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Home My WebLink AboutSOUTH LAKEWOOD HILLS BLK 2 LT 7 Municipality of Anchorage Page ~ of 1 DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~'~--~l,JOil~) .~_ ,4~. PID Number: ~l~l Nam~ ~ ~ ~ ~ ~1~ Wastewater System: Q New ~pgrade Address: __ [~1 ~'~~ ~ ~q61~ ABSORPTION FIELD Phone:~.~ IN°'°~°°ms: ~DeepTrench ~ Shallow Trench ~Bed ~Mound ~Other LEGAL DESCRIPTION soir~b.~;D.~ ~S,.F~. To~, bdvi 'o ' Depth to pipe bottom from original grade: ~ ~/ Gravel depth beneath pipe Number of lines: I Dismce between lines: WELL: ~ New ~ Upgrade Gravel~~ ~Ft. ~ ~ Ft. C~as~etion (Private, A,B,C): Tota~ Depth: Cased To; Total absorption are~: ~ Pipe material:~ ~ ~ Driller: Date Dritled: 8tatic Water Level:Ft. Ir~ ~.~t/l~ ~taller: Date installed:~ / ~ ~ Yield; GPM I:Tmp Set at: Ft. ~Cas[ng Height Ab°ye Gr°u::: TANK SEPARATION DISTANCES ~s~ptic ~ Ho~i~ ~ TO Septic Absorption Lift Holding =ublic/PrivatE Manufacturer: Capacit~s: From Tank Field Station~ Tank Sewer Lines S,~CeW~t~ 1~ {~/ ~- ~ ~ LIFT STATION LineL°t ~,~ ~1 ~ ~ ~ ~ Size in gallons: Manufacturer: ~1 ~+~ "Pump on" ~evel at: T"Pump off' ,evel at; High water alarm at: Foundation ~ ~ Curtain Drain ~ ~O~[- Pump Make & Model Electrical Inspections performed by: Remarks: BENCH MARK Department of Healt~d~ma~ ~e~ices approval '~ ~:'. ,.' ~ Reviewed and approved by: ~2/~/~7~ Dat 12-013 (1/91) MOA 25 Page ~ of ~" Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: '"'J~ ~ [_~'r' ~ PID No.: ~1~ I ~--~ 72-013 A (2/91) MOA 25 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 WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT NUMBER:SW910344 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:ST JOHNS UNITED METHODIST CH. OWNER ADDRESS:1801 OMALLEY RD ANCHORAGE, ALASKA 99516 PERMIT ~ DATE ISSUED: 10/25/91 EXPIRATION DATE:10/25/92 PARCEL ID:01551124 LEGAL DESCRIPTION: SOUTH LAKEWOOD HILLS BLK T 7 OF 2 2 L LOT SIZE: 35000 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD 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 FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS RECEIVED BY: ISSUED BY: DATE: DATE: ROBERTSHAFER, P.E. ROGERSHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694~1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS October 16, 1991 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street Anchorage, Alaska 99501 REFERENCE: South Lakewood Hills Subdivision, Block 2, Lot 7 Request you issue a permit to upgrade the septic system serving the referenced property. An adequacy test was performed on the existing system and the absorption capacity of the system was found to be less than adequate. A test hole was excavated and a percolation test performed in the area of the proposed upgrade. Attached is the proposed upgrade design. The lots in this area are relatively large. Therefore we do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic upgrade. If you have any questions or require additional information for your review, please contact us. Sincerely, RJS/lsu ON SITE WASTEWATER DISPOSALS¥STEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SCALE [ Municipality of Anchorage 825 L Street, Anchorage, Alaska99502-0650 SOILS LOG -- PERCOLATION ~ '2-, ~ ~r s,oPE S~TEP.AN WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT DEPTH? p E Depth Io Wat~ / 1 4 5 6 7 8 10 12 14 17 18- 19- 20- Gross Net Depth to Net Reading Date Time Time Water Drop I ~..'2_~-~1 4,.1~-~ ~ 6, ~', ..~. ¢. ~. ~.~ I L~ ~ , ~ , ~ '1~" 'l 7~ " PERCOLATION RATE J ~ (minutes/inch) PERC HOLE DIAMETER ~ // TEST RUN BETWEEN '~ FTAND~ FT Eagle River, Alaska 9~1~ ' ~ " J ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON ~HIS DATE. DATE: ~ ~J 72~008 (Rev. 4/85) 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 015-511-24~ HAA # 1. GENERAL INFORMATION Complete legal description Lot 7[ Block 2¢ South Lakewood Hills S/D 6860 O'Malley Road, Anchorge, AK Location (site address or directions) Property owner '.. Mailing address Silvia McLain Day phone 346-3361 Lending agency P~udential vista Mailing address , 4241 B Street, Anchoraqe, AK 99503 i~,A§ent Katherine Donahue Addr.es~ Day phone Day phone 244-69_~ 244-~6939 Unless otherwise requested, HAA will be held for pickup. 2. NU[~cllgER OF DEDROOE~S: 3. TYPE OF WATER SUPPLY: NOTE: Individual well xxx 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 OF WASTEWATER 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. 72*025 {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. Name of Firm s & S ENOINEER~C., 17034 Eacle River Loop Ro~d No. 204 Address Engineer's signature Phone_ Date DHHS SIGHATURE [/'" Approved for ..... Disapproved. _ ~,)n( do~J approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date The lvkmicipafity 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 institutioes 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 fo;' e~';'or3 or omissions in the professional engineer's work. Municipality of Anchorage AUG 1 199J DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division,,,,n~,,,,*ck,FM ~FpvMUN1CIPALiTY OF 825 L Street, Room 502. Anchorage, Alaska 99501. (9d~]'~2~-'~%4;4 DIVI ~ ~,~.~-I~ Health Authority Approval Checklist Legal Description: Lo 7- ? A. WELL DATA ~ Lo c~c' 2. Parcel I.D.: Well type /°/~ ~ v'~ Log present (~.~/N) Total depth Sanitary seal If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to Casing height (above ground) ! I ...,c Wires properly protected~/N) Y £ ) Date of test FROM WELL LOG AT INSPECTION Static water level ~ 5- /4 f / /o ~7 / Well production ~ O g.p.m. ~' ' ~ '~ g.p.m. WATER SAMPLE RESULTS: Coliform O Nitrate 0, ¥'-// Other bacteria Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed / o / :30/~l I Tank size Collected by: $ & $ ENGINEERING ~7C~24 Fa.cie River Loop Road No, ~%'~ Eagle River, Alaska 99577 / OO O Number of Compadments__ Depression (Y/(~. Pumper Foundation cleanout ,~'N) ¥ ~- ~ Date of Pumping [/'~ q / '~ ~ ABSORPTION FIELD DATA Date i,nS!alled ) o / '~ o / ¢~ ( soil rating~r fF/bdrm) ~' ~ System type 'T~ z~ z/,I ~- " Width ~ ~ Gravel thickness below pipe (o~ -~ / Total depth Length Effecti~9 absorption area ~ ~'F ~ %onitoring Tube present (~/N))/E J Depression over field (Y/I~ /wO Date of adequacy test , i/ ~ Result~Fail) /o ,~_ ~- j For _'3 bedrooms Fluid depth in absorption field before test (in.); ~L / / Immediately after")~ 5-gal. water added (in.): ~ / '~ ~' Fluid depth ~ / ('' // (ins) Minutes later: c~ Absorption rate = ~ &' 0 -,}L g,p.d. Peroxide treatment (past 12 months) (Y/N) fv ~ ,v ¢ ~"¢¢ ~"~" If yes, give date 72-026 (Rev. 3/96)* . D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons "Pump on"~'Pump off" level at* .~"~Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot / Absorption field on lot '] Public sewer main ;hJ / Sewer/septic service line On adjacent lots ,/ 0 0 ~'7~ On adjacent lots Public sewer manhole/cleanout /v'/~ Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~ o Property line ~ Absorption field Water main/service line /O ¢- Surfacewatefldrainage )O0/~- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / D /r-C-- Building foundation $~0 Surface water ) ~2 0 Curtain drain p, 0~ 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 review of Municipal records that the~pve systems are inconformance~TA~.HA/~ uidelinesineffectonthisdate. ~' Signature / / HAA Fee $ ~ ~- ~ ~ Waiver Fee $ Receipt Number O~OZ ~ ( ~¢¢3~ ) Receipt Number 72-026 (Rev. 3/96)* ^UG-~l-g$ 0S:55 FROU-CTE ENVIRONMENTAL '~lt~, CT&E En~,ronme...I Service. InC. %584 P.02/05 F-B11 CT&E ReL$ 984544001 Cliem Name S & S Engineering Proj t, ct Name/# N/A Client Sample ID Lt 7 Bk 2 So. Lagewood Hills Mawix Drmbng Wa~r Ordered By PWS~ 0 Sample Remaxk$: Client po~ Printed .Oate/Time 08120198 17:18 Colle~led Date/Time 08/18/98 l 1:45 Received DasedTim¢ 08/18/98 15:35 Techn/cal Director: Stephen C. Ede / EPA 300.0 08/10/~8 R~v FRO~~CTE ENVIRONMENTAL T-584 P04/05 F-$11 CT&E EnvironmenTal Services Inc. ]rinking Water Analysis Report for Total Coliform Bacteria =~,w Po,,.r o.,.. A~l~:hur~*l, AK 9~51 ~- 1605 ~E~D I, YSTRC'CT[O~ O,Y REVERE 51DE ~EFORE COL~E~ING ~h}tP~g Tel: 1~7) 562-~3~3 - )-lUST Big cOMPLE, TED B-~ WATER SUPPLIgR SAMPLE DATE: r'~ SAMPLE ~YPE: with llb ~f. ~ ~] l-or- '7. 11,,~ 2 Y,ar Treated W~r Time Collected Fez: 19071 551.53oI TO I~[ cOmPL~TE~ aY Anll~sil s~a~ ~is Water SAMPLE to ~ 5~ple ov~ J0 ho~ ot~ ~t~ may ~ unstable S~plc c~ [o~tg m c~sic: ~amplc ~hauld not be over 41 hou~ old al n~ ~plc vl~ s~M d;iiv~ m~l. Dale R~c;v~ Analytical ~,l~h~: j:3(. Memb~nl Filc~ (~ ~ .Nm:M~'~d~'"~':'''~-'~ "L T;rnr. 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 1. GENERAL INFORMATION Complete legal description Lot 7; blocA 2; SouZA Lak~wood H~s Subdivision Location (site address or directions) 18010'Mall¢ff Koad Property owner Mailing address Lending agency Mailing address Si. John6 United M~thodiat CAuraA Day phone 1801 0'M~¢y Road Anchorage, Alaska 99516 Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Community weld Public water x If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. XX Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front MOA #21 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 ali Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S ,~ 5 ~NGINEERING Add ress 17034 Ea~le Ri,vet Loop Road Ne_. 204 Eagle River, Alaska 99577.. Engineer's signature Phone DHHS SIGNATURE ~_ Approved for ~'~?'/~.~-~'~/)bedrooms. DiSapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: Date, 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 DH HS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025{Rev. 1/91) Back MOA,~F21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /- ~,~-'~ ~:~l~.~'.~ ,..~oo'~ ~.~ ~/~ Parcel I.D. ~/~ A. WELL DATA Well type~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) /~ Date completed,ia~l~¢ N- ~'/- b O Driller Totaldepth / ~ ' Casedto .~0 'f Casing height / Sanitary seal (Y/N) ~./ Wires properly protected (Y/N) c~ FROM WELL LOG Date of test StatiC water level Well flow Pump level AT INSPECTION ~UNiCiPALITY OF ANCHORAGE ~NVIRONMENTAL SERVICES DIVISION l ov 0 4 1991 EIVED Absorption field on lot Public sewer main Sewer service line SEPARATION DISTANCES FROM WELL TO: # Septic/holding tank on lot / ~(~ -h ; On adjacent lots l ; On adjacent lots ! OO ~'~ Public sewer manhole/cleanout Petroleum tank _ A~4~ /~"~J WATER SAMPLE RESULTS: Coliform ¢'~/¥-~L"'.TL~.~.C~"~bt~ Nitrate ---~-~ Date of sample: ! ~ - 2~ ~ '¢i ~ Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ((') ~ .~L)-~J'I Cleanouts (Y/N) I~ High water alarm (Y/N) Date of pumping ~/~ Tank size / Foundation cleanout (Y/N) Alarm tested (Y/N) Pumper ,~/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot t, ~C) ~'On adjacent lots / Oc) TO propertyline ~ ~ ' Absorption field ~-~ '~- Surface water/drainage { ~ P Compartments Depression (Y/N) Foundation (~ ~ Water main/service line ( 0 '1~- 72-026 (Rev, 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) ~ "P~n" level at High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARATION DISTANCE FROM LIFT STATI%~ TO: Well on lot On adjacent I% D. ABSORPTION FIELD DATA Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Surface water Date installed / C) - Length 4/'¢. ~ ' Width Total absorption area Depression over field (Y/N) Results (pass/fail) ~,.~//A- Peroxide treatment (past 12 months) (Y/N) Soil rating ~ System type Gravel thickness (¢, % Total depth Cleanouts present (Y/N) Date of adequacy test /,2/~ for ,¢,,)//A bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot [ COc) ¢' To building foundation On adjacent lots Surface water [ O Curtain drain On adjacent lots ¢ fo~O -k Propertyline ¢' To existing or abandoned system on lot Cutbank ~o/~- Water main/service line Driveway, parking/vehicle storage area 2 r E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA this inspection. S & S ENGINEERING Signature 17034 Eaqle Ri~er Loon Road No. Eagle River, Alaska 99577 Engineer's Name HAA Fee $ Date of Payment Rece,pt Number Waiver Fee: $ Date of Payment Receipt Number 72-026 (Rev. 3/91 ) Back MOA 21 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ANALYSIH HE?OHT EY SAMPLE fo~ WORKo~de=~ 395?6 Date Heport P:lntnd: OCT 25 91 @ 15:59 FAX: (907) 561-5301 Client Sample ID:L7 82 SOUTH LAKE~OOD HILLS PWSID :UA Collected OCT 22 91 ~ 15:00 Received OCT 23 91 ~ L$:30 P[eserved with :A~ REQUIRED Client Name :S & S ENGINEERING Client Aoet :3HSEHOP BPO ! PO [ NONE RECEIVED Ondeznd By : Analysis Completed :OCT 25 91 Send Neports to: Labonatozy Supepvisp~ jSTEPNEN C. gDE lis & S ENGII~ERIHG Releesed~y :~~~ Chemlab Ref ~: 915684 Lab 8mpl ID: 1 I~t~tx: ~ATEH Allowable Pazametez Tested Hesult Unite Rethod Limits NIT~AT~-N O.lO ~g/1 ~Pt 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: H.D,J. I Tests Pezfozmed See Special Instzuctlons Above UA=Unavailable ND- None Detected "See Sample Nema:ks Above NA- Not Analyzed LT-Less Than, GT-O:eater Than ~SGS Member of the SGS Group (SociSt~ GCn~rale de Surveillance) CHEMICAL & GEOI, OGICA£ lABORATORY A DIVISION OF COMMERCIAL, TESTI~VG & ENGINEERING CO. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska {)9518 Drinking Water Analysis Repo~ for Total Coliform Ba~eda TO BE COMPLETED BY WATER SUPPLIER PUBLIC WATER SYSTEM I.D.# '{~PRIVATE WATER SYSTEM $ & S ENGINEERING T~ail~ng Addr~ ~ ~lJ~ Eagle R var Lo'~15 Eagle River, Alaska 99577 7jp Code Mo. Day Year SAMPLE TYPE: Routine Check Sample (for routine sample with lab ref. no.~ Special Purpose ,) [] Treated Water [] Untreated Water TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~ Satisfactory [~ Unsatisfactory [] Sample too long in transit; sample shoutd not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Data Received /~ Time Received Analytic, al Method: Membrane Filter · No, of colonies/100 mi, Time Coltested SAMPLE Collected ay No. LOCATION · ..u,. ilO290 ~ 4L i L--- i ilL j rW~ ~ L ] L I FTI BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Fleer: Direct Count Verification: LSB Fecal Cotlform Confirmation Final Membrane Filter Results Reported By__ T\-~ TNTC = Too Numerous To Count OB = Other Bacteria 900 O000CuDO0000000000000 BGB O, Colttorrn/lO0 mi Collform/10o mi 0000000000000000000~ IS:I.I Form Apploved FHA F~,rm 2573 ~EDERAL HOUSING ADMINISTRATION Budget Bureau N° 63-R296 8 Rev. July 1958 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.mTO BE COMPLETED BY FHA INSURING OFFICE Anchora§e~ A~aska ~ORTOAGORORSPONSOR Harvey C, Daulc South l.~ke l, loo~/SubdivlliOn O'}~lley Road [ELOCK~O. L~O, JBDIVISION NAME TOTAL NUMBER: ~[] BASEMENT Yes [] No ] New installation Can a~i¢ or other area be made into r-I Yes []No WATER SUPPLY BY: } SYSTEM DESIGNED FOR ~[~_~Public system [] Community system [] Individual .o. OF 5DR,t/~S GARBAGE SEWAGE DISPOSAL BY: [] Public system [] Community system [] Individual [] Yes [] No PART II.~TO BE COMPLETED BY HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH It is the opinion of the [] State ~ County [] Local Department of Health that this individual water-,snpply system ~] is [] is not satisfactory as a domestic water supply for the subject property. It is the opinion of the '~ State [] County [] Local Department of Health that this individual sewaSe-disposal sys- tem with proper maintenance: l~Can be expected to function satisfactorily, and [] Cannot be expected to function satisfactorily is not likely to create an insanitary condition ~ATE I SI~.ATURE . "/'~"' J TITLE NOTE: The health authority should complete t4 appropriate opinion statement above and affix date, signature and title in the spaces provided. Use of the above grld for Health Department Inspector's sketch as well as use of the back of this form is at the option of the health authority, PART IIII.~FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that'the Individual water-supply system be considered [] Acceptable [] Not Acceptable Sewage disposal be considered [] Acceptable [] Not Acceptable. DATE SIGNATURE flEALT~ AUTHORITY APPROVAL INDIVIDUAL WATER S~PPLY AND SEWAGE DISPOSAL SYSTEM l[~] CHIEF ARCHITECT ] DEPUT% FOR CHIEF ARCHITECT FHA Form 2573 Rev. July 1958 laaJ~-~ atql /l~ado/d luoJj tuosj ~2uq los 2U[lla~a WIJ.$AS XlddflS-tF:llVh/~ IVrK]IAIONI~NOiiD:IdSNI lO ltlOd:ltl INDIVIDUAL WATER SUPPLY ALASKA DEPARTMENT OF HEALTH Section of Sanitation and ~glneering Southcentrat Re;{ional ACTION ON REQUEST FOR BACTERIOLOGICAL WATER ANALYSIS Your recent request for an analysis of a sample from the Individual Private Water Supply serving Mi. 3-3/~,Ot~lle received /+/21/60 .and examination has been completed. Mr. Harvey C. Daul~ Box 1710, S~r Rt. Spenard, Alaska Records in this office indicate this Individual Private Water Supply to be of ;~""~a%isfactury Questionable Unsatisfactory sanitary status. Analysis shows this SAMPLE to bo :i-~/ Satisfactory. Questionable Unsatisfactory. If an "Unsatisfactory" or "Questionable" status is indicated above, you should take immediate action as recommended below. I. Boil or chemically treat your water supply to protect your family from water-borne diseases as outlined in eh- closed leaflet, "Drink It Pure." 2. Improve your spring--See bulletin HSE-6-2 3. Improve your cistern--See bulletin HSE-6-3 4. Improve your dug well- See bulletin HSE-6-4 5. Improve your driven well--See bulletin HSE-6-5 6. Improve your drilled well-- See bulletin HSE-6-6 7. Relocate your well to a safe location in relationship to your sewage disposal system--See bulletin HSE-15 8. Bottle broken in transit, please send new sample. 9. Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. I0. Contact your nearest [] Local Health Department or [] Alaska Health Deparm~eur, Sanitation office for bulletins, consultation, and assistance. 11. This is a surface water source and subject to pollution by man and animals. An approved water supply source should be developed. SANITA1LIAN'S REMARKS This Form Must Be Filled INDIVIDUAL WATER SUPPLY ~ Sheet for Sal~tple Collection Out Completely. ALASKA DEI'ARTi~ENT ~)F HEALTH Tn~truetions. Section of Sanitation and I~.ng(neerl~g L Request for Bacteriological Analys~s Lab. ~o ............... ~.~.~.-/~_- ........... - "' ' -t' .'" ' Water sample collected by .............. i~"~"~-~'~'~'collecting .Simple) (Date) (Tlrae) Water sample collected from ~fKitchen tap; [] Bathroom tap; [] Basement tap; [] Other (l~st) ...... ~, ........... ~.-.~--,---r · Adare~s premise ~h~ ~ ~ ~ ............ : ........ : ....................... ~e~se place ~n "X" in ghe box before l~m~ which b~g ~ese~be your wg~er supply: ~OU~0B: Well ~ D Dug, ~ Drlve~, ~ Drilled, ~ Bored [~ 8prln~, ~ 01sgem, ~ Ogher (llsg),. .................................. : ......................................................................... D Oreek, ~ ~lver, ~ ~ake, ~ Pond ................................................................................................................ DUG O~ O~T~N CONSTRUCTION: Walls~ ~ Wood, ~ Ooncre~e,~ Top ~ ~ ~ood, ~ Ooficrege, ~ ~eggl, ~Open Top ~0~A~ON: ~ In b~semeng, ~ Basemeng offset, ~ Under ~o~e, Ogher ...................................................................... '- ............................................................................................................ DIS~ANO~ TO: Build~ng sewer or ogher drainage pipe...L.~.:~,L.fee~, ~epgie ~a,~k ..:.:~.({....~eeg, TlIe f~eld .............. fee~, ~eepage pl~ .............. ~ee~, ~esspoot ~:.:'.:.Z.. feeg, Prlv~ .............. feeg. Ogl~er possible 8ouroe~ 0~ eon~amlna~io~ (l~g)....:~....: .................................................................................................................................. ~TD~,: B~ildi~ sewer ~ ~ O~sg ~on, ~ WooS, ~ T~e, ~ ~bre p~e, ~ Asbestos eemen~ ~oing magerial ~ ~pe ...................................................................................................................................................... ~ I~O~ON: Does wager beoome mudd~ or discolored? ~ yes, ~ ~o Whe~? ............................................. 7'"";": .............................................. v..-.----~ ................................... Dl~meger of well ............................ '.::~. ..................... depgh .......................................................... feeg Well e~8in~ m~geri~l ........................................ diameter .................... depth .................................. ~eng~h of drop pipe ............................................................................................................................... Wa~er depth from boSOm .......................................................................................................... :_feeg Pump loegglon: ~ In' well, ~ Offse~ in b~semen~, D In bg8emen~ ~ In ugi~ r~m, ~ On ~op ~ well ~ Ogher (l~g) ........................................................................................................ Do you suspec~ illne~ from ~his: supply? ~ yes, ~ no ~{e~r~8; ..................... ~ ........... ..[--: ................................................................................................................................................................. SAMPLES MUST BE SUBMITTED IN CONTA] EES EP RT TH