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HomeMy WebLinkAboutCONIFER HEIGHTS BLK 2 LT 2( on irPer i_l, S'D' L__P'-- 015- 0ct3- B3 . ,~ 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 I KNEW LEGAL DESCRIPTION LOCA~I ON ~ ~ NO. OF~E DROOMS DISTANCE TO: [ Well ~, p~d Absorption_area8~n ~. PERMIT~~NO. ~ Z Manufacturer/~ _ Mate~al ~ No. o~compartments '~. c p i y in gallons Inside length Width Liquid depth /~ IF HOME'DE: Manufacturer Material kiquid capacitg in ~allons ~= of)ines Length of each 'jn~' Total length ~ lines Trench wi~ D, sta~een lines ~ ~ lop of tile to fin~ht~ ~[~-~° Material bon~ath tile ~ inches lotal~e~fectiw~O. ~abs°rpti°n area kenoth * ~idth Dopth ~MIT ~0. ~  ~ TWo of crib Crib diam~t~ ~ ] ~ Crib dopth Total effective ,~sorption area m Well~/~ Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: [ PIPE MATERIALS t SOl L %EST RATING . REMARKS / 72-013 (~ 3/78) I:::1P P L. t C I:::l N T L. 0 C F:l T I 0 N I....EGFll F'O E:O',q 4-254]i: FINCH "t" H EIMl:::l:i!!; I...11..I M P H F;?. E: '.r' NOR[:, :[ C · LO'T' :!!!;:[ZE ][::t.::L.,:!!;C~ ::i:';(;:!L.tF:IF;~:E F:'I:'EET 'T'"r'F::'E OF::' :!i!;O I L.. FIE::'50F;i:BT I ON $'T'Z"I"EM I .'.:5: TRENCH MF:IXIMIJM I'.,It...IMEJER OF [.:)E[:,ROOM'.:i:: = 4 'T'HE F;?.EE!U :t: REC, :.51 ;.::rE OF THE :!.:.:;CI I L.. F:IDSC~RF::']" 16)1'.4 LE;"r'S'TEM I :L:;: THE L...E!:I',I(]i'T'H [:, ! i'"IEI"4S I 01',1 :[ :E; "lq'"lE L..EI'.,IG]"H ';:' I I",1 FEET ) C F 'TF.lliii: "t"REI'.,ICI..~ OF;i: I.".:,RI:::I I I'.,IF::' I EL.I:,. THE I}EPTH OF:' 61 'T'F~:'.EI'.,IC:H OR PIT .1.'L=.1 THE [:,tS't"FII"4CE E'd:':.:;]"t.,.IE'EN THE ~..':;I...IRFI::I[]:[~.' (.]1::: 'T'HE I}iF;.:OLIl'-41]:, I::~f.,tl:::, 'T'HE [3OT'f'CIPI OF THE E',:':',C:FI',/F:ITI 01"4 ,:: I N FEE'I" ). 'THERL:.'!: 1:5 t",10 SET 1.41 [)TH FOR 'T'F;.':IEI",tCHE::'5. 'THI.:E GF.':Ffv'EL [:,EF="TH I :.:.:; TI-.-IFZ M I t'.,I I MUM [:,EPTH OF' L3F.':FI'v'EL.. ['3ETt.,.IEEN THE OL.rT'I='I=II....L.. F::'I Pl.:ii: I:::IN[:, TI'-IL'}.': [.:.",OTTC$1 OF THE E',:.::CFI',,,'FCI' I ON ,:; l' I'.,I FE:ET). F::'l!ii:l:;?.M I "1" F:IF'F::'L. t CFINT lqt=l:iii; THE F;:'. IE :S F:' O I'.,I :!!.'; :t: D I I.... ]: "['"r' TO l NFORM '1"1-"1 I'."ii; [:,EPI:::i!'T.':TMEI'.4'T' I]:,t...IR I l'.,l[::!i THE I N:!5'T'FIL...L..F:FI" I O1'.,1 :[ NSPECT I C'II'.,tS OF::' FIl",l"r' I.'.IEI....L:5; R[:,JF:ICENT TO 'I"H I ."}:; F::'F;?.OPEF;.:T'T' F:II',ll} 'T'HE I",!UML:.:i~E":F::: OF;' RE':'::';IDEI',ICE:!.:.'; 'THFIT THE 14EI_L I.,.IILL. SER'v'E. E:F:ICI'::]=' I L..L. I NG OF:' I:::ll',l'f ::5'T':?.';TEM I.'.11 THOI...I]" FI NFIL. I N'SPECTI ON FIN[:, FIF'F'F;?.O'v'F:tl .... t!!!:"r' "l]"l 1:5 [)EF:'F:II:;;:TMEI',tT I.,.I I [..['..: DE SUBJECT 'T'O F'F.".OSEE:UT! O1",1. M I I",11 MUM [:, I :!."?I"I:::II"4CE I!ii~E"I"I.,IEEN Ft 1.4EL. L. I::'11'.4[::, F:IN"r' OI",t-S I TE ::5.EI-,.1F:IGE D I :!!!;F::'O:!!i;FIL.. %"r':E;TE]"I I :.5 ::1..~:3C~ F=IEET F=OR F:I F:'F;.:I'v'f=FI"E I.,.IEL. L..; OR '.1..5(ilI TF);2Eh;:.'1 F::'IEET F::'ROM I=1 F:'UDL. IC I.,IEL. t_ DEF'ENDING UPON THE T"r'F::'E OF PUDL..IC I.,IEL.[ P. IELL.. L. OG:ii."; I:::IF.':E RE[;:!LIIRE:[."., I=11',1[:, MUST BE RETLIRNE[:, TO 'T'HE [:'EPf'::IRTME:.'NT I.,.IITHII",I OF:' THE I.,.IEL. L. C::OMF:'L..E'T' I O1",1. CFf]...!I.:.'!]:;i: RE[;-:!L.! I F;i'.EMEI",I'T':!.:.:; J'"Jl:::J¥ I:::IF:'t::'I...'¢. ."]!;F:'EC': I F I C'I=F[' I ON:i!:; FtI",I[:, COI'.,tZ','TRIJ[]:T 1 O1'4 [:, I=I',/FI :[ L.F:tI!~::I...E TCI :[ 1",I:!SUI:;::E PF'.':OF::'E.:.F;:: I t",tSTI=II_LFIT I O1"4. I C IE,r.;i:"l" I F::".,.' 'T' k.t Fq'T' :.1..: I I::IM F-'FtMIL. IF:IF;i: 1.4!TH 'T'HE I',:.:E(.:.!UIREM[.:..'NTS FOF.: I:::'OF;;:TH E:"r' 'THE ML.tN t C: I F:'I=IL I T"r' OF= RNCHOF;.'.FI(]iE. ;2: ! 1.,.I .'[ LI .... I i",I?,TF:IL..L. THE :!.:.';"r':'.":.:;TEM 1 i"4 FICCOR[)FtNCE 1.41 "I"1-"1 THE C:O[:'E:!5. ;ii:: I IJI",I[)E!]:;.':';E;TFIt"J.[:, Tt'"tF:tT THE (]I',I-'.SITE~ :!5[.:.'].,.IER :.:=';"r'::~;TEM MF¢',.' RE[.:.!UIF;?.E' E:.NL..FIRGEMENT IF::' T.HE RES I I:::,ENC:E ]' :i.::; REMC'~[.':'EL.E=.[:, ]"O t NCL. UE:,IE I"ICd:;.:E THF:IJ",I 4 SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99602 276-222~ SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2o COMMENTS PERFORMED BY:_ WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? 72-O08 (7/76) SLOPE ~. SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE __~,..*~L~L~L~L~( m i n u t e s / i n c h ) o PLOT PLAN 152.2o u 89'54'o0"t~ 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 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivisio~n, section~township, range) . r Location (address or directions) (b) Applicant Name ~ Applicant Address (c) ~', Applicant is (check one): Lending Institution~[; Owner/builder I-I; Buyer []; Other [] Telephone: Home --'" Business (explain); (d) Lending Institution ' Telephone Address (e) (f) Real Estate Company and Agent Address Telephone ~.~ - Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family~__ Multi-Family~t []/~/tOtber 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. 4. SEWAGE DISPOSAL Onsite J~ Public [] Community [] Holding Tank [] Note:~f 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) ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA.., 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 -""'~' ~L~/~,/,.~ 4~'/~/~'~//;/~ Telephone DHEP APPROVAL / Approved for ~- bedrooms by ~'-~ .~_~'~;;~' Date /2 -/~ ""~' Approved _~ 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) WELL DATA Well Classification '~""~/~/~/~,7'~' MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) MUNICIPALITY OF ANCHORAGE DEPT, OF HEALTH & ENVIRONMENTAL PROTE, CI?ON t CHECKLIST- FEBRUARY 1984 ~84-4720 ~/.7...,~ , E EIVEO Well Log Prese;t~)N) r Total Depth ///~,.5/ Static Water Level Jr/eT" ~/~l/Z[~/~ Casing Height Above Ground ~ ~ '~ Electrical Wiring in Conduit (Y/N) ~ ~ Separation Distances from Well: To Septic/Holding Tank on Lot /~ ~ ~ To Nearest Edge of Absorption Field on Lot //~' ~ To Nearest Public Sewer Line ~/~ CteanouVManhole ~/~ Wate Sam. e Co,e ,eU If A, B; C, D.E.C. Al)proved (Y/N) /(/'//~ _ Date ,C/o{~pleted <~/2,5/7 ~'(D Yield Cased to //5' Depth of Grouting Pump Set At /1~ ?' ~.~ (~,,~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) , On Adjoining Lots · On Adjoining Lots /~/'~ To Nearest Public Sewer To Nearest Sewer Service Line on Lot ;Date Water Sample Test Results Comments (~/C:~' ~/../~r.A ~'C4:~/'c;V/5'' ~ ,~'~ (3~/'$~'~' SEPTIC/HOLDING TANK DATA Date nsta led */7/Z~ S ze /~~ No. of~mpa~ments ~ Standpipes (Y/N) ~ ~' Air-t ght Caps (Y/N) ~ Foundation Cleanout (Y/N) Depression over Tank (Y/N) ~ Date Last Pumped Pumping/Maintenance Contract on File (Y~ ~ /~ ;for Holding Tank High-Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/H~ding~ Tank: To Water-Supply Well /~ To Building Foundation To Property Line ~ ~ ~ To Disposal Field ~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course Page 1 of 2 72-026(11/84) C.' ABSORPTION FIELD DATA Soils Rating in Absorp. tion Strata..~. Date Installed q/~7/7~. ~ Width of Field .~(-,=,/t ~.~ Square Feet of Absorption Area ~~' ~" Depression over Field (Y/N) Results of Last Adequacy Test I Separation Distance from Absorption Field: To Well __~ Water-Supply To BuildingLot Fou~/~/~on ~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field ~7~ Depth of Field Gravel Bed Thickness ~.~ Standpipes Present (Y/N) Date of Last Adequacy Test _?/,~.~2./~'~ (~ To Property Line ~.~'/(~ To Existing or Abandoned System on , On Adjoining Lots _~./~" To Cutbank (if present) /co'-/-- D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test, Meets MOA ** Che~d Bedroom Rating Against HAA Request ** I certify~t I~ave~hecke'~v/ie.~or conformed to_ a)J .IVl~.A qnd HAA guidelines in effect on the date of this inspection. Signed ~:~/-,,-.~ ~ Date ~/~ Company ~,,l/ MOA NO Receipt No. ~O~ ~ Date of Payment I~-t~ Amount: $ ~ Page 2 of 2 72-026 (11/84) 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 Application Date ~ / ~[' I ~'(.~' GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name <-~'/z~/VJ:2~.~ ~:?z~/,/Z..,~,.~' Telephone: Home Business Applicant Address ?~"Z:~ .~),~,/~ (.~..//~~~~ .~,Z:~ ~./~ (c) ApPlicant is (check one): Lending Institution []; Owner/builder yer []; Other [] (explain); (d) Lending Institution ~.~,.,,~ ,,~,,-- ..~/,.--~=~-.~¢--/.,~.,w Telephone Address (e) (f) Real Estate Company and Agent /~~/''A//~' P Address ~::~ ~,~2~) ~// Telephone ~ - Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family,S' Multi-Family [] Number of Bedrooms ,z// Other WATER SUPPLY Individual Welling' 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'l~' 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) ENGINEERING FIRM PROVIDII~ ... ,NSPECTIONS, 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 ~"'~' Address ¢~'¢~)-~. Date 7/~.4/~- Telephone DHEP APPROVAL Approved for _~ (~_~J/-~ bedrooms by Approved ~ Disapproved Terms of Conditional Approval Conditional 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 WELL DATA Well Classification MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) IIJ,INIC]PAU'IY OF ANO'I~.. I-T DEFT', 'OF HEALTH &~,n~'~Kt.. ~ - FEBRUARY 1984 264-4720 ENVIRONMENTAL .~:;~ i [( '..,,'"~ JUt 2 Legal Description: ~::)7" ,~,,, ~ ~. ~::' .~/~ ,dT',.~ 0"'/_~ If A, B, C, D.E.C. Appro~d (Y/N) ~/& Well Log Present (Y/(~ Total Depth Static Water Level _~lJ~f- Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Y(~ K(~) Date Corn plated -~.~~- Yield Cased to {:~//,~/ Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Y ('~ Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot ,/Z~:~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot //,~" ~ (~ ; On Adjoining Lots To Nearest Public Sewer Line x~/'/~t' To Nearest Public Sewer Cleanout/Manhole .~_?,~ To Nearest Sewer Service Line on Lot Water Sample Collected by ~ ~ . _~/'//~'" ;Date 7/~/~ Water Sample Test Results c~,~7'~_~'.~r.~:~''~/>'~ Comments ~ ~ ~;:~j//~'F=' ~---~~~ To Stream, Pond, Lake, or Major Drainage SEPTIC/HOLDING TANK DATA .o. o, Standpipes (Y/N) F (~) Air-tig~ Caps (Y/N) Y Foundation Cleanout (Y/N) Depression over Tank (Y/N) W Date Last Pumped 7,//~/ Pumping/Maintenance Contract on File (Y/N) /~/ · for Holding Tank High-Water Alarm (Y/N) /Y/ Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holdin~ Tank: To Water-Supply Well /~) ~' ('~ To Building Foundation _~ ~? To Property Line ~'z:~..._~ ~ To Disposal Field /7"~° ~ To Water Main/Service Line W/,/~J' Course /'~/,'~ Comments ~;) ~'/~--' Z~,/~F~ ~~--'~:~ Page 1 of 2 . 72-026(11/84) Do ABSORPTION FIEldeD Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distanc~ from Absorption Filial: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line . ./~./J~ Type of System Design_ Length of Field ~7 '~ Depth of Field /'~- / ~ Gravel Bed Thickness ~ ! ~ Standpipes Present (Y/N) Date of Last Adequacy Test To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~/~ ~ ~,/--'//'~'~ ~~----~ To Property Line ~-~ To Existing or Abandoned System on · On Adjoining Lots /~//~ TO Cutbank (if present) LIFT STAT, O N ~',/[///'~? Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test, Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify tl~ checke~ve/~?e~r conformed to all MOA and HAA guidelines in effect on the date of this inspection. Cig ned ~__-..~-_ Company~H(~ ~- MOA No, Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) ALASKA nuIRo[lm nTAL COF1TROL $ RUIC $, I[1C. (~ngincerin§ l~ I~nuironmcntol Studies 5/22/82 MUNICIPALITY OF ANCHORAGE pr~pT C'": !'r'LT'J s', RECEIVED MERRIL LYNCH 207 E NORTHERN LIGHTS ANCHORAGE AK 99503 SELLER - RELOCATION MANAGEMENT BUYER- SUBDIVISION-CONIFER HEIGHTS BLOCK-2 LOT-2 ADEQUACY TEST FOR SEWER SYSTEM THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 600 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 600 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 900 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 4 BEDROOM HOME. THE SEPTIC TANK WAS PUMPED ON 5/22/82 . SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1250 THIS 4 BEDROOM HOUSE. IS ADEQUATE FOR 1220 U, Jesl 251h Auenu¢ · ^nchoroqe, Alasb 99503 · (907) 276-1361 APPLIC ~IT FILLS OUT UPPER HAL ONLY Pro~erty.~wner "~4 ~ t~ ~ ~ i~,1,_ ~,~r/~ C., ~' R i~'/~0 C~ '~) Phone ~alling Addre~ Zip Code ~ ~1 ~ ~ ~ Buyer Address ZIp Code Lending Institution Phone Address Zip Code RealtyCo.&A~nt C~~ ~ ~'~ ~"~ ~' ~ ~l~ne Address~ ~. ~oE~4~ ~l~&~% ~¢~. ~ ~ ZlpCode ~~ ~7~'1~3~ LegaIDescript~n ~ ~ ~0~ ~ ~~ ~q~tl~ ~ " Street Locati~ ~..fO~ ~Oe~t C Type of Resi~nce~ ,~ ,~ ; ' ~ Single Family ~ Multiple Family No. of Bedroo~ ~ Other Water Supply lndtvidual A~ACH WELL LOG. A w~l log is required for all wells drtlled; since June 1975. Community For wells drilled prior to that date, give well depth (attach log If available). ~ Public Utility Sewer Disposal ~ IndividuaIpubllc Utility ~ ~ ~ ~ ~ ~ Year Indlv~ual I~talled: ~ Holding Tank ~ ~ ~ ~ ~ ~ ~. ~.~ When ~onnec~ed to Public Utility: 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 Inspector/\ ~ ~.~,~\_~ , . Field Notes: NIUNICIPALITY OF ANCHORAGE J.~/,-~.- ~ DEPT. O RECE! ED ( ~ APPROVED BEDROOM8 *CONDITIONS OF APPROVAL ( ) DISAP~OVED ( ) CONDITIONAL APPROVAL*~ DATE / ~,'~ ~ 7 ~ ~ Soils Rating Date ~wer Installed Well To Absorption Area Well Log Reoeived / 3 ~ C' -- 2- 7Z w,,, ,o Tank Septic T~k Size 72-023 (3182) CHEMICAL & GE .,OGICAL LABORATORIES c_ ALASKA, INC. ~ TELEPHONE (907)-279.4014 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. ' >7',,~,; ,'~, ,': ~4~..~, -~ , / / .~, . ..~.~<.,~,, Water Syste~-~am~ ' ' Phone 'No. MailinG:~'~-qr-.e~s ; ' .... '"7' . .:.~,~: ¥ ~ ,i- ·' , , ~ ~'~' .~ **.,~- ..... City State SAMPLE DATE: I,: l Mo, Day Yesr sample Zip-Code [] Treated Water [] Untreated Water SAMPLE TYPE: -~ Routine -r'l "Check Sample (for routine with lab ref. no. [] Special Purpose LOCATION Time COllected Collect1~cl By ' 0~-1220 (b) Rev. 1978 SAMPLE NO. I I , I TO BE COMPLETED BY ~LABORATORY Analysis shows thi.s Water SAMPLE to be: ~ Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 48 hours old at examination tQ indicate reliable results. Please send n~iw samp e. ' Date Received ~ Time Received Analytical Method: [] Fermentation Tube ~embrBne Filter Lab Ref. No. Result* A0.ely~st I r'-l-i I I CT-'] I *No, of colonies/100 mi. or No, of Positive portions, BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Date Collected Source Data Received Time Received p.m.I.ab. No, I~e~umPtlve /Omi 1Omi 1Omi 1Omi 1Omi 1.Omi 0.1mi 24 Hours 48 HOurs Confirmatory 24 Hours 48 Hours EMB Broth 24 hours: Multiple Tube Report: Membrane Filter: Direct Count Verification: LTB Final Membrane Filter Results Reported By ,'. .~., .." - . .... Broth 48 houri: 10mi Tubas PoMtive/Total 10mi Portiere Collform/100ml BGB Collform/lO0ml "~ MUNICIPALITY OF AI~CHORAGE - MUNICIPALITY OF ANCHORAGE DEPT. OF ~:::;'\LT. & L~.~ k~/l~f ENVIRONMENTAL ENGINEERING DIVISION APR ~ ~ Telephone 264-4720 R--- DI R ECTIONS: Complete all parts on page 1. Incomplete reques~ will not be preceded. Please allow ten (10) days for processing. 1,' PROPERTY OWNER ~ PHONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE '2. BU'YER PHONE 3. LENDING INSTITUTION ~: ~q~, I PHONE I MAILING ADDRESS ~ ~ 4, REALTOR/AGENT MAI LING ADDRESS 5. LEGAL DESCRiPTiON Lo'/- ~ [~C-t,~'~,.-, STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS ~ One ~ Four SINGLE FAMILY ~- ~ Two ~ Five ~ MULTIPLE FAMILY ~ Three ~ Six [] Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTI LITY 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY * ATTACH WELL LOG. A well log ~s required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) **If individual/on-site, give installation date .~/'&l( ~ h~ If system 'is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE 'INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. NUMBER OF BEDROOMS TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Ta_~nk or []Holding Tank Size: /,,~-~ {J If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AR EA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SlX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOl LS RATING MANUFACTURER MATERIAL Septic/Holding Tank IAb{orption Area [] OTHER ISewer Line [ Nearest Lot Line 5. COMMENTS [Z~APPROVED FOR ~r' BEDROOMS [] CONDITIONAL APPROVAL(lettermustaccompanycertificate) [] DISAPPROVED DATE I BY (Title) I LEGAL DESCRIPTION 72-010 (Rev. 3/78) P.O. BOX 4-1276 ANCHORAGE, AL~KA 99509 4649 BUSINESS PARK BLVD. Drinking Water AnalySis ; Re~rt f~ Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER~ PUBLIC WATER SYSTEM: P I N u~l© Water Syelem em City State SAMPLE DATE: Mo. Day Year SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no.. [] Special Purpose Zip Code SAMPLE NO. LOCATION [] Treated Water [] Untreated Time .' Collected Collected~=~ By TELEPHONE (~07) 279-4014 TO BE COMPLETED BY LABORATORY LABORATORY: NAME ADDRESS CITY Date Received :.Time Received Analytical Method: [] Fermentation Tube ,~Membrane Filter Lab Ref. No. Result* I F-T-] I * No. ol colonies 1100 mi, or No. of Poaltlve portions. Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Form No. 18-310 (3-78) 06-1220 (b) BAcT~ERIOLOGICAL WATER ANALYSIS RECORD Rev. 1978 -' ' · Date Collected :~ Source Date Received . .~ T,t~e Received p.m. Lab. No. Presumptive 'i 1Omi 1Omi lOml 1Omi 1Omi 1.0mi 0.1mi 24 Hours 48 Hours , Confirmatory ~ :.,~...~. ~ 24 Hours , 48 Hours EMB. i; Broth 24 hours: Multiple Tube Report: Membrane Filter: Direct ~le:a~ r t=mBb~a ne FIIter~~ .Broth 48 hours:. 1Omi Tubes Positive/Total 1Omi Portions Coltform/lOOml BGB C.~llform/lOOmt