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Home My WebLink AboutROCKHILL BLK 3 LT 4Rock Hill lock 3 Lot 4 015-063 -02: *'~ :' MUNICIPALITY OF ANCHORAGE //~1;/~ 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 yJ~_~..~ ~.~H O N E ~(.~¢.~ ~EW LEGAL~SCRI PTION Well t Absorptio ~< ~Z Manu facture~~ Mate~Ta~' No. of ~rtments ~ Liq. c~P~lt.~ ' o ns IF HOMEMADE: Inside length Width Liquid depth ~ ~ DISTANCE TO: Well Dwelling PERMIT NO, ~ ~anufacturor Material Eiquid caOacitg in ~allons ~ DISTANCE TO: Well/~ ¢'~ F°unOati°n~/ Nearestlot~'~ No,%s L~¢c~h Total lengt,%~ Trench widt~ Distance~ines ~ -- . * * inches eff~sorption /f Total area ~ Top of tile to finish grade~ Material beneath tile ~/ inches Length Width Depth PERMIT NO, ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO; ~ Class Depth Driller Distance to lot line PERMIT NO, Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE MATERIALS SOl ~ TfiST ¢ REMARKS , ,. PERMIT NO, I..]F F L I ~.MNT LOCRT 1 ON LEGRL · DEPARTMENT.o~._,_,.~R '" L ' STREET,HERL'TH 264-4728AND'ENV I ~ONMENTRLRNtHL~RSt~E,_ 1.4ELt_ R~4[:, ~3~-~ __, I TE SE~4E~ ( 8181]:6 > t GOENTZEL BLIILDEF.._, INC MFIIN TREE L4 B._* ROCkHILL TYF'E OF SCIIL ME_uF..PTIuN =,¢=,TEM I.=,. TRENCH -" I!, , ,- c MH,:.::IM_fl NLIMBER OF E, EDF..uOM_, = 4 SOIL RRTING (SE,! FT,-"BF.'.)= THE REQUIF.'.ED ~I~E OF THE SOIL RBSORPTION .:,'r_,TEM '-' LOT :,I~.E 48000 SI;!URRE FEET THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF 'tHE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OF.! PIT IS THE [:,ISTF4NCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE E',:.,:CRVRTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRR',/EL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFE. L PIPE RND THE BOTTOM OF THE E::-.iCRVRTION (IN FEET). PEF.:MIT RPPLICRNT HRS THE F..E_,FEiN._,IE, tLIT-¢ TEl INFORM THI_, DEF'RRTMENT DIIRING 'THE INSTRLLRTION IN~,.FEtTIoN_, ElF RNY WELLS RD..TRCENT TO THIS PROPEF.'.TY FIND THE NUi'~BER OF RESIDENCES THRT THE WELL WILL --,ERIE E,R~.kFZLLING OF RNY :=,~=,TEM WITHOLIT FZNRL IN~PECTIGN RND RFFF...¢F~L BY THIS E.EPRF.':TMENT WILL E:E SUB..TECT TO PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS t00 FEET FOR R PRIVRTE WELL OR ~50 TO 200 FEET FROM R PUBLIC WELL. DEPENDING UPON THE TYPE OF PUBLIC WELL. MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNITY SEWER LINE IS 75 PEET. WELL LOGS RRE REQUIRED RND MUST 8E RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLRTION. PER['1 I T E..--.F Z RE:z. E..,EL.E£flE:EF.. ]7::1.., iD:Bi I CERTIFY THRT l: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY THE MUNICIPRLIT¥ OF RNCHORRGE. 2: I WILL INSTFILL THE SYSTEM IN RCCORDRNCE WITH THE CODES. 3: I UNDERSTRND THRT THE ON-SITE SEWER S'T'STEM MR"r' REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THBN 4 BEDROOMS. RPPLICRN"r GOENTiEL BUILE:,ERS INC V4. 0 SOILS LOG ~- PERFORMED FOR; MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVl RONM ENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 2e~ ~720 SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST LEGAL DESCRIPTION: 5 6 7 8 9- 10- 11 12 13- 14- 15- 16- 17 18 19- 20- I-?-- SLOPE sITE PLAN WAS GROUND WATER ~(~ ~ ENCOUNTERED? O IF YES, AT WHAT DEPTH? Gross Net Deoth to Net (~ading Date Time [ Time' Water , Drop I i · PERCOLATION RATE (minutes/inch) COMMENTS PERFORMED BY: TEST RUN BETWEEN FT AND · Well Log 'Fo~ ....~0~./.~~ ....... .5..~./.<~.~0.~...~: .......... ~ ........................... i ......... Location ..... ~.Q..T.. .... ..~../ .... ..~...??..'. '..~.....-. '..~.~.O..d....~... .... ...~.../...L..~ .... .~.--~....t/...~_..: ..... Date completed ~ -/ - 8/ · Depth of well .......... [-..~.~....! ....................................................... Size of casing ........... ...~4..[(~ ............................................................................. Distance to water '~'~ / Distance to water while pumping ..-~.-..~.- ......................... at rate of ........... .~.0 eD ............... gallons per hour. Formation ~rom to 7~ 77 MUNICIPALITY qF ANCHORAGE DFP]', OF/':L:qJ?i & ENVIROF,iM3N blL ~',:d:, CTION Driller DELTA DRILLING COMPANY SRA BOX 394 B ANCHORAGE. ALASKA 99507 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. O ~5- O63--O~, GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address COSA # Expiration Date: Lo'½ ~ Day phone ~ff~ ,-C~ ici. Lending agency Day phone Mailing address Real Estate Agent · . ,~ '~; ~ ¥' ~ Marling Addre~s,~ Unle~S. dtherwise requested;. COSA will be held by DSD for pickup, NU~ BER,OF BiEDROOMS: TYPE OF'WATERSUPPLY: Individdal Well Individual Water Storage Community Class Public Water System Day phone Well TYPE OF WASTEWATER DISPOSAL: [~ Individual On-site [] Individual Holding Tank [] Community On-site [] Public Sewer The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On-Site System's 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 COSAs upon request to homeowners. Certificates of On-Site Systems 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. 4. STATEMENT OF INSPECTION BY ENGINEER ¸5. As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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-sffe 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 S?qR, kio, n~ Address 20~.~ LU, i5i'k Ave, S re, Engineer's Printed Name [.AILS Phone ~-~r~- ..~':j' i (e Date b/izJzo DSD SIGNATURE ~'/' Approved for Disapproved, Conditional approval for bedrooms, t, .?,. 11~0~ . ~%' ~ bedrooms, with the following stip~mh~ Attachments: COSA Checklist Septic System Advisory Well .Flow Advisory Nitrate Advisory X Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other (Rev. 1 II05) Original Certificate Date: Municipality of Anchorage Development'Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 A. WELL DATA ' Well type ~'n'v,~'~. If A, B, or C provide PWSID # -- Date completed ~"-/'~{ Sanitary seal (Y/N) ¥ Total depth.·'~ ft. Cased to ~.e{ ft. CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: ~-~ ~t ~'~V-~ ~ i~ Parcel ID: FROM WELL LOG Date of test Static water level /'~ ~ ft. Well production [ ~ g.p.m. w.ell Log (Y/N) Wires properly protected (Y/N) Casing height (above ground). -i- {~ in. AT INSPECTION 5~,5 ft. > ~, g.p.m. ~,.~{ I , mg/L ~/z=~/zo ti WATER SAMPLE RESULTS: ColifOrm JV'e~ colonies/100mL Nitrate Arsenic: ~D' ug/L date of sample: . B, SEPTIC/HOLDING TANK DATA Tank Type/Material Tank size' ~2.50 gal:..~ ~ Number of Compartments Foundation cleanout (Y/N) ¥ ' Depression over tank (Y/N) Collected by: L~ -~F~ Date installed '~1 Cleanouts (Y/N) High water alarm (Y/N) Date0f. J:)~lrn'~)i.~l., ~ /~O[I Pumper O!1~ ~00 C. ABSORPTION 'FIEL~ ~ATA , t ~1~1 ' Date ins~lled:'~Ji~ .SOU rating (g.p.d./~ or~~ Length 59,, ,, fl. Width ~ ff. Total depth ~,~ ff. Eft. absorptio~ ama ~ ff~ Monitoring tube Date of ad~ua~ test ~[ {L Results (Pass/Fail) Fluid depth in absorption field ~fore test ~,. in. Elapsed Time: {0 min. Final fluid depth ~ Ioo ,' '. ~ ' System type [7~ c Gravel below pil~(~ "~ ft. ~ Depression over field N~ Water added ~rl~) gal. in. Absorption rate >= For ~ bedrooms New depth '7..~. in. ~00 g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed ~ "Pump on" level at Datum / ~E. SEPARATION DISTANCES Size in gallons J "Pump offf level at/ in. Cycles tested.~' Manhole/Access (Y/N) / High water alarm level at~,,'''/ Meets alarm & c~jt,~quirements? in. Absorption field on lot PUblic sewer main Sewer/septic service line Animal containment areas SEPARATION DISTANCES FROM WELL ON LOT TO: Septic, tank/lift station :on lot (00~¥ leo ~-. ~5' ~- S:o '~. On adjacent lots I00 ~+ On adjacent lots J(~lO ~ Public sewer manhole/cleanout ,, Holding tank Manure/animal ex-crete storage areas 1{30 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ' Building fouh~l~tion ~ ~ ' Property line ~; '{' AbSorption field Water main Water service line IO 14' .~ su;face water Wells on adjacent lots J00 ~- ~* ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Pr~operty line (0~' Water Service line IOl-!- Curtain drain ~F, COMMENTS Building foundation I Ol~. Surface water [0DI.~ (N,D~ Wells on adjacent lots 100 ~-~ · Water main Driveway, parld'ng/vehicle storage 'ZS I~. G. ENGINEER'S CERTIFmATION ~"~'.'~'.~? · . : I ce/ti'fy that. I have determined thrOugh field inspections and review of Municipal reco~cls that the above systems are in conformance with MOA COSA gui~de/ir~ in ~ffe~ on this date ,., ~ /, ~, ~~, En,gine~r,'sPr. int, d Name $ Date of Payme:~t ~'--I~I¢:~ Receipt Number (Rev. 4/10) , '.. W~iver Fee $ Date of Payment Receipt Number :'_ Municipality of Anchorage Community Development Department Development Services Division 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 # 111156 A Certificate of On-Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block 3, Lot 4 of Rock Hill subdivision. This inspection revealed a nitrate concentration of 6.41 milligrams per liter (mg/L) was reported for the 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. SGS Ref.# 1111592001 Client Name Spurktand Engineering Printed Date/Time 05/11/2011 9:26 Project Name/# Rock Hill B3L4 Collected Date/Time 04/27/2011 18:30 Client Sample ID Rock Hill B3L4 Received Date/Time 04/28/2011 12:35 Matrix Drinking Water Technical Director Stel~hen C. Ede Sample Remarks: 4500NO3-F - Nitrate/Nitrite - MS recovery is outside of QC criteria. Refer to LCS for accuracy requirements. Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 05/02/11 05/09/11 NRB Waters De,oar tment Total Nitrate/Nitrite-N 6.41 0.100 mgFL SM20 4500NO3-F B (<10) 04/28/11 AYC Microbiolo~ Laborator~ E. Coli Total Coliform Negative I 100mL SM20 9223B A 04/28/ll DLC Negative I 100mL SM20 9223B A 04/28/11 DLC ~< . ZOT~ . / aa r ~ ~ ~Or~ Lot ~ ,Block D ,~.~. ~ ' - ........ Anchorage Recording ~ecinct, Alaska ~T ~RV~ CERTIFICATION LEGEND ff/{~ {~ ~ "., ~.~ ,,'"~ I hereby ~mfy thai ~e su,~ the pr~er~ shown and de~nbed ~- ~rass co~e~,m~ment mc~e?d ~,a~ t~ the ~proveme~s situ~ thereon are w~hin the prop- o =lr~peana/orre~rrecover~ e~ lines o~ do ~ ~er~p ~ en~oa~ ~ odjace~ prope~ a~ that no a = ~xZ hub ~ t~k rec~ered i~emsonadj~oper~yoverlap, or encr~h on the prem~ses · :~8 x~ re~r~tth~ssu~ey in ~estlcn a~ ~h~ throe are ~ r~dways~ utility I~es ~ other eo~nts on said pmpe~y except as indicated here~. Ret Date/z-/~ -~7 Prepared by (907)p79-~PO0 1~. I... BUTTOIV Rog/stored £ond Surveyor 519 ~. ~'/ghth Ave. Ancho~oge, Alosko 99501 Property of: ~-'l~V~ /(~/"h ~/~ 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 HAA # 1. GENERAL INFORMATION Complete legal description Location (site address or directions) q ,ql Mailing address Lending agency Mailing address Day phone ~,, ~,~,~J_~y phone ,.5-~ ¢-' 62 ~O ~ Agent Address Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Unless otherwise requested, HAA will be held for pickup. NOTE: Community well Public water 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 NOTE: 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 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 Address Engineer's signature DHHS SIGNATURE Approved for ¢(:~z,c~,c'ZZ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in 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. 724;)25 (Rev. t/91) Back MOA #21 Municipality of Anchorage , ,~ Department of Health & Human Services ~ HEALTH AUTHORITY APPROVAL CHECKLIST IZ]D~ LegalDescription: L'J~/r~3 ~OC~4/-'/~'1/ ParcelI.D. O/,~- O~-'O~- A. WELL DATA Well type '~- Log present (Y/N) Total depth Sanitary seal (Y/N) Y If A, B, or C, attach ADEC letter. ADEC water system number I',//~. Date completed ~" /' ~ / Driller ~//'~ /..~//~'~-'~, ~-~ Casedto '1 C~ Casing height /7/'*' ( *~'~. H~ou',d~ Wires properly protected (Y/N) )f FROM WELL LOG Date of test ~"/' ~ / Static water level ~'i ~' Well flow /~' Pump level ~'O//"~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot I Public sewer main /~/A Sewer service line II C) AT INSPECTION ·,, g.p.m. 7 g.p.m, i_~_1 · On adiacent ots , I ; On adjacent lots Ill Pu'bl ic sewer man hole/cleanout /~//~z~-- Petroleum tank WATER SAMP.LE RESULTS: Coliform Date of sample: ~'/3, / Nitrate Collected by: B. SEPTIC/H~L,,Bfl~ TANK DATA Date installed ~///E>/e~'/ Tank size 1~,,.~'0 --~ Compartments Cleanouts (Y/N) ~-, Foundation cleanout (Y/N) ~' Depression (Y/N) High water alarm (Y/N) I"'//~ Alarm tested (Y/N) ~/~' Dateo pumpin Pum"e :-: SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot / TO property line Surface water/drainage Onadjacentlots ~ /O'C) Foundation Absorption field I~ Water main/service line ;~J-~ ' CONTINUED ON BACK PAGE 72-026 (Rev. 7/91) Front C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~//3/~ Length ~'~ Width Total absorption area Depression over field (Y/N) Results (pass/fsil) Peroxide treatment (past 12 months) (Y/N) d SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain /~ / I:~, Soil rating Gravel thickness Cleanouts present (Y/N) Date of adequacy test for L,/ If yes, give date System type Total depth bedrooms On adjacent lots ~ I'/O ProPerty line ,~' c~ To existing or abandoned system on lot Cutbank ~,~o/,e~ 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 t~e~d,.ate of this tnspection. Engineer's Name '~Jo~.~/ Spu, r]/.J.,~,..~¢-~ P~- Date ~ (o ,.'~ ~ ~,~- ~ - HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANALYSIS RESULTS for INVOICE $ 57851 Chemlab Re£.$ 92.4704 Sample # 1 Matrix: WATER Client Sample ID PWSID Collected Received Preserved with 9641 MAIN TREE Client Name :TOBBEN SPURKLAND, P.E. UA Client Acct :TOBEENS SEP 3 92 ~ 07:00 lms. BPO# : POS :NONE RECEIVED SEP 3 92 ~ 18:00 [ms. Req# : AS REQUIRED Ozdered By : Analysis Completed : SEP 4 92 Laboratory Supekv~§ot~..STEPHgN._C. ED~ Released Ey: j~ ~.~z_~ Send Reports to: 1)TOBBEN SPURKLAND, P.E. Parameter Results Units Method Allowable Limits NITRATE-N 3.9 mE/1 EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: STUART. Remarks: 1 Tests Performed * See Special Instructions Above UA-Unavailable ND- None Detected '* See Sample Remarks Above NA= Not Analyzed LT-Less Than, CT-Greater Than ~SGS Member Of the SGS Group (Soci(~t~ G~n(~rale de Surveillance) COMMERC iL TESTING & ENGINEERING CB. AK DIV CHEil,~,[CAL & GEOLOGICAL LABORATORY TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518, Drinking Water Analysis Report for Total ColifOrm Bacteria TO BE COMPLETED BY WATER SUPPLIER f-I PUBLIC WATER SYSTEM I.D. # [-,liil I II J ~-.~RIVATE WATER SYSTEM Mailing Address ~' ,~ , ~ c~y 23p Code Mo. Day SAMPLE TYPE: [~outlne [] Check Sample (for routine sample with lab ref. no. [] Special Purpose State ' ~Year ) [] Treated Water ~..~ntrsated Water SAMPLE Time No. LOCATION Collected Collected TO BE COMPLETED BY LABoRAToRy Analysis shows this Water SAMPLE to be: Satisfactory [] Unsatisfactory [] S~mi~lei'too 10ng in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via specia de very mail. t ob Time Received Analytical Method: Membrane Filter No. of C°lpnies/100 mL Lab Re~. No. Result* 92.4704 Analyat A .D.E.C. ~" READ INSTRUCTIONS BEFORE COLLECTING SAMPLE TNTC = Too Numerous To Count OB = Other Bacteria BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count Verification: LSB Fecal Coliform Confirmation Final Membrane Filter Results i Reported By ~ ~: ~-~ //~ .,.-.z ~'~ SGS Member of BGB Coliform/100 mi Coliform/lO0 mi Timi: /7~-~ a.m. p.m. PART ONE OF TWO GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMI'ETAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~-,}~- t~.~(~ / OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date q~ (b) PropertyOwner~LL~',~cJ~. (~J-~-~'~elep~one.'~ome(''~'~'r~°' (c) Lending Institution Telephone Mailing Address (d) · Real Estate Company and. Agent Address ~'C~\ 1~ Business Telephone (e) Mail the HAA to the followina address: or: Check here.~, if hold for pick up. List contact person and day phone number below. S & S ENGINEERING 7034 Eagle RWer L~p Road No. 204 TYPE OF RESIDENCE Single-Family [~ Number of Bedrooms 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. SEWAGE DISPOSAL Onsite/~ 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 fray 8/861 Front ~ ;o ~ a§ed NOIJ. nVO euoqdate± ONi~la=1NIONa $ ~' $ sseJpp¥' UJjL:l ~o eU~N 'uo!~oedsu! s'!~l~o e~ep uo loajJe u! suo!lelnDeJ pue 'seoueufpJo 'sepoo ele~S' pue led!o!unlAI lie ql!M eoUe!ldLUo3 u! s! LUelShS lesods!p Je~eMe~seNt Jo/pue ,~lddns Jelet~ el!s-uo eq; 'uo!~oedsu! pue uo!]e§!lse^u! ,~LU UJOJJ pue Selg e§eJoqouv jo ,~l!led!o!unlN eql uJoJj peu!elqo UO!I~LUJOIU! aLII uo peseq leql hJ!Je^ Jeq:!Jnj I 'u!eJeq pe~eo!pu! eJn~,onJ~s jo ed/~; pue suJooJpeq jo JequJnu eq~ Joj e)enbepe pue leUO!~ounj 'ejes si LUe~S~S lesOds!p ~e~et,~else~ Jo/pue ,~lddns JeleM el!s-uo eq~ leql s~oqs le^oJddV ,~l!Joqlnv qlleeH s!q~ jo uo!le§!~seAu! ~uJ leql ,~JUe^ I '~oleq ut~oqs elep uo!lep!le^ eql jo se pue oleJeq pex!jJe leSS ~LU/~q pe!J!~JeO sV NOI.LVlNI:IO-INI ONV V.L~Va 'HOI:I'¢=1$ =1114 '$.LS=I.L 'SNOI.L3=IdSNI ONlal^Ol:ld INUlJ ONII::I=1=INIgN=1 WELL DATA MUNICIPA .... MUNICIPALITY OF ANCHORAGE (MOA) UTY O, ,F..A.N~,C,I'~Oi~G/..~H AUTHORITY APPROVAL (HAA) DEPT. OF ENVIRONMENTAL PROTECflON~HEcKLIsT ' FEBRUARY 1984 264-4744 JUL P, t_ t988 Legal Description: RECEIVED Well Classification Well Log Present~TN) Total Depth ~'7 ~ f Static Water Level Casing Height Above Ground Electrical Wiring in Conduit4~/N) Separation Distances from Well: '~:~-~Ak//:~'~ If A, B, C, D.E.C. Approved (Y/N) y Date Completed [,~- ~ ~ ~ Yield Cased to ~ ~ ' Depth of Grouting "- ~'t~'~ Pump Set At Sanitary Seal on Casing<:~C~N) '"/ Depression Around Wellhead -/ To Septic/~Tank on Lot \"~"'~ f ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot ~,"7_._"~ ~ "F,' On Adjoining Lots \ To Nearest Public Sewer Line I'~A To Nearest Public Sewer Cleanout/Manhole /-,3//~, To Nearest Sewer Service Line on Lot Water Sample COllected by '~----~, ~ ~ 1'~2;~¢J~' ; Date '~ - '~''/'' Water Sample Test Results ~-----'~ ~-~-""/~"~--~-t""~P~ -- "~/'~' :~ ~'~'T""~ Comments ~ ~'l~Ot~ '~'"'~1" 1-t~' 68 B. SEPTIC/H~ TANK DATA Date Installed ~ I '¢) Standpipes4iC~'/N) V Air-tight Caps ~N) Depression over Tank (Y~) Pumping/Maintenance Contract on File (Y/N)r.~/ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/l~l~/Tank: To Water-Supply Well \ To Property Line To Water Main/Service L~ne Course C~mments ~ ~ Size \'Z-~-(~ No. of Compartments Foundation Cleanout(~YN) "',/ r_~/~Date Last Pumped Temporary Holding Tank Permit (Y/N) To Building Foundation ~ To Disposal Field ~ t To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026 (Rev 8/861.Front C. ABSORPTION FIELD DATA \ ~:::;~C::~'~'/~¢~')"''~ Type of System Design Soils Rating in Absorption Strata Date Installed ~ --~"'"~ ~:;~ I Length of Field ~'~:~ ! Width of Field ~ ~ Depth of Field Gravel Bed Thickness Square Feet of Absorption Area ~ (~(~"¢' Standpipes Presentd~i~N) Depression over Field (Y/~ ~ Date of Last Adequacy Test Results of Last Adequacy Test ~/~, ~-~' ~ .~ '~ Separation Distance from Absorption Field: To Water-Supply Well ~ '~'""~ ~J¢ To Property Line I. ~.~ To Building Foundation "~-~¢' f To Existing or Abandoned System on Lot ¢'~/~¢:~' ; On Adjoining Lots To Water Main/Service Line ~ ~;~ I.~¢ To Cutbank (if present) ~/~;:~ To Stream/Pond/Lake/or Major Drainage Course I ~s;:~E;;;~ To Driveway, Parking Area, or Vehicle Storage Area ~ I ~ Comments Date Installed Size in Ga High Water Alarm Level at Vent (Y/N) Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at g Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request I certify'that I have checked, verified, or conformed to all MCA and HAA guidelines in effect on the date of this inspection. Y Signed .... Date S & $ ENGINEEHiI~I~ '// // - Compan~17054 t=,,,.I,~ giver L~p. I~,~,_~ .~;;~I~No. E.gle River, Al,.,ka Receipt No. Date of Payment ~/~ C~ / Amount: $ Page 2 of 2 72-026 fRev 8/861 Back CHEMICAL & GEOLOGICAL LABORATO~ES OF ALASKA, INC. FEDERAL TAX ID # 92-0040440 Date Report Printed: JUL IS 88 t 16:12 Client Sample ID:L4, E3, ROCKHILL PWSID :UA Collected JUL 12 88 ~ 18:00 ~s. Received JUL 13 88 ~ 14:00 ~s. Preserved with :4 DEg. C Client Name : S & S ENGINEERING Client Mot : SNSENGP P.O.t NONE REC'D Ordered By : M5 Analysis Completed :JUL 15 88 Send Reports to: Laboratory Superv~or.:STEPHEN C. EDE lis & S ENGINEERING Rolea..d Ey: ~L ~. ~ 2J Special Instruct: Chemlab Ref %: 1779 Lab Smpl ID: I Matrix: Water hltowable Parameter Tested Result/Units Method Limits NITRATE-N 1,9 mE/1 EPA 353.2 10 Sample ROUTINE SAMPLE. Re~rks: SAMPLE COLLECTED BY RJS. I Tests Pazformad * See Special Instructions Above UA-Unavailable ND- None Detected ** See Sample Remarks Above NA- Not Analyzed LT-Less Than, GT-Greater Than CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER ~ PUBLIC WATER SYSTEM I.D.# "~RIVATE WATER SYSTEM ! Name Phone No. Mailing Address City ! State Ztp Code Mo. Day Year SAM PLE TYPE: l~-Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose ) [] Treated Water [] Untreated Water SAMPLE NO. LOCATION 2 s I TO BE COMPLETED BY LABORATORY Time Collected Collected By t :oof Analysis shows this Water SAMPLE to be: '1~. 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 ~ ~-/"~ ~ Tim~ Received AnalYtical Method: Membrane Filter * .No. of colonies/100 mi. Lab Ref. No Result* Analyst I m BACTERIOLOGICAL WATER ANALYSIS RECORD '~'~/~L~''~'~) READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter:. Direct Count Collformll00ml · Verification: LTB BGB Final Membrane ~t Re'lite * /~/~* ~ Collform/100ml Reported By ~ ."~.~-~ Date 7/~,~,/~ ~ Time: /~ a.m. TNTC -- Too Numberous To Count OB = Other Bacteria PART I OF Z ~ R,~MAINDER TO FOLLOW 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. GENERAL INFORMATION (a) (b) (c) Legal Description (include lot, block, subdivision, section, townsh'ip, range) Location (address or directions) Applicant Name ~O ~ ~ J~. Telephone ~Home ~- ~ ~ Business ~ Applicant Address ~/ ~/~ ~ ~0~ Applicant is (check one): Lending Institution ~; Owner/builder; Buyer ~; Other ~ (explain); (d) Lending Institution Address Telephone (e) Real Estate Company and Agent ~./f/'~--/-'~¢ ~'~"'"~/~"'~' ' Address Telephone (f) ,-Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family/[~ Multi-Family [] Number of Bedrooms ~ Other 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~ Pubtic [] 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. 72-025 (11/84) Page 1 of 2 ENGINEERING FIRM PROVIDING..~PECTIONS, TESTS, FILE SEARCH, DAT~..~ID 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 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 ~......~,..-.,,.,---,,.,~., Telephone ~ ~ ¢-~ ~ ~ ~ Address e= ~ ~o&~ Date K~.~[~ ~V~, ~ ~9~ DHEP APPROVAL Approved for /~/-/.~(~// bedrooms by Approved ~ Disapproved Terms of Conditional Approval ~ond[tional CAUTION The Muncipality 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 72-025 I11/84) WELL DATA ...... MpN CIPALITY OF ANCHORAGE (MO/~) ; : HEALTH AUTHORITY APPROVAL (HAA) '~ CHECKLIST - FEBRUARY 1984 264-4720 1986 Legal Description: Well Classification Well Log Present~N) Total Depth '/4 Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (~N) Separation Distances from Well: If A, B, C, D.E.C. Approved (Y/N) Date Completed (~- ~ - ~ 1 Yield Cased to '7'~ ~ Depth of Grouting Pump Set At Sanitary Seal on Casing ~N) Depression Around Wellhead (Y/~ / To Septic/l ~o',d:,,~g Tank on Lot } .Z 5 ; On Adjoining Lots ,/C~O ¢'/'''- To Nearest Edge of Absorption Field on Lot /'2.-.~ ~--H ~; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Clean0ut/Manhote ~"~,'//~ To Nearest Sewer Service Line on Lot Water Sample Collected by ~ ~ ~ ~ I,.~,,-1~ ; Date ~ -I~' Water Sample Test Results ~-1 ~~ ~ Comments ~ W./_C:I.J_ ~,/l'~7---/') .~.-'r ~/,-]-c,~,...~::z-~ .~,,-~,~ ~ B. SEPTIC/~ TANK DATA Date Installed Standpipes~f/N) Air-tight Caps ~:)'N) Depression over Tank (Y/~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) '~/~ Separation Distances from Septic/I.~ Tank: ,~ ¢ I~ ¢ ~:~ I Size )'l..~-o No. of Compartments Foundation Cleanout(~N) Date Last Pumped /~ /~Z~ ' for Temporary Holding Tank Permit (Y/N) /D/ To Water-Supply Well To Property Line To Water Main/Service Line Course ,/C:) z~ ~'-/~ To Building Foundation ~ / To Disposal Field (.~ / To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata / E~'c:~ ¢' ~ Type of System Design Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/~[~P. Results of Last Adequasy Test Separation Distance from Absorption Field: To Water-Supply Well / To Building Foundation Lot '.~//,Z~"/. To Water Main/Service· Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Length of Field ~'~' Depth of Field Gravel Bed Thickness ¢;" ~'/~Standpipes Present <iCON) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots '~O To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions /~anhole/Access (Y/N) A "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify,Ih_at[have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. $ & S ENGINEERING Date Signeds~ B 1~6X -- MOA No. c°mP~GLE RiVE~, A~ ~577 Date of Payment ~ / ~o/2 ~ Amount:$ ~0%'~ ~" ' " Page 2 of 2 72-026 {11/84) ,.Tinge - ~' Time Dat~ Date Date Inspector Inspector Inspector Comments Conditional Approval Date Sewer Installed Permit No, Septic Tank Size ~ _~ ~ Holding Tank Size Soils Rating Well To Absorption Area Well Log Received t~ ~ ' Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property OWner ~;0E ¢~ ~ ¢,~ ~:~(~ ; { ~ ~.~,_¢. ~_~..~&, Phone Address Lending Institution {;. ], ~.~,,¢¢, ~ ¢~', Phone Address Realty Co. & Agent Phone Address Legal Description /. (;> .~ /y ~ ~ t'~ ~ f~ ~ d Street Location ~ ~.~ {~) ~ { ~ (- Type p~esidence ~ Single Family C Multiple Family No, of Bedrooms ~ Other Water~upply ~ Individual A~ACH WELL LOG. A well log is required for all wells drilled since June ~ Community 1975. For wells drilled prior to that date, give well depth (attach log if ~ Public Utility available.) Sewa~isposal ~ Individual Year Individual Installed: ~ Pablic Utility When Connected to Public Utility' ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.