septic/holding tank on lot On adjacent lots Absorption field on lot 1 \ o� ; On adjacent lots Public sewer main Public sewer manhole/cleanout r Sewer service line 4- Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate �� li Other bacteria B Date of sample: Collected by: �5-�-2-• B. SEPTIC/HOLDING TANK DATA Date installed Tank size I o00 Compartments Z Cleanoutse6 !) `� Foundation cleanout4Y-M) T Depression (YW High water alarm (Y/N) Alarm tested (Y/N) Date of pumping l - 2 - 92 Pumper U SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: t r Wel I(s) on lot On adjacent lots Foundation �� r 1 t To property line Absorption field ) Watermain/service line C>r� Surface water/drainage � 17,2 'X 72-026 (Rev. 7/97) Front CONTINUED ON BACK PAGE A DIVISION OF COMMERCIAL TESTING & ENGINEEPHN0 00. ,,,G33 B STP.:E T ANC:-iORAU, AL.A8KA 93516 TEt -PHQNE (PQ7) -6_-5343 r -AX• (907) 501-5301 Chant Salapls ID 1,23 14 UWSOX EST. MID : UA Collactod Ct:* 13 12 a, 177:05 hst. Racal9ed OCT 11 5Z 1 14:01 hza. Praeoty0d AS RSQUIRED ANAL,IM R$3ULT3 for INVOICE 1 5965: Chetalnb Raf,I 92,57277 5&rcpie 1 3 matrix: WATER Clitnt R37A :9 & 9 INGMIAINO Client A%at :SN4ENGF AFO& Regt Ozdersd :y :R. SHAVER poll !NONE RECEIVED Analytim CoNplat@4 OCT 16 57 Sand Roports to: Laboretaty supervisor STEPHEN C. aDE 1jS & S ENGINEEF,ING Released Dy ��,, 2) _- ........w.-...._...mrnw..,.e.....,...,-n,e..-,em...v, _.n.-_-.... x., ...pe.n.-.--n.,,. _ - ......e.n..e..-.,-------------- Pazsmsiac ReVIA to UrU to Method Alloatblt Limits NITRATE -N 1.51 rg/1 SPA 353.2/200 0 10 Sample ROUTINE SAWO COLLECTED BY: R.J.S. Renarka: uuenm-..ueme.vvww--... ------------ ---............... vm.w-.•--_---................. ......... 1 Teets Performed Sea Ppociel rm t"ctiona Above U-Cnevsilall* )M- None Detected Sao Snrstl.t Remrzke Abate AA- Not Analynd LT -Loss Than, GT-Ere&taz Than tha SGS Grout (Soci-k4 C%6nl r.^.!A Lir cnrvFilia nre) r 4. 4 COLV I "' `IAL T234 TIN% ENGINEERINaG CO. AK DSIV +*�* A TELr=PHOttW tare. 562-2343 5633 astreet And,oraQ6,Alaska 04518 Drinking-vater Analysis Report for Taal Coliform Bartsch TO BE C QMP(F.TEP, BY WATER SUPPLIER TC BE COMPLETED BY LABORATORY 0 P41861t': WATFFI SY9TEM LG', 0 I_. -F LJ - p1i PRIVATE WATER SYSTEM Analysis gho»s this Water SAMPLE to be: ''ff, 1704 E.Vle, T1Yxr t.QF,- R§ e-1 No. 2 rg "577— M�tlM+y A9dsaa. � car slq'd _ ap c -r.. 17ti''F: �w��J i-� �r:�..J �'�� SAMPLE Z i Rio. tlry Year SAMPLE TYPE: A4outins ❑ Cheok Sample (Tv%r r't)t3tlnh ;o�mpka with lab ref. no. ❑ Special Purpo" ❑ vniraafed walsr SAMPLE Tim* C-01lomted No. LOCATION G t".actMJ By 4 -- 4 A..'1) .E.0 READ INSTRUCTIONS BEFORE -�5v satiafac Lary tQ Unsaml faoary U Smimpla w, king In tran4li, 6ample should not bQ over 30 hours oEd at examination to indfr-ate= reliable resift. Please semi now sample via s; oeml dagvory mall, n�j vete ` , --6 a--': Tim Nocol,ed Anril)r0 :al MAthod: M-Penbrant Firer Nr" of colonies/100 ml, Lab RO: No, Ana at JJ PACTER101.001Cr'AL WATER ANALYSIS RECOnD k1gr4rarts Flit»r: Dimct Count - � Colllorm/100 ml Yctitltotion: L.83 Fecal Gotifofm 0onflrmstion BOB COLLECTING SAMPLE Flnal 10mbrans F111mr Poe=uV@ y - - _ 001110 mrIao ml riwartea ey -- '� Date TNTC m. Too Nomerouu To Cohn) Time: —J CA �..tn. OB = Other Bactoria P.M. Member of the 5G5 Group ($0016t6 Un6rale de Surv@Illance) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL j )C% 7� {(� OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) 4-0 T y3 "?;Z -e w '/ jt5-3 7 -775. Xl� -1 Location (address or directions) C7oLif�T/i �i7. (b) Applicant Name 5 WE2LS Telephone: Home Business -Applicant Address (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution ���� %?a�78� Telephone - (e) Address Real Estate Company and Agent AVIV Address 3333 �e7u(A/ 141i7�- yz-o 95s"oi Telephone _ z7�-5r�G6 (f) Mail the HAA to i r t _ 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 3 3. WATER SUPPLY Individual Well M Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservatior attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite 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 (11/8a) 1W7 /,0V0A/ e-57T 5. ENGINEERING FIRM PROVIDL . INSPECTIONS, TESTS, FILE SEARCH, L A 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 fJ ? S Telephone Address /��' 33=�c SuiT� i�iiJtt�, 99su3 Date �ps�/'�1 +� .t .AV .'eyes'. �T AW CO Js.• • .fees* 00*0 �* • V. REID, JR. e / 0 CE - 225 iae� JrAFPro wa% The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 (11/84) MUNICIPALITY OF ANCHORAGE (MOAN HEA S,kW# THORITY APPROVAL (HAA) MuskOPE�AL SSR' t�EM� - FEBRUARY 1984 VoRC 264-4720 �uL 1 Q 19VLegal Description: �� J�� [� A. WELL DATA It a• r Well Classification If A, B, C, D.E.C. Approved (Y/N)'/_ Well Log Presen (Y/ ) Date Completed /%% Yield x"rte �r i Total Depth Cased tom'�r Depth of Grouting' Static Water Level Pump Set At i✓� Casing Height Above Ground Sanitary Seal on Casing (Y/ ) Electrical Wiring in Conduit(N) Depression Around Wellhead (Y NO) Separation Distances from Well: To Septic/Holding Tank on Lot �/2 ; On Adjoining Lots r 7 To Nearest Edge of Absorption Field on Lot 0.1��� ; On Adjoining Lots ��'Z) t To Nearest Public Sewer Line WA To Nearest Public Sewer Cleanout/Manhole "JI`- To Nearest Sewer Service Line on Lot Z Water Sample Collected by �� f/` G��Gs ; Date 7-2-47 Water Sample Test Results�si Comments B. SEPTIC/HOLDING TANK DATA Date Installed` Size Id -7o No. of Compartments �✓ Standpipe (/ ) Air -tight Cap (Y)N) Foundation Cleanou Y/ ) Depression over Tank (Y65) Date Last Pumped ` Pumping/Maintenance Contract on File (Y/N) ;for �� i✓ /� Holding Tank High -Water Alarm (Y/N) All# Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding F s Tank: To Water -Supply Well To Property Line - To Water Main/Service Line Course Comments Page 1 of 2 72-026(11/84) 0l7� i To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage ° CHEMICAL c� (iE®LOiiICAL LAB®R�7'®RIES ®�' ALASKA INC. '' 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 LA60RATORIES FEDERAL TAX ID # 92-0040440 AiNALYS18 REPORT BY SAPIPLE �lIont i'U# VLRbmi, Neq k: iiOr' Ur{ter iVO. I4l:+b CI ient Slripi i0: L'12j B4 SANPSutl Epi` Cl tent Account Akb,6kP Bate kepoct Printed: JUL 6'i u,r:iu Sample Recd AL L 87 Re teased by - Ordered By : A. WIEN Reports Address #2 Send Reports To: AECS LEE REID ALUu %1 33RD AVE.- C)ila B f ANCHORAGE, AK, 99503 Special ROUTINE SAHPLECOLLECTED BYA, HIEN Instruct: ChemlabRef #: 5791 Lab 5mpI Ill: 1 matrix: ;dater Allowable ParameterTested kesultiunits --------------------------------------------------------------------------------------------- Iiethoa Limits a11hATE--^i i.3mgfi i0 Sample ROUT INE SAMPLE: itemzcks: ANALY3101i:uMPLETED. 7-7-8 LABORATORY SUPEvVILSUR: ".iEPH N C I DE i Testsi-eiformed :t see Special IFist ructionsAbove r'G= hone Detected x ".ee ".ample Remarks Move NA= Dot Analyzeu I,`h-Les9Than, G'I=GreaterTnin CHEMICAL & GEOLOGICAL LABORATORIES OF ALASK4, INC 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE 79562 24 FEDERAL TAX ID # 92-0040440 AtMUMSPEPUIRT e 3AINPLE 1A i VER ML Peg ient -3nip I AD., Luo 84 SAHP-,aXi EST 6ajrjr) I e Vec a jUL z 6'r (maerea to; h hW' -,dki) Mll. 0-1 mi�Hup"OEIAK. Y 56J j'li ti Y ui 1 N I V- wuf'a L� u. 6 A 14 il i� Llistcluct 3r) Gem:G!« 1087'Ce(l Re'sult/ullits iu I , M!, woc". ulder NO. iioL) filet Accowu as keport printeu: i u L > u i &% dljy 2eports Address #2 LEE RE.1 ILI rj i e Rludf 1 a : LABU ".p%, 6I.WL?�tZiu?* bGum!) -- I' ts el for meo bee Specla! InstructionsArjuve fI I D-" None to @! aNlfflarkg Above «=2§%u J& J=Less-filml. Gl�uraarel Thall CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. q, TELEPHONE (907) 562-2343 5633 B Street 4g Anchorage, Alaska 99518 of :: Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIERII TO BE COMPLETED BY LABORATORY 111.131PUBLIC WATER SYSTEM I. �0 PRIVATE WATER SYSTEM f}cC S SCv / Sa �o NamePhone No. bt% 33su/TE r3 Mailing Address City State Zip Code SAMPLE DATE: EWE O 2 e-- 7 Mo. Day Year SAMPLE TYPE: �I!K Routine ❑ Check Sample (for routine sample with lab ref. no. ) ❑ Treated Water ❑ Special Purpose � Untreated Water SAMPLE Time Collected NO. LOCATION Collected 1 ie -,;z.3 If --1 SA��sanl G'ST I o 75/0 2 3 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 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received -2 - o;::? i�r,7 Time Received Analytical Method: Membrane Filter " No. of colonies/100 ml. Lab Ref. No. Result" Analyst E1 a G U m U m U m U m BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count Verification: LTB Final Membrane esulIss Reported By \ TNTC = Too Numberous To Count OB = Other Bacteria Coilform1100ml Coilform/100ml Date 3— Time: 150-P a.m. p.m. n . CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. q, TELEPHONE (907) 562-2343 5633 B Street 4g Anchorage, Alaska 99518 of :: Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIERII TO BE COMPLETED BY LABORATORY 111.131PUBLIC WATER SYSTEM I. �0 PRIVATE WATER SYSTEM f}cC S SCv / Sa �o NamePhone No. bt% 33su/TE r3 Mailing Address City State Zip Code SAMPLE DATE: EWE O 2 e-- 7 Mo. Day Year SAMPLE TYPE: �I!K Routine ❑ Check Sample (for routine sample with lab ref. no. ) ❑ Treated Water ❑ Special Purpose � Untreated Water SAMPLE Time Collected NO. LOCATION Collected 1 ie -,;z.3 If --1 SA��sanl G'ST I o 75/0 2 3 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 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received -2 - o;::? i�r,7 Time Received Analytical Method: Membrane Filter " No. of colonies/100 ml. Lab Ref. No. Result" Analyst E1 a G U m U m U m U m BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count Verification: LTB Final Membrane esulIss Reported By \ TNTC = Too Numberous To Count OB = Other Bacteria Coilform1100ml Coilform/100ml Date 3— Time: 150-P a.m. p.m. MUNICIPALITY OF ANCHORAGE r DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Swb j3fcC k Lj L9$ Z_3 Location (address or directions) Pe.4e�c Cr-eedc (b) Applicants Name 54e,[ Slcauas Telephone - Home Gse-7_.,yBusiness Applicants Address Pv 13ox td7c>&9d (c) Applicant is (check one) Lending Institution Owner/builder ; Buyer E::1 ; Other [—_I (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: (�G�j UC G�-) -?,S3 2. Type of Residence Single -Family f> -Z Multi -Family Number of Bedrooms '5 mI),K- 3. [dater Supply Individual Well f5Z Community Other (describe) Public M Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite l =1 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] 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 regula- tions in effect on the date of this inspection. Name of Firm G,,.a 4« Telephone SSI-(pIS1 Address 1.S L14 P T - A.,� ,4.,._ L.9x Date 6. DHEP Approval -Approved for Approved bedrooms r r �JP.KENGFEER- SEAL) V e ♦�Up )C'UC.if U I � By,- Date Disapproved Conditional Terms of Conditional Approval CAUTION THE 14UNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP 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. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Goy 3,3 MUNICIPALI y OF ANCHOR DEPT. OF HEALTH F< ENVI AL RCTF.CT;: NOV 11934 � ECEIVED Well Classification If A, B. or C. D.E.C. Approved(Y/N) (ei •maie) Well Log Present (Y/N) Y Date Completed `7-19-9t� Yield 3ppcTotal Depth Depth Zoo' x- Cased to 2nD' Depth of Grouting - Static Water Level 2d # Pump Set At Casing Height Above Ground Z'iz' Sanitary Seal on Casing (Y/N) i - Electrical Wiring in Conduit (Y/N) Y Depression Around hbllhead 1Z/N)ti Separation Distances from 4b11: To Septic/Holding Tank on Lot fool On Adjoining Lots > loo' To Nearest Edge of Absorption Field or. Lot iio' ; On Adjoining Lots >I go To Nearest Public Sewer Line V1,4 To Nearest Public Sewer Cleancut/Manhole N/,t To Nearest Sewer Service Line on Lot Water Sample Collected By L . d 4GL v- ; Date /0 - 30 -8V Water Sample Test Results Ccmirents B. SEPTIC/HOLDING TANK DATA Date Installed 7-zo-acj Size /000 acts• No. of Compartments 1z_ Standpipes(Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) N Date Last Pumped &A Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Wall , ( Ob` To Building Foundation To Property Line > (b` To Disposal Field 10' To Water Main/Service Line 4/1 To Stream, Pond, Lake, or Major Drainage Course > toy — 7` Comments - (Page 1 of 21 2m15®84 CHEMICAL & i..'%OLOCICAL LABORATORIi.,j OF ALASKA, INC. " TELEPHONE (907)-279.4014 ANCHORAGE INDUSTRIAL CENTERl,_ or, 274-3364 5633 8 Street } sl�' - x F � Drinking Water Analysis Report for Total Coliform Bacteria s TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY P)CK__({P Analysis shows this Water SAMPLE to be: WATER SYSTEM: I.D. NO. S atisf actory G t r X\ ;t... 1 tt/5 i ��ith� �j�t lyj� ! E) Unsatisfactory Water System Name i Phone No. ❑ Sample too long in transit: sample should I t� Ca Lj T i not be over 48 hours old at examination Mailing Address to indicate reliable results. Please send I� -i 9 S J'-, new sample. 1t 11. City State Zip Code 0 -30 -SS`! SAMPLE DATE: Mo. Day Year SAMPLE TYPE: ® Routine ❑ Check Sample (for routine sample t ❑ Treated Water with lab ref. no. 4 Untreated Water ❑ Special Purpose SAMPLE Time Collected NO. LOCATION �c tk� j w Collected By It( t 2 3 4 5 Date Received I Time Received (> I-5 Analytical Method: ❑ Fermentation Tube 7-Vembrane Filter Lab Ref. No. Result' Analyst EX l I FF7 I I CT7 u m u m *No of colonies/ 100 ml or No of Positive portions 06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1978 READ INSTRUCTIONS Date Collected Data Received Presumptive 24 Hours 48 Hours BEFORE Confirmatory 24 Hours 48 Hours COLLECTING SAMPLE Source a.m. Time Received p.m. Lab. No. 0ml I oml lOml IOmI 1 Broth 24 hours: Multiple Tube Report: Membrane Filler: Direct Count Verification: LTB BGB Final Membrane Filter Results Z, Reported By Date Tlmt 2.0ml I 0.1ml _Broth 48 hours: oml Tube$ Positt"i Total lomi Portlona Coliform/loomi Colllorm/looml p -m. C. ABSORPTION FIELD DATA �e S � Soils Rating in Absorption Strata Type of System Design 9 / Date Installed c3 ✓C _ Y 1 -?0 e �-`36 V Length of Field O'P/4� ` C�/ Width of Field [,291> ` Depth of Field �4X47�� 7­6� Gravel Bed Thickness e eI6 0,s Square Feet of Absorption Area Depression over Field (YN — Results of Last Adequacy Test Standpipes Present (Y/ ) Date of Last Adequacy Test '� p Separation Distance from Absorption Field: / To Water -Supply Well Z/- To Property Line To Building Foundation Zj To Existing or Abandoned System on fi Lot 7-Yi � ; On Adjoining Lots /d / To Water Main/Service Line ,// 1;f—To Cutbank (if present) !L To Stream/Pond/Lake/or Major Drainage Course /nz' To Driveway, Parking Area, or Vehicle Storage Area Commentse�5 D. LIFT STATION Date Instal Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent(Y/N) QRS ping g Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** certify that I have 'ec d, ven ied, or conformed to all MOA and HAA guidelines in.effect on the date of this inspection. !/ � awawd Signed �� Date A(��Re' Company //�� MO No /'��%i A.��j��••••••�'•7�f�40 rte;• % Receipt No. I b' s j!:*�® — /•• .•...•. •.•.•••• ..• Date of Payment o / ��•� Amount: $ G , �• ROY C. REID, J �• i 0. CE_ 2251 .R,°�i Page 2 of 2 72-026 (11/84) 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) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off' level at Cycles tested Surface water _ Date installed C;, _ 87 Soil rating o System type � 1 ,l ► Length 4_2 Width Za 4 Gravel thickness Total absorption area 10_4kt�:_ Cleanouts present¢Y7 1) Depression over field (Y/X Results/fail) �O<S s Total depth '2 \►-1 s'sL-• ) Date of adequacy test k<;;. _ q, for Peroxide treatment (past 12 months) (Y/L4) t"T-, ','� If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: hiG AtiSo In/ 05 . Well on lot \ t z]' On adjacent lots k 12L -f Property line �� ► � To building foundation � �( _�- Toting or abandoned system on lot IA - On adjacent lots , 4- Cutbank � �' Water main/service line (�►_l;- 1-4- Surface l;-1Surface water no Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. 5 3s 5 ENGINEERING 5 � ®O e����®� 17934 Eagle River Loop Road No. 204 ^1- "a°°v Signature Eat; r :..er—R We" - ®T°s 7 za j; �� ' Engineers Name � tl ogil �6333fl@EIUISG acat Como Date 1. ; t_�t�,E,' 3 HAA Fee $ / Zb a Date of Payment /0 .Z/j r � Z— Receipt Number 72-0261Rev. 3/911 Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number 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 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 & 5 ENGINEERING Phone Address Eagle River, Alaska 99577 Engineer's signature 6. DHHS SIGNATURE Approved for�u�co bedrooms. Disapproved. Conditional approval for Additional Comments M 2I ITIF Date \ �— \ — ""_n�wo�.ra t m .isnnznnsneoo � <33 neol:a.i t+AFE.n y A)sem;51Q, bedrooms, with the following stipulations: Date /C'_�_ 3�— l Y 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. 72-025 (Rev. 1/91) Back MOA #21 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata t`{o Type of System Design P Date Installed 8—zee—`r Length of Field -q6 5i / Width of Field �S� Depth of Field iz" Gravel Bed Thickness Square Feet of Absorption Area (aye Standpipes Present (YIN) ^ i Depression over Field (YIN) n/ Date of Last.Adequacy Test Results of Last Adequacy 'lest N/A Separation Distance from Absorption Field: To Water -Supply X11 NO To Property Line to To Building Foundation 710 To Existing or Abandoned System cn Lot hoh� ; on Adjoining Lots - >lov' To Water Main/Service Line N�A To Cutbank(if present) n��e To Stream/Pond/Lake/cr Major Drainage Course To Driveway, Parking Areal or Vehicle Storage Area > o` Comments D. LIFT`ON 1,14A e - Date Installed Dimensions Size in Gallons Manhole/Access (YIN) "pump On" Level at "pump off" Level at High Water Alarm Level at Vent (YIN) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes(Y/N) Comments * * Check I certify on the Signed Company L KB1/d5/s emitted Bedrocm Rating Against HAA Request at I have checked, verified, or conformed to all MOA of this (Page 2 of 21 Date I)s_ �Ce IAZ��—MOA No. ines in effect EN ERS c- EAL r j, J 2-15-84