HomeMy WebLinkAboutCONTOUR ACRES #3 BLK 3 LT 1Com6ue Acxln 43 41 O 11- 1151- 1 1 Name MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT 8 ,<_ - DISTANCES 5*M detw by ad L*Ar i9 vd, 0 995k Phone(s) Permit No. No. of Bedrooms LEGAL DESCRIPTION Lot / Block 3 Subdivision .3 � Township, Range, Section ,:„1 ,e-yuJ s�-z TANKS SEPTIC c15T�h ❑ HOLDING Manufacturer Capacity in gallons Material No. of Compartments TYPE OF SYSTEM TRENCH V BED D W. DRAIN 0 OTHER TO SEPTA: ABSUHPIIUN WELL FROM TANK FIELD WELL LOT LINE FOUNDATION AS -BUILT DIAGRAM (Show location of well, septic system, property lines, foundation, driveway, water bodies, etc.) 0 ��il•Ititil•�■i�����' Dep • °, ■■■■■moi■■■■■I original grade 0, FT Fill added above origi Gravel depth beneath pipe FT FT ■■�i�l-■■■■■�Ir Gravel length Gravel width ■■i�iii■■■■■�'!0 •FT ■■■■liis■rllC Total absorption area 'Distance between lines SOFT: FT Pipe material Soil rating ■■�y!::�►r-�■iInstaller B 21Z _bL01.0 Date installed ���lf� ■■11!�i!1�■!■f ■■�IE�!!7►'�ffl■u'EC'tt►u '00! FIAMANG PRIVATE . OTHER classification (A,B,C) Total Depth Date Installed: REMARKS: UPbiPAfg L� BA 111fut47-0b Inspections Performed by: I , jg?,$ fi'. w Date: I vL09----i__- /I.,W- certiiv hat this inspection was performed according to all Municipal and State guidelines In effect on this date: Health Department Approval: ^_ Az�Date: 00- 72-013 (3/85) MUNICIPALITY OF ANCHORAGE Department of Health & Human Services 825 L Street, Anchorage, Alaska 99501 343-4720 ON - SITE SEWER PERMIT Permit Number: 880082 Upgrade Date Issued: 06/10/88 Engineer Designed Owner Name: WILLIAM HANABLE Owner Address: 5000 COUNTRY CLUB LANE ANCHORAGE, AK 99516 Parcel Id: 017-451-11 Lot Legal: Subdivision: Section; 27 Township: 12N Range: 3W Lot Size 104500 (sq"ft. or acres) Max Bedrooms: This Permit: 3 Total Capacity: 3 Day Phone: 345-6734 SEPTIC TANK: Minimum total septic tank capacity: 1,000 gallons, Each septic tank must have at least 2 compartments. Depth to top of septic tank(s) < 4.0 feet requires insulation over tank(s). INFORM D.H"H.S" PRIOR TO IST & 2ND INSPECTIONS BY ENGINEER, IF AFTER OFFICE HOURS CALL 343-4681 AND LEAVE A MESSAGE CONSTRUCT PER ENGINEERS ATTACHED APPROVED DESIGN THIS PERMIT EXPIRES 12/31/88 THIS PERMIT VALID FOR A SINGLE FAMILY RESIDENCE ONLY I CERTIFY THAT: I. I am familiar with the requirements for on-site sowers 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 not back distances from any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby lot. 4. I understand that this permit is valid for a maximum of 3 bedrooms, I also understand that the capacity of the total system is 3 bedrooms and any enlargement,ill require an additional permit. Signedx (Owner) WILLIA Issued By: DATE: ^� A E� S ALASKA RUlI�011� nTA� COnTR0� R U M, IX . Q Engineerinq & 6nuironmental Studies SPECIFICATIONS FOR ELEVATED BED WASTEWATER TREATMENT SYSTEM LEGAL DESCRIPTION: LOT 1, BLOCK 3, CONTOUR ACRES SUBDIVISION 1.0 GENERAL 1.1 The drawings, sheets .l through 4, shall be part of this specification. 1.2 All materials and workmanship shall meet the requirements of the Municipality of Anchorage, Department of Health & Human Services (DHHS), the conditions of the permit, and all applicable rules and regulations currently in effect. 1.3 All excavations and depths are advisory, and are to be verified or modified in the field by the Engineer or inspecting agency. 1.4 It is the responsibility of the owner or installer to adhere to approved design for the installation, to maintain the specified separation distances and to have the appropriate inspections. 1.5 If the installation is not inspected by an AECS engineer, AECS will not be responsible for the installed system. An engineer at AECS should be consulted prior to construction, to determine the number of inspections that will be required and to explain what these inspections will .involve. 2.0 SEPTIC TANK 2.1 If there is an existing septic tank it may be used if it meets the capacity requirement for the residence and the approval of DHHS. 2.2 The septic tank shall be a UPC -Approved two --compartment tank, constructed of 12 -gauge steel with bitumastic coating and set level on undisturbed soil. If the tank is buried at a depth of 4 feet or less, it must be insulated with an overlying layer of 2 inch burial type polystyrene rigid board insulation. 2.3 The septic tank shall be a minimum of 5 feet from the house foundation, and a minimum of 5 feet from the absorption area. 2.4 The septic tank and bed shall be a minimum of 100 feet from any private well or body of water, 150 feet from Class C wells, and 200 feet from Class A or B wells, unless otherwise specified. Less than the required separation distance must have prior approval or waiver by DHHS or Alaska Department of Environmental Conservation (ADEC). 2.5 Piping shall be fitted with a mechanical watertight calder coupling on the outlet and inlet of the septic tank. Piping shall be 4 -inch solid PVC ASTM D3034 or cast iron, sloped a minimum of 1/4 inch per lineal foot. If the piping is buried at a depth of 4 feet or less, it must be insulated with an overlying layer of 2 inch burial type polystrene rigid board 1200 blest 33rd Auenue, Suite B • Anchorage, Alaska 99503 •(907) 561-5040 insulation. 2.6 Cleanouts shall be installed as designated and capped with air -tight rain caps (Jim caps or equivalent), and extend a minimum of 1 foot above ground level. 2.7 If a lift station is required it shall be a combination lift station septic tank per Anchorage Tank and Welding, Inc. design. 3.0 SEEPAGE BED 3.1 The sand, if specified, shall have a size distribution which meets the requirements of MOA code 15.65.077. 3.2 The gravel for the bed shall be 0.5 to 2.5 inch, screened rock with less than 3% passing #200 sieve residual. All substitutes must have prior DHHS approval. 3.3 The bottom of the excavation shall be level and raked with the backhoe blade to insure that the bottom has not been compacted during excavation. 3.4 The distribution pipe shall be perforated 4 -inch rigid PVC with a minimum crush strength of 1500 pounds and shall meet the approval of DHHS for use as drainfield pipe. All pipes shall be laid level, and spaced according to the drawings. 3.5 Monitor standpipes shall be placed as shown in the drawings. They shall be 4 -inch rigid PVC ASTM D--3034, or cast iron. The section shown with holes may be either drilled 0.5 inch holes on 6 inch centers on opposing sides of the pipe, or a section of regular perforated sewer pipe may be clamped to the solid section with a no -hub coupling or solvent joint. Perforated section shall be located in gravel only. The portion of pipe above the sewer rock shall be solid. A rubber raincap (Jim Cap or equivalent) shall be placed over the top of the pipe. 3.6 Insulation is required, using burial type pol.ystene rigid board insulation. There shall be f inch of insulation for every foot of soil less than the required 4 feet of cover, but there must be at least 24 inches of soil even though insulation is used. The solid pipe extending from the septic tank to the drainfiel.d shall also have 4 feet of cover or an equivalent layer of insulation combined with soil. 3.7 The side walls of the sand and gravel shall be lined with visqueen. 3.8 The side slope of the mound shall be sloped 1 foot vertical to 3 foot horizontal. 3.9 The top and sides of the bed shall be planted with a white clover and red fescue mix or blue grass. 4.0 INSPECTIONS 4.1 This bed will require a minimum of three inspections. The first inspection will be of the open excavation, to assure that the system is installed in the proper soil strata, correct depth and meet minimum specified design parameters. 4.2 The second inspection will be after placement of gravel, monitor standpipes, and distribution pipe, to verify proper installation and position of pipes prior to backfill. 4.4 The third inspection will be after final backfill and grading to ensure that adequate soil cover has been provided over the bed. j O �V AV e -'�� of a` .•• Dar '�'� .•. l �2o Q ` � ' ro' _�!, of 10 � ���+e•• �� �•�r f s y�iH '9k 1 #a** got--.rOrivew,y •• ••• 600.0• •••f povei Sol+ •a 904640 OY C. REID, .1 . : 0 NO.O/'E dfs.00'14 ftofessloo\ , • ; �G s sat f�'/�'••••••••••�,�QtiO.t �. BA//V6R/0GE ROAD Btl- s:jLE, pn(y I HEREBY CERTIFY THAT AN ACCURATE SURVEY OF THE FOLLOWING DESCRIBED PROPERTY t0r /, ezaeA- s CONTOUR ACRES .ODD iY CEGEND PREPARED FOR: WAS MADE ON ,Q!/ elrl d., /9i4 AND THAT THE IM- $' >D � ♦ 4 s?o/v. /Roe, f,�'::f, 60ry CO�de♦ PROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND DO NOT OVERLAP OR ENCROACH ON THE PROPERTY AS BUILT TRYCK \ LYING ADJACENT THERETO, TWAT NO IMPROVEMENTS ON PROP- DRN. FILE N i CK ERTY LYING ADJACENT THERETO ENCROACH ON THE PREMISES eR e_ ��80 WMAN IN QUESTION AND THAT THERE ARE NO ROADWAYS, TRANSMIS- CHK. GRID �.�.�AYES SION LINES OR OTHER VISIBLE EASEMENTS ON SAID PROPERTY JiVG I. EXCEPT AS INDICATED HEREON. F. 8, JOB N0. ' A•/IIS fit:$ �'�•��•� nuw�•� wr...o•s ANCHORAGE. ALASKA, THIS d8'1,4 DAY OF .dayvsl 157¢ Jco/ir•do' /Tecertifisd A 16, 1966, pddsd deck s/ concrete Nm/k s Plod sewer E'.0. * & dr�wwey IMZOM 0 -Cot OF At 1}� 97 �+'�• LESLIELBRATTAINAV "1�r 'vof i Z A %w ed Deck wsteps tt b' N Ard.D' Fix/ `o • 'k ti i4 0' d?'Cont, �6 wrist Sewer a 07c. Pod cold) z{P Divers.'o„v2/"r . C7 -1 ALASKA ENVIRONMENTAL CONTROL SERVO INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561.5040 JOB J l Q 3 /�c re- r# 3 SHEET NO.— CALCULATED BY CHECKED BY— SCALE— OF Y—SCALE ila L, 2<<d OF ! p. DATE_G �o DATE S e Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST PERFORMED FOR: C—:z , / 15 t n C e J a � Ik;f DATE PERFC LEGAL DESCRIPTION: Township, Range, Section:%/� /0 FOTP-M OL— SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 .J c� ✓L q4� JJ�i O ?� ►+tet (SH� s,i7�4r��1 Wry fzo�r.� 4V ertS� y!P?l 4/ �y 0-jr C-0 L b AI. WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT L DEPTH? O P E Depth to Water After ��,,� Monitoring? � Date: Reading Date Gross Time Net Time Depth -ler of Water Net Drop T r �- /03$ O 6 N7 /© y 3 7 /o s8 /b , ,r, a m ,sy ! 1'Z 0 d 'So'ro D if l8 /o e, Sw 9 /2-9 13w l08r 3 8' Q 4 7 a etc feaill.L 20 L_ PERCOLATION RATE (minutes/inch) �P'ERC HOLE DIAMETER % TEST RUN BETWEEN �_ FT AND � FT COMMENTS —74 r 14 S'0 �.c3 �P , -- -0 r c✓o-Pe.^ sem, lS � PERFORMED BY: /4 i I Z. P" k,/ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:,/ SFS�p 72-008 (Rev. 4/85) ALASKA ENVIRONMENTAL CONTROL SERVICE INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561.5040 JOB Q 3 SHEET NO. Of CALCULATED BY DATE CHECKED BY RGAI E 1Z " / „'� IO " I Z"= Al / DATE GRED -ER ANCHORAGE AREA BOR'-'JGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME <tsf�'�'� �! �� '%� MAILING ADDRESS !`9% `� /�L%�� Ph ONE SEPTIC i LOCATION �„*r�/,V�/� (/.C�i'G d1/f/y.�'� �= '� /✓ GAL DESCRIPTION �-� � ��? i�/4���i''��^• ���t%:.�"'= �-'� CESSPOOL OURCES OTHER SOURCES— SEPTIC TANK: C,,/' 'w If =i DISTANCE / n FROM WELL 1I3 MANUFACTURER J �� '� C -'_' L-/WATERIAL INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACI SEEPAGE PIT: r NUMBER OF PITS �. DIAMETER OR WIDTH Z� • LENGTH-K� DEPTH LINING MATERIAL��',e-j�'&- E CRIB SIZE: DIAMETER DEPTH ( DISTANCE FROM: 1 TOTAL EFFECTIVE BUILDING FOUNDATION �G NEAREST LOT LINE ABSORPTION AREA (WALL AR ADDITIONAL ABSORPTION WELL MBER OF MPARTMENTS 1"'<� GALLONS. WELL A&/ ) IW) SQ. FT. TYPE o&'� O/,___, CONSTRUCTION 42,410,-- CGZii7C/�DEPTH i DISTANCE FROM: BUILDING �p�1'�N' NEAREST NEAREST SEPTIC i SEEPAGE FOUNDATION ' y LOT LINE SEWER LINE �Q TANK, SYSTEM /•.j/ CESSPOOL OURCES OTHER SOURCES— APPROVED APPROVED DISAPPROVED REMARKS_%llZ DISTANCES: S�% 'J/�+ ) ,ery INSTALLED BY: PIPE MATERIAL: LOT SLOPE: Ile-) If `;7— REMARKS:�'o,.��Jc f f�fi i Form No. EQ -031 DATE DIAGRAM OF SYSTEM d � r J� y Sf�1/G� S� r APPROVED -{ G.A.A.B. ou GREATER ANCHORAGE AREA BOROUGH 7115/7 � DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 SEWAGE DISPOSAL SYSTEM — APPLICATIONAND PERMIT NAME OF APPLICANT C, "-V 04-wdd-e MAILING ADDRESS 6 9 •q ZI PHONfi�_ •/ INSTALLATION LOCATION LEGAL DESCRIPTION Lt�71 INSTALLATION OF: SEPTIC TANK k.� R SEEPAGE PIT r ✓ t,. DRAIN FIELD OTHER , TYPE AND SIZE OF FACILITY TO BE SERVED 9 9D.CM -_ �` F'�'ii / G FINANCED THROUGH C-,odJUQ-A,1772!)N1+,L- �iTO BE INSTALLED BY u�jS C�� . SOIL TEST RESULTS Z2O�f eli�:m A• �. t.♦ ( -/o-71�fbTE1 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 DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE 1004:5 TYPE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK s - FOUNDATION TO SEEPAGE PIT /DRAIN FIE. SEPTIC TANK TO SEEPAGE PIT WALL 16 / SEPTIC TANK , SEEPAGE PIT 1 ' , DRAI TO NEAREST LOT LINE. WELL TO SEPTIC TANK DRAIN FIELD WATER MAIN TO SEPTIC TANK DRAIN FIELD SEEPAGE PIT _ ALSO CONSIDE SEEPAGE F SEPTIC TANK, SEEPAGE PIT DRAI TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRI EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TA FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALL/ RA !A1 G.A.A.B. OR LICENSED DESIGNER I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF DESCRI/BEE,D SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE `•✓ //v 74 APPLICANT'S SIGNATURE FORM NO. EQ -01 6 SEEPAGE AREA SIZE 660 la' TYPE +�� " DIAGRAM OF SYSTEM GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVTRONMFrITAL QUALITY 3330 "C" Street ANCHORAGE, ALASKA 99503 Performed F o r Candee Construction Legal Description: Lot 1 ,Block____ This Form Reports Soils Log__ XX - Soil Test Must Be Logged To 4' Depth Feet Soi 1 Characteri s tics 1- 2- 3- 4- 5- 6- 7— .8- 9- 10— I I — 12- 13- 14- 16 --- 2- 3- 4- 5- 6- 7— .g- 9- 10-- II- 12- 13- 14- 16 Case # Dated Performed June 10, 1974 . Subdivision—Contour Acres Percolation Test Below Proposed Seepage System - Silty sands, occasional gravel SM Silty sands, medium gravel SM -SP Sandy silt, coarse gravel & sand SP Was Ground Water Encountered? No If Yes, At What Depth? Reading Date Gross Time Net Time Depth to H2O Net Drop Percolation Rate_ Minul;e Proposed Insfal_lation: Seepage. Pit XX Drain Field Depth of InletDepth to Bottom of Pit or Trench— 16' COMMENTS: We recommend 220 sq, ft .per bedroom based on BorQugh standards. Test Performed BY John Jameson Date Certified BY: 'y Date. Parcel I.D. 017-451-11 Municipality of Anc On -Site Water and Wastewater (907) 343-7904 Certificate of On -Site Systems 1. GENERAL INFORMATION 9 01 2016 Expiration Date: I L -Z0-1 Complete legal description Contour Acres #3, Block 3, Lot 1 Location (Site address) 5000 Country Club Lane Anchorage, AK 99516 Current Property owner(s) Allan & Cheryl Scott Mailing address Real Estate Agent Day phone 632-2684 5000 Country Club Lane Anchorage, AK 99516 2. TYPE OF DWELLING: Q Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: Three Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual FX] Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver/Variance request for: Received by: 141 (PQM / /11C� Date: o� COSA to be released to the engineer, unless othervvtse requested by the engineer. COSA Fee $ 59 (0.0(7nnnn Waiver Fee $ _ Date of Payment _ Ot / I / �V i (V Date of Payment Receipt Number 0 550 `"c Q Receipt Number. COSA# ©SCIUJ3g5 Waiver# 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 Certificate of On -Site 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 Firm Anderson Engineering Phone Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name _Michael E. Anderson, P.E. 6. DSD NATURE St #1A M 522-7773 0 49L� 0 ys em pproved for bedrooms �� MI(t: ANDERSON : F System #2 Approved for bedrooms �� s� CE `4381 DisapprovedpROFESS1�Np� �® Conditional approval for bedrooms, with the following sfip61ations Original Certificate Date: �-ZC 4':' The Municipality of Anchorage -Development Services Division (DSD) issues Certificates of Onsite Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet r I- :. c If more than 1 septic system is on the lot: COSA Checklist # _of _ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Contour Acres No. 3, Block 3, Lot 1 Parcel ID: 017-451-11 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 1974 Sanitary seal (Y/N) Y Total depth >182 ft. Cased to >40 ft. FROM WELL LOG Date of test Well Log (Y/N) N Wires properly protected (YIN) Y Casing height (aboveground) >18 AT INSPECTION 8/25/2016 Static water level ft. 172 ft, Well production g,p.m, 5.5 g.p.m WATER SAMPLE RESULTS Coliform 0 colonies/100 mL Nitrate 289 mg/L Arsenic ND ug/L Date of sample: 8/24/16 Collected by: And. Engineering B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/Steel Date installed 7/15/74 Tank size 1,000 gal. Number of Compartments 2 Cleanouts (Y/N) _ Foundation cleanout (YM) Y Depression over tank (YIN) N High water alarm (Y/N) Date of pumping 9-7-2016 Pumper A Plus Home Services Y N C. ABSORPTION FIELD DATA Date installed 611/88 Soil rating (g.p.d./ft2 or f2/bdrm) 165 SFISDRM System type Bed Length 40 ft. IWidth 18.6 ft. Gravel below pipe •5 ft. Total depth 3.5 ft. Eff. absorption area 744 ftz Monitoring tube Y Depression over field N Date of adequacy test 8/25/1.6 � Results (Pass/Fail) Pass For3 _ bedrooms Fluid depth in absorption field before test 1.5 in. Water added 474 gal. New depth 2 in. Elapsed Time: 120 min. Final fluid depth 1.5 in. Absorption rate >= 450 g p d Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed "Pump on" level at Datum Size in gallons in. "Pump off' level at Cycles tested E. SEPARATION DISTANCES WELL ON LOT TO: Manhole/Access (Y/N) in. High water alarm level at in. Meets alarm & circuit requirements? r r Septic tank/lift station on lot On adjacent lots >100 Absorption field on lot > 100' On adjacent lots > 100' r r Public sewer main >75 Public sewer manhole/cleanout >100 r r Sewer /septic service line 5 Holding tank >75 Animal containment areas >50' Manure/animal excrete storage areas >100, SEPTIC/HOLDING TANK ON LOT TO: . r Building foundation Property line >5 Water main >10r Water service line >10r Wells on adjacent lots >100' ABSORPTION FIELD ON LOT TO: Property line >10' Building foundation >10, r � Water Service line 0 Surface water >100 Curtain drain None Noted Wells on adjacent lots >100' Absorption field >5' Surface water >100' Water main >10' Driveway, parking/vehicle storage > 10' F. COMMENTS Septic Tank is more than 40 years old and at the end of its useful life. G. ENGINEER'S CERTIFICATION I certify 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. Date 9/1/2016 COSA brown sheet 10-10-12.doc 'qt- ... .0 ........................... MICHAEL E. ANDERSON :,0 - CE 0 - CE - 4381 210 D rph D o IMS Otim C_ � -I IrA mm iMm WOE c jVA nrm o � ntmi �F A cl.EC,R'C ENE.PobVY ( SEE AGTf) "" 1w, A,,W4 319115 !PbTILM EASEMENT( AS NOTED ON RECL O 'PLAT) IV vu ul t 2/.5.vu MUNICIPALITY OF ANCHORAGE AAL • '� DEPARTMENT OF HEALTH & HUMAN SERVICES_ Division of Environmental Services On -Site Services Section P.O. Box 196650. Anchorage, Alaska 99519-6650.: . 343-4744 , CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # �� 7 "S� % HAA # 1. GENERAL INFORMATION Complete legal description Lo F 1 133 tock 3 Co n k r 11-crer S / D *3 Location (site address or directions) Soap Caun lt-;, CIuS Lune _ /}nc.hon22g e Ak 9951( Property owner 0111 k if/arse H,anar4le Day phone 26S- 3 0 o Mailing address 557oao Couni-r )e Clkh Lane AncAvrage, Ak 99S -IG Lending agency Norwest I`tvrf�yagP Day phone Mailing address Agent lean Wolf. Re Max PC24trjo Day phone 276 - 2.76'/ Address 2600 Cordo(lvi Sf., 44 CA& t-agQ; Ak 995"03 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 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. 72-025 (Rev.1/91) Front MOAM21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is�safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I f urther 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 r lc !1 e T{ecAn i col Seems, c< Phone 3'1S- 3S s Address 11,00 E—SAT Sf. /4 -Ar-/) oc-«ye 4k l9S16- Engineer's signature Date ^ fP± 2-3, 199 y 6. DHHS SIGNATURE Approved for Disapproved. Conditional approval for Additional Comments By: • to 491— ';` 1 '1M•1•••. *to • i.11a�l/e THEODORE F. MOORE ; ►"' ••. CE -3589 bedrooms. auric bedrooms, with the following stipulations: Date a 2G� 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 lnspections"orr 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 (Rov.1/91) Back MOA N21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lnf 10 61oc,k 3_ Con&ur Parcel I.D. A. Well Data Well type i v t If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) N Date completed 19-11( Driller FFan k Aurf Total depth > 16?-, Cased to > y0' Casing height Sanitary seal (Y/N) Y Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump levell SEPARATION DISTANCES FROM WELL TO: AT INSPECTION 9/19/9y 7 O' g.p.m. 6. 2 t g.p.m. Septictholding tank on lot I I 0 ' ; On adjacent lots > r oo ' Absorption field on lot 12 5' ; On adjacent lots > 100# Public sewer main NI• A. Public sewer manhole/cleanout IN. A. Sewer service line -> zs( Petroleum tank None see,, WATER SAMPLE RESULTS: -221, Colfform O c ri( /too M e Nitrate < 0 . I Me / .Q Other bacteria 0 cot //00 r�► -Q Date of sample: 9 / 1919 Y Collected by: FI «t 26" TecA Slc B. SEPTIC/HOLDING TANK DATA Date installed 7/ 15-/ 7 r Tank size 1000 got Compartments -2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression (Y/N) 1y High water alarm (Y/N) iii- A. Alarm tested (Y/N) N� A. Date of pumping ?1(0191 Pumper fi?o/a 60 �e,- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ((0, On adjacent lots > (00' Foundation q To property line Absorption field If 3 Water main/service line 2s' Surface water/drainage > 1,90 ' 72-026 (3W)• Front CONTINUED ON BACK PAGE c `' 'N �ij m O C -M 0 � m -Q n "' O rn 0 Z Colfform O c ri( /too M e Nitrate < 0 . I Me / .Q Other bacteria 0 cot //00 r�► -Q Date of sample: 9 / 1919 Y Collected by: FI «t 26" TecA Slc B. SEPTIC/HOLDING TANK DATA Date installed 7/ 15-/ 7 r Tank size 1000 got Compartments -2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression (Y/N) 1y High water alarm (Y/N) iii- A. Alarm tested (Y/N) N� A. Date of pumping ?1(0191 Pumper fi?o/a 60 �e,- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ((0, On adjacent lots > (00' Foundation q To property line Absorption field If 3 Water main/service line 2s' Surface water/drainage > 1,90 ' 72-026 (3W)• Front CONTINUED ON BACK PAGE C. LIFT STATION ISI- A. Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vend (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" Level at Cycles tested Surface water Date installed r; sl I l 8 Soil rating (GPD/Ft2) 16S A 70cfrr+ System type 3eoC Length Y o ` Width 1 8.0", Gravel thickness O..T 13e f -w Total depth 3. S Total absorption area "7 11!J Cleanout present (Y/N) Y Depression over field (Y/N) _ Date of adequacy test 9 / 19 / 9 V Results (pass/faie Pass for 3 Bedrooms Water level in absorption field before test 10" After test 11.5 it Peroxide treatment (past 12 months) (Y/N) nl c,n & kn o ca,7 o f If yes, give date K A= SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I Z5 On adjacent lots > 100' Property line 60 To building foundation y Al To existing or abandoned system on lot �— to' On adjacent lots 3a' Cutbank N. A. Water main/service line Surface water 1 oo ' Driveway, parking/vehicle storage area 2' Curtain drain None SC'e6 *See eAeloseot le4er ip ferpreh'A,7 adcf«qcy fest refulhr. E. ENGINEER'S CERTIFICATION 1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in�pge�date of this inspection. iw qw 3i `��'��r*►ly N4 ��Rxr��� TA p • Signature Xv Engineer's Name 7-h eo o(bcL E%I" fGG rP : rTHEODORE E. MOORE CE - 35£,9 Date o kM t>,er 2 S'i 19'-2y •r, ,.i rNN HAA Fee $ 3 00 'C Date of Payment I—,Z 7— q Receipt Number_34 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number CIVIL. & ENVIRONMENTAL ENGINEERING • ENERGY CONSERVATION & ANALYSIS THEODORE F. MOORE, P.E. 14530 ECHO ST. PH: (907) 345-1355 September 23, 1994 ANCHORAGE, ALASKA 99516 M.O.A. DHHS P.O.Box 196650 Anchorage, AK 99519 Dear Sirs: The purpose of this letter is to help you interpret the enclosed adequacy test data sheet pertaining to the wastewater disposal system serving the three bedroom residence on Lot 1, Block 3, Contour Acres S/D. According to the as -built inspection report on file at the Municipal Health Department, the wastewater disposal system includes a 1000 gallon septic tank which was installed in 1974 which discharged into a concrete ring seepage pit. In 1988 the system was upgraded by the replacement of the seepage pit by a 744 square foot soil absorption bed with 6 inches of sewer gravel beneath the horizontal distribution pipe network. The original seepage pit was left in place with a valve installed to allow subsequent diversion of the septic tank effluent back to the seepage pit as necessary. At the time of our inspection the valve was still set to direct effluent into the newer soil absorption bed and the seepage pit had no measurable fluid in the bottom. To assess the adequacy of the system we ran measured quantities of water into the system through the second compartment of the septic tank, while monitoring fluid levels in the septic tank and in the soil absorption system standpipes, before, during and after the flow of water was stopped. The initial fluid depth in the soil absorption bed monitor tube was 10 inches, and the maximum depth measured after 555 gallons of water had been added to the system was 13 inches. Two and a half hours after the flow of water was stopped the fluid depth in the bed monitor tube had receded to less than 11 inches. We then added another 125 gallons of water into the system which brought the fluid depth up to 11.5 inches. Based on these test results we concluded that the system was still able to absorb water at faster than the required rate for a three bedroom residence while the fluid depth in the bed was less than the total gravel depth of 12 inches. As I discussed with Dan Roth, the working fluid depth is greater than the 6 inch gravel depth beneath the horizontal distribution pipe network, but it is less than the total gravel thickness, which appears to be at least 13 inches. The relatively rapid reabsorption rate which we measured indicates to me that the system is still functioning adequately, with the absorption being primarily through the perimeter sidewalls of the bed. While nobody can accurately forecast the future lifespan of a soil absorption system, our test results do not indicate that the system is on the verge of imminent failure. I recommend that the system be approved. The presence of the original seepage pit (which is accessible with a simple turn of the diversion valve) provides a valuable safety factor in that it allows for the soil absorption bed to be given a resting period. Please give me a call if you have any questions on the adequacy test.procedures or interpretation. Sincerely, 7_'_J_i7� Ted Moore, P.E. 09/23/94 09:57 CT&E ENVIRONMENTAL LAB SERVICES 9073451355 NO. 616 903 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. TELEPHONIC (007) 582-2343 5633 8 Street Anchorage, Alaska 00518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER ❑ PUBLIC WATER SYSTEM I.D. F 1St PRIVATE WATER SYSTEM 'FiVf a 6! 3 YS- t ass' NM�e Phong No. y S -3 0 �o Sly iAe Gq Wren /411 G f7 e% � !T zia9�6 cer coo SAMPLE DATE: L"_1.�...► Mo. Day Year SAMPLE TYPE: Ci Routine O Check Sample (for routine sample with lab ref. no. ) (I Treated Water ❑ Special purpose 9 Untreated water TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: 9(Satisfactory ❑ 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. Data Received Time Received Analytical Method: Membrane Filter No. of coi0nisS1100 ml. SAMPLE Time Cots oted !1 Lab p.r Result' Analyst No. LOCATION Collected By !1 4 t k ren Nr �_j t z=ao Ivoen T iT t tv� L 3 �II 4 1 �� 5 BACTERIOLOGICAL WATER ANALYSIS RECORD BEAD INSTRUCTIONS Membrane Filter: Mreot Count 40e0errN1100 mi Verlrtcation: LSB isGB BEFORE Fecal coutorm Confirmstion Final Membrane Fitter Results Collloravloo ml COLLECTING SAMPLE Reported By ate _�/ - ---- TNTC = Too NUMOrOUS To count pAPT ON E OF 08 = other Bfaicterta TWQ TQ FOLLOW 09/23/94 09:57 CT&E ENVIRONMENTAL LAB SERVICES -+ 9073451355 NO. 616 002 Commercial Testing & Engineering Co. Environmental LaboratorY Services —A�' g,nCe x940 LABORATORY ANALYSIS REPORT CTtRLRef.# 94.4807-1 Client Sample W LUf 1 BLK. 3 CONl'UURACRES SID /RUNT' Matrix WATER ClientNatne FLNrfOP TECHNICAL SRV Ordered By Project Natne Project# Pwsm UA WORK Order 82359 PrintedAate 09/22/94 @ 10:44 ltrs. Collected Date 09/19/94 @ 12:00 las. Received Date 09/19/94 (4 14:00 tars. Tecluaktil lArectur STLIJIfI :N C. EDD Released SaitupleRxmarks: sAMyLL, cOLLEC FDYN: T.F.MOM' *HOSE/;!// Parameter Nitrate -N ----, QC Results (2ual tluits Method 0.10 U mg/L EPA 353.21300.0 Allowable Ext. Anul Limits Date Date /nit l p 09/21194 CMR Instructions L3A=Unavailable See Special Instn NA=Not Analyzed • • See Sample Remarks Above I.; f - Lcss Than U = Utldetmted, Reported value is the practical quantification limit. GT= Cheater1ban D= Cecondury dilution. 'J LL 5633 8 Street, Anchorage. AK 99518-.1600 — Tel: (9071562-2343 Fax: (907) 561-5301, ENVIRONMENTAL FACILITIES IN ALASKA. COLORADO, FLORIDA, ILLINOIS. MARYLAND, NEW JERSEY. OH10, UTAH. WEST VIRGINIA Alaska Water & Wastewater Services "Preserving The Last Frontier" October 23, 1994 Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On -Site Services Section P.0_ Box 196650 Anchorage, Alaska 99519-6650 Attn: Dan Roth Ref: Septic System Adequacy Test; Lot 1, Block 3, Contour Acre S/D. Dear Dan: At the request of Dan Wolf, Remax Realty, I have performed an adequacy test on the old seepage pit (installed July 1974) at the subject property. Seventeen hours and 20 minutes prior to doing the test the pit was presoaked with 500 gallons of water. Prior to starting the test the following day there was 7.5 inches of water in the pit. Water was introduced into the pit at a rate of 6.2 gpm for a total of 81 minutes'(502 gallons). The liquid level rose a total of 26.25 inches, for a total depth of 33.75 inches. The recovery was monitored periodically over the next 20 hours, and the data plotted on Log vs Log paper. The results indicate that the pit currently is capable of absorbing approximately 530 gpd, and is adequate for a 3 bedroom house (450 gpd). There is an alternator valve on this septic system which should be used to switch flow between the old seepage pit and the newer bed system (installed June 1988). Unfortunately, there is no stem on this valve. It is my recommendation that a stem be installed, so flow can easily be alternated in the future. If you,have any question, please call me a 337-6179. Sincerely, /} A r �C s Cll , _aaPP :n n_ Jef#lq#ya. Garner Owe C sultant Remaxl_WPS Y. P_E_, M.S. �;W(914w_ � I, 1, 0 • •aaia a0a�i +a sa /r, rey A. CE -7953 a� ' w a a•••a � �a aN EaCwa y{.\`�'G'�i 0 Telephone: (907) 337-6179 . Fax: (907) 338-3246 . 8471 Brookridge Drive . Anchorage, Alaska 99504 Dt- , r RECEIVED -'f INSPECTION APPOINTMENTS �°T E TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & DEPARTMENT OF HEALTH &`ENVIRONMENTAL PROTECTIOAIWIRONMENTAL PROTECTION 825 L Street -.Anchorage, Alaska 99501 � ENVIRONMENTAL SANITATION DIVISION NOV 2 5 1981 `, .Telephone 264-4720 RECEIVED � 1\ E C E I Y rtD REQUEST FOR APPROVAL' OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTYOWNER PHONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) . PHONE 2.- BUYER PHONE am MAILINGADDRESS 3. LENDING INSTITUTION PHONE AILING ADDRESS 4. REALTOR/AGENT PHONE �i M (LING ADDRESS 5.; EGAL DESCRIPTION ST EET LOCATION krnak�ffG 6 TYPE OF RESIDENCE NUMBER-OF,BEDROOMS SINGLE FAMILY ❑ One ❑ Four ❑ Other ❑ Two ❑ five ❑ MULTIPLE FAMILY :,_Three ❑ Six 7 WATER SUPPLY JK .INDIVIDUAL* *ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM 4- INDIVIDUAL/ON-SITE* YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. ; 72-010 (Rev. 6/79) 01 THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ ` SINGLE FAMILY - ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM 0INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septi Tank or ❑ Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK 'MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS L; --`APPROVED FOR _ BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BY V 72-010 (Rev. 6/79) Tobben Spurkland P.E. 8155 Cranberry St. Anchorage, Alaska 99502 Phone (907) 243-5302 MUNICIPALITY OF ANCHORAGE Df PT, OF HEALTH & ENVIRONtNKENTAL PROTECTION Gay Greenland !f 7 1981 Shennum RealtyK n � � � � � t.. 209 W.Diamond Blvd. t Anchorage, Alaska, 99503 SEWER ADEQUACY TEST Legal Lotl, Block 3, Contour Acres Dec. 4, 1981 Location Corner of Country Club Lane and Bainridge Residence 3 bedroom single family Owner Farsi Water System Sewer System Date of Test Test Procedure *490 W..646**090 let No. 222 ff r JUNE 25, J Test Results Onsite Well From Municipal Records: Tank Stack Steel Two Compartnebts 1000 gal. Absorption System Concrete Rings Diam. 4.5 feet Depth 6 feet. Absorption Area 810 sq. ft. Soil RAting 220 Installation Date July 1974 Dec. 1, 2, and3 1981 System was inspected on November 30. Crib is 15 feet below ground. Liquid depth 62 inches. Tank was pumped on Dec. 1. On Dec. 2 water was added to the crib in increments of 250 gal. The following measurements of the liquid depth were taken. Water Volume Liquid Depth 0 56 250 65 500 78 750 90 1500 108 Check after 24 hours 66 Approximately 1500 gal of liquid was added to the crib No water flowed into the tank. After 24 hours 1250 gal had been absorbed. This system meets the Municipal requirements. 2. GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received May 12, 1976 Time of Inspection 2:30 p.m. Date of Inspection 5-13-76 Les REQUEST FOR APPROVAL OF Thursday INDIVIDUAL SEWER & WATER FACILITIES FOR Conv. Approval requested by: First National Bank of Anchorage % Sherrie Mailing Address: 646 West 4th Avenue Phone: 279-4481 Property Owner: Terry D. & Beverly J. Karr Phone: 344-3810 Mailing Address: Star Route Box 1596, 99502 3. Legal Description: Lot 1 Block 3 Contour Acres # 3 4. Location: Country Club 5. Type of facility to be inspected Single Family No. of bedrooms 3 6. Well Data: Individual A. Type C. Construction B. Depth Approx. 250' D. Bacterial Analysis u 7. Sewage Disposal System: On-site system A. Installed 1974 B. Installer C. Septic Tank: 1. Size �. n�� 2. Manufacturer o' CK X49 -d UL I�SU&� D. Seepage Pit: 1. Absorption Area i 2. Material E. Disposal Field: Total length of lines 8. Distances: A. Well to: Septic tank Absorption area Sewer Lines , Nearest lot line 2,c>4 Other contamination B. Foundation to septic tank 2,0 4 1, Absorption area C. Absorption area to nearest lot line EQ -034 (1/74) Page 1 of two pages MUNICIPALITY OF ANCHOP,AGC MUNICIPALITY OF ANCHORAGE cE''r OF 1�=>,L „ <: ENVIRONt�nr.-..N1A1_ ;' ;l:CTION DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 2510 East Tudor Road, Anchorage, Alaska 99504 276-2221 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES RECEIVED 1. Type of Inspection: CMRO VA FHA CONV 2. Property Owner: TERAV, [)• + _&ytRLEy J_aq r kARR Mailing Address: SRA A&I , Awa Day Phone: 3*q-agto 3. Name of Buyer: A�;S i . ���p0% Mailing Address: -2!5 j-4 Irr►ki"y Day Phone: 3 33-1od I to ., �/ 4. Name of Lending Institution: h'. Sl AIA -M t' A4r. Ax AAVl - MA1A/ 6 R Mailing Address: (Oq(o (A)• 414-k Phone: 2-14 _,gggP 5. Name of Realtor or Agent: LEoNA en kr--Acry - -ni FeAmc o Mailing Address: A0.1 E . NO . L.G73 &VD. Phone: 216- iq l2 /1 A 413 1 6. Legal Description: Location: Type of Facility to be Inspected: ��^�f141';1/,to No. Bdrms. 8. Water Supply Type of Supply: Public Utility Individual' If Individual, number of dwellings presently served If Individual, depth of well —pTm 2,SO 9. Sewage Disposal System Type of System: Public Utility Individual (on-site) If Individual, date of installation LmftVof' 14 72-003(3/76) try 0,46 Page 2 of two pages - Rei st for Approval of Individual F it & Water Facilities Legal Description Comments Approved Disapproved Date Approv 1;Valid for one year from date signed Greater Ancho rea Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED EQ -034 (1/74) Date S CHEMICAL & GI LOGICAL LABORATORIES 'ALASKA, INC. &m TELEPHONE (907)-278.4014 ANCHORAGE INDUSTRIAL CENTER 274.3364 5633 B Street 6 A I tyb •'`a� u�-WRIES Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY WATER SYSTEM: ,. _ _ Analysis shows this Water SAMPLE to be: r D. NO. 'dSatisfactory . c.',4, -� ❑Unsatisfactory Water System Name / PV No. ' f / ❑ Sample too long in transit; sample should not be over 48 hours old at examination Mailing Address P f to indicate reliable results. Please send f" r ; .;., C . ' new sample. City State f Zip Code Date Received ` SAMPLE DATE: MO. Day Year Time Received r ' "•'' I .,t SAMPLE TYPE: Analytical Method: ❑ Routine ❑ Check Sample (for routine sample ❑ Fermentation Tube with lab ref. no. ► ❑ Treated WaterMembrane Filter ❑ Special Purpose ❑ .Untreated Water SAMPLE Time Collected NO. LOCATION y - Collected By `E Lab Ref. No. Result' Analyst I .t /11 2 f m 3 I I 4 5 I I [❑ *No. of colonies/ 100 ml. or No. of Positive portions. READ INSTRUCTIONS BEFORE 06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1978 Date Collected Source _ a.m. Date Recelved Time Receival p.m. Lab. No. Presumptive l Oml I l Oml 1 101111111 1 1 oml I l oml 1 1.0.1 1 0.1 m I 48 Hours I I l I I I I EMB Broth 24 hours: Broth 48 hours: COLLECTING SAMPLE Multiple Tube Report: 10ml Tubes Positlw/Total 20ml Portions Membrane Flltert Direct Count Coliform/100.1 Verification: LTB BOB Final Membrane Filter Rettitlts Coliform/100ml Reported By Date v Timer{ a.m. p.m. FATE 4F ALASKA ADHW -LAB 2W Ct ARTMENT'OF F EALTH` AND WEV ..,RE Lob. No: DIVISION OFA`"PUBLIC HEALTH,_ BACTERIOLOGICAL- WATER ANALYSIS DATE I OFFICE Records in this office indicate this WATER SUPPLY to be of: PUBLIC- SEMI-PUBLIC. INDIVIDUAL - OTHER -REPORT RESULTS TO ❑Satisfactory. CJ Questionable '❑ Unsatisfactory $ani}arySfalus. I .NAME - - lysis shows this Water SAMPLE to be: Satisfactory ❑ Quesfionable ❑ Unsatisfactory. ADDRESS If an "Unsatisfactory" or "Questionable" status is indicated above CITY --! I you should take immediate action as recommended below. ADDRESS 1. Notify consumers water is polluted. Boil or chemically D SOURCE l r treat this water as outlined in the enclosed leaflet "Drink It Pu"re" SAMPLE COLLECTED BY. i ,2. Increase chlorination'sufficiently to meet recommended residual standards. t �m Determine source of contamination and fake action'_ necessary to maintain DATE COLLECTED TIME COLLECTED a safe wafer supply at all times. Sample Collected From [ i chen Top. - ❑ Bafhroom Tap ❑ .Basement ap - : r2, Check chlorination and other mechanical equipment. Make certain it is ❑ Other (List) functioning. properly. �. e SECTIONMPLETE THIS OTHERWISEUNLESS 4INSTRUCTED. If after checking equipment a disinfecting residual is not obtained, please wire this office for emergency assistanceor advisory services: Well ❑ Dug ❑ Driven ❑ Drilled ❑ 'Bored 5. This is a surface wafer'source and subject to pollution by mon and animals. SOURCE:. El Spring ' E3 Cistern 11 Other k An approved water ;supply�source should be developed. Dug Well or Cistern -Construction: - ❑ Metal ❑Tile Brick or --6, Improve your ❑ spring ❑ dug well ❑ driven well Walls . ❑ Wood ❑ Concrete ❑ Concrete Top - ❑ Wood ❑ Concrete ❑ Metal ❑ Open Top ❑ drilled well ❑ cistern. I LOCATION: ❑ In Basement 0 Basement Offset Under House 7. Relocofe your well to;_a safe location in relationship to your sewage disposal. stem. p Y C3 see enclosure ❑ in Yard ❑ other Building Sewer Septic DISTANCE TO: or -Other Drainage Pipe Feet. Tank Feet 8. Sample too, long -in transit-, sample should not be over 48 hours old at Tile Seepage Cass- examination to indicate reliable results, please send new sample. Field Feel. Pit- Feel.: Pool Feet Privy—,F -ee? - - - Other Possible El Bottle Broken m transit, please send new sample. Sources of Contamination MATERIAL: Building Sewer.- ❑ Cast ❑ Wood ❑:Tile ❑ Fibre ElAsbestos ❑ Alaska Cemlfnt - 9. Contact your nearest' ElLocal Health 'Department or Division of Public Health, sanitation office for bulletins, consultation' and ❑ plastic Joint Material .- Type assistance. y SANITARIAN'S REMARKS ! GENERAL Does Water Become Mudd or Discolored? ❑Yes- ❑ M1lo When? y. Diameter of Well -Depth - _ Feet.` _ - j Well -Casing Mate riot - -Diameter - .Depth - - length of - Water Depth Drop Pipe From Bottom Fbet. - PUMP LOCATION: ❑ In Well ❑ Offset In ❑ In Basement ❑ In Ulily Basement Room On Top _ - D Of Well ❑ Other PURPOSE.OF EXAMINATION: Illness Suspected? ❑ Yes ❑ No - New SourSg of Supply? - ❑ Yes ❑ No Repairs to System? ❑ Yes. -140 ❑� Signafure� j BACTERIOLOGICAL WATER ANALYSIS RECORD R_ INSTRUCTIONS.; am F ( Date Received � � Time ReceivedPm. Lab. No. ON Lactose Broth IOcc IOcc lett IOcc IOcc 1.Occ 1 0.1 cc 24 hours 48 hours -� _—_--_-- _--- Brilliant Green 24 hours 48 hours EMB AGAR Lactose Broth, 24 hrs. 48 hrs. Gram's stain Coliform Density (Most probable No. per 100cc.) MF results Reported by Date This analysis indicates Cplihcrenj Organisms to be: F , Absent fi '` PtSSItFT` l