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HomeMy WebLinkAboutROBINDALE #1 BLK 2 LT 2Robl*ndale #1 Block 2 Lot 2 #051-052-54 Municipality of Anchorage Page of y DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 a Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: SY✓ 9b PID Number: O /— 05 2 SQL Name: Wastewater System: ❑ New ,Upgrade ROY /CH Address: ABSORPTION FIELD Phone: J No. of Bedrooms: 7yT�(�ep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other ��Rating: LEGAL DESCRIPTION SoiI / Or Total Depth from original ?g 8."4x (� GPD/Sq. Ft. A: Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe ' / )_)A &, - 3 Ft. S Ft. Townshi P Ran e: g I') Section: Fill added above original grade: Gravel length: r / 1�13 0 — / Ft. Ft. WELL: 11 New 9W �w lM6 Gravel width: Gravel Ft. Number of lines: Distance between lines: Ft. Classification (Private, A,B,C): Total Depth: C To: Total absorption area: Pipe material: Ft.I Ft. 75") SD. Ft. r � Driller: Date Drilled: Static Water Level: Installer: _ Date installe S Ft. LC Yield:Pump Set at: casing Height Above Ground: - TANK GPM Ft. Ft. SEPARATION DISTANCES Septic ❑ Holding O S.T.E.P. To Septic Absorption Lift Holding Pmbii Private Manufacturer: / �/ A IaI4 A/y/�. Capacity in gallons: 1000 From Tank Field Station Tank Sewer Lines Well- N�A N�/1 60 ' Material: Number of Compartments: 16 y' /o s' L f'/oo� IVIA LIFT STATION Watere LotSa oZ d S3 i Size in gallons: Manufacturer. Line Foundation76 "Pump on" level at: 'Pu vel at: High water alarm at: 3 76 Nl Curtain ,�/ 1� Pump Ma odel I Electrical Inspections performed by: Drain / I BENCH MARK Remarks: //sc C.o. ro Tyh'y Flo �.�P Location and Description: i,✓s /o fed w o2 " d .rrL,/� r.. i✓ert /20 7lor. o F f/u� e Sio . F rP'lQortjo. ao,— LU 1/✓S/i4A TEG Assumed Elevation: cry EXi J 7'..S %c, .✓K r.�rr>�r+,.� C/v7 rrf!,=.17 /.3t, �.e.i ENGINE ,EB15 SEAL N w Oyu �. salsa � ..pr aA�� , ' *a°� //% Dates: 1st, flD!lp+a°le�elp6a°lBg Bsstlapp; c.:; Inspections performed by: _ 2nds�/ice10 el.aev®nor •o oeo.c.iea. a•eel ez ` i id ° Louis A, guferq J re Department of Health nd Hu ices approval 1���°•e. `� �'�� •' �`� PP10Fr� "< V Reviewed and approved by: ate: 72-013 (Rev. 9/91) MOA 25 V Permit No. -- Page 2 of 2 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 Legal Description: ROBINDALE •1 LOT 2 BLK 2 ROBINSON ROAD ELEVATI❑NS HOT�TON GF HOUSE SIDING (NOT TO SCALE) ASV TZ ELEv = I0O.00 M u, y ORIGINAL = GROUND p 94.0 LEVEL AT r 92.0 m 1' ADDED FlIILL{I ON W. ENO TRENCH NO GVT �J 78.0 TANK - 99.5 9.2 09.0 ``� 89.0 184.0 PID No.: SWING TIES A -C = 148.5' B -C = 80.9' A -D = 166.0' B -D = 132.2' _X-- FENCE ® - TEST HOLE • - MONITOR TUBE o - SEWER CLEANOUT ¢ - WELL — — - EASEMENT - LEACHFIELD SCALE 1"=60' 8/19/96 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE1 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:SW960249 DATE ISSUED: 8/13/96 DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES EXPIRATION DATE: 8/13/97 OWNER NAME:WICHERS ROY A OWNER ADDRESS:22714 ROBINSON RD CHUGIAK, ALASKA 99567 PARCEL ID:05105254 LEGAL DESCRIPTION: ROBINDALE #1 BLK 2 LT 2 LOT SIZE: 48575 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION 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) AND 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 ) (NOT REQUIRED FOR WELL ONLY PERMIT) 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: RECEIVED ISSUED BY DATE: 1S- /X', DATE: /3 Eagle River Engineering Services Louis Butera, P.E. P.O. Box 773294 (907) 694-5195 tel Eagle River, AK 99577-3294 (907) 694-3297 fax August 2, 1996 Jim Cross, P.E. Manager, On -Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Robin Dale #1 Lot 2, Block 2 Narrative & Permit Application Dear Mr. Cross: The proposed septic system upgrade will have very limited impact on adjacent properties for the following reasons: 1. The surrounding lots are large, allowing sufficient room for septic sites. 2. Immediate neighboring septic systems are all +30' distance. 3. Reserve space is adequate, due to absorption capacity. 4. Drainage will not be affected and is not a major consideration in our design. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. \1996\96-059A-NAR.DOC SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM LEGAL: Robin Dale #1 Lot 2, Block 2 08/07/96 A. GENERAL 1. The septic plan is for a single family residence only. 2. The drawing and or site plan shall be a part of this specification. 3. All materials and workmanship shall meet the Anchorage Department of Health requirements. 4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. 5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage requirements. 6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi -family wells. 7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. 8. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. 9. Any remaining open test hole excavations shall be filled. B. SEPTIC TANK 1. The existing septic tank shall be pumped, crushed and buried on-site. 2. New septic tank shall be 1,000 gallons minimum, and MOA approved. Tank shall be installed in location shown on plan. C. TRENCH 1. The trench is to follow the natural land contour to maintain uniform total depth of the trench bottom. 2. The bottom of the trench shall be level, plus or minus 1.5". 3. The total depth of the trench excavation is not to exceed 8' at any point. 4. The effluent line within the trench shall be laid level within 0.03'. 5. The trench gravel is to be covered with typar fabric material. 6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed over the leachfield. 7. The area over the trench is to be finish graded to prevent ponding of surface water runoff. 8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS: TOTAL DEPTH = 8' GRAVEL DEPTH = 5' under pipe, 2" over pipe TRENCH LENGTH = 75' TRENCH WIDTH = 3' SOIL RATING= 0.6 GPD/ft2 BEDROOM CAPACITY = 3 SEPTIC TANK = 1,000 gallons minimum Twenty-four (24) hours notice required for all inspections. \1996\96-059a-spc.doc SEPTIC +30' WELL +100' 161.90 0 NEW x 1000 GAL N SEPTIC TANK TH z x W zt c t Uio (h oo APPROX. OD 6 �I LOC. EXIST. Z �\� ABANDON / LEACHFIELD EXIST. TIE IN AT TANK Z o WELL CLEANOUT ti 00 x o� oLn cp HOUSE APPROX, LOCATION LJ? NEIGHBOR'S WELL m NO WELL N❑ SEPTIC W _ _ Q _10' CUTTING ESMNT N 00°11'56' W FENCE ® - TEST HOLE • - MONITOR TUBE ROBINSON ROAD 0 - SEWER CLEANOUT NO SURFACE WATER — WELL EXISTING TANK & FIELD TO BE ABANDONED — — — EASEMENT PROPOSED LEACHFIELD NO KNOWN CURTAIN DRAINS - EXISTING LEACHFIELD SEPTIC UPGRADE PLAN ��•••����� LEGAL: ROBIN DALE #1 LOT 2, BLK 2 �•�� OF• OWNER: ROY WICHERS=�`P•.•'' '•.•5�1�, CONTRACTOR: N A i * :49 TH •'. * �I JOB 96-059 DATE: 08/07/961SCALE 1" = 60' �•� �•��••• •.• •.. •� EAGLE RIVER ENGINEERING SERVICES �,j �• .•• • • .. • • • • • • • • • • • •� c^ LOUIS A. BUTERA 4i CE -6736 AV P.O. Box 773294Aw EAGLE 1 r� .•' (907) 694 RIVER,5995 FAX.S(907) 694-3297 ,`1tl�i�����::•••♦ EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294 Eagle River, Alaska 99577 (907) 694-5195 ERES Project No.: 96-059 Calculated By: LB Date: 8/6/96 Legal: ROBINDALE #1 LOT 2 BLK 2 Single Family 3 Bedroom Dwelling TEST HOLE Deep Trench Subsurface Wastewater Disposal Field Water use at 150 gallons per bedroom = 450 gallons Percolation rate = 16 minutes per inch Wastewater application rate = 0.6 gallons per day per square foot Required absorption area = 750 square feet Trench width (W) = 3 feet Gravel depth (D) = 5 feet Required length = Required absorption area / 2 / D Required length = 750 / 2 / 5 Required length = 75 feet Total Excavation Depth = 8.0 feet of q 49TH ............................... �r �n •'. LDUIS A. BUTERA: J,'•, CE -6736 0��%° pROFFSS\Q �,:O 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 ToPSC)IL OaGAN/L 1 •C' ` 6 SANDY 6RAV5L WI S/r-i �6 COMMENTS GM S)lffY SANDY G1?%VEL G2eY, DRY, ,QED, DC -NSE DF,AISCk AT BoTl'OM BvrrOM of HaLE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? No S L NA D P E Ueplh to Water After �p�/ Monitoring? Date O7 9& ==mmm� r r �" s°(ENGIN�ERrS"Sl3Ag)�45 F L -3PQ �>=L a0's136G4C2II;;PbS°cnp Municipality of Anchorage '� e DEPARTMENT OF HEALTH 8 HUMAN SERVICES „_'- XP ""k 's°ff°'•°� O b b°ObP °°6°C$ 0 825 "L" Street, Anchorage, Alaska 99502-0650 s f`.'.� t`=TFC/ �r��/HI►�Rr'E;�111��� ,Q �,.�.r„� `�W A tp SOILS LOG — PERCOLATION TEST V _• 1 5 q 01137& PERFORMED FOR: W�GH�,2 DATE PERFORMED Q�f LEGAL DESCRIPTION:_R,9B1,N DA4F_ # Township, Range, Section: It� SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 ToPSC)IL OaGAN/L 1 •C' ` 6 SANDY 6RAV5L WI S/r-i �6 COMMENTS GM S)lffY SANDY G1?%VEL G2eY, DRY, ,QED, DC -NSE DF,AISCk AT BoTl'OM BvrrOM of HaLE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? No S L NA D P E Ueplh to Water After �p�/ Monitoring? Date O7 9& ==mmm� �r��/HI►�Rr'E;�111��� PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND 71 1; FT PERFORMED BY: R95 CERTIFY THAT THIS TEST WAS PERFORMED IN Annnon AA11 17 unTu Ai i 0T TC Ar..n u, unrioA nIII MC, ua CC twi CCCCnT nni TLUC MATR r1GTF Municipality of Anchorage DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION POUCH 6-650 ANCHORAGE, ALASKA 99501 SEPTIC TANK INSPECTION REPORT ON ONSITE SEWAGE DISPOSAL SYSTEM AND/OR WELL NAME ADDRESS,< -K &3 K % o G 9� Fl PHONE(S) LOCATION LEGAL DESCRIPTION �� T PERMIT NUMBER *OF BEDROOMS SEPTIC TANK TO ❑ TALE GRAINFIELD /� MANUFACTURER CAPACITY IN GALS. C� FROM NUMBER OF LINES LENGTH EACH MATERIAL #OF COMPARTMENTS WELL INSIDE DIMENSION DISTANCE BETWEEN LINES TRENCH WIDTH LENGTH WIDTH LOT DEPTH yy 0 SEEPAGE SYSTEM TO ❑ TALE GRAINFIELD DEPTH PIPE MATERIAL I INSTALLER FROM NUMBER OF LINES LENGTH EACH TOTAL LENGTH CESSPOOL WELL WELL DISTANCE BETWEEN LINES TRENCH WIDTH DEPTHS LOT yy 0 TILE TO GRADE FILL BELOW TILE FILL ABOVE TILE EEPAGE TRENCH OR ❑ PIT Ol a WIDTH LENGTH -5"DEPTH FOUNOA- TIONcJ ❑ LOG CRIB ❑ RINGS- OIA. FILL MATERIAL DEPTH TOTAL EFFECTIVE ABSORPTION AREA; O. FT. WELL TO CLASSIFICATION DEPTH PIPE MATERIAL INSTALLER FROM REMARKS DISTANCES TO SEPTIC SEEPAGE SEWER FROM TANK SYSTEM LINE CESSPOOL WELL WELL LOT yy 0 LINE Ol FOUNOA- TIONcJ SYSTEM DIAGRAM � 10 F" DEPHRTMENT L. HEALTH HND ENVIRONMENTHL .OTECTION �/ �~ ^ / 2516 E. TUDOR RD./ HNCHORHGE/ HK- 99507 '~ ` 276~2221 ��H, 0 L_ HINq H__,_ �Jr. TIE--, 9 q H: F..: y:.������� PERMIT NO. ( 76895 ) HPPLICHNT SR BOX .12`04- L f.) C A TI. 0 N 204LOCHTION ROBINDHLE LEGHL L2 B2 ROBINDHLE SUBD LOT SIZE 54500 SQUHRE FEET TYPE OF SOIL HBSORBTION SYSTEM IS: TRENCH MHXIMUM NUMBER OF BEDROOMS SOIL RHTING (SQ FT/BR)� 85 THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS: ���If' H_ 0 �f-5.05 ���H ������ ���'� THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD� THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE BETWEEN THE SURFHCE OF THE GROUND HND THE BOTTOM OF THE EXCHVHTION (IN FEET) THERE IS NO SET WIDTH FOR TRENCHES. THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRHVEL BETWEEN THE OUTFHLL PIPE HND THE BOTTOM OF THE EXCAVATION (IN FEET). �1L.11 11' FP, IE ���H h R...- 1 FEE IP, 0�� �0 IL_ V-4� ��� ���� �������� BHCKFILLING OF HNySYSTEM WITHOUT FINAL INSPECTION AND RPPROVHL BY THIS DEPHRTMENT WILL BE SUBJECT TO PROSECUTION MINIMUM DISTHNCE BETWEEN H WELL AND HNY ON-SITE SEWHGE DISPOSHL SYSTEM IS 100 FEET FOR H PRIVHTE WELL OR 200 FEET FOR H PUBLIC WELL WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]0 DHYS OF THE WELL COMPLETION. SPECIFICATIONS HND CONSTRUCTION DIHGRHMS ARE HVHILHBLE TO INSURE PROPER INSTHLLHTION. 9 1-11 T" %e4=lIH__Jo- IE -E, f=u F--" FZ", H, IC-fi V., II ..... .. 0 -7 I CERTIFY THAT 1 I HM FAN ILIHR WITH THE REQUIREMENTS FOR ON~SITE SEWERS HND WELLS HS SET FORTH BY THE MUNICIPAL_ ITY OF ANCHORAGE. 2� I WILL INSTHLL THE SYSTEM IN HCCORDHNCE WITH THE CODES ]� I UNDERSTHND THHT THE QN~SITE SEWER SYSTEM MHY REQUIRE ENLHRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BED�OOMS - . ISSUED BY _11 U�1111kj,Al. DEPI'�,MENT OF ENVIRONMENTAL QUP-I�,;Y ase ju�j 3330 "C Street JUI`l 1974 AWI ANCNO'UGE, ALASK=A 9950 - - - GREATER ANCHORAGE AREA BOROUGH _ - 19EPT. OF ENVIMNMENT E QUALITT Perforaied For _ _Dated Performed ( ) �-7/1 Ley ,l [ascription: Lot Z Block Subdivision_2.J2 fhis Form Reports Soils Log_ `Percolation Test - Soil Test Must Be Logged To 4' Below Proposed Seepage System - Depth I-eet Soil Characteristic=s , Was Ground Water Encountered? If Yes , At 1.4hat Depth?- f 5 itil l-, sem, �. j , P-�0v.w Reading Date ) Gross Time I Plat Time i Depth tofl20 Net prof, -a 6vvJ, L f I J _ - LL4 10- 0.12 -- i s 0+va b f hn t 2' 12- -- I 1. 1 , Was Ground Water Encountered? If Yes , At 1.4hat Depth?- f 5 EI -i -i -i _-- Reading Date ) Gross Time I Plat Time i Depth tofl20 Net prof, --- I I _-----iL---- f I J _ - LL4 I 1. 1 EI -i -i -i _-- Oercoiation r=ate r nuLe Proposed Installatic.n: Seepagr, PIt _ Drain Field Depth o` Ir,Ie De,ih to Bottom of Pit or Trench Test Performed BY -- --.. DateCertified 3V Date Reading Date ) Gross Time I Plat Time i Depth tofl20 Net prof, --- I I _-----iL---- f I Oercoiation r=ate r nuLe Proposed Installatic.n: Seepagr, PIt _ Drain Field Depth o` Ir,Ie De,ih to Bottom of Pit or Trench Test Performed BY -- --.. DateCertified 3V Date Parcel I.D. 051-052-54 Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Complete legal description Location (site address) Expiration Date: . / — _2 J "13 ROBINDALE #1 BLOCK 2 LOT 2 22714 ROBINSO)WRD., CHUGIAK, AK 99567 Current Property owner(s) KRISTAL STRUNK Mailing address Real Estate Agent 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone 317-9080 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well 0 Individual 0 Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariancerequest for: NONE Distance: - Received by: ,�_�__ ` Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Date of Payment Receipt Number COSA # Waiver Fee $ Date of Payment Receipt Number 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. Name of Firm SPURKLAND ENGINEERING Address 203 W. 25TH AVE.,STE.202A, ANCHORAGE, AK 99501 Engineer's Printed Name LARS SPURKLAND 6. DSD SIGNATURE L System #1 Approved for 3 bedrooms System #2 Approved for bedrooms Disapproved Phone 279-3916 Date 8/23/13 OF. �Q 111 LARS- SPURKLAND: Conditional approval for bedrooms, with the following stipulations: By: Original Certificate Date: 7`/ The ni liof nchorage 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. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet E c If more than 1 septic system is on the lot: COSAChecklist# 1 of 1 Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: ROBINDALE #1 BLOCK 2 LOT 2 A. WELL DATA Well type PRIVATE Date completed 1975 Total depth >135 ft Date of test Static water level Well production If A, B, or C provide PWSID # - Sanitary seal (YIN) Y Cased to >40 ft. FROM WELL LOG 1975 UNKNOWN ft UNKNOWN WATER SAMPLE RESULTS g.p.m. Coliform NEG colonies/100 mL Nitrate 2.17 mg/L Arsenic NO ug/L Date of sample: 818/13 Parcel ID -051-052-54 Well Log (YIN) N Wires properly protected (YIN) Y Casing height (above ground) 12+ in. AT INSPECTION 817/13 134 5.8 ft. Collected by: ANSON MOXNESS B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 8/25/96 Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Date of pumping 8/12/13 C. ABSORPTION FIELD DATA Date installed 8/18/96 Length 75 ft. Depression over tank (Y/N) N High water alarm (Y/N) N Pumper .IRs PUMPING SERVICE Soil rating (g.p.d./f:2 or fe/bdrm) 0.6 System type TRENCH Width 3 ft. Gravel below Dioe 5 ft. Total depth a'o ft. Eff. absorption area /5u f12 Monitoring tube Y Depression over field N Date of adequacy test 817/13 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 49 in. Water added 450 gal. New depth 59 in. Elapsed Time: 205 min. Final fluid depth 52 in. Absorption rate >= 450 g p d Any rejuvenation treatment (past 12 mo.) (Y/N & type) NO If yes, give date - D. LIFT STATION Date installed "Pump on" level at Datum Size in gallons in. 'Pump off" level at - E. SEPARATION DISTANCES WELL ON LOT TO: Cycles tested Septic tank/lift station on lot 100'+ Absorption field on lot 100+ Public sewer main NA Sewer /septic service line 25'+ Animal containment areas 50+ SEPTIC/HOLDING TANK ON LOT TO ManholelAccess(Y/N) in. High water alarm level at Meets alarm & circuit requirements? On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout NA Holding tank NA Manure/animal excrete storage areas1D0+ Building foundation 5+ Property line 5+ Absorption field 5'+ Water main NA Water service line 10+ Surface water 100+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10'+ Water Service line 10'+ Curtain drain 50'+(N.O.) F. COMMENTS G. ENGINEER'S CERTIFICATION Surface water 100+ Wells on adjacent lots 100'+ t certify that t 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. Engineer's Printed Name LARS SPURKLAND Date 8-22-13 COSA brown sheet -1 0-10-1 2.doc Water main 1 N Driveway, parking/vehicle storage 10' .-��.gF•a�gslli �'•i49T ... ll RK ND 1� Municipality of Anchorage af0 Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK '9951M650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel LD. ®lriI — D -Z-- f y HAA # i�o O g G1 -- Expiration Date: G — % 8 " o l" 1. GENERAL INFORMATION Complete legal description 1-o i a,' 514a 1Zo 3 1 tt DA I— LF � Location (site address or directions) r o2��1 o loi t4s-m 00 o hon Current Property ownerV_s) v�i �-� �� wra." Day P .e 552— a>- Dq Mailing address Lending agency, Mailing address Real Estate Agent Mailing Address Day phone S j3 Q ' Day phone Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER QF BEDROOMS: T 3. -TYPE OF WATER SUPP�Y: ' TYPE OF WASTEWATER DISPOSAL: .. Individual Well .... -- =r [ Individual On-site [� Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ ,r�„ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services'bepartment (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 andlor water supply system. DSO 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. i Municipality; , pf Anchorage B '. I I :. I 13 • ''r j Development Services Department j Buiiding' Safety Division !, sw itr 1 t On Site Water&`Was.ewater Program ! I ra aw St 4700 South B 9 , • 9 519-6650 . Anchorage, a AK 9 19 6650 A c :. P:I'O. Box i� wvv4v.ci:anchorage.ak.us E ° ' i 907 343-7904 I I I I I, ( ) ' i I ALTH :AUTIH OR ITY APPROVAL CHECKLIST 7HE E Legal Description � �i�!o') ' � K� � � ; �� D ��IN ' ��L' I. �''� I � Parcel ID 'div 1-D� 2 :� A, • WELL DATA Well type I' If A,I B, or C provide PWSID #I I`t Well Log (Y/N) 1 � li` I:'I;I ij ' !Date completed �5 Sanitary,seal (YlN)': + ? ' Wires properly protected (Y/N)_ , 'Total depth I .ft. Cased tom ft. I! i`;I ! Casing height (above ground)_in. . FROM WELL LOG AT INSPECTION `Date of test "eetY_0 Lt Static water, level ft : l I I Well production j�j I� I g p m.? jll II to 9 p m: WATER SAMPLE RESULTS ,I i +, . I I l I j '1 r' to ! (.d b` ��. ' ;Other bacteria w I colonies/100 ml. n Coliform colonies/100 ml ',Nita Jy Ili I (1/klG'lu I I _ _ P %a� Collected b . Arsenic. �mg./l. � ,Date of sample: �/ �D� � y— , I II I' Ii ` I ail I II I' i ih1 ;I I,i' I nt i I i K DATA i B.:SEPTICIHOLDING !TAN I i p I 1 ��1 Tank Type/Material�� ��� it (' I! ; I Date installed f , j " ,f i, I; I IL! 1' I I'� 11+ I, �i Tank size %bow I Igal. Number of Compartments 2- Cleanouts (Y/N) I I C'j• II, Foundation cleanout (Y/N) Depression `over tank (Y/N) High water alarm (Y/N) s I l �i [ ,Date of pumping Pumper C :ABSORPTION FIELD DATA�� I ZI��IIi,I : Y Date installed ! `1� Soil rating (g.p.d /ft or;ftl/bdrm) il5 D , System type i tli�l'�i II I �jlli I ii � r 7n I' Width II31 I.1 ;I'I i 'ft Gravel below pipes :� ft. k Length ft. I 2 1` I h I l I. "' •i jl :! ' I Illi i� lie, i I II Total depth D ft. Eff. absorption area 75D ft !i ,Monitoring tube Depression over field � i ; ;Date of adequacy test �y ! I Results (Pads/Fail) III j I ;; For bedrooms '11 I I j Fluid depth in absorption field before test � in !l f i ; Water added�lgal. I New de' h3 in. ;�,! ��j; II' I I I I I, I, 1 I , ; ;Elapsed Time: fig I Final fluid depth', I I Absorption rate ?� n g.p:d. ''�'i, E ; Any rejuvenation treatment (past 12 mo.) (Y/N & type) I+�� I If yes, give tlate VX I I j II i Is' I I I I, P I j . i // O'//`Z2 ty ///, 90 °i> SON m n m � nim m = O0 pN Z z i fJf O Q T `z 0, m'r m o n m mn0 box m � 1 a z i -V yt � A 'o ' N Fm$¢ rn 2 a a RQZ rrm D e o °�- D m N &96 a. 7 7 i� N �u n o RoP.•ie�.?oM 11AJ-- WE C2-21`-04 1:.:1:23PU :ROM -CUE ESI, SGS ENV SERVICES 901`505301 T -53E P.03/03 F-T2E Drinking Water Analysis Repoli for Total Coliform Bacteria 6AD INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE MIDST BE: COMPLETED BY WATER SUPPLIER r] PUBLIC WA TER SYSTEM It)# PRIVATE WATER SYSTELI ❑ Send Rewms SAMPLE C 200 W. POTTER DRIVE ANCHORAGE. ALASKA 99516 To 907-562-2343 Fax: 907-561.5301 1 1040916 i + Ll L) LE COMPLETED By LABORATORY lamj2laRaceivina- - - Dat©: TirT>°• Temp; Delivery Method: G� Received BY: *.TL'i 0 Sample over 30 ha,rn ok; ❑ Rlt9H sARtPLE----- RauTa —y be unrena0lrr G 48 „our Walver Phone Ik: t, 7a FAX f ------------------ �ACter101d .n...uuu......•...•. iva............. glcal WaterAnrr oia Record YMO.IIUG (P/A) RESULTS: SenttoADEC: Analysts t34 an: ' Total CdYorm: ANC F13K JUN Anal/yt E. Cdl. Dnleliime: AnnlyUcal Mathod: Sent to Client: MEMBRANE FILTER RESULTS, Phoned Diect Counk M Faxed �j �` Colcnles/10pm1 103:81T1110: Ll Ji Membrane Filter Venrcebon. MMO-MUG (PIA) Spoke wixt: TauraraT JLTB: aG8' M Satisfactory EC-- ❑ Unsatisfactory Orled By: r� Srgnolve • DdtelTlme' �'���•.� TNTC +Toa Nunuan to G..we r7 �l'ifr} t)8 .Ot!wrBs.t.rr J:'F0Rb1S1f4cro\Cof: Form.xls _ Form v RV- 0053 10/24103 .�. +rr.wo t.vv wnw fo.... .dnao.. vnrvtr'Lt_ I YNE: Date: Q Z ® i UQ L' tronm Day r..r .15Roudne Treated Water TIMf: Locauon:_ Q 3 AM Iaeroa.l LIyi• YL, nl; 2 V el f I,aTo— Repeat8arTlple i�UnlrvQted WaWr Collector: vnners r,un __�_ (refer to lab no. C3Speclal i(J n9I�OrtaA agr~w. Purpo9e Ic Lan Py: � XSElme as collector L) LE COMPLETED By LABORATORY lamj2laRaceivina- - - Dat©: TirT>°• Temp; Delivery Method: G� Received BY: *.TL'i 0 Sample over 30 ha,rn ok; ❑ Rlt9H sARtPLE----- RauTa —y be unrena0lrr G 48 „our Walver Phone Ik: t, 7a FAX f ------------------ �ACter101d .n...uuu......•...•. iva............. glcal WaterAnrr oia Record YMO.IIUG (P/A) RESULTS: SenttoADEC: Analysts t34 an: ' Total CdYorm: ANC F13K JUN Anal/yt E. Cdl. Dnleliime: AnnlyUcal Mathod: Sent to Client: MEMBRANE FILTER RESULTS, Phoned Diect Counk M Faxed �j �` Colcnles/10pm1 103:81T1110: Ll Ji Membrane Filter Venrcebon. MMO-MUG (PIA) Spoke wixt: TauraraT JLTB: aG8' M Satisfactory EC-- ❑ Unsatisfactory Orled By: r� Srgnolve • DdtelTlme' �'���•.� TNTC +Toa Nunuan to G..we r7 �l'ifr} t)8 .Ot!wrBs.t.rr J:'F0Rb1S1f4cro\Cof: Form.xls _ Form v RV- 0053 10/24103 02-27-04 [4:2370 =ROM-CTIE ESI, SGS ENV SERVICES fr•.f �,� .s s� •r'. h �l� SGS Ref.tf 1040916001 Client `nme Tobben Sptukland P.E. Project Namely/ Lot 2, Block 2, Robindale Client Sample 1D Lot 2, Block 2, Robindale Matrix Drinking Water Sa.nnle Rcrnarks: 9075615201 T-536 P.02/03 =-T29 All Dates/Times are Alaska Standard Time Printed Date/time 02/27/2004 14:08 Collected Date/Time 0212412004 12:30 Received Date/Time 02./24/2004 16:53 Tecbaical Director n C Ede Released Be:2, Allowable Prep Aral)sis PuLmeter Results PQL Units Method Container ID Ltmits Date [rate Inn Watora Department titrate -N 1.06 0,100 mg/L EPA 300.0 B (<=10) 0225,104 l]B M!.crobiology Laboratory Total Coliform 0 col/100mL SM18 9222B A (r--1) 02/24/04 DKC Parcel I.D. # 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 051-052-54 1. GENERAL INFORMATION Complete legal description Robin Dale 41 Lot 2, Block 2 Location (site address or directions) 22714 Robinson Road, Chugiak Property owner Roy Wichers Day phone 344-9719 Mailing address P.O. Box 670834 Lending agency Northland Mortgage Day phone 274-5150 Mailing address 2605 Denali, Suite 100, Anchorage, AK 99503 Agent ,Tack white co./m. Coburn Day phone 563-5500 Address 220.1 c St= --t. r.n-hc-rage AK gg5n3 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well X Community well Public water MUNIC7PALIn. OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION AUG 2 D 1996 RECEIVED NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. MuNiciPAL4. TYPE OF WASTEWATER DISPOSAL: ENVIRONMENTAL �RVICES RAGE ' SERVICES Individual on-site X AUG Holding tank 2 DIVISION 1996 Community on-site RECEIVED Public sewer NOTE: 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. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Eagle River Engineering Services Phone _694-5195 Address p n Box -7-73294, Eagle River AK 99577 Engineer's signature ��� Date Z 6. DHHS SIGNATURE Approved for %�- bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: — C1�7' 1 (iL Date The " c)pality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Apr i Certificates based only upon the representations given in paragraph 5 above by an independent pr(,,;; sional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto 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 x21 nsvx ..Esa O+�a bef.a a.oaun>ws:• � M 4 r' Conditional approval for bedrooms, with the following stipulations: Additional Comments By: — C1�7' 1 (iL Date The " c)pality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Apr i Certificates based only upon the representations given in paragraph 5 above by an independent pr(,,;; sional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto 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 x21 Municipality of Anchorage S°F DEPARTMENT OF HEALTH & HUMAN SERVICES 41//G Ry f Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 344 X996 Health Authority Approval Checklist Legal Description: 80$/N 0,41-L 0 / LoTZ ByZ Z- Parcel I.D.: 05/- 052 "Sy A. WELL DATA Well type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number NSA Log present (Y/N) n1 Date completed 15'7S Total depth 1617' r«w-� Cased to * 136 Casing height (above ground) 1 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y FROM WELL LOG AT INSPECTION Date of test /4 0V136%9C, Static water level 13b Well production g.p.m. f�p 9•p•m- WATER SAMPLE RESULTS: Coliform Nitrate Y $ M6.1I- Other bacteria $ Date of sample: 07L3U1%% Collected by: B. SEPTIC/HOLDING-TANK DATA Date installed 08 Z 9C> Tank size 1000 Number o,A,// fCompartments Z Cleanouts (Y/N) y�3 Foundation cleanout (Y/N) Y Depression (Y/N) /ya High water alarm (Y/N) Date of Pumping NClj Pumper C. ABSORPTION FIELD DATA Date installed 09 /7, (i Soil rating (g.p.d./W-er-�) 0-6 System type TA2EMCf/ Length !S Width 3 Gravel thickness below pipe -5— S Total depth Effective absorption area 7-5'0 Monitoring Tube present (Y/N)r L Depression over field (Y/N) No Date of adequacy test / //-4 Results (Pass/Fail) PA -S3 For bedrooms Fluid depth in absorption field before test (in.); NIA Immediately after= gal. water added (in.): Fluid depth AIM (ins) Minutes later: Absorption rate9 = g.p.d. Peroxide treatment (past 12 months) (Y/N) H14 If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION 1A11A Date installed Manhole/Access (Y/N) High water alar evel at* Cycles.t6sted E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic4vel l4mg tank on lot On adjacent lots Absorption field on lot O3 On adjacent lots ��dO Public sewer main AIIA Public sewer manhole/cleanout i Sewer /septic service line fiZ f Lift station SEPARATION DISTANCES FROM SEPTIC/140=11TGTANK ON LOTTO: It- /o6 44 Foundation P3 ' Property line S Absorption field 15 - Water main/service line -�" /0 Surface water/drainage fi100 Water Wells on adjacent lots f �� SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Building foundation 7., Water main/service line 7110 i Surface water Driveway, parking/vehicle storage area i Curtain drain /A10/Vr 1QP4,eE1(/7 Wells on adjacent lots fw0 F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal recp,4 that'the above: systems are in conformance with MOA HAA guidelines in effect on this date. Signature _ �rsa�Suo-��9�n�9ee9 r �.-. � r Engineer's Name LOUIS ,A()7r✓ 2A � /. � �ON�svl .fi �is�er�anc n as qqo *n oba( )mo r �QUb F -i. IiU 10 Ccl. Date _"/ -� /il%�#s� �p cr•araa*^4r 55�,�r'7 �q_ A�cAwo9P 1591 t .'�'9 HAA Fee Date of Pa Receipt Nt 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 08/bb/lib 14: le 1. I bt is 1 HMNUMHUM r oma•+ acs r --• -� - •--- - ME Environmental Services Inc. AZItIlL Laboratory Division 200 W. Potter Drive Anchorage, AK 99818.1605 Tei: (907) 562-2343 Fax: (907y 561-5301 CT&E Ref.# 963435001 Client PO# Client Nacre Eagle River Eingineering Prbded Da1elTime 08/05/96 16;33 Projedwame/# NIA CollectaiiDateftne 07/3019615:20 Client Sample JD Robin pate #1 212 Received Aate/Time 07/31/96 11:00 Matitx Drinidng Water Tedudatl Dh-eder Ordered By PWS1D Relerdwd By � 813S Member of tho SOS Group (So660 G6ndrale de Surveillance} ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILUN018, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA Allowable Prep Analysis Parameter Results PQL units Nethod Limits Date Date [nit Nitrate•N 1.48 0.100 nv/L EPA 353.2 08/01/96 ESC Nitrite -H 0.10013 0.100 mg/L EPA 353.2 08/01/96 ESE Total Soliform 0 (i collt00mL sm18 92220 07/31/96 TAV } 813S Member of tho SOS Group (So660 G6ndrale de Surveillance} ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILUN018, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA --^MUNICIPALITY OF ANCHORAGE �­, ® 1 DEPARTMEN, jF HEALTH AND ENVIRONMENTk. PROTECTION 825 L Street, AnchoracrP. Alaska 99501 i 264-4720 �;- Date Received: October 26,1977 #1: Time 10:00 a.m. #2: Time #3: Time Date 10-27-77 Thursday Date Date Insp Blair Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: Alaska U.S.A. Federal Credit Union Mailing Address: 777 Juneau Street 99501 Phone: 278-4511 2. Property Owner: Thomas/Gloria Griffin Mailing Address: Star Route 1204 99567 3. Legal Description: Lot 2 Block 2 Rob 4: Single Family Residence: fix) Multiple Family Residence: ( ) 5 6. Phone: 279-9343 le #1 Number of Bedrooms: Number of Bedrooms: One Well System: Individual Well (YJ Community/Public System ( ) Permit # Depth of Well 167' Well Log on File ( ) Construction Bacterial Analysis Sewage Disposal System: On-site System (x) Public Utility ( ) Permit # Installed 1975 Installer Septic Tank Size Manufacturer Absorption Area Soils Rate Material 7. Distances: Well to Septic Tank to Absorption Area to Sewer Line Nearest Lot line Absorption Area to Nearest Lot Line Page Two Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 2 Block 2 Robindale #1 Comments: Affadavit Attached: ( ) Approved: Di Department Worksheet: Letter Attached: ( ) Date: //,7 O / Date: _ MUNICIPALITY OF ANCHORAG 'r 0 �s Department of Health and Environmeptal Protection 825 L Street, Anchorage, Alaska 94501° `1 264-4720 r, ,7 request for Approval of Individual Sewer and Fater Facilities i, 1. Property Owner: �JJG/17n�os1 9'�2to/� - Mailing Address:�04 If 5b/Phone: 2. Name of Buyer: ���! L- % lVGi/2XIv., Mailing Address: Phone:7� 3. Lending Institution: As�G�_ x X. (i1e �er�• _ Mailing Address: Phone: Z�e-'-/6 // 4 . Realtor/Agent : / yye�- //Jy('o��.gi� E/ZLTci � S' f '___- .ems Mailing Address: Phone: r,2 7, 5v2� 5. Legal Description:, Street Location: 6. Single Family Residence: (t Number of Bedrooms: Multiple Family Residence: ( ) Number of Bedrooms: 7. Water Supply: *Individual Well (V) Public/Community System ( ) If Individual Well, well depth A. 7 If Community System, name of system 8. Sewage Disposal System: *bn-site System �) Public System ( ) If On-site System, date of installation: j® Col-`Z.E *NOTE: A well log is required on ALL wells drilled since 6/75. **If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fee of $25.00 must accompany each request before processing can be .initiated. 3/77 06-1220(a). Rev. 1973 f DATE INDIVIDUAL '❑ NAME ADDRESS CITY ADDRESS 11 OF SOURCE ALA" DEPARTMENT OF HEALTH AND SOCIAL SE.' ES DIVISION OF PUBLIC HEALTH Lab No. INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL WATER ANALYSIS OFFICE SEMI-PUBLIC ❑ CHLORINE RESIDUAL PPM REPORT RESULTS TO 7IP ror Analysis shows this Water SAMPLE to be: Satisfactory ❑ Unsatisfactory ❑ Questionable ❑ Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. ❑ Bottle broken in transit, please send new sample. SANITARIAN'S REMARKS COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED TIME COLLECTED' Sample Collected From ❑ Kitchen Tap ❑ Bathroom Tap ❑ Basement Tap ❑ Other (List) Well — ❑ Dug ❑ Driven ❑ Drilled ❑ Bored SOURCE: ❑ Spring ❑ Cistern ❑ Other Dug Well or Cistern Construction: Walls—[-] Wood ❑ Concrete ❑ Metal ❑ Tile Brick or Top — L] Wood ❑ Concrete ❑ Metal ❑ Open Top ❑ Concrete LOCATION: ❑ In Basement ❑ Basement Offset ❑ Under House [-]In Yard ❑ Other Building Sewer Septic DISTANCE TO: or Other Drainage Pipe Feet. Tank Feet. Tile Seepage Cess - Field Feet. Pit Feet. Pool Feet. Privy Feet. Other Possible Sources of Contamination MATERIAL: Building Sewer- ❑ Cast Iron ❑ Wood ❑ Tile ❑ Fibre ❑ Asbestos Cement ❑ Plastic Joint Material - Type GENERAL: Does Water Become Muddy or Discolored? ❑ Yes ❑ No When? — Diameter of Well Depth Feet. Well Casing Material DiameterDepth Length of Water Depth Drop Pipe From Bottom Feet. Offset in In Utility PUMP LOCATION: ❑ In Well ❑ Basement ❑ In Basement ❑ Room On Top ❑ Of Well ❑ Other PURPOSE OF EXAMINATION: Illness Suspected? ❑ Yes ❑ No New Source of Supply? ❑ Yes ❑ No Repairs to System? ❑ Yes ❑ No Signature 06-1220 (b) BACTERIOLOGICAL WATER Rev. 1973 - ANALYSIS RECORD READ INSTRUCTIONSam Date Received Time Received pm Lab. No. Lactose Broth lOcc lOcc locc locc locc 1.0cc 1.Occ ON24 Hours - 48 Hours - -- Brilliant Green REVERSE SIDE 24 Hours 48 Hours EMB AGAR BEFORE Lactose Broth, 24 hrs. 48 hrs. Gram's stain Coliform Density _ _ (Most probable No. per 100cc) MF Results COLLECTING SAMPLE a.m. Reported by Date - p.m. This analysis indicates Coliform Organisms to be: Absent. - Present