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MOUNTAIN MANOR BLK 1 LT 1
Mountain Manor Block 1 Lot 1 #050-671-25 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,, / M//�J//ffEW Z IA l /e . /V E ✓/ L L E PHONE q � �� � ��9d NEW CI LIPGRADE MAILING ADDRESS 6, 2 , .EW41-c X11,I-,e, Ak, 995 77 LEGAL DESCRIPTION Z07- /, Bi- O c /, �T �%i�%^/D 2 d8 A LOCATION ©vE,pLOO,K IfIRC4E NO. OF BEDROOMS 'T U Y DISTANCE TO: Well //© Absorption 61 Dwelling/Q r PERMIT NO.��O/ P Z Manufacturer �UN5-r PLf7-.T7 Material No, of com artments p W~ 5 / ,=4C.I,?SS � Liq. capaci�ingall ons IF HOMEMADE: Inside length Width Liquid depth Y 2 DISTANCE TO: Well Dwelling PERMIT NO. 2 i.- _ Manufacturer Material Liquid capacity in gallons w= DISTANCE TO: Well /19a f Foundation ��' Nearest lot lin �./ PERMIT NO. 77,0 /5 J w Z No. of lines Length of each line Total len w / th of Ines Trench width Distance between Ines F ? ¢ F Top of tile to finish gr de Material beneath tile inches /%j Total effective a sorption area inches �4 . fa, F7% LU Length Width Depth PERMIT NO. 0 a F- wa Type of crib Crib diameter Crib depth Total effective absorption area LU W DISTANCE TO: Well Building foundation Nearest lot line Class Depth Driller Distance to lot line PERMIT NO. J LU DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS PVC, PLA-s7-ic . SOIL TEST RATING 2Fo INSTALLER 114X VE 6 ' REMARKS e® ��4 S' .�� • Ar •'4 `". ' 0 to °ti'q' I �$*as .sI{}a• ..H .00H.. � e U all (I 1 R`tL Earl P. Ellis :% NO. 1745@ ; .� d APPR D DATE LEGAL l 7% 40T 1, RLOCX 1. /LI7 • /f%gAl0,2 .vie . P40 K -I- qA IJ W T' !!I !i. � �:: 1! � If, !(:::,. N ��� DEPHRTMENT OF HEHLTH HND ENVIRONMENTHL PROTECTION STREET/ HNCHQRHGE, HK99501 264^4720 PERMIT NO ( 79015�If".41 EFIXT EF lot p"qp Fp! pI :0 -y HPPLICHNT MERLIN R NE;ILLE LOCHTlON OVERL0III K CIRCLE LEGHL L1B1 MTMHNOR S/D TYPE OF SOIL HBSORBTION SYSTEM IS MHXIMUM NUMGER OF BEDROOMS � ] SOIL RHTING (S) FT/BR)— 280 Ir g mi cu < 2? A 1 14113 V NET (v _T" 1 cItI 04,4 7E§ pq ;I JE� lot Fin UT; 1,; jj: Q Fi- Q :1 I'M OF FM SYSTEM WITHOUT FINHL INSPECTION HND HPPROVHL BY THIS ---~— bHRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN H WELL HND HNY Con ~SITE SEWHGE DIMUS HL SYSTEll IS 100 FEET FOR H PRIVHTE WELL/ OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL OTHER R. UIREMENTS MHY HPPLYSPECIFICHTIONS HND CONSTRUCTION DIHGRHT's H�E MYHILH�LE TO INSURE PROPER INSTHLLHTION� �IF�i:, P 11,11 J: IT �:.. ::: F: Jr. 171 ID unn awl Fit E�� Fo. :11 ��;:::� "� RND WELLS HS SET ENLHRGEMEHT IF THE I CERTIFY THRT 1� I HM FHMILIFIR WITH THE REQUIREMENTS FOR ON~SITE SEWERS RND WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE 2� I WILL INSTHLL THE SYSTEM IN HCCOR0HNCE WITH THE CODES. SIGNED-..... ..... ... ..... _.... ~~^�__~_~_-~�~~' HPPLICHNT MERLIN NEYIL VI2 0 Et E GEO'. 4CHNI CAL Et DEVEL%.,?MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-27SOIL LOGEarl2 Soils Ett Foundations Land Development Performed for: Name: -- SL ILLR /VEd/LL E Tel . No. Mailing Address:_�'S,X, A6or�3c) IN, E,4e,6x iQir;E/g 7 Legal Description: Lor / , f3zK. /, �►/j� /t//VWpI 5c/.,] Depth (feet) 0 1 54 2 3 4 5 6 7 8 9. 10 117 Soil Characteristics rQ.4v�[cYSc��' S4AI..D `c C7P G�a'..j -5/::,> C7 P /pG,-eE7-6 ,�En/�f� s ra F 3��rr S�>va r✓ RZOT el-oll cI 2esn 01/3,,Q Ali) .tea aj�-- 12 Poe6. �� Ml,�7114 13 14 15 BO �ToNP QF � j- 16 Ground Water Encountered: Yes No ''-� If yes$ what depth Proposed Installation: Seepage Pit Drain Field Comments: Performed by: - Date: -�'� 7 9 TatDritting �firb ���I�ALIT�'OF AN I IOP.AGL by ENVIROMY.FiNTAL P,:u,CCTION DOC Co. dba JUL 1 SULLIVAN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2759 RECEIVED OWNER OF LAND = DEPTH OF WELL ADDRESS — STATIC LEVEL OF WATER FT LEGAL DESCRIPTION DRAW DOWN FT. DATE - Started Ended GALS. PER HR PERMIT NUMBER KIND OF CASING KIND OF FORMATION: From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to__Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to - Ft. Froin__Ft. to _Ft, From Ft. to Ft. From. ___ _.-_Ft. to Ft. From Ft. to - Ft. From Ft. to Ft. From Ft. to _ Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From `Ft. to Ft. From Ft. to Ft. From Ft. to Ft. ` From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to ' Ft. From Ft. to Ft. MISCL. INFORMATION: DRILLER'S NAME 2. TYPE OF RESIDENCE Single -Family 12 Number of Bedrooms 3 3. WATER SUPPLY Individual Well ® Community ❑ Public ❑ I � i 11 )'(x` . 0 ( 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 ISI 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. Page 1 of 2 72-025 (Rev eieM Front -71 O MUNICIPALITY OF ANCHORAGE U - DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL =� - C�) L/ OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date Oo f 2 / /987 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) 4-0 11Gl_ ocAr Man r S/p Location (address or directions) O C4 lao lr C i r -c re _�. �1 le R I %C*P. (b) Property Owner FlowarO( Re lar ��g Telephone: Home Business Mailing Address '�ZU S. Di-aw�•e � o -_ 6. i.. t. /.,7 At T V O'TO'i9 (c) Lending Institution Reale f'tee Pac.v4c 110,r405'eTelephone S2!ry -020& Mailing Address R o. fjex IUaH /} 20 „ cAoras/r 99,; -to - - (d) V Real Estate Company and Agent Pynamic Rea t61!Z — Cv//le`4 /Koeol tz Address __ 5yl W. /I(oi/Aera 4crhAy L3/--( 4ACA0mq-r 99sy Telephone 277 -7rri7 (e) Mail the HAA to the followino address: or: Check here El, if hold for pick up. List contact person and day phone number below. 2. TYPE OF RESIDENCE Single -Family 12 Number of Bedrooms 3 3. WATER SUPPLY Individual Well ® Community ❑ Public ❑ I � i 11 )'(x` . 0 ( 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 ISI 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. Page 1 of 2 72-025 (Rev eieM Front MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 Legal Description: kc,> 2i Q tocA 1 P4oua/-gin Manor S/ A. WELL DATA Well Classification PrivaFe If A. B, C, D.E.C. Approved (Y/N) N.A. Well Lo Present Y/N Y 3 �rn mtc j 10//y /87 9 ( ) Date Completed 7/ 6 f Yield m r (0o Total Depth 8 y Cased to 8 y Depth of Grouting N,.4, Static Water Level 611 Pump Set At = et' Casing Height Above Ground 2'y Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) 1,� Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot 12 B A, c• ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot 1 26 ' t ; On Adjoining Lots 60 ' ,{o C'&'+ To Nearest Public Sewer Line Cleanout/Manhole — To Nearest Public Sewer To Nearest Sewer Service Line on Lot Water Sample Collected by FlA40I 7-0[6 Svc.( —;Date —1,21(Y /87 Water Sample Test Results Seths."r O coA%r'A "ILOV m I 3 B mo/Q /\(I kale /Y Comments New we fl eettect 1 Z6 ' � S w o,{ s kc -/Wt /? k- C 13S ' ;E"M C--- a F eA'4 ad( freACA We 11 911 Cs/oboe 0% /z "c e � 0-'00'40- cenoC/ 3 i G C,o, � l/oe In GG✓r� / ©Connn.^!r o�ri..e.wot�. Nl.�V WG1l lUy aT 'Ch oai B. SEPTIC/HOLDING TANK DATA / \/ Date Installed E / 6 / 79 Size2S! _a0! _ No. of Compartments 2 Standpipes (Y/N) Y Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) N Pumping/Maintenance Contract on File (Y/N) N. A Holding Tank High -Water Alarm (Y/N) N. 4 Separation Distances from Septic/Holding Tank: To Water -Supply Well 1 2e' To Property Line 16' To Water Main/Service Line N A Course '> 1 0' Comments "'WWey r ,eoixto) �vdvn MOA Page 1 of 2 72-026 (Rev Bi86) Front Date Last Pumped (O/ 17 / 6 7 6y Tl;? s ;for GTS Temporary Holding Tank Permit (Y/N) N. A. To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage c� CHEMICAL &GEOLOGICAL LABORATORIES OF ALASKA, INC. '` 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ineoAnroAies FEDERAL TAX ID 11 92-0040440 Tl� ii J, A Srim 1 1 x : Vatpr ci!epVr,:, 110,61 wqy, -,. iit til` i onvil m Rego 11,/ dr, 0 sA) . ft'll': !0 ANKA � -, ` .,U! I S81) ivi, 0 Nov di ' is.t ("e"Ap, ih _• CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. uwow�Towrts TELEPHONE (907) 5622343 ANCHORAGE INDUSTRIAL CENTER 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: L (') See h on back I.D. NO. Water System ame Phone No. I y5-3TJ <-ctiC' S Mailing Address A.,C(lC-- City State zip code SAMPLE DATE: E707 I 'y Mo. Day Year SAMPLE TYPE: ® Routine ❑ Check Sample (for routine sample with lab ref. no. 1 ❑ Treated Water ❑ Special Purpose ® Untreated Water SAMPLE Time Collected NO. LOCATION Collected By 1 I Lof f l3/k1 /rFn h7rt o S/DI 3:t5"r/rr7- F- I -T 2 3 a 5 bl s TO BE COMPLETED BY LABORATORY �7Analysis shows this Water SAMPLE to be: ILI 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 / 0 //���% Time Received Analytical Method: /6-2a ❑ Fermentation Tube Membrane Filter Lab Ref. No. Result' Analyst ��'py�?-y IXm I m L m L m No of colon res/ 100 ml. o, No. of Posq,e pn,ons 06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1983 READ INSTRUCTIONS Membrane Filter: Direct Count D Coilform/100ml Verification: LTB BGB _ BEFORE Final Membran II Re 0 Coilform/100ml Reported By Date.. Time: ! a.m. COLLECTING SAMPLEP.M. TNTC = Too Numerous To Count Municipcz._ ty of Anchorage October 30, 1987 P.O. BC 196650 ANCHORAGE, ALASKA 99519-6650 (907) 343-4200 TONY KNOWLES, MAYOR DEPARTMENT OF HEALTH & HUMAN SERVICES Robert A. Shafer, P.E. S & S Engineering 17034 Eagle River Loop, Suite 204 Eagle River, Alaska 99577 Subject: Waiver Request for Lot 1 Block 1 Mountain Manor Subd. Waiver Number WR87-066 Dear Mr. Shafer: Your request for waiver for the subject lot has been approved.', The required 100 foot separation from a residential seepage pit to a private well has been waived to 80 feet. Although there are higher than normal nitrates level in this well at 3.8 mg/1, it is my opinion that this level is not a direct result of the separation distance encroachment. The wells in the area of this subdivision and other surrounding subdivisions have this same approximate nitrates level. This waiver approval applies to this separation and any future upgrade of require separations be met or another department. Sincerely, R" Daniel J. oth Civil Engineer On -Site Services cc: Gus Andress, P.E., Manager, On -Site Services/Water Quality existing seepage pit/well either facility will waiver approval from this w A A Octobers 27, 1987 ROBERT A. SHAFER CIVIL ENGINEER 694-2979 HEALTH AUTHORITY APPROVALS Dan Botta UN/CIPAIlT ENVIRONMjNrgV o, Mun.ieipat ity og Anchanage ANcyo 1 SERVICES FO Depa,itment og Hea2#h and Human Senv.icu IVISN OCr27198.7 825 L S,tnee Anchoh.age, A.Za�ska 99501 SEWER 8 WATER MAIN EXTENSIONS �t /CEI REFERENCE: Lot Black 1 Mountain Manan (i, CD V C Dean Dan, TER INSPECTION Request you ghant a waivers gon the ho4izontat 3epakation distance between the septic system on Lot 1A 7"nact C Bnoadwaten Heights and .the pn.ivate wett .located on the ne4e4enced pnopenty at a distance ob 80 Beet.. ENGINEERING STUDIES AND REPORTS A %isk anatys.is has been pengonmed and it appeaa,& that no baCtetiat- og.icat Pottution is po,64ibte Kum this soukize.. Attached gars, yours nev.iew ane the 40ttowing documents: WELL INSPECTION & A. Coti.gonm and nitrate anatys.is ag waters taken gnom the weU FLOW TEST toeated on the tegenenced pn.apenty. B. A plot plan showing negative di-6tancu between on -,site wastewaters disposal systems and weUs. SITE PLANS C. A pnag.iZe ag the Land and bu j ")! tivZen the weft and septic s y6 tem. ROAD DESIGN D. Risk anatys.is waivers nev.iew wo4kshee,t. It .iz ours opinion that .the han.izontaZ sepakation distance prsesc4ibed by 18AAC72.021 is not nequ.ined .in this ease. SOIL TEST Ig yo"ie-qui) add.iti,onat .inganmation, please contact us. '4eerseZy PERCOLATION IS TEST��- R nt A. Shagen, P. E. S/ss STRUCTURAL& i MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 All s o n �fi C � � FFF g A :.•4 s �'r d f 0 Y U M , 1l c 40 t,4k F-3 SCALE �p m � A 03 m - � D Z r- 0 n ILI 1r 7 or, SCALE �) ��� ���t�i � �f P(�1 rel { � ��✓/��1� �tST.�C..� S 2 0 ��TLan ���2r�A" 1 -Pv1 r-j� — -A5.-Z2 VTS 2.2 P;.rs. -topby DOC, Co. dria SULWAN WATER WELLS P.O. BOX 272, CHLIGIAK, ALASKA 99567 * TELEPHONE 688-2769 INER OF LAND DEPTH OF WELL tip oRESS STATIC LEVEL OF WATER- FT, GAL DEWRIFTI DRAW DOWN FT. ,TE - Storted Ended GALS. PER HR .. . .... RMff NUMBER KIND OF CASING _-_6 ;F a<7 4D OF FORMATION: Ft. to.___ _ Ff, Ft. to--- Ft. From Ft. 4&44A to—. Jt. From- --fl. am Ft. From-- --Ft. t0 --..----- Ft. am Ft. From - ft to----- - Ff. rnn--Ft, From ---Ft. )m Ft. From-- --Ft. to - -Ft. )m—Ft. From-- )m—Ft. Frow—--ft. to FlOnl --------- Ft. to-----.-- Ft. From-- --Ft. SCL. INFORMATION:` *7*4r a 7-0 4; 'q -7 Y DRILLER'S NAME Afl b ri 11- n t4 00c, co-, cIDa SUILIVAN WATER, WELLS, P. U. H 0 X 272, (A-1 U G I A K, A i/\ S K A J'! 5O 7 , I F_ F Pi i ON ! G88 2 7 59 R E C EIV D OWNER OF LAND .... ..... ... ADDRESS LEGAL D ESCR I [YI BATE - Started Ended PERMIT NUMBER KIND OF FORMATION From Ft. to_ _'. Ft. .... .... From_ Ft, to Ft. From Ft. to Ft. From -_Z_ .... Ff. FtFrom. Flo-il _Ft. to---- —.__._.Ft.____ it) From __Ft. to ------- H to to Ft., From Ft. to Ft. From Ft. to Ft Froin Ft. to t. l rout _--'_Ft. to. -.k,t. From to-- --___-__Ft. From - _Ft. From - i-oill 1 t. From Ft. io Ft. Vroln. Ft. to i't From_ Ft. to- MISCL. INFORMATION i* 11 G H 01 `. I iJ_ I! I R ILVEJ, ()I N I EN i 1. DR \YN DOWN F? C 'I'S. IIEP HR iC FIN 1) OF ( Vs i NG From Ft, to. ft. From t. to t. Flo-il i it) Ft From H to Vt. from L to Ft From h to Ft. Froin t. to F to i-oill 1 t. to hole i t. to t . Frum Ft. to- I -c i.!olll Vt_ to IF. Feow Vf, to 'oil) Ft. to I From Ft. to DRIL1,ER'S CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. y TELEPHONE (907) 562"2343 ANCHORAGE INDUSTRIAL CENTER 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: I I I I (') See h on back I. D. NO. Fla )LA?4e 7—ec&lira/ Sewrc¢/ Water System Warne Phone No. ( H 6_3 e52 /=c A 0 SX Mailing Address A• CAoe- ode City State zip code SAMPLE DATE: / ( `y Mo. Day Year SAMPLE TYPE: ® Routine ❑ Check Sample (for routine sample With lab ref. no. t ❑ Treated Water ❑ Special Purpose © Untreated Water SAMPLE Tlme Collected NO. LOCATION Collected By 1 I Loi" f, 13((:1 M it -n (7q n o S /D I 3: r s'r'rr 7Tr=rf 2 3 4 5 S TO BE COMPLETED BY LABORATORY ]Analysis shows this Water SAMPLE to be: t(J 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 / 0 //r/p% Time Received lO 6 Analytical Method: ❑ Fermentation Tube Membrane Filter Lab Ref. No. Result' Analyst 1W.?-/ IX© C)(�6 *NO of Colonies/ 100 ml. o/ No. of Po9frve romons 06.1220 tbt BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1983 READ INSTRUCTIONS Membrane Filter: Direct Count O Coilform/100ml Verification: LTB BGB BEFORE Final Membran 11 Re Coilform/100ml - Reported By_ Date Tlrne: �a.m. COLLECTING SAMPLED.M. TNTC = Too Numerous To Count CHEMICAL & GEOLOGICAL LABO W J � -- ' RATORIES OF ALASKA, INC. `goopn*['HI[s� 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID k 92.0040440 ANALYSIS REPORT BY SAMPLE Client PO# VERBAL Req #: Work Order No. : 3408 Client Smpl ID: L1, BI MTN MANOR S/D 10-14-87, 1515 Client Account : FLATTOT Sample Rec'd : OCT 15 87 Date Report Printed: OCT 19 87 9 15:43 Ordered By TED MOORE Released By : 2�64-- Send Reports Address #2 Reports To: FLATTOP TECHNICAL SERVICE 14530 ECHO ST ANCHORAGE, AK. 99516 Special Instruct: Chemlab Ref #: 8042 Lab Smpl ID: 2 Matrix: Water Allowable Parameter Tested Result/Units Method Limits -- - --------------------------------------------------------------------------------- NITRATE-N 3.8 mg/1 10 Sample ROUTINE SAMPLE Remarks: ANALYSIS COMPLETED: 10-16-87 _ --_-LABORATORY SUPERVISOR: -STEPHEN C. EDE JdApt4�C. 2w-<� I Tests Performed See Special Instructions Above ND= None Detected See Sample Remarks Above NA= Not Analyzed LT=Less Than, GT=Greater Than FLATTOP TECHNICAL SERVICES, CML & ENVIRONMENT,U ENGLNE.ERINC • LNL:RGY C:ONSERVAPON & ANALYSIS 1-1111"ODORS P. MOORE, P.E. I'll: (907) 345-1355 October 19, 1987 14530 E.CIIO S`I', ANCHORAGE, ALASKA 99,516 Colleen Moening Dynamic Realty 501 West Northern Lights Blvd. Anchorage, AK 99503 Dear Ms. Moenin�: I'er your request, on October 14, 1 conducted adequacy tests of the water and wastewater disposal systems serving t:he Vern Smith resid.2nce (liRG # 4650200+) on Lot 1, i31_ock 1, of: i�7ountain Manch- /D in Eagle River, located on Outlook Circle. The wastewater disposal system consists of a 1250 gallon fi_bergl.ass septic tank followed by 65 feet of soil absorpti.on trench contalnaiug 8 feet of. gravel, The system wa: designed and approved for a three bedroom residence, approved the tank is sized for a 4 bedroom resideTice. The soil absorption trench is slightly undersized for a 4 bedroom residence„ To test t:he adequacy of the system, I added measured amounts of water through the cleanout: at the end of the trench while monitoring fluid Ieve.l.s there and in 1 -he septic tank. The trench was dry at the StE3rt of the test, and the measu",d ab;;Orpt loll 'Cate was more than adequate for a three bedroom residence. I arranged for the septic: tank to be pumped on Oct:vber 17, 1987, The well which was drilled to serve the residence at elle time of const:rtiction in 1979 extends into the bedrock to a depth of 300 feet., and had a reported yield of 25 gallons per hog,°- Apparently, this ,yield decreased to the point where the owner 11ad, to abandon that well. and have Sullivan Water Wells drill. a new one in .July of 1981,.This new well has a notal depth of 84 feet, with perforations in the casing between 61 and 64 fQet where a water bearing aquifer 1,ias encountered. Despite the fact that the old well casing was cut off below ground level., the new property as -built survey prepared September 28 shows the old we 11. local-i.on instead of the new one. On the day of my test, the static waiter level in the new well. was 61 feet below the top of the: cas-ing. To determine its yield I pumped the well. until. the water level. was drawn down to the pump intake, apd then measured the recovery rate. After doing this two times I was able to determine that the sustained yield of the well. is 3 gallons per minute, which is adequate for any single family residence, I also took wiat:er samples to test for contamination, but the results have not yei been reported. As part of the process of SeCUling Health Authority Approval. of these systems, the engineer must verify that certain other factors are in compliance with Muni.ci_pal code, According to a similar report prepared by S & S Engineering in. November, 1985, the new well did have the required conduit around the electric wiring, and the well, was over 1.00 feet: from any portion of a septic system on an adjoining lot,. Unfortunately, I found this not to be the case. There was no conduit of the wiring, and I measured a horizontal distance of 80 feet to tare cleanout pipe of and undocumented septic system ort Lot lA, Tract- C, of Broadwater Heights S/D. Before Health Authority Approval can be obtained, these issues must be'resolved" The missing conduit' can be installed relatively easily, however a formal waiver will have, to be requested for the inadequate separation distance. A steep down-- hil.I slope from the well to the septic :system t• - ill help securing the waiver, however relatively porous soils, Sha ilow ah aquifer depth, and tite fact: tat tate septic system i.s undocumented all work against :it. The !lealth Department wi11 require a formal eng:inec.r.i-ng report describing all relevant factors before deciding on ti -10' request, l bcl.icve there is a reasonably good chance they wiLI issue the waiver, but of course cannot guarantee Lhat. l cannot explain t•;hy neither the well (IriIIer nor the engineer who prepared the 1985 health Authority Approval took care of these problems,,. The unfortunate result is that your client must now face delay and ad(}itional i expense _rt resolving problems which existed, but were unreported, at the time of purchase. 1 see no option other thatr taking care of these problems now, however I await your approval before proceedi.lig. 1_ also recommend that you have the land surveyor correct the error in wel..l 1OCatl.011 of his as -built- property survey. Please give me a call. if You have any questions. StncereIY, Ted Moore, P, F,. 08 g 1077 Municipality of Anchorage a fir. , �,� a0 �1li On-Site Water and Wastewater Program ail 1. (907) 343-7904 16. o �D s"aro/ Certificate of On-Site Systems Approval Parcel I.D. 050-671-25 Expiration Date: 14`f �— 15 1. GENERAL INFORMATION Complete legal description Mountain Manor Block 1 Lot 1 Location (site address) 18524 Outlook Circle Current Property owner(s) Herman & Merisue Bowerfind Day phone Mailing address 18524 Outlook Circle Eagle River, AK 99577 0 Real Estate Agent Day phone 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 • 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ril Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Distance: / WaiverNariance request for: �� _\,� �� l` ,Ii4 %, / Date: I 1/P> Received by: N �, g� COSA to be released to the engineer,un- o herwise request•d by ,. engineer. COSA Fee $ t52 00 Waiver Fee $ Date of Payment 1 /i I /1 g Date of Payment Receipt Number 0 144 icl Receipt Number COSA# OS 0,310 I 1 Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are)in compliance with all applicable Municipal and State codes, ordinances,and regulations in effect at the time of installation. In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system.These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed above. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone Date 1/10/2018 �� .of ALximk 6. DSD SIGNATURE1K. 8 .,„ I . V.:1p t A System #1 Approved for 1-( bedrooms �••:Steven�. I�annone System #2 Approved for bedrooms r� q., CE-8149 1; • Disapproved I,1evpR s.so`.� N\\����� Conditional approval1 for bedrooms, with the following stipulations: -. ... ..j F,qNC/ - � ON-SITE 0 WATER AND WASTEWATER oz PROGRAM „Co-: • D,o O6 . �F/T SERN�- By: l (/vim. ` _ l Original Certificate Date: 1 — 1 I / The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet f •- If more than 1 septic system is on the lot: COSA Checklist# 1 of 1 Structure served by this system i Certificate of On-Site Systems Approval Checklist Legal Description: Mountain Manor Block 1 Lot 1 Parcel ID:050-671-25 A. WELL DATA Well type PrivateIf A, B, or C provide PWSID# Well Log (Y/N) Y Date completed 7/1981 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y Casin hei ht above round in. 24 Total depth 84 ft. Cased to 84 ft. 9 9 ( g ) FROM WELL LOG AT INSPECTION Date of test 7/1981 8/25/2017 Static water level 60 74 ft. ft. 3 3.1 g.p.m. Well production g.p.m. WATER SAMPLE RESULTS: 7.71 Coliform NEG colonies/100 mL Nitrate mg/L sample: PES N D 12/21/2017 Collected by: Arsenic ug/L Date of B. SEPTIC/HOLDING TANK DATA 6/6/1979 Tank Type/Material Sunset/Fiberglass Date installed Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N/A Date of pumping 12/20/2017 Pumper JR's Pumping C. ABSORPTION FIELD DATA 6/6/1979 Soil ratingd./ft2 or ft2/bdrm) 280 SF/BDRM System type TRENCH Date installed (g.p.d./ft2 66 ft. Width 2.5 ft. Gravel below pipe 8 ft. 1056 2 Total depth 12 ft. Eff. absorption area ft Monitoring tube Y Depression over field Date of adequacy test 8/25/2017Results(Pass/Fail) PASS For bedrooms Fluid depth in absorption field before test 0 in. Water added 610 gal. New depth 2 in. Elapsed Time: 60 min. Final fluid depth 0 in. Absorption rate >= 600+ g.p.d. N Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at in. "Pump off' level at in. High water alarm level at in. Datum Cycles tested Meets alarm&circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: 100+ 100+ Septic tank/lift station on lot On adjacent lots 100+ 100+ Absorption field on lot On adjacent lots Public sewer main 75+ Public sewer manhole/cleanout 100+ Sewer/septic service line 25+ Holding tank 100+ 50+ 100+ Animal containment areas Manure/animal excrete storage areas SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5+ Property line 5+ Absorption field 5+ Water main 10+ 10+ 100+ Water service line Surface water Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water main 10+ Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS Survey on file. G. ENGINEER'S CERTIFICATION ..6".. \\`' kk I certify that I have determined through field inspections and OkP' ,N## review of Municipal records that the above systems are in 0.g'•, • j,_ "*-4,,,‘, *# conformance with MOA COSA guidelines in effect on this date. % Engineer's Printed Name Steven Pannone ������ •, •••��everi}2.•f5annone: � Date 1/10/2018 0���4y�• CE-8149/ COSA canary sheet_2-6-15.doc Municipality of Anchorage R„ • Development Services Department , Building Safety Division SAE tY K On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On-Site Systems Approval # OSC 181011 A Certificate of On-Site Systems Approval inspectiond f Lot 1potable water was recently conducted on the well water supply on Block 1 of Mountain Manor subdivision. This inspection was ealed a foritrate the concentration of 7.71 milligrams per liter (mg/L) reported property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On- Site Systems Approval. Nitrate Fact Sheet From Northern Testing Laboratories,Inc. Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water. Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water wells. SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners, food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the soil. TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry oxygen. For this reason, methemoglobinemia is referred to as "blue baby" disease. The EPA limits the concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization. TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home water treatment systems such as softening or iron filtration does not readily remove nitrate. The best method for limiting nitrate in well water is source control. This can include avoiding overdosing of fertilizer near the well and maintaining good separation distances between septic tank leach fields and the well. A special anion exchange filter that contains a media with a strong affinity for negatively charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate. TESTING: Nitrate analysis is usually done by one of the several "wet chemical" methods using a spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect the activity of nitrate in water. This laboratory uses several different wet chemical methods approved under the public water supply laboratory certification program. They also have test kits available, which the laboratory uses to perform an inexpensive "screening test", and with which the homeowner can monitor the change in nitrate levels from their well. They recommend comparing the test kit results against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples. CtarlQr�flZgtA;n Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and 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. 050 - 6.11 - 25- HAA# D50X53 „ •. Expiration Date: q - 1. GENERAL INFORMATION; Complete legal description , i�%am4c.; k ic4rtor Loi 1 r 6/oc_k 1 Location (site address or directions) 1 R 5211 01.•i-1 oo k L t rd e Current Property,owner(s) (al rnn n ,.l Only: c: c. W.'//tio: + Day phone 61'1 0792 Mailingaddregs 1852,V (h.flouAC C;rde, EAyle A',.ierZkl. 99577 - Lending agency Day phone Mailing address Real Estate Agent Y6t•}%c i A WI -11 he, + Day phone 360 -0cl6 S Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. -1 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 19 Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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 sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7R 2 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, -ordinances, and regulations in effect at the time of installation. Eagle River Engineering Services Name of Firm 10421 VFW Rd,, Suite 201 Address Eagle River, AK 99577 Engineer's Printed Name Lli Oiief 9. b✓oe) 5. DSD SIGNATURE _z Approved for _i_ bedrooms. Disapproved. Phone 699-5/95 Date 6113105- Conditional l13%os Conditional approval for bedrooms, with the following stipulations: Additional Comments Note: The well for this property meets existing State and 1%lunicipal Codes. There are nitrates present. It is suggested that periodic testing be performed to insure the wells continued suitability. Current nitrate concentration is 7.83 mg/1. EPA maximum concentration is 10.0 mg/l. More information on nitrates is available from the On -Site Services Program, at 343-7904. Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: ( /�� Original Certificate Date: t0 > o� " (Rev DIM) Municipality of Anchorage • �` Development Services Department Building Safety Division ` On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST' Legal Description: A)%Oj44ain Ahoe, l f 1, C3lock 1 Parcel ID: 0!Er., - 67/'25 A. WELL DATA Well type ;_Lvc le If A. B, or C provide PWSID # Date completed/ -_7 I Sanitary seal Total depth eft. Cased to -i-q_ft. FROM WELL LOG Date of test 7 f A I Static water level go ft. Well production 3 g.p.m. WATER SAMPLE RESULTS: Coliform —jC,)_colonies/100 ml. Arsenic: e6d mg./I. B. SEPTIC110110tVINIGTANK DATA Nitrate I. S3 mg./I. Well Log (9N) Ye—r Wires properly protectedN)_ Casing height (above ground) 2 c( in. AT INSPECTION s/a.3 /o, - S6 ft. Other bacteria U colonies/100 ml. Date of sample: Collected by: d of le 5 &Iz , r. n TankType/Material 5Nrise Pre1us5 Date installed 6/6/7T Tank size 1250 gal. Number of Compartments _; Cleanouts d)N) YC5 Foundation cleanout (ON) 4-ri Depression over tank (Ya _&0- High water alarm (YO ..yo Date of pumping 5/2 3 /a > Pumper JX '3 9,..!4, .4 C. ABSORPTION FIELD DATA Date installed 6/6179 Soil rating (g.p.d./ft' or /bdrm _:aG System type �awn c 1, Length 46 ft. Width z S ft. Gravel below pipe `b ft. Total depth _L2, ft. Eff. absorption area 1056 ft' Monitoring tube Depression over field Date of adequacy test 5/2 3/o S Results as Fail) OG S 5 For y bedrooms Fluid depth in absorption field before test __ in. Water added boa gal. New depth_L7 7.y Elapsed Time: 60 min. Final fluid depth CJ in. Absorption rate >= 600 g.p..ld. Any rejuvenation treatment (past 12 mo.) (Y/& � type) �U If yes, give date _t D. LIFT STATION Date installed Size in gallons `Pump on' level at _ in. Tp�iffiC aadl t _ in. Datum -` Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO (Y/N) High water alarm level at Meets alarm & circuit requirements? Septic tank/lif4letion on lot 1:219 On adjacent lots + I OG Absorption field on lot 12 7 - On adjacent lots f I Oa Public sewer main t 73 Public sewer manhole/cleanout t 1 UU Sewer /septic service line Holding tank SEPARATION DISTANCES FROM SEPTIC/! ebOlf! TANK ON LOT TO: Building foundation 1 2 - Property line I& Absorption field ✓ Water main +10- Water service line i IV Surface water f I GO Wells on adjacent lots f 1 DU - in. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 2 6; - Building foundation 1-7- Water main f / U Water Service line f 10 Surface water +100- Driveway, parking/vehicle storage Curtain drain +50- Wells on adjacent lots t" 1UU F. COMMENTS G. ENGINEER'S CERTIFICATION i certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed NameLAfr4440� R. Woo Date 411 3/o h HAA Fee S 7 Waiver Fee $ _ Date of Payment �/)�S Date of Payment Receipt Number. 3 r- Receipt Number (Rev. 12101) Eagle River Engineering Services Christopher R. Wood, P.E. 10421 VFW RD. Suite 201 Eagle River, AK 99577 June 13, 2005 Dan Roth Manager, On -Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Mountain Manor Ll Bl Four Bedroom Approval request Dear Mr. Roth: (907) 694-5195 tel (907) 694-3297 fax Eagle River Engineering Services (EKES) was contracted to conduct a Health Authority Approval Inspection, including well flow and septic adequacy test, at the above property. Upon review of the records on file at the Municipality, we noted that the septic tank was 1250 gallons, good for 4 bedrooms, and that the leachfield was oversized for a 3 bedroom single family home. Based upon our calculations from the as -built and soil rating, the leachfield is sized for 3.8 bedrooms. The leachfield was dry prior to, and after, the addition of 600 gallons of water. The system was installed in 1979, and has not developed a water table. In light of these facts, we are requesting the On -Site Department to approve this septic system for 4 bedrooms. If you have any questions please call our office at 694-5195. Sincerely, EAGLE RIV12D ENGINEERING SERVICES Christopher R. Wood, P.E. Principal \2003\05-062nEDROOM REQUEST LETTER Eagle River Engineering Services Christopher R. Wood, P.E. 10421 VFW RD. Suite 201 Eagle River, AK 99577 June 17, 2005 Dan Roth Manager, On -Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Mountain Manor Ll BI Well abandonment Dear Mr. Roth: (907) 694-5195 tcl (9o7) 694-3297 fax Eagle River Engineering Services (ERES) has verified that the "old well" shown on the as -built survey for the above referenced lot has been abandoned. The abandonment of this well took place previous to the current homeowner taking occupancy of this property. A HAA conducted in 1985 by S&S Engineering documented this abandonment. If you have any questions please call our office at 694-5195. Sincerely, EAGLE RIVER ENGINEERING SERVICES sto her R. Wood P.E. / P + Principal \2003\05-062WELLABANDONMENT LETTER 05-27-05 04:04PN FRN-CT&E ESI, SCS ENV SERVICES SCS REEK 1052872001 ClkutName Eagle River Engineering Project Nsme/N Mountain Valley Est L8 B 1 Client Sample ID Mountain Valley Est L8 B 1 Matrix Drinking Water Sample Remarks: 9075615301 T-863 P.02/04 F-152 All Dateafrimex are Alaska Standard Time Printed Datefrime 05!27/2005 12:27 Collected Datefrime 05/232005 16:00 Received DatelTime 05242005 10:25 Technical Director Stephen C. Ede Allowable PteP Analysis Panunew Results PQL Units Method Cmtainet ID Limits Date Date Mit Waters Department Nitrate•N 7.83 0.100 microbiology Laboratory Total Coliform 0 mg/L EPA 300.0 B (<-10) 0524103 JIB coV100mL SM209222B A (<-1) 0524/05 TLF 05/26/2005 11:15 9073449821 JRS SEPTIC PAGE 02 JRc Pumping pp Box 773415 Eagle P ivcr, AK 99577 (907)694-6454, ti1111ng InfoneMton " - ---- � .� Pa! aconn w0�nat Job Description- 12000 16524 Outlook Circle P.O. Number. Terms: Net 30 Eagle RNer, AK 99677 Salssrw Nikae (907) 694-0792 Map Book: Service Agreement Number. 016670 Older Date: 16 -May -2005 Service Date: 23-May2005 12.00 am Technician: Tony Job Type Repeat Map Grid: 67 _ _ - —• - _-1 Cross Streats: Stilhvater Drive Job She IMomston _ --- I Job moments: Last service 09x08'04 10 Pet (Pumped tank .levels normal 16624 Outlook Circle I Eagle RW. AX 99577 (907)694-0792 301-0659 Glen Service TYPO oty Septic Service 15K 1 Additional Location Comments: Ns on house 2 story brown house w/ dark brown trim. 2 dogs co talned. Pipes next to auks on N side of house and Visible. I Tax PNCent: g Price Each X 2 Men ^ Tax Extension Actual $12500 No No (125.00 Diagram: I.— ,raid .--.Tani c/o Gallons Planned: 1200 Gallons Actual: Hose Length. 3 Double Tank: ❑ Pump System: WJ Baffles Inlet: [] Battles Oull [ J NonTaxable Total Taxable Taal Tax Toul Grand Total Estimated Charges: $125.00 $0.00 50.00 $125.00 Actual Charges: Customer agrees to the terns and conditions printed on the back. THIS IS A BINDING AGREEMENT. Signature and Title of Customer Representative Date Accepted by JRs Pumping Date Accepted For your added convenience we accept: American Express, Deaver, Visa and Master Card payments over the phone. Ater 30 Days accounts will be bemad over to collections. $23.00 For NSF Chew Returned. 'V'- •� � � r` . :alta ��o.00 A K Im S I nn r In xu o�Cu 13 � z o 1 n y qi o F1 0 le° a Imlri� i m Il' • z 3 .ou Z¢9/ Soo -09-21W PSo .00 �DAAm ;a 3r- In LA IOC 0%0 ID kO SD 2«•1 :OS Inas mN 00 AC O 0 N 10 � CO O (A a a •••1 D C) C -1 A :0 S V=r 1+ 3r- Q V"m -•--=-4{ m -4 ^J;a _ "• �o In a -$ r" r+ OO -I O C7 co /n SO ,vm -I-+ -m cc mA N OI B ID 7 Z O N -'t. r- -4OCl) a+ m -Cm '1 Co D -I m .••• S 2 -4 S. O .••• v m co i Alo ID m -1 -•1 -1 m U1 m Z S m S a = ca 0 -t LJ (D Z rD D 2 Om LA ;o m [:)0 r A 30 1- N Cl Cl "" D a.• Dm O 'O •••. m 3 0 1 to "' :L In in 0 .2 S to 0 2 m 3 0 v a Cl D= Cn 33 cna Gr- c ar) mm=D 0 .+ '•'7c r - ma Vt 7c d 7c S A 1 :03 A--1 :2 ;U (A ro -1 O C) = O o mN a '2 C m W O m m r- rn CD -4 F •0 .TI .- 0M 021•+ 1•+D c:o =0In IOC 1 I0-1Ho O a •'CC '+ -nD Z-/ZZN.�m.•••-•1 Ln C f 1'- 0 • fnmO m3C'f2 C �r O 11 w N --1 Nm N '0 m1m ca mO-4 T N < 2v I= W n m- •0 m A r- r- 2- O A S S N -�• cc r- z K O O D O -•1 a -1D nAD--I C'7Na2 c <2•••I O I C) 11 -1 « 3D '007- -1 fna2 N w WN -i-•1DDm r+NO 1•+ O aM v) C) 1 aD .'= 1 D 0 z m m Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 ON-SITE SEWER/WELL SUBMITTAL COMMENT SHEET To: Chris Wood Legal description: Mountain Manor Block 1 Lot 1 The attached paperwork has been reviewed and Is being returned for the following reasons: ❑ Original signature or stamp missing on ❑ Calculation error in design. ❑ Additional soils information needed. ❑ Water monitoring results inadequate. ❑ Discrepancy in information submitted. ❑ Topographic information missing or inadequate. _ ❑ Incomplete; missing ❑ Incomplete; missing ❑ Additional adequacy test information needed. ❑ Water sample unacceptable. _ ❑ Measured/proposed distances/dimensions missing. _ ❑ Locations of all soils, percolation and water monitoring tests not shown. ❑ Proposed system too deep for soils information submitted. _ ❑ Well log required. ❑ Omission in narrative. ❑ Insufficient fill over tank or field._ ® Other. Is there more than one well on property. Name of reviewer. Jeff Date: 6/16/2005 Please supply the necessary information and re -submit your request. LEAVE THIS FORM ATTACHED TO THE PAPERWORK 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 I I— I -aS 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) S K=�/�.t r.S t✓ — `�1'"1 L�L.J /-�+-tZu1-- — o.�-��4sz� � �-- L -(L., (b) Applicant Name VI541=&-� S,u 1-0.4 Telephone: Home (n�lc± -moi' I a� Business 153 2 70¢3 Applicant Address (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Address (e) Real Estate Company and Agent Address —_ Telephone tufa I t�e HAA to the following address: 6, 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Telephone e Individual Well Pr- 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 Er Public ❑ Community ❑ Holding Tank ❑ 0 Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-02s (11,84) T, 5. ENGINEERING FIRM PROVIDING ..4SPECTIONS, TESTS, FILE SEARCH, DAT,, ,ND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtainedfrom 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 Telephone Address 1A — - - i Date A �t Seal, aye c U` tr 6, DHEP APPROV_TALV-� Y ,b Approved for edrooms by .Z C _Date _ Approved _ Disapprove 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 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 72-028 (11/84) CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562.2343 5633 8 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 dz�;-S It'j es!��F14 &9q—Z'3 Name Phone No. -.✓46 / i !o X Mailing Address n City State Zip Code SAMPLE DATE: /- I g Mo. Day Year SAMPLE TYPE: Aaf Routine ❑ Check Sample (for routine sample with lab ref. no. 1 ❑ Treated Water ❑ Special Purpose A93 Untreated Water SAMPLE NO. LOCATION Time Collected Collected B 1 U _.-:::C- 1 'P, L-�' I I o .aoA z 3L 4 I 5 1 TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: KS , 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 // -/ F. c'), Time Received __ /21't� Analytical Method: Membrane Filter ' No. of colonies/100 mi. Lab Ref. No. Result" Analyst /40-4 -// m U CTI U m U CD U CZ1 BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS Membrane Filter. Direct Count BEFORE verification: LTB COLLECTING SAMPLE Collform/100ml Final Membrane Filter Result n Coilforrn/100ml Reported By _ 4z,:1-2 e / Date Time: p.m. TNTC = Too Numberous To Count OB = Other Bacteria A. WELL DATA 1.3 MUNICOEPT.' I SOF ANCHOf,+gGE MUN HEALICIPALITY OF ANCHORAGE TH AUTHORITY APPROVAL (HAA) ENMb7p**NTS PRO E 71ON CHECKLIST - FEBRUARY 1984 NOV 20=m 264-4720 lqw Legal Descr�ipltion: LE'Gr. Y 1 ri' ' � Well Classification 54r. If A, B, C, D.E.C. Approved (Y/N) N It, Well Log PresentO/N) Date Completed 'moi" Sl Yield 20 e—F" -t— Total —Total Depth $41 Cased to S�F-� Depth of Grouting Static Water Level ' Pump Set At Casing Height Above Ground Electrical Wiring in Conduit ON) Separation Distances from Well: Sanitary Seal on Casing49N) Depression Around Wellhead4w) D To Septic/4ele<ing Tank on Lot 12-e� ; On Adjoining Lots lL--A=> t-1 To Nearest Edge of Absorption Field on Lot ('2 3 ; On Adjoining Lots cab 1 } To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole r' [iTo Nearest Sewer Service Line on tot Water Sample Collected by `-' Ls.�Gin! Gr�a� )G ; Date Water Sample Test Results Comments �nl .� 1t c «J 6KGc5�c Satz 20 CnPl-d { f-hta Is pc� "C'Fk�. ��1c, .�+3 SEPTIC/FW&69iNG TANKD A Date Installed (V —6 . r19 Size 1ZAG_b No. of Compartments Z StandpipesCYN) Air -tight Caps ON) Foundation CleanoutY�N) Depression over Tank (Y/Q Date Last Pumped Pumping/Maintenance Contract on File (Y/N) IQ n for Holding Tank High -Water Alarm (Y/N) "' Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Heldii g Tank: To Water -Supply Well l To Building Foundation I b To Property Line To Water Main/Service Line _ Course —_ Id Comments Page 1 of 2 72-026(11/84) t r To Disposal Field To Stream, Pond, Lake, or Major Drainage 5. LEGAL DES RIPTION DAYE RECEIVED INSPECTION APPOINTMENTS STREET LOCATION TIME TIME TIME DATE SINGLE FAMILY DATE DATE ❑ Two ❑ Five ❑ MULTIPLE FAMILY j Three ❑ ' Six — XiC y� \ l-.CJLLJ INSPECTOR 0 INDIVIDUAL* INSPECTOR INSPECT R since June 1975. For wells drilled prior to that date, give well MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE depth (attach log if available.) DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIERtT: OF 1 :"ALTH & • 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL rROTECTION YEAR ON-SITE SYSTEM WAS INSTALLED. ENVIRONMENTAL SANITATION DIVISION j0N 51980 Telephone 264-4720 pp�CCrr REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND 91iW,B� jjV&RES DIRECTIONS: Complete all par on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. R RTY W ER PH NE [� I I�LJ• (�i MAI�JI DtGrA,7D ESSn \nJl PROP ESIDENT If different from above) PHONE 2. BUYER PHONE MAILING ADDRESS 3. UJG IN TI UTION PHONE 0.5 b✓ -7 MAILINGADDRESS Cil' ?Y ,\ h 4. REALTOR/AGENT PHONE MAILING ADDRESS 5. LEGAL DES RIPTION rl 1 Ci• / 't�lY\VY ' STREET LOCATION L��C_1_ 6. TYPE OF RESIDENCE NUMBER OF\BEDROOMS SINGLE FAMILY ❑ One ❑ Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY j Three ❑ ' Six 7. WATER SUPPLY 0 INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAWON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) apS CHEMICAL & GEC .OGICAL LABORATORIES G. ALASKA, INC. TELEPHONE (907)-279.4014 ANCHORAGE INDUSTRIAL CENTER —� 274.3364 5633 B Street usowwrawi[e Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY WATER SYSTEM: Analysis shows this Water SAMPLE to be: I.D. NO. 171 Satisfactory Water System Name Phone No Mailing Address City State Zip Code SAMPLE DATE: Mo. Day Year SAMPLE TYPE: ❑ Routine ❑ Check Sample (for routine sample El Treated Water with lab ref. 1 ElUntreated Water ❑ Special Purposee SAMPLE Time Collected NO. LOCATION Collected By 1 2 II 3 J 4 5 ❑ 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 Ref. No. Result' Analyst I I m I I m ETI I m I m +No. of colonies/ 100 ml. or No. of Positive portions. 06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1978 Date READ INSTRUCTIONS Date BEFORE COLLECTING SAMPLE Hours Multiple Tube Report: Membrane Fllter: Direct Count Verification: LTB Final Membrane Filter Results. Reported By _Time Received 10m1 10m Source _ a.m. - p.m. No. 1 om1 I 1.0ml I 0.1ml Broth 24 hours: Broth 48 hours: 30ml Tubes Posltive/Total 10ml Portions col lform/100rt11 BGB Coliform/300m1 Date Time a.m. p.m. June 11, 1990 X.R. Tsfeville Star Route Box 2:30VI Eagle River, Alaska 91577 Su Ject i Lot 1 3lock l .Mountain Manor Sub.li.vision ipproval for yaur individual sewer and water facilities oar, not bo granted until the following item has been coxiApluted (1) he water a7"alvsis report ba delivered to this Office Eroln C'heia Lab, 5633 ss Street, for our review. If there are: any further questions, please call this office at 264--4721. Sincerely Robert C. Pratt, R.S. .Assooi.a.te Specialist 01C., Alaska Statebank Mortgage. Leon Department 3113 Ea3t northern. Lights ;3uulevarl 99503 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH 8, MUNICIPALITY OF ANCHORAGE (MOA) EN"W' IWAL PROTEcT" HEALTH AUTHORITY APPROVAL (HAA) NOV CHECKLIST - FEBRUARY 1984 O 264-4720 rr Legal Description: L-�'� '^ I r F) A. WELL DATA Well Classification 5 4 r If A, B, C, D.E.C. Approved (Y/N) 01" Well Log Present/N) - Date Completed 7 � el Yield 9 C> 64pN Total Depth 48 Cased to 8q�' Depth of Grouting - -- Static Water Level �� Pump Set At Casing Height Above Ground — � Sanitary Seal on Casing49N) Electrical Wiring in Conduit ON) Depression Around Wellhead Separation Distances from Well: To Septic/14eloing Tank on Lot l Z`c� ; On Adjoining Lots t 1 ��� -4 i I To Nearest Edge of Absorption Field ori Lot On Adjoining Lots 1 �b To Nearest Public Sewer Line �' To Nearest Public Sewer t Cleanout/Manhole r' hl To Nearest Sewer Service Line on Lot Water Sample Collected by �� �r s ��GtnJZ �-rt �eJC ;Date -eA5' Water Sample Test Results Comments p' F�2 c4tL 2-dGekd { I-h� IS A�* 1711-� �pn.f�a�.�. c- .F{kC. y�'fcr psi- t3. si s..t , IFJb-a- mr,J B. SEPTIC/Ha6B�ING TANK DATA Date Installed (0-6-19 Size;Z5-b No. of Compartments Z Standpipeso/N) Air -tight Caps ON) Foundation Cleanout fQN) Depression over Tank (Y/Q Date Last PumpedS- Pumping/Maintenance Contract on File (Y/N) A ; for Holding Tank High -Water Alarm (Y/N) �° Temporary Holding, Tank Permit (Y/N) p Separation Distances from Septic/He'ding Tank: To Water -Supply Well L 2 To Building Foundation I b 1 To Property Line ) o t r To Disposal Field To Water Main/Service Line — Course Comments Page 1 of 2 To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Z�v 6L_ Type of System Design Date Installed — 'Z `I Length of Field _ r Width of Field ''��x Depth of Field Gravel Bed Thickness (v' Square Feet of Absorption Area l =I' Standpipes Present (VN) Depression over Field (Y/I,,,� Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well k2_42> ( To Property Line 1 C) 4 - To Building Foundation Lot t4 To Water Main/Service Line \b_I * To Stream/Pond/Lake/or Major Drainage Course _ To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons To Existing or Abandoned System on I On Adjoining Lots �p To Cyrtbank (if present) A p ,_ 1 4 - Dimensions Manhole/Access (Y/N) "Pump On" Level at "Pump Off' Level at High Water Alarm Level at Vent (Y/N) 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, orconformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed `a ' RB 4969 I �l — ZD ` P i 44- JAIVF>°�Lf�U eWe� Date Com 'dpi — g%¢� MOA No. 3-7_003 ,^ Receipt No. a(o� ll°l ,: Date of Payment I I C'�) `(,�S Amount: $ Page 2 of 2 72-026 (11/84) T C Roberl A. Shafer kip ®n No. 1457-E :' a'or OF rr; AW S. LEGAL DES RIPTION DA E'RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE (y\ INSPECTOR INSPECTOR INSPECT R MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIONT. OF I!-ALTH & 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION ENVIRONMENTAL SANITATION DIVISION J'jN 51980 0* Telephone 264-4720 C REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND 91;i11�e�ii4j-0ES DIRECTIONS: Complete all par on page 1. Incomplete requests will not be processed. Please allow ten (10) daysfor processing. 1. R- RTY W ERE PH N $ depth (attach log if available.) �� q quo W INDIVIDUAWON-SITE** 77 YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY MAI L ESS NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. PROP ESI DENT If different from above) C& `' PHONE 2. BUYER PHONE MAILING ADDRESS 3.IyG IN TI UTION � PHONE 0.5 TZ ? i ---7 1 MAILING ADDRESS Cif �v , 5a Y.' 4. REALTOR/AGENT PHONE MAILING ADDRESS S. LEGAL DES RIPTION STREET LOCATION ;Y... V 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS SINGLE FAMILY ❑ One ❑ Four ❑ Other ❑ Two ❑ Five ❑ MULTIPLE FAMILY 12N, Three ❑ 'Six 7. WATER SUPPLY INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled EJ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM W INDIVIDUAWON-SITE** 77 YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY - NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) ao _,/}- / j�J 7a -Nn in.,, F/7Q1 THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ TWO ❑ FOUR ❑ FIVE ❑ OTHER ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 0-r-,— ` Q 1\— � 1 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER r ❑Septic Tank or ❑ Holding Tank Size: If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS 6.o APPROVED FOR � BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE BYP- �: 7a -Nn in.,, F/7Q1 CHEMICAL & GEC—OGICAL LABORATORIES G_ ALASKA, INC. TELEPHONE (907)-2794014 ANCHORAGE INDUSTRIAL CENTER ^� 274-3364 5633 B Street v ueowwrowiae Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY WATER SYSTEM: I.D. NO. Water System Name Phone No. Mailing Address City State Zip Code SAMPLE DATE: m Mo. Day Year SAMPLE TYPE: ❑ Routine ❑ Check Sample (for routine sample with lab ref. no. l ❑ Treated Water ❑ Special Purpose ❑ Untreated Water SAMPLE Time Collected NO, LOCATION Collected By 1 1 2 3 4 5 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 Ref. No. Result' Analyst � I m i FT7 i CEI ED FTI *Noof colonies/100 ml. or No. of Positive portions. 06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Rev. 1976 Date Collected READ INSTRUCTIONS Date Received 24 Hours BEFORE a.m. Time Received o.m. Lab. No. 0.1ml EMB Broth 24 hours: Broth 48 hours: COLLECTING SAMPLE Multiple Tube Report: 10ml Tubes Positive/Total lomi Portions Membrane Filter: Direct Count Collform/100ml Verification: LTB SGB Final Membrane Filter Results Collform/100ml Reported By Date p.m. 00limcbmss Arr Col Jech foil Samples of Water for, 1,1101 Colihow-r-iin, B;tcteria Examnionation This Smater =1011m, dumm wali-I vv-issnt i:s very cniflujo quantAm in collecting Water sompley vvdl have to, rc�avh flim fP--bovkaory a% quickly a -,m po,-Able within 48 hc)Urs afte-rcoli ecoon" After 48 hows, Me Nile, ttaCWHOltv,l iC3iW301ySiS i,-- hri-paired and resampling will be nec- vissarv. Slnw" --lho-atcry Whim my: (i e. fp1mi'al liuiively In vA WIN W1 j! Immy"de"sz -"k§'wuk -�"AIIH ar FTIVIF'S Firtmemed als Allman: U) Ruman, as -mmars m .k .'.i:'&.. aktadwd "df-, - fioc uuil= is! ? not-ou:1200 ASK Invy v mulp 1xv Ishmquyl imater fit m"I freely Vkh, a fully opencel oullet for 11hree I, a3 ,d[' 'Nrvvvv� FWAve Am NO)i� �V WITIA. Iit-to 1"k'ksd'l'kq Hood StIttle oil um €^'aipd a. x, rerno"llvivig cetp Kshfh the ot'ller, ke..-7p '11 Mn MITIfe mul A- Aside (it the cap, Mi ""he' to wKs 'AmiuSaid. r PAY atlz;.iwitinq to smik! sjKlashing. Immediately rephuse cap, baint thist �'� .r 1YOR, LUZ rICT all UgH Oka to SIN the cay, f) kivic, Ono din Y'u kirno' I�vhich is "'T() f-lF. CCIMPLETED 01f SUPPLIER." FM jr, all opplovanato bialas carafAy, includiiiq yooir IvibHc water systent identification number (if) OAK)j llsmvv�o -hi,, Alwashon Wipuirtimint of F,,nvironmerstal Consprvation if you do not know vocir 01 munhar, (Pktom"' vuauck' suopfic's' -Inly) 511 'Per"k " vttln� ""';lrevilifly is ellmiilliiq, whe vw0h lah forret I've reansa remmlm Ar algamsm (if a'rKjhkr alyntems foo r total cWHorm bacteria are defined in the WrIcloy; Amoter bV ?hc.' F,-)cpartrnem of MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date Da f ?-14 /987 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) 4�of9� Q(a_ ck T I-cou,114;n Ptanor SIP Location (address or directions) Ouf lco(r Ccrc(e gr (b) Property Owner �Jorua.o( RG(ac Telephone: Home Business Mailing Address 220 S Or -"7e koe GI.,t7X/on At. T. 07039 (c) Lending Institution �. Ftev Pac,#Gc M0,r4o9cTelephone S-6'✓ � 20✓} Mailing Address F.cp. Box loaf'eo A*c/ioraf 99S -to (d) Real Estate Company and Agent Dv.1a.Mic F(ta.U/y /`-roeottr Address 5CG ( Gt/ /Yo.- Ae�� kkr C'40 94.Sa3 Telephone 77 — 76// (e) Mail the HAA to the following address: or: Check here El, if hold for pick up. List contact person and day phone number below. 2. TYPE OF RESIDENCEN a' , Single -Family Number of Bedrooms 3. WATER SUPPLY Individual Well ® Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite 59 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. Page 1 of 2 72-025 (Rev 8/861 Front HOea (99/9 Aa8) 9&0-aZ Z to a a6ed '+laonn s,aaaulbua leuoissalo.id ayl ui suoisslwo jo saoaaa ao} algisuodsai lou si 96eaoyouy to AlgediownVI 941 -panssi si aleoilpeo a aaolaq elep az (leue ao suoiloadsui lonpuoo lou op SHH(] to saaAoldw3 -sluawaimbaa alels pue leaapa} wepeo A}slles of aapio ul suoilnplsui bulpuai 91941 pue sawoy to siaseywnd of tselonoo use sly; saop SHHQ 941 eNseIy to amS 841 ul paaalsibej Jeaulbue leuolssa}oid luapuadapui ue Aq anoge 9 4dea6ejed ui uanl6 suolleluasaidej a4l uodn Aluo paseq sa;eol}i>aao Jenwddy (;uoUlnb 4lIB9H sanss. (SHH(]) saolnaaS uewnH PUB 411eaH to luaw;jeda(] a6eao4ouy }o Allledlolunlnl a41 NOunVO 1eu011ipu0O I lenoaddy IRU6111puo0 }o swaal panoaddesi(]panoaddy X 1'. 9 _ OT -_Q/ ale(] (q swoapaq 0 Jo} panoaddy pvb�-( IVAOUddV SHHa '9 oo�,®pom 410� +OISSq AV Ar �' 6BSE • 3J • 0 4 Jr : 3aoow•d aaoaoaNi ,d Owego* ..:......................o -0 :....f /30 ....... i wo Q617 y b•••......•• a4 POS s,aaaui6u3 9 f'"a'L �y y 4'1 uo WOY 57(F 7'-/da5 �ovb �� �m va�rri�r �y v� vn�r n jo rn,ys2iv0�7S � �' p� p» a .nom � nom} - L $ 7 -1 -?-7 01 ale(] ll 5,04 ssOjppv — SCI-Sh 0 auo4dela1 G75 j ��v dal a#n� waid }o aweN 4'uoiloedsul s141 to alep eql uo )0e1}a ui suoileln6aa pue'seoueuipio'sepoo ale;S pue Iedqunlry Ile 4l!m eouelidwoo ui sl walsAs lesodslp jalemelsvm ao/pue Alddns aaleM ells-uo 941 'uoiloadsui pus uoile611sanui Aw woal pue sap) 96eao4ouy to Apledloiuny+l 94l woe} paulelgo uollewjo}w a4l uo paseq le4l (;uan aaglanl I •uiaja4 paleoipui ainlonils to ad (l pue swooapaq to aagwnu 94l ao} alenbape pus leuollounl'ales sl walsAs lesodslp aalumalsem ao/pue AIddns ialum alis-uo ayl le41 smogs Jenoaddy (luoglny 411eaH siyl }o u011e61lsanul Aw legl A;iaan I 'Molaq umogs alep uoilepllen 94110 se pue olaaa4 pexl}}e leas Aw Aq pal} lia0 sy NOIIVWHOdNI (INV V1Va `HOk1V3S 3-113 `S1S31 `SNOIlO3dSNl °JNIa1AOdd WWW ONIE133NION3 '9 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 Legal Description: 6.of 1t G %c.l< i Matin /Aln manor S//h A. WELL DATA Well Classification Privak If A, B, C, D.E.C. Approved (Y/N) Nr A. Well Log Present (Y/N) Y Date Completed 7 / 8 IYield wpm p r._ Total Depth 8 Y Cased to 8 `/ Depth of Grouting N, A. Static Water Level 61' Pump Set At 8t' Casing Height Above Ground 211 r` Sanitary Seal on Casing (Y/N) — Electrical Wiring in Conduit (Y/N) i X Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot 12 8 A� c. a, ; On Adjoining Lots > too To Nearest Edge of Absorption Field on Lot 128 t ; 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 K, 4. Water Sample Collected by%af409 Te CA Svcr —;Date — 100Y tY / B7 Water Sample Test Results SanljuC&r m1 Comments New we 11 1�caiect l26' csw odc sy,kc 135' :�r>m C•-. aF [n<t 01 french _ Wc11 91 Cs/aloe oeeJAc"Ce� d6o^G C•G, / //1e in Gev/,v 0fconnve'r O(. i'i �Cwo�. Neo Wetl /Uc/ a/115"cliva B. SEPTIC/HOLDING TANK DATA / Date Installed / 6 / 7 9 Size12No. of Compartments a Standpipes (Y/N) 1' Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) N Date Last Pumped lo/ 1 7/ 6 7 6X J H `s Pumping/Maintenance Contract on File (Y/N) N• H . ; for Holding Tank High -Water Alarm (Y/N) N. A• Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well 128 To Property Line 16' To Building Foundation Y To Disposal Field E 0 To Water Main/Service Line N.A. To Stream, Pond, Lake, or Major Drainage Course 7 100' Comments "W%id¢�y MdA. Page 1 of 2 72-026 (Rev 8/66) Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 2 a o 0 '/(3drm Type of System Design Tren chi Date Installed 6 /6 / 7 9 Length of Field 6.6 Width of Field 30" O Depth of Field t 2 1 Gravel Bed Thickness a Square Feet of Absorption Area f D 5 1( Standpipes Present (Y/N) Depression over Field (Y/N) N Date of Last Adequacy Test (0/11 / 8 Results of Last Adequacy Test AderuaFe _vr 3 bedroom..r Separation Distance from Absorption Field: To Water -Supply Well 12B r To Property Line 23 To Building Foundation 2 2 To Existing or Abandoned System on Lot N. A. On Adjoining Lots > 30' To Water Main/Service Line N. A, To Cutbank (if present) N, 4. To Stream/Pond/Lake/or Major Drainage Course faa' To Driveway, Parking Area, or Vehicle Storage Area -_� .s0 Comments Trench 06h/ a -t 6V inn i! of /rsf D. LIFT STATION N.A 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 56 7A0--(_ Date 10 / /9 / 6'7 Company Ftuf/Gn Tec% Svcs MOA No. a7 -OT Z Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (Rev 8/86) Back OF A4 IAf �9 Engineer's Seal r.r G9 a� A'..........................� 0�f 7� Q.......................� © 9.eT EODQRi: F. MOORE ®e . ` CE - 3539 • tU'AV