HomeMy WebLinkAboutT12N R4W SEC 10 LT 52A (BLM) HEFTY DRILLING Well Water - it's naturally betted 3540 AKULA DRIVE TELEPHONE: ANCHORAGE, ALASKA 99516 (907) 345-0593 Date Drilled : 6-24-93 Static Water Level 45 . Feet Draw Down N/A Feet Norm Burgess 8936 Gloralee Anch. Ak 99502 Gallons Per Minute 12 Total Feet of Casing 140 Type Material Drilled: 0 ft. 138 ft. to to to 138 ft. Clay 140 ft. Fine gravel W H20 to to to to to to 3540 AKULA DPJVE ANC~0RA~, Al( 99515 (907) 345-0593 ~ 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:SW930166 DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES OWNER NAME:BURGESS NORMAN W & OWNER ADDRESS:8848 GLORALEE ST ANCHORAGE, ALASKA 99502 PAGE 1 OF 1 DATE ISSUED: 6/21/93 EXPIRATION DATE: 6/21/94 PARCEL ID:01121362 LEGAL DESCRIPTION: T12N R4W SEC 10 LT 52A (BLM) LOT SIZE: 21428 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION 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 343-4329 OR 343-4681 AFTER BUSINESS HOURS 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 PROVIS~ DATE: .LOT Flou s£ R.0. ~'. LOT ~/] LOT s2 A HOUSE JE~/£LL LAKF LOT ~/~ D.I.R S£~ER ' BLM LOT ..c2A, SEC I0, TIZN~ -SIT~c PLAN ..SCALE: I'''= NOTE: THIS IS NoT A Su~VEyEb PLAT. ALL LOCATIONS /~RE A?P RoX IM~TE'. Tom Fink, Mayor vtunic p lity of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 June 16, 1993 Ted Moore, P.E. Flattop Technical Services 14530 Echo Street Anchorage, Alaska 99516 Re: Waiver Request For T12N R4W Section 10 BLM Lot 52A, Health Authority Number HA930266, P.I.D. 011-213-62 Dear Mr. Moore: Your request for waiver of the required separation distance of 75 feet between a single family well to a public sewer line has been denied. The requested separation distance is 38 feet. As stated in the memorandum dated January 3, 19851 from the Alaska Department of Environmental Conservation, section 3, paragraph a), "Consider how much of a waiver is requested (what % of the separation needs to be waived)." The subject waiver is requesting approximately a 50% reduction in the required separation distance of 75 feet. This is an unwarranted reduction in the required separation distance when considering that there is adequate area on the subject lot to construct a well and maintain the required separation distance from the public sewer line in question.' It should also be noted that the subject well was drilled without a permit from this office. Had the property owner applied for a permit when the well was drilled in 1991, we would have required that all separation distances be satisfied. If you have any questions of the above, phone. Daniel J. Roth Civil Engineer On-Site Services please contact me by /~6hn Sm~hh, P.E. ~Prog ra~f Manager On-Site Services #220 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR# ~q.~.~ PID# 011-213-62 Date Received: May 27r 1993 Legal Description: T12N R4W Section 10 Lot 52A Engineer: Ted Moore, P. E., Flattop Technical Services 14530 Echo Street, Anchoraqe, Alaska 99516 Applicant: Norman W. Burqess Waiver Requested: WEll on property to be 38 feet from an along east side of the property. 8" sanitary sewer HA# ~[3~ Permit Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: List Conditions or Reasons Waiver is NOT Granted: for above: ~F Date: Name of R~vi~wer Rec ~: 24729/8089 Amount: $ 590.00 Date Paid: 5-27-93 STATE OF ~J~SKA DEP~Tb~EHT OF NATU~AJ~ I~ESOII~CES DIVISION OF GEOLOGICAL AND GEOPHYSICAL SURVEYS WATER WELL RECORD LOCATION OF W-ELL t-.L.:'V ' F' ~ - ' BOROUGH SUBDIVISION LOT BLOCK SECTION QTRS TOWNSHIP RANGE MERIDIAN ON E]E Os DIRECTIONS: WELL OWNER: WELL DEPTH: DATE OF COMPLETION: F~ASU~ING POINT: ~"l~tOp of easing Depth of hole: /~an ft Oground surface Oother: Depth of easing: /~S' ft { ~¢ - ~/ BOREHOLE DATA: Depth STATIC WATER LEVEL: '~,~ ft. Date Material type and color. .. · From TO ~'~, .... )/-~l.;/~/ ~[~[~1~' C ~ t ~1 Oair rotary '- ~cable tool ~other: / ~ ]~ ~ .~/~(C~~ /(~ ~(~ /(~... ,7,/ /~)1 USE OF WELL: ~domestic ~irrigation ~monitor / .,' ~publi6 supply ~other: ~, /~ /0 ~ /.?., . . / C~SING: Sg~ck-up,~Ott ft. Diam: ~ t/ . ~, .. ~ IR,5' I~-' / WELL INTAKE: ~ opon end · ,,"',,.'I,V (4,~ ~..t L.~. [~..or~l-~m)IL:.~~ I~/ 0 perforated ~open hole !/3;~/J~/~ ~A'~¢/'2~-'~' ~ /,~& /~/' Depths of openings: to ft SC~EN TYPE: Diam: -in Slot/Mesh Size: Length: ft Set Between and ft - G~VEL PACK TYPE: Vol~e used: pepth to top: GROUT TYPE: Vol~e: Depth: from .ft to __ft ~S: P~PING LEaL ~D yIELD: MAY ~ 7 1993 /6Of~ .after ~ h=s p~pln~ 'lO ~m ~",,,~a]c~pality of A'nohora~e P~ INTAKE DEPTH:~ft ' Horsepower: . DeDt. Health & Human Services Date P~p Installed ~ -~- ~ · · . CONTeSTeR INFECTION: WATER ~HEMISTRY S~LE TAKEN?, ~yes ~no nil ~TA~,., ~,,~11 ~,.~/ :~, Well d~'sinfected upon Complet~'6n? ~es ~no R~gistered Business Name Signature of Authorized Representative ~ Date PLEASE MAIL WHITE COPY OF LOG WITHIN 45 DAYS TO: DGGS PO BOX 77-2116 EAGLE'RIVER, AK. 9957.7 THEODORE F. MOORE, P.E. PH: (907) 345-1355 OP T EHNICA.L .SE CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS 14530 ECHO ST. May 27, 1993 ANCHORAGE, ALASKA 99516 M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 RE: BLM Lot 52A, Section 10, T12N, R4W, S.M., Well - Sewer separation distance waiver Dear S~rs: By means of this letter we are requesting issuance of a separation distance waiver allowing the existing well on the subject lot to be 38 feet from an 8" sanitary sewer which runs along the east side of the lot. We are also applying for a HAA certificate and a well permit, since we cannot find any evidence that an on-site well permit was ever issued by your office. A site plan, copy of the driller's log, copy of the sewer as-built, and water sample test results are also enclosed to assist you in yom' review. For your infol~ation, the as-built property survey describes this lot as BLM Lot 52A (P85-277), Lakehm'st S/D. According to the chiller's log the well was drilled on 8/5/91 by All Alaska Well Drilling and has a total depth of 138 feet and a yield of 10 gpm with the pump set at 135 feet. On May 10, 1993 we conducted a yield test on this well. The initial static water level stood at 40 feet below the top of the casing. Steady pumping of 552 gallons of water from the well at the maximum pump output of 8.1 gpm caused the water level to be drawn down to the level of the pump intake. After the well had recovered for only 5 minutes we were able to pump an additional 172 gallons of water from the well at the maximum pump output without the water level being drawn back down any lower than 131 feet. Based on our test data we determined that the yield of the well is 6 gpm, which is more than adequate for M.O.A. approval of a three bedroom residence. Water samples collected on May 5 were satisfactory, showing 0 coliform or other bacteria per 100 mi., and undetected nitrates. The Gloralee Street Lateral to C-4 Trunk sanitary sewer was installed in 1974 and runs 10 feet west of the east property line of Lot 52A, in what is now designated as a utility easement. A relevant portion of the AWWU sew~er as-built is enclosed. The sewer line is 8 inch diameter Class 2 ductile iron pipe, buried approximately 10 feet below ground level. This type of pipe was designed to be used for drinking water and is similar to the more commonly used Class 50 D.I.P. used for sanitary sewers, except that it is lined on the inside with cement to provide additional corrosion protection. The following is a breakdown of how waiver analysis points could be assigned using D.E.C. SCRO's 1985 "Separation Distance Waiver Guidelines". Category Points Distance to aquifer (aquifer depth 135' - sewer depth 10' = 125') Soil so~ption (well log reports predominantly silt between 10' and 135') Soil type (predominantly soil with perc rate slower than 50 rain/inch) Water table gradient (assume 0%, parallel with ground surface) Horizontal ~paration (38 feet~ Total 7.1 3.5 3.0 2.9 0.8 17.3 Based on this point assignment there does not appear to be any threat of contamination. Further mitigating factors include: (1) the aquifer is confined/artesian, meaning that contamination originating in the mediate vicinity would not be able to make its way into the aquifer, and (2) the sewer line was constructed to a high standard Class 2 ductile iron pipe, and has special corrosion protection, gasketed joints and was pressure tested before being placed in service. Additional tests for inorganic contaminants were conducted on water samples collected by the owner in August of 1991 (results enclosed). For the above reasons, it is my professional opinion that the requested waiver can be granted without concem as to potential contamination of the subject well by effluent leaking from the portion of the sewer line which passes closer than 75 feet from it. Please give me a cai if you have any questions on this analysis. cc: Norman Burgess Sincerely, Ted Moore. P.E. LoT $ I House L ~ R.o.~', LOT -IA HOUSE LOT 3A JE~ELL LAKE ~VEL , -~ LOT D.I.R S£~VE R BLN1 LOT 521~, .SITE- PLAN l:)A-r E NOTE: THIS IS NOT A SuRVE'tEb 'PLAT. ARE APP RoX ~M/V1-E.. ~~MMERCIALTESTING & ENGINEERING CO. Chemlab Ref,~ :93.1960-1 Client Sample ID :BL~I L52A Matrix :WATER LAKEHURST s/D GARAGE ROSE BIB 5633 8 STREET ANCHORAGE, AK 99518 TEL: (907) 562-2343 lAX: (907) 561-5301 Client Name :FLATTOP TECHNICAL SRV Ordered By :T.F, MOORE'.~ Project Name Project~ : ~ - : PWSID :UA ,WORK Order :65686 Report Completed :05/07/93 Collected :05/05/93 @ 15:00 hrs. Received :05/05/93 @ 15:40 hrs. Technical Director :STEPHEN, C. F~DE Released By Sample Remarks: ROUTINE SAMPLE COLLECTED BY: T~F. MOORE. QC Allowable Ext, Anal Parameter Results Qual. Units Method Limits Date Date Init See Special Instructions Above UA = Unavailable See Sample Remarks Above NA = Not Analyzed Undetected, Reporte~ value is the practical quantification ;/imito LT = L~:~ss Than Secondary dilu~ion~ G~' = Greater ~han ~SGS Member of the SGS Group (Soci~t~ G~n~rale de Surveillance) ENVIRONMENTAL SERVICES IN ALASKA COLORADO. UTAH. LLINOIS. OHIO, ~AARYLAND. WEST VIRGINIA. NEW JERSEY SOUTH CAROLINA CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (997) 561-5301 ANEL¥SIS REPOR! E! 3ANELE gox WORHorde~t 37388 Pate Report Printed: AUG 29 91 e 15:32 Client Sample ID;WELL HEAD PWSID :UA Collected AUG L6 Received AUG 16 91 @ 14:10 h~s. Pre{e~ved with :AS REQUIRED Client Na~ :BURGESS, NORMAN Client Aoct :BURGNC BPO { PO t NONE RECEIVED Ordered By :NORMAN BURGESS Ar~lysls Comploted :AUG 26 91 Send Reports to: Laboratory Supo=visox. ;S[E~NEN C. ED~ , ~ i)BURUESS, NOR~AW Chemlab Roi t: 914193 Lab Sapl ID: 1 ~at~ix: MAIEH Allowable Pala~aeter TeateO Result Units ~ethod Lll~lto PRIVATE I~DI¥IDUAL WATER n/a n/a ALUMIHH~ 0.17 ~/1 EPA 200.7'ICP ARSENIC HD(O.02~?~/ ~/1 EPA 200.?'ICP BARIUId 0.014 n~/1 EPA 200.7'ICP CADNIU~ ND(O.02$) n~/1 EPA 200.?'ICP CALCIUH 10 n~/1 EPA 200.?'ICP CUROHILP~ RD(O.OI$) n~/l EPA 200.?'ICP COPPER ND(O~JL~ n~/1 EPA 200.?'ICP IRON ~0.26/ n~/1 EPA 200.?'ICP LEAD HD(O.02S) ~g/1 EPA 200.7'ICP ~AGNESIUM 5.8 n~/1 EPA 200.7'ICP MANGANESE 0.019 n~/1 EPA 200.7'ICP PHOSPHORUS ND(O.S) n~/1 EPA 200.?'ICP POZASSIUM ND(2) mR/1 EPA 200.?'ICP SILICON 3.4 n~/1 EPA 200.?'ICP SILVER ND(O.OI3) ~/i EPA 200.7"ICP SODIUI4 36 ~g/1 EPA 200.?'ICP ZINC ND(O.OS) ~g/1 EPA 200.?'ICP NIIP~YE-W RD(O.IO) ~/1 EPA 3S3,2 iQ CHLORIDE $,$ n~/1 EPA 325.3 SULFATE 3.6. n~/1 EPA 375.4 SOLIDS, lOYAL DISSOLVED 220 rna/1 SH2OgE HARDNESS as cae03 49 mR/1 RWEOgA ALKALINITY as Cae03 124 n~/1 EPA 310.1 CONDUCIIVIIY 25S u~ho{/cm EPA 120.1 , pH ,? 8.33 unrra EPA 150.1 IOIlL COLIFORM 0 col/lO0 ~1 SM908 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # (~)1 HAA # 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent N, ,4. Address No-' ~,'~ ~ ~ r'~'~--¢~ Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Individual well ~-~ Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72°025 (Rev, 1/91) Front MOA#21 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 inves!!gation and inspection, the on-site water sul~ply 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 ~'/~ f'/~f 7'~c~ n'~ c~ / Address /"/5- ~ 0 ~c~ .~./ /~c~or~/¢ .. Engineer's signature ¢/-'~ ~ ~ Phone /~ ¢¢~-'/~' Date DHHS SIGNATURE 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 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. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Parcel I.D. Well type p m ,/a f'~_ If A, B, or C, attach ADEC letter. ADEC water system number /¥, ~. Log present (Y/N) Y' Date completed ~' / ~ ?/q :~ Driller /'/¢~/'~, Total depth I.yo ' Cased to Sanitary seal (Y/N) Y' Date of test Static water level Well flow Pump level1 FROM WELL LOG I ¥O ' Casing height ~Jo" Wires properly protected (Y/N) 'r' INSPECTION (N.//. - New AT IZ. .g.p.m. g.p.m. M_nh: SEPA~ATION~ISTANCESFR~)MWELLTO: an~d. ~dl,.~ff Ca~[~ ~,.,;t~ ¢o~¢.~/~. Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line N.A. ( (>~, lic 5'~o.,~); On adjacent lots N, N, /I-. ; On adjacent lots /~, 7~' ---¢ Public sewer manhole/cleanout Petroleum tank Nona WATER SAMPLE RESULTS: Coliform (~ c~(//O©,"h~ Date of sample: ~"/~ ~/"~ '~ B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Nitrate ~ ~2,!~e/~ Collected by: Tank size Foundation cleanout (Y/N) Other bacteria Compartments Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage On adjacent lots Absorption field Foundation Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C, LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA N, ~-. Date installed Length Total absorption area Date of adequacy test Width Manufacturer Manhole/Access (Y/N) "Pump off" Level at .Cycles tested On adjacent lots Soil rating (GPD/FF) Gravel thickness Cleanout present (Y/N) Results (pass/fail) Surface water System type Total depth Depression over field (Y/N) for Bedrooms Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) After test If yes, give date Well on lot To building foundation On adjacent lots Surface water Curtain drain E. ENGINEER'S CERTIFICATION SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots Properly line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area I certify that I have checked, verified, or conformed to all MOA and HAA guidelines !n.~..~e.~C~!r~ the date of this inspection. Signature %~ ~ ~ ' ' ..... '' Engineer's Name ~*Eo¢o¢, F./~°0~ ~ ~::~ ~'~ H~ Fee $ t~ .O( h Waiver Fee $ Date of Payment ~.- ~ ~ - ~ % Date of Payment Receipt Number ~ ~ ~ ~°1 1%~ Receipt Number 72-026 (3/93)* Back MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# ~ ~ - ~"~ ~,~-[~'-.~ HAA# ~ ~o~,~,(,--~ ,.,~(~ 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent N, A, Address Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Individual well / Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1/91) Front MOA #21 Engineer's signature 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. NameofFirm ~1~ ~¢-¢? 7-e~ ~ ,~ ; c~-[ _~er~'~ ~e~r Phone ~'5 Address /Y~Zo ¢c~o ~/_, ~ncXor¢~(,. ~ ~~ ~ ~ Date DHHS SIGNATURE Approved for Disapproved. bedrooms. 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 DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 ' ' (~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: J~*~ ~-oT 52~A $~¢ lo, TVZN, ~',Jur Parcel I.D. A. WELL DATA Well type PR~vA-~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) ~/ Date completed '7lB Jell Driller AL~- Total depth 13~'' Cased to 13~' / Casing height Sanitary seal (Y/N) 7 Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test '7/~]~l Static water level 2. S we,, f,ow ,o g.p.m. Pump level I ~-~ I~' SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot N,A, ;On adjacent lots N,~, Absorption field on lot N.~- ; On adjacent lots Public sewer manhole/cleanout Public sewer main~ ;3g" ~- Sewer service line ~ ~-5" WATER SAMPLE RESULTS: Coliform ~ co! //oo ~.¢_. Nitrate Date of sample: ,,5'-/,~c"/? .~ Petroleum tank ~.,¢4~'e~-/'~'( Other bacteria Non~- Collected by: F(~/-/o/~ 7'ec~. B. SEPTIC/HOLDING TANK DATA N, A, (._P~, Date installed Tank size Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y/N) Alarm tested (Y/N) Date of pumping Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot On adjacent lots Foundation To property line Absorption field ' Water main/service line Surface water/drainage 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Well on lot D, ABSORPTION FIELD DATA Date installed Length Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots Surface water Soil rating Gravel thickness Cleanouts present (Y/N) Date of adequacy test for Well on lot If yes, give date To building foundation On adjacent lots Surface water Curtain drain E, ENGINEER'S CERTIFICATION System type Total depth bedrooms On adjacent lots Property line To existing or abandoned system on lot Cutbank Water main/service line Driveway, parking/vehicle storage area HAA Fee $ / 7 Date of Payment Receipt Number 72~026 (Rev. 3/91 ) Back MOA 21 Waiver Fee: $ ,~--~g3 ¢(J7~ Date of Payment '--5~'- 2-~--?~ Receipt Number '~ 7~,7~ ~ ~/~',~"~ ~) Engineer's Name Date /v?~.,y Signature ~.-~~ ~. ~ I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. 07x02/93 09:11 CTCE ENUIRONMENTAL LAB SERUICES ~ 5451355 NO. 493 5)[ Chemlab Ref.% ~93o3089-~ client Sample ID ~L52A, SEC 10 Matrix ;WATER T12N EAST HOSE BIB FAX: (9(17) 56t-5:~0~ Client Name :FLATTOP T~?,CHNICAL SRV Ordered By Project Name : Project~ : ~SID :UA WORK Order :6773;! Report Completed : 07/01/93 Collected :06/29/93 @ 12.'30 h~ Received. :06/29/93 Technical Director:S~-C, EDJ5 Released ~y : .~,~/Y~3',~,.,.-~~' Sample Remarks: ROUT~N~ BA~IPLE COLLECTED bY: CHRIS, QC Allowable Ext. Anal Parameter Results Qual U~its Method Limits Date Date InJ Nttrate-N 0.10 U mg/L EPA 353,2/300.0 10 06/30 L[ See Special Instructions Above UA = Unavailabl~ See Sample Remarks Above NA ~ Not: Ar[alyzed Undetected, Reported value i~ the practical quantification limit. GT = 5ess Than Secondary dilution. GT = Greater ~han ~ ~"~ Member of the 8~ Group ($001~,¢ GCnsr.le de Survei,lance) LOT Flou $ £ R.o.u. LOT '7/J GLOI~^L£E s2 A HOUSE LOT SA LAKE Nr~ LoT ~A CLASS D.I.R SEk/£ R BL~ LoT $2A, ~gd Id), .SITE PLAN 3CALE: I''= 3D' 'bA-TE s/cJ3 NOTE: THIS IS NoT A SuRVEyED PLAT. ALL LocATIONS iRE A?PRoX tMATE..