Loading...
HomeMy WebLinkAboutMCMAHON BLK 4 LT 2McMahon Block 4 Lot 2 #017-041-09 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 I of 2 www ci.anchorage ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: •S w 06 G 15'/ PID Number: O / 7 - o y I - 09 N"N fFnd t' �wra•� 13ue4 Wastewaters stem: ❑ New ®U rade y P9 Aaa•ss Jsy`-/ L,oervrrns Sh. 919X-/1cr-2_8S'Z ABSORPTION FIELD Pnon• Number d Setr s 3 Y Y - / 8 Y6 3 O Deep Tr«rJt O SMlbv TI•aal t] tisa 0 Mara o Omar LEGAL DESCRIPTION SaR«ng T"DOM it= ongvugrape GPD/Ftl Ft. elo La suCamawn Dem b ppe txxicm han «ramal prep• Gaud mph b«Ndh ppe q 2 HC ",:292&7 FI. FI Tovnsap Range Seawn Fu Alai drove mgnW 7b• Gavd L•rplh FI. FI. Well: EY/ST ❑New Upgrade Gadrah Nan«dr»a Distance w.«I.Ne FI. FI Classification (Prada. A S. Q Tdd Dspn Cera Ip 1,X1 acsapion V"Pqm Md«ui FI. Ft Fit 1 9) —30 3 V Drjw Dal• Dni a Salic rod« L•vd InwlNr A- D«• instdlw 6 Ft yNa Pump S«0 Casing HaroM Abov Gana TANK GPM FI. Ft SEPARATION DISTANCES ® Septic ❑ Holding ❑ S.T.E.P. ❑ Other. To From Septic Tank Absorption Field Lift Station Holding Tank lublrjPnvate Sewer Line mandan,.w b 1 filp/a Q %LGn k12J*4fJ St'i'r Gr Won M««W Nu d Ca•panmeres I s„rt.�.wr« > TGp• > /�,r _ .., LIFT STATION w aau« LW Line 12s 7 to Gd 'Pump W. Nvd at 'Pump df W.d Nron wit« ram « Fanadm y 1 "I s s • 2.7 � _ in n in Pump Mak• d Mood Eleancd V West ro pertaniea by Cunrn Drrn Remrks Ory enol s hrc 16A 9 o,,/v BENCH MARK Lorrtgn ria Desawlwn act ernpebite l oma- eked Y3of/o,n of t/.lin `e- Nr✓ Co n.i AifUrrlea NrY1KK1. II Ft C ryul/O/In Engineer's Stamp Inspections performed by: SSC Dates: 1" 2 n Development Services Department Approval r:,�; • ;�' , , 49T" CV • Conditional Approval Date: . 4 THEODORE F. MOOR F • J.•• CE -3589 Reviewed and approved by: Date: i Is I*-+�' a ` Q ; •'•� ���e PERMIT NO: SW060151 PID NO: 017-041-09 EXISTING SOIL ABS. SYSTEM r iIII�IIIIN 1 IIIIIIIIIII. rIIIIIIIII/. VIIIA VIII/. II/II/. HILI. II/III rLiliill�I /ILIIIIIII rIIIIIIIIII IIIIIIIIIIII /ILLI,IIII • , 1 /II%I/yyy IIIIIIJ LY .II/I .ILI rIIeIII[.II ///IIIII.II.IIIII SWING TIES: I PAGE20F2 .F. i i `I NEW 1250 -GALLON DEEP BURIAL SEPTIC TANK ELEV. 102.9' 8.5' SOIL COVER INV., 1250 -GALLON 93.T DEEP BURIAL SEPTIC TANK PROFILE VIEW SCALE: 1" = 5' I" (;F A4 e-, J .�..................�..., . TH<`ODOR. F. "'JORE ; B •t\`�; .^7P Ali.: '%`• K4, IIIIIIIIIILILI/. TO: YIIIIIIIIIIIIIIII. I.II.I/II/.I FDN C.O."C" 8. • VIII/IIIIS.T. • • • VIEW S.T. C.O.PLAN DBL. C.O. 1 ELEV. 102.9' 8.5' SOIL COVER INV., 1250 -GALLON 93.T DEEP BURIAL SEPTIC TANK PROFILE VIEW SCALE: 1" = 5' I" (;F A4 e-, J .�..................�..., . TH<`ODOR. F. "'JORE ; B •t\`�; .^7P Ali.: '%`• K4, MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Jun 13, 2006 Expiration Date: Jun 13, 2007 Permit Number: SWO60151 Parcel ID: 017-041-09 Legal Description: MCMAHON BLK 4 LT 2 Design Engineer: 0019 FLATTOP TECHNICAL SERVICES Site Address: 012451 LORRAINE ST Owner Name: ANDY & JUDITH BUCK Lot Size: 40219 SO. FT. Owner Address: 12451 LORRAINE STREET Total Bedrooms: 3 Permit Bedrooms: 3 ANCHORAGE. AK 99516-2852 This permit is for the construction of: ❑ Disposal Field ❑✓ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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 engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling (907)343-79D4 ( 24 hours). ( Not required for a Water Supply Permit only). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: Date: e' // -� /0& Date: C- Municipality of Anchorage .. Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 ON-SITE SEPTICMELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 017 — 011 — 09 Propertyowner(s) - Anf!!!v d� 7440'fA 9"c4 Dayphone T'YY- /Byes Mailing address I ZNcf 1,0.1raent SJ Zip Code 99516 Site address m< Zip Code V. A Legal description (Sub'd, Block & Lot) S/ -b Legal description (Township, Section & Range) Lot Size q6�l'9 Sq. Ft. THIS APPLICATION IS FOR (®all that apply): Absorption Field ❑ Septic Tank IR Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Number of Bedrooms 3 THIS APPLICATION IS AN: Initial ❑ Upgrade IR Renewal ❑ 1 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. (Signature of property owner or authorized agent) Permit/Rush Fees: y60 Waiver Fees: Date of Payment: 6/ X2/06 Date of Payment: Receipt Number: 8 ) 591 Receipt Number: (Rev. 11105) CML & ENVIRONMENTAL ENGINEERING • ENERGY CONSERVATION & ANALYSIS TED MOORE, P.E. 14530 ECHO CANYON ROAD PH.1FAX: (907)345-1355 ANCHORAGE, AK 99516 E -Mail: tgmoore@gci.net lune 12, 2006 M.O.A. DSD P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: The purpose of this letter is to provide the required design narrative in support of our application for a permit to replace a collapsing septic tank on Lot 2, Block 4, McMahon S/D, located at 12451 Lorraine Street. A site plan and specifications are enclosed for your review. The replacement tank will be installed at the location shown on the site plan. The topography of the lot slopes downward toward the west The proposed project will have no significant impact on present or future water supply and wastewater disposal systems serving adjacent properties, nor will it have any significant impact on reserved space -surface and subsurface, or on drainage. Please give me a call at 345-1355 if you have any questions on this submittal. Sincerely, Ted Moore, P.E. r.1 LOT 1 LOT 2, BLOCK 4 McMAHON SID 0 %......'si � HOUSEINSTAL N�W 4. - 1260 -GALLON 'SEPTIC TANK WELL/NIIIIIII� IIIIIIIII/�ABANDON EXISTING IN/IIIIII� INIIIIIII� IIIIII/III� 000 -GALLON SEPTIC TANK I; EXISTING , SOIL ABS.; SYSTEM /Ilh I' LOT 3 (VACANT) , , , , * ' 49 m k,* *� 'j . ................. �F... 7is.Yrz-t►.. �.. 'p • TEODOREF.MOORE i CE -3589 A� ►��o fe sala �� LOT 10 WELL OUSE LOT 9 i LOT 8 OUSE o LOT 2, BLOCK 4, McMAHON SID SEPTIC TANK REPLACEMENT SITE PLAN FLATTOP TECHNICAL SERVICES 1 INCH = 50 FEET 14530 ECHO CANYON ROAD DRAWN BY TFM ANCHORAGE, AK 99516 _JUNE, 2006 NOTE: THIS IS NOT A SURVEYED PLAT. ALL LOCATIONS SHOWN ARE APPROXIMATE. .i -- _ i i i i LOT 8 OUSE o LOT 2, BLOCK 4, McMAHON SID SEPTIC TANK REPLACEMENT SITE PLAN FLATTOP TECHNICAL SERVICES 1 INCH = 50 FEET 14530 ECHO CANYON ROAD DRAWN BY TFM ANCHORAGE, AK 99516 _JUNE, 2006 NOTE: THIS IS NOT A SURVEYED PLAT. ALL LOCATIONS SHOWN ARE APPROXIMATE. em—ttop 7echnicaCSen ices 14530 Echo Canyon Roa,(Anchorage,.Ax99516 Thone (907) 345-1355 Lot 2, Block 4, McMahon SID 12451 Lorraine Street Septic Tank Replacement Specifications 1.0 General: 1.1 The scope of the project consists of removing an old 1000 -gallon septic tank and replacing it with a new 1250 -gallon septic tank located outside the 100 -foot radius around the well. 1.2 Construction shall be as depicted on the approved site plan. Minor deviations from these drawings may be allowed or required by the engineer conducting the inspections. All construction procedures and material specifications shall conform to Municipal and State requirements. All separation distances shall be in conformance with Municipal requirements, unless specifically waived. 1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work around any buried utilities. 1.4 Unless agreed otherwise, the contractor shall be responsible for any tree clearing and grubbing necessary to complete the project. 1.5 The contractor shall provide adequate cover material and rough grading over all system components to ensure that proper drainage is achieved after settlement and that there are no residual depressions. Insofar as possible the contractor shall minimize damage to trees and existing lawn areas. 1.6 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after the soil is compacted, as well as placement of topsoil and reseeding all areas disturbed by the construction. 2.0 Septic Tank 2.1 The existing septic tank must be properly abandoned by thoroughly pumping, removing the top and backfilling with soil, or burial elsewhere on site. 2.2 The new 1250 -gallon, 2 compartment septic tank shall be Municipally approved and shall be set level on undisturbed soil. The tank shall be fabricated of l0 gage steel to allow for a burial depth in excess of 6 feet. Each compartment shall be equipped with a watertight manhole cover and a 4" cleanout. Care shall be taken to achieve the required 100 foot separation from all wells. 2.3 A foundation cleanout shall be installed at the point of tie-in to the existing waste line coming from the house and a double cleanout in the discharge line between the new tank and the seepage pit. 3.0 Inspections: 3.1 A total of 3 engineering inspections will be required during the course of the project: (1) initial discussion with the contractor to finalize the location of the tank and construction procedures, (2) after the tank is set level and piping connected but prior to backfill, and (3) after rough backfill and grading is complete. 3.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in advance to ensure the availability of the engineer. i MUNICIPALITY OF ANCHORAGE 1 p DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264.4720 ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME L PHONE❑NEW N 4f6AJ 33312 UPGRADE MAILING ADDRESS LEGAL DESCRIPTION ,J Z u�.f ovC-yy1-- .Z8 77W A 3r�1 LOCATION L/ y Nb.OF BED OOMS Well qOI DISTANCE TO: Absorption area Dwelling PERMIT NO. UY _ it Q W< Manufacturer Material No. of Compartments N Liq, capacity in gallons IF HOMEMADE: Inside length Width Liquid depth 6 Y DISTANCE TO: Well Dwelling PERMIT NO. —00Z _ F Manufacturer Material Liquid capacity in gallons D m= DISTANCE TO. Well / Foundation 5 Nearest lot line PERMIT NO. �7� O J LL Z No. of lines Length of each ling Total length of line Tre ch wi }h Distance between lines F Z W •� wlwhwr. ^ IL F- Top of the to finish grade Material beneath the Total effect aab41 ea O C7UC— ::5,-'5'-"Tch s� Ej .s�tion Length Width Depth PERMIT NO. ' W F W� Type of crib Crib diameter Crib depth Total effective absorption area a DISTANCE TO: Well Building foundation Nearest lot line Class Depth Driller Distance to lot line PERMIT NO. W DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE TERIALS PtAL ^� NZ72 s S SOIL TEST RATING INSTALLER ' RE KS � � o � ?; '••sof-�i �. ' Tx TA •... .:....... * i Ak 17 i THOMA/ P. • •a •: 24 0 • - LBq f g r Lei SL APPHCrJED DATE LEGAL Cjq 4L- 72413 (Rev. 3/78) V 1 MUV4 I C I FOAL I TY OF= AtVCHC7F;tACE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 OtV—S I TE SF=WEFz F�EFZM I T PERMIT NO: 840651 UPGRADE DATE ISSUED: 08/01/84 APPLICANT: JOE MCLIN ADDRESS: 7125 OLD SEWARD HWY ANCHORAGE, AK 99502 CONTACT PHONE: 349-6561 LEGAL DESCRIP: SUBDIVISION: MCMAHON LOT: 2 BLOCK: 4 SECTION: 28 TOWNSHIP: 12N RANGE: 3W LOT SIZE:. 40000 (SQ.FT. OR ACRES) I certify that: 1. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska, 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. SIE APF ISE DATE: -�/ /p - DATE: -:�/ ASA �4 S n &'•ENGINEERS, INC. S 7125 OLD SEWARD HIGHWAY ANCHORAGE. ALASKA 99502 (907) 7496561 SOIL LOG PERCOLATION TEST X SOIL LOG PERCOLATION TEST '. BEDROOMS JOB NUMBER PERFORMED FOR_- _j DATE PERFORMED/•�/�_-___ LEGAL DESCRIPTION ____ _/__'_/.ZV/¢,.SEL°- Z$,_Tj. ZJj_ R 3_ w SLOPE SITE PLAN G.p-•Z.$T 13 114) 2 � • � 1—fL 3 ? % • U.� Sws c',� �O 6 S�1 7 8 9 X10 11, c.Jry OrAa.s..Y�J z i/ ?) VV 2.s - 3•s' r�rrJ11 .S�•..-�lr b-r->•�l, 0 � �llaf' Sc'/7I d �o N.:fr.%.�q1 n• 2.U0 m r •• •• WAS GROUND WATER w / (: ••• Gr J 0 .r ENCOUNTERED? �V.O r:. 12 S '; .• I 1_ IF YES. AT WHAT 19` •' •�C..tir,�Q 1 / r 4GP DEPTH? • 14• � • � y • �O ■■ME 4�j�J ■■L- ■■ 17 18 O TO r •• •• WAS GROUND WATER w / (: ••• Gr J 0 .r ENCOUNTERED? �V.O r:. 12 S '; .• I 1_ IF YES. AT WHAT 19` •' •�C..tir,�Q 1 / r 4GP DEPTH? • 14• � • � y ■■ME 4�j�J ■■L- ■■ 17 18 O TO 20 0 • HOMAS MIT 1 2248-E Sr ��• W S L O P E Reading Date Gross Net Depth to Net Time Time Water Drop 1-� �tl ®4r�; ....... ••�•��`�o n DEPTH 'hjLt'i:OLATION RATE _------ (minutes/moht E TEST RUN BETWEEN __— FT AND _.. ._-- FT COMMENTS,;C NM gC).__AbbA)6-- ?vvlCt(f__Tv-vTtriz - C ) / tC0 c�___SP.__Sor�s PERFORMED BY. ��—+•"�'<•`/G.-� .. CERTIFIED BY __ ... . _.--..._.. DATE: ■NoNo ■ ■■ME ■■L- ■■ M■ MINME MMMM�E■I W S L O P E Reading Date Gross Net Depth to Net Time Time Water Drop 1-� �tl ®4r�; ....... ••�•��`�o n DEPTH 'hjLt'i:OLATION RATE _------ (minutes/moht E TEST RUN BETWEEN __— FT AND _.. ._-- FT COMMENTS,;C NM gC).__AbbA)6-- ?vvlCt(f__Tv-vTtriz - C ) / tC0 c�___SP.__Sor�s PERFORMED BY. ��—+•"�'<•`/G.-� .. CERTIFIED BY __ ... . _.--..._.. DATE: cs.no-1 _S G( -'TER ANCHORAGE AREA BOROI'"N ` DtrARTMENT OF ENVIRONMENTAL QUAII. r• r 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 2798686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING NAME G /¢/'G __ .r'F/,°/L ADDRESS •� ��%��/t/ PHONE -15LV LOCATION /�/�i�/�%4I✓ LEGAL DESCRIPTION SEPTIC TANK: / NUMBER OF DISTANCE FROM WELL :5f- MATERIAL STGe� COMPARTMENTS '%'i s:/91exe src�z �� ,/GGsLI,16 LIQUID CAPACITY ZOaO GALLONS. INSIDE LENGTH INSIDE WIDTH-DEPTH- SEEPAGE IDTH DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS / OUTSIDE DIAMETER OR WIDTH , LENGTH , DEPTH LINING MATERIAL lL'l— /• DISTANCE FROM WELL /�� BUILDING FOUNDATIOW__!� f NEAREST LOT LINE �z5) TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) �" �j SO. FT. TILE DRAIN FIELD: / / / TOTAL LENGTH / DISTANCE FROM WELL �-�� , FOUNDATION . 5—Q Zt NEAREST LOT LINE Z'o f , OF LINES NUMBER OF LINES DISTANCE BETWEEN LINES /_ TRENCH WIDTH IN. TOTAL EFFECTIVE �0 SO. FT. LENGTH OF EACH LINE � 0 " � / ABSORPTION AREA �� ..�/ DEPTH: TOP OF TILE TO FINISH GRADE / / DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE�a_ WELL: DISTANCE FROM / / WATER TYPE1/'/G/nom DEPTHr2`� .BUILDINGFOUNDATION.I�SAMPL ✓e NEAREST / NEAREST / SEPTIC p / SEEPAGE /'` / OTHER 44✓� /' LOT LINE �� . SEWER LINE :! �-TANK 4 L� , SYSTEM, CESSPOOL d r , SOURCES*_"±7%V DIAGRAM OF SYSTEM DISTANCES: DATE ��/4J '� APPROVED/�7'�,� : GREATER ANCHORAGE AREA BORIJUGH •+ DEPARTMENT OF ENVIRONMENTAL QUALITY ` 9500 TUDOR ROAD POUCH 6.630 ANCHORAGE, ALASKA 99502 TELEPHONE 279.6666 SEWAGE DISPOSAL SYSTEM — APPLICATION AND PERMIT NAME OF APPLICANT R� INSTALLATION LOCATION ' LEGAL DESCRIPTION �a r INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FACILITY TO BE SERVED PERMIT N011407 1407 �34ry oli6/tet/ '/ MAILING ADDRESS PHONE DRAIN FIELD OTHER FINANCED THROUGH TO BE INSTALLED BY sl--rze-= SOIL TEST RESULTS ._,i�./+'0�NOTEI THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION, 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE Poo get • TYPE ��IAr .TD SEEPAGE AREA SIZE MINIMUM DISTANCES. REOUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT � � DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK . SEEPAGE PIT �0 DRAIN FIELD TO NEAREST LOT LINE. , / WELL TO SEPTIC TANK 40 SEEPAGE PIT DRAIN FIELD ALSO CONSIDER AREA WELLS. / WATER MAIN TO SEPTIC TANK �0 SEEPAGE PIT /v DRAIN FIELD SEPTIC TANK. SEEPAGE PIT._. DRAIN FIELD TO RIVER. LAKE. STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION S FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. HEALTH AUTHORITY OR LICENSED DESIGNER TYPE DIAGRAM OF SYSTEM 1 CERTIFY THAT 1 AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28.60 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. s o DATE / APPLICANT'S SIGNATURE Ly ,J -VI ("**A Carl Reall Lot 2 Blk 4 McMahon Subd. Measured well depth at 242 feet. Cased to the depth of 242 feet. Well produces 12 gallons per Tinute. Static water level is at 210 feet. HEFTY DRILLING 3540 AKULA DRIVE ANCHORAGE. AK $9516 (907) 345-0593 C W I CREATL'P. AHCHORA^E ARRA BO 'r';j HEALTH DEPAETHEHT CASE. d 327 EAGLE STREET ARCHORA6E, ALASKA 93501 Performed For_Cr,,,/ Date Performed Legal Description. Lot B.oc 5.1Adiv:sicr r Ac— This Fern Reports a: SoilsLo"�" >—�� percolation fest Depth Feet Soil Characteristics f/// Pon/ocz 6e/rurrn hori2chs a I'r rPra /;C. 710 6✓ /J Ire've/y rrmricird cul'/h n701J14(ee ron/rnf. Tie Ch Js ee,";,eag l wj't 6 a h,yl ".4 O Coq lrny. Was Ground Water Encountered? /1/n What Depth Location Sketch Frcposed Installation; ,Seepag-e Pit L/ Drain '"Meld Depth Of Inlet —� i> Leptn To bottomOf Tit Cr ':rent COMUNTS� . .. _1— f Test Performed By:�p� Data Certified By; Date 7 q�.�_ /f71 ALASKA ENVIRONMENTAL CONTROL SERVIC" ; INC. #3 1220 West 25th Avenue Suite ANCHORAGE. ALASKA 99503 276-1361 279.2917 JOBGL Z M cM lg N(JPJ SHEET NO. . 1�1 OF CALCULATED BY V %K DATE -0 -311e - CHECKED BY DATE SCALE 1 3✓J � i — – — 1 5/ I _ I i — i r i r I i IST , •J I I 7.F 1 1 I 1 � I --- - . - - - H - ——'— I' 39• i i I � � — yr cRla , U8' 975— ' 57� 7- — �- -- L— -- I -52 ' s�Pr►t:.. drrK 1 1 , j -HOUSE 48.6 I --:---VE-- i I r , 1 ; I. I 1 I _ 1 -- r • I 1 , 1 r : i — – — 1 5/ I _ I i — i r i r I i IST , •J I I 7.F 1 1 I 1 � I --- - . - - - H - ——'— I' 39• i i I � � — yr cRla , U8' 975— ' 57� 7- — �- -- L— -- I -52 ' s�Pr►t:.. drrK 1 1 , j -HOUSE 48.6 I --:---VE-- i Parcel I.D. Municipality of Anchorage Development Services Department Building Safety Division Onsite Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519.6650 www.muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING 017-041-09 1. GENERAL INFORMATION Complete legal description Lot 2, Block 4, McMahon Subdivision Location (site address) 12451 Lorraine Street Anchorage, AK 99516 _-Mt--- COSA# QSC 1614 03 Expiration Date:01/2110 Current Property owner(s) Judith and Andrew suck Day phone 440-4163 Mailing address 12451 Lorraine Street Anchorage, AK 99516 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, COSA will be held by DSD for pickup. 1 2. NUMBER OF BEDROOMS: — r-OO.L 4) -1 t4S'a' 3. TYPE OF WATER SUPPLY: Individual Well (] Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site❑ Individual Holding Tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -She Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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, 1 verify that my investigation, based on procedures outlined in the Certificate of Onsite Systems 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. Name of Finn Anderson Engineering Phone 522.7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. Date 4/262010 ..F a.. • . , 0, :MIQiAa E ANDERSON.�� 6. DSD SIGNATURE s; 'CE -4381 1/ Approved for L bedrooms. f Fp - Disapproved. f 1 �R� a�sw •��' Conditional approval for bedrooms, with the following stipulations: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other BY:Original Certificate Date: JR" lural Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.muni.org/onske .(907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: Lot 2, Block 4, McMahon SubdMsion Parcel ID: 017-041-09 A. WELL DATA Well type Private If A, B, or C provide PWSID # _ Well Log (Y/N) N Date completed unknown Sanitary seat (Y/N) Y Wires property protected (YM) Y Total depth 242 R Cased to 242 ft. Casing height (above ground) >18 in. FROM WELL LOG AT INSPECTION Date of test 6119/66 W30/10 Static water levet 210 R 206.8 ft Well production WATER SAMPLE RESULTS: 12 g.p.m. 7.4 9 - p.m - Coliform 0 colonies/100 mL Nitrate 4226 mg/L Other bacteria 0 colonies/100 mL Arsenic: N/� ug/I Date of sample: 3/10110 Collected by: S. Gilbert B. SEPTICIHOLDING TANK DATA Tank Type/Material Sepuc,1Steai Date Installed e123M6 Tank size .1,250 gal. Number of Compartments TWO Cteanouts (YM) Y Foundation cleanout (YM) Y Depression over tank (YM) N High water alarm (Y/N) N Date of pumping 3X19/10 Pumper A Plus Home Services C. ABSORPTION FIELD DATA Date installed 9n1 & 8,184 Sal rating (g.p.d./ft= or ft2/bdrm)150 SF180RM System type Crfblrrench Length 23 c/55 T ft. Width 23 G4.5 T ft. Gravel below pipe 7 C/5.5 T ft. Total depth 14 G15.5 T ft. Eff. absorption area 1. 93 f 2 Monitoring tube Y Depression over field N 3x30/10 Date of adequacy test Results (Pass/Fail) Pass 9�f� For bedrooms Fluid depth in absorption field before test 17 C/9 T In. Water added 660 gal. New depth 18 CH6.5 T In, Elapsed Time: 1.440 min. Final fluid depth 17 C19 T in. Absorption rate >= 600 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed Size in gallons 'Pump on' level at _in. 'Pump ofr level at —in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Manhole/Access (YIN) High water alarm level at in. Meets alarm ti circuit requirements? Septic tank/lift station on lot >100' On adjacent lots >100' Absorption field on lot Public sewer main N/A >100, Sewer /septic service line >25' On adjacent lots >100, Public sewer manhole/cleanout N/A Holding tank N/A Animal containment areas None Manure/animal excrete storage areas None SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Watermain N/A Wells on adjacent lots >100' Absorption field >s Water service line >10' Surface water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: >100' Property line >1Q Building foundation >10' Water main >10, Water Service line >10' Surface water >100' Driveway, parkingivehicle storage 1 >25' Curtain drain None Noted Wells on adjacent lots >100' F. COMMENTS: Septic System Absorption Area consists of a 23'x 23'x 23'x T Deep Crib and a 55'x 4.5' x 5.5' Trench. A second bench out of the crib Is still operational, but appears flooded. G. ENGINEER'S CERTIFICATION I cer* that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Michael E. Anderson, P.E. * 49MI Date 4127n010 '1 - PR >.' • COSA Fee $ _ !1 9 o Waiver Fee $ Date of Payment _ V7,ho Date of Payment Receipt Number 19 y5 Ll 6 $ Receipt Number (Rev. 11/05) 0 SGS ReLN Client Name Project Name/B Client Sample ID 1latrls Sampic Remarks: 1101040001 Anderson Engineering Lot 2, Block 4 McMahon Lot 2, Block 4 McMahon Drinking Water Printed DatcJlhne Collected DateMme Received Date/Time Technical Director 03/18/2010 16:06 03/10/2010 14:45 03/10/2010 15:53 Stephen C. Ede Allowable Prep Analysis Psrametcr Results LOQ Unit Method Comainer lD Limits Date Date Init Metals by ICP/MS Arsenic 5.00U 5.00 ug/L EP200.8 C (<10) 03/11/10 03/12/10 SCL Waters Department Total Nitratc/Nitritc-N 4.26 Microbiology Laboratory Colony Count 0 Total Coliform 0 Fecal Coliform 0 0.100 mg/L SM20 450ONO3-F B (<10) coVl00mL SM20 9222B coV100mL SM209222B cOVl00mL SM209222B A (<200) A (<I) A (<1) 03/17/10 AYC 03/10/10 DLC 03/10/10 DLC 03/10/10 DLC ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 FAX MEMORANDUM DATE: May 11, 2010 TO: Deb Wockenfuss FROM: Mike Anderson, P.E. SUBJECT: Lot 2, Block 4, McMahon Subdivision COSA We have made the following revisions in accordance with your comments: 1. The septic system serving the property is sized for four bedrooms. The septic tank, placed in 2006 is 1,250 Gallons. The absorption pit constructed in 1971 has an absorption area of 588 square feet (23'x23'x23'x15'x7' Deep). The absorption trench constructed in 1984 has an absorption area of 605 square feet (55' Long x 5.5' Effective Depth). The total absorption area is 1,193 square feet. The absorption rate was visually rated at 150 square feet per bedroom. The absorption area is therefore large enough to accommodate a 4 bedroom home. 2. The septic tank pumping receipt is attached. 3. The trench effective depth has been modified to reflect the as built in the DHHS archives. A revised "Brown Sheet" is attached. 4. An updated surveyor's as built is attached. 5. The comments on the second page of the "Brown Sheet" have been revised. A new sheet is attached. 1 Lc�T l L3 T 1' L` LOT 'L 4o'zInsS:F. �..� ". 513 t"flL Gi+t>FAp10UT4 3 1 N A L 0 2.3K4.7� WuorTtwl F�71JGG 0 I % un WrIf 13%9tN14NT 12'T�12'RlC1= _ WaWtT 1S-1•� ' LoT• 3 PLOT PLAN _ ASBUILT Y- SCALE I'='so GRID 28 5 Prolect No. 1�'05) Lang & Maoclates, Inc. 11500 Daryl Avenue, Anchorage, Alaska 99515 907 522-6476 Phone o Registered Land Surveyors 9073 522-4625 rax I hereby certify that I have surveyed the following deeorl!»d properly '�`• "' "'�'qs 1.07' Z/ Rxcx.�41...McMr•H�r+ 5u*yoIV141urJ [t'LaT-fo5-bv) �Q:' •�" Anchorage Recording District, Alaska, and that the Improvements situated thereon are within the property lines and do not encroach onto the property — ........... — adjacent thereto, that no Improvements on the properly lying adjacent thereto • encroach on the surveyed premises and that then are no roadways, tronsmlselon lines or other vislble easements on said property except as Indicated hereon. " - ' "' .. "" ""' .KENNETH L - Dated this the —.LL,F,}� '_ Day of M4 -1010 at Mahoroge. Alaska 9` LS -5202 lt to the responsiblilty of the owner to determine the existence of any PR+�•U.1lP easements, covenants. or restrictions which do not appear on the recorded 0 q eseloKM subdivision plat. . ■ i .. �..... ,�. �� 0000, rC :FLUS P—^ 3E 01 INVOICE # 36956 A+. HOME SERVICES, INC. CUSTOMER 7501 E. 140th Avenue Anchora;e, Alaska 99516 345-1890 11.451 Loeraiae Street Anchorage, AK 99516 Block Lot DATE DESCRIPTION AMOUNT 03-09-10 pdfnl, 5coic $133 100 m jilk; ii, AM '•:AWWU's"1A09"rAoinaaambe ■n A6g. S"':-- TOTAL REMARKS /Gallons k�_N Septic Leach Area Holding Tank ...t PROBLEM AREA — CALL FOR MORE INFORMATION ::1 NEEDS TO BE DONE AGAIN IN 6 MONTHS tn� Good Shape — Sludge buildup on bottom Jim cap missing orCut standpipe to 1' above ground needs replacing Standpipes /jn2j Time CJ Floater on top Ll Needs Septietrine LRP Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING I Parcell.D. 017-041-09 HAA# H�Oo20/y� r Expiration Date: -7— O Z2- 1. 1. GENERAL INFORMATION Complete legal description Lot 2 Block 4 McMahon Location (site address or directions) 12451 Lorraine Street, Anchorage, AK 99516 Current Property owner(s) Ernest Peter Jr. & Maria Zseleczky Day phone 907-064-5083 Mailing address 12451 Lorraine St., Anchorage, AK 99516 `Gg nency U.S. Inspect/Cendant Mobility Day phone 703-293-1529 Mailing address At: Evans Duclair, 3650 Concorde Pkwy, 9100, Chantilly, VA 20151 Real Estate Agent Julie Jewell fD Dynamic Properties Day phone 907-223-3211 Mailing Address 3111 C Street, Anchorage, AK 99503 Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site Individual Water Storage ❑ Individual 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 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. DSD 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 Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. (Rw. 1 M) 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 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Finn Pannone Encl. Svc., LLC_ Phone 272-8218 Address P.O. Box 102954, Anch. AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. Date Lill #/0 Z Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. 71c reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. 71csc conditions arc outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. PES can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner fisted above. Any reliance upon or use of this report by any other person or party is not authorized nor will it confer any legal right whatsoever. 6. DSD SIGNATURE ✓ Approved for -? bedrooms. Disapproved. ... .... ... ................ ,N%Steven R. Pcnnone:* %• No. CE 8149' * Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: ✓ Z-1" • /:2 Original Certificate Date: 47Lf i Expiration Date: Reissue Date: (Rw 11M) Municipality of Anchorage ' Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196850 Anchorage, AK 99519-8850 www.ci.anchorage.sk.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: _Lot 2 Block 4 McMahon SID Parcel I.D.: 017-041-09 A. WELL DATA Well type P If A, B, or C provide PWSID # _ Well Log W Date completed L!LV",VV-)Yl Sanitary seal Y Total depth 242 ft Cased to 242 ft FROM ILL -r-6 HCl �1 �1- e_fW� lir; ll�ng Date of test 6/19/1966 Static water level 210 ft Well production 12 9 -p.m WATER SAMPLE RESULTS: Wires properly protected Y Casing height (above ground) 24•• in. AT INSPECTION 4/13/2002 205 ft 4+ 9 -p.m Coliform :�colonies/100 ml Nitrate a,31 mgll Other bacteria --C7 colonies/100 ml Dale of sample: 4/14/2002 Collected by: _Laura Pannone B. SEPTIC/HOLDING TANK DATA Tank Type/Material Steel r Date installed/810/1971 Tank size 1000 gal Number of Compartments 2 Cleanouts Y Foundation cleanout N Depression over tank N High water alarm N/A Date of pumping 4/6!2002 Pumper _Isaacs C. ABSORPTION FIELD DATA T � Date installed rio 1 41378r it rating (g.p.d.tft2 or ft2/bdrm) I d System type Crib/french Length / 5'��ftk _/ c Cri c!� Ct,; rrenc 1. rrgt wrdtn �YlI ft Gravel below pipe 7 7 ft Total d41A1 /15 5- Effective absorption area 588 5 ft' Monitoring tube Y/Y Depression over field NM Dale of adequacy test 4/13/2002 Results (Pass/Fail) Pass For 3 bedrooms Tkvuclj(sce coAlmlen 5 se-<-t6h) Fluid depth In absorption field before test 31 in Water added450 gal. New depth3l In. Elapsed Time: 0 min Final fluid depth 31 In Absorption rate >= 450 g.p.d. Any rejuvenation treatment (past 12 mo.) (YM & type) _N If yes, give date (Rev. 11/89) D. LIFT STATION \ Date installed 'Pump on' level at Datum E. SEPARATION DISTANCES N/* Size in gallons _ n level at Cycles test Manhole/Access In High water alarm level at In Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 70" On adjacent lots 100'+ Absorption field on lot 115'+ Public sewer main 100'+ Sewer /septic service line $5' On adjacent lots _100'+ Public sewer manhole/cleanout 100'+ Holding tank 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10' Property line 50'+ Absorption field 41V Water main 501+ Water service line 50'+ Surfacewater 100'+ Drainage 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line _ 20'+ Building foundation 40 Water main 100'+ Water Service line 100'+ Surfacewater _ 100'+ Driveway, parking/vehicle storage 20'+ Curtain drain 100'+ Wells on adjacent lots 1001+ F. COMMENTS fldequacy {e5i (��furrt�ed 6nTr�n�lt flaofcltuln ;n laundry rt)om func�;olsus Pico, D"'Me poc+-CIOanoSi� G. ENGINEER'S CERTIFICATION :�P '" + -ej I certify that 1 have determined through field inspections and : 1 Q TH :. �e MV�.........:�....� review of Municipal records that the above systems are in •...�r...» conformance with MOA HAA guidelines in effect on this date. (� �ySteven R, Fcnncne a Engineer's Printed Name Steven R. Pannone. P.E. �Ic , No. CE 8149 ��' 0 ..r� Date �l RIdZ Pzo.... ..... �S' HAA Fee $ J� Waiver Fee $ Date of Payment Z Date of Payment Receipt Number Receipt Number (Rev. 1IM) a. e ' I ', � � `'•'' r?' '�' :; •Yy: $: is <'"' • •pt i.. \i V'/'' .'-�`.i�,•+�ZI )/ lrn r•,':Lf 1. i`/' ,''./� .yfe t, L tt r� r' ` t \\(v;\ c • \ . , r �pl� ° w. 1 i � �t> ,. ' J w <J!•t .1 �•.!.' !,A{`,}<.,!YY.t ..},.''..: ,,ris. ra /}Yty,,:...`Yz.J. •,: .� a ! t\ly l',n�l+ , ! 1,(/lt 1 ytlr ,lt S. ls.... w•. kr r a N�rd. (> r yi(fY tv j! tr s*. C•J\ , ♦•t-L'f l., t< i<M•r tl �:) y �(\1 i'i w t \v( r , rinr4a i,`,� 4'j r��L• i);'C`<.i+'t �\•f �\ ',w'. ,/SK ti<n,, .�/i C^.rSi\I, ?,V,.t�cr r,.f '.�5�� -•r� ��,tZl !(tj I It is4;the;:jesponsibilrity Lif the.'bwner:aoydetermi =;: the•:existence of,any::easelnerits, covenants, pr re i�,r'str..ictions ythich•do<not^anpear on;.the recorded s .t'division:plat':*Under,,�no.:circimistanceslshould anv i Fdita;hereoh b6-used;-'for'con's truction or;for-esta `.•.lishing .boundary.!or�fence'linesr;T.he'surveyor. �V -'•'.resporisibility..for--the'initial=:'transacti.on only. LOT": z • :,:.:A.. BLOCK. 'o:. a:r y'.L'�f:�. �i'f�'i `�,I�•AM1: '� i` •. f�j / -,�P�.•••...... �o xJJ 1 ' r••James rl I---:oV s1 Ka :• :..: 1566.5.; ;^�'e�✓ :, /� •. ao O 1 e t 7 Vapt f.t i { • 4. )1 i '• ' V >f {::i j},niy v`a'r ., lit '.. ,..: �� '�.. 1•. 1;.. .. 8,,� f ... r, I ub-+i1"} •:iris,,:. ',, .a� �l,t: NOTEEASEMENTS F R�C&D'OTAk THOSE .- • ... SHOWN ON THE RECORD�EDTHCRPLAT, HARE NOT .';-7t:' HEREON.. %.., HEREON.,.• /;�f ':'": LEGEND' +.. • ® BRASS CAP MONUMENT 0 IRON PIPE �• ��..� 0 : REBAR PRORCOR.PHD, 1`1 ANHORA CGE:-RECORD�ING' DISTRIC'TI❑'"!'° ° T""`'' � � � �• 1 PREPARIEDI BY:•.DOWLING et ASSOCIATES' a<.;' ::. i•:'.� �� •• - I426'. HYOER - STREET;:::'' :.''• ;'r':s:` ANCHORAGE; ALASKA.99501' ' REVISION DATE: BY:'' SCALE: /f; '; y WORkORDER: FIELD BOOK: GRID: Z 3 , _I jUne Bim' ....; .. , 30 '• _8�4 —283 e ,• I It is4;the;:jesponsibilrity Lif the.'bwner:aoydetermi =;: the•:existence of,any::easelnerits, covenants, pr re i�,r'str..ictions ythich•do<not^anpear on;.the recorded s .t'division:plat':*Under,,�no.:circimistanceslshould anv i Fdita;hereoh b6-used;-'for'con's truction or;for-esta `.•.lishing .boundary.!or�fence'linesr;T.he'surveyor. �V -'•'.resporisibility..for--the'initial=:'transacti.on only. LOT": z • :,:.:A.. BLOCK. 'o:. a:r y'.L'�f:�. �i'f�'i `�,I�•AM1: '� i` •. f�j / -,�P�.•••...... �o xJJ 1 ' r••James rl I---:oV s1 Ka :• :..: 1566.5.; ;^�'e�✓ :, /� •. ao O 1 e t 7 Vapt f.t i { • 4. )1 i '• ' V >f {::i j},niy v`a'r ., lit '.. ,..: �� '�.. 1•. 1;.. .. 8,,� f ... r, I ub-+i1"} •:iris,,:. ',, .a� �l,t: NOTEEASEMENTS F R�C&D'OTAk THOSE .- • ... SHOWN ON THE RECORD�EDTHCRPLAT, HARE NOT .';-7t:' HEREON.. %.., HEREON.,.• /;�f ':'": LEGEND' +.. • ® BRASS CAP MONUMENT 0 IRON PIPE �• ��..� 0 : REBAR PRORCOR.PHD, 1`1 ANHORA CGE:-RECORD�ING' DISTRIC'TI❑'"!'° ° T""`'' � � � �• 1 PREPARIEDI BY:•.DOWLING et ASSOCIATES' a<.;' ::. i•:'.� �� •• - I426'. HYOER - STREET;:::'' :.''• ;'r':s:` ANCHORAGE; ALASKA.99501' ' REVISION DATE: BY:'' SCALE: /f; '; y WORkORDER: FIELD BOOK: GRID: Z 3 , _I jUne Bim' ....; .. , 30 '• _8�4 —283 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES �1 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. # CAD — C U \ - Cc) HAA # l 0 f- 0 OI` 6q 1. GENERAL INFORMATION Complete legal description l.of ? f31�<kMy 1'le- tzhen SID Location (site address or directions) ► 2 YS I l orratn a Sf . Property owner PPFtr t rtctriq Zselecz kt, Day phone Shy- So,93 Mailing address I2 YSl L.erratxe S11.0 rfnchon?T!s Ak 993-1! Lending agency SPA F00 Pttari-y �t Day phone s�s2-s6z6 Mailing address S6o E 3yr'/}✓e�n�gt. 04rc 995,63 Agent N.A.C Rr��nanc�� Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 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 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. 72-02S (R.I. 1/91) Front MOA X21 S. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm FlaHvj! T-ccbn rca! Ser..l c r Phone 3'1S- 17S5 - Address I15-30 j5cAo Sf. A-' ch On ge, 995'r6 Engineer's signature Date .. •w,......;,y ........................ 1 : THEODORE F. AIOORE ; if ��� ,•. CF - 3589 6. DHHS SIGNATURE �i`�Pryi'�� _ Approved for Zit -a bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 0 Date aA 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. 72M(Rw.191) SWk MOA.21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST CDDS Legal Description: -=oT 2 BLk 4 Ylc MANori Parcel I.D. G.rLr=(/ 4.10' A. WELL DATA Well type PRIVATE If A, B, or C, attach ADEC letter. ADEC water syst NA - N /ggumber � SN rµ iv. y Lo resent Y/N 9 P f ) Datecom completed LIV. REP�N p 1% er V NK. NK. Totaldepth 242 Casedto 242 Casing height 2� Sanitary seal (Y/N) y Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test 6 / 19 / 81or 812o/172 Static water level 212oR'T 0' Z' � c� Well flow 2 g.p.m. > 7.R g IST ro 215 $ Pump level > rn au 4.0 j SEPARATION DISTANCES FROM WELL TO: N IIM1 tank on lot 70, ; On adjacent lots >/oo l Absorption field on lot 120' To C-0- ; On adjacent lots > /oo' Public sewer main ? 100 Public sewer manhole/cleanout > /oo Sewer service line /P! 65 PetroleumtanktoN6 OBSERVED NOTO; well - SePAOL TaAlv sgvara/tvn ctu faace tool leya/ o/ /7�ne of 40J/ fl -Fran, . WATER SAMPLE RESULTS: Coliform O eal //oe me Nitrate /• 6 04 �� Other bacteria Ota/ Date of sample: 5120112 Collected by: FLATTOP Tech S✓LS B. SEPTIC/HOLDING TANK DATA Date installed, 9Ito III Tanksize-1000 GAL Compartments 2 Cleanouts (Y%N) -� y Foundation cleanout (Y/N) N Depression (Y/N) tJ High water alarm(Y/N) N.A.Alarm tested (Y/N) N . Date of pumping I I N112 Pumper DENALI PVMPIN6 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Weli(s)onlot"'`7o Onadjacentlots >loo Foundation Io To property line *~ 95 Absorptionfield `4' CO. To c.o. Water main/service line ^ 60' Surface water/drainage _- ? loo' NUTS: well - S"ht T'atA it $epcfmhsA auiance wee lC a/ t*lme,of injlaue%o . 72.026 (Rev. 7/90 Fr t V -CONTINUED ON BACK PAGE C. LIFT STATION N. A. Date Installed Size in gallons Vent (Y/N) "Pump on" levet at High water alarm level Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots' Surface water Date Installed CRIB 9/)DI7l 2'reENcH 8I13j89 Soil rating -ISO 13YEDRn System type CRIB 4 T`R04CIl 'CRIB'. 23r 239 23 s ISI1 , Length lRENeg SS' Width lkt4cM 4 = NS' Gravel thicknessTR18 : 7 _ cot in : IH RlNCN 5.7' Total depth r4s rN�H: ts' Total absorptionIarea It 9S v Cteanouts present (Y/N) Y — Depression over.field (Y/N) NDate of adequacy test n LO A s Results (pass/faii) PASS for 3 bedrooms r Peroxide treatment (Past 12 months) (Y/N) 00445 K40 I✓N o F If yes, give date N • A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellonlot- 120' FRon C.O. Onadjacentlots > f0o� Property line-- 710 To building foundation _39' FRom C-0. To existing or abandoned system on lot N.A. Onadjacentlots '> 4oE Cutbank—>j22' Water main/service line >/00' Surface water >/O0) Driveway, parking/vehicle storage area > 20' Curtain drain -Wqe OBSERVED E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. w�E OF A�q >tit Signature�-•, P.••••......, S 4 • •••�`� • TH f V i *� 49 _ Engineer's Name ?h4rootae e r Ftcpow %•""""""'••••••••� * f Date b/Z7/92 * THEODORE T. L00RE R �, •� CE - 3589 ' . 4 �t�•..� Ems' HAA Fee '$ 712. ZWaiver Fee: $ Date of Payment Date of Payment Receipt Number Receipt Number. 72-M 111.. LRl) 8"k MOA 21 0 9A3W n. n MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH d HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES �1 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date 6-Z$'Sg 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, Location (address or directions) 17'4-1 40,V,_i,1E (b) Property Owner e-'4?e1' Telephone: Home _36-- O. 37 Business %;'S 3,113 Mailing Address 142y ( 0reR6J/'1 eQ�r7(I �s}'^ 9° /z c/fJA" (c) Lending Institution 1�� �/1r'�+fQ� Telephone Mailing Address /" Ki, (1-:1Eil �jL,o& (d) Real Estate Company and Agent R,04M/T ' — 0)12Of Of s'0 Address %7�2 (n C�dicji`II n� ��1.T03 Telephone (e) Mail the HAA to the following address: or. Check here gold for pick up. List contact person and day phone number below. S US A'o a (1 2(C'5 -S(//3 / 2. TYPE OF RESIDENCE Single -Family Number of Bedrooms 3 3. WATER SUPPLY Individual Well Community ❑ Public ❑ 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( 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 77-0751R" 61661 F, of 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 regulations in effect on the date of this inspection. Name of Firm /7�-r C_ Telephone sL �-SO O Address /�'D 33 ^� 57Zsr,- Date A. a S*• 4 �= DHHS APPROVAL Approved for g bedrooms by Date Approved \ Disapproved Contlitional Terms of Conditional Approval CAUTION 0 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. Page 2 of 2 . 72.025 ne. 8161 e.C. . MUNICIPALITY OF ANCHORAG� ^ O /-7 /� 7 ENVIRONMENTAL SERVICES DIVISi. A MUNICIPALITY OF ANCHORAGE (MOA, ( V HEALTH AUTHORITY APPROVAL (HAA) JN 2ti 1988 CHECKLIST -FEBRUARY 1984 284.4720 �% L RECEIVED Legal Description: 7-7-- 8�« T /i�h/h✓ 77AA1 X36J -let- 9,8 A. WELL DATA Well Classification ��/��� If A, B, C, O.E.C. Approved (Y/N) 4, 4 Well Log Present (Y© Date Completed fi/iKA"Af Yield / r , Total Depth a Cased to / 2 Depth of Grouting AIJ4 Static Water Level f z/9 r Pump Set At ±6 r Casing Height Above Ground Sanitary Seal on CasingION) Electrical Wiring in Conduit ON) Separation Distances from Well: To Septic/Holding Tank on Lot %O Depression Around Wellhead (Y6 I, On Adjoining Lots /ey r To Nearest Edge of Absorption Field on Lot * ; On Adjoining Lots /QU r 10 To Nearest Public Sewer Line AAA To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by /¢tT 5 fi •ww/ ; Date &-Z3 Water Sample Test Results 30G '1".-8- A(170 flS O.GB Comments A !"llEzL 610 745 6'Z3 41. tfAmt64rr, ()) -11FR A00eh" Dewmei ✓ B. SEPTIC/HOLDING TANK DATA Date Installed 9-/0-%/ Size (O'" No. of Compartments y Standpipes ON) Air -tight Caps) Foundation Cleanout (Y© Depression over Tank (Y& Date Last Pumped 5-/3-8.7 Pumping/Maintenance Contract on File (Y/N) �/A ;for Holding Tank High -Water Alarm (Y/N) -4 Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well n 70" To Property Line /D t To Water Main/Service Line ri Course /vy -s- Comments n SOS AKV/ArJb /A/ /97/. Page 1 of 2 72-026(11/84) To Building Foundation /D To Disposal Field 410 r To Stream, Pond, Lake, or Major Drainage Z_ 7, 301 f/.f/1frW .1 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design 5-X4 -Iwe. W ejeJJDate Installed "/h %-/0-71. 77�/Cr/ -/j-8g Length of Field xw as s► ' Width of Field I/-, 14S� Depth of Field T. &-lew /Sf Gravel Bed Thickness e,[19 7 7Aexld✓ 57_-5- Square s Square Feet of Absorption Area // ij Standpipes Present6N) Depression over Field (YAP Date of Last Adequacy Test Results of Last Adequacy Test /mapaA27- Separation Distance from Absorption Field: To Water -Supply Well / ea I 70 To Property Line n VL To Building Foundation Lot To Water Main/Service Line /0 -& To Stream/Pond/Lake/or Major Drainage Course - To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Datee Size inn Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) _ Comments ; On Adjoining Lots To Existing or Abandoned System on 7 -0n7 - To Cutbank (if present) n� Dimensions Manhole/Access (Y/N) "Pump Off" Level at •• Check Permitted Bedroom Rating Against HAA Request •• Vent (Y/N) Cycles during Adequacy Test. Meets MOA Icertify that Ihy�{/¢�h/ey?e�d,v/9rifled, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed _,:� (Nt� Dale +��wrage Company __ / 5 MOAN q 42 g �P,iF••OF A4�s+A Receipt No. 0To,p�o COS o20 �S� y * , 4 �Gfij • r+ Date of Payment 6 -a�' '�� �••• .• ..... f Amount:$ ��%D• .• rXS tF Y G RM JR. O CE - 2251 ` nJ 4. A_ eel Page 2 of 2 72-026 (11,84) d Carl Reall Lot 2 Blk 4 McMahon Subd. Measured well depth at 242 feet. Cased to the depth of 242 feet. ✓ Well produces 12 gallons per minute. Static water level is at 210 feet. HEFTY DRILLING 3540 AKULA DRIVE ANCHORAGE, AK 99516 (907) 345-0593 n n MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) a9 1-2- Mr-M411ON t)2N haw SEC. 2f Location (addreis o,'tlirections) 3S/�-o53 7 265:31 (bj • Applicant Name S ~ FALG Telephone: Home Business +• • Applicant Address 2 Bti��� ANC H AK, Q/1576 (c) 'Applicant is (check orie): !+ending Institution ❑ ; Owner/builder Buyer ❑ ; Other ❑ (explain); ' 1, . r •-.. / (d) Lending Institufior►= Address (e) Real Estate Company and Agent Address (f) I Telephone Telephone 2. TYPE OF RESIDENCE Single -Family jK Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well tg: Community ❑ Public ❑ 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 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 (11,641 Byt_2 MCM17110/1 r n 5. ENGINEERING FIRM PROVIDINU INSPECTIONS, TESTS, FILE SEARCH, D^.A AND INFORMATION N1 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/cr 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 Addre Date :�( i -so /o DHEP APPROVAL Approved for ( bedrooms by/ 6�"Zel a Date Approved Ilk -1_ Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph S above by an independent professional engineer registered in the Stale 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 72025 (11/84) n /_�I7zl>!11SLA" MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1884 284-4720 nrvl�,�.v kn, v n, R.IIyMVC CEPT. OF HEALTH & ENVIRONMENTAL PROTECTION U N 2 51986 RECEIVED Legal Description: Sq L2 M'01140041 TO rq ,R314 SEC, 29 Well Classification W) I vi n0R L If A, 8, C, D.E.C. Approved (Y/N) & /9 Well Log Present (Ye K Date Completed 01VIWOWAI Yield iZ GPM ;0( i,/7 i / Total Depth 2 yz Cased to -2'17, Depth of Grouting NA Static Static Water Level 210 Pump Set At I&R&OV& i Casing Height Above Ground 2 3 Sanitary Seal on Casing 6)IN) Electrical Wiring in Conduit &N) Depression Around Wellhead (Y(9 Separation Distances from Well: i� To Septic/Holding Tank on Lot 70 ; On Adjoining Lots X00 To Nearest Edge of Absorption Field on Lot IW' -t- ;On Adjoining Lots ©O To Nearest Public Sewer Line To Nearest Public Sewer �A Cleanout/Manhole — To Nearest Sewer Service Line on Lot N Water Sample Collected by �� . Ki>' ITCNdC!< ; Date _6 L20/e6 Water Sample Test Results STs FACTOR y Comments X --5F-F- 47-mcigm Gf/EaDR)l/ tek,5 arty 'T B. SEPTIC/HOLDING TANK DATA Date Installed d Size /00() No. of Compartments 2 Standpipes &N) Air -tight Caps ®N) Foundation Cleanout (Y16 Depression over Tank (Y© Date Last Pumped O .2r)1* h Pumping/Maintenance Contract on File (Y/N) n4/& ; for _aZ Holding Tank High -Water Alarm (Y/N)— Temporary Holding Tank Permit (Y/N) f/A Separation Distances from Septic/Holding Tank: To Water -Supply Well %O To Building Foundation r To Property Line To Disposal Field In ,-I- To Water Main/Service Line ,,''Course D " ominents b Page 1 of 2 72-026(11184) To Stream, Pond, Lake, or Major Drainage $LL-�. 2 M cmoolll C. ABSORPTION FIELD DATA f Soils Rating in Absorption Strata 15-0Type of System Design 7195AICa</ Date Installed TACWCO VLV-61 CRIB I fi(D I Length o1 Field �r r Width of Field M6Vca y— y S C&A 23x 25 X 3 X Jti ' Depth of Field f +1 I S S �C/{ (6 Jr / Gravel Bed Thickness moos s CRI13 7 Square Feet of Absorption Area IRK; (� 06CM8 Sg Standpipes Present 19N) Depression over Field (YQl Date of Last Adequacy Test _1i/A Results of Last Adequacy Test -IVA Separation Distance from Absorption Field To Water -Supply Well Inn r� To Property Line go / To Building Foundation SD / To Existing or Abandoned System on Lot N �� ; On Adjoining Lots 1/67 4- To Water Main/Service Line N A- To Cutbank (if present) /VIM To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Ares Comments �nLt�i oo -? c ��- D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at _ High Water Alarm Level at Tested for Electrical Codes (Y/N) _ Comments Dimensions Manhole/Access •• Check Permitted Bedroom Rating Against HAA Request •• DIF Level at Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA Icertifythatl av c ad, ver�'lie'd.2'conformedtoallMO andHAAguidelinesineffectonthedateofthisinspection. Signed " Date 6 Company MOA No. CV -S' Receipt No. p �.�� OF /��'� Date of Payment 3 l07 �� O •��O•.�• Amount: $ —,�o ovl1 • Tkt er's AN' . ; 49 RrTkcrlat N 6vF ....... ..... .., E `�`/ ORlccE& REPORT .00-01 C. afro. a. Page 2 of 2IF -2251 72-026 (11,841 ,114.f iW 10- J L LAEORATO¢t(ES,.INC. LABOR`IRY I.D. # Y3 7127 OLD SE%VARD H1GHN,..' ANCHORAGE, ALASKA 99518 � (907)344-8551 BACTERIOLOGICAL WATER ANALYSIS t TO BE COMPLETED BY HATER SUPPLIER FOR LAB USE ONLY DATE COLLECTED TIME COLLECTED TYPE OF SYSTEM "OPTH DAYTEAR ^ AM ❑ PUBLIC INDIVIDUAL ❑ RESUBMIT SAMPLE L Sample rejected because: I.D. NO. (PUBLIC SYSTEMS) CIRCLE CLASS CHECK ONE 00. MORE I A B C Residential.: ❑ Sample too long in transit. Sample should not be over 30 hours. NAME OF SYSTEM TELEPHONE NUMBER ,� �, ;.I._ _ L �/ � _ � ❑ Sample received too late in week SYSTEM ADDRESS Z S'' ��/�- ❑ Not in proper container ❑ Leaked out ❑ insufficient information provided. CITY STATE ZIP CODE �� l ! Please read instructions on form. ❑ Other (Specify) LOCATION WHERE SAMPLE WAS COLLECTED T6 COLLECTED BY:( 1 NA U E) I-�: �_ v' RECEIVED FROM TYPE OF SAMPLE RECEIVED PY (CHECK ONLY ONE THV COLUMN) DATE % TIME DRINKING WATER ❑ CHLORINATED ANALYTICAL METHOD: ✓CHECK TREATMENT ❑ FILTERED UNTREATED OR OTHER ❑ MEMBRANE FiLTER ❑ RAW SOURCE WATER ❑ FERMENTATION TUBE ❑ NEW CONSTRUCTION OR REPAIRS / ❑ OTHER(Specify) Date 6 Time Started bk70�Ei 6 trnm Date d Time Completed IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NON -CONFORMING SAMPLE? ❑ YES NO PREVIOUS COLLECTION DATE LABORATORY RESULTS ANALYSIS (IF OTHER THAN TOTAL COLIFORM) •EQUESTED Analysty ,t`211.2/L.,<, ❑ RESUBMIT SAMPLE ' SEND REPORT TO:(PRINT FULL NAt!E,ADDRESS AND ZIP CODE �F- �iV C • Test unsuitable because: NAME _`1 _r ILLC �`1 moi. �.� [:J Confluent Growth ADDRESS if HL'i� I l f- ❑ TNTC CITY r};'y ( f� STATE L Ll ZiP I %� c —/ SATISFACTORY 2 UNSATISFACTORY ❑ BACTERIOLOGICAL WATER ANALYSIS RECORD FOR LAB USE ONLY c/ TOTAL COLIFORMS Me^brane Filter: Direct Count n Coliform/Inoml Verification: LTB BGB ❑ FECAL COLIFORMS Final Membrane Filter Results Coliform/100ml 0 OTHER P.epor;ed By Date Time A.M. P.M. READ SAMPLE COLLECTION INSTRUCTIONS ON BACK OF FORM