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HomeMy WebLinkAboutGLACIER VIEW HEIGHTS #4 BLK 3 LT 7Glacier View
40
Heights #4
Block 3
Lot 7
#050-501-31
Municipality of Anchorage '° •,
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program, 4700 Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page 1 of 3
www.cl.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW070059 PID Number: 050.501.31
Zabel fer RemillardWastewater
System: ❑ New ® Upgrade
And,ep
for Loop Eagle River, AK 99577
ABSORPTION FIELD
Pnaw NlnDer of BW roortr'
0 Deep rr«rcn o $Mllow rrwrar ®ew 0 Mood O ouwr:
LEGAL DESCRIPTION
Tool Devdhamongrnalgraa
0.3 GMT?
1 Ft.
Block W aubdnr .
Dapm It, pipe bdnera hon edgnal grade
Gravel dspth beMedl F."I
3 7 Glacier View Heights Subdivision
3 Ft.
0.5 Ft
TlowtV, Rerge: eeawn:
FMaddedabovednpnYprude:
Gravel LerjM
1.3 Ft.
10 Ft.
Well: ❑ New ❑ Upgrade
or..el.otl,.
Nw et/Mea
DnoVo. bnreen/nee
17 Ft.
3
5 Ft
claovftalq jpmate. A a. D)
Toot Depen:
Goad u,
TUW eworpoan vu
Ppe Material
ExistingPrivate
n.
fl.
170 Fe
Perforated
DnINr-
One Dmtvi.
.SW WI Water Level.
InnnkM:
Dns InotoW
Ft.
GLW Construction
611012007
Y*d
"sn n
u+w H"ht Aoove Grwne
TANK
GPM
FL
FL
SEPARATION DISTANCES
® Septic ❑ Holding ❑ S.T.E.P. ❑ Other:
To
Septic
Absorption
Lift
Holding
ublWPrlvate
Man" eaI I.
ro
From
Tank
Field
Station
Tank
Sawar Una
Existing
1250GnJ
won
127.3
139.6
-
120
Mnnw
w. a .r a ca y.n .nu.
surl.wnn
100+
100+
LIFT STATION
..::,, -r
anu sa-ver
Lw u»
36.5
.,•r, .,Ga
12.4
A
-Pwnp on' Mrei n
py(�pafr levN n
•r,'
Hph weIV &W. at.
wad
Fldn
N
� .
I,72.�.. `•Jv in
In.
50+
Pump M.ke a ModN
EMct,"i lmpenm wp.norrrwl by.
Cunnn Orrn1
Re co
Reconfigured field, deleted 135 SF and added 170 SF due to
BENCH MARK
Lxalan end Dowriptkn
house addition. Revised total area is 2045 SF
Finish floor of new addition
p..,,rh.d levetwn
100.0 FL
Engineer's Stamp
Inspections performed by: PANNONE ENG. SVC, LLC Dates: 1" 101612006
.•�� OF q�
2nd 611012007
�p ,..•••• .. �+
♦i
Development Services Department Approval
: �?.•'
'';♦i
a:
Conditional Approval Date:
g, ... ........1....
....... .. •
♦j .Steven R. Pannone: i
J
Reviewed and approved by: 1 Date:.
♦ 't
♦ No�C1E 8149
♦♦i ce%... �
;��;......
•
PERMIT NO: 070059 RECORD DRAWING P.I.D. NO: 050-50141
WASTEWATER DISPOSAL SYSTEM
LOT 7 BLOCK 3 GLACIER VIEW HTS S/D, NO.4
6 \
\
SrJT4 Bq
HO Exim
\\
SEPTIC
S&S ENG`/ ISTG BED SYS M / EXIST 50g \ \
T 3 x67'Lx0.5 j SEPTICT \\ ,
INSTALLED NEW .0. ' TO REMAIN \ \ \
ON LINES TO FACILIT TE M2 5 \
CLEANING OF LI ES
\ FC . \
T1 , 7.3 \\ -
INSTALLED N EADER
LINE TO ALL DI RIBUTION 139.6 EXISTG \ \
LINES. WELL \
\
S&S
OR SEPTICS
.W DRAIN FIELD\
17'Wx10LFx0.5 ED-
170SF TOTAL ADD'N
TEND 3 LATERALS 8LF
TO SOUTHEAST-/
APP'N RAT -
BEDROOMS
AREA REOU
30 -WIDE BE
67 LFx 30' Wx
TOTALAREA
REMOVE 135
ADD 170SF (1
0
iN RATE: 5-15 MPI
0.3 GPDSF
4 (600 gpd)
RED: 2000 SF
0.5' EFF DEPTH
0.5 ED, 1.0' TD
:)1010 SF
Tx0.5 ED)
Steven R. Pannone
CE 8149
11-5-07
0
—1�NEW 12'X16'
Cl ADDITION TO HOUSE
-A EA /IN 10' OF
PROPO D ADDITION
APPROX 5 SF.
REMOVE P ES 8 GRAVEL
COMPLETELI',FILL W/ PIT -RUN
GRAVEL 8 COMPACT.
�—'_.__---.—
ARE7UNDEVELOPED
`
NO SEPTICS `
WAN 100 FEET
0
RECORD DRAWING
SWING TIE TABLE:
A B
C1 17.1 14.3
C2 23.1 20.0
C3 288 25.6
AREA UNDEVELOPED
NO WELLS OR SEPTIC
W/IN 100 FEET
NOTES:
3) Maintain 10' separation to all lot 5) Install expansion bed at the
1) All work shalt be performed In
lines and water lines, unless noted same elevation of exisfg.
accordance with AMC15.65.
otherwise.
6) Install sand layer under
2) Materials used shall be In
4) Lots served by private water gravel to maintain 4'separation
accordance with those specified In
systems. No wells within 100' of to ground water and a level bed.
AMC15.65, Wastewater Disposal.
proposed system.
trAHtU 1 -UH: PANNONE ENG. SVC, LLC
Michael & Jentler Remillard P. O. BOX 102954
22830 Eagle Glacier Loop ANCHORAGE, ALASKA 99510
Eagle River, AK 99577
696-4232 227-3522 P, 272-8218 Fax
DATE: 11.5.07 PLAN
SCALE' 1•=5n•
PERMIT NO: 070059 RECORD DRAWING DETAILS P.I.D. NO: 050-50131
WASTEWATER DISPOSAL SYSTEM
LOT 7 BLOCK 3 GLACIER VIEW HTS S/D, NO.4
w-wm r3x
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=-Wn3 33
NO M313
eno lens
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RECORD DRAWING
•
r
PREPARED FOR:
r....::....::•••
none
StevenCE
8149
Michael B Jenifer Remillard
# 11.5-07j
��
22830 Eagle Glacier Loop
•.,, ••'
Eagle River. AK 99577
0
6964232
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LJ
U)
m -x own
=-Wn3 33
NO M313
eno lens
ua wvm
M011WNMe
Air yy
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�........
..... Z
RECORD DRAWING
•
r
PREPARED FOR:
r....::....::•••
none
StevenCE
8149
Michael B Jenifer Remillard
# 11.5-07j
��
22830 Eagle Glacier Loop
•.,, ••'
Eagle River. AK 99577
";rt P� �&
6964232
W
_J
Li
0
OL
PANNONE ENG. SVC, LLC
P. 0. BOX 102954
ANCHORAGE, ALASKA 99510
227-3522 P. 272-8218 Fax
SATE: 11-5-07 DETAILS
;ALE: NTS
MUNICIPALITY OFANCHORAGE I '1
Development Services Department
On -Site Water & Wastewater Program 11
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650 \b
(907) 343-7904 1 ��
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: May 11, 2007
Expiration Date: May 10, 2008
Permit Number: SW070059 Parcel ID: 050-501-31
Legal Description: GLACIER VIEW HEIGHTS #4 BLK 3 LT 7
Design Engineer: 0062 PANNONE ENGINEERING SERVI( Site Address: 022830 EAGLE GLACIER LOOP
Owner Name: MICHAEL & JENIFER REMILLARD Lot Size: 48503 SO. FT.
Owner Address: 22830 EAGLE GLACIER LOOP Total Bedrooms: 4 Permit Bedrooms: 4
EAGLE RIVER . AK 99577-9527
This permit Is for the construction of.
R Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction must be in accordance with;
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72 ) and Drinking Water Regulations (18AAC80 ).
3, The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by catling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received
By...Date: (??C5T
Issued By. bc;0C 1yZ- --anti Date: / cq-%
Municipality of Anchorage °
•
Development Services Department
� Building Safety Division
On -Site Water and Wastewater Program , . ...
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orglonsite
(907)343-7904
ON-SITE SEPTIC/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 19.5-n- n l- SI
t��
Property owner(s) �ehlLYC�bay phone I(n
r'
Mailing address Zip Code
Site address 2215a iC,I E �n eLCtr php Zip Code 9 C16
Legal description (Sub'd, Block & Lot)
Legal description (Township, Section & Range)
Lot Size (IS X03 Sq. Ft.
THIS APPLICATION IS FOR (®all that apply):
Absorption Field
191
Septic Tank
❑
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
M
Number of Bedrooms 4
THIS APPLICATION IS AN:
Initial
❑
Upgrade
Renewal
❑
certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 5 Waiver Fees:
Date of Payment: D Date of Payment:
Receipt Number. Q Receipt Number:
(Rev. 11105)
Pannone Engineering Services, LLC P.O. Box 102954
Consulting Engineers Anchorage, Alaska, 99510
(9071272-8218 (907) 272-8211 Fax
May 6, 2007
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
4700 S. Bragaw Street
P. O. Box 196650
Anchorage, Alaska 99519
Subject: Lot 7, Block 3 Glacier View Heights S/D, No. 4
Septic System Reconfiguration Permit Renewal Request
Ladies and Gentlemen:
I am writing in response to your Review Comments dated May 2, 2007. I will respond to your comments in
the same order that they were presented. Please note, this work was started under Permit Number
SW060072 and was terminated due to winter weather.
Comment: Please identify the 4 standpipes after the tank and determine why the first two found after the tank
are filled.
Response: The first two stand pipes are the original double clean -outs installed in 1991. The second two stand
pipes are clean -outs on sweep tees to clean the lines running west. There is obviously a blockage between the
first set and the second set of clean -outs. The Owner has been notified and he will coordinate to have the lines
cleaned.
ctc- Comment: Please explain how pit run gravel will prevent effluent from migrating through the decommissioned
section of the bed.
Response: Gravity. Please note: This work was performed under the original permit and an inspection was called
in on October 6, 2006. The material excavated from the footings of the new building (a silty sand to silty gravel)
was placed in this area and compacted.
Comment:Your profile does not show the 5 laterals of the original bed.
Response: Revised Section to show the three pipes to be extended.
Comment: Per AMC 15.65.060.H.5. "The distance between the outermost perforated distribution pipes and the
sidewall of the absorption bed must be no more than three feet".
Response: Revised plan to extend field to southwest.
Comment: The profile shows that the bottom of the system is within 4' of ground water.
Response: Based on Record Drawing information, the bottom of the field is 4.2 feet above ground water.
Added this information on Detail Sheet.
Pagel of 2
Page 2 of
If you have any questions or concerns, please contact me at 227-3522 or 272-8218.
Sincerely,
Steven R. Pannone, P.E.
Civil Engineer
Attachments:
Q\Work\Letters\7-3 Glacier View Hts.002.doc
PERMIT NO:SWO60072 DESIGN DRAWING P.I.D. NO: 050.50131
WASTEWATER DISPOSAL SYSTEM
LOT 7 BLOCK 3 GLACIER VIEW HTS S/D, NO.4
101
EXISTG
SEPTIC--"
S&S ENG
INSTALLED NE)
ON LINES TO FACII.
CLEANING OF
INSTALLED N
LINE TO ALL DI
JES <
5.
:ADER
UTION
LINES.
'-,AREA VELOPED S&S EN
NO, S OR SEPTICS TH
PROPOSED DRAIN FIELD ADD'N
I17'Wx10LF4.5 ED
170SF TOTAL ADD'N
EXTEND 3 LATERALS 8LF
TO SOUTHEAST J
PERCOLATION RATE: 5-15 MPI
APP'N RATE: 0.3 GPDSF
BEDROOMS' 4 (600 gpd)
AREA REQUIRED: 2000 SF
30 -WIDE BED: 0.5' EFF DEPTH
67 LFx 30' Wx 0.5 ED, 1.0' TD
TOTAL AREA:I 010 SF
REMOVE 135 $F
ADD 170SF (10LFx17k0.5 ED)
G �
T`04
TG BED SYSTEM / EXIST 50g
x 671 x O.SED SEPTIC T •,
• TO REMAIN
\FC
T1 27.3
T I /
\� / Crap✓ 139.6 EXIsrG
WELL\�
'I
12 — PROPOSED 12'r16'
ADDITION TO HOUSE
17.0 AREA WIIN 10' OF
PROPOSADDITION
APPROX VDI
REMOVE P ES &GRAVEL
COMPLETEL$:FILL W/ PIT -RUN
GRAVEL & COMPACT.
AREA UNDEVELOPED \
NO WELLS OR SEPTICS
WIIN 100 FEET _
l01
DESIGN REVISIONICLARIFICATION
AREA UNDEVELOPED
NO WELLS OR SEPTIC
WON 100 FEET
, ��
NOTES:
1) All work shall be performed in
3)Maintain 10'separation to all lot ur""""`"......
lines and water lines, unless noted same elevation of exlsrg.
•.••�04
accordance with AMC75.65.
otherwise. ) y
6 Install sand layer under
`��P'(.............,
�•' �••• ��
2) Matedals used shall be in
q) Lots served by pdvate water gravel to maintain 4'separation
qg Tx ♦
accordance with (hose specified In
to round water and a level bed.
systems. No wells within 100' of 9
�.. ° .. . .... I...
AMC15.65, Wastewater Disposal,
proposed system.
0, Sievan R. Pannone
--PREPARED FOR:
PANNONEENG. SVC, LLC
Michael 8 Jenlfer Remillard
P. O. BOX 102954
BOX
�j . CE 8149
5.7-07 •
22830 Eagle Glacier Loop
Eagle River. AK 99577
ANCHORAGE, ALASKA 99510
g�
♦♦'• ......
-352 P. 72-8218 Fax
'•�•�
696.4232
DATE: g3-0s
a
u
PERMIT NO:SWO60072
N
r
v
a
O
DESIGN DRAWING DETAILS P.I.D. NO: 050-501-31
WASTEWATER DISPOSAL SYSTEM
LOT 7 BLOCK 3 GLACIER VIEW HTS S/D, NO.4
0
,.i
101
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Pannone
REPARED FOR:
PANNONE ENG. SVC, LLC
a tSteven R. �l
a
'•. C-6
Michael & Jenifer Remillard
P. O. BOX 102954
9 1#�
7 9 ��
♦�44���
22830 Eagle Glacier loop
River, AK 99577
ANCHORAGE, ALASKA 99510
o •� •
Eagle
227-3522 P, 272-8218 Fax
u Ott, ;'CF'��•
DATE: 4.3-06 DETAILS
is
SCALE: NTS
N
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water 8 Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650 n
(907) 343-7904 V
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT lo1D�
Upgrade
Date Issued: May 01, 2006
Expiration Date: May 01, 2007
Permit Number: SW060072 Parcel ID: 050-501-31
Legal Description: GLACIER VIEW HEIGHTS #4 BLK 3 LT 7
Design Engineer: 0062 PANNONE ENGINEERING SERVI( Site Address: 022830 EAGLE GLACIER LOOP
Owner Name: MICHAEL & JENIFER REMILLARD Lot Size: 48503 SQ. FT.
Owner Address: 22830 EAGLE GLACIER LOOP Total Bedrooms: 4 Permit Bedrooms: 4
EAGLE RIVER , AK 99577-9527
This permit is for the construction of:
❑✓ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72 ) and Drinking Water Regulations (18AAC80 ).
3, The engineer must notify DSD at least 2 hours prior to each Inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, seated, and heated to prevent freezing.
Received By:
Y2:. L -_&0/VW Date: '5v2 oc,
Issued By. { her Date: 5.11 /0
Municipality of Anchorage
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
www.muni.org/onsite
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050.501.31
Property owner(s) Michael & Jenifer Remillard Day phone 6964232
Mailing address22830 Eagle Glacier Loop, ER AK Zip Code 99577
Site address 22830 Eagle Glacier Loop Zip Code 99577
Legal description (Sub'd., Block & Lot) Lot 7. Block 3 Glacier View Heights SID No. 4
Legal description (Township, Range & Section)
Lot Size 48,503 Sq. Ft.
THIS APPLICATION IS FOR (® all that apply):
Absorption Field
Septic Tank ❑
Holding Tank ❑
Privy ❑
Private Well ❑
Water Storage ❑
Number of Bedrooms 4
THIS APPLICATION IS AN:
Initial
❑
Upgrade
Renewal
❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
Pannone Engineerinq Services, LLC
(Signature of property owner or authorized agent)
Permit/Rush Fees: 1160 Waiver Fees:
Date of Payment: Ll - Z rJ = 0 & Date of Payment:
Receipt Number: Receipt Number:
(Rev. 11/05)
Municipahiy of Anchorage
4.: Tyj1Y/w r CO. IAx 1!NfSll•.\nc6nrigc,.11uxkn!NASI!A(N:ill•Tchph�mc l!NIiI:14:1 hi111. 1',x4!N)7).14&82(N)
C
47(N)lHmg:ncSl mo •.\na•hnmgc, .\laslm tk),illi s.•ci.
a�a�c.numLorg
Mayor Mark Begich
Iluildina Safety Di%3sion
19 April 07
Michael R Jennifer Remillard
22830 Eagle Glacier Loop
Eagle River, AK 99577
Subject: Expired On -Site Water and/or Wastewater Permit
Permit Number: SW060072
Legal Description: Glacier View Heights #4 Block 3 Lot 7
Dear Mr. & Mrs. Remillard:
An On -Site Water/Wastewater Permit, number SW060072 issued by this office for a single-family
system, will expire on 01 May 07. Permits are valid for 365 calendar days from date of issue.
If this was a well permit and the well has been drilled, a well log must be sent to this office for
documentation of the installation and to close the permit.
If this permit was for a wastewater disposal system, an original as -built inspection report must be
sent to this office for review, approval and documentation. This as -built inspection report must be
signed by the licensed Professional Engineer who inspected the installation of the system. As -built
inspection reports are required to be submitted within 30 days of the completion of the system.
If no system was installed under this permit, and you are still planning to install a well or wastewater
disposal system, a new permit must be obtained from this office. A one-time renewal fee for a
second year may be issued for a $115.00 if the renewal application is received on or before the
expiration date of the original permit. When applying for a new permit, the fees are $460.00 for a
wastewater permit and $175.00 for a well permit. eE_A.1rXAv
If you have any questions, please call this office at 343-7904. 412(.107
Sincerely,
5�i;/p -- 0 93 7 72-
Daniel
2Daniel J. Roth
Program Manager
On -Site Water and Wastewater Program
Enc: Copy of permit
Community, Security, Prosperity
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
ON-SITE SEWER/WELL SUBMITTAL COMMENT SHEET
To: PES
Legal description: Glacier View Helghts #4, 1331_7
®Permit ❑C.O.S.A. ❑Inspection Report
The attached paperwork has been reviewed and is being returned for the following reasons:
Please identify the 4 standpipes after the tank and determine why the first two found after the tank are filled.
2. Please explain how pit run gravel will prevent effluent from migrating through the decommissioned section of the bed.
3. Your profile does not show the 5 laterals of the original bed.
4. Per AMC 15.65.060.H.5. 'The distance between the outermost perforated distribution pipes and the sidewall of the
absorption bed must be no more than three feet'.
5. The profile shows that the bottom of the system is within 4' of groundwater.
Name of reviewer: Deb Wockenfuss
Date: May 2. 2007
Please supply the necessary information and re -submit your request.
LEAVE THIS FORM ATTACHED TO THE PAPERWORK
Municipality of Anchorage
Development Services Department
Building Safety Division
% On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
ON-SITE SEWER/WELL SUBMITTAL COMMENT SHEET
To: Pes
Legal description: Glacier View Heights 94, B3 L7 #2
®Permit 0C.O.S.A. ❑Inspection Report
SAI."
The attached paperwork has been reviewed and Is being returned for the following reasons:
1. The profile shows the wrong width.
2. Please change your note from 4' of topsoil and seed to 60
.
Name of reviewer: Debbie
Date: May 9, 2007
Please supply the necessary information and re -submit your request.
LEAVE THIS FORM ATTACHED TO THE PAPERWORK
PERMIT NO: SW06 DESIGN DRAWING P.I.D. NO: 050-501-31
A
EXIST'G
SEPTIC� //
S&S ENG/
WASTEWATER DISPOSAL SYSTEM
LOT 7 BLOCK 3 GLACIER VIEW HTS SID, NO.4
11.4 V
c5C2 \� \
TG BED SYSTEM
x 671. x 0.5ED
5%/
�FC /
1 TI �
'ROPOSED IELD ADD'N
x67LFx0.5ED \�� /Z)"3
F TOTAL ADD'N \\ X /`
\ SSS EN 5% \\M1i�
E ST'To'4 BR , \
HO
/ EXIST 51
SEPTIC T
TO REMAIN \
7
\117.3 \\
1139.6EXIST'G
PROPOSED 12'x16'
ADDITION TO HOUSE
AREA WIIN10'OF
PROPOSf D ADDITION
APPROX 5 SF
WELL
REMOVE PliES 6 GRAVEL
` \ ` COMPLETEL'�'FILL W/ PIT -RUN
AREA EVELOPED GRAVEL 8 COMAAC�T.
NO WELLS OR SEPTICS
WAN 100 FEET `-_' --_--
DESIGN CALCULATIONS: AREA UNDEVELOPED \ `
PERCOLATION RATE: 5.15 MPI NO WELLS OR SEPTICS
APP'N RATE: 0.3 GPDSF
BEDROOMS: 4 (600 gpd)
AREA REQUIRED: 2000 SF
30 -WIDE BED: 0.5' EFF DEPTH
67 LFx 30' Wx 0.5 ED, 1.0' TO
TOTAL AREA:2010 SF
REMOVE 135 SF
ADD 201 SF (67LFxTx0.5 ED)
WAN 100 FEET u �!
*R E D
g AA REVELOPED
/NO WELLS OR SEPTIC
WAN 100 FEET
""' `�.
3) Maintain 10'separation to all lot of m5mu expansion mu at me
1) All work shall be performed In
lines and waterlines, unless noted same elevation of exist'g.
accordance with AMC15.65.
otherwise
Eagle River, AK 99577
696.4232
6) Install sand layer under
2) Materials used shall be in
4) Lots served by private water gravel to maintain 4* separation
accordance with those specified in
systems. No wells within 100' of to ground water and a level bed.
AMC15.65, Wastewater Disposal.
proposed system.
tVAKtU I-IJK:
PANNONE ENG. SVC, LLC
Michael & Jenifer Remillard
P. O. BOX 102954
22630 Eagle Glacier Loop
ANCHORAGE, ALASKA 99510
Eagle River, AK 99577
696.4232
227-3522 P, 272-8218 Fax
DATE: 4-3-06
1
PLAN
SCAT F• 1-=,,n-
PERMIT NO: SW06
DESIGN DRAWING DETAILS P.I.D. NO: 050-501-31
WASTEWATER DISPOSAL SYSTEM
LOT 7 BLOCK 3 GLACIER VIEW HTS S/D, NO. 4
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PREPARED FOR:
Michael & Jenifer Remillard
PANNONE ENG. SVC, LLC
.pteve
P. O. BOX 102954
E 8 49
I.. . .
...........
22830 Eagle Glacier Loop
Eagle River, AK 99577
ANCHORAGE, ALASKA 99510
227-3522 P, 272-8218 Fax
I
6964232
11 %saks
DATE: 41111
DETAILS'
SCALE: NTS
Pannone Engineering Services, LLC
P.O. Box 102954
Consulting Engineers Anchorage, Alaska, 99510
(907) 272-8218 (907) 272-8211 Fax
Apri13, 2006
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
4700 S. Bragaw Street
P. O. Box 196650
Anchorage, Alaska 99519
SUPERSEDED
Subject: Lot 7, Block 3 Glacier View Heights S/D, No. 4
Septic System Reconfiguration Permit Request
Ladies and Gentlemen:
I am writing to request a permit to reconfigure the existing septic system at the above
referenced property be issued for this property. The existing system serves a four-
bedroom house. The Owners are wishing to expand the living room with an addition that
will encroach upon the existing septic system. I am proposing the removal of the existing
system within ten feet of the proposed addition, and adding the lost area (approximately
135 so along the south side of the field by adding a three-foot wide addition to the length
of the existing field at the same elevation of the existing field (an addition of 201 so. I
performed a recent investigation of this system. The system had approximately one inch
of standing water in the field on March 27, 2006. The Owners live and work out of their
house and they were in the process of doing laundry during my visit, which would
account for the standing water. The lot is 48,503 square in size. There is adequate room
on this lot for the reserve system as proposed by S&S Engineers in 1991. If during the
course of the reconfiguration it is found that the existing bed is in failure, we will
perform test holes and develop a design to upgrade the septic system. A request will be
made to your department to modify the permit to an upgrade.
1. Soils. See the soils logs on file with your department. Ground water was
monitored at a depth of 3.5 feet on June 27, 1991. Bedrock was not encountered in the
test hole. It is my opinion that the overall soils appearance of the soils, an application
rate of 0.3 gallons/day/square feet should be used.
2. Trench Design.
a. Percolation Rate:
b. Application Rate:
c. Number of Bedrooms:
d. Design Flow:
e. Min. Absorption Area:
f. Total depth:
C:\Work\Letters\7-3 Glacier View Hts.001.doc
15-30 Min Per Inch
0.30 gpdpsf (500 sf/br)
4
600 gallons per day
2000 sf
0 feet
g. Area Removed
h. Replacement Area
i. Effective Depth:
j. Width:
k. Reduction Factor:
1. Minimum Length:
m. Design Length:
n. Effective Absorption Area:
13SVpE RIGEDED
0.5 feet
3 feet
0.0
67 feet
67 feet
201 sf
3. Surface Water: There are no surface waters within 200 feet of the proposed septic
system.
4. Topography: The average topography in the area of the proposed septic system is
approximately 5%.
The proposed installation will not affect the future development of the surrounding or
existing lots.
If you have any questions or concerns, please contact me at 227-3522 or 272-8218.
Sincerely,
•����aaaa�l
•
i 49 it /\
Steven R. Pannone, P.E.
Civil Engineer
• ...... .......... ....,
C.Steven R. Ponm
Attachments: ,, •., No. CE 8149
)'NaESSva3y
�aaaaa���•
C:\WORK\LETTERS\7-3 GLACIER VIEW HTS.001.DOC
rA
PERMIT NO:SW060072 DESIGN DRAWING DETAILS P.I.D. NO: 050.501-31
WASTEWATER DISPOSAL SYSTEM
LOT 7 BLOCK 3 GLACIER VIEW HTS SID, NO.4
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CE 8149
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Michael & Jenifer Remillard
22830 Eagle Glacier Loop
Eagle River, AK 99577
6964232
IM-NV313 33enoo
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PANNONE ENG. SVC, LLC
P. O. BOX 102954
ANCHORAGE, ALASKA 99510
227-3522 P, 272-8218 Fax
TATE: 4'3.06 IDETAILS
Municipality of Anchorage Page I of.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: __~'_~"'~"'~"~-J~ 16'~_[~/~') PID Number: ~~ [~ t ~
ame: ~~ ~,~F~ ~ ~ ~~ Wastewater System: ~New D Upgrade
Address:
~,~ ~ ~, ~~_ ABSORPTION FIELD
Phone:
-- No:of Be~-- ~ Deep Trench ~ Shallow Trench ~ Bed ~ound ~ Other
Total Depth from original grade:
LEGAL DESCRIPTION ~ ~ soi,,~i.~: 0.~ ~/sq.~,.
Lot: ~_ Block: ~ ~ Subdivision: ~Depth to pipe bottom from original grade:f Gravel depth beneath pipe
Township: ~Range: ]S.c,iZn: ~"FiU added above original grade:~ ' --*' Ft. Gravel length:
WELL: ~ew [3 Upgrade ~~~ Numbe~lines: IOistancebelweenlines:
8,c): ] Tota~ Depth: Cased To: ITota~ absorption area: Pipe material:~t~
Driller: I Date Drilled: Static Water Leveh ~lnstaller: ~ate insla~led:-
Yield: Set at: t Cas' g Height Above Ground:/ T~ ~ 1~
GPM[ ~ Ft. ~ ~ --~' ~ s~
SEPARATION DISTANCES ~)~Septic ~ Holding
From / Tank I Field Station
Surface [ ~ z'~-.~~ ~ I I ~'7'-,' ,
Water
· Lot I , ~',_1 ,,~,~ 1
.und t,o.
Curtain I .
$.T.E.P.
anufacturer: [Capacity in
LIFT STATION
Size in gallons: [ Manufactur(~,.~__~~ --
'"'~u~m~rr," le"~;I ~~'7~;' I~vel at.,~h water alar~"~ at:
BENCH MARK
Inspections perforrned by: ~,'
L
Department of Heal~um~ices approval
Reviewed
and
approved ?.___.¢¢JX.. ._
Location and Description:
Assumed [--levation:
_. ,OD
' ~,, "~' ..
72-013 (1/91)MOA 25
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · 'l"elephone: 343-4744
On-Site Waslewater Disposal System and/or Well Inspection Report
72-013 A (2/91) MOA 25
C��e ti iced Drilling lKog
me co. "A
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK. ALASKA 99567 • TELEPHONE 6882759
OWNER OF LANDt-
i
ADDRESS
LEGAL DESCRIPTIOy C t' (�i -"'F
1�
DATE. Started Ended /
r
PERMIT NUMBER
DEPTH OF HELL r�? 9. C .
STATIC LEVEL OF WATER FF. a
DRAW DOWN FT.
GALS. PER HR 7r,.c
KIND OF CASING 17)�
KIND OF FORMATION: 4
t, C`f{1•i�i.��t STif.C�10
From `� Ft. to �
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GE
MUNICIP
DM
MISCL. INFORMATION: � ERV DIVISION
EIJVIRONM
APR 14 1992
RECEIVED
DRILLER'S NAME
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW910190
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:REMILLARD MICHAEL WAYNE
OWNER ADDRESS:P.O. HC 83 BOX 1559
EAGLE RIVER, AK 99577
DATE ISSUED: 7/11/91
EXPIRATION DATE: 7/11/92
PARCEL ID:05050131
LEGAL DESCRIPTION: GLACIER VIEW HEIGHTS #4 BLK
3 LT 7
LOT SIZE: 48503 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
ISSUED BY: v~g--~'-'~~~--~-
DATE: ?///,/~/ _
ROBERTSHAFER, P.E.
ROGER SHAFER
July 5, 1991
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERfNG STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Lot 7; Block 3; Glacier View Heights;
Request you issue a permit to drill a well and install a septic system
per our ¢~ached site plan dated July 4, 1991.
As can be seen from the attached soil logs the groundwater levels on
the property fluctuate. The high~st level found was at 3.5 ft. below
the ground surface. We have proposed an elevated bed system with the
receiving soils to be just under the organics. A sand filter leveling
course is specified with a thickness varying between 2.5 ft. and 4 ft.
due to the slight slope on the property (SEE SHT. 2 of 2)
Due to the large lot sizes in the area, we do not anticipate any
adverse effects on neighboring properties by the insta~ation of the
proposed we~ and septic systems.
If you have any questions or require any additional information for
your review~, please contact us.
E~T A. SHAFER, P.E.
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
I-EGA[. DESCRIPTION: b"~ ~'~'~
2
3
4
7
8
10
~2
~3
~4
17
~8
Township, Range, Section:
{~,,1~~ SLOPE
SITE PLAN
WAS GROUNDWATER
ENCOUNTERED?
S
IF YES, AT WHAT
DEPTH? ~ oL
P
E
Depth to Water
Readin9 Date Gross Net Depth to Net
Time Time Water Drop
2O
PERCOLATION RATE _~ {minutes/inch) PERC HOLE DIAMETER _(-~2'~
FT
PERFORMED BY: ~, ~, ~ ~-i~i£:~ '~,~:4:~-!-:.[!')(:' I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCO"DANCE W*~¢~t~¢ ~,¢~PAL GUIDELINEF~gFECT ON THIS DATE DATE:
72-008 (Rev. 4/85) ~gle gNor, Alasks *'~ v /
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION 'TEST
PERFORMED FOR: '~--~'~ ~,-,---~'~-~"~
LEGAL DESCRIPTION: ~.-'"~ ~.~'~ ~ ['"'/~-~'1 I~
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19-
20-
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
/
Depth to Waler After,~:LI/o ~
monitoring? -- 17-- Oate: ~-'~"'~-~ I
SITE PLAN
Gross Net Depth to Net
Reading Date
Time Time Water Drop
/:45 \ '/. TM
PERCOLATION RATE '~-[ (mmutes/~nch) PERC FIOLE DIAMETER
17034 F.a~k~ Rive? Loop i~o; o; ,~ ,)~ I~ __ __ _ CEI.
ACCORDANCE V~,T~I~I~,I~i~i&?~I~.~.,~b~I,,G)PAL ~'~ID~I'~,/E T ON TI'tiS DATE. DATE:
COMMENTS
PERFORMED BY:
72-008 (Rev. 4t85)
CER'flFY THAT THIS TEST WAS PERFORMED IN
DEPARTMENT OF HEALTH & HUMAN SFRV CES
.... - ....
825 L Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLAT ON TEST ~'
LEGAL DESCRIPTION: L T ~ 3~Z~C?~ ~/~¢Township, Range, Section:
SLOPE SiTE PLAN
S
/ L
IF YES, ATWHAT ~ O
12 DEPTH? ~ p
E
Deplh to Watrlr Alter ~' t
Gross Net Depth to Net
Reading Date
Time Time Water Drop
z ?
~a 6 l~f~ q -- 7 Yz "
I ~ I,' ~o~. ~ P" ~
~ -~ z..' zo p~) ~ 9/~" /~"
14
15
16
17
18
Jo ~j?sP Loop Road No. 204 PERCOLATION RATE ~ (m~nutes/mch) PERC HOLE DIAMETER __
72-008 {~ev. 4/g51
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# ,t"~..~[~) -~23t-~\ -- '~'
1, GENERAL INFORMA'rlON
Complete legal description
Lot 7; Block 3; Gla~ier View H~ight~ -:Subdivision
Location (site address or directions)
Eagle Gla~i~r Loop
Property owner
Mailing address
Michael R emillard
Day phone
HC 83 Box 1559 Eagl6 River, Alaska 99577
Lending agency
Mailing address_
Day phone
Agent PEPPERS CONSTRUCTION Day phone
Address P.O.Box 771064 Eagle River, Alaska 99577
694-9681
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ,¢
TYPE OF WATER SUPPLY:
Individual well XX
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
XX
72-025 (Rev. 1191) Front MOAII21
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/orwastewater disposal system is safe, functional and adequate for the number of bedrooms
and typeofstructureindicated herein. I furtherverifythat 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
Engineer's signature
DHHS SIGNATURE
Approved for
Disapproved.
Conditional
17034 EagJe River Loop Road No. 204
bedrooms.
approval for
Phone
Date
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 (Bev. 1/91) Back MOA ~I
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~
A. WELL DATA
Well type"'~'~'\J~¢-,' If A, B, or C, attach ADEC letter.
Log presentd~N) Y ~ Date completed
Total depth '~"~2 z~ Cased to
Sanitary seaf~)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
Parcel I.D.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~ / ¢;~
Absorption field on lot ~.4
Public sewer main
ADEC water system number
\\//~ \ I::)riller
'¢'-"¢-'~'~ Casing height
Wires properly protected (~N) ""/
g.p.m.
Sewer service line
AT INSPECTION
; On adjacent lots _
; On adjacent lot,,;
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample:
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed \~ ~\~-P"
Cleanouts<~N)
High water alarm (Y/N)
Date of pumping
Tank size
Foundation cleanout ~N)
Compartments
'/ Depression (Y/~
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot L/~-~ On adjacent lots
To property line \ ~ '~' Absorption field
Surface water/drainage \
c;~ I '~' Foundation_
Water main/service line_
72-026 (Rev. 7/91) Fronl CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
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
Length
Total absorption area
Depression over field (Y/d~
Results (pass/fail)
Width
Peroxide treatment (past 12 months) (Y~
Soil rating ~:;~, '~ ~ ¢'~%ystem type
Gravel thickness ~,~' Total depth
Cleanouts present~-1GN)
Date of adequacy test
for z¢¢--
bedrooms
If yes, give date
On adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~.~1
I
Property line
To building foundation To existing or abandoned system on lot
On adjacent lots ~ 14'' Cutbank ~D I~ Water main/service line
Surface water \ ~~'k~ Driveway, parking/vehicle storage area
Curtain drain ['~0~
E. ENGINEER'S CERTIFICATION
Signature
Engineer's Name
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
):]NGINEEI?ING ';~'~' .... ~ :~ ":" '''~ '"" ~'
&
$
17034 Eagle River Loop Road No. ~04
Eagle Rivet', AlasI{a 99577
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUM3d~ SERVICES
ENVIRONMENTAL SERVICES DIVISION
ON-SITE WASTEWATER DISPOSAL SYSTEM INSPECTION
ENGINEER FIELD AUDIT
TIME:
LEGAL DESCRIPTION:
ENGINEER:
EXCAVATOR:
AUDITOR:
COMMENTS:
SIGNATURE
AUDITOR:
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMr-'RCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA99518 TELEPHONE (907) 562-2343 FAX:(907) 56%5301
ANALYSIS RESULTS for INVOICE # 52611
Chemlab Ref.# 92.1439 Sample ~ 4 ~at~lx: WATER
Client Sample ID
PWSID
Collected
Preserved with
L7 B3 GLACIER VIEW HTS.
UA
APR ? 92 ~ 17:10 h~s.
APR 8 92 ~ 14:00 hrs.
AM REQUIRED
Analysis Completed : APR 10 92
Client Name :S & S ENGINEERING
Client Acer :SNSENGP
BPO# :
Req# :
Ordered By :ROGER S}~FER
Send Reports to:
i)S a S ENGINEERING
2)
PO# :NONE RECEIVED
Parameter Results Units Method Allowable Limits
NITRATE-N ND(O,IO) mE/1 EPA 353,2 10
Sample ROUTINE SAMPLE COLLECTED BY: R.J.S.
Remarks:
1 Teat~ Performed ' See Special Instructions Above UA~Unavailable
ND~ None Detected '" See Sample Remarks Above
NA- Not Analyzed LT-Less Than, GT-Groatet Than
~'~ S~S Member of the SGS Group (Soci~t~ GCn~rale de Surveillance)
CHEMICAL & GEOLOGICAL LABORATORY
A DIViSiON OF COMMERCIAL TESTING & ENGINEERING CO.
TELEPHONE (907) 562-2343 5633 B Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY LABORATORY
TO BE COMPLETED BY WATER SUPPLIER
[] PUBLIC WATER SYSTEM I.D. fi ~
,,,¢~PRIVATE WATER SYSTEM
!/d3., ...t e i::iver Loop Road No, 204
Mailing AOO,~9lc R;vur, Ala5ka ~2
City
Mo. Day
SAMPLE TYPE:
~ Routine
[] Check Sample (for routine sample
with lab ret. no. )
[] Special Purpose
Slalo Zip Code
Year
[] Treated Water
[] Untreated Water
SAMPLE
No. LOCATION
1
41
Collected
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Collected
By
Analysis shows this Water SAMPLE to be:
/1~. 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.
T me Received
Analytical Method: Membrane Filter
No. of colonies/100 mi.
Lab Ret. No. Result* Analvs/
BACTERIOLOGICAL WATER ANALYSIS RECORD
Membrane Filter: Direct Count
Verification: LSB
Coliform/100 mi
Fecal Coliform Confirmation
BGB
Final Membrane Filter Results
Rel, orled By ~',"~ ~;/
TNTC = Too Numerous To Count
OB = Other Bacteria
Date
PAR]- ONE OF TWO
REMAINDER TO FOLLOW
Coliform/100 mi
L,~ a.m.
p.m.