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HomeMy WebLinkAboutMOUNTAIN PARK ESTATES #2 BLK 2 LT 7 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE [] NEW D & B General, Inc. 549-6965 []UPGRADE MAI LING ADDRESS P.O. Box 10-1349 Anchorage, Alaska 99511 LEGAL DESCRIPTION L7 B2 Moun%ain Park Estates #2 LOCATION NO. OF BEDROOMS Hillslde Drive , Well Absorption area Dwelling PERMIT NO. 820271 DISTANCE TO: I 105~ 5~ 10~ ~- ;~ Manufacturer Greet Materia~tee 1 No. of compartments 2 ~ L q.]~c(~y n ga ons wellFI HOMEMADE: Inside length Width Liquid depth v DISTANCE TO: Dwelling PERMIT NO. [ -~ ~: Manufacturer Material Liquid capacity in gallons -I- : Nearest ~ t~ DISTANCE TO: Well 1061 i Foundation 25~ lot line 10 ~ PERMIT NO, u ~. Z No. of lines Length ~_f(~l] line Total leln~h~c~f~,~ lines Trench wi~Jt~.~ Distance between lines -' -~ ~u 1 inches I- ~ r~ Top of tile to finish grade Material beneath tile Total effective absorption area ~ 5' 66 inches 115~ sq. ft . Length Width ' Depth PERMIT NO. ~1- Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Class Depth Driller Distance to Jot line PERMIT NO. DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS PVC, Cast SOIL TEST RATING INSTAILLER D & B General, Inc. REMARKS APPROVED DATE LEGAL E .F .F . 7/22/82 P.E . L. S . 72-013 (Rev. 3/78) PFF. hh! ][T NO. FiF:'PL. i: i F!F:F:cr' T ': L7 B;2 .NT PP, RK ES]" 82 L,O'T SIZE MR>.','iI'"iLth! ?-,_',UMELER (:iF' E:Er::,F~'OC;i',I':: = 4 THE RE!:!I_I:[RED SIZE FIF -r'L:¢' cqT1 F!.E:SCLF<F'T!FI'.,I S'¢STEM Ic' THE LENGTFi DIMENSION iS THE LENGTH (iN FEE:T) C)F 'I"HE TRENCH OR DRRINFIEL. D. THE DEF'TH OF R TF.'.ENCH OF..: PIT iS THE DISTF:INCE BETNEEN THE SURF£:IE:E 5'F THE C~F.:OLiND F4. ND THE BOTTOM OF THE E>-::'CR',,,'FIT!OI',! (l'N FEET). "r;..IEF..'E IS NO sE'r i,.!IDTH F'OF.: TRENCHES. THE GR,C~',,,'EL DEPTH iS THE !"t:[NIhiUM DEPTH OF GRR',/EL BETI,.!EEN THE OUTFF~.LL PIPE RND THE E~OTTOhl OF THE EXC£:i',,,'RTION (IN FEET). PE,.r,:'h! 'r T RF'F'L. I CF!N.T H FF:; THE F.tESPONL.; ! 81L I ]-Y T ~' " ~,","' ................ :NF.,.,mr! THIS E,EF'.C~RTMENT E:,URZNG 'T!...E' ' '""":-~-' ~'" '- NEM_S RD..:rRCE!'.-iT -r': '?.[-I.T.'.::: Pr-::OF'ERT'=' RN[:, '¥ :[ NSTFIL. LF~T I Oh! .: Nz, ",....L.T .~ ... N.z, OF i:iNY . .... H,.:' i"Jtfi"lr';~"l'7' I,~IF RESZE:,E.NCES THRT 'THF' !.,.!Fl I i.d~l t MI.I',i:EMU!',! DISTRNCE BE:TNEEN R NELL RNC', RNY' ON--S:;ZTE SEI.qRGE DiSPOSFIL.. SYSTEM iE; :LEiO FEET FOR Fl PR]:VR'TE t4ELL. OF.'. ;L58 TO .~D(!i FEET FROM R F'UE~L!C I,.iELL DEPEN[)ING t..tPON THE TYPE OF' PUBLIC .WELL. MI!'-,!ihtUM DISTFINCE FF..:Oi"! R PF.:IVRTE HELL TO P, PR!VFtTE SE!,.IEF..' LINE IS 25 FEET RND "FO R COMh!UN:~TY SEWER LINE ;iS ",:"!5 FEET, 14ELL.. L.OGS RF.:E RE6!UIF.:ED RND MIjST BE RE.'TUF.:NE[:, TO THE [:,EPF!F..:TMENT NI"FHIN ];EI DffT'S OF THE i4ELL COMPLETION. OTHER F.:EC!UiRE,~'!ENTS .hiW'/ F~PF'LY. SPECiFiCATIONS RND CONS]'RL~CTiON DIRGF.:Rh!S FIRE ff',"RI!....RBLE TO INSURE PROPER INSTi~!J_RTION. :[ CERTIFY' THF!'T' iL: I RPt FFIhIZL_TF~R I.,IZ'TH THE RE:.':'L."IREPIENTS FOR ON-SI'TE SENE:RS F4N[-" WELLS RS SET FORTF~ BY THE MUN:(E:ZF'FffL. ZT'T' OF' RNC:HORRGE. 2: Z t,.!ZLL !NSTRLL. THE SYSTEM ZN FICE:ORDRNCE .[,.!:TH THE CODES. :::: I UNDEF.:STRND THRT THE ON-"SZTE SEI4ER SY'STEM i"tRY RE(;!UZRE ENL. RRGEMEI"YF IF 'Fi4E RESZDEN. E:E iS REMODELED 'TO INCLUDE FtORE 'Fi-'!FIN 4 BEDROOMS. 'J:'5Si..,;~:~;} ~.,v ............ [ ....... z' ,, -,, -% ~ ~..t ..... ,jru' ., ¢ MUNIcIP£'~L.~T Y OF DEPARTMENT OF HEALTH AND EI'~IVIRONMENTAL PROTECTION 825 L. Street, Anchorage, AlasJca 99501 2G4-4720 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: 1 2 4 7 10 12 13 ~4 17 18 20 COMMENTS PERCOLATION TEST SLOPE WAS GROUND WATER /!,: ~ ENCOUNTERED? / U IF YES, AT WHAT DEPTH? DATE PERFORMED: t" ! .... ;{, ~'v:' SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop Reid, Jr. No. 2251-E PERCOLATION RATE TEST RUN BETWEEN ~o "~ ~ 7 ~"/ , (minutes/inch) ~' FT AND ' ~ FT . PERFORMED BY:_ / / ~',; ' CERTIFIED BY: 72-008 (6~79) SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF D~ILLED AT THE ~ATE OF 9z:~00 PER ~OOT. PROPERTY OWNER L'~. C. C. ~u. cE. 338-2~72 DRILLER Be2o'~.~.e. CJ..c~ o.fi ~c~rfl. p_c~'z/c. ~R.~ !7oR. L.o, WELL LOG: ~UNICIPALITY OF ANCHORAGE DFPT Oc J'7 'I.T] ! ~' ENVI RO; .IM,_-i'. A_ ' .,O, £C/ION 1982 Co4.L o~ 942X2A. n.g: ,~22o00 pe~..tiao/c. X 375 ~ee~-: :~8250o00 COST INCLUDES ALL .A.O. A~= ~.~ ~O. ~o=~O~ O~ S~= ~.~..m~. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOr THE SUM O~ ~~/, THANK YOU VERY MUCH. BERNIE CLAUS OF RAMPART DRIL~ING WORKS SERVICE CHARGEOF 1Va% PER MONTH WILL BE ASSESSED ON PAST ~ACCOUNTS. .~ WATER WELL RECORO STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological 8~ Geophysical Surveys Drilling Permit No. NO. LOCATION OF WELL (Please complete either In, lb or Ic.I ~.~,.~. ,,v. Io.llSoro.gh Suhdivieion Lo, S~o,, '~'11 I/'qtrs' Section No. TownohiPN~] Range ED Meridian Mt~s~ark 7 2 _o~_o,_o~ -- s~ w~ lc.il DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS ~. OWNER OF WELL: Address: Hillside Drive & Saunders. Street Address and Area of Well Location Feet Below 4. WELL DEPTH: (final} 5. DATE OF COMPLETION 2. WELL LOG Surf.ce 530 ft. 02 -- OA -- 87 Materiel Type Top Bottom 7. USE: ~ Domemtic ~ Public Supply ~ Indumiry ~ Irrigation ~ Recharge ~ Commericel -- ~ diem, ~ in. fo~ ~ ff. Depth Weight ~ / diem., in. to ft. Depth Sflckup . ft. production increased to .2 ~pm Ty,.: Open end o~.=.,.~ 6" ~cllw~ then ~urged with Seckfil[ing 6rav,l p~ck cabl~ tool foF ~ hfs then lO, STATIC WAT(R LEVEL: ~0 ,ft, O~ pumped to 480' and left to ~Abo~. or ~eemo. ,end ,.r,o~e then p~ped to the 480' lev(~l )1. PUMPING ~EVEL betow lend surfe~e end YIELD ........... j ............... ft. efter hrs. pumpin9 .~ g.p.m. DEF OF HEAL' ~ ENVIRO~ ~ENTAL PR()TE~riul: ~ Neet Cement ~ Other: ~_~ ~ . [~t Length of Drop Pipe ft. c0pocily ~g.p.m. ~fl ~nnk tn 4qo-- This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Alpine ~ri]li~ ~ ~e~prlses A& 9!n8 Form 02-WWR (11/81) COpy Distribution: WHITE-Stole DGGS, PINK-Oriller~ CANARY-Customer Parcel I.D. # 1. GENERAL INFORMATION (Must be completed prior to submittal)'"' ::'~i~ i :-.  MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES · . .:.. 343-4744 ........... · CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF, -' .-.' ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAM L¥:DWELLING . . - · : (a) Legal Description (include 10t, block, subdivision, section, township, range) Location (address or directions) (b) Property owner Mailing .Addrees (c) t. ending Institution Mai!lng Address.. (d) Roal Esta{e' C6rfi'pany. an~l Agent Address'- Telephone: (home) E usiness .M. OME' (e) Mail the-HAA to the following address: (or check here ,~ hold for pick uP.) ' '" List contact person and day phone number below: /.L: - ', 2. TYPE OF RESIDENCE Sing le-Family~' Number of bedrooms 3. WATER SUPPLY Individual Well J~ Community [] Public [] Note: If commun ty we system~: must have wr tten conf rmation.from the.Stat~ Departm, ent of Environmental- ' Co'nser~ati'Offa~tt~sting to th legality'and status. - ............................. · 4. SEWAGE DISPOSAL' - Or~-siteJ~ !-. Public [] Community ~';' ~ Holding Tank E],.,~: i N 'If'co mun y' ye em, m ~ [ Environmental ' ot~: rn~ it ~ell s t ~ ust have written confirmation'from the State Depa ment'o C0nservati~fi te.~ ing he iega {y a'~d s 724)25 (Rev. 7/88) Page' 1 of 2 - ~"' ' ' ~ ~ ~.o ~ e6~d (88//. '^~'d) '>tJo~ s,j@eu!Bue leUO!SSejO~d eq3 u! SUOlSSl~O Jo sJOJJ8 Joj elq!suodseJ ~ou s! E)BI~JOLIoUV JO ,~l!l~d!o!unlAI eq.L 'penss! s! E)lI~O!J!lJ90 8 ~?JG,q 8~? eZ~I~U~ JO suoilo~dsu! lonpuoo ~ou op sHHEJ jo see~old~] 's~ue~eJ!nbeJ e~ls pu~ I~epe~ U!~lJ@O XJS!l~S OlJepJo u! suo!~nl!~su! Bu!puel J!eq~, pue se~oq ~o sJes~qoJnd Ol ~sel~noo ~ s~ s!ql seop SHHQ eq.L 'e>tSel¥ jo e~,~lS eq~ u! Jeeu!Bue i~uo{ssejoJd ~uepuedepu! ue,~q @Aoq~ S qdeJB~ed u! ue^!B sUO!l~lUeseJdeJ eql uodn XlUO pes~q p@~ogpeo i~^o~dd¥ ~lNoqln¥ q~,l~eH senss! (S HHQ) seo!AJes u~nH pu~ q~l~eH jo lUe~l~d@Q @B~Joqouv. jo X~!l~d!o!unlhl leAOJddv I~UO!l!puoo 1o swJO.L ~ MUNICIPALITY OF ANCHORAGE (MOA) I,~/¢,~,/ Health Authority Approval (HAA) ML~'Y OF ^NcHcICC~:KLIST - FEBRUARY 1984 [NVIRO~TAL SERVICES DIVI310N 343-4744 ' . R[CEIV[D A. WELL DATA Well Classification Well Log PresentCN) Date Co m pleted '~,/1-'~/~ Z- 4~/~/~ 7 Yield Total Depth J~-~D~Cased- to /~¢/- Depth of Grouting Static Water Level /~,~, Casing Height Above Ground Electrical Wiring in Conduit ~)N) SEPARATION DISTANCES FROM WELL:' To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line '" To Nearest Sewer Service Line on Lot /[¢ou~/7-~ Water Sample Collected'by Water Sample Test Results Comments if A, B, C, D.E.C. Approved (Y/N) Pump Set At ~7~' / Sanitary Seal on Casing¢/N) . DepressiOn Around Wellhead (Ye ; On Adjoining Lots //'¢/ ' ; On Adjoining Lots To NeareSt Public Sewer Clean°ut/Manhole ;Date B. SEPTIC/HOLDING TANK DATA Date,nsta,,ed Standpipes ~) DepressiOn over Tank (Y~ PumPing/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) Air-tight Caps(~) No. of Compartments Foundation Cleanout ~N) Date Last Pumped ;for -" Temporary Holding Tank Permit (Y/N) .PEw 4 LZ_ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well /,/~ / To Property Line /O To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course To Building Foundation To Disposal Field /O f /C~o/ + Comments 72-028 (Rev. 7/88) Front Page 1 of 2 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y~) Results of Last Adequacy Test Type of System Design Length of Field /42,~ ! Depth of Field Gravel Bed 'Thickness ~" Statndpipes Presen~N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: ~lq / 2..,5/ To Water-Supply Well To Building Foundation Lot To Water Main/Service Line ¢/- to- 'Fo To Property Line To Existing or Abandoned System on ;On Adjoining Lots /0 To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Cutback (if present) t0o D. LIFT STATION Date Installed X.,,~//4J. Size in Gallons "Pump On" Lev61 at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dirnensions Manhole/Access (Y/N) "Pump' Off" Level at ~~ Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and inspecti°n~...-,A ....~'~c~ Signed / J/.X~,r//v~¢~ Q....~/~-- , Company ~ ~ ~ ~~; ~ ~ MOA No. Receipt No. Date of Payment Amount: $ d~l-l,C~:j~i~leai,Lnes in effect on the date of this ~;' ~h:.l~:' :~ Engineer's Seal Receipt No. Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF A SKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER PUBLIC WATER SYSTEM I.D.# ,~PRIVATE WATER SYSTEM Name Mailing Address City SAMPLE DATE: Phone No. ,4K. State Zip Code Mo. Day Year SAMPLE TYPE: [~ Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose .) ~ Treated Water Untreated Water SAMPLE NO. LOCATION 3 I 5 I Time Collected Collected By 7: ~o,~ -rTz TO BE COMPLETED BY LABORATORY s;iS showS this Water SAMPLE to be: tisfactory [] Unsatisfactory [] Sample t~o long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* 90.~278 ~ Analyst WA.E.A.AL S,S" CO" READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter:. Direct Count Veritication: LTB Final Membrane Filter Results .apo.ad TNTC = Too Numberous To Count OB = Other Bacteria BGB Coliform/lO0 mi Coliform/100 mi Time: /.~7~./~'~ a.m. p.m. pART ~ OF TWO REMAINDER TO FOLLOW CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. Client Sample ID:L7 B2 MOUNTAIN PARR EST #2 PWSID :UA Collected AUG 28 90 @ 07:30 h~s. Received AUG 28 90 @ 11:00 hrs. Preserved with :AS REQUIRED 5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562~2343 FEDERAL TAX I.D. #92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order ~ 26787 Date Report Printed: AUG 30 90 @ 12:31 Client Name : PERATROVICH, NOTTINGHAM ~ DRAGE Client Acct : PERATRT P.O.) NONE RECEIVED Req ~ Ordered By Analysis Completed :AUG 29 90 Send Reports to: Laboratory Supervisor :STEPHEN C. EDE IJPERATROVICH, NOTTINGHAM ~ DRAGE ReleasedBy : /~~ 2) Special HOLD FOR PICK UP. CALL 345-5297 UPON COMPLETION. Instruct: Chemlab Ref #: 903278 Lab Smpl ID: 1 Matrix: WATER Allowable Parameter Tested Result Units Method Limits NITRATE-N 3.9 mg/1 EPA 353.2 10 Sample SAMPLE COLLECTED BY TR. Remarks: ROUTINE SAMPLE. 1 Tests Performed ' See Special Instructions Above UA-Unavailable ND= None Detected "See Sample Remarks Above NA= Not Analyzed LT%ess Than, GT=Oreater Than MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACiLiTY 264-4744 Application Date GENERAL INFORMATION {MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Locat'ion (address or directions) (b) Property Owner '-~-/g~5 ' ~.4H/~CT~'T- Telephone: Home "' Mailing Address ,5? /'~ .I,I.3o,~.o:,¢6ff ~ , ~C~'I (c) Lending Institution ' ~_~ b~ Telephone Mailing Address" 0-~¢%'¢~ t,[,-~,)~-~ 0~-¢~'~ (d) Real Estate Company and Agent '~ ~,¢ ~ Business Address Telephone (e) Mail the HAA to the followinq address: or: Check here Lvr, if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family'~ Number of Bedrooms WATER SUPPLY Individual Well'~;;~' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL OnsiteXJ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. Page 1 of 2 72-025 fRev 8/861 Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verity that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. /, Name of Firm ~-~ Telephone Address /F-r-~ ~J ~~r~/ /~/~ ~"~/;~F ~ /~-/, Date DHHS APPROVAL Approved for 7'~-,~.--~ (.~'T)bedrooms by Approved ~ __ Disapproved Terms of Conditional Approval Conditional CAUTION 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 inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 fRev 8/86) Back MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 WELL DAT,~ ~,- C£1 Well Classification Well Log Present{~) Total Depth _~".~0 Static Water Level Legal Description: If A, B, C, D.E.C../Ap~oved (Y/N) Date Comp?ted l"/~"-~Z~p,~ Cased to /~-¢~ Depth of Grout ng /'J//~ ~'~ / Pump Set At Sanitary Seal on Casingl~N) Depression Around Wellhead (Y~ ; On Adjoining Lots Casing Height Above Ground Electrical Wiring in Conduit~Y.~ Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot //~' /, ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot M/~''7/ ; Date ~- _.~/r~.¢¢, To Nearest Public Sewer Line CleanouVManhole Water Sample Collected by Water Sample Test Results Comments ¢ B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes &) ~ Air-tight Capst~N) Depression over Tank Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-.SuP'ply Well . To Prope,~ty Line. ~ ~ To water Main/Service L[n~ '~ · Course ..... ~. /d-'O Size /~" ~ No. of Compartments Foundation Cleanout~N) Date Last Pumped ~-' ~"~'-~"~' /~/~'~ ,*J//~' ;for /'//~' Temporary Holding Tank Permit (Y/N) /'///~ To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage ~Comments ..... :' ,, :- Page I of 2 72-026 fRev 8t86) Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~7~Z'z~' ~2~¢' ! Width of Field ~ Type of System Design Length of Field Depth of Field ~, Square Feet of Absorption Area // Depression over Field (Y/N) (~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~J~ Gravel Bed Thickness Standpipes Present'N) Date of Last Adequacy Tesf, / To Property Line To Existing or Abandoned System on ! ; On Adjoining Lots /42 "'/'- To Cutbank (if present) / /O ",-" LIFT STATION  / Dimensions : ~/.-- ~4~ Manhole/Access (Y/N) "Pump On" Level at ~ "Pump Off" Level at High Water Alarm Level at ~..~ Vent (Y/N) . Tested for ~es during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments '~.~........~. ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I ha~/~ec/l~, ~rifi~d, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~.-t~..~ '~"L//-~'"~' Date Company /~-~5 MOA No. Receipt No. (~,3 ~ ~ Date of Payment ¢.~ - '~ --~"- ~ Amount: $ //,,7 ~, ~a (2 , Page 2 of 2 72-026 fRev 81861 Back Box 1369, STAR ROIa~I'E z~k ANCItORAGE~ A~ASgA 99502 ~.4_-77'1.4 SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF DRILLED AT THE RATE OF ~,2~.00 PER FOOT. PROPERTY OWNER ,,~. C. C. ~u~!:. - ..~.~.,-,~1,'~ 9 . · oL , 3.~5~c.: o.~'. DRILLER WELL LOG: d.m' u.Z..e..Ix{; ( 24. ;!mz.t .~.,;:,.e. I';t. cm.o.. ) 1riO .,veo*.. o" t,-~L,r.',: .~L";~.d.','~'~ .ie .~-:-',g',.,".. _ ~"' hn L Lo:;. On.e. l~o t,~e.'~o~..'.e_, t Su.!,m.~,~.LOle Po,v.?. 4b.n:;.Ld Im .i:L.~ .'n.L.' ~',q. 1,ri ~."~.". ~UNICIPALITY OF ANCHOEAC-~ DFOT C~ :..-.-,.T:~ ENVIR.J; ~;,..~t,. A_ ' .o._%.rlON Jo.,.5 0 . O0 Co.~.t o'~ ~~.: $22.00 /~e.t ¢oo.t X 375 ~t~t: ' o~ INCLUDES ALL ~BOR AND MATERI~ FOR COMPL~ION OF SAID ~RILLING. T~ANK YOU VERY MUCH. BERNIE C~US OF RAMPART DRILLING WORKS DAT~ ~.~ 78.U~, 19~2 . ~ . ~x ~ f ~ERVICE CHARGE O F I~% ~ER ~O~H WILL BE ASSESSED ON PAST~AGCOUNT~. ~,, WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Deologicol a GeophysicoI Sur~eys Drilling Permit No. A.D. L, No. LOCATION OF WELL (Please complete either la, ~o or lc,/ -.~ ....... Io.llBorough Subdivision Lot Block Ib~.I I/4gtrs. Sec ti on No. TownshiP N[] ! Range E[] Marldion Mt~s~ark 7 2 --a,--o~--o,-- sE3 w[] Ic.JlDISTANCE AMD DIREcTIoN FROM ROAD INTERSECTIONS $. OWNER OF WELL: Address: 1Tillside DrlYe & Street Address end Areo of Well Feet Below 4. WELL DEPTH: {finol) 5. DATE OF COMPLETION ~oteriol Type Top Bottom ~ti~ ~nll ~1~ e. ~Cobl* ,oo~ ~Rotory ~Oriven 7. USE: ~ Oomeltic ~ Public Supply ~ Industry ~ Irrigetlon ~ Recherge ~ Commerloal ~edrock ~ f.,, w,, ~ ;14 A~m, ~,...~,,. ,o1~5 ,,.o.,,~ w.,,~, 17 ,~,./". ~ ~ diam. in. fo ft. Depth $fickup . ft. produotlon increased to .2 ~pm Type: 0~ eP_~ . DI,meter: Set batwaan ft. and ft. ~,~ ~ ~ ~ ~11~ ~r~ ~ Backfilling Gravel peck cAbZe ~oo~ Eo~ ~ ~ ~Aen ,O. ST~T~C W~TE, ~EVEL: 140 .'. p~ped to 480' and left to ~bo~. or ~,e,owlondsurfoce Date ~OV~ ~V~~; ~ ~ Equipment used: sounder then p~ped to the 480' lev,~l II. PUMPING LEVEL below lend suttees end YIELD ...... ~ .... J -----~'m ........ ff. after__hr., pumping .~ g.p.m. fl. utter hrs. pumpifl$ '' - Ii.GROUTING Well Grouted: ~ YII ~ No Material: ~ Neet Cement ~ Other: Length of Drop Pipe ~ft. cupocity ~'P'm' 2 ~ Subm. D dst ~ Centrifico, to be 440' I4. REMARKS: well surged with cable tool after ~econd p~p test found well fillDd ~i'th fine silt 16, WATER WELL CONTRACTOR'S CERTIFICATION: 15. Wat,r Temperature ' o ~ F ~ C This well wes drilled u~der my jurlsdlctio~ end this reporl is true tothe best of my knowledge end belief; A~lp~ ~t]~g & E~t~prlses A~. 9!n8 ' R~gistered Business Name Contract License Number ~ - ~ulhorlz~d ~epresentali~~ / Form OE"WWR (Il/St) Copy Distribution; WHITE-State DGGS~ PlNK-Driller~ CANARY'Customer CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Wate/r Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER ,,.-B~PRIVATE WATER SYSTEM Mailing Address . City State Zip Code Mo. Day Year SAMPLE TYPE: .,,-[2:-I~outine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose .) [] Treated Water ,--~E%Untreated Water SAMPLE NO. I IZ7 2 I 31 4 LOCATION Time Collected Collected (~ ,/'d~./' ~ __ TO BE COMPLETED BY LABORATORY Date Received Time Received Analytical Method: Analysis shows this Water SAMPLE to be: ~ 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. 16¥3 Membrane Filter * No iof colonies/100 mi. Lab Ref. No. Result* ~ ~°~'-~1 FT~ I ~ I Iq-1 I I---F1 I i-I-1 Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter:. Direct Count Verification: LTB Final Membrane Fil~/~R. eCts ..~ Reported By TNTC = Too Numberous To Count OB = Other Bacteria BGB Coilformll00ml 0 Coilformll00ml Date O ;~/~ ~"'/~ Time: /"¢~ a.m. PART 1 OF 2 REMAINDER TO FOLLOV! CHEMICAL & GEOLOGICAL LABORATORIES OF INC. ANALYSIS ~EPO~T BY SABLE fo~ Work Ozde~ ~ 5337 Date ~epo~t ~rinted: FE~ 29 88 ~ 08:57 Client Sample ID:LT, B2 RT. PARK EST. PWSID :UA Collected FEB 24 88 8 16:15 h~s. Received ~B 24 88 ~ 16:43 bxs. PzesezYed with :NONE Client Name : AECS Client Acct : AKECSRP P.O.$ NONE REC'D Req ~ Ordered By : Analysis Completed :FEB 26 88 Send Reports to: Laboratory Supervisor :STEPHEN C. EDE i)AECS Released By : ~ 6. ~ 2) Special Instruct: Chemlab Ref $: 9202 Lab Smpl ID: 1 Matrix: Water Allowable Pa~amete~ Tested Result/Units Method Limits NITRATE-N 4.4 mg/1 EPA 353.2 10 Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY A, WEIN. I Tests Performed * See Special Instructions Above UA=Unavailable ND= None Detected ** See Sample Remarks Above NA= Not Armlyzed LT=Less Than, GT=Gzeater Than :~ POLAR ELECTRIC, INC ~- 7801 Schoon Suite M 20 18 ~.: ANCHORAGE, ALASKA 99518 Phone 349-2814 ~ ~.Z/ ~-/,c~.//i'~ · . ~AY WORK ~ CO~RACT ~ ~A ~OTY. MATERIAL , '~ICE 'mOO [~ "~ : DE~RI~ION ~ WORK ~ ' OTHER ~ARG~ .TOTAL OTHER ~ ~OU~ '.- ~BOR HRS. ~o~ ~o. TOTAL OTHER Work ordered by ~~ TAX Signature. f hereby acknow~ge the ~tis~clo~ completion of the ~ove d~b~ wo~ ' ~AL MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 1. GENERAL INFORMATION (a) Legal Description (include lot biock, subdivision, section,,t~wnship, range) Location (address or directions) (b} Applicant Name q~ /~~ Telephone: Home ~/~ Business (c) Applicant is (check one): Lending Institution D; Owner/builder; Buyer ~; Other ~ (explain); . (d) Lending Institution Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: //0z,O Telephone TYPE OF RESIDENCE Single-Family.l~' Multi-Family [] Number of Bedrooms -'~ Other WATER SUPPLY Individual Well,~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) 5. ENG;INEERING FIRM PROVIDI. INSPECTIONS, TESTS, FILE SEARCH, E, A AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Telephone DHEP APPROVAL Approved for ¢/~ ~"~(~) bedrooms By %'~-~'"~ '~' ~ ~ Date Approved I~ Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) ,,~ (b) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE INSPECTION FOR HEALTH AUTHORITY APPROVAL ~ ~'~- OF OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date '~/,~-/~;' '7 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, secltion, township, range) Location (address or directions). ,~pplicant Nerve '..)/~//~'-.~ /~,.-~l~I/?~'~'/~T'Telephone: Home Applicant Address -~9 ¢0~ ~0 ¢0U ¢/~ (c) APplicant is (check one): L~nding Institution []; Owner/builderJ~'; Buyer []; Other [] (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address Terephone (f) Mail the HAA to the following address: 7 Telephone TYPE OF RESIDENCE Single-Family J~' Multi-Family [] Other Number of Bedrooms WATER SUPPLY Individual Well ~,' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite I~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 72-025 (11/84) ENGINEERING FIRM PROVIDh iNSPECTIONS, TESTS, FILE SEARCH, D ~ AND INFORMATION ~ As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~'~'~.-~ //V(~, Address /~---~00 Date Telephone Approved for 3 bedrooms by Approved Disapproved Conditional .'~ Terms of Conditional Approval ~ ~0 L.4TEf¢ T/%4././ vl'bf/~£ /,4-/ Date CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPALITY A~HOi~LTH~'"" "'~" AUTHORITY APPROVAL (HAA) ENVIRONMENTAL SE~V~CI~$ I~IVI$~,~I. iECKLiST _'~':r FEBRUARY 1984 FEB 6 1987 284-4?20 Legal Description: RECEIVED Well Classification Well Log Present Total Depth Static Water Level Casing Height Above Ground Electrical Wiring in Conduit CN) Separation Distances from Well: PR/~'/'/~ ~'~--~ .Ii A, B, C, D.E.C. Approved (Y/N) Date Completed Cased to ! '~',~' / 220,(2 Depth of Grouting ' /~//9c Pump Set At' /"// 7,-,~' '~ Sanitary Seal on Casing (~)N) Depression Around Wellhead (Y~) To Septic/Holding Tank on Lot 1/O 1~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /t~"" · On Adjoining Lots To Nearest Public Sewer Line ,~_//Of To Nearest Public Sewer Cleanout/Manhole /'~/_/~ To Nearest Sewer Service Line on Lot Water Samp e Co ected by Water Sample Test Results Comments lO0 /©0 / B. SEPTIC/HOLDING TANK DATA . Date Installed Standpipes Depression over Tank (Y/~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: TO Water-Supply Well / To Property Line ~tr~ To .Water Main/service Line ~/~' Course /00 !: Size IZ, D NO. of Compartments Air-tight Caps (~)N) Foundation Cleanout &N) Date Last Pumped ///Z,./~ -! ,for Temporary Holding Tank Permit (Y/N) / To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 . . 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed T/.~-~-~/~ ~'~ Width of Field Square Feet of Absorption Area Depression over Field CN) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line ,~/-~ Type of System Design Length of Field ' /O,.,,.~ Depth of Field Gravel Bed Thickness 1133 Standpipes Present (~) Date of Last Adequacy Test T/.s Frgc To Stream/Pond/Lake/or Major Drainage Course To Driveway, Par.king Area, or Vehicle Storage Area Comments To Property Line JO r To Existing or Abandoned System on ; On Adjoining Lots '.--~) /-'~'' To Cutbank (if present) /~//~ I00/''/' D. LIFT STATION Date installed Dimensions ~ Size in Gallons Manhole/Access (Y/N~.~'''''''~''~ "Pump On" Level at ~,.//,/~ "~evel at High Water Alarm Level at /~ ~ Vent (Y/N) Testedfo, / V/T/~ Pumping Cycles during Adequacy Test. MeetsMOA Electrical Codes (Y/N)~ Commen~~ ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I hav,¢ ,%~k/ed.[ v~er~ied, o~conformed to all MO.A and.HAA g uidelines in effect on the date of this inspection. Signed Q~~.,,~ Date Company ~ ' ~C, MOA No. ReceiptNo. /00 / 0¢0[ Date of Payment Amount: $ Pr TF4 H Page 2 of 2 72-026 (11/84) ALASKA ,iidlROFImEFITAL COFITI OL S hulC S, IFIL ~.§i~ecrJ.~ 6 ~oJronmmtd Smdics KEN ZI~OWSKi 9501 SLALOM DRIVE ANCHORAGE ALASKA 99516 SELLER-JAMES W LAMBERT 0,~2/~ ~87 KEN ZIROWSK! 950] SLALOM DRIVE ANCHORAGE ALASKA 99516 70004 LEGAL:MT PARK ESTATES #2 BLOCK 2 LOT 7 ADEQUACY TEST FOR SEWER SYSTEM ADEQUACY TEST DATE-01/12/87 THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 1188 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 450 GAELONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 2000 GALLONS. BASEl) UPON THE TEST DATA THE SYSTEM iS ACCEPTABLE FOR A 8 BEDROOM HOME. SEPTIC TAN]< ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR THIS 3 BEDROOM HOUSE. THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON 01/12/87 . THiS REPORT DOES NOT VERIFY THE INTEGRITY OF THE PIPING FOR THE WATER SUPPLY OR WASTEWATER SYSTEM. FLOW TEST ON WELL WELL Fl, OW DATE--01/12/87 A FLOW TEST WAS PERFORMED ON THE WELL. 211 PUMPED AT A RATE OF .88 GPM OVER A DURATION OF THE DRAWDOWN WAS 255 ' WITH A RECOVERY TIME OF 220 FEET. BEDROOM HOME. AND THE STATIC WATER LEVEL WAS THE WELL !S ADEQUATE FOR THIS GALLONS OF WATER WAS 2 HOURS. 1285 MINHTES ~200 LUgsl 33rd ~ucnue. Suite J~, Aochora§e. Alaska 99503.(907) 561-5040 -JMLLABORATL. rilES, INC, LABOP TO,, I.O , i I' 7!2,7, OLD SEWARD HIGHWAY ' -' ! ANCHORAGE, ALASKA 99518 ' J (907)344=8551 __ BACTERIOLOGICAL YATER ANALYSIS ' i' TO BE COMPLETED BY WATER SUPPLIER FOR LAB USE ONLY I DATE COLLECTED I TINE COLLECTED I TYPE OF SYSTEM I MONTH DAvY YE~AR~., I ~i/~ AM J ri PUBLIC'~INDIVIDUAL [] RESUBMIT SAMPLE [ ) !is 2Fi/ I /~(ufUPM I '-- Sample rejected because' J I.D. NO. (PUBLIC 'SYSTEMS) CIRCLE CLASS CHECK ONE OR MORE ' Jl I , I I I. J A B C ~ [] Sample too long in transit. NAME OF SYSTEM ·7 . _ ? ,EPHONE NUMBER SYSTEM ADDRESS CITY STATE ZIP CODE LOCATION WHERE SAMPLE WAS COLLECTED. ._. ~ COLLECTED BY:(SIGNATURE)(~ /)7~L).~/ /' TYPE OF SAMPLE ~ / (CHECK ONLY ONE THIS COLUMN) ' ~DRINKING WATER ~CHECK TREATMENT [] RAW SOURCE WATER [] NEW CONSTRUCTION OR REPAIRS [] OTHER(Specify) [-)CHLORINATED ~FILTERED ~q~NTREATED OR OTHER IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NON-CONFORMING SAMPLE? F1YES ~NO PREVIOUS COLLECTIDN DATE ANALYSIS REQUESTED (IF OTHER THAN TOTAL COLIFORH) SEND REPORT TO:(PRINT FULL NAME,ADDRESS AND ZIP CODE Sample should not be over 30 hours. [] Samole received too late in week []Not in proper container [] Leaked out [] Insufficient information provided. Please read instructions on form. [] Other (Specify) RECEIVED RY ANS~L METHOD: g F~R~E~;T~T]O~, TUB~ Date & Time Completed LABORATORY RE~SULTS [] Other Bacteria C] Test unsuitable because: [] Confluent [] TNTC SATISFRCTORY [~ UNSATISFACTORY [] BACTERIOLOGICAL WATER ANALYSIS RECORD FOR LAB USE ONLY ~ TOTAL COLIFORMS Membrane Filter: Direct Count ~ Verification: LTB ~-~ FECAL COLIFORMS Final Membrane Filter Results ~] OTHER Reported By READ SAMPLE COLLECTION INSTRUCTIONS ON BACK OF FORM ? BGB Date Time Coliform/IOOml Coliform/lOOml ALASKA ENVIRON~MENTAL CONTROL SERVI' ~, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 SHEET NO, OF CHECKED BY. DATE sc~ / ~3o' APPLI('-'NT FILLS OUT UPPER HAl'-' ONLy Property O,,~ner ~ ~) C ~ ~7~:)~g/'5~7/~ ~ C ~ Phone Buyer ~/~ ~u~,.~ ~ ~ ~¢~ /~_ .//~ ~/d ~, z~, cou~ ~-// Lending Institution / ~ ~/~ L ~/~ ~ ~ /~ ~/~/~ Phone Address ~/ Realty Co. & A~nt Address ~/~ Legal Descript~n ~ Street Locati~ ~ Type of Resi~nce  Single Family Multiple Family No. of Bedroo~ ~ Other Water Supply  Individual ~ ~ A~AOH WELL LOG. A w~l Icg is required for all wells drilled since. June 1975. ,.~]~ d ~j~/ For wells drilled prior to that date. give well depth (attach Icg if available). Community ~ Public Utility Sewer Disposal ~ Public ~ility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED, Time Time Time Time Date Date Date Date Inspector Inspector Inspector~(~,L~ Inspector 0,~_~C~,' Field Notes: ~ / /~¢~ DEPT, OF ~~''LT;t ?' ~NVt~Oi ( ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL Soils Rating Date ~wer Installed Well To Absorption Area ~ 0b Well Log Received ~ Well to Tank ~ ~ ~b Septic T~k Size 72-023 (3182) ,CHEMICAL & Gl LOGICAL LABORATORIES ,; ALASKA, INC. TELEPHONE (907)-27g-4014 ANCHORAGE INDUSTRIAL CENTER · 274-3364 5633 B Street Drinking water Analysis RepOrt for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: I.D. NO. Water System Name . ii " Phone No~ Mailing Address City . State Zip Code MO. Day Year SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose [-1 Treated Water [] Untreated Water SAMPLE NO. I LOCATION Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~' S'atisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 48 hours old al examination to indicate reliable results. Please send new sample. Date Received Time Received Analytical Method: [] Fermentation Tube r~'~Membrane Filter Lab Ref. No. '':'?, / r-'. /- I I I Result* Analyst * No of colonies/100 mi. or No. of Posihve portions READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-3.220 (b) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collected Source Date Received Time ReCelve(t !~.m. Lab. NO. Presumptive 10mi 10mi 10mi 10mi 10mi 1.0mi 0.1mi 24 Hours 48 Hours :onflrmatory 24 Hours 48 Hours EMB Broth 24 hours: Broth 48 hours: Multiple Tube Report: 10mi Tubes Positive/Total 1Omi Portions Membrane Filter: Direct Count Collform/lO0ml Verification; LTB BGB Final Membrane Filter Results CoIHorm/100ml Reported By Date .