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HomeMy WebLinkAboutNORTH SLOPE BLK 1 LT 7 DEI~ TMENT OF HEALTH AND HUMAN SER¥ iS ...... Environmental Health Division ~ 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Na.,e DISTANCES ^ddress TANK FIELD WELL Phone(s) I Permit No. No ol Bedrooms WELL Block Subdiv ~on ~ FOUNDATION Township, Range. Section AS-BUILT DIAGRA~ ~Show Iocahon of well, septic system, property hnes, Joundahon, ~t~ ~ ~ ~ $~ d ....... y, waterbod ..... lc.) TANKS i ~ SEPTIC 0 HOLDING Capacity m gallons /' ~TRENCH ~ BED ~ W. DRAIN ~ OTHER ~ OrlgiRal grade ~ t 0 F~ ~' ~ ET ~ ~'~ ~ ~ , Fdl added above original grade Gravel depth benealh p~pe Totalabsorpt~on~rea / Distance between lines . % / r~ WELLS ~ PRIVATE ~ OTHER ddentifv) Classd~¢~ ~A.B.C} ' ~otal Depth ET Cased to RE~ARKS: I ~:'/-~ d~4,,~97q ced{fy thai th{s ~pspeclion/~ -/,owas pedormed accordmg.t~ag Health Depadment Approval: ~ate: 72-013 (3/85) PEF;,'I"I I T I'~1(]~ ". DATE I SSUED:~ 08 / 12/G',5 A F'F:'I_ ]; [3AN T ." ADDRESS C£]NTA[;T F'I.,]C)Iq[E :: I E)ANO f::' I I\IE % S~]..:.S IENl:i) I NEER I F. IG IEAGI_E RIVtER, AK 99577 4:,94--2979 LIEGAL I,)E,SE.F,,.[ F': C £}'1" S I Z E: MAX BEk')F:~:OOMS: !3UBDIV]:SIGN: NI]RTH SLOPE SECTI[)Iq: 32 TOWNSH:[P: 14N 75()C)0 (SQ.FT. OR ACRES) 3!; LOT ." 7 RANGE: R1E BLOCK DEPTH 'T'O F'IF:'E BOTTOM (F:']".) GRAVEL. DEF'TH (FI". TOTAL. DEP'T'H (I::"T.) GRAVEl_ I~]:DTI"'I (PT'. [-)RAVEl_ I_ENG'f'H (FI'.) E.}RAVEI_ VCILI..IFIE (CU;, YDS. ) TANK SIZIE (GAl_S) SOIl_ RATING (SQ.FT. /BR) I_isted below are the c)ptions available to you in designing your sep.tic system, Choose 'the optior~ that best ~its youp site. ~ EE D 2.0 ~.~ 0.5 54-. 0 ~ 54 ,, 0 l:, 000.0 ~:.~ 32'.0 / ~.:- DIEF'TH TO PIPE BGTTOIq < 5,,[5 FT. RE(~UIRES INSU[..ATIBN · :~. L:E:F:']"H ICI F"IF'IE BO"f']"OId .:~ 4.0 FT. MAY RE[2UIRE A LIFT STAT:ION ~.:- TANK MUST HAVE AT LEAST TWO C[]I~IPAR'TMENTS I c:er"Li£y %.ha'k:' 1,. I am familiar' with' the ~*equir'ements fei- c.~n.-site sewer-s and wells as set For. th by the Municipality of Anchor*age (MOA) and the Stat~ o¢ Alas[,:a. 2?. I will :i. nst.all the system in ac.:copdance with all MDA c:edes and 'pegulatiens, and in (:omplianc:e wi'l:.h {he design cr'itepia of this per'mit. :Z;. I will adher'e to all MOA and State o¢ Alaska peguipement~ Fop the set bac:k distances ~'r'om any exi~'l'..:i, ng well, wasCewater~ disposal sys'Lem of public sewer'age sys'Lem on this o~* any ad.jacent op near'by lot. 4. ]: undepstand Chat:. this per'mit :i.s val:i,d ¢or' a maximum C)F 3 bed~-ooms and any enla~*gement will I*equipe an additional per'mi't... IF A LIFT STAT:[[)N IS tI',ISTALLIEI) IN AN AREA [;OVERED BY f'IDA BUILDING CGDES, I"HE:N (].) AN EL, ECI'RICAL PERId]:T AND INSF'EE;TION I"IUST BE OE;TAINEE); (2) AS-"E;U]:LTS WILL NC]T ~;4E APPROVED I*JIT'HOUT AN ELECTRICAl_ INSPECTI[)IM REI='OR]-iI AND (3) THE ELECTRI(SAL tgi]RE M[JST BE: DONE IE{Y A I_IEHE:NSED EiLEC'I"RIF2IAIq. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECT'ION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] SOILS LOG PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 2 4 5 6 7 8 9 13 14 ~ A. 5ha~r 16 17 18 19 20 SLOPE I I'Y T I IF YES, AT WHAT I E DEPTH? ~'~ SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop ~ ?~.--~..~.~ IZ_:-.~ot~~--,,,--,~-'~.~_ PERCOLATION RATE ~--'--'--'--'--'--~' (minutes/inch) TEST RUN BETWEEN ~' FT AND ~'~ FT COMMENTS ~i/~ ~.~vK ~--.~.~ c..-,, ./'-~--~L ,~.~,'~~ {=~r~_ ~," _, t-~ ~ PERFORMED BY: ~ ~ qon~* CERTI PH. 694-2979 72-008 (6/79) · MUNICIPALITY OF: ANcHORAgE DEPT. OF ~E ~LTH & ~ENVI,~ON~SNTA[ I ~ROTECTION 'ED © PP • • -�• Municipality of Anchorage o4n' • {„, On-Site Water and Wastewater Program K ,. (907) 343-7904 s..+rr- r CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 015-151-26 Expiration Date: /I-,9-7-1 7 1. GENERAL INFORMATION Complete legal description SOUTH LAKEWOOD HILLS #1, BLK 6. LOT 7 Location (site address) _11151 WILDWOOD DR ANCH AK Current Property owner(s) WELLS FARGO BANK Day phone Mailing address Real Estate Agent Day phone 2. TYPE OF DWELLING: \ 2 3 4 5 ;, ® Single Family (w/wo ADU) Q4` ' Duplex cfFA rQr 1 ❑ Multiple Dwellings (Single Family and/or Duplex) ( � _ 3. NUMBER OF BEDROOMS: 4 (5, a � � C WA 4. TYPE OF WATER SUPPLY: TYPE OF WAS TETER DISPOSAL: Individual Well ® Individual • Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: AA— Date: 77277; ? COSA to be released to the engineer, unless otherwise requested by the engineer. miummem COSA Fee $ •66 Waiver Fee $ Date of Payment 4/Z510 Date of Payment Receipt Number C4( /03071Receipt Number COSA# © /9/4/61,-- Waiver# Or • 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm MIKE N ANDERSON, P.E. Phone 727-8864 Address 4661 NATRONA AVE. Engineer's Printed Name MIKE N ANDERSON, PE Date 9/23/17 °• 49TH •Y• dd 6. DSD SIGNATURE e *. MICHAEL N. ANDERSON " rle System #1 Approved for bedrooms. ¢$� J�,� ,,y77�4 9 .,•� A It •� •sa System #2 Approved for bedrooms. tg ;f5l � `e Disapproved. Conditional approval for II bedrooms, with the following stipulations: 4GE Np� , �Q LU .e \ ;O cncr � z o ¢ � � = ,1W DE r=te 111)!1})11��� By: v\--•` Original Certificate Date: f —/ 7 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other • COSA blue sheet 10.10.12 doc If more than 1 septic system is on the lot: • COSA Checklist# of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: SOUTH LAKEWOOD HILLS #1, BLK 6, LOT 7 Parcel ID 015-151-26 A. WELL DATA Well type Private If A. B, or C provide PWSID# Well Log (YIN) N Date completed 1975? Sanitary seal (Y/N)Y Wires properly protected (YIN) Y Total depth 212 ft. Cased to 212 ft. Casing height (above ground) 18"+ FROM WELL LOG AT INSPECTION Date of test 9/1812017 Static water level ft. 121 ft. Well production g.p m. 5+ g.p.m. WATER SAMPLE RESULTS qq Coliform NEG colonies/100 mL Nitrate • l l mg/L Arsenic: ND uglL Date of sample: 9-18.17 Collected by: Mike Anderson B. SEPTIC/HOLDING TANK DATA -OLD 1975 DATA Tank Type/Material FIBERGLASS X 2 Date installed 814/75 Tank size 2x 1000 gal. Number of Compartments 2 Cleanouts (YIN) Y Foundation cleanout (YIN)Y Depression over tank (YIN) Y High water alarm (Y/N) NA Date of pumping TOTAL REPLACEMENT Pumper C. ABSORPTION FIELD DATA—1975 SYSTEM Date installed 814175 Soil rating (sf/bedroom) 1.2 System type DEEP TRENCH Length 66 ft. Width 2 ft. Gravel below pipe 3.0 ft. Total depth 8.0 ft. Eff. absorption area 396 ft2 Monitoring tube Y Depression over field N Date of adequacy test 9-18-17 Results (Pass/Fail) FAIL For 4 bedrooms Fluid depth in absorption field before test in. Water added_gal. New depth in Elapsed Time min. Final fluid depth in. Absorption rate >= g p d Any rejuvenation treatment (past 12 mo.) (Y/N & type) UNKNOWN If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN) "Pump on" level at in. Pump off level at in.High water alarm level at in. Datum Cycles tested Meets alarm &circuit requirements? E. SEPARATION DISTANCES-OLD 1975 DATA WELL ON LOT TO: Septic tank/lift station on lot *88'+ On adjacent lots 100'+ Absorption field on lot •90'+ On adjacent lots 100'+ Public sewer main 100'+ Public sewer manhole/cleanout 100'+ Sewer/septic service line 50'+ Holding tank 100'+ Animal containment areas 100'+ Manure/animal excrete storage areas 100'+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 10'+ Property line 10'+ Absorption field 10' Water main 1001+ Water service line 50'+ Surface water 100'+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10 Water main 100'+ Water Service line 50'+ Surface water 100'+ Driveway. parking/vehicle storage 10'+ Curtain drain 50'+(None Known) Wells on adjacent lots 100'+ F. COMMENTS `- CONDITIONAL COSA, COMPLETE NEW SEPTIC SYSTEM, NO WAIVERS REQUIRED. ASBUILT SURVEY, ENGINEERING, MOA PERMIT, EXCAVATION, ETC.. ESCROW AMOUNT S30.000 FOR TOTAL REPLACEMENT ' ,11*1N.►+1 !h 9 4rgpe <<c. f 1 tvap M'i4Fe- - G. ENGINEER'S CERTIFICATION { OF /3/...,.714‘ I certify that I have determined through field inspections and II t9. ,x `11 ' •�.vd¢r review of Municipal records that the above systems are in r*: 491 conformance with MOA COSA guidelines in effect on this date. •••• ... . Engineer's Printed Name MIKE N. ANDERSON. PE =MICMAEL t . AA:Gtksc.r4 9 Date 9/25/2017 • \k` EZ -~ `w COSA canary sheet_2-6-15 doc 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 Applica'~ibn DaJte .. May 28, 1987 GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 7~ Block I~ North Slope Subdivision ~ ) Location (address or directions) (b) Property Owner Home Savinqs Telephone: Home Business 276-1451 Ext, Mailing Address ATTENTION: Pete Kalamarides/221 East Northern Lights, Loan S~rvicing Department, Anchorage, Alaska (c) Lending Institution Telephone Mailing Address same as above (d) Real Estate Company and Agent non& Address Telephone Mail the HAA to the followino address: or: Check here r~, if hold for pick up. List contact person and day phone number below. S & S ENGINEERING - 694-2979 17034 Eagle River Loop Road, Suite 204 Eagle River, Alaska 99577 (e) TYPE OF RESIDENCE Single-Family r~ 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 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 I of 2 72-025 (Rev 81861 Front ENGI~IEERIN'G 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 verify that my investigation of this Hea, Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequat~ 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 S & $ ENGINEERING 17034 Eagle River Loop Road No. 204 Address Telephone Date DHHS APPROVAL Approved for bedrooms by Approved /'"'"'- Disapproved Conditional Terms of Conditional Approval Date 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 (Rev 8t86) Back MuN~CIPAt-Y[Y OF ANCHORAGE ENviRONMENTAL SERVICES DWISION AUG J 1987 WELLf E EIVED Well Classification Well Log Present ~/N) Total Depth ~-~! ' Static Water Level Casing Height Above Ground Electrical Wiring in Conduit CN) Separation Distances from Well: To Septic/Holding Tank on Lot Cased to ~f MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 Legal Description: /L...r ~ /~-/~- (' If A, B, C, D.E.C. Approved (Y/N) Date Completed ~ ~/¢ ~ ~, t~ Yield Depth of Grouting Pump Set At f~,/c_ Sanitary Seal on Casing (~) Depression Around Wellhead (Y/~L)~ To Nearest Edge of Absorption Field on Lot /~r~ '+ ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Line ~,.l/¢~_ To Nearest Public Sewer Cleanout/Manhole t,J/~ To Nearest Sewer Service Line on Lot Water Sample Collected by ~ ~'~ L~ ~L,,~.,4c:~z.u,J~. ; Date ~ ~ Water Sample Test Results _~ '~"'/~'c'~c/~:~Z-%' ~c'-~/Z' /~ ' 7/z~$ 4- Comments \~/~.~c t//,~.z._,% /'~=--¢~j"~r'~,~ '~-2~c/-~ ~'¢~¢~ B. SEPTIC/HOLDING TANK DATA Date Installed /! ~ Standpipes ~) Air-tight Caps (~N) Depression over Tank (Y/~ Pumping/Maintenance Contract on File (Y/N)/'~/7''//~r Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: Size /~o0 No. of Compartments Foundation Cleanout (~)/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line To Water Main/Service Line Course /or'C/- Comments ~'~ ~' % To Building Foundation /~/'f To Disposal Field ~ / ~ To Stream, Pond, Lake, or Major Drainage Page I of 2 72-026 fRev 8/861 Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area / Depression over Field Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well /c'x_'~ To Building Foundation To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area ~'~~-L)/~/''~'''L- Type of System Design /5/~-/'~ Length of Field ~"// Depth of Field z.¢, ~ / Gravel Bed Thickness [,.¢. ~ Standpipes Present ~N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots 3o To Cutbank (if present) 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 during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and. HAA guidelines in effect on the date of this inspection. Si ne~ & S ENGINEERING g ~ Dat~ 17034 Eagle Ri~er Loop Road No. 204 C°m~e ~Jvs;', A~s~= ~77 MOA No. ~~ ~':':';?"~ ' Receipt No. / ~ ~ / ¢~ Date of Payment ~ ~ Page 2 of 2 72 026 !Rev 8 861 8ack WELL DATA Well Classification Well Log Present~/N) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal De~s~ription: L~'T MUNICIPALITY OF ANCHORAGZ: DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION ,t F JE t V E D Total Depth ~;, I, I Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (~/N) Separation Distances from Well: To Septic/H--.,91~'~Tank on Lot ~'¢. If A, B, C, DEC. Approved (Y/N) Date Completed ¢¢ ~ ~.~r GL- Yield , ,% Cased to ~ ~ Depth of Grouting [ ~' Pump Set At A.- "~ ~:~' ~c~ ~ Sanitary Seal on Casing~:[~:N) Depression Around Wellhead (y/~i~ ; On Adjoining Lots To Nearest Edge of Absorption Field or[ Lot To'Nearest Public Sewer Line '~) j~ Cleanout/Manh01e /OJA Water Sample Collected'by- ~ ~, ~ Water Sample Test Results Comments ~. ~:~' t'k' ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~'~ t~l ~"~l'~ ;Date B. SEPTIC/~G TANK DATA Date Installed \\~'~-~¢ Size / ¢ No. of Compartments ~ Standpipes ~;~N) Air-tight Caps ~N) Foundation Cleanoutd~N) Depression over Tank (Y/,I~ ~ iDate Last Pumped ~"l¢~"*,,b~ Pumping/Maintenance Contract on File (Y/N) j /¢~ ; for / Holding Tank High-Water Alarm (Y/N) '¢/'~ Temporary Holding Tank Permit (Y/~) 14,/A Separation Distances from Septic./.b~ Tank: To Water-Supply Welt ~ ~ j'~ To Property Line To Water Main/Service Line Course To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 72-026(11/841 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata "223-"~ ~ Type of System Design Date Installed \t~ ~ ~ _ (~,~ Length of Field ~/ Width of Field "7---~ I~' Depth of Field Square Feet of Absorption Area Depression over Field (Y/c/~P Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well 1 ~ I'''~ To Building Foundation'~/~"~/~ Lot Gravel Bed Thickness Standpipes Present (~N) ~..~t~ of Last Adequacy Test To Water Main/Service Line I ~ [ W To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line ~.~ ~ To Existing or Abandoned System on ; On Adjoining Lots '~ [~ To Cut~ank (if present) Comments 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) "Pur~p Off" Level at ~.~ // Vent(Y/N). /"~Jmping Gycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ¢ g' ~ [l~l/~'~ll~l[~'Blkl~~' Date Company $~ P, 1. .~_Ax MOA No. ,/~.¢"-'-'-' ¢ ~ ~ Receipt NoF-'AGLE RIVER, AK 99577 Date of Payment ~)~ l,~'~~-J Amount: Page 2 of 2 72-026 (11/84) ~~ CHEMICAL ~ <' & GEOLOGICA~ LABORATORIES OF ALASKA, INC. FEDERAL TAX [D # 92-0040440 ANALYSIS i~EPOi~ BY S~,MPLE $~ple Rec~d : 0U~ 24 O? Send Reports ~'o: 17034 EAGL~ RIV~ LOOP ~LE RIVER, AK, 9957'7 Work 0~de? No, : !860 Date Repo~t Printed: JUL 20 87 g i7:43 instruct: Chemlab Ref g: 7043 Lab ~pI ID: 2 ~Iatrix: Water AiIowabie ?aC~T~ete~ Te~ted Result/Unit8 Method gimits TOTAL COLIfOrM 0 col/lOOmI Remarks: None ~etected ~,~ See Sample Remacks ~!ot Analyzed LY=:Less 'fhan, G't'=Gceater Than CHEMICAL & GEOLOGiCAL ~ORATORIES OF ALASKA, INC. FEDERAL TAX ID # 92-0040440 ~I'iALYSiS ID: LiS 1~!, N Reports To: 17034 EAGLE RIVR~ £007 RD., ~204 EAGLE RIVER, AK. 99577 Released By ~ ~doresu ~2 Instruct: Chem!a ~ef ii: 7043 L~) cA'lei ID: 1 aatrix: ~ater Parameter Tested Result/Units Method Lbnits Sapte ROUTI~R BiMPLE Remarks: ABALYSIS COMPLETED: 7-20-87 ~a= Not Analyzed LT=Less ~aa, Gr=Oreater Than :: : CERTIFICATE OF INSPECT ON FOR 'HEALTH AUTHOR TY AppROV,~E : OF ON-SITE SEWER AND wATER FAC L TY 264-4720 ,Application ate GENERAL INFORMATION "' (a) Legal~ion (include ~k. '~bdivisi~n, section, township, range) '  ocation (addr~ or directions) ' - ~ ~ ,~ (b) Applicant ~ame ~ ~~ *elephono: Homo ~ ~-~ ~usiness Applicant Address ~ ] ~~ ~ ~~~ (c) Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~; Other (explain); (d) Lendinglnstitution ,~f-./~-~ ~Lr/r~z;L.-.--'Telephone (J Address C'"~'-'/7~-~"_ ~-/'t.~'-'z.- ~. ,~.... (e) Real Estate Company and Agent ~ Address (f) ~ the HAA to the following address: TYPE OF RESIDENCE Single-Family~ Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well~ Community [] Public [] Note: If comm unity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 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. )proval ShoWs that the on-site water supply and/or Wastewater disposal system is safe, functional and ad~ ~mber of bedrooms and :~ype of structure indigated herein, I fudher verify that based on the information obt~ Municipality of Anchorage files and from my investigation and inspection the on-site water supply an~ [er disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect e~'~% i ildate of this inspection. · -- iName of Firm .~ & .~ i:NGINI:I:lJ!N~ Telephone ~;~ SR" 196X ____ ~;;:e:, ~OL~ RIVER, AK, 995~ ~ [ ~ ~ ~' DHEP APPROVAL Approved for ,~"~/~-/_ (/'?~'.~bedrooms by Approved ~ _ Disapproved 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 m paragraph 5 above by an independent professional e. ngineer 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) '~ CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, 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 SYSTEra Name Phone No, Mailing Address City State Mo. Day Year Zip Code SAMPLE TYPE: I~F Routine . [] Check Sample (for routine sample with lab ref. no. [] Special Purpose ) [] Treated Water [] Untreated Water SAMPLE NO. LOCATION 41 Time Collected · Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: [~ ~atisfactory [] 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 delivew mail. Date Received Time!Received AnalY~tical Method: Membrane Filter * N~ of colonies/100 mi. Lab' Ref. No. Result* Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATEI Membrane Filter:. Direct Count Verification: LTB Final Membrane Filter Resu~s 4 TNTC -- Too Numberous To Count OB = Other Bacteria , ~.NALYSIS RECORD Coilform/10Dml BGB Date Time: Coilform/100ml t/ ~'~ (/ a.m.