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HomeMy WebLinkAboutNETTLETON ACRES #3 BLK 1 LT 2A Municipality of Anchorage Page [ of .~ _ DEPARTMENT OF HEALTH AND HUMAN SERVIO. ES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report N~m.: Wastewater System: ~ New ~ Upgrade Address: ABSORPTION FIELD Phone: No, of~Bedrooms: ~Deep Trench B Shallow Trench Q Bed ~ Mound B Other Soil Rating: Total Depth from original grade: LEGAL DESCRIPTION o, b Lot: Block: Subdiv~ion: Depth to pips bottom from original grade: Gravel depth beneath pipe Township: Range: Section: Fill added above original grade: Gravel length: , Gravel width: Number of lines: Bistance between lines: WELL: ~ New B Upgrade ~ ' Ft. ~ /&' Ft. Cla'ssification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Drilled: Static Water Level: Installer: Date installed: Pump,Set at: Casing Height Above Ground: SEPARATION DISTANCES ~eptic ~ Holding U S.T,E.P. TO Septic Absorption Lift Holding Public/Private , Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~O~ ~ ~ Material: Number of Compa~ments: su,,o~ LIFT STATION LOt ~ Size in gallons: ~anufacturor: High water alarm et: Cudain ~ Pump M~ Electrical Inspections pedormed by: Drain Remarks: BENCH MARK Loc~tion and Description: I Assumed Elovation: ENGINEER'S SEAL Inspections performed by: *~A- ¢~¢Ac-r Dates: 1st 6E-814~ Department of Heal~ an¢ ~umaB. Services approval Reviewed and approved by: 72-013 (Rev. 9/91) MOA 25 A S - 3 ~ZL_.T_ · WASTE:WATER A~$a,qPri'[~N ~Y'gtEM ..... Lots 2A, BL~ Ne~t[eto~ Amres / ~o~c_c~-m~. / ~ New Well 1,5o0 g I~ v New twln-tre~/:h .' Splitter In;'~a!~ted PANNONE ENG, SVC, P, 0, BOX 142025 ANCHORAGE, Al< 99514 ~ 7-t4- 6 I AS-BUILT PREPARED FOR~ Randall Moss 2960 C Street ~ 200 Anchorage, AK 99503 AS-BUILT DETAILS ~/ASTE~/ATER A~SORPTInN SYSTEM Lo~s SA, B~ock 1 Nett~etom Acres J 0I 7 W i~0NV293 NOI~VONflO~ PREPARED FI]R, R~nd~ll Moss 89G0 C Stcreetc ~ 200 Anchor~§e, AK 99503 STEVEN R, PANNONE, P,,E, P, D, BOX 148085 ANCHORAGE, ALASKA 99514. 874-0308, 878-8818 FAX DATE, .~7~- 13 - % NOT co SCALE AS-]~UILT PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW940346 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:MOSS 1L~NDALL H & SHARON A OWNER ADDRESS:6820 LOUISE CT PARCEL ID:01506256 DATE ISSUED: 9/19/94 EXPIRATION DATE: 9/19/95 LEGAL DESCRIPTION: NETTLETON ACRES I~3 BLK 2A 1 LT LOT SIZE: 63741 (SQ. FT.) NUI~ER OF BEDROOMS: 5 THIS PERMIT: 5 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) A_ND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 (24 HOURS) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: /,-:>, .-,. //> .. DATE: DATE: August 3, 1994 Department of Health and Human Services Anchorage, Alaska Re: Onsite sewer system design for Nettleton Acres No. 3 Blk. 1 lot 2A. Dear DHHS, This is a request for an onsite sewer permit for an proposed residence located at the above address. Test pits were excavated as shown in plan view. The soil profile showed a uniform sandy/silty gravel to a depth of 18 feet with a percolation rate of 20 min/inch. No impacts to the surrounding properties are foreseen. Ail have onsite systems already and appear to be preforming adequately. This and the surrounding properties are served by on site wells as shown in plan view. The required set-backs are easily obtained within the confines of the lot. The topography of the area is sloping to the west at about 20%. The lot has 63,741 square feet. RECEIVED August 3, 1994 8EP '~(~ 1994 D Municipaljly o! ^nctlor~tge Department of Health and Human Ser~.tc~e~alth&HumanService$ Anchorage, Alaska Re: 0nsite sewer system design for Nettleton Unit No, 3 Blk. 1 lot iA. Dear DHHS, This is a request for an onsite sewer permit for an proposed residence located at the above address. Test pits were excavated as shown in plan view. The soil profile showed a uniform sandy/silty gravel to a depth of 18 feet with a percolation rate of 20 min/inch. No impacts to the surrounding properties are foreseen. All have onsite systems already and appear to be preforming adequately. This and the surrounding properties are served by on site wells as shown in plan view. The required set-backs are easily obtained within the confines of the lot. The topography of the area is sloping to the west at about 20%. The lot has 63,741 square feet. Sincerely, s M. Wright P.E II Z _~ ~- __l LL 0 6,3 Ld 0 0 © r~) Ld L~_ ~ 0 o Z c , * / / / 0 Z 0 7 ILl J I ,/ 0 0 --[] 0 I~1 CD C '"0 0 I "13 0 0 l-r1 U') Z 0 0 .4" CLEAN 4-0' 4"CLEAN OUT FROM SEPTIC TANK 4" CLEAN OUT PkAN VIEW 4"CLEAN OUT :RIC 70 LIN. Fi 4." PERFORATE S -- 4" MIN. COVER ELEVATION PIPE FROM SEPTIC TANK FILTER FABRIC 4." PERFORATED PiPE DRAIN ROCK SECTION ~"~'5"' -".'.~:~ ~.. ~, .~;. ~.) ./ ...... ~ ~.,, JAMES U, WRIGHT :~ . .~o~ NETTLETON ACRES NO. ,3, BLK. 1, LOT 2A Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ~-o~, '~- c,,~ DEPTH (FEET) I' ]- 1- 2- 3- 4- 5- 7- 8 1 Township, Range, Section: CO'/' '~,./¢. SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED7 S L IF YES, AT WRAT O DEPTH? P E DBP(I~ t° Water Alter .~OMoniloring? , {]ale: ~'~/{~ Gross Net Depth to Net Reading Date Time Time Water Drop 30 , ~ PERCOLATION RATE TEST RUN BETWEEN Z-(..D (minutes/tach) PERC HOLE DIAMETER / FTAND FT 2, OMMENTS PERFORMED BY: 24\e'~--ct¢=, ( ,5/¢-¢~ ~ r',14. O~ .... I /"'/'(/~f'-~, ~\]'~'.¢' ~ 'j' CERTIFY THAT J'HIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES iN EFFECT ON THIS DATE. DATE ~--~/~/ 0"?/ 72-008 (Rev. 4/85) Municipality ol Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: DEPTH (PEET) 2- 3- 4- 9- 0- 1- 2 4 5 6~ .7 - 8- 9- ~0- ~,,/ ); JAMES M, WRIGHT '~ ~'-,,~ DATE PERFORMED:'~~ ~7 Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? si'rE PLAN L IF YES, AT WHAT O DEPTH? p E Oepth lo Water After /~/(,~ ~ Monitoring? . Dab J Gross Net Depth to Nat Reading Date Time Time Water Drop /O /o ~ ~ [o , ~- z__ PERCOLATION RATE TEST RUN BETWEEN (m~nutesnnch) PERC HOLE DIAMETER ~ FT AND ~)"~'~__,___~ FT 30MMENTS ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: /~, ~.~L~ 72-008 (Rev. 4/85) · . '" DRILLING, INC. ' · RECEIVED Well Owner~ ',- , ,'~;7'77~ /~: 7~/~/ ~ MunicipalltyofA~lt ~m ....... D~t. Hearth A Hu~A~erwces ~atton (addr~s of: Township, Range, S~tion, tf known; or dtstan~ main ~ad. ' Size of casing '-' Depth of Hole. ' '~.feet Cased to "1 · :' feet Static water level_ ':.~t ft. (above) (below) land surface, Finish of well (check one) open end ( X ); Screen ( ); Perforated ( ). ~ Describe screen~br perforatio, i ..... · Well pumping test at__ ' gallons per (ho~tr) (minute) for- of drawdown from static level. hours with 1r'4Y~; ' ,, ~ Datebfcompletlon._Lt' :"l'~ ",3 _ Depth in feet from ground surface .TO." TO.. po .TO ?~r~ .TO__ WELL LOG Give details of formations penetrated, size of material, color and hJrdne~ F;r.n,'l,,, '..r' ,'~'1: '"..~l~.y/col.:bly L "" TO TO TO~ TO .TO. , . .TO .... .TO .TO i¢ipa tyo P.O. BO, .96650 ANCHORAGE, ALASKA 99519-6650 (907) 343-4200 ~7~R~ Tom Fink, MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES January 8, 1988 Anita Whitney % S & S Engineering 17034 Eagle River Loop Road #204 Eagle River, Alaska 99577 Subject: Lot 2A Block 1 Nettleton Acres Subdivision #3 Permit #870091, On-site Sewer/Well Permit A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1987o Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as-built inspection report (three-part form) must be sent to this office for review and approval, and for documentation. Effective January' 1, 1988, a new fee schedule is in effect. When re-applying for a new permit, the new fees are; $90.00 for an on-site sewer permit; $50.00 for a well permit; $140.00 for a combined sewer and well permit. If there are any further questions, please call this office at 343-4744. Si rely, Robert W. Robins Program Manager On-site Services RWR/ljw enc: Copy of Permit 1 '? 034 1~!, ,, 1:.,i ,, t ,J':':l~ ;2'.0 q f F~13,1,1i.,:tl Vii:, L)l!i!:i7' i'l I ? DEl:':' I J'J 23 SCALE PERFORMED FOR: LEGAL DESCRIPTION: ~_ ~"~ ~. ~ 10 11 12 13 14 15 16 17 18 19 20 Municipality o! Anchorage DEPARTMENT OF HEAL'I'H & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST I Township, Range, Section: //~ ~ ~ SLOPE SITE PLAN WAS GROUND WATER 'k I ENCOUNTERED? )"~,(.~ S IF YES, AT WHAT DEPTH? P E Deplh Io Water Altar ..~ 1/ Moniloring? ~ ~.~ ~-, Date: , Reading Date Gross Net Depth to Net Time Time Water Drop ~'.~o /o '/ ~" ~l' ~/~" ~ ~ ~. ~ .,, ~" ~; z~ ~ ', ~ ~/~" 7~.. PERCOLATION RATE ~-~' (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN Y FT AND ~ _ FT COMMENTS U.-~ F~- ~.~' '~/,~,~ Ab~. ~-,~ ~-.~,~,~ ~ L~-. S & S ENGINEERING /~/~ / PERFORMED BY: ~,l. ~ .... , ......... ~ //~ ~ CERTIFY THAT THiS TEST WAS PERFORMED IN 72-008 (Rev. 4/85) / / Municipality of Anchorage DEPARTMENT OF HEAL'I-H & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: DATE PERFORMED: 1 2 3 4 5 6 7 8 9 I0 11 12 13 14 15 16 17 18 19 2O p, Range, Section: //~.,k~f /'~'&v,-( ~'~ ~t_ /~-/ SLOPE SITE PLAN / WAS GROUND WATER ~"~ lC2 ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water After Meniloring? /,J~C~ (]ale: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE E DIAMETER TEST RUN BETWEEN ~ FT AND FT ~ COMMENTS ./~"~ 17034 Eagle Rlvm' L~p R~d No. 2 ~ PERFORMED BY: ;. = ,,- = ..... .-_ ~~~ CERTIFY THAT THIS TECT WAS ACCORDANCE WITH ALL S,ATE AND MUNICIPAL GUIDELI~FFECT ON THIS DATE. DATE: ,~ /~P/Y/ / / 72-008 (Rev. 4/85) PERFORMED IN 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 Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone 4 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 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 WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 12-025 {Rev. 1/91) Fronl MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and typeofstructureindicated herein, lfurtherverifythat based on the information obtained from the Municipality of Anchorage files and from my inves~Lgation 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 .k-~k/.;.~o,~ ~, Address ~'-~- ¢" Engineer's signature ~~- -~£ "~ C Phone A,,-'c~ / /'.-/lC ~ 5.F/~f Date E?.- ~ '- ¢'~'- DHHS SIGNATURE Approved for .-~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Ce~ificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Laboratory Division Drinking Water Analysis Report for Total Coliform Bacteria 2oo w, ~o. er o~v~ Anchorage, AK 99518-1605 READ .[NSTRUCTION, g ON REVEILgE 81DE BEFORE COLLECTING SAMPLE Tel: (907) 582-2343 MUST BE COMPLETED BY WATF, R SLrPpLIER g PUBLIC WATER SYSTEM I.D. # ~ <PRIVATE WATER SYSTEM tn o~and,~sults ~ ~9end lnvole~ V ¢ ~_ _~ 0 r~ .<?- /~_ Ct_ _L ................. Q gend Invoice SAMPLE TYPE: )Routine Repeat Sample (for routine sample with lab ref. no. ) O Special Purpose Time Collected SABLE LOCATION dt" ¢('¢.'¢'¢'/') CoJlectod By Treated Water Untreated Water Fax: (907) ~61.~301 Analysis shows this Water SAMPLE to be: .~ Satisfactory Unsatishctou Sample over 30 hours old, results may be unreliable Q Sample too long in transit: sample should not be over 48 hours old at examination to indicate reliable results, Please send new sample via special delivery mail. 1 Da te Received ~./J Time Received I~} ~' Analysis Began I ~ Analytical Method: fir~ -Mombrane Filter Q MMO-MUG * Number of colonies/100 mh f ok n.~r ~^ Result* Anah/st i: 96. 3365~ : ~ Sent to A,D,ILC. A ach Fb'lo Jun Dm: Time'. Client notified of unsatisfaeto~ results: Phoned Spoke with Date: Time: BACTERIOLOGICAL WATER ANALYSIS RECORD Faxed E3 MMO-MUG Result: Total Coliform Membrane Filter: Direct Count ' Verification: LTB Fecal Coliform Confirmation BGB Coil (~ Colonies/lO0 mi COLIFIRM Comments: Final Membrane Filter Resu[t~ Coliform/lO0 mi Date (~'~2,.~(.. Time /~'""~' brs Member of the 8(38 Group {$O~i~t~ G{nerale de Surveille,dce) 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # .. (:~/,_~- C~'Z- ~ ~, 1. GENERAL INFORMATION Complete legal description ~o-c- '~A ~'7-]~ ~¢,c/~_ I Location (site address or directions) &, ~ ~,2 /_ c,u¢ &~. c_:-~ - Property owner ~.R~u~,q ~ (_ ~ ~ ~.s Day phone Mailing address ~?o ¢~r,s~ ~'-c / ~'~,Wc~/, At/__ Lending agency Day phone Mailing address.. Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ 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 WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1191) Front MOA #21 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/orwastewaterdisposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverifythat based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~)A/~o~v¢: ¢.~,~, ~'v'c_ Address Engineer's sig nat u r¢-~-----~ DHHS SIGNATURE Approved for Disapproved. /% Conditional approval for bedrooms. · ~ bedrooms, with the foltowing stipulations: The ±nsp~cbhg eng±neer~supp2¥ tb±s o£~±ce ~±th a =ev±se8 accurate as-built of the newly constructed wastewater system servinq this lot. This condition shall be comDleted by no later than August 1, 1996. 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 paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA ~1 MuniciPality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L'' Street, Room 502. A.chorage, Alaska 99501. (9~)[~(~-i~'/~J}~ [ D JUL 2 5 1996 Health Authority Approval Checklist Municipality of Anchorage O~pt. Health & Human Services LegatDescriptioni ~A~l N~'r~-ccc~'vo,v A~._~ ~..~ ParcelI.D.: ¢1~' - A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) IfA, B, or C, attach ADEC letter. ADEC water system number Date completed q- / 6-- 9' I Cased to ~-,5-' Casing height (above ground) ~ Wires properly protected (Y/N) AT INSPECTION Date of test Static water level Well production FROM WELL LOG t ~ g.p.m. ~?- ~ g.p.m. Nitrate WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed q'-t 5z~.9 t~ Foundation cleanout (Y/N~ Date of Pumping /,9 ~-~4D Pumper ABSORPTION FIELD DATA t~ ~'~'~ t Other bacteria ~ £~ '- Collected by: ,~ - k ,~,ri'~thext,,oOa2 ~: Fluid depth in absorption field before test (in.); Fluid depth (ins.) Minutes later: Peroxide trealment (past 12 months) (Y/N) Tank size /~c'¢c~ Number of Compartments '&- Cleanouts (Y/N) ~' Depression (Y/N) /--4 o High water alarm (Y/N) ~ Date installed c?_t 5z- q,/o Soil rating (g.p.d./ft2 or fiZ/bdrm) e,, & System type 23 '17. Length ~ o' Width 2. Gravel thickness below pipe ~ Total depth / ~ Effective absorption area / ~'O Monitoring Tube present(Y/N) ~. Depression over field (Y/N) ~ Date of adequacy test b4~ ~d4'~%A'r0, Results (Pass/Fail) ~:"A~Z For ~ bedrooms Immediately after gal. water added (in.): __ Absorption rate = g.p.d. If yes, give date LIF'F STATION Date installed Manhole/Access (Y/N) ~ High wat~ *Datu,2~ztcs.t~ted m Size in gallons __/------~ "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line ; On adjacent lots .; On adjacent lots Public sewer manhole/cleanout Lift station /OO SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 7'2 ~ Property line ~-/C~ Absorption field Water maln/selMce line /Oo+ Surface water/drainage /ca, '~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Property Line .~-~0 Water main/service line Surface water loo q- Driveway, parking/vehicle storage area Curtain drain Wells on adjacent lots /~c9 "-c- ENGINEER'S CERTIFICATION ! certify that I have determined thrufield inspections and review of Municipal reco)~lJ tha in conformance with MOA HAA guidelines in effect on this date. Signamre~~ - Engineer's Name Date HAA Fee $ ~ ' ~ Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number CT&E Environmental Services Inc. Laboratory Division ~,w~,~,~',~,~,,~-,~,~,,w~,~,e,a,,,~,a~,,a~,~,,wm,~-,a 200 w. Potter Drive Anchorage, AK 9051 8.1608 Tel (907) $62,2343 FAX: (907) 561-5301 CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID Sample Remarks: 963049001 Pam~one Bng Srv, 6820 Louise CT 6820 Louise CT Drinking Water Client PO// Printed Date/Time 07/26/96 16:18 Collected Date/Time 07/25/96 07:30 Received Date/Time 07/25/96 10:00 Technical Director ParQmeter Results PQL Unlt~ ~itrate-N 1,51 0.100 mg/L Nitrito-N 0.tOOu O,tO0 mg/L Total Coliform 62 O~ W/O ~OLl Allowable Prep AnMy~i~ Method Limite Date Date Init EPA 353.2 07/25/96 SM18 92228 07/25/96 TAV IJJ~~ Member of the SGS Group ($oci~t6 GJ)nOralo de Surveillance) J[NVIRONMENTAL FACILITIES IN AJ.JkSKA, CALIFORNIA, FLORIDA. ILLINOIB, MARYLAND, MICHIGAN, MIS$OURI, NEW JERSEY, OHIO, WEST VIRGINIA DE~IORIP¥10N AMOUNT ~. ~MOuN) TOTAL MA'FERIAL TOTAL PAY THIS AMOUNT Tha~k You ~ 96, ~ mr Water REI~ARK~