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Home My WebLink AboutALPINE TERRACE BLK 1 LT 4Alp ine Terrace Block 1 Lot 4 #015-243-28 kATru MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME `�ANnii� i�E+ALLt PPHO/N�E-/ �i`1�1•• 1Ok1f ❑ NEW QUPGRADE MAILING ADDRESS - `®Q ©� N � ��C�IJ 11IlI'1 rC! LEGAL DESCRIPTION n LOCATION �EQSES t�1 A � TERRAC.E OR\VE Rrt' �� NO. OF BEDROOMS � VY DISTANCE TO: Well Absorption area Dwelling PERMIT NO. ®� . 40T 9) P ZZ W� Manufacturer Material ` No. of compartments w Liq. capacity in gallons © IF HOMEMADE:0 Inside length 1A Width MIA Liquid depth + 0 C Z DISTANCE TO: ell Dwelling PERMIT NO. _ FQ- Manufacturer Material Liquid capacity in gallons W= DISTANCE TO: Well Foundation Nearest lot line PERMIT NO. LU LL Z F Z W No. of lines Length of each line Total length of I% Trench width `3 inches Distance between lines Ill C Top of tile to finish grade (t Material beneath tile 0 inches Total effective absor `tion ar a pe W Length Width Depth PERMIT NO. a F Wa WWell W Type of crib i a er T ff iv ab rption area Building foundation Nearest lot line DISTANCE TO: J Class Depth Driller Distance to lot line PERMIT NO. WBuilding r DISTANCE TO: foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS N SOIL TEST RATING .}— 1 INSTALLER O '6 'rC� REMARKS ut VE ct to n An of- wpb +111411j&t= Fm"em P a A ED DATE LEGAL 'N� k\1 72-013 (Rev. 3/78) � �� Cl F=' n �� ' DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION . 825 'L' STREET, ANCHORAGE, HK. 99501 264-4720 #:3 r-4 I �L-A EF_ F_* k-1 F=l IZEi F-"- 1=4 F---- FEE F::"F- Kr -1 'u PERMIT NO. ( 780636 ) APPLICANT DYHNMIC REALITY 501 W. N. LTS. 279-7611 LOCATION LEGAL LT.4 BLK1 ALPINE TERRACE S/D LOT SIZE 0 SQUARE FEET TYPE OF SOIL HBSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT/BR)= 85 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: L's F=- F� -T ;a* ��EE: I C. -a F—;:"F=;"-lF CE- THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCHYHTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET) ��C-I LJ I F;;:,- F=- E-A :F. E: F=, -F 11 �r-4 I---- :E. 11 !T* C:-:# 921 C-3 Fl L_ I ci r4fF. ^ ` PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. I " *EF. F:" r-4 F E: F�� BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND -APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND ANY'ON-SITE SEWAGE DISPOSAL SYSTEM 15 100 FEET FOR H PRIVATE WELL/ OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. * -F FrXF=' It F;-:-F=:E-. E-_'-F=!=-F_7ME3F_=Fe , I CERTIFY THAT 1: I HM 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. ]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED:- APPLICANT ALITY ------------ ' ISSUED B _____DHTE__{�'��-��-�L_ \'V] 2 GREs_ _ _R ANCHORAGE AREA BOA GH Department of Environmental Quality W 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAM�A) WKWs��a MAILING ADDRESS �• 'ax "�Z/DS PHONE LOCATION C� �7iSive LEGAL DESCRIPTION SEPTIC TANK: DISTANCE i C�� NUMBER OF FROM WELL/O_d ANUFACTURER O%'p�r� MATERIAL �L COMPARTMENTS INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY /000 GALLONS. SEEPAGE PIT: / NUMBER OF PITS DIAMETER OR WIDTH �Z, LENGTH _z? DEPTH LINING MATERIAL (76 L �"CRII! SIZE: DIAMETER DEPTH DISTANCE FROM: WELL W. i TOTAL EFFECTIVE BUILDING FOUNDATION3z NEAREST LOT LINE ABSORPTION AREA (WALL AREA) �spl� SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE `Va�/ !w CONSTRUCTION BUILDING NEAREST FOUNDATION, LOT LINE CESSPOOL OTHER SOURCES NEAREST SEWER LINE APPROVED DISAPPROVED REMARKS DISTANCES: INSTALLED BY:L� PIPE MATERIAL: C/1VS� TOa� LOT SLOPE: p� REMARKS: o a -So'/ Form No. EQ -031 DEPTH SEPTIC TANK_ DIAGRAM OF SYSTEM S";> AJ(e Lo �-eir _30 v Gives DISTANCE FROM: SEEPAGE SYSTEM 5,v�iC_ DATE S Z. 3 APPROVED yl. G.A.A.B. C'/15po but lb,/ GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO 3330 "C" STREET ANCHORAGE, ALASKA 99503 f TELEPHONE 274-4561 3 � SEWAGE DISPOSAL SYSTEM - APPLICATION AND PERMIT NAME OF APPLICANT -o MAILING ADDRESS �" 2if)`S J PHONE INSTALLATION LOCATION LEGAL DESCRIPTION f/ INSTALLATION OF: SEPTIC TANK SEEPAGE PIT ,., �I� DRAIN +/ FIELD OTHER TYPE AND SIZE OF FACILITY TO BE SERVED 3 �-�•� Aw�r— &� FINANCED THROUGH LU (�9 TO BE INSTALLED BY v�v �'V-• n r17 c� 27 I SOIL TEST RESULTS o S ^ , -NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED M? ..P%! /73 –• FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE /000 TYPE` - S AZZO SEEPAGE AREA SIZE 12 x / 2 n 6 TYPE ems' ©AU �A(,.QQ�� 1el �B9LG�/iR,��'�•,�o MINIMUM DISTANCES, REQUIREMENTS �&"iDIAGRAAM/O� SYSTEM 4— / FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL '..� SEPTIC TANK 16 , SEEPAGE PIT 8 DRAIN FIELD _ TO NEAREST LOT LINE. WELL TO SEPTIC TANK /00 SEEPAGE PIT /00 —. DRAIN FIELD ALSO CONSIDER AREA WELLS. h / WATER MAIN TO SEPTIC TANK /y SEEPAGE PIT /0 ' DRAIN FIELD / U SEPTIC TANK, 2 S SEEPAGE PIT 0 4 DRAIN FIELD — TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. l vu uI e. G.A.A.B. OR LICENSED DESIGNER I CERTIFY THAT 1 AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE S—�LzZx/ APPLICANT'S SIGNATURE FORM NO. EQ -016 LIL R/ GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTA QUALITY 3330 "C" Street ANCHORAGE, ALASKA 9950 - Case # Performed For 4�- Dated Performed Legal Descripti n: Lot Block / Subdivision This Form Reports Soils Log Percolation Test - Soil Test Must Be Logged To 4' Below Proposed Seepage System - Depth Feet Soil Characteristics 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 11 — 12- 13- 14— Was Ground Water Encountered? LA) If Yes, At What Depth? J� - J I—J—J--j Reading Date Gross Time Net Time j` Depth to H2O Net Drop I Rate Minu-('-'e Percolation Proposed Installaticn: Scagr, Pit Drain Field Depth of Inl et ^ _ D�u,t th to Bottom of Pit or TrencFi COMMENTS: Test Performed BY kla- �- � sz.e� DateCertified BY: GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY Case # 3330 "C" Street ANCHORAGE, ALASKA 99503 Performed For '7n -L Dated Performed ,� ?3 Legal Description: Lot ockSubdivision /,,�e 7e7o-ra--•-e._ This Form Reports Soils Log Percolation Test - Soil Test Must Be Logged To 4' Below Proposed Seepage System - Depth Feet Soil Characteristics 1-- 2- 3- 4- 5- 6- 7- 8- 9- 10- 11- 12- 13- 14— Was Ground Water Encountered? #() If Yes, At What Depth? Reading Date Gross Time Net Time Depth to H2O Net Drop Percolation Rate Minute Proposed Installation: Seepage Pit Drain Field Depth of Inlet Depth to Bottom o Pit or Trench— COMMENTS : ?-5 7 ibCk A// /t-) 0t, �� :K'�� Gt( �-"b Test Performed BY S= Date Certified BY: Date Municipality of Anchorage. O• ` 1C Development Services Department r u Building Safety Division On -Site Water 8 Wastewater Program flStreet ) P.O. Box 196650 t1✓^tr��,�✓l) Anchoraora gee,, AK AK 9 99519.6650 www.muni.org/onsite 1 (907) 343-7904 .Ar,�' CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-aL43-.7,8 COSA# D Ory 1. GENERAL INFORMATION Expiration Date: Complete legal description ALPINE TERRACE SUBDMSION: LOT 4, BLOCK 1 Location (site address) 7601 SOLDOTNA DRIVE • ANCHORAGE. AK 99507 Current Property owner(s) DULCY BOEHLE Day phone 345-1882 Mailing address Lending agency Mailing address Real Estate Agent 7601 SOLDOTNA DRIVE • ANCHORAGE. AK 99507 Day phone DEAN O'MALLEY w/ NOVA PROPERTY MANAGEMENT Day phone 229-2014 Mailing address 8340 RAINY PLACE • ANCHORAGE. AK 99518 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well N Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site 0 Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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 samples. (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 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. 1 further verify that based on the Information obtained from the Municipality of Anchorage riles 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. Date Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines 8 Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily )dentifiablo features. The operational life of all wells and septic systems depend on the local soils condition, groundwater 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 the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE V Approved for --q-- bedrooms. 337-6179 re /Zo /O-? Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory V Arsenic Advisory Maintenance Agreements Supplemental Engineer's Reort Nitrate Advisory Other By: GL/ (ae.. 11105) k�cY J.• •�• aei ON-SITE ' 17iG1: WATER AND : WASTEWATER : PROGRAM Lj Original Certificate Date:8� a 82 O % l Municipality of Anchorage • Development Services Department Building Safety Division + On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage. AK 99519-8850 ' www.muni.orglonsite (907) 343-7904 i CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: ALPINE TERRACE SUBDIVISION: LOT 4, BLOCK 1 Parcel ID: O /5- % Y 3-2 S A. WELL DATA *SEE ATTACHED KEN JOHNSON WELL INSPECTION Well type PRIVATE if A. B, or C provide PWSID# N/A Date completed 1973 Sanitary seal (Y/N) YES Total depth '36 ft. Cased to '36 ft. FROM WELL LOG Date of test Static water level _ ft. Well production —9 -P.M. WATER SAMPLE RESULTS: Coliform 0 colonies/100 ml. Nitrate 4.54 mgA. Well Log (Y/N) NO Wires property protected (Y/N) YES Casing height (above ground) 12+ in. AT INSPECTION 8/7/2007 22 ft. 7.16 g.p.m. Other bacteria 0 coloniesM00 ml. c ,Arsenic: ND ug./L. Date of sample: 8/7/2007 Collected by: GEG Ltd. B. SEPTICYHOLDING TANK DATA 5/24/1973 Tank Type/Material SEPTIC/STEEL Date installed 8/11/1978 1000 Tank size gal. Number of Compartments 1 1 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (YIN) N/A Date of pumping 8/1/2007 Pumper McDONALD'S PUMPING C. ABSORPTION FIELD DATA 5/24/1973 / SEEPAGE PIT/ Date installed 8/11/1975 Soil rating (g.p.d./ftro<E�85 85 System type DEEP TRENCH Length 12/21 ft" Width 12/3 ft. Gravel below pipe 6/7 ft. •8.92/ Total depth •10-54 ft. Eff. absorption area 540 ft' Monitoring tube YES Depression over field NO Date of adequacy test 8/7/2007 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 30/31 in. Water added 623 gal. New depth 42/49.75 in. Elapsed Time: 150 min. Final fluid depth 29.25/37 in. Absorption rate >= 600+ g,p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date — D. LIFT STATION Date installed "Pump on" level at —in. E. SEPARATION DISTANCES Size in gallons "Pump oft Manhole/Access water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 50,+ 789 • On adjacent lots 100'+ Absorption field on lot 102' TO SEEPAGE PIT C/O On adjacent lots 100'+ Public sewer main N/A Sewer /septic service line 25'+ Animal containment areas 50'+ Public sewer manhole/cleanout N/A Holding tank N/A 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 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parkingivehicis storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots '97' F. COMMENTS X -d •SEE ATTACHED WAIVER, GRANTED 8/28/1985 So:- L.) 4 G. ENGINEER'S CERTIFICATION I certify that 1 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 JEFFREY A. GARNESS Date g IZo /vim COSA Fee $• 00 Waiver Fee $ Date of Payment. I -01 % I O 7 Date of Payment Receipt Number D (y 1 79 Receipt Number (Rev. 1 V05) 05/26/2007 19:34 907-3481-U893.1 PAGE 05 KEN JOHNSON DRILLING CO. WATER WELL DRILLING PUMP SALES AND SERVICE 44 Years Alaska Drilling (907) 243.2282 Tax I.D. w 92.0068950 KEN JOHNSON FAX (907) 2433852 3163 LINDEN DRIVE ANC RAGE, A SKA 99502 DATE NAME Dw IC. Botr� (e_ PHONE 3 4 s- IS SZ ADDRESS IJei2 I!;A T_A1 I ZIP gfi_g'I t - LOCATION BL �7� UBD. r PUMP DATA: HP�VOLTSZCPHLAMPS�MODE� Ge,�, J�Sd y -r7 -Z CONTROLS --� PUMP INTAKE DEPTH �!JK DROP PIPE SIZE TANK SIZE a TYPE a2Qb-�Lr FILTERS t TYPE v' WELL DATA: CAS SIZ DEPTH,.. WATIER LEVEL// -'GPM DD WELL S E PITLESS:TYPE � VELL - REMARKS: KEN JOHNSON CWD/PI NWWA CERTIFIED Y ' FROM Nova Property Management PHONE NO. : 907 344 2816 Aug. 18 2007 04:19PM P2 �Y P.9 iw ayr-oo ASBUILT-NO CORNERS SET THIS DATE. 1 ` , ti & ASSOCIATES LAND 1 HEREBY CERTIFY -THAT I HAVE SURVEYED THE SCALEt FOLLOWING DESCRIBED PROPERTY OF a4�� A�.oii✓E TE.�,n9cEs��c><ors,�ec�i DATE: r P� ......... AND THAT. NO ENCROACHMENTSIEXIST EXCEPT AS r INDICATED. IT IS THE RESPONSIBILITY OF THE � r V'..4 � S OWNER TO DETERMINE THE EXISTENCE OF ANY GRID: EASEMENTS, COVENANTS, OR RESTRICTIONS. •R WHICH DO NOT APPEAR ON THE RECORDED SUBDI• D...n. MIA 5-....d M VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB` ��', LS -6 ai ANY DATA HEREON BE USED FOR CONSTRUCTION-�7-,ro �f;�'a; •�/,�'•y��,� OF FENCE LINES, OR FOR ESTABLISHING BOUND- ARY LINES. DRAWN RADIUS AND THE 80 FOOT WELL RADIUS SHALL BE FLAGGED 3Y A REGISTERED LAND SURVEYOR PRIOR TO CONSTRUCTION. \ PONOING WATER \ 100 FOOT / \ CREEK SETBACK / \ EXISTING SEPTICTANKS �0•/� BE \ / COMPLETELY P� \ABANDONED CUTBANK. A 45' \ Or0Q WEAUEST KER TO THE \ •P� DRAINFlSELD. A Si„O o EXISTING 4 HOUSE EXISTING DRAINFl � TO BE COMPYLETEL ABANDONED O f�pR OJ / � / l ` INSTALL FOUNDATION \ CLEANOUT \ \ 0 FOOT LOT UNE - WAIVER REQUESTED PROPOSED 1500 GALLON FIBERGLASS ADVANTEX TREATMENT SYSTEM w/ PUMP -PROPOSEb DRVNFlEID. 9VATE A TRENCH THAT VAULT wC DUAL CHErVE. IF CRANKY IS 5.5 FEET DEEP MAXIMUM BY 7.5 FEET WIDE BY FLOW HE BEP VAULTO. D NOT 20 FEET LONG. ADD 2.5 FEET OF M.O.A. FILTER INSTALL THE PUMP VAULT AND INSTALL SAND AND 0.5 FEET OF CLEAN, WASHED SEWER DOUBLE VANTEXCLEANOSS AFTER THE DRAINROCK. THE DISTRIBUTION LINE IS TO BE 1.25 ADVANfEX' INCH PVC w/ I' HOLES SPACED 7 INCHES ON CENTER. (30 HOLES TOTAL) IF GRAVITY FLOW CAN BE ACHIEVED, THE DISTRIBUTION UNE IS TO BE 4 INCH PERFORATED PVC AND INSTALL CLEANOUTS ON EACH END OF DRAINFIELD.,, 11 4/14/2003 DRAWN BY: ALASKA WATER S WASTL«7ATER SCALE_ C.J.G. .--.____ CONSULTANTS, INC.4 6001 DF9AR0 ROAD. SUITE 74 • ANCHORAGE. AK 0050 • PNONF (907/}p.6179 • FAX (907)334-3766 11" - 30' PREPARED FOR: PHONE NUMBER: PAGE NUMBER: DULCY BOEHLE (907) 345-1882 2 OF 4 LEGAL DESCRIPTION: ALPINE TERRACE SUBDIVISION; LOT 4, BLOCK 1, DESIGN FOR PROPOSED SEPTIC SYSTEM UPGRADE A. GOmess,r -7953 2V�AS14CA NVATER & «'ASTENVAr TER .�. CONSULTANTS. INC.. ..� 6901 OEBARR ROAD. SORE 26 • AH-SOWGE. AK 92504 • PHONE: C207)3,37-6179 • FZ- 907 246 • WEdSnL SOIL LOG - PERCOLATION TEST LEGAL DESCRIPTION: ALPINE TERRACE SUBDIVISION; LOT 4. BLOCK 1 PERFORMED FOR: DULCY BOEHLE DATE: 4/2/2003 (feet ORGANICS TEST HOLE 1 t GM SOIL CLASSIFIC ATI ONS ORG ML CL OL MH CH OH GW- GP GM GC SW SP SM SC I ^J DS(EI pmj1NC0-- ```-• M11WI 2 12:08 I w5l 4 BEDROOM HOUSE 3 12:08 SW SP -SM SM/ML DEPTH TO GROUNDWATER DATE +13.5' 4/2/2003 7.5' 4/11/2003 12:07 DS(EI pmj1NC0-- ```-• SYSTEMr-E e ?✓ �• �..a.Kr....... 7953 --------------- ----------- _--T— NET TIME (MINUTES) WATER LEVEL READING NET DROP (INCHES) 4/2/2003 1 12:07 DS(EI pmj1NC0-- ```-• SYSTEMr-E 2 12:08 mr+c 0' 4 BEDROOM HOUSE 3 12:08 — 6' — 4 12:09 1 0. 1 5 12:09 SITE PLAN I TH/I / — -- 12:11 2 DATE READING CLOCK TIME NET TIME (MINUTES) WATER LEVEL READING NET DROP (INCHES) 4/2/2003 1 12:07 — 6" — 2 12:08 1 0' 6' 3 12:08 — 6' — 4 12:09 1 0. 6' 5 12:09 — 6. — 6 12:11 2 0' 6' 7 12:11 — 6' — 8 12:13 2 0' 6- 9 12:13 — 6. — 10 12:15 2 0' 6' 11 12:15 — 6- 12 12:17 2 0" 6' :90 PERCOLATION RATE <1 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES) TEST RUN BETWEEN 5 FT. AND 5.5 FT. A FOUR HOUR PRESOAK WAS PERFORMED: ❑ YES ® NO SOILS LOGGED BY: JEFFREY A CARNESS PERCOLATION TEST PERFORMED BY: MATT FISHER COMMENTS: *BELIEVED TO BE MIGRATING EFFLUENT FROM THE EXISTING SEEPAGE PIT PERFORMED BY AKWWC, INC. I, JEFFREY A. GARNESS, CERTIFY THAT THIS AS ERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEUNES IN EFFECT ON THIS DATE: 1 06/02/2007 19:00 907-348-8931 :!`rl��►�e� 1er✓a� A P -K4,14( ?z IQ5 S//41O-7 7 PAGE 03 jC l/V e l(115 etmkvr q � i L h Z C a n E ° ' g CJ o u u G f0 p„ C C.C. r / L n O c j 5 0 Qar 0.� C CS v, E U f. ca 4. _ E I IT MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES A HIM Division of Environmental Services An 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�- �i+�� HAA# WQ6�")Ci 039, 1. GENERAL INFORMATION Complete legal description LoT 4 QLK h ALPINE TERRACE Location (site address or directions) 7601 SOL DOTNA DIRWE AtgcOoRAGE, A Mite Property owner GREG WALKER Day phone 3.f S- 7559 Mailing address SAME Lending agency C IT`( MQ&TG4GE Day phone 277-0700 Mailing address 121 WES 7 FIRE4/9E D A-nGA 9` IM 3 Agent Nand Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well L__� 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 NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm FLATTOP TECO SVCS Phone 3 45` 13 SS - Address 14530 ECHO ST- , AXC14 A -j-, 195/6 Engineer's signature T2�1 L" 11<94' 1f . Date U -41^d-9; J993 77ff +d _ P �THcODO?c F, r.100f:E � r� 0509 6. DHHS SIGNATURE —A— Approved for bedrooms. Disapproved. Conditional approval for Additional Comments By: bedrooms, with the following stipulations: Date7— 2 2 - & The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA 4121 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT y sj* I ALPINE TERRACE Parcel I.D. A. WELL DATA Well type PRWATE If A, B, or C, attach ADEC letter. ADEC water system number Log present(Y/N) Date completed 1913 Driller GCn k Total depth yOr-N6' ocr 1973 ItAA Cased to 20' -29' Casing height Sanitary seal (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level Wires properly protected (Y/N) T SEPARATION DISTANCES FROM WELL TO: -716' To Ftasr ((&00 «1) Septic/holding tank on lot 89' To :5 Comb (std' ►) ; On adjacent lots } 1co � Absorption field on lot los' To C.o. ; On adjacent lots foo' to C.0. Public sewer main N, A. Public sewer manhole/cleanout N.A' Sewer service line ("0, Petroleum tank NoNe o135ERVC: b � Wa t ver r;a uc o4 9/Z&/8S- WATER '/26/8SWATER SAMPLE RESULTS: Coliform O col -1 /C>U rrht Nitrate 2.91 M% Le Other bacteria O Col //Go �+.0 Date of sample: -S11'1 %9 3 Collected by: FeATToP TECH Svc S B. SEPTIC/HOLDING TANK DATA s11 1 83 Io00 r.44 Soy 6Ac Com 1 ,ns/��o) Date installed Q1t� /7R Tank size Compartments —2� � Cleanouts (Y/N) Foundation cleanout (Y/N) Y Depression (Y/N) N High water alarm (Y/N) N.A. Alarm tested (Y/N) N- A Date of pumping T/4193 Pumper RbTo '1000TCR SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: 76' FieoM moo GAL Wells) on lot 89' FRoM soc 6AL On adjacent lots > 100 r Foundation (o F-eom C• 0, To property line �' 30' Absorption field C.O. Water main/service line Surface water/drainage > too, 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE MUNICIPALITY OF ANCHORAGE AT INSPECTWWRONMENTAL SERVICES DIVISION 5/11/13 'UN 10 1993 t3 # 7.1 EC,IVED g.p.m. > P. > 21r SEPARATION DISTANCES FROM WELL TO: -716' To Ftasr ((&00 «1) Septic/holding tank on lot 89' To :5 Comb (std' ►) ; On adjacent lots } 1co � Absorption field on lot los' To C.o. ; On adjacent lots foo' to C.0. Public sewer main N, A. Public sewer manhole/cleanout N.A' Sewer service line ("0, Petroleum tank NoNe o135ERVC: b � Wa t ver r;a uc o4 9/Z&/8S- WATER '/26/8SWATER SAMPLE RESULTS: Coliform O col -1 /C>U rrht Nitrate 2.91 M% Le Other bacteria O Col //Go �+.0 Date of sample: -S11'1 %9 3 Collected by: FeATToP TECH Svc S B. SEPTIC/HOLDING TANK DATA s11 1 83 Io00 r.44 Soy 6Ac Com 1 ,ns/��o) Date installed Q1t� /7R Tank size Compartments —2� � Cleanouts (Y/N) Foundation cleanout (Y/N) Y Depression (Y/N) N High water alarm (Y/N) N.A. Alarm tested (Y/N) N- A Date of pumping T/4193 Pumper RbTo '1000TCR SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: 76' FieoM moo GAL Wells) on lot 89' FRoM soc 6AL On adjacent lots > 100 r Foundation (o F-eom C• 0, To property line �' 30' Absorption field C.O. Water main/service line Surface water/drainage > too, 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION N. A.. Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA "Pump off" level at Cycles tested Surface water _ .5/2y1 -Z3 SLeFAGE PIT c' SEs1°AEE Pir Date installed 911(( 7S IREK0 Soil rating 8S �BpRM System type AND -rRfnitN S.PIT 12KI2K(o'Df6P u 1 ! Length lk*mc11 21' Width IRE110 32 Gravel thickness -7 Total depth (3 PIT TREµti 'tort AL Total absorption area 2SS 4 29y = 582 Cleanouts present (Y/N) Y Depression over field (Y/N) N Date of adequacy test 5//7 A3 Results (pass/fail) Pass for I bedrooms Peroxide treatment (past 12 months) (Y/N) HONE KNOwrt of If yes, give date NA SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 105' To C.0 • On adjacent lots-* 97' Property line To building foundation 38FRan C.a. To existing or abandoned system on lot N.A• On adjacent lots So Cutbank s. A • Water main/service line 40 Surface water > too' Driveway, parking/vehicle storage area 30' Curtain drain Noun OMERVE'D * ;* U/ctlrer ►7eedaod (see afFxcAec( ✓'ifl'40) E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature L&5. -e - 11% M.4-� Engineer's Name Th ev,56- -e F. HO 01"e Date 7""e- 9, 199 3 HAA Fee $ 170 " Date of Payment 6-16-23 Receipt Number -24778 3 72-026 (Rev. 3/91) Back MOA 21 .01F A�. 0 • . 9TH � 04104041%too* **%,IV**eo*..; 6.t s THEODORE F. AACORE rn • •. CE - 358? ly Air o' O Waiver Fee: $ Date of Payment - �- Receipt Number Munic.,pality of Anch )rage aw Department of Health and Human Services Tom Fink, 825 "L" Street Mayor P.O. Box, 196650 Anchorage, Alaska 99519-6650 343-4744 July 15, 1993 Ted Moore, P.E. Flattop Technical Services 14530 Echo Street Anchorage, Alaska 99516 Subject: Waiver Request for Lot 4 Block 1 Alpine Terrace S/D Waiver Request #WR930032, PID #015-243-38, HA930298 Dear Mr. Moore: Your request for waiver(s) of the required 100 foot horizontal separation of a septic system to a private well has been approved. The approved separation distance(s) are the leachfield on Lot 4 Block 1 to the well located on Lot 4 Block 1 Alpine Terrace Subdivision of 97 feet. This waiver approval applies to the existing septic system to well separation only. Any future upgrade to either will require all separation distances be met or another approval from this department. Sincerely, Daniel J. Roth Civil Engineer On-site Services ljm:#6 Concur: Jroghn Sm' h, P.E. ram Manager On-site Services ' - ., o c- 'tet r 'IUNICIPALIT`' OF _:NCHORAGE Department of Health ndr_uman Services On-site Services Section Waiver Review 11%orksheet w R # PID# HA4 Permit Date Received: June 10, 1993 Legal Description: _ Lot 4 Block 1 Alpine Terrace Subdivision Engineer: Ted Moore, P.E., Flattop Technical Services 14530 Echo Street, Anchorage, Alaska 99516 Applicant: Greg Walker Waiver Requested: Lot 4 Block 1 Alpine Terrace leachfield to the well on Lot 5 Block 1 Alpine Terrace of 97 feet. Criteria: 1. Geology: A. Water Table B. Soil Sorption C. Permeability. D. Water Table Gradient E. IIorizontal Separation TOTAL: 2. Special Conditions: 3. Other: Points: Waiver is Granted: Waiver is NOT Granted: List Conditions or Reasons for above: Date: By. Name of Reviewer Rec #: 24778/8358 Amount: $ 590.00 Date Paid: June 10, 1993 To Whom it May Concern: The undersigned are property owners of Blk. 1, Lot 5, Alpine Terrace subdivision, next to Renee and Greg Walker, who own Blk. 1, Lot 4. The septic system on the Walker property is located 97 feet upward of our water well, 3 feet short of the required 100 feet. To date, this has not caused a problem and we don't expect that it will in the future. For this reason we do not object to the 3 foot shortfall. However, we reserve the right for retribution and remedy should it become a problem in the future. Edward P. Nelson Notary Public My commission expires: A--PN006 Ethel H. Nelson Notary Public My commission expires: I rHE !..IEEE IA., 4uFsr/,qA, o,v Lar S W&s PRIllfp /Q'7/ r"XRE IS NO LOG AvA11.RE4.4 FOR TAOf wEGL, ri-fEAoe A buA(at OF U✓ F_ L L t 1065 1N TK F Iqnf k/?1P10c,,vpl-.6 AXFA. TK,EJE pP-tI L 0&,S /A/PfCHrEA vE12Y CeNslsrEtiT Sz-leAr/F1cmrloti oF S O1LS 86NEH.7-h/ T[-lE .ruR.ps}CE OF T/`CE 6RoNivD Ct,vT"t AAI 610PARE.,,7- COA-'F1tiEP 4t?WlF6A ftr AppRox�rl�►rEcy' SO' Is FuCOWAIMCPEA TINA 15 +PPRoxir,rrTEce 3S-'oF SILTY 6R,19►vELf � rnA,AoJ rR,4r NgvE ,vo L -A7 mA,rR LAYER 4r (o ¢ ' of 54,vp6RAviL 4 t�-i4TER !s AA160 awreREd rkIj Iv/4TE R )i- /`lI*NY of 77.ff �''}i 1PEA wE Ltj r/HE,v RIfEJ AP)OiPcXi m. -97 -ELY SO' IN TrfE C#S/.vGJ r0 geove rltE TDP of rl-eE CAfIX-j /A-,PIC#TIAG TH C Agt"IFER Ij uabER PRO' 'fu1P,E. fW Pu1PID1F5 OF P01,vT MERE IS A w8cl- L 06 *A1 LOT $LK I +LPIAE rERl?*CE IvN1CH IS NExr PooR ro 7uE /-or 9fPL.r1Ab FOR TILIIS I-141vEI? AND rW0 t Orf AwA y PROM TkF !„EGL IA., QuIf r/OR'. IlElt SRMPICf 4'F i¢REA D -ELL IN 7-1l,6 fN/YEl9/,ATE 19REo9 OF PeE G,-Ccc 1N Z? UCf r10,- ItiDiCR r ND B,#LT,EI4r/J ,g,#o A/I7'I?f+TET O f S kgro c r -ELL 2. # ,w,/f R�-P rwG oruE?s 3. 3 o, '.5f /. 9 ». f' /f IA., Ti-cE AR E q AR E CIV69R OzwA p 4A J9 *-f P-19 w/ DF. S. A. �`. C. S. W 6. OF Fay S. R. D. PO/ NT W4T-ER TThBtE sEpric i4iroArrivA1 rneA ew ow t or ¢ A/pgnr. /4 DEEP . AQWIFER AT �¢� y0�sEOARAiT�oN � � /D ,Y=.22*5- 37.2— OIL, .2 0IL SAR877OA/ r o f HO) s v 6= 3.6 00 I I tERH,=A A-) Ti ay. o t o �.s+01-0)(s )3 ( / IA) A DE R TA &E (RgVj Lov t>eol fEnt C. tr�w tO,p�FE�E�t V t �. e LO,RI20,vrl4L S EPAR,9 rlOV 97' 2. 9 619,1tN0 7,61TAL /4, � � 0 (1,14:5-10 Al R N r G09/VER .� LA3P-9SOL) 3D q 6a 9 CIVIL & ENVIRONMENTAL ENGINEERING • ENERGY CONSERVATION & ANALYSIS THEODORE F. MOORE, P.E. PH: (907) 345-1355 M.O.A. DHHS Attn: Dan Roth or John Smith P.O. Box 19-6650 Anchorage, AK 99519 July 22, 1993 14530 ECHO ST. R E C E I ��RAGE, ALASKA 99516 J U L 2 2 1993 Municipality of Anchorage Dept. Health & Human Services RE: Waiver request dated 6/9/93 allowing 97' separation between wastewater disposal system on L4, B 1, Alpine Terrace and private well on L5, B 1, Alpine Terrace S/D Dear Sirs: The following is the report you requested regarding the "non -conforming" wellhead you observed during your site inspection of the well on L5, Bl, Alpine Terrace. On the basis of our field inspections and follow-up discussions with the property owner, we have determined that the visquene you observed wrapped around the lower portion of the well casing is part of a slip collar. This was installed several years ago to eliminate a prior problem with frost jacking the well casing up and shearing off the waterline at the pitless adapter. The collar was constructed by excavating around the well casing to a depth of approximately 8 feet and wrapping the casing with a couple of layers of folded "visquene". Vertical strips of 1.5" thick burial type "Insulfoam" insulation were then fitted around the casing, and the "visquene" was folded back down over the outside of the insulation. The top of the "visquene" was taped to the well casing to prevent the possibility of water infiltration inside the collar. Finally, a stovepipe type aluminum collar was installed around the well casing above the top of the insulation for further water protection. I am not aware of any code violations created by this slip collar. Secondly, per your requirement, we have installed a new well seal and flexible watertight conduit surrounding the aboveground portion of the wires leading into the well casing. I trust that the information contained in this report will be sufficient for you to proceed with issuance of the requested waiver. Sincerely, Ted Moore, P.E. cc: Greg and Renee Walker CIVIL & ENVIRONMENTAL ENGINEERING • ENERGY CONSERVATION & ANALYSIS THEODORE F. MOORE, P.E. PH: (907) 345-1355 June 9, 1993 M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: 14530 ECHO ST. ANCHORAGE, ALASKA 99516 By means of this letter we are requesting issuance of a separation distance waiver allowing the existing wastewater disposal system on Lot 4, Block 1, Alpine Terrace S/D to be 97 feet from the existing private well on Lot 5, Block 1, Alpine Terrace S/D. A site plan, water sample test results and copies of other relevant documents from DHHS isles are enclosed to assist you in your review. There are no driller's logs on file for the wells on either of these two lots, however the enclosed log for the well on Lot 5, Block 4, Alpine Terrace (located approximately 600 feet to the southeast) appears to be similar in most respects. According to records on file at DHHS, the well on Lot 5, Block 1 was drilled at least as early as June of 1971. On May 19, 1993 we collected water samples from this well and measured the static water level to be at 6 feet below the top of the 3 foot high casing, with a total well depth of 52 feet below the top of the casing. The water sample test results were satisfactory, showing no coliform or other bacteria per 100 ml., and 2.45 mg/1 of nitrate -N. In our opinion, this moderate nitrate level does not indicate the presence of septic contamination, since it is a typical background level for this area. This measured nitrate level is similar to the 2.91 mg/l reported for a sample collected from the well on Lot 4, Block 1 on 5/17/93, 1.9 mg/l reported for a sample collected from the well on Lot 8A, Blk 4 on 4/24/92, and 3.3 mg/l reported for a sample collected from the well on Lot 7, Block 3 on 6/18/92 (copies of lab reports enclosed). According to records on file at DHHS the wastewater disposal system serving the residence on Lot 4, Block 3 was originally installed in May of 1973 and consisted of a 1000 gallon septic tank followed by a concrete ring seepage pit, which was reported to be 108 feet from the neighbor's well. The original septic tank is only 76 feet from the well on Lot 4, but this was a legal separation distance at the time. In August of 1978 the system was upgraded to 4 bedroom capacity by the addition of a 500 gallon septic tank between the original septic tank and the pit, and by the addition of a 21 foot long soil absorption trench containing 7 feet of sewer gravel extending in a northwesterly direction away from the seepage pit. The Municipal inspector apparently failed to recognize that the new septic tank was only 89 feet from the Lot 4, well instead of the 100 feet which was then required. A 1985 adequacy test by our firm revealed that discrepancy, and a well -septic tank waiver was issued on 8/28/85 (copy enclosed). In conjunction with a new adequacy test conducted on 5/17/93, which now requires that the separation distance to wells on surrounding lots be measured, we discovered that the sump at the end of the 1985 soil absorption trench extension is 98 feet from the well on Lot 5. This discrepancy was also apparently not noticed by either the contractor or the Municipal employee who inspected the system during construction. The present waiver request is for 97 feet to allow for a possible underground projection of the trench slightly closer towards the well. At the start of our 5/17/93 adequacy test, the fluid level in the sump at the end of the trench was 7.5 feet below ground level. We were able to add a total of 836 gallons of water to the system within a 2 hour period without causing the system to become surcharged. As water was being added directly into the sump at the end of the trench, the fluid level in the sump rose 1.5 feet to the level of the horizontal distribution pipe but no further. Once the flow of water was stopped, the fluid level in the sump receded to within 0.25 feet above its original position within less than two hours. Based on this observed behavior, we concluded that the system continues to be able to absorb water at an adequate rate for a 4 bedroom residence. The topography in this area slopes generally down from the southeast to the northwest towards Little Campbell Creek. Although the ground elevation in the vicinity of the well on Lot 5 is approximately 10 feet lower than the ground elevation in the vicinity of the trench on Lot 4, the slope is such that any effluent daylighting from the trench should it fail would not tend to flow towards the well. The soils log for Lot 4 indicates that the system is constructed in GW material, with no groundwater encountered. The soils log for Lot 5 also shows no groundwater to a depth of 16 feet. The well log for L5, B4 indicates sand and gravel to a depth of 20 feet, with hardpan and clay between 20 and 41 feet. Since the subject well on L5, B 1 has a total measured depth of 49 feet BGL, it is assumed that the aquifer was encountered in the vicinity of 47 feet. The fact that the static water level is 3 feet BGL indicates that the aquifer is confined and artesian, which means that there is virtually no potential for contaminants originating in the vicinity of the well to make their way into the aquifer being drawn upon by the well. The following is a possible assignment of waiver analysis points using D.E.C.'s 1985 "Separation Distance Waiver Guidelines for SCRO". Category Points Vertical distance to aquifer (47' - 13' = 34') 4.4 Soil sorption (7 x 0) + (21 x 3.5) + (6 x 1.5)/34 = Permeability (7 x 1) + (21 x 3) + (6 x 1.5)/34 = 2.43 2.32 Water table gradient (down towards creek - assume 0% towards well) 2.9 Horizontal segU.on:: Total 14.93 Based on this point assignment, the SCRO guidelines would indicate that no bacteriological pollution is possible and that chemical pollution is unlikely. When this is coupled with the facts that the aquifer appears to be confined and artesian, the water samples indicate no bacteriological contamination and background nitrate levels, and the deviation from the required standard of 100 feet is extremely small, we feel that the requested waiver can and should be granted. Please give me a call if you have any questions on this waiver request. Sincerely, Or ,J Ted Moore, P.E. cc: Greg and Renee Walker O SE PVC- 5YSTEM APPRot. LOCAT'o14 O Flattop Technical Services 14530 Echo Street Anchorage, Alaska 9()r,, 05�i • e ., , • e 011 THEODORE F. MOORE�j CE - 3589 #,rte,••.....• 4r 5& PTI C SYSTE r I -C,7' 7, B 1,&C k- if LOT 4 BLK I , ALPINE -TERRA SCALE: ("=5c)/ NOTE. THIS IS N 'DATE'. s A SURVEYED P1,. �q 3 ALL LOCATIONS D wN PY : ARE 4PPROYCl MAT. COMMERCIAL TESTING & ENGINEERING CO. y� b ENVIRONMENTAL LABORATORY SERVICES SINCE 1508 Chemlab Ref.# :93.22$3-1 Client Sample ID :L5 B1 ALPINE'rERRACE Matrix :WATER Client Name :FLATTOP TECHNICAL SRV Ordered By :T.F. MOORE Project Name Project# PWSID :UA REPORT of ANALYSIS 5633 8 STREET 9518 SOUTH HOSE Fill ANCHORAGE, AK 9 TEL: (907) 562-23432343 FAX: (907) 561-5301 WORK. Order :66235 Report Completed :05/25/93 Collected :05/19/93 @ 11:15 hrs. Received :05/19/93 @ 16:00 hrs. Technical Director :SP C. EDE Released By :_w- _. Sample Remarks: ROUTINE SAMPLE COLLECTED BY: T.F. MOORE. QC Allowable Ext. Anal [parameter Results Qual. Units Method Limits Date Date Init ----------------------------- --------------_-----I--------------.._- Nitrate -IN 2.95 mg/I. EPA 353.2/300.0 10 05/211 LLH See -Special Instructions Above--^-____________________ _ UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT .,ess Than D = Secondary dilution. GT = Greater Than Ife��" BGS Member of the SGS Group (Societe Generale de Surveillance) ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA COMMERCIAL TESTING & ENGINEERING CO. AK DIV ALA®rCHEMICAL & GEOLOGICAL LABORATORY MC ATORY TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER ❑ PUBLIC WATER SYSTEM I.D. # © PRIVATE WATER SYSTEM r— (a ere 30--/3f� Name Phone No. 1 YtS3 0 &.c ly Sf- Mailing Address AA c A or C8y state Zip Code SAMPLE DATE: LTJ L L1J L.Ll� Mo. Day Year SAMPLE TYPE: G� Routine ❑ Check Sample (for routine sample with lab ref. no. } ❑ Treated Water ❑ Special Purpose ER Untreated Water SAMPLE Time Collected No. LOCATION Collected By 1 I G.5 L71, A (p i4 e . Te rm c e (l : iy ,�,-►��7n 2 3 4 5 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: Satisfactory ❑ Unsatisfactory ❑ Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received J // � Time Received 1 �o1910 Analytical Method: Membrane Filter ` No. of colonies/100 ml. Lab Ref. No. Result' 93.2233 — Z BACTERIOLOGICAL WATER ANALYSIS RECORD Analys Membrane Filter: Direct Count O Coliform/100 ml Verification: LSB Fecal Coliform Confirmation BGB Final Membrane Filte esuitsgColiform/100 ml Reported By G� Date �- 2 ^ < TNTC = Too Numerous To Count Time: /GO C-) a.m. OB =Other Bacteria BART ONE OF TWO r��SGS Member of the SGS Group (So REMAINDER TO FOLLOW ZLABORATORY CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANALYSIS RESULTS for INVOICE It 54984 Chemlab Ref.# 92.2902 Sample I 1 Matrix: WATER Client Sample ID L7 B3 ALPINE TERRACE NORTH HOSE BIB PWSID UA Collected @ hrs. Received JUN 18 92 @ 12:30 hrs. Preserved with AS REQUIRED Analysis Completed : JUN 20 92 Laboratory Supe ie r EPHEN C. EDE Released By e-, Client Name :FLATTOP TECHNICAL SRV Client Acct :FLATTOT BPO# PO# :NONE RECEIVED Req# Ordered By :TED MOORE Send Reports to: 1)FLATTOP TECHNICAL SRV 2) .................................................................................................................................... Parameter Results Units Method Allowable Limits ------------------------------------------------------------------------------------------------------------------------------------ NITRATE-N 3.3 mg/l EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: UA. NO TAG FOR THIS SAMPLE. Remarks: .................................................................................................................................... 1 Tests Performed See Special Instructions Above UA -Unavailable ND- None Detected See Sample Remarks Above NA- Not Analyzed LT -Less Than, GT -Greater Than rvN S13S Member of the SGS Group (Socidtd Gdndrale de Surveillance) CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. LASORATO RY 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 Client Sample ID L8A B4 ALPINE TERRACE PWSID UA Collected E hrs. Received APR 24 92 E 14:30 hrs. Preserved with AS REQUIRED Analysis Completed APR 27 92 Laboratory Supe vie r STEPHEN C. ED Released By : to 1e— ANALYSIS RESULTS for INVOICE # 53144 Chemlab Ref.# 92.1738 Sample # 5 Matrix: WATER Client Name :FLATTOP TECHNICAL SAV Client Acct :FLATTOT BPO# POS :NONE RECEIVED Req# Ordered By :TED MOORE Send Reports to: 1)FLATTOP TECHNICAL SRV 2) ..................................................................................................................................._ Parameter Results Units Method Allowable Limits ----------------------------------------------------------------------------------------------------------------------------------- NITRATE-N 1.9 mg/1 EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: UA. NO TAG FOR THIS SAMPLE. Remarks: ----------------------------------------------------------------------------------------------------------------------------_ 1 Tests Performed See Special Instructions Above UA -Unavailable ND- None Detected See Sample Remarks Above NA- Not Analyzed LT -Less Than, GT -Greater Than 1518211 SGs Member of the SGS Group (Societe G6n6rale de Surveillance) xv 51 1, a L 0�4� �' PAYNE R 5 = tE ON 2 s 1 11261 PG 11260 11261 11250 11251 E. 115 WE. 11301 / Q�R2 2A / J s 113010 5 11300 11301 V% L�� SNON?JNE Q x a /A 2 11300 11361 2 11500 SCHRAM 2 Ov / CO` 11411 MUM KLATT RD. _ 7801 7851 6 116 /8 /7 /6 11611 /3 5 /5 j 11621 /2 7801 11620 3 /9 °2� 4 11641 '800 /4 1C-dfogE44 2/ /D s 7961 22 7941 8001 9 8 \7901 8000 IVF 8041 8101 23 79003 � 8141 7851 ,t`�P 8100 24Q�7850 2 8140 7801 4 ' 5 6 ALPS AVE. w � Q 11401 7420 75$0 7530 / 2 3 4 11361 11360 _ 11361 12041 / - k I 11400 2 9 / / 2B OCr( 4. 11401 / swl. ;C o 12050 J 3 � 0 Ism 11401 / CASSETTA 0i43• J 7420 COLESTC'[ T A *1, SV 11561 4 � � =4 5 6 7v 2 �s0 ♦/' 11561 11461 2A 11400 2 11461 2 Q 7430 7440 7500 7510 J #� 11500 SCHRAM 2 Ov / CO` 11411 MUM KLATT RD. _ 7801 7851 6 116 /8 /7 /6 11611 /3 5 /5 j 11621 /2 7801 11620 3 /9 °2� 4 11641 '800 /4 1C-dfogE44 2/ /D s 7961 22 7941 8001 9 8 \7901 8000 IVF 8041 8101 23 79003 � 8141 7851 ,t`�P 8100 24Q�7850 2 8140 7801 4 ' 5 6 _ / 2 3 4 h S WL . 41 _ 12041 / 11501 2 2 r o5 6 / 4. swl. ;C o 12050 H��ff,115oo I Ism 5ug $lot 3 0i43• T A *1, T O r►; 3 Nad 11561 4 � � 12101 2 2 �s0 ♦/' 11561 110 uRcn . 2 12141 #� s VW 6 b 11601 L PIN , ADDENDA C /� l '�V� 3 12101 /D 5 4 3 Ns 7641 2 / \ - ,10 . 7701 11651 ��. SOLDOTNA DR. \7561 9 7700 7740 6 8A 9A ?Ivl 7541 7 117001 #4 t 6 8. 11825 11845 Fi,o s4 7 CIRCLE D . 4 11865 11851 11800 11830 / B / 11800 \ 11900 119013 / 7 3 9 2 3 11901 118 Q� 3 11930 2 w 4 2 2 11921 6 11925 ' > 11 11945 X 5 TEf ACE 4 11940 / 011941 / 5 7441 �ALATNA AVE. 7440 7500 7540 m 7600 7700 I J - 11500 SCHRAM 2 Ov / CO` 11411 MUM KLATT RD. _ 7801 7851 6 116 /8 /7 /6 11611 /3 5 /5 j 11621 /2 7801 11620 3 /9 °2� 4 11641 '800 /4 1C-dfogE44 2/ /D s 7961 22 7941 8001 9 8 \7901 8000 IVF 8041 8101 23 79003 � 8141 7851 ,t`�P 8100 24Q�7850 2 8140 7801 4 ' 5 6 _ / 2 3 4 h 12041 / 12041 / 2 W HI LSID EW o 12050 ADDENA SUB 12101 2 12100 12101 2 2 12141 -k �0 3 , ADDENDA C '�V� 3 12101 _ � ( 12201 � � I W / 199M r r _�..,sc�►-'.ao��`D�' i��Ei�H� I[�®�7C� L-�.. 1�.1�Y�IDI®II��.�1Ts .��%,.�A�'.�:��®� ,'�.' .t � �� feet. SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF 6 18,00 i DRILLED AT THE RATE OF �$ PER FOOT. s PROPERTY OWNER Mr, Jim Suer li 3 SRA X397 99502 . 1 LOCATION OF WELL SITE itaux. DRILLER Bernie Claus of gampart.,Drilling Works WELL LOG: .. 1 0----22' Gravel and boulders. 22_--51+' Sandy wet clay, Some signs of silty water. ;"--801 Sandy gravel; 80--119' Hardpan. Some signs of water at 112 feet* e gravel Producing 10 GPM.' Water cleared up after casing to 123' 119-224 Water bearing gr 8 Artesian flow 25 minutes after 100% draw down. 1/2 horse pump should be installed `to 100 feet, Cost of Drillings $2214.00 Well seal: $22.50 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF THANK YOU VERY MUCH. #2236.50 BERNIE CLAUS OF RAMPART DRILLING WORKS DATE—OCt..--lstd—%o � , SERVICE CHARGE OF 11/2% PER MONTH WILL SE ASSESSED ON PAST D CCOUNTS. �FWei I Log For.... , LocatTOlCI,....C..r?��'s'��.�, v�'�.: .,��`:-'r..�' �E�r {�-c 'Date completed ...... ,,'2e-Zx e7 .................................................... Depthof well......1�'. , . , .,�� ................................................................... . Size of casing.. ................. Distance to water.. t' . ° . ......... /161..�Z,&-„!'.......... Distance to water while pumping .... 1�✓....... ; ,_.� 9r z......................at rate of....... c ...... . . ................gallons per hour. Formation I from I to �Y I 41-1 21 � � � �t !✓ / ,.i !"/'yf ',,� t” fr7�i� �` .'i/ fy/� ...Sdr..:CyF DELTA DRILLING COMPANY SRA BOX 394 B ANCHORAGE. ALASKA 99507 Driller GRR ANCHORAGE AREA BOw4j1;GH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAMEA� A��'e/1/�MAILING ADDRESS___.C_�_�PHONE LOCATION d LEGAL DESCRIPTION_ lr/ SEPTIC TANK: DISTANCE / FROM WELL ICC �C ANUFACTURER INSIDE LENGTH INSIDE_ WIDTH NUMBER OF J MATERIAL 57�cEl COMPARTMENTS r LIQUID DEPTH ---LIQUID CAPACITY /06"() GALLONS. SEEPAGE PIT: NUMBER OF PITS z . DIAMETER OR WIDTH _�_�_, LENGTH _.� DEPTH I ININC-, MATERIAL OTSX/Z�L-4-_ CRIgBSIZE: DIAMEI E_R ___DEPTH DISTANCE FROM: WELL -AV / TOTAL EFFECTIVE BUILDING FOUNDATION 3Z, NEAREST LOT LINE ___- . ABSORPTION AREA (WALL AREA) �5� SQ. FT ADDITIONAL ABSORPTION WELL: TYPE !Z)O/ �!� __ CONSTRUCTION _ DEPTH BUILDING NEAREST NEAREST SEPTIC FOUNDATION �� . , LOT LINE - SEWER 'LINE---_—, TANK _ CESSPOOL OTHER SOURCES APPROVED DISAPPROVED _— REMARKS DISTANCES: INSTALLED BY: 57e/ -/:f 17 PIPE MATERIAL: (Wg/ TDA) LOT SLOPE: p �% REMARKS: o s n "'� -' / O/N sn5,.J/ n A Form No. EQ -031 DIAGRAM OF SYSTEM s�� 7/7 S«"py5'� 1b pZo _ DISTANCE FROM: SEEPAGE SYSTEM _ DATE S 2`Y��3 APPROVED G.A.A.B. C'%c f1 µ) f' o r MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM ANWOR WELL INSPECTION REPORT INAivrt PHONE ❑NEW AUPGRADEMAILING ADDRESS Sol 0012-Tt{�-P-0 4.�E•�-iTS LEGAL DESCRIPTION --- — LOCATION �h� NO. OF BEDROOMS " Y DISTANCE TO: Well Absorption area Dwelling PERMIT NO. a Q UJ- y Manufacturer _ Material L No. of compartments Li acit in allons 9� capC y g IF HOMEMADE Inside length � Width Liquid depth 1_ O Jt=2 Z DISTANCE TO: ell Dwelling PERMIT NO. O Q _' F Manufacturer _._er,al------------_.___..— PJlatcrval -_____i- -- l-iquid capacity in gallons _j W = Wel! DISTANCE TO: Foundation Nearest lot line, L + J PERMIT N0. / � 3 J LL Z P ? w No. of lines Length of each line Total length of Ii es Trench width Distance between lines `c Q H ¢ h Top of tile to finisgrade 1 tt� . inches Material beneath the �f _ Total effective absorLttion area �0 � inches r LU Length Width Depth PERMIT NO. Q F- 0.a w Type of cribr is er b T ff iv abs rption area W DISTANCE TO: Well Building foundation Nearest lot line J J Class Depth Driller Distance to lot line PERMIT NO. W --- DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS �b- SOIL TEST RATING Q INSTALLER C _15 t ffCt 0 REMARKS yco_ It Ci Q I SOO C � Al T C V LEGAL P A ED ` ^tDATE 72-013 (—R,,3/78) Municipality of Anchorage August 28, 1985 POUCH 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWLES, MAYOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Theodore F. Moore Flattop Technical Services 14530 Echo Street Anchorage, Alaska 9951_6 Subject: Lot 4 Block 1 Alpine Terrace Subdivision - waiver. Dear Mr. Moore: This Department hereby waives the separation distance beween septic tank and well on the subject lot to 89 feet. This waiver is valid for the existing septic system only. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/pah GREATCR ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVTPf1NMENTAL QUALITY 3330 "C" Street ANCHORAGE , ALASKA 09503 r,erformed For 7,, Legal Description: Lot P'ffock , This Form Reports Soils Log___ _ - Soil Test Must Be Logged To 4` Depth Case Dated Performed f/ � 3 -Suh(Iivision A Percolation Test 3elow Proposed Seepage Systef^ - Feet Soil Characters s ti cs ---- 1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 11 — 12- 13- 1 2- 3- 4- 5- 6- 7- 8- 9- 10- 11- 12- 13- 14— Was Was Ground Water Encountered? PO If Yes, At What Depth? Reading Date Gross Time Net Time Depth to H2O Net Drop Percolation Rate Minute Proposed Installation: Depth of Inlet COMMENTS: ?'7 Seepage Pit Drain Field Depth to'Bottom of Pit or TrencF- -e Test Performed BY_1 S-= %:�,u_e�-- -Date Certi fied BY: Date �i• DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION r� YLHLULAI IUN TEST . ouu. ��, ..r�.r. �_, •'-+c• 9H502 276.2221 SOILS LOO - PERCOLATION TEST PERFORMED FOR: DOIZ►a 10 601m4- DATE PEriFORMED: Ia -ZS -77 LEGAL DESCRIPTION: LOT 5 I.�Lk 1 A -PrNE TJ' CZAC-C- SUFI D 1 2 3 4 b s 7 8 9 10 11 12. 13- 14- Is. 3- 14.1b. to . 17- 18. 7.18. 19. 20. COMMENTS_ P_eo-e¢>4 0er,aJ14 (oQ 6xooy GRA VrL . Tg^e,c c+.-,( (,G c SSD`( GPAUEL_ -T�'.j►G>� 511—T, WAS GROUND WATER�O ' L GI't-lr G M -" ENCOUNTERED? O T D • No, W A.7s4L _ - P r IF YES, AT WHAT _ E DEPTH? PERCOLATION RATE (�N IN IN • (n►Inut�a/fnd+) = I `' TEST RUN BETWEEN (7 FT AND FT PERFORMED BY:�' 1 L�F�-j rr�1�-Z! /.1 �f I_ILJ�iC CF.nTIFIFD BY:_ 77 CA^ Ono) DATE: �- wO-400 -4 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 610 v 2U, 1986 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) G,af y a(ac Fc 1 A�lJ��t Ter ee SID Location (address or directions) 76oi Scyt'edoFnC, Dr: (b) Applicant Name Sohn Miffer Telephone: Home 34fr-60"V 7 Business Applicant Address 3801 Ma it hew-rfir- An honne Ak 195-16- (c) Applicant is (check one): Lending Institution[]; Owner/builder ® ;Buyer[]; Other ❑ 'explain); (d) Lending Institution Frt f' /uaf / 13a4kr a 76 — 63 00 /�ti Telephone Z Address Sol W. 3G 1 i4KG�lllrCeL�� /9-k 99So3 (e) Real Estate Company and Agent nl. A C3e�no So�v c�w�er (f) Address Telephone Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family ® Multi -Family ❑ Other Number of Bedrooms y 3. WATER SUPPLY Individual Well [0 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 19 Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 ``1 f 3. WATER SUPPLY Individual Well [0 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 19 Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (11/84) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION R 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 Flu #op lechAica/ Ser4;1Cvr Telephone 3YS-'13 Address 116,3 o Echd Sit AAC/?Vrarle � i4lt 995/6 Date Ala✓ 20 1956 %.% ♦'�®eek • "o Ar 0* TH p ... ................ ...i...� THEODORE F. MOORED ` / Engineer's Seal CE - 3589' •...... • •' DHEP APPROVAL Approvedfor; T bedrooms by 4&a2 Date Approved Disapproved Conditional Terms of Conditional Approval CAUTION ll- 21-86 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) A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPALITY OF ANC'TH AUTHORITY APPROVAL (HAA) CEPT. CF HEALTH & ENVIRONutCNIAL FKOTECT(or4CHECKLIST6 4F 720RUARY 1984 fi0v 2 ",)1988 R�CEI V ED Legal Description: Laf w Ar (» int lrerrtice C / D Well Classification Prt ask If A, B, C, D. E.C. Approved (Y/N) N• �• Well Log Present (Y/N) N Date Completed li Z3 Yield 7 7. YO 9 -RP) rued[, I1/19 AAK p<r 0,73 HNA. Total Depth `�� Y5Cased to 10 'YS Depth of Grouting N• A Static Water Level l `l l Pump Set At > 2 Casing Height Above Ground 18 Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) N Separation Distances from Well: 76 40 firr f *To Septic/Holding Tank on Lotq7, t.-.9 ; On Adjoining Lots > loa ' To Nearest Edge of Absorption Field on Lot IOS+ 1+ Go, ; On Adjoining Lots To Nearest Public Sewer Line N. A• To Nearest Public Sewer Cleanout/Manhole N. A • To Nearest Sewer Service Line on Lot N. A. Water Sample Collected by T FM ; Date U / 18186 Water Sample Test Results saftc �brr -' /ta Co <<�°'n'' a'- o �'tr locxc/-Cri cL Comments S dy �yccwts►t+r fe of 7. Y g0ln CaWe- wef/ alrau� dau,., �0 2Z' - Wer'( -sro fic xtn ev'� koa watvtr trs�r� 4•i Sfc�e �rrr,l a„ bl �.S`ly�" SrPa+^d�ion y6 firtt S e/oftc lank- c&'Me lege/ a:f hm'- a/ tt-u Yruc froom B. SEPTIC/HOLDING TANK DATA S/ Z q / 7 3 Joe> a czar L eAw y,r{m en t Date Installed 81 l r / 7 8 Size •OO a f No. of Compartments 2 comnarl w edr Standpipes (Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) N Date Last Pumped If ltd /&K- Pumping/Maintenance &6Pumping/Maintenance Contract on File (Y/N) N•A • ; for N. A - Holding Tank High -Water Alarm (Y/N) N•A• Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: 7d-' %s wi lGL7t7�'d To Water -Supply Well I5 qac To Building Foundation 6 �rar4 C. d_ To Property Line 30# To Disposal Field l9' 4"e AV C.C'A To Water Main/Service Line N. A. To Stream, Pond, Lake, or Major Drainage Course [S o Comments WCl %tc izta k• S�parc+rfinn l.�ar--cut- tttu+�i by S. !`Carrrt an 01216 /6S. S �arakon �, (GOO qv�r fec�+k cuarr �f ect` 14.n� a� Co�tSl�. Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata &'S in' /43Type of System Design -%-C!V!!fe n; f &"• TJ'4fcy S_/ZY/T3 seAr a pit- .5;040 'e P;f 121 tcr2' x6'cdoslp Date Installed tr pt Length of Field 107 Width of Field 1're^ 3 2" tc; Depth of Field 13' -!o bof4.11 o dc frtAc h 2�8 Sa�4gt Gravel Bed Thickness Square Feet of Absorption Area ?9 Y Tiencb Standpipes Present (Y/N) Y 2 To � Depression over Field (Y/N) N Date of Last Adequacy Test 11111? / 6� Results of Last Adequacy Test 4,?*uacfe dor Y 6edevO"tr Separation Distance from Absorption Field: To Water -Supply Well 1QS'' 4:101n C. Cl. To Property Line J l0 To Building Foundation 3a, ;(,-wm c. c'. To Existing or Abandoned System on Lot M A . ; On Adjoining Lots 7 30 ' To Water Main/Service Line M. A • To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course t 60 ' To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION t4,4. Date Installed Size in Gallons "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 ** Check Permitted Bedroom Rating Against HAA Request ** Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed � G�- T 7n& -,t- Date It 12U / &K Company FkAi a Tecti Svcr MOA No. Receipt No. ��-) 4 0o 0 -/— Date of Payment 070 - 4 o S^yC� Amount: $ Page 2 of 2 72-026 (11/84) -0s2 41"OF A4 44 ®e�a� Engineer's Seal AW 0*: j�TH'. ••9*�� 00 ..........................E ��... ......�:.....�... •. THEODORE F. MOORED rr I�` % CE - 3589 _, Ar Municipality of Anchorage August 28, 1985 POUCH 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWLES. MAYOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Theodore F. Moore Flattop Technical Services 14530 Echo Street Anchorage, Alaska 99516 Subject: Lot 4 Block 1 Alpine Terrace Subdivision - waiver. Dear Mr. Moore: This Department hereby waives the separation distance beween septic tank and well on the subject lot to 89 feet. This waiver is valid for the existing septic system only. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/pah .� f''NNICIPALITY OF ANCHORAGE -- - D�.SSION OF ENVIRONMENTAL HEALTH DEPARMENT OF HEALTH AND ENVIRONMENTAL PROTECTION AppLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1, General Information Application Date (a) Legal Description (include lot, 'dock, subdivision, section, township, range) (O ke I A f.17 i -TP rr et C e Location (address or directions) 760 t 501 e,& {w0 (�,�� cue �7 7 35"S� (b) Applicants Nasse john Telephone - Home3�s�®y7Business Applicants Address ?60( (r''ii'e (c) Applicant is (check one) Lending Institution ; Owner/builder ; Buyer Other [� (plain); (d) Lending Instituti0n4A1a CR4 Telephone (e) Real Estate Co. & Agent Address Telephone. (f) ?iail the .AA. to the following address: -7-7 2. Type of Residence Single -Family 1:E1 14mlti-Family 1=1 Other (describe) Number of Bedrooms 3. Water Supply Individual •,yell f5:q Community Public Note: If com unity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. Sewage Disposal Onsite %t'�-'• Public E::1 Community = Holding Tank = Note: if co nit? well system, must have written confirmation from the State Department f ?nvironmental Conservation attesting to the legality and status. [Page I of 2; 5. Engineering Firm Providing Inspections Tests, File Search, Data and Information 6. '" 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 onsite water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection.., Vlell S"Aic S- jpc enj4vo7 vJ 77 Fee/ W'Gu I et utL k me v4- o © y)/W I , niloIt ctfic,� . S<< b� c��le,� My `{�J/9`ti'+-s{ ll, i�'t U�4 i.n Name o Firm jF( H-dx, Vp�L►r+�ccc �[?ryi'c8° / Telephone 3 YSs jZ4a Address@ .530 hSA- �- /}�ichC>rcic e /�lz 9 576 ®`� OF Ab Date a6 , / �� '' • ° . „� • • v,.r TH d.....Y........Y.......::.� (ENGINEER SEAL) 0 THEODORE F. OC)RE�• DHEP Approval 0 °/'r�l2io�,3�°®•"04- Approved for bedrooms By D to ®/ Z=S` --e Approved Dis ved Conditional Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. EMPLOYEES OF DEEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 ►IlhFx OF ANCHopAW MUNICIPALITY OF ANCHORAGE (MOA)( *f KALFH & ?,AL PRoTkCTIO,N HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: Le Irly m e Terrace 1111_w- 16 A. WELL DATA Well Classification Preval-e If A, B, C, D.E.C. Approved (Y/N) IYA- Well Log Present (Y/N) N Date Completed 1973 Yield Total Depth 7 69' Cased to 7 6-9 Depth of Grouting IV, h Static Water Level 2s, Pump Set At t�(gle Casing Height Above Ground 18+Sanitary Seal on Casing (Y/N) Y Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N) N Separation Distances from Well: 1 7 7` 4v�nf To Septic/Holding Tank on Lot 69' 46—cetoaa( t ; On Adjoining Lots > 00 To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots !OG r To Nearest Public Sewer Line lytA- To Nearest Public Sewer Cleanout/Manhole M4. To Nearest Sewer Service Line on Lot N,A Water Sample Collected by -rFm ; Date 71 i916s Water Sample Test Results S&{UAC/0ry -- %lU Colmer'- Comments u/el( Sep kc Sep alet/To o wau i C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ��eS, 471143 DRPr Type of System Design .5eWm p; f uU �re�ch 7ro S e#r �� g T�—he pr of Date Installed �_/fT� n tr Length of Field �- �� 2r �� lvnw Width of Field *e-ench 32" wird{ Depth of Field � _ f''`end' Gravel Bed Thickness 71Dlr — *"oc4 Square Feet of Absorption_z 54 Area ^ E � Standpipes Present (Y/N) `t Depression over Field (Y/No Date of Last Adequacy Test Uont drl✓iow 1, 712-21kr �— Results of Last Adequacy Test 17�e 4rAf e:&AE eA r.Grou S'ar10kc016Py +— Separation Distance from Absorption Field: To Water -Supply Well /06, r To Property Line 30 , To Building Foundation ..3 fTo Existing or Abandoned System on Lot 14,A, ; On Adjoining Lots ? 301 To Water Main/Service Line N - To Cutbank (if present) A&A . To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area 30 Comments D. LIFT STATION fV,g Date Installed Size in Gallons "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 ** Check Permitted Bedroom Rating Against HAA Request ** Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed _`7J'-�� 5Date 0( /f? A95 - Company F16C fye TCc111«(S"5U MOA No. d59-0S_?- Receipt 59-aS2 Receipt No. ♦4 14 Date of Payment ♦ OF At Amount: $ A!,f;Q'; • E giri��l � ?: 49TH :-yam �•J •••...:1 Page 2 of 2: THEODORE F. MOORE I+CE - 3589 •' �,� Ar 72-026 (11/84) ; / p ••...••�� AV 0 A+Home Services 15900 Francesca Drive Anchorage, Alaska 99516 345.1890 • MOM DATE 7 -,1* - TAA M, 11 er 7&01 '501alo-n a." Vr. DATE DESCRIPTION CHARGES CREDITS BALANCE PREVIOUS BALANCE -310 �r d v C 07�� nig BALANCE DUE .� . If this statement does not agree with your records please notify us at once. STA TEMENT PIPF-e 114 M.O.A. Dept. of Health and Human Services Pouch 6-650 Anchorage, Alaska 99502 Dear Sirs: On behalf of John Miller, the property owner, I am requesting that you grant a waiver of the well -septic tank separation distance requirement for Lot 4, Block 1, Alpine Terrace Subdivision, located in the Hillside area. I am enclosing copies of pertinent documents from the file for your consideration. By way of background, the system was originally constructed in May of 1973 for a 3 bedroom home. The 1973 Health Authority Approval checklist showed a well -septic separation of 70 feet, which was legal at the time, but it also indicated approval for 4 bedrooms rather than three. This error was noticed at the time of resale in 1978, and the Municipality required an upgrade of both the septic tank and the absorption area. An additional 500 gallon septic tank was installed between the original septic tank and the absorption area, and a 21 foot trench was added to the original seepage pit. This trench, like the original seepage pit, is located over 100 feet from the well. The second septic tank, however is only 89 feet from the well, which was not legal at that time. The 1978 inspection report, approved by the Municipality, fails to provide information on the well -septic separation. I believe a waiver can be justified on the basis that deviation from standards is relatively small, and because non -conforming septic tank is farther from the well than original one which was legal at the time of construction. 0 �v Q! the the the 7 When 14 tested, the wastewater disposal system proved to be able to handle the design flow for a 4 bedroom residence, and the well water sample tested showed no contamination by coliform bacteria. Please process this waiver request as soon as possible, and feel free to call me if you have any further questions. Thank you for your prompt consideration. •0 A4\ 49TH .*4 /..s.......................� 00. .. MA e THEODORE F. MOORED• I CE - 3589 �yw~Ar �s �'••......••'. e r c Sincerely, Theodore F. Moore Municipality of Anchorage August 28, 1985 POUCH 6-650 ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWLES, MAYOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Theodore F. Moore Flattop Technical Services 14530 Echo Street Anchorage, Alaska 99516 Subject: Lot 4 Block 1 Alpine Terrace Subdivision - waiver. Dear Mr. Moore: This Department hereby waives the separation distance beween septic tank and well on the subject lot to 89 feet. This waiver is valid for the existing septic system only. Sincerely, 4. . /!- Stephen S. Morris Civil Engineer On-site Services SSM/pah MUNICIPALITY OF ANCHORAGE Department of Health and Environmental Protection 825 L Street, Anchorage, Alaska 99501 279-2511, ext. 224, 225 est for Approval of Individual Sewer and Water Facilities 1. Property Owner: -"% l— `` M41 c ,9_71� n.; �'5 1E If U) C.. �.. Mailing Address: p IA,, � Phone:11_3o ti f-2Rn�CiSt��C/}1 f. G4foct 2. Name of Buyer: i° h, ti c� �cc� _�_To .-T Mailing Address: Phone: 3 q q _ -7j q 3. Lending Institution: 5;pa KA ti. - /M o ielo Mailing Address: 3�D "�" . �Su`,`(c ASO f 3 Phone: ) %'7-osq .3 4-e 4. Realtor/Agent:T�t,&i a r,'c, lir a] L4 CC I I )c k; S rY�_iIle,� Mailing Address: jVcj,Phone: Q22-2(�/] 5. Legal_Descript ion: o� ` - �-T /,�I ,j r �_'2.2igc� � j(;�. Street Location: /J 6. Single Family Residence: G>0 Number of Bedrooms: 4 Multiple Family Residence: ( ) Number of Bedrooms: 7. Water Supply: *Individual Well Public/Community System ( } If Individual Well, well depth l% � If Community System, name of system 8. Sewage Disposal System: On-site System Public System ( ) If On-site System, date of installation: i02A ab f L4 '33 *NOTE: A well log is required on ALL wells drilled since 6/75. 3/77 INI U 4 1 C: i10' 1"", V T R 0 L( T tO TI 1� P D E, AR kV OF F4 E A'L I H A NI D r 8� 2 5 1 S L r L A,�I Ch A la S jl-� 4 Jvo % IL C) 4 - A, 2 0 Lj C 1977 e7: L November 8, 'T" �O)L- P - Da e ha':-`= j I 7 S It s, i',1 t j- oTnpgp -y- Suite 250 277-0543 201 C Street, 3 - ------- 2. The Equitable Relocation Service (I. 1' 17 120 M2nt�g _ptlLpq�t, Suite 630 San Francisco, California -94164 T)t iol Lot 4 Block �a C r i 1 Alpine Terrace Subdivision - -------- 4: S i n (-,,, 1 c1., PC'S , " 11"0: (x) n,lb e- r o T: 0 1A Four C�-o Jr�iber ol-om, well Sys t el-i'l I, d i C a'I I IL X) 3t M Dep nth 6. s e w FA e I-0 s a 1- S Un - S J t Sy em X T 1) 1 i- C P t;,, Approx 1973,irista',. 1 -Ink Sj-,ze -r, sor--tiai-,, Area 7. D i s t a. n c -I, s, Well tO -SePtiC to Ahsorpt-ion ------ t o Septi:- Ij i n c s o r 1,;-. 1, ,t Al, cm T,age 1 h0 of He�,ILh imc-' Eri'.T --'LrD nim c-, a.1 P o t_—, c t 1' 0 11 i C' U C'. S t or 17.I -,p (D va E : c! C,'C' Lot 4 Block 1 Alpine Terrace Subdivision A A f f a d. av J. t 'I'l t 4C-- a c h e a: D i s a p,, jr,0,J U . M- C, c L 10— C'C fth sh December 14, 1977 mat Northern Lights Boulevard Anchorage, Alaska 99503 SuPects Lot 4 Block 1 Alpine Subdivision The subject property needs to upgrade to meet the four(4) bedroom requirement. Before we can approves the request the following mush be completed. (1) Add a 500 gallon septic tank to the existing 1,000 gallon tank. (2) The seepage pit was adequate filly for a three(3) bedroom. Thessefore, an additional twenty(20) feet of treHch with six(6) feet of screened h to 2;1 inch gravel will be needed below the drainpipe. The absorption area must start at the top of the existmbg seepage pit, with a ten(10) feet separation between the two. Temporary approval may be granted if monies are escrowed so the project can be completed by June 30, 1978. A permit must be obtained prior to any construction. if there are any further questions, please contact this office at 264.4720. Sincerely, Robert C. Pratt, R.S. Sanitarian RCP/ljh cc: Spokane !Mortgage Company 3201 C Street, Suite 250 99503 AP November 6, 1978 Elizabeth Risk Management Associate Specialist Lot 4 Block 1 Alpine Terrace Subdivision The sewer system on the above subject property was inspected and approved by this department on May 24, 1973. The approval was for a three(3) bedroom single family dwelling. on October 25, 1973, a request for approval of individual sewer and water facilities was submitted to this department. The request was for a four(4) bedroom single family dwelling. Through inspector error the request was approved for a four(4) bedroom single family dwelling by this department. On November 8, 1977, we received a request for a four(4) bedroom dwelling and it was disapproved because the original installation was for a three(3) bedroom only. On August 11, 1978, Mr. Allers from this department inspected and approved the installation of a five-hundred(540) gallon septic tank and an additional twenty-one(21) feet of leaching line off of the existing seepage area. This installation now qualifies the home for a four(4) bedroom dwelling. If there are any further questions, please contact this office at 264-4720. Robert C. Pratt, R.S. Associate Specialist RCP/ljw enc: Municipality of Anchorage MEMORANDUM DATE: 11-1-78 TO: Rolf Strickland, Environmental Health Division Mgr. FROM: Risk Management SUBJECT: Request for additional information regarding: EXrM0"XXAncident septic/sewer upgrading Accident Date 5/73 thru 11/77 Our File No. pending Vehicle No. Location Adverse operator Dynamic Realty Please furnish the following information to Risk Management so that we can give further consideration to this claim. Workmen's Compensation Claim Form ADL -210 Supervisor's Report Medical Authorization Return to Work Notice O Exactly how many working days has this employee lost from work �] Auto Accident Report (Completed by employee) Police report : APD AST E� Notice of Claim (Completed by claimant) Itemized repair estimate Itemized repair cost — after the damage has been repaired Itemized repair estimate (vehicle damage) Supporting documents xxx 1 Other: May we please have a complete copy of your file on this problem from May, 1973 up to and including the present? F7TX—j Per the attached we need the items marked above If the information requested above has not been sent, please do so immediately. If you are unable to give information pertaining to this incident, please advise Risk Management at 264-4201. Please attach this request to your return correspondence. Thank you, Elizabeth }' Risk Management 95-013 (6/77) NOTICE OF CLAIM AGAINST: MUNICIPALITY OF ANCHORAGE 0 ANCHORAGE SCHOOL DISTRICT ( McNICIPAL-ITY USF ONLY ( Inir: ( Time Ci o I NOTE: This form should be filled out in as much detail as possible to assist the Municipality in evaluating your claim and upon being completed it should be filed with the Municipaly Clerk, Municipal Annex, 630 W. Fifth Avenue, Anchorage, Alaska within four months after the date of the occurrence of the injury or damage. I, the undersigned, do hereby submit, under oath to the Municipality of Anchorage, Alaska, this Notice of Claim for damages to my person or property pursuant to Section 17.06 of the Municipal Charter, and I do hereby intend to hold the Munici- pality liable for such damage claimed herein. CLAIMANT: Name: pp Telephone c;) -1 Home Address: 550 1 (1) . Y,c,en. Mailing Address:�.�, , v DATE AND LOCATION DATA OF INJURY OR DAMAGE: Date: Place: PROPERTY INVOLVED: (Month) (Day) (Year Description: r:a-T If vehicle: Year License Number: MUNICIPAL DEPARTMENT INVOLVED: Department: Municipal Employee: AMOUNT CLAIMED: Make : Model (if known) $ �'jg j Please attach an estimate or itemization of the damages claimed. DESCRIPTION: (Nature and extent of injury or damages. Please describe in detail) 95g�- MANNER OF OCCURRENCE OF INJURY OR DAMAGES; (Please explain in detail what happened aizr v?hsa the Municipality is liable. Use attachment if additional space is necessary.) c v . L� �-• -�.� , .x , , � r 3 � � , 19 '1 �t1 1 � 1 > �� l c ! y a— 9 'Z p3 ucf 13 �, n D to ci✓v. Cin- YLa Ga_ , f�ci2 l \ +WITNESSES: (including automobile passengers, police, doctors and all others having information concerning the claim.) NAME: NAME: NAME: NAME: NAME: DATE: STATE OF ALASKA ) THIRD JUDICIAL DISTRICT ) I, and say: ADDRESS: ADDRESS: ADDRESS: ADDRESS: ADDRESS: SIGNATURE:_�_u�l being first duly sworn upon oath, depose That I am the claimant in the above NOTICE OF CLAIM for injuries, that I have read the foregoing NOTICE OF CLAIM and that the information and statements therein are true as I verily believe. s SIGNATURE: SUBSCRIBED AND SWORN to before me this -2- day of Notary Public in and for Alaska My Commission Expires: . 19 06.1220(m) Rev. 1973 DATE ALAsnp DEPARTMENT OF HEALTH AND SOCIAL SEkra;ES DIVISION OF PUBLIC HEALTH Lab No. INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL WATER ANALYSIS OFFICE INDIVIDUAL ❑ SEMI-PUBLIC ❑ CHLORINE RESIDUAL PPM REPORT RESULTS TO NAME : 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 TIME COLLECTED Sample Collected From ❑ Kitchen Tap ❑ Bathroom Tap ❑ Basement Tap ❑ Other (List) Well — ❑ Dug ❑ Driven ❑ Drilled ❑ Bored SOURCE: ❑ Spring ❑ Cistern ❑ Other Dug Well or Cistern Construction: Walls —❑ Wood ❑ Concrete ❑ Metal ❑ Tile Brick or Top ❑ Wood ❑ Concrete ❑ Metal ❑ Open Top ❑ Concrete LOCATION: ❑ In Basement ❑Basement Offset F-1 Under House ❑In Yard ❑ Other Building Sewer Septic DISTANCE TO: or Other Drainage Pipe Feet. Tank Feet, Tile Seepage Cess - Field Feet. Pit Feet. Pool Feet. Privy Feet. Other Possible Sources of Contamination MATERIAL: Building Sewer - ❑ Cast Iron ❑ Wood ❑ Tile ❑ Fibre ❑ Asbestos Cement ❑ Plastic Joint Material - Type GENERAL: Does Water Become Muddy or Discolored? ❑ Yes ❑ No When? Diameter of Well Depth Feet. Well Casing Material Diameter Depth Length of Water Depth Drop Pipe From Bottom Feet. Offset in In Utility — PUMP LOCATION: ❑ In Well ❑ Basement ❑ In Basement ❑ Room On Top ❑ Of Well ❑ Other PURPOSE OF EXAMINATION: Illness Suspected? ❑ Yes ❑ No New Source of Supply? ❑ Yes ❑ No Repairs to System? ❑ Yes ❑ No Signature 06-1220,Ib) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1973 READ INSTRUCTIONS Date Received Time Received am pm Lab. No. — Lactose Broth locc 10cc locc locc locc 1.0cc 1.0cc ON 24 Hours --- - 48 Hours- Brilliant Green REVERSE SIDE 24 Hoare 48 Hours EMB AGAR BEFORE Lactose Broth, 24 hrs. 48 hrs. Gram's stain Coliform Density - (Most probable No. per 100cc) MF Results COLLECTING SAMPLE a.m. Reported by Date p.m. This analysis indicates Coliform Organisms to be: Absent Present a L JY `{ bREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3500 Tudor Road, Anchorage, Alaska 99507 279-8686 Date Received �A Time of Inspection o a Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER &+NATER FACILITIES FOR 1. Approval Requested By: f� Address: '7 i 9 50 hone : 2. Property Owner: rc,_/ Phone: 3. Legal Description:c- 4. Location: 5. Type of Facility to be Inspected: Number of Bedrooms: 6. Well Data: ��-----� A. Type — - �, B. i Depth C. Construction D. Bacterial Analysis 7. Sewage Dis.00sal Svstem:<-.�', A. Installed � j_� B. Installer C. Septic Tank: 1. Size c c+ -2. Manufacturer Ci pp_ D. Seepage Pit: 1. Szej X 4 2. Material E. Disposal Field: Total. Length of Lines �- 8. Distances: A. Well To: Septic Tank 7 Absorption Areae, Sewer Lines Nearest Lot Line Other Contamination B. Foundation to Septic Tank Absorption Area C. Absorption Area to Nearest L t Line d Regjec•t for Arpprova'l of Individual Sewer & Water Facilities E'age, Twin 9. Comments: ,Annroved/r�� , � Disapproved Date /r ,_-%„� _ Approval Valid for One Year From Date Signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM, I certify that the information contained in this request for approval to be a true and accurate representation of the sulbiect sewer and Nater facilities located at: Signed Date