HomeMy WebLinkAboutCINERAMA TERRACE BLK 3 LT 15MUNICIPALITY OF ANCHORAGE
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On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
I Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
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On -Site Wastewater Disposal System Permit
Permit Number: OSP241026 Effective Date: 3/5/2024
Work Type: SepticTank Upgrade Expiration Date: 3/5/2025
Tax Code Number: 02056104000
Site Legal Address: CINERAMA TERRACE BLK 3 LT 15 G:3341
Site Mailing Address: 16401 BLACK BEAR CIR, Anchorage
Owner: RAMEY ANDREW & Lot Size in Sq Ft: 184511
Design Engineer: FIRST WATER CONSULTING Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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
Received By: �5 "KT, —(" L Date:
Issued By: Date: > 5- -2()?-
UH C� PD A\ L�TY OF '-` HCH0R „ G ,=
r'
Development Services Department �\Phone: 907-343-7904
On -Site Water & Wastewater Section — Fax: 907-343-7997
ON -SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 020-561-04
Property owner(s) ANDREW RAMEY & LILIANA NAVES Day phone
Mailing address 16401 BLACK BEAR CIRCLE, ANCHORAGE, AK 99516
Site address 16401 BLACK BEAR CIRCLE, ANCHORAGE, AK 99516
Legal description (Sub'd., Block & Lot) CINERAMA TERRACE BLOCK 3, LOT 15
Legal description (Township, Range & Section)
Lot Size 184,511 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑ Initial ❑
Single Family (SF) El
Septic Tank 0 Upgrade 0
(w/wo ADU)
Holding Tank ElRenewal ElDuplex
(D) El
Privy ❑
Multiple Dwellings ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
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: .2 2 5 Waiver Fees:
Date of Payment: Z�ZB�z�/ Date of Payment:
Receipt Number: -610 2r, Receipt Number:
Permit No. Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / firstwaterAK@gmail.com
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February 27, 2024
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: CINERAMA TERRACE BLOCK 3, LOT 15
The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic
tank on the above referenced lot. We propose to install a 1250-gallon HDPE tank per the
attached design to serve the existing 2-bedroom residence with a 4-bedroom septic system. We
would recommend a 1500-gallon HDPE tank be installed for current functionality and future
consideration or flexibility. No groundwater was noted in the MOA on-site file, but if
groundwater is encountered during installation an epoxy coated steel septic tank may be required.
The lot and area are served by private water and any encroaching wells, easements, … must be
staked prior to construction. The design will not impact any of the neighboring properties.
Please contact us if you have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241026, Curtis Townsend, 03/05/24
FIRST WATER CONSULTING
NO WELLS WITHIN
100' OF PROPOSED
SEPTIC TANK
CINERAMA TERRACE BLOCK 3, LOT 15
DESIGN DETAILS:
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241026, Curtis Townsend, 03/05/24
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
SEPTIC ABSORPTION
Address - ~0¢ WELL
LEGAL DESCRIPTION LOT LINE ~ ~ 1 ~
J Block J SubdwIsiOn
Lot 1~ ~ CJn~m~ ~c~c~ FOUNDATION No~ ~n ~t ~ Hot i~
Township, Range, Section
~ C ~t ~ (/ ~t ~ ~ ~ ~' ~' AS-BUILT DIAGRAM (Show Iocat,on of well. septic system, property Imes, foundat,on.
d.veway, water bod*es, etc.)
~ SEPTIC U HOLDING // ~ ~, ~
-%
Material No. of Compadments ~ ~
TYPE OF ~Y~TEM ~
~h to plpe bottom from ' ~Totaidepthfromorlgln.igrade ~,~ ~ ~ ~: '~ ~
original grade ~*~ - ~ FT ~ t _ 7 f ET ~
Fill added above original grade ~Grave, depth beneath pipe
~ PRIVATE ~ OTHER(Identifv) ~,. ~ ~'~,:
Insta[ie~ Date Installed: ~, /
Inspections Pe~ormed by:
~e e eeee~eee, e eteele~e~ee ee~ e
I ~' ~ ~- cindy 'hat this inspection was pedorme, according to all ~
Municipal and Slate Duidelines in effect ~ da : ~,...%THEOOO~EcE. 3589F' 'MOORE
Health ,epadmen, Approval: Date. ~'2 ¢ --~¢
:[ C.;E:I::~T :1: I:::'Y "f'H(:.'~T ::
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F::' Ii!i: R M I "l"
Ch,,m~er' Addr, es!i~.~,' 7800 DIi:BAI::~:R :H:71
AI',I C H 0 R A [:,:.ii Eli'. ,., A K 9 9 5 () 4
Par'(:::et Id: 020- 115-02
Lot. L. ega I: Subd :L v :i. s i on: C I I',II!!!'.RAM(-~ 'H~.RR(-'~CE I..,ot. ," 15
Sect :i,c~n: 1 'l"ownsl'~ip." ,1. lr, I Range: 3W
L,,crL Size: g..,5A (sq,.'~"l:... or' a(:::~-e:s)
Max Bedr'.oorns: 'H"i :i,s l:::'er'mi'L: /.I. "f'crLal Cal:)ac :i.t.y: 4
B ]. [)C: t.:: ,", :':,;",
tar'ii.:: IIiL.I/.~!V~] I"I&vV(!,..? at. ].east. ;.-'.? compar, tment, s. Depth '!:.o top o~' sept.:i,c rani.:: (s) .::', /.I.,C~
~' e e:'l:, p e? q u i r' e s i I"1 '!!L~ L,( ]. E.;~'J.'.. i C)ii C:)V E.? I" t. ,.":':'~ I'"[ J< ( S ) ,,
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,:!..'d"l cJt 'IL,u¥'N:':U I ,J ..-;:. v I c: es w i .1:.. h i n ':~ (') (::Jays (::) ~' we 1 ]. (.::(::)['nj] 1 (.:.:,:,t. i c)n ,,
I C E R"I" I 1:::' Y T H A T' ,~
:1.,, :1: am fam:i.l:i, ar' w:i.t.l"~ '!:.he r'e;quir'-e:mer'lt.s for' c)n-.s:i, te seweps ar'icl wells a~i set
['or.t.l"~ by t. he Mun:i.c:i. pality o{' Ant:hot'age (MOA) .and t. he St. ate o[' A].asl,::a,
~:r::'. ,, :[ w:Lll ins'l:.al], t. he system in acc:or'clar~c:e with all Iq[lA c:c:,cles and r'egu!at.:i.c~ns,
an,:::l in cc)rapt:Lance wit. h the des:i, gn ct, it. er'ia (::)f' tl'~:i.s pePm:i.t.,,
3, :1: w~i'.t. 1 adher'e t.c) all MOA and St. at.e o~' Alasl.::a PE.)qLi:J.I"E.)m(~I"~t.s J'C)I" ti'h(':.:.) ~(¢')'t. back
d:i. st. ar~c:es {'r, om any ex:i. st:i, ng we].:l., ~asteNa'Ler' dispc)sa], syst. em or. publ
4. bed['ooms,
4 I::) ecl ~" c)c)ms
4,, t ur-~c:ler, st,ar"~d that 'l:.his per'm:i.t :i.s va].:i.d fc)r' a maximum
ats,,::) unclepst, ancl that t.t'"~e capac::i.t.y c)~' the t. ot. at syst. em
,::':u"iy ,:~.:,r'llar'.gemerlt ~.~:i.:l. 1 r. equ:i.r'e an add:i.t, ic:,rlal pePmit,,
$~C_FION
LOT ~, 8/.0¢t'c 3
~(NE-R4PIA TE~RAd~
S/Zz/~'lattop Technical Se~vic
pe,,n ~,,': T~..~. 14530 Echo Street
Anchorage, Alaska 995
Lot 15. Block 3, Cinerama Terrace
Specifications and Design Notes
1. The design of the soil absorption system i$ based on a measured
percolation rate of 13 minutes per inch, which requires 180 square feet of
absorption area per bedroom, or a total of 720 square feet for the proposed 4
bedroom system. The absorption area requirement is met by a 101 foot long, 5
foot wide drainfield with 2 feet of sewer gravel beneath the distribution pipe.
2. The configuration of the system shall be as shown on the plans except
that minor modifications may be allowed or required by the engineer conducting~'~<~~.~
the inspections. The drainfield shall be constructed parallel to the contour of the ~.~.-~<
slope with the bottom of the gravel level and 6.5 feet below the ground surface.
3. All material specifications and construction practices shall be in
conformance with M.O.A. requirements.
4. Special care shall be taken to minimize damage to existing vegetation and
to restore the site to smooth contours.
5. Three inspections will be required: ( 1 ) initial stakeout, (2) after
drainfield is excavated, but before gravel is placed, and (3) after gravel is placed,
septic tank is installed, and pipe laid, but before final backfill.
PERFORMED FOR:
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99518
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
D~.~ o,~
'?,';, I
I~... .... .*..*............ III
I · ' ORE F MOORE .Z. J I
I *.&.'. cE. 3589 .,"_~W I
I ...... I
I '!1~ .' ~,p~ ....... .\ v~.'~ I
DATE PERFORMED:
LEGAL DESCRIPTION:
2
3
4
5
6
7
8
14
15
2O
Township, Range, Section:
SLOPE
frachdn
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
Date: ,..,C/t?(8~
Depth to Water After
Monitoring?
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time ("l/t) Water Drop
~ ~ I ~ ~t ~ Og tO ~ g "lit tJ//("
PERCOLATION RAT~/ J~"~ (minutes/inch) PERC HOLE DIAMETER
~EST RUN aETWEEN ~ O' FT AND 5",...4' FT
PERFO"MEDBY: m/~, ?~"~'.rS''";'~ I ~ ~ CERTIFY THAT THIS TEST WAS PERFORMED i.
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
PERFORMED FOR:
Flattop Technical Serv1ces
14530 Echo Street
Anchorage, Alaska 99516
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99§02-06§0
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
LEGAL DESCRIPTION:
O. pl.
2
3
4
7
8
10
12
14
15
16
17
18
19
2O
COMMENTS
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
SITE' PLAN
Depth to Water Alter
Monitoring? Dale:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND __ FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE:
THEODORE F. MOORE, P.E.
PH: (907) 345-1355
ClVIL& ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
MUNICIPALITY OF ANCHORAGE
July 12,1989 DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
Susan Oswalt
M.O.A. Dep't. of Health and Human Services
P.O. Box 196650
Anchorage, AK 99519
'JUt_ 1 g
RECEIVED
Dear Ms. Oswalt:
On May 30 you issued permit # 890084 for a well and septic system on Lot
15, Block 3, Cinerama Terrace $/D. This is to advise you that, after discussions
with the excavator and owner, we have come up with a revised configuration that
better suits their needs and still provides the same absorption area in the area
between the two test holes shown on the site plan. I am enclosing a revised plan
and cross-section for your information. Please give me a call if you have any
questions.
CC:
Deborah Green
DeAr moun Excavating
Sincerely,
Ted Moore, P.E.
T
PI. AN I/1~14/
~'~CT I¢N "A-A "
Parcel I.D. #
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 AU?HORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
_Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone ~/-~/5-y
Day phone ~-~
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~
3. TYPE OF WATER SUPPLY:
Individual well
Community we!I
Public water
NOTE:
ing to the legality and status of system.
If community well system, provide written confirmation from State ADEC attest-
4. TYPE OF W.~TEWATER 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. ' ''~' ' ': ~ i:.',:' :';!'
72-025 (Rev. 1/91) Front MOA#21
Se
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 inves.ti_gation and inspection, the on-site water
supply and/or wastewater disposal system isin compliance With all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Engineer's signature
Phone
DHHS SIGNATURE
X Approved for 4
Disapproved.
Conditional approval for
.... ' ':l~dr°oms, With ~the following stipulatiOns:
Additional Comments Note: The well for. this property meets existinq
State and Municipal Codes, There are nitrates present, It is
suqqested that a periodic teSting be performed to insur~ *.h~_ wmlls
continued suitability, Nitrate concentration is 4,6 mg/1, EPA
m~imum ~.nn~ent~t~on i_~ !'0'_0_ 'rog/!.
5ality of ~'~'~horage 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
~·l~'rOfession ,al engirC&~r registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and'.'tl~ei~'l~nding 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.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: j..o//- I~ ~ ('OC~''~
A. Well Data
Parcel I.D.
Well type pr.~,~/~
Log present (Y/N) 'r'
Total depth ~ 5/'? ~
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed 7/Eo/<~ Driller Prlp,~
Cased to '3 ~/ ('t~/o be~roc/%) Casing height
Wires properly protected (Y/N)
'30~
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG AT INSPECTION
8 g.p.m. ~. 0 +
MUNICIPALI 11 L)r ~1~, ~'~.,~"
ENVIRONMENTAL SER¥ ICES DIVISION
~ 1994
g.p.m.
RECEIVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot t I
Absorption field on lot 15'(2'
Public sewer main '
Sewer service line
; On adjacent lots ~> ~oo '
; On adjacent lots ;> ~oo'
Public sewer manhole/cleanout /',/, ~.
Petroleum tank No. ~
WATER SAMPLE RESULTS:
Coliform 0 co I/(o0,~ ~ Nitrate O, 15- r~ (-,~ Other bacteria
Date of sample: ~l (~-¥/93 j '~./to/~ ~ Collected by: f::/~,/-,'~(~
B. SEPTIC/HOLDING TANK DATA ~w~ ~ o..c n~J,~,~,( ~Ci//-~," ¢~,
Date installed ~/ IE~/~'~ Tank size I ~,.~-O ,~! Compartments
Cleanouts (Y/N) ~" Foundation cleanout (Y/N) 'r' Depression (Y/N)
High water alarm (Y/N) /V, ~. Alarm tested (Y/N) h/,
Date of pumping Al,/J-. ('_ R~_oof~nc~ .i ~r[- co~//~A~umper I~1, ~. ('
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot I~0' On adjacent lots 'P' ~(.,o' Foundation
To property line ~-0' Absorption field 5-0' Water main/service line
Surface water/drainage ~, ~
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION N,
Date installed
Manufacturer
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed 8/'/<~ / ~"~ Soil rating (GPD/Ft2) I~
Length '7 E.' Width 15" G ravel thickness
Total absorption area I ~c;~ c~' Cleanout present (Y/N)
Date of adequacy test N. ,4. ( N 4co) Results (pass/fail)
Water level in absorption field before test
z~'/~'~ System type ~'
I,O Total depth ~' - '7'
Depression over field (Y/N)
N
for ~ Bedrooms
After test
Peroxide treatment (past 12 months) (Y/N) /~/ If yes, give date
Well on lot 1,5'-~7 ' On adjacent lots ;::=, t oo' Property line
To building foundation
On adjacent lots ;>
Surface water ~
Curtain drain ^Ion ¢
lO0'
To existing or abandoned system on lot /V,
Cutbank hi,/i. Water main/service line
Driveway, parking/vehicle storage area do'
E. ENGINEER'S CERTIFICATION
I ced/fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date ofthis~ection.
, ~,~;~: · , ~ ~ :,
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026(3/93)* Back
MAR-- 4-- =J 4 F R'r I'-~ -- 22 FLATTOP TE C: H N 'r C A L
mAi~ Ga 'cia 11:g?F:~vl NTL ~
P. 02
~4530 ~cho $~.
NORTHERN TESTING LABORATORIES, tNC,
Repo~ Da:et o3/o¢/94
29668 EP~ 353.3
15~3 Clne~ama ~o~a~m
units Re~ul~ * ~DL ~epared~uslyzed
mq/l 4.6 1.3 03/03/94
RECEIVED
MAR 4 1994
~UmC,pahiy ol Anchora
Oept. Health & Human SerVices
SINCE 190B
Commercial Testing & Engineering Co.
CT&E Ref.~
Client Sample ID :L15 B3
Matrix :WATER
Environmental Laboratory Services ~,'~'~'~,'~,'J.~'.~'~'~.fJJf~e'~,'~,'JJJ~J~fsf~ffJf~~
REPORT of ANALYSIS 5633 B Street
: 94. 0568-3 Anchorage, AK 99518-1600
CINERAMA T~R. KITCHEN TAP Tel: (907) 562-2343
Fax: (907) 561-5301
Client Name :FLATTOP TECHNICAL SRV
Ordered By :
Project Name
Project# :
PWSID :UA
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: CHRIS.
WORK Order :75604
Printed Date :02/10/94 @ 14:03 hrs.
Collected Date :02/04/94 @ 14:00 hrs.
Received Date :02/04/94 @ 14:20 hrs.
Technical
Released By . ~
Parameter
QC
Results Qual Units
Allowable Ext. Anal
Method Limits Date Date Init
Nitrate-N 0.15
mg/L EPA 353.2/300.0 10
02/07 LLH
* See Special Instructions Above
** See Sample Remarks Above
., U = Undetected, Reported value is the practical quantification limit.
[~D = Secondary dilution.
Member of the SGS Group (Soci~t~ G~n~rale de Surveillance)
UA = Unavailable
NA = Not Analyzed
LT = Less Than
GT = Greater Than
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
COMMERCIAL TESTING & ENGINEERING CO. AK DIV
CHEMICAL & GEOLOGICAL LABORATORY
TELEPHONE (907) 562-2343 5633 B Street
Anchorage, Alaska 99518.
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
[] PUBLIC WATER SYSTEM I.D. #
[] PRIVATE WATER SYSTEM
Name Phooe No.
Mailing Address
City
State Zip Code
SAMPLE DATE:
SAMPLE TYPE:
Mo. Day Year
r~ Routine
[] Check Sample (for routine sample
with lab ref, no,
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
No. LOCATION
31 I
SI
Time Collected
Collected By
J 1 7- :oo N TI~I~
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
~" Satisfactory
[] Unsatisfactory
FI 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 \\/~-- ~.
Time Received I~'-~ \ ~
Analytical Method: Membrane FlEer
* No, of colonies/lO0 mi.
Lab Ref. No. Result*
I
Analyst
A.D.E.C. /]:_ -'-~ ~,_,., ,G~,. ~ BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS Membrane Filter: Direct Count ~ Collform/100 mi
BEFORE
COLLECTING SAMPLE
Verification: LSB BGB
Fecal Coliform Confirmation
Final Membrane Filter Results/~.
Reported By ~"/~ '/~/<~-"~ Date
TNTC = Too Numerous To Count / Time:
Coliform/100 mi
OB = Other Bacteria
~SGS
Member of the SGS Group (Soci~
PART ONE OF TWO:
REMAINDER TO FOLLOW
~CHEMICAL & GEOLOGICA~LAB ORATORY
DIVISION OF COMMERCIAL TESTING &I~£NGINEERING CO.
TELEPHONE (907) 562-2343
i 5633 B Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform,Bacteria
TO BE COMPLETED BY WATER SUPPLIER
[] PUBLIC WATER SYSTEM I.D. # [
I~1 PRIVATE WATER SYSTEM
Name Phone No.
Mailing Address
City State Zip C,~de
SAMPLE DATE:
SAMPLE TYPE:
Mo. Day Year
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
'~,, Sati ,sfactory
[] 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 deliver7 mail.
Time Received /~ '~'~
Analytical Method: Membrane Filter
* No. of colonies/100 mi.
SAMPLE Time Collected
Lab Ref. No. Result*
No. LOCATION Collected By
Analyst
A .D.E.C. V",~'-q'/-/_~'~,~' BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
Membrane Filter: Direct Count
Coliform/100 mi
BEFORE
Verification: LS B
Fecal Coliform Confirmation
BGB
COLLECTING SAMPLE Final Membrane ~esults
TNTC = Too Numerous To Count
Da te
Time:
Coliform/100 mi
OB = Other Bacteria
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16. WATER WELL CONTRACTOR'~ CERTIFICATION= ~ ': LL"' :?~: "''~'T~'~"~:~:~' ' , ' ' ' ' ~ ~ . '
. . . , .: ....... · ,,.-..., -.~ . . · .,. : . ... ~ .;~?,,.,.;~.,~.~t~ :~. ~.~:,~y.,., ,: 5, Water .T~mperatu'r~.' = "'~ U F ,', ~ C,:' .~-"~,,
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Thl~ ~ell ~a~ dr~lle~nd~r,~ jurisdiction and Ibis report l~ true to the b~t ut my knomledge and be ef~ ' ' '~,'. .... ' . "'~. ~ ,. ".
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L For~ O~-WW~ (11/~1) COpy DIItribution; WHI~-81~Ie D~G~ PIN~-Drilllr~