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HomeMy WebLinkAboutROBINDALE #1 BLK 1 LT 3 ·, Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: '~----'-~'~4¢)~"~¢' PID Number: ~::~ ,~1D~'~---------------------------~ Na~~~ ~. ~~~ Wastewater System: D New ~Upgrade Address: ~.¢, ~ , ~¢% ~1~ ABSORPTION FIELD No. of Bedrooms: Phone: ~ -- ~~ ~ ~ Deep Trench ~ Shallow Trench ~ed ~ Mound ~ Other Soil Rating: Total Depth from original g~d~ LEGAL DESCRIPTION ¢.~ ~/sq. ~. ~ Block: ~ Subdivision: ''~ Lot:, ~1¢~~ Depth lo pipe bottom from ori¢i~a~e:. Ft. Gravel depth beneath pipe~.~l Ft. Township: Range: Section: Fill added above original grade: Gravel length: WELL: ~ New ~ Upgrade Oravelwidth: ~ Ft. ~ Ft. Numb~lines: Distance between lines: Classification (Private, A,B,C): Total Depth: Cased To: ITotal absorption area: ~ipe material:~l~ Driller: Date Drilled: Static Water Level: Installer: Date installed: Yield: Pump Set at: Casing Height Above Ground: ~ ~,. ~,. ~ ~ TANK SEPARATION DISTANCES ~eptic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding =ublic/Private Manufacturer: ~ ~ Capacity in gallons: From Tank Field Station Tank S .... Lines ~ · [ Number of Compartments: Well )~ ' ~1 -- ~ ~ Material~~ , Surface Water I~'+ ~ ~ ~ ~ LIFT STATION/~ LineL°t ~ t ~ I ~ ~ ~ Size in gallons: Manufacture, Foundation ~f ~1 ~ / ~ "Pump on"~Pump off" level at: High water alarm at: CurtainDrain ~M~ ~ ~ ~ ~ ~ ~ Pu~& Model Electrical Inspections performed by: Remarks: ~~ ~~ BENCH MARK Location and Description: Assumed Elevation: ENGI~EAL ' f rm d 1~034 Eagle River L~ Road No 204 Department of Health a~d Human Services approval '~-"~"..,~ ¢~ .,,, Reviewed and approved by: .~ ~ Date' ~-~2 -ZZ '~?ROFES~ 72-013 {Rev. 9/91) MOA 25 Permit No. ~ Page '~- of ~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report 72-013 A (Rev. 9/91) MOA 25 ~ SAM COTTEN DRTLLZNG CO. Box 296 Eao.]e River, Alaska 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 (UPGRADE) PERMIT PERMIT NUMBER:SW920236 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:SCHROEDER STEPHEN C & OWNER ADDRESS:S. R. 3, BOX 7140 CHUGIAK, ALASKA 99567 PARCEL ID:05105250 LEGAL DESCRIPTION: ROBINDALE #1 BLK 1 LT 3 DATE ISSUED: 8/14/92 EXPIRATION DATE: 8/14/93 LOT SIZE: 48573 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD 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) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: DATE:. DATE: August 10, 1992 ROBERT SHAFER, P E. ROGER SHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street Anchorage, AK 99519-6650 REFERENCE: Robindale Subdivision, Block 1, Lot 3 We request you issue a permit to upgrade the septic system serving the referenced property. An adequacy test was performed on the existing system and the absorption capacity of the system was found to be inadequate. A test hole was excavated and a percolation test performed. The approximate location of the test hole is located on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your review, please contact us. Sincerely, Roger J. Sh~fer, P.E. RJS/LSU/lsu 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 I"= 40' SCALE ROBINSON DRIVE PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? E Depth to Water After ,d~ Oate:'"~ Menitorieg? Gross Net Depth to Net Reading Date Time Time Water Drop ,/ ~ -~ ,,x+o ~ /~' t+ PERCOLATION RATE [~"' (minutes/inch} PERC HOLE DIAMETER TEST RUN BETWEEN "~ '/?''*' FT AND ~' '/'?'-' FT $ 8, S ENGINEERING "'~//~ CERTIFY THAT THIS TEST WAS PERFORMED IN PERFORMED BY: AGGORDANGE WIT[~ ~-V~g A~I~If,4t.~:~L GUIDELINES IN EFFEGT ON THIS DATE. DATE: RI:::'PLZE:IRNT STE',,,'E SCHROEE:,ER. 14.~:%~EBRR RORE:, SF L. OCFITION - ~//~ LEGFIL L3: BZ ROBZNE:,FILE ~LIBE:, LOT SZZE ~SDDEID SQLIRRE FLEET T'T'F:'E I:lF' S;I]ZL I]E,..,LIRE, FIIJN : :,i'Ell :ENI]:H L" i"IAXIMUH NUHBER OF BEE:,ROOHS = 3: SOIL RRTING TliE REQ[ IRE[E:, SIZE Elf "FHE ~CI~V~S?RF'TZCIN. N 5;YSTEM THE LENGTH E:,ZHENSZON ZS THE LENGTH ,::ZN FEET.'.', OF THE TRENCH OR I}RF:I~NF'ZELD. THE E:,EF'TN OF ~ TR. ENCFI OR PZT ZS TFIE DZSTFINCE BETP.IEEN THE S;URFACE OF' THE GROUND FINE:, THE BOTTOM OF' THE EXC~VFITZON ,::ZN FEET::,. THERE ZS NO SET NZE:,TH FOR TRENCHES. THE GRAVEL E:,EF'TN ZS THE PIZNZHUH DEF'TH OF GRFIVEL D~TP.IEEN THE OUTFRL. L. F'IPE RND THE DOTTOH OF THE EXC~',,,'FIT~ON (ZN FEET). EITHER R Cl..ASS I OR II NSF' RPPRO',,,'E[:' PLANT MAY BE INSTRL. L. ED. R CI]NTINUOU:.S MFIINTENRNE:E AGREEMENT IS REQUIRED. IF R MRINTENFINC:E FIGREE:r,IENT IS NOT KEPT CURREN-F YOU i',IF-IY E:E REC.!UIRED T'O ENLFIRGE THE :Si]IL FIE:$ORF:'TION '_:F,,YSTE[,'I Rl'.,IE:v."OF;.: YOLI MAY E:E .:,LIE,... E_. T TO PF.:CSEC_TIOI'.,I. IF FI CLASS I :,T:,,_, IS US;EE:' THE LENGTH I ET. _.LH:,:, II .:T::,TEI1 I:, IJ':SE[:, THE LENGTH "-EET. BF:ICKF'ILLING [:IF I::iNY S;Y'.:.;TEH 1.4ITHOUT FINAL INSPECTION FINE:' FIF'F'RO',,,'FIL F:3Y TI'"I.T.S; E:'EPF:IR'FNENT 1.4ILL BE SUB...TECT TO PRO'Z, ECUTION. ' MINIHUM [.',IS.;TRN~.:E 'BETHEEN R 1.4ELL FINE:, RNY ON-SITE 9ENRGE DISPOSFIL SYS'I.IE}"i ][~!; :l.6JEI I::EET FOR R"~PRI',,,'FITE HELL OR 2Cl~] FEET FOR Fl F:'UBI_IC WELt... HELl_ L. EICiS; RF.:E REQUIRE[:, RND MUST BE RETURNEE:, 'f'O T'HE E:,EF'RR]'T'IENT t.,.IITHIN 3:EJ I.)F;IYS:; OF' THE I,.!ELL COi"IPLET]:ON. '.5F'ECIFICR]'IONS RN[:' CONS;TRUCTION DIRGRRHS; RRE R',,,'RI. LRBLE 'FO INSURE F'I;.'.OPEI:;.: INSTRLLRTION. IF:' F_:E F:.: iplt ][ T' ",,.-"FnL. l" E:. F'F.:u}R Cn~'-.ItlEE %-"EF-~ F:: F'F-:C}~"-'l~ ::[ '_1"~; ::E' L.UEE i C:ERTIFY TNAT 1: I RI"1 FRi%IILIRR HITH ]"HE REQUIREMENTS FOR ON-'::;I'T'E SEP.IEF~'.:] RN[.', NELL.S FIB SE]" FORTH E:Y THE i'"IUNICIPRt..ITY OF RNCHORRGE. 2: I FIIL..L INSTFILL THE S'-r'STEI,d IN RCCORDRNCE HITH THE C:ODES. ::!:: I UI'.~[:,EI*~%':;]"RN[:, TF'IFIT '[HE ON-SITE LC, E!.,.IER SYSTEM MFIY REg!UIF.:E ENLARGEI'dENT :IF' THE:: F;'.E'..-T, IE:,EI'.JC:E,~ F.'.EI'"IOE:,ELF~ "l"~I NCLI. J[:,E I"IORE 'I"HFIN 3: E:EE:,ROOH$. RF'PL. I CRNT '..:;,TE',,,'E SCFIROEE:,ER O fl' E GEO', ,ZCHNICAL ~ DEVEL ~,)MENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Soils 8 Foundations Earl Ellis 688-2280 SOIL LOG Land Development Perfomed for: Legal Description: Depth (feet) Soll Charactertsttc~ o 1 2 3 4 5 9 10 ,. 15 16 · Ground Water Encountered: Yes No Proposed Installation: Seepage Ptt__.~ Comments: ' ~,,~- ,-wt~'~. ~,~ ~-~ ~"" If yes, what depth Drain Field Performed by: ~ ~-.~2 . DUPLICATI~/ SIGNED PART 3 WILL BE RETURNED WITH REPLY WAR A--� UNIU AUTY OF ANCHORAGE � tvr Development Services Department '��' Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval 051 _051? - 5-0 Parcel I.D. 05-1-=05J- 0--52 Expiration Date: ✓2 Z 1. GENERAL INFORMATION Complete legal description Robindale #1 B1 L3 Location (site address) 22639 Robinson Road Current property owner(s) Mark Saddler Day phone Mailing address Po Box 671027 Chugiak, AK 99567 Real estate agent 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic El Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ -S 5 Waiver Fee $ Date of Payment 1 //2JZO�;'o Date of Payment Receipt Number (9 �f g 5� Receipt Number COSA Sr_ -70( 0 ZZ 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. Reliance on this report by another person is at their own risk. Pannone Engineering Services LLC highly recommends buyers hire their own engineer to evaluate this report. Name of Firm Pannone Engineering Services Address P.O. Box 1807 Palmer, AK 99645 Engineer's Printed Name Steven R. Pannone P.E. Phone (907) 745-8200 Date `2_©c:%S3 moo, • - y 6. DSD SIGNATURE * 4 T IC System #1 Approved for 3 bedrooms Steven R. Ponrione CE 8149 System #2 Approved for bedrooms -O Disapproved 1��OFESSI Conditional approval for bedrooms, with the following stipulations: ,,V)))))I1))0, . Original Certificate Date: I —,?—q _2-0 20 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 Stale of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Septic System Advisory Well Flow Advisory COSA Checklist blue sheet Nitrate Advisory Arsenic Advisory Other COSA Checklist Legal Description: Robindale #1 B1 L3 If more than 1 septic system on lot: COSA Checklist # 1 of 1 A. WELL DATA X Well log is filed with Onsite (or attached) Date drilled 1976 Total depth 184 ft Cased to 40 ft ❑O Sanitary seal is functioning correctly 01 Wires are properly protected Casing height (above ground) 12 in. Date of flow test for COSA 1R0,2020 Static water level at beginning of test 154.2 ft. Comments B. TANK DATA Age of tank(s) 1976 years Tank type/material 5`' Measured operating fluid level in septic tank 40°+/ - FE -1 Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA Bed & Trench Parcel ID: Structure served by this system 1 vs.2 --6v 051 -12115A-5-2- Well production at time of test 1.0 gpm Water storage tank volume n/a gallons Well disinfected for coliform test? ❑ Yes ❑✓ Nc FA Coliform bacteria is Negative Nitrate :5.-7 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L - ® Arsenic less than MRL (ND) Collected by Pannone Engineering Date of Sample 1/2012020 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Which system tested (date installed) 1992 Adequacy test date 112 012 02 0 0 ALL standpipes present per record drawing Results Q Pass For 3 bedrooms Total measured depth from grade 4-2* ft (max) Fluid depth prior to test 0.5 in Measured depth to pipe invert from grade 3.5-1.5 ft (min) Water added 450 gal ❑ N/A — pressurized field 2.5 New depth in ❑® Monitor tubes go to bottom of effective. If not, state 360 depth into effective Elapsed time min 0 Code -required soil cover over field Final fluid depth 0.5 in ❑ System presoaked Absorption rate '450 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: 'System insulated per 1992 inspection report. / see comments below COSA Checklist yellow sheet no E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ❑✓ Yes Community Sewer Manhole/Cleanout > 100' M✓ Yes if No ft 71 Yes if No Neighboring Tank > 100' Q✓ Yes if No ft Private Sewer/Septic Line > 25' P- Yes if No Absorption Field on Lot > 100' Yes if No ft Holding Tank > 100' M✓ Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' ❑✓ Yes if No [21 Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' [�✓ Yes if No ft 0 Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' Q Yes if No ft Surface Water > 100' ft ft ft ft ft 0 Yes if No ft Property Line > 5' ❑✓ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' 0 Yes if No ft Private Wells > 100' Fv� Yes if No Water Main > 10' 0 Yes if No ft Community Wells > 200' r7l Yes if No. Water Service Line > 10' 121 Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ED Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑✓ Yes if No ft Wells on Adjacent Lots: Water Main > 10' 0 Yes if No ft Private Wells > 100' ❑✓ Yes if No Water Service Line > 10' F✓ Yes if No ft Community Wells > 200' Yes if No Surface Water > 100' 0 Yes if No ft F. ENGINEER'S COMMENTS Bed field is 50-60% used. Existing trench has been abandoned in place. G. ENGINEER'S CERTIFICATION l certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet 49..-- --�. ... Steven t,. Pannone', CE 81 ^g •�w0 ft ft iM ft 2/4/2020 littps://eplans.inuni.org/projectdox/ReportViewer.aspx?ReportPatti=/Reports/ProjectFlow - Changemarks&DataSourceNarne=DataSourcel &RootWebURL=&ProjectlD=1761 &W FlowlnstancelD=1780 .. 1 of 1 , . Find I Next c. ve '. LANS Changemarks Report Project Name: OSC201023 Workflow Started: 01/27/2020 5:53 AM Report Generated: 02/04/2020 03:06 PM C cle = Complete? : Status = Department - Snapshot File = idiarkup Mame = Changemark Subject Changc,narS. Details - f a; nup D..=.te = Updated By : Applicant Response 3 False Unresolved Onsite Well and Septic ' ;Robindale #1 B1 L3 - checklist.pdf TJE Changemark #01 Please supply a phone 02/04/2020 3:04 PM Tim Ecklund 7 number for the owner or (L. ?Pl agent to gain permission to do a site visit 2 False Unresolved Onsite Well and Septic ' Robindale #1 B1 L3 - AB.pdf Ije_1_30_2020_9_43_29 ; Changemark #01 Per the survey provided it 01/30/2020 9X13 AM Tim Ecklund appears the 1976 trench thaniz� :was G supposed to be abandoned still has fop 7 �r- AO �S standpipe showing indicating; the trench may still be in use. Based on the TH data Ci 1,7D C 12. 1pLI��S i for the bed the trench could potentially encroach on 2 ./1h k•tx/ s` Ground water. Please state ion the COSA the status of g: #-A V this trench and any need remedial action that may need to be taken. 1 Jrue !Resolved Onsite Well and Septic: Robindale 91 B1 L3 - checklist.pdf 'TJE iChangemark #01 Pid for this tot is 051-052-50,: 01/29/2020 8:17 AM ! Tim Ecklund Please correct the i:references on COSA True True Resolved I Onsite Well and Septic i Robindale 41 B1 L3 - checklist.pdf TJE Resolved ;Onsite Well and Septic :Robindale #1 61 L3 - checklist.pdf TJE httos:HeDlans.mtini.ora/omiectdox/RenortViewer.aSDX?ReoortPath=/Reports/ProiectFlow - Chanaemarks&DataSourceName=DataSourcel&RootWebURL=&ProjectlD=1761&WFlowlnstancelD=1780 1/1 M z D rn CoA rn I �- ���.. r o y^ � f rn 0NC Imo Aivc J �v00 ? } M z D rn CoA rn I �- ���.. 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A .. . (0). g• 19 i g„6j7,0 10009 �, dZ 10� � 19 1 51195, 110006 / Fv 1 101 IV 110-1 R, - LAND 5URVEY1NG f 1 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..fl f~)~)\- 05D-~ 1. GENERAL INFORMATION Complete legal description Lot 3; Block 1; Robindale Subdivision Location (site address or direction~) 22639 Robinson Road Property owner Steve a~d A~lene Schroeder Day phone 688-3055 Mailing address _ Lending agency-'-, PACIFIC ALASKA MORTGAGE ~ ' Day phone ' 258-7534 AddreSs 13135 Old Glenn High~a¥/-Suitel00, Eagl6 River,-: Alaska:--9957? ~ .-;.J.-.'' Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS; 3 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. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank . Community on-site Public Sewer If commUnity wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1/91) Front MOA#21 s~ue~uu~oo leUO!~!ppv euoqd LLg66 e~se?! ".~e^!~_ elbe___ 'ON peo~l dooq ae^!~ elBe:a PE:O/L eJn~BuB!~ s2eeu!l~u:l sse~ppv ~uJ!H ~o eUJBN 'uop, oedsu! s!q~. jo e~,ep e4), uo ),oejje u! suoRelnSeJ pue 'seoueu!pJo 'sepoo e~,S pu~ led!o!unlAl lie q~!~ eoUe!ldLUOO u! s! Lue~s~S I~sods!p ~e~e~e~,se/~ ~o/pue ~lddns ~e~,~/~ el!s-uo eq~ 'uop, oedsu! pub uo!~D!~se^u! ,%u LUO~J puc sel!J eSe~oqou¥ Jo ,~,]led!o!unlAl eq~, ~uo~j peu!e~,qo uop, eLu~oju! eq~ uo peseq ~eq~,~jpeA ~eqMnj I 'u!e~eq pe~eo!pu! eJ n~,on~),s jo edX~, pue SLUoo~peq ,tO ~eqLunu eq~, ~o,t e~,enbepe pue leUOi~,oun,t 'e,t~s 9! LUe),S/~9 I~sOds!p ~e),~e~set~ ~o/pue Xlddns ~e~,~t~ e~,!s-uo eq~, ~,eq~, st~oqs uop, eo!ldde le^o~dd¥ ~,poq~nv q~,leeH s!q), jo uop, eSp, seAu! ~LU ~,eql XJpeA I '~Aoleq u~oqs e~,ep uoNep!leA eq~, jo se pue o~,e~eq pexg~e I~es/~LU Xq pe!j!Mea sV - - EFI::INIDN=1 Ag NOIJ-O=ldC3NI .40 .LN=IIN~IJ.Y.LS .g  Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~--'~ ~ ~:'~-¢- \ '¢~oI~,,.~.D/~.¢.. ~'~t~ Parcel I.D. A. WELL DATA Well type Log present~/N) Totaldepth Sanitary seal If A, B, or C, attach ADEC letter. ADEC water system number Date comPleted ~- ~,[ ,~J L~ Driller Casedto ,~f-c~ i 4- Casing height Wires properly protected t~TN) Date of test Static water level Well flow Pump level FROM WELL ,LOG AT INSPECTION I...j., ~) "C g.p.m. U, SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service iine ; On adjacent lots On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform c./ Date of sample: B, SEPTIC/HOLDING TANK DATA Date installed Cleanouts~/N) High water alarm (YZ~ Date of pumping Nitrate ~, ~ "~'~[~- Other bacteria Collected by: S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 Tank size I ccc> Compartments Foundation cleanout (Y~;J:} ¢J Depression (Y~ *'~ Alarm tested (Y/N) 'J& ' , ¢1¢- Pumper '~ ~-... ,J SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot lC To property line Surface water/drainage On adjacent lots Absorption field Foundation Water main/service line 72-026 (Rev. 7/91) Front ' ,' CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA elec~ ISTANCE FROM LIFT STATION TO: VVell on lot On adjacent lots Manufacturer Manhole/Access (Y/N) ~ "Pump on" level at ' ~evel at .~~Oycles tested Surface water D. ABSORPTION FIELD DATA Date installed Length Width Total absorption area Depression over field (Y~I~ Results (pass/fail) /~//~ Peroxide treatment (past 12 months) (Y/(~ Soil rating O.z¢ ~'~¢//~,. er', System type ¢'¢'~ Gravel thickness ~, ~ Total depth ¢/, Cleanouts present (~N) Date of adequacy test for ~J/,~' If yes. give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot \~" To building foundation On adjacent lots ,~¢ ~4- Surface water Curtain drain ~J/,~ On adjacent lots ~.~o ~ 4- Property line To existing or abandoned system on lot Cutbank ~l,a, Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature 17034 Eagle River Loop Read No, 204 _¢ ~ .¢ ~, ,~ ~ Engineer's Name ~.~.',,"..~ .."~..." HAA Fee ~ Receipt Number Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA99518 TELEPHONE (907)562-2343 ANALYSIS BESULTS fox INVOICE ~ 57291 Chemlab Ref.~ 92.4334 Sample t 3 Matzix: WA~ER FAX: (907) 561-5301 Client Sample ID : L3 B1 ROBINDALE S/D PWSID : UA Collected : AUG 20 92 @ 11:00 h~e. geceived : AUG 20 92 @ 14:00 hzs. Pzoeerved with : AS RNQUIRZD Client Name :S & S ENGINEERING Client Acer :SNSENGP SPOt : Ordezed By :R. SHAFER PO~ :NONE RECEIVED Analysis Completed : AUG 21 92 Send Repozts to: 1)$ & S ENGINEERING Parameter Results Un/ts Method Allowable Limits NITRATE-N 1.4 mN/1 EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: RAY. Remarks: 1 Tests Per£ormad ' See Special Instructions Above UA=Unavailable ND= None Detected '* See Sample Remarks Above NA= Net Analyzed LT=Loss Than, GT=Greate~ Than ~1¢1~111~ _~r~_~ ~Aamhar r~f fh~ ~ ~rn,,n (~nni~t~ ¢=¢m~mla dP. SurvP.illaP.ce~ CHEMICAL & GEOLOGICAL LAB ORATORY A DIVISION OF COMMERCIAL TESTING. &:ENGINEERING CO. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 995 t 8 Drinking Water Analysis Report for Total Colifqrn~ Bacteria TO BE COMPLETED BY WATER SUPPLIER [~' PRIVATE WATER SYSTEM ~ SAMPLE DATE: MO, SAMPLE TYPE: ~ Routine Day Year Z~p C<x~e [] Check Sample (for routine samp!~:,.~,:_.~ with lab ref. no. -'~* · ' Treated Water [] Special Purpose [] Untreated Water SAMPLE Time No. LOCATION Collected 21 31 41 51 I Collected By TO I~E COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: / Sati,.sfactory Cl Un{atisfactory [] Sar~ple too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send n~w sample via special deliver, mail. Analytical Method: Membrane Filter * No. bf colonies/100 mi. Lab Ref. No. 208~! Result* Analyst A .D.E.C. READ INSTRUCTIONS Membrane Filter: Direct Count Verification: LSB BEFORE Fecal Coliform Confirmation BACTERIOLOGICAL WATER ANALYSIS RECORD Coliform/100 mi BGB COLLECTING SAMPLE Final Membrane Filter Results ..~ Reported By ~ ~ TNTC = Too Numerous To Count Coliform/100 mi Time: /~OO a.m. p.m. C3R _- ~th~_r R~nt~ri~ APPLIC~'~NT FILLS OUT uPPER HAv ''~ ONLY 'Property Owner ~.'~ .~ '.~_[Jt"l~_.~ ~ Phone Buyer Address ~ ~ ~j~ g F<~ ~ ~C.t~ Zip Code Realty Co. & A~nt Phone Address Zip Cods Legal Description ~ ~ ~b~ I ~o~'} ~L~. Street Locati~ Type of Resi~nce ~Single Family Multiple Family No. of Bedroo~ ~ Other Water Supply lndivdual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. Community For wells drilled prior to that date. give well depth (attach tog if available). ~ Public Utility Sewer Disposal  Individual Year Individual Installed: Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time -- Date Date Date Date \ / Inspector Inspector Inspecto~ ~. ~...~ ,nspec,o ........... ....... Field Notes' ,.~.~ ~ ~~ ~ ~ ~ ~ O CT121982 ( ~APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAP~OVED Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received ( ~h ~ w~, to ~ank S~ptio T~k S~z~