HomeMy WebLinkAboutBRENNER LT 4Brenner
Lot 4
#075 - 061 - 85
M -VV DRILLING, Inc.
P.O. Box 10-378 • 10300 Old Seward Highway
(907) 349-8535
ANCHORAGE, ALASKA 99511
Well Owner CERLEW INVESTMENTS
DRILLING LOG
Use of WeILUomest is
Location (address of: Township, Range, Section, if known; or distance main road
Lot 4 Brenner Sub.
Size of casing _h" Depth of Hole _141_ _ feet Cased to___1_41.111__feet
Static water level 24_ ft (aharu) (below) land surface. Finish of well (check one) open end ( XXX );
Screen ( ); Perforated ( ).
Describe screen or perforation_.
Well pumping test at 15 gallons per
of drawdown from static level.
Date of completion_ November 21, 1983
(r)
minute) for 1 hours with 1D0/
WELL LOG
ftx
Depth in feet from
ground surface
OTO 2
2 TO_ -- - 5
1L
Give details of formations penetrated, ze�f p.txaria] color and hardness
p��1s�( } �V a
Casing stickup
co
Backf i11�
5_TO__ ___8_ Or an i r s
8 TO___ 24 Graval with gilt (clamp
24 TO 80
____ 8.0 TO 114
110 TO 129
129 TO 135
Silt with gravel
CraveLwith Gilt
Silt with clay & gravel
Clay with _gravel (damp)
135 TO _13R Gravel with clay (damp)_
13R TO 144._ taterhea.r.ing_gravel
TO
TO
TO
TO
TO
r
-NWWA Certified Contra .tt. r
'U rtificate No's. 814
1 CUSTOMER
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 075-061-85
1. GENERAL INFORMATION
Complete legal description Brenner Subdivision Lot 4
Location (site address) Brener Circle C. Girdwood
Current Property owner(s) Marcus Tingle
Mailing address
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
COSA# DV) 15
Expiration Date: fy8/nG
PO Box 163, Girdwood, AK 99587
Day phone
2. NUMBER OF BEDROOMS:
3
3. TYPE OF WATER SUPPLY:
Individual Well (]
Individual Water Storage
Community Class Well
Public Water System
0
0
0
TYPE OF WASTEWATER DISPOSAL:
Individual On-site 0
Individual Holding Tank 0
Community On-site ❑
Public Sewer (]
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal andlor water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation,
based on procedures outlined In the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system Is (are) safe, functional and adequate
for the number of bedrooms and type of structure Indicated herein. I further verify that based on the Information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) In compliance with all applicable Municipal and State codes,
ordinances, and regulations In effect at the time of installation.
Name of Firm Watkins Engineering, Inc.
Address P.O. Box 110443, Anchorage, AK 99511-0443
Engineer's Printed Name Cindy W. Ellis
Phone (907) 349-1851
Date 5-Z-06,
�`� Et.
*7 4911
5. DSD SIGNATURE `a {
V Approved for 3 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stip
By:
V:. CI 1 y W. Ellis
CE•tosn
.r'Y OF Ake %rs
••
ON -SE
IT • %
:tns
WA• STFWA ER
PROGRAM •: k`;
Attachments:
COSA Checklist _L Arsenic Advisory X
Septic System Advisory Maintenance Agreements
Well Flow Advisory Supplemental Engineer's Report
Nitrate Advisory Other
(RM. 11105)
Original Certificate Date: 5140U
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 995194650
www.muni.orglomfte
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL. CHECKLIST
Legal Descriplon: Brenner Subdivision Lot 4
A. WELL DATA
Wen type Pri If A, B, or C provide PWSID i _ VVen Log (YIN) Yes
Date completed 11/21/83 Sanitary seal (YIN) Y Vires properly protected (YIN) Yes
Total depth 144 It Cased to 141 It, Casing height (above ground) 24+ in.
FROM WELL LOG AT INSPECTION
Date of test November 21. 1983 Apd119, 2006
Static water level 24 It. 37
Well production 16 g.p.m. 6.6 g.p.m.
WATER SAMPLE RESULTS:
Conform 0 colonies/100 mL Nitrate <0.1 mg&L Other bacteria <4 colonies/100 mL
Arsenic: 0.0118 mgf Date of sample: 4/19/06 Collected by: Cindy EMs
B. SEPTICIHOLDING TANK DATA
Tank TypelMatedal NA - AW WU sewer service Date installed
Tank size gal. Number of Compartments Cleanouts (WN)
Foundationfdeanout (Y/N)E_ Depression over tank (YIN) _ High water alarm (YIN)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed NA Sol rating (g.p.d./R2 or ft%/bdrm) System type
Length E. WIdih R. Gravel below pipe ft.
Total depth It Eft. absorption Brea f9 Monitoring tube _ Depression over field
Date of adequacy test Results (Pass/Fall) For _bedrooms
Fluid depth in absorption field before test in. Water added gal. New depth in.
Elapsed Time: min. Final fluid depth in. Absorption rate n g.p.d.
My rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date
Parcel ID: 075-061-85
D. UFT STATION
Date installed NA Size in gallons Manhole/Access (YIN)
'Pump on" level at in. "Pump off' level at _ in. High water alarm level at
Datum Cydes tested Meets Warm d drat requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WEU. ON LOT TO:
Septic tankAift station an lot NA On adjacent Iota NA
Absorption geld on lot NA On adjacent lots NA
Public sewer main 80+ Public sewer manhole/deanaut 81*
Sewer /septic service line 25+" Hotting tank NA
In.
Animal containment areas 100+ Manure/animal excrete storage areas 100+
SEPARATION DISTANCES FROM SEPT1C/HOLDING TANK ON LOT TO:
Building foundation NA Property line _ Absorption field_
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property lire NA
Water Service line
Building foundation Water main
Surface water Driveway, parking/vehicle storage -
Curtain drain Wells on adjacent lots
F. COMMENTS: 'Wet to sewer main deanout In center of Brenner Circle is 81 It. Waiver is requested. "Sewer
service line on property was moved in 1988 to maintain proper separation to well, per conned card (copy attached).
0. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review Of Municipal records that the above systems ere in
conformance with MOA COSA guidelines /n effect on this date.
Engineer's Printed Name Cindy W. Ellis
Date Mav 2.2008
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
11 o3
Waiver Fee S / cr9
Date of Payment St - 0 6
Receipt Number
7760 3
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.orglonsite
(907) 343-7904
Arsenic Advisory
Certificate of On -Site Systems Approval # 060151
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
4 of Brenner Subdivision. This inspection revealed an arsenic concentration
of 11.8 micrograms per liter (ug/L) for the property's well water sample.
The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems.
While private wells are not subject to this regulation, EPA standards are
based on existing health information and can therefore be used to gauge the
relative quality of water from private wells. Information on arsenic is
available from the On -Site Water and Wastewater Program website
(www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
SCS Refq
Client Name
Project Name/N
Client Sample ID
Matrix
Pw.SID
1061902001
Watkins Engineering
Brenner Lot 4
Brenner Lot 4
Drinking Water
0
All Dates/Times are Alaska Standard Time
Printed Date/time
Collected Date/rime
Received Date/time
Technkal Director
04/28/2006 13:08
04/19/2006 13:35
04/19/2006 16:25
Stephen C. Ede
Sample Remarks:
Parameter
Results
PQL
Allowable Prep Analysis
Unita Method Container ID Limits Date Dale kit
Metals by IDD/MS
Arsenic
Waters Department
Nitrate -N
Microbiology Laboratory
Total Coliform
11.8
ND
<4OIL NoColl
• 5.00
ug/L EP200.8
0.100 mgt. EPA 3532
co1/100mL SM20922213
C (<-10) 04/24/06 0427/06 WAW
D (<-10) 04/19/06 ALR
A (<-1) 04/19/06 TLF
na ,)elm ROM
IMV. IAnaRD)
Y /
�4
ti
OC
lk
Z
o
.
&
5
i,
t5
.D
S
ADle gb
c`--\
• \
E.Yi3TiNG. L
01 TP'1
r.� rouse
off.
lit
N 'LeS 6
\\�
rb
N
to
0 3
0
N. l(((•,y�/
�',
/�
/R`,NNeR {
•.a.a+e VIA01140UAC
ccea
LEL Naawa)
rano MKT
.Rant eaawo 0IIIAa
101 LtAbel IMAM
r
il
.'
•
% — & PAVEL 1
_ - r '
. OR'/Ve- r ,
D ' 1-
. ..e
l
%" R:55,00'•
L = 47,94"
SURVEY CO 1CA11ON
.�****a**ii,,
4�:•�E• •,••• ••,
%41,/Sr ••' •.
,IR.
Prepared by
Robert E. Johns, Jr. & Assoc.
Professions! Land Surveyors
1700 BRINK DR.
ANCHORAGE, ALASKA 99504
PLOT PLAN
1 as 1n 'S—.00111••••.
'
"tat
et M'..4 ^I
IM IRI MOP
non• ..n
Owlet/ •'.r l
ninny a r
a .m
a.. r.
."
I... Ins'
'r -/ • • 1 )
/ �(
t( �.
40
IR . /
1 e7,."1
..)arra. a
M, w• 1M ISO M Y
I..wer �-a.a—
low
st
FOUNDATION AS-BUILT
L earl C Y,. a. Iamb)
I.,.
Scale: 11. _ 301
Rec. Lot S.F.
Rec. Plot File No.
/ -
- ,4-7
• `
•. 13 •' OBERT r. • NS, •� t
0tb• �., 4121-5 :' ae1�
♦♦ �e •'•. •••' t ♦
• •^ems '•'...•........,•• JCI e
�'II `efessiond �" .. 4.
Oat. Surveyed:
0C
Drown Dy. T
Checked 0E31
wawa,) .� A.mbm
.MLLa
an M. M M eat
mbwwr. le ado noes
Y_. M r wyO.tlwlr,
1
Da le Drawn:
4-10-06
Grid:
.4813
W 0
678
FINAL STRUCTURE AS-BVILi
L earn a
Legol Description:
BrWit enner Subdivision
Jena J. IaN
Ian p� w -
.wary ..t
el � ••
4._
SOMPa•
Ir. and �' awl
°
anto
are
~am
❑ LAT SURvEY
0 FOUNDATION AS-BURT
❑ FINAL .SIRUCTIINE As-euLT
❑ POT PLAN ... AS-eUXT ...
® A$-IMIILt TO CSI.•IERS
SURVEY TYPE
• SET REBAR_
0 FOUND RCBAR p_mb-.e
OCT::::-) ASSUMED ELEV. -X—K--K-,
SYMBOLS
LOT SURVEY ... IWOtRAPHY
SET 0 IRRvrnOAn(w AS-BUTT. . NO CC•4175 SR
:: s:
DRAINAGE ASPHALT
WOOD FENCE 127.41 CONCRETE
METAL FENCE I//,y2.l Wn0P OFCK
PLOT PLANS & LOT SURVEYS
NOTE:
GROUND AND VISIBLE WILL BE
CLEANOUTS, SIDEWALKS. DRIVEWAYS,
LCCATON, ONLY. SNOW
FROM BEING SEEN AND LOCATED.
IJNIF"E OTHrR.W!9E NOTrn
IT 15 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 SUPDIVISION PL.AT.
ONLY THOSE IMPROVEMENTS ABOVE
SHOWN. FENCES. WELLS, SEPTIC
ETC.. ARE SHOWN IN THEIR APPROXIMATE
MAY PREVENT SOME IMPROVEMENTS
Al L DISTANCr9 AR" RFrnRO
UNDER NO CROUMSTANCES SHOULD AN AS-BUILT BE USED FOR CONSTRUCTION OR FOR ESTADLISF' R40 BOUNDARY OR FENCE LINES.
THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTOR ONLY AND ASSUMES FINANCIAL LIABILITY ONLY FCR THE COST OF THE SURVEY.
LISTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
10 ROT
O
Natal/ O-na
CUM (AINIARD)
Zara COWES
PRPIT Mao) IMAM
eat .a_ IMAM
RCAA .AZIONI .,..,I
SURVEY CERTIFICATION
PLOT PLAN
1 May aely Pet I lw MMI! Naas/
..Mer a— ew.N.d lama M M1
ow Oa en pa a leYb 1 M m.
yMaraM saw MM. an boa
SL
FOUNDATION AS -BUILT
away Ina 1
kao Mtin.. A. -VA H aria M as
landala darn M Ii r11n a - Mae
ea M N .. sw..FMee wl weep
— NaaYa
FWAL STRUCTURE AS -BUILT
l Rlaf c A«m e. away away lad
e'+ wawa - ho -aa pea el Pe
Nara • F" .k'SW Wit .awaa r Nam
...an.. re : �.....M. AFI was
❑ LDT SURVEY SURVEY TYPE
❑ FOUNDATION AS -BUILT
❑
FINAL STRUCTURE AS -BUILT
❑ PLOT PLAN ... AS -WO ... LOT SJRVTY .. , TCPOCRARry
2 A• -BURT , Nn CORNERS SFT 0 PE•Spw•T^1TCN AS-euiy . . NC CLnvpS SF{
PLOT PLANS & LOT SURVEYS
IT IS THE THE BUILDER ORIOR TO
CONSTRUCTOR. TOI VERIFY PROPO ED BUILDINCOWNER. GRADE RLL TIVE
TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE
THE EXISTENCE OF ANY EASEMENTS. COVENANTS OR RESTRICTIONS
WHICH 00 NOT APPEAR ON THE RECORDED SUBDIVISION PL. AT.
UNDER NO CIRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR
THE SURVEYOR TAXES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONL
LISTED DISTANCES PREVAIL OVER SCALING
-0
Prepered by
Robert E. Johns, Jr. & Assoc.
Professional Land Surveyors
1700 BRINK DR.
ANCHORAGE ALASKA 99504
Scale: 11• = 30'
Date Surveyed;
Date tknwn:
4-7-0G
Rec. Lot S.F.
Brawn by.l.
Rec. Plot FBe No.
:TAcked bEct.7
4-10-06
Loyd Description;
LOT 4
Brenner Subdivision
"'d` 4813
W.Dfi78
SYMBOLS
• SET REI3AR DRAINAGE
FENyc
�o� FOUND Rr.BAq
`C_% ASSUMED ELEV. .X._R_N. M� L CE
NOTE:
LEM
ASPHALT
CONCRETE
WOOI nrcv
ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL 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 DISTANCrF ARE RET'ORf IUNI F S OTHFRWICE NOTFn
CONSTRUCTOR OR FOR ESTABLISHING BOUNDARY OR FENCE LINES.
Y AND ASSUMES_ FINANCIAL LIADIUTY ONLY FCR THE COST CF THE SURVEY.
RCDUCTON
• REI' MAY CAUSE ERRORS IN SCALE.
SGS
SGS Refit
Client Name
Project Name/ft
Client Sample ID
Mattis
PWSID
1061902001
Watkins Engineering
Brenner Lot 4
Brenner Lot 4
Drinking Water
0
All Dates/Times are Alaska Standard Time
Printed Date/TIme 04282006 13:08
Collected Date/Time 04/19/2006 13:35
Received Date/time 04/19/2006 16:25
Technkal Director Stephen C. Ede
Sample Remarks:
Parameter
Results
PQL
Units Method
Allowable Prep Analyru
container ED Limits Ate Date
Metals by ICP/MS
Arsenic
Waters Department
Nitrato-N
Microbiology Laboratory
Total Coliform
11.8
ND
<4 OB. No Coli
• 5.00
0.100
ug/L EP200.8
mg'L EPA 3532
co1/100mL SM20 9222B
bit
C (<-10) 04/24/06 04/27/06 WAW
B (<-10) 04/19/06 ALR
A (<-1) 04/19/06 TLF
Mayor Mark Begich
Municipality of Anchorage
P0. Box 190650 • Anchomgc, Alaska 995I9 -C450 • Tclryfionc (907) 343-8101 • Fax 19071343-R200
4700 Ilei aiw St reel • An horngc, Alaska 99507
wMwmatal.org
Building Safety Division
May 8, 2006
Cindy Ellis
Watkins Engineering
P.O. Box 110443
Anchorage, Alaska 99511
Subject: Waiver Request for Brenner SID Lot 4
Waiver Request WR#: 060015
Parcel ID # 075-061-85
HA060151
Dear Cindy Ellis:
Your request for a waiver of the required 100 feet horizontal separation from the
public scwcr cleanout to the private well has been approved. The approved separation
distance is 80.0 feet.
This waiver approval applies to the existing public sewer cleanout to private well
separation only. Any future upgrade to the on-site wastewater disposal system will
require all separation distances be met or another approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-7904.
Sincerely,
oodall
ivil Engineer
On -Site Water & Wastewater Program
Community, Security, Prosperity
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.clanchoragc.ak.us
(907) 343-7904
Waiver Review Worksheet
WR#: 060015 PID#: 075-061-85 HA/Permit# HA060151
Date Received: May 8, 2006
Legal Description: Brenner S/D Lot 4
Engineer:
Cindy Ellis
Watkins Engineering
P.O. Box 110443
Anchorage, Alaska 99511
Applicant: Marcus Tingle
Waiver Requested: 80 Horizontal separation from well on lot to public sewer manhole cleanout
Criteria: Geology Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
Total:
7.16
2.66
1.72
4.50
2.2
18.2471
Waiver is Granted: X
Waiver is not Granted:
List Conditions or Reasons for above:
Date: 5/2/06
By: Joe Goodall
Name of Reviewer
Rec#: 79603 Amount:S1� Date Paid: 5/8/2006
Conclusion: Grant Waiver Total Points:
18.247i
State of Alaska:
Separation Distance Waiver Guidelines for S.C.R.O.
(State of Alaska Memorandum to District Office Engineers dated January 3, 1985)
Waiver Request for: Brenner S/D Lot 4
Parcel ID#: 075-061-85
Waiver Request Number WR#: 060015
Waiver Requested: 80 Horizontal separation from well on lot to public sewer manhole
clean-out
Engineer: Cindy Ellis
IIA060151
Sewer Manhole Cleanout
The well and sewer cleanout has had the 80 foot encroachment for
over 20 years and there is no sign of nitrates. The sewer cleanout is
not considered a continuous source of contamination. For purposes
of Waiver point application the bottom of the cleanout sewer line is
assumed to be 10 feet deep.
Well Data
The well depth is 144 feet deep. This encroachment has existed for
more than 20 years and the water sample results for Nitrates,
Coliform, and Bacteria all meet the municipal standards. Arsenics
are elevated but the sewer encroachment would not be a factor since
arsenic is a naturally occuring mineral.
State of Alaska:
Separation Distance Waiver Guidelines for S.C.R.O.
(State of Alaska Memorandum to District Office Engineers dated January 3, 1985)
Waiver Request for: Brenner S/D Lot 4 -
Parcel ID#: 075-061-85
Waiver Request Number WR#: 060015
Waiver Requested: 80 Horizontal separation from well on lot to public sewer manhole
clean-out
Engineer: Cindy Ellis
IIA060151
Water Table Points lin
Depth of well: 141
10
131
Depth of septic system:
Distance from the bottom
of the system to the highest
water table In feet
Point
Value
0 0
8 1
17 2
24 3
30 4
40 5
85 6
100 7
290 8
1000 9
10
• Straight line Interpolation Is permitted between any two values
Soil Sorbtion
7.16
Points an
2.66
Soil Type I Point Value jI 14 1 +(I 56 3.5 + 30 1 + 19 3.5
Clean Gravel 0 l 131 J 1 131, 131 131
Fractured Rock 1
Course Clean Sand 1.5 +( 6 14.5 + r 6 12.5 + r 0 1 0 + x 0 1 0
Sand w/Small Amt of Clay 2.5 131 J 131131 J 131131 J L 131 J
Silt 3.5
Clay and Sand Equal 4.5 0.1 + 1.5 + 0.2 + 0.5
Clay 6 0.2 + 0.1 + 0 + 0
`Use the predominant soil type but values can be averaged for a mixture
Permeability
Soil Type f Point Value
Clay(will channel)
Silt and Sandy Clay
Clayey Sand
Fine Sand
Sandy Gravel
Fractured Rock
Course Sand (30 grit)
Clean Gravel
0
2
3
1.5
1
0.9
0.4
0
Points on
1.72
1311.9 +[ 31, 2 +f 30,.9 +(131, 2
+11311 3 +1 131, 3 + 131, 1 + f1131, 1
0.10 + 0.85 + 0.21 + 0.29
0.14 + 0.14 + 0.00 + 0.00
*Use the predominant soil type but values can be averaged for a mixture
Gradient
4.5
% Slope I Points Value
-60% 0
-30% 0.3
-20% 0.7 slopes toward well
-10% 1.2
-5% 2
0% 2.9 } flat
5% 4.5
10% 6 slopes away from well
60% 7
*If the gradient Is unknown, assume the worst case
Points on
4.50
Horizontal Points 1.26
80
Horizontal
Separation
In Feet
Point
Value
0
25
50
75
100
150
200
300
0
0.7
1
2
3
5
6
7
2.2
*Linear Interpolation between two point value Is acceptable. Horizontally means
straight line distance to the well not the contaminate travel distance to water table
which may be greater.
Jan
. .
•
t •Sac4;... '• S' •
,
Watkins Engineering, Inc
P.0 Box 110443, Anchorage, AK 99511
(907)349-1851 cwellis@gcLnet
May 2, 2006
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
RE: Brenner SID, Lot 4, Girdwood
Waiver Request for Well to Sewer Cleanout
To Whom It May Concern:
We respectfully request a waiver for the distance from the private well serving Brenner
S/D, Lot 4 to the sewer cleanout on the main located in Brenner Circle to 80 ft of
separation distance.
The main line was installed and the house connected on November 8, 1983, as noted
on the connect card. On November 21, 1983, the well was drilled. The well is 144 ft
deep, with layers of silt above the aquifer.
I believe that the reduced distance from the well to the sewer main cleanout will not lead
to contamination of the well or to the aquifer for the following reasons:
1) Satisfactory water analysis from the subject well (even after 23 years),
2) Well depth of 144 ft provides substantial vertical separation,
3) Soil strata between the aquifer and the surface provide an adequate barrier,
and
4) Difference in elevation, with ground level at the well 6.65 ft higher than the
ground level at the sewer main.
The water analysis on the well from a sample on 4/19/06 reported no nitrates, no fecal
coliform, Tess than 4 colonies/100 ml other bacteria, and Arsenic at 11.8
micrograms/liter (pg/I). Although the Arsenic level is above the limit of 10 pg/I, this is a
naturally occurring element and is not due to contamination from the sewer cleanout.
The lab report is attached.
Watkins Engineering, Inc., May 2, 2006
Brenner Lot 4 Waiver Request, page 2 of 2
The well log is attached, showing clay and silt above the aquifer which provide a barrier
to vertical migration of sewage. The well has a total depth of 144 ft.
The topography of the area prevents migration of fluids from the sewer cleanout toward
the well. Relative elevations are noted on the attached site plan. There is a difference
of 6.65 ft or between ground level at the well and ground level at the sewer cleanout.
Based upon these facts, I believe that the potential for contamination of the subject well
and the aquifer is minimal. Therefore, I request that the required distance from the well
to the sewer cleanout be waived to the existing 80 ft.
Thank you for consideration of this request. If you need any further information, please
call me at 349-1851.
Sincerely,
Cindy . Ellis, P.E.
President
(s,11 -VV DRILLING, Inc.
P.O. Box 10378 • 10300 Old Sewawd H.ghway
(907) 3498535
ANCHORAGE, ALASKA 99511
Well Owner CERLEW INVESTMENTS
DRILLING LOG
Use of WelLDomest is
Location (address of: Township, Range, Section, if known; or distance main road
Lot 4 grenner_,Suh.
Size of casing._fi' __Depth of Hole _1A1_feet Cased to__ hlail.Jeet
Static water ]eve]_a_ft. (aharn) (below) land surface.
Screen (
);
Perforated ( ).
Describe screen or perforatio
Finish of well (check one) open end ( XXX );
Well pumping test at 15 gallons per Gem) (minute)
of drawdown from static level.
Date of completion November 21 , 1983
WELL LOG
for�__hours with 1nnY ,_ ftx
Depth in feet from
ground surface
__$-TO 24
24 TO 80
8n TO 1111_
110 TO 129_
129 TO 134
____133.20 118
11RTO 1GL
TO_
TO
TO
TO
TO
Give details of formations penetrated a �n'of aterial�Lcolor and hardness
IC{` . n•, 1u
0..114`` ti:‘, ,�1, SIA to•n•
Casing stickup
_Backf711
Organ.; rs
("ravel
t'`1•tIIS6k1
A'1�k-'1 •
---—
t Pp'ir
wit e i l t itla,n?)
Silt with crave]
_I1rnxuLwith silt
_ S11t with clay & gravel
rley, with gravel (damp)
rrnypl wlrErlay_y lrinmp).
W. t prhp-r r gravel
i) , %Cdr%�f��t.l.
14 /t if
•T]1C1VA Certified Contractor
•Qertificatc No's. 811
I — CUSTOMER
s
DONE P
S.S.
ST•TIONINGS
P T LOCATION
,R TO
TION3 SHOWN
TOP ELEVATIONS
D CONDITIONS
M.AS 3
LANCES ARE
ITER OF
3 OVER ALL
LIN 6 SERVICES
T COVER.
SRLNNEP SUBDIVISION IS • SUBDIVISION OF LOTS 23A 6 30 OF U S. SURVEY 3034,
LOCATED W17HuN N. E.1/4, SEC. 15, 6 N W. 1/4, SEC IT, T MN, R22, IS la
BREN
ttaVYtt
5
iD
STA 2+719 12.7 LEFT
9t.aTHL v. EF -4
tIrvvE -133.70 4a SERVICE TO NNect WHOLE
RIVA�M�KD'ELL STA 2170. 12.3 UR,
STAR 0500 NEW [ ($3 OK
' tf IC4ii 5ISSA� Ito
N W' - 12 a •3R
NEN. +7+7410.4 L()T 29
SL INN 420Ae12sri AS
41"
N ER SU'B'DIVISION
3
Ise
e
r
Y
EMOTE CLE•VOUT
0
0
w'
TA 4+w 1+00 A30
ONSTRUCT Ca F
TOP EL. +HAM3I.47 ASB
PV. EL. 42-3-15
125 TRS% ASB
2
50'
rot DENOTES 4'INSULATNVI
INSTALLED DUR NO COHSE
99
D14MSSIIOh[[3�E APCLASB
TSM NO.2
NAIL 1TREE
PTI 4
HTH'
BRENNER ROAD
911 9• p1?
'PI• $
YSROM MN
WAS SUBDIVIDED • RECORDED
ALYESKA HIGHWAY
LOT 62B
To \
w \
0
LEGEND
_TA 0500
STA OR $2.90 ILS' LEFT
EXISTING MIL EE -3
TOP EL.119.6T )TMP N0.1)
MN INv 103.5T
1 LOT E
j HOLLYS
HOLLOW
O PROPOSED MANHOLE
Q . PROPOSED CLEANOUT
-4 SERVICE CONNECT
-- PROPOSED SANITARY SEWER
TH 0 SOILS TEST HOLE
--PROPERTY LINE
SUBDIVISION BOUNDARY
O WELL
•
ePrem /twa/U &wd d4zwir 3198
�
h
. .
t
CO or .tir.¢J
CC
.W N W• d W 1-
1 wCDFZim
rl Qm • 2 g
N 2
rase. 0 00
0
0
6
0.0
0. 4 W
11-
0 0
O 0
W W
0 007
8
0
Brenner Subdivision
SUBDIVISION
TAX CODE 075-0618 RID
Brenner Road
BUILDING ADDRESS
••••7
W
2
0
a
S
4
4
QO
cc
O
a
cn
J
5
rzz
J -J J
4 J
W g 4 K E
C r
:W0F$m0
• .1— 2 0 0 0.
F- ❑ 0 0
2 z
a
On
re 0 • < 'il-
1
•a 0 0
f•., t..
U
1 W 0 J
0
2
O a
U
0
2
2 '
4
C
2
0
x 8
07
rn eW
T
O
Z
S w
O
J
Z
zvgJ
LISLE
cc
;;a;�+
Oat¢
76 Ca
CI-
N a N
F -o F•G
2<2<
.70w0
N N
W
N
5 o
W U
M
w
M
0
N
1-
d
0
i
2
f
•
65 i
CC :7T ann., mr•��
04/18/2006 12:35 5625427
AWWU
PAGE 05
.r: 4 ;1 ar
:UB.4t
: ION:
INDICATE
NORTH
Asehbver
frtsnr Pd
STREET'
BLOCK: I LOT: 9
07.5- OW VSoct
SEWER SERVICE LINE SKETCH
SHOW LOCATION OF CONTROL MANHOLES/CLEANOUTS
ALLEY
ZE MAIN: C TYPE MAIN: Dif CONNECT DEPTH AT MAIN CONNECT DEPTH AT Prop. Line
)NNECT LOCATION: voe= cl;$.1.12 to ekg;",tt j 94k%, *tell joCz4-.pn.,
)MMENTS: W ntHri SP'2VIC P CQ-urJ at-+ +o h•114, t,! {a p:Capte
MYC+ rlr,CP - p -.v\ 4Jt 11 o.J
pAasag gy a...l(yr
SPECTED BY: 14 1
DATE: F D -2-9-e6
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
F �• • P 1.. 1 -
Parcel I.D. # —. �
HAA #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 4; B&ennek Subdi.vi4ion
Location (address or directions)
Bkennek Road
(b) Property owner F.V. I. C. #4009-351-327 Telephone : (home) Business
Mailing Address ATTN: Ray Geeven 440 Ecut 36th Avenue_ Anchorage, AK
(c) Lending Institution Telephone
Mailing Address
(d) Real Estate Company and Agent Jack White, Company ATTN: Jack VandenBeng
Address 3201 C Street, Suite 100, Anehonage, Ata.fza 99503
Telephone 563-5500
(e) Mail the HAA to the following address: (or check here C Xif hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
-- 7O 4-Eagie-River Loop -Rodd No. 204
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family E X Number of bedrooms
3. WATER SUPPLY
Individual Well ❑(x Community ❑ Public E
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ❑ Public (AD( Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88)
Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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. 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 s & S ENGINEERING
17034 Eagle River Loop Road No. 204
Address Eagle RivPr, Alaska 99577
Date _
Telephone
6. DHHS APPROVAL
Approved for
Approved
bedrooms by
Disapproved
fr
Date /`,Q
r
Conditional
Terms of Conditional Approval
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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. 7/88) Back
Page 2 of 2
A. WELL DAT,
Well Classification 11-_____
1 -fir - --- - - Well Log Present (Y/N) _ -_- _ Date Completed _it j- 1 :-
Total Depth_ /11 Cased to /�-7/. 1_ Depth of Grouting ._ _ _ /v/4
Static Water Level _ _ __ '-__
Casing Height Above Ground c2_-__ — __ Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot _/�V[__ ; On Adjoining Lots -i
To Nearest Edge of Absorption Field on Lot - KVA ; On Adjoining Lots ____/
To Nearest Public Sewer Line _ 7 /3 _ To Nearest Public Sewer Cleanout/Manhole raf)
To Nearest Sewer Service Line on Lot
Water Sample Collected by = _ 5 JJ t N ,►f r N ; Date . __-Jam?_ o± -'01)
Water Sample Test Results A II
Comments
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: _ ,1�� ��� �_ ='•
If A, B, C, D.E.C. Approved (Y/N) A/a_
Yield _ . AA-
( -1- t(:))
Pump Set At
Depression Around Wellhead (Y/N) 1J
B. SEPTIC/HOLDING TANK DATA
Date Installed . _ - _ Size
No. of Compartments
Standpipes (Y/N) - Air-tigCaps (Y/N) - _ -__ _ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contact on File (Y/N) - ; for _-
Holding Tank High --Water Alarm (Y/N) _- Te rary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC H DING T
To Water -Supply Well — __ ____ _ __ __-_ _ _ __ __ __ To Bui ing Foundation _
To Property Line ______-_-_- To Dispos. Field
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course _
Comments d N_ C.<__�� _ <_-ca1J1� G _f : c_L
72-026 (rim 7/88) Front
Page 1 of 2
r<]Ij r i1 -1-t
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Stra a _ ___ Type of System Design
Date Installed Length of FieldWidth of Field Depth of Field
ravel Bed Thickness
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well
To Building Foundation
Lot ; On Adjoining Lots
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To roperty Line
To Existing or Abandoned System on
To Cutback (i •resent)
D. LIFT STATION
Date Installed
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
Dimensions
Meets MOA Electrical Codes (Y/N)
Comments
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and H A guidelines in effect on the date of this
inspection.
Pumping Cycles during Adequacy Test.
Signed
SENGINEERING
Company . 17034 Eagle River Loot? Road No:. r4)4
Eagle R.iWer, Alaska a957Y
Date
2 C.
MOA NoL�. �.�-_'�
Receipt No /7/)
(1/(:,
Date of Payment c) �� F Cl
72-026 (Rev, 7/88) Back
Receipt No.
ine rf � a1
E rt;_x
4;)-i
Fee: $
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
FEDERAL TAX ID # 92-0040440
31ient Sample ID:L1 IBRENNER 3/0
PWSID :UA
(ot.lec_ted FEB 9 90 N 15:30 hrs.
};.eeei.ved FEB 9 90 0 16:30 hrs.
Preserved with :AS REQUIRED
ANALYSIS REPORT BY SAMPLE fox Work 0rdol 1) 19760
Date Repori. Printed: FEB 15 90 i3 16:52
Analysis Completed :FEB 12 90
Laboratory Supe -v `or STEPHEN C. EDE
Released By : Supe
�/
Special.
Instruct:
Client Name . S fr 3 ENGR
Client Acct : SNSENGP
P.O.I1 NONE RECEIVED
Rey 4
0rdered By : R. SHAEEER
Send Reports to:
11S 9 0 ENGR
2)
Chemlab Ret 13: 900065 Lab Srnpl ID: 1 Matrix: WATER
Allowable
Parameter Tested Result units Method Limits
NITRATE; -N 130(0.10) mq/l. EPA 353,2 10
Sample SAMPLE COLLECTED BY R.D.J.
Remarks:
1 Tests Performed
ND- None Detected
NA-- Not Analyzed
yzed
See Special Instruction:-; Above
Seo Sample Remarks Above
I,T-Los.. Than, GL -Greater: MAI
0A-Unavai Thh hie
0EEDE C(N
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
ABOR A TORIES
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
FEDERAL TAX ID # 92-0040440
ANALYOJO REPORT BY SAMPLE fo. gook Order_ 'I 19YRO
(kite Repot 1`r-intod: FEB l5 90 0 1(:50
C1:ion1: Sample 10:54, BBRENNER S/1) Client Name 9 0NOR.
FWO11 :110 Client Acta . SN0199F
Collected 1001 9 90 p 1.5:110 his. P.0.11 NONE RECEIVED
Received FEB 9 90 0 16:30 hrs. Ren 0
9reseived with :AS REQUIRED Ordered By R. SHAEFER
Analysis Completed :
5abor_ator.y .Supervisor :STEPHEN C. RDE
Released Rv .
Special
Instruct:
Cbernlab Rol 4: 90006; Lab Smpl. ID: 2 Matrix: WATER
Ycuamotez 'Tested
TOTAL COL 10060
Sample 9AMPLE, COLLECTED BY R.1) -J.
Remarks:
Rosult
Units
eel / 1.00)01
1 Tests PefiellYwd See Specie] lnstiuctionAi:JOvo
,11- Noon Detected '.,_=e 3tarnp10 Remarks Above
RA- Nei lg; lly'zc[1 LI -Less Than. GT -f i t.ai. e,r '1'ltin
:rend Ropor.tE to:
1 )ii t4 S 1NGR
2.)
lot hncl
Allowable
Limits
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 LD.#
PRIVATE WATER SYSTEM
Name
Mailing Address
Phone No.
S & S ENGINEERING
17034 Eagle River Loop Roado.-204
Eagle River, Alaska 99577
City
SAMPLE DATE:
Mo.
0
Day
State
SAMPLE TYPE:
Routine
Check Sample (for routine sample
with lab ref. no
❑ Special Purpose
Year
Zip cede
C Treated Water
❑ Untreated Water
SAMPLE
NO. LOCATION
1 I Lof4 . Qre-Air er S.L_
2
3
4
5
Time
Collected
Collected
By
j �3a
TO BE COMPLETED BY LABORATORY
Analy s shows this Water SAMPLE to be:
Satisfactory
LI Unsatisfactory
LH 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 /C036
Analytical Method: Membrane Filter
* No. of colonies/100 ml.
90.0065
L
Result* Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter Results //
Reported B ��yY -4-1.---pate
CD
BGB
TNTC = Too Numberous To Count
OB = Other Bacteria
Collform/100m1
Coliform/100m1
Time: /706 a m.
PART ONE OF TWO
REMAINDER TO FOLLOW
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL 'Y ,
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
ti8f Ff Lii/ F L f iv 2 [--': 1_ L 9
Location (address or directions)
,-s K4 /JI» ! S NC- - ifQ,O9
Zji7
(b) Applicant Name la :l f t`25' J 61
.Telephone: Home _ Business
'
Applicant Address y:0 /kr-
_-#�
Applicant is (check one): Lending Institution 0 ; Owner/builder,, ; Buyer 0 ; Other 0 (explain);
(c)
(d) Lending Institution
Address
(e) Real Estate Company and Agent
Address
Telephone
(f)
Telephone
/v/p
Mail the HAA to the following address:
UV TEO ( Ai -04r JO V%/i
K % O3
2. TYPE OF RESIDENCE
Single -Family Multi -Family 0 Other
Number of Bedrooms -3
3. WATER SUPPLY
Individual Well 1g Community 0 Public 0
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite 0 Public 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
72-025 (11,84)
5.
ENGINEERING FIRM PROVIDING.; INSPECTIONS, TESTS, FILE SEARCH, DATA 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 _ p c „ —LA/(
Telephone
Address 1200 q2 i /)4/(7-L 4 Y?'RJ `a
Date 12- LI -7 f 576
6/
6. DHEP APPROVAL_
Approved for 714`°'ce'e bedrooms by ”' Date p`i'ma-
Approved 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 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.
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Well Classification PR %I)/4
Date Completed //2 /� 3
Legal Description: Lei I3eENIVEI 5L't
LCLt1 RZF Eco . /
If A, B, C, D.E.C. Approved (Y/N)
Well Log Present'( N)
Total Depth /
Static Water Level
Yield
Cased to /17//) / Depth of Grouting __ A/AL
Pump Set At a/W(4/010V
Sanitary Seal on Casing ON)
Casing Height Above Ground 2, 0
Electrical Wiring in Conduit 6/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
1Sc6PMPW
Depression Around Wellhead (Ye
/V/A ; On Adjoining Lots
fV ; On Adjoining Lots
l 00 /IL- To Nearest Sewer Service Line on
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
To Nearest Public Sewer
Lot
Water Sample Collected by i, KAIra/ tic" 1< ; Date /z//
Water Sample Test Results 54 %7,5F/9 -C
Comments PEf GUELL FLOttY zb�f
B. SEPTIC/HOLDING TANK DATA
Date Installed Size No. of Compartments
Standpipes (Y/N) Air -tight Caps (Y/N) Foundation Cleanout (Y/
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contract on File (Y/ A ; for
Holding Tank High -Water Alarm (Y/ ) . Tem. .ry Holding Tank Permit (Y/N)
Separation Distances from Septic/ o in: T. nk
To Water -Supply Well To Building Foundation
To Property Line To Disposal Field
To Water Main/Service Lin- To Stream, Pond, Lake, or Major Drainage
Course
Commen
Page 1 of 2
72-026(11/84)
L I )-E:14/NEI� r&&
C. ABSORPTION 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 Present (Y/
Depression over Field (Y/N) Date of Last Ade. s y 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 Majo 1rainage Course
To Driveway, Parking Ar::, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed Dimensions
Size in Gallons
"Pump On" Level at "Pump • evel at
High Water Alarm Level at ff Vent (Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
Manhole/Access (Y/N)
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have he ed, ver ied, of conformed to all MOA an/d.HAAA guidelines in effect on the date of this inspection.
Signed ;. ���1`, /'tom" Date /�a 1/ 7/ '
Company �! C //VC MOA No. — VC ` D 2- V
Receipt No. /0 0 / 0 Z3
Date of Payment /2- t, G
Amount: $
A17740/11/164/ r `Il WFC.(.
Page 2 of 2
72-026 (11/84)
�t2 wfirCdc WfLE
1€3 5r TE
0 co . N
qo
Y est e
Qz� C
ase... p,.,,.noeeod'ie ael!
DY C. R) 1D, JR.
/CE - 2251 epy
E e M' a 4':.
. ,, .. ''sn T.
ALASKA biIUI
�On
C
'TAL COnT OL S MOICCS, inc.
engineering & E.nuironrnental Studies
1200 West 33rd Ruenue, Suite B • /\nehoroge, [lcske 90503 (901) 561-504I0
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
ri PUBLIC WATER SYSTEM LD.#
J
X PRIVATE WATER SYSTEM
E(j_`) 6L- 6-0610
Name Phone No.
1 Z-00 (A). > /i1) -LIE
_- -
Mailing Address
-mac /4- 4K
City
SAMPLE DATE: I_�A-
mo.
6
Day
State
SAMPLE TYPE:
Routine
Check Sample (for routine sample
with lab ref. no )
L1 Special Purpose
SAMPLE
NO. LOCATION
Year
Zip Code
I Treated Water
! Untreated Water
Time Collected
Collected By
1 I L- G SAW - /6c(0
jsi
2
3
4 L_
51
11
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
Satisfactory
Li Unsatisfactory
Ll 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
/6 V0
Analytical Method: Membrane Filter
* No. of colonies/100 ml.
Lab Ref. No. Result* Analyst
1
CD
L±J
1 1
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Membrane Filter: Direct Count _
Verification: LTB
Final Membrane Filter es Its
a
Reported By__.
TNTC = Too Numberous To Count
OB = Other Bacteria
BGB
Date
Time:
0
Coilform/100m1
Coilforml100m1
011
i
Kbo
a.m.
p. m.
ALASKA ENVIRONMENTAL # 2
CONTROL SERVIC INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
JOB
SHEET NO.
PENNER six,
OF
CALCULATED BY.- f LL DATE 21516'45._ -
CHECKED BY-_%_/� TAW-
DATE
SCALE.-_ 20 - -- DE T•4/L ! i1_6_/
C f0
PRI /ATF
wad
ntr
F40Us E
2V
PRIVRrr
SEw�
LINE