Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
SKY RANCH ESTATES #1 BLK 5 LT 10
Onsite File #015-301-28 Per Owner, both wells are in use as of 2019. Certified Drilling Log ® DOC CO dba ® ® AMOPOWBILL & CDLE ULLIVAN WATER P.O. Box 670269, Chugiak, AK 99567 588-2759 OWNER OF LAND: Julian Fischer ADDRESS: 11960 Steeple Chase Circle Bore Hole Data Depth From To LEGAL DESCRIPTION Sky Ranch Estates #1 Block 5 Lot 10 DATE: 8-9-19 0 2 PERMIT NUMBER: OSP191341 DATE OF ISSUE: 8-5-19 TAX IDENTIFICATION NUMBER 01530128000 Is well located at approved permit location: ®Yes ❑No Method of Drilling: Flair rotary ❑cable tool Depth of Well: 265' Casing Type: Steel Wall thickness .250 inches Diameter: 6 inches, depth 265 feet Liner type Static Water Level: 221 feet Recovery Rate 25 ® gpm ❑ gph Method of Testing Air Well Intake Opening Type: ® open end ❑open hole ❑ Screened Start feet Stopped ❑ Perforations Start feet Stopped Grout Type: Bentonite Volume: 50lbs Depth: from 2 feet, to 42 feet Well Disinfected Upon Completion: ❑yes ❑ no Method of Disinfection: Chlorine 50 PPM Comments: 2 4 4 11 11 94 94 109 109 134 134 186 186 220 220 224 224 239 239 247 247 259 259 265 Casing Stickup Overburden Clay w/ Gravel Silty Sand & Gravel Clay w/ Gravel Sand Clay & Gravel Sand & Gravel w/ Cobbles Silty Sand & Gravel Sand & Gravel Wet Tight Silty Sand & Gravel Sand & Gravel w/ Clay 4 GPM Hardpan & Boulders Sand & Gravel Water Drillers Name: Cole Sullivan ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. Matsu Borough: Department of Environmental Conservation. Wei? .Driliia; C, -Permit ,qumber. . V%, --Q: ' 1 13 Date ax, Issue; Parcel Ic-f entir, cat -01, Legal Descry 00,1 P P' rO rtly Owl V c) Pump Installation -Date: -Plimp Intake Depth Eatow Top ofWell C3.91n,,, feet PvEr2P "ARtLuffteturer's Name: PlImp Model: Pump size hp PMES,t.Adapter Hurial Depth, feet PRILISS Adapter Manufacturer's -Nianje. PRIM Adapter Insfalier: 4))01 - Well %Mpfccted u*p0j, Compietioll? 'Yes [_-?No 1Tetfwd. of Disilifecti(J11; A)MME11t,3: `UMD 131stallerANjaw—, Ar r/ V tteRtjon, Tie ;Dump j, U e) -shall provide a pu,,-np installation, jag the D witiin 30 days of pJ L -d V -4,M Gr3e,oyo,V e 6v 0 t 619 V OoveIOP'nent Services bepartment Building Safety r)ivij,,1Orj on -S'te W'3i-P-r,& WaStewater Proqr= 41 0 CIr, Orp Roc d P.O. Box 196650 Ic 4r A Milo Anchorage, kik: R95t07 7- 1 -5 k S Y (907 * 1 .43-7904 Pump Installation Log Wei? .Driliia; C, -Permit ,qumber. . V%, --Q: ' 1 13 Date ax, Issue; Parcel Ic-f entir, cat -01, Legal Descry 00,1 P P' rO rtly Owl V c) Pump Installation -Date: -Plimp Intake Depth Eatow Top ofWell C3.91n,,, feet PvEr2P "ARtLuffteturer's Name: PlImp Model: Pump size hp PMES,t.Adapter Hurial Depth, feet PRILISS Adapter Manufacturer's -Nianje. PRIM Adapter Insfalier: 4))01 - Well %Mpfccted u*p0j, Compietioll? 'Yes [_-?No 1Tetfwd. of Disilifecti(J11; A)MME11t,3: `UMD 131stallerANjaw—, Ar r/ V tteRtjon, Tie ;Dump j, U e) -shall provide a pu,,-np installation, jag the D witiin 30 days of pJ L -d V -4,M Gr3e,oyo,V e 6v 0 t 619 V �,""""'Y MUNICIPALITY OF ANCHORAGE ocnt / On-Site Water &Wastewater Program �c S. r;` PO Box 196650 4700 Elmore Road = Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 ,t 1 ` or http://www.muni.orglonsite "" . T N. ,/ cpal'tInent 4NCMON p.. On-Site Water System Permit Permit Number: OSP191341 Effective Date: 8/5/2019 Work Type: Well Initial Expiration Date: 8/4/2020 Tax Code Number: 01530128000 Site Legal Address: SKY RANCH ESTATES #1 BLK 5 LT 10 G:2737 Site Mailing Address: 11960 STEEPLE CHASE CIR, Anchorage Owner: FISCHER JULIAN &ANGELA G Lot Size in Sq Ft: 15326 Design Engineer: Total Bedrooms: 4 This permit is for the construction of: ❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy El Private Well 0 Water Storage All construction shall 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 shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: 1. Old well shall remain in service or be decommissioned in accordance with AMC15.55. 2. To close out this permit, please submit the following: a) Well log b) Pump install log c)Water sample results for total coliform, nitrates and arsenic d) Decommissioning log for old well, if not remaining in service. Received By: 7‘ I /-- -- Date: ri/7 •Issued By: 6(24 (�'Z Date: • ©rbit MUNICIPALITY OF ANCHORAGEER: '^,'/I • Development Services Department }` Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Q 1 5 301 25 000 RUS H Parcel I.D. L• ', � � � • • 'Y anc 5 a - • j Property owner(s) T1; cher or JA-^9elaPlr„r Day phone 1C)7 -7WU -Z4S5- Mailing address 114 60 Steep/c Charc G rc/e /4-n c ay-e A-14- 715-/ Site address 1/70 S+e p/e C,40,se Crr-ale, .�►c�Gor. �, ,4k r?S/ Legal description (Sub'd., Block & Lot) sky IaiicA 5 I/s; Lo+ /0, a/ock 5 Legal description (Township, Range & Section) hie I/4(SEI/`f Sec+; ,' ZZ ,Twr►sksp 12 Ngr01/4 Lot Size Sq. Ft. Number of Bedrooms it Ra^9� 3 wept e.,�srJMe t:a,rt APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial u Single Family (SF) Er (w/wo ADU) Septic Tank ❑ Upgrade ❑ Duplex (p) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well Water Storage ❑ USW] THIS APPLICATION INCLUDES A 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 owner or authorized agent) Permit/Rush Fees: 3 V) Waiver Fees: Date of Payment: ? 1,61(9 Date of Payment: Receipt Number: G Mb Receipt Number: Permit No. 0319<g I3gI Waiver No. G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc 1o+ sep +'� o„. ..O,F Amo 9 r'ea`Kr 1ha /00 ' Qa,P,`� `,i s�400 �� 49TH /\ Sao S/t�p/ 9 ..,Ke eth L. Dreyer,: ,`)V VA� o Pe, LS-8202 Q O Cht 4.4:0 ,h. SSE mi '.••..,...... ,,°o c�RcLE °°°000000���� Prcpo4e) well• 61 norms o•F L0+ 5 .scpbc Al / txisfie j Je?) )r04*d ,r/W/) IOU ' 0.00. o L.+ I i R.�20. 0p, N 5l•P }iG rarer -14•e vt / 0 0 I GRAVEL • DRIVE .N ..'. • � CV 24.2 V- a SHEDa 0 28.7 111.111.111111E3-6-0 LOT 11 ° 18.1 G`i 34.8 1.0 2.7N CO O Vs 2 01 .7CO CT) N CNC SN EXISTING HOUSE 0 Ci) GD W LOT9 0 48.3 O O U N 0 e O Z LOT 10 TAe 73nop.dseol well w.'// N1*e /' 4// re 9 ,'"fe1 fe�0a ra7iveNs ,A, ______ /,,i 9 ✓11 R✓1 FSCI /— 10' UTILITY EASEMENT S89°59'22"E 128.50' 10' WALKWAY 'b"W A.,:y«vrnw/v,w\x �wzs�uL•, „\,•"\',\\"\.,'•‘•‘.4\.V.wcvrwroNr LEGEND: SET FND ORDERED BY: EXCLUSION NOTES: It is the owners' responsibility to determine \ E the existence of ony easements, covenants, or restrictions 5/8"RB w/CAPD 5/8" RB 0 which do not appear on the recorded subdivision plot. NOTE: 3.25" AL.MON. MONUMENT 441 Under no circumstances should ony data hereon be used for HUB & TACK 0 ,.v.v.,.‘v,v,Avw•,.v,\,•”.v.o•••. •. ,A,,,,v..,.,,w4v,.v,ww.w.v.v•.v,v, construction or for establishing property lines. FENCE- -x- x — SURVEY CERTIFICATION: LANTECH hos conducted o OVERHANG- physical survey of this property os shown on this WOOD DECKS- I I drawing and that the improvements situated there-CONCRETE- I • • •I on are within the property lines and no encroach- ASPHALT- I - 1 ments exist other than noted. GRAVEL- I I AS—BUILT O F: LEGAL DESCRIPTION: SEPTIC STANDPIPES- QS LAND & CONSTRUCTION SURVEYORS-PLANNERS-ENGINEERS WATER WELL- 440 WEST BENSON BLVD. # 103 (fax) 561-6626 LOT 10, BLOCK 5 ANCHORAGE, ALASKA 99503 (907) 562-5291 WORK ORDER NUMBER: DATE: SCALE: NUMBER: JAN. 12, 2001 1'=20' PLAT 71-166 SKY RANCH ESTATES N0. 1, UNIT N0. 1 2001-L-017A DRAWN BY: CHECKED BY;GRID NUMBER: BooK/PAG E: WPJ. t. 2737 497/42 Geveiopment Services oapartment Suilding Safety Division On -Site 4 c+rLr & W(:stewatar PrOGf Gm 4704 Bragaw 51ree7 �� P.O. 6ax 19bb50 Mark 8egicn Ancyarwa, ,AK 99513-bb50 Mayor Im. muni.oro!ansire (9071143-7904 Pump Installation Log Weil Driuine Permit Number: SW_ Dar, -el Identification Number:_ Legal Description sj</>/ RANG 13 Pump Installation Date: F( T1 -,Y--r -In Date of Issue: _ ,4AW'A A— A),rn�/2Ac[dress: %�- puoap Intake Depth Below Top of WeE Casing: 1 -/ Dfeet pump manufacturer's Name: Pump Model:.7,!rC 3 %1 SNS pump Size .31,E hp Pitless AdapterYBuriai Depth: J® feet Pidess Adapter Manufacture�r''a Name: pitless Adapter Installer: /j/,+ `iti/ell Disinfected 'Joan Cample ion. V=s T� iylethod oo7f 1"4;4- > Comments: pump Installer Name: Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation. 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 MAI LIN G ~ A_~I~,~R ESS.4 HONE ~'~W '~ 7 -- ~/-~'~ / ~ [] UPGRADE LOCATION Well Absorption area ""1 I m ~Lq cap~ tV 0ga onsl .... nsde engt /Wdt -- ~ I IWell Foundation /,./ ~ · ~ No. of Iin~s Leng~J~of~c~ lir~ Tota~ lengtl~- of I' es Trench width ~ ~ ~ T~ of tile to finlsb 9rode )/ ~ Mate~{eatb tile NO. OF BEDROOMS .ERM,T NO. Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. Distance betwee ines Total effective al ~orption are ,' Length Type of crib ,~''61sTANcE TO: DISTANCE TO: Width Crib diameter Depth Crib depth PERMIT NO. Total effective absorption area Well Building foundation Nearest lot line Depth Driller Distance to lot line PERMIT NO. Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS c.£ ./ SO,LTEBTRATIN) REMARKS 24013 (Rev. 3/78) DATE LEGAL Date completed ....... (~.f....'.. :~Z., .~.:, ~ ......................................................................... Depth of well ......... ~i~..!-.:.~ ....................................................................................... Size of casing ............ ~[.:[i,..~.i ............................................................................ Distance to water .......?..-.~...~.~ ................................................................................ Distance to water while pumping ......................... :z ..... ': ...................... at rate L/ // DELTA DRILLING COMPANY SRA BOX 394 B aNChORaGE· ALaSka 99507 ElF F'I._ I E:FINT L 0 (:: I::1T ]: 0 I",! I.,..EG FIL. B'.OOl',lE~:"r' CREH I:::'. O. ~;T EE:E'L. li'~ LJ]T :tC;I E:LI'( 5 :E;I':::'¢ F'.FI[",ICH LE~;T. 'i~:~. T?F'E OF SOIL FIBE;O[~:F'T'IOI",I S;'¢$"FE'.f"I :[:B: I"RENC:EI P1FI'?::II'"IIJi"I I',!L.IIq[3E:[-".: OF' BE[.',ROOi"I:5 .... q. THE': RE[;!L~.*[ RE:[:) E; Z ZE OF' 'l-HE E;O I L FIErSOF~:F'T I ON :~i;YS'I'EI',I :[ S: THE: LENGTH D ]:l'lE:l',l.fi; t ON :( 5; THE [..E:I'.,IEi"f'H (: I N FEE T' ) ElF THE -FF:".bZNCH (IR [:,F:.'FI I NFl EL.D. THE !::,E:P'I"H OF' El TRENE:H EffR P I'r 1.'s THE: E:,I'.'STEIIqC:E' BE:THEEI'.,I THE ':7, I.J[~:i::EIC:E OK THE: GROIJIqD F:II'.,I[) TI-IE E:O'T'TC)FI OF' THE [E',:.:',CR'v'FI-['IOi'.,I (: IN FEE-f). THEF?.E :[% NO SET !4I[)"l'H F'OF~! THE GfRFP,/E]... DE'.Ir:'TH Z?.: THE PI:[I'..!IFIUI'"I PEP'TH CIE:' E'iRRVE:L.. BE:T!-,.IE:E]",! THE: OUTFEIL.!. FII",I[:, THE: E[EFF"I"OI'I OF THE E:::.~',CFI'v'FI'TZOi",I (ZN FEET). I::'E]¥.ri"IIT I:'tPPLIE:FIF,IT HF'I.':.:.: THE: F4:E~SF'EJNS:[EJ:[I..ITY TO II~,IF'I:DI:~rFI "f'H]:5: E:,EF'FIF~:TI'1E:NT C,U[R:[NEi THE II",I:i~TFII..L.F:ITION IIq'J~;I':'[EE:TIO["~:FJ OF I:::ll",l"¢ HEL.LE; FID..ZrF:IE:EI",IT 'TI] "f'.HI'.~i F'F.:CII::'ER'I"'¢ i:!f',l[:' THE NI..If,JBE~fE'. Of:: FE:E:E;):I)ENCE-C.!: THF:I-I- THE HEL..L. HIi.L '.iE;ERb'E. ................. qF' !~.,,J! ~'.:::~ <: ;.'_:.;?.~ ::* :E ~,'~,,11EE; IF=`' EC C::: 'T' ]E C:* IP.,!I :'::?::'.,; t=~ F~;~:: E: !~:." EEC E;::~ Ltl % F.;.-:'.: EE; E:: ...................... BF:ICI.,::F :[I..L :[ NG Ed::' FIN"r' '_:;'¥'E;TEr,1 f41 THOUT I:']: r.~RL. INSPECT I OIq EIND RF'F'RO',,,'E!L E¢'r' TH :( S I)EF:'F:Ii;?.'I"FIFZNT I.,.IIL. L BE: SI..JB,;rECT TO PROE;EE:!JTIEII".L IJF'Eff.,I THE T"¢F'[':': OF' F'UE~L. IC P.!EL.[.. ]; CERT]:F"r' 'l"Hl::l'r' 1.: :i: RI',1 FFlt',I:[L. IFII:~: H:(TH THE; F?.EL.':ilJIF::Ei',IEhlTE; F'OI;?.'f'H E¢¥' T'HE FIIJNICIPFILI:'r'"r' OE' FINChlO[?.FIEiE. 2': I HII..L IJ'.,15;-I"FIL. L. TFIE 57¥'!~;TE:i',1 IN FIC:COF~:[::,F~NC:E HIT'H THE: E:O[:,E~;. 3:: I L.INDE:F;'.5;TFIr.,ID THFIT THE OI'.,I--.E;ITE '.E;IEHEF;[: 5;'.r'E;TEI',I 1'4Fl'-r' J'~:E.'g!UIf4'.E: E3.,!LFIF:'.GEHE:NT' IF: THE £,::[E'E;ZDE:i",ICE .1_'9 REi'"ICI[.':'E;L..ED 'TO INCL.UE:'E I'"lOf:~:E THFIN t t,tl,I Nthti,ER OF [:~.P~.~ .h =- ' ' ' Y '1 -"" C} ,''~'"' '= · NO ' ' H]P]H FOB: ~ ": ' "'- i;:'~: I'IENT HI t I E;~ '>L E )E,£ 'f lC ¥'~::05,F,£:L 'J ] .?lLttl DIE,'IRNC:E DE-II,IF..EN P, HELL FIN[', fli'.t¥ OM-S.I"IE .c.,Et,.[Flt~E [',!SF'¥~;":.,qL F,V'..:Z[EI,1 15 V,I. 0 Performed fo Legal Descri This form re~ Depth F~et 6 7- 8- 10- ll - /3.5 /AN'~-'g ro u n d/~ aie r encountered? -W(~ ...... If yes, at what dept, h? Reading Date Gross Time Net Time i)epth to W,m:r Net Drop Pu rcol a t i on ra tm ifil lid te, Pr~i)osed.insLallat~on: .>e~'p,~le Pit Drain Field :.iuvUI of Inlet ...... . UepU~-[~'~(,(t~m'~'pi~ or Lr(u,ci. ' ................... COiI~'.[IITS: ......... r ~ "'"'i'-' ': ''~ .... ~ ........ :'- :.''~ a C. AL _�lp'j'i.:i p /(!�5 > .t4Zi� l57 1 D= rD� cvetc J �- July 6, 1977 t176364 Mr. Terry Hix 4830 Kenai Avenue Anchorage, Alaska 99504 .gubj eot.~. i Permit Expiration Dear Mr. Hix: A permit issued by thiF3 de~partment for well and/or on-site sewer installation on Lot 10 Block 5 Sky Ranch Estates has expired since the issue date exceeds erie (1) year. In the ew~nt you still plan to install the well and/or on-site sewer system~ a n~:w permit is rsq~[ired. The original soil test may be used to obtain a current permit. If the well has been drilled~ a well log should be sent to this department to document the installation date. If you have any questions regarding the above matter, please do not hesitate to contact this office irm]~ediately at 279- 2511~ extension 224 or 225° Sincerely~ Les M. Buchholz~ Sanita:~ian LNB. i Jh E:,IEF'FII:~':"I'i"IENT OF' HEFIL.'I"H FIND E.{' I .[ 1 ..L 1,11 II:.N 1 h L F:'E' L' "l'ErX T '[ ON · = ~.' ~: : . ~ .....': ~' ::' ,::.,_fi( E. TLI[:,I:Ii';;: E'.E:',., tINE. H_k GL, RI':::. i"ll:':l::':;Z[ i"11..11',1 NIJI' IE L[.. OF' E:EEE:.,F;;:I3Oi"I:E; .... '-1. IIIE. ;,.E::tdU:[b,E£D 2;].2.1E OF 'tHE _:;O:[1_ FIE,.E, OF..F:'f:(uN 5~E,'f'EI1 ~.E,. , "E L E'4G'"- D r,'Ef., ~;ZON ]E; THE LENG'"I~ ,: ZN :'~'1") OF;~'r~.E TRENCH OR E:,E:FIZI'.~F;':[EL.[::,. THE B, EF'TH OF FI 'TE:ENCH O1~'. F'Z"I' ZE;, THE E:,~];.1.FI[~::E..;, E:E'~'I~.IEEN THE: E;LIR:FFICE OF' THE: GROLII'.~E:, RND THE 13OTTC$1 OF 'rile E:d;:R%¢~ION ,:: ~ I='IEE:¢.,. lIE:NE ~:, 14LI ..,E.I kl.[DItl ~ I_.Jf*. iI,..ENCHI ...... ~ %. ~ ',:"", '"= 'I"HE; GRFIVEL. I::'IEFq"H ~E; THE I'"IZN~HUH DEF'TH~OF G~:FI~,"~... E,b.]~JELN THE OUTFFIL[.. F'ZF:'E I;:11",11) THE: [.-llLII IZfF:' THE EZ::'OZ:R',,,'FIT]:ON ,(ZN PEET::'. E, iI.Llf',la OF RN"r' $'¢:¢"['E1~ L,IITIqI:ilJT FINFll. Ii'.iS;F'EC'rlr_'d',~ FIND [::,l"_::l-::'f'lF;;~l"l"lEEi",l'l'' I.,.I'[LL E=[.L' ':' '" '' : ...... :' -1 ' c. :' -' .... r : I"I]:N~(I"IUi"I D~LS;TF:INCE ,-..., .... . - ._,= - : ,==-,: .: _ _ . ,=.,,c:.-, .... ,' E,E'II..IEEN I.'I"~b. IELL I=Ii'.,ID Fli"',l"r' ..,N _,]. FE ._,EH .GE. E,'[E;F'OE;RL =.,~..,~E.i'l 'LEE FE:.'E:T F":'II:;". FI I='P.:fVI::'ITE klE:L.t.:5, O,<;: ;~:OO I~E. E f F,Ok. Fl FUBL.[... kIEL. I_.. 14EI..L L..L ::, f ll".l:: t;;:E:g!IJZI:~::F:I:::, FIND I'%IST E:E fi'ET ~:,',¢~:O TO TI-lIE DEEI='FII:i:Tt'IEi",IT .t,4:[THII"4 O1=' 'f'HE: NELL COI"IF'I.ET T Oi',l. :k.,.. ~ / ').'i;F'EE: ]: t::' :( E:l=fr ~[ Oi'.4E; FIND CI:rNS;TB;:UCT l ON., E:, I IqGF:?RJ4~; RI:;,'E Iq, i.q .[ LHI ,LE. 'f'O [1,I:,1 .ILL IlLI4 ....... E:'¢ ..... : :1: E:EI:Ci-;rFr'.r~ "I'HRT ::1.: :1:I::1t"1 FRI'q;[L.):FIF.: N;~"FH 'rilE: REE,~UIREMENT2; I=OF.;.': ON-S:[TE E;E:blEF..'5:; ¢~ND klELL. E; RE; 5;E']" F'OF,'TH E:'¢ THE i',IUN;[C:~:PRI_.:¢T'.r' OF f:iNCHOF;:RtSE£. ;;a: :[ N;I:I_~L );I'.,iE;TRL.L.. THE 5:WSTEI,1 :[1'4 I:~E:CORDF~NCE 1.4:£TH THE COPES. :S:: ]; UiqL'.',ERE;TFIND THRT THE Oi'.,I--E;ZTE E;E!.,.IEF.: $"r'STEi'"l i'"IRV I;;!Eg!UZRE ENL. FtRC4Ei'4ENT ~F: THE I:;?.E~;:[DEI',ICE :IS REi'"iO[)ELED "fO ;INCLUDE i"IORE THRN 4 BEDROOI'"IE,. RF'f:'U ] E:RNT "f'E R I:~:"r' x,,:,L EL Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 RO. Box 196650 Anchorage, AK 99519-6650 www. ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parc'el I.D. 015-301-28 1. GENERAL INFORMATION Complete legal description Expiration Date: Lot 10, Block 5, Skyranch Estates #1 Location (site address or directions) 11960 Steeple Chanse Circle Current Property owner(s) Dan gstes Day phone 786-3485 Mailing address 11960 Steeple Chase Clrcle, Anchorage, AE 99516 Lending agency Alaska USA/Dennis Comeau Dayphone786-2000 Mailing address 4000 Credit Union Drive, Anchorage, AK 99503 Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by: NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding Tank [] Community On-site [] Public Sewer The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Cedificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 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) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. 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 less than 30 days old. Certificates are valid for one year for properties served by Class A or B wells or a public water system. The iVlunicipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72 025 Rev 01 001' 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 based on procedures outlined in the Health Authority Approval Guidelines for the Health Authority Approval application show 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 applicable Municipal and State codes, ordinances arid re~ula ions ineffect at the time of installation. ~,?~ EFIG NEERING 1'Z~34 Eagle River Loop Road No. Name of Firm $,,~le River, Alaska 99577 Address Engineer's Printed Name Robert C. ¢,nwan bedrooms. DHHS SIGNATURE P'"" Approved for F Disapproved. Conditional approval for Phone ~ '~' 7' _.)_c¢ 7~ Date ....... ' ), ~ · , ,,,. ~ bedrooms, with the followino stipulations. Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: Original Certificate Date: Reissue Date: Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section 825 "L" Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.ancho rage.ak.us (907) 343-4744 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~?? / O,~ ,'~ ~//' .~/~V'/Z/f"/~'~ ~¢'7- '~'/ A. WELL DATA Date completed ~/ Total depth ~' ft Cased to FROM WELL LOG Date of test / ~/~-/~ / Static water level ~- / ft Well production /O g.p.m WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi Nitrate eL'5' Date of sample: ~//~-///~'/ Collected by: B. SEPTIC/HOLDING TANK DATA If A, B, or C provide PWSID # __ Sanitary seal Parcel I.D.: ~;:~/~'-~ Well Log t~% Wires properly protected "~ Casing height (above ground) / ~- in. AT INSPECTION ~*~ g.p.m __ mg/I Other bacteria O S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle Rivel-, Alaa!<a 9~577 colonies/100 mi Dat~installed ~/ Tank size /Z~ gal Number of Compartments Cleanouts ~ .FoundatiOn cleanout c.~ Depression over tank ,A/"/_) High water alarm ~ Date af pumping ~i/'~ '~ ~o Pumper C. ABSORPTION FIELD DATA Dateinsta!led /'0//~//~/ Soil rating (g.p.d./ft2or~ [~) Systemtype Length /2~ ft Width ,:.,2 / ft Gravel below pipe ~ / ft Total depth /O ~ff Effective absorption area~,~.//zf¢ Monitoring tube~''~ Depression over field Da. te of adequacy test ~/~. Results(,P,_ass/Fail) ,/~'~:55 For ,~)///~'bedrooms , ~i~ll/uid/.~/./4--/_. %,'./.~ P absorptiS~ore ~ ? ~/,~. ~t ~ /_p ~,~ /~// / depth--in test ~ln Water added gal. New depth in. Elapsed Time:. / / rain Final/'fluld depth ~ in Absorption rate >= ~-~&'~P g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) ,'~/¢,p'¢'~ ,~W/~¢/,/ If yes, give date 72-026 (Rev. 01/00)* D. LIFT STATION Date installed ~../S~ze in gallons "Pump on" level atI _~/in "Pump off" level at Datum ,~ Cycles tested E. SEPARAToI~NN DISTANCES in Manhole/Access High water alarm level at __ in Meets alarm & circuit requirements SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/li~--s4et4~ on lot //0~ '~- On adjacent lots Absorption field on lot / E)O/7- On adjacent lots Public sewer main Sewer/septic service line Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main Drainage Property line ~ ~- Water service line /O f Wells on adjacent lots ,/o~) ~'% SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ,/~//- Building foundation ~' Water main Water Service line / o ~ / dqJ ~ Curtain drain Surface water Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION Absorption field Surface water Driveway, parking/vehicle storage $ & 5 ENGINEERING 17034 Eagle River Loop Eoad Eagle River, Alaska 99577 ~.~' ~,,,~ [ certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Date ~ / ,~ ¢'/0 0 HAA Fee $ Date of Payment ~/?- ~'/~-/2 Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 01/00)* 08:32 FROM-CTE ENVIRON~NTAL 5815301 T-$80 P.03/03 F-2§? CT&E Environmental Services Inc. Laboratory Division ~ 200 W. potter Drive Anchorage, AK 99619-160B Drinking Watez Analysis Report for Total Coliform Bacteria Tek 1907) RB2-2343 , . E$IDEBEFORE COLL£CTINGSAMPLE Fax: (907 561-6301 ~ iNSr~VCrZOtVS ON ~V~SS ~ ~ _ ....~ TO BE M . MUST BE COMPLETED BY WATic, F. ~urr .An.~is shows this Wat~' SAMPLE to be: [] _PUBLiC WATER SYsTEM LD.# [ I I tI I~ C~ Satisfactory ~PRIVATE WATER sYSTZM. 0 · Sendin~olct Q Send Result~ SAMPLE DATE; ,,b~RPLE TYPE: outlne o Repeat Sample (for routine souffle with lab ref. no Cl Special Purpose SAMPLE LOCATION 1005B 2 Month Day ~ TrL Untreated Water Unsatisfactory ri Sample over 30 hours old, results may be unreliable ' [] Sample too.[o~n~ in u~m. s. it; s~mpl? not be'over,~ou~s olU at cxammauun to indicate reliable ~sul~. Ple~e new s~ple ~a ~ial ~ivp~ mail Anal~lenl Method: ~b~e Filter * Number of col9~ie~10~mL ' ~f. No. R~ult* Analyst - Aath ~b~ Jun Comments: Time Collected Collected By · BACTERIOLOGICAL WATER ANALYSIS RECORB' Date; __~ Time: Cllent~Ofl~;ed of unsatisfactory results: MMO-MUG Rtsu|t: TotM Coliform Membrane ~llter: Direct Count Verificationt LTB ,, BGB Phoned Spoke with Date: Time: Colonie~100 mt COLIFIRM · Collfo~_rm/100 mi Time 117 r~ hfs Fazed Faxed EN~qRONMENTAL FACILITIES IN ALASKA. CALIFORNIA. FLORIDA, ILLINOIS, I~ARYLAND, MICHIGAN, MI0$OURI, NEW jERSEY, OHIO, WEST VlRGII~'~ 09-27-00 08:31 FRO~I-CTE ENVI RONh~NTAL ~d~l~ CT&E Environmental Services Inc, 5615301 T-GSO P.02/09 F-297 1005692001 S & S Engineering Skyraneh Est ~tl LI0 B5 Skyranch Est #1 L10 B5 Drinldng Water CT&E Ref.# Client Name Project Name/# Client PO# Printed Date/Time 09/26/2000 12:57 Collected Dntefrlme 09/21/2000 12:00 Received Date.ri'line 09/21/2000 12:10 Client Sample ID Technical Directora, Stephen C. Ede Matrix d~ ~ Ordered By Rele~e PWSID 0 Sample Remarks: Allowable Prep Analysis Parameter Resulis PQL Uni{s Method Limits Dste D~ Init Waters Depar ~l~en~ Nilrate-N 0.500 U 0.500 mg/L EPA 300.0 10 max 09/21/00 SCL M~erobiolo~ Labor&to~ Total Coliform col/100mL SMI8 9222B 09/21/00 JDT 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 Parcel I.D.# ~)!~' _~01-~ v NAA# 1. GENERAL INFORMATION Complete legal description Location (site address or directions Property owner Mailing address Lending agency J / ] Day phone Mailing address Agent Address Day phone 2. NUMBER OF BEDROOMS: 3, TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: TYPE OF WASTEWATER DISPOSAL: NOTE: Individual well ~,'/,'/, _ Community well Public water If community well system, provide written confirmation from State ADEC attest.. lng to the legality and status of system. individual on-site ','AT~)~ _ Holding tank Community on-site Public sewer If community waetewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72~25 (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 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. S & S ENGINEERING Phone Name of Firm Address EagJe River, AlasEa 99577 DHHS SIGNATURE ~ Approved for )-"~ L",/~ bedrooms. .,..' Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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 indepengent professional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICESJUL Environmental Services Division 825L Street, Room 502. Anchorage, Alaska 99501. Health Authority Approval Checklist Legal Description:/~OT- ,/O?/_~-¢ ~' ~'/~V,~,4'/V~--/¥ ~r"E-T' Parcel I.D.:~/')!,'~-'.~O/ A. WELL DATA Well type '~,"2_ Log present'N) Total depth Sanitary seal~l~/N) If A, S, or C. attach ADEC letter. ADEC water system number Date completed I~-/~-'/~/ Cased to ~ ~'~ / Casing height (above ground) Wires properly protected ~'~N). FROM WELL LOG AT INSPECTION Date of test } ~- / ~- / d~'~ f _ Static water level ~2~ / ~_ / '~Z / Well production ] O g.p;m, ~'° ~ g.p,m. WATER SAMPLE RESULTS: Coliform O Date of sample: '?~//~ il, SEPTIC/FcI~;;t31NG TANK DATA Date installed /Of/¢//~.~/__ Tanksize Foundation cleanout (Y/N) ~$ Depression (YIN) ~O Dateof.Pumping.~/~/~¢ _Pumper C. ABsoRpTIoN FIELD BATA Nitrate O, 7 2. Other bacteria Collected by:__ 1~034 Eagle River Loop ~oad No. 204 Eagle River, Alaska ~$77 Number of Compartments ~-- Cleanouts (Y/N) High water alarm (Y/N) / Date installed /~)/q p/ _So,lrating (g.p.d./fF~dr~). /~-~¢ Systemtype ~'T&~--~"~/'"/(/-/- Length ,~¢~- 2 / Width L~A/~( Gravel thickness below pipe ~ / Total depth /O / Effective absorptien area ~, Z~ ¢ Monitoring Tube present (Y/N) ¢~5 Depression over field (Y/N) ~O Date of adequacy test :~//~/~¢ Res,Its (Pass/Fail) ~ ~¢, For_ ~ Y~ bedrooms Fluid depth in absorption field before test (in.); Fluid depth -~ (ins) Minutes later: / Peroxide treatment (past 12 months) (Y/N) /L/0 Immediately afterd¢,,Cgal, water added (in.): Absorption rate = ~)('~ '7~- .g.p.d. If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed /"! ,/,~ Manhole/Access (Y/N) High water alarm level at* Cycles test~ed ~ E, SEPARATION DISTANCES Size in gallons "Pump on" ~p off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main /V Sewer/septic service line On adjacent lots /'00//"' On adjacent lots /~)4~ /J- Public sewer manhole/cieanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLD:i~G TANK ON LOT TO: Foundation c~ / Property line /~2 x-/L Absorption field Water main/service line /(..) ~L Surface water/drainage /O(-~ '~- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Surface water Curtain drain Building foundation ~ ' Water main/service line Driveway, parking/vehicle storage area /<~'/,ZO kc'/,,/ Wells on adjacent lots /'00 ~ ENGINEER'S CERTIFICATION .,...,~,%~,~.,~, . ~ ~ AL ~ I cer,l~ that l have determined thru field inspections and review of Municipal rec~,~ ~b.o~ms are in conformance with ~A ~AA ~idelincs in effect on this date. Date HAA Fee $_ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* ~ o0% FROiJ-CTE ENVIRONMEHT^L 5615301 T-B04 POI/04 F-372 CT&E Environmental Services Inc. Laboratory Division 200 W. Potter Dnve Anchorage, AK 99518 Tel' (907) 562-2343 Fax: (907) 561-§301 99.3344-1 S&$ EnQin(;ering L10 85 Sxyranch Drinking Water Clieflt pO/h pnnted Date/T~me: 7/13/99 23:00 Collected Daterf~me' 7112199 15:55 R¢ceive~l DateFf[Ale: 7/12J99 17:00 Tecnrfical D~r~c~- Stephen Erie Results PQL units Allowable Prep AnalyS~s Method LlrnltS Date Dale Init :~ C~)liform (Mr) 0 col/1 O0 mi SM9222B 7/32/99 0.72 0 5 mgic EPA 300 I0.0 7/12/99 SCL · ,.: MUNICIPALITY-OFANCHOI~.OE ~- -.'; :-.--"::~.,.._ . DEPARTMENT OF .HEALTH & HUMAN SERVICES Division of'Environmental Services: On-Site Services Section :- ~- ~ P,O, Box 196650 Anchm'age, 'Alaska - 99519-6650 APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION > "' '':~ ' ::" '~": ' ........ ) ;~Complete legal,description Lo~ lOi Bgoc~ 51 '8~q ~cnch . Loc~tion [S'ite address or directions) I 1 e~O 8~.p~ Cha~e ~?',?,:Proper~own~r~ L~off A. L~n~e ' :' "::' Dayphone~' 345-68~8 ...... Mailingadd~e~.,..q P.0. Box 1~2621 kne, horag~,: AK 99511 .~,;~,, ,.~ .~.~ . ~..,~ ,. ~. ,~. 't. Londmg agency - " ' Day phone~ - .,., ;, Mailing address .- . . , - ~.:-~ :-,' Address' ~2~0 C S~ .S~ ~0~ Anchoraq¢,- AK 99503 ,.: ' ~' . , : .': :;~. ;;~[~ unle~s o'the~ise requested, Iff~ ~ill be held fo~ plck~o: :' . .'~ ' ~' "z.'~ ~NUMBEROFBEDROOMS: .':_ ' ~ ' , ..... ..... ,-~PE ..- WATER ,,,,,,.,.., ..- .. , - ..... . ~. ':":.. Communt~_ well -.... ' ..... : ........... ......... .. .::~-.=._ · . . . ....... NOTE: If communi~ w, ll ~o~ provid0 wd~on confirmation from ~tato AD~ .?:,>~.:,:.:~/,.- -::,.,:-;~ Individual on-site :, . ., XXX ....... ............. g tank - ...~,~,..~'~,t_ :~;p ....... Holdl ,. -NOTE: If commun~ Wastewater system,'provide~ wri~en Confirmation'from State ADEC aResting to the legali~ and status of s~tem. · As cert flea:b,~'m'Y semi :A~'i~e:c~.hb~'~t0 and a~'0~ the va idation ~late 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, fu notional and adequate for the number of bedrooms and type of structure indicate¢ herein. I further veriht that based on t~e information obtainedfrom the Municipality of Anchorage files and from my inves.ti_,qation and inspection, the on-site water supply and/or wastewat~r disposal sYstem is in compliance with all Municipal and State codesj ordinances, and regulations in effe~t on the date of this'inspection, "-": :~'": -' '~ ' Phone '~''~ ~"&~/~ SIGNATURE ................ ' "' '""' ......... 6. b~r6~ms,'~ with the'.foll0w ng Comments :' '" ' ' The Mun~mpahty of Anchorage DepArtment of Health and Human 8e~wces (DHHS) msues Health Au~thonty Approval Certificates based only upon the representations given in paragraph 5 above by an indenendent professional engineer registered in the State of Alaska, The DH HS does this as a courtesy to purcnasers of homes and their lending institutions in order to satisly Certain federal and state requirements, Employees of DHHS do not .¥ nduct ns ect ons or ana yze data before'a certificate is issued The ~unicipallty ?f Anc,h,o,r,a. ge is no~ 9~ .P. ,, ....... ~.~. ...... - ' . "' · ~ ' - . , '-, Municipality of Anchorage Department of Health and Fluman Services HEALTH AUTHORITY APPROVAl. CHECKLIST A. Well Data Well type Log present {t~i~l) Total depth Sanitary seal ~N) If A, B, or C, attach ADEC letter. ADEC water system number /U)//~ ~/'2,,9.~ ' Casing height /.2 ' '-~ Wires properly protected (~1) g.p,m. Cased to FROM WELL I.OG Date of test I ,iL J ~ I ~ \ Static water level ~ 0 ~ / Well flow ! 0 Pump level1 (,,{~ ~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot. Absorption field on lot Public sewer main Sewer service line AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: I/..~/, / _(",) / ,,9- ZT' m~//,-, Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts ~N) _ High water: alarm (Y/I~ Dale of pumping Tank size /~r_J Compartments Foundation cleanout(~N) _ Y~'- Depression (Y/~J /~J/,A- Alarm tested (Y/I~ /~/-~-'-} -~1 Pumper ~* /-~44~ SEPARATION DISTANCES FROM SEPTIC/F'N~ING TANK TO: Well(s) on lot /Ob To property line [O Sudace water/drainage On adjacent lots { 0(3 Ij Foundation Absorption field ~ r Water main/service line loo '4- 72-026 (3/93)' Front CONTINUED ON BACK PAGE · Date install / -/~" -~ Manufacturer Size in gallons ~ Manhole/Access ~/~,1) Vent (Y/N) _"Pump o~l-a[.......~ / ~'~uump off" Level at :iegeht::;rAale~ re crnt Id;;; Ico d e s (y/N)~~~ SEPARATION~STATION TO: ~.~.~ Well on I.~¢---~' On adjacent lots Surface wat'~e ~RPTION FIELD DATA Width ~//1/,~, Gravel thickness "~;,2 ' { Total depth / 0 ' Date installed Length ~-~ Tolal absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/~ Cleanout present (..~N) Results ,~'/~"-~' Depression over field (Y/N) /~'~;~' for /'7/ Bedrooms After test If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots / OO ~W Property line ~' / To existing or abandoned system on lot Cutbank /~J,'~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I ce~'fy that I have checked, verified, or conformed to all MOA and HAA Signature Engineer's Name '~¢~ ~-'~ ~- (~',- 72-026 (3~93)' Back Waiver Fee $ Date of Payment Receipt Number CT&E Ref.~ Client Ealnple ID Matrix CT&E Environmental Services Inc. Laboratory Division ~/~.g/~.~ZT~x~x~'~V~.~.(~J~-~O'~£~~ Laboratory Analysis Report 95.0392-1 L10 BLK5 SKY ~CH EST WATER Client Name S & S ENGINEERENG WORK Order 12321 Ordered By RAY Printed Date 02/02/95 ~ 13:19 hrs. Project Name Collected Date 01/31/95 ~ 11:24 hrs. Project~ Received Date 01/31/95 @ 12:20 hrs. PWSID UA Technical Director STEPHEN C. EDE Sample Remarks: SAMPLE COLLECTED BY: J.W. QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 0.24 m~/L EPA 353.2 10. 02/01/95 CMR * See Special Instructions Above UA = Unavailable ** See Sample Remarks ~Lbove NA = Not Analyzed U- Undetected, Reported value is the practical quantification limit. LT = Less Than 200 W. Potter Drive, Anchorage, Al( 99518-1605 -- Tel: (907} 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA Time Time Date Dst e ' Inspector [)ate Inspector Inspector Conditional Approval Date Sewer installed Soils Rating Permit No. Septic 'rank Size Holding Tank Size Well To Absorption Area Well Log Received Well to Tank Property Owner Mailing Address Buyer Address Lending Institution Address Realty Co. & Agent Address Legal Description Street Location Type,g] Residence ,~ingle Family [] Muitiple Family [] Other ;Supply APPLICANT FILLS ()UT LOWER HALF ONLY No. of Bedrooms Phone Phone ATTACH WELL LOG. A well Icg is required for all wells drilled since June Individual Community Public Utility Sew,~ge Disposal ;~ Incllvidual [] Public Utility ~ Holding Tank 1975. For wells drilled prior to that date, give wall deptl~ (attach Icg if available.) ¢/ When Connected to Public Utility:_ NOTE: THE INSPECTION FEE MUST ACCOMPANY r[ACH REQUEST BEFORE PROCESSING CAN BE INITIATED.