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Home My WebLink AboutWHALEY #5 BLK 1B LT 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division d~" ) -- ,J ) ,J 825 "L" Street, Anchorage, Alaska 90502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Address TANKS '~ SEPTIC [] HOLDING Material No, of Compartments DISTANCES FROM"~ SEPTIC ABSORPTION WELL TANK FIELD WELL LOT LINE .~0 FOUNDATION AS-BUILT DIAGRAM (Show location of well, septic system, prope~y lines, foundation, driveway, water bodies, etc.) TYPE OF SYSTEM [] TRENCH ~i~ BED [] W. DRAIN [] OTHER Total depth from original gr de Depth to pipe bottom trom ~/~_ original grade O -- 0'~"' FT :ill added above original grade~.... ~" "/""FT Gravel depth beneath pipe~) ~, ~,. ~.~- Gravel width Graveileng,h ~"~-,~' /FT ~"~' /~FT Total absorption area Distance between lines Number of lines Soil rating ~ Pipe material ~ / ~-~e~ SQ FT ~"/0 tnst alle~' ~ ~ gf-~ .,~0~. Date Ins~aOed WELLS '~PRIVATE [] OTHER ¢ldentifv) Classification (A,B,C) Total Depth ~:T Casedto Installer Date Installed; REMARKS: Inspections PerfOrmed b · Mu0i0ipal and State guidelines in nllest on I Health Department Ap 72-013 (3/85) cedity that this inspection was pedormed according Io all Date' '~: F:' E: R M I 1' Owner Name: O~n~:~r Adch"es~: ~9(Y36 CHZCAGOL. LOOP ANCHORAGE Al< 99577 I...ega.!.: Subdivis:i.c~n~: WHALEY ~5 Lot: 1 Block." Sec:t:Lon: 10 'T'c~wnship',~ 15N Range~ 1W Size 'l"h:Ls Pepmit.~ (~ T'cd:al :~apacicyi T'ANI<~ Miliimum 'l'.ot.a]. Sept. lc: tank capac:it.y~ peqt.tip(:,~s ir~;L/:[a'[J.c~n ovep 'Lank(s). 4 1,750 gallons,, Eac:h ~septic: D::p'Lh t.o 'Lop of :epCic t. ank (s) < 4.0 'TO BIS INS'fALLED :[lq ACC:ORDANCE: WITH ENGINE':ERS DESIGN,,NOTIFY DHHS F:'R]:(]R 'I'C] P,I...I... tN!i!;F)EC"I'tC]NS. EXISTING S[ii]::']'IC ]'ANK ANZ) BED TCI ABANDr.)NED PROF'Ii.]:~L.Y. TH:IS PERMIT ]:S ISSUED FOR THE E×IST!NG 4 BEDROOM SINWLE FAM:!:LY RES]:DENCE OI',ILY, AND EXI::'IRES ON 12/:3 ]: C[:.f~ I IF'Y TI...IA"[': 1,, I am .[amil:i.~al" wi'l'.h the peqL~irem[:en't.s {'cH" eJn.-s:i, te sewel"s and we].].si~ ass set. for'.'Lh by t. he MLu'lic:ip~:~l.i't.y o{ Ar'lc:homage (MOA) arid 'LI]e St. ate (:)~' Alaska~ I will inst. all the syst. em in accordance ~k~it.h all MOA codes and peguJ, at. ic)ns, at'id in coml:)].iance t,~JJ.'Ll'l the design c:r, itE)pia ]: will aclheP~ t.o all MOA and St.a'Le of Alaska requipemer'r[.s ~oP t. he set bac:k dJ~H[.o.r'll::i~f~ [Pc:)lil ally e)listJ, ng ~,~)].l, i~as'~.ewat.~,r' (]ispo~i~a.]. system or pub].ic I Lli]c:lcel'~S'Eatlqd t. ha'L Chis permit, is valid fPP a max:i, mum of' 4. bedr'ooms. I ,a].~o undepst, and Chat t. he capacity of' the t. cr~..al system is 4 bedr'c~(Dms and any enlargement e ditiona! pepmit !:)ATE ~ S i g n e d: I ssu[?d 825 L Street, Anchorage, Alaska 99502-0650 .... · o.~/~ SOILS LOG -- PERCOLATION TEST · .......' ~? Township, Range, Section: 7 8 9 10 12 17 18 19 20 SLOPE SITE PLAN WASGROUNDWATER ENCOUNTERED? IF YES, AT WHAT OEPTN? Depthto Waler After ,~! Monitoring? Date: Reading Date Gross Net Depth to Net Time Time Water Drop ~//,o ~. ~-~-~? /?~,/- 4,/' ~o ,v/,,/ .¢,e- .,/~ PERCOLATION RATE /~"* ~' (minutes/inch) PERC HOLE DIAMETER __ TEST RUN BETWEEN -,~ FT AND ¢ FT PERFORMED.~: 4-~"" 4-' ,J,",~ , ~ zJ,.:.~ CERTIF~T.ATT.,STEST.VASPE.FO.MEO.N ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) MunicJpalily o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICE 3- 4 5 6 7 8 9 10 11 13- 14- 15- 16- 17 18 19 20 COMMENTS NEER'S SEAL) SOILS LOG -- PERCOLATION TEST Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? :. ElD, JR. ~r IF YES, AT WHAT DEPTH? SITE PLAN Depth Io Water Alter L~/_ / Monitoring? 7 ' "" Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ TEST RUN BETWEEN __ (minutes/inch) PERC HOLE DIAMETER __ FT AND FT ACCORDANCE WiTH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4185) _ ALASKA EnuIRo mEIqTAL COBTROL $eRUICE$, IlqC. [n~linecrinq [- [~nui~onrn~nt~l LOT .1.!, [{ILOC31< lB, !~I'-iAL[~iY ~l:~ii SUJi{ID:[VIS~XI:iN Al.]. fila'cRr'.:La~l~ ar'id ~::(:]lldZtJ.(:)rls I:gf 'i':l'i(~.-' i'- e g u ]. a I:: J. c,i"! s ~:: u r rer'i 'l:: i y All ,:::~).'c:avatic)r]s a~"i(::l dep'!':i"l!~ are advisory, by t h~'e which ~(::,~.~:[,::1 pul: -hh~a :['f 'l::l'ie :Lr'ls'l:allatic)r'~ :i.~:~ n(:~t :i.n~!.pec'i:.ed by ari AECS ertgii'ieer'~ AE(2S ~i:t.:[ ric)t be respr::~risib].e 'for in~ta:l, led ~y~tem,~ Ari engineer at AECS sluould be r'luml:)er' (::)'f inSl:)ecti, on~s tha'b ~-~,iZt. 1 be required and 2.0 ~3[.:iF::'T ]: (I; TA!'.H< :1:'[: ti"ier'[e :i.~ an exi~.±:ip, g septic tank it may be used if i'!:. !nee)'h!~ the c:al:~a(:::i, hy r"equ±rement 'f~::~' 'l:l"ie ,~'e~:iic:ler'lc:e~ The str'uctL!ral i~'itegr:i, ty o'i~ tlue tai"il< -12-',61 a mJ.l'qi, mum c)'f: 5 'fCef:~,t 'from ~4t 2 W~s~ ss~b &venue · &ncho~e. &i~sk~ 99503 · (907) 279-~;553 gr'avei 'for" the bed ~:~dia].l be 0:5 '1:.o 2~5 ii,ch, 200 ~:[.ev~,~ ~/:L][ ~BL.tb~5'L:Z~CL.U~:e~ [~l~..[~'~: J"t~.ve pI."J.c:,Y- DHHE; -i'li(a !s :i, (::h:a !s]Cil::,~.g of 't:h~.:a mound ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 CHECKED BY. DATE SCALE .........~'~ ....... ~i ~"'i"~'"'"T "~ ' i~~ri ~ ~i'~ ......... ~?i'" i~g~_~ ', /~ ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 West 33rd Avenue, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 CHECKED BY DATE )- '~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE [~i~N EW NAME , .~Z~"~ ~-'~-~ ~ ~" ~ ~ UPGRADE ~AILING ADDRESS LEGAL DESCRIPTION LOCATION ~ NO, OF BEDROOMS ~ DISTANCE TO: ~ ~ Manufacturer Material No. of compartments ~ ~ Liq. capacltv ]n gallons Inside length Width Liquid depth ~ IF HOMEMADe: , ~ Well Dwelling PERMIT NO. ~Z DISTANCE TO: O z ~ Manufacturer Material Liquid capacity ]n gallons ~ DISTANOETO:7 Well /~ , Foundation ~7' Nearest]°tlin°/7 ~ PERMITNO, -- No. of lines Length of each ~ ~ ~ Top of tile to finish grade ~ / Material beneath tile Total effective absorption area O Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Wel] Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO, ~ DISTANCE TO: Bui]dlng foundation Sewer line Septic tank Absorption area(s} OTHER PIPE MATERIALS REMARKS APPROVED , 72-0~3 (Rev. 3/78) [:,EF'FID. TI'~ENT OF HEFILTH ~ f~[ ENVIRE~NHENTF:IL PRO'TECTI:N ....... '"L. '" ._, ! F. Er=T., FINCH 3F4'FIGE, FII-::: 2(5,fl.--.4'/ZID : FINCHO[;:FIGE a:~, ~_L.:.! : ERGL.E RIVER FFL]_.ItNF. Ef~:E:"r' E:RO[,.ihi FHUFIE. FIE:'E:'~:ESS: Si:;:2' [:: -.I IU .: .I. HI .... t:1i'( :,.:'"'-'¢"- ~ ,:,, ,' ," , - - ~ .,:~ ~L, BLOCK: iD LOT: LEGRL DESC:RIF'TZON ..... ;I..JE[ ik t:i.JN: ,tH, t~b, LOT SIZE 0 S6L FT. TOHNSHZF': -- RI:I['~GE: ~. SECTION: -.. i'lFli,':;lf'lLl['l f-~L.If'IE:ED: IEIF E,E[F.UUII:, = O .:lOlL ~[IFlt~ = 8 ~D E~ (SCL FT. ,.'"E:~:.:, LI_,TE[ E, EL_H I:::I[;:E THE '' -,-c : p, IlL I~:,LE TO '¢OU iN [:'ESZGNZNG SEPTIC -,~_,TEfl. 2HOO'~;E THE OF'TZON ]"HFiT BI .... FiTS Z L.,iR~ iF ~ THFIT: i. I Ftl"l FRI"IILZFiR HITH THE REZCCJZF4tEHEI'.4]-S FOR ON-SiTE _,EHER_,:- - :' RN[:, I.,-IELL.'5 RS_El FOR?H E:'-r' THE I'tLINIC;IF'FIL:[T'¢ F~F_ I.-I[J~.]Hi['HjF.- - FIf'4[;' THE STF!TE OF tlLH:,i...H.: 2. I 14ILL ZNSTFIL_L THE :~'.::]EII iN FiC;CORDF!KICE I.,.li-rH THE C:ODES RND Hff,/E F:ECEI'¢ED FI C;OP'¢ OF THE C:CI[)E SLII,II,'IFi~:'¢ I:1~.~[:, DIFIGF:FiI',I RTTFIC:Hh'IENTS HHICH IS PRRT OF IH_:,' F'ERI"IZ T. 2. I UN[:,ERSTFff.4D THFIT THE Ohl.-SZ-FE _,EI. IE~. S'¢STEH P'lff.r' F;E6!I_IIF'.E ~NLFIFb]EP'IENT IF' THE F:ESI[:,ENCE IS REI"IO[;,ELED TO INCLUDE P1ORE THFIN C~ PERI'lIT FI L.I... hiT HFiS THE REz, FuN:,ZE, ILtT~ TO INFORM F ER_Lf~KIEL DIJF;I[.4I] THE INSTRLLFITZOI'.4 INSF'EC:TiON':;_ ._ OF RN'.r' HELLS R[:,..)'RC:ENT TO THIS F~_FEFT~' '--'-,' " FIN[:, THE NLI[IEER OF F'.ESZ[:,EI'.,IZ:E'E TI. IRT THE HELL HILl .... ER E.. IF R LIFT STFITZCN l.:, INSTRLLEI::,., FIN EI_ECTRZC:IaL PE~:I'"t'IT FiND ZNSF'EC:TZCH~4 IIIJ:] BE OBTFIZNE[:,. FI_, E, UZL.[_, C:FINNOT F3E HFF~_ E_ F.I]:THC~LI-F FIN ELE_TF. ILHL .[N_,FbL. TIuhl REPO~:T. THE EL. EiTP'Ii:FIL HORI.(,I"IUST E,E DONE D'.? FI L]:C:ENSE[:, ~ i L3NEE:, FIPF'L t C:RNT ?_=,LIED E~'F' ' r':.~. 'r E:R CIHI'-,t [:'FITE MUNICIPALITY OF ANCHORAGE Department/ ~ Health and Environmenta? ~rotection p~~/ ~. ~' · 825 ~ Street, Anchorage, AK. L~501 264-4720 ~c/) * * * HANDWRITTEN PERMIT * * * Permit ~J[~,7 ~---~ ON-SITE SEWER PERMIT ! Location: Phone Number: C~ Legal Description: ~ ~ ~-~ ~jA~7%. Lot Size: Type of Soil Absorption System Is: Trench: Drainfield: Seepage Bed: %// Holding Tank: Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is: DEPTH ~,' LENGTH ,~ . GRAVEL DEPTH ~-~ WIDTH The length dimension is the length(in feet) of the tre~ch~r drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). · ~ REQUIRED SEPTIC(HO')~NG) TANK SIZE = /~O~ GALLONS Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of' residences that the well will serve. · * * TWO(2) INSPECTIONS ARE REQUIRED * ~ ~ Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Min-imum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is, 2'5 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days Of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 3L 1 9 I certify that: (!) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that 3 bedrooms. Signe~: ~ ,.,~ Issued by: an Date: '~'lr, the event that a lift station is installed an swP/o24 !electrical permit and /nspec'ti6n must be ~ brained. As-builts cannot be approved i ~ the electrical inspection is received in ~t~is ~,ffice, The electrical work must be per- formed by a licensed electrician," MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST XSOILS LOG [] PERCOLATION TEST LEGAL DESCRIPTION: 4 5 6 7 8 9 10--- 11 13- 14- 15- 16- 17- 18- 19- 20- DATE PER FORMED: ~--~.~ SLOPE IND' ATER/ r7 SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop Ho, 1457-~- PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN ~ FT AND COMMENTS /~0/~/ ''~c3/Z//~''~' /;~'Z ~'- / ~ ~'~ ~ PERFORMED BY: ~ ~ ~ f~,t~J~l~ CERTIFIED i FT CHUGJGK, ALASKA 688-3199 I, I DRILLING Co. WE SERVE ALL ALASKA POST OFFICE BOX 42 - CHUGIAK, ALASKA 99567 KODIAK, ALASKA 486~1826 OWNER OF LAND .....S.p.enaa..~ill ................................................... DEPTH OF WELL ......~....F.~ ............................................................... ADDRESS ....... ~-...a,...,Bo:4...~O..~a ....................................................... ~ STATIC LEVEL OF WATER FT...l.Q.O...E.%~...in..h.ale. .................... WELL - SITE :....~.e:~e.~..~...C,,~.e.ek.=-.W.a~..'L~e....Su~ ......................... DRAW DOWN FT...~-S.'~......~..~ .............................................................. DATE - STARTED ...................................................................................... GALS. PER HR .......Z1.Q.Q ................. .(3.5...G~ls...p_~r...gin.,.). ...... DATE - ENDED .....2..-.1.7..-..~..9 .................................................................. KIND OF CASING .....i..~....~.i~..~.~....8.~. ............................................. KIND OF FORMATION: FROM .....D. .............. FT. TO ......3.Q ........... FT..~.a~...~...~r'~.v.~l FROM ......~: ............ FT. TO .----~6 ...........FT..I~a.z, et~)etl~ .............. FROM .....8.~. ........... FT. TO ......~.O ........... FT~U.]~Cl~. ................. FROM ......91 ............ FT. TO ......915 ........... FT..ELazcl~p~u .............. FROM "'"9~' ........... FT. TO ......9~) ........... FT. -~.%~e~ .............. FROM .....1.0.0 .........FT. TO .....ll~ ........ FT..Ita.r.d;pan..~;...~.and FROM .....1.'[.9 ......... FT. TO .....12.6 ........ FT..]~D.~dP~E' ............... FROM -...~.2.~. .........FT. TO ..-...~..~--5 ........ FT..H,a,F~oa, l~ .............. FROM .....1..315 ......... FT. TO ......L151~. ........ FT..HarriDan .............. FROM ....1.6.9 ......... FT. TO .....1.~.1 ......... FT..~O.~. .............. FROM .....L7.2 ......... FT. TO .....£.7-5 ........FT..E~r~...&..~dpan FROM '"-%"76 ......... FT. TO -....4-~-~ ........FT. -~8,.llel ....................... MISCL. INFORMATION: FROM ...1 ~. ........... FT. TO ...:I...9.0 ............ FT. $~[~...£~...G.r~v..e 1 FROM ...1.9~ ............ FT. TO ...ZQ~ .............FT.$.ar~d...~W.~.%er... ( Bad ) FROM ...ZQ.6 ............ ET. TO ...22.9 ............. FT.$.and...Gr. aw..el.. FROM ...2,.~.0 ............ FT. TO ...2..~1~1 ............. FT.~la~ ...................... FROM ...~.~. ............ FT. TO ....~..~.~ ............. FT.G..~.~.Y..~.~.....~..~..~..~.~ FROM ....................... FT. TO ........................ FT ................................. FROM ....................... FT. TO ........................ FT ................................. FROM ....................... FT. TO ........................ FT ................................. FROM ....................... FT.<~O .~.~ .................... FT ................................. FROM ........ FROM ........ .................. FT .................................. FROM ......... ..[I~........~T. '~..~ ................... FT ................................. rtl ~ g~o DRILLER'S NAM ...'.~ .%,.~¥, , :~ ~ ................................................' MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES · :343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) (b) Location (address'0~'d'irectio~s)'']? . . ,i .'"". ~roportyo net Mailing Address.· '~¢ -~' (c) ConOin~ Institution' ' MaiHn~ Address ' Telephone: (home) Business (d) Real Estate Company and Agent Address Telephone Mail the HAA to the following address: (or check here'~ if hold for pick up.) List contact person and day phone number below: (e) 2. TYPE OF RESIDENCE Single-Family'j~[ ( Number of bedrooms 3. WATER SUPPLY Individual Weli'l~. /' 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~r, '/' Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 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 th is 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 "~--~'~' Telephone Address Date D..s APPROVA' Approved '~-Disapproved Conditional Terms of Conditional Approval 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 ssued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72~025 (Rev. 7/88) 8ack Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) MU~0F ^NCHO~,,Ic.'~CKLIST - FEBRUARY 1984 ~NVit~ONMEN'rAL SERVICES DIVISION 343-4744 Legal Description: /-'/ JUL 2 6 1989 A. WELL DATA RECEIVED Well Classification Well Log Presenti~N) Date Conlpleted Z---/?--?~' /''' Total Depth Z--'~/ Cased to ~---~! Depth of Grouting /d/,,~- Static Water Level / ~'~,,5"" '"' Pump Set At /J/~ Casing Height Above Ground ~ ""/ Sanitary Seal on Casingi~_.~N) Electrical Wiring in Conduitl~N) Depression Around Wellhead (Y~ SEPARATION DISTANCES FROM WELL: / To Septic/Holding Tank on Lot /O,~-.-- ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot //~'/ f ; On Adjoining Lots To NeareSt Public Sewer Line ,,4J//~- To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ~--.5'/~ ~'' Water Sample Collected by ,~-~'4%~ /~. ~J/£,~/' Water Sample Test Results ~'''tz~-'~ ~ r'~/~ Comments ~J~'z~. ~-z~,.J -2-~¥?- ~--~/-~?. ~/ ~ ~"~ If A, B, C, D.E.C. Approved (Y/N) .~/"~ Yield &,.z- ~,,~/'d / B. SEPTIC/HOLDING TANK D~TA Date Installed ~/'/-~"~ Size Standpipes CN) Depression over Tank (Y~_~ Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) Air-tight Caps~N) j No. of Compartments ~ Foundation Cleanoul(~N) Date Last Pumped '~'J/"f' /-J/~ ;for ,~)/~ Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: Tq Water-Supply Well To Property Line To Water Main/Servide Line To Stream, Pond, Lake or Major Drainage Course Comments '~* To Building Foundation /¢' To Disposal Field ~' 72-026 (Rev. 7/88) Front Page 1 of 2 seu!leP!n8 ¥¥H pue VOIAI lie o1 peLuJOJ. UO0 JO 'peu!Je^ 'peHoeqo e^eq I )Bql Xt!:Heo I .~ls@nbel:l VVH tsuleBV 6u!t~W LUOOJpe8 pell!LuJed ~toaqo.. ~BJuewwo0 lSe.L ,~oenbaPV 6ulJnp seioXO 8u!d~nd ~ 1~ Io^o9 .tt0 dUmd,, (N/A) sseooV/eloq U~lAI suo!sueuJ!a NOIJ.¥J.S J.-II1 ~ .~/i~, (lueseJd ~!) >Joeqlno o/ ..~...~ ~/ s)O'l 6u!ulo[pv uo '. uo uJ~)e,~$ peuopueqv ~o 6uli~!x:a oI au!-I A1Jedo.~d oJ. ~ , ~'dZ ple!-I to qlP!M /..~.-¢¢. ei~J1S uo!ld~osqv u! 6u!leW si!os ¥.LYa a'l~ll:i NOI.LclEIOSEI¥ 'O CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.:~ TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER PUBLIC WATER SYSTEM I.D.# '"~PRIVATE WATER SYSTEM Phone NO. Mailing Address City State Zip Code Mo. Day Year SAMPLE TYPE: "~Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose .) .D. Treated Water Untreated Water SAMPLE Time Collected NO. LOCATION ,~.. Collected B j 41 'TO BE (~OMPLETED BY LABORATORY saSiS shows this Water SAMPLE to be: tisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate re~iable results. Please send new sample via special delivery mail. Date Received Time Received Analytiq? Method: · 7-- Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* 6426 ' J I I Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD BEFORE COLLECTING SAMPLE READ INSTRUCTIONS Membrane Filter, Direct Count ~) Verification: LTB BGB Final Membrane Filter Results Reported By .__.~-~ Date Time: TNTC = Too Numberous To Count OB = Other Bacteria ~ CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ,~~'k 5633BSTREET ANCHORAGE, ALASKA99518 TELEPHONE(007) 562-2343 FEDERAL TAX ID # 92-0040440 ANALTSiS HEPORT tT SAMPLE £o~ Hark O~de~ ~ 15027 Date Repo~t Printed: JUL 20 89 8 19:01 Client Sample ID:L1 BiB UHALEY PWSID :UA Collected JUL 19 89 8 08:15 Received 3UL 19 89 @ 12:30 Pzese~ved wi~h :AS REQUIRED Anal~s~ Completed ;JUL 19 89 Laboratory Supezvisez :STEPHEN C. EDE / Client Name : A E C S Client Acct: ARECSRP P,O.~ HOHE REC'D Req ~ O~d~zed By Send Reports l)A E C $ Special Chemlab Re£ ~: 6426 Lab Smpl ID; I ~at~ix: WATER Allowable Pa~arnetez Tested ~esult/Unit8 Method Li~4ts NITRATE-N 2.0 m~/1 EPA 353,~ 10 Sample ROUTINE SAI~PLE Relon[k~: SAMPLE COLLECTED BY A. WIEN. 1 Tests PeY£oz~ned ' See Special Instzuctione Above UA~HnaYaiiable ND= None Detected "Sea Salnple Remzks Above NA~ Not Analyzed LT~Lese ~han, GY-G~eater Than ', ~ MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date /~/~ (a) Legal Description (include lot~ block, subdiv±$ion, section, township, rar~e) Location (address or directions) (b) Applicants Name ~/~'3/ 4~,~-4-/ Telephone - Home Business (c) (d) Applicants Address ~ Applicant is (check one) Lending Institution Buyer~; Other~_~(explain); ~ ; Owner/builder Lending Institution X~I~c/d~ M.f/~ f-~Z~L'-,~A/- C, ~7. Telephone Address /~z~/-/ ~ ~/_~ A/r/'~zv'~/z~4 ~ ~ ~4/<. ~ ~j-~t. (e) Real Estate Co. & Agent Address (f) Telephone Mail the HAA to the follow, n§ address: e o Type of Residence Single-FamilyV--~ Number of Bedrooms Multi-Family~--~ Othe~ (describe) Water Supply,- Individual Well ~ Community ~ Public ~-~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Sewage Disposal 0usite~ Public~-~ -Community~--~ Holding Tank~--~ Note: If community well system, must bare written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. En~ineerin~ 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 regula- tions in effect on the date of this inspection. Name of Firm Address 3/3 (ENGINEER SEAL) DHEP Approval Approved bedrooms Approved ~ Disapproved __ Terms of Conditional Approval Coadit CAUTION T~E MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DEEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN p~a_RAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER 'REGISTERED IN THE STATE OF ALASKA. THE DHEF DOES THIS AS A COURTESY TO pURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN.FEDERAL AND STATE REQUIRE- HEN*TS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 A. ~ELL DATA Be MUNICIPALITY OF ANCHOPAGE (MOA) ~ALTH AUTHORITY APPROVAL (HAA) MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTIO~J CHECKLIST - FEBRUARY 1984 Well Classification Well Log Present (Y/N) Total Depth 2~/~ Cased to Static Ware= ~e~t /70 ' Casing F~i~ht Abo~ Ground Elect=ical Wiring in Conduit (Y/N) SeDa~ation Distances f=cm Well.· To Septic/Holding Tank c~ Lot To Nea=est Edge of Absc~ption Field on Lot To Nearest Public Se%~r Line 2~/~-r DeDth of Grouting /~/~ Pump Set At ~O~ Sanitary Seal on C~sing (Y_/N) %// Depression kscund Wellhead (y/N)/~/ ; On ~k~joiningLots ~/~ ; On AdjoiningLots To Nearest Public Se~r Cleancut/Manhole /~//~ To Nearest Se~= Se=vice Line on Lot __~0 / Ware= Sample Test B~sults ~2~j~/--~/ ? ~e 4~c//dp /t~m~-~ ' S~IC~ ~ ~A Date Installed /z~/~-? Size /~O~ ~L- No. cf C~ar~nts Standpipes (Y/N) >/ Air-tight Caps (Y/N) ~/ Foundation Cleanout (Y/N) Depression overt Tank' (Y/N) .4/' Date Last Pumped Pumpi~/Maintenan~ Contract on File (Y~)~/ ; for Holding Ta~k High-Ware= Alarm (Y/N) //~ Temporary Holding Tank Permit (Y/N) Separation Distance-~ ~rcm SeDtic/Hold~ng Tank: To Water-Supply Well /~ / To Building Foundation 3~ / TO Property Line To Water Main/Se~vic~ Line Course Corm~nts To Disposal Field d' ~ To Stl. e~u, Pond, Lake, c~ Major Dr_ainage [Page 1 of 2] 2-15-84 Soils Rating in Absorption St=ara /JO rW.f~.~. Type of System Design~¢~4~/~ Date Installed /z~/~_~ Length of Field 36 ~ Width of Field 7_6) ' Depth of Field 2 / Gravel Bed Thickness Square Feet of Absorption A=ea ~ ~¢, ~ Standpipes P~esent (Y/N) Dep=ession ove= Field (Y/N) /f/ Date of Last Adequacy Test .sul s of ast a quacy Test Separation Distance f~ Ab~czPtion Field: To Water-Supply Well /~ / To P=o~erty Line /7 / To Building Foundation 47 / To Existing c~ Abandoned System cn Lot /f/~ ; On Adjoining Lots m~-~ 3~ / To Wate~ Main/Service Line ~J-' To Cutbank(if present) To St~eam/Pond/Lake/c~ Majo= Drainage Course To D~iveway, Pa~king A=ea, c= Vehicle sro=age A=ea O~-d~ / De Date Installed Size in Gallons "Pure9 On" Level at High Water Alarm Level at Tested fo= Electrical Codes(Y/N) Ccm~ents Dimensions Manhole/a ss (Y/N) "PUn~ Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. ~eets ~DA ** Check Permitted Bedroom Ratin~ A~ains~ FAA ~quest ** certify that I have checked, ~rified, c= confcF~ed to all MOA HAA Guidelines in effec~ on the date of this ine~ection. KB1/d5/s [Page 2 of 2] 2-15-84 HEMICAL & G OLOGICAL LABORATORIES 0 ',ALASKA, INC. '~ELEPHONE (907) 662-2343 ANCHORAGE INDUSTRIAL CENTER 5633 B Street Drinking Wa{er Analysis Report for Total C°liforml Bacteria TO BE COMPLETED B~' WATER SUPPLIER WATER SYSTEM: water S~m ~m~ Mailing Address SAMPLE DATE: ~ ~, Mo. (*) See h on back I.D. NO. gg-27qo Zip Ca<Je SAMPLE TYPE: ~ r-i Routine i [] Check Sample (for routine sampl~ with lab ref. no. ) [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. LOCATION 2 IA/o` &- Time Collected Collected By TO BE COMPLET'ED BY LABORATORY Anal¥~sis shows this Water SAMPLE to be: ~]/S a ti s"f actory [] Unsatisfactory r"l sar~ple too long in transit;'sample should not be over 30 hours old at examination to indicate reliable results. Please send ne sar~ple via special delivery mail Tim~: Received Anal~, tlcal Method: M ermentatlon Tube ernbrane Filter Lal~ Ref. No. Analyst Result* READ INSTRUCTIONS BEFORE COLLECTING SAMPLE ,06-122S ~) BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filtec Direct Count Verification: LTB Final Membrane Filter Results 'Reporled By ~~~ Date '~ Time: · TNTC = Too Numerous To Count BGB Coilformll00ml Collformll00ml It~'-~l.. Y l '~t I' ~1~ I A I I. I [ ~ ~r~ X~ ~1 I ' I ~reby ce~i~ that I ]An~ra~ R~di~ Di~i~, Alaska, / lin qu~tion e~ th~ t~e are ~ road~YS, ~ansmi~ion lin~ or oth~ vls~ble ~sements on Revisions: ka h ]Oat~ et Angora, Ales t ~ ~ ~ ay ~BARNARD ENGINEERING