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Home My WebLink AboutSEAVIEW HEIGHTS BLK 3 TR 45eoview H ights Block 3 T act 4 #011 - 271 -04 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program, 4700 Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 Page 1 of 3 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: OSP101012 PID Number: 011-271-04 Name: John Just Wastewater System: [] New [] Upgrade Address: 6644 W. Dimond Boulevard ABSORPTION FIELD Phone: Number of Bedrooms: [] Deep Trench [] Shallow Trench [] Bed [] Mound [] Other: LEGAL DESCRIPTION soil Rating: Total Depth from original grade: 1.2 GPD/Ft2 8.5 Ft. Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe: 3 4 Seaview Heights 3,5 Ft. 5 Ft. Township: Range: Section: Fill added above original grade: Gravel Length: 0.2-0.3 Ft. 58 Ft. Well: [] New [] Upgrade Grave[ width: Number of lines: I Distance between lines: 2.5 Ft. 1 Ft. I Classification (Private, A, B, C): Total Depth: Cased to: Total absorption area: Pipe Material: Private (E) Ft. Pt. 580 Ft2 3034 PVC Driller:. : Date Drilled: Static Water Level: Installer: Date Installed: Ft. Whitters Construction 7/1/2010 Yield: I Pump Set at: I Casing Height Above Ground: GPMI Ft.I Ft. TANK SEPARATION DISTANCES ~ [] Septic [] Holding [] S.T.E.P. [] Other: T~To Septic Absorption Lift Holding ~ublic/Private Manufacturer: Capacity: F,om~ Tank Field Station Tank Sewer Line ANCH TANK 1250 GaL Material: Number of Compartments: We,, 127.3 168.1 50' STEEL 2 Surface Water 100+ 100+--~/! LIFT STATION Lot Line 35.7 48.3~ Size: Manufacturer: Gal. Foundation 10+ 10+ "Pump on~ level at: "Pump off' level at: I High water alarm at: in. in.J in. Curtain Drain 50+ 50+ Pump Make & Model Electrical Inspections performed by: Remarks: BENCH MARK Location and Description: Door Jam of Garage Assumed Elevation: 100.0 Ft. Engineer's Stamp Inspections performed by: PANNONE ENG. SVC, LLC Dates: 1st 7/1/2010 Development Services Department Approval Conditional Approval Date: (Rev, 04/06) / - 15% i = 5% I ~NO WELLS OR I / SEPTICS W/IN ,'-IRESERVE 4- BR SAS (P) 200' OF PROPOSED / 150LFxS'EDx2.5'W, 8.5'TD / ,, ,,'CT,Or - 15% ~ 15% C2~_ 10.0 / ~..'-IPRtMARY 4 BR ,S. AS (NEW) 20' ELECTRI ,.?,AL 1%.¢r'~ 1158LFx5'EDx2.5 W, 8.5'TD EASEM :NT-I i /,r, nz% ,~ iSEE PROFILE & SECTION ..../ THI~_.__./ ~ ___ \ ' - _::.: .................. .._ ., 3 '~'-~-.~5_"~ ...................... "'%~% ~ 1,0009 SEPTIC TANK (E). ----. ~"'1 ......... ..' ........ T---_~P,/iABANDONED PER CODE ~ ~ ~' 1 ~ --,..,'~'~2 ............ ~',~ -"t-- 5?.~-~--POWER POLE (PP) ~ SAS (el I_ 15% PER CODE~'~- ~ '~' ,'~ r....12509 SEPTIC TANK (NEW) ~ / /--~. "-...j~./ ~ ~NSTALL DCO A~E.R TANK / / .. --- :~ --:' ~.,. ~WELL (E) / V/ 16~.1 1/27.51 ~/~RA / / ~ ~"~ °;~ .) / I S'~PTICA (;E (E)-/ /~ % ~ I S( REA (E)--~ ~LJ /~-------__/.z-FCO (E) I ~ \ w~'¢~ ' :- °-~ - ~ LWELL (E) -% N_,3 BR HOUSE (1[) ~ TO BE RE~OO, ED ~ TURI'IAGAIN ARM --/¢% i.'~¥ /~' ,...- ~UD ~-~ATS ~,,,, ,,"~ / ~W/ I / CO A B T2 PP T1 ~8.~ '125.5 ~~ I -I-2 ~8.8 124.7~ I G1 '1'17.7 ~38.0 I c2 ~o.~ ,~.s M2 84.~ @2.3 I TH-~ 136.3 153.~ NOTES: P~O]~--..~ ~rN'G ~'C, ~ F ' 9/15/11 RECORD DRAWINGS P.O. BOX 100217 ANCHORAGE, AK 99510 PHO,E (907)272-s21a FAX (907)272-~211 ./E." ~~¢, so,,~ ?. SEAVIEW HTS S/D Block 5 TRACT ~ ¢~~~ ..... NO ~ ~~~'¢~F~'~ :)11-271-04 John Just ~ · · ~ PERMIT NO. 6644 W. Dimond Blvd f~.. ..~%~ OSPlOlO~2 ~ ~ncho~, ~ ~9502 '%?~;~o~s,~, SPECIAL PROVISIONS TO SPECIFICATIONS 1. ALL CONSTRUCTION WAS INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON-SITE WASTEWATER DISPOSAL SYSTEMS. 2. ALL WAS IN ACCORDANCE WITH THE A~-FACHED SPECIFICATIONS. 3. SCOPE OF WORK: 4-BEDROOM HOUSE UPGRADE, NEW 1250g SEPTIC TANK, ABANDONED EXISTING TANK PER CODE, NEW DRAIN FIELDS, ABANDONED EXISTING FIELD. 4. GROUNDWATER IS NOT EXPECTED TO BE ENCOUNTERED DURING EXCAVATION, AS EVIDENCED BY THE SOIL TEST HOLE INFORMATION ABOVE 16 FT. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 12 FEET BELOW EXISTING GRADE, STOP WORK & NOTIFY THE ENGINEER IMMEDIATELY. PRIMARY FIELD RESERVE FIELD TH~I 97.1 -0'5 -O'B- J X / '~' X /fFilter Fabric 3.5' ~.0.5' / X ,,///~Drain rock 6" above pipe SM J -- ~ o,~ ~ ~(~ inv i' ~ ~t-..-'~Drain rock below pipe inv. ~ --88,6 r~ GP 2'5'1__ 10' [----~- 2.5' -14 ~ No groundwater min monitored SECTION z ~o ~ ~' ~o ~ ~z ~ ~ ~ 99.3 _ , · _ ~EW 1250 g 94.7~, ~ TANKSEPTIC -~ 93 6 --88.6 A~ B R EVIATI 0 N ~ PROFILE DEEP TRENCH SS LON~, S' ED, S.5'T.D. CU COPPER DIP DUCTILE IRON PIPE TH TEST HOLE DESIGN PARAMETERS LEGEND FC FOUNDATION CLaN OUT UPGRADE SEPTIC SYSTEM --w w WATER LINE/ T~ TANK CLEAN OUT NO. NO. BEDROOM: (4 gpd) WELL RADIUS C~ CLEAN OUT NO. TANK SIZE: 1,250 g~llon M~ MONITOR TUBE NO. PERC. RATE: 1- 5MPI R.t. RIGID INSU~TION SOIL RATING: 1.2 gpd/SF ~ ss ~ ss EXIST'G SEPTIC DCO DOUBLE CLEAN OUT AREA RQD: 500 SF ~ ss ss NEW SEPTIC DV DIVERTER VALVE SYS. ~PE: TRENCH, 5'ED, FS FLOW SPLICER MIN LENGTH: 50 LF USED: 0 CHAINLtNK FENCE (E) EXISTING 1 EA 58LFx2.5'WIDE, 5'ED,8.5' TD (P) PROPOSED TOTAL AR~: 580 SF (N) N[W ~%~ Dote NOTES: 9/15/1t RECORD DRAWING P.O. BOX 100217 ANCHORAGE, AK 99510 ... ...~ ~ PHONE (907) 272-8218 FAX (907) 272-8211 ~.~~~..' '.~%.~ ScaleNTS SEAVIEW HTS S/D Block 3 TRACl 4~~~-~~'''a' ~° 6644 W. Dimond Blvd .. . On-Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On-Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP101012 Tax Code Number: 01127104000 Work Type: Septic Upgrade Permit Effective Dates: May 20, 2010 to May 20, 2011 Design Engineer: PANNONE ENGINEERING SERVICE Subdivlslon: SEAVIEW HEIGHTS Site LegalAddress: SEAVIEWHEIGHTS BLK 3 TR 4 G:2322 Owner/Address: JUST JOHN W & EVA S 6644 W DIMOND BLVD ANCHORAGE AK 995023902 Site Mailing Address: 6644 W DIMOND BLVD, Anchorage Lot Size In Sq Ft: Total Bedrooms: 238674 4 epartment This permit Is for the construction of: Y 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 Ddnking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours pdor to each inspection. Provide notification by calling (907) 343-7964 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction dudng freezing weather must either:. A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing, Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, Alaska 99519-6650 www.muni.org/onsite (907) 343-7904 ON-SITE SEWER,/VVELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 011.271.04 Property owner(s). John Just Mailing address6644 W. Dimond BIvd Site address 6644W. Dimond Legal description (Sub'd., Block & Lot) Seavlew Hts, Block 3 Tract 4 Legal description (Township, Range & Section) Lot Size 238,674 Sq. Ft. Day phone .Zip Code 99502 .Zip Code 99502 Number of Bedrooms 4 THIS APPLICATION IS FOR (~3 all that apply): Absorption Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage [] THIS APPLICATION IS AN: Initial [] Upgrade [] Renewal [] I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. Pannone Engineering Services. LLC (Signature of property owner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number: (Rev, 11/05} Waiver Fees: Date of Payment: Receipt Number: Pannone En§ineerin§ Services LLC Steven R. Pannone, Principal Registered Professional Engineer E-mail: ~;t ~,veC~pa nen~a k.com May 4, 2010 Municipality of Anchorage Development Services Department On-Site Water & Wastewater Program 4700 S. Bragaw Street P. O. Box 196650 Anchorage, Alaska 99519 Subject: Seaview Heights S/D, Block 3 Tract 4 Septic System Permit Upgrade Request Ladies and Gentlemen: I am writing to request a permit to construct an upgraded septic system be issued for this property. The proposed systems will serve an existing three-bedroom house. The house is planned to be remolded into a four bedroom house. Currently the lot is developed. The lot is served by a private water supply. The existing septic system shall be abandoned in place per code. A new drain field will be installed north of the existing field and will be sized to handle a four bedroom waste stream. The surrounding developed lots are served by private water systems. The private wells are located over 100 feet from the proposed soil absorption system. The community well is located over 200 feet from the proposed upgrade. 1. Soils. A single test hole was excavated by PES on April 28, 2010. See the attached soil log. Ground water was monitored for seven days. No ground water was monitored to a depth of 14 feet below ground level after the monitoring period. Bedrock was not encountered in the test hole. It is my opinion, based on the results of the percolation tests and overall soils appearance; an application rate of 1.2 gallons/day/square feet should be used, using a conventional wastewater treatment system. Soil Absorption System Design. a. Percolation Rate: 1 to 5 Min Per Inch b. Application Rate: 1.2 gpd/sf c. Design Flow: 600 gallons per day d. Min. Absorption Area: 500 sf e. Total Depth: 8.5 feet f. Effective Depth: 5 feet g. Width: 2.5 feet h. Minimum Length: 50 feet i. Design Length: 50 If j. Effective Absorption Area: 500 sf k. Septic Tank Size: 1,250 g Septic Mailing: P.O. Box 3.00217, Anchorage, AK 99510-0217 Physical: 615 East 82nd Ave, Cuite B6, Anchorage, AK 99503 Telephone: (907) 272-8218 FAX: (907) 272-82:13. Page 2 of 2 3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and the existing drain field. The proposed drain field upgrade will maintain at least 100 feet from all surface water and drainage ditches. 4. Topography: The average topography in the area of the proposed septic system is approximately 5 percent based on the survey information. The proposed installation will be greater than 50 feet from the shoulder of the steep slopes. 5. Drawing Markings: The Drawings are marked "For MoA Review Only". When written notification that the review is complete and that there are no further comments is received from MoA On-Site Department, the note will be removed and "Issued for Construction" drawings will be issued. The proposed installation will not affect the future development of the surrounding or existing lots. There are no wells or septic systems within 100 feet of the proposed septic location. If you have any questions or concerns, please contact me at 272-8218. Sincerely, Sleven R. pannc~ ~ CE 8149 ~ Steven R. Pannone, P.E. Owner/Civil Engineer Attachments: Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 Physical: 615 East 82"d Ave, Cuite 86, Anchorage, AK 99503 Telephone: (907) 272-8218 FAX: (907) 272-82~.1 J i Trec~ 4 ,' I I I I ~ 15% J - 5% I jNO WELLS OR I SEPTICS W/IN /-IRESERVE 4 BR SAS (P) 200' OF PROPOSEr / 150LFxS'EDx2.5'W, 8.5'TD SYSTEM i / JSEE PROFILE & SECTION -- 15% ,- 15% / ,,--IpRIMARY 4 BR SAS (P) 20' ELECTRI ;AL ---- 1% / / 150LFx5'ED×2.5'W. 8.5'TD ' tact ' z~-l,O00g SEPTIC TANK (E). ' ' , - Trabt y TURI~'AGAL,~ ARM ~OT~S: PANNONE ~NG SVC, LLC h, P.O. BOX ~00217 ANCHORAGE, AK 995~0 ~.-x~.~, ..... '~Q~i~j~ ISSUED FOR CONSTRUCTION PHONE (907) 272-8218 FAX (907) 272-8211 ~*:49__ ~,~'~'~'~"* 11-1 "~, ':":$'i;?~W Sco~e SEAVIEW HTS S/D Block 3 TRACT 4 ... ~ 3i1-271-04 John Just rl~,.~:.. CE 8149 ..",~ PERMIT NO. 8644 W. Dimond Blvd rjl .. ........ ... PLAN Anchorage, AK 99502 Sheet 10F5 SPECIAL PROVISIONS TO SPECIFICATIONS 1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON-SITE WASTEWATER DISPOSAL SYSTEMS. 2. ALL WORK SHALL BE IN ACCORDANCE WITH THE ATTACHED SPECIFICATIONS. 3. SCOPE OF WORK: 4-BEDROOM HOUSE UPGRADE, NEW 12509 STEP TANK, ABANDON EXISTING TANK PER CODE, NEW DRAIN FIELDS, ABANDON EXISTING FIELD. 4. GROUNDWATER IS NOT EXPECTED TO BE ENCOUNTERED DURING EXCAVATION, AS EVIDENCED BY THE SOIL TEST HOLE INFORMATION ABOVE 16 FT. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 12 FEET BELOW EXISTING GRADE, STOP WORK & NOTIFY THE ENGINEER IMMEDIATELY. "~'"~" SECTION I ~ I II II / ' A B B R EVIATIO N S ,_,, ...-.--,¢, ,~...,,r~%~.:.-;-.~q:?.. -.;~-,x<.,.-,,<..~2 - CU COPPER DEEP TRE~H ~ L~, I' ED, I I' T.D. e~ Ductile ~ON P~P[ PfiOF~LE ~H T[S~ HOLE DESIGN PARAMETERS LEGEND FC FOUNDATION CLEAN OUT UPGRADE SEPTIC SYSTEM w--~ WATER LINE/ T~ TANK CLEAN OUT NO. NO. BEDROOM: (4 gpd) WELL RADIUS C~ CLEAN OUT NO. TANK SIZE: 1.250 9ollon STEP M~ MONITOR TUBE NO. PERC. RATE: 1- 5MPI R.I. RIGID INSU~TION SOIL RATING: 1.2 gpd/SF -- ~ --" -- [XIST'G SEPTIC DCO DOUBLE CLEAN OUT AE~ ROD: 500 SF DV DIVEETER VALVE SYS. ~PE: TRENCH. 5'ED. --" -- ss. NEW SEPTIC FS FLOW SPLICER MIN LENGTH: 50 LF USE: ~ CHAINLINK EENCE (E) EX,ST~NC 1 EA 50LFx2.5'WlDE. 5'ED.8.5' TD (P) PROPOSED TOTAL AREA: 500 SF (N) NEW ~ ~ ~[.~'t~ 5/19/10 P.O. BOX 100217 ANCHORAGE. AK 99510 JSSUED FOR CONSTRUCTION PHONE (907) 272-8218 FAX (907) 272-8211 ~:' ~( Stoic ..... SEAVIEW HTS S~D Block ~ TRACT ~~ ....... ~oh~ ~ust ~j~' CE 8~4g '~ ~ER~IT NO. ~644 W. Dimond Bird ,j ~.. .~ sw~ ~ ~" ....... "~ Shee~ 2OF~ SOILS LOG - PERCOLATION TEST TEST HOLE 1 SLOPE Sn'E PLAN OR TOPSOIL /~-- 6 ~~ / [_.4----[ /I-' ~ % Tract 2 10- GP G~L & ~ ~ ~ .... W~ GROUND WATER SLOPE ~4 ENCOU~ERED? ~ BOH 15 -- IFYES, AT.AT TH 1 DEPTH? ~-' 17 -- DEPTH TO WATER A~ER MONITORING? 18 DATE: 5~10 PERO~TION ~TE 2.2 (min~nch) PERC HOLE DIAM~ER 6 i~h~ TEST RUN BE~EEN 5.5 ~ ~D 65 ~ COMME~S: Test hole excavatcd b~ F]i~tstone Const. Test Hole ~s pr¢soak¢d ~fore ~rc test. Pcrc test r~ for o~c hour. ~st three reading re~ed on this PERFORMED BY: Steven R. Pannone~ P.E. I ~E~I~ THAT THIS TE~ WAS PERFORMED I~ WITH ~LL STATE A~D MUniCIPAL GHIDLI~ES I~ E~FE~ O~ THE DATE O~ THIS TEST. NOTES: P~O~ ~O ~C, I]C ti, 5/5/10 - ' P.0. BOX 102954 ANCHORAGE, X~ 99510 ~ ..... ~~ PHONE (907) 272-8218 FAX (907) 272-8211 ~2.' ~:}~% Sco,e SEAVIEW HIS S/D Block 3 TRACT 4 dohn ,Just ' ~xe:~--~x -- , Tr.'ct 4 -- Lol 5 Tract SEPTIC Mar~ 03 10 11:bbp donn ..,u,,,,..i,, "2'~ - PLOT PLAN ~ A2~BUILT . ~- , 1751 George Bell Cl~le, Ancho~go, Alaska 99515 (gO7) ~-6476 Phone 9 E, ~ACTERIAL AJ~ALYSIS SB.'~AGE i~ISPOSAL SYSTEM: LJEPARTMENT Or.F ~WIROPnJ~NTAL ~UALITY ~..~0 TUDOR ilOAD &'.;a-.mAGr, ,~L.ASr, A 99507 REQUEST FOR APPROVAL OF INDIVIDUAL SBqER AqD WATER FACILITIES FOR F/94 ,UbS}ER OF ~EI)ROC/1S ...... ---_2_ _ · oATA, ~.,, TYPE /4, I HSTALLER APPROVAL r,h"r,-,'.<"F FOR SE'..!ER PAGE 'P. !0 REQUIRED ;EASUREMERTS ~!ELL 'FO $~P'FIC TA..:( ~ / !ELL TO ~'~'~'~"~' Cf ~-~ '/ ,,.:c, ,'-~u~. PIT. HELL TO PROPERTY. LI2E ............ E, '!ELL 'FO OT.'IER POgOIT;L.;.C CO;iTAIIIi!ATIOI,! ~!'~ '/ F, FOU[-DATIOi.! TO SEPTIC TAI.,!I(. ~ '/~- C,,, FOUNDATIOH TO SEEPAGE PIT.__ Il, SEEPAGE PIT TO PROPERTY LIilE_. ,~PPP, OVAL ,~¢~I:.} FOR O. :,-- YE*.:': FP~ DF,,TE sIr:T!E'.~, (~RI:].ATI~R Ai,IQ.,I,[OI~CE AREA BOROUGH DEP~THEi.,Fr OF F_I,,~/IRONIVENTAL .o, UALITY DATE STATE OF ALASKA r ~,RTMENT OF HEALTH AND WE 'RE DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS Lab. No. OFFICE PUBLIC [~ SEMFPUBLIC F--~ INDIVIDUAL F--J OTHER REPORT RESULTS TO' NAME ADDRESS CITY ADDRESS Of SOURCE SAMPLE COLLECTED BY DATE COLLECTED TIME COLLECTED Sample Collected From [] Kilchen Tap [] ~lhroom Top [] Other IUstl em Well- [] Dug [] Driven [] Drilred [] Bored SOURCE: [] Spring [] Cistern [] Other Dug Well or Cistern Conslruction: Brlc~ or Walls - [] Wood [] Concrete ~] Melal [] Tile [] Concrete Top - [] Wood [] Concrele [] Melal ~] Open Top LOCATION: [] In Ba~emenl [] Basemenl Ogset [] Under House [] tn Yard [] Other Building Sewer Septic DISTANCE TO: or Olher Drainage Pipe__ Feet. TanI' Feel Tile Seepage Cass- -- Field Feet, pit Feet, Pool-- Feel privy Feet Olher Posslble Sources of ContamlnaHon Asbeslos MATERIAL: BuHdlng Sewer - []IronCaSl [] Wood [] Tile [] Fibre [] Cemen~ Records in this office indicate this WATER SUPPLY to be of: 3 Safisfaclory [] Questionable [] Unsatisfactory Sanitary Slatus. Analysis shows this Water SAMPLE lo be: Satisfactory [] Questionable [] Unsalisfadory, If an "Unsatisfactory" or "Questionable" status is indicated above you should lake immedlale action os recommended below, I. Notify consumers waler is polluted. Bail or chemically treat Ihil water as outlined in Ihe enclosed leaflel "Drink It Pure," 2. Increase chlorination suffi¢ierdly to meet recommended residual standards, Determine source of conlarnlnofion and take action necessary to maintain a safe waler supply al all limes. 3. Check chlori~alJon and other mechanical equipment. Make certain it is lunclioning properly. 4. II aller checking equipmenl a disinlecting residual is hal obtained, please wire Ihls office for emergency assislance or advisory services. 5. This is a surlace water source and subject Io pollution by man and anlmals. An approved water supply source should be developed. 6. Improve your [] spring [] dug weft [] driven well [] drilled well [] cistern. __7. Relocate your well fo o safe Iocallon in relationship to your sewage dlsposalsyslem. [] see enclosure B. Sample leo long in Irans~h sample should not be over 48 hours old at exomlnalion lo indlcate reliable results, please send new sample, [] Bogle Broken in Iranslh please send new sample. 9. Contact your nearest [] LocaIHeallhDeparlalenlor [] Alaska GENERAL: Does Water Become Muddy or Discolored? When? [] Yes [] No Diameter al Well, Deplh Feet. Well Casing Material Diameler Deplh Drop Pipe From Botlom__ Feel PUMP LOCATION: [] In Well [-]BasemenlOffset In [~ In Basement [] Room On Top [] al Well [] Olhor PURPOSE OF EXAMINATION: Illness Suspecled? [] Yes [] No New Source at Supply? ~] Yes [] No Repairs lo System? [] Yes [] No Division of Public Health, sanilation office tar bulletins, consuRation and assistance, SANITARIAN'S REMARKS Signature READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD Date Received : Time Received pm Lab. No. Lactose Broth 10cc 10cc 10cc 10cc J 10cc 1,0cc 0.1cc I 24 hours 48 hours Brilliant Green 24 hours 48 hours EMB AGAR Lactose Broth, 24 hrs. -- ¢8 hrs.. Gram's slain Coliform Density. (Most probable No. per 100cc.} MF results Reporled by This analysis indicates Coliform Organisms Io be; om Dote pm Absent Present-- FHA Furm 2573 Form Approved Rev. July 1958 FEDERAL HOUSING ADMINISTRATION Budget Bureau No. 63-R296.8 HEALTH AUTHOI~TY APPROVAL PART I.--TO BE COMPLETED BY FHA INSURING OFFICE MORTGAGEE SERIAL NO. Gene ~R~b.y Etdem MORTGAGOR OR SPONSOR PROPERTY ADDRESS Alaska State B~nk j 6644 ~. Dtmond Blvd. ' BLOCK NO. LOT NO~ 'rOT~L NUMBER: Con u~ic or othor uroa bo made Into BASEMENT ~ New installation additional bedrooms? LIVING BEDROOMS .......... (If Yes, how many~) WATER SUPPLY BY: SYSTE~ DESIGNED FOR ~ Public system ~ Co~l~UllJ~ system ~._in~ividua] NO, O¢ BgRMS. GARBAGE DISPOSAL SEWAGE glSPOSAL BYJ ~ Public system ~ Commuuity system ~ Individual ] ~ Yes ~No PART II.--TO BE COMPLETED BY HEALTH DEPARTMENT J~ALTH DEPARTMENT INSPECTOR'S SKETCH It is the opinion of the ~ State ~ ConDty ~ Local Department of Health that this ind{vidua] water-supply system is is upp y It is the opinion of the ~ State ~ County ~ Local Department of Health that this individual sewage-disposal sys- tem with prope~ maintenance: ~] Can be expected to function satisfactorily, and i /-"; ~ Cannot be expected to J~nction satisfactorily is not likely to create an insanitary sondition ff ,/', .... ~/I J ~ '~ //~ , ,' ~ -, .- TITLE August 4, 19~1 Environmental Specialist NOTE: The health authority should complete the appropriate opinion statement above and of~x dote, signature and title in tho spaces provided. Use of the above grid for Health Department inspector's sketch os well as use of the b~ck of this form is at the option of the health authority. PART Ill.--FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Compliance Inspe~ion ~eporc, and recommend that'the Individual water-supply system be considered ~ Acceptable ~ Not Acceptable Sewage disposal be considered ~ Acceptable ~ Not Acceptable. DATE SIGNATURE ~ CHIEF ARCHITECT DEPUTY FOR CHIEF ARCHITECT HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form 2573 Rev, July 1958