HomeMy WebLinkAboutLAKE O THE HILLS BLK 1 LT 5Lake O The Hills Block 1 Lot 5 #015-331-16 On -Site Wastewater Disposal System Permit Permit Number: OSP161335 Tax Code Number: 01533116000 Work Type: Septic Upgrade Permit Effective Dates: December 06, 2016 to December 06, 2017 Design Engineer: PANNONE ENGINEERING SERVICES Subdivision: LAKE O THE HILLS Site Legal Address: LAKE O THE HILLS BILK 1 LT 5 G:2639 Owner/Address: BREAUX RANDY & BELINDA LIVING TRUST BREAUX R L & B V/TRUSTEES 11401 MOUNTAIN LAKE DR ANCHORAGE AK 99516187 Site Mailing Address: 11401 MOUNTAIN LAKE DR, Anchorage Lot Size in Sq Ft: 54479 Total Bedrooms: 4 This permit is for the construction of: Y Disposal Field N Septic Tank N Holding Tank N Privy N Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Special Provisions: 1. At time of construction, 12 inches of clean water will be added to the percolation hole (twice). it seeps away within 10 minutes, construction may begin immediately. If the 12 inches of water does not seep away in 10 minutes, a percolation test will be ran continuously until two consecutive water drop readings are within 1/16th of an inch. All readings shall be recorded and submitted to MOA Onsite. MOA is to be notified 2 hours prior to conducting this test. 2. Steep slope fill (shown on profile) required prior to approval of inspection report. Received By: Date: Issued By: l ('(A (_f11VtoCV Date: 12 O(, ,201(0 C 11 MUNICIPALITY OF ANCHORAGE Development Services Department n; On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 I)rpartnuut Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Work Type: Septic Upgrade Permit Effective Dates: December 06, 2016 to December 06, 2017 Design Engineer: PANNONE ENGINEERING SERVICES Subdivision: LAKE O THE HILLS Site Legal Address: LAKE O THE HILLS BILK 1 LT 5 G:2639 Owner/Address: BREAUX RANDY & BELINDA LIVING TRUST BREAUX R L & B V/TRUSTEES 11401 MOUNTAIN LAKE DR ANCHORAGE AK 99516187 Site Mailing Address: 11401 MOUNTAIN LAKE DR, Anchorage Lot Size in Sq Ft: 54479 Total Bedrooms: 4 This permit is for the construction of: Y Disposal Field N Septic Tank N Holding Tank N Privy N Private Well N Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80). 3. The wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Special Provisions: 1. At time of construction, 12 inches of clean water will be added to the percolation hole (twice). it seeps away within 10 minutes, construction may begin immediately. If the 12 inches of water does not seep away in 10 minutes, a percolation test will be ran continuously until two consecutive water drop readings are within 1/16th of an inch. All readings shall be recorded and submitted to MOA Onsite. MOA is to be notified 2 hours prior to conducting this test. 2. Steep slope fill (shown on profile) required prior to approval of inspection report. Received By: Date: Issued By: l ('(A (_f11VtoCV Date: 12 O(, ,201(0 5 Municipality ®f Anchorage Development Services Division On -Site Water and Wastewater Program **** VARIANCE/WAIVER REVIEW **** Waiver#: OSV161136 COSA#: Permit#:OSP161335 PID#:015-331-16 Legal Description: Lake O The Hills Block 1 Lot 5 Engineer: Pannone Engineering Services Applicant: Randy & Belinda Breaux Your request for a waiver of the required 50 feet horizontal separation from the absorption field to the excessive slope has been approved. The approved separation distance is 5.5 feet. This waiver approval applies to the proposed absorption field only. Any future upgrade to the on-site wastewater disposal system will require all separation distances be met or another approval from this department. ❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected adjacent property. ® Adjacent properties are not affected by this waiver. ............................................................................... Waiver is Granted: X Waiver is not Granted: Date: 12/0 6I.? o (1, Approved by: Name of Reviewer .............................................................................. **** VARIANCE/WAIVER .REVIEW **** MUNICIPALITY OF ANCHORAGE Community Development Department Development Services Division 6 On -Site Water & Wastewater Program NOV 14 2016 Phone: 907-343'7904 Fax: 907-343-7997 ON-SITE SEWERIWELL PERMIT APPLICATION Parcel I.D. 015-331-16 Property owner(s) RANDY & BELINDA BREAUX I Day phone Mailing address 11401 MOUNTAIN LAKE DRIVE, ANCHORAGE, AK Site address 11401 MOUNTAIN LAKE DRIVE, ANCHORAGE, AK Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) LAKE O THE HILLS B1 L5 Lot Size 54,479 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (M all that apply) Absorption Field ❑X Initial ❑ Single Family (SF) 0 (w/wo ADU) Septic Tank ❑ Upgrade 5 Duplex (D) F-1Holding Tank ❑ Renewal F-1 Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: STEEP SLOPE SEPARATION Distancez5.51 I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: GiPq,OD Date of Payment: U /ly/;v/ t., Receipt Number: O" oZ�JoZ�J3% Permit No. 0_S P ll 1 ol3 35 Permit App__ : L. -c Waiver Fees: 215,DP Date of Payment: I I h q " (.O Receipt Number: O h2't c� Waiver No. IOSVILPI) 3 GO Pannone Engineering Services uc Steven R. Pannone, Principal Registered Professional Engineer E-mail: steveCcDoanengak.com 5 December 2016 Subject: LAKE O THE HILLS B1 L5 Septic System Upgrade Permit Request Design Narrative This is a design narrative for a permit to install an upgrade septic system to be issued for this property. The proposed system will serve an existing four-bedroom (4BR) dwelling. Currently the lot is developed. This lot and the surrounding lots are served by private wells. The well on this lot is over 100' from the system, and there are no wells on the surrounding lots within 200' of this system. The existing drain field is in failure and this permit will be to install an upgrade system. 1. Soils. One test hole was performed by PES in November of 2016, and groundwater was monitored for at least seven days. Ground water was not observed at a depth of 18.5' below the surface in the test hole monitor tubes in November of 2016. Bedrock was not encountered in the test hole. Based on the results of the percolation tests and overall soils appearance; an application rate of 1.2 gallons/day/square feet was used for a conventional wastewater system in the area of the test hole. Due to the existent soil morphology no pre-soak of the test hole is required. Paragraph 3 of Table 3-8 of the EPA Design Manual (Onsite Wastewater Treatment and Disposal Systems) provides two conditions in which a presoak of the soils for a percolation test are not required. First is if the soil is sandy with little or no clay. Second is if 12" of water that is introduced into the test hole seeps completely away in less than ten minutes twice. These are either-or conditions not both -ands due to the construction of the sentences. Further in Paragraph 4 the conditions required for completion of the percolation test in sandy soils are met when two successive water level drops do not vary by more than 1/16th of an inch and the test has been conducted for one hour with readings in 10 minute intervals. When these conditions are met the soil is assumed to be in a saturated state which is the intent of pre-soaking the soil (to ensure the water is in a saturated state) and a percolation rate for the existent soil 2. Soil Absorption System Design. a. See Sheet 1 of the design package. 3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain field. The proposed drain field upgrade will maintain at least 100 feet from all surface water and drainage ditches. 4. Topography: The proposed system will be placed to the west of the existing house. The area slopes generally from the center of the lot down to the northwest and down to the south and southwest with the area surrounding the proposed absorption field being generally level. There are steep slopes within 50' of the septic system (see Waivers). - S. Waivers a. Slope Separation: We are requesting an absorption field to steep slope separation waiver for this upgrade. There is a slope greater than 25% within 50' of the proposed upgrade. The grade breaks to 40%± occurs 5.5'± to the northwest of the proposed system. Using the realistic (HSG A) infiltration lines the system will not daylight within 50' of the upgrade absorption field along Section A -A. The soils in the area of the test hole are of HSG A morphology. Using the worst case 25% infiltration line (HSG D) the system will daylight at 29.4' along Section A -A. Soils removed from the trench during construction will be used to create a more moderate slope. We are requesting a steep slope separation waiver to 5.5'. Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 Physical: 332 East Manor, Anchorage, AK 99501 Telephone: (907) 272-8218 FAX: (907) 272-8211 Page 2 of 2 The proposed installation will not affect the future development of the surrounding or existing lots. If you have any questions or concerns, please contact me at 272-8218. Sincerely, Steven R. Pannone, P.E. Owner/Civil Engineer Mailing: P.O. Box 100217, Anchorage, AK 99510-0217 Physical: 332 East Manor Ave, Anchorage, AK 99501 Telephone: (907) 272-8218 FAX: (907) 272-8211 - / 41v r /TRUE No� SCn E : r= 50' I72 75 ('A/ J� / / ^ / / INSTALL ABSORPTION FIELD P 32.OLFx2.5'Wx8.0E.D., 12.5'T.D. / .� W/ COs AND MTs c} /o+ 7 // / i 1 70.2 WE 16.3 � OI 5 1131.2 \ 119.4 W I / ( INSTALL DCO & DV— IAFTER TANK (P)� WE L (Eii W , i W II �� 6 NOTES:' Pt11`I1`IONE 1:1`IG SVC, LLC Date FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 12/5/2016 PHONE (907) 272-8218 FAX (907) 272-8211 �p Scole P.I.D. NO LAKE 0 THE HILLS B1 LS 015-331-ts DRAWN RANDY & BELINDA BREAUX fiieveii 'R: Panrioiie' PERM I T JRL SPx 11401 MOUNTAIN LAKE DRIVE CE 8149 0xx XX SITE PLAN ANCHORAGE, AK 99516 Sheet I OF 3 96 � ---------------------------p0.GNP`v ' —_ 5--- —92 —88 BO— /S\a oa PNA G%AO qb% rV _ GPS � -S4 MEO 25% WF\6WOR54 C WE) 2. - ASSU tHSG 0 - — 25.9 6 0 — — — — a —50 — — — — — — —`— — — — — o 76 DESIGN PARAMETERS PRIMARY SEPTIC SYSTEM NO. BEDROOM: 4(600 gpd) TANK SIZE: 1250g PERC RATE: 2.1 MPI SOIL RATING: 1.2 GPD/SF AREA ROD: 500 SF SYS. TYPE: DEEP TRENCH 8.0'ED MIN LENGTH: 31.3 LF USE: 32.0LFx2.5'Wx8.O' E.D., 12.5' TD TOTAL AREA: 512 SF NOTES: FOR CONSTRUCTION DRAWN IJRL SECTION —'++ w —WATERLINE / WELL RADIUS —SS n — NEW SEPTIC PANNONE ENG SVC, LLC P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 LAKE 0 THE HILLS B1 L5 RANDY & BELINDA BREAUX 11401 MOUNTAIN LAKE DRIVE ANCHORAGE, AK 99516 ABBREVIATIONS TH TEST HOLE (P) PROPOSED (E) EXISTING CO CLEAN OUT N0. MT MONITOR TUBE NO. TYP TYPICAL Date 12/6/2016 ...... .. P.LD. NO 015-331-16 �S�OVM R.� IIDORQ PERMIT N0. CE 8149 ;,G} OSP161335 Sheet 2 OF 4 SPECIAL PROVISIONS TO SPECIFICATIONS 1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF ON—SITE WASTEWATER DISPOSAL SYSTEMS AND AND IN ACCORDANCE WITH AMC 15.65 AND 15.55. 2. SCOPE OF WORK: INSTALL NEW SOIL ABSORPTION SYSTEM. 3. GROUNDWATER WAS NOT ENCOUNTERED TO A DEPTH OF 18.5 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL TEST HOLE. IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 18.5 FEET BELOW EXISTING GRADE NOTIFY THE ENGINEER IMMEDIATELY. 4. THE CONTRACTOR (BOTH WELL AND SEPTIC SYSTEM CONTRACTORS) SHALL HAVE ANY WELL LOCATION AND SEPTIC LOCATION STAKED AND ANY LOT LINE AND WELL RADIUS SHOWN ON THE PLAN WITHIN 30 FEET OF THE PROPOSED SYSTEM STAKED BY A REGISTERED LAND SURVEYOR BEFORE STARTING THE WORK. 5. THE CONTRACTOR IS RESPONSIBLE FOR ALL R.O.W. AND OTHER REQUIRED PERMITS, OTHER THAN THE ATTACHED. 6. THE CONTRACTOR SHALL CALL FOR LOCATING OF ALL BURIED UTILITIES. 7. THE CONTRACTOR SHALL PROVIDE 24 HOUR NOTICE TO THE ENGINEER PRIOR TO START OF WORK. ALL SURVEYING AND LOCATES SHALL BE IN PLACE PRIOR TO NOTIFYING THE ENGINEER. B. THE CONTRACTOR SHALL NOTIFY THE ENGINEER OF ANY DISCREPANCY BETWEEN THE APPROVED DRAWINGS AND SITE CONDITIONS/LIMITATIONS POTENTIALLY CAUSING THE NEED TO MODIFY THE DESIGN. 9. AT THE COMPLETION OF THE WORK, THE CONTRACTOR SHALL SUBMIT RED—LINE AS—BUILT DRAWINGS TO THE ENGINEER. THE RED—LINES SHALL INCLUDE PIPE LENGTHS, ORIGINAL GROUND ELEVATIONS, PIPE ELEVATIONS, AND,: TANK ELEVATIONS. 10. THE CONTRACTOR SHALL PROVIDE PHOTOGRAPHS OF THE SYSTEM INSTALLATION TO INCLUDE BOTTOM OF EXCAVATION, TOP OF PIPE WITH CLEAN—OUTS AND MONITOR TUBES INSTALLED, INSTALLED TANK AND FINAL GRADING. 1 1. THE CONTRACTOR PROVIDED DATA (UPON WHICH THIS RECORD DRAWING IS BASED) APPEARS TO REPRESENT THE PROJECT AS CONSTRUCTED. THIS DATA IN CONJUNCTION WITH THE PERIODIC FIELD OBSERVATIONS BY THE ENGINEER (OR HIS DESIGNEE) AS REQUIRED BY AMC 15.65 DOES NOT GUARANTEE THAT THERE ARE NO HIDDEN DEFECTS BY THE CONTRACTOR. _ 12. THE CONTRACTOR SHALL SIGN THE FOLLOWING: I CERTIFY THAT ALL WORK WAS PERFORMED IN ACCORDANCE WITH THE APPEND PERMIT, AND ANY AND ALL CHANGE ORDERS, AND THAT THE AS—BUILT REDLINES ARE TRUE AND ACCURATE REPRESENTATION OF THE PROJECT AS CONSTRUCTED. CONTRACTOR: BY: TITLE: DATE: NOTES : PANNONE ENG SVC, LLC P.O. BOX 102954 ANCHORAGE, AK 99510 PHONE (907) 272-8218 FAX (907) 272-8211 �P ' •••• 874°�""OPB Dote 12/06/2016 FOR CONSTRUCTION Scale NTS LAKE 0 THE HILLS E31 L5 RANDY & BELINDA BREAUX 401 MOUNTAIN LAKE DRIVE ANCHORAGE, AK 99516 P.I.D. NO 015-331-16 DRAWN JRL PERMIT NO. OSP161335 DESIGN NOTES Sheet 4 O 4 TEST HOLE 1 OR TOPSOIL SOILS LOG — PERCOLATION TEST 1 BROWN SLOPE I TE P N 2. ML FILL 0 3 2 J 5 6 Tv y TEST HER 8 HOLE STD 9 10 Silty SAND & I GM/SM GRAVEL (LT 11 BROWN) / 12 13 14 SLOPE WAS GROUND WATER 15 ENCOUNTERED? N 6 TH 1 IF YES, AT WHAT 17 DEPTH? —NA—' 18 DEPTH TO WATER AFTER MONITORINGP — DRY BOH DATE: 1ONOV2016 DATE PERFORMED: 03NOV16 NO GROUNDWATER CLOCK WATER SOIL TEST RESULTS/ANALYSIS • PERCOLATION RATE 2.1 (min/inch) (Hydrologic Soils Group: HSG A) • PERC HOLE 2 1135 70 MM I �NDIAMETER 6" • TEST RUN BETWEEN 5 FT AND 6 FT • TEST RUN FOR OVER AN HOUR, LAST THREE READINGS PROVIDED. COMMENTS: Test hole excavated by A+ HOME SERVICES. Test Hole was NOT required to be presoaked before Perc test due to sandy material (Table 3-8, Para.3, EPA Design Manual). PERFORMED BY: Joseph Lawendowski. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST. FOR CONSTRUCTION NOTES PANNONE ENG SVC' LLC � Dote 12/OS/2016 P.O. BOX 102954 ANCHORAGE, AK 99510 p ""' PHONE (907) 272-8218 FAX (907) 272-8211. Scale �:• NTS .I. P . NO LAKE 0 THE HILLS B1 L5 015-331-16 RANDY & BELINDA BREAUX PERMIT NO. DRAWN SRL CE 8149 11401 MOUNTAIN LAKE DRIVE osPxxxxxX SOILS LOGS ANCHORAGE, AK 99516 Sheet iii 34 3 O 4 READING DATE TIME NET TIME LEVEL READING NET DROP RATE (MPI) 1 0310 V16 1130 6.255" 2 1135 10 MIN 11 .329" 5.064" 1.9] 3 1136 fi265" 4 1146 10 MIN 11.136" 4.871 2.05 5 114] 6.265" 6 115] IO MIN 11.134" 4.869" 2.05 MUNICIPALITY OF ANCHORAGE 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•e J}t� PHONE EW �I.-J �� _,�,� El UPGRADE MAI LING ADDRESS 17a S' Liq LEGAL DESCRIPTION V,�`-'r` ' LOCATION ( f/ NO. OF BEDROOMS OZ\�''t Well Absorption awe��t Dwelling p PERMIT NO �� Uy DISTANCE T0: l ! o a Q Manufacturer / : Materi l?.� „ „ n No. of�ompa-tmept� LU '/ L� !f 3tiX-l�..F' l rn < Li ,'capacity in gallons Inside length Width Liquid depth o IF HOMEMADE: y Well Dwelling PERMIT NO. DISTANCE TO: O z Q x F Manufactur Material ons ❑ Well , Foundation n.t- Nearest lot line V PERMIT NO. -7,8 �- J wx DISTANCE TO: ' 1 i� J LL Z Z w No. of lines Length of each n i Total length of lines 7j Trench width inches Distance betwe n ines P-� F Top of tile to finish grade � Material beneath tile Total effective bs t''�n �jea ❑ , inches o�O Length Width Depth PERMIT NO. w C7 E- Type o rib Crib iameter rib depth Total effective ab n area d w° wWell N Building foundation est lot line DISTANCE T0: J o Depth Driller Distance to lot lin PERMIT NO. —/ 6O? 1 / ! J of w Building fou d tion Sewer line Septic tank t l Absorption area(s) 11 i f DISTANCE TO: l OTHER PIPE MATERIALS �Q SOILTEST RATING f L D t INSTALLER r _ REMARKSeta t t �f fi s PAP APPROVED DATE LEGAL ������ ~��� , ^ DEPHRTMENT OF/ `�HLTH HND EN�IRONMENTHL P/ `ECTION , � �TREET,�HNC I, RHGE/ HK99501 ` ` 264�4720 WA 1.. 1... K 141 Is. "'E. �, 1. -V Ell "T W W EE. FQ F" W HQ 011 1 T PERMIT NO_ ( 780728 ) HPPLIWIN! CHHRLES PRICE 1727 B SRH ]44 1270 LOCHTION OFF MT LHKE ROHD LECil HL L5 S1 LH -,,:E O THE HILLS S/D � LOT SIZE 55000 SQUHRE FEET TYPE OF SOIL FIB SCAR BTION SYSTEM ITRENCH MHXIMUM NUMBER OF GEDROOMS = 4 SOIL RHTING (SQ FT/BR)­ 125 THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS� �E.-E V 1-1 �10" 101 "? FT:: II. �"11, it, -- LI� � THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIELD. THE DEPTH OF H TRENCH OR PIT IS THE DISTHNCE BETWEEN THE SURFHCE OF THE GROUND HND THE BOTTOM OF THE EXCHVHTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES THE GRHVEL DEPTH IS THE MINIMUM DEPTH OF GRHVEL BETWEEN THE OUTFALL PIPE HND THE BOTTOM OF THE EXC9VHTION (IN FEET). lot IETE oil U 3: Hot EVE ED; ���K J- 'T. C:.- , �- IN N K 71; 1: TE! EE — ��!F�4 PF::,1! 11 IC-)i�� PERMIT 8PPLICHNT HHS THE RESPONSIBILITY TO INFORM THIS DEPHRTMENT DURING THE INSTHLLHTION INSPECTIONS OF! HNY WELLS HDJHCENT TO THIS PROPEFITY HND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE �NO 1-1 < 22 Do 3: X (TWAG lFr-"., '117��� ~�~ BRCKFILLING OF HN9 SYSTEM WITHOUT FINHL INSPECTION HND HPPROYHL BY THIS DEPHRTMENT WILL BE SUBJECT TO PROSECUTION MINIMUM BETWEEN H WELL HNKj HNY ON�SITE SEWHGE DISPOSHL SYSTEM IS 100 FEET FOR H PRIVHTEWELL/ OR 150 TO 200FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL - WELL LOGS HIRE REQUIRED HND MUST BE RETURNED TO THE DEPHRTMENT WITHIN 30DHYS OF THE HELL COMPLETION OTHER MHY HPIC, LYSPECIFICHTIONS HND CONSTRUCTION DIHGRHMS HRE HVHILHBLE TO INSURE PROPER INSTHLLHTION 1"" 142 ITZ vW1 X -11 ­ 1f::'" 1 F-;". ���Q 1-9. FEA Fl.8� �JL., I CERTIFY THHT 1� I AM FHMILIHR WITH THE REQUlREMENTS FOR SEWERS HND WELLS HS SET FORTH BY THE MUNICIPHLITY OF HNCHORHGE. 2� I WILL INSTALL THE SYSTEM IN RCCORDHNCE WITH THE CODES. ]� I UNDERSTHND THHT THE OTE �EWER SYSTEM MHY REQUIRE ENLHRGEMENT IF THE RESIDENCE IS ORE BE , � CHHR R PERFORMED FO LEGAL DESCRIP SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION TEST Pouch 6.650, Anchorage, Alaska 995OZ-727ral:2221 �,2 7'?n SOILS LOG - PERCOLATION TEST DATE PERFORMED: OZf hol SLOPE }W. C�. k-0 1106 17- 18- '91 20 COMMENTS PERFORMED BY: 79-nnA (7/7rl k -.)- -5 WAS GROUND WATER S ENCOUNTERED? L 0 P IF YES, AT WHAT E DEPTH? SITE PLAN I VA DEPTH Gross Time (FEET) Depth to Water Net Drop 2 3 4- _7 6- 7- 8- 9- 10- 11 12- 13- 14 --- SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION El PERCOLATION TEST Pouch 6.650, Anchorage, Alaska 995OZ-727ral:2221 �,2 7'?n SOILS LOG - PERCOLATION TEST DATE PERFORMED: OZf hol SLOPE }W. C�. k-0 1106 17- 18- '91 20 COMMENTS PERFORMED BY: 79-nnA (7/7rl k -.)- -5 WAS GROUND WATER S ENCOUNTERED? L 0 P IF YES, AT WHAT E DEPTH? SITE PLAN I VA Reading Date Gross Time Net Time Depth to Water Net Drop _7 Reading Date Gross Time Net Time Depth to Water Net Drop PERCOLATION RATE TEST RUN BETWEEN CERTIFIED (minutes/inch) FT AND — FT DATE: rev ev MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN. SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING J 1 Parcel I.D. # 1. GENERAL INFORMATION 2. 5A 4. HAA# Complete legal description 1_o> S 13/a c k 2 La ke -O - The - lfrlls -S /D Location (site address or directions) 11 yoi M fn k-eu12'e PriL g Property owner Char Irl d-Totc!?o•e It,7e PrC c e Day phone 3 Y 6- l6 6 P - Mailing address Il for f" l ocAn lialn DricIC' 1+fpr_ c !2r /1-k 996" /6 Lending agencyrbrF woflh ttb�fq �q�_ Day phone Mailing address Agent P01I.v i"toone Uct realt <r � Day phone 6y6 y Address y 2 `f / "S4 Q An cAo22r 41 -It 9196-0.3 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water q --.4 NOTE: 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 Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (R". 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 furtherverify 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 _ Flcr>t fv j, Tech n (ca! Se ryrc J Phone Address I'LE 3 EcAo S�., A-r-)cAoratge, A -k %95 /j( Engineer's signature 'J._ T in4011_ Date til 10/ 6. DHHS SIGNATURE J,� Approved for bedrooms. Sy Disapproved. Conditional approval for Additional Comments vL' � 4 4 oaa a a •neae •• r1 •e. •• 1 S�A ea . . . . . . . . . . .eae aaf?aan C; S� bedrooms, with the following stipulations: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approvaf 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. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 • Anchorage, Alaska 995010 (907) 343A7p aPAtijv {3t A .11' Health Authority Approval Checklist Legal Description: 1,a !3 1 i crke- ®'- 7 -he -017,r Parcel I.D.: R {,_. iU D A. WELL DATA Well type Prfyoe/ c If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/1) Date completed 6/Z/7 Total depth 201, Cased to Sanitary seal (Y/1) Date of test Y 00'Y I FROM WELL LOG Casing height (above ground) 20" Wires properly protected (Y/N) Y Static water level / .9 Well production t O g.p.m. WATER SAMPLE RESULTS: Coliform 0 co( /100 rn e Nitrate O. 1 m q/ •e Date of sample: q / / 196' Collected by: B. SEPTIC/HOLDING TANK DATA AT INSPECTION H // l 91!5r Other bacteria NonB ffepr'0C&a( 7'echnfcal S'eevi Date installed S I Y % 7 9 Tank size 1250 qol Number of Compartments 2 Cleanouts (Y/1) Y CO Foundation cleanout (Y/M Y Depression (Y/M N High water alarm (Y/1) N. A. Date of Pumping 6 119 /9S Pumper C. ABSORPTION FIELD DATA Roto Rool-er- N Date installed _YM / 7) Soil rating (g.p.d./ft' or ftZ/bdrm) System type ''wench Length 31Width W 8 it Gravel thickness below pipe 96 a Total depth 12 ' Effective absorption area 5 28 0' Monitoring Tube present(Y/N) Y Depression over field (Y/N) H Date of adequacy test `y / 1 / 9 11� Results (Pass/Fail) Pa4f For Y bedrooms Fluid depth in absorption field before test (in.); 70 Immediately after 7 2 /gal. water added (in.): 8G Fluid depth (ins.) Minutes later: /38 Absorption rate = , 6OO g.p.d. Peroxide treatment (past 12 months) (Y/M None Gcnaw., If yes, give date D. LIFT STATION N. �. Date installed Manhole/Access (Y/I) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* "Pump off' level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 17 6" ; On adjacent lots Absorption field on lot > l 76 ; On adjacent lots 13S , -);n Public sewer main N. A. Public sewer manhole/cleanout Sewer /septic service line > 25 , Lift station N. 14 N. A. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 8ear. !P, Properly line 65 Absorption field 5 Water main/service line >2s � Surface water/drainage '> 100 ' Wells on adjacent lots t 30 ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation 18'+ Per oW, re2, Property Line ZS' Water main/service line Surface water > 100' Driveway, parking/vehicle storage area 1S Curtain drain None Seel) Wells on adjacent lots , 130' ENGINEER'S CERTIFICATION X - t. 1 certify that 1 have determined thrtt field inspections and review of Municipal records th4�t4e above systemskg in conformance with MOA HAA guidelines in effect on this date. �. cnneo�a, Signature - ''/I{/)K/`�,.C_ r .'�O P06 B h0�000 �'JO �• Engineer's Name Th e .,C& re F. M CCI-e Enginecong Seal Hete,•"` , Date `i / 1 o / 99' HAA Fee $ 300 -�, Waiver Fee $ Date of Payment �/ Il 2 � Date of Payment Receipt Number ZI % j� L7 S Receipt Number Rev. 8/95 OSS: haa.wk.doc 04f09i9G 15:37 CT&E ESI ANCHORAGE -> 9073451355 NO.930 DOG ME Environmental Services Inc. 'Zothk Laboratory Division Drinking Water Analysis Report for Total Coliform Bacteria 2d0'", Potter DriveArlChorage. AK 99518-1605 READ INSTRUCTIONS ONREVERSE SIDE BEFORE COLLECTING SAMPLE Fax: (907) 561 343 301 MUST BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY # Analysis shows this Water SAMPLE to be: O PUBLIC WATER SYSTEM I.B. Satisfactory Q PRIVATE WATER SYSTEM p unsatisfactory 9 Send Resu�lts a Send Invoice zil ♦r to rrrv,A nrV' igr tog —Zava�env'r wit" 5, V*v omn r. ame 13�� __ 3 4-►3s^s Day t'11 V11��tYm er r#A �S� �vmvfr fHS3D �clw \54 �nQA ns 0 Treated Water gq,r'f its^ -. Untreated Water O Send Results ❑ Send Invoice empmyhae, _ M'itt ntln+ TSYmrw »I q tin -r I ' zil E2 SAMPLE DATE: Month Day Year SAMPLE TYPE; Tj Routine 0 Treated Water C Repeat Sample (for routine sample if Untreated Water with tab ref. no. ) n Special Purpose Time Collected SAMPLE LOCATION Collected By 14154 Pima Print Comments: O 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 special delivery mail. Date Received Time Received O Analysis Began Analytical Method: Membrane Filter MMO•MUG Number of colonies/ 100 mi. Lnb Ref. No. Result' nalyst 04 gb1103 = __ Sent to A.D.E.C. Anch . Fbks Jun 13 Fared Date Time: Client notified of unsatisfactory results: 3 Phoored Spoke with Faxed pate: Time BACTERIOLOGICAL WATER ANALYSIS RECORD NIiMO-MUG Result: Total Coliform E. Coli Membrane Filter; Direct Count O Colon icsl100 m Verification: LTB Fecal Colitor Confirmation Final Memli gin Filter esu Reported By` BGB COLIFIRM Time f V" — _ hrs r.''rc. T"" K,nvo"us r" Caxnl pli . (;,tier n+t¢ria re) BGS Member of the SGS Group (Soci6tt G9nerale de Surveillance) v Alrcr tar iu o FN1nDMi+.e+'+•' •. ^'•'T'r *+ n• A' ASKR Poe tFAoNIT A GI rto'nn ••' n'n'C uw4vi w+•n +"•'-w!.•,i • 'CS 04/09/96 15:36 ME ESI ANCHORAGE -> 9073451355 NO.930 PO4 CT&E Environmental Services Inc. jxtL 4-1 Laboratory Division I1I'.Iri/0IlI Rii Laboratory Analysis Report CT&E Ref.# 961103.9037 Collected Date 04/01/96 Client Sample ED L5 BI LAKE O HILLS SIDI 1103.03 Matrix Drinking Water Technical Director PWSED 0 Released BYE— Sample Remarks` Parameter Results DC PQL Qual Nitrate -N 0.100 U units Method Allowable Prep Analyefs Snit _ Limits Gate Date _ 0.100 79/1. EPA 353.2 04/02/96 EMB 200 W. Potter Drive, Anchorage, AK 99518-1605 -- Tee (907) 662-2343 Fax. (907) 561-5301 3180 Peger Road, Fairbanks, AK 99709-5471 — Tel: 19071474-8656 Fax: (907) 474-9685 ENVIRONMENTAL FACILITES IN ALASKA, CALIFORNIA. FLORIDA, ILLINOIS, MARYLAND. MICHIGAN. MISSOURI, NEW JERSEY. 01+10. WEST VIRGINIA MUNICIPALITY OF ANCHORAGE M • '-° DEPARTMENT OF HEALTH & HUMAN SERVICES M j Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I. D. # 1 - "]-Q) 1- up 1. GENERAL INFORMATION Complete legal description 51Gc1< HAA# VA �()Q0-a1� S D o, lre-4-7,6e- hN(fj Location (site address or directions) l('/ 01 N0"a}urn d- ke Dr7r.c Property owner 13 e Day phone 3Y9 -15-/1 Mailing address IIqa/ P'rfn, Lake Drir,rc Anch�, A -k 99s -r6' Lending agency r=trSI IN1af'/ Oe40 k 0� A-nco Day phone 276-6300 Mailing address P.O- (30x 100720 fFnchora +k 99s(G Agent n)•A• ( Re J'-inanre) Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water V_ 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 C= IaF y 7—e�yn<<a� Sertl«P✓ Phone 3 Address 11 -16 -so macho S�, /}nctic��a�/e } 99SIr Engineer's signature �i�- m � Date 74j�v-W 3 199 2 .O 5s At @3 AF.s • Vis, -'' •••M1`o'_: n;,lA Fv 7Y•' 4`3T 1� ..a . ........• .. q e TiiEiCUi:c .� .:r +•pis � 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: 91 Additional Comments 11ITIC; 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. 72-025 (Rev. 1/91) Back MOA 421 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: SZ/ tee ke- -O - the- lfel f Parcel LD A. WELL DATA Well type Prtver-FP If A, B, or C, attach ADEC letter. ADEC water system number m /�• Log present (Y/N) `r Date completed 6/2179Driller C";'kd Ort///qq Total depth 20 l t Cased to 2 oy Casing height ?o" Sanitary seal (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG 6/ 2/ 79 l6S� to SEPARATION DISTANCES FROM WELL TO: Wires properly protected (Y/N) Y AT INSPECTION 3126-192 1011�=PALITY OF ANCHORAGE Its. ENVIRONMENTAL SERVICES DIVISION g.p.m. S. 93' t �'1992 14/10 RECEIVED Septic/holding tank on lot 17o' + ; On adjacent lots > too' Absorption field on lot 170 + ; On adjacent lots MUNbGP. I Ml - a - OF ANCHORAGE A. Public sewer main N14- Public sewer manhole/cleanout NI APR - v 1992 Sewer service line > 25 Petroleum tank None Seep WATER SAMPLE RESULTS: RECEIVED Coliform 0 Co( / 100 A Nitrate a I ny IX Other bacteria O ca(/ wc, M4 Date of sample: 3 / ? `/ / 9 2 Collected by: F fa>tfoin ?eeti S� c B. SEPTIC/HOLDING TANK DATA Date installed 57/011 79 Tank size f2SGgat Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression (Y/N) N High water alarm (Y/N) N• R • Alarm tested (Y/N) N• R Date of pumping 3 /2(, /9 2 Pumper Rc4{0 RaOfer_ SEPARATION; DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 170' 7O' - On adjacent lots > t �'� t Foundation 17' from c. O. To property line �G Absorption field ^ 5" Water main/service line > 2s Surface water/drainage > 162 0' 72-026 (Rev. 7/91) Front - - CONTINUED ON BACK PAGE C. LIFT STATION N, /} . Date installed Size in gallons Vent (Y/N) High water alarm level Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed 5`/ f (-/ /' 9 Length 33 Width On adjacent lots Soil rating N' "Pump off' level at Cycles tested Surface water _ 2S a'15c(rl- System type -Tench Gravel thickness Total absorption area - 2C5 r.:7' Cleanouts present (Y/N) Depression over field (Y/N) Results (pass/fail) Date of adequacy test for Total depth I2 4 1 13 S-19 2 bedrooms Peroxide treatment (Past 12 months) (Y/N) None 1 �nacun of If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 1 7G'+ On adjacent lots �> ton Property line To building foundation To existing or abandoned system on lot N, A, On adjacent lots '> 30' Cutbank to' Water main/service line -> Z5 Surface water -_� (6,0' Driveway, parking/vehicle storage area iS Curtain drain None seen 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. ,.yy4: ,+ Aa At Signature �'/ %//� • ;�.e� Theao2e,r� r. r Engineer's Name Ntoo� .�u �a0Y0aY ieo.••a••v es•••.�„�.,� Date Apr-, I3; 19 9 2 Ta 4.: ,° .•....,, e HAA Fee $ / Waiver Fee: $ Date of Payment Date of Payment Receipt Number /417/ 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 RE31]LTS fox INVOICE Che;alab Ref A 92.114:3 Sariple ff 2 Natri.x: WATER J.ient Sample ID LS B1 LAhE-O-TNF.-If LI,S S'IEST PWSiD UA ("ollocted Received MAR 24 92 fI 16:05 hrs. Pr.eso):vod with AS REQUIRED (,'ii.ent }tame :FLATTOP TECHNICAL SRV Cli.ont Acct :FLATTOT BPO# POt3 :11011E RECEIVED Reqs Ordered By knalysis Completed MA11 25 92 Sena Reports to: Laboratory Supervisor STEPHEII C. EDIT 1)PLATTOP TECHNICAL SRV R.eleasod Y,y r. _ 2) . Pa.rametei i` Results Units 1dothod Allowable Liroi.ts -------.-- _-_.. 1IITRATE.-i; ND(O.10) r¢y/1 EPA. 353.2 10 Sar,ple ROUT112, StSIPLE COLLECTED BY: DA. - NOTAG.EOR THIS SAWLE. 1.= ^Tests':°ers.ormedL "= See'Special'Inst7:uctions Above U1, thiavriiiable- 1(D--hone Detectod 's e0 Sample ROniarks ribovp N).•• 110t An Ivzed LT -Less '.(tea;), G'T'=Greater 'Tubi 2 C^S Member of the SGS Group (Societe Generale de Surveillance) c UPE �O� LABORATORY CHEMICAL &CSE®LOGICAL I4RORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 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. # © PRIVATE WATER SYSTEM F(,44,p 3 GIS- /35 5 Name Phone No. 1y53o Cc%a Mailing Address /}kora e 99s -1C chy State Zip Code SAMPLE DATE: O 3 2 `1 Z Mo. Day Year SAMPLE TYPE: Routine ❑ Check Sample (for routine sample with lab ref, no. ) ❑ Treated Water ❑ Special Purpose R Untreated Water SAMPLE Time Collected No. LOCATION Collected By 1 I L S� (31 1 -cd e-O-TAt- ('fr((f Gr44 l: 3GP!`t T-f� 2 3 4 5 TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ,-lf 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 Time Received OC� Analytical Method: Membrane Filter No. of colonies/100 ml. Lab Ref. No. Result' Analyst l � 52.1143 ( m u m U m O.E.C. 0 ,3 2S 9 �l" e— BACTERIOLOGICAL WATER ANALYSIS RECORD A. READ INSTRUCTIONS Membrane Filter: Direct Count Coliform/100 ml BEFORE COLLECTING SAMPLE TNTC = Too Numerous To C OR — C)fhar Rar_toria Verification: LSB BGB Fecal Coliform Confirmation i Final Membrane Filter Results � / / Coliform1100 ml Reoorted By / r �� Date f� / a.m. PART ONE OF TWO REMAINDER TO FOLLOW p.m. _e,\ Y C, ,n tiA,. - DATE RECEIVED INSPECTION APPOINTMENTS y TIME NUMBER OF,BEDROOMS TIME TIME ' ❑ Two Five MULTIPLE FAMILY ❑ Three ❑ Six DATE DATE DATE c�L— since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) INSP CTOR INSPECTOR INSPECTOR ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. MUNICIPALITY OF ANCHORAGE sc LTH & MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION: DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 It p� 7 • /i' J 1 J ENVIRONMENTAL SANITATION DIVISION RECEIVED Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTYOWNE PHONE MAILING ADDRESS Is 1l—/f— PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE MAILING ADDRESS 1 �f 3. LENDING INSTITUTION PHONE U,,'7_ 0b �... / ZG MAILING ADDRESS 4. REALTOR/AGENT PHONE MAILING ADDRESS - 5. L GAL DESCR�IPTION ,p 6 ®. STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS ❑ One Four ❑ Other SINGLE FAMILY ❑ Two Five MULTIPLE FAMILY ❑ Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* *ATTACH WELL LOG. Awell log is required for all wells drilled COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM LA INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) a-16 THIS SIDE FOR OFFICIAL USE ONLN 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ TWO ❑ THREE ❑ FIVE ❑ OTHER ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED `r 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED s� `) INSTALLER ❑Septic Tank or ❑ Holding Tank Size: 1 If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL E 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS APPROVED FOR BEDROOMS ❑ CONDITIONAL APPROVAL (letter must accompany certificate) ❑ DISAPPROVED DATE �j D ---r c)- 0 r� BY iL O W� uuoautoll[s Ir W"lt-e0 1% lcnl nOICAL L.A®ORATOR ES OF AI P.O. BOX 4-1276 - ANCHORAGE, ALASKA 99509 Drinking Water Analysis Report for Total TO BE COMPLETED BY WATER SUPPLIER PUBLIC WATER SYSTEI l� I Public Meiling I.D. NO. City state Lip . uuv SAMPLE DATE: F —F�4 �iK. Mo. Day Year SAMPLE TYPE: ❑ Routine ❑ Check Sample (for routine sample with lab ref. EJ Treated Water ) [IUntreated Water ❑ Special Purposee SAMPLE Time Collected NO. LOCATION `= Collected By READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Form No. 18-310 (3-78) 06-1220 (b) 'Rev. 1978 Date Collected -Date Received. 24 Hours 'i Mick INC,TELPHONE (907)279-4014 ESS PARK BLVD. 1 Bacteria C} BE COMPLETED BY LABORATORY LABORATORY: NAME ADDRESS CITY Date Received /2 d `G _ ?� Time Received Analytical Method: ❑ Fermentation Tube YMembrane Filter Lab Ref. No. Result' Analyst 0 e No. of colonies 1100 ml. or No. of Positive porilons. BACTERIOLOGICAL WATER ANALYSIS RECORD Source a.m. Time Received P.M. Lab. No. — 10m1 loml 1 rhl 10m) loml 24 Hours 48 Hours EMB Multiple Tube Report: Membrane Filter: Direct Count Verification: LTB Final Membrane Fllter a ts_ Reported 1.Oml 0.1ml Broth 24 hours: Broth 48 hours: 10ml Tubes Positive/Total 10ml Portions Cot Iforr0ll 00m) _ Date Thee: / l 177-7 a.m. . F 3 4 5 READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Form No. 18-310 (3-78) 06-1220 (b) 'Rev. 1978 Date Collected -Date Received. 24 Hours 'i Mick INC,TELPHONE (907)279-4014 ESS PARK BLVD. 1 Bacteria C} BE COMPLETED BY LABORATORY LABORATORY: NAME ADDRESS CITY Date Received /2 d `G _ ?� Time Received Analytical Method: ❑ Fermentation Tube YMembrane Filter Lab Ref. No. Result' Analyst 0 e No. of colonies 1100 ml. or No. of Positive porilons. BACTERIOLOGICAL WATER ANALYSIS RECORD Source a.m. Time Received P.M. Lab. No. — 10m1 loml 1 rhl 10m) loml 24 Hours 48 Hours EMB Multiple Tube Report: Membrane Filter: Direct Count Verification: LTB Final Membrane Fllter a ts_ Reported 1.Oml 0.1ml Broth 24 hours: Broth 48 hours: 10ml Tubes Positive/Total 10ml Portions Cot Iforr0ll 00m) _ Date Thee: / l 177-7 a.m. L�llozj,5 YJ December 29, 1978 #780728 Charles Price Star Route A Box 1727B Anchorage, Alaska 99597 Subject: Lot 5 Block 1 Lake O'The lulls Subdivision A permit issued by this department for well and/or sewer system has expired. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. if you have drilled the well, a well log should be sent to this department to document the installation date. if there are any further questions, please contact this office at 264-4720. Sincerely, Les N. Buchholz, R.S. Senior Environmental Specialist L"NB/l jw encs copy of permit