HomeMy WebLinkAboutCLEARVIEW 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 1PHONE
LITTLE 'T~t'ppl= t't_ 1'~¥5-0'~'7~ ~.EW
UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
NO. OF BEDRO~S
i
Well
DISTANCE TO:
~, "OT J~ [ Absorption area Dwelling PE~ NO~
~Z~ Manufacturer~ ~ ~ Ma~_ · ~ No. ofcompartme~
Liq, capacity in gallons
J ~.~ IF HOME'DE:
Well Dwelling PERMIT NO.
~ ~ DISTANCE TO:
O Z ~ Manufacturer Material Liquid capacity in gallons
Q Well Foundation Nearest lot line PER~I~O.
~ ~ "O. Of lin~ ken"th of e~h~ne Total lend, lines Tro~ch ~"dth~ inchos Distance bet~e~ lines
~ ~ Top~f~ *~[ile tol~tfinish ~rade Material beneath tilo ~ inches lotal~effectiue absorptign~~area ~,
Length 'Width Depth PERMIT NO. '
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
m Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOIL TEST ~TI~G ~ _
INSTALLER
REMARKS ~ ~ ~ ~,-
MUNICIPALI~ OF AN~( ,~E ~ ~ t J
_~,~ ~-;,',~, ............. ~ ' ~~ I , ~,,,
,-,.~'"'_'"' -.., ...... '~uL ~" ~ XX ~./
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
MUN I C I PA~L I TY' O~F ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET~ ANCHORAGEs, AK ~9501
2&4-4720
ON--SITE SEWER & W~ELL PERMIT
PERMIT NO:
DATE ISSUED:
840559
07/10/84
APPLICANT:
ADDRESS:
LEGAL DESCRIP:
LOT SIZE:
MAX BEDROOMS:
JUDY M LAMB
SRA 1627-C
ANCHORAGE, AK ~9507
SUBDIVISION: CLEARVIEW
SECTION: 24 TOWNSHIP:
1.25A (SQ.FT. OR ACRES)
4
LOT: 7 BLOCK: NA
12N RANGE: 5W
Listed below are the options~available to you in designing you~ septic
system. Choose the~option that best Fits your site.
DEPTH TO PIPE BOTTOM (FT.)
GRAVEL DEPTH (FT.)
TOTAL DEPTH (FT.)
GRAVEL WIDTH (FT.)
GRAVEL LENGTH (FT.)
GRAVEL VOLUME (CU. YDS.)
TANK BIZE (GALS)
SOIL RATING (SQ. FT./BR)
TRENCH
8.0
4.0
12.0
2.5
72.0
50.0
1 ~ 250.0 **
145
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
I certify that:
1. I am familiar with the requirements for on-site sewees and ~ells as set
forth by the Municipality of Anchorage (MOA> and the State o~ Alaska.
2. I will install the~system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
5. I will adhere to all MOA and State of Alaska requirements, for the set back
distances from any existing well~ wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot.
4 bedrooms and
4. I understand that this permit is valid for a maximum of
any enlargement will require an additional permit.
IF 'A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES~
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) A~S-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (5) THE
ELECTRICAL WORK MUST BE DONE BY.A LICENSED ELECTRICIAN.
SIGNED ........... i DATE:
SOILS LOG
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
L 'T "7
HH
[] PERCOLATION
TEST
SLOPE SITE PLAN
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
O
P
E
Gross
Reading Date Time
TEST RUN BETWEEN
Net
Time
FT AND
Depth to
Water
(minutes/inch)
__ FT
Net
Drop
PERFORMED BY:~
72-008 (6/79)
CERTIFIED BY:
DATE:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~"/SOI LS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12,
13
14
15
16
17
18
20
SLOPE si:r[ PLAN ·
I L'r'
®eee,
49~_.~
2225-E
WAS GROUND WATER IS.
ENCOUNTERED? N O O
P
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE /~1~O M~,,,~A, ~ (n~
TEST RUN BETWEEN FT AND ~ FT
COMMENTS
PERFORMED BY:
DATE:~
72-008 (6/79)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysical Surveys
Drilling Permit No.
LOCATION OF WELL (Pleaee complete either la,'lb or lc.) A.D.L. No.
Street Address and Area of Well Location
Feet Below 4. WELL DEPTH: (final) 5. DATE OF COMPLETION
Material Type Top Bottom
/~" ~ ~ / ~ D Auger ~ Jetted 0 Bored 0 Other:
~ X ~,~ ~ diam. in. ,o__ ft. DePth. $,Jckup ~ ft7
...~ ~;q 0 Above or ~ Below.land surface
~;-~ / ft. after hrs. pumpi~ ~p.m.
/ __ ~V~,?.;~.~O~,~N3 Material: 0 Neat Cement 0 Other:
~0~ .... Length of Drop Pipe ff. cepecify g.p.m.
15. Wafer Temperature ~o ~ F~ ~ C
This well ~es drilled pnder my~u~sdlction end this report is true to the beet of my knowledge end belief;
Registered Business Name/-' Contract License Number
Authori~e~ Re~ntative
Form O~-WWR (~1/81) Copy Distribution; WHITE-State DGGS, PiNK-Driller, CANARY-Customer
• .�c e�
'-° Municipality of Anchorage °
On-Site Water and Wastewater Program
(907) 343-7904
Certificate of On-Site Systems Approval
Parcel I.D. 015-242-46 Expiration Date: 1 ^ I IC(
1. GENERAL INFORMATION:
Complete legal description CLEARVIEW; LOT 7
Location (site address) 8141 Alatna Ave.*ANCHORAGE,AK 99516
Current Property owner(s) Stuart&Elizabeth Johnson Day phone 402-560-0916
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ Waiver Fee $
Date of Payment Date of Payment
Receipt Number Receipt Number
COSA# Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101-Anchorage,Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: 10/2../i
•0000����
In conducting this evaluation,GEG provided an engineering evaluation of the well and/or septic system OF 4 ' 04
in accordance with the guidelines and regulations established by the Municipality of Anchorage and -\(<.. .!• .-
industry practices. The reported results describe the condition of the system/s on the date/s of the nn''11
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or • •
/�� P. �`'tI
encroachments may exist that were not identified during the evaluation. The operational life of all wells ,. "- F '•-7*O
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, Q J '• t
groundwater levels (that may fluctuate during the year), quality of construction (materials and
workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and / .. Q
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the r J�f ' A. Garess.
system/s; therefore. GEG makes no warranty(express or implied) regarding the future performance of (//•)7.0' CE_, ' .' �O
the well or septic system. GEG makes no representation whether an alternative well or septic system VO,/ . •• .e¢Q
can be installed on the property in the event either of the current systems fail to perform adequately in 4 / •'•Gu $'• co'o
the future. The content of this report is for the sole benefit of the person/party that retained GEG to1�edprotess•onO\o
perform the evaluation. Reliance upon the information provided in this report by any other person or ���OOOO�ao
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
System #1 Approved for V bedrooms
System #2 Approved for bedrooms �,
Disapproved _ ON_S�T L.
,q� E ;
Conditional approval for bedrooms, with the fol_ int, 14i\ //D m=
P T ATER
� ROGRAM
SERVICE •
�of Original Certificate Date:(O— 1 —13
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 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: CLEARVIEW; LOT 7 Parcel ID: 015-242-46
A. WELL DATA *TO BEDROCK
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 8/15/84 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth 130 ft. Cased to *122 ft. Casing height(above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 8/15/84 8/9/17
Static water level 20 ft. 37.5 ft.
Well production 5 g.p.m. 4.0+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 ml. Nitrate 2.12 mg./L. Collected by: GEG, Ltd.
Arsenic: <5.0 ug./L. Date of sample: 9/13/2018
B. SEPTIC/HOLDING TANK DATA *PANEL ON OUTSIDE OF HOUSE
Tank Type/Material SEPTIC/STEEL Date installed 8/6-9/07
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout(Y/N) YES Depression over tank(Y/N) NO High water alarm (Y/N) *YES
Date of pumping 41411Q) Pumper Akeit -- 0.
C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE AT MT
Date installed 8/6-8/07 Soil rating Cp.d t2or ft2/bdrm) 0.8 System type DEEP TRENCH
Length 50 ft. Width 2.5 ft. Gravel below pipe 8 ft.
Total depth *11+ ft. Eff. absorption area 800 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 8/9/17 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 4 in. Water added 639 gal. New depth 23 in.
Elapsed Time: 120 min. Final fluid depth 16 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) NONE KNOWN If yes, give date -
• 1984 TRENCH APPEARED TO BE DRY UPON ARRIVAL AND REMAINED DRY THROUGHOUT THE ADEQUACY TEST
• ON 9/13/18 THERE WAS APPROXIMATELY 16"OF LIQUID IN THE DRAINFIELD
'a
*PER 8/8/2007 MOA ELECTRICAL INSPECTION REPORT
**SEE ATTACHED MAINTENANCE REPORT
D. LIFT STATION (PRE-SEPTIC TANK PUMP VAULT)
Date installed 8/6-9/07 Size in gallons 264 Manhole/Access (YIN) YES
"Pump on"level at ** in. "Pump off' level at '* in. High water alarm level at ** in.
Datum ** Cycles tested ** Meets alarm & circuit requirements? ** ki ft
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot
100'+ On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25+ Holding tank 75'+
. Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 7'
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
. �� ( . •
G. ENGINEER'S CERTIFICATION P,.••• •1•
I certify that I have determined through field inspections and • • •
••;.........''••'•. .. • ♦
review of Municipal records that the above systems are in i
conformance with MOA COSA guidelines in effect on this ••• ••• ^•• ••••• • •
date. ♦c^• J: ry •. Gar
Engineer's Printed Name JEFFREY A.GARNESS •••�/s,•
•• —7953 � iv=
•
•
Date qz4A s • I .ROFESS W:4.4�•
"
LICENSE �lilli `���
#AECC884
(Rev. 10/12/12)
•
MUNICIPALITY OF ANCHORAGE
Development Services Department ': Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Lift Station/Pump Vault
Maintenance Log
Owner S% e tJc f 1 JDh/f/Sor(/Street Address Q I C.r / ALc7L/Vct
Septic Tank:
-Sludge level inches -Pumping: required vesn(;) •Pumping completed el no
Lift station:
•Pump basket cleaned no -Effluent filter cleaned de no
-Control floats cleaned no -Proper float settings confirmed Ca no
-Operation satisfactory dp no
Alarm System:
-Dedicated electrical alarm circuit do no -Audible and visual alarm inside dwelling a no
-Alarm system operation tisfact...o.,9 not satisfactory
Manhole Riser
-Ground water intrusion at riser to tank connection es
'Ground water intrusion around pipe penetrations es -Weep hole functional 6; io
-Manhole lid: Functional no Insulated no Properly Secured no
Other
-All manufacturer required inspections and maintenance completed a no
Comments:
Qualified Maintenance Provider: c�
Technician , 6/1/ Wy€t-s Date of maintenance / -X-/7
Company /I TG PGtMPirAy-- -
Signature Date 9-
Mailing Address: P. 0. Box 196650 ' Anchorage, Alaska 99519-6650 *wwrv.muni.org
•
•
./ \ 4PG` 8vi
•`t �_ Municipality of Anchorage
On-Site Water and Wastewater Program1;
(907) 343-7904 6 8 g �0 77, SAFETY
Certificate of On-Site Systems Appro ? I AUG 1 b 7.011
Parcel I.D. 015-242-46 Expiration : -2— ti
w
h
1. GENERAL INFORMATION:
Complete legal description CLEARVIEW; LOT 7
Location (site address) 8141 Alatna Ave. *Anchorage 99516
Current Property owner(s) Herman &Donna Meiners Day phone 907-321-5807
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
• Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class _Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: `-2� Date:
/2 / I
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ o Waiver Fee $
Date of Payment T-1'1—fl Date of Payment
Receipt Number 5,5-6 Receipt Number
COSA# Ci()W\ 135g Waiver#
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the.Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101-Anchorage, Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: /3)/1.
QQOC
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system o Q` 4 tl.
in accordance with the guidelines and regulations established by the Municipality of Anchorage and "" --Vo
industry practices. The reported results describe the condition of the system/s on the date/s of the � A
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or , .H ' ...7UUpn
encroachments may exist that were not identified during the evaluation. The operational life of all wells ; *VV
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, 4V
groundwater levels (that may fluctuate during the year), quality of construction (materials and VA
workmanship), and the water usage of the family utilizing the system's. These conditions can vary,and a,. .... . i
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the Qnn • J: f e, A. .rness.
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of unn E-795
the well or septic system. GEG makes no representation whether an alternative well or septic system UV 9s ceO
d •glf'J
can be installed on the property in the event either of the current systems fail to perform adequately in Pre
the future. The content of this report is for the sole benefit of the person/party that retained GEG to �� aprofess�°�°QQ
perform the evaluation. Reliance upon the information provided in this report by any other person or
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
System #1 Approved for q bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations: G
r
pN\
29,0%-:>
By: ' Original Certificate Date: O - al r)
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 Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12.tloc
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 CLEARVIEW LOT 7 Parcel ID: 015-242-46
A. WELL DATA 'TO BEDROCK
Well type PRIVATE If A, B. or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 8/15/84 Sanitary seal (YIN) YES Wires properly protected (Y/N) YES
Total depth 130 ft Cased to *122 ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 8/15/84 8/9/17
Static water level 20 ft. 37.5 ft.
Well production 5 g.p.m. 4.0+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 ml. Nitrate 2.18 mg./L. Collected by: GEG Ltd.
Arsenic: < 5 0 ug /L Date of sample- 8/8/17
B. SEPTIC/HOLDING TANK DATA *PANEL ON OUTSIDE OF HOUSE
Tank Type/Material SEPTIC/STEEL Date installed 8/6-9/07
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) 'YES
Date of pumping 8/15/17 Pumper MCDONALD'S PUMPING SERVICE
C. ABSORPTION FIELD DATA 'BELOW EXISTING GRADE AT MT
Date installed 8/6-8/07 Soil rating •.p.d./ 'or ft2/bdrm) 0.8 System type DEEP TRENCH
Length 50 ft. Width 2 5 ft. Gravel below pipe 8 ft.
Total depth '11+ ft. Eff. absorption area 800 ft' Monitoring tube YES Depression over field NO
Date of adequacy test 8/9/17 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 4 in. Water added 639 gal. New depth 23 in.
Elapsed Time: 120 min. Final fluid depth 16 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date •
-1984 TRENCH APPEARED TO BE DRY UPON ARRIVAL AND REMAIN DRY THROUGHOUT ADEQUACY TEST
`PER 8/8/07 MOA ELECTRICAL INSPECTION REPORT
D. LIFT STATION (PRE-SEPTIC TANK PUMP VAULT) "RERECMOVOMALOF LIDMEND SET SCREWS BE DRIVEN TO PREVENT
Date installed 8/6-9/07 Size in gallons 264 Manhole/Access (Y/N) YES
"Pump on" level at 11 in. "Pump off' level at 5 in. High water alarm level at 41 in.
Datum BOTTOM OF TANK Cycles tested 3+ Meets alarm &circuit requirements? `YES
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 75+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 7'
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
4.
G. ENGINEER'S CERTIFICATION x\' .•••"• • • • `•••.,•4_••
• G7 11
I certify that I have determined through field inspections and a 49 ''
review of Municipal records that the above systems are in •
conformance with MOA COSH guidelines in effect on This • • . i
date. I r^-. J:ff 7 A. a ness :
MUNICIPA~.ITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES.
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description LoT -7
Location (site address or directions) ~ [ ~{ [ A~.o~-,~%
Property owner "-~-~.-~-~-
Mailing address ~ q ~
Lending agency
Mailing address.
Day phone E~ ~5--~o7-~
Day phone
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: LT/
3. TYPE OF WATER SUPPLY:
e
Individual well
Community well
Public water
NOTE:
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site ~
Holding tank
If community well system, provide written confirmation from State ADEC attest-
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-~25(Rev. 1/91) Front MOAt/21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I 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.
NameofFirm I o[,~ .-~,~,,-I/..L~o,~ "~ ~
Address ,~3'~ ~ /=~"'~.-~ '~ ~-~3
Engineer's signature ~ ~
Phone
DHHS SIGNATURE
//~ Approved f°r' ;~/'~- bedrOoms.
Disappr0ve~:l.
Conditional approval for
bedrooms, with the following stipulations:
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 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. "-'~
/2,,13~Stl~.l/B1) Back MOA~I21
SEPTIC SYSTEM ADVISORY
Prior to a recent adequacy test on the septic system for this lot, ~_~ inches of
standiung water was observed in the absorption field. This indicates that
approximately ~ % of the absorption area is inundated. However, this system
did meet the minimum absorption requirements for a ~- bedroom residence.
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: L,o'~" "1
Parcel I.D.
A, Well Data
Well type ~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
¥
Date of test
Static water level
Well flow
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~)/~5'/e~ I{. Driller ~ L,'~
Cased to ~__~9 Casing height ,~. L~
Wires properly protected (Y/N)
FROM WELL LOG
Pump level1 /~'~/o,~q
SEPARATION DISTANCES FROM WELL TO:
i~o t_
Septic/holding tank on lot
Absorption field on lot
Public sewer main
AT INSPECTION
g.p.m. '7 ~ g.p.m.
Sewer service line
I i,, o
; On adjacent lots 77 2-~,~
; On adjacent lots ~'~
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
/,/
Date of sample: 7
Nitrate
1, ~,,~ Other bacteria
Collected by: q-7..~ .
B. SEPTIC/HOLDING TANK DATA
Date installed 'vii ct/<~ ~
Cleanouts (Y/N) y
High water alarm (Y/N)
Tank size
Foundation cleanout (Y/N)
Date of pumping
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
Compartments
y Depression (Y/N)
Alarm tested (Y/N) t-v'//,,~,
Pumper ~ ~-~:3 ~r--o~
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION ~//~
Date installed
Manufacturer
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codas (Y/N)
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lot's
Surface water
O. ABSORPTION FIELD DATA
Date installed -7///? / ~ ~/
Length /~,_.~ Width
Soil rating (GPD/FF)
Gravel thickness
System type
Total depth
Total absorption area 7' ~/-~ Cleanout present (y/N)
Date of adequacy test ~/P-7/q ~/ Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Depression over field (Y/N)
for /7/
After test '7'/?
If yes, give date
t,-,I
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ! ~ '("
To building foundation .~..~
On adjacent lots ~ ~
Surface water /'~ ~ ~ ~'
Curtain drain J~ ~ ~1 -C
On adjacent lots )~>'/o-~ Property line
To existing or abandoned system on lot
Cutbank ~ z> Water main/service line
Driveway, parking/vehicle storage area
Io
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines indffect on the date of this;inspection.
Signature
Engineers Name
Date ~,~,
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~~~~-~,~e,~,j~,j~'~,~,~,~,J~,~-lJ~'~e,J~
CT&E Ref.# 94.4964-1
Client Sample ID LOT 7 CLEARVIEW
Matrix WATER
LABORATORY ANALYSIS REPORT
ClientName TOBBEN SPURKLAND, P.E. WORK Order 82603
Ordered By TOBBEN Printed Date 09/30/94 ~ 15:18 hrs.
Project Name CollectedDate 09/27/94 ~ 14:45 hrs.
Project~ ReceivedDate 09/28/94 ~08:30 hrs.
PWSID UA
Technical Director
STEPHEN c. EDE
Sample Remarks: SAMPLE COLLECTED BY: T.S.
Parameter Results
Nitrate-N 1.~
QC Allowable Ext. Anal
Qua] Units Method Limits Date Date Init
mg/L EPA 353.2/300.0 10 09/28/94 CMR
* See Special Instructions Above
** See Sample Remarks Above
U = Undetected, Reportedvalue is the practical quantification limit.
D = Secondary d/lution.
UA = Unavailable
NA = Not Analyzed
LT = Less Than
GT= Greater Than
5633 B Street, Anchorage, AK 99518-1600 --Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
Drinking Water Analysis Report for Total Coliform Bacteria
READ INSTRUCTIONS ON REVERSE sIDE BEFORE COLLECTING SAMPLE
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~~-~-~,'j~'j~'~'~'J~'l~'~'~,'~,'~rt~,'~
5633 B Street
Anchorage, AK 99518-1600
Tel: (907) 562-2343
Fax: (907) 561-5301
MUST BE COMPLETED BY WATER SUPPLIER
PUBLIC WATER SYSTEM LD. # Jill
PRIVATE WATER SYSTEM
[] Send Res'u~ [] Send Involce
Day
[] / Treated Water
~5/ untreated Water
SAMPLE DATE:
Month
S~vIPLE TYPE:
~ Routine
[] Repeat Sample (for routine sample
~Sth lab ref- n6. )
[] Special Purpose
Time Collected
CoUected By
qS' 'TT ,
Prim
SAMPLE LOCATION
TO BE coMPLETED BY LABORATORY
si2 shows th/s Water SAMPLE to be:
tis-factory
[] Unsatisfactory
Sample over 30 hours old, results may
be unreliable
ia Sample too long in trmasit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send'
new sample via special delivery marl.
~/z~
08~a
.$EP 2 ~ 19%
Date Received
Time Received
Analysis Began
Analytical Method: J~M~mbrane Filter
[] lvfMO-MUG
* Number of colonies/100 mi.
Lab Ref. No. Result*
Xnalyst
Jun
Date: q ! a~)]q~Time:
Client n6tified of unsatisfactory results:
Phoned Spoke with
Date: Time:
Faxed
Faxed
Comments:
BACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-lVlUG Result: Total Coliform
Membrane Filter: Direct Count
Verification: LTB
Fecal Coliform ConfL,-mafion
Final Membrane Filter Results
F~ Coli
~ Colonies/100 mi
BGB ! COLIF[RM
Coliform/100 mi
TP,"'ffC ' Too Numerous ~'o Count
OB - O~her
TWO TO
Member of the SGS Group (Soci~t& G&n&rale de Suweill~nce)
ENVIRONMENTAL FACILITIES IN ALASKA. COLORADO, FLORIDA, ILLINOIS. MARYLAND, NEW JERSEY. OHIO. UTAH. WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Gommunity well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attest!rig to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I 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 I ~Jo~l ~ ~¢ ~.[a.~t.~ '~' Phone
Address ~C~ ~ I~J~ ~V~.C~, '~'~- ~"~
Engineer's signature '~, ~ Date
DHHS SIGNATURE
X Approved for ~ L~'54'). bedrooms.
Disapproved.
Conditional approval for
bedrooms, with
the following stipulations:
Additional Comments
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.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /~ ~ ~/~¢'V'/~C~'" Parcel I.D.
A. WELL DATA
Well type ~
Log present (Y/N)
Total depth
Sanitary seal (Y/N) ~V/'
If A, B, or C, attach ADEC letter. ADEC water system number
/ Date completed ~'/~' / ~ ~ Driller A/oh,,I ~-.
I
I ~ Cased to ! ~-'~-- Casing height ~ /
Wires properly protected (Y/N) Y
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
FROM WELL LOG AT INSPECTION
g.~ ~ ~ ~
; On adjacent lots ~ 1'7-~
· On adjacent lots ~' 1'7-~
Public sewer manhole/cleanout h//,~
Petroleum tank I'"//ib
WATER SAMPLE RESULTS:
Coliform ~ f Nitrate
Date of sample: l~'~:::~ /: I~Jq2--
Other bacteria ~ -'"'
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed "7~./~ ~
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size
Compartments
Foundation cleanout (Y/N) "// Depression (Y/N)
Alarm tested (Y/N)
-'~'/, / ~ ~ ~ Pumper /
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot > /~
To property line ,~ ~'G~
Sudace water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
NoN
Manufacturer
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lotS
Surface water
D. ABSORPTION FIELD DATA
Date installed '7/~/,/~ ~
Length /o_~ Width
Soil rating
Gravel thickness
Total absorption area
Depression over field (Y/N) .
Results (pass/fail) ~
Peroxide treatment (past 12 months) (Y/N)
Cleanouts present (Y/N)
Date of adequacy test
for
System type
Total depth /~' "' ,2/
bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /~ ~
To building foundation ~ -'~
On adjacent lots
Surface water /~f/~
Curtain drain IV/I;;)
On adjacent lots ~' ~-'/~"~ Property line
To existing or abandoned system on lot
Cutbank ~ ~:;) Water main/service line
E. ENGINEER'S CERTIFICATION
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Engineer's Name
Date
HAA Fee $ //~'~) '
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
A~ALI$I$ gE$l~T$ fo; IllVOIC; I 59058
Chemlab gef.t 92.5397 Saeple S 1 #at:ix:
WATER
FAX: (907) 561-5301
Client ~e]tple ID : 8141 ALATIIA AVEHUE
PW~ID : UA
Collected : OCT 1 92 ! 14:00 hze.
Received : OCT 1 92 e 15:15
?Eeee:ved with : AS EEQUIRED
Client Name :TOBBEH SPURELAND, P.E.
Client Acer :TOBBKN$
Ordoxod Sy :
Analysis Co~leted : OCT 2 92
Labo:atozy Supo;~e9z~EPHE# C. tOE
Send Ropo:te to:
1)TOBBEN SPUI~KLAND, P.E.
~aramoteE Ses~L~ta ~-~ DMts Method Allow&bid ~Mte
RO~IIM~ SAMPLE COLLECTED BY: STUART.
Tests PerfozMd * See Special Instructions Above UA-Unavailable
Hone Detected '* See ~a~le Renm~ks Above
Not Analyzed LT-Less Than, GT-G:eater Than
Member of the SGS Group (Soci&t& G&n&rale de Surveillance)
&GEOLOGICAL LABORATORY
TESTING& ENGINEERING CO.
TELEPHONE (907) 562-2343
' ~ ~, Drirtb~n~lWater Analysis Report for Total
TO BE COMPLETED'IBY WATER SUPPLIER
[] PUBLIC~ WATER SYSTEM I.D. # '1~
PRIVATFFWATER SYSTEM ;
Name I --'~''~'" i.~v · -- -:- -,w Pho~No.
I [-,I lc I./ I
~. Mo. Day
SAMPLE TYPE:
[] Check Sample (for routine sample
with lab ref. no. t~ )
i-I Special Purpose
SAMPLE
No. LOCATION
,I
41
Year
[] Treated Water
J~i,,.Untreated Water
Time Collected
· ~ 56.33 B Street
Anal~
3E COMPLETED BY LABORATORY
is shows this Water SAMP~ to be:
isfactory
r-1 U~atisfactory
[] S~nple too long in transit; sample should
rl~be over 30 hours old at e'Xamination
t(~ndicate reliable results. Please send
'f~v sample via special delivery mail.
'nme'Received ' ! ~17~
Analytical Method: Membrane Filter
* No. of colonies/100 mi.
Lab Ref. No. Result*
'
I
t
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
TNTC
OB =
BACTERIOLOGICAL
Membrane Filter: Direct Count
Verification: LSB
Fecal Coliform Confirmation
WAT~.
ANALYSIS RECORD
BGB
Coliform/lO0 mi
Final Membrane
= Too Numerous To Count
Other Bacteria
Coliform/100 mi
aom.
HUNICIPALITY OF ANCHORAGE
DIVISION OF E~VIRONNENTAL HEALTH
DEPARTI~NT ~F HEALTH AND ENVIItON~NTAL PItOT~CTION
APPLICATION FOK NF~LTH AirfHOItlTY APFROVAL CERTIFICATE
General Information
(a) Less1 Description (include lot,
Location (address or directions)
(b) Applicants Name
Applicants Address
Application
block, subdivis_~ion, section, tovnship, range)
I
4.7 ~ * ~. ?6/
Business
Telephone - Houe
Telephone ~ · V 7 ~90
(c) Applicant .is (checko.~.~n~) Lending Institution ~-~; Ovner/~r~;
Buyer[-----[; Other I I(explain); ' '
(d) Lending Institution ~lA$~
Address ~N~
(e) Real Es~a~e Co. ~ Agent
Address
(f)
Telephone
Mail the HAA to the following address:
2. T[pe of ttesidence
Single-Family.~.
Number of Bedrooms
3. Water Suppl~
Individual Well~--]
Multi-Family ~--~
Other {describe)
Communi~y ~ Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Se~a~e Disposal
0nsite.,~. 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]
e
5. En~ineerin~ Firm Providing Ins~ections~ 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 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 Maanicipality 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 regula-
tions in effect on the date of this inspection.
7:/'¢
Name of Firm
Date
(ENGINEER SEAL)
Telephone
DHEP Approval
Approved for/'7~: bedrooms
Approved ~, Disapproved
Terms of Conditional Approval
CAI~flON
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON T. HE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE D~EP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. 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.
(DHEP SEAL)
~4/eJ/DlS
[~age 2 of 2]
7-19-84
A®
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classification
Well Log P~esent (Y/N)
Total Depth ! '~O Cased to
Static Water Level ~L¢;
Casing Height Above Ground i,~'~
Electrical Wiring in Conduit (Y/N) ~/
Separation Distances frcm Well:
To Septic/Holding Tank on Lot
MUNICIPALITY OF ANCHORAGE
DSPT. OF HEALTH &
ENVIt~ONMENTAL PROTECTION~
NOV 7 I984
Date Completed
RECEIVED ·
Legal Description: k~T 7,
If A, B, or C, D.E.C. Approved(Y/N)
~4~'/ ~ Yield
Depth of Grouting N 0 ~
Pump Set At !
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
% O O ~ ~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot J(~9 +~ ; On Adjoining Lots
To Nearest Public Sewer Line NOJ",J'~ TO Nearest Public Sewer
C leancut/Manhole
Water Sample Collected By
Water Sample Test Results
Conarents
To Nearest Sewer Service Line on Lot
; Date 11/7/~ ~
B. SEPTIC/HOLDING TANK DATA
Date Installed '7~/~
Standpipes (Y/N)
Depression over Tank (Y/N)
Air-tight Caps (Y/N) y
~ Date Last Pumped
No. of Compartments
Foundation Cleanout
Pumping/Maintenance Contract on File (Y/N) W/~r ; for
Holding Tank High-Water Alarm (Y/N) ~///A- Temporary Holding Tank Permit
Separation Distances frcm Septic/Holding Tank:
To Water-Supply Well JdO ~"~ To Building Foundation I'%,I
To Property Line ~d) ~ To Disposal Field
To Water Main/Service Line
Course
~¢3 ~/~- To Stream, Pond, Lake, or Major Drainage
Comnents
Receipt #
Date Paid:
Amount: L~
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ 0 ~ I ~ ~ ~
Width of Field ~ ~
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of last Adequacy Test
N
~~-~ Standpipes Present
Date of last Adequacy Test
Type of System Design
Length of Field ~ ~
Depth of Field ~, ~ _ ! u/
Gravel Bed Thickness (~/:
(Y/N) ~'
Sep~on Distance frc~ Absorption Field:
~ 0 ~) ~ ~' To Property Line I ~) ~
~) To Existing or Abandoned System
; On ~x]joining Lots N O~ ~-
~_O ~ ~ To Cutbank( if present)
To Water-Supply Well
To Building Foundation
To Water Main/Service Line
To Str~eam/Pond/Lake/or Majo~ Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
De
LIFT STATION ~//~
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dime ns ions
MamJ~ole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
~ets MOA
Comments
** Check Permitted Bedrocm Rating Against HAA Request
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed ~
Ccmpany~
KB1/d5/s
[Page 2 of 2]
Date
MOA No.
~.,'I
2-15-84
HEMICAL & GEOLOGICAL LABORATORIES OF ALASKA,
TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER
5633 B Street
Drinking water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
Water System Name
Mailing AddresS
I.D. NO.
P~one No.
State Zip Code
S~RouLE TYPE:
tine
D Check Sample (for routine sample~!
with lab ref. no.
D Special Purpose
1-] Treated Water
~;YlJntreated Water
SAMPLE
NO.
I
I
I
LOCATION
Tim Collected
Collected By
TO BE COMPLETED BY LABORATORY
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.
Date R.ceived //' 2- '¢' ¢
Time Received /.~
Analytical Method:
El Fermentation Tube
El Membrane Filter
Lab Ref. No. Result*
I Il'-]
J ~
J ~
Analyst
06-122o 0~)
Rev. 19a3
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
Membrane Filter:. Direct Count
Verification: LTB
Final Membrane Filter Results
BGB
Date / I - ~ - ~ ~'
Time: / /-~c~ ~
Coilformll00ml
ColllormllOOml
iomo
COLLECTING SAMPLE TNTC = Too Numerous To Count