HomeMy WebLinkAboutT13N R3W SEC 13 LT 3 OF GAAB TR97/AKA BLM L107 (TR 97 BEING SW4SE4SW4NW4) (2)
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~ ' MUNICIPALITYOFANCHORAGE , _ _ ' ~ . _.
(~I~,~'~) '-DEPARTMENTOFHEA~.TH&HUMANSER~/iC~Si:' '~-
-.~ ~: Division of Environmental Services; --, ·
::, _t- . , :~, ......- . ~,. On-Site Services Section ." .;~.'.,~ ~
P.O. Box 196650 Anchorage. Alaska 99519-6650 343-4744 .- '..
~_~-~ocation (~it~ address ordimction~) . ~ .
.... '3. ~PE OF WATER SUPPLY: - _.-
Individual well
' Commun'ty we
. . .... ':~-':: ... . . . ..... . . ' . .- . ' ~ , ._ _ ~;['~-, :.,._ ..... : . ..:: ."
- ~ Pub c water
.. 4. ~PE OFWASTEWATER DISPOSAL.-:-/ : : :- ......... : ...... :~ -z '~ ~' ---r ' ~ ~-.',~,,
' ~: .- -/ - ~lndividual0n-site {-.~.
· ,~-'- ~::::'~:' :'~- --:~ "t ":Cc
. ~ ..... .. . . . .... ~ .~ ~ Pubhc sewer.?.~-~:~.:~:~.,.~.~:.~ .... ~ ..... ~ ....................
~ - "'~:/;~ ;"NOTE ~, wfi~en confirmation fromStateADEC'-?- -
a~esting to the )egaliG '
72~025(Rev. 1/91) Front MOACY21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L. ~ 'Tr.. I o 7~ 5~ c f2., 'T t 3 N.~ r~ 3 uc~ Parcel I.D.
Ao Well Data
Well type
Log present (Y/N) N
Total depth qO'~ ~ p~r ~' ~£_~
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~ I '/'-/7 Driller
Cased to ~/'¢, ' ~- Casing height
Wires properly protected (Y/N)
FROM WELL LOG
_g.p.m.
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
I'"1'
Septic/holding tank on lot N.A.
Absorption field on lot
Public sewer main II (3'
Sewer service line
.¢~(~J ; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank~ he'
WATER SAMPLE RESULTS: ~/ ~n~ ~ ~e~ ~'*~ ~/~ p~o~ ~ ~'~1~
Coliform 0 Cot /eoO~ Nitrate ~ O. /~(.~ Other bacteria No~e rego.'~
Date of sample: ~5-~ ?~ Collected by: ~/~f~ ~ch~;~/ ~u,~
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size
Foundation cleanout (Y/N)
Compadments
Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72_026 (3/93)O Front CONTINUED ON BACK PAGE
04×06/9S 1S:39 COMMERCIAL TESTING ~ 907345135S N0.168
,~tK CT&E Environmental Services Inc.
Laboratory Division ~'~"~e'lJ~:~'~',~J~'~e'.e'~'~'~'l,~l~lJl~f~ff~~
Drir&ing Water ~alysis Repo~ for Total Coliform Bacteria 2~ w. ~o.er o,~,
Anchorage. AK 99618-1605
~AD I~TR UCT[O~ O~ ~FER~E ~IDE BEFOg' COLLECTING S~MPLE Tel: (9071 562-2343
~ST BE CO~LET~D BY WATER SUPPLER ~
TO Bg COMPLETED BY LABO~TORY
PRIVATE WATER SYSTEM
Send Re~tt& ~ 3'end lnvolee
r E1 SendResults
Mouth Day Year
SAMPLE TYPE:
~ Routitte 0 Treated Water
0 Repeat Sample (for roatlne sample ~' Un{reared Water
with lab ref. ad. )
[] Special Purpose
TiRIa Collected
SAMPLE LOCATION Coll~led By
Analysis shows this Water SAMPLE to be:
,J3''~ Satisfactory
I~ Unsatisli~ctory
rj Sample over 30 hours old, resulls may
be unreliable
0 Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. P~e~e send
new sanlple via special de}ivery mail.
Date R~eeiv~d
'rime Received .
Analysis Began
AnalyticatMethod: ~ Membr~eFJlter
O ~O-MUG
* Number ofcoloq~gs/100 mi.
Lab Ref, No. Result* Analyst
~.1270
~ ~
Client notified of unsntisfaetory result:
"/' .tr V,../ i Date:
BACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-MUG Result: Total Coliform £. Coil
Membrane Filter: Direct Count 0 Colonies/lO0 mi
Yerifieatlon: L'rB BCB COLIF]RM
Fceat Coliform Confirmation
Fhmi Membrane $~ter ResultS/
..por.~.~ _ / :^ 0'3 .a,. ~:- 6. ~ ~'
Coliform/tOO mi
Time ./~ hr$
Faxed
Faxed
84×18/95 08:22 COMMERCIAL TESTING ~ 90734S1355 N0.236 ~02
CT&E Eef.#
CT&E Environmental Services Inc.
J~bor~tow Division
~.~e-~ Laboratory Analysis Report
WA?ER
Ordered By TED MOORE
ProJecu Name
200 W Potter [}rive, All0horage, AK 99518-1605 -- Tel: (907) 562-;2343 Fax: (907) 561-5301