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HomeMy WebLinkAboutGOLDEN HILLS BLK 2 LT 1 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion?;;<HV No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. 015 122 33 GOLDEN HILLS 2 1 LAVALLEE MICHAEL P & DONNA J 10000 CURVI ST ANCHORAGE, AK 99507-7032 03 08 2023 115 FPS 7FR07P4-3W230 .75 14 MARTINSON PELLETS ANCHORAGE WELL & PUMP SERVICE 7640 KING STREET ANCHORAGE AK 99518 NAME MUNICIPALITY OF ANCI-IOI~RAGE DEPARTMENT OF I~EAI_TH &ENVIRONMENTA[ PROTECTION ENVIRONIVIENTAI_ ENGINEERING DIVISION 825 LStree~-Anchorage, Alaska 99501 Tdephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WEI..I.. INSPEOTION REPORT MAILING ADDRESS DESCRIPTION LOCATION Well q' Absorption are~ DISTANCE TO: L'd a / ~l~ / Manu[acturer~ ~ ] Liq. c~ DIS-FAN, Dwelling Material NO. OF BEDROOMS Liquid cl~j~t I1 IF ROMEMADE: I hlside length WMth I Dwe,,,,C/""~.L~ / --.~_~ ..... ~ ............. ,'~ _ ~..._~ .... No. of lines~ of ~ach lin~ Fotal leith of lines I 'P~ench ~Jt~ Distance bet~e~r~lines Top of tile to finish made$ ~' zT< ~3 7/ ~ ~)~ inches . Material beneath file , · Total ffective'abso~tion area Length Width Depth PERMIT Type of crib Qib diameter Crib depth Total effective absorption DISTANCE TO: Well Building foundation ~ea~:~s[ !~ [m~ Depth Ddllm I Dist~mce to lot line ~PERMI-F NO. DISTANCE TO: Building foundation ............. ~ ......... J~ Sewer line Septic tank IAbsorption area(s) Class OTHER PIPE MATERIALS 30 SOIL TEST RATING R EMAR KS DATE I_EGAL PER. MI T NO. APPL I CFINT L. OCFIT I ON L. EGFIL FOF.:EMOST ENTERFI,.I=,E=, STAR F.U_ITE Ft B,*'.,U ,=,.~-[ ..... _._ ..,-_,r 4L-¢ .__,±..~ CUR',/I STREE]" LOT 2L BLOCK 2 GOLDEN: HILLS: S,,'D LOT SIZE 5478.~ 'SE~JRRE F'EET l_ E i'413 T I-i.",-= T"/PE: OF SOIL aBff, OF. tPTIOH .L~¥.STEH IS: TRENOH ~,,,-,~,' = /I/Ed THE RE6~ ..... IRED SIZE OF THE '~FIIL aBSORPTION ;=,/_~M~' ~ '' I~: IC, EF"'TH= 2t.~_ 13RRk,~EL THE LENGTH DIMENSION IS THE LEHGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. 7'HE [:,EF'TH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFFICE OF THE GROUND aND THE BOTTOM OF THE ENCRk,'RTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE FIND THE BOTTOH OF THE ENCA'¢RTION (IN FEFT). F'ERMIT RPPLIC:RNT HR--, THE RE_,FON..,IBILIT"r' TO INFORM THIS DEPARTMENT DLIRING THE INSTALLATION '[NSPE]]TIONS OF F4N"r' WELLS BDJROENT TO THIS PROI='ERT¥ aND THE NLIME~ER OF F..Ez, IEENCE~ THaT 'THE WELL WILL SERVE. _..PI_:..T ][ C~t'-.t__E; RI~:E REL-::~U .T.F.:E [:, E:,~.,F..F"'~ ...... ILLING OF aN'v' S'¢STEM 14ITHOUT FINAL IH_,FECTION'= ' " · aND RPPRrWRL. B'-r' THIS [:,EPRRTMENT WILt. BE SUBJECT TO PF..U.=,ECUTIUN. MINIMUM DISTANCE BETWEEN a WELL AND RN'¢ ON-SITE SEWAGE DISPOSAL S'¢STEM IS :~.£~O FEET FOR a PRI'¢RTE 14ELL OR 15E~ TO 2E40 FEE]' FROM a F'UaLIC WELL. DEPENDING UPON THE T'¢F'E OF PUBLIC WELl_ MINIMUM DISTANCE FROM A PRIVATE WELL TO R PRIVATE SEWER LINE IS 2'.5 FEET aND TO A COMMUNITY SEWER LIHE IS 75 FEET. WELL LOGS aRE REQUIRE[.', aND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]:E~ DFt?S OF THE WELl_ COMPLETION. [)]'HER: REQUIREMENTS NAb' aPPLY. SPECIFICATIONS aND CONSTRUCTION DIaGRaMS aRE R'¢BILRBLE TO INSURE PROF'ER INSTAt_LRTION. PEF;-:I~'I I ]' E;-'~:F" ][ F,-:" ES E:.E C:EI',IBEF-: ..~.-~: i... I CERTIF'¢ THaT ].: I AI"I FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SE[4ERS AND WELLS aS SET FORTH BY THE MUNICIPALITY OF aNCHORaGE. 2: I WILL.. INS"FALL THE SYSTEM IN aCCORDaNCE WITH ]'HE CODES. 2:: I UNDERSTAND THaT THE OH-SITE SEWER SYSTEM MaY REQUIRE FNLARGEMENT IF' THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 2: BEDROOMS. :. I GNE[;': ...................................................... RF'F'LI CANT FOREt"IOS]' ENTERPRISES P'l L! I'-4 :[ (:::.. I IF:-' R t._ I -l" °'r" ,:! F R I'-4 C.':: ~-t F} t--t F:I ,.-_i E DEPRRTMENT HEFILTH FIND EN'¢ fRONHENTRL q:O'f'ECTION 825 ~L STREET, RNCHOF,'FIGE, RK. 264-4720 [4 E b L_ Ft i'-4 IZ:, C, ~'-4 --. S I T BE S ( ) SQLIRRE I:'EET SOIL RRTING THE REQUIRE[.'., SIZE OF ]'HE SOIL FIP.,SORPTION SYSTEM IS: lr)E::-.P'T-FI== )1 L_ EE I'q L3 "T" ,-I ='= ~ ~ GF-tF,%.-'EF£L_ E--IEEF"-ir-14*= "~ THE LENGTH DIMENSION IS THE LENGTH (.IN FEET) OF THE: TRENCH OR DRI3INFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DIS'TRNCE BETNEEN THE StJRFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET). THERE IS NO SET HIDTH FOR TRENCHES. THE GRFIVEL DEPTH IS THE MINIMLIM DEPTH OF GRRVEL. E:ETP.IEEN THF OUTFRI_t_ PIPE RND THE BOTTOM Of: THE ENCf~'¢RTION (IN FEET). PERMIT FIPPI_~C:IRNT laFIS THE RIESPONSIDII..IT'¢ TO INFORH THIS DEI~RRTrdENT DURING THE , INSTFILLRTION INSFECTICN. OF RNtr' NELLS FIDJRCENT ]'0 THIS PROPERTY RND THE ~'II_IFIBER OF RE'g~DENCEq THRT THE WELL NILL BRCKF~LLZNG OF RNY SYSTEM N~TFIOUT FINF~L [NSPEC'rZoN RND RF'PROVRL DY THIS DEPRRTMENT HILL BE SUBJECT TO PROSECUTION. MINIMUM DISTRNCE BETHEEN Ft NELL RND RNY ON-SITE SENFIGE DZSPOSFtL. SYSTEM IS ~.~O FEET FOR ~ PRIvY'rE [,.IELL~ OR ~.~O TO 2D~ FEET FROM ~ PUBL.~C NELL DEF'ENDING UPON THE TYPE OF PUBLIC W~LL. HELL LOG~ ~RE RECiUIRED RND MUST BE RETURNED TO THE DEPRRTr,IENT WITHIN ]~O DFIYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRH~ RRE FIVRILRBLE TO INSURE PROPER INSTRLLRTION. PERhl :1: 'F E,-,.F ZF,'E_.. E--,ECEP'i[.-'JE:':F-: 2:.1_ .... ~L::--~'- 80 I CERTIFY TFIRT 1: I RM FRMILIRR 14ITH THE REQUIREMENTS FOR ON-SITE SEHERS RND NELLS RS SET FORTH BY THE MUNtCIF'RLITY OF RNCHORFIGE. 2; I NILL INSTFILL THE S'¢S]'EM IN RCCORDRNCE NI'I"H THE CODES. :~: I UNDERSTRND THFIT TIiE ON-SITE SENER SYSTEM HRY REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE HOP, E THRN L~ BEDROOMS. S I GNED: ................................................................ RPPL I CRNT /-t .-- ! SSUED B'¢_ ._ E V_~. 2 ; PERFORMED FOR; ~i. LEGAl,. DESCRIPTION; 12 13 14 15 16 17 18 19 20 COMMENTS PERFORMED BY: iF ES; AT WHAT, ' ,- DEPTH? .... , . ' ~ .... ',,: - '.,_':' :.,;'-~ : ' '::~'._ '..i'"-.:.:;.';.._v." :' ~" ' PERCOLATION RATE ~'~ nc") 72-008 [7/76) [~O~RTY OWNER: LOOATION: DEPTH OF WELt: DRII~JING LOG: STATIC LEVEL: YIELD 13 DRILLING CONTRACTOR: ~OREMOST HONES 1~2~ DIAMETER: 6" ~ - 255 25 - 35 35 - 53 53 - 7O 70 - 75 75 - 92 92 ~109 109 -122 122 -137 137 -142 brown gravelly olay brovaais~ grey clay and sand sand and gravel ss~d~ gravel s~d some olay ssnd~rock~ and clay (hardpsn) mostly sm~d and gravel~ little ols~ more clay~ less s~md ~d gravel some seep~e ~ s~dy ol~ more cl~ less s~md~ little seepsge co.se s~d ~d gravel aq~fer~l~ge rock at bottom 605 from bottom 2o+ gal./min. 40" off bottom COOK INLET ENTERPRISES 1424 E.27th Ave~ Anchorage, Alaska 99504 276~2025 investigation of this Health"Autho~i~ Appr0'~ai' a~Plicati°n shows th'a{'~h~ 0n:si{e ~atet suPpiy~, '~;~;~;"~ and/or wastewater disposal system is safe, ~d'nctio~al and adequate for the numbe~ of bedrooms' · and Wpe of structure indicated herein, I fuAher veriW that based on the information obtained from. · the MunicipaliW of Anchorage files and from my invest~ation and ins'p~tion, the on:~ite water~" -'.'- "~'upply and/or wastewater d~spo~l system is in c~mpl~anCe With all Mu~ici Pal and stat~ Codes," ordinances and regu at ons n eff~t on the'date~of ~'his n'spe~tion.': : ' ;" "" ~;~ ................. Da - , Legal Description: Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LOT' ~ b 6,1~- ¢ou~e.,a,~,u.-% %/P Parcel I.D. Cased to A. Well Data Well type Log present (Y/N) Total depth Sanitary seal (Y/N) if A, B, or C, attach ADEC letter. ADEC water system number rJ~~j- ~ Date completed ,2//-~ Driller 2o~ t,,J~'? F_.,~¢-.~,.~ X Casing height .> 12. Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow ?--~:~ .g.p.m. Pump level1 v SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot . / ~-'~ / 4-_ Public sewer main fw Sewer service line > ~-~- or~ AT INSPECTION / g.p.m. ; On adjacent lots ; On adjacent lots > ~ ©o ' Public sewer manhole/cleanout Petroleum tank ~ ~/~ ~. i00/ WATER SAMPLE RESULTS: Coliform'~ (~/ Nitrate ~". 6 ~' I~/~ Other bacteria ~ Date of sample: ~G/q':¢ Collected by: ~-~¢-P-'~ -q ~ ~. SEPTIC/HOLDING TANK DATA t~ ~ ~ ~. ~ ~.w,~ /~ ~ Date installed ~ / ~o Tank size I ~%0 Compadments ~ Cleanouts (Y/N) N~- ~ ~oundation cleanout (Y/N) ~¢~ Depression (Y/N) High water alarm (Y/N) ~/A Alarm tested (Y/N) ~/~ Date of pumping ~/~ ~/~ Pumper ~ c po~E SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: / Well(s) on lot I "55/_4- On adjacent lots > I co Foundation To property line >'" ~' Absorption fi.eld 1 7../ (~ Water main/service line > ~ O' oe¢or, ,-~ Sudace water/drainage ~-_.~o,.., ,,~ c¢~~'o 72-026 (3/93)° Front CONTINUED ON BACK PAGE LIFT STATION /,j D~ Manufacturer Manhole/Access (Y/N) Size in gallons "~--.. _ '~at Vent (Y/N) ~on" level at High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE~FT STATION TO: W~ On adjacent lots water Date installed c//~,o Soil rating (GPD/FF) zs'o ~¢/~'System type Length G'7 / (~ Width Z, ' ~' Gravel thickness Total absorption area ~.o0 ~ Cleanout present (Y/N) ~ Date of adequacy test ~/~/95- Results (pass/fail) .~-~-~ Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) r,J c/LlO" ~' Totaldepth I1'-'~0"® I+'(~) Depressbn over field ~Y/N) for ~-. Bedrooms After test 7~ If yes, g~e date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: / Well on lot ~ ~'~ ~ On adjacent lots ~ ~czcD Property i/ne To building foundation (~ iZl..5" F¢~ ~.~,.,~do To existing or abandoned system on lot On adjacent lots >'> 0¢¢r~ --- ~o' Cutbank 14 ¢, Water main/servioe line Surface water q.?o~ Curtain drain ~/A E. ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area I cerb'fy that I have checked, verified, or c~ ~nformed to afl MOA and HAA gu/defines in effect on the date of this inspection. HAA Fee $ '~4~'~), Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number Alaska Water & Wastewater Services "Preserving The Last Frontier" Municipalfty of Anchorage Department of Health and Human ServSces Division of Environment. al ~er-vic~s On-Site Services Section [').0. BOX 196650 bhnoho rage, ~].ask~ 99519.-.6650 Ref: HAA, Leg 1, Bk 2, Golden Hills S/D To vohom ~ may oencern: The sub.jeer property is '.served by an privake well and sepl;ic system, an analysis of each system is summarized as SEPTIC SYSTEN: 'Tine se;ptic tank ,a~as pumped on consequently, the ~rench had the ppport, un~.ty to recever fer about 24 hours (4 people living in house, 240 gel. lens approx. ) pr'ior to my art-5 vel (5/26/95) = Upen initial inspection 71' 'found the t~ench te have 5'--9" o-f water in tr. flcce I'di I'/g to the inspec l;~on l*cepo i'- ~, there is 9'-10" dr-ainrock belot,~ the pipe, and the boba.]_ system dept;h is J.O" = Z fouDd the total depth at the sump 1;o be 14 feet belo¢l grade., Perhaps fill t, Jas added9 The so5].s te~h done in 1980 was only 15 feel; deep. The septic tank (Grr~ar) almost .i. 5 years; old al'id is pl~obably reaohil]sj khe ,~nd of Us6~fu ] ..] re. Ig was QPk~ exposed ~l l'ld inspected for' st;ructuf-a] int. cgriLy_ l'he buyer sho 'ld ant. Scipo. te) replacing it N¢D~in the next 5 I int;roduced ~ater into the sL!mp.., at; the end of the trench, at an aw~rage rate of 6.6 gpm for a total of: 91 minutes (600 gallons). Tho liquid level rosa i'7.5" The sy%tem r~3i~overy l*iAs faQi'l~tol'e(~ foF 120 Blinutes, and plot;ged on lo9 vs. log po. poi . Based ttpon a line thr'ough t-I've last sys l;c:r,] is cur r'ent, ly absorbing 600 gpd_ 'lhis I;est cot]se I-Va-l; 5 ve because there is st;ill 2'-7" of "vi r'g:i n" dt-ainroc;k t,¢hich has yet to be ubil}zed. Based upert i;I-~5, s dat. a the system ~Jas deemed to be ~('tequate for a 4 bedpoom house (600 gpd). WELL: The wetl was Lasted eoncur'r'ei~i_:l.y with tho septic system_ The si;erin ].eve! ~as 50 -feet Water ~¢~as i'~tJmpe(J al: ai fate o'f ¢,_6 gpm fer' a total o'l' 9[ IlliDLItSeS (600 DU r;Ll~g tine first 20 minute,s of the I;esL the [.,,ater' ] eve] Telephone: (907) 337-6179 · Fax: (907) 338-3246 · 8471 Brookridee Drive · Anehorave Alaglca cIqql3/I dropped ;80 fae)t 1;o a tol:.al depth of 70 1'~.i:.~ For bhe nexl; 71 ff~nubes ~he ]eve] remained unchanged_ In shor-t, Lhe (~;. 6 gpm). ~'fi tar the pumpin9 was stopped, the recover-ed lO0~ 5. n less than 50 l~Yint.lte~s.. data the ~e] 1 [~as de~mcd bo be a~cJeqtlat8 for a 4 bedroom lloL!Se (600 Gl)l)). you have any question, please oa].] me a 55'7--6179. NOTE: The adequacy of a septic sy.ste~l :is ~nf).uenc:ed by joii'~t::~ (wh/ich Call ~)e danlage~d by se:[~:~m/].c activity and .sept. Z¢~ sys te~m (ci~a~'ett¢~ Dut: t.s, sanitary napl<ins~ m~:sc Col]tiril.lal bas]s. Oonsec~uel'ltl?, tl'l~ t'esults of ti]is adequacy test are only valid for Lhe spee~f_~c day o~~ the test_ CT&E Ref. # Matrix CT&I: Environmental Services Inc. Laboratory Division v~z~'~~~~~c-~~ .i12o 1 Laboratory Analysis Report WATER Client Sample ID L1 BLK2 GOLDEN HILLS S/D BATHROOM SINK Client Name AK WATER & WASTEWATER SERVICES WORK Order 13470 Ordered By JEFF GARNESS Printed Date 03/29/95 @ 11:36 hrs. Project Name Collected Date 03/26/95 ~ 14:00 hrs. Project~ Received Date 03/27/95 ~ 10:00 hrs. PWSID UA Technical Director STEPHEN C. EDE Sample Remarks: ROUTINE S~24PLE COLLECTED BY: GARNESS. QC Allowable Ext. ~al Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 4.64 mg/L EPA 353.2 10. 03/27/95 CMR * See Special Instructions Above UA = Unavailable ~* See Sample Remarks Above NA = Not Analyzed ~ = Undetected, Reported value is the practical quantification limit. LT = Less Tha~] D = Secondary dilution. GT = Greater Than 200 W. Potter Drive, Anchorage, AK 99518-1605 -- Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA : No Corne~$ Set Thi~ Oat~ I hereby certify that I have ~rv~,~ad fha ~ollowing d~ecfibed property, Lot.---/-/-oreck -~'"" tho improvom~tt'"lituatod thlr~n are within the pro~rty lioel I~ do not overlap or encroach'on the pr~rW lying adjacent t~reto, that no i~ro~ntt on ~op~ty Book No. Page, No, 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 \.-~ - / ~- :~ ?) HAA # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range.) Location (address or directions) (b) Property owner ,.~Lr,~ ~:C),~:/~.~ ~-SD.~'.~ (c) ' ' ¢ / T Mailing Address /~.~ (d) Real Estate Company and Agent Mailing Address ~L:)'-~ Lending Institution (e) Telephone'(home) Telephone _ 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: Business Single-Family I];~ Number-/of bedrooms Individual Well B~ Community D 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 DI~ On-site~ PublicD 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 ~ ,to ~ eDed ')poM s,Jeeu!bue leUO!SsejoJd eql u! suo!ss!t.uo Jo sJOJJe JO,t elq!suodsaJ ~ou s! ebeJOqOUV JO &!led!o!unlAl eqJ_ 'penss! s! eieo]JRJez) e eJojeq e~ep ez/~leUe Jo suo!~oedsu! ~onpuoe ~ou op SH HQ jo see,~oldcu3 's~ueLueJ!nbeJ e),e~s pue leJepeJ u!e~Jee ,~js!les o~ Jap Jo u! leu!puel Jieq~ pue setuoq jo sJeseqoJnd oh /,se~Jnoo e se @]kl~ seep SHH(3 eq.l_ 'e~Sel¥ jo e~e~S eq~ u! peJels!SeJ Jeeu!bue leuo!ssejoJd ~uepuedepu! ue ,~q e^oqe S qde~t~eJed u! ue^!5 suo!le~uaseJdeJ eq~ uodn XlUO peseq le^oJddv X~!Joq),n¥ qlleeH senss! (SHHCI) seo!^Jes uemnH pue q~leeH jo ~ueLu~JedeQ @6eJoqouv jo X~!led!o!u nv~ eq.J. le^mddV leUOR!puoo jo suJJe.k leUOpdpuoo pe^oJddesK] .-~ pe^oJddv ~--¢2~- ~ eleG~ : ,~~._~ AqsLuooJpeq~',~--Jojpe^0JddV 'lYAOt:ldd~f SHHO '9 lees s,Jeeu!bu3 / / // / o :/~/_~,¢~ euoqdele& "D~ "~~::~,~, jo,s'~JooeeN 'uo!~oedsu! s!ql ~o e~ep eql uo ~oejje u! suoRel e~ p .P P 1 IS pu~ led!o!un~ I1~ ql!~ eou~!ldmOo u! s! melsts leSOds!p ~ele~e~se~ ~o/pue tlddns Jele~ el!s-uo eql 'uoRoedsu! pue uoRe6!lseAu! fm moji puc sel!~ e6moqouv jo &!lediolunR eql mo~t peu!elqo uoRem~o~u! eq~ uo peseq 1~ ~eA ~eql~n~ I 'u!e~eq peleo!pu! e~n~on~ls ~o ad~l pue smoo~peq jo Jeqmnu eql ~o~ el~nbepe pue leUO!~ounj 'ejes s! me~s~s lesods!p ~ele~else~ ~o/pue 11ddns ~e~e~ el!s-uo eqi leq~ s~oqs leao~ddv ~lpoqlnv qlleeH . s!q~jouoReSRseAu!~m~eq~tjpeAI '~oleq u~oqse~epuo]~plleaeq~josepueoleJeq pex!~jeleeS~mXq pe!l!~eosV NOI~Y~OJNI QNY Y~YQ 'HO~S ~31J 'S~S~ 'SNOI&O~dSNI 9NIQIAO~d ~1~ 9NI~NIgN~ '9 A. WE-~L DATA: MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: Well Log Present (Y/N) ~ Date Completed o]/.../ Total Depth~Z~'2~i Cased to g'~-'°( J~Depth of Grouting Static Water Level ~ i I Pump Set At Casing Height Above Ground Electrical Wiring in Conduit (Y/N) If A, B, C, D.E.C. Approved (Y/N) Yield 4 cljOl~,¢l, '-(- Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments ; On Adjoining Lots ~'~'C) /./2~. ¢ ;On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole · Date /~/Z Z/~ SEPTIC/HOLDING TANK DATA Date Installed '~/~'~'~ Size Standpipes (Y/N) Y Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) /'?/;~::~ ~,~'~ No. of Compartments Air-tight Caps (Y/N) H Foundation Cleanout (Y/N) /'-'~/ Date Last Pumped / /(,,~7//3~-- ;for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well /('~O / To Property Line ~-'~ ~'-~ [ To Water Main/Service Line ~/~]~ / To Stream, Pond, Lake or Major Drainage Course To Building Foundation To Disposal Field Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ./~ ~¢~')C"~ . Type of System Design Date Installed ~ Length of Field Width of Field ~(~1~ ~ Depth of Field Gravel Bed Thickness ~/~¢ ~-~¢ Statndpipes Present (Y/N) Square Feet of Absortion Area Depression over Field (Y/N) /k~) Date of Last Adequacy Test Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation //~'*°C~ /1/ To Property Line :::~?O / //~/'~ / To Existing or Abandoned System on ;On Adjoining Lots To Water Main/Service Line ~ ~ / To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area ~ ~ Comments Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at /"Pump O~ ..... ~__ High Water Alarm Level at /~/ ~ent (Y/N) _ Tested for ~ _ Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/~ Comments **Check Permitt/~Bedroom R~ng Against HAA Request** I certify that I//h/~____~/hecked, ~d, or conformed to all MOA and' HAA inspection.//////X' / Signed __////~/4~'/~(' W ¢----~ ' CompanyDate : 2~:r2(/c~ /' MOA No. L~-'~:: ~/¢~(¢ effect on the date of this Receipt No. Receipt No. Date of Payment ~ - /c~ '-C7 ib Waiver Fee: $ Amount:$ ,/ ~/~ ~ . CO C) Date of Payment : Z.-;i,':: Engineer's Seal 72-026 (Rev. 7/88) Back Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. FEDERAL TAX ID # 92.0040440 ANALYSIS REPORT BY SAMPLE for Work Order % 19015 Client Sample ID:LlJ~%GOLDEN HILLS PWSID :UA Collected DEC 22 89 @ 13:30 h~e. Received DEC 22 89 @ 14:30 hrs. Preserved with :AS REQUIRED Date Report Printed: DEC 26 89 @ 1~:12 Client Name : CORWIN & ASSOC Client Acct : CORWINP P,O.~ NONE RECEIVED geq ~ Ordered By : J. KRgSS Analysis Completed :DEC 22 89 Send Reports to: Laboratory Superv. l~or~i.~_~TEPNEN C. EDE I)CORWIN & ASSOC Released Ey : ~z-~ ~ ~_..~-~ 2) Special HOLD UPON COMPLETION FOR PICK UP. Instruct: Chemlab Ref ~: 9020 Lab Smpl ID: 1 Matrix: WATER Allowable Parameter Tested Result Units Method Limits NITRATE-N 3.0 mR/1 EPA 353,2 10 Sample ROUTINE SAMPLE. SAMPLE COLLECTED BY J, KRESS. Remarks: I Tests Performed ' See Special Instructions Above UA:Unavailable ND~ None Detected "See Sample Remarks Above NA= Not Analyzed LT~Less Than, GT~Greater Than DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DA'rE INSPECTOR I NSP ECTOR INSPECTOR MUNICIPALITY OF ANCHORAGE MUNICIPALIT'( OF ANCHORAGE DEPT, C)F  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIONi. NViRONM[ ~/~ 825 L Street - Anchorage, Alaska 99501 I!CTION ENVI RONMENTA L SANITATION DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWFR~[H..~IL~Lj-) DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1, PROPERTYOWNER I PHONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2, BUYER PHONE t~ i c/, ,,a ~.. (_.2/_~ r~ / ~o~, ;z..7~ .~ ~.z._7 MAILING ADDRESS 3. LENDING INSTITUTION I PHONE I MAILING ADDRESS 4, REALTOR/AGENT ...............__ PHONE MAI LING ADDRESS 5. LEGAL DESCRIPTION L ~.~ / g z/~ _ '2_ C~ o L ,t~-~, /Y~ ~ c ~ STREET LOCATION 6, TYPE OF RESIDENCE NUMBER OF~BEDROOM8  ~ One ~ Four SINGLE FAMILY ~ Two ~ Five ~ MULTIPLE FAMILY ~ Three ~ Six Other 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY PUBLIC UTILITY *ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drillgd prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM ,~ INDIV' DUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-S TE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) LI .~.~ L_) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED EZ]PUBLIC UTILITY Connection Verified INSTALLER "~, ~'~,i':,~ .. []Sep. t[c Tank or I~] Holding Tank ...... . ~-, Size: I ~) -~ If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4' DISTANCESwELL TO: Septic/H°lding Tank Abs°rpti°n Area ISewer Line INearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS ~PPROVED FOR ~:~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY