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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
1 ENVIRONMENTAL ENGINEERING DIVISION
825 L Street
- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION
REPORT
NAME
NFW
F1MkUPGRADE_
MA ING ADDR SS
LEGAL DESCRI TION
r
A, I,
LOCATIO
NO. OF BEDROOMS
or e
W II
Absorption area f
D e lingPERfV�fT
NO
DISTANCE TO:
G7-9
2
w2
Manufacturer
Material �+
No. of compartments
2-1
~
CAI
Liq.c pacit i allons
Inside length
Width
Liquid depth
IF HOMEMADE:
Y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
_j 0z
O Z F
Manufacturer
Material
Liquid capacity in gallons
0
I a
f
Foundation
Nearest lot line
P MIT
w =
DISTANCE TO:
h d,41
-DISTANCE
92
J LL z
Z w+
No. of lines
Len Beach ling
Total le th of line 0
Trench vvidUi
inches
Distance between lines
` V
CC 1�—
Top of tile to fi ish grade r
Material beneath tile
Total effective absorption area
p
inches
- 7
Length
Width
Depth
PERMIT NO.
ILL!
C7
F-
Type of crib
Crib diameter
Crib depth
Total effective absorption
area
a
U.1°
W
Well
Building foundation
Nearest lot line
DISTANCE TO:
Class
Depth
Driller
Distance to lot line
PERMIT NO.
a
w
�
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
Y
4-11
SOIL TEST RATING
o>aA/t-0c&ti
0
3d�
INSTALLER A
REMARKS
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of 'qt-ayel
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APPROVED
DATE LEGA-LL
/ l
L 0-/-
72-013 (Rev. 3/78)
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (5Q FT/BR)- 125
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
IL12 ��12 ��Fw%rlE=:L__ 1"","
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHIWFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND HND THE BOTTOM OF THE EXCAVATION (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).
Fz? 0 (it k.A :1 Fit EE El ��F:., 1"" :1 '1 ��r-J 1 2" EE= AL 21 & Ef C! FR L. L. CA VA�
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.
0- hi lC_y �'_"" 3E 14 ST FA Er CD w x c) ros, ��F.E-i" Ff EE CA LJ 3: FZ EE E>
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAY,.':";
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS HRE
AVAILABLE TO INSURE PROPER INSTALLATION.
E>EEC3EwVqE3E=FT
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.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
SIGNE__________________
ISSUED BY__��__��'_^^~`�- _DHTE___^ ��-���~- Y4.��
��- ----- --���-//�'��� �---« /� ,/
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DEPARTMENT
HEALTH HND
ENVIRONMENTAL
iQTECTIOW
825 'L'
STREET, ANCHORAGE,
HK. 99501
264-4720
t4EEL.L. FAKAE>
PERMIT
NO ( 820178 )
APPLICANT
KIRK MCGEE
BOX
851
99510 276-8243
LOCHTION
LEGAL
L5 ANOTHER SID
LOT SIZE 45300 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (5Q FT/BR)- 125
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
IL12 ��12 ��Fw%rlE=:L__ 1"","
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHIWFIELD.
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND HND THE BOTTOM OF THE EXCAVATION (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).
Fz? 0 (it k.A :1 Fit EE El ��F:., 1"" :1 '1 ��r-J 1 2" EE= AL 21 & Ef C! FR L. L. CA VA�
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.
0- hi lC_y �'_"" 3E 14 ST FA Er CD w x c) ros, ��F.E-i" Ff EE CA LJ 3: FZ EE E>
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAY,.':";
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS HRE
AVAILABLE TO INSURE PROPER INSTALLATION.
E>EEC3EwVqE3E=FT
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.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
SIGNE__________________
ISSUED BY__��__��'_^^~`�- _DHTE___^ ��-���~- Y4.��
��- ----- --���-//�'��� �---« /� ,/
ALASKA MIROW11TAL COnTROL SMICeS, Inc.
6nqineerinq & 6nuironmental Studies
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1220 West 25th Auenue • Anchorage, Alaska 99503 • (907) 276-1361
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BOX 13609 .STAR ROUTE A ANCHORAcml, AX.ASgA 00502
344-7"714
SIX INCH WATER WELL DRILLED AND CASED - T-ro-'it'•HE'DEPT
DRILLED AT THE RATE OF 23. On PER FOOT.
''PROPERTY OWNER
LOCATION OF WELL S
DRILLER nc n �c GL. u 6 or 'cnpa, ,t
WELL LOG:
0-----24' TTL S� U. !. AaueL. .icue�ztL �„L1LL 1JacL %e'L�.
OF It 05 t
243-7923
24----41' Cou ✓uc GLc�,,
41----.jU' to `�C.CUL. rc ^ �J;LCJ2,te(r rlL^Uo.( •
58,---405' 33c.&tacL. z Sedrrr mtat* Rc6k.
_ate,t vj_elLd o.; .5o, -Le .,,, w{.L ptoc'bjc,} .ort at 7'C0
33 �hocsia-r -� a
;`cAe A O -r fsO,ZOLL4 tock at 03-15 L
` ' �
o �1, a. _
F n ^i'c;':
on.e �w! ;�_ � ,
r
7a-�e,L '`cr c'r. �oduc-t-ia, ouet a -LL �hotm an clout a'. 7;
-,,at-;
r�� how'z. h.� �,
30 ,"_CC t ar dhZ UUna 1 �L�ed " Gtc L �y ..Lc -et
24 hou,�
•f uze
.�� ,�e 4liau.Ld be 1 �00 �a
103 0 C g ads ae,z dace.
330 cnd kr., k cam ,in.r,: at I.
g..a,L4 ;ee,�
.;°a o
52G gut,� in
ca4tl all- as` '. 350
ita
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF u050.00
THANK YOU VERY MUCH.
BERNIE CLAUS OF RAMPART DRILLING WORKS
DATE i;.at� '
SERVICE CHARGE O F 1 %s% PER MONTH WILL 8 SSESSEDr O PA DUE ACCOUNTS.
" . MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES M
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel 1. D. # LY:.n - C�q 33 -,1)J-I HAA # W �°1 � 0 3).)
1. GENERAL INFORMATION
Complete legal description
Got 5; Another Subdivision
Location (site address or directions) 16550 Chasewood, Anchorage, Alaska
Property owner Kirk and Marilyn McGee Day phone 345-1827
274-8639
Mailing address
Lending agency Day phone
Mailing address
Agent Kay England/JACK WHITE COMPANY Day phone 563-5500
Address 3201 C Street, Anchorage, Alaska 99503
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 99
3. TYPE OF WATER SUPPLY:
Individual well xx
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site y(
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
S. 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 furtherverify 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
Phone
S & S ENGINEERING
Address 17034 Eagle River Loop Road No. 204
liagie River, Alaska 99577
Engineer's signature
6. DHHS SIGNATURE
Approv-ed for bedrooms.
----Disapproved.
Conditional approval for
Date
bedrooms, with the following stipulations:
Additional Comments ,SFE AITA-CHED MET 12 T3 ALL-
Co1_ep-N ED
By: �GE i SZ`L LT -4 Date L f G G%_
111Th
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 orderto 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
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: &J'S' ` Parcel I.D.
A. WELL DATA
Well type t'M& ►f- If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) W Date A" - f Z -�n Driller iiZoaals-Jitiq I1.1
oJ>�5
Total depth Cased to !q D �t Casing height
Sanitary seal (Y/N) N Wires properly protected (Y/N)
Date of test
Static water level
Well flow
FROM WELL LOG
- 121- !j-0
�o
Pump level V I<
- we.(( h fdpro{�rAciured I&- Z — -J
SEPARATION DISTANCES FROM WELL TO:
// +
AT INSPECTION
MUNICIPALITY OF ANCHORAGE
( — C I MORLNMENTAL SERVICES DIVISION
� 40V 1 2 1991
P.M.
�cC RCEIVED
Septic/holding tank on lot cryo f f- ; On adjacent lots 00
Absorption field on lot /00 ' ; On adjacent lots ! D D 1 "
Public sewer main /J /64 Public sewer manhole/cleanout A
Sewer service line Z Petroleum tank 6) OA) Ij:LDLI) PJ
WATER SAMPLE RESULTS: �. '
Coliform _"�; I i � �64Lf6 tom- Nitrate �►� J t S&C s � ,� Other bacteria ZCPa
Date of sample: (' D (" I Collected by: �6
B. SEPTIC/HOLDING TANK DATA
Date installed 4- 3 b Z Tank size I Zs [7 a W( Compartments
Cleanouts (Y/N) V Foundation cleanout (Y/N) G Depression (Y/N) K)
High water alarm (Y/N) ( /14 Alarm tested (Y/N) N� 1.4
Date of pumping — Z 3 '" q Pumper O✓ A !n�► r N �►'U��
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s)onlot (' �� On adjacent lots (. Db Foundation
To property line ` Absorption field Water main/service line 7 y
t
Surface water/drainage ( t)o t
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent(Y/N)
High water alarm level
p on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
SEPARATION DISTANCE FROM LIFTST ION TO:
Well on lot On adjace lots
D. ABSORPTION FIELD DATA
"Pump off" level at
Cycles tested
Surface water _
Date installed 'T 2-2 _ Z Soil rating Z S � System type __71i:'&
Length 3 Width 2 Gravel thickness -5 to Total depth 9 0 l 3
Total absorption area Cleanouts present (Y/N)
Depression over field (Y/N) fJ Date of adequacy test
Results (pass/fail) —� S S for ^t bedrooms
Peroxide treatment (past 12 months) (Y/N) -J I IL4 If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lotron t On adjacent lots I no f Property line ( O �
To building foundation to Y- To existing or abandoned system on lot �J 4
r . �
On adjacent lots t Cutbank y Water main/service line Z S 4
r �
Surface water j go t Driveway, parking/vehicle storage area f
Curtain drain
E. ENGINEER'S CERTIFICATION
1 certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in 4N to of this inspection. �
Olr A4
S & S ENGINEERING
Signature P Road No,
Engineer's Name Eagle River, Alaska 99577
Date
— e 11
�U �
HAA Fee $ l &
Date of Payment U- 2- �
Receipt Number 2'�1
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
It1-nuFE551\J1',�+
November 19, 1991
Re: Lot 5, Another Subdivision - Health Authority Approval
To All Parties Concerned:
The private well which serves the subject property has been
deepened and hydrofractured as a means of increasing well
yield. The reported yield prior to the hydrofracture procedure
was 0.28 gallons per minute. The tested production after the
hydrofracture procedure was 2.9 gallons per minute. All parties
concerned are advised that the current reported yield may
increase or decrease with time.
Joh Smith, P.E.
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
Client Sample ID:LS ANOTHER S/D
PWSID :UA
Collected NOV 1 91 @ 11:40 hrs.
Received NOV 1 91 8 16:00 bra.
Preserved With :AS REQUIRED
ANALYSIS REPORT BY SAMPLE for WORRorder# 39894
Date Report Printed: NOV 6 91 @ 09:33
Client Name :S 4 S ENGINEERING
Client Acct :SNSENGP
BPO # PO # NONE RECEIVED
Req #
Ordered By :R. SHAFER
Analysis Completed :NOV 4 91 Send Reports to:
Laboratory Supervisor EPHEN C. EDE 1)S & S ENGINEERING
Released By : G ��� 2)
....................................................................................................................................
Chemlab Ref #: 915901 Lab Smpl ID: 1 Matrix: WATER
Allowable
Parameter Tested Result Units Method Limits
-------------------------------------------------------------------------------------------------------
NITRATE-N ND(0.10) mg/l EPA 353.2 10
Sample ROUTINE SAMPLE COLLECTED BY: R.D.J.
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
Ash S13S Member of the SGS Group (Societd G6n6rale de Surveillance)
10
17034 Eagle River Loop Road
Eagle River, Alaska 99577
I
ROBERT A. SHAFER
CIVIL ENGINEER
694-2979
PROJECT:-- l 1r__k 4 U"" �� Q£�� `M'61*0 �-eV DATE OF TEST:
LOCATION OF WELL (Legal Description): /Ay lcsiliop 6
1 t
WELL DEPTH: ��� FT. CASING: �� FT. SCREEN:
DATE DRILLING COMPLETED: �' !/ {U
—' � DRILLER:
STATIC WATER LEVEL (Top of Casing): 1 FT. DATE: - 1 ^�
CLOCK
TIME
ELAPSED TIME SINCE
PUMPING STARTED/
DEPTH TO
DRAWDOWN!
PUMPING
STOPPED, MIN.
WATER, FT.
RECOVERY
RATE, GPM
REMARKS
0
(SWI)
0
0
Start 641 FLk4l
L�
1
5
\
3
10
15
20
2_
257.4
30
l
2.
p 3
35
40
45
50
55
60 (1 hour)
90
ZIS"
120 (2 hours)
p
'Z Wy
Z40
2_
G
150
180 (3 hours)
�JiUI �M
210
D
O
_
240 (4 hours)
�QI.00d.•� OpDY4y�4YLV
RECOVERY
� `T �l
t 0
0
.
® TPS
10
15
[A <.
20
lfj
25
30
35
Comments:
V1► �� 1 I Flow is not Guaranteed
AA Subsequent Variations
Can Ocdur•
MAWIPAMU
N COV 12 19A
t. i-l��zt��i-i�►��r� services
SIX INCH WATER WELL DRILLED --
---—OUT TO THE DEPTHD�NOF
DRILLED AT THE RATE OF 4 23.00 PER FOOT.
PROPERTY OWNER Mr. 9c 'sirs. (Kirk & Marilyn) McGee 345-1827
QnL-A_ h� ,r
LOCATION OF WELL SITE Lt. ,!� Blk. Sub. 16550 Chasewood Anchorage, AK
DRILLER Bernie Claus of Fampart Drilling Works.
WELL LOG:
Initial Water Well deepened from 405 feet to 705 feet. Invoice 225 feet.
405 - 705' A sedi-metamorphic bedrock. Several areas of weathered fissured
bedrock with potential water bearing granular formations. An aquiferous
area between 693.to 698 showed good latent water supply, however, with
high resistance (fine porous rock) not allowing the water to break in with
good quantity. Several times during the year (spring & fall) this Well
should improve dramatically as more pressure from a greater quantity of
water from any moderately heavy rainfall occurs. This Well should, with use,
improve greatly from what it produces presently.. 240 GPD. This Well, poten-
tially should prove to be 1,200 GPD. Time should prove this information cor-
rect. Hydrofracking may or may not speed up the breakin of water thru this
fine porous rock.
Water recovery at its full static level should be within approximate sixty
feet of the surface.
All effort was ;made to afford the greatest amount of water possible in this
Well. :pow, time is of the essence as this Well increases in yield.
511,000.00 paid on this account 6-29-90. $23.00 per ft. x 225 ft: $5,175.00
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF $4,175-00
THANK YOU VERY MUCH.
BERNIE CLAUS OF RAMPART ILLING WORKS
DATE July 127 1990
SERVICE CHARGE OF IV2% PER MONTH WILL BE ASSESSED ON PAST DUE ACCOUNTS.
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KIRK MCGEE
KIRK MCGEE WELL FRAC l NG 15/08/91
ANCHORAGE WELL & PUMP SERVICE
NAME:
JOB LOCATION:,
DATE DRILLED:
DRILLED BY:
WELL DEPTH:
CASING DEPTH:
ORIGINAL PRODUCTION:
STATIC LEVEL:
FRAC DATE:
PRODUCTION PRIOR TO FRAC:
PRODUCTION AFTER FRAC:
CHANGE IN PRODUCTION:
FRAC SETS:
WATER INJECTED:
PACKER SETS:
REMARKS:
TIME
KIRK MCGEE
16550 CHASEWOOD
ANCHORAGE, AK
5/15/82 & 7/12/90
RAMPART DRILLING
705 FT (ORIG 405 FT)
58 FT
1.25 GPM
164 FT
8/13/91
17 GPH TESTED: 8/13/91
147 GPH TESTED: 8/22/91
765% INCREASE
5
1395 GALS
1
JOB
ACHORAGE WELL & PUMPS SERVICE
6901 Tanaina Drive SHEET NO.
ANCHORAGE, ALASKA 99502 CALCULATED BY
(907) 24.14 !n
T.,.. CHECKED BYr
SCALE
OF
DATE___..__.
._..--- LA
APPLI( 'NT FILLS
OUT UPPER HA` ' ONLY
Property Owner p �`�
Time
/F14,ne
Mailing Address
Zip Code
Date
Buyer AC
Inspector
Inspector
Address
Zip Code
Inspector
Lending Institution // J /
Phone
( ) APPROVED BEDROOMS
(' ) DISAPPROVED
( ) CONDI ONAL PPROVAL•
DATE 2
BY:
'CONDITIONS OF APPROVAL
Soils Rating
Address
Zip Code
Well Log Received
Realty Co. & Agent
Phone
Address
Zip Code
Legal Description
Street Location
Type of Residence
Single Family
❑ Multiple Family No. of Bedrooms
❑ Other
Water pply
Individual
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
Community
For wells drilled prior to that date, give well depth (attach log
if available).
❑ Public Utility
Sewer .,'sposal
EVIi
ndividual
Year Individual Installed:
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
( ) APPROVED BEDROOMS
(' ) DISAPPROVED
( ) CONDI ONAL PPROVAL•
DATE 2
BY:
'CONDITIONS OF APPROVAL
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well to Tank
Well Log Received
Septic Tank Size
72023 (3182(
ALASKA 6101ROnCY PTAL COnTROL SCC IUS, InC.
engineerinq & Cnuironmental Studies
September 21, 1983
Municipality of Anchorage
Department of Health & Environmental Protection
825 L. Street
Anchorage, Ak. 99501
Re: Health Authority
On September 19, 1983 our company collected a water sample from the
house located on Lot 5 Block 0 Another Subdivision. The property owner
is Kurk McGee. The water analysis was satisfactory. A copy of the
report is attached.
The well is located 104 feet from the septic tank and over 104 feet from
the leach field. The electrical wires are encased in conduit. All the
standpipes are capped. The well casing stands are 2 feet above ground
and has a sanitary seal.
—Of
ILL 4
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1200 West 33rd Auenue, Suite B • Anchorage, Alaska 99503 • (907) 276-1361
Municipality of Anchorage
Development Services Department 1 ►':
Building Safety Division
On -Site Water 8 Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 020-093-34 HAA# C1 Z V
1. GENERAL INFORMATION Expiration Date: —17— O 3
Complete legal description ANOTHER SUBDIVISION: LOT 5.
Location (site address or directions) 16550 CHASEWOOD LANE • ANCHORAGE. AK. 99516
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
LARRY do HOLLY DRAKE Day phone 345-8466
16550 CHASEWOOD LANE • ANCHORAGE, AK. 99516
Day phone
CAROL BUTLER w/ REMAX PROPERTIES Day phone
2600 CORDOVA STREET • ANCHORAGE, AK. 99503
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
3
257-0116
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 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.
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
❑
Individual Holding tank
❑
❑
Community On-site
❑
❑
Public Sewer
❑
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 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.
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $ ��: s --at, or prior
to closing for the engineering services provided.
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 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 ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone 337-6179
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, AKWWC, Inc. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & 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 identifiable 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. AKW WC, inc. 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
Approved for 3 bedrooms.
Disapproved.
Conditional approval for
Date 03
f eA.�Gprr s..
—7953 eeG
�0Wn Professlol °_��
bedrooms, with the fllowing stipulations:
WASTEWATER
Attachments: �/ '.,�cn_•.• •••5����,
HAA Checklist Manitenance Agreements ���i��0 ••i��\�
Septic System Advisory
Well Flow Advisory
Supplemental Engineer's Reort ���J11J1)i111111
Other
By: Original Certificate Date: G ` Z 7- U3
(Rev. 12101)
0
M
0
FA
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Sragaw SL
P.O. Box 196650 Anchorage, AK 9951"650
www.cl.anchorage.sk.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ANOTHER SUBDNISION• LOT 5 Parcel ID: 020-093-34
A. WELL DATA *WELL DEEPENED FROM 405' TO 705' ON 7/12/1990
Well type PRIVATE If A. B, or C provide PWSIDff N/A
Date completed 05/5/1982 Sanitary seal (Y/N) YES
Total depth 705 fL Cased to 40+ ft.
FROM WELL LOG
Date of test 7/12/1990
Static water level 60 ft.
Well Log (Y/N) YES
Wires properly protected (YM) YES
Casing height (above ground) 12+ in.
AT INSPECTION
5/13/2003
120 ft,
Well production 010 g,p.h, 04.19 g,p,m
WATER SAMPLE RESULTS: 'WELL FRACTURED IN 1991 AND REFRACTURED IN 1996.
ALSO NEW PUMP INSTALLED IN 1996.
Coliform a_ colonies/100 ml. Nitrate 0.1 mgA. Other bacteria 0 colonies/100 ml.
5/20/2003
Arsenic: N/A mgA. Date of sample: 5/13/2003 Collected by: AKWWC, INC.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEEL Date installed 4/3011982
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (YM)Y, ES Depression over tank (YIN) NO High water alarm (YM) N/A
Date of pumping 5Z13/2003 Pumper DENALI PUMPING
C. ABSORPTION FIELD DATA BELOW EXISTING
Date installed 4/3o/lasz Soq rating p.d r ftilbdrm) 125
Length 33 ft. Width 3 fL
System type DEEP TRENCH
Gravel below pipe 8 ft.
Total depth'1. 0.411 ft. Eff. absorption area 510 ft' Monftoring tube YES Depression over field NO
Date of adequacy test 5/13/2003 Results (Pass/Fall) PASS
Fluid depth in absorption field before test 39 in. Water added 6f 6 gal.
For 4 bedrooms
New depth911 in.
Elapsed Time: 28 min. Final fluid depth42_25in. Absorption rate >= 600+ g.p,d,
i ' 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.
Datum
E. SEPARATION DISTANCES
Size in gallons
High water alarm level at
Cycles tested Meets alarm & circuit requirements?,
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankpift station on lot
100'+
Absorption field on lot
100'+
Public sewer main
N/A
Sewer /septic service line
25'+
On adjacent lots 1000+
On adjacent lots 1000+
Public sewer manhole/deanout N/A
Holding tank N/A
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 100+ 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, parking/vehide storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION o r
o� • /9S�D�I
I certify that I have determined through field inspections and y
review of Municipal records that the above systems are in • "' ' ' • • "' • • "' • • • • ' •
conformance with MOA HAA guidelines in effect on this date.
OO P .J fir y A. rness;
Engineer's Printe Na a JEFFREY A. GARNESS Q . E-7953 •••.�:�
Date S 1 t3 3 >1*a ea ' • • .... • • VUOL
HAA Fee $ 395.
Waiver Fee $
Date of Payment 62-13-03 Date of Payment
Receipt Number 3((,19 Receipt Number
(Rev. 12/01)
a
cNAS003 IC3 /
P
99 lift �
115
to 1
w0 33iOa
5-19-03; 2:08PM;
SG91
SGS ReO 1032613001
Client Name AK Water & Wastewater Consultants Inc.
Project Name/# 16550 Cbasewood Ln
Client Sample 1D 16550 Chasewood Ln
Matrix Drinking Water
;907 5615301 # 2/ 3
All Dates/rimes are Alaska Standard Time
Printed Date/time
05/16/2003 11:41
Collected Date/rime
05/13/2003 12:40
Received Date/I7me
05/14/2003 9:07
Technical Director ` Stephen C. de r
Released B
Sample Remarks:
Allowable Prep Analysis
Parameter Results PQL Units Method Limits Date Date Init
Waters Department
Nitrate -N O.lOOU 0.100 mg/l. EPA300.0 (<=10) 05/14/03 JS
Microbiology Laboratory
Total Coliform
coVl00mL SM189222B (<=j) 05/14/03 SKW
In
U
5-19-03; 2:OePM;
;907 5815301 >< 3/ 3
mm
CT&E. Environmental Services Inc.
mmtlm L Laboratory Division t'o®a®mos000eosmomoommmmmoroorrvmmem.�ms�mo►aimr®oma
200 W. Potter Drive
finking Water Analysis Report for Total Coliform Bacteria Anchorage. AK SIMI8-1605
READ INSTRUCTIONS ONREVERSE SIDE BEFORE COLLECTING SAMPLE Tel: (907) 562-2343
Faz:(907)661-5301.
MUST BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY
o PUBLIC WATER SYSTEM I.D. fl Analysis shows this Water SAMPLE to be:
PRIVATE WATER SYSTEM Satisfactory
O Unsatisfacto
O. Send Resuks O Send Invoke
Noes„ b oa um�r
.. rY
. 0 Sample over 30 hours old, results may
be unreliable
O Sample too long in transit; sample should
not be over,�+Chours old at examination
to indicate reliable result'. Pleate send
new sample via special delivery mail. -
Datelleeeived -� a
Time Received
Send R !/s1,16 Send Invoice �Q
Analysis Began
alr aW11 f,z--
SAMPLE DATE: Em m
Month Day Year
SAMPLE TYPE:
Routine
O Treated Water
O Repeat Sample (for routine sample
Untreated Water
with lab ref. no: )
/�
O Special Purpose
Time
Collected
/ SAMPLE L C'ATION
Collected
By
�1s391, r te p
/2 0
640•
•
deme hinl
Analytical Method:. A!r Membrane Filter
O. MMO-MUG
1032613—A— Result*,
Analyst
clto
Sent to A.D.F.C. Anch Fbks Jun ❑
Fazed
Date: Time:
Client notified of unsatisfactory results:.
Phoned Spoke with Fared
Date: Time:
BACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-MUC Result: Total Coliform E. Coli
Membrane Filter. Direct Count IliS 0� Gtym foCi� _ Colonles/100 ml
Verification: LTB
Fecal Coliform Confirmation
' Final Membrane Filter Resuli
Reported By/•
Comments:
P.GB COLI FIRM TNTC- Too Numerous To Coom
OB-orkefooeeerk
Date
. Coliform/100 mi
Time O D 3o hrs
Member of the SGS Group (SocidtA Gdndrale de Surveillance)
•' -•- •••..•••..w .une•nnm ue:.M 1"C" AWIA WFFr VMINIA
6-13-03; 2:04PM;
drinking Water
;907 $615301 0 1/ 1
CT&E Environmental Services Inc. „
200 W. Potter Drive "
Anchorage, AK 99518-1605 r
Telephone: (907) 562-2343
.Facsimile: (907)561-5301
200 W. Potter Drive
Re ort for Total Coliform Bacteria, Anchorage, AK 9951.6-1605
Tel: (907) 562-2343
YF.R.VRSME.BEPORECOLLBCrIN�SifMPM fax: (907).561-5301
BY
o PUBLIC WATER SYSTEM I.D. #
., nvn�sR•1c WATRR CY.STEM
SAMPLE DATE: • '® '
FI
Afontp Day Year
SSiPLE •ITPE:
][0 i Roptine
((( C) liepeat Sample (for raytine saGiple
withlob rrGiw: —)
13 Special Purpose
Comments:
. O _ Treated Water
Untreated Water
Time
Collected
ti, / 0 Date' Time•
" J • . a Pk14eNLN ' -
BA;CTERIOLOPICAL WATER ANALYSIS RXCORD
MrAO--MUG Result: Total Cullform B Coil
WSembraheFilter: Direct Count CAlonies(lObml
Verification: LTB BGB _ COLIFIRM
Fecal Coliform Confirmation 1
Final Membrane filter Results Coliform/I00 ml
Reported By Time - brs
Collected
By.
Analysis shows this Water SAMPLE to be:
Satisfactory
O Unsatisfactory
13 Samplc.over 30 hours old, Tesults may
be unreliable ,
O• Sai pj too folig iri.trznsi sample should 1
noEbepveatfi6grs ald'at examination
to indicate reliable results. Please send I!
•near sanlplei via special delivery.mail
Date Xteeti ed' ' - A' 3 .
Time Received
Analysfi Began
Analytical Method: � Membrane Filter '
o mmommuo
10 ml.
1032730' — Result* Analyst
fmolzN
Sent to &D.E.C. • Ancb Fbks Jun
F3❑xeA
Date: Time:
Ciieni notitied of unsatisfactory results:
❑ ❑
Phoned Spoke with Faxed
•Lws.Ls 6n c r....... tc.:.i6•d f:6nd•n 1e -Ru..re;lt...�.�
TNTC -Too Numerous To Count
03 -0(her BocMta