Loading...
HomeMy WebLinkAboutMAJESTIC VALLEY ESTATES BLK 2 LT 10 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT DISTANCES Address ..... ~ TANK FIELD WELl. Phone(s) 15ermitlNo. ' ~'o. o~ ~dtSbr~s' WELL - ' ' LE~SCR~T,O. LOT LINE / 0 ~j~c ~ ~c~ FOUNDATION -- / Township, Range. Section - i AS-BUILT DIAGRAM (Show location of well, seplic system, property hnes, foundation. '~--~ ~ ~ j~l W ', ~ ~--~ drlveway, waterbodms, etc.) TYPE OF SYSTEM - ~TRENCH ~ BED ~ W. DRAIN ~ OTHER _ · '.01 ~ . Fill added above original grade Gravel depth beneath pipe ~ FT ~, ~- ET Total absorplion area Dislance bet .... lines Number of lines Soil raling Pipe malerial / o." D PRIVATE ~ OTHER (Identify) Classificatio n (A,B.C, Tola, Depth Cased ,o ~/: Installer ~ Date Installed: · .......... REMARKS: ~ x ~J"~ DII~I ] -- 11034 ~le ~w~ L<mp Road N~ ~ ~ Municlpa~ annotate ouidehnes in effect on Ihis da e ? ~ -- / / 72-013 (3185) )')lii:'M i ,WT I Ol',l F:'F;:C)M AF:'I:::'f;;:C!VIZ)D li!;l",[(?J il: NE:Ii!i:P. ' E; O',EE; I (!:il',] I'"ll..!!ii~ }" ?,AVI_:i: )DH['-I~ii; AF:I:::'I:W.)V .... ~.'.11. F'I::~: I OFi'. i(;! CC}I",IS'I'I':~t}C'I ! I:)l",l ,, NOT' I t::'Y ~:)l'"lI"l!i;~ I:.':d.Cl:::'[ll:;~li? Cd..[.. I I",.I~;~F:'ECT :1: ON!!;. :OF,.'.ih:l:NF'liiii:L)::) IEXC,t::!V¢::I'f !01',1~!:; Mt.J~F~T :~:'~!!: OP!ii!lNl!!:1:) Ai',[O CI..EiSIE:O ON 'f'HIE S¢.:~FIiE UI::;: l":','t!!: f...llli:.&TF'i:O I::)VF::I:d',I ;I: I:iil'l"f' ,, 'l'l"i :l: ~ii; f:::"EJ::?.I"1:1: T I (ii~ F:'UI::¢ ~.'~ .4. i::-,'N S :[ t'q(i"~L. Ei: F:(:.l?"l I I...Y Fk!:!;!ii:i :!: )::';,IZI',I(:::I:i C)I',.II.."¥' Cd,.I):) [ii: )','. l:" I I:RE!!~ I::~lq :t.;.:.~:/3 1 18V, lEX .l: [ilFF :r. N(:'¢ }..:',Ii:il:) I"II.I'.ST BIE I:::'1::~0 PIi.:F;'J....Y ¢lB¢::'fl',l):)t::)hllii::O ,, I. :i: I:::'t' S'f ¢.YI I [::)lx[ I:.~lii:[:,!l.J :1. I::dZS !:ii:I_[i!:E;TF~ I CAI.. I 1"4SI::'I!::E;'I :I; (:fi,.! ,, (E,,.?INEER'S SEAL) 1¢%, (y!:' ,,? . ', ~ Municipality of Anchorage ~,~ ~12~' ,"~ ~'o~'}~~ DEPARTMENT OF HEALTH & HUMAN SERVICES ¢ ~ 825 "L" Street, Anchorage, Alaska 99502-0650 ~,~,.,~ ~ ,~ ~:~ SOILS LOG -- PERCOLATION TEST ~ ~ SITE PLAN ' ; SLOPE 1 3 / 7 8 ~ WAS GROUND WATER 10 ~M "' ~"'~ ENCOUNTERED? ~ f IF YES, AT WHAT E Deplh to Water After ~ t3- t, Aoniloring? ~2 Date: \\~1[ '~ Gross Net Depth to Net Reading Date Time Time Water Drop 15 16 17 18 19 2o PERCOLATION RATE % (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEE~2FT AND FT COMMENTS 11034 Eagle Hlyer ~uup a~ I~o. W84 ~/~ // PERFORMED ~ R~er: Alaska 99577 /~./ ~/' CERTIFY THAT THIS T~T W~S PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDZ~N~F~CT ON THIS DATE. DATE: 72-008 {Rev. 4/85) GRE/~ER ANCHORAGE AREA B0k. dGH Department of EnvironmentsI O. uslity 3330 C Street Anchor@ge, Alaska ggs03 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION ~J I~, ~1 I' h Ct;z~ b. LEGAL DESCR,PT,ON SEPTIC TANK: o~ ~'~"~ DISTANCE ~ 0 FROM WELL MANUFACTURER INSIDE LENGTH INSIDE WIDTH ~ DRAIN FIELd: I -~ °~ .,~.~ ~,o~w~.. ~0 ~o~.o. MATERIAL ~.C:,C)-~ LIQUID DEPTH PHONE NUMBER OF COMPARTMENTS LIQUID CAPACITY~-"~ GALLONS. NUMBER OF LINES ABSORPTION AREA DEPTH: I TOTAL LENGTH/ NEAREST LOT LINE ,,~'~-~ OF LINES q -~ ~ ~ SQ. FT, LENGTH OF EACH LINE~~j~(~-L4'~l ~ i J DEPTH OF FILTER TOP OF TILE TO FINISH GRADE g MATERIAL BENEATH TILE l ~_ IN. ABOVE TILE WE LL ~,---'- DISTANCE FROM: BUILDING NEAREST NEAREST SEPTIC FOUNDATION_ LOT LINE SEWER LINE .... TANK CESSPOOL OTHER SOURCES APPROVED_ DISAPPROVED REMARKS SEEPAGE SYSTEM DISTANCES~'/ INSTALLED BY: I J~'~ ¢-~ ~ SEWER LINE D~ PIPE MATERIAL: LOT SLOPE: DIAGRAM OF SYSTEM Form EQ-032 BUILDING SKETCIt Lol Location Sketch including tho p]otling o! the location al any adverse influ*nces: SEE ATTACHED SUBJECT PIIOTOGRAPIIS FRONT 6 REAR STREET SCENE Real Estate Services Corporatim~ Drillinl~ Ce. .~...-~,=~( ''~' We~l lacatien ~addrees & legal deseriptiun) ~'ELL CONSTRUCTION LOG Depth of wet ~'~- ft. Caein~: depth ~-~'~ ft. Static water lave[~,~' ft. (above. below) land surface. Date Finish el well: (open-end, screen, perforated, open-hole, other) Describe inlervals and size; Well yield tested by (pumping, hailing, air) al. for L/¢ . heirs with _~ ~_ ~[. ~1 dr3.dnwn USOS ~,o _Date well completed_ ,,-- K" ' ~ " Nearest community ~Y-.f, ;, r/~' /~ './":./~, LoceJJon sketci~ or re[earks ~al/min. DRILLER'S MATERIAL LOG Depth below lend surface ~n feet Give description of strata penetrated (size of material, color, hardness of driliinR, and water content) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D, # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 10; Block 2; Majestic Valley Subdivision Location (site address or directions) Vallihi Circl~ Property owner Mailing address Lending agency Mailing address Laura Cain P,0, Box 230146 Anchoraq¢, Day phone 696-2887 AK 99523 Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WAS'rEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public'sewer NOTE: XXX If commuhity wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA 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. NameofFirm S&SENGINEERING ~ Phone ~'~'¢'¢7/') Address Ea:tle River, Engineer's signature ././~. _~ DHHS SIGNATURE (/ Approved for /~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments _ . Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in pdragraph 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. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~.oT' A. Well Data Well type Log prese.~l) Total depth Sanitary seal ~) Date of test Static water level Well flow Pump level1 J~C~ ~ fvl/~Ze~l"/c YALL~YParcel I.D. If A, B, or C, attach ADEC letter. ADEC water system number Date completed (-~ / c~c~ Driller Cased to (~/' ! Casing height Wires properly protected (~N) FROM WELL LOG ':E/BALL FLooo // g.p.m. AT INSPECTION g~¢;i~,ONM~.NTAg sERViCES DtVlSiON ~' ~ g.p.m. RECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/heldin9 tank on lot Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots /0o '-/- Public sewer manhole/cleanout / (~ %'~ Petroleum tank ~.~ '~ WATER SAMPLE RESULTS: Coliform (~ / [G'O~ Nitrate Date of sample: ---q~/~ / ~ B. SEPTIC/HOLDiNg-TANK DATA Date installed r-J//5' I~7.~.Z __ Cleanouts (Y~) ~__~, ~,l~ ~"/~ Other bacteria 0//oo/-~ C0llectedb/byl ,~"f~' E--~FU~/M~/~,//O~ -- Compartments 'Depression (Y/~ High water alarm (Y~). Date of pumping Tank size / ~_~C~ Foundation cleanou~N) Alarm tested (Y/N) Pumper ~ SEPARATION DISTANCES FROM SEPTICkN~=EHNG'TANK TO: 1o/~ Well(s) on lot /~)L~ / ~ On adjacent lots To property line /O C/-- Absorption field Sudace water/drainage. (/ Foundation ~ [ Water main/service line ,/- 72.026 (3/93). Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPAR~TION~ STATION TO: .~n. Jot--'-~ On adjacent lots D. ABSORPTION FIELD DATA Date installed / 2, / 2_./ Length Width /'-'- Manufacturer Manhole/Access~_YjN)-'~'- ...----'/~"Pump off" Level at ~ycles tested Surface water Soil rating (GPD/FF) l_~'{~'~/,~,¢C System type .~'~ / Gravel thickness ~, %' Total depth ~ / Depression over field (Y/~ ~ ~---~ ~,/-~'~) Bedrooms Total absorption area ~'~ Date of adequacy test ,~//~-'~ / ?<~- Results~'~ail) /~/gr-,J.~ for Water level in absorption field before test J.'~ After test Peroxide treatment (past 12 months)(Y/N),~E)/L j~-~c'J L~/''* J/' J If yes. give date Cleanout present(~l) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / To building foundation On adjacent lots Sudace water [ ( Curtain drain ,,,'~'- On adjacent lots (~ ©~-~/-~ Property line / ~_~ / To existing or abandoned system on lot Cutbank Nd)/d~/¢,~¢¢,~'C-r~J?"~Watermain/service line / (~ /'~/ Driveway, parking/vehicle storage area /~) E. ENGINEER'S CERTIFICATION I cerb'fy that I have checked, verified,..or~conformed to all MOA and HAA guidelines in effect, on.the~date of this inspection. .. ~ . . .: :.~ -~,- ,,:~ .~ ,: , ~":".-'";/::7-'~" ~':-"..~: ..... ? .~%? Signature Engineer's Name Date HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)' Back CT&E Ref.# Client Sample ID Matrix Commercial Testing & Engineering Co. Environmental Laboratory Services ~/~7/~7~z/~?~?~/7/7/7~'.~.~/7~77/~/7/~'£?/?/7~J/J~f/~z~~ LABORATORY ANALYSIS REPORT 94.2072-3 L10 BLK2 MAJESTIC VALLEY S/D WATER ClientName S & S ENGINEERING Ordered By R.J.S. ProjectName Project# PWSID UA WORK Order Printed Date CollectedDate ReceivedDate Teclmical Director Released By: 78094 05/10/94 ~ 10:38 hrs. 05/05/94 ~ 10:50 hrs. 05/05/94 ~ 12:45 lu's. STEPHEN C. EDE Satnple Remarks: ROUTINE SAMPLE COLLECTED BY: S.S. QC Parameter Results Qual Units Method Allowable Ext, Anal Limits Date Date Init Nitrate-N 0.25 mg/L EPA 353.2/300.0 10 05/06/94 MCE * See Special Instntctions Above ** See Sample Remmks Above U = Undetected, Reported value is the practical qum~tification limit. D = Secondary dilution. UA = Unavailable NA = Not Analyzed LT = Les s Than GT = Greater Than 5633 B Street, Anchorage, AK 99518-1600 --Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA COM M ERCIAL TESTING ENViRON¢¢ENTAL LASO.mATORY SERVICES ENGINEERING; CO. Drirfi<in; Water ~&r~atysis R~,po:L for' Total Colifo,_wn B a~..~ ~ .:.,~:~:**?:..,.?, .~,e:~ READ INSTRucTIO:Y$ O,'Y PU~PT~RSE SIDE B~z~ 0~5. COLLECTING $,,t~fPLE r-ri: (,07) s_=2-23~'3 ; '7 p~-- on~ or ~7~D BY WATER SUTPL~?. :~CS ............ WATER SYSTEM 2_\'~LE D ATE: Routine ~fonth Da)' Year Repeat Smmpte (for routine sample with lab ref. no. ) Special Purpose S.&~EP LE LOCATION /__07"/0/~L,/<' Z Treated V/afar _ Untreated Water Time Collected Collected By TO BE r-ox4-~I ~T~ BY L.z..~O?~&TOR~'' .&nal)'sis shows t?2s Water < ' ~ ~ - S~mu[c over qn ~,,-~ -!~ 7e~ may be ~eiiab!s S~o!e too long in u~h: s~~'~ <hO'dR no[ oe os~, ~8 hours cid at to indicate reliable :as'aT new s~ms!e :% . Date ~ecen'ed Time Received 1 .~zbxical Method: Lash:in.: F:::-:: .x,D, rO-.M'UG Result: Total Celif?m y, fembraneFiiter: Direct Count Verificadom LTB ~ ",~' ~- ofcolonies/i00 mi. Lab ReL No. 7~Y, 2~aT'Z Sent to .~ D.E.C. Resuit' Client notified of unsatisfactoc: results: .&q ai?'st Phoned Spoke ,~ith BACTERIOLOGICAL WATER AX.&LYSIS RECOZLD E. CeE. (~ Colonie$/100 mi BGB C O L ~' 'ZPC',I~_ Fecal Coliform Confirmation Final .Membrane Filter Result/st Coliform/100 mi MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I,D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) LOT I0; BLOCK 2; Majestic Valley Estates; Location (address or directions) (b) Property owner Mailing Address (c) Lending Institution Mailing Address Roke~.t We~t Telephone:(home) 349 (,)~ang~ES.t. Ancke~ag¢, A.Ea~ka 99501 Telephone Business (d) Real Estate Company and Agent P¢.r~:n~, R¢.aZ,f:y/ GerJrg¢_ Perh~.ns Address 17~9 Eagle_ Riv¢_~ Road~ Eagle. Riu¢.r~ Ak. 99577 Telephone 694-3594 (e) Mail the HAA to the following address: (or check her~, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eagle RNer Loop Road Eagle River, Alaska 99577 TYPE OF RESIDENCE Single-F'amily J~ Number of bedrooms WATER SUPPLY Individual WelN~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Consei:vation attesting to th legality and status. SEWAGE DISPOSAL On-site [~ Public [] Community [] Holding Tank [] Nole: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 ')JJOM S,JSeU!J.~u9 leUO!SS@JoJd eq~ u! SUO!SS!LUO JO SJOJJe JOJ. elq!suodsaJ lou s! el~eJoqouv jo ,q!led!o!un~ @q.L 'penss! s! m, eo!~RJeO e e~ojeq m, ep eZXleUe Jo suo!loedsu! jonpuoo jou op S}-{HC] ,LO seeXotd LU:3 'slueuJeJ!nbeJ e~els pue leJepe~ u!e~Jeo XJs!les ol JepJo u! 8u!puel J!eql pue sewoq jo sJeseqoJnd oh 4se~Jnoo e se s!ql seop SHHCi eqj. 'e>lSel¥ ,to elm, S eq~, u! peJeis!iSeJ Jeeu!Sue leUO!SS@,toJd ~,uepuedepu! ue Xq e^oqe S'qdeJl~eJed u! ua^!8 suoRm, ueseJdeJ eq~, uodn/~lUO peseq le^oJdd¥ X~poq~,n¥ q~leeH senss! (SH HC]) seo!^JeS ueLunH pue q~leeH jo ~,UeLU~Jedeci e6eJoqouv ,to X+!led!o!un~ eq_l. leUO!l!puoo leAoJdd¥ leUO!~!puoo ,to sLuJe_l. peAoJddes!C] X peAoJddv Xq SLUOOJpeq ~ JOJ peAo~ddv 'IVAOI=IddV SHHa '9 ~)Ni~i~INION~ $ '8 S euoqdele/ wJ{-I ,to eweN e~ea sse~pp¥ ,,-~/, ~. ~' Health Authority Approval (HAA) <,~,,~'~' ~."~¢g-'J,/ CHECKLIST- FEBRUARY 1984 ~.i~.~-~' ~ ¢¢;~:'"'"~----~,, ~. ~ 343-4744 . ~' )~ % . ~.. ~ LegalDescription: ~/~ A. WELL DATA Well Log Present (Y/N) ~ _Date Completed ~ - 7 ? Total Depth ~ Casedto ~ ~ Depth of Grouting Static Water Level _ % ~ Pump Set At ,' Casing Height Above Ground / ~ + Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) ~ Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ( ~O ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /0~ '¢ ; On Adjoining Lots To Nearest Public Sewer Line ~/R To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ~ ~ ~ Water Sample Collected by ~ ~ ~ ~elN~C¢~ ;Date t / Water Sample Test Results ~5~RO%¢~ ~ ~Ro~¢~ Comments If A, B, C, D.E.C. Approved (Y/N) H~ Yield 0 ~-~¢~ ~q) B. SEPTIC/HOLDING TANK DATA Date Installed -~'/~-'7~-Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) __ Holding Tank High-Water Alarm (Y/N) /~J/~ SEPARATION DISTANCES FROM SEPTIC/H44;NL-G~NG'TANK: ! 'Z. So No. of Compartments ~ Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) ¢ k) Date Last Pumped ~~ ¢~- ~ ~ N/~ ; for ~-- Temporary Holding Tank Permit (Y/N) ~/~ -Fo Water-Supply Well To Property Line To Water Mainr/Service Line 'Fo Building Foundation To Disposal Field /oo f To Stream, Pond, Lake or Major Drainage Course Comments .'Lc,,,,/( ¢¢ 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed / ~ '%,2, Width of Field .D. ~ ~' Square Feet of Absortion Area cf b (~ Depression over Field (Y/N) A~J/ Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot ! ~- ' To Water Main/Service Line ~Oo/T /o/f- ,-~-0 ¢/L~I~'/''' -"' Type of System Design Length of Field ,Z./..~ ~ Depth of Field ..~' z Gravel Bed Thickness I Statndpipes Present (Y/N) Date of Last Adequacy Test To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments / To Property Line / To Existing or Abandoned System on ; On Adjoining Lots / CO "~ To Cutback (if present) D. LIFT STATION Date installed ~ Dimensions Size in Gallons % Manhole/Access (Y/N) "Pump On" Level at 0~ `%'~ ~/% "Pump Off" Level at High Water Alarm Level at l~ '~ Vent (Y Tested for .~ PumPing Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments .:~. ,, **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effe~ inspection. Signed $ & S Company 17034 Eagle River Loop Road No, 204 River, Alaska. Eagle Date . MOA No.C~ ¢ ~ ReceiptNo. ~/~0~F d'~) c-//¢) Receipt No. Date of Payment ,~ ~¢C/~ Waiver Fee: $ Amount: $ //.~ ~ ~ ~ O Date of Payment 72-026 (Rev. 7/88) @ack Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~" ~ -- 5633 B Street ,~~ Anchorage, Alaska 99518 --, Drinking Water Analysis Report for Total Coliform Bacterm TO BE COMPLETED BY WATER SUPPLIER [] PUBLIC WATERSYSTEMI.D.# ~ I I I t I I ~'PRIVATE WATER SYSTEM Name Phone No. S &S ENGINEERING 17054-~e RI;'~' L~""¢I~~N~, ~,04 Mailing A~l,i~]~ River, Alaska 99577 City State Mo. Day Year SAMPLE TYPE: [gt~Floutine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose SAMPLE NO. LOCATION Zip Code Treated Water Untreated Water Time Collected Collected By II TO BE COMPLETED BY LABORATORY sa SiS shows this Water SAMPLE to be: tisfactory Unsatisfactory Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received Time Received _ Analytical Method: ~ ~ 5o Membrane Filter No. of oolonies/100 mi. Lab Ref. No. Result* Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direct Count. ~ BGB_ Verification: LTB_ Final Membrane Filter Results ~) Reported By SL~'-"~' '~Date- Time: _ Collform/lOOml Collform/lOOml p.m. TNTC = Too Numberous To Count OB = Other Bacteria PART ONE OF TWO REMAINDER TO FOLLOW CHEMICA L & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (90~i 562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order ~ 17021 Date Report Printed: SEP 28 89 ~ 18:52 Client Sample ID:LOT 10 ELK 2 MAJESTIC VALLEY PWSID :UA Collected SEP 25 ~9 ~ 14:20 hrs. Received SE? 26 89 @ 12:40 hrs, Preserved with :AS REQUIRED Analysis Completed :SEP 27 89 LaborersW Super¥i~or :STEPHEN C. EDE Released By : ~,~-"~ ~. ~ Client Name : S & S ENGR Client Acct: SNSENGP P.O.~ NONE RECEIVED Req ~ Ordered By : Send Reports to: 1)S & S ENGR Special Instruct: Chemlab Ref ~: 7730 Lab Smpl ID: 1 Matrix: WATER Allowable Parameter Tested Result/Units Method Limits NITRATE-N 0.21 ~/1 EPA 353.2 lO Sample Remarks: Tests Performed * See Special Instructions Above UA=Unavailable None Detected ** See Sample Remarks Above Not Analyzed LT=Lees Than, GT=Greater Than DATE RECEIVED INSPECTION APPOINTMENTS ~{2.~&:)-C/'.-~-~ -' TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPI CT~ MUNICIPALITY OF ANCHORAGE MUNICIPALI~ OF ANCHO~GE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~EPT' OF HEALTH &  825 L Street - Anchorage, Alaska 99501 E~I~ONMENTAL PROTECTION ENVIRONmENTAL SANITATION DIVISION ~/~Y 1 9 1981 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND DIRECTIONS: Complete all parts on page 1, Incomplete requests will i~ot be processed, Please allow ten (10) days for processing, I PHONE 1. p~ERTY OWNER M~ILING ADDRESS /~ ~ ~[~,~ ~ /~,[~ ./~ PHONE PROPERTY RESIDENT (If different trom aoove~ ~, BUYER MAILING ADDRESS  PHONE 3, LENDING INSTITUTION MAILING ADD~ESS -- 5. LEGAL DESCRIPTION Lo1'- ( o ;TREET LOCATION 6. TYPE OF I~ESlDENCE SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One ~ Four E~] Two [~ Five [] Three [~] Six [] Other WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. Awell Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth {attach Icg if available.) '~. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. ~2-010 (Rev. 6/79) 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2, WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified _ [~]Septic Tank or [~]Holding Tank THIS SIDE FOR OFFICIAL USE ONLY NUMBER OF BEDROOMS [] ONE [] THREE [] FIVE [] OTHER TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING Size: give dimensions: TYPE OF TANK If Tank is homemade TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line MANUFACTURER MATERIAL Septic/Holding Tank IAbsorption Area ISewer Line INearest Lot Line 5. COMMENTS DATE ~ APPROVED FOR _ i~' BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev. 6/79) MEMO. 06-1220(a) Rev. 1973 DIVISION OF PUBLIC I-I£ALTH II~DI¥1DUAL AND SEIki-PUBLIC BAClERIOTOG'ICAL WATER ANALYSIS '2601 Lab No. OFFICE INDIVIDUAL [] SEMI.PUBLIC [] CHLORINE RESIDUAL PPM REPORT RESULTS TO NAME ADDRESS CITY . ADDRESS OF SOURCE ZIP CODE COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY DATE COLLECTED ~/ '~J" Sample CoJiecled From [,?Kilchen Tap ~ Bathroom Top ~ Basement Tap ~ Other (Lisl) Well- ~ Dug ~ Driven ~Drilled g Bored [] Tile Brick or [] Open Top [] Concrete [] Under House Septic I /'~! , Tank /_,.~'_~') Feet, Feet. Prlvy-- Feet. [] Fibre [] Asbestos Cemenl SOURCE: [] Spring [] Cistern [] Other Dug Well or Cistern Construction: Walls--[] Wood [] Concrele [] Metal Top -- [] Wood [] Concrele L~ Metal LOCATION: Basement [] Basement Offset GENERAL: Does Water Become Muddy or Discolored? (~ Yes [] No When? /~. f ! ' '~ Malerlol ~ ~F'~Jz' Diameter Depth ZN PURPOSE OF EX~INATION: Illness Suspected? ~ Yes ~ o js61ysis shows Ibis Water SAMPLE to be: factory [] Unsatisfactory [] Questionable [] Sample too long in transit; sample should not be over 48 hours old at examlnat[on fo ~nd[cate reliable resuhs. Please send new sample. [] Bottle broken in transit, please send new sampie. SANITARIAN'S REMARKS CHEMICAL & GI~,~LOGICAL LABORATORIES (,~' ALASKA, INC. TELEPHONE274-3364(907}'279'4014ANCHORAGE §633INDUSTRIAL B Street CENTER Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER I.D, NO. Water System Name ~ Phone No. Mailing Address City State Zip Code s*MP,E D,,TE'. l--f'] Eq--I Mo. Day Year SAMPLE TYPE: D Routine [] Check 8ample (for routine sampls with lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. 1 2 3 4 5 LOCATION ' l I I Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: [] Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Date Received Time Received Analytical Method: [] Fermentation Tube [] Membrane Filter Lab Fief. No. L J L J Result* Analyst I ~T~ *No olcolonies/1OOml or No of Positive portions. READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 {b) Rev, 1978 BACTER IOLOG ICAL WATER ANALYSIS RECORD Date Collected Source ab. NO. Presumptive lOml lOml lOml lOml lOml 1,Omi o,lrnl 24 Houri 48 Houri Confirmatory 24 Houri 4e Houri EMB Broth 24 hours= __Broth 48 IlOUrs= Multiple Tube Report: lOml 'rubes Polltlve/Totel 1Omi Portlona Membrane Filter= Direct Count Collform/lOOml Verification= LTB BGB Reported By Date