HomeMy WebLinkAboutLITTLE BEAR BLK 1 LT 3Little Bear
Block 1
Lot 3
#014-061-20
I R -_"(L_
DEPARTMENT OF HEALTH AND ENV! F:Of` MENTAL_ r'ROTEiW T I i i --1
2510 E. TUDOR RD.: ANCHORAGE, AK 99507
PERMIT NO. 76,304
APPLICANT ED RINNER
LOCATION BABY BEAR PLACE
LEGAL L3 B1 4wFE+Y BEAR S/D
41*7t4e
MINIMUM DISTANCE BETWEEN A WELL AND
100 FEET FOR A PRIVATE WELL OR 200
WELL LOGS ARE REQUIRED AND MUST BE
E 1.1m L f-'Ot'1F'L ET I rltd
:1ts WELLSLEY ("'J'
'44-4l'-' .
0
L.O'1' SI:•.'.E ' 400 SQUARE
AN`•e' ON-SITE SEWAGE DISPOSAL. .TF rI I'S
FEET FOR A PUBLIC WELL...
RETURNED TO THE DEPARTMENT I••.i I -m i td
lir- Zvi __ a -
SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO I td'.:;L�F� E F= -1
INSTALLATION.
�=• ' r i T `f " E� g �1 �� A R F° R -.A r -A EF- °-e-" F= " F-`' IF' F--' R --R M T
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON --SITE SEWERS
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
1-2
�O
SIGNED:._.__._..
APPLICANT ED RINNEfR:
ISSUED BY— __ ----- ---4t 1. � _GATE._
AND WELLS AS SET
u
�q %W
d
J J e
eo
LUJ
b
MIN
q
z
LU
0.
w w w w w w w
�Fy E Im �E E4 FF ®H E
w w� 6u w w w
w w w w w w w w
J. rJ
ct fir•; ..i
N' Gl• �C; G?t rl
w w w w w w w w
® G�
VA ® a r4 C:i V. 04 W04
w w �. w w w w
e�
a
E®+ E
W
z
dw
1�
z
w
U
UA
C'i
rri
Co
(a
�
I
it
1
w w w w w w w
�Fy E Im �E E4 FF ®H E
w w� 6u w w w
w w w w w w w w
J. rJ
ct fir•; ..i
N' Gl• �C; G?t rl
w w w w w w w w
® G�
VA ® a r4 C:i V. 04 W04
w w �. w w w w
e�
a
E®+ E
W
z
dw
1�
z
w
U
UA
Municipality of Anchorage
• --\ Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904 X4
CERTIFICATE OF ON-SITE SYSTEK4§ APPROVAL
FOR A SINGLE FAMILY
Parcell.D. OfK-o6/-2rJ COSA# blewcr�
Expiration Date: Il2.107
1. GENERAL INFORMATION
Complete legal description —L tr h3 13 /oe k I 1-t 14 -le Oeoo- -C a
Location (site address) 67 2 f 3 u 4 X 13 to D rr Le
r
Current Property owner(s) Ronotee 1N,I-ene ncio-4-c&cr Dayphone 3119 -S18,1
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
672/ r3u4,, Ijeg- Dri�l. Nnc�rorcraP- A 4 99Sc+7 -2203
A•leykra WA Day phone
136eCc&
"c Zanrt.
Pi..den Ar Lf Day phone 76
Z- - T.r 7- y
3 S e,/
fen it°�
Pornf Dom, rt eti+„
A-4 94S a?
❑
Individual Holding tank
❑
IN
Unless otherwise requested, COSA will be held by DSD for pickup. Pla ve- ew it R CF*/k�� @ 762-7sZy
wRln i-eadY %� p�tk-�
2. NUMBER OF BEDROOMS: 3 COsi4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual On-site
❑
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
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 Systems 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 Onsite 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
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 F_lcaf f e Tech, .net S'tc-r Phone -SVS-- iSSs—
Address lyS3d Echo C&A -vol Roe- AVC4, . A-4ws'/45"
Engineer's Printed Name 'ThQo eA, .r E'E• r"clo-f Date 1 o / r o / o i<
5. DSD SIGNATURE
?_ Approved for 3 bedrooms.
Disapproved.
^eaaaae •. eeeH ele Ne•ieM
..................
'. Ss;ODp7E f. moc*E ;•
�••. to/�',.•;
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By- Original Certificate Date: 10112106,
0 01
(Rev. I IMS)
Municipality of Anchorage
' Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Awl -3. Ls loc k / . 1.. P-10, 847r{r- S/D Parcel ID: O 1 I - 06/ - ZO
A. WELL DATA
Well type P✓! If A, B, or C provide PWSID # = Well Log (YIN) Y
Date completed 3 _/ Z3! 7 7 Sanitary seal (YIN) 'r Wires properly protected (YIN) `t
Total depth _2L—ft. . Cased to Zft. Casing height (above ground) Te in.
FROM WELL LOG AT INSPECTION
Date of test Z/ 2a / T 7 9 / 2 - / 7-00e-
Static
066Static water level Z3 ft. /'/ ft.
Well production Z4 g.p.m. 6.3 t g.p,m_
WATER SAMPLE RESULTS:
Coliform _Q�__colonies/100 mL Nitrate O.zB6mg/L Other bacteria 0 _ colonies/100 mL
Arsenic: L ppb date of sample: -Y/Z-? /06 Collected by: F /a /,6� iscA S'. c
B. SEPTIC/HOLDING TANK DATA NA CAwtvcc f uL liG Stc. eo-)
Tank Type/Material Date installed
Tank size gal. Number of Compartments_ Cleanouts (Y/N)
Foundation cleanout (Y/N) _ Depression over tank (Y/N) _ High water alarm (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA N. * L A wcvc.c P&1&1;c
Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) System type
Length
ft. Width
ft. Gravel below pipe ft.
Total depth _ ft. Eff. absorption area _ft2 Monitoring tube _ Depression over field_
Dale of adequacy test Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ in.
Elapsed Time: _ min. Final fluid depth _ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type)
If yes, give date
D. LIFT STATION M' A
Date installed
'Pump on' level at _in.
Datum
E. SEPARATION DISTANCES
Size in gallons
,Pump off" level at _ in.
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot tJ• A•
Absorption field on lot N • A•
Public sewer main — 100
Manhole/Access (YIN)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots W A
On adjacent lots IV.
Public sewer manhole/cleanout > 100-
Sewer
ao•
Sewer /septic service line 2 S"• Holding tank M.
Animal containment areas Manure/animal excrete storage areas N•
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ".A.
Building foundation '" Property line - Absorption field
Water main - Water service line - Surface water
Wells on adjacent lots -
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: N• A.
Property line - Building foundation - Water main
Water Service line _ Surface water — Driveway, parking/vehicle storage
Curtain drain Wells on adjacent lots
F. COMMENTS _ r •ur
F'
in.
r• '
G. ENGINEER'S CERTIFICATION = * Vu
1 certify that I have determined through field inspections and
review of Municipal records that the above systems are in ......
conformance with MOA COSA guidelines in effect on this date. % T"" .r- F. uocae
Engineers Printed Name Th eo ado •"Y -e ,;; ., ,
Date Ot�v er fU 2GU
COSA Fee $ `r'3 O -� Waiver Fee $
Date of Payment I I t 0 �0k Date of Payment
Receipt Number Receipt Number
(Rev. 11105)
SCS ReO
1065821002
Client Name
Flattop Technical Srv.
Project Name/N
Flattop Tech Svc
Client Sample ID
L3 B 1 Little Bear
Matrix
Drinking Water
MSID
0
Sample Remarks:
Parameter
Metals by ICP/MS
Arsenic
Waters Department
Nitrate•N
Microbioloov Laboratory
Total Coliform
Results PQL
ND 5.00
0.286
0
0.100
All Dates/rimes are Alaska Standard Time
Printed Date/time
10/052006 15:34
Collected Date rime
09272006 12:00
Received Daterrime
09272006 13:28
Technical Director
Stephen C. Ede
Allowable Prep Analysis
Units Method Container ID Limits Date Date [nit
ug/L EP200.8
mg(L EPA 353.2
C (<10) 0929/06 10/03/06 WAW
B (<10)
coUl00mL SM209222B A (<I)
a
0947/06 ALR
0947/06 DPT
• 1
Thank you -
.:
200W. POTTER DRIVE
SGS/CTBE ENVIRONMENTAL SERVICES ANCHORAGE, ALASKA 99ste
Tel:907-set-2343
aq G oqL Fax: 907-5615301
Drinking Water Analysis Report for Total Coliform Bacteria*
READ IN3TRUCTION3 ON REVERSE SIDE BEFORE COLLECTING SAMPLE
MUST BE COMPLETED. BY WATER SUPPLIER
C) PUBLIC WATER SYSTEM toe _
153 PRIVATE WATER SYSTEM
❑ Saul Results ❑ Sand Invoice' '
uv Sl b..AcoprgN
Cardnr.r
F/aF tie%
anw w.ner
rrNrror .
u...m,s.a.r .
I'/s 3o E<�a lA�
R/l •
.99s:/C
SAMPLE COLLECTION:
Oats:' O9 F 27 2UQ ,
rw ar rw
All MI.
Locsuom�e/'3,I3/�-'(, Lrff/t Stumm' S
Transported
a Lab By: [9 Same as collector
TO BE COMPLETED BY LABORATORY
Sample Receivine•
Date:
Delivery Method,
Received By:
Comments:
.......................................................
Bacterloloaical Water Analysis Record:
Analysis Began:, cj r ��O C.
Analyst T /i
Analytical Method:
❑ Sad Resldp
I arc
❑ Sample orer 30 hom sld.
.. Remits may be wrNtada
Walw
F Remote Loc bona
lab Ref No. .
1065821„
o Sad 4woke
Routine ❑ Treated Water
0 Repeat Sample ® Untreated Water
(refer to lab no.
.13 Special Purpose
❑ RUSH SAMPLE .
Phone tl:
Fax M -
..................................................................... •...:......
Sem' to ADEC:
MM0.7t1UG (PIA) RESULTS: AMC FBK JUN
Total CdYolm: DateIrsne:
• E. can:
MEMBRANE FILTER RESULTS:
Direct C -ant �� CdonNsltoetliL
Sant lo Client
Phoned Faxed
[� Daw*rlme:
IN Membrane Filler ve rra orc 822ke, wth,
❑ MMO-MUG (P/A) Tr✓Crww LTH
{Bce or Satisfactory
••..ror.., •{
EP ❑.Unsatisfactory
Reported B7NTd • Tr Mnr,ar. q C.un1
By: !• Date/Time: lO�..L �e tP /�.: vo os ��
FormarvV nnsa iw,7ma
I.S••
.I I
rNp
TI o$4Itt bitaoar.-
:.
�'.•
. w
�}
�'�{
�,I
sttatiVrrxEaf'r.
i�' ..!
i
.:.
�
I
'
Zj
LAJ�i
+
''?
'•..,—:.1.._._' :• .:
'I
.:
Ria":. I
;:{,
0
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section 44. NICIPALITY Or ANc.NukgU't
P.O. Box 196650 Anchorage, Alaska 99519-6650 tNVIRUNMENTAL SERVICES L)IVISfpN
343-4744
CERTIFICATE OF HEALTH AUTHORITY NOV z ` 1996
APPROVAL FOR A SINGLE FAMILY DWELLING R [CEI VE
D
Parcel I.D. # t 4 — 06 ( ^o? -0 HAA # f1 lh16 _
1. GENERAL INFORMATION
Complete legal description L.o k 3 gk I It L �`T'T"Q_r_ P, F,4,0– S%
Location (site address or directions) (o-72-1 Pmt/ kg_�
Property owner 7POV Li—y � 31� MAye-J4',�-O Day phone coN,-P,+ -46rf '' '
Mailing address Cow -to,-_— A.6S-j�7�
Lending agency 0
Mailing address Ij b
Day phone 'Sj l
Agent c-"sZ-ks-nrJC_- S'IaN1jV/1 Day phone 33 E-1676
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
TaF� 11-`t `7 Wou1-D
3. TYPE OF WATER SUPPLY:
lal/� `� CWS!~- o•J
Individual well 11/4%
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA M21
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
Address
Engineer's signature
Alaska Water &
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
X37-6179
Gq �5•.e sn�rt.o oSL �V
C a
& ens.
r
%Ogg.� SFO �'FOf9°Sa'go
�N>�.��
bedrooms, with the following stipulations:
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 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 1121
�4yMG4'�ci
Municipality of Anchorage Ro�MF�y
DEPARTMENT OF HEALTH & HUMAN SERVICES j
Environmental Services Division *®k o�
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4 lsc�.
Health Authority Approval Checklist ,,
Legal Description: Lo'T 3� �K 1 Lt��t_- Parcel I.D.:
9P_.A-2- SID
A. WELL DATA
Well type Pte° If A, B, or C, attach ADEC letter. ADEC water system number A
Log present (Y/N) NY jc--S Date completed �2 /-7'
Total depth C1If Cased to 40/4, Casing height (above ground) :>- z
Sanitary seal (Y/N)
Date of test
Static water level
y tfS
FROM WELL LOG
2�•7�
Wires properly protected (Y/N) \f C --S
AT INSPECTION
Well production 12 9•p•m• S'(06 g•p'm.
F=o(2 'z, a 1B t-4VuC-s . Com P •�
WATER SAMPLE RESULTS: f tea" `P I'j mss `r:%A �
tJrz�wfla �� -ra 3.z'.
Coliform ck Nitrate I (O '"G Q Other bacteria 51
Date of sample: f I �1� Collected by:—N
w��- Co[,,r�n�-� u�z��s4 eou�e�•
B. SbMC/HOLDING TANK DATA j
Date installe Tank size Number of Compartments _
Foundation cleanout (Y/ i� Depression (Y/N) High water
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Length Width
Effective absorption area
Date of adequacy testZ
Fluid depth
Soil rating (g K.Iftz or
Gravel thickness below p
Monitoring Tube present (Y/N)
Results (Pass/Fail)
field before test (in.);
(ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)'
'/N)
System type
Total depth
pressi ver field (Y/N)
For
Immediately after_ gal. water added (in.):
Absorption rate = g•p•d•
If yes, give date
D. LIFT
Date installed
Manhole/Access (Y/N)
High water alarm I
E. SEPARATION DISTANCES
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in
"Pump off" level at*
r
Septic/holding tank on lot 6J /✓! On adjacent lots X00 P g t,( L sow vr�f-
Absorption field on lot tj LA On adjacent lots I op
Public sewer main lODr:* Public sewer manhole/cleanout 100f
Sewer /septic service line
Lift station
ON DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation
Water main/service line
SEPARATION DISTANCE FROM
Property line
Surface water
F. ENGINEER'S CERTIFICATION
f certify that l have
in conformanc wit
Signature
Property line Absorption field__
Surface water/drainage s on adjacent lots
BSORP I N LOT TO: v
g foundation Water main/service line
Driveway,
Wells on adjacent lots
inspections and review of Municipal
?s in effect on this date.
'A
area
Engineer's Name// A n����°��'
Date f I /Z3 / /G
- �oFEas,o`'
are
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
I HW _..--
'--si os tiz
Z HW -
06L0 -t eZ
_£ H W_
Od70+SZ
Ir,
ALFAFAWAVWAF��AW"AFArOMWAWAWAFArAFffAFA
ME Environmental Services Inc,
CTP- Ref.# 966163001
Client Name AK Water & Wastewater Services
Project Namel# 6721 Baby Bear Dr.
Client Sample TD Hose Bibb
Matrix Drinking Water
Ordered By
Client PO#
Printed Date/Time 11/19/96 13:11
Collected Date/Time 11/15/96 14:10
Received Date/Time 11/15/96 14:20
Technical Director. StephenC. Ede
PWSID Released
Sample RC1llarlG4: u
Sample collected by: Garness
Allowable Prep Anatq
Parameter Resuits POL Units Method Limits Date Data
Nitrate -N 0.316 0.100 mg/L SM 4500-14O31' 10 max 11/15;
Totat Coliform 0 col/100mL SM18 92226 11/13;
21 OR W/O COLI
tI-F-EL`i
CT&E Environmental Services Inc.
Laboratory Division r.�O�,rossr/�irrrd•I�'��'I./�.r/i•1r���I'.�r�w��•Ij�w.r�r��
200 W. Potter Drive
)rinking. Water Analysis Report for Total Coliform Bacteria Anchorage, AK 996183 1605
562-2343
AD INSTRUC17ONS ON REVERSE SIDE BEFORE COLLECTING SAMPLR Fax: (907-) 561-5301
MUST BE
p PUBLIC WATER SYSTEM T.D, #
PRIVATE WATER SYSTEM
BY WATER SUPPLIE
SendResulrs Sendlnvoice
- onla0. e
al.l synem amv.—Oalm�pvy ama �j S !7 ~
one tlM sr
Alaska \Nater &
Mu m7A Ipa
nnh-
$47i t3rt.okridgs pr.
am a oar
Id
p Sen lu O Sendlnvoiee
SAMPLE DATE: / - 9 O
j E0
Month Day Year
SAMPLE TYPE:
Routine
O Repeat Sample (for routine sample
with lab ref. no. —)
q special Purpose
SAMPLE LOCATION
&-1';11 ley
Comments:
z.
;6
r
a Treated Water
Untreated Water
Time Collected
Collected By
(A.:'gorm Cess
Please NMI
TO BE COMPL41 bi) 151 rrr.Dwly
Analysis shows this Water SAMPLE to be:
Satisfactory
O Unsatisfactory
0 Sample over 30 hours old, results may
be unreliable
o Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new Sample Via specie l delis ry`marl•
Date Received 5
1�-
`
Time Received
Iti
--'—�
Analysis Began
Analytical Method: MemObr�UFilter
• Number of colonies/ 100 mL
Result* Analyst
C9fi ,X133 T -Y = :_
r:
S1 Anch rbks Jun
Pax=•.
Date: Time: �
Client notified of unsatisfactory results:
Phoned Spoke with Fs`
Data: �^ _ _ Time: __
BACr.ERIOLOGICAL WATER ANALYSIS nCORD
MMO-MUG Result: Total Coliform
E. Coll
Colonies/100 int
Membrane Filter: Direct Count rxrc -ru-IN
BGB ,�..-� COLIFIRM, _� -
Verification: LTB ��.� P8 .. oreer Hoct<ria
Fecal Coliform Confirmation
Coliform 100 ml
Final Membrane Filter Resu is {
r�, 'L (a C16 Time �—�- hrs
AJ
Reported By
U ` ❑ate
(ah ,�tn S Member of the SGS Group (Soei60 Generale de surveillance) -c —
v nJln ]SIL G7
Mt (A IPALITY OF AN. HORAGf,
DEPAR'hhi OF HEALTH MID ENV 1RONMU l_. PROTECTION
N
825 i., Street, Anc1ioracie, Alaska 9950 1
279-2:57.1` -ext. 224 or 225
Date nece.i.ved. August 15, 1977
l
Time 11:00 a.m. ;r2.< Time -- - #3; Time
Date 8-15.-77 Monday Date Date ------
11—;IP
.._..__--Irls P _Wi11isInsp
:DQi I; `r FOR APPRt�`Jl:i, Dl' TPdDIV :DUAL iFdT; SIDD WA'.nET ,1ACILITIES
l Len(I i -ng TIIStituti.on Request, Amfac Mortgage
Ma.;.lislg Address- 705 West 6th Avenue Phone. 277-8688
2. Property Owner; Sebring Builders _ :'hone: 344-3069
Mailing Address.- Star Route A Box 1540C 99507
3. Legal Description; Lot 3 Block 1 Little Bear Subdivision
4. Sinule }'ani -ill y Residence: (xi Number of Bed.roows ?
Mul' LiTDle Family Residence: ( i Nuriiber of s.F',drooms:
wC 1 Svs,-eln; In!.Iiv-idual W__!_- 1x1I oIT17,11a171tYj -'Labli.0 SySteIR
?_'er.Iru-t I 76304Deoth of Well -v Well Lo; on File ; �
Const-uc !�ac�terial Analv�>is Satisfactory
( ci.:>�.- _c tlon Approved _ y.__
Sewage DiSL)OSal. Sw3teln
1�i=rn.rc 1
Septic_ 1'a.nk Qize
AhSor_Dti.on Area
Cin--sPi blic Utility ix3
In ;ta 1 led install --r
Manul.C:cl,uI e
sol..L _iRate Piater.i-al
'Distolices : WCC --1i to- Septic T ;nk t:0 Hi-: or_7tion Area _
to Sewer "kill_-', 'Nearest. t_iot linE; .Absorpt:i_o.n ti:ea
to Nea.resf- LC.,t Line
['age Two
Department o1- Health and T�,nvi.u:cr;ment.a,.. ;.rote^ct:t.an
Requ,�st for Approval of Individual Sewer anti Water Facilities
Legal.. Desc_ipt.on:Lot 3 Block 1 Little Bear Subdivision
('omnie-nt s :
fT -Attached-
Letter Attached: ( )
' rjprove!Aa Da. -.eL
_. _.. _.__� _..__ .�
?.i_fidilpi"OVE?tJ _. Date. _.._.."_.._._._....—d.........__._.....�...____
Dei_ ri.mer.t idar She -t:
^\MUNICIPALITY OF ANCHORAGr
Department of Health and Environmental Prp!�ect,}on,
825 L Street, Anchorage, Alaska 9950;,.(,;
279-2511, ext. 224, 225 i:„ :>: :; ;•- , . r. ,.
�--t�equest for Approval of Individual Sewer and Water Eacil�it�s
1. Property Owner:
;Mailing Address: ���/io�/ 5 �U��_ Phone: �jl
2. Name of Buyer:
Mailing Address: _ A —w— Phone:
3, Lending Institution:---
�j
.Mailing Address:Phone:
'4. , Realtor/Agent:
Mailing Address: Phone:
'S. Legal Description:
Street Location: /��� /���2 ��<� ✓ e
'6. Single Family Residence: ( } Number of Bedrooms:
'7.
8.
Multiple Family Residence
( ) Number of,Bedrooms:
Water Supply: *Individual Well Public/Community System ( )
,If Individual Well, well depth l
,If_, Community System, name of system
.Sewage Disposal System: On-site System
If On --site System, date of installation:
*NOTE:
i
3/77
( ) Public System ( )
A well log is required on ALL wells drilled since 6/75.
L)EPHRTMEW (j, HEALTH AND FINIVIRONMENTAL i ,::(:lTECTION
8'25 -J.' !-n'TREET, ANG-FICIRAGE, AK. 99! 01
279-2541
PERMIT NO, (' ',;76:V3'
VIPPLUMN'T SIERRINI'li SRH BOX 1,540C
1 ... OCH11,01,14 HAR'y 1-In'AR,
LE(inl_ L.3" 81 LIT'RE REAR SUBD
MINIMUM C-4,' T'ANCE BETWFN A WELL ONE., HNY ON, -S 1E.
F(JR A Pf;,*SVHTE WELL OR 00"i FEET F _I., A
lt4l FFEI L
WE'LL. LOGS ANI',', MUS -4 HW' RETUR 0 Hi
CW_ MF, W( LL, ("0171PLETION.
OTHER' MAY HIPPLY, ISPEC IF: T, 1 -INS, 1,44
HVHII_FlBI..F' 'TO U -J.' URF PROPER IN' TALLRY.",fi.
I CERTIFY THAT
l: I AM ifAMTLIHR 141TH THP..'
ON -51 TE:
FORM I -,.,Y THE MUNICIPALITY OF 1ANCHORAQW.
2
W I T T : 1 WILL JN'S'lHLI_. 'I!IE 'r` 'I IN ACCORU." N "-F_
s
4
L -T .1�31121F' FEE.'r
-At IS
WAK DISK.`
IC IELL,
DE ARTPU T ITHIN 30 [."AYS
CONS ()N DIAGIR'Arl-S AR'Un'
J. "n
'.-wu�S AND klEL.L'S' svl.
T' SUED
DATE ....,.4+.._......_.....,..._.... mk
06-1220(a) Ray. 1973
hi. L DEPARTMENT OF HEALTH AND SOCIAL S ICES
DIVISION OF PUBLIC HEALTH Lab Na.
INDIVIDUAL AND SEMI-PUBLIC
DATE BACTERIOLOGICAL WATER ANALYSIS OFFICE
INDIVIDUAL ❑ SEMI-PUBLIC ❑ CHLORINE RESIDUAL PPM
REPORT RESULTS TO
NAME - -
ADDRESS _
CITY
ADDRESS
OF SOURCE
ZIP CODE _
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
ther
SOURCE: ❑ Spring ❑ Cistern ❑ Other—
Dug Well or Cistern Construction: -
Dug
Walls—[-] Wood ❑ Concrete ❑ Metal ❑ Tile Brick or
Top — ❑ 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 Diameter Depth
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 INSTRUCTIONS Date Received Time Received
am
'-pm Lab. No.
Lactose Broth Tocc locc
locc locc locc 1.Occ 1.Occ
ON 24 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
Reported by
a.m.
Date p.m.
This analysis indicates Coliform Organisms to be:
Absent
Present