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Home My WebLink AboutT12N R3W SEC 23 SW4SW4SW4NW4TI ZN R3W SW4$W4$W4NW4 #015-494-12 10/07/13 ll:58AM A~CH~RAUE ~E£L & ?U~P 1907~43074~ p.O~ Well Drilling Pe arcel ldeltfifica~io~ Number: ~ ...... . : Legal Description /I Pump Model: Pump Size ~ hp Pilles$ Adapter Mauufaclurer', Name; .......... Pump lnmlter Name: Anchorage Pump & Well Service 330 East 76m Avenue Anchorage, Ai[3aka 99518 Phone: 907-243~0740 Fax: 907-243-0742 Attention: The pumg inst~lter shall provide a pump ix:~ta ,~don 'ogm ttx,~ DSD witi~in 30 d. a3,~ of pumF-, instal!orion. 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 No. of lines ! MAILING ADDRESS LEGAL DESCRIPTION'"' -OCATION Manufacturer ~ Material Liq, capacity in gallons wellF/ HOMEMADE: r inside length Width DISTANCE TO: J Dwelling Manufacturer DISTANCE TO: Well //~,6 t Foundation ~5I I inches Material beneath tile~ ~ inches Depth Crib depth NO~, OF BEDROOMS Top of tile to finish Length Type of crib r DISTANCE TO: Well Building foundation Class Depth Driller DISTANCE TO: Building foundation Sewer line OTHER PIPE MATERIALS SQIL TEST RATING / 7 7 REMARKS PERMIT NO, No, of compartments Liquid depth PERMIT NO, Liquid capacity in gallons PERMLT Total effective absorption are PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line Septic tank PERMIT NO, Absorption area(s) 72-013 (Rev. DATE ISAACS PUMPING SERVICE (Norm Tibbetts, Owner) 6218 Quinhagak Street, ANCHORAGE, ALASKA 995'07 Phone 563-3300 4553 DE.I:ARflIEIIf ElF F1E, ALIH AND ENVIRONME]'qTAL PI;::OTE[]TION E.I ....L. ,;~1 H,E.E I ~ At IL,K,~RAIJE 'ERMI'F NO: 8¢..16.¢ 1 lATE IS!3UED: 1}/C3/85 :ONTACT I::'HONE: DERRII_ D. BERG-[' 5800 MOOSE MEADOW LN.. ANCHORAGIE, AK 995 16 :~Zl. 6-376 1 E~ E: B.~ EE F;: .EGAL DESCR]:I:?: SUBDIVISION: SW1/4SW1/4SW1/4NW1/4 LOT: NA ' BLOCI<: NA SECTION: 23 TOWNSHII=': 12N RANGE: 3W .fiT SIZE: 2.;:¢A (SQ.F'T: OR ACRES) , lAX BEDROOMS: 3 ist. ecl be].o~ ar-~, the ~apt, ions available t.o yoLt in designing yoor septic · ystem. Choose the option that best ~'its your sit. e. . ,EPTH TO PiPE EIOTTOM '(FT. ) ' 4:0 4. l} .4',: 0 . I,hVE[,.. DEF'TH (FT.,~ ~ 8.0 ~'~_, ~ ,:.'~, ,.~ OTAI_ DEPTH (FT.) .~ !.2~ 4.5 '/.. 5 RAVEl_ WIDTH (F'I'.) ~5 20.'0 5,,(} RAVEL LENGTH (FT.) 54.0 40..0 58..0 RAVEl_ VOLUME (CU. YDS. ) 26..-8 29.7 43.0 ANK SIZE (GAL. S) 1,000.0 ~¢~ 1,000.0 ~' ~.,000.0 OIL RATING (SI:!.FT. /BR) 177 177 177,~ -~('-~ TANK MUST HAVE AT I_EAE'T TWO COMPARTMENTS (:::er't i £y 'Lhat.: 1.. I am i'ami].:i, ap ~:['El"l t. he requiPen-~en'[:s For' on-site 'seweps and wel:[s as set: ~'or'~:l"~ by the Municipality oF Anchor'age (MOA) and the S{ate of Alaska. 2. i wi]:l install the system in accopdance with all MOA codes and regulations, and :in compliance with the design cr'iteFia oF this penmit. 3. I will adhere :.o all MOA and State oF Alaska r, equiremeflts t'o:* the set back distances Fnom any existing welt;, wastewater disposal syst. em or public sewepage system on this or any acljacent or near'by lot. 4. I understand that. 'Ehis permit is va].id ~or. a maximLtm o¢ 3 bedr'aoms and any enlargement wi].l r-equil*e an addit.:ional pepmit., A L.IF'T S]"A]"IOIq IS .INS:T'AI..LED IN AN AREA COVERED BY MO~ BUILDING CODES, HEN (1) AN EI_EC'TRICAL F:'ERIfllT AND INSPECTION MUST BE: OB'rAINED; (2) AS-BUll_TS ill_L NOT BE APPROVED WI]"HOUT AN ELEC]"RIC~L INSPECTION REF'ORT; ~ND (3) THE. % .................................. ..... . ' ~F'PL: CANT': DERR ]~ERGT ~ ......................... Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST ~,. (ENG~.~S SEAL) PERFORMED FOR: '~"3A','-~'f / LEGAL DESCRIPTION: ,,_~ ~.~/'/~ /~l,~.l /~r 1 2 3 4 5 7 8 9 10 11 14- 16- 18- 19- DATE PERFORMED: Township, Range, Section: ~,,~, 2 3 )'" i~ f~.J WAS GROUND WATER ENCOUNTERED? SLOPE SITE PLAN S L IF YES, AT WHAT O DEPTH? p E Oeplh Io Water After Monitoring? Dale: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE /'~'~' O';~(l~nutes/inch) PERC HOLE DIAI~ETER TEST RUN BETWEEN ~'~ FT AND ~ ~Z..ET ~ r-~UNICIPALITY OF ANCHORAGE,~-~ Hea~ [ and Environmental Protec ,on ~ ~ Fourth Floor West 825 L Street Anchorage, Alaska 99501 264-4720 INSPECTION REPORT ONLSITE SEWAGE DISPOSAL SYSTEM FROM WELL MANUFACTURER TERIAL COMPARTMENTS INSIDE LENGTH_ INSIDE WIDI-H LIQUID DEPTH LIQUID CAPACITY /~ALLONS. TILE DRAIN FIELD: DISTANCE FROM WELL ~ of Llnes ABSORPTION AREA DEPTtI: TOP OF TILE 10 FINISH GRADE FOUNDATION__ DISTANCE BETWEEN LINES NEAREST LOT LINE TOTAL LENGTH OF LINE TRENCH WIDTH__ IN. SQ. FT, LENGTH OF EACH LINE DEPTH OF FILTER TOTAL EFFECTIVE MATERIAL BENEATH TILE IN. ABOVE TILE IN, SEEPAGE PIT: Log Crib Rings BUILDING FOUNDATION DIAMETER OR WIDTH ., EENGTH ,, DEPTH Crib SiDe: DIAMETER___DEPTH . DISTANCE FROM: WELL TOTAL EFFECTIVE _, NEAREST LOT LINE ABSORPTION AREA (WALL AREA) SQ. FT. Well Class: Depth: Well Distance To: Lot Line Bldg: Sewer Line: Pipe Materials: ~_~0 -- # of Bedrooms: Installer: Rem~ks: · DATE PERHi"I' NG. ( 7775.7 FF .~ LOCFI'T I LEGFIL E,.[L...t I Ri:,. LGI _-,I,::_E ±OEIOEIEI L:;I;¢JFIRE FEi:;!- -I'~¢F'E (iF .':,...iL. IIE~i. JI~.EI J._i',l _-T_,iE:.i'I IS;: T'RENCH HFh~'::IMLIt'I NUi'IEER OF E:EDRGEd"IS '3: =,_iL TNE I...ENGTH DtMENE;ION ]:E; ]'HE LENGTH (iN FEEl) UP TNE TRENCH ON }RFIlNF'IELD. ]'FIE [:,EPTH OF FI TRENCH OR PIT IS THE: BIS-I:FINCE E,'ETWEEN FIdE SURFFICE OF THE GROUND FIND THE E:OTTOM OF THE E',:.::CFI'v'FITIGN (IN FEE'f'). THERE t'..:'; NO SET ~,I]:[.',-I"H FOR TRENCHES. THE GRFlVEL [:,EPT'H t:t~ THE: MiNIHUH DEPTH OF GRFI',,,'EL BE'I"HEEN THE OUTFRLL PiPE FIN[:, THE: E:O'T'I'OH O1-" THE EXCFIVFFI" i ON ':: I N -, FEET). ~::" F~ EZ: 1-:-:: F~ ~LTi ~SL F" L. ~:~ ~.-~ T' ~ F" -l'- X'":3" ~-.t R F'RCKFIGE F'L. RNT I"ll:~? BE INS'TRLLED R'T' THE PERMi'T'T'EE'"S OPT'ION SUBJECT 'f'O THE FOL,LEH4ZNG CONDITZONS: t. EEI'I"HER R C:L.R~;S I OR~Ii NSF FIF'F'RO',/ED F'LFtNT FtFt'? BE INSTFILLED. 2. R CGNTINUOLIS MRINTENRNCE ~GREEMENT IS REQUIRED:,. iF' R f'tRIN'TENFINCE RGREEMENT Z% NOT KEPT CURRENT YOU MR'¢ BE REQUIRED TO ENLRRGE THE SOiL RBSORPT~ON S'YS'T'EFI FIND/OR '¢OU fdFl'? BE SUBCEOT TO PROSECU']'ZON. BRCKFtL. LING OF RN'¥' S'¢S"FEM WITHOUT FINRL IN'_:;PBCTION RND RPPROVflL B"r' THIS DEPFIR't'MENT W]:LL BE SUBJ'ECT TO PROSECU-flON. ~"" HINIMUM DI'.:_;'T'RNCE BETI.,.IEEN Fl WELL RND RN"r' ON-SITE SEHRGE DISPOSRL '-:;'T'STEP1 I:5 '~ ±00 FEE]- FOR Fl PRIVRTE HELL. OR 200 FEET FOR Fl PUBLIC HELL OTHER REQUIRE[tEN-f'S fc[Fl'T' 1'3PPL% SPECIFICFIT~ONS FiND COI'dSTF,'UC-fION DIFIGRRHS FiRE ~'~' FlVRZLFlBLE TO INSURE F'ROPER INSTRLLFfT'ION. '"'~ i CERTiF~r' ]'HFI'F Z: I FlH F'RMiLIFIR W:[TH 'THE REQLItREMENTS FOR ON-SZ']'E SEWERS FIND WELLS FlS SE]' F'OR-I'Iq B'¢ T'HE I"IUNICIPRL. IT'~' OF RNCHORRGE. ~ 2: I HiLJ- ~N2;TFIL[.. THE S'r'S"I"E["I IN RCCORE:'FINCE WZ'T'H TNE CODES. 3:: I UNDERS]"RNI) THRT THE ON'-SI'I'E S;EHER S'YS'I'EH ['iR'T' REQUIRE ENLRRGEIqENT iF' T'HE '" RESIDENCE IS REMODELED TO INCL. GDE HORE THRN 5~ BEDROOI"12;. ~ ~-" _, I UNE[.~ ..................... ' RF'F'L I a:RNT ESTFlER ER ICKSON 1:.:,' '-" .......... .IFF E2' ....... [::'IdlE-. .................... ","-~.--::' ¢:~- ALASKA E:,,dlROJqmeJqTAL COrlTROL SeMulCe$, (~ngineerin§ $ I~nuironmenlel Studies 10/10/85 50634 JEANETTE GRIGGS SELLER-D BURGT JEANETTE GRIGGS 5800 MOOSE MEADOW LANE 5800 MOOSE MEADOW LANE ANCHORAGE ALASKA ANCHORAGE ALASKA MUNICIPALITY OF ANCHOP, AOI~ DI:PT. OF HEALTH & ENVIRONMENTAL PROTECTION RECEIVED LEGAL:T12N~ECT 23 SW1/4 SWi/4 SW1/4 NWl/4 ADEQUACY TEST FOR SEWER SYSTEM ADEQUACY TEST DATE-10/1/85 THE TYPE OF ABSORPTION SYSTEM IS A CRIB WITH AN UNKNOWN AREA. THE SYSTEM IS CAPABLE OF ACCEPTING 110 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 56 GALLONS. THE SYSTEM IS UNACCEPTABLE BECAUSE THE SURGE CAPACITY IS LESS THAN 75 GALLONS. THE SYSTEM IS NOT CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY. SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1000 IS ADEQUATE FOR THIS 3 BEDROOM HOUSE. THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON 9/9/85 . FLOW TEST ON WELL WELL FLOW DATE-10/1/85 A FLOW TEST WAS PERFORMED ON THE WELL. 571 PUMPED AT A RATE OF 4.5 GPM OVER A DURATION OF 2 THE DRAWDOWN WAS 12 ~ WITH A RECOVERY TIME OF 20 AND THE STATIC WATER LEVEL WAS 171 FEET. THE WELL IS ADEQUATE FOR THIS 3 BEDROOM HOME. GALLONS OF WATER WAS HOURS. MINUTES 1200 LUcsl 33r~J Aucnue. Suile J~, Anchorage. Alaska 99503,(007) 551-5040 'l 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 264o4720 GENERAL INFORMATION (a) Legal D~scription (include lot, block, subdivision, section, township, range) Loc~{i~' (ad~r~s~.~r '~irections) (6) .,-A~plican't Na~,~A]epS/F'IA[~ gO~ Telephone: Home (~)' App]i~n~]s'(~h~c~ ~ey~nding Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain); (e) Real Estate Company and Agent Address ~ IFA~ TZED ~, Telephone J~ ~ --0~0 / (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family'~ Multi-Family [] Number of Bedrooms ~ Other 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 [] Commu'nity [] Holding Tank [] Note: if community well system, must have written confirmation from the State Department of Environmental Conservatio~ attesting to the legality and status. 72-025 (~ 1~84) Page 1 of 2 5. ENGINEERING FIRM PROVIDI[~ INSPECTIONS, TESTS, FILE SEARCH, DA'iA 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 At]thority 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 flies 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 /~J~(~-~ //Irf~,, Telephone ~(~/-%~"'0 ~0 EPTIC "6. 'i DHEP APPROVAL Approved for Approved bedrooms by 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 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE ~ 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 /Z/'~Sch~ GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) AF~liSghtAddress ' · ;t''h WP/~_ ~0 ~D~ ~0~ (c) Ap"plic'~t ii (chbdk ode) L(~n(J ng Inshtution []; Owner/builder []; Buyer []; Other [~ (explain); t~Ei~T~£, , ... ' ' """ '" Id) Lending I'n~titutloh ~'~'~; ~ ~/)~ Telephone 2&C- ,e, Real Estate Comb, n, and Agent. ~¢¢4q (f) Mail the HA.~ to the following address: TYPE OF RESIDENCE Single-Family [~ Multi-Family [] Other Number of Bedrooms , ~ WATER SUPPLY ,. : t. ,. m Com Individual Well munity [] 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 OnsJte [~ Public [] Community [] Holding Tank [] Note: If corn munity Well system, must have written confirmation from the State Department o{ Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 i ~ ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of t he 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 /:~'-~--/~ ~'/~f~' · Address /-~0 Date / / Telephone DHEP APPROVAL Approved for ' Z edrooms ,,~l~roved Di~prc, ved Conditiona~ Terms of Conditional Apprd~al Date 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 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the I~rofessiona! engineer's work. ; Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 ,MUNICIPALITY OF ANCHORAQ~. DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION 2 0 198 264-4720 Lega, Description: WELL DATA Well Classification Well Log Present (~N) ~r/'V~/~ If A, B, C, D.E.C. Approved (Y/N) Date Completed /~' //~/~ Yield , ~'/~' Depth of Grouting Pump Set At J.,~ / Sanitary Seal on Casing (Y/N) Y Depression Around Wellhead (Y/N) /'~ Total Depth ~Z~ / Cased to Static Water Level /f~ 3 ~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/F-',c2, d:,~g Tank on Lot To Nearest Edge of Absorption Field on Lot _ · To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments 9~/~'~/~Ft~~/ ; On Adjoining Lots /00 ; On Adjoining Lots /00 ~'~/~ To Nearest Public Sewer ~/ To Nearest Sewer Service Line on Lot ~, W/~, ~. ~, ;Date B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Y Air-tight Caps (Y/N) Depression over Tank (Y/N) Y Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from SePtic/14e~ T~nk: To Water-Supply Well ~ / Size /000 No. of Compartments /L/ Foundation Cleanout (Y/N) Date Last Pumped .~/~/~'~" /~//'~ ;for /"'///~ - Temporary Holding Tank Permit (Y/N) To Building Foundation '~' / ~ To Property Line To Water Main/Service Line Course /¢/~ /00 z ¢. TO Disposal Field /'~' ¢ ~ To Stream, Pond, Lake, or Major Drainage Page 1 of 2 ' 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /Z//~./¢~ Width of Field ~, ~ Square Feet of Absorption Area ~-Z Depression over Field (Y/N) Results of Last Adequacy Test /'V/~ Separation Distance from Absorption Field: TO Water-Supply Well To Building Foundation ~'Z ~2¢/'~ '~ Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line ~' '--~"~ / To Existing or Abandoned System on Lot ~-0/.'.'.'.~ ; On Adjoining Lots ~'/¢O To Water Main/Service Line · ~-'~-"f N'¢'~' ~:~;~ To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course ./V/.~ To Driveway, Parking Area, or Vehicle Storage Area Comments ¢4=A¢/¢)¢¢ /~,/~'/~'-/'~"/~/~g'£/~",~/ /'~)"/ <:~///~ D. LIFT STATION Date Installed Size in Galloas "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) ~ Comments ~ Dimensions ~ Marvel at~'~ Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all M CA and HAA guidelines Signed ¢~¢'. ¢¢' ~ /~'~ Date /bT~/O/~¢' Company /¢J~"4 ~¢, MOA No. ~-¢Z¢ Receipt No. ~?~ ¢ O~ Date of Payment ~-~ ~ ~ Amount: $ _ ~ ~ ~ Page 2 of 2 72-026(11/84) in effect on the date of this inspection. Municipality of Anchorage MEMORANDUM DATE: February 26, 1986 TO: File: T12N R3W Section 23 SW¼ SW¼ SW¼ NW¼ FROM: Civil Engineer, On-site Services SUBJECT: Waiver of 100 Foot Separation Requirement Between Septic Tank and Well for Above Referenced Property A risk analysis was performed to evaluate the likelihood of well contamination from a septic tank on the property. This risk analysis indicated that contamination was very unlikely. Based on this analysis a waiver to 96 feet was granted for the separation between the septic tank and well. This waiver is valid for the existing septic tank only. Stephen S. Morris Civil Engineer On-site Services SSM/ljw cc: A.E.C.S., Inc. ,? . ,, '-.,~:IZ.L -, - - .r -.,5'~- z.. ';'~?/ ? )2, ~' ~ .' ''1 ' "~ .,/>. _ .5-~ ,,.~/ -:':., I-,:'> .... 7/// ' . .. .. / / ~_ ......... I ~ ~ ............. ' SUBSURFACE EXP L-ORATIOI~'! /.~,.-/(/'-/ 2. TYPS OF EXPLORATJON~L ~7~' ~'' -W 3. SURFACE ELEVATION~ DEPTH DRILLED. ~OEPTH~END SHIFT. TIME DISTRIBUTION 8. CASING LOG TOTAL LENGTH LENGTH sUPPLIES AND REPAIRS (ITEMIZE) , i MATERIALS AND REMARKS ,~ - , ,~ SUBSURFACE EXPLORATi~' /~X~,/./ .,,,, -., .~I~. , . , ~ ,~ ,~ ?~.~, ,~-~,-_.oL, .o '~-/I SUPPLIES AND REPAIRS (ITEMIZEI CASING LOG ~. TOTAL SAMPL£ SOILS LOG MATERIALS AND REMARKS ..~?, / L DRILLEI CASING LOG i~ g. TOTAL SAMPLE SOILS LOG <./ I<-::.-' ~.6 t? i ~ MdN CLPALrT,: ~ ~ i DEPT. ~~ I I I .I I I '1 t - ~x'TZ'::M ~ / c.' .4 .... /~.' ~'~ ~~u ..... ~,~:..~ ---- - .... CHEMICAL & t,EOLOGICAL LABORATORIES' OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER ~i~ PRIVATE WATER SYSTEM Name Phone No. Mailing Address City State Zip Code Mo. Day Year SAMPLE TYPE: '1~ Routine [] Check Sample (for routine sample with lab ref. no. _) [] Special Purpose [] Treated Water ~ Untreated Water · SAMPLE NO. LOCATION I IrB~u~ Mt' Time Collected I MUNICIPALITY OF/ANCHORAG2 DEPT. OF HI]ALI'H & ENWRO,~MENT^' PRO~'ECT~ON RECEIVE~ Collected TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~atisfactory [] Unsatisfactory [] Sample too long in transit; sample should 'not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received r-~-/i~ ~ Time Received ' 1 ~ Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* I i-i-1 I Flq J ~ ] FT-1 BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane FIIte~ Direct Count Collformll00ml Verification: LTB BGB Final Membrane Filter Results , /L'~ Collformll00ml .epo.edS, p.m. TNTC = Too Numberous To Count OB = Other Bacteria ALASKA ENVIRONi*,=NTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 56].-5040 SHEETNO. OF CALCULATEO 8Y -~*~'0'~'~)5 DATE CHECKED BY. DATE / / Z4 ~ REC£1VED