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HomeMy WebLinkAboutALDERWOOD BLK 1 LT 10 Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 E TE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL~ ~" '~/_ ~. ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLIA~,~., Parcel I.D.# ~1 -~\,~-t~,~ HAA# ~'~c~Ch/'t",.-'-'-'~l~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) Alderwood Sub. Lot 10, Block 1 Location (address or directions) 6202 Airquard Road, Anchorage, AK (b) Property owner V.A. Mailing Address 235 E. 8th Ave., (c) Lending Institution N/A Mailing Address Telephone'(home) Anchoraqe, AK Telephone Business 271-2222 (d) Real Estate Company and Agent The Realty Store/Dan Huckaby Address 8040 Opal Circle, Anchorage, AK 99502 Telephone 245-1022 (e) Mail the HAA to the following address: (or check here ri, if hold for pick up.) List contact person and day phone number below: Pick up by Engineer 2. TYPE OF RESIDENCE Number of bedrooms Single-Family [] 3. WATER SUPPLY Individual Well:~ 3 Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site-E] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I 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 FirmEagle River Engineering Services Telephone 694-5195 Address P.O.B. 773294- Eagle River, AK Date 6. DHHS APPROVAL Approved for --~ bedrooms by Approved '~ Disapproved Terms of Conditional Approval Conditional The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 Mu nicipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) ,c~o~/~bl~alth Authority Approval (HAA) ,,,-,~,~/f'~_.. m~/~I~CKLIST - FEBRUARY 1984 ~O~,~~[,~t~c~ ~ 343-4744 Legal Description: ~'¢ ~ /¢ A. WELL DATA Well Classification Well Log Present (Y/N) Total Depth ~'/'"~' Cased to Static Water Level 5-g / /-¢-- If A, B, C, D.E.C. Approved (Y/N) "~/4 Date Completed est'. /~'~ ("f'""'-,'~.) Yield ~'~ ' Depth of Grouting ~ ~ ~ ~,,,,,',,,,r Pump Set At /' Casing Height Above Ground '/-¢-/' Electrical Wiring in Conduit (Y/N) /Y SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot Sanitary Seal on Casing (Y/N) ~ Depression Around Wellhead (Y/N) /v' ;On Adjoining Lots '"'"/~ ; On Adjoining Lots '~'/'* /// / To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot /-'/'-'/ Water Sample Collected by ,¢'?'".¢/'""~ "- Water Sample Test Results ~---~,/,"~'--, = ~¢ To Nearest Public Sewer Cleanout/Manhole B. SEPTIC/HOLDING TANK DATA Date Installed Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) No. of Compartments Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) .SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation To Disposal Field 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in ~ffe~;t-on;.th~.'d~ of this inspection. Signed ~ Eagle Rivcr EnDn~;er!ng ~-~ ..... Company., P.o. ~ux 7732~,4  Eagle River, Al< 995TM Date 6,~i-5~ ~ MO~ No. ~ I Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 '~, ' ~J~.axtr'~t. ,g EOLOGICAL LABORATORIES OF ALASKA, INC. ~- -- - 43 5633 TELEPHONE (907) 562 23 .~nchorage, Alaska 99518 ~-"~ Drinking Water Analysis Report for Total ColIform Bacteria TO BE COMPLETED BY WATER SUPPLIER E3 PUBLiC WATER SYSTEM I.D.# I I I I I I ] PRIVATE WATER SYSTEM Name Mailing Address EAGLE RIVER ENGIt~EERII~C~R¥1OES EA~LE RIVER, AK 99577 P. O. 80X 773294 694-5195 City State Mo. Day Year SAMPLE TYPE: ~, Routine ' [] Check Sample (for with lab ref. no. [] Special Purpose routine sample .) SAMPLE NO. LOCATIO~ Zip Code [] Treated Water ~ Untreated Water TO BE COMPLETED BY LABORATORY saSiS shows this Water SAMPLE to be: tisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Plea. s_e send new sample via special delivery;mall. Date Received Time Received Analytical Method: Membrane Filter * No. of colonies/100 mi. Time Collected Lab Ref. No. Result* Collected By 8766 Analyst ~:'~ - . BACTERIOLOGICALWATER ANALYSIS RECORD~t'~)[~~ READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter. Direct Count Collform/lOOml Verification: LTB RGB Final Membrane Filter Results ~ Reported By c:::~,~__: Time: Colllorm/lOOml p.m. TNTC -- Too Numberous To Count OB -- Other Bacteria PART ONE OF TWO REMAINDER TO FOLLOW C=HEMICAL~ & GEOLOGICAL LABO~ORIES OF ALASKA, INC. FEDERAL TAX ID # 92-0040440 Cllen: S~le ID:LIO ~1 Co!lezt~d DEC 5 &] ! !3:15 ~eccived DES 5 B9 ~ 15:00 Date heFort ?r~r,te~: DEC ? 89 ¢ !7:55 Client ~e : EAg~[ &IVY& ~C~ Chen: Acct: EAGLEEP P.O.~ ~0~ ~ECEI75D Oz~e~e6 ~y : LOU ~U~& Anal7s~ Co~?lese~ :DEC 6 $9 5end Zepo~ts La~czatozy Sup~rvisoz :SiE?h~N 'C. ~DE I)£AGLE ~iV~9. / /z 2) / ! Ins:ruer: ~homiah R(f ~: BT~ Lab 5mpl iD: ! ~c:rxx: Wk?E~ XITE. kT£-N h~(O.lO) .~/1 E~A 353.2 10 EAGLE RIVER ENGINEERING SERVICES Lou Butera, P.E. P.O. Box 773294 Eagle River, Alaska 99577 Telephone (907) 694-5195 January 24, 1990 Mr. John Smith, P.E. M.O.A./D.H.H.S. 825 L Street Anchorage, AK 99501 MUNICiPALiTY OF ANC~ DEPT. OF HEALTH & ENVIRONMENTAL PROTEC'I'ION RECEIVED Re: Alderwood Sub., Lot 10, Block 1 Dear Mr. Smith, We have submitted a request for a Health Approval for the above lot. The lot has an on site private well and is connected to public sewer. There was no well log on file for this lot. File records show an initial system installed in 1969 with a well of 65 feet. Later approval in 1979 shows an unconfirmed depth of 116' System diagrams dated 1969 do not correlate with present well location. Abandoned seepage pit was 90' from present well location. There was a permit issued in 1982 for a new well with no log turned in to M.O.A.. Either the new well was not drilled, or it was, and the well log was not turned in. We have searched M.O.A, D.G.G.S., permit holder, and various well drillers for possible log with no results. We have also searched the front of the home with a Shonestadt Metal Locator for a possible 2nd well in the indicated location with no results. We ask that a Health Authority number be issued based on the following: The well does not violate any distance separation requirements. Static water level is measured at 56' showing casing depth to at least that level. Probing of the well shows a minimum depth of 138' (Our tape stopped at that point with possible obstruction). The well located on lot 11 is 29' distance from lot 10 well and shows an aquifer depth of 181 feet with similar well flow rate. Proximity would indicate similar well aquifer conditions allowing extrapolated well data. If you have any questions or concerns, please contact me at 694-5195. Sincerely, Louis A. Butera, P.E. cc: The Realty Store -.-- > Sewer 10' Line ,,,, .-~~- -~~nhol Sewer Co ~ Seepa@e Pr'c ,6 HSE ALderwood Subdv, LiO, B1 M'W DRILLING, Inc ..... ~3x 110378 · 10330 Old Sec, ard H Qhw~y (907;, 34g-8535 ANCHORAGE, ALASKA 99511 .~¢d ~- z/~fDE:>,,D DRILLINO LO(} l',ocation (addresa of: Town,hip, Range~ S~ctJon, i! known; or distance m~in ro~rl __ T 1 1 , 1~1 Al~,~rwnnd ~u~. ~ Anc~ora~ Size of c~ing ~," Depth of Hole l 81, ~'eet Static water leve;I 80 $t. (~i<~ ~low) l~d surface. ~een ( )1 . Perforated ( Des~lbe scre,n or pe~tio~:' WeE pumping tes~ at !~a ~ (m~ute) for~ ! hourt with of drawdo~n from Depth in feet from ground surface 0TO- 2 2 TO, 2,7 27' TO, ~ 35 TO 70 70 TO ?4 74 TO 116 116 TO 150 fi0 .TO 181 TO_ Ca~ed to 1251 feet l:'tnish of well (check one) open end ( X ); ~ nox ~m .;"/.:' ::' f' WELL LOG . ~ v ~, ~' - r' '~,,~-.~, ,; ,. . :. -.~..._, :. .;~ i%' ;".:1;..,, . .., . ~ ~ . ., , , . ,.~,: ~. ,:' ,;, . .'.. '~ "Sand ~:'~e graving,. '' material, color and hardness ___TO ...... TO ......... ......... TO, ......... TO. 2 -STAT£ tGAAB-H D- ] ~ GRF~TER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM ~OL~) LtfiJl) ADDRESS LEGAL DESCRIPTION SEPTIC TANK: DISTANCE FROM WELL ~,~ I LIQUID CAPACITY ! (~0(~ GALLONS. COMPARTMENTS INSIDE LENGTH LIQUID DEPTH __ SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OE PITS / LINING MATERIAL ~'.~ NEAREST LOT LINE 21 I TILE DRAIN FIELD: OUTSIDE DIAMETER OR WIDTH LENGTH , DEPTH DISTANCE FROM WELL /~7 BUILDING FOUNDATION . f TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ~~L~~SQ. FT. DISTANCE FROM WELl TOTAL LENGTH FOUNDATION. NEAREST LOT LINE OF LINES NUMBER OF LINES DISTANCE BETWEEN LINES TRENCH WIDTH IN. TOTAL EFFECTIVE ABSORPTION AREA SQ. FT. LENGTH OF EACH LINE DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE. IN. ABOVE TILE WELL: LOT LINE DISTANCES: A-X~= // TYPE 7-o2?- t; 7 DATE _ . , BUILDING FOUNDATION. WATER SAMPLE ./,JO ,NEAREST OTHER ~ APPROVED HEALTH AUTHORITY GAAB-H D-2'~ GREATEI ANCHORAGE AREA HEALTH DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 ,_,.)ROUGH 279-2511 Case No. c~ ~ SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT RESIDENCE ADDRESS ~ LEGAL DESCRIPTION APPLICATION TO INSTALL: SEPTIC TANK TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH F ~ PERCOLATION TEST RESULTS MAILING ADDRESS ~ '~ O-~ LOCATION OF INSTALLATION Z07- PHONE NO. , DRAIN FIELD , OTHER SEEPAGE PIT TO BE INSTALLED BY Z-/C~'~/v-~c ANTICIPATED DATE OF COMPLETION BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT THIS IS TO SERVE AS ~/~-/)' /~~PERMIT TO INSTALL A _.,~/~~ ~~.~ AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED ~-~ ~)~-~~ . SEPTIC TANK SIZE ~ TYPE ~/~EEPAGE AREA ~~. TYPE ~~IAGRAM OF SYSTE~ DISTANCES: /~//LJ Authority ! certify that I am £amilia~ with the ~equ~-ements of C-reate~ Ancho~a[e A~ea Borough O~dL~a~ce No. 28-68 and that the above described system is in accordance with said code. DATE APPLICANTS SIGNATURE ~-:~d.'~- d~.~) z. ~,.~ ~ <Permit ~: 821170 .January 31, 1983 TO: Permit Applicant Subject: Lot 10 Block 1 Alderwood Subdivision A permit issued by this department for an individual well and/or on-site sewer system has expired as of December 31, 1982. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal Ordinance. If you have drilled the Well, a well log needs to be sent to this department for documentation of the installation date and to C'lose the permit. If a private engineer inspected the installation of the on-site sewer system, please have them send us the as-builts for our files and documentation. If there are any further questions, please call this office at 264-4720. Sincerel~ Robert C. Pratt, R.S. Acting Program Manager Sewer and Water Program RCP/ljw enc: Copy of Permit SWP/057 PERMIT NO. APPLICANT LOCATION LEGAL f-ILIf-I I C: I F"'"'~=I L I T'T' C~F RFIC:H"~ -R~SE DEF'ARTMENT C HEALTH AND ENVIRONMENTAL ~ 3TECTION ,_,~5 'L STREET., RNC:HORAGE, AK. 99501 264-4720 I4ibb PiE:bi IT (821~70') GRINDLE & KOON COMPANY 2900 ILIRMN8 DRIVE 8NCH 9950i: AIR GUARD ROAD L 10 B 1 ALDERWOOD LOT SIZE ~__--'-:~.~__~ SQUARE FEET MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR t50 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIMATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DR~S OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. PER[4 I T E.~-.' P I RE"'-=- DECEI'IBER -~::L. 1''~- -°-'''-~- -- I CERTIFY THAT 1' I 8M FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2' I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. S I GNED' APPL I CANT ~_djR I NDLE.. &lC]ON COMPANY , V4. 0 I~IE~LL- PEF~M 1: T' R£R ~.bqR~ ~ ~ [ CE~T [F~ Tt.~T '~4. g MUNICIPALITY OF ANCHORAGE EJqVIRONi,',[NTAL  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER I PHONE Mr. and Mrs. Robert Mitchell[ None MAILING ADDRESS 6204 Air Guard Road, Anchorage Alaska PROPERTY RESIDENT (If different from above) PHONE Same None 2, BUYER PHONE Jimmy D. and Busrin Owens 753-1186 MAILING ADDRESS 21-463 E Citrus Ave. Elmendorf AFB, Alaska 3. LENDING INSTITUTION I PHONE Nat Bank of the North MAILING ADDRESS Calais Office 3301 C St Anchorage, Alaska 4. REALTOR/AGENT PHONE NU-WAY Realty James k. Lewis, Broker 333-8412 MAI LING ADDR ESS 2422 Glacier St.. Anchorage, Alaska 99504 15. LEGALDESCRIPTION Lot 10, Block 1, Alderwood Sub STREET LOCATION 6204 Air Guard Road, Anchorage Alaska 6. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four [] Two [] Five [~ Three [] Six [] Other 7. WATER SUPPLY [~ INDIVIDUAL* I--I COMMUNITY [] PUBLIC UTI LITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) Onconfirmed ~.16 ft. 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** PUBLIC UTI LITY **If individual/on-site, give installation date N/A 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 APPOI NTM ENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE [] PUBLIC UTI LITY Connection Verified []Septic Tank or [] Holding Tank Size: If Tank is homemade give dimensions: NUMBER OF BEDROOMS [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SlX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOl LS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line [] OTHER 5. COMMENTS DATE LEGAL DESCRIPTION 72-010 (Rev. 3/78) {~'~-APPROV ED FOR __""~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED ~~ BY (Title) c,.a.c mC. P.O. BOX 4-1276 ANCHORAGE. ALASKA ~ 4~49 BU$1NE88 PAFIK BLVD. Ddnking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER I.D. NO. City State Zip Code Mo. Day SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose Year [] Treated Water [] Untreated Water SAMPLE NO. LOCATION Time Collected Collected By TELEPHONE (1107) 279-4014 TO BE COMPLETED BY LABORATORY LABORATORY: NAME ADDRESS CITY Date Received ~/7/- 7? Time Received / ~ 7 (:~ Analytical Method: [] Fermentation Tube l~'Mem brane Filter Lab Ref. No. Result* Analyst ,~ I--]--I F-i-I J I * No. of colonies 1100 mi. or No. of Positive porflona. READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Form No. 18-310 (3-78) 06-1220 (b) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collected Source Date Received Time Received __ p.m. Lab. No. Presumptive ':t~~10mi 10mi 10mi 10mi 10mi 1.0mi 0.1mi 24 Hours 48 Hours Confirmatory 24 Hours 48 Hours EMB Broth 24 hours: Broth 48 hours: Multiple Tube Report: 10mi Tubes Positive/Total 10mi Portions Membrane Filter: Direct Count Collform/100ml Verification: LTB BGB Final Membrane Filter Resu~' ~' "/~ ~ Coliform/lO0ml 06-1220Ca) Rev. 1973 DATE ALA DEPARTMENT OF HEALTH AND SOCIAL Sr;ES DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMI*PUBLIC BACTERIOLOGICAL WATER ANALYSIS Lab No. OFFICE INDIVIDUAL NAME SEMI.PUBLIC [] CHLORINE RESIDUAL PPM REPORT RESULTS TO ADDRESS CITY ZIP CODE ADDRESS OF SOURCE Analysis shows this Water SAMPLE to be: [~] Satisfactory [] Unsatisfactory [] Questionable [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. [] Bottle broken in transit, please send new sample. SANITARIAN'S REMARKS COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED Sample Collected From [] Other (List) TIME COLLECTED : '? [] Kitchen Tap [] Bathroom Tap [] Basement Tap Well- [] Dug [] Driven [] Drilled SOURCE: [] Spring [] Cistern [] Other__ Dug Well or Cistern Construction: Walls-- I~ Wood [] Concrete [] Metal Top -- [] Wood [] Concrete [] Metal LOCATION: [] In Basement [] Basement Offset []In Yard [] Other Building Sewer DISTANCE TO: or Other Drainage Pipe Tile Seepage Cess- Field Feet. Pit_ Feet. Pool_ Other Possible Sources of Contamination MATERIAL: Building Sewer- [] Cast Iron [] Wood [] Tile [] Plastic Joint Material - Type GENERAL: Does Water Become Muddy or Discolored? When? [] Bored [] Tile Brick or [] Open Top [] Concrete [] Under House Septic .Feet. Tank Feet. Privy __ [] Fibre [] Asbestos Cement Feet. Feet. [] Yes [] No Diameter of Well Well Casing Material Diameter Length of Drop Pipe Offset in PUMP LOCATION: [] In Well [] Basement On Top [] Of Well [] Other PURPOSE OF EXAMINATION: Illness Suspected? New Source of Supply? [] Yes [] No Depth Feet. _ Depth Water Depth From Bottom Feet. In Utility [] In Basement [] Room [] Yes [] No Repairs to System? [] Yes [] No Signature READ INSTRUCTIONS ON, REVERSE SIDE BEFORE COLLECTING SAMPLE 06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1973 am Date Received Time Received pm Lab. No. Lactose Broth 10cc 10cc 10cc 10cc 10cc 1.0cc 1.0cc 24 Hours 48 Hours ......... . Brilliant Green 24 Hours 48 Hours EMB AGAR Lactose Broth, 24 hrs. 48 hrs. Gram's stain Coliform Density (Most probable No. per 100cc) MF Results Reported by This analysis indicates Coliform Organisms to be: Absent Present DIRECTIONS FOR COLLECTING SAMPLES OF WATER FOR BACTERIOLOGICAL EXAMINATION Read Carefully and Follow Instructions Exactly Bear in mind that water analysis deals with materials present in very minute quantities. The least care- lessness in collecting and handling may give rise to results which are misleading. Samples are accepted at the regional laboratories in the early part of the week (Monday-Wednesday) unless there is an emergency or prior arrangements have been made. Arrangements should be made to have the water samples reach the laboratory as quickly as possible and within 48 hours after collection. After 48 hours, the significance of the bacteriological analysis is impaired. In collecting samples from TAPS or PUMPS proceed as follows: (a) Thoroughly flush tap or pump by allowing water to run freely for five minutes. Shut off water and flame the outlet with torch or burning paper. The flame should not be merely passed over the outlet but should be applied until fixture shows indication of being hot. Flame should be directed against inside edge. (c) Open fixture so that a smafl stream flows. (d) Remove bottle from mailing tube. Hold bottle by the lower half in one hand and with the other remove the screw cap with the fingers, leaving foil protecting cover in place. Fill the bottle to the shoulder. Replace cap with foil cover, screwing firmly into place but do not apply pres- sure which will split cap. (e) Pack bottle carefully in mailing tube enclosing this completed information sheet. DO NOT COLLECT SAMPLES FROM FIRE HYDRANTS, YARD HYDRANTS, DRINKING FOUNTAINS OR SIMILAR OUTLETS WHICH ARE DIFFICULT TO DISINFECT PROPERLY. STERILE WATER SAMPLE BOTTLES ARE AVAILABLE UPON REQUEST FROM: Dept. of Health & Social Services Dept. of Health & Social Services Dept. of Health & Social Services Southeastern Regional Sanitarian Southcentral Regional ,~anltarlan Northern Regional Sanitarian Pouch J 338 Denbli Street, MacKay Bldg. 604 Barnette Street Juneau, Alaska 99801 Anchorage, Alaska 995~1 Fairbanks, Alaska 99701 Or District Offices in Fairbanks, Juneau, Ketchikan, Kodiak, Nome, i~almer, Soldotna and Valdez. Consult local telephone directory for sanitation offices located in these communities. Anchorage area -- ~ontact Greater Anchorage Area Borough Department of Environ- mental Quality. FHA Fornf2573 u.s. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Budget Bureau No. 63-R296.8 Rev. July 1958 FEDERAL HOUSING ADMINISTRATI~ HEALTH AUTHORITY APPROVAL . INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--tO BE COMPLIED BY FHA ~NSURING OFF~E MORTGAGEE SERIAL NO. M~TGAGOR OR S~NSOR ~ROPE~ ADDRESS SU~IVISlON NAME .5~~ ~K NO. TOTAL N~s ~S~ ~ New inscaJ]adon LIVING UNITS 6eO~O~ ~ ~ Yes, how mon~) ~bJic system ~ ~mmunJ~ system ~ Individual ~. of ..~. GAR.GE'DI.OSAL ~WAGE DIS~SAL BY~ PART II.~TO BE COMPLIED BY HEALTH DEPARTMENT HEALTH ~PARTME~ INS~OR'S SK~CH ,_ .......... ~__ -~ ~ , ~_~ ........... . ....... . - It is the opinion of ~e ~ Sure ~ Coun~ ~ ~al Department of Health that this individual water-,upply .system ~ i~ ~ is not sati~hctory a~ a domestir water supply for the subject proart. It i~ the opinion of the ~ Sure ~ County ~ rmal Department of Health that thi~ individual sewage-di,posal sys- tem with proof maintenance: ~ ~ ~ expired to function sati~h~orily, and ~ Onnot ~ exacted to hn~ion ~ati~h~orily is not likely to c~ate an in~nit~ condition r " ~A~ SIGNATURE / ~ J' ~/ space.-, provi~d. I h~ve r~i¢wfl the ~oregoing and the ~inent FHA Complig~ce Ins~ion Repo~, and r~ommend that the Individual water-supply system ~ considerfl ~ Accep~ble ~ Not Accep~ble wa dis~sal ~ c~sidered ~ Acceptable ~ Not Acceptable. DA~ SIGNATURE ~ CHeF ARChiTECT HIALTN AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form Rev. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [] Septic tank. Septic Tank: Distance from well,~feet. Material Total liquid capacity, Inside length, Cesspool: Distance from: Well, Inside diameter, feet. Inside width feet; fimndation, feet. Depth, [] Cesspool. gallons. Capacity inlet compartment,. t~et. Liquid depth, Number of compartments .feet. gallons. feet; nearest lot line at [] front, [] side, [] rear, feet. Liquid'capacity, .gallons. Lining material SECONDARY TREATMENT consists of [] Tile disposal field. Tile Disposal Field: Distance from: Well, Total length of tile lines,. Trench width Length of each line Type of filter material: [] Gravel. Depth of filter material beneath tile,~ Seepage Pits: Number of pits .... Outside diameter, feet. Distance from: Well, __ feet; building foundation, Inspection made by: [] State. [] Seepage pits. Other. . feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet. Number of lines Distance between lines, inches. Total effective absorption area in bottom of trenches feet. Depth, top of tile to finish grade, [] Broken stone. Other inches. Depth of filter material over tile, feet. square feet. inches. Date of inspection Depth,. feet. Lining material feet; nearest lot line at [] front, [] side, [] rear, [] County. [] Local Health Authority. Inspected by 19__ inches. REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main,__ __ feet. Size of maifl~ _inches. Individual wells [] are [] are not customary in neighborhood. Give most recent rc.<ord of failure of wells in immediate vicinity to furnish adequate supply of water Properties in neighborhood [] are [] are not being developed with both individual water-supply and sewage-disposal systems. Lot size: feet wide, feet deep. Dwelling set back from front property line, feet. Individual water supply from: [] Drilled well. [] Driven well. [] Dug well. [] Bored well. Diatanc~ of wort from: Building fi)undatfion cast iron sewer seepage pit, Well construction: feet; tile sewer, feet; cesspool, .feet; nearest lot line at [] front, [] side, [] rear,. feet; septic tank,_ feet; disposal field, feet; other sources o£ possible pollution, 'feet. Diameter, _inches. Total depth, feet. Type of casing, A~proximate depth to pumping level of water in well. feet. Approximate yield, Sealed watertight to depth of feet. Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill. Well cover: [] Concrete. [] Wood. [] Metal. Openings in well cover watertight: [] Yes. [] No. Pump: [] Shallow well. [] Deep well. Length of drop pipe, feet. Pump capacity, Located in: [] Basement. [] Pumproom off basement. [] Pumphouse above ground. [] Pump pit. Pumproom properly drained: [] Yes. [] No. Pump mounting watertight: [] Yes. [] No. Type of storage: [] Pressure. [] Gravity. Capacity, gallons. Has bacteriological examination of water been made? [] Yes. [] No. If answer is "yes," give date Quality of water [] is [] is not satisfactory for human consumption. Installation [] does [] does not comply with approved exhibits, if any. Inspection made by: [] State. [] County. [] Local Health Authority. Inspected by Date of inspection 19 Depth of casing, .gallons per minute. gallons per minute. (TITLE) feet, feet; 19__ HlJD-Wa~h., D. C.