HomeMy WebLinkAboutBROADWATER HEIGHTS BLK 1 LT 6
','~ER A1VCHORAGE AREA BQROU~JJ.
.~rtment of Environmen~cd Quc~4t~l~l: ~]'l:JJ ANCHOIJA(~I: AIJFA BOIJI"H I~J-J
3500 Tudor ~oad -- Pouch 6-880
:~'~m?.ho':age, Alaska 98,502
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
N? 864
LOCATION ,~. ,C_,
SEPTIC TANK: ~cc_~ ~>~( ~ c:~:~
DISTANCE FROM WELL ~-~ d~ ,'~:=~'~/ MATERIAL
LIQUID CAPACITY /~L~c-': '~ GALLONS. INSIDE LENGTH
LEGAL DESCRIPTION
NUMBER OF
C~PART~TS
LIQUID
INSIDE WIDTH DEPTH
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PITS / OUTSIDE DIAMETER
LINING M A T E R I A J ,~':'?~Z:~r/~ ~" '-'
NEAREST LOT LINE ,'~-~
OR WIDTH
'
LENGTH ~c~') , DEPTH
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
BUILDING FO U NDATIO "N~-~- ? ~.
SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM
NUMBER
ABSORPTION AREA
FOUNDATION ~ , NEAREST LOT LINE
DISTANCE BETWEEN LINES ~[f~CCH WIDTH
SQ. FT. LENGTH OF EACH LINE
TOTAL LENGTH
OF LINES
~1 _N~T~rI~'EF F ECTI V E
DEPTH: TOP OF TILE TO FINISH GRADE
DEPTH OF FILTER MATERIAL BENEATH TILE
IN. ABOVE TILE
WELL:
LOT LINE
DISTANCES:
~. DISTANCE FROM .~- WATER
DEPTH , BUILDING FOUNDATION. SAMPLE__, NEAREST
NEAREST ~-:,~,/- . SEPTIC
-~') ~ SEEPAGE .~-~,/~ ~ ..... OTHER
!
SEW ER LIN E ~"~'~~: TANK-' ~"~ ("~' .~" ~ . , SYSTEM /£1C?~ _.. ,CESSPOOL ,SOURCES
DIAGRAM OF SYSTEM
DATE
FALTH AUIHORITY
Gr~A'l ER ANCHORAGE AREA BU~uUGh
DEPARTMENT OF' ENVIRONMENTAL QUALITY
3000 TUDOR ROAD POUCH 6-650
ANCHORAGE, ALASKA 99502
TelePhONe 279-8686
SEWAGE DISPOSAL SYSTEM APPLICATION AND PERMIT
MAILING ADDRESS ~/~/ ~~:~f~ PHONE
INSTALLATION OF: SEPTIC TANK SEEPAGE PIT DRAIN FIELD OTHER~/~ ,
TYPe and size of faCilitY TO Be served ~ ~~~ fJ/~/~/---~~/~f~/~~/ /f~
TO BE INSTALLED BY~
SOIL TEST RESULTS ~ /~/~ ~ ~ /~; THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED ~
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF' ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC TANK size . TYPE_
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIt ~:~
SEPTIC TANK TO S~EPAgE PiT Wall
SEPTIC TANK ~/ SEEPage PIT J~
, ., DRAIN fielD~/~
TO NEAREST LOT LINE.
WEllTO sePtiC TANK ~ / SEEPage Pit
DRAin FIELD ~ ~
ALSO CONSIDER ARea WELLS.
WATER MAIN TO SEPTIC TANK //~/ /' SEEPAGE PIT
DRAIN FIELD //~ /
TO rIVER, LAKE, STREAM.
DRAin FIELD
CAST IRON into AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP Of
EXCAVATION 5 FEET into UNDISTURBed SOIL.
4 INCH DIAMETEr CAST IRON SIP~HON PIPES ON SEPTIC TANK AND SEEPAGE Pit
Fitted WITh Airtight REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
/
TYPE
DIAGRAM OF SYSTEM
OR
LICENSED DESIGNER
CerTIFY THAT I AM fAMILIAR WITH The REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGh ORDINANCE NO. 28.68 AND THAT THE ABOVE
R&M
Civil Engineers
ENGINEERING & GEOLOGICAL CONSULTANTS
229 EAST 51st. AVE. - P.O. BOX 6087 - ANCHORAGE, ALASKA 99503
TELEPHONE 907-279-0483 TELEX 090-35419
Geologists Land Surveyors
JAMES W. ROONEYo P. E.
MALCOLM A. MENZIES, P.E., L.S.
JAMES H. WELLMAN, P.E.
June 19, 1972
lq &MNo. 26525
RALPH R. MIGLIACClO
Engineering Geologist.
Mr. Thillman Wallace
Wallace Construction Company
Box 529
Chugiak, Alaska 99567
RE: Test Hole and Soil Log Report for Sanitary System
Lot 6, Block 1, Broadwater Heights Subdivision
Dear Mr. Wallace:
We are submitting herewith the test boring results and our comments re-
garding soil conditions encountered at the subject site. This investigation
was performed in accordance with your request of June 15, 1972, and those
procedures outlined in a letter dated September 13, 1971 by Mr. Roll Strict-
land of the Greater Anchorage Area Borough Department of Environmental
Quality.
A single test hole was put down within the Lot 6, area for the purpose of
defining general subsurface soil conditions for the proposed sanitary system.
Excavation was accomplished with a tractor-mounted baCkhoe and the test
hole was extended to a total depth of 6 feet below ground surface. One sam-
ple was recovered from the bottom of the test hole and retained for grain
size analysis. The sample will be held in storage, up to approximately one
month, for possible testing before it is discarded . The final log prepared
for the test hole has been included in Drawing A-0i.
Ground water was encountered in the test hole at a depth of 6 feet.
We appreciate being given this opportunity to be of service to you. Should
you have any questions with regard to the above, please do not hesitate to
contact us.
Very truly yours,
R & M ENGINEERING & GEOLOGICAL CONSULTANTS
./James W. Rooney~
JWR:wb
cc: Greater Anchorage Area Borough
.Ii IA. Il:Al
T.H.-I
6-15-72
0.0'~
SAND W/SOME
ORGANICS (SW)
\9-b
2.0~
SANDY GRAVEL (GW)
4.01
SANDY GRAVEL W/COBBLES (GW)
6.0'
Note: Bedrock encountered dr' d depth of 6.0' with woter seeps in
bedrock. Hole exc(~voted with trdctor mounted backhoe.
F~ Engineering E~ Geologic¢~l Consultont$
Steve Stuff Property
LOG OF TEST BORING
Anchorage Alask(]
,DATE 6-15-72 'ISCALE. I"= I' IOWN e~ GAW ,IOHKO BY WED J,..oJ. No. 26525 IDWe NO. A-OI
AS-BUILT
I hereby cattily that ! ha~e surveyed the following
described property:_. ~.~ ~'..l~_j. d~'/,a_,C.~_~L.7 .......
AnchoraBe Reco~ing Precinct, Alaska, and thai the
improvements sit~ated thereon ar(~ within' the property
11~o~ ~t'~ ~ ' . '
' _P · .~ uo ~0~ o¢or]~p or o~t'oSo~ O~ tho propcr~v
lying adjacent thereto, that no improveme,ts on
erty ly~n~ adjacent th~eto encroach on 1he pr~m~.
Ot~eslio~ and that there are no 1,)adways.
line~ m' other vMble easements on said property
as indi-ated hereon.
Date~ u~ Er~gle River. Alaska
this ~ C~ _day of/~_~<~,.x"Z._ 19
ROBERT C. Jf3IINSON "<'*-
8'7 () 12 ()
Ci:t!'qTA C T F'Hii:)N E:
,.]'ACK WFII'I"E: CO,, / F:'ANNY MAE
:!. () '::? 21ii~ OL..D Gt...E:NI~.I. HWY,,
i!i!:AGL. E: R I Vli!i:F:?., Al< 99577'
di., 94- 55 () 0
L..!!!::GAI .... DESCR I F':': SLIBD I V I S I ON: BROADWA"I"EF~: HTS,, LOT: 6 BLOCK ::
~:'c,r'.th I:::,¥ the Mun:i.c:i. pal:i, ty ~::~F Anchc, r'age (MOA) and the State ol:' ~'::~lasl.::a
~) teach ~'letd
x~x}' u~iL
®
RIOHT OF
EXISTING LEACH FIELD
NE;,/ LEACH FIELD ::::::::
CLEANOUT - ·
SCALD 1' = ~1t'~,~'
WELL SITE PLAN
LEGAL, LBT 6, 3LBCK 1, BRDADWATER HTS,
BWNER~JACK ~/HITE REALTY
CBNTRACTBR~SULLIVAN WATER k/ELLS
EAGLE RIVER ENGINEERING SERVICES
Pn BX 773~94
EAGLE RIVER, AK, 99577
694-5195
STATI(;'.LEVEL OF ~,¥ATER FI,!:.b ~ ~:~ ~ ':'/" ~''' t
DRAW DOWN FT.:~' ' '~'~"~' ' ' '~ .... ~'"'~' ~'. ~
GA~, PER HR' " '- '~ ?' ~ ..... :~'"'""' ~'''
. , .. ~ .,~',* . ~ ? ;* .~.,:~ , .~ .,,
KIND OF FORMATION:,· t ' -~' '> '"' "'~ .... [ t,, '-~
'..!~..:, ~. : -
· ..-.. .:.;~ ..... ¢, ..: ~. .' , ~ ..' ';..:. :..':..? . ':' ~,
' at° ' ' '
From d~ ?' ' ~''~ '~ ...... '"' '" : ' ~ ' '" '~
,. ,..~, .",' ~ . .. . ~;~..-..~';' ~' .
From ~ Ft. to ~ ~ Ft. Od~~~ "' , '"
,;. .~ ...~'~ ~' .... ' ...
From Ft. to - ' Ft. - ~ '
F~m I~ Ft. to Ft.
From
From.· Ft. to . Ft.
From Ft. 1o Ft.
From Ft. 1o F[~'
F?om, Ft. lo ' FI,
From/./I~ Ft.
From Ft.
From.] c/..] Ft.
From · Ft.
From ~,~1 Ft.
From .~2'~' Ft.
From Ft.
From Ft.
From Ft.
Fromm, o Ft. to
From . Ft. to__
From Ft. to
Ft. to ' Ft.
Ft. lo Ft.
Ft. to.. Ft.
__Ft. to ' FI~_
to.~ ..~.~/_r:t.."L3.~,~,q c~c.~" _g-~",~ ~ ' - From
_ ' From
t0 Ft. gg <~ ' 'From'
Ft. ~o~ ~o4,~ ' ' From
Ft. From
.Fi From Ft. to Ft.
MISCL INFORMATION:
I ·
/ '7 '7'0 T'~',- '
DRILLER'S NAME /: , / .' .... '-----.~'
. /,"'~"~ 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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA# ~ (~tO~
1. GENERAL INFORMATION
Complete'legal description
Location (site address or directions)
Property owner
Mailing address
Day phone
Lending agency
Day phone.
Mailing address
Agent '~A-¢~-~ ~ G~-Z ,~ TyEm,J
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE .OF WATER SUPPLY:
Individual well
NOTE:
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. *TYPE OFWASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
79q)25 (Rev. 1/91} Front MOA#21
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.
S & S ENGINE!~::~: '¥
Name of Firm 17~1~. i:~_l~ RiYer I.~,~.,. ' r.~d.
Eagle River, Alaska 99577
Address
EngineeCs signature r-' ~' '
Phone
DHHS SIGNATURE
l,-/''/ Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following
stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representatipns 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.
Municipality of Anchorage OCT 'l 8
DEPARTMENT OF HEALTH & HUMAN SERVICES MUN~C~.^m'Y O~
Environmental Services Division ~NVlRONN~NTALSERWC~
825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 343-4744
Health Authority Approval Checklist
Legal Description: ~.7-~.~, z~Z.,R'/]' ,,~,~Z/-,"~.~,,~.~'/~ 7/-~ ~/~.7~ Parcel I.D.:
A. WELL DATA ~
Wel~ type ~/~ If A, B, or C, a~ach ADEC le~er. ADEC water system number
Log present~N)_~ ~,~,~ Datecompleted.~/~ / ~
Tota~depth ~//~ZI C,~,~)' ~/~' ' ~ .
- ' "T ..... , ~ /~~asing height (above ground)
Sanitawseal(y/N)'~ / /~
Wires properly protected (Y/N)
/
Date of test
Static water level
FROM WELL LOG
-
/122'
/
Well production
/
WATER SAMPLE RESULTS:
g.p.m.
AT INSPECTION
Coliform .-~
Date of sample: ,/y~//+~'
SEPTIC/HOLDING TANK DATA
Nitrate
Collected by:
Other bacteria·
$ & S ENGINEERING
17034 Eagle River Loop Road No, 204
Date installed ~/~ ~- Tank size
/
Foundation cleanout~j).,~. ~//~5' Depression (Y//~
Date °' Pumping ~F/~/~ Pumper. ~ ~
ADSORPTION FIELD DATA
Date installed ~' /~ ~
Length ~/ / .Width
Eagle River, ~laska 99577
Number of Compartments / Cleanouts (Y/N) .~-~
High water alarm (Y/N) /',//,'~
/
Soil rating (g.p.d./fF or~ /,~- ~' System type ~),~
/'~- / Gravel thickness below pipe ~ /
Total depth.
Effective absorption area. F~ ~ Monitoring Tube present) ~ Depression over field (Y~
Date of adequacy test ]O/~/~q Results~Fail). ~ For /~ bedrooms
Fluid depth in absorption field before test (in.); .. ~" Immediately after'gal, water added (in.):. Z 'W ~"
F~u~d demh.~'~' (~ns) ~nu~es ~mer: ~ ~bsorp~ion ra~ = ~ ~' g.p.d.
Peroxide treatment (past 12 months) (Y/N) /~O/V'~-~-~L~A/If yes, give date
72~026 (Rev. 3/96)*
LIFT STATION
Date installed _ ~ Size in gallons
...... ~'>' "Pump on" eve[ at
Manhole/Access [,¥/r~) ~/ I .... '
High water alarm level at* ~' *Datum
Cycles tested _
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot_ /00//'
Absorption field on lot __~0~
Public sewer main ~//'~
Sewer/septic service line
SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK ON LOT TO:
Foundation ._. ~/'~'- Property line ~--~- _ Absorption field
"Pump off" level at* _
On adjacent lots _
On adjacent lots _ /0~ /~-
Public sewer manhole/cleanout __ /V'//~'
Lift station _ >'///~ /
/
Wells on adjacent ots /Od~/'f~
Water main/service line ~_~-~ Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line _ / (~/¥- Building foundation _
Sudace water _/~/~
Cu~ain drain ~
Water main/service line _
Driveway, parking/vehicle storage area
Wells on adjacent lots _
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and reviev
in conformance with M,~A~ HA~guideli~es in effect on this date:
Signature ~'~/
Engineer's Name //~ ~ ~
Date '~ //J-/~ ~
are
HAAFee $_~ 0"C-'
Date of Payment./,0
Receipt Number _ z~ ~_//~.
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
MEMORANDUM
W~_~ER WELL ADVISORY
HEALTH AUTHORITY APPROVAL
During a recent Health Authority Approval on-site inspection
and test of the potable water supply well on Lot ~
Block _ [ of ~)/~O~//~ Subdivision, the well's
productivity was determined to be , 3~ gallons per minute.
The minimum well productivity required by this Department
(AMC 15.55) for a ~ bedroom residence is , ~ ~ gallons
per minute. Although the subject well currently exceeds this
minimum requirement, all parties concerned are advised '' ~ the
production capacity of the well may fluctuate. Restriction
of riCh-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies Of the subject
Health =~ho~zty Apprcva!.
QCT-12"§B 14:52 FRO~I-OTE Ei~VIRONFEt~TAL
T-844 P.O~/03 F-452
CT&E Reg.#
Client Name
Project Name///
Client Sample [D
Matrix
Ordered By
~ample Rcrmaks:
995534001
S & S ~gin=criag
Lot 6: Rlk 1: Broactwa[er
Lot 6: Blk 1: Broadwa~er
Drinking Water
0
Client
Printed Dar.t/Time 10/12/99 11:56
Collected [,.,~edTime 10/07/99 17:20
Received 13.,tetTime 10/08/99 12:40
T~chnical ] ~irector: ~tephen C. Erie
Resutts
ToTal Co[iform
0 coL/lOOmL S~18 922~B
2.05 G.5OO n~/L EPA 300,0
10108/99 r~p
10 max 10708/99 10108/99 SCL
CLIENT:
~JAI~I EXTENSiOn,S
SEWER & WATER 3 )
4)
ONSlIE
WELL RECOVERY TEST DATA
WELL LOCATION (legal):
TEST DATE:
WELL DEPTHi / /
CASING DEPTH:
ROBERT C. C OWAi~, R E.
ROBERT A. SNAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (90~) 694-1211
TESTED BY: ~./~,~-d~/__,,'~}~Z~~
WELL DRILLER: ~-~1/~
~E ~mLL~D: ~/~
TEST PROCEDURE;
1) Craw water down lo pump.
2) Shut pump off 15-60 min.
-record time
-record meter reading
Turn pumpom Drawdown,
Shut pump otf.
-record time
-record meter reading
Calculate gal./miu, recovery.
MISC DATA:
Casing Height:
Sanitary Seal?
Wires In Conduit?
Grading O.1(.?
Pump Depth:
Samples Taken?
Date:
]'.EST DATA, START TIME: . /~/P-~ STATIC WATER LEVEL:
TR,AL II UMP II T, E II METER II
OFF _/~ ~-~¢:~ ~ ~
OFF
3 ON
OFF
OFF
4 ON
OFF
OFF ~~ _
5 ON
OFF
~ESULTS_: WELL CURRENTLY PRODUCES: ~, _~
FLOW RATE NOT GUARANTEED--SUBSEQUENT VARIATIONS CAN OCCUR.
1034 HOR ri I EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, AlaSKA ,<~9577
MUNICIPALITY OF ANCHORAGE ~)
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include Iot~lock, subdivision, section, township, range)
(b)
(c)
Location (address or directions)
Property Owner
Mailing Address
Lending Institution
Mailing Address
Telephone: Home /'~,/~Business
~ ~/~, ,4-~, ~/~,~ a -- ,..3 ~¢4-
Telephone
(d) Real Estate Company and Agent
Address
Telephone
(e)
Mail the HAA to the followina address: or: Check hereJ~,, if hold for pick up.
List contact person and day phone number below. --
TYPE OF RESIDENCE
Single-Family~
Number o[ Bedrooms
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.
SEWA~ISPOSAL
Onsite~3 Public [] 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 1 of 2 72-025 (Rev 8/861 Front
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 °f this i~ ~r---/'2-~ ~¢,
Name of Firm Telephone ,,,~'___---~_ /
Address ;~ -,2- ~ ~z--~,E~'- ~
Date //~ / ~- -- ~ "
o
Approved for __...._.._.c_.__bedrooms by
Approved ;.,~ Disapproved Conditional
Terms of Conditional Approval
Date
CAUTION
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.
Page 2 of 2 72-025 ~Rev. 8/86) Back
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
MuNiCiPALITY OF ANCHOI~j~_[..T. H AUTHORITY APPROVAL (HAA)
ENViP, ONMENTAL SERVICES DIViSIO~HECKLiST . FEBRUARY 1984 264-4744
NOV 1 2 !987 Legal Description: ~_~./z
RECEIVED
Well Classification .-~/,,~o/~ ~--~."~,,/.'¢ If Aa B, C, D.E.C. ApProved (Y/N)
Well Log Present (Y/N) /v' Date Completed/o- ?-.~,-~'~' Yield
Total Depth ~'~f-~'~z°/ Cased to Depth of Grouting
Static Water Level 5'~'/ ~ Pump Set At
Sanitary Seal on Casing (Y/N) ~Y'
Depression Around Wellhead (Y/N)
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
!/~ ; On Adjoining Lots /O~ · ¢'
' To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
/---/~-~'" Size /0o~ No. of Compartments
Air-tight Caps (Y/N)
¥ Foundation Cleanout (Y/N) Y'
Date Last Pumped '.,,3"~i~7":.
· for
Temporary Holding Tank Permit (Y/N)
To Building Foundation /'~' ~' ' ~''
To Disposal Field /z /
To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-026 CRev 8'86~ Front
MUNICIPALITY OF ANCHORAGE
. IRV,CES D,v,s,ON
NOV 1 2 1987
Soils Rating in Absorption Strata /z
Date Installed ~l~-tP'~'-I 1i'~ ~
Width of Field / ~ z
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well //'~ /
To Building Foundation
Lot /V ~
To Water Main/Service Line
'v~'~e/r'~' Type of System Design
Length of Field ~
Depth of Field /o /
,_.Gravel Bed Thickness ~ ~ ~ ~
~,,?~ C:~ ~"'""4~ Standpipes Presen~ (Y/N) 7'
Date of Last Adequacy Test ---?'-~,~/' ~-/~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~:-~/"~ / ~ [~/~/~'~'"~/'
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots. '/~:><~ '
TO Cutbank (if present)
D. LIFT STATION ~//~"
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions '
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request
I certify tha]l~ave cffi~, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed 0/,._.~ r/~,//~,/-~/.~/!~ Date
Compa~~~/c~~ MOA No,
Receipt No. [ ~ ~ [ ~ ~ / ~
Date of Payment /~/
Amou.t: $
Page 2 of 2
72-026 fRev 8'8R~ Back
BESSE, E PS & POTTS
October 2, 1987
Mr. Dan Bowles
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
Anchorage, AK. 99501
Re: Broadwater Heights, Lot 6, Block 1
Dear Mr. Bowles:
Attached is the health authority approval form for the referenced
property. When we started the process of checking the well and
septic, we found the existing well would produce approximately
seven (7) gallons per hour, which is totally inadequate for a 3
bedroom home. (see the punp test results) The existing well had
been drilled originally to 384 feet deep. During the period
10/24/85 to 10/31/85 the well was drilled to 644' by Sullivan
drilling. While water quantity improved the flow was still
inadequate. Approximately six hundred feet of water is in storage
in the 6" casing. At 1.5 gallons per foot, approximately 900
gallons of water is in storage in this well.
In mid-September 1987, a new well was drilled (see as-built). This
well was drilled to a depth of 362 feet. We completely purged the
well four times. The well driller did the same thing several
times. After doing the purging, ~a monitored recovery. Overall
recovery on this well stabilized at 31 gallons per hour. During
the flow test for the new well, we monitored the existing well.
Interestingly enough one did not affect the other.
Between the two wells, the total water storage is over 1200 gallons
in the casing. The two wells produce 38 gallons per hour.
The existing onsite sewer system is adequate. The primary problem
was the lack of water which hopefully we have corrected.
Sincerely,
~'/'~ Merrell, PE '
Partner
jm~
cc: Fannie Mae - Alaska
ENGINEERING, PLANNING, SURVEYING
2220 E 88th Ave./Anchorage, Alaska 99507'/Telephone 907-349-6451 1344-1352
"Providing a quality personalized service to those building Alaska's future"
i'
W~t.L
0 OLD
'v,,/~: L.,L
tURV[yOR'S CERTIFICATION
I HEREIY DERTIPY THAT I HAVE IURVEYED THE
PROPERTY DEI(;RIBED ON THII PLAT AND THE
IMPROVEMENTS EITUATED THEREON ARE LOOATID
AS O#OWNON THIS PLAT.
OATEO TNl. ~d'~,,. DAY OF ,'~~''~ ,Il ~..~--.
LEGEND
(~ ' LOT CORNERS
FOUNDATION
DRAINAGE ARROWS
I SCALE' I" = "~0* I C-C
DATE, c~/'~,~ FLD. aK.,
ANCHORAGE, ALASKA 99507
BESSE, EPPS POTTS
?.220 E. 88'th. AVE,
DWG. NO.
CflK. BY,
3444352
34g-6451
DRAWN
LOT ~,' fSLoc.~
NOTES '
I, IT IHALL IE THE REIPONIIIILITY OF THE iUILDIH OR OWNER TO VilIFY THA1
IUILDING LOCATION SHOWN MEETI ALL iUlOlVlllON COVENANTE AND ZONING
ORDINANCES.
i'D iT IS THE RESPONSIBILITY OF THE BUILDER TO VERIFY ALL ELEVATIONS WITH
REIPECT TO ALL UTILITIEI~& DRAINAGE,
S. THII PLAT REPREIENTI THE PARCEL OF PROPERTY DESCRIBED BELOW TAKEN
PROM THE RECORDED PLAT DEICRIIING THAT PARCEL. INITRUMENTE RECOROED
PRIOR TO OR APTER THE IlrlLINS OF THE RI¢OROED PLAT ARE NOT SHOWN ON
THIS PLAT.
4. THE INFORMATION ON THIS PLAT IE FOR THE UEE OF LENDING INETITUTIONE
SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXIETINS STRUCTURES AND
PLATTED LOT LIHEI OR EAIEIIENTI , THE PLAT Il NOT TO Il UIED FOR
POIITIONINB ADDITIONAL ITRUCTUREI OR IIrENCEI.
..... I J.L .:,.. .....
DOC Co. ~l~a
'OWNER
ADDRESS
LEGAL l
DA~
PERMIT
KIND
From ", : - Ft.
From __
From
mrom~Ft~-t0~.~l)' J
From · '~- Ft.
From
From
Fr°m "' 'i'~. ?',
From ~ ' "'Ft.'to 'i'(;>' ":Ft ='~
From--
From Ft. to Ft. (~,J,,9 ~'g ":.~ ~E,,~.,~,'~'"--' - ~ From ~ Ft. to : ~ Ft.
6~-.,~ :: :. ~; ·
From ~<':..~t.'t~ · ',
From ~' ,Ft. to Ft."- From
From ,, ,Ft. to ' Ft. ~ From Ft. to :
DRILLER'S NAME
BESSE, EPP$ &
2220 EAST 88 AVENUE
ANCHORAGE, AK 99507
(907) 349-6451
WATER W~.r.n TEST
Block: !
Name:
Addres~:
r~ rial Reading on Meter:
.DRA~ GALLONS . G~tLo-3 ~,,'~! d ' METER
D~ TTf4E GPM A VOLUME ~'¢~ ;~¢~ ;/~/¢¢[ READING
Procuz~zn kate: '~, ~=-~- GP£4 24-.;i:--- 2a?ac'_z'f Gallons
BESSE, EPPS & POT'fS
2220 EAST 88 AVENUE
ANCHORAGE, AK 99507
(907) 349-6451
WAT~Z t~.r.t. TEST
Subdivision:
Lot:
Block:
Address
·DRA~' GALLONS i': G/~ZLo..$ .c7/'~/ d METER
~-~"~ 5' LOG OF DRILLING by A 6,
OWNER OF LAND ~ ................ /.~... .
.....
DAT~TA~T~D '..~.;:;~. ~..'~-'- ........ ~.,~ .......................................
.........................................
L DRILLING COMPANY
/
DEPTH OF WELL ,..?-.,d.....~'.. ..... t. .........................................
STATIC LEVEL OF WATER FT..,.~.......S~.... ....................
DRAW DOWN FT ........ ,~ '~ ~
......... GALS. PER HR ............ ¢.~-....-~)-. ............................... ~ ..............
KIND OF CASING ..................... .~ ...................................
KIND OF FORMATION:
D FT
......................... TO .....
FROM
F~o~...~L....~ ..........
.rRO~..kL ......... ~. 2~ ~ ~ ~:~'b ~,,,¢~'~
A~.~.-~ ......... ~ · *~--~.~ .......... ~-~--~ -
FROM ........................
FROM ........................ ~. TO.~;.: ...................................................
~o~..¢~..M..l. ..... ~. ~o.~..~f.~ ..... ~.~...~/....' ...............
FROM ........................ FT. TO ........................ FT ...............................
FROM ........................ FT. TO ........................ FT ...............................
FROM ........................ FT. TO ........................ FT ...............................
FROM ........................ FT. TO ........................ FT ...............................
FROM ........................ FT. TO ........................ FT ..................... ....%.:.: ........ FROM ........................ FT. TO ........................ FT ...............................
FROM ............ : ........... FT. TO ................: ....... FT ............................... FROM....: .......... ] ........ FT. TO ........... :.i....:::~."FT ............. : .................
MISCL. INFORMATION: : ........
.~ r?.g /'-, ,-,-'~... "':~ ~' '/-".--I~" ": ..... / ~- . _.. · .............
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 * TELEPHONE 688-2759
OWNER OF LAND j,/.~
ADDRESS 7q t~ ~,
LEGAL DESCRIPTION ·
PERMIT NUMBER
DEl'TH OF bELL {~ ?~
STATI(' LEVEL OF WATER FE
GALS. PER HR /0
KIND OF FORMATION:
From.~.~ Ft. to $"'a~ ~"~' Ft.
From ~"a~Ft. to ~'~0 Ft.
From Ft. to Ft.
From .~"~'O Ft. to__~_.~"Ft.
From g~" Ft. to---~.~.~Ft.
From/_}Tq Ft. to ~q~.Ft.
From. Ft. to Ft.
From Ft. to Ft.
From__Ft. to Ft.
From Ft. to , Ft.
From , Ft. to Fl
From Ft. to Ft
From Ft. to
From Ft, to Fl
From__Ft. to Ft._
From ,Ft, to Ft.
From Ft. to _Ft.
/
From Ft to_ , Ft.
From Ft to Ft.
From Ft, lo__ Ft.
From Ft. to Ft,
From Ft. to Ft,
?
From Ft. to Ft..
From___ Ft. to Ft.
From Ft. to Ft.
From. Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to. Ft
From Ft. to Ft.
From ,, Ft. to Ft. __
From .Ft. to Ft~
MISCL. INFORMATION:
30% ' 7"~ 6 44 z oc7' I?5"
DRILLER'S NAME
NORTHERN TESTING LABORATORIES, INC.
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS. ALASKA 99709 907-479-3115
2505 FAIRBANKS STREET ANCHORAGE, ~LASKA 99503 907-277-8378
Besse, Epps, & Ports
2220 E. 88th Avenue
Anchorage, Alaska 99507
Source: L6 Bi Broadwater
Sample ID#: A092487-1
Date Arrived: 9/24/87
Time Arrived: 0850
Date Sampled: 9/23/87
Time Sampled: 0957
Date Completed: 9/28/87
Parameter Unit
Result ADEC MCC*
Nitrate-N mg/L
0.15 10
Reported By:
Carol
J. Garrison, Vice-President
* MCC = Maximum Contaminant Concentration
NORTHERN TESTING LABORATORIES, INC.
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS. ALASKA 99709 907.479-3115
2505 F,~IRBANKS STREET' ANCHORAGE, ALASKA 99503 907.277-8378
Quality Control Report
Client: Besse, Eppd, & Putts
ID#: A092487-1
Listed below are quality control assurance reference samples with a known
concentration prior to analysis. The acceptable limits represent
a 95% confidence interval established by the Environmental Protection
Agency or by our laboratory through repetitive analyses of the
reference sample. The reference samples indicated below were analyzed
at the same time as your sample, ensuring the accuracy o£ your results.
Sample# Parameter Unit Result
Acceptable Limit
EPA WS378-6 Nitrate-N mg/L 0.93
0.84 - 1.02
Reported By: ~ . /3~._t~l~_~. Date: 9/29/87
............ ---- ;~_--_-- ------- _ 7_--_-- ~._--_--__--_--_--_--_--_--_--_--------__---_-- .................
arol J arrlson, Vice President
NORTHERN TESTING LASORATORIES INC.
600 UNIVERSITY PLAZA WEST, SUITE A
2505 FAIRBANKS STREET
FAIRBANKS, ALASKA 99709
ANCHORAGE. ALASKA 99503
907..479-31 ~5
9O7.277-8378
Besse, Epps, & Potts
2220 E. 88th Avenue
Anchorage, Alaska 99507
Source:
Sample
L6B1-Broadwater
ID#: A092587-1
Estates
- New
Well
Date Arrived: 9/25/87
Time Arrived: 1251
Date Sampled: 9/25/87
Time Sampled: 1145
Date Completed: 9/28/87
Parameter
Unit
Result
ADEC MCC*
Nitrate-N mg/L 0.12 10
Reported By:
Carol
Date:
9/29/87
J. Garrison, Vice-President
* MCC = Maximum Contaminant Concentration
NORTHERN TESTING LABORATORIES, INC.
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-~.79-3115
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378
Besse, Epps, & Ports
2220 E. 88th Avenue
Anchorage, Alaska 99507
Source: L-6, B-l, Broadwater
Sample ID#: A090987-4
Parameter Unit
Nitrate-N mg/L
Result
0.76
Date Arrived: 9/09/87
Time Arrived: 1015
Date Sampled: 9/08/87
Time Sampled: 1130
Date Completed: 9/10/87
ADEC NCC*
10
Reported By:
Date:
9/10/87
Carol J. Garrison, Vice-President
* MCC = Maximum Contaminant Concentration
NORTHERN TESTING LABORATORIES, INC.
600 UNIVERSITY PI_AZT. WEST. SUITE A FAIRBANKS, ALASKA 99709 907-~79-3115
2505 FAIRBANKS STHEET ANCHORAGE. ALASKA 99503 907-277-8378
Quality Control Report
Client: Besse, Epps, & Potts
ID#: A090987-4
Listed below are quality control assurance reference samples with a known
concentration prior to analysis. The acceptable limits represent
a 95X confidence interval established by the Environmental Protection
Agency or by our laboratory through repetitive analyses of the
reference sample. The reference samples indicated below were analyzed
at the same time as your sample, ensuring the accuracy of your results.
Sample# Parameter Unit Result
Acceptable Limit
EPA WS378-6 Nitrate-N mg/L
0.95 0.84 - 1.02
Reported By:
Date: 9/10/87
Carol J. Garrison, Vice-President
APPLIC, .iT FILLS OUT UPPER HAL, 3NLY
Property Own~,r "'~J~J (~'~, ~i;,, ~,~ ~.,.,, ~ ~" ~ ~ ~ ~ Phone
Mailing Addre~ ~
~ :. -;, ~ ~ Phone
Address Zip Code
Co. & A~n - ~,c%,~ ~ ~ ~ Phone
Legal Oescript~. L
,ypeofResi~nce (75 '"~ [~ ~ - k -
~ Sinole Family
~ Multiple Family No. of Bedroo~
~ Other
Water~upply
~ndivldual A~ACH WELL LOG. A w~l Io~ is required for all wells drilled since dune
~ Oommunity For wells drilled prior to that date, eve well depth (attach Io~ If available).
~ Public Utility
Sewer pisposal
~ndividual Year Indiv~ual Installed:
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
~ ~ ENVIROi-IM ~,'A'; ,~' 2CTtON
¢_ o,K. RECEIVED
( i~PROVED BEDROOM8 *CONDITION8 OF APPROVAL
( ) DISAP~OVED
( ) CONDITIONAL APPBOVAL*~
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
~ Well to Tank Septic T~k Size
72-023 (3/82)
EXCAVATION
ROBERT A. SHAFER
CIVIL ENGINEER
694-2979
WORK
April 3, 1982
Dynamic Realty
ATTENTION: Don Beattie
501 West Northern Lights Boulevard
Anchorage, Alaska 99503
Dear Mr. Beattie,
Reference: Lot 6: Block 1: Broadwater Heights Subdivision'
A sewer system adequacy test was performed on the system
located on the referenced property as you requested.
The septic tank was pumped and verified to have a capacity
of 1000 gallons. The seepage pits were tested over a
period of 24 hours. The percolation rate within the seepage
pits indicated that the system was adequate for three bedrooms.
It can be concluded from this test that ~'he waste water
disposal system serving the three bedroom residence
is currently functioning adequately. However, the system
cannot be guaranteed against subsequent failure.
If we may be 0f further assistance, please do not hesitate
to call.
cc: MuniCipality of AnChorage
Department of Health and Environmental Protection
SRB 196X EAGLE RIVER, ALASKA
William J. Travis
c/o Katy Nash
Dynamic Realty, Inc.
P.O. Box 677
Eagle River, AK 99577
Subject: Lot 6 Block 1 Broadwater tteights
Approval for the individual sewer and %;ater facilities cannot
be granted until the following items have been completed:
An outside water tap was not available. Please call this
office to make arrangements to have an inspector to meet
you at the site.
A four (4) inch cleanout needs to be installed to the
leaching area.
Please notify this Department for a reinspection when the
noted discrepancies have been corrected. If there are any
further questions, please call this office at 264-4720.
Sincerely,
RP234Ip/EH
Robert C. Pratt
Associate ~' '
Lnvlronmental Specialist
~'~-'""'~"" . MUNICIPALITY OF ANCHORAGF
/;~~~,! ' DEPARTME OF HEALTH AND ENVIRONMEN
t,~~~'~}) i 825 L Street, Anchorage, AlasKa
"!!~' ' _ 279-2511~ ext. 224 or 225
~.~-~ ~.~p < ~' Date Received: ~t_ 24, ~'977
Time __~ 92: Time
Date q-~-n~~ Date
Insp ~~ Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER ~D WATER FACILITIES
PROTECTION .
99501
# 3: Time
Date
Insp
1. Lending Institution Request:
First National Bank of Anchorage
Mailing Address: Post Office Box 720 99510
Phone: 276-6300
2. Property Owner: Steven/Rita Stuff Phone:
Mailing Address:
Star Route Box 2304
99577
694-2525
4:
Legal Description: Lot 6 Block 1 Broadwater Heights Subdivision
Single Family Residence: (x) Number of Bedrooms:
Multiple Family Residence: ( ) Number of Bedrooms:
Well System:
Permit #
Construction
Individual. Well (x) Community/Public System ( )
Depth of Well Well Log on File ( )
.. Bacterial Analysis
Sewage Disposal System: On-site System (x~ Public Utility
Permit # Installed June 1972 Installer
Septic Tank Size
Absorption Area
Manufacturer
Soils Rate
Distances: Well to Septic Tank
to Sewer Line Nearest Lot line
to Nearest Lot Line
Material
to Absorption Area
Absorption Area
MUNICIPALITY OF ANCHORAGE
.... HUNICIPALITY OF ANCHORAGh DEPT. OF HEALTH &
.:/'" ,,O, "'~'k,. Department of Health and Environmental - ' , .ENVIRONMENTAL PROTECTION
,, ~,~[~'.," 825 L Street, Anchorage, Alaska 99501
'~~' 279-2511,~:~t. 22~, ~2s AUG ~ 4 1977
'~;~ue~ ~o~ A~ro~ o~ In~.v~u~. ~w~r ~n~ W~,~ ~ac.~_~LEIVED
Mailing Address:
Mailing Address:
Phone:
.3.
Lending Institution:
Mailing Address: P.(~.%c~C
Realtor/Agent: ~~
Mailing Address: '~O~
Legal Description: ~T_OO~kO~b% _~e~,C~%
Street Loca'tion, ~%.L.t_~¼ ~_~.
Single Family Residence: (~<) Number of Bedrooms:
Multiple Family Residence: ( ) Number of Bedrooms:
o
Water Supply: * Individual Well
If Individual Well, well depth
If Con. unity System, name of system
Public/Community System ( )
Sewage Disposal System: On-site System (X) Public SI'stem
If On-site System, date of installation:
*NOTE: A well lo9 is required on ALL wel].s drilled since 6/75.
3/77
Page Two
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description:
Lot 6 Block 1 Broadwater Heights Subdivision
Comments:
Affadavit Attached: ( ) Letter Attached
Approved.: Date:
D~sapprove
Date:
Department Worksheet:
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received 2/21/75
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
2/24/75
1. Approval requested by:
Mailing Address:
2. Property Owner:
Mailing Address:
Steve Stuff
Eagle River Phone:
Same Phone:
3. Legal Description:
4. Location: 0££ Skx1ine Drive
5. Type of facility to be inspected
6. Well Data:
A. Type Drilled
C. Construction Standard
7. Sewage Disposal System:
1972
1. Size
1. Absorption Area 572 sq/£t
Total length of lines
A. Installed
C. Septic Tank:
D. Seepage Pit:
E. Disposal Field:
Distances:
e
Lot 6~ Block i BroadwaterHeights
Single Family
No. of bedrooms 3
B. Depth
D. Bacterial Analysis Satisfactory
B. Installer Wallace Construction
1000 gals 2. Manufacturer Wallace
2. Material
Concrete rings
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
, Absorption area
, Other contamination
12' , Absorption area
C. Absorption area to nearest lot line
, Sewer Lines
EQ-034 (1/74) Page 1 of two pages
?age 2 of'two pages - Re st for Approval of Individual er & Water Facilities
Legal Description Lot 6, Block 1 Broadwater Heights
Comments
Approved~ ~.Z
Disapproved
Date
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
Date
EQ-034 (1/74)