HomeMy WebLinkAboutSOUTHFORK NORTH BLK 1 LT 3.Sou -h Forik North
Lot 3
Z3/ock 1
0*78 - /y/
/;z
Municipality of Anchorage Page _I_ of 3
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: fWggOlS'1 PID Number: o7S lti1!
Name: K k 14 C_ko
Wastewater System: ElNew ❑ Upgrade
Address:
!o C. ille- sr, E / Batu Ji
ABSORPTION FIELD
Phone�9y
rooms:
No. of Bedrooms:
/
Ar Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other
LEGAL DESCRIPTION
Soil Rating:
V*
Total Depth from original grade:
GPD/Sq. . Ft.
/f O
Lot: Block: Subdivision: ``
3 1 Fol.&
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
8•d'
y//o✓7ti
oti7
J 0� Ft.
Ft.
Township:
Rae.e:
w
Section: u
Sct
Fill added above original grade:
Gravel length: L o
Ti3N
I\ I
/
Q — 0,S Ft.
7 ` Ft.
WELL: P/New ❑ Upgrade
Gravel width: /
Number of lines:Distance
between lines:
-wA'—
Ft.
Ft.
Classification (Private, A,B.C):
7
Total Depth:
���
Cased To:
1/3
Total absorption area:
Pipe material: g7 U
3y
'r /'LIL7 r2f
Ft.
Ft.
/c'/z1 SQ. Ft.
k�C• 3U
Driller:
Date Drilled:
6 _A6 eM
Static Water Level:
�}S FL
Installer:
-0Com... .,
, 71
Date installed:
6-8-
Yield:
3
Pump Set at:
1/n Ksrowr
Casing Height Above Ground:
2
TAN K
tV GPM
. Ft.
Ft.
SEPARATION DISTANCES
JXSeptic ❑ Holding ❑ S.T,E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manufacturer:
Capacity in
From
Tank
Field
Station
Tank
Sewer Lines
Ayd �, PN/
^gallons:
45-(570
Well
+07 7
eA
ys
�A
cif
�T
Material:
STGELSurfac
Number of Compartments:
Z
Water
+Yav `
4 -loo'
LIFT STATION iv,4
Lotr
-t-jU
.
3�
I
a -3o
Size in gallons:
Manufacturer: -
Line
Foundation"Pump
.3
'
NA
on" level at:
"Pump " vel at:
High water alarm at:
Curtain
v
V
�A
Pump Make &
Electrical Inspections performed by:
Drain
Remarks:
BENCH MARK
.
Location and Description: /, ✓
/' �,f WZe,ilt 7-
Assumed Elevation:
s B3
ENGINEER'S SEAL
40
�.onfle
Inspections performed by: Dates: 1st �-s g
2nd d-8-
..«.."fee 00411 »
A ; Louis A.Butera
��®,
Department of Health and Human Services approval
s�• CE -6736
Reviewed and approved by:Date:
.:
72-013 (Rev. 9/91) MOA 25
Permit No. SW900151
Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 Teliephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: South Fork North L3 Blk 1 PID No.: 07814117
r
JA SWING TIESo
A -C = 59.6 0� ryA-0 = 105.3' (k 21. 0-0 115.5,N
d� \
a
P
\w
\ a':
\ k
5CALE I"=100'
ELEVATIONSREQ_ BA Z. NW LOT CORNER 11/3/98
(NOT TO SCALE) ASSUMED ELEV = 335.83
M ENGINEER'S SEAL
ORIGINAL
GROUND o OF 4 4 k%�
LEVEL AT: p O �/
p * : 49 TH*�0
491.9 ...... .. .. ........ G
TANK NO GWT �• ••••�
507. 07.2 505.9 505.9 -
OC.........................
\497.9 OO �••. •LOUIS A. BUTERA
O !P CE -6736 O
04��4 PROFESS\ONP����o
Nov -03-913 05:01P K2 EiILLINC, SERVICES
907 694-6344 P.01
%Lxrtifirb Prilling ung
by
"co. dba
SULLIVAN WATER WELLS
P.O. BOX 670272, DHUGIAK, ALASKA 99667 • TELEPHONE 888-2768
OWNER OF LAND 4Ez=S Cqt r' k.AQL�Si4ri�
ADDRESS 10 G i A AO., T`f aj J A me �ff Q
LEGAL DESCRIPTIONUW-7)4�,,,eK )oATrf
a 4.4_1 4,. i 3
PERMIT NUMBER qYQ X L bate of Issue
TAX INDENTIFICATION NUMBER , 07r -f4 36
Is well located at approved permit location? Kpirvs [i No
Method of Drilling: rr rotary ❑ cable fool
Depth of well: _ A C) �
HOLE
Casing Type _b7jf:Sk ._Wall Thickness . o7S Z inches
Diameter G 11 inches, depth 9- j feet
Liner Type; A t D -Jr
/a
Casing Stickup Above Ground: rad feet
Static Water Level (from ground level); feet
pumping levee_—feet after--hrs. pumping gpm
Recover Rate: S gpm
Method of Testing: __, ��
Well Intake Opening Type: ❑ Open End P.V159n Hole
[-j Screened; Start_ —feet Stopped feet
Perforations Start fe�e2_Stopped feet
Grout Type: 1rTa i•1'a Volume04� l3J'
Depth: from f7 feet, to �� feet
ti
'
Pump Intake Depth,
Pump Size hp Brand Name
Well Disinfected Upon Completion?4:;-Yes C1 No
i
4 oj,5,
1 14 .joa) t
Method of Disinfection:
Comments:
A94 east A<,= ; ,7 Q
Driller's Name
Bi=ll re
T.
r'Sa4eu)CK` 6�94I AaZS crr
f7iu—ct a115�a.recnorage
sent. Health & Human Servtoae
ATTENTION: It is the responsibility of the property owner to submit a copy of the welt log to the proper authority. Municipality
of Anchorage: Department of Health & Human Sew ces and/or Department of Environmental Conservation. Matsu Borough:
Department of Environmental Conservation_
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:SW980151
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAME:HEIKES TRENA L &
OWNER ADDRESS:10714 COLVILLE STREET
EAGLE RIVER, ALASKA 99577
PARCEL ID:07814117
LEGAL DESCRIPTION:
SOUTHFORK NORTH BLK 1 LT 3
LOT SIZE: 481524 (SQ. FT.)
NUMBER OF BEDROOMS: 5 THIS PERMIT: 5
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
PAGE 1 OF 1
Ise m
1 \0 m
DATE ISSUED: 6/04/98
EXPIRATION DATE: 6/04/99
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 BY: DATE:
ISSUED BY:- P_f/z�
DATE: Gj ¢ - 7-0
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
February 27, 1998
Jim Cross, P.E.
Manager, On -Site Services
Municipality of Anchorage
P.O. BOX 196650
Anchorage, AK 99519
Re: South Fork North Lot 3 Blk 1
Narrative & Permit Application
Dear Mr. Cross:
The proposed well and septic system will have very limited impact on adjacent properties for the
following reasons:
The surrounding lots are large, allowing sufficient room for septic sites.
2. Immediate neighboring septic systems are all +30' distance.
3. Reserve space is adequate, due to absorption capacity.
4. Drainage will not be affected and isnot a major consideration in our design.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\ 1997\98-005 -NAR. DOC
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box 773294
Eagle River, Alaska 99577
(907) 694-5195
ERES Project No.: 97-005
Calculated By: LB
Date: 2/27/98
Legal: South Fork North Lot 3 Blk 1 TEST HOLE 1
Single Family 5 Bedroom Dwelling
Deep Trench Subsurface Wastewater Disposal Field
Water use at 150 gallons per bedroom = 750 gallons
Percolation rate = 11.4 minutes per inch
Wastewater application rate = 0.8 gallons per day per square foot
Required absorption area = 938 square feet
Trench width (W) = 3 feet
Gravel depth (D) = 8 feet
Required length = Required absorption area 12 / D
Required length = 938 / 2 / 8
Required length = 59 feet
Total Excavation Depth = 11.0 feet
.......11.1 .............
LOUIS A. BUTERA.' O
J '•, CE -6736
004��O�O OF ESSSSo�Po� -
000 "3 - - - 95'
98-005-cal.xls 4:32 PM2/27/98
PERFORMED FOR: A li1—ka DATE PERFORMED:
LEGAL DESCRIPTION:7&4,rh F.'k Alo/Th L 7 ill Township, Range, Section:
1 H SLOPE SITE PLAN
7H!FEET) D III1 —1
t
2
3
4 6
5 b
6
7
r
8 a•
9-
10
10
11 0.
,r
12-
13-
14-
15-
16
21314 1516 U
17
18-
19-
20-
COMMENTS
81920COMMENTS
TS/ /'9an/CS
6W wi Ti? fan
allo/ S/l>�Co�s/sT4H�
roT%pH 11 77/
0
ON
WAS GROUND WATER
ENCOUNTERED? o
S
IF YES, AT WHAT /) 0 a x
DEPTH? /^ P
E
Depth to Water After Y
Monitoring? r� Dale:
Reading
Date Gross
Time
Ys'E kL t a.l4
Depth to
Water
Net
Drop
e7
- SO
44
A
{�s' �(IEfNQ44KEEfkS
aA•a,J.a,.:uF V LL
�-
2
of e
Municipality of Anchorage
S
n=
• DEPARTMENT OF HEALTH & HUMAN SERVICES
?
S't toui5 A. +morn
'r
825 ••L" Street, Anchorage, Alaska 99502-0650
�� a�"�y;�
5
Is. ' z-3
,• ``
A
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: A li1—ka DATE PERFORMED:
LEGAL DESCRIPTION:7&4,rh F.'k Alo/Th L 7 ill Township, Range, Section:
1 H SLOPE SITE PLAN
7H!FEET) D III1 —1
t
2
3
4 6
5 b
6
7
r
8 a•
9-
10
10
11 0.
,r
12-
13-
14-
15-
16
21314 1516 U
17
18-
19-
20-
COMMENTS
81920COMMENTS
TS/ /'9an/CS
6W wi Ti? fan
allo/ S/l>�Co�s/sT4H�
roT%pH 11 77/
0
ON
WAS GROUND WATER
ENCOUNTERED? o
S
IF YES, AT WHAT /) 0 a x
DEPTH? /^ P
E
Depth to Water After Y
Monitoring? r� Dale:
Reading
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
- SO
2
39 /y
S
3 3' o
5
Is. ' z-3
38 °
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN d FT AND �? FT
PERFORMED BY: �j�rs ImoCERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: r ✓ ��
72-008(Rev.4/85)
LEGAL DESCRIPTION: 7e,,7h F/'k /11e17-.4 L 3 I3/ Township, Range, Section:
DEPTH SLOPE SITE PLAN
FEET TC Q
1 '
2 0
3 °O
4-
5
6
'0
7 0
8
9 O
10-
11 \
12
13
14-
15-
16
415 16
17
81920 18-
19-
20-4
COMMENTS
1/ "1,
lJW WiT/1 jl111/ 4r!
%- 7W
immo�
NONE
■E■■
■"■■
■KIN■
■■11■
Emilio
MIMEMO
EN
■smo
-rg
:a
WAS GROUND WATER
ENCOUNTERED? N D
S
IF YES, AT WHAT OL x
DEPTH? NIA p `3
E
Depth to Water After
Monitoring? dr7— Date:
Reading
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
i.c
,.
n
l
2-zs- �s so
Municipality of Anchorage
3 �l6
DEPARTMENT OF HEALTH & HUMAN SERVICES,"
t•%s'nGG »..:=
825 "L" Street, Anchorage, Alaska 99502-0650
'<
SOILS LOG - PERCOLATION TEST;>
c _ ;
3
s
16.72
PERFORMED FOR: A (4r—ko
DATE PERFORMED:
LEGAL DESCRIPTION: 7e,,7h F/'k /11e17-.4 L 3 I3/ Township, Range, Section:
DEPTH SLOPE SITE PLAN
FEET TC Q
1 '
2 0
3 °O
4-
5
6
'0
7 0
8
9 O
10-
11 \
12
13
14-
15-
16
415 16
17
81920 18-
19-
20-4
COMMENTS
1/ "1,
lJW WiT/1 jl111/ 4r!
%- 7W
immo�
NONE
■E■■
■"■■
■KIN■
■■11■
Emilio
MIMEMO
EN
■smo
-rg
:a
WAS GROUND WATER
ENCOUNTERED? N D
S
IF YES, AT WHAT OL x
DEPTH? NIA p `3
E
Depth to Water After
Monitoring? dr7— Date:
Reading
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
/ a
l
2-zs- �s so
3 �l6
3
3
s
16.72
39 ire
61
6r2 z
/O
3 's/ie
1-116
PERCOLATION RATE l/l 6 (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
PERFORMED BY: /�-J I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE.
72-008 (Rev. 4185(
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: South Fork North Lot 3 Blk 1
2/27/98
A. GENERAL
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health and State
Department of Environmental Conservation requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet
Municipality of Anchorage, Department of Environmental Conservation requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any
adjacent multi -family wells.
7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer
approval.
8. It is always recommended that a surveyor locate the nearest lot line position and the location of any
easements.
9. Any remaining open test hole excavations shall be filled.
B. SEPTIC TANK
1. Septic tank shall have a minimum capacity of 1500 gallons and be of approved MOA design.
C. TRENCH
1. The trench is to follow the natural land contour to maintain uniform total depth of the trench bottom.
2. The bottom of the trench shall be level, plus or minus 1.5".
3. The total depth of the trench excavation is not to exceed 11.0' at any point.
4. The effluent line within the trench shall be laid level within 0.03'.
5. The trench gravel is to be covered with typar fabric material.
6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed
over the leachfield.
7. The area over the trench is to be finish graded to prevent ponding of surface water runoff.
8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any
Class "C" well, or 200 feet to any community well.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH = 11' GRAVEL DEPTH = 8.0' under pipe, 2" over pipe
TRENCH LENGTH= 59' TRENCH WIDTH= 3'
SOIL RATING = 0.8 GPD/ft2 BEDROOM CAPACITY = 5
SEPTIC TANK = 1500 gallons
\1997\98-005-spc.doc
Twenty-four (24) hours notice required for all inspections.
i
SINGLE FAMILY ON-SITE WORKSHEET
ERES PROJECT NUMBER: 97-005
CALCULATED BY: LB
LEGAL DESCRIPTION: South Fork North Lot 3 Blk 1
NUMBER OF BEDROOMS: 5
WATER USE PER BEDROOM: 150
GALLONS
PERCOLATION RATE: 11.4
MINUTES PER INCH
DEPTH TO GROUNDWATER: 17
FEET
DEPTH TO IMPERMEABLE LAYER: 17
FEET
USABLE SOIL STRATA
ANTICIPATED DEPTH OF COVER: 3
FEET
TOTAL USABLE DEPTH:
11
MOUND OR BED SYSTEM
USABLE SOIL STRATA DEPTH:
8
WASTEWATER APPLICATION RATE:
0.5
GAUSQ.FT
ABSORPTION AREA REQUIREMENT:
1500
SQ.FT
MINIMUM BED LENGTH
12 FEET WIDE BED
125
FEET
15 FEET WIDE BED
100
FEET
TRENCH SYSTEM
WASTEWATER APPLICATION RATE:
0.8
GAUSQ.FT
ABSORPTION AREA REQUIREMENT:
937.5
SQ.FT
SHALLOW TRENCH OPTIONS
DEEP TRENCH OPTIONS
5 FEET WIDE TRENCH
3 FEET WIDE TRENCH
EFFECTIVE REQUIRED TRENCH
EFFECTIVE REQUIRED TRENCH
DEPTH (FT) ENGTH (FT)
DEPTH (FT)
ENGTH (FT)
1 164
4
117
2 131
4.5
104
2.5 119
5
94
3 109
5.5
85
3.5 101
6
78
4 94
7
67
8
59
9
NA
10
NA
DESIGN SPECIFICS
FIELD SYSTEM:
GRAVEL DEPTH:
TRENCH OR BED WIDTH:
LENGTH:
TOTAL
EXCAVATION
DEPTH:
98-005-cal.xls
D (B=BED, S=SHALLOW TRENCH & D=DEEP TRENCH)
8 FEET
3 FEET
59 FEET
11.0 FEET
4:32 PM2/27/98
Municipality of Anchorage
Development Services Department -
Building Safety Division .
On -Site Water and Wastewater Proaram
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 995196650
www.ci.anchora9e.ak.us
(907) 343-7904
OM
/I�j' r;
y
CERTIFICATE OF HEALTH A THON T Y AFjPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 6 7fr' 7Nl"l i HAA nn303 a a
Expiration Date: D - O 3
1. GENERAL INFORMATION
Complete legal description Sos,>2 ~h _ /2/,"- 7,7,
Location (site address or directions) _ a''r /
Current Property owner(s) &E'er' '/ %re'rve L!ti c-lro Day phone e-76-- "G -7V -P,
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
ooP ' 7 7 / CG 3 .6•.r 4 2i. rte- .41& 97,x-77
__ Day phone
i�r��e••fi4% �slz Day phone 6V5.6 6r7e
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
S
3. TYPE OF WATER SUPPLY:,
TYPE OF WASTEWATER DISPOSAL:
Individual Well
19
Individual On-site
0
Individual Water Storage
❑
Ind:vidual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations -given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be. reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Eagle River Engineering Services
I`dwrrtc of Firm ' v ,... n R 273794 Foo- River, ' Fiwrre
Address
Engineer's Printed Name Date 7 ��
y_OF -44(
5. DSD SIGNATURE
t� Approved for ✓�
Disapproved.
Conditional approval for
Louis A Buten
CE -67]6
bedrooms.
bedrooms, with the following stipulations:
�- •• ,••••.^ •, •ice
i
Additional Comments 0j:, ON-SITE-
WATER AND
PROGRAM
i10
Attachments:
HAA Checklist X. Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory. Other
By: to. /� Original Certificate Date: % q — D .3
(Rev. 01102)
Municipality of Anchorage
• a'' Development Services Department°_
Building Safety Division -
On -Site Water & Wastewater Program S " T
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: .54af2 Fah /'/"n` L 7'. Parcel ID: 07k -/y/-i 7
A. WELL DATA
Well type If A, B, or C provide PWSID # Well Log (Y/N) k
Date completed Sanitary seal (Y/N) i Wires properly protected (Y/N) Y
Total depth -20O ft. Cased to Casing height (above ground) in.
s
FROM WELL LOG AT INSPECTION
Date of test 6 " 9i G' /O "a 3
Static water level 4S ft. 6-.2 ft.
Well production 3 g.p.m. 6 g.p.m.
WATER SAMPLE RESULTS:
�ff Coliform 0 _colonies/100 mi. Nitrate O, .?6 mg.11. Other bacteria colonies/100 ml.
k Arsenic: °'0'o X mgJI. Date of sample: -7 Collected by: e:�fsfJ
B. SEPTICIHOLDING TANK DATA
Tank Type/Material 574 -ed. / Date installed OTIF
Tank size /3-00 gal. Number of Compartments Cleanouts (YIN) i/
Foundation cleanout (YIN) ' _ Depression over tank (YIN) High water alarm (YIN)
Date of pumping i0 - ay —03 Pumper .112.E
C. ABSORPTION FIELD DATA
Date installed �- 9& Soil rating (g.p.d./ft2 or ft2/bdrm) 0`(F System type Tome �� h
Length S y ft. Width 3 ft. Gravel below pipe g ft.
Total depth / / ft. Eff. absorption area 9 VV ftZ Monitoring tube % Depression over field /0
Date of adequacy test 6 -lo -oz Results (Pass/Fail) P,fIr For S bedrooms
I Fluid depth in absorption field before test 3X in. Water added975• gal. New depth `V/ in.
Elapsed Time: 9f0 min. Final fluid depth -Ur in. Absorption rate >= 750 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION /✓%r
Date installed
"Pump�evelt in.
Datum
E. SEPARATION DISTANCES
Size in gallons Manhole/Access (Y/N)
"Pump off" level at in. High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot /a 7 On adjacent lots
Absorption field on lot /4"1—"
Public sewer main N 1.4
Sewer /septic service line
ras. r
On adjacent lots
t/o 1 1,
Public sewer manhole/cleanout N /y
Holding tank A� l.9 Y ivu'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line
Absorption field rio
Water main ^1/q Water service line 5
Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line too Building foundation fro
Water main^1J-'
Water Service line f 3 Surface water t
Driveway, parking/vehicle storage
Curtain drain lv/A Wells on adjacent lots %y '
F. COMMENTS
..OF 44(
�9f
ti A
G. ENGINEER'S CERTIFICATION.
..7.49
I certify that 1 have determined through field inspections and
•' Sao&»».....' ..
review of Municipal records that the above systems are in
with MOA HAA in effect on this date.��
Louis A, Buten ;
�� ti CE4736
conformance guidelines
Engineer's Printed Name
„�-
Date 6 -
HAA Fee $ �� Waiver Fee $
Date of Payment v Date of Payment
Receipt Number Receipt Number
(Rev. 12/01)
SGS Ref.#
1033289001
Client Name
Eagle River Engineering
Project Name/#
L3, B 1, South Fork North
Client Sample ID
L3, Bl, South Fork North
Matrix
Drinking Water
Sample Remarks:
I
All Dates/Times are Alaska Standard Time
Printed Date/flme 06/17/2003 12:05
Collected Date/Time 06/10/2003 11:31
Received Date/Time 06/10/2003 17:00
TechnicalDirector, hen C E
C
Released By L '
Parameter
. Results PQL
Units Method
Allowable Prep Analysis
Container ID Limits nate Date Init
Metals Department
Arsenic
0.00200 U 0.00200
mg/L EP200.9
C (<=0.05)06/11/03 06/13/03 JMP
Waters Department
Nitrate -N
0.306 0.100
mg/L EPA 300.0
B (<=10) 06/10/03 JS
Microbiology Laboratory
Total Coliform 0
coVI00mL SMIS9222B A (<=]) 06/10/03 KAP