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HomeMy WebLinkAboutT12N R3W SEC 15 SE4SE4NE4SE4 (W PTN)Mll';iM' Permit Number: #SWI81343 Date of Issue: 9127118 Parcel Identification Number: 01529104000 Date Started: 9-30-18 Date Completed: 10-15-18 Is well located at approved permit location? x Yes ❑ No Legal Description: T 12N R3W Sec 15 Se4SE4NE4SE4 (W PTN) Property Owner Name & Address: Glen & Judith Wardle 5711 E 104th Ave Anchorage, Alaska Borehole Data: Depth (ft) Method of Drilling x air rotary ❑ cable tool Soil Type, Thickness & Water Strata From To Casing type: steel stick-up 0 2 Wall Thickness:.025 inches cohbly silty gravel 41 177 Diameter: 6 inches Depth: 177 feet Liner Type: steel cobbles & boulders 177 184 Diameter: 5 inches Depth: 0-248 feet cobbly gravelly silt 184 239 Casing stickup above ground: 2 feet Static water level (from ground level): 236 feet silt); sandy gravel H2O 239 248 silt 248 252 Pumping level: 248 feet after 2 hours Pumping 2 gpm Recovery Rate: 9 gpm Method of Testing: pump Well Intake Opening Type: x Open End ❑ Open Hole ❑ Screened Start feet Stopped feet ❑ Perforations Start feet Stopped feet Grout Type: bentonite granules Volume: 2-bgs Depth: Start 0 feet Stopped ? feet Pump: Intake Depth 247 feet Pump size. 75 hp Brand Name Goulds 7HS07 Well Disinfected Upon Completion? x Yes ❑ No Method of Disinfection: chlorine tablets Comments: Well Driller: Alpine Drilling & Enterprises Mailing Address Ancorage AK 99511 M Phone: 907-343-7904 On -Site Water 6eWastewater Section Fax: 907-343-7997 Development Services pawrtrQ &e- nt Pump Installation Log Well Drilling Permit Number: 181343 Date ofIssue:9 _27 -18 Parcel Identification Number: 0 16 291 04CDO Legal Description Block Lotper Owner Name & Address: T1 2N R3W Sed 15 SE4SE4NE4SE4 (W Glenn & 7udith Wardle PTN) 5711# 104th Ave Anchorage, Alaska Pump Installation Date: 10 -24 -18 Pump Intake Depth Below Top of Well Casing: 247 feet Pump Manufacturer's Name: Goulds Pump Model: 7HS07 Pump Size: '75 hp Pitless Adapter Burial Depth: 5 feet Pitless Adapter Manufacturer's Name: Martinson B-10 A Pitless Adapter Installer: a row P u m p & We I I E -E Well Disinfected Upon Comp ,j,eti,on!? fR Yes " 0 No Method of Disinfection; Comments: Pump Installer Name:David Harper Company:AArow Pump & Well Service, LLC Mailing Address:PO Box 110496 City: Anchorage State: Alaska zip: 99511 Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. MIUNICIPALITY OF ANCHORAGE M > SERVICES DEPARTMENT 907-343-7904 On -Site Water and Wastewater Section Fax: 343-7997 www.muni.org/onsite Well Decommissioninis` a I Legal Address: Subdivision M T12N R3W Section'15 _LotsE4sE4?J9--15�-4? ("7100 On-site Water & Wastewater Section certified contractor performing the well decommissioning: Name: Signature: David Harper Company: Alpine Drilling & Ent Well decommissioning date 10-27-18 Method of decommissioning: AMC 15.55.0601-1 a. F] b. F] c. n1l Location: Use the space below to provide a drawing of the property showing the following items. . North arrow •Decommissioned well location N ® Location of other water wells on the property • Two separate swing -tie distances for each well shown on the drawing Note: The swing -tie distances shall be measured from either permanent structures or the property corners. 1 'Pim R_ a— G:\Development ServicesXBuilding Saf*XOn Site Water and Wastewater\Forms0ient FormskWell Decommisioninq form.doc SGS Ref.# 1186515001 Client Name Residential Testing -Cash Account Project Name/N Glen Wardle Client Sample ID Kitchen Sink Matrix Drinking Water Sample Remarks: Printed Date/Time Collected Date/Time Received Date/Time Technical Director 11/19/2018 10:22 11/15/2018 15:00 11/15/2018 15:30 Stephen C. Ede Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Units Date Date Init Microbiology Laboratory E. Coli Negative 1 Mini, SN121 9223B Total Coliform Negative 1 I 00mL SM21 9223B A 11115118 NRO A 11/15/18 NRO 2of4 "`C1PA"r. MUNICIPALITY OF ANCHORAGE • On-Site Water&Wastewater Programed4 PO Box 196650 4700 Elmore Road • Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 ,� ; " / http:/lwww.muni.org/onsite ' FI _ lei 1)cpartmcnt ACN ON p'E On-Site Water System Permit Permit Number: OSP181343 Effective Date: 9/27/2018 Work Type: Well Upgrade Expiration Date: 9/27/2019 Tax Code Number: 01529104000 Site Legal Address: T12N R3W SEC 15 SE4SE4NE4SE4 (W PTN) G:2537 Site Mailing Address: 5711 E 104TH AVE, Anchorage Owner: WARDLE GLEN A& JUDITH L Lot Size in Sq Ft: 42900 Design Engineer: Total Bedrooms: 3 This permit is for the construction of: ❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 2 Private Well 0 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 Special Provisions: To close out this permit, please submit the following: 1)Well log 2) Pump install log 3)Water sample results for total coliform, nitrates and arsenic 4) Well decommissioning log for existing well. Received By: a1!:,i Date: 9 I Issued By: 0111 I 4,1 ,et9 Date: All � 8 UNICO "' 4 L1TY IFA NCHAGE 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. O j ; ? 1 1 U 4_ Property owner(s) Gtr s 6t� l d, Day phone 3C0O--c? 5 l Mailing address Site address 1 ( ( F 1 04-1-L' Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) T 12_M R.3u) SEC 1 C SC4 SELI. NE4 SC4 Lot Size Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) Ki (w/wo ADU) Septic Tank ❑ Upgrade ® Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify hat the above information is correct. I further certify that this is in accordance with appli le Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: IL 1 5 Waiver Fees: Date of Payment: 9/2(o/l i Date of Payment: Receipt Number: 0001 f Lb Receipt Number: Permit No. O SP I s 3L1 3 Waiver No. G:1Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Permit No. SW940307 • Page 1 of 3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On—Site Wastewater Disposal System and/or Well Inspection Report Legal Description: P12, T12N, R3W, Sec. 15 5E4SE.INELISE`I PID No.: 01529104 (W PTN S 89'54'39" w — - — 132.00' — N 30' PERC N RADIUS • PROPOSED ,--- --/- w o SYSTEM c Li U p ro W f- J O O N OO r —. 0 In Z 00 iPARCEL 17 ----- g UNDEVELOPED 18" DIA: BIRCH TREE oo _ g LOT v) ,..........-----------. i — — nu .f, 48 xi i .. . . N ® EXISTING c 0. v o.ro Y. > E)- 1, HOUSE e `'' � aov R. Q ^- d v aF-- w o' � \ TBM 'i 100' -0 c o c A. v w a \ a� m.(1, chi o \ . oo l.4)..•( DRIVE %: :: _Ne .° a v � � to c •5. WELL4i1 o0 0 -® & L 'a • EXISTING ------ ,........‘%„,_ .•+‘• SEPTIC kcc. 9F' 4/.'' S 89'56':10" w STANDPIPES _ 1,;(, 111.9111� `,r'y'1,��: 132.00' o?4Z1 ( �r TBM. .IS. .TOP NORTH EXISTING FIELD • ERTW. WRIGHTEDGE OF 'WELL E. 104th AVE. • CASING. EL.= 100.0' p.�s'&•„••.c 8156 01'4'N SITE PL AN RECORD DRAWING ''sftf::� Scale: 1 "= 40' Dot- / el _ J08 H:94009 FILE:940160SP PLOT SCALE: 1"L 40' T' IATE:8/6/:14,1 i qf Municipality of Anchorage Page / of ! DEPARTMENT OF HEALTH AN[) HUMAN SERVICES ENVIRONMENTAl_ SERVICES DIVISION P.O. BOx 196650 · Anchorage, Alaska 995'19-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~/' ¢2~(~)~'7 Pie Number: ~X~2 ~~-W~ ~~ Wastewater System: ~ New ~pgrade ~'~/ ~ /~ ~ZY ~/~¢~ ABSORPTION FIELD . ~- ' 2~ ~el) Trench ~ Shallow Trench ~ Bed D Mound ~ Other Lot: Block: ~ ' Subdiv~ion: .T°wnshi~' Range~ Section: /~ Fill added aboveOodginal grade: Ft. Gravel length: ~z~ Ft~ Numb~of lines: Distance between lines: · WELL:~ ~ New ~ Upgrade Grave~width: ~ Et, ~ FL --Classificat[°n (Private, A,B,C):~/~ Total Oeptb:/~ Ft. ~Cased To: Ft. Total absor tion area'.~9~ SQ. Ft. Pipe~ ~ ~ am. 7~ ~. ~/~.~ TANK SEPARATION DISTANCES ~ptio ~ Ho~in, TO Seplic Absorption Lift Holding Public/PHvate Manufacturer: Capacity in gallons: From Tank Field Station Tank SewerLines A~~ ~ s.~.c. ~A WA M~ ~ M~ LIFT STATION Water L~tto ~Z 3]~ ¢ ~ / Size in gaflons: Manufacturer: Foundation ¢~; ~¢¢ ¢ ~ ~ "Pump on" level at: "Pump off" level at: High water alarm at: Cudain Electrical inspections pedormed by: Drain ~ ~l ifa ~A ~A Pump Make& .ode, Remarks: BENCH MARK Location and Description: Department of HeaJ~ a~d~man Services approv~ Beviewed and approved by: Date:/~ -3/-~ Permit No. SW940507 Pege 1 of ,~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 545-4744 On-Sif. e Wastewater Disposal System and/or Well Inspection Report Legal Description: Parcel 17, T12N, R3W, Sec. 15 PID No.: 01529104 S 89~54'39'' W 132.00' 0 WELL 30' PERC PROPOSED: :SYSTEM~-, /~ PARCE'L ~-~ 18" DIA, TBM .oo 17 EXISTING HOUSE 100' DRIVE EXISTING SEPTIC STANDPIPES S ~6'.10" W 152.00' .TBM..IS. TOP N.ORTH EXISTING FIELDj EDGE OF WELL E. 104th AVE CASING. EL_.- 100.0' SITE PLAN RECORD DRAWING Scalei 1"= 40' 95.00 9q .00 ~ .00 UNDEVELOPED ~ ~ LOT o o Permit No, SW940507 Page 2 of 5 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-.6650 Telephone: 54-5-4744 On-Si'(e Wosteweter Disposal Sys(em end/or Well Inspection Report Legal Descrlptlon:Porcel 17, T12N, R3W, Sec. 15. SYSTFM RECORD DRAWING ~__~ PERC1 39.6' Z 9.00 TBM EXISTING WELL (SEE SHEET 1 FOR ELEV,) HOUSE PIB No.: 01529104- 96.00 ,21 :3 FOR PROFILE. 1000 GAL swing' Tie SEPTIC TANK· Dimensions 1 2 %..LL RADIUS A 89.8 79o2' B 98.5 69.9 , DATE: 8/7/94 Permit No. SW940307 Page 3 o~ 3 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: .34.3-4744 On-Site Wostewoter Disposal System and/or Well Inspection Report Legal Description: Parcel 17, T12N, R3W, Sec. 15 PID No.: 01529104 I I I III I I III I LI I I~1 I I IlU ""o ~1~1~ I I I I~1 I I ~11 I m El I Iii I.III ~ ~ I I I tl I ~11 I I LI I~1 I I1~ I I L~ ~ ~ ..... ~ II IIII M EE~I I I ~ I I I I I III~ I ~ fL~l.~rl'l~ I I ~-I I I I IIII e^oqv uoRonuqluo3 ~ Z ,- '>'. ° ° + + ROBERT W. WRIGHT CE 8~56 Date: JOB ,~: 94016 FILE:94016PRO PLOT SCALE:I"= 10' OATE: 8/7/94 MTJNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT NUMBER:SW940307 DESIGN ENGINEER:ROBERT W. WRIGHT, P.E. OWNER NAME:WALDEN DARRYL F & SHARON A OWNER ADDRESS:5711 E 104TH AVE ANCHORAGE, AK 99506 DATE ISSUED: 8/22/94 EXPIRATION DATE: 8/22/95 PARCEL ID:01529104 LEGAL DESCRIPTION: T12N R3W SEC 15 SE4SE4NE4SE4 W PTN) LOT SIZE: 42900 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 (24 HOURS) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: DATE: DATE: ~V,'ight-Ala~ka Engh~eering Services · 6004 Glenkcrry Dr. · Anchorage, AK 99504 August 7, 1994 Municipality of Anchorage Dept. of Health & Human Services On-Site Services Division P.O. Box 196650 Anchorage, AK 99519-6650 Well & Septic System Permit Parcel 17, T12N, R3W, Sec. 15 Dear Sirs, With the submittal of the attached design package and Permit Fees check in the amount of $320.00, the owners of the above noted lot, Mr. & Mrs. Darryl Walden request the granting of Septic Upgrade permit for a three bedroom house. Should you have any questions or require additional information, please feel free to call or fax me at the numbers indicated below. Sincerely, Telephone (907) 338-6230 · Fax (907) 337-5182 %¥right.Alaslta Engineeri~g Services · 6004 Gle~kerry I)r. · A~,cl,orage. AK 99504 August 7, 1994 W.O. 94016 Site Narrative The following site narrative describes the probable impacts of an on-site wastewater disposal system for Parcel 17. The subject lot is located in Sec. 15, T12N, R3W, at 5711 E. 104th Ave. The lot contains 1.0 acres more or less. Access to the lot is off E. 104th Ave., to the upper portions of the lot. The lot is well developed and cleared over the southern 2/3, with few birch and spruce trees. The northern 1/3 appears to be undisturbed terrain covered by Willow and Alder brush, interspersed with Birch. Lot slope is generally at flat, except for the southern 25 ft., which slopes at 20+%. The lot is bounded on the west by a developed lot, and on the south by E. 104th Ave. The lots to the north and east remain undeveloped. 'l'he design drawings indicate the surveyed separation distances between improvements on the developed lot to the west. All Municipal separation distances have been observed. All required well separation distances have been maintained from all portions of the proposed wastewater disposal system. Both wells within the area are upgradient of the proposed system. The general slope of all lots along the eastern end of 104th Ave. off Birch Rd. is to the north. All run-off and drainage flows by sheet drainage from the shoulder of the road to the north. No drainage courses are located within 100 ft. of the proposed system. No adverse impact involving drainage is forseen for any adjacent lots by the installation of this proposed system. Only one lot directly adjacent to and therefore affected by the proposed system is developed. It presently has both a well and on-site wastewater disposal system. The remaining portions of this lot, available for' reserve area, are more than adequate should the existing system fail, and require installation of new systems. The installation of this on-site wastewater disposal sy.%t,~4~,ill not adversely affect any adjacent lots. ~.~-*¢ OF ~/~'%, Wd~-Alaska Enqineeri~ Se~ces ~ 49~ ~,, ~;~'~ Robe~ W. Wright, P.E. ~ ~, 0c-8i58 . ~ ~ -~ 4~L' ............ .,~%~ ~ . Wright-Alaska Engineering Services 6004 Glenkerry Dr. * Anchorage, AK 99504 , Telephone: (907) 33§-6E30 Fax: (907) 307-51§3 Percolation Log Report/Soils Log Performed for: Mr. Darr¢ Walden Hole No:_1 Date: -//18/94 Legal DescripUon: Lo( NA Block NA Troc( NA Subdivision: NA Tgwnship, R~nqe, Section: T12N, RSW, Sec. 15, Parcel 17 Groundweter ~ Oross Net Depth to Net Adiusted Encountered? Yes Reading Da~e Time Time (min,) Water~in,) Drop (in,) Rate (min./in,~ 7/18/94 1927 2:52 1 12 At whet depth? 1~ ~2 7/18/94 1934 3:09 1 12 (Beqfn Per(elation Test) Water level after ~2 7/18/94 1939 3:46 5 6 .96 1944 4:08 5 6 1.05 7/18/94 Monitoring? NONE ~ 7118194 1949 4:19 5 6 1.10 7/18/94 1955 4:25 5 6 1,15 Date: Z/2~/94 ~ 7/18/94 20;00 4:26 5 6 ~ 7/18/94 20:05 4:26 5 6 1,13 Percoloflon Rote ~ 7/18/94 20:11 4:24 5 6- 1.12 1,14 mln/ln. ~ 7/18/94 2017 4:29 5 6 1.14 Comments:_ Performed by: Bob Wrlghf I, ~ Certify [hot this test wns perf~r~e~ ~cordonce with ~11 Store & Municipal guidelines in effect on ~his date. Date: 7//~/~ ' :' '"' <2" thick. Moist. clean I ~ ~ ~ ~ _,, .'. appears to be NFS F-q--f--F-q F--F-T T F T C d '-T--F-q--] 9 _':'~ ,'"' Slope Site Plan 10_ '. Level Perc'd= 4.5 fo 5 I 13 ' '"'"~ ~. '"'"~]~, Percolation Test Rate Adjustment All percolation tests conducted for this project have been completed using a 4" diameter tube in a 6" diameter hole. The annular space between the tube and the hole walls is filled with 3/8" pea gravel. The following adjustment has been made to all readings to account for the volume occupied by the annular gravel pack. h: 8 d: 5.25 h. d - 0.344 h P: 0.344 The porosity of the gravel has been determined using two identical 64 oz. containers. One filled with water, the other with gravel. The depth of water (h) was measured. Water was poured into the gravel container. The depth of the remaining water was measured. P= (h-d)/h. The correction factor 'R' was calculated using the formula from page 76 of Dr. O. Benjamin Kaplan's book "Septic Systems Handbook": ri: 2 r2:3 1 r2. rl = 1.5 radius of 4" diameter perc tube radius of 6" diameter perc hole C :- 1.5 I~P'~C2 1~. = 0.636 C2 R: 0.64 R= Vl/V2 where Vl is the total water vol. in the hole, and V2 is water volume with no gravel. Example: 6" water drop in 2:13 min. 2.22 - 0.37 6 0.37 min/in with gravel pack. 0.37 .--- = 0,578 0.64 0.57 min/in without gravel pack in 6" hole, August 7, 1994 W.O. 94016 Parcel 17, T12N, R3W, Sec. 15 Absorption Area Calculations: Soil percolation rate is 1.14 min./in. (see percolation logs). Application rate for design purposes= 1.2 GPD/s.f. Number of bedrooms= 3 Gallons of septic effluent/bedroom/day= 150 3.150 = 450 gals/day 450 - 375 s.f. required absorption area 1.2 Assume a deep trench, where depth= 5 ft. 375 - 37.5 I.f. 5.2 Therefore, assuming side wall absorption only, trench= 38 I.f Use one trench, 38 ft. long, with endpoint effluent entry. 94002CAL.MCD Permlt No. Page 1 of 7 Municipality of Anchorage DEPARTMENT OF' HEALI'H AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-¢650 Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: Parcel 17, T12N, R3W, Sec, 15 PIB No,: 30' s 89!54'39" w 132.00' PERC PROPOSED: SYS'rEM--~ WELL ~-~ PARCE'L '~----~.I8" DIA. BIRCH' TBM \ 17 EXISTING: HOUSE TBM IS TOP NORTH EDGE OF :WELL E. 104th: AVE. CASING. EL.= 100.0': GENERAL SITE Scale: 1"= 100' s 89"56'!0 132 EXISTING PLAN ~.qO UNDEVELOPED GO LOT )0 (ISTING ~EPTIC STANDPIPES ROBERf W~C/RtOHT,~ ~ ~ DATE: 8/6/94 JOB #: g4009 FILE:g4016GSP PLOT SCALE: 1"~ 40' Permit No. Page 2 of 7 Municipolity of Anohoroge DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 1966.50 Anchorage, Alaska 99519-66.50 Telephone: 545-4744 On-Site Wostewater Disposol System ~]nd/or Well Inspection Report Legol Descriptlon:Porcel 17, T12N, R3W, Sec. 15. ~-°o / i S 88'43'39" _j 0 TBM WELL (SEE SHEET 1 FOR ELEV.) PID No.; /t 96.00 NOTE: SEE SHEET 3 FOR PROFILE. 1000 OAL SEPTIC TANK WELL RADIUS °N_I 8' DIA. BIRCH TREE lO1.00 2.00' 99.00 EXISTING HOUSE 97.00 )0 100.OC [-g ~ROBERT W. WRIOHTt DATE: JOB #; 94016 FILE¢ 94016SYS Permit No, Poge 3 of 7 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchoroge, Aloska 99519-6650 Telephone: 54.,3-4744 On-Site Wastewoter Disposol System ond/or Well Inspection Report Legal Description: Parcel 17, T12N, R3W, Sec, 15 RID No,: e^oq¥ uoRontuRuo0 eeS 0 0 0 ._0. ~: > 0 0 ROBERT W. WRIGHT CE 8156 JOB #: 94016 FILE:94016PRO PLOT SCALE:l"= 10' OATE: 8/7/94 Permit No. Page z~ of 7 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-¢650 Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: Parcel 17, T12N, RSW, Sec. 15 PID No.: 2:t:' Filter Fabric. Elev.= 92.5 4" Perf. Pipel inv; Eiev~= 9210 -Sewer: Rock TRENCH SFCTION Scale: 1'= 2" Bottom of Trench. Bev.= 87,0 __._~_ Water Level While Digging Elev.= 85,0 JOB #:94016 FILE:94016TRN PLOT SCALE:l"=2' 0AT£:8/7/94 Permit No. Page 5 of 7 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone: 343-4744 On-Site Wostewoter Disposal System and/or Well Inspection Report Legal Description: Porcel 17, T12N, RSW, Sec.15 PlO No.: Z JOB #: 94016 EILE:§40~6TNK PLOT SCALEM"=$' DATE: 8/7/94 Permit No. ~~~ ~W.O. 94016 ALL CONSTRUCTION SHALL ~ IN ACCORDANCE WITH CHAPTER 15.65, WA~ DISPOSAL ~EGULATIONS OF THE MUNICIPAL COO~ A5 CURRENTLY AU~NDEO, INSTALL NEW 1000 GAL SEPTIC TANK AS SHOWN ON THE DRAWINGS. RECORO INLET AND OUTLET ELEVATIONS OF THE TANK, TANK SHALL BE PLACEO ON UNDISTURBED NATIVE SOIL, SITE TOPOGRAPHIC SURVEY CONDUCTED ON 7/30/94, EXISTING STRUCTURES, WELLS, SEPTIC SYSTEMS OBSERVED WITHIN 200 FT. OF THE PROPOSED SYSTEM SITE ARE SHOWN ON DESIGN DRAWINGS. 4 5 ANY DEVIATION FROM THE DESIGN MUST BE AUTHORIZED BY THE ENGINEER IN WRITING PRIOR TO ITS INCORPORATION INTO THE SYSTEM. CONTRACTOR TO LOCATE ALL UNDERGROUND UTILITIES, PROPERTY LINES~ EXISTING WELLS, WATERWAYS, SURFACE AND SUBSURFACE DRAINAGE FACILITIES, LAKES, PONDS, ANO OTHER FACILITIES REQUIRING SEPARATION DISTANCES FROM THE PROPOSED SEPTIC SYSTEM. CONTRACTOR TO STAKE PROPOSED SYSTEM PRIOR TO CONSTRUCTION, NOTIFY THE ENGINEER OF ANY OBSERVED CONFLICTS PRIOR TO CONSTRUCTION. 6 7 CONTRACTOR TO NOTIFY THE ENGINEER AND OHHS 24. HOURS PRIOR TO COMMENCING WITH CONSTRUCTION, A MINIMUM OF THREE INSPECTIONS ARE REQUIRED. THE FIRST INSPECTION SHALL BE OF THE SUBGRADE PRIOR TO PLACING THE SEWER ROCK. THE SECOND INSPECTION SHALL BE AFTER THE PLACEMENT OF GRAVEL, DISTRIBUTION PIPING, STANDPIPES, TANK, AND OTHER COMPONENTS AS SPECIFIED, THE THIRD iNSPECTION SHALL BE AFTER THE WORK IS COMPLETED, CONTRACTOR SHALL DELIVER TO THE ENGINEER A SET OF RED-LINED, AS-BUILT DRAWINGS SHOWING ALL OATA AS SPECIFIED IN SEC, 15.65.F.2, 3, 4, 5, 6 OF MUNICIPAL WASTEWATER DISPOSAL REGULATIONS WITHIN FIVE DAYS OF THE FINAL INSPECTION. INVERTS SHALL BE MEASURED TO THE NEAREST HUNDREDTH OF A FOOT. SWING TIE LOCATES SHALL BE MEASURED TO THE NEAREST TENTH OF A FOOT, THESE AS-BUILTS SHALL BE USED BY THE ENGINEER TO PREPARE AND SUBMIT RECORD DRAWINGS TO DHHS. 8 9 ALL EXCAVATION DEPTHS ARE ADVISORY. THEY ARE TO BE VERIFIED AND MAY BE MODIFIED BY THE ENGINEER IF ACTUAL FIELD CONDITIONS VARY FROM THOSE USFD TO PREPARE THE DESIGN DRAWINGS. EXCAVATE THE ABSORPTION TRENCH. BOTTOM OF EXCAVATION SHALL BE LEVEL AND SCARIFIED. RECORD ELEVATIONS AT BEGINNING, MIDDLE, ANO END OF TRENCH BOTTOM. CONSTRUCTION EQUIPMENT SHALL NOT OPERATE ON THE FLOOR OF THE EXCAVATION. ANY MATERIAL COMPACTED BY THE OPERATION OF THE CONSTRUCTION EQUIPMENT SHALL BE REMOVEO AND REPLACED WITH UNCOMPACTED MATERIAL. 10 PLACE THE SEWER ROCK TO THE SPECIFIED DEPTHS. DO NOT CONTAMINATE SEWER ROCK WITH NATIVE MATERIAL OR SPOILS FROM EXCAVATION, LEVEL ROCK SURFACE TO ::b 1" PRIOR TO INSTALLING THE PERFORATED PIPE. I1 ALL PIPE SHALL BE PVC CONFORMING TO ASTM D.3054 OR ENGINEER-APPROVED EQUAL MINIMUM SOIL COVER SHALL 8E 3 FEET OVER THE PIPE AND 4 FEET OVER THE SEPTIC TANK. ONE INCH OF INSULATION MAY BE SUBSTITUTED FOR 1 FOOT OF SOIl. COVER. (SEE NOTE 12) MOUND SOIL AS NECESSARY TO MAINTAIN 4' OF SOIL COVER OVER SEPTIC TANK. 1.3 14 ALL INSULATION BOARD SHALL BE 2" THICK DOW HI-35 [NSULBOARB OR ENGINEER-APPROVED EQUAL. CENTER INSULBOARB WIDTH OVER SEPTIC TANK. (IF NEEDED TO GAIN REQUIRED COVER.) OEOTEXTILE SHALL BE MIRAFI 140S OR ENGINEER-APPROVED EQUAL. LAP ALL JOINTS 2' MIN. 15 i6 COVER THE DISTRIBUTION PIPE WITH A MIN, OF 2" OF SEWER ROCK, AND COVER WITH GEOTEXTILE BEFORE PLACING INSULATION AND/OR BACKFILL, MATERIAL USED AS FILL SHALL BE CLEAN AND FREE OF ORGANICS, TRASH AND CONSTRUCTION DEBRIS. 17 SLOPE ALL FILL MATERIAL TO DRAIN AT 2Y. MIN. SLOPE, AND .3:1 MAX SLOPE, AND IN SUCH A MANNER THAT PONOING AT OR NEAR THE DRAIN FIELD BORS NOT OCCUR. THE FILL SHALL BE LEFT AT 6" HIGHER THAN SHOWN TO ALLOW FOR SETTLEMENT. SEED SURFACE AFTER CDMPLETING INSTALLATION AS PER MUNICIPAL SPECIFICATIONS. 18 RECORD THE FINISH GROUND ELEVATION OVER THE BEGINNING, MIDDLE, AND ENO OF SYSTEM, (Untitled) PARCEL: 015-291-04-000-95 CARD: 01 OF 01 RESIDENTIAL SINGLE FAMILY STATUS: RENUMBERED TO/FROM: 1 WALDEN DARRYL F SHARON A 5711 E 104TH AVE 0 ANCHORAGE T12N R3W SEC 15 SE4SE4NE4SE4 (W PTN) PARCEL 17 AK 99516 6617 SITE 5711 E 104TH AVE LOT SIZE: 42,900 ---DATE CHANGED ....... DEED CH ANGED .... UTIL: PRIVATE WATER % OWNERSHI P: SEPTIC TRAFFIC : LOW LEASEHOLD : ACCESS : GOOD INSP DT: 0 7/87 LAND ONL WELL: N 0 8/89 EXTERIOR TOTAL ROOMS: 06 BEDROOMS ~.' 03 ] : 0 FULL BATHS : 1 HALF BTHS: 1 : 0 RECREATION ]~4S ADD'T FIXTURES Page 1 MUNICIPALITY OF ANCHORAGE He~ h and Environmental Prote Lon Fourth Floor West 825 L Street Anchorage, Alaska 99501 264-4720 INSPECTION REF'ORT ON-SITE SEWAGE DISPOSAL SYS'i'EtA SEPTIC TANK: INStE]B L.ENGltl ..... INSIDE WIOlli __ L. IQUIO DEPTH _ LIQUID CAPACITY_[~O GALLONS. [ TOTAL ! ENGTH DISIANCE I ROM WELt_ tOO~_FOUN 3ATtON .~.7 ~--_NEARZS, T LOI LINE .~_Q ..... OF LINE- ~ I O ~_'rREnCH WIDTHJ~glN. TOTAL EFFECTIVE ~ of Lines .... DI%TANCE BE1 WEEN LINES ~ ~ ~q' ABSOId", '~O;i AHLA ~ ~ .... SQ. FT, LENG FH OF {~ACH LINE .~__ I [O DEPI~h iOl Gl 1IL~ IO I INIS~I GiiADE ~._ ~MAF:RIXNL B[NEATI* T LE ~ .... N. ABOVE TILE ~ IN. SEEPAGE PIT: DIP, METER ...... OR WIDTH ~, LENG TI L~. DEPTH Log Crib Rings Crib Size: DI,'\b,,~E1 ER _._OEPTlt OISTAN(:E FROI,,4: WELL TO'F/~ L EFFECTIVE BUILOING FOU4[)A O , NBARESI LOT LINE ..... ABSORPTION AREA (WALL AREA) SQ, FT, We 11 ~.., ,'.~'- 5 Class~-~. ~'* Depth: Well Distance To: Lot Line Bldg: ~o~ Sewer Line: Pipe Materials: ~[~ ~"~ ~ of Bedrooms: ~ ~} __j Installer: ~ CO ~. I Remarks: ~6~ ~.. ~' ~ ~ q,~-' 7 ~/ , ~. .-~' , ~1 . 'i I I ~l I. I:.ili: ,ll:l ~11 .I.II.I. I :[[ll"d -. m..ll::.lf ' ~h and Lnvlronmental Prote~on Fourth Floor West ' · , x'.,' ~' I i 825 L Street ' ' Anchorage, Alaska 99501 264-4720 ,,; INS, ECTION REPORT ON-SITE SEWAOE I)ISPOSA[ SEPTIC T/d/K: DISTANCE 1~ ~ ~ / , I ~ ~lt~ COMPARTMENTS__ FROM ¢/LLL _ . MAf;LJFAC]URER . ...... WIDflt-°~elN. TOTAL EFFEC fIVE [)EPn~ OF fILTER ~ ~ ~N m~OVE riLE SEEPACE PIF: Log Crib/. _Rings ..... Cr~.b ,(]i.z¢: OlAMETEti___IjEP¥tt __DISI'ANCEFP. OM: '/'/ELL eli. 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TI'lIE ~;"r"J=;I [EP'I ]: I",1 I::IE:(3131~:DI:::IhI(31:~: H 1 :3:: I I.Ip,IDlii:l~::~:;ll::~l",ll) I'1"11:::1'~ TI'Ill 131",I-<i=:;IYIZ '.i.i;l=:141Et:;~ :i~;'¢'J!!;"l'l:il'"l I'"lF:l"r~ I:;~:[~:I~:!I...IIFi:I::~ I~l",ll...F:lt:;?.l]!il!i:f"lt~::N1 IF: tI"IE: I,i:[:?.::i;II)l:i;hlL:l:i; Iki; I:'~:I:!:I'tCH>E[.li[I> IO INC:I.LID[~: I'"lCIi;i:li!: -1't'11::11"4 3: CONSULTING GEOI_C)GIST SOILS LOG Performed for Location Soil Type 0 6 ~ 12 ~ 14 16 18 2O Water Level Remarks Total Depth of Excavation Groundwater ( ) Not Reached Classification Method ~isual ( ) Sieve Analysis () ]2- Material at Total Depth Bedrock ~)'""Not: Reached Depth, if Reached Gary F. Player, Consulting Geologist MUNICIPALITY OF ANCHORAGE ~J ~ 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. # (~/~--,-~-- ~.~-~ _ HAA# ~,1"~°1~h(~-~ GENERAL INFORMATION Complete legal description --~'P¢4~. ~ 1"'7, ~'~cc /~- -~'-'l~ ~'\~ Location (site address or directions) __~ Property owner Mailing address Lending agency Mailing address F711 2 . Day phone Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~-;~ '~ TYPE OF WATER SUPPLY: NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Individual well Community well Public water ,, ~.~ ;.: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. .., 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, I/91) Cr0nt MOA~I 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 ~hat the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verifythat 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, arid regulations in effect on the date of this inspection. Address ~.O ~ ~ /~-,L~ ,~- ,.~.~ ~ Engineer's signature "~--~' c?W~'''2 Date.. &' DHHS SIGNATURE Approved for -~ Disapproved. Conditional approwd for bedrooms. bedrooms, with the following stipulations: Additional Comments ~ote: The well for this property meets existinq ~t,at9 and Mt~nicipal Codes. There are nitrates present. It is continued s~itability. Nitrate concentration is 6.33 mg/1. EPA m~,~ ..... ~~n ~s ~e ..... m~,/I. By: ~ ~ Date .. / . ~ 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 DH HS does this as a courtesy to purchasem of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. MUNICIPALITY OF ANCHORAGE MEMORANDUM WATER WELL ADVISORY HEALTH AUT[{OR~i?Y APPRO%TAL NO.~ ~_~ 5~ During a recent Health Authority Aioprova1 on-site inspection and test of the potable water suploly well on Lot Block of~,%~ 1~ '~I.~AJ-~ ~%t Subdivision, the well's productivity was determined to be~, ~ gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a ~ bedroom residence is ~.~/ gallons per minute. Although the subjecu well currently exceeds this minimum requirement, all p~rties concerned are advised that the production capacity of tl~e well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:~ A. Well Data Well type if A, B, or C, attach ADEC letter. ADEC water system number ~k~ Date completed ~.,~' / ~'7,~- Driller / ,~3 Cased to /~/-;> Casing height ~'/ Wires properly protected (Y/N) ~ Log present (Y/N) . Total depth Sanitary seal (Y/N) AT INSPECTION g.p.m. (~,, ~'//~ g.p.m. /,~ FROM WI"LL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhoie/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Date of sample:_ Nitrate ~¢ ~ ~) !,~4,~// Other bacteria _ ~/~¢~ ~, ¢ / Collectedby: r~¢ B. SEPTIC/HOLDING TANK DATA Date installed __ Cleanouts (Y/N) _ \/ Tank size / P-¢'~) Compartments Foundation cleanout (Y/N) _ ,~// .Depression (Y/N) ~/A~ Alarm tested (Y/N) i"///~ Pumper High water alarm (Y/N) Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I O To propertyline .. ~ Sudace water/drainage 72-026 (8/9~) ' Front On adjacent tots /-- J'~' ~ Foundation Absorption field / ~ Water main/service line CONTINUE[) ON BACK PAGE C. LIFT STATION ~.~ Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~/'7/q ~-// Length 3 ~, (~ Width Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/FF) /~ Gravel thickness Cleanout present (Y/N) ~ Results (pass/fail) '~;:;:~ System type Total depth Depression over field (Y/N) for After test ~"///&- If yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ I t~ To building foundation q 0 On adjacent lots '~ 70 Sudace water t'~ I O Curtain drain t",.I [ ~O On adjacent lots ~- /~'c~ Property line To existing or abandoned system on lot Cutbank i'q ~ k ~ Water main/service line Driveway, parking/vehicle storage area ;:> / E, ENGINEER'S CERTIFICATION I ce~'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on ihe date of this inspection. Signature Engineer's Name HAA Fee $ ,'~ Date of Payment Receipt Number 72-026 (~)' ~ck Waiver Fee $ Date of Payment Receipt Number ,,~4~.~ CT&E Environmental Services In(;. CT&E Ref.~ Matrix Client Sample ID 95.2624-2 WATER L40 BLK4 SAND L~%KE ~2 Client Name TOBBEN SPURKI~, P.E. WORK Order 15804 Ordered By Printed Date 06/30/95 ~ 13:21 hrs. Project Name Collected Date 06/27/95 ~ 13:10 hrs. Project# Received Date 06/27/95 ~ 14:35 hrs. PWSID UA Technical Director STEPHEN C. EDE Sample Remarks: S~d4PLE COLLECTED BY: QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init Total Coliform 0 t~/100ml SM16 909A 06/28/95 ~AV See Special Instructions Above UA = Unavailable See Sample Remarks Above NA = Not ~zalyzed Undetected, Reported value is the practical quantifioation limit. LT = Less Than Secondary dilution. GT = Greater Than CT&E Ref.~ Matrix Client Sample ID CT&E Environmental Services Inc. Laboratory Division ~z~,~z~'~?~6'~~ 95.2558-1 Laboratory Analysis Report WATER T12N R3W SEC 15 Client Name TOBBEN SPURKLA~D, P.E. WORK Order 15683 Ordered By Printed Date 06/27/95 © 13:55 hrs. Project Name Collected Date 06/22/95 ~ 13:00 hrs. Projects Received Date 06/22/95 $ 14:10 hrs. PWEID UA Technical Director STEPHEN C. EDE Sample Remarks: SAMPLE COLLECTED BY: LARS. Qc Allowable Ext. ~al Parameter Results Qual Units Method Limits Date ]3ate Init Nitrate-N 6.33 D mg/L EPA 353.2 10. 06/23/95 DJS See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D = Secondary dilution. GT == Greater Than 200 W. Potter Drive, Ancho~ase, Al( 9951 8-1 605 Tel: {907) 5~2-2343 I:ax; (907) 581-5301 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICNIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA MUNICIPALITY OF ANCHORAGE ' DIVISION OF ENVIRONMENTAL HEALTH DEPARTME~£ OF HFALTH AND ENVIRONMENTAL PR(Ii'EC~ION APPLICATI(~ b~)R HEALTH AUTHORITY APPROVAL CERTIFICATE 1. C~ne~al Infornlation Application ])ate _~/~._"__~.~_~.P" (a) Legal Desc~.iption (include lot, block, subdivision, section, tcwnship, range) Location (add~ess or, di~.~ections) 2b~ ? t ! OiL, / o_~L? ~c ~..~k~_ ..~__ ..... (c) Applicant is (che~ o~) ~ndin~ Institution ~[; ~,~r/b~il~r (e) ~al Estate ~. & Agent Address Telephor~ 2. ~y3~_,~__o~j_ ]~sidence, Si~]gle-Family [-~_~ Number of Bedrcoms Other~ (describe) 3. _W~_ t_~e ~i _S_qj ?j~ .ly- Note: If co~mity ~911 system, must have w~itten confi~mmtion fn~cn~ the State Depa]:,t~nt of ~viror~rental Conservation attesting to the legality and status~ Is tJ%e ~.~11 adequate fo~? the numker of bed~ocms specified in this HAA (Y/N) 4. ~wa__(.t~ D__i, sposgl Onsite t.--_~__L~ ~' Public [~ Core,unity ~ Holding Tank L~_--ji Is the wastewater disposal system adequate for tile p. umb~z? of bedrooms (Y/N) [Page 1 of 2] 2-15-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 A. WELL DATA Well Classification_~g~c~ Well Log P~esent JY/N) ~ Total Depth /~O Cased to Static Water I~vel ~O MUNICIPALITY OF ANCHORA(3~ D[PT, OF HEALTH & ENVIRONM[NTAL PROTECTION JUL 9 1984 RECEIVED Lega,~]. Description: 7~/~, ? ~ ~/-~/~' Casing H~ight Above Ground_ - r~L/" Sanitary ~al on Casing !Y/N~ Elect~.~ical wiring in ~nduit (Y~} ~' ~p~ession ~ound ~l~ead 3Y~)~ Sep~ation Distan~s f~ ~11: lO0 ~ ~ TO 5~a~est Edge of ~so~ption Field oD ~ ~0.~ _; ~ Adjoining ~ts To Nearest Public ~ Line .~ __ To ~est Public Clean,t/Manhole :~ ~/~ To m~est ~ ~vi~ ni~ on ~t Wate~ Sa~le Collected By ... ~ ~ .. __; ~te ~ ~ ,~' ~ ~ Wate~ S~le Test ~sults ~.~%~t C~nts ~ ~ ~.~._~ /~7~ B. SEPTIC/HOLDING TANK DATA Date Installed __~//'77 size /0~ No. of Cc~pa~tn~nt:s ~, Standpipes (Y__~..) x/ Air-tight Caps (Y/N) y__ Foundation Cleanout (Y/N) ~/ Depression o~ Ta~ (Y~) ~ ~te ~st P~d ~/f.~'~ Pu~ing~aintenan~ C~n~aet ~ File (Y~) ~ _; fo~ Holding Ta~ High-Wate~ Alarm (~) IV~ . ~a~y Holdi~ Tank Pe~it (Y/N) Separation Distan~s ~n ~ptie~olding Tank: TO Water-Supply ~11 -~__ /0~,~ To ~ilding F~ndation ~q' TO Pro~=ty Li~ ~, ~ ~l~ ~ TO Dis~sal Field ~ 0 To ~ter Main/Seryi~ Ji~'~ To S~e~, Pond, ~e, ~, ~ajor ~aina~ l,,l v [Pa~ 1 of 2] 2~15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~-~o~[~ / ~['7'7 Width of Field ~t~,~ Square Feet of Absorption Area Depression over Field (Y/N) ~/ Results of Last Adequacy Test Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) of Last Adequacy Test ~/£~/~ Date Separation Distance from Absorption Field: To Water-Supply W~ll lO~/ TO P~operty Line ~t~ .C~. Ca.~c,~,~e,~/~ To Building Foundation To Existing or Abandoned System cn Lot ; On Adjoining Lots To Water Main/Service Line To Cutback(if present) To Stream/Pond/Lake/c~ Major Drainage Course To Driveway, Parking Area, c~ Vehicle Storage Area D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request I certify that I have checked, verified, or confc~m~d to all MOA HAA Guidelines in effect on the date of this inspection. .. ~., Y,"~. ' Signed Date Company MOA No. Blld51s !',.. ,:!',. ' '.?:', [Page 2 of 2] 2-15-84 6.pHEP Approval Approved for Approved~ 5. ~E~_neer~inU ?irm~ Prgvid- i~n~q~j£nspe.?.__.tjo__n~!t.s__~.~[Ya~ta .__~ld ~nfom~tion effect on the ~te of ~is ins~etion. Sig~d by ~% oF ~-~' ( ENGINEER SI~) ~ .~./No. a 2 p b -. r' Disap~o*d fi2 ~ditio~al [2] Ter~ cf Conditional Approval ~e Municipality of Anchorage Departm~nt of ~3alth and Environmental Peotection dces not guarantee t~m continued satisfactory [mrforma~ce, of the water supply and/or the wastewate~ disposal system. 'l~is approval indicates that, as of the validaticn dato showa above~ based on the data and information furnished b~ an er~ineer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func~ tional for the number of bedroc~as aed type of structure indicated° ( D~E? SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] !~.MICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATFR SYSTEM: E-'[- I j I ] j (') see h °n back I.D, NO. Phone No. Water System Name Mailing ~dre~ State City SAMPLE DATE: ~ ~-~ [%~/'~ Mo. Day Zip Co<le SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ret. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. LOCATION 3 I Tlrna Collected Collected By TO BE COMPLETED ElY LABORATORY Analysis shows this Water SAMPLE to be: [] 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. [)ate Received Time Received Analytical Method: [] Fermentation Tube ,I~'M em bran e Filter Lab Ref. No. Result' Analyst I I EE3 06.1220 (b) Rev. 1983 BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direct Count Verification: LTB_ Final Membrane Filter Result¢ BGB__ (;oilformll00ml TNTC = 1'oo Numerous To Count