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Home My WebLink AboutZODIAK MANOR ALASKA BLK 5 LT 7 MUNICIPALITY OF ANCHORAGE o� Development Services Department cq p p =�- }� Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 015-012-10 Certificate of On -Site Systems Approval L Expiration Date: > Z Z Z 3 Legal description ZODIAK MANOR ALASKA BLK Site address 8621 Pluto Dr Anchorage Current property owner(s) James and Martha Galvin 5 LT 7 X The On-site system(s) is/are approved for 4 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: r By Original Certificate Date: 2/22/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approvaljune 2022 PUIUHJC JP„UTYOoF Development Services Department On -Site Water & Wastewater Section Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I. D. 015-012-10 Complete legal description ZODIAK MANOR ALASKA BLOCK 5, LOT 7 Location (site address) 8621 PLUTO DRIVE, ANCHORAGE, AK 99507 Current property owner(s) JAMES & MARTHA GALVIN Day phone 2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS 3. TYPE OF WATER SUPPLY: ® Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ® Community Septic or Public Sewer 5. SEPTIC TANK: ❑ Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age NA - See advisory if steel older than 20 years 6. ABSORPTION FIELD: n AWWTS f l Bed n Deer) Trench n Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ ?'0 S C N l-�F_Distance: / l s i By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ a go Date of Payment o2 f q 2 2�Qa3 COSA # `� C a 3 /Ua-� Waiver Fee $ Date of Payment Waiver # COSA Application.doc 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / FirstWaterAK@gmail.com February 17, 2023 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: ZODIAK MANOR ALASKA B5, L7 – WELL TO SEWER MAIN & MANHOLE Per the attached as-built survey by Kenneth G. Lang dated February 8, 2023, documents provided by AWWU and MOA On-Site record documents as well as the recent approximate location of the private sewer line by One Stop Services– we have generated a sketch of the water and wastewater systems serving this property. Based on this information, we are therefore requesting a retroactive waiver of 45’ to the existing sewer mainline and manhole between the referenced well be granted at this time. Granting of this waiver is justified in the fact that the well is physically located up gradient of the sewer line with no potential surface effluent interaction possible or reaching the well head. The recent attached CAN water samples show no bacteria and nitrates were analyzed at 1.67 mg/L that indicates the subject encroachment has not adversely impacted the water quality for approximately 50 years. It appears the existing well was drilled in the early 1970s prior to the sewer main being installed and there were no separation distance requirements between a private well and private sewer service line at that time. AWWU said they could not find any waivers of this install, which may have been lost by GAAB and it also appears this property was previously approved. Per record documents, it appears the subject sewer mainline, and manhole were watertight constructed. Also, per MOA records, previous approvals, inspection reports, COSAs/HAAs and waivers have been issued and that numerous well logs show that the aquifer is protected via geological confining soil layers. There have been no known issues or influence over the past several decades from these encroachments. Cleaning up and granting of these waivers will not impact any of the neighboring properties. Please contact us if you have any questions. Respectfully, Curtis Huffman, P.E. Attachments: As-Built Survey & Sketch p�cnt Municipality of Anchorage P.O. Box 196650 e 4700 Elmore Road Anchorage. Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997 http://www.muni.org/Onsite Development Services Division On -Site Water and Wastewater Program * * * * VARIANCE/WAIVER REVIEW * * * * Waiver#: OSV231006 PID#: 015-012-10 Permit#: OSC231027 Legal Description: Zodiak Manor Alaska Block 5 Lot 7 Engineer: Curtis Huffman, PE Applicant: Curtis Huffman, PE Your request for a waiver of the required 75' horizontal separation from the water well to the sewer main has been approved. The approved separation distance is 45'. In addition, your request for a waiver of the required 100' separation from the water well to sewer manhole has been approved. The approved separation distance is 45'. This waiver approval applies to the water well only. Any future upgrade to the on-site water system will require all separation distances be met or another approval from this department ❑The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. ❑ Notarized letter(s) of nonobjection have been received from the owner(s) of the affected adjacent property. ® Adjacent properties are not affected by this waiver. Waiver is Granted: X Waiver is not Gran ed: ._ Date: Z 2 3&OZ3 Approved by: Name of Reviewer **** VARIANCE/WAIVER REVIEW **** COSA Checklist WELL ONLY.docx COSA Checklist Legal Description: ZODIAK MANOR ALASKA BLOCK 5, LOT 7 Parcel ID: 015-012-10 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____ A. WELL DATA Well log is filed with Onsite (or attached) Date drilled CIRCA 1971 Total depth *173 ft Cased to UNKNOWN ASSUMED 40’+ ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 2/2/2023 Static water level at beginning of test 97 ft. Well production at time of test 3.16 gpm Water storage tank volume NA gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate 1.67 mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date 2/2/2023 Comments *Per GAAB form in MOA file. B. TANK DATA – PUBLIC SEWER Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA - PUBLIC SEWER Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist WELL ONLY.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100’ Yes if No NA ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No NA ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No *45 ft Community Sewer Manhole/Cleanout > 100’ Yes if No *45 ft Private Sewer/Septic Line > 25’ Yes if No **5+/- ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS *Waiver requested and assumed per AWWU and MOA documents. Separations at sewer install appears to only have required 50’ to sewer main and manhole to private well. See attached letter. **No separation stated for private sewer line and private well at time of construction and appears to have met existing code. G. CERTIFICATION & 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 Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 2/9/2023 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 2/17/2023 NOTE: DUE TO SNOW & ICE COVER, SOME SURFACE LEVEL FEATURES ARE APPROXIMATE. PLOT PLAN --- AS BUILT —X_ SCALE _1" =_30__ GRID _ SW 2336__ Project No. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, in c . (907) 522-6476 Phone `"� kenOlongsurvey.com �S �� Professional Land Surveyors jonothanOlongsurvey.com �OFA�q\ll trovisOlongsurvey.com �e'�,• ,SL�, I hereby certify that I have surveyed the following described property: LOT 7, BLOCK 5, ZODIAK MANOR ALASKA SUBDIVISION (PLAT No. 65-92) Anchorage Recording District, Alaska, and that the Improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the __g—__— Da __ �r ��e _ y of __, s"'-__, at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. 49TH *r KENNETH G. LANG f acs •, o 5202 .•� % ,1 1F9F0• ¢�St=,s� . •DS�1Qi ih�'y�FFSS IONA� �a�s State of Alaska AECC963 13030 Sues Way, Anchorage, AK 99516 907-350-9566 / FirstWaterAK@gmail.com February 22, 2023 Municipalities of Anchorage On-Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 RE: ZODIAK MANOR AK B5, L7 – ADDITIONAL OWNER INFORMATION FOR MOA FILE We recently received the attached information from the property owner and although it does not affect the COSA issuance, we are forwarding it to the MOA to add it to the referenced file. Per the attached Walataka as-built survey and owner there appears to be a sewer cleanout in the driveway. One Stop Services had interference from the house, existing well and other improvements in this area and it appears in these wintertime conditions that most likely the private sewer service line goes to this cleanout and then to the sewer connection. We have therefore adjusted this area on the attached sketch showing this service line accordingly. Also per the owner, there was a fire in 1981 and that the structure was torn down to the studs and was rebuilt with the garage added on and that AWWU sewer hookup occurred in the late 1970s before the fire. The owner also stated that the sewer line likely runs under the garage and back deck to the cleanout into the house as we visualized, and One Stop Services located per the previous submitted letter and sketch. Please contact us if you have any questions. Respectfully, Curtis Huffman, P.E. Attachments: Walatka Survey Modified As-Built Survey & Sketch FIRST WATER CONSULTING ZODIAK MANOR ALASKA B5, L7 NOTE: WITH WALATAK CO: ScGl-�_ r"=3o" dr;ve'A.,o7 ov�r�Ga \ \ ME U Z_ \ C_ S G .r' S 1 VA 3 Q° a X65•° AL1 CLF v -,-,;n I° pF NGT E: This As-bui't shall not be used for any purpose ct,icr than financing requ i rem3flts. Unds r no c i rcumstance� � should any data hareon he used for Recerl#'�d 5-6-96 e w construction or for estahlistring boundary or fence lines. AS -BUILT NO CORNERS SET THIS DATE F cfi c, Fac.. `•- - - �,! t�V 'UF�ssi�rs EASEMENTS OF RECORD, OTHER THAN C, �( THOSE SHOWN ON THE RECORDER Ig BZ-�� PLAT ARE NOT SHOWN HEREON. FW I hereby certify that I have performed a L o �a ee's in- spection of the following described roperty: I�1a.,ar, k.__ - Ld. Anchorage Recording Precinct, Alaska, and that the improve- ments situated thereon are 'within the property lines and do not overlap or encroach on the property lying dc adjacent thereto there- to, that no improvements on property lying adjacent encroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Anchorage, Alas a 8 Z -L'5 4', dayo r� _ �19 this FRED WALATKA & ASSOCIATES Engineers and Surveyors _ SEE OTHER MOA ON-SITE DOCUMENTS. SPECIFICALLY THE ADJACENT PROPERTY -ZODIAK MANOR ALASKA LOT 8, BLOCK 5 THAT HAS AREA WELL LOGS, AWWU DATA, MOA WAIVER SUBMITTAL & MOA APPROVAL, ETC.... G' ~,'fER ANCHORAGE AREA BORO' H D~-I)ARTUENT OF ENVIRONMEN'F^L QUAI..~ f 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM ' "~ MAILING SEPTIC TANK: DISTANCE FROM WELL}~LQ_!- LIQUID CAPACI[Y / ~ NUMBER OF O l~?~':ql~l' .._MATERIAL ~. (~.L*(~'~i":(..G (OMPARTMENTS GALl. OldS. INSIDE lENGTH ~__ INSIDE WIDTH LIQUID DEPTH. SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PLIS ] OUTSIDE DIAMETER _ _ OR WIDTH ~r(~ ! , LENGIH_~--z- '') I t . DEPTH__ LINING MA1ERIAL~E ~ ...... DISIANCE FROM WELLJ~(>( [t~3~ )~__ , , BUILDING FOUNDA[ION. NEARES[ LOT LINE'~I t~_ ~ _. TOTAL EFFECIIVE ABSORP[ION AREA (WALL AR~q~"'"__~_ ~ SQ. FL TILE DRAIN FIELD: DISTANCE FROM WELL ,( /~2TRENcH wIDTH OF FILTER MAfER{AI BENEATH TILE ~ DISIANCE FRONt BUILDING FOUNDATION TANK , SY STE_':'!Z; DIAGRAM OF SYSTEM :OUNDATION NUMBER OF L~.i~E~.$~ . DISTANCE g~l / ABSORPTI~'q AREA .... ! SQ. FT DEPTH: TOP OF TIlE TO FINISH GR ' ~ WELL: 1 yp E,~.', G'L NEAREST LOT LINE , SEWER DISTANCES: IOTAL LENGTH , OF LINES ...~, _ IN. T/O~' L~FFECTIVE IN. ABOVE TILE WATER SAMPLE ., NEAREST OTHER CESSPOOL , SOURCES GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OP' ENVIRONMI'"NTAL QUALITY 3500 TUDOR ROAD POUCH 6-650 ANCHORAGE, ALASKA 99502 TELEPHONE 279-8686 SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT NAME OF APPLICANT ~'*'~//'~ ~'~/'~/~'"~ MAILING ADDRESS ~/ ~//// ~PFIONE ~/~ INSTALLATION LOCATION --/~ ~ ~/ ~ LEGAL DESCRIPTION .~D~ ~/, ~;/ ~ ~'~///~ ~/~/2~/ INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH SOIL TEST RESULTS OOMPLET'ON DATe ANTIC'PATE SEEPAGE Pit DRAIN FIELD OTHER TO BE INSTALLED 13Y NOTEs THIB PERMIT lB NOT VALID WITHOUT ~OIL TEST FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY BYSTEM WITHOUT FINAL INSPECTION BY THE HEALTH DEPARTMENT AUTHORrrY WILL BE SUBJECT TO pROSECUTION, SEPTIC TANK SIZE ./~2J~ MINIMUM DISTANCEB, REQUIREMENTB FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT ~ SEPTIC TANK J~'~/ ., SEEPAGE PIT J~-'~'~) / ., DRAIN FIELD TO NEAREST LOT LINE, · SEEPAGE PiT /~;*~ ALSO CONSIDER AREA WELLS. SEEPAGE PIT ~/~/~ / GRAVEL. BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. HEALTH AUTHORITY OR LICENSED DESIGNER SEEPAGE AREA SIZE/'~/~/~-'~'~ - TYPE DIAGRAM OF SYBTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE A~EA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SA[D CODE, DATE :~>~:/ APPLIOANT'S SIGNATURE ~(~'~,~ ~ n ' ~EflT OF E~i"IRr'~''~r* .... q:iA~ DE, A, ' .... 3500 TUDOR ROAD ANCItORAGE, ALASKA 99502 CASE Performed For George B. Collins Date Performed 9/21/71 Legal Description: Lot 7 Block 5 Subdivision Zodiac Mano~ This Form Reports Soils Log Depth Feet Soil Characteristics Brown silty sand (SM) Gray sand (SW) Gray silty sand (SM) Gray fine sand (SP) Was Ground Water Encountered?__~o___ If Yes, At What Depth? Reading Date Gross Time Proposed InstaTT~a~n: Depth Of Inlet COMMENTS: Net Time ; Depth to H20 I Seepage Pit x Drain Field Depth To Bottom Of Pit .. 16~.square feet of drainage area is required per bedroom. Net Dro~ ' --O-~-{-~--'~e--~-~(-F-~-y--..~iB~al '±'e'~-x~-Services, Ins Date: '2. GF~ ..,TER ANCHORAGE AREA BOROUGi DEPARTMENT OF ENVIRONMENTAL QUALITY 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 DATE RECEIVED:.~V~J//TA TIME'. / '~'~P. REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES FOR APPROVAL REQUESTED BY: ~m~[ ~/~ ADDRESS:_ d~/ /3~ PHONE:. PROPERTY LEGAL DESCRIPTION:, TYPE FACILITY TO BE NUMBER OF BEDROOMS: WELL DATA: A. TYPE '~-- DEPTH C. ~IZE D. E. CONSTRUCI'ION ~/~//~{A'~e;~ BACTERIAL ANALYSIS 6. SEWAGE DISPOSAL SYSTEM: SEPTIC TANK (IF HOMEMADE, SHOW DIAGRAM ON 1. SIZE 12..J'O AGE, 1 71 3. MANUFACTURER ~-~__~,~ BACK) 4. INSTALLER · FOR SEWER & WATER FACILI', ~S APPROVAL RFQUE PAGE TWO B. SEEPAGE PIT 1. SIZE_~/ 2. LINING /~ C. DISPOSAL F~I~D 1, NUMBER'O~NES 2. TOTAL LENGTR~ 7. REQUIRED ~EASUREMENTS C WELL TO D WELL TO E WELL TO F G N A ! II ' WELL TO SEPTIC TANK WELL TO SEEPAGE PIT SEWER LINE PROPERTY LINE OTHER POSSIBLE CONTAMINATION FOUNDATION TO SEPTIC TANK· FOUNDATION TO SEEPAGE PIT SEEPAGE PIT TO PROPERTY LINE 8. COMMENTS: ( .: :/.> :y] ' APPROVAL VALID FOR ()NE YEAR FROM DATE SIGNED. GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALIT FEDERAL HOUSING AOI41NISTRATION Budget Bureau No, 63-R0296 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PARY I.--~¥O BE COMPLETIED BY FI4A INSUIJlNO OFFICE MORTGAGOR OR SPONSOR MORTGAGEE Hatantlska Valley [lank David Doyl~ SURDIVISION NAME ~ Public system PROPERTY ADDRESS ~'?1 PILIto 12r~w: T BASEMENT J [] New installation 1 Yes L~ No E~] Community system SERIAL NO. J BLOCK NO. LOT NO. ~ ,--7- Public system El Community system :~] Individual PAR'J' II.~.~TO BE COIgIPLEItED BY HEAL,tH DEPARTMENT HEALTH DEPARTMENE INSPEC'~OR'S SKETCH It is the opinion of the [] State [] County Local Department of Ilealth that this individual water-supply system [~] is [~ is not satisfactory asa domestic water supply for tile subject property. -X- It is the opinion of the [] State [] County [~ Local Department of Health that this individual sewage-disposal sys- tern with proper maintenance: ~Can be expected to function satisfactorily, and is not likely to create an insanitary condition, . - ~l~reh ~, 107lL~'°NAYuRE. >"' / El Cannot be expected to fimction satisfactorily --,~,,: .- !I. nvironmental ~pectalist provided. PART III0~FOR USE OF FHA C)FFICE ¥O ?HE ClliEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that the Individual water-supply system be considered ~] Acceptable ~-] Not Acceptable ~wage disposal be considered [] Acceptable [] Not Acceptable. HEALTH AUT.ORITY APPROVAL F.A Form 2573 INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM .o,, July J~S8 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM Septic Tank: Distance from well.__ Total liquid capacity, Inside length, Distance from: Well, Inside diameter, feet. Material gallons. Capacity inlet compartment, .feet. Inside widtfil feet. Liquid depth, leet. feet. Depth. SECONDARY TREATMENT consists of [] Tile disposal beld. Distance from: Well Total length of tile lines, Trench width Length of each line Type of filter material: [] Gravel. gallons. feet; nearest lot line at [] front1 [] side, [] rear.__ lc'et. Liquid capacity1 gallons. Lining materia[ [] Seepage pits. Other feet. Lining material feet; nearest lot line at [] lront. [] side, [] rear. [] Local Health Authority. Inspected by feet. square feet. inches. feet; Inundation. feet; nearest lot line at [] Iront, [] side. [] rear. feet. Number of lines Distance between lines, inches. Total effective absorption area in bottom of trenches, feet. Depth. top of tile to finish grade. [] Broken stone. Other Depth of filter material beneath tile,~ inches. Depth of filter material over tile, Number of pits . , Outside diameter, &-et. Depth, Distance from: Well, leer; building foundation. inches. REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main, feet. Size of main1__ inches. Individual wells [] art' [] are not customary in neighbgrhood. Give most recent record of failure of wells in immediate v~cimty to furnisb adequate supply of water Properties in neighborh~xod [] are [] are not being developed with both individual water-supply and sewage-disposal systems. Lot size: feet wide, .feet deep. Dwelling scl back from front property line, feet. Individual water supply from: [] Drilled well. [] Driven well. [] Dug well. [] Bored well. Distance of well from: Building fl)undation, cast iron sewer, feet; tile sewer. seepage pit, ~;zet; cesspool. Well construction: Diameter, inches. Total depth, Approximate depth to pumping level of water in well, Sealed watertight to depth of feet. feet; nearest lot line at [] front, [] side, [] rear, feet; septic tank, feet; disposal field, feet; other sources of possible pollution. .feet. Depth of casing gallons per minute. feet Type of easing,. feet. Approximate yield, 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. ~ump: [] Shallow well. [] Deep well. Length of drop pipe feet. Pump capacity, 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 bacteriological 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. [] Lex'al Health Authority. Inspected by Date of inspection 19 feet. gallons per minute. 19__ gpo 889.088 DATE D ARYMENI' OF HEAL¥H AND WFI*' DIVISION OF PUBLIC HEALTH BACTERIOLOGICAL WATER ANALYSIS REPORT RESULTS TO---- NAME ADDRESS CITY SAMPLE COLLECTED DATE COLLECTED °n'I Well- [] Dug [] Driven [] Drilled [~ Bored SOURCE: [~ Spring [~ Cislern [] Other Dug Well or Cistern Conslrudlon: Brick or Walls . [] Woad [] Concrele [] Melal [] Tile [] Concrete lop · [] Wood [] Con, role ~ Melal [] Open tap Lab. No. OFFICE [~ Of Well [] Olher-- PURPOSE OF EXAMINATION: Illness Suspecled? [] Yes [~ No Records in Ihls office indicate Ibis WATER SUPPLY to be of: Analysis shows Ihil Water SAMPLE lo be: [] Sot[dactory [~ Questionable [] Unsaf~sfaclory. Il an "Unsallslaclory' ar "Questionable" status Ji indicated above you should take immedJele action as recommeoded beJew. -- I. NoliJy consumers water is polluled. Boil or chemically treal Ih~s water as outlined in the enclosed lea~lel "Drink II Pure." 2. Increase chlorJnalJon sufficiently to meal recommended rosJdua~ standards. DelermJne source al contamlnollon and toke aclJon necessary to maJnlain a sale water supply al all I~me$. .3. Check chlori,~otian and other mechanical equipmenl. Make certain it is ~unct~oning properly. [] dr[lled well ~] cistern. SA NITARIAN'S RI:MARKS Signature RE__Ag I N STR~U CT~IO N..~S. ON REVERSE SIDE BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD Dale Received Laclose Broth 24 hours 4B hours Brllfianl Green 24 hours 48 hours EMB_ Lactose Broth, 24 hrs. Coliform Densily Time Received . 48 hrs om pm _ Lab. No. AGAR .(Most probable No. per 100cc j Absenl_ Present-