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ALDERWOOD PLACE LT 3
Aiderwood Place Lot 3 #050-281-67 ^ M IJ t%J I C:,* I F 0:!!h L_ I -T'- 'Y (3 F:- �t'%J Cl� " C.] V< f-�k C3 EE ' DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ~- 825 L STREET, ANCHORAGE, AK 99501 264-4720 PERMIT NO: 850478 DATE ISSUED: 08/07/85 APPLICANT: PAUL D. MILLER ADDRESS: 129 TOAKOANA EAGLE RIVER, AK 99577 CONTACT PHONE: 6949302 LEGAL DESCRIP:SUBDIVISION: ALDERWOOD PL. LOT: 3 SECTION: 14 TOWNSHIP: 14N RANGE: 2W LOT SIZE: 444E4. (SQ.FT. OR ACRES) BLOCK: MA ' I certify that: - - 1. I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State of Alaska. 2. 1 will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 3. 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 t on this or any adjacent or nearby lot. SIGNEDDATE: ' �y APPLICANT: -PAUL ISSUED BY DATE: ~ LOCATION OF, WELL (Please complete either lo, Ib or Ic.) 'i WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological a Geophysical Surveys I i Drilling Permit No. A.D.L. No. lo. Borough Subdivision Lot Block Ib. t/4 qts. Section No. Township N0 Range EQ Meridian I 1 Anch Alder>+oo 3 of—of— f _ sp Wp Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL: Paul Miller 129 TOakoama Address: Eagle River Ak. Street Address and Area of Well Location L. WELL L06 Feet Below Surtoe• ( final) 4. WELL DEPTH: OF COMPLETION 5. D1TOE tf Material Type Top Bottom 1 Lostilit 0 3 6. O Cable tool n Rolo►y [:] Driven C] Dug ❑ Auger ❑Jetted ❑ Bored ❑ Other:', Sand Gravel 3 18 60 7,USE: @ Domestic O Public Supply [] Induslry Irrigotlon C] Recharge Commerical'; Test Well C] Other: L1^8 SandW Sandy Gravel 95 100 r.rA,VA1 watiar 100 105 S. CASING: C] Threaded E] Welded diam. 6 In. to 10 i ft. Depth Weight 17 lbs./ft. diem, In, to ft. Depth Stickup It. 9. FINISH OF WELL: Type:' Oren Hole—Diameter: 61 Slot/Mesh Site: Length: Set between ft. and ft. Bockfilling Gravel pack OF ANCHORAOU 10. STATIC WATER LEVEL: 78 ft. 10 8 8: IPALl7Y DEPT. TECTIOP� ��-T Date Above or U Below land surface Equipment used: 11 . PUMPING LEVEL below land surface and YIELD 100 ft. after 1 hn. pumping 12 g. p. m I it. after hrs. pumping g.p.m, , 12.GROUTING Well Grouted: 0 Yee C] No i Material: C3Neat Cement 0 Other: 13. PUMP: (if available) HP Length of Drop Pipe ft. capacity 9 -p.m - 0 Subm. C] Jet 0 Centrifical C] Other '1 14, REMARKS: 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Water Temperature ° C] F C] C This well was drilled under my jurisdiction and this report Is true to the best of my knowledge and belief; ' 1415478 Regist�red Business Nome Contract License Number Address: noxaf3illa Signed: Date: i Authorized Representative i Form 02-WWR (11/81) Copy Distribution: WHITE -State DOGS, PINK -Driller, CANARYCustomer Municipality of Anchorag _a On -Site Water & Wastewater Program (907) 343-7904 t"p�jol5�� CERTIFICATE OF ON—SITE SYSTEMS APPROVAL j?&1 ssue y Parcel I.D. 050-651-15 Expiration Date: C7 —,Q �2 —� 7 1. GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address Real Estate Agent MOUNTAIN VALLEY ESTATES 4216 BIRDSONG DRIVE *EAGLE KENNETH BOGGS BLOCK 5. LOT 3 AK 99577 Day phone C/O AGENT 4216 BIRDSONG DRIVE *EAGLE RIVER, AK 99577 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER I ISPOSAL: Individual Well Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Received Date: COSA to be released to the engineer, unless otherwise requested by the engineer. - ,n 1 k a _ &?; COSA Fee $ Waiver Fee $ Date of Payment .rc . � i to of Payment Receipt Number - Receipt Number COSA # _) / ©_- Waiver # Distance: 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seat 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. Phone Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the systems on the cartels of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend on a variety of variables including, but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the systems. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express orimplied) regarding the future performance of the well or septic system_ GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the cumen; systems fail. The content of this report is for the sole benefit of the personiparty who retained GEG. Reliance upon the information provided in this report by any otherperson orparty, including but not limited to subsequent property purchasers, is not authorized. In short GEG disavows any legal duty to anyone other than the person/party who paid for this report. 6. DSD SIGNATURE System #1 Approved for ___L� bedrooms. System #2 Approved for Disapproved. Conditional approval for 0 bedrooms. Date bedrooms, with the following stipulations: 337-6179 SUM VCE -7953 ............. eco, 1k,�'Oro f es sio�°oc -VVV—�\s\tllllU (il Q��`` �(Y OFrtrrj ON-SITE WATER AND m WASTEWATER o PROGRAM J Jll���l Original Certificate Date: —/' /- /'5� The M6nicipA�r 0Vorage Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatations 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. ATTCHMENTS: V / COSA Checklist Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other raw.. nxnsi 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: MOUNTAIN VALLEY ESTATES #1; BLOCK 5, LOT 3 Parcel ID: 050-651-15 A. WELL DATA Well type PRNATE If A, B, or C provide PWSID# N/A Date completed 10/22/82 Sanitary seal (Y/N) YES Total depth 79 ft. Cased to 78 ft. FROM WELL LOG Date of test 10/22/82 Static water level . 5 Well production 10 — 9 -p.m -WATER SAMPLE RESULTS: Coliform 0 colon iesl100 ml. Arsenic: ND ug./L. Nitrate 0.366 mg./L. Date of sample: 4/15/15 Well Log (YIN) YES Wires properly protected (YIN) YES Casing height (above ground) 12+ in. AT INSPECTION 9/24/13 5.28 g.p.m. Collected by: GEG. Ltd. B..SEPTICIHOLDING TANK DATA *PUMPING IS PERFORMED AS REQUIRED BY MAINTENANCE PROVIDER Tank Type/Material STEP/STEEL Date installed 10/6-17/06 Tank size 1500 gal. Number of Compartments E Cieanouts (Y/N) YES Foundation cleanout (YIN) YES Depression over tank (YIN) NO High water alarm (Y/N) YES Date of pumping *6/11/13 Pumper NORTH STAR PUMPING C. ABSORPT16N FIELD DATA QUANICS AEROCELL SYSTEM Date installed 10/6-17/06 Soil rating (g.p.d./ftlbr /bdrm 3_0 System type SHALLOW TRENCH Length 4E _ft. Width 5 ft. Gravel below pipe 0.5 ft. Total depth *4.6 ft. Eff. absorption area 200 fe Monitoring tube" YES Depression over field NO Date of adeouacy test 9/24/13 Results (Pass/Fail) PASS - For 4 bedrooms Fluid depth ih absorption field before test 0 in. Water added61 99 gal. New depth E in. Elapsed Time: E min. Final fluid depth E in. Absorption rate >= 600+ g.p.d. Any'rejuvenption treatment (past 12 mo.) (YIN & type) NONE If yes, give date – D. LIFT STATION *PER MAINTENANCE REPORT Date installed 10/6-17/06 Size in gallons 1500 Manhole/Access (Y/N) YES "Pump on" level at TIMER in. "Pump oft" level at TIMER in. High water alarm level at 46 in. Datum BOTTOM OF TANK Cries tested * Meets alarm 1£ circuit requirements? YES E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankfiift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Sewer /septic service line 25'+ Public sewer manhola/cieanout N/A Holding tank N/A 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 N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line *1' Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parkingtvehirle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS WR#070004 G. ENGINEER'S CERTIFICATION I cerdly that I have datennined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS Data (Rev. 11MM ADVANCED WASTEWATER TREATMENT SYSTEM MAINTENANCE AND REPAIR AGREEMENT BETWEEN MUNICIPALITY OF ANCHORAGE AND �rj t0 fn THIS MAINTENANCE AND REPAIR AGREEMENT made and entered into as of this Day of of 20115, by and between ri)i-3,a eaKtOVL , herein the "OWNER," and the Municipality of Anchorage, herein the "MUNICIPALITY." In consideration of the mutual covenants contained herein, the parties to this Maintenance and Repair Agreement agree as follows: 1. Advanced Wastewater Treatment Systems. Municipality grants permission to Owner to utilize and operate an Advanced Wastewater Treatment System (AWWTS), described as located at (legal description). 2. Definitions. Alteration. Any change to the design or function of an AWWTS that includes the installation or removal of any parts, components or pieces not included in the original construction permit and design. Certificate of On -Site Systems Approval (COSA). An approval by the Municipality of existing water and wastewater disposal systems given at the time of property sale and title transfer in accordance with Anchorage Municipal Code (hereinafter, "AMC') 15.65. These approvals certify that /, the systems are adequate for the homes that they support and meet the codes that were in place at the time of system construction. Damage. Any man-made or natural change in a system that would inhibit the system from performing as designed. Maintenance and Repair. The scheduled and as needed replacement of existing parts, components and pieces of an AWWTS that were included in the original design which would allow the AWWTS to continue to perform as designed. Permit. An On -Site Wastewater Disposal Permit as required by AMC 15.65 to construct and operate an AWWTS. 3. Term. The term of this Maintenance and Repair Agreement shall begin on the date of approval by the Municipality to operate the installed system or issuance of a COSA, and shall continue while the AWWTS is in use or is operational or until the property is sold or title is transferred by the owner and a new COSA is issued to the new owner or transferee of the property. 4. Alterations, Installation and Removal of Additional Equipment. Prior to performing any alterations to an AWWTS, the owner agrees to obtain an On-site Wastewater Disposal Permit from the Municipality in accordance with AMC 15.65. 5. Maintenance and Repairs. A. Throughout the term of this Maintenance and Repair Agreement, the Owner shall maintain their AWWTS in a satisfactory condition capable of producing treated septic effluent in accordance with the equipment's approval for operation in the Municipality. The owner shall enter into a service agreement with an AWWTS r service and maintenance provider approved by the municipality and the manufacturer of the AW WTS for the entire term of the AW WTS. In addition, it shall be the responsibility of the Owner during the term of this Maintenance and Repair Agreement, and any renewals thereof, at the owner's sole expense, to pay for any and all: (1) repair(s), (2) maintenance, (3) adjustment(s), (4) replacement costs, and (5) inspection costs. B. Owner agrees to comply with all applicable ordinance, laws, regulations, rules and orders for the AW WTS. C. Upon request by the Municipality, the owner agrees to provide the Municipality a written schedule of routine maintenance and repairs which have been performed on the system. When a record of maintenance is documented and maintained by the system vendor, the owner agrees to allow the Municipality access to this information. D. Owner acknowledges that the fine for failing to maintain and repair an AW WTS may be assessed in accordance with AMC 14.60 for improper discharge. E. Owner agrees that only maintenance and repair personnel approved by the Municipality will inspect and make any necessary maintenance, repairs or permitted alterations to the system. F. Owner agrees to grant the Municipality reasonable access to test and inspect the AWWTS upon 24 hours written notice. G. Owner agrees that any sale or transfer of title of the property will not occur without a new Certificate of On -Site Systems Approval. H. Owner agrees that the AW WTS installation and maintenance requirements as provided by the AW WTS vendor/installer and approved by the Municipality are the governing guidelines for the construction, maintenance and repair of the Owner's AW WTS. 6. Nonwaiver. The failure of either parry at any time to enforce a provision of this Maintenance and Repair Agreement shall in no way constitute a waiver of the provisions, nor in any way affect the validity of the Maintenance and Repair Agreement or any part hereof, or the right of such party thereafter to enforce each and every provision hereof. 7. Amendment. A. This Maintenance and Repair Agreement shall only be amended, modified or changed by a writing, executed by authorized representatives of the parties, with the same formality that this Maintenance and Repair Agreement was executed with, and such writing shall be attached to this Maintenance and Repair Agreement as an amendment. B. For the purposes of any amendment modification or change to the terms and conditions of this agreement, the only authorized representatives of the parties are: a. Owner: b. Municipality: Director, Community Development or designated authority C. Any attempt to amend, modify, or change this contract by either an unauthorized representative or unauthorized means shall be void. 8. Jurisdiction: Choice of Law. Any civil action arising from this Maintenance and Repair Agreement shall be brought in the Superior Court for the Third Judicial District of the State of Alaska at Anchorage. The laws of the State of Alaska shall govern the rights and obligations of the parties under this Maintenance and Repair Agreement. 9. Severability. Any provisions of this Maintenance and Repair Agreement decreed invalid by a court of competent jurisdiction shall not invalidate the remaining provisions of the Maintenance and Repair Agreement. OWNER: By: � (signature) Date: 2R,,I1KH9 r u �j�(tDVI (print name) STATE OF ALASKA ) ss. THIRD JUDICIAL DISTRICT ) The foregoing instrument was acknowledged before me thiQl't ' day of -)U y-ve— 20S,by 1�jrit�c u�� 3C�rlor STATE OF ALASKA NOTARY PUBLIC a< NOTARY PU ICF R AL SCA. Ashlee LaVigne a My Commission es: 2isl Zrik IJ My Commission Expires: April 28, 2018 MUNICIPALITY: By: (signature) Date: (print name) Title: • Municipality of Anchorage On -Site Water and Wastewater Program " - --(907) 343-7904 -------- Upp '' V�t� Certificate of On -Site Systems Approval JUN 2 9 2015 . Gretchen Stuller Parcel I.D. 050-281-67 Expiration Date: 1. GENERALINFORMATION Complete legal description AlderWOod Place, Lot 3 Location (site address) 10132 Lee St. Current Property owner(s) John Smith Day phone Mailing address 10132 Lee St. Eagle River, AK 99577 - Real Estate Agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family andlor Duplex) . 3. NUMBER OF BEDROOMS: 3 4. -.TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well El Individual ❑ IndividUalWater Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer WaiverNanance request for: Distance: Received by: Date: / Z --. COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $fo Waiver Fee $ Date of Payment Zel bta Date of Payment Receipt Number A1E3uta Receipt Number COSA #�. 3�( �� 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.. In conducting an adequacy test, 1 attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this system. - All systems eventually fail and satisfactory test results donot guarantee future performance of the system,,nor do they guarantee that there are no hidden defects or encroachments. -Therefore. we cannot provide any warranty . for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the. owner listed . above... - _ Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 1.00217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone Date 6/26/2015 ; ,meg • • '9 6. DSD SIGNATURE ystem #T Approved for bedrooms . Steven 11 ttriritina : " GE 6149 . System #2 Approved for bedrooms ^, Disapproved Conditional approval for bedrooms, with the following stipulations: By: Theni Anchorage upon the representations given I of Anchorage is not responsible 7 ATTACHMENTS: COSA Checklist' Septic System Ai Well Flow Advisc If more than 1 septic system is on the lot: COSA Checklist # of i Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: Alderwood Place, Lot 3 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed 10/8/1985 Sanitary seal (Y/N) Y_ Total depth 105 ft. Cased to 105 ft. FROM WELL LOG Date of test 6/15/2015 Static water level E ft. Well production 12 9 - p.m -WATER SAMPLE RESULTS: Coliform Neg colonies/100 mL Nitrate 4.06 mg/L Arsenic ND ug/L Date of sample: 6/15/2015 B. SEPTICIHOLDING TANK DATA Tank Type/Material /� Tank size gal. Numbe mpF25 artments _ Foundation:c1sanout (Y Depression over tank (YIN) _ Date of pum Pumper C. ABSORPTION FIELD DATA Parcel ID: 050-281-67 Well Log (Y/N) Y Wires properly protected (YIN) Y Casing height (above ground) 12+ in. AT INSPECTION 6/15/2015 70 ft 5.8+ 9.p -m. Collected by: PES Date installed _ Cleanouts (Y/N) High water alarm (Y/N) Date installed Soil rating (g.p.d.M2 or fe/bdrm) System type Length ft. Width / Gravel below pipe ft. _ Total depth ft. Eff. absorption area Monitoring tube Depression over field Date of adequacy test Results (Pass/Fait) For _ bedrooms Fluid depth in absorption before test in. Water added gal. New depth - in. Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed "Pump on" levelat Datum Se Manhole/Access (Y/N) u ve t in. High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot N/A Absorption field oaJot N/A Public "sewer main 75+ Sewer /septic service line 25+ Animal containment areas 50+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation l er main s on adjacent to N FIELD ON LOT TO: Property line _ Water Service line F. COMMENTS Survey As -built on File line lurf,ce water Wells on adjacent lots On adjacent lots 100+ On adjacent lots 100+ Public sewer manhole/cleanout 100+ Holding tank 100+ Manure/animal excrete storage areas 100+ G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name Steven R. Pannone Date 6/26/2015 COSA canary sheet 2-6-15.doc Absorption fiel Surface water Water main Driveway, parking/vehicle storage Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program v 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ei.anchorage.3k.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. HAA Expiration Date: fro .10(a 1. GENERAL INFORMATION Complete legal description Location (site address or directions) 10132 Lee St. - Eagle River, Ak., 99577 Current Property owner(s) John Parker Day phone 696-0926 Mailing address Lending agency Day phone Mailing address Real Estate Agent Barbara Crittendon Dayphone 689-1909 Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer EN The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. 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 Health Authority 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 S & S Engineering, Phone 694-2979 Address 17034 Eagle River Lp. Rd., Eagle River, Ak., 99577 Engineer's Printed Name Robert C. Cowan • Date / 0 /r 0. - is +i 3ROBERT C COWAN 5. DSD SIGNATURE C.-8801 Approved for bedrooms. arc =`~•. Disapproved. +1+hI'LN-L;P_-90 Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: o lor— (R., 0110]) Municipality of Anchorage ••, • �' Development Services Department ' Building Safety Division S, ,,, On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH /AUTHORITY APPROVAL CHECKLIST Legal Description: �J { i4l DEQ Parcel ID: A. WELL DATA Well type7avlfm Date completed U I$S Total depth JL ft. If A. B, or C provide PWSID #_ Sanitary seal (ON) _)�;g Cased to 105 Ift. FROM WELL LOG Date of test Static water level -7b Well production (Z 9 p m• WATER SAMPLE RESULTS: Coliform 0 coloniesl100 ml. Arsenic: — mg./l. Well Log Y/) \1 Wires properly protected&) —l�— Casing height (above ground) 191 " n. AT INSPECTION ID 0 5.5 r g.p.m. Nitrate 2AY� mg.11. Other bacteria O colonies/100 ml. Date of sample:�'>l0G Collected by: S¢S-&"r't'rcwj'vr,, B. SEPTICIHOLDINGTANK DATA ?()6(_IC. SL�+e2 Tank Type/Material 1� Tank size "gal. Number of Foundation cleanout (YIN) es; Date of C. 19 -SORPTION FIELD DATA Dale installed ` a Length Total depth Date of adequacy test Fluid depth in absorpti Cleanouts (YIN) over tank (YIN) _ High water alarm (YIN) Pumper Soil rating (g.p.d./fie or f?lbdrm) _ ft. Width Elapsed T� min. type Gravel below pipe ft. Eff. absorption area ft Monitoring tube _ Depression over field Results (Pass/Fail) For _ bedrooms eld before test _ in. Water added_ gal. New depth_ in. Final fluid depth _ in. Absorption rate >= g p•d• treatment (past 12 mo.) (YIN & type) If yes, give date e D. LIFT STATION 'POF L(<_ S19C-6tjZ Date installed Size in gallons _ 'Pump on' level at _ in. 'Pump off" level at_ Datum Cycles tested E. SEPARATION DISTANCES Manhole/Access alarm level at in. Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: ?Ofs c- Stvcc &eL Septic tank/lift station on lot N R Absorption field on lot I0 R Public sewer main r7 r r Sewer /septic service line On adjacent lots _ NA On adjacent lots On Public sewer manhole/cleanout 100 f Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: nvgLl C— Building foundation 01A Property line orption field Water mainservice line Surface water Wells on DISTANCE FROM ABSORPTION FIELD ONLOTTO: orsLlcr Property line foft Building foundation Water Service line Curtain F. COMMENTS G. ENGINEER'S CERTIFICATION Wells on adjacent lots Driveway, parking/vehicle storage I certify that I have determined through field inspections and .. " �G review of Municipal records that the above systems are in .. ~ conformance with MOA HAA gua' n effect on this date. y, i voem c. alonwCC awl ; Engineer's Printed Name 471. Date y0 15�c1t%;: -::51%4': HAA Fee $_ y�sn.m Waiver Fee $ Date of Payment UJ /'t j,-K)C!5 Date of Payment Receipt Number `1��11U� �{�SY�_ Receipt Number, (Rev. 12101) 10-03-06;11:37 ; -Sf3$- SCS Rer-4 1056307001 ClientName S & S Engineering Project Namem Lot 3 Alderwood Place S/D Client Sample D) Lot 3 Aldetwood Place SID Matrix Drinking Water Samole Re=rks: ;907 661 6301 x 2/ 4 All DattdTimes are Alaska Standard Time Printed Date/Tlme 09/292005 13:52 Colketed DateMme 09232005 12:40 Received DateMmc 09232005 15:48 Technical Director Stephen C. Ede Allowable' Prep Analysis Pammtter Results POL Units Method ConWWID Limits Date Date Init Nitrate -N 2.47 0.100 mg/L EPA 353.2 Microbiology Laboratory Total Coliform 0 eoVl00mL SM20 92228 B (x10) 09/23/05 AZS A ("I) 0923/05 TLF 10-03-05:11:37 ; SGS/CT&E ENVIRONMENTAL SERVICES ;907 561 6301 >r 4/ 4 200 W. POTTER DRIVE ANCHORAGE. ALASKA 99S1 B Tel: 907-562-2343 Fax 907551-5301 Lab Pat No. Drinking Water Analysis-Reportfor-iotal.Coliform Bacteria - 056307 U3 'READ pTR SUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE MUST BE COMPLETED BY WATER SUPPLIER I1��a II 1111 I@I 0 PUBLIC WATER SYV" Mar MfOATE WATER SYSTEM 0 Send Resuln SAMPLE COLLECTION: Dow: 13 Send Resulls 13 Send bvdw SAMPLE TYPE: TnnapenM to Lab By. aeme as COI"r other. TO BE COMPLETED BY LABORATORY Sample ReeeNina: Delivery MW Received Comments ❑ Routine ❑ Treated water 0 Repeat Sampo 13 Untreated Weber (refer to lab no _ 1 ❑ Special Purpose ❑ Sample wee 70 horn oft ❑ RUSH SAMPLE Result may be Omssebls ' ❑ M NOW We Phone #. F°0 i Fax ...................................................................................................................... as*., ..... see........... Badertolootcal Water ArWvsls Record: I roalft"WMI: ADEM �r MMD•MUG (PW RESULTS: AMC FSK JUN Analysis Bean: % z3/oi✓� •/A'DO TOW Coworm: me: Analyst 7/- E. Core ' Sem b Ceerlt Analypral Mrbod: MEMBRANE FRYER RESULTS: Phoned Q Fond Q Dow Cant calo"16009ml. DaWTima• Membrane FAter ' v. Janson Spoke wNh: MMO-MUG(P/A) LTB-COGE Satisfactory • � ,.,,,,,,, { E • t]] Unsatisfactoryyr TMTC.T..n.w WCwr Reported By: " Datemme: -7,j P--00— %7 �Jy a.warrn. W. Form R FW -0053 12M7103 1Wseslnat0l%ANK,GroupDatalPub k1D000MEMTT*RMSIapprovedlCa Form 121703Jb ._... —.1. _..__...I --._..... ... ..__.. 4P: 7.3 -•,� r q �/•A...17 i 16 u�.• V se fJ �„ 71f �I i fie r. •.. .���.��.. f_:'.i 7'l J.ra.. AS•Buiur 1 hereby certify that 1 have surveyed the following described property: 1-0 7 3 f�L� -Ir v.•... • .! iia c .a �� r u• Anduaage Recording Precinct. Alaska, and that the improve- ments situated thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no Improvements on property lyin t adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines or other visible casements on said property except as indicated hereon. Dated at Eagle River, Alaska � this !• . '• day of A 19_ 8� ROBERT C. JOHNSON 7?c� SCALL': Registered Land Surveyor No.;66-1.5 1" • t f -U Ik)x 77-0456, Eagle River, Alaska 99577 I'hone (907) 694-2543 MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services D On-Site Services Section /� �j n y P.O. Box 196650 Anchorage, Alaska 99519-6650 ry �L 343-4744 Ax �% g CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING,( q Parcel 1. D. # L'— ^ 2) * � -( HAA # 1. GENERAL INFORMATION Complete legal description Lot 3, Alderwood Place S/D Location (site address or directions) 10132 LAP Street Property owner Ed & Carol Burroughs Mailing address Day phone 694-8551 Lending agency Day phone Mailing address Agent Prudential Vista/Barbara Crittenden Day phone 694-5500 Address16635 Centerfield Drive, Eagle River, AK 99577 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well xxx Community 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: Individual on-site Holding tank Community on-site Public sewer XXX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) From MOA M21 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 c F. s ENGINEERING Phone 6 cty- a y 7`1 17034 Eagle River Loop Road No. 204 Address __ . Engineer's signature 6. DHHS SIGNATURE Vf Approved for 711 bedrooms. Disapproved. Date C/ f K/ g q ROBERT C. COWAN N C� f:ti. CE -8 801 Conditional approval for bedrooms, with the following stipulations: Additional Comments Date 6 - -� _�), - qq CAUTION ,x The "Municipality of Anchorage Department of Health and Human Services (:: - HS) issues Health Authority Approval Certificates based only upon the representations given in paragrapin 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 �)��N 1999 DEPARTMENT OF HEALTH & HUMAN SERVIC Environmental Services Division .riuN►c►PALITY of ANCHURAGE 825 L Street, Room 502 • Anchorage, Alaska 9950j1'�V I(q%WW* DIVISION Health Authority Approval Checklist Legal Description: L -dT 3/ 42-/Yrrt 6VO6 0 ✓� Parcel I.D.:— A. WELL DATA Well type./ /D/ ✓1 f1JALIf A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) VC S Date completed IMM S Total depth ZC5 Cased to /a 7 / Casing height (above ground) Sanitary seal (Y/N) FROM WELL LOG Date of test /Cze 16 Static water level 7tcl Well production / Z g.p.m. WATER SAMPLE RESULTS: Coliform 0 Wires properly protected (Y/N) 7�5 AT INSPECTION % cP /q / 79 ` g.p.m. i4 /ZhsTAiGToi.4 03 y P,, .1 Z /2L-vm4.rvC. Nitrate a . S- / Date of sample:-�(ff Collected by: B. SEPTIC/HOLDING TANK DATA Date installed N114 Tank size Numbed Foundation cleanout (Y/N) Date of P C. ABSORPTION FIELD DATA Date installed /V /A Length ression (Y/N) Pumper Other bacteria " 5'EN49SEMMra&- 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Cleanouts (Y/N) High water alarm (Y/N) Soil rating (g.p.d./W or ft2/bdrm) System type Width Gravel thickness Total depth Effective absorption area Monitoring T present (Y/N) Depression over field (Y/N) Date of adequacy test esults (Pass/Fail) For bedrooms Fluid depth in absorption floe �eforest (in.); Immediately after gal. water added (in.): Fluid depth (ins) Minutes later: Absorption rate = g.p.d. treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)' D. LIFT STATION Date installed N /i4 Size in gallons Manhole/Access (Y/N) High water alarm level at* Cycles E. SEPARATION DISTANCES "Pump *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: "Pump off" level at* Septic/holding tank on lot N Z^ On adjacent lots _ Al A- Absorption field on lot N� On adjacent lots /� Public sewer main S Public sewer manhole/cleanout %C Sewer /septic service line Z :7 Lift station N 114 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation tv A Property line Absorption field Water main/service Ii Surface water/drainage Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line N 1A Building foundation Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain Wells on adjacent lots F. ENGINEER'S CERTIFICATION -7a�Vi I certify that I have determined thru field inspections and review of Municipal recQAW7&k1firA1bms are AV in conformance =UidZefies in effect on this date. -0 -y #Signature Engineer's Name 8'd 4 r C Co We g -- \ RpBfRT C. COWAN •• � � r CE Date ` h R R f <; �• „ HAA Fee Date of Payment Receipt Number !� 4 /,"a 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 06/16/1999 10:02 9076941211 JUN -15-12 11:30 FROM -CTI 3NVIRONI PAL cra EnwkcmmM l*l savioks Ihc. ME Itt-f-f Client Na mo Project Nmi!/# Client Stttnple ID Maou ov arad Ply I'WSPIi 992614M s Ar § Fissim"as N/A Lot 3 Akla* od pl U:inldisA 111►** S AND S ENGINEERING 5619201 PAGE 02 T-717 P.02/04 F,-071 CPleratt Mk P'thtted Daste/'liauG 06,15199 19:Z7 Calleetal pm olfte 06110/99 11:30 1Rstallred Dntanum 05/101" 113:50 Tett" IN, Stephe/n� C. Ede 0 itadataaed PayZ11 n./ ryI a If I Attowabt• Prop Anstysis ParawAter Retutie p" u"Its Method LjO111 arty Date Init Total coliform 0 cotJ100mt. $Nis 92214 06/10/99 RAP wltrata-k 131 0.500 "/L EPA $00.0 10 fox 06/10,90 0000/99 M O N 3 _ - c� in NT G �y o N0 m" �� n Is N 41211 FRW-GTE ENYIIIONhENTAL S AND S ENGINEERING 5615301 PAGE 01 T-TTT P.04/04 F-OTI T'�t +�r ni rttAl SerWcas Inc. t,tlbatarfol�r �ilvtiibh �' Drinking 'dater Aiiollysig MA.01NSTM ICUONS ON A 0 a PV 0LIC WATbR SVSTFM I.D. M ;/PR1Vkft WATER tusk 200 W. Poner Drove for Total Coliform Bacteria Anc• AK 99618. 406 V11�Rr�WCOLIEC7T1'NGS"PLE Tel (9071542-2343 ee�$ a s*�e Rn+.m a s.t taws awn, ... „� SAMPLE t)ATE: M'014 Aai' . Year SAMPLE TYPE: x iRotltlne o T'etltsd Witter Q Repttnt NOR* 00 W0110 tlldh►6 ix V"Voeted waur 14Ith I*b ret. ho.._ ._ , .. . 11 M Spec141 hrpOdt Time SAMPLE LOCATION Collected By c Flaw Pru+ aM;ly;is Shows 9113 Water 3AMPLE to be: 3amisfactory q LhmxsNttsfitrtory U Sample over 30 hours old, results may be unrothble a 9amrtDls too tons to tr n it-, sample should not be over 44 hours old at exatmnsttan to lridtrate tch9ble results- Pkav scdd new arnpk via Spec 1 d tvery mall. D.It+t [treeired r 014 91 Tl Ree saw elved_.,,.s, Analysis 8"as Aaalyttot Metbod:embane Filtar +IMO-MUQ _• M_amberot'eoi_onieW100ml. .. Result- Anslyll 99 X14 I Moo Jen Fe�r11 Dam, Time Client aotitled of unsatisfactory malts: T Q PORM Spoke with FFaxra Tune. J1ACT1ffU0Lti CAL NATER ANALYSIS RECORU MMO-Mild ketals: Tali) CSW** - E. CW1 �D MrMbrsae 11ter: d)rest Cadet Coleales/1 ml =' Verifleadop: LTB dGE CitlFi4tM rrc• .�. S:o r.a«�� ...- Petit) tob(ornt Ct►nfirbmAtlda -�..re* 1' itlal membrtlNS li lttlt Iia ColKorm 104 ml loported by 040 :. � I Time Comments. Moil" W tort soil Group, mosoi Gdnsrals de sw"dienael . . ENVIRONMENTAL PADUTIES 04 d1./1►SRA. CAWO01lNIA. FLORiRM. WN&S. MARYLAND. NGCMICAN. MISSOURL muw jMsEr. Ofob. WEST vigGiNtA 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 tZ 14 �gS 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) _ o -T 3 /- Lr Location (address or directions) L GF � Br, LST t�.G1.(a� t.-4nuS� ``�I C3L-VY Ttt-1.� (b) Applicant Name ��`� tLr( Telephone: Home )a� `1-q �Z Business � �7G Applicant Address 12`1 T���' �G ppr,,4 �', t� 0� vv -_t_ (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution 1-�`sUT�J�t� Telephone Address es (Z -L - (e) Real Estate Company and Agent tJ v ttjv' Address Telephone (f) Mail the HAA to the following address: .,;e y ngcneer� Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family 9 Multi -Family ❑ Number of Bedrooms 3 3. WATER SUPPLY Other 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 ❑ Publics( 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. 72-025 (11/84) 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 Firm A n & gn9inearing Telephone Address SRR 196x • /_ Date 6. DHEP APPROVAL %Approved for Elil—t (, bedrooms by Approved r Disapprove Terms of Conditional Approval z Conditional CAUTION • � � ',;fir^. °•� ?� H� n eer' ••• Mo. 1 A37'e.' C-, � J'� •• +� • 'mss e .m ti 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) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: o"T" -3 A. WELL DATA Well Classification 5' If A, B, C, D.E.C. Approved (Y/N) N/Q Well Log PresentON) Date Completed I L> - B `635' Yield (Z- 6;tF;&� Total Depth low Cased to l 05 ` Depth of Grouting Static Water Level i8 f Pump Set At Casing Height Above Ground t S K Sanitary Seal on Casing4'N) Electrical Wiring in Conduit&V/N) Depression Around Wellhead (Y/Q> Separation Distances from Well: r aIP To Septic/Holding Tank on Lot ; On Adjoining Lots N To Nearest Edge of Absorption Field on Lot A On Adjoining Lots p To Nearest Public Sewer Line t15 To Nearest Public Sewer Cleanout/Manhole ► �t To Nearest Sewer Service Line on Lot 2.7 4 Water Sample Collected by �S'r 5� ��r icl-J� ; Date 12 - Z - SS' Water Sample Test Results Sa't is Comments B. SEPTIC/HOLDING TANK DATA rJ led Standpipes Depression over Tank (Y/N) Size Air -tight Caps (Y/N) Pumping/Maintenance Contract on File (Y Holding Tank High -Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well To Property Line To Water Main/Service Line Course No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped ;for Holding Tank Permit (Y/N) To Building Foundation To Disposal Field Comments G-c�*�*)�'� r� 'rc" F��T'"- tiC� �'���E�'L Page 1 of 2 72-026(11/84) To Stream, Pond, Lake, or Major'6KQJnage C. ABSORPTION FIELD DATA t_3 IP Soils Rating in Absorption Strata Date In Width of Field Square Feet of Absorption Area Depression over Field (Y/N) — Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well _ To Building Foundation Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Property To Exishi% or Abandoned System on Lot ; On Adjoining Lots To Water Main/Service Line To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments 'ro _A",;::1-ML_t <-- D. LIFT STATION I`) Ili Date Installed Size in "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments — Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumpin es during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA a7sv AA guidelines in effect on the date of this inspection. S 8 S Engineering Signed S_ SRB r - Date Company EU,c,ie °fiver, Alaska 99571 MOA No. -3 Receipt No. �. 62 Date of Payment /,.,1 -�—� S, Amount: $ S�, Uo Page 2 of 2 72-026 (1184) p,e; a c /Y CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 rf Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY ❑ PUBLIC WATER SYSTEM I.D.# I I I q I sis shows this Water SAMPLE to be: PRIVATE WATER SYSTEM &► OL.LQ(n5 Name Phone No. Qo,3QX- 4-919 Mailing Address cc f e 2lu e --ii' City I State Zip Code SAMPLE DATE: ( t7I I? I S Mo. Day Year SAMPLE TYPE: la' Routine ❑ Check Sample (for routine sample with lab ref. no. 1 ❑ Treated Water ❑ Special Purpose ❑ Untreated Water SAMPLE Time Collected NO. LOCATION Collected By 1 1 LG 3 Ql��t'wo�c� 4(aee' I : ao C°e3 2 I 3 I 4 5 1 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE na y 4 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 Received kf- Time Received lY:Ol? c„k Analytical Method: Membrane Filter * No. of colonies/100 ml. Lab Ref. No. Result* Analyst K� FT] m I ED BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter. Direct Count Verification: LTB Final Membrane Filter R sults el Reported By TNTC = Too Numberous To Count OB = Other Bacteria BGB Date Time: Coflform1100ml Cj ilform/100m1 J l a.m. p.m.