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WENTWORTH BLK 2 LT 6
(1)EA wsAh *00,R -ba3 -a3 i cfk Municipality of Anchorage Development Services Department Building Safety Division e On -Site Water and Wastewater Program : T; 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ek.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. 008-023-2.5 HAA# ID30L+1;(O Expiration Date: 12, — 10 — O 3 1. GENERAL INFORMATION Complete legal description J of Block 2 Wentworth Subdivision Location (site address or directions) 3240 Fast 410` Avenue Current Property owner(s) Kathleen Carey Day phone 9-157-049-5 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Unless otherwise requested, HAA.w111 be held by DSO for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System Day phone Day phone TYPE OF WASTEWATER DISPOSAL: ® Individual On-site ❑ ❑ Individual Holding tank ❑ ❑ Community On-site ❑ ❑ Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage Is not responsible for errors. or omissions In the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Anderson Frialneering Phone 522-7773 Engineer's Printed Name Michael F. Anderson- P.E. Date ' 9/4/2003 5. DSD SIGNATURE 4:'• 49th AEL E. ANDERSON No. CE -4381 Lf Approved for bedrooms. ���o'''• •� •• 44� ::: ••,4 Disapproved. .0 Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist x Septic System Advisory Well Flow Advisory WASTEWATER J O Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: 0 - 03 Municipality of Anchorage ' Development Services Department Building Safety Division On-Sfte Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.d.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Lot 6. Block 2. Wentworth Subdivision Parcel ID: 008-023.23 A. WELL DATA Well type Private If A, B, or C provide PWSID # Date completed rinknown Sanitary seal (Y/N) X Total depth _ ft. Cased to -AL-ft. FROM WELL LOG Well Log (Y/N) b Wires properly protected (YM) Y Casing height (above ground) s24 in. AT INSPECTION Date of test 8/24/2003 Static water level ft. 15 ft. Well production 1.5 g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/l00 ml. Nitrate _J_ mg./I. Other bacteria 10 colonies/100 ml. Date of sample: 812412003 Collected by: MF -A B. SEPTIC/HOLDING TANK DATA — Lot Served by Municipal Sewer System :Tank Type/Matertal Date installed Tank size gal. Number of Compartments _ Cleanouts (Y/N) Foundation cleanout (Y/N) _ Depression over tank (Y/N) _ High water alarm (Y/N) Date of pumping C. ABSORPTION FIELD DATA Pumper Date Installed Soil rating (g.p.d./ft? or ft2/bdrm) _ System type Length ft. Width ft. Gravel below pipe ft. Total depth ft. Eff. absorption area ----fl? Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail) For _ bedrooms Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ in. Elapsed Time: i min. Final fluid depth _„ in. Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date D. LIFT STATION Date installed `Pump on' level at _ in Datum E. SEPARATION DISTANCES Size in gallons `Pump off* level at _in. Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Manhole/Access (Y/N) _ High water alarm level at Meets alarm & circuit requirements? Septic tank/lift station on lot NIA On adjacent lots NIA Absorption field on lot NIA On adjacent lots WA Public sewer main >75' Public sewer manhole/cleanout 100' Sewer /septic service line >25' Holding tank QUA SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption field Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Building foundation Water main Water Service line Surface water Driveway, parking/vehicle storage Curtain drain F. COMMENTS Wells on adjacent lots G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Michael E. Anderson, P.E. Date 91412003 HAA Fee $ 31 rJ Waiver Fee $ _ Date of Payment Q� S�d3 Date of Payment Receipt Number 0AIN_ Receipt Number (Rev. 12100) i 49th�•'s>o- NEL E. ANDERSON No. CE -4381 G in. ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 522.6779 (FAX) September 4, 2003 Ms. Kathleen Carey 3240 East 41" Avenue Anchorage, AK 99508 Attention: Andrea Schulze RE/MAX Properties, Inc. Subject: Lot 6, Block 2, Wentworth Subdivision Well Flow Test Dear Ms. Schulze: A flow test was performed on the well and water system currently in place on Lot 6, Block 2, Wentworth Subdivision on August 24, 2003. The test began at 1:02 P.M. and water was allowed to flow through a 5/8" hose connected to a flow meter and to an exterior hose bib. Flow through the hose began at 3.0 gallon per minute but dropped steadily until it stabilized at 1.5 gallons per minute. The test was completed at 5:05 P.M. that same date. The static water level was originally measured at 15' below the top of the casing at the start of the test and stabilized at 18' over the majority of the 4 hours. It appears some blockage may be in the water system caused probably by aging and corrosion of the internal piping. The average flow, however, exceeds the Municipal requirement for a two-bedroom home. A sample taken from the water system was tested for quality and found to be free of Nitrates and Coliform. Other bacteria was measured at 10 colonies, which is at the upper limit allowed by the City. The well should be chlorinated in the near future to remove any bacteria from the system. Sincerely, Michael E. Anderson, P.E. Attachments 09-02-03 11:43ALI FROM -CUE ESI, SGS ENV SERVICES 9075615301 T-841 P.02/02 F-810 CME Environmental Services Inc. 200 W. Potter Drive Anchorage, AK 99515-1605 Id For CdnIirmatioelepho2e: (907) 562-2343 Facsimile: (907) 561-5301 200 W. Potter Drive )dnking Vater Analysis Report for Total Co iform Bacteria Anchorage, AK 99516.1605 R.AJ)J1YST*uCTIPNSONVEl'. E'SIDE-8a0AECO CTINGS:4J1PL,6 rel: (907) 562-2343 Fax: (907) 561-5301 MUST BE COMPLV(ED BY WATER SUPPLIER i TO BE CQMPLPTFt) fav t.An� n' nD%7 13 PUBLIC WATER SYSTEM 1 ?. it 0 PRIVATE WATER SYSTEM 93 Send Results q . Sen,llnvolce . 1 r4Y Zip q sewizesutrx q Still. Invoice SAMPLE DATE: y rO..t —11 Month SAMPLE TYPE: Routine q Repeat Sample (for routine satriple vith4ab ref. -no, s ) q Special Purpose r SAMPLE LQCATJ0;1 f �r�+r T�ioctl..Z� LJC7v; WL7riTt� .t ,17_.! J. O 3 . Day Year (3 Treated Water ` y< ilntrtated Water Time Collette( Collected By. e.',.�u Ve✓I Pk+u Print BACTERIOLOGICAL WATER MMM -MUG Result: Total Coliform Membrane Filter: Direct Count Verification: LTB Ne BGA Fecal Coliform Confirmaticn Final Membrane IlterRes+dts 6oi�.�fa�lor Reported By Date Comments: Analysis shows this Water SAMPLE to be; 0)< Satisfactory 13 Unsatisfactory 4 Sample.over 30 hours old, results may be unreliable Cl Sample too tong in transit, sample should not be•over30fiours old'at examination to indicate reliable results. Please send .netiv sample via special delivery.rnail. Daae Received � _T„ �,� Titrte Received Ar:alysls Began _ � Oy " Analytical Method:ivlembrane Filter fi]7 MMQ-iVlilG 1_2". - ._ .. _10in]. 1035429-A .Result*' Analyst I11,ol Aneh Fbks Jun '+r Fa-sd Time: :t Ctlent notified of unsatisfactotj�icsults: p3bnhl 'Spoke with Faxed •t; . f'+m Time: R'CORD E. Cali ' Colonles/140 ml COLIFIRk4 _ Coliform/100 ml Time �_ hrs .r4,.,h.,,frhPt:rsr,rouolSoc!6t6G6ntraledeSuiveillance) INjCOCU00 Ne"A"llf To Costar OR -ou$Eacwrin off, 09-02-03 11:44AM FROM-CUE ESI, SGS ENV SERVICES sib$- �. SGS Ref-# 1035429001 Client Name Anderson Engineering Project Name!# Lot 6, Bll- 2, Wentworth Client Sample ID Lot 6, Blk 2, Wentworth Matrix Drinking Water Sample Remarks: Parameter Qualifiers Results PQL Waters Department Nitrate -N 0.100 U 0.100 Microbiology Laboratory Total Coliform 10 OB, No Coli 9075615301 T-842 P.02/03 F-811 All Dates/Times are Alaska Standard Time Printed Date/Time 08/30/2003 8:40 Collected Date/Time 08/24/2003 17:00 Received Date/Time 08/25/2003 12:17 Technical Director LLStephs . Ede Released Units ( Method mg/L I EPA 300.0 SM 18 9222B Allowable Prep Analysis Container ID Limits rmlr n,,. Init B (<=10) 0825103 11B A (r--)) 0825103 ]S re/max agent service center 907-258-9005 OtV LOf LDDJ AD -LZ 2V f"2w4QA J Tare D" J&Wfti 0074881410 To:1 11e East 4� ill8treet_ 76.6 Plot Pin D a Lot 5 Shea _ FO PIIS 09/04/03 12:40P P.002 Vui Drh: AMM Trw 0:1 M L L Prank Staftp IU. Certify that Wx Plat Plan no wemvd by me or and ray direct :gems om and that to tke beet of my kaawlodgc. then ere no Aer lmpto. eaia or comaehmeats. if any, as the prop.rty other than those that we & wa. Tbia Plot plea sham eat be DODatmed to zeprorent a botmdary MDT". Let S. Mwk P, lfaatwwrlb Subdit'ition (9240 E 42A Street.) Re—Vu Amodates Aft Joe Mosso Seiler. Carey $qw. Cherry &V"Ied by Iosco SW"Y t 515 Gait Aeeaoe Fatrbnala, Alam 99701 Ph., 807 439 1408 Fax: 007 458 1418 Soale 10 a 80 prswa by: DG Mocked Ordered D7/31103 Ddioered: 08/20/09 0 /tip VL pw1of1 wbe�r�uo fenr r1sullbdivirlim a� z w 7 76.6 Plot Pin D a Lot 5 Shea _ FO PIIS 09/04/03 12:40P P.002 Vui Drh: AMM Trw 0:1 M L L Prank Staftp IU. Certify that Wx Plat Plan no wemvd by me or and ray direct :gems om and that to tke beet of my kaawlodgc. then ere no Aer lmpto. eaia or comaehmeats. if any, as the prop.rty other than those that we & wa. Tbia Plot plea sham eat be DODatmed to zeprorent a botmdary MDT". Let S. Mwk P, lfaatwwrlb Subdit'ition (9240 E 42A Street.) Re—Vu Amodates Aft Joe Mosso Seiler. Carey $qw. Cherry &V"Ied by Iosco SW"Y t 515 Gait Aeeaoe Fatrbnala, Alam 99701 Ph., 807 439 1408 Fax: 007 458 1418 Soale 10 a 80 prswa by: DG Mocked Ordered D7/31103 Ddioered: 08/20/09 0 /tip VL pw1of1 ANDERSON ENGINEERING Telephone: 907522-7773 Engineering Services PO Box 240773, Anchorage, AK 99524 Date: August 24, 2003 Legal: Lot S. Block 2, Wentworth Well Depth: 48' Static Level: 1S Tvoe of System Tested: M Single -Family ❑ Multi -Family Tim of Test Performed: Well Flew Onlv n Sentic Adeauacv Only Farscimile: 9075225779 Project#: 02-261 Inspector: MEA # Bdnns. 2 ❑ Commercial n Both Time Flow Rate (gpm) Volume (gats) Cum. Volume (gals) Well Static Level Oil ST Liquid Level (in) 11T41 Liquid Level (in) MT# 1 Delta (in) MT#2 Liquid Level (in) MT#2 Delta (in) Meter Reading Comments 1:02 >2 Ft. 16 22820 Start 1:17 3.00 45 45 18' 22886 132 2.00 30 75 18' 22895 3.05 1.18 110 185 18' 23005 405 1.50 90 275 18' 23095 5:05 1.53 92 367 18' 23187 End Well Flow ( 1.50 JAverage Gats/Mln Well Flow Recovery. Date Time ST MT#1 MT#2 Static Comments 82403 5:10 1S Full Recovery ❑ NA N Yes ❑ No ❑ NA >2 Ft. Lf Public Water Suoo-h Does septic tank need pumping? Is well wire in conduit? Is wells sanitary cap Installed? Elevation of well casing above ground level: ADEC Code Comoflance: ❑ Yes ❑ No a NA 0 Yes ❑ No ❑ NA N Yes ❑ No ❑ NA >2 Ft. Lf Public Water Suoo-h PWS ID # Is this system currently In compliance? A Yes Test Results. ,E Passed ❑ Failed ,,,^ r Reviewed By: , �' 1 CO. N NA ❑ No Date: q'`/'0-7 MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services} O DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # d © 9- ^D °T 3 ^ 23 HAA # dQgrc�,11`123 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address 'irectionsJ� �', (b) Property owner�c" . Mailing Address..'I, _�,r _ . Telephone (c) Lending Inst Mailing Address s.z 8' Telephone : (home) Business (d) Real Estate Company and Agent Address GJ /lJoYl�etn �t !�� Q�u�• Telephone "2ray (e) Mail the HAA to the following address: (or check here if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Z'*4 Single -Family X Number of bedrooms 3. WATER SUPPLY Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ❑ Public.' Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 7M25 (R. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of thevalidation date shown bell w, I vent tr d sposalhat my esystem sion of this Health Authority Approval shows that the on-site water supply and/orfunctional.and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from d� the rdisposal system s lity of Anchorage in compliailes and nce with m my fall Municiion and pal and inspection, the on-site water supply State codes, ordinances, and regulations in effect on the date of this inspection. Telephone o279 S rJ3 Name of Firm pG6? Address �a lja7t o`t-Yo c 6 B' /Avec (.�,r z t Y�,E 9S.T'a Y— Date 3 l] 6. DHHS APPROVAL Approved for � bedrooms by = (-*,i -S m n -H Date Approved x Disapproved Conditional Terms of Conditional Approval _ 6/1/90 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in 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. Page 2 of 2 72-025 (Rev. 7/88) Back PSG SO`, MUNICIPALITY OF ANCHORAGE (MOA) �tO���,G� • Health Authority Approval (HAA) %���� CHECKLIST - FEBRUARY 1984 343-4744 n`o t� e`�® Legal Description: A. WELL tCTA Well Classification %Jrr d8�e If A, B, C, D.E.C. Approved (Y/N) �9 Well Log Present (YI6)--Date Completed ��' °+O z r` Yield J_-& ; /'"+ Total Depth–Y-9—' Cased toDepth of Grouting Static Water Level / Pump Set At LxG.tes n . Casing Height Above Ground 3 Sanitary Seal on Casing &9N) Electrical Wiring in Conduit 6J) Depression Around Wellhead (YO SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot 4/_ - ; On Adjoining Lots NVQ To Nearest Edge of Absorption Field on Lot /✓�A ; On Adjoining Lots AJ q To Nearest Public Sewer Line /oa t' - To Nearest Public Sewer Cleanout/Manhole /D D To Nearest Sewer Service Line on Lot ZJ -t Water Sample Collected by / i. 'e 1c ; Date Water Sample Test Results Commentsae'�i/ccJ �es� 4'�/4��9 G✓t j� o>�e/�n� ��riy�ie� l►5 B. SEPTIC/HOLDING TANK DATA Date Installed Size Standpipes(Y/N) Depression over Tank (Y/N) No. of Compartments Air -tight Caps (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High -Water Alarm (Y/N) Date Last for eanout(Y/N) Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPT. C OLDING TANK: To Building Foundation To Water -Supply Well To Disposal Field To Property Line To Water Main/Service Line' To Stream, Pond,�Li Comments p4ajor Drainage Course 72-026 (Rev. vee) From Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test — SEPARATION DISTANCE FROM To Water -Supply Well To Building Foundation Lot To Water Main/Service Line Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statnd es Present(Y/N) Dat f Last Adequacy Test I D: 4- To Property Line On Adjoining Lots To Stream, Pond, Lake,,drMajor Drainage Course _ To Driveway, Pa>Kg Area, or Vehicle Storage Area D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments o� To Existing or Abandoned System on To Cutback (if present) — Dimensions Manhole/Access (Y/N) . "Pump Off,Lev % s -_ Vent (Y/N) _ "Check Permitted Bedroom Rating Against HAA Request" Pumping Cycles during Adequacy Test. ��en K1 b I certify that I have c ecked, verified, or conformed to all MOA and HAA gtr�efi sd���4f�gt on the date of this inspection. Q y Signed Company �e°°ee°° 3 G gineer's Seal Date °a e MOA No G i �l Do/ "L. ° IFR C. REID, JR. ®O`' °e CE -2251_.0 - eeeo oe" ?roPessiotr�� Receipt No. Date of Payment ` -7 U Amount: $ % O _ U C Receipt No. _ Waiver Fee: $ Date of Payment 72-026 (Rev. vas) Beck Page 2 of 2 • MUNICIPALITY OF ANCHORAGE Department of Health & Human Services y { DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I. D.#_ 41A8–d23-Z3 HAA# ���dJq?' 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, 'section, township, range) W Location (address or directions) (b) Property owner — Telephone : (home) Business Mailing Address (c) Lending Institution Mailing Address Telephone (d) Real Estate Company /and Agent �) d%/� �rz5�z�fJ /ema_ ZtfR/6 Address �eo//�" /�/ �iJ/2Tc Ei' A/457i�� Telephone �,,y-8 � 0 0 V (e) Mail the HAA to the following address: (or check here if hold for pick up.) List contact person and day phone number below: rf5 A1C/y P 2. TYPE OF RESIDENCE Single -Family Number of bedrooms 2 3. WATER SUPPLY Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ❑ Public y Community ❑ Holding Tank ❑ Note: If community well system,.must have written confirmation from the State Department of Environmental Conservation attesting to the Iegailty and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 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 A:�!:� (:�_ 5 Telephone 2� -7 :7— 5 -5,%5" - Ad d re Date OF A4 4 C : 49TH '^ .fir j' •••..•. ..• o•...,.y eai • LE C. REID, :R. u CE -2251 a 6. DHHS APPROVAL Approved for z bedrooms by 1c ` (�Date �5 Approved Disapproved Conditional Terms of Conditional Approval CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible forerrors or omissions in the professional engineer's work. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) AM) • � Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 �i 343-4744 Legal Description: G 6 /J 2: A. WELL DATA Well Classification j Gkj 11 r� If A, B, C, D.E.C. Approved (Y/N) —T Well Log Present( /N) Date Completed d1J<A)@-Gel k! Yield Total Depth Cased to Depth of Grouting 1tv/ ,41t Static Water Level Casing Height Above Ground — Electrical Wiring in Conduit((Y N) Pump Set At / Sanitary Seal on CasingWN) Depression Around Wellhead (Y/1�11 SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ; On Adjoining Lots A�4— To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots 1" To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole /O To Nearest Sewer Service Line on Lot 4f_ +_ Water Sample Collected by o�"C� --W419-N 6&_AJ ; Date 49-16 _49J: Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA U - Date lostalled Stan Size No. of Compartments Depression over Tank,(Y/N) r -tight Caps (Y/N) Pumping/Maintenance ConPdston File (Y/N) Holding Tank H i g h -Water. Alarm, (Y/ SEPARATION DISTAN( ES.FROM.SEPTIC/ DING To Water Supply -Well To Property Line' a - To Water Main/Service Line To Stream, Pond, Lake` ir,Major Drainage Course 4. Comments .-85 Foundation Cleanout (Y/N) Date Last Pumped for Temporary Holding Tank Permit (Y/N) TANK: Building Foundation To Diaoosal Field 72-026 (Rev. 7/88) Front Page 1 of 2 1 ' Q. C. ABSORPTION FIELD DATA in Absorption Strata Date Instal Width of Fi Square Feet of Absortion A Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSOR To Water -Supply Well To Building Foundation I nr To Water Main/Service Line Type of System Design. Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present(Y/N) Date of Last Adequacy Test FIELD: To Property Line 1, To Existing or Abandoned System on On Adjoinin To To Stream, Pond, Lake, or Major Drainage Course . To Driveway, Parking Area, or Vehicle Storage Area Comments D. WT STATION Date Size in Gallons --- "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments present) Dimensions Manhole/Access(Y/N) "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have ch ked, verified, or conformed to all MOA and HAA guidelines in effect on the ate of this inspection. %s+rcau Signed / /%•ms•4e•e•'O••,®Fe•. Hp•a`. Compa 470 • evj•j;y���YV• �e n Engineer's Seal Date4�d eML MOA No. E5>, -0.g `/ Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7188) Back Receipt No. — Waiver Fee; $ — Date of Payment Page 2 of 2 )VA. REID, JR. e i 2251 e° maa ••ee.=•'seCO�O. w O MUNICIPALITY OF ANCHORAGE • � Department of.Health &Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY ON-SITE SEWER AND WATER FACILITY FOR SINGLE FA Parcel I.D. # � LOS l °D'� L' HAA # ` 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section Go'T S SLc'. Z"" :G%J7lheTif Location (address or directions) (b) Property owner Mailing Address (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address zoo y- tj "Jee7 Telephone z4- ZBb! (e) Mail the HAA to the following List contact person and day F A25 -e5 hd,< a?. 4PPROVALOF LY DWELLING range) rjJ SCG ephone : (home) Business Telephone ass: (or check here'lKif hold for pick up.) number below: 2. TYPE OF RESIDENCE/ Single-Familyi N mber of bedrooms 3. WATER SUPPLY / Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site ❑ Publicg 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. 72-025 (R.V. 7/88) Page 1 of 2 e_S g-."- m5wrl-etCrA- 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by myseal 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 14EC5 Telephone Address I ��y W 33r� /h/w /}X Date 6. DHHS APPROVAL Approved for X bedrooms by Approved —A Disapproved Terms of Conditional Approval Conditional P,CAUTION',- Z7/ SSS3 4 r it, Prot 1 1 AV L � Date zfj, The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 Rev. ]/88) Back Page 2 of 2 • MUNICIPALITY OF ANCHORAGE (MOA) G \yoF�� ��5�� • u Health Authority Approval (HAA)1 CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: ®�(,�t�� T>3,(l �iiJ s�G z8 A. WELL DA%A Well Classification 7)eIV47e If A, B, C, D.E.C. Approved (Y/N) WI4 Well Log Present (YoJ Date Completed ��%�pi1) Yield j+00 674" ��``�� r A k Total Depth y�o Cased to-1—°—Depth of Grouting /,✓�i� Static Water Level 1Y"' Pump Set At Casing Height Above Grounder� 3 Sanitary Seal on Casing&N) Electrical Wiring in Conduit LIN) Depression Around Wellhead (Y© SEPARATION DISTANCESFROMWELL: To Septic/Holding Tank on Lot ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot �✓ ; On Adjoining Lots 414 d0 r /Ot7 To Nearest Public Sewer Line y -r To Nearest Public Sewer Cleanout/Manhole r To Nearest Sewer Service Line on Lot X5- Water SWater Sample Collected by hin" A)rd ; Date Water Sample Test Results BAd- 7— Comments Comments Meal fi-"i R57- aet-1- LAW?# ✓AR/t/A %1V flzP/✓E �L�/GGbtIC� . B. SEPTIC/HOLDING TANK DATA Date Insh&c! Size Standpipes (Y/N Depression over Pumping/Maintei o. of Compartments Air -tight Caps (Y/N) File (Y/N) Holding Tank HighfWate('li WF7r (v/N SEPARATION DISTANCES FROMSE To Water -Supply -Well " Foundation Cleanout (Y/N) Date Last Pumped ;for Temporary Holding Tank Permit (Y/N) PTIC/FtGLLDING TANK: To Properfy Lii)e' To Water Main/Service Line To Stream, Pond, Lake or Majdr.Drainage Course Comments Building Foundation To Dis)5Qsal Field 72-026 (Rev. 7/88) Front Page 1 of 2 dw- 62- GioJ'TdoRAI C. ABSORPTION FIELD DATA ;P {, Soils Rating in Absorption Strata Date In ed Width of Field Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION To Water -Supply Well To Building Foundation Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present(Y/N) Date of Last Adequacy Test Property Line To Existing or Abandoned System on Lot On Adjoining Lots To Water Main/Service Line To Cutback (if To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Instal e Size in Gallons C "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments t) Dimensions Manhole/Access (Y/N) "Pump Off' Level at Vent(Y/N) � Pumping Cycles during Adequacy Test. `"Check Permitted Bedroom Rating Against HAA Request" I certify that I have checked, verified, or conformed to all MOA and HAA gu inspection.�/ t Signed 4&--9y +� Company 19LTGS ¢/J Date 8'"�"�"�9 MOA No. UZy� Receipt No. /J f / C7 Receipt No. Date of Payment J Waiver Fee: $ — Amourft: $ �7��1 Ci Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 the date of this �0 Engineer's Seal ...s rd L, Alpine Drilling & Enterprises INVOICE Domestic — Commercialo Pump & Water Systems N- P.O BOX 110496 Job Name /Location Anchorage, Alaska 99511 F / ((90077) 345.0202 3�I- 0 4I �-- Tn A F t ) I2�3 /inn fQ�l��(s�(�rC. Q� I IV-�r ll: Q. / 11 \ `I IVd U PHONE a �. �j7q_555 ( Kim Lane -Marston g, E DATE ,ZO jq QUANTITY DESCRIPTION AMOUNT 3sln dvlcl clI Je tl� i f Ica-hovl' Inc ( z f 49 ,c_ kdci 13' I 61I (A 11 � _ dui LABOR HOURS RATE AMOUNT TOTAL MATERIAL TOTAL LABOR WORK ORDERED By DAIS CAMP TOIAL LABOR PAY THIS AMOUNT Thank You SIGNATURE (I Hereby Acknowledge the Satisfactory Completion of the Above TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date April 16 1985 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 6, Block 2 Wentworth Subdivision, Section 29, T13N, R3W Location (address or directions) 3240 East 41st Street, Anchorage (b) Applicant Name Ralph Nelson Telephone: Home 562-4894 Business Applicant Address 3240 East 41st Street, Anchorage (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder 15; Buyer ❑ ; Other ❑ (explain); Owner of existing home with existing well (d) Lending Institution Telephone (e) Address Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single -Family] Multi -Family ❑ Other Number of Bedrooms 2 3. WATER SUPPLY Individual WellZ Community ❑ 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 Onsite ❑ Public $1 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. 72-025 111,941 Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. 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 Ted F ; and Assari at me Telephone (907) 274-9517 Address 810 East Ninth Avenue, Su Date April 16, 1985 6. DHEP APPROVAL Approved for7. (A bet Approved v I Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or a;telyte data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the �J 'u MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1964 264-4720 +' Legal Description: Lot 6 tgq�{n[d�,a�tgq{garF Subdivision Section 29, 6¢6Y3N�F BB�TTH & ENVIRONMENTAL PR TE A. WELL DATA APR 1 ;v Well Classification individual If A. B pproved (Y/N) No 4/15/85' -% CE 1 / ' to 4 - IN Well Log Present (Y/N) Date Completed Yiel 1 Total Depth b0 + Ca( sed to-- \ Depth o routing 0 + Static Water Level 40 + Pump Set At Casing Height Above Ground Wiring in Conduit (Y/N) n Distances from Well: To Septic/Holding Tank on Lot 11� Around Wellhead (Y/N) On Adjoining Lots 2001+ 200'+ To Nearest Edge of Absorption Field on p LoteOn Adjoining Lots To Nearest Public Sewer Line lz0*u � o Nearest Public Sewer 4/B � gill 2 Cleanout/Manhole ° f d/+� To Nearest Sewer Service Line on Lot Water Sample Collected by Nils Lindholm Date 4/15/851 Water Sample Test Results Attached Comments Inspection made of existing well; 2+ feet snow at site• well completed before occupancy of owner -driller not known. B. SEPTIC/HOLDING TANK DATA 'V!!1'C cJ6u/d/ y�i8�95 Date Installed Standpipes (Y/N) Depression over Tank (Y/N) Size Air -tight Caps (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 Course Comments Page 1 of 2 72-026(11784) No. of Compartments Foundation Cleanout (Y/N) Date Last Pumped for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA �Pv&2 ,Sewer.� 3/'eS Soils Rating in Absorption Strata Date Installed Width of Field 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 To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course _ To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Type of System Design Length of Field - Depth of Field Gravel Bed Thickness — Standpipes Present(Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on On Adjoining Lots To Cutbank (if present) Dimensions Manhole/Access (Y/N) "Pump Off' Level at Vent(Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have ch , verifi d; or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed %/Uy_l Date 4/16/85 Company Ted Forsi & AssociateVOA No. ST85-028 Receipt No. — Date of Payment Amount: $ Page 2 of 2 72-026 (1 1Y84) Ted J.°ro,i, Y No, 3265.E V4o %`lin( J Vit)\c\\ .CHEMICAL &GEOLOGICAL LABORATORIES OF ALASKA, INC. r� TELEPHONE (907) 5622343 ANCHORAGE INDUSTRIAL CENTER 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER II TO BE COMPLETED BY LABORATORY WATER SYSTEM: (') See In on back I.D. NO. Z 7 -7,/ ✓q51 -f Ji�� v 11 Yr�ict / l - /IQ/JG7 / V��•Slli7 /T water System Name n Phone No. 7t) Te�Fi� ¢J7Ssnc C �%Q �. 9t1Aze Mailing Address �ff, .9Y,501 City state. zip Code SAMPLE DATE: RE E = I D IJ I Mo. Day Year SAMPLE TYPE: ❑ Routine ❑ Check Sample (for routine sample t ❑ with lab ref. Treated Water ❑ Special Purposea ;E`Untreated Water SAMPLE Time Collected NO. LOCATION Collected By I"7- 2 3 4 5 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 �S Analytical Method: ❑ Fermentation Tube Membrane Filter Lab Ref. No. I Fl,gq-jo&I Result' Analyst m I I m l I m I m •No,. of colonies/100 ml. or No. of Posmve porvons 06-1220(b) BACTERIOLOGICAL WATER ANALYSIS RECORD Re, 1883 READ INSTRUCTIONS Membrane Filter. Direct Count Coilformltooml Verification: LTB BGB ' Final Membrane Filter Results Coilform1100ml BEFORE Reported By = —Date Time: `���' a.m. p.m. COLLECTING SAMPLE TNTC = Too Numerous To Count t GREATER ANCHORAGE AREA BOROUGH Dapa..tmenti of Environmental Quality J 3500 Tudor Road, Anchorage, Alaska 99507 279-9636 (� Date Received - - \v Time of Insnection� l� ]✓ate of Insnecti,on- 7 REgtJrST FOR APuR01AL OF INDTVIDUAL SEINER & WATER FACILITIES FOR 1. Aoeroval Requested Bv: a Address: �J. t2 0= Fhone:o27i� 2. Property 07nere-7TJ� ' Phone:,i y� i. regal Description::Z— '�-- 7% 4. Location: oaf SST �/ 5. Tyne of Facility to be ln>Spected:TT�� Number of Bedrooms: 5. "Jell Data: A. Tvne_ �,,� Gt? 9. Depth T C. Construction D.� Bacterial Analysis 7. Sewage Disposal Systemic �G A. Installed - 8. Installer C. Septic Tank: 1. Sizer - 2. Mianufacturer D. Seepage Pit: 1. Size 2. Material E. Disposal Field: Total T_ergth of Lines 9. Distances: A. Viell To: Sentic Tank_ Absor"""ntion Area Sewer Lines �jngrpst Lot .'.ine^���ki-Other Contamination B. Foundation to Sp -tic Tank Absorotien Area C. lbsorutinn area to Dlearast Lot eine Request for Anrrovai oi_ ndividual Sewer &'dater Facilit-1s Page Two 9. Comments: GEJ -el( oOGt, 1� � �. �� �� �• `� v., Aonroved Di;ar. proved Date•- A.r oaal ''alid for One Year From Date Sioned .Greater Anchorage Are-) ?orounh, De,:artment of Environmental Quality nTq,:,?A61 OF SYSTEM. I certify that the information contained in this request for approval to be a true and accuraty representatign of the gti�iect sewrr and 'Nater facilities located located at: - Signed Date REPORT OF INSPEC71ON-INDIVIDUAL SEWAGE -DISPOSAL SYSTEM PRIMARY TREATMENT consists of ❑ Septic tank. ❑ Cesspool. Sepik Tank: Distance from well, feet. Material,—_— Number of compartments Total liquid capacity, gallons. Capacity inlet compartment, - _gallons. Inside length,----- feet. Inside width. _feet. Liquid depth, feet. Cesspool: Distance from: Well, feet; foundation, __feet, nearest lot line at ❑ front, ❑ side, ❑ rear, feet. Inside diameter, _ feet. Depth, feet. Liquid capacity, gallons. Lining material SECONDARY TREATMENT consists of ❑ Tile disposal field ❑ Seepage pits. Other Tile Disposal Nelch - - Distance from: Well, feet, foundation,_ feet; nearest lot line at ❑ front, ❑ side, ❑ rear,_ feet. Total length of tile lines,— —feet. Number of lines-- Distance between lines, feet. Trench width, _inches. Total effective absorption area in bottom of trenches, square feet. Length of each line,_ feet. Depth, top of tile to finish grade, _ inches, Type of filter material: ❑ Gravel. ❑ Broken stone. Other— Depth of filter material beneath tile, -inches. Depth of filter material over tile,' inches, seepaya pits: Numher of pits— .. Outside diameter, feet. Depth, feet. Lining material Distance from: Well, feer, building foundarion, feet; nearest lot line at ❑ front, ❑ side, ❑ rear, feet, Inspection mode by: ❑ State. ❑ County. ❑ Local Health Authority. Inspected by Date of inspection 19 REPORT OF INSPECTION -INDIVIDUAL WATER -SUPPLY SYSTEM Distance to nearest public water main,_. --feet. Size of main, inches. Individual wells ❑ are ❑ are nut customary in neighb9rhood. Give most recent rorord of failure of wells in immediate vicinity to furnish adequate supply of water Properties in neighborhood ❑ are ❑ are not being developed with both individual water -supply and sewage -disposal systems. Lot sin: feet wide, --feet deep. Dwelling set back from front property line, feet. Individual water supply from: ❑ Drilled well. ❑ Driven well. ❑ Dug well. ❑ Bored well. Distance of well from) Budding foundation, ..—feet, nearest lot line at ❑ front, ❑ side, ❑ rear, feet, cast iron sewer,—feet; tile sewer —feet; septic tank, feet; disposal field, feet; seepage pit,— —feer, cesspool, feet; other sources of possible pollution, feet. Well construction: Diameter, inches. Total depth, feet. Type of casing, --_ Depth of casing, feet. Approximate depth to pumping level of water in well, feet. Approximate yield, gallons per minute. Sealed watertight to depth of feet. Exterior space around casing sealed with: ❑ Cement grout. ❑ Puddled clay. ❑ Ordinary backfill. Well cover: ❑ Concrete. ❑ Wood. ❑ Metal. Openings in well cover watertight: ❑ Yes. ❑ No. Pump: ❑ Shallow well. ❑ Deep well. Length of drop pipe, feet. ftlmp capacity, gallonsperminute. Located in: ❑ Basement. ❑ Pumproom off basement. ❑ Pumphouse above ground. ❑ Pump pit. Pumproom properly drained: ❑ Yes. ❑ No. Pump mounting watertight-. ❑ Yes. ❑ No. Type of storage: ❑ Pressure. ❑ Gravity. Capacity, gallons. Has bacteridlogical examination of water been made? ❑ Yes. ❑ No. if answer is "yes," give date Quality of water ❑ is ❑ is not satisfactory for human consumption. Installation ❑ does ❑ does not comply with approved exhibits, if any. Inspection made by: ❑ State. ❑ County. ❑ Local Health Authority. - Inspected by. -- Date of inspection 19_ FRANK BETHARD MORTGAGE LOAN DEP, HEAO OFFICE NA [riONAY, BAND OF ALASKA BOX 600 ANCHORAGE, ALAIIA PHONE 272-5544 TITLE 19_ GRID 809080 V.S. GOVERNMENT PRINTING OFFICE: IS7I.9% 55357.71 -'^ GREATER ANCHORAGE AREA BOROUGH Department of Environments] nuality 3500 Tudor Road. Anchorage, Alaska 99507 2'79-8686 Date Received // 7 jTime of Inspection `0 Date of Tnsnect.ion / 1. Approval Requested Address: YMA 2. Pronerty Owner:_ 3. Legal Description: REQUEST FOR C APCROVALfOF INDTVTT)UAI. SL!1P & INATER FACILITT.:S FOR 1-G ,hone: ala K Phone: iZ--1 t 4. Location:_ J 5. Type of Facility to LA Tnsrer_t.ed:������{,��(,(y�F����f'� Number of Bedrooms: 6, Well Data: B. Denth A. Tyne �/—`1L�,.. _ C. Construction /tel _Gr /J y` ��G-✓ „ Bacterial Analysis 7. Sewage Disposal System:7 A. Installed >� l' e � �� Installer ler C. Septic Tank: 1, Size 2. Manufacturer ---- D. Seepage Pit: 1.. Size 2. Material E. Disposal Field: Total Length of Lines____ 8. Distances: A. Well To: Septic Tank_ Absorption Area , Sewer Lines Nearest Lot hire Other Contamination— y! B. Foundation to Septic TankAbsorption. ArAa��� C. Absorption Area to Nearest Lot Line Request for Approval of I{,vvidual Sewer & 'Water Faci_litie F ge"Two 9. Comments: oved Date 9:20-7 Z� Aporoval Valid for One Year From Date Signed Greater Anchorage Area Sorouoh, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to he a true and accurate representation of the suniect sewer and water facilities located at: Signed Date os-1L6U ta, DEPARTMENT OF HEALTH AND SOCIAL SE ES DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS DATE - Lab. Ne. OFFICE Records in this office Indicate this WATER SUPPLY to beef: - PUBLIC ❑- SEMIPUBLIC �._ INDIVIDUAL OTHER _ satisfactory ❑ Unsatisfactory Saint Status. REPORT RESULTS TO. ❑ ry ❑Questionable ry arp NAME f ADDRESS. City - ADDItl55 .. - -OF'SOiIACE- ... SAMPLE. COLLECTED BY . - ... am DATE COLLECT ED TIME COLLECTED - pre Sample Collected From ❑ Kitchen Top ❑-Bathroom Tap ❑Basement Tap. ❑ Other flist) . � s Well ❑ Dug ❑ -Driven .QDrilled ❑ Bored SOURCE: - ❑ Sprig '❑ Cistern ❑ Other Dug Well or Cistern Combustion: Drick or wall. - _❑: Wood ❑ Concrete - ❑ Metal ❑ -TDe - ❑ Concrete Top. ❑µroe [3Concrete❑ Metal ❑ Open Top - -. LOCATION: ❑ In Basement -. ❑. basement OBere ❑ Under Beazer ❑ In Yard ❑ Otheri�� Building SewerS.Phe Peet DISTANCE TO: or Olhei Drainagefte - Feel. Task TSI. - Seepage - - Cess- : - Field . Feet. At Peet, Pool - Peet.. Privy . ,Feet. Other Possible Somessof Conleminmion - ❑Asbastw MATERML: Building Sewer. ❑. BCo t ❑- Wood ❑' Tile. ❑:Fibra '.Cement. ❑- Plastic joint Material — Type GENERAL:. Does Water Demme- Muddy or Discolored? :El yes -❑: No When? Diameter of -Well 'Depik- - - Feet. --'Wall Ca Iuq - .. Material Dfameler Depth Length of - - Water Depth -Peel Drop Pipe From Bottom - .PUMP -LOCATION:-o UBlity -.. ❑:ImWell ❑ Offset to Basement ❑-ln Basement ❑ ZRoom 1303TOZ [3 Other PURPOSE OF EXAMINATION: Blum Suspected? ❑I Yes -❑' No - NewSemceofSUPPly4 ❑.Yes -1:1 No Repairstosystem?- ❑-. Yea ., 13 No READ INSTRUCTIONS ON Analysis shows this Water, SAMPLE to ba: - - Q`Satisfactory.❑Questionable ❑. Unsatisfactory, If an '!Unsatisfactory" or."Questionable' status is indicated above- . you should take immediate action as recommended below. 1. Notify consumers wateris polluted. Boll or chemically treat this water as outlined in the enclosed. leaflet "Drink It Pure." - 2. Increase chlorination sufficiently to meet recommended residual standards. Determine source of contamination and lake action necessary to maintain amfe watersupply at all times. - S. Check chlorination and other mechanical equipment. Make-certainit is functioning properly. -- - C If after checking equipment a disinfecting residual is not obtained, please wire this office for emergency assistance or advisory services. - _� S. This is a surface water source andsubject to pollution by man and animals. An approved water supply source should be developed. - - -_ 6. Improve your - ❑ spring ❑ dug well ❑ driven well ❑ drilled well ❑ cistern - 7. Relocate your well to a safe location in relationship to your sewage disposal system. ❑ see enclosure - - - 8. Sample loo long in transit; sample'should not be over 48 hours old at examination ta- indicate -reliable results, please send new sample. - ❑ Bottle Broken in transit, pleasesendnew sample. - _ —,9. Contact your newest ❑ Local Health -Department or ❑'Alaska Division of Public Health, sanitation office for bulletins, mnsultation and assistance,.:. - - SANITARIAN'S REMARKS - - 06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD Dine Receival _ Time Received Par -Lab. No. Larissa, Broth - - - leer llkc Ince - lace 1 face l.acc. 0.1ce_ 48 be. REVERSE SIDE - � --- --�. - BriBimu Green - - - - -24 hours _ BEFORE 46 hours Bra AGAR COLLECTING SAMPLE MW_E- 98 . Lactose Broth, 24 lure, vs Gam's erns rte^ .. -yColdotm Density. -:.:. (Mast probable No. pw hare.) - _Detergent Test ... - __.... _. _ _ .am 4.. -1hipodedby Data -This analygrsindicaleeGoitfmm Orgonlsmsao be¢, ....:Absent 31 October 1963 Y terans Administration Regional Office tie Case 4o. DL 143 960 AAA 'sower Building; Lot 6, Block G 7th and Olive Way Wentworth Subdivision Seattle 1, Washington Anchorage, Alaska Attention; Mrs. G. 0. Story, Mortgage Loan Examiner Dear Mrs. Story: The information regarding the canter and sewage disposal systems serving; Lot €i, block 1, Wentworth subdivision has been reviewed and found satisfactory by this department. kn Viet) of the data included in the enclosed cor'respondeacc, it Is our opinion that the systems can be expected to function as intended. The Greater Anchorage Health District gives its approval of both systems this elate of October 31, 1963. Sincerely, medical Dtrector Donald =1 Penner, R.S. Sanitarian DHN rsa Uncl (4) ADAMS CORTHELL • LEE • WINCE & ASSOCIATES CONSULTING ENGINEERS ROX 1266 ANCHORAGE TEL. SR 7-3773 RICHARD S. ADAMS BOX 843 FAIRBANKS TEL. 456-4653 ALAN N. CORTHELL AlPt LIAT[C W.I. HARRY R. LEE ARCTIC ALASKA TESTINS LA90RATORIEM FRANK W. WINCE October 7, 1963 W/O 5107 Mr. Robert Diggins C/o State Realty 300$ Spenard Road Spenard, Alaska SUBJECT: Water Sample - Lot 6, Block 2, Wentworth Subdivision Dear Mr. Diggins: A sample of water was taken from the kitchen tap at the subject site and tested for the presence of coliform. The test Indicates no coliform I present. Data regarding the well log were not available. The water remains clear. The pump Is In the well, and the location of the well with respect to sewage disposal fa::Ilities is shown on our report dated September 30, 1963. Very truly yours, ADAMS. CORTFIELL. LEE. WINCE & ASSOC. !Yank W. Wince, P. E. F'WW/ma ADAMS CORTHELL LEE WINCE & ASSOCIATES CONSULTING ENGINEERS BOX 1266 ANCHORAGE TEL. BR 7-3773 BOX 843 FAIRBANKS TEL. 456-4653 AFPILIATCG WITH ARCTIC ALASKA TESTING LA80RATURIES Mir. Robert Ulggins c/o :'hate UnnIt 300.5 5ponard Road Jenard, t.1.aM RICHARD S. ADAMS ALAN N. CORTHELL HARRY R. LEE FRANK W. WINCE optenber 30, .563 Anchorage, Alaska U/0 5107 ;OMC'.t': Percol_ation test and sewerage layout m Lot 6, Block 2, Dear -Mr. Diggins: A percolation tout has Wan "peri`oywr::d On tilt) S??i:; jactJ lol';. d.nta. ere iho;qn on],,R-jot 1 attached. 'Th noTeolallon tsto --'mr doterfr -uod to be 1. Inch per 10r3s thaia I Hdinuto. Tho se;re:ra e e5,ys-;ern W80 Inspected and the following pertinent data are pro*dods Distanco from art 1.1 Material TO:sl liquid capacity Inside length Inuido width .liquid depth Pdt%ifbbt? " of. pits live WnIn_; i+taterlsl i)1.Si:l83aU€s from well. 11intpnoc Brom building O:I. tenco from nearest lot line 70 .feet Portland cement concrete 6 feet 51 Hot 4 feet One pp f8 ft. y 8 M ij' ft. Log 707 ft. 116 it. 11 ft. (rear) A aample of the well water was collected for bacteriological examination the rea an of which will be forwarded when received, Very truly YtIX0, ADAMS • CORT3ir,LL . LTM13 • MOB & AS S00. I cenk W. "vJ':i,nce, P.E. &ac. I 0 I" NET Ok6P I`� -7/ r a.. -7/