HomeMy WebLinkAboutLITTLE BEAR BLK 1 LT 4Little Bear
Block i
Lot 4
014-061-21
DEPARTMENT OF HEALTH AND ENVIRONMENTAL MENdTAL r-'ROTECTION, �
5-10 E. TUDOR RD.: ANCHORAGE, RAGE: At:::. 99507
276-2221
I._ Ems` Ez- F=` ii ai I _T_
PERMIT NO. 76305
APPLICANdT EC:' RIN 1 EF: L:M:_ 0 WELLSLEY CT 344-11-1.
LOCATION BABY BEAR PLACE
LEGAL L.4 E.1.4��E�4 BEAR _. /D LOT SIZE _ e:11.00 '_'��'!I tFlRF-.: FEET
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON—SITE 'SEb1AGE DISPOSAL SYSTEM I,---
100
_:100 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ?t=i t7nYs
OF THE WELL COMPLETION.
SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER
I N S3TAL.LA T I ON.
�_" • E-`� "T• '`e ° 1"-1 -° �' 9� STM_: CV N K�: °T° Imo.. F:: f= F F, : R._!
I CERTIFY THAT
1: I ANS! FAMILIAR WITH THE: REQUIREMENTS FOR ON—SITE _,EWERS AND WELLS `!'=; =.F_ C
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
: I WILL INSTALL STALL THE SYSTEM IN ACCORDANCE WITH THE: CODES.
DES.
APPLICANT
ISSUED
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• Municipality of Anchorage `
On -Site Water and Wastewater Program
(907)343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 014-061-21 Expiration Date: R
1. GENERAL INFORMATION
Complete legal description Little Bear, Block 1, Lot 4
- Location (site address) 6711 Baby Bear Dr
Current Property owner(s) Andrew Ratliff and Monica Moser -Ratliff Day phone _
Mailing address 6711 Baby Bear Dr Anchorage, AK 99507
Real Estate Agent
2. TYPE OF DWELLING:
Q Single Family (w/wo ADU)
❑ Duplex
Q Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
(]
Individual
❑
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
0
WaiverNariance
Received by: �`� "tf "" Date: 5 2,L)
S
COSA to be released to the ng eer, unless otherwise requested by the engineer. -
COSA Fee $ 13 ^
Waiver Fee $
Date of Payment 51,9115
Date of Payment
Receipt Number r�Y 3r3���
Receipt Number
COSA#
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. 1 further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply
-
and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at
the time of installation.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system, nor do they guarantee that there are no hidden defects or encroachments. Therefore we cannot provide any warranty
for future performance-, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage.Ak. 99510
Engineer's Printed Name Steven R Pannone
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms
System #2 Approved for _ bedrooms
Disapproved
Date 04/21/2015
Conditional approval for bedrooms, with the following stipulations:
By: Original Certificate Date:
The M icipal' f Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represent ions 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.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSAblueshw t c
If more than 1 septic system is on the lo}:
COSA Checklist # _L_of +
Structure served by this system +
Certificate of On -Site Systems ApprovalChecklist
Legal Description _ `r I Bear, Block 1, Lot 4 Parcel ID: 014-061-21
A. WELL DATA
dell type a If A, B, or C provide PWSID # Well Log (Y/N) Y
Date completed 02/22/1977 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 93 ft. Cased to 4Q+ ft. Casing height (above ground) 18+ in.
FROM WELL LOG AT INSPECTION
Date of test 02/22/1.977 04/21/2015
Static water level 22 ft. 31 ft
Well production 25 9 -P.M. 6.4+ 9—
p.m-WATER SAMPLE RESULTS:
Coliform Q Q oolonlesl100 mL Nitrate 0. qO -7 mg/L
Arsenic Nom• ug/L Date of sample: TA 16-0? 5 Collected by: PJS
TANK DATA
Tank sizegal.
Foundation cleanout (.
Date of pumping
Date installed
Number of Compartments _ Cleanouts (Y/N)
_ Depression over tank (YIN) — High water alarm (Y/N)
Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2 or rm) - System type
Length ft. Width Gravel below pipe ft.
Total depth ft. Eff. absorption area ftz -Monitoring to Depression over field _
Date of adequacy test Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption field before test in. Water added gal. 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
Date installed —Sinai Ilons
"Pump on" level at in. "Pump otP' level at
Datum Cycles tested
Manhole/Access (Y/N) _
fiig er alarm level at
Meets alarm & circuit requin
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots 100+
Absorption field on lot On adjacent lots 100+
Public sewer main 75+ Public sewer manhole/cleanout 100+
Sewer/septic service line 25+ Holding tank 100+
Animal containment areas -5.O+ Manure/animal excrete storage areas 100+
PTIC/HOLDING TANK ON LOT TO:
Building founProperty line Absorption field
Water main Water service line Surface water
Wells on adjacent lots
ABSORPTION FIELD ON LOT TO:
Property line Building foundation _
Water Service line Surface water -
Curtain drain Wells on adjacent lots
F. COMMENTS
As -Built on Ne
G. ENGINEER'S CERTIFICATION
I 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 Steven R. Pannone
Date 04/21/2015. .
COSA canary sheet_2.6-15.doc
Water main
Driveway, parking/vehicle storage
Y
Municipality of Anchorage
Development .Services Department
Building Safety Division,^
On -Site Water & Wastewater Program
f
ye�.
Individual Well
4700 Elmore Road
Individual On-site
❑
P.O. Box 196650
❑
Individual Holding tank
Anchorage, AK 99519-6650
Community Class Well
❑
www.muni.org/onsite
❑
Public Water System
(907) 343-7904
Public Sewer
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 014-061-21 COSA#
1. GENERAL INFORMATION
Expiration Date:
Complete legal description LITTLE BEAR S/D; BLOCK 1, LOT 4
Location (site address) 6711 BABY BEAR DRIVE * ANCHORAGE, AK * 99507
Current Property owner(s) SHAWN & DELOIS MCWILLIAMS Day phone
Mailing address 6711 BABY BEAR DRIVE * ANCHORAGE, AK * 99507
Lending agency Day phone
Mailing address
Real Estate Agent HEIDI HEHNLIN W/ REAL ESTATE BROKERS OF AK Day phone 297-2912
Mailing address 3300 C STREET, #202 * ANCHORAGE, AK * 99503
Unless otherwise,requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
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 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 samples. (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. STATEP:RENT OF INSPECTIO14 BY ENGINEEI?
As certified by my seal affixed hereto and as of the validation date shower below, 1 veiify that racy
investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
. H. t /;r «emote , to disposal S fa. is /aro! safe functional and adequate -
shows
that the ori -,Slee `waater Sb. I / an0 wastewater p al ti'S. 7? (ane)
for the number of bedrooms and type of structure it 1dicated herein. 1 further verify that based on the
t ti obtained r,.,. the f l;ty, r , h files and fro. L-,vest;.-ation an.'�. inspnectinn the
inlormauOrl vutanied uviii uic ivri.lnicipairiy, Oi rvnC� vraga ��� � u ,� ,e, ,;.y �.- • yam• r�����,',
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
GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Enaineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of al/ wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
Phone
337-6179
Date `ca 2q )/1
ey A,,rness:
CE -7951
(� • • AcG
'5'0fessio� o
other person or party is not authorized, nor will it confer any legal right whatsoever.
a. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
At 'Ltt"ler its.
1110SA Checklist
Septic System Advisory
Well Flow Advisory
i a:A__ _ a
v
`tts�- ;utaGiy
Jam: ON-SITE `•�►
WATER AND : R'
WASTEWATER
bedrooms, with the following stipulations PROGRAM
Ar enic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date: 7
F
(Rev. 11105)
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
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: LITTLE BEAR S/D; BLOCK 1, LOT 4 Parcel ID: 014-061-21
A. WELL DATA *ASSUMED BASED UPON SURROUNDING WELL LOGS. SEE ATTACHED.
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 2/22/1977 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth 93 ft. Cased to *40+ ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 2/22/1977 6/23/2011
Static water level 22 _ft. 36 ft.
Well production 25 _g.p.m. 7.09+ 9 -p -m -
WATER SAE RESULTS:
"2
Coliform . colonies/100 ml. Nitrate716mg./L. Collected by: GEG, Ltd.
Arsenic: ug./L. Date of sample: 6/23/2011
B. SEPTIC/HOLDING TANK DATA IPUBLIC SEWERI
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
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft'or ft2/bdr System type
Length ft. Width ft. Gravel below pipe —ft.
Total depth —ft. Eff. absorptio ea— ft2 Monitoring tube— Depression over field
Dateof adequacy test t7!� Results (Pass/Fail) Forbedrooms
Fluid
Fluid depth in absor ' n field before test — in. Water added —gal. New depth in.
Elapsed T' min. Final fluid depth — in. Absorption rate >= g,p,d,
Elapsed e -t- m in.
T
y v rejuvenation
io m tt
rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N
"Pump on" level at in. "Pump off' level High water alarm level at in.
Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A On adjacent lots N/A
Absorption field on lot N/A
Public sewer main
Sewer /septic service line
*50'+
25'+
Animal containment areas 50'+
On adjacent lots N/A
Public sewer manhole/cleanout *50'+
Holding tank N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Water main
Wells on adjacent lots
Property line Absorption
Water service line Surface water.
SEPARATION DISTANCE FROM ABSORPTION FI
Property line .
Water service
iCart9 drain
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Surface water
Wells on adjacent lots
TO 1983.
/ certify that l 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 Prrrined Na e JEFFREY A. GARNESS
Date b
TO:
Water mai
PUBLIC SEWER
Driveway, parking/vehicle storage
COSA Fee $� U Waiver Fee $
Date of Payment 40 - 3d — Date of Payment
Receipt Number_ 06p. D q `-t Receipt Number
(Rev. 11/05)
P'•.V CE -+795 /tel m
D����ofessio� co'
SGS Ref.#
1112717001
Client Name
Garness Engineering Group, Ltd
Project Name/#
Little Bear B1, L4
Client Sample ID
Little Bear B1, L4
Matrix
Drinking Water
PWSID
0
Printed Date/Time
Collected Date/Time
Received Date/Time
Technical Director
06/29/2011 8:08
06/23/2011 17:10
06/23/2011 17:25
Stephen C. Ede
Sample Remarks:
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) 06/27/11 06/28/11 NRB
Waters Department
Total Nitrate/Nitrite-N 0.763 0.100 mg/L SM20 450ONO3-F B (<10) 06/27/11 AYC
Microbiology Laboratory
E. Coli Negative 1 100mL SM20 9223B A 06/23/11 ACF
Total Coliform Negative 1 100mL SM20 9223B A 06/23/11 ACF
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6126 [AST T:NO AVENUE
ANCHORAGE. ALASKA 90607 -77
SUBSURFACE EXPLORATION
Shift Report of Operations
I. OWNER PEDERSON CONSTRUCTION, INC. PROJECT Dawn Subdivision, Lot 109 Block 2
t. TVP[ OF EXPLORATION Domestic well, 6"
a. CONTRACTOR STM STATES ASSOCATES
[ 22w
OUIPMENT NAY[
4. CONTRACT NO.
MOLE NO.
16 SURFACE ELEVATION WEATHER
OEPTH•LEGIN SHIFT OEPTH.ENO SHIFTOEPTM ORILLCO
•
S. PERMAFROST LNCOUNTER[O: FROM TO
T. MATER LEVEL DATE S SHIFT
S•
TIME DISTRIBUTION HOURS
TOTAL
LENGTH
DRILLER
CHURN DRILL
FISHING
Herb Johnson
617
1711"
3
ROTARY DRILL
PULL CASING
4
718"
BOOM TRUCK
STANDEY
HELPER
139@10"
6
8.5"
TRUCK
WELDING
7@111
SURGING
PUMPING
•• LoANNU LOG
NO.
LENGTH
TOTAL
LENGTH
1
10'
10'6
2=
617
1711"
3
719"
24110"
4
718"
33216"
5
714"
139@10"
6
8.5"
451311
7
7@111
55' 3j"
8
699"
62'01"
9
590"
6711"
10
5*3 '
7214"
11 1
6'o" 178
@4"
12 13'0"
8114@1
'lot long
to. SOILS LOG.
SAMPLE DEPTHS
NO.
FROM TO
0 39
39 80
80 90
RIG HOURS
SAMPLE MATERIALS AND REMARKS
Tight sand gravel
andy clay and gravel interbedded
Water bearing, 12 gallon per minute. water �
level21 feet from surface IJ
W
DEPT. OF HEALTH 81
mr-cr-14 Pool"d
oC
Water level: 21feet. 12 gpm production.
DRILLER INSPECTOR
904 : 9 - /,. - �!S-
Jajzl 0'.
Amm 776'W44 -Y
o? 3bc) 4� -P cl- 0p 3 B
. . . . . . . . . . .
�Wrll -W --- ME
O
00
A
6'On', en Acry--is
O
00
A
F
lsuI3
r
W.W.D.
Water Well Drilling
+� 1 Phone 349-3809
Anchorage, AK.
Well Owner `!-��i�"�j `"cam- Date
Well Location Phone
Size Casing' Depth of Hole 7 Cased to ?9 feet
Static Water+-evel Meet Well Test Q Gat per Minute for Hours
Date
,of Completion
WELL LOG
AUTHORIZATION TO DRILL
W
I hereby authorize W.W.D: Drilling to proceed with the above work. Payment shall be made in the following manner:
C3J
Rig up Minimum (50% of anticipated depth) feet. @ per foot
Balance due upon completion. (1
In the event it is necessary to institute legal proceedings to collect any amounts due on this contract, I agree to pay an additional
sum of Ten percent (10%) of the original contract price as attorney's fees, plus costs, for legal proceedings.
Name
Date Address
MUNICIPALITY OF ANCHORAGE
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES E1pA(i�
Division of Environmental Services flyr SFA
On -Site Services Section SFR►/y0 PgGF
P.O. Box 196650 Anchorage, Alaska 99519-6650
44 le`SF'p X2199, S/on,
CERTIFICATE OF HEALTH AUTHORITY e/v
APPROVAL FOR A SINGLE FAMILY DWELLING fQ
/ 1
Parcel I.D.# " I - % -a.) HAA# %K
1. GENERAL INFORMATION
Complete legal description
Lot 4; Block 1; Little Bear Subdivision
Location (site address or directions) 6711 Baby Bear Drive
Anchorage, AK
;r
Property owner Gary Ransom Day phone ( 916) 264-7800
Mailing address 155 Parkside Terrace Auburn, CA 95603
Lending agency Day phone
Mailing address
Agent Rona Mason/ Personal. Service Realty Day phone 279-8877
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well xxx
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 xxx
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
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 reol4tic ,,}gl gRjo the date of this inspection.
'EAyle River Loop Roar} No. 204 e
Name of Firm j I c A y�4A!aslea 99577 Phone t f c/
Address /
iJ
Engineer's signature Date
Nj
y ROBERT C. COWAN
6. DHHS SIGNATURE sr;+ CE -8801
X/ Approved for `� bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
B �Y/;.,_ . ,;�z
Y: Date L/ 12
—�
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 021
Municipality of Anchorage FRo�gtiryo�
DEPARTMENT
OF HEALTH
& HUMAN DSERVICES SOP �y0 h5
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907 34�'3+-444'99,
k
Health Authority Approval Checklist e/v�
Legal Description: Lig-T' t3 LO (,X I Parcel 1. D.: 0 1 14 7 L? C-
r_slwa4a•7_rr_1
Well type ��` `Yrs If A, B, or C, attach ADEC letter. A/DEC water system number
Log present &N) y } Date completed d- ( 3 /' 7
Total depth cl 3
Sanitary seal (Y/N)
Date of test
Static water level
Well production
tS
Cased to � () r
FROM WELL LOG
laal`77
WATER SAMPLE RESULTS:
Coliform 0 Nitrate
Date of sample: '�/ i -I ` % `1'7
B. SEPTIC/HOLDING TANK DATA POALI C --
Date installed
Foundation cleanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA`
Date installed
Length Width
Effective absorption area
Date of adequacy test
Tank size
Casing height (above ground)
Wires properly protected (JN)
AT INSPECTION
/tq,/`-7
11 4
I
Y �. 5
g.p.m. 3 I + g.p.m.
i"o 3 Y Pvw?PO 4 PI- V
d. Other bacteria
S & 5 ENGINEERING
Collected by: +7014 Paolo River Loop Read No 204
Eagle River, Afaska 99577
Number of Compartments
Depression (Y/N) High water
Pumper
Soil rating (g.p.d./ft2 or
System type
Graveytt4ickness below pipe Total depth
Tube present (Y/N) Depression over field (Y/N)
Results (Pass/Fail)
Fluid depth in absorporrfield before test (in.); Immediately after.
Fluid !�ept�h.(ins) Minutes later:
Peru Ade treatment (past 12 months) (Y/N) _
72-026 (Rev. 3/96)"
For bedrooms
gal. water added (in.):
Absorption rate = g.p.d.
If yes, give date
D. LIFT STATION
Date installed
Manhole/Access (Y/N) _
High water alarm level at*
"Pump on"
*Datum
Cycles tes
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ",/ A -
Absorption field on lot
Public sewer main
- 5-
Size in gallons
On adjacent lots
On adjacent lots
"Pump off" level at*
"?,J 14
N)A
Public sewer manhole/cleanout
Sewer /septic service line Lift station d v 1A
-J� wrct- C a Yf -v 4,A InS;A ti.3 (ll 't r -O IqS°, 3
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation Property line
Water main/service line Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTI LD ON LOTTO:
Property line
Surface water
Gurfain drain
F. ENGINEER'S CERTIFICATION
foundation
Wells on adjacent lots
Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots
l certify that I have determined thru field inspections and review of Municipal records
in conformance
with MOA HAAA quidelines in effect on this date.�-V
Signature
Engineer's Name G� k Ct C wr1�J"
1A =RC
Date ���r �q -7
h,
HAA Fee $ �y�"� �� q Waiver Fee $
Date of Payment 9/� /i Date of Payment
Receipt Number Receipt Number
72-026 (Rev, 3/96)*
CE -8801
are
de,
ME Environmental Services Inc.
Laboratory Division
Drinking Water Analysis Report for Total Coliform Bacteria
READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE
MUST BE COMPLETED
a PUBLIC WATER SYSTEM I.D. #
ja PRIVATE WATER SYSTEM
BY WATER
pI SendR vier SmdGrvolce
.. »clovwa
17034 Eagle River Loop Road No. 204
Fft°"NVnL%qte River, Alaska "
NombwMaHOSAOMM
City zip Caft
O SedRdsalb O Seadlnrolee
zm .
e.ZLP C4&
SAMPLE DATE:
SAMPLE TYPE
MM
b,-
Ro■tisre
C Repeat Sample (for routine sample
with bb rot nes► )� -
t] Special Purpose
SAMPLE LOCATIOM
MI
a . Treated Watam-
;t Untreated Water
Time Collected
Collected I BY
Lei y et -+c 'Vii
Pled. Pfat
Comments:
TO BE COMPLETED BY LABORATORY
An sis shows this Water SAMPLE to be:
p Satisfactory
Q Unsatisfactory
O Sample over 30 hours old, results may
be unreliable
• Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mai:.
Date Received �-- l
Time Received —_
Analysis Begat
Analytical Metbod: z Membrane Filter
G MMID-MUS
• Number of colonies/100 ml.
--160,c No. Result* Analyst
- 03 1
97.4611;
somwAiLLC_. Auk Fbb Jas Q
Fazed
Dat*: Times
Clieat notified of unratiafactory results:
13
Pboms Spam W" Fixed
❑
Date: Time:
BACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-MUG Result: Total C011forae E con
Membrane Filter. Dired Count Colonies/100m1
Veritiestiou: LTB BGS COLIFIItM
Fetal Coliform Confirmation -
Final Membrana Filter Rmahs C7 Coliform/100 ml
I Tim*__ hrs
Reported B7�. .{,�ataertJ%r-''
rNm ra.,ve....e ro Corr
OB-oawHowde
mew ieocav nwln WEST VIRGINIA
CT&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
Parameter
CT&E Environmental Services Inc.
974617003
S & S Engineering
N/A
Lot 4, Blk 1 Little Bear S/D
Drinking Water
Results
I
Client PO#
Printed Date/Time 08/19/97 15:47
Collected Date/Time 08/14/97 10:45
Received Date/Time 08/14/97 11:10
Technical Director: Stephen C. Ede
Released By
Allowable Prep Analysis
PQL Units Method Limits Date Date Init
Nitrate -N 0.100 U 0.100 mg/L SM18 4500-NO3F 10 max 08/15/97 JBL
Total Coliform 0.00 col/100mL SM18 92228 08/14/97 TMW
BABY Diltis N GRIeE
77
of
i P I
�
H w Ni
r �NC yr
•x•11 � ✓ .r-1
W
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r
T L..�. 60.0
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r �
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I
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l7 `7.A.
o
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N
tib•... Y.D •5 Ii}.
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i.
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WN
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I
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triio
• w "i a .
•'f'r'a,
1 4:1 h
r 1 [•} ay CA �1 tY
C`r
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7
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\,
I.nst.ituti_on
MUNICIPALITY OF ANCHORAGE-,
Amfac
Mortgage Company
DEPARTM,
OF HEALTH
AND ENVIRONMEN
!_ ['f:O"I"L.CTION
99501
825 L Street ,
Anchorage, Alaska
99501
" "_
2'79 25 .:': ,
ext. 22 or 2.2.;3
1
Date Received:
June 20, 1977
-L i.me
10:00 a.m.
$2: Time
'3: Time
Date
6-21-77
1most Tuesday Date
Date
Ins]
--. Peatt
_ 7 n= �.'
insp
REQUEST
FOR APPROVAL OF INDIVIDUAL
SEWER AND
WATER FACILITIES
I_. Lo :di.ng
I.nst.ituti_on
Request.
Amfac
Mortgage Company
Mailing
Address: 705
West 6th
--------
Avenue
99501
Phone: 277-8688
i, Property Owner: _Sebring Builders^____._______-_..___ Phone: —344-3069
Mail:i-ng Address: Star Route A Box 1540C 99507
Legal Description: Lot 4 Block 1 Little Bear Subdivision
4 : S.ingl.e FaIDi.ly Residence-. (xX) Nuiaber or. Bedr-oorris : ��— three
P1ul.tipie I''arn.ily Res i dente : ( ) Number of Bedrooms: _
f.
t�Jell System: individual_ We-ji (x�x Community/Public ty/Publi.c System ( }
♦ jj ' Well I..og on ' 111E,
( )
TJ :� �il•.l 1, ?Y Dept -h oY Wlel, 80.�.___��__..
ions -ruct .or. Bacterial An alys-i s
Seg -:rage D1 Sf c): al Systcnl: On --site System ( ) ?? Public IJt-L cr ( )
1)CI mit Installed Installer
r
Septic Tank_ Size I�ianurac-r_er
°,.usorption Arca Soils Rate 4at-erial
7, D stances: Well to Septic panic to Absorption Area
-o Sewer. Line Nearest Lot line Absorption Area
to IdearesL Lot Line
r
P,a�je Two
Department. of 13ca th and Env'i.ronrncntal. Protect.i.on
Request for Approval of Tridi_vidua" Sewer and Water Facilities
Legal Description: Lot 4 Block 1 Little Bear Subdivision
Comments:
Affadavit Attached:A ( )
Approved:
Disapproved:
Department Worksheet:
Letter Attached.: ( )
Date:
Date:
1.
N1
MUNICIPALITY OF ANCHORAG'1UMCIPALIT or
Department of Health and Environmental Protpgtbpp,,-j;,; ,.
825 L Street, Anchorage, Alaska 95f50�Jttri ir, i. P.,o % :TIC)t
279-2511, ext. 224, 225
t for Approval of Individual Sewer and Water Facilities
Property Owner
Mailing Address:
Name of Buyer: _
Mailing Address:
Phone:
Phone:
3. Lending Institution:
Mailing Address: Phone:
4. Realtor/Agent: _
Mailing Address:
5.
V
Legal Description
Street Location:
Phone:
Single Family Residence:
Multiple Family Residence:
Number of Bedrooms:
( ) Number of Bedrooms:
7. Water Supply: *Individual Well Public/Community System ( }
If Individual Well, well depth �0
If Community System, name of system
8. Sewage Disposal System: On-site System
If On-site System, date of installation:
( ) Public System ( )
*NOTE: A well log is required on ALL wells drilled since 6/75.
3/77
06-1220(a) Rev. 197,3 «
DATE
INDIVIDUAL ❑
NAME
ADDRESS
CITY
ADDRESS
OF SOURCE
ALA. DEPARTMENT OF HEALTH AND SOCIAL S. ICES
DIVISION OF PUBLIC HEALTH Lob No.
INDIVIDUAL AND SEMI-PUBLIC
BACTERIOLOGICAL WATER ANALYSIS OFFICE
SEMI-PUBLIC ❑ CHLORINE RESIDUAL PPM
REPORT RESULTS TO
ZIP CODE
Analysis shows this Water SAMPLE to be:
❑ Satisfactory
El 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 El Kitchen Tap- ❑ Bathroom Tap ❑ Basement Tap
❑ Other (List) _
Well — ❑ Dug ❑ Driven D Drilled ❑ Bored
SOURCE: ❑ Spring ❑ Cistern ❑ Other
Dug Well or Cistern. Construction: - -
Walls —❑ Wood ❑ Concrete ❑ Metal ❑ Tile Brick or
Top — ❑ Wood ❑ Concrete ❑ Metal ❑ Open Tap ❑ 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
El Plastic
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 C] No Signature —
06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD -
Rev. 1973
am
READ INSTRUCTIONS Date Received Time Received pm Lab. No.
Lactose Broth lOcc lOcc lOcc lOcc lOcc 1.Occ 1.0cc
ON24 Hours
48 Hours
Brilliant Green
REVERSE SIDE 24 Hours
48 Hours
EMB AGAR
BEFORE Lactose Broth, 24 hrs. 4B 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