HomeMy WebLinkAboutGRANITE VIEW BLK 7 LT 2Granite View
Block 7
Lot 2
#014-302-10
MUNICIPALITY OF ANCHORAGE
DE. tTMENT OF HEALTH AND HUMAN SERI cS
_ Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NameDISTANCES
13e'yy-`? IT S-A
Tp
FROM
SEPTIC
TANK
ABSORPTION
FIELD
WELL
Address
3 U .� � Na,tfi C/rG/G /Qnc/ia--•ye iiK P 1'j-09
WELL
2
Phones) Permit No. No. of Bedrooms
3yy2i6� 666.21/4 3
LEGAL DESCRIPTION
LOT LINE
�f b
yo
< z
Lot
Block
Subtliwson
C.n�
FOUNDATION
"y
CIO
/
Township, Range, Section
% /2 N !Z .3 �
AS -BUILT DIAGRAM
driveway, water bodies,
(Show location of well,
etc.)
septic system, property
lines, loundation,
TANKS
SEPTIC ❑ HOLDING
Manufacturer
Art r 4 0'-a e—
Capacity in gallons
/0 C"o
Material
No. of Compartments
TYPE OF SYSTEM
E)"iRENCH ❑ BED ❑ W. DRAIN ❑ OTHER
Depth to pipe bottom from
original grade FT
Total depth from original grade
g FT
Fill added above original grade
FT
Gravel, depth beneath pipe
S� FT
o
Gravel length
8 FT
Gravel wiom
% t 'V'PA S/o-% FT
V
Total absorption area
qb D SQ FT
Distance bet wej' lines
%" FT
Number of lines
Soil rating
/S a SOFT
Pipe material
Installer//
Qehe6("C
Date Installed
Q /
�l/-Ub dA����`�'j'�'
_
O
00 4.1
WELLS
❑ PRIVATE ❑ OTHER (Identify)
o
12,
O
Z
Classdicahon (ABC)
Total Depth
FT
Cased to
FT
Installer
Date Installed:
"--
-" -
Y�
2.0
REMARKS:
—
Go
—
i N
nfr-re S S*in PAJ /iqe. 'fv /,vcrs� >itS'cr/a-"%cG
N/r'f'H 7 "pyow C1(•f'r"vd-2Lk Sr'aa�
SCale:
Inspections
Date:
/fir=
.3h,
Performed
n"'�fy�^
by:
-
ENGINEER'S SEAL
n
G certify that this inspection was perlormed according to all
I // ,yam
Municipal and Slate guidaf nes in elfecl on this dale: ;7-Z a v —
Health Department Approval: Date:.
79_ntq MlArl '� L/
^
'
� ��act �X -1 "w" �����FOE ���
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION *
' 825 L STREET, ANCAORAGE, AK 99501
�
Ell NJ 10 1 - 0 !E.-..� M FEE bi FEE K tic QA;P F:,.. J "I��
PERMIT NO:
DATE ISSUED:
APPLICANT:
ADDRESS:
CONTACT PHONE:
LEGAL DESCRIP:
LOT SIZE:
MAX BEDROOMS:
860244 `
07/21/86
BETTY ASH
3038
N. CIRCLE.
ANCHORAGE, AK 99507
349- 768
SUBDIVISION: GRANITE VIEW
SECTION: 22 TOWNSHIP: 12N
14368 (SQ"FT. OR ACRES)
3
Listed be1ow areLhe options
available to you
system" Choose Lhe option that best [its your
BY
0 H/EU���U�
DEP|H |O PIPE 130 11 (FT">
4"0
8RAVEL DEPlH (FT.)
5,0
�TOTAL DEPTH (FT.)
9,0
GRAVEL WIDTH (FT.>
2.5
GRAVEL LENGTH (FT.) �
46"0
GRAVEL VULUME (CU"YDS")
23.5
TANK SIZE (GALS)
1,000"0 **
SOIL RATlNG (SQ"FT"/BR)
152
LOT: 2
RANGE: 3W
in designing
site"
BLOCK: 7
your septic
** TANK MUST HAVE AT LEAST TWO COMPARTM .TS
�..... --- --- ... ....�����
I
. certiiy that: `
1. I am familiar with the requirements for on-site sewers and wells as set
forth by the Municipality of Anchorage (MOA) and the State of Alaska"
2, I will i1-1 stall the si�ystem in accordance V4ith all MOA codes and regulations�
and in compliance with the design criteria of' this permit.
3 I will adhere to all MOA and State of Alaska requirements .1or the set back
�
distances {rom any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or, nearby lot.
� 4. I understand that this permit is valid for a maximum off 3 bedrooms and
� any enlargement will require an additional permit,
IF A LIF[ STAlION IS
INSTALLED IN AN AREA
COVERED
BY
MOA BUILb/NG
CODES,
THEN (1) AN ELECTRICAL
PERMIT AND INSPECTION
MUST
BE
OBTAINED; (2)
AS~BUILTS
WILL. NOT BE APPROVED
WITHOUT AN ELECTRICAL
INSPECTION
REPORT; AAD
(3) THE
ELECTRICAL WORK MUST
BE DONE BY A LICENSED
ELECTRICIAN,'
!S[GNED
SM. ICA
ISSUED
DATE:
-h.~_-~_~
DATE:
.._704 lsi�_
(ENGINEER'S SEAL)
e Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES t��
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST �t
PERFORMED FOR: C7zyledir t C�yn.1'fictG'!7 �/�-- DATE PERFORMED: it
�� _196i -
LEGAL DESCRIPTION:.yra')de View 8 L Township, Range, Section: S ,, 2 z-F12ts"1z_3Lr
T SLOPE SITE PLAN
1 q�. 1 L 2
3 (n1 0, nt y itire o f S w,d s+ lF) eui eL
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5
6
7
8
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10-
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13
rN' 1
14
15
16
17
18
19
GP
rr ra.rzl ) (oil S ii'il i5 niaS.t�'f
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P y rock ,,,,x117 ENCOUNTERED?
5ewe�
Coarla b(ad( ScnS
L
6e..1-WeeN IF YES, AT WHAT O
DEPTH? P
t -)1l j/ 6r" E
Depth to Water After c� y C
Monitoring? Date:
V1 O
-�4' d
Reading Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
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G d
zoo
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33"
Z1
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6U
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PERCOLATION RATE (minutes/inch) PERC HOLE DIA
TEST RUN
�BZ/FTAND 3 FT
lVrn 2 F
cCSo GJrtS'COMMENTS �0 J-4--GA> d�tq
r 'Kt 6 Ae_ wYS W '7'H-/ b AVbISs614 /a7CL"A/ cuyt/tiu '1�/ Gf�L
PERFORMED BY: 4/ e C S Ie - f %! CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFF , nN THIS nATF nATF G whl'v /XO v
72-008 (Rev. 4/85)
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GUSTAV V. JOHNSON
CONSULTING ENQUIEgn
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AAROW PUMP & WER EROCE, LLC
P.O. Box 110496
Anchorage, AK 99511
Office: (907) 346-9355 • Fax (907) 333-8976
Eagle River: (907) 622-9335
--�y / CUSTOMER
r �
-30 3 /1/4 ir ` t�,'r c e
ST/N Ago 5e 7
014- �307--10
MWOOCE
N° 07875
JOB SITE
ra0W3 � /l/rtl.
`
4 -7- of 6 J I-
- .J
/M�Q(I.CE
� I -0 •7
77-0-2
WELL DEPTH
SSM.
CHLORINATED
PUMP DEPTH
S LLESPERSON
QUANTITY
DESCRIPTION
PRICE
AMOUNT
-o U,
i Qv` 6'\ -9 P o
70
4 e
,
w -el l i 'tom L0Ps71�
W!
to a Q h
w6e 4 etc k
' Ir
u rM t- r rG je
ra to I eq
LABOR
RATE
AMOUNT
TOTAL MATERIAL
O
Ila
o. Q
6
TOTAL LABOR
360
-22
no
WORK ORDERED BY
DATE COMP.
TOTAL
LABOR
^ PAY THIS AMOUNT
y �O
Thank You
w — SIGNATURE
(I Hereby AcknowledgeSatisfactory Completion of the Above Described Work and agree that If above work Is riot paid for in 90 days I agree 10 allow Aarow
Pump 3 Well Service, L.L.C. the right to remove unpaid for equipment and charge for labor already performed 8 labor to remove unpaid for equipment.)
TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE
SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS.
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services M�
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 01it - �Q' \n
1. GENERAL INFORMATION
Complete legal description Gof 2, L'/oeGc -7, 6-rzt/niI-e (/r.ew
Location (site address or directions)- 3 319 Nmrth C(r-cl
Property owner Oef- ,X ASA _ Day phone 277 —3S3,b'
Mailing address 3038 Norte �rcEL} °AAc�ia� ev hk 99so7
Lending agency seQW-e Mc�h%Tfe Day phone GK z S -d Z6'
Mailing address Sha 6 3 y - 4k 919S-03
Agent N A Re Fin ancln-r- Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1191) Front MOA 021
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify 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 FW'{:!;�ri 7echl7r'ca/ SerL1ccw Phone 9 11,6"-- i3SS
Address 1 `r' S3 o rE/cho Sf. A/7 cloor7r A k 9997(
Engineer's signature DateMuy 27, /992
-7
6. DHHS
SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employeesof DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA 021
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOT 2, OLK 7y 6RANirE ✓16k/ Parcel LD
A. WELL DATA
Well type PR WATE If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Y Date completed 1 O 17160 Driller SWAFFARD DRILLING
Total depth 100' Cased to 100, Casing height 15 e
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
Io/716O
4s' /
J
SEPARATION DISTANCES FROM WELL TO
Septic/holding tank on lot
J)0'
Absorption field on lot
13E,
Public sewer main
y too r
Public sewer service line
a ADO r
WATER SAMPLE RESULTS:
Wires properly protected (Y/N)
AT INSPECTION
s/2ilgZ '
oz
Z
F)
8 2 /
f "i
6 �C
-_e
m y
y r
r
M
N
rte- -G
g.p.m. 7 3
g.p=ra'.
o
MMID
N
®<
0
�
In n,
� m
On adjacent lots y /oo
t
On adjacent lots too,
Public sewer manhole/cleanout > toot
Petroleum tank NoNe 08SER✓ED
Coliform /lCPo m t Nitrate 0. I my Other bacteria O ca f /100 sn�
Date of sample: .5 12d9 2 Collected by: FLATTOP TEct! 61C9
B. SEPTIC/HOLDING TANK DATA
Date installed 7I 29
4 ($b Tank size 1000 GAL Compartments
Cleanouts (Y/N) Foundation cleanout (Y/N) Y Depression (Y/N) N
High water alarm (Y/N) N • /t. Alarm tested (Y/N) N,A
Date of pumping 5'/2x/92 h,, lsaacf
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 110 - - On adjacent lots I I0 Foundation—
To
oundation To property line 40 Absorption field i5 r - Water main/service line
u
Surface water/drainage
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent(Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots
"Pump off' level at
Cycles tested
Surface water _
Date installed 729 s14/ 8;6 Soil rating 152 Q'190kM / System type TRE�Ic4
Length 4$ Width 14 Gravel thickness S� Total depth q /
Total absorption area 4go a, Cleanouts present (Y/N) i
Depression over field (Y/N) _ N Date of adequacy test 5121112
Results (pass/fail) PASS for 3 - bedrooms
Peroxide treatment (Past 12 months) (Y/N) Nouf KnlOwn( — If yes, give date u •A
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 13S — On adjacent lots > /o0 1 — Property line 2 0
To building foundation G0 To existing or abandoned system on lot tS
On adjacent lots >2o Cutbank NA. Water main/service line
Surface water y/oo ( Driveway, parking/vehicle storage area ?0
Curtain drain NONE o gSER✓9?)
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature J'/�- c T 712e.,e ti
Engineer's Name _ T6 eOckre- F. I•-toar'<-
DateMrAy %. /99?
HAA Fee $ / 20 .rte
Date of Payment
Receipt Numbers—��%(� )
72-026 (Rev. 3/91) Back MOA 21
AV
&A' •' (�; �
.f d
}:THEODORE K. AAOORE p a"✓f
Q X
CE -3589 '}-7411
Waiver Fee: $
Date of Payment
Receipt Number
�; r4C%04AG[ AYF9
uJ •�a
c
r � 9
'C9/P£0 lATN49Y �
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received (0 5
Time of Inspection 0
Date of Inspection 2- � 7 �/-
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
1. Approval requested by:
Mailing Address: d i e Phone: ,27E:-7 —, 7&'-323�7 X
2. Property Owner:�h e f_Phone: 34- -3 4;"-
Mailing Address: 20-5 -� �a r p
3. Legal Description:
4. Location: 30 --3,p
5. Type of facility to be inspected d,,_,jZ�No. of bedrooms L�
6. Well Data:
A. Type -Q B. Depth
C. Construction 61 I~ �`/d _7 y D. Bacterial Analysis (I/ K "e5 %�
7. Sewage Disposal System: �,�_�� -2'w dytg�.W�
A. Installed
C. Septic Tank: 1. Size
B. Installer
D. Seepage Pit: 1. Absorption Area
E. Disposal Field: Total length of lines
8. Distances:
2. Manufacturer
2. Material
A. Well to: Septic tank Absorption area _
Nearest lot line Other contamination
B. Foundation to septic tank Absorption area
C. Absorption area to nearest lot line
EQ -034 (1/74)
, Sewer Lines ,
Page 1 of two pages
Page 2 of two pages - Rey,Asst for Approval of Individual s & Water Facilities
Legal Description
comments
Approved A 4
z Disapproved
Ap roval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental
DIAGRAM OF SYSTEM
Date /(9 "%y
Quality
I certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these faci ities
are operating satisfactorily.
SIGNED
EQ -034 (1/74)
Date
�1
` GREATER ANCHORAGE ARLA BOROUGH
Department of Environmental Quality
3330 "C" St., Anchorage, Alaska 99503 s 274-4561
r_
6. Legal Description: Lot 2 Block 7 Grantte View S/D 3038 North Circle
Location:
7. Type of Facility to be inspected: sgl family dwelling No. Bdrms. 3
8. Water Supply
Type of Supply: Public Utility _ Individual xxx
If Individual, number of dwellings presently served 1
If Individual, depth of well unknown
9. Sewage Disposal System
Type.of System: Public Utility Individual (on-site) xx
If Individual, date of installation unknown
REQUEST FOR APPROVAL OF
11 1VEI)
INDIVIDUAL
SEWER & WATER FACILITIES JU1' 25 1974 ANq
1.
Type of Inspection:
CMRO _ VA xxx
GREATER q
EPT. NCJ�Qjt�y�p� AREq BOROUGH
FHA DOF EN 11V tV!.HEN7Ai ataY
2.
Property Owner:
Louie J Schroyer
Mailing Address:
3038 North Circle
Day Phone 344 2356
3.
Name of Buyer:
Charles Robert Ash
Mailing Address:
5301 Dorbrandt No 4
Day Phone 274 4157
4.
Name of Lending Institution:
Alaska Statebank
Mailing Address:
310 E Northern Lights
Kefl--E-S'tate
Phone 279 7637
Dept. Ext 30
5.
Name of Realtor or
Agent: None
Mailing Address:
Phone
6. Legal Description: Lot 2 Block 7 Grantte View S/D 3038 North Circle
Location:
7. Type of Facility to be inspected: sgl family dwelling No. Bdrms. 3
8. Water Supply
Type of Supply: Public Utility _ Individual xxx
If Individual, number of dwellings presently served 1
If Individual, depth of well unknown
9. Sewage Disposal System
Type.of System: Public Utility Individual (on-site) xx
If Individual, date of installation unknown
,lune 260 1974
Alaska Statebank
310 East florthern Lights Boulevard
Anchorage. Alaska
99503
ATTENTION.. Rosie Parks
SUBJECT: SeweandwaLe fa facilities
serving Lot 2" Block 7, Granite View
Subdivision
near Mrs. Parks:
The subject Property was inspected and the following discrepancy found.
a) The well casing must be extended above the qr be exposed or the
surrounding terrain lowered. egroan the well sto eSPrevent
there must be sufficient drainage away
standing water neer the casing.
A water sample has been taken and sent to the State Lab and results are
pending.
if you have any questions please reel 'Free to contact me at 27445611,
extension 135.
Sincerelys,
Los Buchholz. P.'S..
Sanitarian
LB/ko
cc: Louie 5chroyer
3038 North Circle
Anchorage, Alaska
99507
.d
Alaska�Jl
SMteba! lk 310 E. Northern Lights Blvd. Anchorage, Alaska 99504 9071277-7681
Greater Anchorage Area Borough JUL ' 01974 AM
3500 Tudor Rd
Anchorage Alaska 9 EAT%ANtHPRAGE AREA BOROUGH
DEPT. P ENVIRON ,NtNtAt QUAIITY
Subject: Water and Sewer Facilities serving Lot 2 Block 7 Granite View
Subdivision --3038 North Circle.
louie Schroyer
Mr. Buchholz:
The above property has had the deficiencies corrected as per your
letter of June 26, 1974. Please reinspect the property and send
the inspection on to me.
Ans /y
Real Estate Dept.
Alaska State Bank
ADH—kSE-6-F1 (e) TArrE "A1"R S 'TIT .E TO:
This Form Must Be Filled lNDINIDUAL �1A•I•EC"IcRi°SUPPLY Please Look on Reverse of
Out Completely. Sheet for Sample Collection
ALASKA DEPARTMENT OF HEALTH Instructions.
Section of Sanitation and Engineering
Request for Bacteriological Analysis
/ Lab. No............
Water sample collected b .. K
% , ( """
(Name of person collecting sample) (Dat) (Time) -
Water sample collected from ❑ Kitchen tap; KBathroom tap; ❑ Basement tap;
❑ Other (list) ......................
r I // yf�.7
Address premise where source is located.......... 5?_ �... y�...,e.l..".----
(Mr.)
(MTs.) �. G�
Mail repoA to (Miss) ..S2.h " ', x� �.,p a C/1 a2...... 5 .pit../ °..--• ...............................
(Name) (Box No. or street address) (City)
Please place an "X" in the box beforeite s which best describe your water supply:
SOURCE: Well — E] Dug, E] Driven, gilled, ❑ Bored
❑ Spring, ❑ Cistern, ❑ Other (list)...............................................................................................................
❑ Creek, ❑ River, ❑ Lake, ❑ Pond .......................................................................... ......................................
.DUG WELL
OR CISTERN CONSTRUCTION: Wails — ❑ Wood, ❑ Concrete, ❑ Metal, ❑ Tile, ❑ Brick or Concrete Block
Top — ❑ Wood, ❑ Concrete, ❑ Metal, ❑ Open Top
LOCATION: ❑ In basement, ❑ Basement offset, ❑ Under house, ❑ In yard
Other............................................................................................................................:.....................................................
DISTANCE TO: Building sewer or other drainage pipe..............feet, Septic tank ..............feet, Tile field ..............
feet, Seepage pit ..............feet, Cesspool .............. feet, Privy .............. feet. Other possible sources
ofcontamination (list) .................................. .................. ........ --- ................................. ............. -- .......................
MATERIAL: Building sewer — EI Cast iron, ❑ Wood, ❑ Tile, ❑ Fibre pipe, ❑ Asbestos cement
Jointmaterial — Type ................... ......... ............ ------- ................... ..............................................................................
GENERAL INFORMATION: Does water become muddy or discolored? f] -yes, ❑ no
When? -•-- .....-/--t -----
Diameterof well........a.......................................... depth........ ....................................... :......... feet
Well casing material:. � .F .: ................. diameter. ................... depth..... --------- ..................
Lengthof drop pipe --- .......................................... .......................................... ................... .....................
Waterdepth from bottom ..... ............................ .......................................................................... .feet
Pump location: ❑ In well, ❑ Offset in basement, f In basement
❑ In utility room, ❑ On top of well
❑ Other (list) ....................................................... ------•--••------........------................
Do you suspect_ illness from this supply? ❑ yes, N no
Remarks: ........ ..........-•---.........................._..........-••---.........................--•-•-.......-----••---•-------------•-••-•...........................
PLEASE DRAW A SKETCH IN THE SPACE BELOW. THIS SKETCH SHOULD SHOW LOCATION OF HOUSE, WATER
SUPPLY SOURCE, SEPTIC TANK, SEWER, DRAIN LINES OR OTHER SOURCES OF POLLUTION AND DISTANCES
3ETWEEN WATER SUPPLY SOURCE AND ANY OF ABOVE FACILITIES.
SAMPLES MUST BE SUBMITTED IN CONTAINERS PROVIDED BY THE ALASKA DEPARTMENT OF HEALTH
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ADH -HSE -641 (f) •.��•.._ • -
(4M) 1668
lab. No
INDIVIDUAL WATER SUPPLY
-
n Ta ALASKADEPARTMENT OF HEALTH SoUtheentral 1 KJ()ii all
Section of Sanitation and Engineering osatca
ACTION ON REQUEST FOR BACTERIOLOGICAL WATER ANALYSIS
Your recent request for an analysis of a sample
from the Individual Private Water Supply Mr,, L. d`, Schroy er
Lot 2 13100k 7 BMX 41419
serving Gr nit [j#Ah —�ji€anitr�on
SPC3i4ciY`(1s Alaska
received 1/31/61 :Ind
examination has been completed.
Records in this office indicate this Individual Private Water Supply to be of =' Satisfacto
sanitary status. ,- ry Questionable Unsatisfactory
Analysis shows this SAMPLE to be tisfactory Questionable
Unsatisfactory.
If an "Unsatisfactory" or "Questionable" status is indicated above, you should take immediate action as recommended below.
1. Boil or chemically treat your wate
closed leaflet, "Drink It Pure." r supply to protect your family from water -borne diseases as outlined in en -
2. Improve your spring—See bulletin HSE -6-2
3. Improve your cistern —See bulletin HSE -6-3
4. Improve your dug well — See bulletin HSE -6-4
5. Improve your driven well—See bulletin HSE -6-5
6. Improve your drilled well—See bulletin HSE -6-6
7. Relocate your well to a safe location in relationship to your sewage disposal system—See bulletin HSE -15
8. Bottle broken in transit, please send new sample.
9. Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results.
Please send new sample.
10. Contact your nearest El Local Health Department or 0 Alaska Health Department, Sanitation office for
bulletins, consultation, and assistance.
11. This is a surface water source and subject to pollution by man and animals. An approved water supply s
should be developed. ource
SANITARIAN'S REMARKS
f
Signature
Pi'