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HomeMy WebLinkAboutROVIER BLK 1 LT 6 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 LEGAL DESGRIPTION LOGATIO~~.~~ ~ ~ ~ / NO. OF BEDROOMS kiq. coOac~g~s IF ~OM[MAD[: Inside length ~idt~ kiqui0 depth  ~ DISTANCE TO: Well Dwelling PERM~ Liquid capacity in 9allons ~ ~ ~ D]STANCE TO= Wel~~ Foun~o~ ' Trench width Distance No. of I'~s m ¢/ Length of each I~O 3 ~ inches ~ ~ Top of tile to finish grade ~¢es Total effectiveCsorption ~ ~ ¢~ Material beneath tile~O~ area Length Width Depth PERMIT NO. Total elf 6eve ab orption are / ANC~~ , ~ C~~ Depth Driller Distance ,o Io, line PERMIT NO.C/ ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING INSTAELER REMARKS 72-013 (R e~,~ F.'ERMIT NO. .,, DEPRRTMENT ' HERLTH RN[:, ENVIRONMENTRL j:OTEC:T iON 825 "L" STREET, Rt'.,tCHORRGE., RK. D958Z 264-4728 ,:: 8±060C~ ) RPPLtC:RNT MICHREL. N FRRZRR L. OC:RTION RRBBIT CREEK ROR[:, LEGRL LOT E; BLI< i ROYIER SUB LOT SIZE 4356E~ SL.]URRE FEET "- cF. __ -'"- .... " IL., ~~"¢~ ' 1~,-~: OF ql]IL RE:SORPTION =~=I'E t : TREtqCFI ~('m]'~~/~'%. / t TFIE REf:.!LI!RE[:, SIZE C'F THE L::O!L FIE:SORPTION =-r=,TErl I::,: V THE LENGTH DIMENSION IS THE LENGTH ,::IN FEET::, OF THE TRENCH OF;.'. DRRINFIEL.D. :"HE DEPTH OF Ft TRENCH OR PIT IS :'FIE DISTFINCE BETI.,.!EEN THE F;LIF..'F:RCE OF '.'FFIE GROUND RND THE BOTTOM OF THE EF.IC:RVRTION ,:: IN FEET::,. THEF.:E !'_:-; NO SET i4IDTH FOR TRENCHES. THE GRR',,,'EL DEPTH IS THE HINIMUM DEPTH OF GF:R',,,'EL_ BE]"HEE'N THE OUTFRLL PIPE FIND THE BOTTOM OF 71-.IEi EXCR',,,'F.ITiON ,::I.1'.4 FEET::,. PERMIT RPPLICR.NT FIBS TNE RESPONStDIL. IT'¢ 'TO INFORM TNI'Z.; DEPRRTMENT DURING THE INSTRI_LRTION INSPECTIONS OF RN'¢ HELLS RDJRCENT TO TNIS PROPERTY FINE:, THE NUMBER OF RESIDENCES THRT THE HELL HILL SERVE. .......... 'T"~.-.~,.E-, ,:: 2: _'::, Z ?-~]~:2;PEEC: 1- Z ,]~P-4:E; F~F:E F~-:E,;~LJ ]: F:E[:, BRC,k':FILL. ING OF RN"? S'¢STEM HITHOUT FINFIL INSPECTION RND RPPRO',,,'RL B"? THI':-; C, EPRRTMENT HILL BE SUB..TECT 'TO PROSEC:UTION. MINIMU.H DISTF.hNCE BETHEEN R HELL RND RNV ON-SITE SENRGE [)ISF*OSRL SYSTEM iS ~ FEET ELf': R PF.':IVRTE HELL ('ID: ~.5~'I TO :'";'¢l~."l FEET FREM R PUBLIC HELL DEF'ENDING -LF'i~N THE T'¢F'E OF PUBLIC HELL MINIMUM DISTRNC:E F.'ROM FI PRi',/RTE HELL TO R PRIVRTE SEHER LINE IS 25 FEET RND ]'0 R COMMUNIT'.'r' SEHER LINE IS 75 FEET. HELL. LOGS RRE REQUIRED RND MUST BE RETURNED TO TFIE DEF'RRTMEN]~ NITHIN ]:C'i DRh"S OF TFIE HELL COMPLETION. OTHER REQUIF-':EMENTS MR"¢ F.'IPPL",". SPECIFiCRTIONS F'!ND CONSTR. UCTION [:'iRGRRMS RRE RVRIL. RBLE TO INSLIRE PROPER INST'RLL..RTION. I CERTIF'¢ THRT i.: I FiM FRMILII"3R HITH THE REQUIREMENTS FOR ON-SITE SE!4ER. S RND HELLS RS SET F'ORTH B'¢ THE MUNIC'IF'RLIT'¢ OF RNCHORFIGE. ;2: I HiLL !NS]'.'RLL THE S"r'STE?! IN RCCORDRNCE HI]"N THE CODE'.-];. 3:: I UNDER"];TRND THRT THE ON-SITE SE!.4ER '.='";"¢STEM t"1R¥ REQUIRE ENLRRGEMENT IF :"FIE RESIDENCE IS REMODELED TO INCLUDE MORE THRN ]: BEDROOMS. V4. Et I MUNICIPALITY OF ANCHORAGE DEPARTIVIENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST [~ PERCO LATION TEST PERFORMED FOR: ~C~.}'~ ~.Y'V'~-~r'- DATE PERFORMED: LEGAL DESCRIPTION: 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 ~_ ENCOUr~TERED? ~') © o P E IF YES, AT WHAT · ' DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN 7 FT AND ~ FT 'q// ~¢~' .. 72-008 (6/79) 0 0 0 0 0 0 0 0 0 0 0 mm U. mm tJ. m, mm Lt. LI. m, I.t. t.I. 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 /'~\'~- \'~ \- C'~I HAA# 1. GENERAL INFORMATION Complete legal description L. o F f~ Location (site address or directions) Property owner /~ i cA ~ i /,~. /cCd. Mailing address Mailing address Day phone Address '~ 0 0 0 C ST'. ? c) .,7 ~ ~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ '~ TYPE OF WATER SUPPLY: Individual well 'X' Community well NOTE: Day phone ,~' 6-~_- ~H (~ 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 AD£C attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and 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 A _,((.] C-~ ,~'~(.. Address Engineer's signature (~~ D/~S SIGNATURE Approved for ~-'/¢'¢~ ~}~ bedrooms. Disapproved. Conditional approval for Phone bedrooms, with the following stipulations: Additional Comments 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. 72q)25 (Rev. 1/91) Back MOA 321  Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: J-o-F ~ i.~l/< I Y~ev~6¢' ParcelI.D. ~)/ A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. Y ADEC water system number Date completed I c~ Art ~- ;~) Driller Casedto ~ ~' ~ Casing height I ~" Y Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG AT INSPECTION g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I 0 :~- i Absorption field on lot ~ 0 ~ / RECEIVEO ; On adjacent lots ; On adjacent lots Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform ~ Nitrate Public sewer manhole/cleanout Petroleum tank Date of sample: "~ ~' -~'/;' I~ 9 '~- ~ Other bacteria Collected by: '-~' · B. SEPTIC/HOLDING TANK DATA Date installed A I,L O- Cleanouts (Y/N) ~' High water alarm (Y/N) Date of pumping I ~. Iq ~ ] Tank size I dj ~ ~ ¢'¢' \ Compartments Foundation cleanout (Y/N) ~' Depression (Y/N) I.///¥ Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot } 0 2. ' On adjacent lots To proPerty line I 0 ,~-' AbsorPtion field Surface water/drainage IV¢ r~/~ Foundation z'l Water main/service line 72-026 (Rev. 7/91) Front . CONTINUED ON BACK PAGE C. LIFT STATION I~/ /~¥ Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed A V, ~;- ~ I Soil rating I"z. 6) gP/Gi~ System type Ocz Length ~- O ' Fq" Width '3.¢ py Gravel thickness ~', O PT Total depth Total absorption area 3-~-~ o ,Sg- Cleanouts present (Y/N) )/ Depression over field (Y/N) ik/ Date of adequacy test J ¢ 5~ Results (pass/fail) r2c,.ss ~' for -~ Peroxide treatment (past 12 months) (Y/N) IXJ If ~e~s, give date · ~,......~_i ¢.,,¢," 51-,,~,-,d,¢.,.9 W~.z~ vcc,s ,'z... ¢"~'ei.d SEPARATION DISTANGE FROM ABSORPTION FIELD TO: Well on lot I O qo To building foundation On adjacent lots · LI Surface water ,A./o Curtain drain /V'¢ On adjacent lots l o o .~- p'~' Property line /;T' To existing or abandoned system on lot Cutbank /V'¢ ¢ (. Water main/service line Driveway, parking/vehicle storage area bedrooms ~//I ,5'o ," 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. Engineer's Nam Date HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev. 3/91) S~ck MOA 21 .sEP 22 *92 14:35 MORTHERM TESTIM6, RMCHORA6E P,£/3 NORTHERN TESTING LABORATORIES INC · 907) 4~311§ * FAX 4583125 L AVENUE FAiRBANK,~ ALASKA ,99701 (' ' 35:30 INDUSTRIA -'..~ ~.~ ~o~ (~O7) 277-8378.* ~AX 274-9~5 250~ FAIRBANKS STREET ANCHORAC~, ~,~ ~-~ ' ' CU~0t~r ~GI~ Lab~ Cu~e~ ID ~eth~. Pa~a~or Un~ · ReSuLt ~ovle~ · SEP ;2;2 '92 ::L4:35 HORTHERH TESTING/ RHCHORAGE P,3/3 ............................... :,,..;: ...... Drinkin§ Water Analysis Report for Total Coliform Bacteria': 1'0 BE COMPLETED BY CLIENT PUSUC WATER SYSTEM I,D, PRIVATE WATER SYSTEM .AMPLE TYPE:' -~ Routine. 'L Special Purpose Phone '~ ~/~ ' ~'/C.-,/.~' Purchase Order No. '1 Check sample (for original contaminated sample.with iab'referenoe no,_ /IETHOD OF ANALYSIS: ~ MF Membrane Filter [] Treated Water ~ Un(reared Wa'tar [] MPN ~ Most Probable Number 4 ;nature of Representative FOR LABORATORY' USE ONI.Y · .,. ~2. r i,,,~,~,., l..i TO BE COM.m*Ec, mY'L'ASOp, A"rO"V Received at: ~Anch. ~ Fbk$. Date Received ! :'q/~_~ ~"'~' - Time .oceived: Ne~ Sample Dpe .... COMMENTS,' . SATISFACTORy UNSATISFACTOR~ RESAMPLE OTHER SACTEalA ' TOO NUMEROUS TO COUNT 'U R OB TNTC Total Coliform ff01o,~eS per!/00 ml~ Time 09/17/'92 07:41 ~907 271 393:3 ~A+ HOME SERVICES, L~C 15900 Francesca Drive Anchorage, Alaska 99516 345-1890 or - 345-2444 "::¥'~-~""~'- "" :' CUSTOMER Block Lot , DESCRIPTION · -. ::~::fi:.?i~;~_.::?i~i,_::~%/~ :..:-..-...~ :.):: !..:::::::._.~:..._-. . - - _ ~'.~OB~M ~;CALL FOR MORE · ' "~'-:¥:::' ~. NEEDS m BE DONE A~IN IN 6 Mo~i' ~' .. , :. .:.. :_.. ; : q. .: ,;. ? .:? . .. ,_ , .', ::-. :... ,'_::~ - -.~:Go0d8h~pe t-.' · .. ~81ud0eb - - '~ jim cap missing or - "Q'Out . .: :.:_ ..'t ..~ 'n~ds replacing . '-- · ..~ . ..;;::..-;~::~.-.:::.~..::::,-' '~ _ . ouSTOME~-~OPY ~_ ~..' ~ ~_ -. . ::~ -~-.~_~:-~.-~_~__~-_-/,.: . ~RMATION 's :'..?~!;,:.~ ~:-:/~:'i::!'''bipe ~b~ 1;: ~bSv~ i:i 'i"~;':!~:i:~ _0r( -' '- :':)....:. '~-~.: :.: ~EP,.FOR YOUR RECOR . : > .:. :. 0 0 0 0 0 0 0 0 0 0 0 ARCTIC SLOPE CONSULTING GROUP, INC. Engineers · ArchRects · Scien[ists · Surveyors WELL LOG LOCATION: Subdivision: Lot: Block: Client's Name: DATE: Address: TESTER: d..-,,,.Ol.,P Initial Reading on Meter: DRAW TIME GPM GALLONS GALLONS FIELD MONITOR METER DOWN VOLUME TOTAL LEVEL READING o, 9;£~ 0 09 o 2' '¢.o* t o ', t ~ 6 , ~? o / c~ z. l aZ :2'-'2" 6%3% ~,o' to,Z~ 6,2% t 9 ~ 9q :x'--c." 13, o' lO:t43 6,,'¢3 ~9~ 9~ ~'-.6" 6929 NOTE S: Productioff'.Rate: > 6 GPM 24-Hour Capacity ~ Zq ~-- 0 Gallons MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Location (address or directions) (b) Property owner ' /~//1' o Telephone: (home) ~f"~c-G'?/7 Business Mailing Address ~.~'~.4::~ /~,~/'/J'-~'r-¢g/~ )~),~w'/ (c) Lending Institution Telephone Mailing Address (d) Real EstateCompanyandAgent C ~,o /[' /.,.'/,FL- R ~'~ ~ ~'* -- .ff'.,C ~Z/,~ //¢/~,._ /¢ Address (e) Telephone '~' 7'('/- fi'7~'~ Mail the HAA to the following address: (or check here ,~ hold for pick up.) List contact-person and day phone number below: 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 th legality and status. SEWAGE DISPOSAL On-site ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72~025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND 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, funct ona end 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. Nameof Firm /~'-~'~/ ~',,/,,~->" ~- ~ Telephone ~ ~--~/ Address ~ ~ ~. ~A~ ~//. ~/~. ~~ / Date ~4 ~ ~ ~ ~ ~X ,'~ ~ 6. DHHS APPROVAL App roved fo r¢~-~(/~/~ed rooms by Approved X Disapproved Terms of Conditional Approval Conditional Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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 erro[s or omissions · in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 *.,'l,x~ · /'~ MUN CIPAL TY OF ANCHORAGE (MOA) Ei,,j.~'i~I~ICIP'~'Ut 'i'(~,~-)2/',G~- Health Authority ApProval (HAA) NVh~"'NM~NT'\LL~/DI'/I$10i'.4 CHECKLIST - FEBRUARY 1984 ~ 343-4744 A. W~LL DATA Well Log Present (Y/N) ~ Date Completed ~/~-- Total Depth ~// Cased to ~/z Depth of Grouting Static Water Level ~ ~ ~ '~'~ ?O' Casing Height Above Ground / ~ ~ Electrical Wiring in Conduit(Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot / ~/ ' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Serv.iqe Line on Lot Water Sample Collected by Legal Description: If A, B, C, D.E.C. Approved (Y/N) /V/Zc Yield /--~_q?,~ ('_/~) Pump Set At ~-.Z',~, ~., Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots /10 To Nearest Public Sewer Cleanout/Manhole .,,~.//¢t ~ ?~_5' ;Date /2--/-5'--8 [~' Water Sample Test Results Comments }0 ¢,o No. of Compartments B. SEPTIC/HOLDING TANK DATA Date Installed ~"/~/ Size;¢ Air-tight Caps (Y/N) ~' Foundation Cleanout fY/N) / Date Last Pumped /,~--z~-- /A/// ;for Temporary Holding Tank Permit (Y/N) StandpipeS (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) ./~'.~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: TO Water-Supply Well / ~ / / / /~ To Property Line To Water Main/Service Line To Building Foundation To Disposal Field AL To Stream, Pond, Lake or Major Drainage Course Comments ¢- ~,'/'* /¢/.///j' nc,~¢r¢,/~' 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed · ~/~/ Width of Field ~ .,;7 ~' Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test /.2.0 0~/z~2 r/',o, Type of System Design :~ Length of Field ~- ~O* Depth of Field ~ ,.7, .5' ' Gravel Bed Thickness "~ ~ ' ~, O~9 Statndpipes Present (Y/N) /%/ Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line ..¢'E) "'¢' To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ;¢c- ,c"r~,.. OW/If /¢~ To Property Line ~ To Existing or Abandoned System on ; On Adjoining Lots ._5'c~ //" To Cutback (if present) /~ ,e Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Manhole/Access (Y/N) "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 that I have che. cked, y~rif~ or conformed to alt MOA and HAA guid inspection.,/.~ / _~~ Signed Company Date /'~ MOA No. Receipt No. 0~-~¢~ Date of Payment Amount: $ /-'//-~ ¢(~ Receipt No. uide[Jnes in effect on the date of this ~,,f:. Or ,~(.,~ 't- ~:,,,,',,;7;% .............. A~, A Engineer s Seal Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 2~?0 F2KST 88 AVl~'aJg A.~~ AK 99507 ¢9O7) 349--6451 WATER Wk~.r. TEST Date: ~TI~: not: 81o~: / , Initial R~ding ~ Meter: / ~ ~ 727 , 0,03 Production RaTe: Gp.~! 24-Hour Capaci~.¢ Gallcns HOME SERVICES, INC 15900 Francesca Drive Anchorage, Alaska 99516 345-1890 or 345-2444 CUSTOMER Block Lot INVOICE # 3 4 1 5 DATE DESCRIPTION AMOUNT . ::' ::. " ' X /' ..... '' ~ ~ (~;i~t ~-r: ~ .~d,~ ~ ~_.'~i-Y ~ PSOSLE~ ~8~LL ~0~ ~0~ I~08~I0~ ~ Good Sha~o ~ Slod~o ~ulldo~ on bottom ~loator on to~ --PLEASE PAY FROM THIS INVOICE-- NORTHERN TESTING LABORATORIES, INC. 600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASK~ 99709 907-479-3115 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY CLIENT ~ PRIVATE WATER SYSTEM City State SAMPLE DATE: /-~-~ /_~ o~¢Phone Mo. Day Year Zip Code TO BE COMPLETED BY LABORATORY ~Anch. [] Fbks. Received at: Date Received Time Received Next Sample Due COMMENTS: SATISFACTORY SAMPLE TYPE: {~ Routine [] Special Purpose Purchase Order No. ~., Treated Water [] Untreated Water ~ Check Sample (for original contaminated sample with lab reference no. Sample ' Time 2 3 4 5 6 7 .) CollO¢:ed by 8 9 10 Signature of Representative Laboratory Ref. No. FOR LABORATORY USE ONLY UNSATISFACTORY U RESAMPLE R OTHER BACTERIA OB TOO NUMEROUS TNTC TO COUNT Direct Final *No. of Total ~/[~for~..~olonies per 100 mis. lime NORTHERN TESTING LABORATORIES, INC. 600 UNIVERSITY PLAZA WEST SUITE 2505 FAIRBANKS STREET FAIP, B4NKS. ALASKA 99709 ANCHORAGE. ALASKA 99503 907-,179-3115 907-277-8378 Besse, Epps, & Ports 2220 East 88th Avenue Anchorage, Alaska 99507 Attn: And), Ports Source: L6-B1Rovier Sample ID#: A121588-3 Date Arrived: 12/15/88 Time Arrived: 1604 Date Sampled: 12/15/88 Time Sampled: 1400 Date Completed: 12/15/88 Parameter Unit Result ADEC MCC* Nitrate-N mg/1 <0.01 10 Reported By: ~ ~ Dale: 12/19/88 Francois Rodigari, Anchorage Operations Manager · MCC = Mmximum Contaminant Concentraiion NORTHERN TESTING LABORATORIES, iNC. 600 UNIVERSTY PLAZA WEST SU TEA 2505 FAIRBANKS STREET FA~PBANKS..A;_~SKA 997C9 ANCHORAGE ,:~ ASKA93505 037-z79 3115 907 277-~37g Quality Control Report Client: Besse, Epps &?otts ID#: A121588-3 Listed below are quality control assurance reference samples with a known concentration prior to analysis. The acceptable limi%s represent a 9~% confidence interval established by the Environmental Protection Agency or by our laboratory through repetitive analyses of the reference sample. The reference samples indicated below were analyzed at the same time as your sample, ensuring the accuracy of your results. Smnple # Parameter Unit Result Acceptable Limit EPA WP284-3 Nitrate-N mE/1 0.13 0.10 - 0.18 Date' '1o 19/88 Reported By: _ ..... ._ .... 2_~._ ..... F~ancois Rodig~r]_, Anchorage Operation Manager = I Time ~' ? Time ie Date Date Date Inspector Inspector Inspector Comments~1 i ,~..~ Conditional Approval Date Sewer Installed Permit No. Septic Tank Size /'~' Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Buyer Address Lending Institution ~o~) ~- ~,% ¥ ')~{~ ~.~ ,):~, Phone~-I , Phone Realty Co. & Agent ~, ~ '~,~'~, ©~ ~'~-~- ~P'~,~ Address Type.gf Residence E~Single Family [] Multiple Family No. of Bedrooms [] Othsr Wato~ Supply UI Individual 0.~ ~ ]~ ATrACH W~:I_I. LOG. A well log is required for all wells drilled since ,June [] Community : t07§. For wells 0rilled prior to that data, give well depth {attach log [] Public Utility available./ Sewage Disposal [] Individual Year Individual Installed: )c) ~ [] Public Utility When Connected to Public Utility:_ [] Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, CIJEMICAL & G~-~OGICAL LABOR_,4TORIES ~' AL.4SKA, INC. TELEPHONE {907)-279-4014 ANCHORAGE INDUSTRIAL CENTER Drinking W~ter Analysis Report fOr Total ColifOrm Bacteria TO BE COMPLETED BY WATER SUPPLIER .. WATER SYSTEM: I.D. NO, / ' / ~ ~,/'~ Water System Name ~" Phone No. Mailing Address r'/ · ~,.~ City SAMPLE DATE: Mo. Day State Year Zip Code" SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no, FI Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. LOCATION 2 Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~,.Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send n.ew sam Die. Date Received Time Received ?' Analytical Method: [] Fermentation Tube -~. Membrane Filter Lab Ref, No. Result* Analyst I · ~rNo. of colonies/100 mi. or ~o. of Positive DOt[ions READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 (h) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collecte¢l Source Time ReCelvee ~,m, Lab. Presumptive 10mi 10mi 10mi 10mi 10mi /.Omi 0,1mi 24 Hours 48 Hburs Confirmatory 24 Hours ' ' 48 Hours EMB Broth 24 hours: Broth 48 hours: Multiple Tube Report: /0mi Tubes Positive/Total 10mi Portions Membrane FIIter~ Direct Count CoIlform/100ml Verification: LTB BGB Final Membrane Filter Results ~ ~ ' t I Collform/Z00ml Reported By : Date '~ ' ~ ~ ~: .... L