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HomeMy WebLinkAboutROLLING HILLS ESTATES BLK A LT 2On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSPI61221 Tax Code Number: 01107224000 Work Type: Septic Upgrade Permit Effective Dates: August 04, 2016 to August 04, 2017 Design Engineer: PANNONE ENGINEERING SERVICE Subdivision: ROLLING HILLS ESTATES Site Legal Address: ROLLING HILLS ESTATES BLK A LT 2 G:2124 Owner/Address: KEETON GARY L & CELA B 7251 SAND LAKE ROAD ANCHORAGE AK 995021827 Site Mailing Address: 7251 SAND LAKE RD. Anchorage This permit is for the construction of: Lot Size in Sq Ft: 26400 Total Bedrooms: 2 Y Disposal Field Y Septic Tank N Holding Tank N Privy N PrivateWell N WaterStorage 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received Issued By By: —Date 0 o Date: I M614(AeACY4 MUNICIPALITY OF Community Development Department Development Services Division I * On -Site Water & Wastewater Program E_ �0 ANCHORAG '� "' ' 1 2016 Phone: 907-3434S�4_ Fax: 907-343-7997 &WPENGYON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 011-072-24 Property owner(s) GARY 8, CELA KEETON Mail ing addres's 7251 SAND LAKE RD, ANCHORAGE, AK Day phone Date OD -J-9101 (P Site address 7251 SAND LAKE RD, ANCHORAGE, AK e2 10' Date of Payment: Legal description (Sub'd., Block& Lot) ROLLING HILLS EST,�rf L2 PermitNo. OS [Ulm Legal description (Township, Range & Section) Lot Size 26,400 Sq. Ft. Number of Bedrooms 2 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (0 all that apply) Absorption Field FX Initial Single Family (SF) IR (w/wo ADU) Septic Tank R Upgrade Duplex (D) El Holding Tank F-1 Renewal Multiple Dwellings Privy F-1 (SF and/or D) Private Well F Water Storage F-1 THIS APPLICATION INCLUDES A VARIANCE I 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 Permit/Rush Fees: 60-00 Waiver Fees - Date OD -J-9101 (P of Payment Date of Payment: Receipt Number: 6ougalcl, Receipt Number: PermitNo. OS [Ulm Waiver No. permit App_-'- : - ! L.,:c - Pannone Engineering ServiceS LLC Steven R. Pannone, Principal Registered Professional Engineer E-mail: steve(@r)anenRak.com 3 August 2016 Subject: ROLLING HILLS EST, BA L2 Septic System Install Permit Request EMERGENCY UPGRADE— SYSTEM COMPLETELY FAILED Design Narrative This is a design narrative for a permit to install an upgrade septic system to be issued for this property. The existing system is in failure. The proposed system will serve an existing two-bedroom (2BR) house. Currently the lot is developed. The surrounding lots are served by private wells. There are no wells within 100' of this system. 1. Soils. One test hole was performed on this lot by PES in July of 2016, and groundwater was monitored for at least seven days. Ground water Was not observed to a depth of 17.5' below the surface in the test hole monitor tube after the 7 -day monitoring period. Bedrock was not encountered in the test hole. Based on the results_of the percolation tests and overall soils appearance; an application rate of 1.2 gallons/day/square feet was used for a conventional wastewater system in the area of the test hole. 2. Soil Absorption System Design. a. See Sheet I of the design package. 3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain field. The proposed drain field upgrade will maintain at least 100 feet from all surface water and drainage ditches. 4. Topography: The property slopes from the West to the East at 15%-20%. The area surrounding the proposed system slopes from west to east at a 15%-20% slope. The proposed system is not within 50' of any steep slopes. The proposed installation will not affect the future development of the surrounding or existing lots. There are no wells within 100 feet of the proposed septic location. Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 Physical: 332 East Manor, Anchorage, AK 99501 Telephone: (907) 272-8218 FAX: (907) 272-8211 LLJ 0 -0 C:) (A �D LLJ z 3: NOIES DRAWN I JRL SITE PLAN 06 -t- Fill, WELL E I N\I 44 ABANDC C;�EPT RE�' N�E 0 1\ PER MOA CODrE VERIF' �DJION OF EXISTING COLL/ LINE, R&R 11 NEEDED\ /CRIB( 00 Lo \N F 'V 1�1 I %N 1 2 WELL E -110. 2BR m SFD DRIVA_I AY N-STAI-17 1'000q SEPTIC TANK P K P 41. W/ DCO BEFORE & A F:T E FRY INSTALL DRAINFI:ELD P 3; 21.OLFx2.5'Wx6.0'E.D., 9.0'T.D. W/MT & GO AT ENDS -FD I WELL (E)�/ 03 1 ccl� I MI PAMONE ENG SVC, LLC P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 ROLLING HILLS ESTATES BA L2 GARY & CELA KEETON 7251 SAND LAKE. ROAD ANCHORAGE, AK 99502 AND ABANDON n & A� A < 0�i Ld �6 * 7 63. 1 r -SEPTIC `�AREA�� 28.6 1 EPTIC - - - - - - - - - �REAn 4- 1 r -SEPTIC I I �-�AREA�� I I I I w ..... 08/03/2016 Scale -'�4 0 47H.. * I " = 50' P.I.D. NO 011-072-24 a an ops PERMIT NO. kt. L.. CE i149 OSP161067 1 OF 3 1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON—SITE WASTEWATER DISPOSAL SYSTEMS AND AND IN ACCORDANCE WITH AMC 15.65 AND 15.55. 2. SCOPE OF WORK: INSTALL CO'S AND MT'S AT ENDS OF EXISTING FIELDS. R&R CORRUGATED LOW DENSITY POLYETHYLENE PIPE WITH 3034 PVC. INSTALL DCO BETWEEN TANK AND FIELD & ALONG SOUTHERN DRAIN FIELD. 3. GROUNDWATER WAS NOT ENCOUNTERED TO A DEPTH OF 16 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL TEST HOLE. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 16 FEET BELOW EXISTING GRADE NOTIFY THE ENGINEER IMMEDIATELY, 4. THE CONTRACTOR (BOTH WELL AND SEPTIC SYSTEM CONTRACTORS) SHALL HAVE ANY WELL LOCATION ANDISEPTIC LOCATION STAKED AND ANY LOT LINE AND WELL RADIUS SHOWN ON THE PLAN WITHIN 30 FEET OF THE PROPOSED SYSTEM STAKED BY A REGISTERED LAND SURVEYOR BEFORE STARTING THE WORK. 5. THE CONTRACTOR IS RESPONSIBLE FOR ALL R.O.W. AND OTHER REQUIRED PERMITS, OTHER THAN THE ATTACHED. 6. THE CONTRACTOR SHALL CALL FOR LOCATING OF ALL BURIED UTILITIES. 7. THE CONTRACTOR SHALL PROVIDE 24 HOUR NOTICE TO THE ENGINEER -PRIOR TO START OF WORK. ALL SURVEYING AND LOCATES SHALL BE IN PLACE PRIOR TO NOTIFYING THE ENGINEER. B. THE CONTRACTOR SHALL NOTIFY THE ENGINEER OF ANY DISCREPANCY BETWEEN THE APPROVED DRAWINGS AND SITE CONDITIONS/LIMITATIONS POTENTIALLY CAUSING THE NEED TO MODIFY THE DESIGN. 9. AT THE COMPLETION OF THE WORK, THE CONTRACTOR SHALL SUBMIT RED—LINE AS—BUILT DRAWINGS 10 THE ENGINEER. THE RED—LINES SHALL INCLUDE PIPE LENGTHS, ORIGINAL GROUND ELEVATIONS, PIPE ELEVATIONS, AND TANK ELEVATIONS. 10. THE CONTRACTOR SHALL PROVIDE PHOTOGRAPHS OF THE SYSTEM INSTALLATION TO INCLUDE BOTTOM OF EXCAVATION, TOP OF PIPE WITH CLEAN—OUTS AND MONITOR TUBES INSTALLED, INSTALLED TANK AND FINAL GRADING. 11. THE CONTRACTOR PROVIDED DATA (UPON WHICH THIS RECORD DRAWING IS BASED) APPEARS TO REPRESENT THE PROJECT AS CONSTRUCTED. THIS DATA IN CONJUNCTION WITH THE PERIODIC FIELD OBSERVATIONS BY THE ENGINEER (OR HIS DESIGNEE) AS REQUIRED BY AMC 15.65 DOES NOT GUARANTEE THAT THERE ARE NO HIDDEN DEFECTS BY THE CONTRACTOR. 12. THE CONTRACTOR SHALL SIGN THE FOLLOWING: I CERTIFY THAT ALL WORK WAS PERFORMED IN ACCORDANCE WITH THE APPEND PERMIT, AND ANY AND ALL CHANGE ORDERS, AND THAT THE AS—BUILT REDLINES ARE TRUE AND ACCURATE REPRESENTATION OF THE PROJECT AS CONSTRUCTED. NO. BEDROOM: 2(300 gpd) TANK SIZE: 10OOg PERO RATE: 3.7MPI SOIL RATING: 1.2 GPD/SF AREA ROD: 250 SF SYS. TYPE: DEEP TRENCH 6.0'ED MIN LENGTH: 20.8 LF 21.OLFx2.5'Wx6.0' E.D., 9.0' TD TOTAL AREA: 252 SF NOTES: FOR CONSTRUCTION I DRAWN I JRL I SITE PLAN CONTRACTOR: W., TITLE: PAMONE LNG SVC, LLC P.O. 8OX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 ROLLING HILLS ESTATES BA L2 GARY & CELA KEETON 7251 SAND LAKE ROAD ANCHORAGE, AK 99502 WATER LINE WELL RADIUS - SS — SS � NEW SEPTIC ABBREVIATIONS TH TEST HOLE (P) PROPOSED (E) EXISTING GO CLEAN OUT NO. MT MONITOR TUBE NO. TYP TYPICAL CLDPE CORRUGATED LOW 0 DENSITY POLYETHYLENE 08/03/2016 '_ 7m NTS P P.I.O. NO ... .... 1 1_2L2-24 even =1 a"no�p;' '3 PERIM 0 N CE 8149 No OSPI61067 0 ........ 4 She, Sheet 0 3 OF 3 TEST HOLE 2 F --- O—R —1 TOPSOIL 1 — SM WATER LEVEL READING 2— Ed I 19JUL16 1041 2BR 6�26" OR Silty SAND ,3 -- 10 MIN (ORANGE) 4- CD 3 1052 — 5 — — 4 1102 6 8.97" 2.71" 3.7 5 7— — 6.26" — — 6 SIM Silty SAND 8 — 3.8 W1 SOME GRAVEL 9- 10 11 12 13 14 15 16 17 17.5 E30H DATE PERFORMED: 19JUL16 NO GROUNDWATER SOILS LOG — PERCOLATION TEST SLOPE TEST HOLE I I / SITE PLAN 15%-20% CLOCK TIME NET TIME WATER LEVEL READING 2 Ed I 19JUL16 1041 2BR 6�26" — — SFD -D 10 MIN 9.28" 302'. 3.02" CD 3 1052 WAS GROUND WATER ENCOUNTERED? N IF YES, AT WHAT DEPTH? - NA DEPTH TO WATER AFTER MONITORING? - DRY - DATE: 26JUL2016 READING DATE CLOCK TIME NET TIME WATER LEVEL READING NET DROP (`MpT E I 19JUL16 1041 — 6�26" — — 2 1051 10 MIN 9.28" 302'. 3.02" 3.3" 3 1052 — 6.26 — — 4 1102 10 MIN 8.97" 2.71" 3.7 5 1103 — 6.26" — — 6 1113 10 MIN 8.92" , 2.66" 3.8 SLOPE IN I SOIL TEST RESULTS /ANALYSIS • PERCOLATION RATE 3.8(min/inch) (Hydrologic Soils Group: HSG A) • PERC HOLE DIAMETER 6" • TEST RUN BETWEEN-6FTAND7FT. • TEST RUN FOR OVER AN HOUR ' LAST THREE READINGS PROVIDED, COMMENTS: Test hole excavated by A+ HOME SERVICES. Test Hole was presoaked before Perc test. PERFORMED BY: Joseph Lawendowski. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE A h1r) KAI mir IVA[ r I I 1111 1 KI PC I AT CC CC�nlkl 710C n A TC nE 7UIC 7CC� NOTES: PAMONE ENG SVC" LLC FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 ROLLING HILLS ESTATES BA L2 DRAWN JRL GARY & CELA KEETON 7251 SAND LAKE ROAD SITE PLAN ANCHORAGE, AK 99502 F5 05/03/2016 soale NTS P.I.D. NO 011-072-24 PERMIT NO. OSP161067 Sheet 2 OF 3 5. LEGAL DESCRIPTION DA, RECEIVED INSPECTION APPOINTMENTS .TIME TIME TIME DATE DATE DATE SINGLE FAMILY '��Two [:1 Five D MULTIPLE FAMILY INSPECTOR INSPECTOR INSPECTOR 0 iW 11 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & PROTECTAVIIONMENTAL P"OTECTION DEPARTMENT OF HEALTH & ENVIRONMENTAL 825 L Street - Anchorage, Alaska 99501 J Ul_ 2 9 1981 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Completeall partson page 1. Incomplete requests will notbeprocessed. Pleaseallowten (10) days for processing. 1. P I !jQPERTY OWNER N HONE MY f-Mrcl'S L h N e_ PUBLIC UTILITY MAILING ADDRESS S'Tqw PROPERTY RESIDENT (if different from above) PHONE 2. BUYER C-eJd-^ PHONE ary 4NO e 0/�L7 MAILINGAIDDRESS 3. LENDING INSTITUTION PHONE 162 2A —zV_5—/ e�f V-0 MAI LING ADDRESS 4. REALTOR/AGENT PHONE teW 1�7 e - MAILING ADDRESS 9'34 - 5. LEGAL DESCRIPTION 4 STREET LOCATION Satd 6. TYPE OF RESIDE19CE NurviBER OF BEDRUUM�i E__1 One 0 Four El Other SINGLE FAMILY '��Two [:1 Five D MULTIPLE FAMILY El Three 0 Six 7. WATER SUPPLY $Z-4 INDIVIDUAL* ATTACH WELL LOG. A well log is required for all wells drilled 0 COMMUNITY since June 1975. For wells drilled prior to that date, give well Ell PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE-' YEAR ON-SITE SYSTEM WAS INSTALLED. PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PRC 3E INITIATED. 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE 2r'SINGLE FAMILY D MULTIPLE FAMILY NUMBER OF BEDROOMS ONE Er --'THREE 0 FIVE 0 OTHER D TWO EJ FOUR ED SIX 2. WATER SUPPLY E;�`INDIVIDUAL D COMMUNITY El PUBLICUTILITY Connection Verified_ PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM E!<�IVIDUAL/ON -SITE 0PUBLIC UTILITY Connection Verified PERMIT NUMBER DATEINSTALLED INSTALLER - E]Septic Tank or E:1 Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELLTO: Septic/Holding Tank bsorption Area Nearest Lot Line Absorption Area to nearest Lot Line Cu U--') e— a, V- 5. COMMENTS &:�AAPPROVED FOR BEDROOMS 0 CONDITIONAL APPROVAL (letter must accompany certificate) 0 DISAPPROVED DATE B "�� exa� fv- MUNICIPALITY OF ANCHORAGL Department of Health and Environmental Protection 0.1, 825 L Streetf Anchorage, Alaska 995 264-4720 equest for Approval of Individual Sewer and Water FacilitiTs PropertyOwner: /JF- I S Mailing Address: ___&A_Phone: 2. Name of Buyer: Mailing Address: an r�:_ -4 i2ffi�2 Phone: 5;z 71'�� -S Vz \J 3. Lending Institution: Mailing Address: _ Phone: �Z7�-66.6 4. Rea ltor/Age nt: Mailing Address: 3 Phone: -;? 7 5. Legal Description: Lor 616alr -.5 7,'V 7 _: -c S Street Location: 7,2 6. Single Family Residence: Number of Bedrooms: cZ multiple Family Residence: Number of Bedrooms: 7. Water Supply: *Individual Well Public/Community System If Individual Well, well depth If Community System, name of system 8. Sewage Disposal System: *bn-site System f�o� Public System If On-site System, date of installation: *NOTE: A well log is required on ALL wells drilled since 6/75. **If on-site sewer system is over two(2) years old, an adequacy .test is required by this department. A fee of $25.00 must accompany each request before processing can be initiated. 3/77 MUNICIPALITY OF ANCHORAG--FL, DEPARTM., OF HEALTH AND ENVIRONME1. "L PROTECTION 825 L Street, Anchoraap.. Alaska 99501 264-4720 Date Received: February 10, 1978 #1: Time 1:30 p.m. #2: Time #3: Time Date 2-15-78 Wednesday Date Date Insp Pratt Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: Coast Mortgage % Judy Peterson Mailing Address: 4797 Business Park Boulevard Phone: 279-0665 2. Property Owner: Mailing Address 3. 4 : Willard Gene Nelson 7251 Sand Lake Road Phone: 243-1862 1 4 Lot 2 Block A Rolling Hills Estates Subdivision Legal Descr pt on: 7251 Sand Lake Road Single Family Residence: (x) Number of Bedrooms: Multiple Family Residence: ( ) Number of Bedrooms: 5. Well System: Permit # Construction Two Individual well Community/Public System Depth of Well Well Log on File Bacterial Analysis 6. Sewage Disposal System: On-site System (x) Permit # Installed Septic Tank Size Absorption Area Public Utility ( ) Installer Manufacturer Soils Rate 7. Distances: Well to Septic Tank to Sewer Line to Nearest Lot Line Nearest Lot line Material to Absorption Area Absorption Area Page -Two Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 2 Block A Rolling Hills Estates Subdivision Comments: Affadavit Attached: ( ) Letter Attached: ( ) Approved: Date: Disapproved: Date: Department Worksheet: M-09� �0 EL61 : (Gp!s joqjo eaS) 0,10 IMV IVNOIIVN831NI VOJ ION *JdV ---------- ------------------ —03-01A08d 39MA03 30NVHnSNI ON 008C IL61 --- ----- !nbei sej oj, wj0=1 Sd nb 0*' 0"") "0) A83AI13a IV103dS N 33SS3�jaav 0j. NUIL1301 1U0 Gassaippe k 8 01 1,8A110P qJIM 0 SE PMAJ18P gjaqm pue t 0 &M W04m 04 SmM 'Z 99 S33IA83S KIUO eaSS01M 04 XABAIJOP 411M 91 IdIMS _0 ..... F118ALIOR—�We"M wM4M 04 imoqS -1 w �A _A_% S NNAM S334 ___ _ zi S 0 JjtN0jj 0011dO 3003 diz aNV 31VIS "O'd NO SOd d sn1d) �Joe_ is 11VW (131411833 80A IdI3338 2. GREATER ANCHORAGE AREA BOROUGH partment of Environmental Quality r,ee_t, Anchorage, Alaska 99503 274-4561 Date Received in.— Time of Inspection VA dYM&O Date of Inspection ja—lt'n—rlb REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR quested by: 4 Mailing Address: —K 01 Phone: Property Owner: C�amko Phone: ZJ4'4— (-,nL,,r) Mailing Address: 1) a I) I 'L 0 j CDCAA. 3. Legal Description: e'htj �� L-'� I ty Y- " M1 4. Location: I L-a-tA AZ�LL--Q� 5. Type of facility to be inspected A*Nlt'lo '�a No. of bedrooms 6. Well Data: A. Type I I nnA A , k a � B. Depth C. Construction D. Bacterial Analysis 7. Sewage Disposal System: A. Installed B. In tll�er C. Septic Tank: 1. Size D. Seepage Pit: 1. Absorption Area E. Disposal Field: Total length of lines 8. Distances: 2. Manufacturer 2. Material A. Well to: Septic tank Absorption area . Sewer Lines _, Nearest lot line , Other contamination B. Foundation to septic tank . Absorption area C. Absorption area to nearest lot line Un O'�A 1117/1% Paae 1 of two Daaes I Page of two pages - R(' st for Approval of Individual er & Water Facilities Legal Description I Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in thi,s request forapproval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. I I SIGNED Date EQ -034 (1/74) 6yl- / \ , 0 0 GREATER ANCHORAGE AREA BOROUGIi___. 4 MUNICIPAL11Y OF ANCHOPAr75 Department of Environmental Quality DEPARTMENT OF HEALTH & 3330 "C" St., Anchorage, Alaska 9 9 5 0 3 - 2 7 4 f14�5al%IMENTAL PROTECTION REQUEST FOR APPROVAL OF DEC 121975 r% INDIVIDUAL SEWER & WATER FACILITIES RECEIV 1. Type of Inspection: CMRO VA FHA CONV 2. Property Owner: /j -S 6 /J Mai -ling Address: Day Phone 3. Name of Buyer: CA) L S !o A) Mailing Address: VI) Day Phone ,2'H- 5 4. Name of Lending Institution: �e / 7- Y 212c / Al'C _&),� LE'16A2-� &6. Mailing Address: Phone c;_77,;� - 61 a) 5. Name of Realtor or Agent: Mailing Address: &,K�43 �Cl tle�e Phone 7/ 47 z 41 5x�� 5�;V�_77_ - L_ - � 1 6. Legal Description: ze) z 0 ck' z Z/ A-) Z�' z S S / 1;7 /C- S Y3 Location: 7,2-5-1 51,7,vD 4A;Le4­9Z_2 Aime /V Z 14- 7- 601AJ4 Soo�14 6A) Skub L144E-6� S_ 7. Type of Facility to be inspected: /Z No. Bdrms_ 8. Water Supply Type of Supply: Public Utility Individual X If Individual, number of dwellings presently served I f I n d i v i du a I , depth o f we I 1 -//,0 9. Sewage Disposal System Type of System: Public Utility Individual (on-site) If Individual, date of installation _/ , ate azz 6;11nloe� 0 q-- �;2 7 r4,/_ ;�7zay EO -0371 (1/74) 1;VIIA's- (4, , '- -� '5; -, /Z t , '-) <i GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality "C" Street, Anchorage, Alaska 99503 274-4561 let JATU �330 eived Date Rec of Inspection 'A Date of Inspection T� S REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES FOR 1. Approval\ -f- sted by: Mailing Address: Phone: 2. Property Owner: Phone: Mailing Address: 3. Legal Description: "L 4. Location: 5. Type of facility to be inspected No. of bedrooms 6. Well Data: A. Type C. Construction 7. Sewage Disposal System: B. Depth Al� D. Bacterial Analysis A. Installed B. Installer z��If5 C. Septic Tank: 1. Size 2. Manufacturer D. Seepage Pit: 1. Absorption Area 2. Material cl'n�z I E. Disposal Field: 8. Distanc�s: Total length of lines A. Well to: Septic tank Absorption area a 9/ , Sewer Lines Nearest lot line , Other contamination B. Foundation to septic tank I , Absorption area C. Absorption area to nearest lot line —,?o /-/ I Fo-nia (1 /71l) P;incs 1 nf fiar) n;inoc Paq,,e 2 of two pages - Re "" ;t for Approval of Individual �r & Water Facilities Legal Description Comments 17 Approved Disapproved Date. Approval Valid for one year from date signed Greater Anchorage Area 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 Date EQ -034 (1/74) GREATER ANCHORAGE AREA BOROUGH__ Department of Environmental Quality 3330 "C" St., Anchorage, Alaska 99503 - 274-4561 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES 1. Type of Inspection: CMRO VA __)(_ FHA CONV 2 Property Owner: ;T4 'A-fie� 5 WOO t6l J Mai -ling Address: Day Phone,?Z/V we _4 -7 3. Name Of Buyer: ;?4 tj /9 6 zy o a) K' 1,:ago tO t)l M 0 &1L) (34 P D Mailing Address: ,7dx/cj Aj,,�gj,4 Day Phone 34/1 2,�O 4. Name of Lending Institution: 7' 1, A) Mailing Address: /Wj/A/ &61�0—kf Phone.27141q?l CY,"T �1 3 5. Name of Realtor or Agent: '3-e- SS &0,00 16- A) rW&0j-6,J J?6_ 01) ca 3 Mailing Address: _Ct'q e) 4 e g 1 V69, A< -fqr *2 7 P h o n e 6. Legal Description: 2 0 r '22 ./3 1 .0 C Location: :5t4,,j L IK 6 kD19 Q zu f) 1) 1 " V N b (4.5 t Q 1) ed - AL 67 Koo � I I .� a 1, 6z�ftueelJ 14, /_ /_ g k',O 5-PI-361Zk 6 Q IV 16 S V -d . 7. Type of Facility to be inspected: SEK No. Bdrms. 8. Water Supply Type of Supply: Public Utility Individual If Individual, number of dwellings presently served If Individual, depth of well IV 0 f 9. Sewage Disposal System Type of System: Public Utility Individual (on-site) If Individual, date of installation A.Z o-r7<&� q w AJ evA.,-e-le i s A4,157- 40 F /ri/vi e-, C141-4- AC)6,u 7- e e I C Azr� EQ -037 (1/74) REQUEST FOR APPROVAL OF cV7 INDIVIDUAL SEWAGE AND WATER FACILITIES hoo-L (Fill out in Triplicate) o f person requesting approval 2 of propertV� owner 3. r 4. Numlel,,of be 5. Wate x,,, -Ana lys i s 94 ,47, 4,wss�a a. Bacterial, b. Detergent 1 1 6, Well data: a. Type / jlz�l (�&� LIP 544--`1 b . Depth c . Casing, Size de Distance from well to closest existing; or prop I. Sewer line 2. Septic tank 3. Seepage Area--ZJQk 4. Cesspool - 5. Property Line 6. Other sources Of Possible contamination, i.e., creeks, lakes, housesD barn� drainage ditch, etc. A/0 Ive 7. Sewage disposal system. a. Age of system b. Septic tank capacity in gallons c. Name of septic tank manufacture� 1. If "home made" show diag.r d.* Disposal field or seepage pit S, 1. Distance to Property line to house foundation4L�7 el Percolatior� Test 'results f. Percolation Test performed by 11 Use the reverse.side of this form to show diagram. Diagram should include '-7�he foil,owing information: ppoperty lines; -well location, house location� 7��rtic tank location, disposal area location, location of percolation testq direction of ground slope. 9. The il,T��,-witi.n on this form is true and correct t -o -'the best of my knowledge. Signature of App cant V 0- - - '_ __ - �-­ I ]:0 BE FILLED OUT BY HEALTH DEPARTMENT PERSONNEL '.::D�he above described sanitary facilities are hereby approved, subject to the __ -4*11 lollowing conditions - Conditions: The above described sanitary facilities are disapproved for the following reasons*. 7 Ig —na L 19. Approval lis valid for one year following the date of approval. CPJ; cw N �,3 7 a Cherry Van Orman ERA Bass 836 L 15th. Ave Anchorage, Alaskq 99501 Tobben Spurkland P.E. 8155 Cranberry St. Anchorage, Alaska 99502 Phone (907) 243-5302 MUNICIPALITY OF ANCHORAGE DEPT. OF I!U-1-111H & ENVIRONMENTI"L j � CL-CT10N S E W E R A D E q U A 0 Y T E 6 T '98" U'- I ZI. 1 1 A G - RECEIV E' D' Aug.12,1981 Legal: Lot 2, Block A, Rolling Hills Location: 7251 Sand Lake Road Owner: Frank Ray Residence: Three Bedrooms Water; On Site Well Sewer: No Municipal Records. Septic Tank and Cribs probably installed in the 1960's. Date of Test: Aug. 10 and 11, 1981 Test Procedure: Tank wqs pumped by owner on Aug. 7. At that day 37 inches of liquid war, measured in crib. On Aug. 10 crib was charged with water and the water level monditored. The following readings were taken: Liquid depth in septic tank 24Y2 inches Liquid depth in crib 3 01/2 Add 200 gal. 42 Add 200 gal. 46Y2 Add 200 gal 5OY2 Ena filling at 12:15 pm Check depth at 7:20 pm 38 Check ddpth at 12:00 noon 33Y2 Test Result: During a 24 hour period this system absorbed between 500 and 600 gal. The minicipal code required an absorption rate of 150 gal. per bedroom, or 450 gal for a three bed room house. This system meets this requirement. OF At X'III N 2225-E J E 25a 1971 ONAL Municipality of July 31, 1981 825 " L" ST R E ET ANCHORAGE, ALASKA 99501 (907) 264-4111 GEORGE M. SUI-LIVAN, MAYOR DEPARTMENT OF HEALI IA AND ENVIRONMENTAL, PROTECTION Francis L./Faye N. Ray 7251 Sand Lake Road Anchorager Alaska 99502 Subject: Lot 2 Block A Rolling Hills Estates Subdivision I Approval for the individual cannot be granted until the completed: (2) (3) sewer and water facilities following items have been The water analysis report needs to be submitted to this office from the Chem Lab, 5633 B Street, for our review. The septic tank pumped with a receipt submitted to this office. An adequacy test needs to be performed on the existing leaching area. This test will determine if the system is adequate according to National Standards. A listing of private firms performing the test is enclosed. This report needs to be submitted to this office for our review. If there are any further questionsr please call this office at 264-4720. Sincerely, James S. Roberts, R.S. Associate Environmental Specialist JSR1ljw cc: Home Federal Savings and Loan 535 D Street 99501 Sherrie Van Orman/Janie Olson ERA Bass Realty 836 East 15th Avenue 99501 CHEMICAL & GiviOGICAL LABORATORIES tff ALASKA, INC. TELEPHONE (907)-2�79-4014 ANCHORAGE INDUSTRIAL CENTER 274-3364 5633 8 Street �RAMRIES ri ; lAn %A1n+ar nalysis Renort for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER,.,' TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: WATER SYSTEM: W. NO. ,Satisfactory El Unsatisfactory water System Name Phone No. El Sample too long in transit; sample should not be over 48 hours old at examination meilingAddress to indicate reliable results. Please send new sample. zi� code State City j, Received F SAMPLE DATE: Time Received Mo. Day Year Analytical Method: SAMPLE TYPE: • Aoutine 0 Fermentation Tube • Check Sample (for routine sample with lab ref. no.— El Treated Water 'Membrane Filter • Special Purpose 1-J,untreated Water, SAMPLE Time, I olli6ted, Lab Ref. No. Result* Analyst NO. LOCATION Collected By j; r 7� 2 FT1 3 FT -1 4 1 F 5 *No. of colonies/100 mi. or No of Positwe portions. - - 'iRioL-66ICAL WATER ANALYSIS RkORO 06-1220 (b) BACT Rev. 1978 Date Collected Source READ INSTRUCTIONS a.m. MO Received Time Received — 11-11111- Lab. No. Presumptive 10ml 20ml 20ml 10ml 2011131 1.0ml 0.1ml 24 Hours BEFORE 48 Hours matory 24 Hours 48 Hours EMB - Broth 24 hours:— Broth 48 hours: COLLECTING SAMPLE Multiple Tube Report: 10ml Tubes PollithrO/TOtOl 1011111 Portion$ Membrane Filter: Direct Count Coliform/106ml Verification: LTS 8GB Final Membrane Filter Results Co"form/100ml Reported By Date Time- ANCHORAGE CESSPOOL PUMPING Star Route A, Box 144 ANCHORAGE, ALASKA 99502 Phone 344-2632 or 344-2453 I LLu - I DcmK — 10 SERIES 609 66-1220(a) Rev. 1973 DATE ALI. DEPARTMENT OF HEALTH AND SOCIAL S tES DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL WATER ANALYSIS Analysis shows this Water SAMPLE to be: Satisfactory E-] Unsatisfactory Questionable Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Bottle broken in transit, please send new sample. Lab No. OFFICE INDIVIDUAL SEMI-PUBLIC F] CHLORINE RESIDUAL PPM REPORT RESULTS TO NAME ADDRESS CITY ZIP CODE ADDRESS F SOURCE SANITARIAN'S REMARKS COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED TIME COLLECTED Sample Collected From [j Kitchen Tap Bathroom Top Basement Tap E] Other (List) Well — C] Dug El Driven D Drilled 0 Bored SOURCE: I-] Spring I-] Cistern 0 Other --- Dug Well or Cistern Construction: Walls — tj Wood D Concrete D Metal 1-1 Tile Brick or Top — F] Wood [] Concrete E] Metal El Open Top [I Concrete LOCATION: 0 In Basement Basement Offset El Under House []In Yard 0 Other Building Sewer Septic DISTANCE TO: or Other Drainage Pipe—Feet. Tank—Feet. Tile Seepage Cess - Field — Feet. Pit — Feet. Pool Feet, Privy Feet. Other Possible Sources of Contamination MATERIAL: Building Sewer - 0 Cast Iron 0 Wood 0 Tile 0 Fibre [] Asbestos Cement F1 Plastic Joint Material - Type GENERAL: Does Water Become Muddy or Discolored? [-I Yes 0 No When? Diameter of Well Depth Feet. Weil Casing Material Diameter Depth Length of Water Depth Drop Pipe From Bottom — Feet. __6f f Mat in In Utility PUMP LOCATION: F] in Well 0 Basement E] In Basement Room On Top C] Of Well n Other PURPOSE OF EXAMINATION: Illness Suspected? [I Yes n No New Source of Supply? E] Yes 0 No Repairs to System? 0 Yes L] No Signature 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1973 READ INSTRUCTIONS Date Received Time Received am pm Lab. No. ON REVERSE SIDE BEFORE COLLECTING SAMPLE Lactose Broth Iocc Iocc Iocc Iocc Iocc I.Occ I.Occ 24 Hour. Gram's stain 48 Hours (Most probable No. per 100cc) Brilliant Green 24 Hours 48 Hours a.m. Date -P.M. EMB AGAR Lactose Broth, 24 hrs. 48 hrs.--- Gram's stain Coliform Density (Most probable No. per 100cc) MF Results Reported by a.m. Date -P.M. This analysis indicates Coliform Organisms to bei Absent, Present Jack Porter 3766 Arctic Boulevard Anchorage, Alaska 99503 Subject: Lot 2 Block A R011ing Hills Estates Subdivision currently the subject property is not served by public water or public sewer. if there are any further questions, Please contact this office at 264-4720, sincerelyp LOS N- BUChh0lzr P, -$- Senior Environmental Specialist Department of Health 4#4 Eavironmentll protertion 3330 C Street Anchorage* Alaska 99601 274-45EI 4.1 Vetember 23# 1975 Security Pacific Mortgage 319 West Sth Avenos Anchoraq*�� Alaska SMI SubJectl Lot 2,81atk A Rolling Hill$ SubdiviSIOA 72SI Und Lake Read Door Sir: This departoont Inspected the subject property on December 16. 1975. The well toastruction is approved, however* there is some question as to the sever system, This departsent approved the property during previous years on information in our file$ dated 1969. to 1969 t ' b* Property Is listed as having a Septir, tank and seepage pit. During the December 164, 1975 in$ ectiao, tbw owner stated 4, drainfield existed and therefore otjU ona,standpipe was ovident. This information is in I conflict with our ragords which ia4itatv a pit reQuiring a#Other' standpipe and a percolation test# This department will not grant 44Y tYpe Of 8PPrOVAI 04til tb* stsftd� pipe is installed and the pit tested as to absorPtion COacitY, The septic tank must also t�* puwpod as no St44000 Oxi$t*d Pri*r to this year. If there are Any further questionso please tontaet this office At 274-4561, extension 135* Sincerely" ADHW - LAB -'2W DAE STATE UF ALASKA r ARTMENT OF HEALTH AND WE RE DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS PUBLIC SEMI-PUBLiC F� INDIVIDUAL [:] OTHER REPORT RESULTS TO— NAME Lab. No. OFFICE Records in -this office indicate this WATER SUPPLY to be of: Satisfactory El Ovestionable El Unsatisfactory Sanitary Status. Analysis shows this Water SAMPLE to be: Satisfactory EJ Cluestionable 0 Unsatisfactory. If an "Unsatisfactory" or "Ovestionable" status is indicated above you should take immediate action as recommended below. Notify consumers water is polluted. Boil or chemically treat this water as outlined in the enclosed leaflet "Drink It Pure " ON REVERSE SIDE BEFORE COLLECTING SAMPLE Lactose Broth locc 1 Occ locc SAMPLE COLLECTED BY 2. Increase chlorination sufficiently to meet recommended residual standards. 48 hours am Determine source of contamination and take action necessary to maintain DATE COLLECTED TIME COLLECTED Pm a safe wafer supply at all times. Sample Collected From Kitchen Tap E] Bathroom Top Basement Top —3. Check chlorination and other mechanical equipment. Make certain ;I is El Other (List) functioning properly. COMPLETE THIS SECTION UNLESS OTHERWISE INSTRUCTED —4. If after checking equipment a disinfecting residual is not obtained, please wire this office for emergency assistance or advisory services. Well - D Dug El Drive. El Drilled El B.red —5. This is a surface water source and subject to pollution by man and animals. SOURCE: EJ Spring El Cistern 0 Other An approved wafer supply source should be developed. Dug Well or Cistern Construction: Brick or —6. Improve your El spring El dug well E] driven well Walls - El Wood 0 Concrete D Metal Tile Concrete Top - 0 Wood 0 Concrete D Metal Ll Open Top C3 drilled well 0 cistern. LOCATION: El In Basement 0 Basement Offset El Under House 7. Relocate your well to a safe location in relationship to your sewage 0 In Yard El Other disposal system. E) see enclosure Building Sewer Septic DISTANCE TO: or Other Drainage Pipe— Feet. Tank.Feef. Sample too long in transit; sample should not be over 48 hours old at Tile Seepage Cess- —8. examination to indicate reliable results, please send new sample. Fi.ld—Feet. pit —Feet. Pool—Feet. P,ivy�Feet Other Possible El Battle Broken in transit, please send new sample. Sources of Contamination MATERIAL: Building Sewer - E) Cast El Wood El Tile 0 Fibre Ll Asbestos Iron Cement _----9. Contact your nearest El Local Health Department or 0 Alaska Division of Public Health, sanitation office for bulletins, consultation and El Plastic Joint Material -- Type assistance. GENERAL: Does Water Become Muddy or Discolored? El Yes EJ No SANITARIAN'S REMARKS When? Diameter of W.11 Depth Feel. Well Casing Material Diameter— Depth Length of Water Depth Drop Pipe From Bottom Feet. PUMP LOCATION: El In Well Offset In EJ In Basement B.sem.nt El In utility Room On Top E) Of Well L1 Other PURPOSE OF EXAMINATION: Illness Suspected? 1:1 Yes No New Source of Svpplv? 11 Yes No Repairs to System? 0 Yes 0 N. Signature BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS Date Received Time Received Pm Lab. No. ON REVERSE SIDE BEFORE COLLECTING SAMPLE Lactose Broth locc 1 Occ locc 24 hours 48 hours Brilliant Green 24 hours 48 hours Lactose Broth, 24 h,s. Coliform Density MF results Reported by This analysis indicates Coliform Organisms to be; 48 hrs. Gram's stain --- (Most probable No. per 100cc.) Date Absent blAIL U1- ALAbKA ADHW - LAB .:2w 1) iRTMENT OF HEALTH AND WE1,r­1E Lab. No. DIVISION OF -PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS DATE OFFICE PUBLIC SEMI-PUBLIC 1-1 INDIVIDUAL n OTHER REPORT RESULTS TO— NAME ADDRESS CITY ADDRESS OF SOURCE SAMPLE COLLECTED BY DATE COLLECTED— Sample Collected From El Other (List) — Records in this office indicate this WATER SUPPLY to be of: D Satisfactory [1 Questionable [I Unsatisfactory Sonitary Status. Analysis shows this Water SAMPLE to be: :1 Satisfactory 0 Questionable 11 Unsatisfactory. if an "Unsatisfactory" or "Questionable" status is indicated above you should fake immediate action as recommended below. —1. Notify consumers wafer is polluted. Boil or chemically treat this wafer as outlined in the enclosed leaflet ��n�;nh If Pnr� " —2. Increase chlorination sufficiently to meet recommended residual standards. am Determine source of contamination and fake action necessary to maintain TIME COLLECTED Pro a safe water supply at all times. E] Kitchen Top Bathroom Top E Basement Top —3. Check chlorination and other mechanical equipment. Make certain it is functioning properly. SECTION UNLESS OTHERWISE INSTRUCTED —4. If, after checking equipment a disinfecting residual is not obtained, please i wire this office for emergency assistance or advisory services. Well - EJ Dug C3 Drive. El Drilled B ... d —5. This is a surface wafer source and subject to pollution by man and animals. SOURCE: 0 Spring 0 Cistern EJ Other An approved water supply source should be developed. Dug Well or Cistern Construction: Brick or —6. Improve your El spring El dug well 0 driven well Wells - El Wood E3 Concrete D Metal Tile Concrete Top - 0 Wood El Concrete 0 Met.] Open Top El drilled well El cistern. LOCATION: 0 In Basement El Basement Offset El Under House —7. Relocate your well to a sale location in relationship to your sewage El 1. Yard 0 Other disposal system. El see enclosure Building Sewer Septic DISTANCE TO : or Oth er Drainage Pipe— Feet. Took— 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—Feet. Pit.Fe.t. Pcol—feef. Privy—Feet Other Possible U Bottle Broken in transit, please send new sample. Sources of Contamination MATERIAL: Building Sewer - E] Cos' El wood EJ Tile 0 Fibre 0 Asbestos t your nearest 0 Local Health Deportment or 0 Alaska Iran Cement 9. Confac El Plastic Joint Material -- Type Division of Public Health, sanitation office for bulletins, consultation and assistance. GENERAL: Does Water Become Muddy or Discolored? El Yes No SANITARIAN'S REMARKS I Diameter of Well I Occ Depth Feet, Well Casing Material Diam.ter_Depth Length of Water Depth Drop Pipe From Bottom Feet. PUMP LOCATION: 0 In Well Offset In El In Basement E] 1. Utility Room On Top El Of Well 0 Other Basement PURPOSE OF EXAMINATION: Illness Suspectedl Yes No New Source of Supply? El Yes El No Repairs to System? El Yes El No Signature BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS Date Received Time Received Pm Lab. No. ON REVERSE SIDE BEFORE COLLECTING SAMPLE Lactose Broth 1 Dec I Occ I Occ I Occ I Occ I.Occ 0.1cc 24 hours 48 hours Brilliant Green 24 hours 48 hours Lactose Broth, 24 hrs. 48 Coliform Density ME results Reported by This analysis indicates Coliform Organisms to be: AGAR ,'x stain (Most probable No. per 100cc.) Absent 06-12;0(a� Rev. 1973 DATE INDIVIDUAL El NAME — ADDRESS CITY — ADDRESS OF SOURCE 1,7 ALA , , OF HEALTH AND SOCIAL SF, �"ES Lab No. DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL .'WATER ANALYSIS SEMI-PUBLIC CHLORINE RESIDUAL PPM REPORT RESULTS TO ZIP CODE OFFICE Analysis shows this Water SAMPLE to be: Satisfactory F1 Unsatisfactory 0 Questionable E] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Noitle broken in transit, please send new sample. SANITARIAN'S REMARKS COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED TIME COLLECTED Sample Collected From [I Kitchen Tap [I Bathroom Tap Basement Tap F-1 Other (List) Well — F] Dug F] Driven E] Drilled Ej Bored SOURCE: C Spring [] Cistern FI Other --- Dug Well or Cistern Construction: Walls — F1 Wood 0 Concrete E] Metal El Tile Brick or Top — F1 Wood F-1 Concrete Ej Metal Open Top El Concrete LOCATION: 0 In Basement Ej Basement Offset 0 Under House E]ln Yard F1 Other Building Sewer Septic DISTANCE TO: or Other Drainage Pipe—Feet. Tank—Feet. Tile Seepage Cess - Field — Feet. Pit — feet. Pool — Feet. Privy —Feet. Other Possible Sources of Contamination MATERIAL: Building Sewer- El Cast Iron Ej Wood L] Tile E] Fibre 0 Asbestos FI Plastic Joint Material - Type Cement GENERAL: Does Water Become Muddy or Discolored? E-] Yes F] No When? Diameter of Well Depth Feet. Well Casing Material Diameter Depth —Depth Length of Water Drop Pipe From Bottom — Feet. Offset in In Utility PUMP LOCATION: E] In Well L Basement In Basement f-1 Room On Top F-1 Of Well El Other PURPOSE OF EXAMINATION: Illness Suspected? E] Yes F] No New Source of Supply? El Yes E] No Repairs to System? El Yes E] No Signature 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Re�. 1973 READ INSTRUCTIONS Date Received Time Received am __pm Lab. No. Lactose Broth locc Iocc Iocc locc Iocc I.Occ I.Occ 24 Hours ON 48 Hours Brilliant Green REVERSE SIDE 24 Hours 48 Hours EMB AGAR BEFORE Lactose Broth, 24 hrs. 48 hrs. Gram's stain Coliform Density (Most probable No. per 100cc) MF Results COLLECTING SAMPLE a.m. Reported by Date p.m. This analysis indicates Coliform Organisms to be: Absent Present STATE OF ALASKA ADHW LAB - 2W r IARTMENT OF HEALTH AND WF ARE DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS DATE PUBLIC SEMI-PUBLIC 7 INDIVIDUAL [j OTHER . REPORT RESULTS TO— NAME ADDRESS CITY ADDRESS OF SOURCE SAMPLE COLLECTED BY— DATE COLLECTED Sample Collected From 0 Kitchen Top 0 Other (list) Lob. No OFFICE Records in this office indicate this WATER SUPPLY to be of: El Satisfactory El Questionable 13 Unsatisfactory Sanitary Status. Analysis shows this Water SAMPLE to be: 0 Satisfactory 0 Questionable 0 Unsatisfactory. If an "Unsatisfactory" or "Questionable" &tofu& is indicated above you should take immediate action as recommended below. 1. Notify consumers water is polluted. Boil or chemically treat this water as outlined in the enclosed leaflet "Drink It Pure." —2. Increase chlorination sufficiently to meet recommended residual standards. am Determine source of contamination and take action necessary to maintain TIME COLLECTED pm a safe water supply at oil times. E] Bathroom Top 0 Basement Top �3. Check chlori�atinn and other mechanical equipment. Make certain it is functioning properly. 4. If after checking eqvipmenf a disinfecting residual is not obtained, please wire this office for emergency assistance or advisory services. Well - L1 Dug C3 Driven 0 Drilled 0 B.red —5. This is a surface water source and subject to pollution by man and animals. SOURCE: D Spring 0 Cistern 0 Other An approved water supply source should be developed. Dug Well or Cistern Construction: Brick or 6. Improve your El spring 0 dug well 0 driven well Walls - 11 Wood 0 Concrete El Metal 0 Tile 0 Concrete Top - 11 Wood 0 Concrete 0 Metal D Open Top 0 drilled well El cistern. LOCATION: El In Basement 0 Basement Offset El Under House —7. Relocate your well to a safe location in relationship to your sewage 0 In Yard El Other disposal system. 1:1 see enclosure 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 of Tile Seepage Ce's. examination to indicate reliable results, please send new sample. Field—Feet. pit —Feet. Pool�Foet. Privy Feet Other Possible L] Battle Broken in transit, please send new sample. Sources of Contamination MATERIAL: Building Sewer - 0 Cost 0 Wood 171 Tile E) Fibre Asbestos Iran Cement —9. Contact your nearest El Local Health Departmentor D Alaska 1.1 Plastic Joint Material ­ Type Div . ision of Public Health, sanitation office for bulletins, consultation and assistance, GENERAL: Does Water Become Muddy or Discolored? 0 Yes No SANITARIAN'S REMARKS When? Diameter of Well —Depth Feet, Well Casing Material Diameter_Depth Length of Water Depth Drop Pipe From Bottom Feet. PUMP LOCATION: El In Well E3 Offset In El In Basement o In Utility Basement Room On Top El Of Well El Other PURPOSE OF EXAMINATION: Illness Suspected? 0 Yes 0 No New Source of Supplv? 0 Yes El No Repairs to System? Yes El No READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE Date Received Signature BACTERIOLOGICAL WATER ANALYSIS RECORD am Time Received Pm Lob. Nc Lactose Broth I Occ locc locc I Occ I Occ I.Occ 0.1cc 24 hours 48 hours Brilliant Green 24 hours 48 hours Lactose Broth, 24 firs. 48 —liform Density— MF results Reported by This analysis indicates Coliform Organisms to be: AGAR Gram's stain —(Most probable No. per 100cc.) Absent.