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HomeMy WebLinkAboutBRENNER LT 1&Ex\obt SJ. X11 4•(:)*"\c,•-•(310‘,40_, Permit # Applicant: Location: MUNICIPALITY OF ANCHORAGE Department of Health and Environments' Protection 825 , Street, Anchorage, AK. 9501 264-4720 * * * HANDWRITTEN PERMIT * * * ELL lktif348fteedmaINIMINNER PERMIT ailing Address: rac_�� 0/ eL� Legal Description: / G 7 - Type Type of Soil Absorption System Is: Trench: Drainfield: Maximum Number of Bedrooms: Phone Number: Seepage Bed: 7 Q. Sox //9 6«eat - 2 7e?3 x.63 Lot Size: 9 -3 / Holding Tank: Soil Rating(sq.ft/br) The Required Size of the Soil Absorption DEPTH LENGTH AVEL DEPTH WIDTH The imension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 &41-* * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that 3 bedrooms. SWP/024(1/81) ,Pcnp Issued by: Date: 4` /e47 P'reA9 Well Owner Cerlew Investment s M -V/ DRILLING, Inc. P.O. Box 10-378 • 10300 Old Seward Highway (907) 349-8535 ANCHORAGE, ALASKA 99511 DRILLING LOG Use of Well Domestic Location (address of: Township, Range, Section, if known; or distance main road Tnt 1 Brenner Sub. Size of casing 6" Depth of Hole 136 feet Cased to 115 feet Static water level 21 ft (above) (below) land surface. Finish of well (check one) open end ( Screen ( ) ; Perforated ( XXX ) . Describe smell or perforation Liner - 4" Galy. steel set at 106-136, bottom 3' perforated Well pumping test at 10 gallons per Num) (minute) for 1 hours wit1L_] 00 sHr of drawdown from static level. ); Date of completion November 16, 1 953 WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness O TO 9 Casing stickup 2 TO 4 Organics 4 TO 15 Gravel with silt & clay 15 TO 24 Gravel with ocr. boulder 24 TO 71 Gravel with silt 71 TO 90 Silt with gravel 90 TO 115 Gravel with silt 115 TO 118 Boulder 118 TO 121 Hardpan 171 TO 131 C3sy & Silt, Soft & damp 131 TO 134 Gravel with clay (damp) 134 TO 136 Waterbearing gravel TO TO TO NAAFWA Cei tilled Cun ti ac tur Certificate No's. 814 & 973 1 —CUSTOMER Parcel I.D. 075-061-82 Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 Certificate of On -Site Systems Approval Expiration Date: 1. GENERAL INFORMATION Complete legal description BRENNER; LOT 1 Location (site address) 132 BRENNER CIRCLE *GIRDWOOD, AK 99587 Current Property owner(s) ALIZE' LA CROIX Day phone 310-2474 Mailing address 132 BRENNER CIRCLE `GIRDWOOD, AK 99587 Real Estate Agent Day phone - 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 2 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well © Individual 0 Individual Water Storage ❑ Holding Tank 0 Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer NI WaiverNariance request for: N/A Distance: - Received by: 7f- COSA to be re! ==_^ b the engineer, unless otherwise requested by the engineer. Date: 4/z 7A--- COSA /:Y COSA Fee $ 52 e Waiver Fee $ Date of Payment iB l/4attlrs Date of Payment 113 Receipt Number /d4 Receipt Number COSA # 06015/367 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, b�r$dn*ocedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, saws 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 Garness Engineering Group, Ltd. (GEG) Phone (907) 337-6179 Address 3701 E. Tudor Road, Suite 101, Anchorage AK, 99507-1259 Engineer's Printed Name Jeffrey A. Garness In conducting this evaluation, GEG provided an engineering evaluation of the welt and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend on a variety of variables including, but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property In the event either of the current systems fail. The content of this report is for the sole benefit of the person/oarty who retained GEG. Reliance upon the information provided in this report by any other person or party, including but not limited to subsequent property purchasers, is not authorized. In short, GEG disavows any legal duty to anyone other than the person/party who paid for this report. 6. DSD SICyNATURE ��77 System #1 Approved for _G bedrooms System #2 Approved for Disapproved Conditional approval for Date &[ 2 J/ - s i E7 s ,zry .�4a� Ay 1'OFESS1i� rrrra���� \VQP�\s' OF t c6, /y4,. J= ON-SITE `G z-I�� WATER AND bedrooms JO WASTEWATER o1 �'� PROGRAM 4 bedrooms, with the following stipulation°S. /)) /V -sE k \%' $��, By: Th un cibattt .,' - , sge Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations 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 Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other 4c ---) Original Certificate Date: l - 6 t COSA blue sheet &1-12.tloc If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: BRENNER; LOT 1 Parcel ID: 075-061-82 A. WELL DATA Well type PRIVATE If A, 8, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 11/16/83 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 136 ft. Cased to 115 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 11/16/83 6/12/15 Static water level 21 ft. 30 ft. Well production 10 g.p.m. 6.50 g.p.m. WATER SAMPLE RESULTS: Coliform Q colonies/100 ml. Nitrate /'JO mg./L. Collected by GEG. Ltd. Arsenic: / -Dug /L Date of sample: 6/12/15 B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER 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./ft2or ft2/bdr System type Length ft. Width ft. Gravel below pipe ft. Total depth ft. Eff. absorptio - -a ft2 Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail), For bedrooms 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. 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 offlevel .I High water alarm level at in. Datu Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A Absorption field on lot N/A *75'+ Public sewer main Sewer /septic service line Animal containment areas 25'+ 50'+ On adjacent lots On adjacent lots 100'+ Public sewer manhole/cleanout **81 Holding tank N/A Manure/animal excrete storage areas 100'+ 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Properly line Absorption field Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD • • TO: Property line Buildin , ,. • .ation Water main Water service line Surface water Driveway, parking/vehide storage Curtain Wells on adjacent lots F. COMMENTS *PER THEODORE MOORE, P.E. DRAWING DATED 5/91 **WR#910020 G. ENGINEER'S CERTIFICATION ! cerflfy that !have determined through field inspections and � ,t : � 4 O review of Municipal records that the above systems are in conformance with MOA COSH guidelines in effect on this 11 ( 4 date. OP.L e•messi d Engineers Printed Name JEFFREY A. GARNESS 9 . Date -lir .. c 2 lcAoo pd'Droressio� e' (Rev. 11105) ROMEO aInlw .=eat GAY. (a) ,ioNT RAMI SETBAOt SCE ammo SOMA= RETAILS o. 0'4:30 h / #441 SO, a4 �J /)- 0 0 138.17' S89° 19' 32"E 1111111j5 THERE ISA 2COIREAM PROTECTION/NZ MAINTENANC,� EASEAENr ON RIMER 510E OF THE STREAM IN ACCORDANCE W&THAMC 21,45210 ONLY PERNRICO USESAREALLOWEDYRTNINTHIS SETBACK. *G 0 / / UNDEK NO dRCUMSTAM ES SntiULL AN A6-6oJLT EiE U5GU Etas -CCNSTnUCiv,l CR 7CR ZETIEL,DIING .aCWi A. - =173. THE SURVEYOR TAXIES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES RNANOAL UABIUTY ONLY FOR THE COST CF THE SURVEY. LISTED DISTANCES PREVAIL OVER SCAUNG, REPRODUCTION MAY CAUSE ERRORS IN SCALE LOT SUR M Y SURVEY TYPE FOU!ffiIAnk1 AS -BUILT ❑ FINAL STRUCTURE AS -BUILT PLOT FUN ... AS -BUILT . LOTSURVEY... TCPCCFAPRY rI AS-TjL'II.T . , . }t0 CORNERS E'f L RECERTFCAIICN AS -BUILT ... NO CCfbIENS. SET PLOT PLANS & LOT SURVEYS IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO CONSTRUCTION. TO VERIFY PROPOSED BUILDING GRADE RELATIVE TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE THE. EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS WHICH DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. SYtv980LS PROMO • SET REBAR um. DRAINAGE o FOUND REBAR .0 0 3 wow FENCE me ASSUMED ELEV, M X :( METAL FENCE /4'1 ASPHALT. CONCRETE WCOD DECK SURVEY CERTIFICATION .,,.r. ? W... herebynrtth YAt 1 nave'ra,.relY =PROW IShe. W Noon aid barbel have. ad teat 1 hTa :int or mons,' m t th..M anne Goan dee- and la 3230 at a. y n"- m vdedou end Willa eha a _ _ons hv» 031433 Msalurtl Ne PA Gent NDA:ICN A aUiC 33.:.t E. Nene r, hereby Netry 00 3 Noe as fam.d st A.-euit ewwY of the aadt o1 an thb Jet oea that N M sa hoe cad as .naoodaartte sett akee a -- ruses r,CLW, V4AL STRUCTURE AS -BUILT Ono p.rama ei A.-aui iIrMy et me structure en RR Im and Met Si the demi a.e RrratatIY, at aluan `rem .�. Lt. and red Lncmaco late eat :Nem Slei- Cr a '-0• • ' n.A t. yass .._,,Ley ,.• . Y' iOBE4 t1..TCHNs x,R • -4171-9' NOTE: ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE YPLL BE SHOWN. FENCES, WELLS SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS. ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION. ONLY. SNOW MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED. ALL DISTANCES .ARE RECORD UNLESS OTHERWISE NOTED, Prepared by Robert C. Johns, Jr. & Assoo. ProfeSsional Land Surveyors ANCH.CiACE, t t 4 095C4 SURVEY 9 r - COl ;. O I • 06/14/15 t Nr -; RAJ h:.od aJM ifOcte Drown: ic.rla. C,A O'!... al: I-1 Rt1 A1 Lage,i Dsscrio:ion: Lot 1 RGGA]A11=�? 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 Parcel I.D. # O'1 J ILIO 4 - ga 1. GENERAL INFORMATION Complete legal description HAA# WQc'1ab.�1-k Lor I BRegAt ,e s -/b Location (site address or directions) :BREKkgte C(RcLE , G IRD1✓000 • Property owner OKE STot,-rEt4 BERG Day phone .6 59- 8660 Mailing address Fo. BoX 805GIRDWooT •Ak ,99587 6r/A C. Lending agency .� 6o w, 7"u do Roap< Mailing address—. Agent .JACk V -NeocK R6RG iAck ire ,Fee-2ret Day phone cry'e 7:15-0-3f f,..t F , Day phone ` 762 - 31,13 Address 320/ NC` Sf., Anchor y,. 4k 9903 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 2 Ns 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 #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm FL 4TT0P TEON. SVCS. Phone 3 S- 13SS Address 1L453o ECHO Sr AucN. fFk R9s/6 Engineer's signature- Date 7u11e 6 /99Z 4%. OF At X110 dr 0. grAPA,2%**. . •• V 0 '�` . 49 -- . * 0 ,..., ,# „ye+ S THEODORE F. MOORE : 0 +>tvii VA,,`•. :3589`4.• z' v 4! 6. DHHS SIGNATURE 4A� ���7 %L,' Approved for 2- bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By .- o H N Sit tn-f Date CIO 2 - ' CAUTION The 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 #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT l BREMNER s%D Parcel I D A. WELL DATA Well type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed 111 i471 83 Driller 141 - Total- Total depth 13 6 Cased to H 5 t Casing height 3 r Sanitary seal (Y/N) y Wires properly protected (Y/N) MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION FROM/ WELL LOG ATINSPECTION Date of test 11 !83 61 ► l9 Z Static water level 2 1 2 2r B.T. o, c. Well flow to gpm >6.1+ Pump level 6o JUN - 8 1992 RECEIVED gpm SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot q.fl . A tv v S EwEk') ; On adjacent lots 4,A Absorption field on lot N, A. ; On adjacent lots K.A . Public sewer main c. 79 Public sewer manhole - WAIVER GRAMTEb Sewer service line 32 Petroleum tank N o/1E oasERvED WATER SAMPLE RESULTS: Coliform Q col /lop r, c Date of sample: (o ill 94 - Nitrate 4 v • l -e bis/at Other bacteria 0 cal boo e Collected by• FLATTOP TECii. Svcs . B. SEPTIC/HOLDING TANK DATA N. 4. (A. wkic4. Sewed Date installed Tank Compartments Cleanouts (Y/N) Fou High water alarm (Y/N) Alarm tested (Y/N) Date of pumping Pumper ation cleanout (Y/N) Depression (Y/N) SEPARATION . TANCES FROM SEPTIC/HOLDING TANK TO: Well(s) o •t On adjacent lots To • operty line Absorption field Surface water/drainage 72-026 (Rev. 7/91) Front Foundation Water main/service line CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "P p on" level at "Pump off" level at High water alarm level Cycles tested Meets MOA elect c codes (Y/N) SEPARATpN DISTANCE FROM LIFT STATION TO: Well on4ot On adjacent Tots Surface water D. ABSORPTION FIELD DATA N.4. (fIWINGC SLwtr) Date installed Soil rating System type Length Width Gravel thickness Total depth Total absorption area Cleanouts present (Y/N) Depression over field (Y/N) Date of adequacy test Results (pass/fail) for bedrooms Peroxide treatment (past 1 months) (Y/N) If yes, give date SEPARATION DIST NCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots Property line To building .undation To existing or abandoned system on lot On adja•ent lots Cutbank Water main/service line Surf.ce water Driveway, parking/vehicle storage area Curtain drain 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. 40:46:41"111 II% Signature0 c L �• s : 49! T$ Engineer's Name Vi� dareF--/`-too< /. •..... 0 THEODORE F. MOORE ; E 44 ii741%1 to o"...' Date J'urie B !992 HAA Fee $ Date of Payment Receipt Number a 3-9arit 72-026 (Rev. 3/91) Beck MOA 21 &0) Waiver Fee. $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY Alk088, A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. Client Sample ID : PWSID Collected Received Preserved with . Analysis Completed Laboratory Supexvi_ Released By 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 L1 BRENNER WEST HOSE BIB UA JUN 1 92 0 12;15 hrs. JUN 1 92 @ 14:55 his. AS REQUIRED : JUN 3 92 o� -STEPHEN 'C, IDE Parameter NITRATE -N ANALYSIS RESULTS fox INVOICE # 54279 Chemlab Reza 92.2440 Sample t 1 Matrix: WATER Results Units ND(0.10) mg/1 Client Name :FLATTOP TECHNICAL SRV Client. Acct :FLATTOT BPO# : Req@ : Ordered By :TED MOORE Send Reports to: 1)FLATTOP TECHNICAL SRV 2) Method Allowable Limits EPA 353.2 10 PO# :NONE RECEIVED f Sample ROUTINE SAMPLE COLLECTED BY: CHRIS Remarks: .M....a.a.WWWWWW1WWW.s.MReMWWW .v3.a.....®ma...a.n..mw eiMMMMM . ..1a..,R..W_.WWWW arwm_.,,woqx.=„p.R._...;.dft®.n...mm..®., 1 Teets Performed ND- None Detected Nk- Not Analyzed * See Special Instructions Above. ** See Sample Remarks Above LT -Less Than, GT -Greater Than UA -Unavailable r�1SGB Member of the SGS Group (Societe Generale de Surveillance) CHEMICAL & GEOLOGICAL LABORATORY 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 FLATT°P CI4, SVCS 34S- 1355 Name Phone No. 1'453o ECI4o ST Mailing Address ,4 N C [� . City SAMPLE DATE: SAMPLE TYPE: 0 Mo. 0 Day Routine ❑ Check Sample (for routine sample with tab ref. no. ❑ Special Purpose SAMPLE No. LOCATION 1 1 Lor 1 B RE u>,(602 2 ( WEST 14 os: Rib 31 4 State 9 Year RS(6 Zip Code ❑ Treated Water Untreated Water Time Collected Collected By D t t (S— C ft tr 5I A,D,E.C..S� READ INSTRUCTIONS BEFORE.. TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: If—Satisfactory O 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 01192, Analytical Method: Membrane Filter No. of colonies/100 mi. Lab Ref. No. Result* Analyst 92.2440 BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count Verification: LSB BGB Fecal Coliform Confirmation 0 Coliform/100 mi COLLECTING SAMPLE' Final (Membrane Filte Rert:Its Coliforml100 ml= Reported By�J 1 Date f � ' �l / V TNTC = Too Numerous To Count OB = Other Bacteria PART ONE OF TWO REMAINDER TO FOLLOW B.M. P.M. 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 Parcel I.D. # - Not - 1. GENERAL INFORMATION Complete legal description HAA# owl \n\ 1.o .1, 6re,ner S (.D Location (site address or directions) t3renner Ctrcfe, Gcro(w000( Property owner Mailing address Lending agency Mailing address Agent N. A Mtke S/a1len h et:7 Day phone 65'9 ' 8660 P v• i3c>x Bas Gc rdcua /4 91s -a 7 . 6. A-. Day phone Z4 7- 3 V 2 15'00 w. !Semon (3fv� , ��cloeayej 4.cc `j9503 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 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 4t21 Baa Vow AoEs (1.6n'Ae ) szo-aL •NJOM s,a90u16ue leuolsse oad ay4 u! suo!sslwo JO saoaaa alglsuodsaa mu s! a6eaoyouy imedlolunv ayl •penss! Si a}eolf!>,aao a aaoiaq elep az/Clam JO suo!4oedsu! 4onpuoo fou op SHHa to sea/oldw3 •s4uewaa!nbei 9121S pue 18.10P8j. ule4aao /4s!}es u! suo!}nmsu! 6u!puep alay) pue sewoy m saeseyoand o; AsaJnoo ase sly; swop SHHa ayl •mlsely m ems ay; u! paaa1sl6aa aeeul6ue leuolssamad 4uapuadapu! ue Aq anoge g ydea6wed u! uani6 suolleluesaadeJ eq uodn Apo paseq se4eompeo lenoaddy Alpoy4ny y4leeH swiss! (sHHa) sadvues uewnH pus y4leaH m;uewIaedaa a6eaoyouy;o,4lledlolunv1 eq NolIneo 4- 70- % e'ea s}uawwoo leuo!4lppy :suopind!}s 6ulnnolloi aye g4lnn 'swooapaq /6/o2 /S elea 91Sb6 =i-6' ' ?4 ' OV -7v4' .7{5 • '-1 o£5h/ ssaaPP`d Ssz, - Sh auoyd fr »n✓?. S iv, r% b) J wall 10 aw8N •uo!}oadsu! s!ql to amp ay4 uo page u! suo!}eln6aa pue `saoueu!pao 'sapoo aims pue Iedlo!unw !le yfIM aouelldwoo u! s! wa><sAs lesodslp aa4enna4senn ao/pue Aiddns aa}eM ails-uo eq;} 'uogoadsu! pue uol4e6Rsenu! Aw wow} pue sag a6eaoyouy ,4!!edloluniAI eq4 woad paulmgo uoRewaolu! ay4 uo paseq 48111 A4laan aay4aN 1 •u!aaaq pa4eo!pu! aan4ona}s ads(} pue swooapaq to aagwnu ay} ao} al<enbepe pue Ieuo!4ounl `ales s! we4sAs lesodsip aa4enna4senn ao/pue I(lddns amain eus-uo ay4 4ey4 smogs uo!}eolldde lenoaddy A4laoypny y4IeaH s!q1 uoRe6l4sanu! Aw 18114 Ajpan i 'nnoleq unnogs amp uogepllen an Jo se pue olaaay pemie Zeas /q paWIaao sy ao� lenoadde Ieuol�lpuo0 •penoaddesla •swooapaq Z aoj. panoaddy x 't' ``'l'j���m 3af11dNJIS SHHa °9 �Hn 66A�.> iSSeitUd I J37 4,11 • 685E - �%. �t 321OOW '4 3e0003H1 ; �� -s V 44 7V i0-•+4` -1-2-074/1, einleu6ls s,ieeul6u3 1133NION3 AS NO1103dSNI AO IN3W31H.S °S Legal Description: A. WELL DATA Well type Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST G,o 1, cSren"er S/D prt rtTG Parcel I D If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) i Date completed 11 / 16 / 8,3 Driller M _w Total depth 13 ( Cased to lir Casing height a' + Sanitary seal (Y/N) t' Wires properly protected (Y/N) i FROM WELL LOG AT INSPECTION va ro c.7 Date of test it 7a3 1Y/ 16/9/ o c AA ii •"- iU Static water level 2 / 2,3' 13.7: a C. Io Well flow 10 g p m 3..,5" gIli.�, Z Pump level ^ > Y 7n - moo .c4 SEPARATION DISTANCES FROM WELL TO: e)" f° Septic/holding tank on lot N. 4. C awrc.'(4-. ,Sewer) ; On adjacent lots X1.4. Absorption field on lot N..4. ; On adjacent lots N. 4. Public sewer main Public sewer manhole/ Teanou� 8 / Public sewer service line 32' Petroleum tank None $ e e•, rri rn 4 � r ri WATER SAMPLE RESULTS: Coliform O //00 m .Q Nitrate o. / Pr, /-e Other bacteria 0 1la0A, -e Date of sample: y / to / 9 / B. SEPTIC/HOLDING TANK DATA N. A (i4-wc c.4 Collected by' Flaillop "Tech S'ac sewer) Date installed Tank size Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y/N) Alarm tested (Y/N) Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot On adjacent lots Foundation To property line Absorption field Water main/service line Surface water/drainage 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION N. a. ( /4 w wu Sew e/') Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA N.A. CA “11416C Se er) Date installed Soil rating System type Length Width Gravel thickness Total depth Total absorption area Cleanouts present (Y/N) Depression over field (Y/N) Date of adequacy test Results (pass/fail) for bedrooms Peroxide treatment (past 12 months) (Y/N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots Property line To building foundation To existing or abandoned system on lot On adjacent lots Cutbank Water main/service line Surface water Driveway, parking/vehicle storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on ��thhedate of this inspection. Signature %�frtert-.e.. i./4..9..7.'•�.c(.- ' i� Theodore r /`-too.-+E ; 1;0... .; .,. • /. Engineer's Name Date Nay 20/ /99/ i • . THEODORE P. MOORE if • 4 • CE - 3589 c ' t4 4.4;•• ••'� ` r.rlotessioltit 41.4, HAA Fee $ Waiver Fee• $ S` .0�O 3C(962 - Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 ANALYSIS REPORT 3Y SAMPLE fox WORKorder4 33451 Date Report Printed: APR 20 91 t 19:32 Client Sample ID:11 BRENNER S/D BACK HOSE BIB PWSID :UA Collected APR 18 91 4 12:30 hrs. Received AYR 18 91 C 17:20 hrs. Preserved with :AS REQUIRED Analysis Completed :AP[ 19 91. Laboratory Supervisor :STEPHEN C. EDE Released By Chemiah Ref #: 911529 Lab Snip] ID: Parameter Tested NITRATE -N Client Name :FLATTOP TECHNICAL ERV Client Acct :FLATTOT BPO # Req # Ordered By :TED MOORE Send Reports to: 1;FLATTOP TECHNICAL SRV 2) Matrix: WATER Result Units Method Sample ROUTINE SAMPLE COLLECTED BY: CHRIS. Remarks: 1 Tests Performed ND- None Detected NAF Not Analyzed ND(0.10) mg/1 EPA 353.2 See Special Instructions Above " See Sample Remarks Above LT -Less Than, GT -Greater Than OA-Unavailahle PO # NONE RECEIVED Allowable Limits 10 ' CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 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 FL A -r -To P TE c l-1 Name SvCS 3t3SS Phone No. I `eS30 EC Op $T. Mailing Address fi ntcH, AK ggs16 City SAMPLE DATE' 0 Mo. Day State 9 SAMPLE TYPE: Routine ❑ Check Sample (for routine sample with lab ref. no ) ❑ Special Purpose SAMPLE NO. LOCATION 1 1 LOT t RRFNNl=E 2I 3 1 4 1 5 Year Zip Code ❑ Treated Water Untreated Water Time Collected Collected By VV. 30 TO BE COMPLETED BY LABORATORY Anal s shows this Water SAMPLE to be: 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 4//g/9/ Time Received /720 Analytical Method: Membrane Filter * No. of colonies/100 ml. Lab Ref. No. Result* Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD A.D.E.C. Membrane Filter. Direct Count O Coliformt100 mi Verification: LTB BGB Final Membrane Filter Results c Coliform/100 mi 1-/—/c, Reported By L� Z � w —� _ Date -5/ 7 TNTC = Too Numerous To Count OB = Other Bacteria Time: PART ONE OF TWO REMAINDER TO FOLLOW a.m. p.m. o*, *OF**** •. 4 I,. • of CO* : THEODORE E. MOORE t • C -3589 ttr'i` -‘11eiveorow— i_Or i, StENNER s,'p S ITE PL,4N 5c4: I"=3o` Dara : S79/ o -'N C Y: TrI1 NorE; TMs cs Nor ASuRutYa)PI..,4T G.GCA4T10NS A 17 z ' pRe) xfIIATE is • Ivi -w ORIUJNG, Inc. kia N t7 pr+ 10-375 • ¶0300 Old Seward Highway (90 7) 349-5535 ANCHOfAIE. ALASKA 99511 DRILLING LOG Wen Owner Cer1.ew Investments—Use of WeILDIMRetie. Location (address of: Township, Range, Section, if known; or distance main r0&___. Lnt 1 Arpnnpr Sub. Size of casing 6" Depth of Hole 136 leet Cued to iii feet Static water level 21 ft (ahtxiu( (below) land surface. Finish of well (check one) open and ( Screen ( ) ; Perforated ( XXX ) . Describe same or perforation_ Liner - 4" Galy_ Rtepl apt At 106-116. 1nttnt Al pp+dammare Well pumping test at._10_gallons per (Mut) (minute) for_._ 1 hours of drawdown from static level. Date of completion Nnvpmher 16, 1,481 WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness n TO ? Caring st icvnp_ _Z_TO 4 Organics 4 TO 15 Gravel with silt & clay 15 TO 24 Gravel with ocr_ boulder 24 TO 71 Gravel with milt JUN 41991 ALTO 9n Si i r with gravel 90 TO 115 _Gravelwitb silt 115 TO 118 BWO der • 118 TO 121 121 TO_1 I L- 131 TO 134 134 TO 136 TO TO___ TO ASYI Municipality of Anchorage Dept. Health Pt Human Services. Harahan _ r1ny s. sttr Soft 6 damp1/(7-eLt- �,�j��----- G=avel with rlav_____(dAmp) WAterhearing_gr__avpl NWWA Cei tit rvj Wilts a . Certificate No's. E14 & E13 1—CUSTOMEr, I m r r N0 SIAIG8C'S T N 27' 0 O T1 r m rn A _t • m r 1 1. �1 rn = 0 0 t. r �2 m 0 D n Aav1iNVS 03SOdO2id 1Va3N39 A W N cu fl0 L ii D ZD ; nijn ]1 t7 n0 r A D O N n fr/i 7 (•" x"4 pmm7 N2 DE mD Orn ttn/1p 023 nc 2Dir �rD 0m fc (n r•mm. OC 0 'I) 4D Z Z f/1 myrn Dm Am nCj1 NN n D" ' 2 Dnp 24 ---4 O m_ 2 T (n t! Tr -. 7"'1x0 0'..-.4 m. S. urn () n- m !9 m•4 D!^ fn. .rxr, 7 3m fp-Dl t!+ ulO r f .ifj m O" v m o= 0 rn 1r`v,<z< �m z `m T D T7 7 -'t r -- >d' 0 -- ,. D i 0 1 • D T In N c, n • O mZ D ip ••< -; In it n n p -( Inr Am T D 1Rr12 1 ✓ r , , T' rn 0 < 0 (1 V1 f, N!(z J In p N .m 310%i N.W 03SCdOad rn rn z v S31ON NOLLOnaiSNOO { -"v (A r c1 'Dis1 U u' Ox 4 ^t rn p r m r r 0 r' r r- * vi. f^ 1 �Y r/4 " 1\- { I 11 m rn 11 1VNO: LVN FIOV9t1HZ (11 1f1,11. r— I(,1) L r lo 2 0 = 1n m p z 1 •til TO z ALYESKA HIGHWAY r 0 -1 0) m PL AID 1600A9B SIA +i(fl- CONSTIUCT C.U. Et -•3B INV. E4. -1247-e• 125 78.08 n STA 0+00 CONSTRUCT M.H. OIE-3A � e -RAV INV. {11i-6-90. 123.89.ASB SE IN\. 1-20--B-8.. 123 81'ASB 1,-- -6N u .+42+e3 I J, �Y • ,j p Tom Fink, Mayor Municipality of Anchorage A* 410 Department of Health and Human Services cfl1hs 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 June 5, 1991 Ted Moore, P. E. Flattop Technical Services 14530 Echo Street Anchorage, Alaska 99516 Subject: Waiver Request for Lot 1 Brenner Subdivision Waiver Request #WR910020, PID #075-061-82 Dear Mr. Moore: Your request for a waiver of the required 100 foot separation of a private well to a public sewer cleanout has been approved. The approved separation distance is 81 feet. This waiver approval applies to the existing well and public sewer cleanout only. Any future upgrade will require all separation distances be met or another approval from this department. S' ncerely, Cour: Atv Daniel oth //ohn Smi P.E. Civil Engineer Program Manager On-site Services On-site Services DR/ljm W,IvF_P RF II/EW FDiQ Lar / BRE,vatR Sue. 07s"-06/-S'2 IAvlf1 vE13 Ff5CQvEsT fun16/j tve9/002 o HifiUEI_lEQuEfTEP IS S/ fill_ f/PU,-+ 14-Ft[ 7g pkiNic SEt. Alf_ LL-LL P/177 — —T HE k'5t.i. /S j 36 fEo.r Peen to/ rH //f' PEET OF C. s/NG. T/tl f 144LL 15 Or/L16-0 7714140_466, SfviRAL Li9YE1'; OF S/L rf CLAPS 1.v1T1/ eat L;/MvEL. #FT4.FE.t, 134 FEET ,vivD /3` FE1r /s 4 E,q.v SeAvEL. 1,... rHt L.749 ___Cl /?04//1//ti6 THRok6H , r. ''m T/i( weLL /t L oC, TEp 8/ FEET FROAc T'/-re faIii /c is AT 1HE set,—En 2/A/F cL r/'I Q k T U-/illH'' END o___P rieR fe fr o, L1Nf- /N Til/f Pula S-4C Willer/ rli/f G. F.-L 15 Locsi THE SEL L I S O/+/ Tiff riG w a ,f/DE OF /4 r 6/0 SLOPE FRo rrw E (Le/fa/014r. 4 04 C• c C. to 4 W 1-1i( 8 Yr v gifiF / Oj' r-1-r ,91.L. P/P1s A Purr/LE rife", w T i.,gTE:I' T/Geri O I *, i S, 4"L 130nAro/?r 5.4 PLES /tiP'c,grk THERE ARE No /ViT/PAT Ff OETE<MOL E fetid as 0.4(r/r/4 PResEi1ir" ,5,oFA.D.E,C.5,P.w.6. lear 5,C.R.O, Po i'n G+, rte Niece Qo rroM op C. a. /a` .•, ,% = 2-4 . / +7 7. I sdePnoN_Z2,-) +i (if: )‘ 7 ¢ >z 124 3. PERtiE4 P« /rY /¢ 2./ wq TFp r»z'if 6NAP/EwT AJ3ung WORSE CATE -/al 1. 2 ijP/zor4LSEA,9/e477oN S1' .:. -1--:--16=.21,2 2.2 /6. 2 a ti CL us/oN ii- P / v 6" ft 4 j' RE oi-PAA,TE19 l T " P TECHNI AL SER I( CIVIL & ENVIRONMENTAL ENGINEERING • ENERGY CONSERVATION & ANALYSIS THEODORE F. MOORE, P.E. 14530 ECHO ST. PH: (907) 345-1355 May 17, 1991 ANCHORAGE, ALASKA 99516 M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: L02_9 I voao seoinaeS usWnHLluoH °Idea eOsaotaouy Amp.cl!oiunm 1661 Z AM a3A13D3d By means of this letter we are requesting a waiver of the normally required 100 foot separation distance between a private well and a public sewer cleanout down to 81 feet for the well on Lot 1, Brenner S/D to the cleanout at the end of the sewer stub serving Brenner Circle in Girdwood. A site plan and the sewer as -built drawing and well log are enclosed to assist you in your review. According to the driller's log the well was completed in November of 1983 and has a total depth of 136 feet and a yield of 10 gpm. The well log indicates that the aquifer supplying this well is confined, and that the effective depth to the water table is 132 feet below ground level. On April 18, 1991 the static water level stood at 23 feet below the top of the casing. Steady pumping of 722 gallons of water from the well at an average pump rate of 3.5 gpm caused the water level to be drawn down to a maximum of 47 feet. Based on the test data we determined that the total yield of the well is in excess of 3.5 gpm, which is more than adequate for any single family residence, and also exceeds the FHA criteria of being able to supply water at 3 gpm over a 4 hour period. Research of the AWWU as -built drawing of the Brenner Circle sanitary sewer indicated that the sewer cleanout at the upstream end of the sewer is probably within the 100 foot radius of the well on the subject lot. On May 7, at our request Greg Anderson of the AWWU Girdwood office had the sewer cleanout located by his staff, and he reported that the measured distance from the sewer cleanout to the subject well is 82 feet. The only reason this waiver request is for 81feet is to allow for the possibility that another person could come up with a different number using a different measurement procedure. The topography in this area slopes gently towards the southeast at approximately 5%. In our opinion there is virtually no possibility of the sewer cleanout being a source of contamination to the well. Due to the configuration of the sewer line, it would be impossible for a sewerline blockage downstream to cause wastewater to back up to the point where effluent could leak out of the cleanout. In the unlikely event that such a blockage occured, the effluent would leak out of the manhole at the intersection of Brenner Road and Brenner Circle first. Furthermore, there is a surface drainage course between the sewer and the well which would effectively capture any effluent before it could make it to the well. The following is a tabulation of how the points could be assigned using the 1985 separation distance waiver guidelines promulgated by D.E.C.'s SCRO. Category Points Water table (based on 132 feet to the aquifer) 7.16 Soil Sorption (predominantly silt) 3.5 Permeability (predominantly silt) 2.0 Water table gradient (assume -10% as worst case) 1.2 Horizontal separation (81 feet) 2.24 Total 16.1 Based on this waiver point analysis, it appears that the waiver can be granted without concern over potential contamination to the well by wastewater from the sewer cleanout. This conclusion agrees with our opinion based on field observations and analysis. Sincerely, Ted Moore, P.E. V140 t' a*RA*` UNICIPALITY,OF;ANCHORAGI• „. EPAh i MENT OF HEALTH AND; ENVIRONMENTAL. PROTECTIO DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 GENERAL INFORMATION • (a) Legal Description (include lot, block, subdivision, section, township, range). Application Date Location (address or directions), (b) ' Applicant Name IA r.1a 14''' Telephone: Homed‘ Business -6,/o7 Applicant Address ' 94. u$ p /t,%# ,9ivC i. (c) Applicant is (check one): Lending Institution 0 ; Owner/builder ❑ ;.Buyer 0 ; Other (d) Lending Institution Telephone Address (e) Real Estate Company and Agent 7�+-tIC alk -*1 ."�%1 Address (f Telephone (f) Mail the HAA to the following addr ss: 41't ; s MN_ . TYPE OF RESIDENCE Single -Family �t Multi -Family 0 Other Number of Bedrooms 2` 3. WATER SUPPLY Individual WeII4 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 0 PublicA Community 0 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 1 of 2 5 ENGINEERING FIRM PROVIDING INSPECTIONS,'TESTS, FILE SEARCH, DATA AND INFORMATION ` n ,,'.: r P hof Ff r ...01:‘lirIVW � ! -` W1f .44 .As certified by my seal affixes ireto and as of the validation date shown bei , 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. 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 in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm /g3,-14- } L� .e -P -i-;-1 Telephone 6/ 5/c 7 Address � ` r>�L E3ir.� - , , t r. q.7�0 3 Date ems/ 3C7� DHEP APPROVAL Approved for Approved 62) of . • • B. W•1'NE ND 0 N •P ;• /'C -448: •.� c~ a ®8 �6 1,y...•..•..••••scy'®-.1 klitlioalb.w 3F.•. 1C'°o bedrooms by Date Disapprq•p• Conditional Engineer's Seal /•.er/0 Terms of Conditional Approval Adlik 4414* dhep CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a 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. WELL DATA MUNICIPALITY OF ANCHORAGE (MOE+, HEALTHgKCApryppygE(HAA) CHECKIA$T. - ffE Fkf 164 ENV IROAkITIV ROTECTION 'Legal s n• A RECEIVED Well Classification dI vAdX If A, B, C, D .C. A proved (Y/N) iv/ Well Log Present (Y/N) Ye— Date Completed ////6�g. Yield 5 M. 6/z1/8'6. b'6. Total Depth / 3 & Cased to 116-- Depth of Grouting /'V Static Water Level allirt 2/ / Pump Set At lob 1 Casing Height Above Ground 3 e /C Sanitary Seal on Casing (Y/N) /..s Electrical Wiring in Conduit (Y/N) ��S Depression Around Wellhead (Y/N) Mo Separation Distances from Well: To Septic/Holding Tank on Lot /v0A2& 6).i4W« f; On Adjoining Lots Wave eratirtiao To Nearest Edge of Absorption Field on Lot NDA.,6 ; On Adjoining Lots A100/5 To Nearest Public Sewer Line e 3 1 To Nearest Public Sewer Cleanout/Manhole //,00 1 To Nearest Sewer Service Line on Lot Z Water Sample Collected by jO, ost.ofer"SDri/ ; Date 4/21794 Water Sample Test Results "�T� s >C1-374,' Comments �' B. SEPTIC/HOLDING TANK DATA Date Installed Size No. of Compartments Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N) Date Last Pumped Pumping/Maintenance Contract on e (Y/N) ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tan To Water -Supply Well To Building Foundation To Property Line To Disposal Field To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Abs. .tion 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 Present (Y/N) Depression over Field (Y/N) Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: 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 To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments N ©NE D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump Off" Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments -At NE ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I h . ve ch Sig Company Receipt No. verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. ..�,�.� Date 3 cl MOA No Date of Payment 1- \ -V--0 Amount: $ (p S £ThC7 Page 2 of 2 72-026 (11/84) Engineer's Seal CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER O PUBLIC WATER SYSTEM I.D.# PRIVATE WATER SYSTEM Nsw i��, ,� „� . I-57 0-2 Name ne No. �O Gv- Mailing Address 46vC-A • City SAMPLE DATE: D Mo. 14910 1 603 z Day State 46. SAMPLE TYPE: Routine Check Sample (for routine sample with lab ref. no ) 0 Special Purpose SAMPLE NO.LOCATION Loh AT 2 3 4 5 Year Zip Code ❑ Treated Water O Untreated Water Time Collected Collected By 9 Van, td TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: Val 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 bey N. Time Received lol Analytical Method: Membrane Filter No. of colonies/100 ml. LabRef. No. Say/- ,2c 4 Result* Analyst Imo. -pcG READ INSTRIInT!ONS BFFORF r•,,{ BACTERIOLOGICAL. WATER ANALYSIS RECORD Memhrane Filter: Direct Count Verification: LTB Reported By. TNTC = Too Numberous To Count OB = Other Bacteria BGB Date Coilform/100m1 (,a Time: l v C✓ a m i P.m.