HomeMy WebLinkAboutBRUCKNER LT 2
MUNICIPALITY OF ANCHORAGE
., DE ITMENT OF HEALTH AND HUMAN SER' -'S
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name ,~. 4~v.~ '~y~'l.~ ~..~¢-' I'~ DISTANCES
SEPTIC ABSORPTION
~ddress WELL
7'2z '7 1 TANK FIELD
Phone(s)~ 4~ ~ INo. oI Bedrooms+ WELL ],~'
LEGAL DESCRIPTION LOT LINE ~
Lot ~ J Block J Subd~wm~
. - J ~Yu~/ FOUNDATION
Township, Range, Section
5~1/~ ~ 4 ~ ~5U ~[ ~ A~-BUILT DIAGRAM (Show ,ocabon o, well. septic system, property lines. ,oundat,on.
dnveway, water bodies, etc.)
TANKS i
~ SEPTIC ~I~Ti~ ~ HOLDING
'~a,u~L Capacdy In gallons
........... o
TYPE OF SYSTEM ) ~~sr~,~ ~[~,~
~TRENCH D BED D W. DRAIN ~ OTHER /~...~
or,9i,a~ wade /~ FT / ~ FT ~
~dl added abov hal grade Gravel d~pth bene~t~
~ FT ~/ FT
_ 1~4~' ~[ ~0' FT ~0/' FI
Total absorpbon area Distance between hnes ~
U~ SO FT ~T Z. FT
Number 01 hnes J Soil rating Pipe material
~J I~ SOFT ~
Installer Date Installed
WELLS ~ ~tL:(~- ,)
~ PRIVATE ~ OTHER fldentifv)
Cl~smficm~on (A,D,O) ~ mai Dep[h Oased to ~
REMARKS: t ~="1~'~
I ~ ce~i~that Ihis inspection was peflormed according lo all
Health Depa men App o a: - ~ - - ' : 2 - : ;:~)::'~ ~ .~-~~-_ '~, ::'.t~::,~:~::?,::
72-013 (3/85)
;/-J :i. 'l'. h
all I"tEh~.~ ar'.,,.';:l
,'..?d';i'?' e;,:;..': i ?1~. i r"~,:';.i *.,'..~e 1 ]., ~,,,~a'.e;t. ~;.~,w~'a'l;..,;.;.;.;,r'- c! i :+:.po'.sa ]. !!i!.~y'~.t.e;.:qTi Of pLd;;;, ii. i C:
t"l '!'.h i
~ I? ~I,,, ~ L
I0'
I 2¢-o
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anch.orage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:__
LEGAL DESCRIPTION:
Township, Range, Section: %'~..)~/'~ S4 'T'lc~h) i--'~l LA.!
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
(FEET)
\
- I
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Oepth to Water After
Monitoring?
Read ng
Dale;
D ] Gross
ate [ Tin2_e-
;,IT ~-,~ LAN
P ERC'~ATtON RATE
TEST RUN BE1WEEN
Net
Time
Depth to
Water
.... [minutes/inch) PERC HOLE DIAMETER
F1 AND ______FT
¢" ' ' -4'~.~,~-~'2x~-¢ ~.~t., ~';~ CERTIFY THA~ THIS 'TEST WAS PERFORMED
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUtDELINESIN EFFECT ON THtS DATE, DATE: ........ -- ..........................
72-008 (Rev. 4t85)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME IPHONE
MAILING
LOCATIONp~ [ ~O* ~ NO.~ BED~OM~ // ,~'
~ Iw"'. ~/~ IAbs°~pti°na~ 'i D~.i,i.g /~ ,~ PE~T¢O.'
m~ ~Z ManufactureF'-N' ~ [~ ~~ -- __~ ~ Ma~~ No. of compartments ~
~ ~ DISTANCE TO: Well ~/ Dwelling PERMIT NO.
~Z
~_~oZ~ Manufacturer . ' /~ Material Liquid capacity in gallons
Well Foundationz~~ '~. Nearestlotli_~0 ,~
DISTANOETO:j Lengtho~31ineJ Tot~h~flines/-- inches
d~ Total effectiv ab or tio ' re
"~ ~ Top of tile to fin,sh gra ,~ Mater[al~eneathtile inches
~ Length Width ~epth ~ PERMIT
~ ~ Type of crib Crib diameter rib depth Total effective absorption area
~ Well ~Building foundation Nearest lot line
~ DISTANCE TO:
~" Class~/V '~ept~.~ ~ ~r/ ~r~ Distance to lot line P ERMITNO.
~ · I Build~u~d~tio~ ' Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
t
INSTALLER '
REMARKS ' '
/
/
., 1/..-,'
13 (Rev. 3/78)
PERMIT NO.
~-lLIr~ IC:I F" 3LIT'T' CIF R~-JCH( i:RISE
DEPRRTMENT OF .JERLTH RND ENVIRONMENTRL P~.~TECTION
825 'L' STREET.. RNCHORRGE, RK. 9950±
224-4?20
~4ELL Rr-~C, ~Dr-~--SITE _~.EL.JEE: F'ERF1 IT
( 830042 )
RPPLICRNT
LOCRTION
LEGRL
· . HME=, K ~(NER E,0,-,_.o_ E.R.
' '- '-'- .... '" ' _,#~_,4E1_.
F E. UF I..i=,E[., ~.' E, RUCKNEF.. c- --. - ?
Ti5NRitW S4 L5
99577
LOT SIZE
294-9622
999999 SQURRE FEET
TYPE OF SOIL RBSORPTION SYSTEM IS: TRENCH
MRXIMUM NUMBER OF BEDROOMS
SOIL RRTING (SQ FT?BR)= i50
THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS:
[)EF"TH= 11 LE~i]TH= 4-5 i] R R"..-' E L DEF'TH= 5
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUND RND THE BOTTOM OF THE EXCRV8TION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE
RND THE BOTTOM OF THE EXCBVBTION (IN FEET).
RE[:. SEPT I C: TR[~-:] $ I ZE= 1~="~ L---~-:--~ ,3RLLC,[-~5
PERMIT RPF'LICRNT HRS THE RESF'ONSIE:ILITY TO INFORM THIS DEPRRTMENT DURING THE
INSTRLLRTION INSPECTIONS OF RNY WELLS RDJRCENT TO THIS PROPERTY RND THE
NUMBER OF RESIDENCES THRT THE WELL HILL SERVE.
TL4~] (2) I r-4SPEC:TIC~[4--'3 RRE RE,E4LIIRE[:,
BRCKFILLING OF RNY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS
DEPRRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS
±00 FEET FOR ~ PRIVRTE HELL OR 150 TO 200 FEET FROM ~ PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET RND
TO R COMMUNITY SEWER LINE IS 75 FEET.
NELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS
OF THE NELL COMPLETION.
OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE
RVRILRBLE TO INSURE PROPER INSTRLLRTION.
PEF.:r'I I T E:~::F' I RES DE,~Er-IBER _~-::L.. I ~:_=~._--<:
I CERTIFY THRT
t: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH BY THE MUNICIPRLITY OF RNCHORRGE.
2: t WILL INSTRLL THE SYSTEM IN RCCOR[:,RNCE WITH THE CODES.
_-'.':: I UN[:,ERSTRND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THRN :'~ BEDROOMS.
~F'L%- T~I CRNT .: RMES ~E:UCKNER
I SSIJED E : ___: ....... ~:_ V4. 0
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOl LS LOG
[] PERCOLATION
TEST
PERFORMED FOR: ~/-------.-~'~- ~---.- -
LEGAL DESCRIPTION:
1
2
3 ~.~t
4
7
$
10
12
13
~4
~ober~ A,
16
17
19
~ .5--
b~'~S~ (~ I bTy (~p~.lb
DATE ~ERFORMED: ~--
SITE PLAN
SLOPE
WAS GROUND WATER
ENCOUNTERED?
AT WHAT
TH?
V Gross Net Depth to Net
Reading Date Time Time Water Drop
2o
PERCOLATION RATE .4 (minutes/inch)
COMMENTS
72-008 (6/79)
5'(o¢'o
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOII. S [()G
l"] PEHCOLATION
[ESI
1
2
3
5
'?_
10
~3
14
17-
18
2O
COMMEN]S
SLOPE
WAS GROUND WATER
ENCOUNTERED?
ldo
o
P
E
IF YES, AT WHAT
DEPTH?
SITE PLAN
Reading [ "Date Net Depth to Net
I
PERCOLATION RATE (minutes/inch) "
TEST RUN BETWEEN FT AND -- FT
PERFORMED BY:
CERTIFIED BY:__
DATE.:
(6/19)
RETUfq TO:
glvislon of Geological and G /site1 Surveys (DGGS)
3001 Porcupine Ortve (Telep. ,~e: 277-6615)
Anchorage, Alaska 99501
WATER WELL RECORD
Drilling Company Name
STATE OF At~ASKA
DEPARTHENT OF NATURAL RESOURCES
U.S.G.S, Local liD.
Drilling Permit No.
LOCATION OF WELL '1 Please complete either la, lb, or lc, A.UoL, rio.
la. Borough Subdlv)slon Lot Block lb. Fraction Section No. Township Range Mer~dtan
/ / / N/S E/W
lc. Distance and Direction from Road Intersectlons ~t. OWNER OF WELL:
Add ress:
Street Address and Area of Well Location
2. WELL LOG Feet Below 4. WELL DEPTH: (completed) Surface Elevation Date of
Surface Compl et ion
Materla) Type Top Bottom ft.
5. i~ Cable tool ~Rotary ["'}Driven ~'~ Dug
~. usE: F-1Domest~c ~Pu~llc supp%y E]~ndustry
, r I a . '~ F-'~ Irrlgat Ion ~"'-~ Recharge[--~ Cormnerc iai
['--~ Test Well ~--~ Other:
7. CASING: [] Threaded []Welded
)n. to ft. Depth Weight lbs/ft.
in. to ft. Depth
8. FINISH OF WELL:
Type: O ~ ameter:
Slot/Mesh Slze: Length: ,,
.., Set between ft. and ft.
Fltt{ngs:
9. STATIC WATER LEVEL: ft.
[] Above l"'laelow land surface
MUNICIP) ITY Ur Ai~'i'iO~a~ Type of Measurement:
L~Cr ~Jr rl~,,, ~ 10. PUMPING LEVEL below land surface
__ ft. after hrs. pumping g.p.m.
.~"r~T 4 r-/ 4~O/'1 ft. after hrs. pumplng g.p.m.
11. WELL HEAD COMPLETION: [] In Approved Pit
KI LI'I cU []pttle,s Adapter__ inches above grade
12. GROUTING: Well Grouted: [] Yes []No
Material: ["']Neat Cement [] Other:
13. PUMP: (if available) HP
Length of Drop Plpe ft. capacity __ g,p.n
Type: [-'~ Submers I ble E~Rec i Procat ~ng
[] Jet E~ Other:
t4. REMARKS:
15. WATER WELL CONTRACTOR'S CERTIFICATION:
This well was drilled under my jurlsdlction and this report Is true to the best of my knowledge and belief:
Registered Business Name Contract License Number
Address:
~ ~ . Date:
Signed: ' - r Auth(~r izod' Repr~sentat ive
Form 02-WWR Copy. Distrlbutlon: WHITE - State DGGS, PINK - Driller, CANARY - Customer
Rick Mystrom,
Mayor
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
http://www.ci.anchorage.ak.us
343-4744
May 29, 1998
Stephan R & Susan B Jones
21918 Grasser Road
Chugiak, Alaska 99567 5311
Subject: Lot 2 Bruckner Subdivision
Permit #SW970099, PID #051-072-72
The subject permit, issued May 20, 1997 by this office for a
single family well and/or on-site wastewater system, has
expired as of May 20, 1998.
A new permit must be obtained from this office for a well
and/or on-site wastewater system NOT installed by the
expiration date.
If you have drilled the well, a well log must be sent to
this office for documentation of the installation and to
close the permit.
If a licensed Professional Engineer has inspected the
installation of the on-site wastewater system, the original
as-built inspection report must be sent to this office for
review, approval and documentation. Ail inspection reports
must be submitted within 30 days of construction completion.
When applying for a new permit, the fees are: $320.00 for an
on-site wastewater permit; $120.00 for a well permit and
$440.00 for a combined on-site wastewater and well permit.
~If. you_have any~questions,
On-site Services
please call this office at 343-4744.
enc: Copy of Permit
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW970099
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:JONES JACK JAY
OWNER ADDRESS:21918 GRASSER RD
CHUGIAK, ALASKA 99567
PARCEL ID:05167272
DATE ISSUED: 5/20/97
EXPIRATION DATE.: 5/20/98
LEGAL DESCRIPTION:
BRUCKNER LT 2
LOT SIZE: 62338 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT:
THIS PERMIT IS FOR THE CONSTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED'AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVIZ__
/00
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 /~'~/~/Z'~' ~
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal De.s~ription (include lot, block., subdivision, section, township, range) .
(b)
Location (address or directions)
Property Owner/'~k,~.~,--)/~/.~,,u,,./~/~,~,_,* Telephone: Home
Mailing Address/~//
Business
(C) Lendinglnstitution d~c;~ .~./¢~;/).~(~/t~.-~--~A~., Telephone
Mailing Address ~ ~~~/~.~~
(d) Real Estate Company and Agent ~'~ ~/.,~/,,~¢Z¢
,..
(e) Mail the HAA to the followin~ address: or: Check here B, if hold for pick up.
~ist oontict person and day phone number below.
$ & S ENGINEERING
17034 Eagle River Loop Road No. 204
TYPE OF RESIDENCE
Single-Family J~
Number of 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.
SEWAGE DISPOSAL
Onsite/l~ 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 fRev 8/861 Front
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 $ & $ ENGINEERING
17034 Eagle Ri,vet Loop Road No. 2~g4
Address E=~!_~ ~!¥er, A!_~_-k_- 99577
Date
Telephone
DHHS APPROVAL
Approved for ,,~'~z~z..,- (rz~ bedrooms by
Approved ,~r~ Disapproved
Terms of Conditional Approval
Conditional
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 fRev 8/86) Back
-'''M'-U-N'IclpALITY OF ANC"ORAGE (MOA)
DyV~,.,~ur'~EALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
Legal Description:
Well Classification
Well Log Present.N)
Total Depth
Static Water Level
'~:~.\,J/>-~'~ if A, B, C, D.E.C. Approved (Y/N)
Date Completed ~,'7._ ~ ~"L.- - ~5'~ Yield
Cased to ~' I ! --"-'"-
Depth of Grouting
Casing Height Above Ground
Pump Set At
Sanitary Seal on Casing
Depression Around Wellhead (Y~
Electrical Wiring in Conduit I~/N)
Separation Distances from Well:
To Septic/Hofdm'g Tank on Lot
To Nearest Edge of Absorption Field on Irot
To Nearest Public Sewer Line Cleanout/Manhole
Water Sample Collected by ~
Water Sample Test Results ~~~
Comments ~ ~ ~' ~
~_ ,~C::> ; On Adjoining Lots
1 ~ , On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
B. SEPTIC/I.I~LDIN~ TANK DATA
Date Installed E~,- I?~ ...~r'~ Size ~'l...~--~ o No. of Compartments
Standpipesd~N) Air-tight Caps~N) Foundation Cleanout (Y~
Depression over Tank (Y~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/14efdl~g Tank:
To Water-Supply Well ~, ~ ~
To Property Line ~ ~.~ N'
To Water Main/Service Line
Course \ ~
Comments
Date Last Pumped ~'~
~_3/~ 'for
Temporary Holding Tank Permit (Y/N)
To Building Foundation .~'
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026 fRev 8/861 Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ~ ~"O ':¢~/1F¢2- Type of System Design
,
Date Installed ,i~ ~ ~ ?..- -~"~ ~ ~ ~ ~'7 '')¢ Length of Field '~ c:> '"'~'--.==='T~
Width of Field ~ c~' II Depth of Field ~ ~' !
Square Feet of Absorption Area
Depression over Field (Y~[~
Results of Last Adequacy Test
Gravel Bed Thickness ~' !
c~c?" ~ Standpipes Presen~)N)
Date of Last Adequacy Test ~.'Z-- ~ I,¢f ~'~
Separation Distance from Absorption Field:
To Water-Supply Well \ ~
To BuildingLot F°undatl~n/~,-
To Water Main/Service Line ~. c~ I A--
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 ~ J'~
To Cutbank (if present) ~ /~:
LIF
"Pump On" Level at ~~
High Water Alarm Level at ~
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
~~ycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that J J"c.v.e. cC~c~k,~:l, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
S & S
Signe~034 ~_._=la River Leap Road No. 204Date
Com~,~ River, Alaska ~5~ MOA No.
Receipt No. / ~ ~ / ~ O / ~
Date of Payment , ~/~ ~~
Amount: $
Page 2 of 2
72-026 fRev 8/86~ Back
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
FEDERAL TAX ID # 92-0040440
ANALYSIS REPORT BY SAMPLE
Client PO# : VERBAL
C1 lent Smpi ID: LT2 BRUCKNER
Req #:
Sample Rec'd : DEC 14 87
Ordered By :
Send
Reports To:
$ & S ER$INEERIN$
R SCBAEFER
17034 BASLE RIVER LOOP RD., #204
EAGLE RIVE, AK. 99577
Work Order No. : 4333
Client Account : ~SER~
Date Report Printed: DEC 17 87 9 11:53
Released By : 2~c--~
Reports Address #2
Special COLLECTED 12-14-87
Instruct:
Chemlab Ref #: 8608 Lab Smpl ID: I Matrix: Water
Allowable
Parameter Tested Result/Units Method Limits
NITRATE-N ND(O.IO) mg/i 10
MUNICIPALiTy OF ANCHORAGE
ENVIRONMENTAL 'SERVICEs DIVISION
,:?L~'? 2. C 1987
RECEIVED
Sample
Remarks:
ROUTINE SAMPLE
ANALYSIS COMPLETED: 12-16-87
LABORATORY SUPERVISOR~ STEPHEN C. EDE-''-~ ~''- ~'/-~"~'~--'~'
._L
1 Tests Performed
ND= None Detected
BA= Not Analyzed
See Special Instructions Above
See Sample Remarks Above
LT=Less Than, 5"T=Greater Than
,~'~,' $ ¢. ha C__~---P
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
Name Phone No.
Mailing Address
C~ty / St Zip Code
Mo. Day Year
SAMPLE TYPE:
/~--Routine
[] Check Sample (lot routine sample
with lab ref. no.
L~ Special Purpose
.) [] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
2 I
MuNICIPALW~ OF
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
'~ Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received
Analytical Method: Membrane Filter
* No. of colonies/100 mi.
Lab Ref. No. Result*
l-ill
I
I
I
Analyst
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS Membrane Filter: Direct Count
Coilform/10Oml
BEFORE
COLLECTING SAMPLE
Verification: LTB
Final Membran~ ,~f
Reported .y__y__~
BGB
Date
Time:
Coilform/100ml
TNTC - Too Numberous To Count
OB = Other Bacteria
PART ! OF 2 REM~II~IDER TO FOLLOW
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date
(a) Legal Description (include lot, block, subdivision, section, township, rar~e)
Lot 2 Bruckner Subdivision
Location (address or directions)
(b) Applicants Name Chris/James Bruckner Telephone - Home Business
Applicants Address Box 772471 Eagle River, Alaska 99577
(c) Applicant is (check one) Lending Institution ~-~ ; Owner/builder ~
Buyer ~--~ ; Other ~--~ (explain);
(d) Lending Institution First National Bank of Anchorage Telephone
Adidas. ss Eagle River Branch
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. T,vpe of Residence
Single-Family ~
Number of Bedrooms
3. Water Sup 1
Individual Well ~
Multi-Family
three
Other (describe)
Co'mmunity~ Public~
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
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 Providin~. 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 regula-
tions in effect on the date of this inspection.
Name of Firm
Telephone
Address
Date
DHEP Approval
(ENGINEER SEAL)
~ .-'/ ~,/ this property
Approved forthree(3~edrooms BY/;','}' '/'/:'/r.;<~'',,.- .. .. .., . uate Oct 17~...1984
-/
Approved xx Disapproved Conditions3. __
This Department has received
written confirmation from the
engineer(S&S Engineering) that
the conditions have been met
and this property is now in
full compliance with MOA Codes.
Therefore, this Department is
issueing a full approval of
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DEEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PA/{AGRAPH 5 A~OVE 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 REQUIRE-
MENTS. 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.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
MUNICIPALITY OF ANCHORAGE
APPLICAT~O~ ~OR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date_~---Z~"~
(a) Leg~ Description~ Z~J f(includec/f'/~; ~-_/l°t' block.,~/zpsubdivision,~ ~.- i3 ~'secti°n'~-- ~.".~"t°wn'ship'cl ~7~ range)
(b)
Location (add~ess
Applicants Name
Applicants Ad~es,
(c) Applicant is (check one) Lending Institution ~ ; Owner/builder~;
Buyer ~ ; Other ~-] (explain);
(d) Lending Institutionq/-~f'~'~ ~' /7/~' ~ Telephone
(e) Real Estate Co. & Agent
Address
Te le phone
2. Type of Residence
Single-Family.]~
Numbe~ of Bedrooms
Multi-Family .-7
Other (describe)
3. Water Supply
Individual Well ~ Conmunity ~ Public ~--~
Note: If c~,~.~nity ~11 system, must have written confirmation from the State
Department of Environn~ntal Conservation attesting to the legality and status.
Is the ~11 adequate fo~ the number of bedrocms specified in th
4. Sewage Disposal
Onsite~ Public ~ ~nity ~ Holding Tank
Is the wastewater disposal system adequate for the number of b~dr
[Page 1 of 2]
2-15-84
5. En.gineerin~ Fimu Providing Inspections, Tests, Data and Information
I certify tha~.I~ee checked, verified, c~. oonformed to all MOA HAA Guidelines in
effect" on ~.he'
Name o~ F~_ _ ~ .......... Telephone
(ENGINEER SEAL)
Date
~ bedrccms
Disapproved F-~
6. DHEP Approval
Aplmsoved for-
Approved ~-~
Terms of Conditional App~oval~.~'/F79~
./,../~,,,o B'~, ' ' '
The Municipality of Anchorage Depa~tn~nt of F~alth and Environmgntal P~otection does
not guarantee the continued satisfactory performance of the water, supply and/o~ the
wastewater disposal system. This approval indicates that, as (:~ the validation date
shown above, based on the data and information furnished by an engineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and func~
tional fo~ the numbe~ of bedrocks and type of structure indicated.
(D~EP SEAL)
7. Mail the ~ to)the fo.~owing addres/:.
,' " I/ -Z/ '
KB2/d5/s
[Page 2 of 2]
2-15-84
Be
MUNICIPALITY OF ANCHORAGE (MOA) ~uN~r~/9~ ~~
/
.... i.z RECEI .ED'
Well ~ ~e~nt ~te ~le~d /~//3/~ Yi~ld~~
Total.p. ~[ Ca.d.
' ,. ' /"
Static Water ~1 ~/
Casing ~ight ~ G~nd ./~
Elee~ie.l Wi. lng in ~nduit (~h
~p~ation Distance ~ ~1!: ~'-
TO ~a~est ~ of ~tion Field on
To ~est ~blic ~ Line ~/~ To ~est ~blic ~--~
Clean~t~a~ole , ~ ~ To ~est
Wate= S~le Colle~ed By '~(~ ~~/~ ~ ~--~ ~ ....
SEPTI, C/HOLDING TANK DATA /2~--~
Date Install.~ed P,~ Size ~ No. cf ..
Standpipes~ ..Air-tight CapsO/%~ Foundation Cleanou ,
Depression ove~ Tank ~ Date Last P ,umpe. d
Separation Distances f~om Septic/Holding Tank:
TO Property Lin8 _DO
To Water Main/Servi~s Line
course
To Disposal Field
/~///~/To/~eam, Pond, Lake, c~ Major Drainage
· - ,~/,/'"f'~.f/~ ~ " . '~ ~.._' -..,_
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption. Strata
Date Installed ~2~/0c~-~
Width of Field ~O r,
Square .Feet of Abso~pti.~_~.~ea
Dep=esslon
Results of Last Adequacy Test
/5~ Type of System._~sign
' Length of Field ~ /~ ,
Da e 'of Last Adequacy Test /%~C ~/
Separation Distance f~cm Absorption Field:
To Buildi~ Foun~tion ~ ~ To Existing or ~ndo~d Sys~m ~
To ~te= Mai~=vi~ Line T0' ~t~( if ~e~t-) .... '
To ~i~,y, P~ki~ ~ea, ~ Vehicle St~a~' ~ea ~ /~
D. LIFT STATION
Date Installed
Dimensions
Size in Gallons ~ ~' /~/,~ Manhole/Access(Y/N)
,,Pump O~,, Level at ve~t ~ ,` "Pump Off" Level at
High Water Alarm Le '~ ' ~ Vent (Y/N)
Tested for Pumping Cycles du~ing Adequacy Test.
Electrical Codes (Y/N)
Cc~ents
** Check Permitted Bedroom Rating Against HAA R~ques't
I certify ~a~ I~_ .ave checked, verified, c~ confc~ed to all MOA HAA Guidelines in effect
on the_ ~ ~ .~i~.~nSpection. , !
.......... /1 '::'
2-15-84