HomeMy WebLinkAboutBONIBROOK #2 TR A-1-2Bonl*brook #2
Tr A-1-2
#006-284-27
11/27/2012 02:33 9072430742 AWPS, INC. PAGE 01/
I Uar tnl7n3-
Mark Segich
Mayor
"'ell Drilling Permit Number: SW
Pu p Installation Log Ooh ^1—a1
Date of Issue:
Parcel Identification Number:
Leval e Deon Pro scriptioper .tv
Owner Name &o' 4ddress: 1v i Rel,� -90,
Pump Installation Date: .2t -NIL I Z
Pump Intake Depth Below Top of well cusjog!V3!Sfeet
Pump MLanufacturer's Name:
FumpModel; /—ZtS
Pump Size /
X2- hp
Pitless Adapter Burial Depth; I feet
Pitless Adapter,44anufacturer's Name:
FldeSs AjOpivr 7n,)jn3jQr: AMr
W -A D'SMfexied 1190A � El
Mttba,a,:,iFT'Asia eLl"Wt:
Comments:
Pump installer Name: AO -P 5
Attention: The pump installer shall pjovjde a pwnI installation log to the DSD within 30 days of pump installation_
i:::[ F:' F:' L. :[ C J:::l IH"F
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L. Ii.:-'.' (:ii i::! L.
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TFi: F!-...Z-;;;i: E~C~Nf.,I:[BROOP:: S;?[:, '~;2 L..OT :SIZE
PI 1' [-,! :[ ?IUH .t.')].' :5'T!q. NCE E~E?,'HEEN f::~ HE:t....L. !:aN[:, RN',~: ON-.".5 :[ TE :SEHFIGE D :[ :E:F'O:~i~RL..
:!.~2)E~ FEET FOR FI F'RZ'v'F!TE HELL. OR :l.'.~;e~ TO 2(~)Ci FEET F'ROH FI PUBL. ZC HEL. L.
...f1" C ~,! TFfE T'¢F'E OF F:'L E:L l' C: HEL..L.
H:[?-,i:[HUN DZ~5'T'FIh, ICE FF'.ON F! F'RIVf¥!"E HE:L.L. TO FI F:'F?.I',,,'I::TTE :~2;E:HER LiNE
TO i:a COHHUH~'i"? :E;E:HEF: LINE lIE; '?~S FEET.
HEL. L LOGE; Rf;rE RE(;~UIRED F~f.,i[;, HU'.ST BE RETLIRNED 'TO THE DEF:'F!?.'T'HENT H]:'T'H;[I'-,f
OF "f'F'IE HEL. L COHF'LETZON.
O"FHE:F~ REQLfIF?.EHENT~; HR'~' RF'PL.?. SF'ECIF'ICFI"F]:Oh,!:E; RH[:, COF,IS;TF?.UCT :[ ON
~::I',/FI ]: Lf:IE L E: T[I ]: [.,IE(;t..If',~iEE F'ROF'EF: :[ f'~STF~LL.F?I"Z
I C:E:R'T' I F"? "['HF:YT
::L: :E FmH F' F:! ?! I' L ]: FI F: HZ-!"F! THE Fi:E(;:!U:[F,"..:Et,iE:NT:5 F'CL[~'. ON-.S:!'T'E 'SE!.,.!EF?:!E; FIND HEL..L.:!ii; ¢::!E; :SET
FOI.';?.TH Ei~'.¢ THE: Hi_IN :[ E: t' F'¢~L :[ T'.r' OF'
;2:: :[ H :[ EL. :[ N:!~;"r'FtLL.. THE :F.';'.r':ii!;TEH ! N F!CCOF:.C',F!NC:E H !' '1"[4. THE
FIF:'PL. :1: ['.':¢q. NT DR',,,' I [.', r'l ..:tONES;
'J':::'~:. :.F"' B" 'Ft"I"E .............. ~
ALASKA ENVIRONMENTAL
CONTROL SERVIC INC.
!200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO,
CALCULATED BY ,J T K
CHECKED BY--
SCALE i "= 20'
A- -/-9_
DATE
DATE -
WELL
~ OU,5 E..
0
U
Z
Z
0 0 O' 0 0 0 0 0 0 0 0 0
RECEIVED
ALASKA ,,dlROFImeFITAL COFITROL $e,,.ICeS. Ir'lC.
~n§in¢¢rin§ 6 ~nuironmcnt~l S1uclics
MICHAEL BONIFACE JONES
2733 C01, LIE HILL WAY
ANCHORAGE ALASKA
99504
SELLER-
8/26/86
MICHAEL BONIFACE JONES
2733 COl, LIE HILL WAY
ANCHORAGE ALASKA
99504
60454
LEGAL:BONNI BROOK #2 BLOCK A--1-2
FLOW TEST ON WELL
WELl, FI,OW DATE-8/21/86
A FLOW TEST WAS PERFORMED ON THE WELL. 836 GALLONS OF WATER WAS
PUMPED AT A RATE OF 6.96 GPM OVER A DURATION OF 2 HOURS.
THE DRAWDOWN WAS 24.3 ' WITH A RECOVERY TIME OF il00 MINUTES
AND THE STATIC WATER LEVEL WAS ?5.3 FEET.
THE WELl, IS ADEQUATE FOR THIS 3 BEDROOM HOME.
1200 Uaest 33rd Aucnue, Suite B · Anc}~oraqe, f~lc~sko 99503 .{907) 561-5040
MUNICIPALITY OF ANCHORAGE //'~' '
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Locatlo6 (addre.ssor directions)
(1~¢" CApplicant ~lamo :J~,tO~ J~iF'/f¢~ 4¢N~ Telephone: Home 35.~ -7/~ 7
,(c)' .' Appfi~nt'is (cffeck bn'e): (ending Institution ~ ' Owner/builder ~'; Buyer B; Other ~ (explain);
Business
(d)~'Le0ding?s'titution,, , ,. , ,. _ ~,
Telephone
Addrbss .... ·
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family[] Multi-Family []
Number of Bedrooms ~'
Other
WATER SUPPLY
Individual Well.~' Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite [] PublicJ~, Community [] Holding'Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page I of 2 72-025 (11/84)
5.
ENGINEERING FIRM PROVID~,~G INSPECTIONS, TESTS, FILE SEARCH, L,., rA AND INFORMATION ,
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, 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 AEC
Address [~-~OI~ (4.)
Telephone __ -OqO
Approved for ~//~2--, bedrooms by ~
Approved _ Z~'""" , Disapproved
Conditional
Terms of Conditional Approval
CAUTION ,:,
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations g!ven in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does ~hls~ asa courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
A:
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: 7~... _{_- ._~ :~.,-_-
If A, B, C, D.E.C. Approved (Y/N) /1//'/,~''
Well Log Present
Total Depth /
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit ~/N)
Separation Distances from Well:
To Septic/Holding Tank onLot
Cased to
Date C°mpleted I I//~"/~:~/Depth of I'-'Grouting
Pump Set At
Sanitary Seal on Casing (I~N)
Depression Around Wellhead (Y/~
~/j~r ; On Adjoining Lots
~V/~ · on Adjoining Lots.
J O~/"~" To Nearest Public Sewer
J O~ ~ To Nearest Sewer Se~ice Line on Lot
· Date ~/~1 / ~
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Man hole
Water Sample Collected by
Water Sample~t Results
Comments ~ I~R
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
HOlding Tank High-Water Alarm~(Y/y)/ .~.
Separation Distan cos f rom Septi~o~i n/~nk
To Water-Supply Well ' / --
To Pro Line
rice Line __
-~ :.,, ' Ceurse
?jC n,l,_ .
~. -page 1 of 2 .
Size No. of Compartments
Cleanout (Y/N)
Pumped
; for
porary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
72-026(11/84)
Co
"/'Kc
AB$OFIPTION FIELD DATA
Soils Rating in Absorption Strata Type of System Design
Date Installed ____ Length of Field
Width of Field ____ _ Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area __ Standpipes Pr~,,t'Y/N)
Depression over Field (Y/N) __ __ Date of Last A.d.,~uacy Test __ ~_
Results of Last Adequacy Test /A
Separation Distance from Absorptio~Ffd:/ /~ ~
To Water-Supply Well ~ ~ /! , / To Property Line ___ _
To Building Foundation ! / To Existing or Abandoned System on
Lot / ; On Adjoining Lots ___
To Water Main/Service Line J To Cutbank (if present)
To Stream/Pond/Lake/or Major .~j~ge Course ......
To Driveway, Parking Are~'2Cehicle Storage Area ....
Comments j . .
D. LIFT STATION
Date Installed
Dimensions
Size in Gallons
Manhole/Access
"Pump On" Level at at
High Water Alarm Level at Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted B oOm Rating Against HAA Request **
I certify t h at~h a,~e~,Lk~e d~.'' . ., ..__..~. v~if~d,...._., or,~onformed_ to all MOA and HAA guidelines in effect on the date of this inspection.
Company ~I~C
Receipt No. <c:~_,0
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Dm I'VE RECEIVED
~:~' I NSPECTI ON APPOI NTM E NTS
TIME TIME TIME
INSPECTOR I NSPECTO'R INSPECTOR
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION
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.
~. PROPERTY OWNER PHONE
MAI LING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
MAI LING ADDR ESS
E
MAI LING ADDRESS
4, REALTOR/AGENT J PHONE'
I
MAI LING ADDRESS
LEGAL DESCRIPTION
STREET LOCATION
TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
6o
,ntt Rqso5
NUMBER OF,BEDROOMS I
[] One [] Four []
[] Two [] Five
~ Three [] Six
Other
7. WATER SUPPLY [~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for ail wells drilled
since June 1975, For wells drilled prior to that date, give well
depth (attach log if available,)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
[~ PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTI LITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] I NDIVI DUAL/ON -SITE
r--} PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
[] ONE
[] TWO
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
NUMBER OF BEDROOMS
[] THREE [] FIVE
[] FOUR [] SlX
[] OTHER
Absorption Area to nearest Lot Line
Septic/Holding Tank
IAbsorption Area lSewer Line
Nearest Lot Line
5. COMMENTS
DATE
[~ APPROVED FOR -~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)
DATE COLLECTED DAY
I.D, NO. (PUBLIC'SY$¥ENS)
MANE OF SYSTEM
SYSTEM ADDRESS
CITY
STATE
LOCATION gHERE SAHPLE gAS COLLEC
'COLLECTED BY:(:
TYPE OF SAMPLE
(CpECKONLY ONE THIS
/~DRINKING WATER
( ~CHECK TREATHENT
RAW SOURCE ~ATER
NEW CONSTRUCTION OR REPAIRS
OTHER(Specify)
BY li TER .IER
TZI~ COLLECTED
TYPE QF S.YSTE#
~ PUBLIL~Z/IDIVZDUAL
CIRCLE CLASS
A B C
TELEPHOHE NUMBE
ZIP CODE
[~CHLORINATED
DFILTERED
,~ITREATED OR OTHER
[~ ESUBNIT SAMPLE
Smmple ~eJected becluse:
~IECK ONE OR gORE
[~Semple too long tn transtt.
~le should not ~ over 30 hours.
~ ~le ~cetved t~ late ~n ~ek
~t tn prope~ container
~Leaked out
~ ]nsuffJc~en~ Jnfo~tton p~vtded,
Please ~ad Instructions on ~om,
~her (Spectf~)
RECEIVED FROM
RECEIVED RY
ANA.~L~AL HETHOD:
L~rNE]qBRANE FILTER
E]FERHENTATION TUBE
[HE
Oate& Time 5tarred ~-~
IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NON-CONFORMING' SAMPLE?
I~ YES PREVIOUS COLLECTION OATE
ANALYSIS REQUESYED (IF OTHER THAN TOTAL COLIFORM)
SEND REPORT TO:(PRINT FULL NAHE,AOORESS AND ZIP CODE
ADDRESS I~) (,~/~-~"~r/J~_~ :~_~
CITY~$TATE ~...~~ZIP ~
BACTERIOLOGICAL MRTER ANALYSIS RECORO
FOR LAB USE ONLY
[~TOTAL COLIFORMS
FECAL COLIFORNS
OTHER
Date & Time Completed
LABORATORY RESULTS
[:] Other Bacteria
I-1 Test unsuitable because:
r-) Confluent Growth
[3 T. TC
SATISFRCTORY ~//INISATZSFACTORY []
BGB
Date
Coltform/lOOml
Coltform/lOOml
Time A.M.
P.M.
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter Results
Reported By
READ SAMPLE COLLECTION INSTRUCTIONS ON BACK OF FORM
HEMICAL & Gi LOGICAL LABORATORIES ' ALASKA, INC.
TELEPHONE (907)-279-4014 ANCHORAGE INDUSTRIAL CENTER
~. 274-3364 5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
-... I.D. NO. ,,':~ ~
Water System Name ~/ ,/Phone No. ~',
Mailing ~dress ?t
City Zip Code
Day
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
State
Year
[] Treated Water
[] Untreated Water
SAMPLE
NO,
4
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[~,~Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate rel able results. Please send
new sample.
Date Received ,
Time Received ,.
Analytical Method:
[] Fermentation Tube
~" Membrane Filter
Lab Ref. No. Result* Analyst
I FT-I
I
I
I l-r-i
*No. of colonies/lO0 mi or No of Positive portions
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
a.m.
Date Recelv~l Time Recelv~<l p.m. Lab. No.
Presumptive 1Omi 1Omi 1Omi 1Omi lOml 1.0mi O.]ml
24 Hours
48 Hours
Confirmatory
24 Hours
48 Hours
EMB Broth 24 houri: Broth 48 houri:
Multiple Tube Report: /0mi Tubes Positive/Total 10mi Portlona
Membrane Filter: Direct Count Colllorm/~00ml
Verification: I_TB BGB.
Flnel Membrane Filter Results ,'. ~,, Collform/~O0ml
Repor t~l By , Date , ,~
Time: "~ ,- a.m.