HomeMy WebLinkAboutGRANITE VIEW #1 BLK 4 LT 1 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 o Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: <~"~/ q ~ ~-C) ', L_ PID Number: ~'~ I I"i ~ .~ [ -~ ~'~ ~: ~A%'~, ~ t~NX~ Wastewater System: ~ New '~Upgrade Address:~¢~) C~."~ ~J~ t)~./~{-~;' ABSORPTION FIELD Phone No of ~odrooms: ,,~ ~ Deep Trench ~ Shallow Trench ~Bed ~ Mound ~Other LEGAL DESCRIPTION so, Ratin9: Total Depth Irom original 9rade: GPD/Sq Ft. Lei: Block: Subdivision: Death lo pipe botlom Irom original grade: Gravel depth beneath pipe Township: Range: Section: Fill added above original grade: Gravel length: Ft Ft. Gravel width: 'Number of lines: Dislance between lines:.Ft WELL: New Upgrade Ft Classification (Privale. A.B.C): Total Depth: Cased To: Total absorplion area: Pipe malarial: Ft Fl SQ. Ft. Driller: Dale Drilled: Static Water Level: Installer: Date installed: Yield: Pump Set at: Casing Height Above Ground: ~, ~, ~,_ TANK SEPARATION DISTANCES ~ Septic._~kl°lding 7J S.T.E.P TO ~ Seplic Absorption Lift Holding Public/Private Mamm~faclurer: Capacity in 9aliens: From Tank F,eld Slat,on Tank S ..... Lines ~[~/ t "F /~t~ ~.. ~ Material:g; b~~ -~ ( Number olOompayments: wen /O ~& SUwaterrface ~t/A L I FT STA'r I O N Lot Size in gallons: Manufacturer: Line "Pump on" level al: "Pump off" level at: Higb water alarm at: Foundation Drain Remarks: BENCH M~RK Assumed Elevation: ENGINEEWS SEAL Inspections performed by: ), % Dates: 1st -'~/'¢ %; ~i-,¢~--~* ~opartment of Heal~ and ~uman Services approval Reviewed and approved by: ~~-~ ~ Date: ~-/~- ~4 72-013 (Rev 9/91) MOA25 Abondoned Trench Foi(ed LE % % q. % % £5 0 £5 ~ned- £75,00 50 75 .tOO SCALE: 1' = 50 FT. TDBBEN SPURKL. AND P,E, 203 W ]STH, AVENUE ANCH, AK, 99501 LOT 1 BLOCK 4 GRANITE VIEW #1 9000 £LARIDG£ PLACE 9]ANE PROVOST i' X i0' CONDUIT RAIN CAP TYPICAL PUMP ACCESS GAL VANIZEB LB. 4 FT, DF CDVER DVER TANK CAULDER COUPLING TYPICAL 3000 GAL, H~71_~]IN5 -f'~IVK TO ALARM PANEL ~ DIRECT BURIAL I,IIRE ]' PVC CDNDUIT HIGH IYA TER ALARM --F MERCURY Sk/ITCH FLOA l I 6,3 ANCHDRA6E TANK I~RENCD STANDARD ALARM SENTINEL IT DSI 9 VT fTI]B~EN SPURKI_~ND P.E~ 6751 W, DIME]NJ) BLVD, (qfl7) P4FI-Sf195 9000 CLARIBGE PLACE PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW940012 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:HEATH C DIANE OWNER ADDRESS:9000 CLAIRIDGE PLACEY ANCHORAGE, AK 99507 DATE ISSUED: 1/25/94 EXPIRATION DATE: 1/25/95 PARCEL ID:01430117 LEGAL DESCRIPTION: GRANITE VIEW BLK 4 LT 1 LOT SIZE: 18000 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: HOLDING TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 4 o THE ATTACHED APPROVED DESIGN. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTENATER ]DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80 THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY:~ ISSUED BY: DATE: DATE: ,% % -FE]BBEN SPURKLANB P.E, 203 W '15TH, AVENUE ANCH, AK, 99501 Abondoned Trench Fo/led £x/s$/n9 1~ ,ol Fo/fed ~Bed- R 75,00 VACANT 8.5 SO 75 100 SCALE; 1' = SO FT, 125 150 II Lilt I BLOCK 4 GRANITE-~IEI,/ #1 9000 CLARIBGE PLACE' BIANE PROVgST IISEPTIC SYSTEM DESIGN DATE, ~£C 16, 1993 SHEET, 1/2 GRID, 2334 RAIN CAP TYPICAL PUMP ACCESS 1' X i0' CONDUIT GAL VANIZED 4 FT. OF COVER OVER TANK -- CAULDER COUPLING TYPICAL TD ALARM PANEL DIRECT BURIAL k/IRE '--i' PVC CONDUIT 1.5 HIGH F/ATER ALARM MERCURY Sk/ITCH FLOAT /I 13,18 STANDA£O .2000 5AL, HZ]LDIN~ 6.3 ANCHORAGE TANK ORENCO STANDARD ALARM SENTINEL IT flSI 9 VT LOT i ~LDCK 4 GRANITE VIE~/ #1 DIANE PROVOST 9000 CLARIgGE PLACE I DATE, DEC, I6, 1993 I SHEET, _P/£ sRI]j,a°334 MUNICIPALITY OF ANCHORAGE Environmental Heallh Division .".~ / 825 %" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT _IzZ_~; B bo; o/ TANKS L] SEPTIC [] HOLDING TYPE OF SYSTEM TRENCH ~X~ BED ~,~ Wi DRAIN [] OTHER WELLS DISTANCES WELL SEPTIC ABSORPTION TANK FIELD WELL i_LJZ ,, / / LoT uNE _~: 0 FT FT FT .,~..PRIVATE [] OTHERfldentifv) '(:i::~h¢~(~i: i~YJ ' ~ota Depth Cased Io REMARKS: 571;+ FT Scale: Inspections Perlormed by Municipal and Slate guidelines in effect on Ihis dale: .4~_~ . , .~_ ~., ..~ ~-. Health Depadment Approval: _~ ~%~ '/~[~ ' '"-~'~-~-~ Date. 72-0~3 (3/85) J,~mos F. $izemore ~ 1517 E JAMES SIZEMOREE & ASSOCIATES EENGINEEE]::~,'S & SURVEYORE~ 641EI SWI'T'ZEIRLAND DRI ANCHORAE~E, AL. ASKA 995:[6 F:'HOIxtE: 345- 1572 Munic:ipa].ity o.6 Anchol'"age Department o';: Healt. h & Human Serv:i. cr....,~, IRe: I....ot. I....:i. ne Waiver, Sept~.c System Upgrade Gentlemen: I am request:i, ng a waiver o.F the 1C) '~:t,, ].(::).1:~ lir]e setback along t. he Nol,"th bc)t.u"ldry (:)¥ g ].~{{Zl Gl'"ani te Vi ew Subdi vi si on 'Lo provi de r"oom to upgrade the ch."ai n-f: i el d (sm the ]. ot w:i. th a sha]. 1 c:)w bed system hav:Lng an area o.F :[:1.57 sq. ~'L:,, The lot :i.s bc)rdered on the Nor"th by an ur'~develop~,d por'Eion o~: SDut. h C:i. rcle Way. As sl"~owr'~ C]l"l tl']E~) I::'1 Crt Pi 6U'] ~, thE? we]. ~c)rl,:: with on the lot. I am avai].al:)le 'Lo discuss this ~itl"~ you at your (:::(:)r]v:E E. tr](::(.:e. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorege, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] SOILS LOG PERCOLATION TEST PERFORMED FOR: DATE PERFORMED: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 ['1/- 14 15 16 17 18 19. 20' SLOPE SITE PLAN THEODORE F, MOORE CE-3589 .o' COMMENTS ,,4b SO r/¢ ~1~o~ ~ e¢-~ WASGROUND WATER ENCOUNTERED? IF YES, AT WHAT Reading Date Gross Net Depth to Net Time Time ( ¢'f~ ,)) Water ¢re ..Socdx ~./oo t~.'z~ eo ~ ,' lo ~o ~ ¢,' H% ~o 8~a/~ PERCOLATION RATE "~ ~-~ (minutes/inch) --.' ~-,,,5'7 ~l /~'~--~r~ TEST RUN BETWEEN ~-~ FT AND ~'~ FT CERTIFIED BY: ~'-,c~"~"/..¢~¢'~ DATE: 72-008 (6/79) MUNICIPALITY OF ANCHORAGE DEPARTMFNT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] SOILS LOG PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 2 4 5 6 7 8 9 10 11 12 14 16 17 18 19 ~ THEODORE F. MOORE CE - 3589 20 - SLOPE DATE PERFORMED: SITE PLAN WAS GROUND WATER S ENCOUNTERED? ~ L o IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND ---- FT DATE: 72-008 (6/79) GR[' "ER ANCHORAGE AREA BOP' Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME LOCATION MAILING ADDRESS LEGAL DESCRIPTION PHONE SEPTIC TANK: DISTANCE ¢ ~ .~ ~. FROM WELL/~,)¢) /~'~, MANUFACTURER ,~/~'~' ~'/~'¢?~/ MATERIAL INSIDE LENGTH ~ INSIDE WIDTH '~ LIQUID DEPTH ~ ¢~ NUMBER OF - ;'/E*'¢" / . COMPARTMENTS ,/ LIQUID CAPAC ITY/g')~'2~'' ) GALLONS. NUMBER OF PITS '-- . DIAMETER --- OR WIDTH//~2 LENGTH ½/¢'~, DEPTH ~ l~/?{:Al' ~'// LINING MATERIAL/~/;,~//¢¢¢ CR[E~-SlZ~E~- DIAMETER%DEPTH ~ DISTANCE FROM: WELL/6C~) /~,~¢~///<~,'¢a · / / TOTAL EFFECTIVE BUILDING FOUNDATION/P?~-, NEAREST LOT LINE /(2 ABSORPTION AREA (WALL AREA) ~'~?~ SQ. FT. ADDITIONAL ABSORPTION /~"~/'~ WELL: TYPE CONSTRUCTION BUILDING NEAREST FOUNDATION_ LOT LINE CESSPOOL OTHER SOURCES APPROVED DISAPPROVED NEAREST SEWER LINE REMARKS DEPTH DISTANCE FROM: SEPTIC i SEEPAGE TANK SYSTEM DISTANCES: /~/~// /!/&'% //~, INSTALLED BY: ~-~,~>,'~/E.~ }KC'~ , PIPE MATERIAL: LOT SLOPE: REMARKS: Form No. EQ-O31 DIAGRAM OF SYSTEM DATE APPROVED . SEWAGE GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 PERMIT NO, DISPOSAL SYSTEM m APPLICATION AND PERMIT NAME OF APPL,CANT INSTA'.'..AT,ON LOOAT,ON PHONE ,-EGaL DESCRIPT,ON /0 T / /3/4 4, INSTALLATION OF: SEPTIC TANK ~/ SEEPAGE PIT TYPE AND SIZE OF FACILITY TO BE SERVED ~ ¢)1~O~)~ , DRAIN FIELD ., OTHEr FINANCED THROUGH COMPLETION DATE ANTICIPATED __ /~ ~/ TO BE INSTALLED BY NOTE~ THI~4 PERMIT iS NOT VALID WITHOUT SOIL FINAL. INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ,ANY SYSTEM WITHOUT FINAL INSPECTION bY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION· MINIMUM DISTANCES, REQUIREMENTS FOUNDATfON tO SEPTIC TaNK __i~ fOUNDatiON TO SEEPAGE Pit ¢~ ~ , DRAIN fIELD SEPTIC TANK TO SEEPAGE PIT WALL /L"~J- "/ SEPTIC TANK 6-- SEEPAGE PIT PO , DRAIN FIELD TO NEAREST LOT LINE, WELL TO SEPTIC TANK _/~ DRAIN FIELD ./¢¢-/ ' ID WATER MAIN TO SEPTIC TANK . DRAIN FIELD /L~ ¢ SEPTIC TANK, //Df) j . - SEEPAGE PIt. /~g2/ TO RIVEr, LAKE, STREAM. , SEEPAGE Pit __, ALSO CONSIDER AREA WELLS. / · SEEPAGE , DRA,N P,ELD /CO" . CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO Crib CROSSING GAP OF EXCAVATION S FEET INTO UNDISTURBED SOIL· 4 INCH DIAMETER CAST IrON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT EITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS rEGArDING INSTALLATION· I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF Greater ANCHORAGE Area BOROUGH ORDINANCE NO. 28-6B AND THAT TBE ABOVE DESCRIBED SYSTEM lS IN ACCORDANCE WiTH SAID CODE. : ~:, ~ ::~/~. ,ATE_ ? APPLICA.T'SSIGNATUrE ,' / TO F R Laura Crow o Fifth Floor M SUBJECT Request of Refund for Permit DArE 10-24-79 l?lease make arrangements for a refund for the following. The obtained a sewer permit to upgrade, but found that it was only a broken pipe and the system did not require an upgrade. The permit has been oaneelled and a ref~nd has been requested.. Receipt 4~ 4490 ~ohn L. Show~en 9000 Clarldge Place Anchorage, Alaska 99507 In the amount of $20.00 Account ~ 2460 ~l%lank you. REPI. Y Laura J~ ?~ard Sewer and Water Seotion x 4720 RediF~rm® 4S 471 SIGNED SEND PARTs 1 AND 3 WITH CARBON INTACT - PART 3 WILL BE RETURNED WITH REPLY. DATE // I~-1 El 1'-4 I CZ Z F~ Fi I__ .]: T' DEPRRTMENT FtPPL ! CANT :~0 ~ IV ~'~O0J [ ] l LOCRTII]N ~ CZ,.,tA.P--,IOG~ TYPE OF SOIL. RE:SORSTION SYSTEM IS' LOT SIZE /.~ ~:,~; SI_~LIRRE FEE'r THE RE~Y).UIRE['., SIZE 0F THE SOIL. FIE:tSORPTIOI, :.Br'~TEM []:, E P ']- H == /(~ L_ E] P-4 _.~ 1 THE LENGTH DZMENSION IS THE L :~(]TI~I EE'I-') OF THE l'REl'-dCqfXt~i~, r)RFIINFIELI5 THE DEF':FH OF R TRENCH OR F'IT I'._~'~'Ft-I~x~f)'t~S_;"i*~al'.,!~..-:.E BETWEEN THE ~Ik~R,I~:,]:E OF THE GROUND RN[:, THE BCITTOM OF THE E::'-:E:B',,,'F~]"~OH THERE I:S NO SET b]IDTH FCiR TR~NL:H~'~,."~ FIND THE BOTTI_-IM Of THE EZCR'¢I~x,T~'~ yF~i:]T) PERMIT FflPPL, IC:I:INT HFIS THE~RE_C]P'(.d'.4SIE:ILI. ITY 'ro INSTlaCCRT:ON INSPECTIC)¢: i:,f: NUMBER OF RESIDENCES THWF THE,,)}~L~ 14ILl cERVE DEPFIRTMENT [.]ZLt_ BE SLIBJECT,"~I F'ROSEC:L~ON. ZSE FEET FOR R F'RZ,/RTE I.,.IELL.:~ O~ d. 58 TO 28¢ FEET FROM R F'UBL. Z : NELL NELL L..OI]S RRE RE6IIJIREB, laN[) ['1 IST [?,E RE~ OF THE HELL E:OHPLETi'~. , OTHER REQUIREMENTS P1R~ RPPLW $PECIFI RVlaILRBL. E TEl ZN:,URE PRI~N~'f'FII_LR-FION. DEP~I'dT D)IJRING THE THIS PRCIF'ERTj'r' FIND THE SEI la OSFIL S'-r'STEM IS HE \T',r'f~E IOF F'UBLIC: P.!ELL . DEF'~,~RT~M~I'-,!T NITFIIN ~O DRYS C:Cff~ISTR,I~C:T I Of.] D I RGRRf'1S RRE I C:EFitTIF'¢ :?-IRT ±: I 81"1 FRMII_IFIR NITH THE RECJ. IJIR:I;~i''1E~'-,fTS FOR ON-SITE SEH[:ZFRS Ri.lC, lqELLS RS SET FORTH B~r' THE ML.INICIPRI_ITY OF RNE:IiORFIGE. 2: I !-dILL INSTFILL THE S'¢STEM If': F'IE:CI.-.~R[))FINCE I.qITH THE CODE.LS,. ~: I I_INDERSTRHD THRT Tide i]i[.].-SI"rE SEHER S"r'STEM P1RY REC!IJIRE ENLHRGEMENT IF THE RESIDENCE IS REMODELED TO INCLLIDE MORE THRN ~ BEDROOMS. S I FINED: ....... _-- ............................. RPPL IClaNT _. /0' Y [ _':.GSUED [.~'¢ ................... Z .................................... E. I:I'/E ............................ ¥'~. 2 Performed for Legal Description This form reports D e p t h Feet 7~ 1 t - GREATER ANCUORAGE AREA BOROU' Department of Environmental Qu ~ty 3330 "C" Street Anchorage, Alaska 99b03 8OII,$ LOG - PE!ROI,ATION TEST Soils 10g ~__ Percolation test Was ground water encountered? .... /~_..d2 .....If yes, at what depth? ..................... Reading Date Gross Time Net 1 ime _!)e_p_t_h__t?__W__~_t__e_~ Net Urop Percolation rate --minute. ........... Drain Field Proposed installa~n: Seepage Pit ..... _~f~.~_. ........ . :~cpth of Inlet __._~_~.~._tF . Depth td bottom of 040 GREATER ANCHORAGE AREA BOROI Departnlent of Environmental Qu~ !ty 3330 "C" Street Anchorage, Alaska 99{)03 SOILS LOG -' I)EROLA'FION TEST Perf.o, creed for. S_o _u~n d~ Legal Description: Lot_~ Block_lZ~._t Granite View Subdivi This form reports: ~-~il~-q~----' Percolation 'test tt., '.' AUG b 197q GREAiER ANCIIORAGE AREA BOROUGEI DEP[. OF ~b, ENTAI. QUALIIY Date Performed sion Depti~ Feet 1 -- 2- 5 - Bottom of test hole 9~ Was ground water encountered? _.N__o~ ......... If yes, at what depth? Reading Date .~ Gross Time Net Time _?j_)t_}]_t~_~?_te~r Net Drop ......... Depth to bottom of pit or trench :;eHt:h of Inlek ............... . .......................... C011IlEitTS: _. ~._gronnd ~ter.o.r~ock---anco.~e~ .................................. ............................................... Ci:rTi-~i ~5i" iii "i ................. :: .......... ~-i--- l]'~i-Cii' :- Performed By ;_,~.. _C_[o~_ton ............... ' - Y C.on~,~-u~t~n .Te ............... Lab Eq 040 (G/74)  MUNI CIPALIT~,OF ANCHORAGE DEPARTMENT OF HEA~i'H & HtJMAN SERVICES_ Division of Environmental Services , _On-Site Services Section · · P.O. Box 196650. Anchorage, Alaska 99519-6650 .. : . . :,... ;,i..., -.343~4744 CERTIFICATE OF'HEALTH AUTHORITY , APPROVAL FOR A SINGLE FAMILY DWELLING I.D.# OIL]-~_OI- 1'~ '' ' HAA# .complete legal descriptiofi L°'~'- I- ~'~ LC -~'~.~-4.' ~L I'ocation (site address or directions) perty owner __J~.,~.,~,( '~wJg¢. ~- ~ ~/--z-r~4.) ' _ Day phone Ad dress M~.i'ling address ' Lending agency'---P-~-/~'' ' l~ ~"~": i~*/'.~h /~,:¢-~-~':" "~ Day phone.~l~- Day phone Unless otherwise requested, HAA will be held for pickup. OFWATER SUPPLY: '-" IndividUal well ~/' Community w'~'ll ..... Public water ';'" ii'(:~ -; NOTE.: If community weft-system, provide written confirmation from state ADEC attest--/~",'i' OF WASTEWATER'"I~ISPOSAL:: ( ';. ::': 'i'-.'" ';". '":-'-:::': . ' ~ "'"' -.~2~ ' , ,:,,'.:r' .- NOTE:- If communitylWasteWater::system;':pr~vide,Written bonfirmation from State ADEC ", ';' attesting to the legalit'y a~d,Staf~s' ~f sysfem. ,-' " : ., 72-025 (Rev. 1/91) Front MOA#21 ~ ' ~": * ':* 5; : STATEMENT OF INSPECTION.,BY.'ENGINEER : - ~ i'- .' As certified by my seal affixed:hereto,.a, nd as of the validatio~ date Shown be ow, I verify that my., ,- 11. investigation o'f ihisHeaith AUt%ritY ~proval'application shows that :[he on-site water SuPply,'. · and/or wastewater'dispO-~'al'Syste'm i§ Safei"fUnCtiOnal"and'adequatefc r the nUmber of be'dr~omS,- :," and ~pe of structure ind ca{ed here, n fuAherver ~that based, on the information obtained from: the Mun c pa ty of Anchoragef les~aBd from-my investigation and inspection, the on-site wate supply and/or wastewater;,disposal:system' is in. compliancewith all Municipal and ~ · ordinances, and regulations in':effect 0n.the date.of this nspection . ,~ Name of Firm -' ;'~:" ~:' ~ ~ ~ ~ ;:'~'~' ~- ~ Phone ~7t- ~"/~ Addre~ '~ . -. ' ' . Engineer's signature Date 6'' ' r DHHS SIGNATURE · '~' 'Approved for bedrooms. Conditional approval for '' "bedr°om~';r Wi'th the f011'0Win'g' ~t'iPul~ti0ns: . '% r~ ~ Additional Comments The MuniCipality of ~%chorage 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 .':;nr~f&ss ona b-n~ neerre~ stered ntheStateofA aska.TheDHHSdoesthisasacourtesytopurchasersofh0mes. i: ~'i,': ;;i~'t-i-{~i?endin~'inst tUti~ns in'order_t0~tis~ Certain i~deral and staie requirements Employees of DHHS do not GENERAL INFORMATION Complete legal description MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site services Section . P.O. Box 196650 Anchorage, Alaska 99519-6650 . : , :' 343,4744 'CERTIFICATE OF:HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Location (site address or' directions) Property owner D~'~.HC ¢~'Ot/'os, Jr ( Mailing Agent ' Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: -~ TYPE OF WATER SUPPLY: /, Community well NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. ,., TYPE OF WASTEWATER DISPOSAL:" Co munity on-site .::: Public sewel1~ :i: ) , :'"', :t ::~!,','~:::: .. ! : ~ ' NOTE: If community wastewatersYstem, p~oVideWritten Confirmation from State attesting to the legality and status of systei~. ., ' 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 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. EngineeCs signature Phone DHHS SIGNATURE Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments T~e Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Apprbval:Certificates based only upon the representations given in paragraph 5 above by an indepenuent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A, Well Data Well type -~-~ Log present (Y/N) Total depth ,,~ Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 / FROM WELL LOG If A, B, or C, attach ADEC letter. ADEC water system number Date completed I ~ ~ '/ Driller Cased to ~;' ?,"~¥ Casing height Wires properly protected (Y/N) AT INSPECTION g.p.m. SEPARATION DISTANCES FROM WELL TO: 8~l~c/holding tank on lot / Absorption field on lot Public sewer main Sewer service line ), ,.5' ~'~ WATER SAMPLE RESULTS: Coliform ~'~ Nitrate Date of sample: / ?i/¢~//¢-- B.-S~=~,-~/HOLDING TANK DATA .;c / ¢/ Date installed · ~,,,'¢ ,¢ ?, Tank size Cleanouts (Y/N) / High water alarm (Y/N) Date of pumping SEPARATION DISTANCES FROM ~/HOLDING TANK TO: Well(s) on lot ... / To property line Sudace water/drainage MUNICIPALI I Y OF ENVIRONMENTAL SERVICES DIVISION .g.p:,.m'ii:'. 0 2 1994 RECEIVED ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank ~J ~ Other bacteria Collected by: ~ ~ ~ ~::: F') ¢'9¢:) Cornpartrnents Foundation cleanout (Y/N) I'--./ Bepression (Y/N) ~',/' Alarm tested (Y/N) /"/'/"/~ Pumper [/ On adjacent lots ';;~, '-/'~ Foundation Absorption field ["'///%: Water main/service line 72-026 (3/93)° Front CONTIN U E D ON BACK PAGE C. LIFT STATIOn[ Date installed ~"~, Size in gallons ~ Vent (Y/N) \ "Pump on" level at High water alarm level ~', C, ycles tested Manufacturer Manhole/Access (Y/N). "Pump off" Level at Depression over field (Y/N) for After test If yes, give date Bedrooms Meets MOA electrical codes ('~IN) SEPARATION DISTANCE FROM ,L,I Well on lot "On a~iot~' Sudace water. D. ABSORPTION FIELD DATA - Date installed So11,r,ating (GPD/FF) ...... System type ~. ' Total depth Length Width ',, .Gravel thickness Total absorption area Cleanout ~%sent (Y/N) Date of adequacy test Results '(pass/fail) Water level in absorption field before test '", Peroxide treatment (past 12 months) (Y/N) '., SEPARATION DiSTANCE.FROM ABS ELD " /' "",.. Property line Well on lot On adjacent lots/? To building foundation / To existing or abandoned system on lot On adjacent lots Cutbank ,r W~ter main/service line Sudace water Driveway. parking/vehicle storage, area Curtain drain " E. ENGINEER'S CERTIFICATION I ceCJfY that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. HAA Fee $ 'J-~'¢ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number ztE COMMERCIAL TESTING ENVIRONMENTAL LABORATORY SERVICES & ENGINEERING CO. RZ4D L, YS TR UCT£O??S O,Y ~ '/~?,I~ SID~ ]ZEP'OP,~F COLL£CT£:VG S,4: ,~ PLr. 5~UST BE CO~'~LETED BE' WATER SUPPLER t~ Se~A R~:~ds ~, Ser:.d Znvoice Month Day Year < Routine 0 Treated Water x.j Repeat Sample (for routine sampte T7/ Untreated Water N with lab ref. no. ) · E Special Pu~ose Time Collected S.AJd~PLE LOCATION Collected By 5523 S STREET A,'ICHOR.zGE..AK 33515 TEL: (907) 5~2-2345 FAX: ,~ 7 -~' -~' TO BE CO*~LEYED Bk' LA~OK&TORY .A..n~ysis shows tbJs Water .SA_\~LE to be: ~ Safis:%cton- Sa?Is over 30 hours old, resSu may be ,o,.~ ,~. L-a~it; sample shoed nx be over 48 hours old at ex~2naffon to in~ca:e rdiable ,~m~. Please send new s&mnle ~ia soeci~ ~" ~ · ' DateReceiYed ' ~ TimeReceN'ed ~ -~ah-tical Method: ~lsmbrmns ~ ND. fO-},gjO ~ Number ofco!onies/!00 mi. Lab Ref, No. Result* Sen:to AD.E.C. ~ Fb~ Faxed Date: ~{--~ T/me: Cl/eut notified of unsatisfacto~' results: Phoned Spoke with Faxed Date: ~~ BACTERIOLOGICAL WATER AxN'ALYSIS RECORD 5L~,fO-3175G Result: Total Colifm'~m Membrane Filter: Direct Count Verification: LTB Fecal Coliform Confirmation BGB E. CoE C OLEF];R_M Colonies/lO0 ml Comments: Final Yfem bra ne F..~er Results Coliform/lO0 mi -7~JV!~ONLISNYA~ SS~',,qCES iN ALASKA, COLORA©O. UT'~' COMMERCIAL TES'r'ING & ENGINEERING CO. ENVIRONMENTAL LABORATORY SERVICES Drinking Water Analysis Report for Total Coliform Bacteria ~633 8 STREET ANCHORAGE. Al'< 99518 READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECThYG ~A/rI?£E TEL: (907) 562-2343 FAX: (907) 561-5301 MUST BE COMPLETED BY WATER SUPPLIER o P ,Lic WATER SYSTE I IIIlll g PRIVATE WATER SYSTEM (D Send Resultx [] Send lm,oice SAMPLE DATE: Month ZLE TYPE: urine [] peat Sample (for routine sample J~ with lab ref. no. ) . O Special Purpose Time SAMPLE LO CATION Collected Day Year Treated Water Untreated Water Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: rx~-.~ Satisfactory Unsatisfactory 0 Sample over 30 hours old, results may be unreliable [] Sample too long in transit; sample should not be over 48 hours cid at examination to indicate reliable results. Please send new sample via special delivejy rr]ail. l),?te Received ,--[ ~/~/~_ Time Received )~ 6 -o Analysis Began ];¢7'?`'g' / AnablicaI Method: )ff...Membrane Filter [] MMO-MUG * Number of colonies/100 ml, Lab Ref. No. Result* Analyst Sent to A.D.E.C. (Anc,~ Fb~ Jun Client notified of unsatisfactory results: Phoned Spoke -aSth Date: Time: Faxcd Faxed Comments: BACTERIOLOGICAL WATER ANALYSIS RECORD 1VhW[O-bftJG Result: Total Coliform Membrane Filter: Direct Count Verification: LTB Fecal Coliform Confirmation Fioal Membrane Filter Results. Reported By. ~ ///ff~ E. Cold __ Colonies/lO0 mi BGB COLEFIRM Date //~c/_~ Time Coliform]100 mi hr, ENVIRONMENTAL SERVICES IN ALASKA. COLORADO, UTAH, ILLINO PART ONE I]F TWO: REtlAINDER TO FOLLOW TATC TM Too ~,turnezou~ To Count OB :OthcrBacterla INA COMMERCIAL TESTING & ENGINEERING CO. ENVIRONMENTAL LABORATORY SERVICES Chemlab Ref.~[ :93.6511-1 Client Sample ID :9000 CLARIDGE Matrix :WATER REPORT of ANALYSIS 5633 B STREET ANCHORAGE, AK 99518 TEL: (907) 562-2343 FAX: (907) 561-5301 Client Name :TOBBEN SPURKLANI.), P.E. Ordered By :TOBBEN SPURKLAND Project Name : Projec't~ : PWSID : UA WORK Order :73804 Report Completed :12/06/93 Collected :i2/03/93 @ 15:45 hrs. Received :12/03/93 @ 16:00 hrs. Technical Director:Sg~T~}l~ C. EDE Released By : Sample Remarks: SAMPLE COLLECTED BY: TS. QC Allowable Ext. Anal Parameter Results Oual Units Method Limits Date Date Init Nit~ate.-N 0.10 U mg/L EPA 353.2/300.0 10 12/06 DJS * See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D = Secondary dilution. GT = Greater Than ~SGS Member of the SGS Group (Soci~t~ Gbnbrale de Surveillance) ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date / GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Proper~y Owner'---%¢'~"" ~-',4~ ,~e,,... Telephone: Home ~¢/'¢' ~P¢¢ Business Mailing Address ~:~0 0 ~--'~/?" "~/ (c) Lending Institution Mailing Address Real Estate Company and Agent (d) Address Telephone Telephone (e) Mail the HAA to the followina address: or: Check hereN, if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family ~ Number of Bedrooms WATER SUPPLY Well~t~ Community [] Public [] Individual Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite 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. Page 1 of 2 72 025 (Rev 8,'86~ Fronl ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is sate, 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 flies and from my investigation and inspection, the on-site water suppJy and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this insoection. . NameofFirm ~/~/',~'~,~-~ ,~--~-'*,,',~,~'/~,,~e-,-'-Z],~m-, Telephone ~/- ~'/~ 7 DHHS APPROVAL Approved ~ ~isapproYed u Conditional Terms of Conditional Approval Engineer's Seal 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. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 fRev 8/861 8ack MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4744 Legal Description: Well Log Present (Y/N) //'b'b Date Completed / ~/'7~.: Yield Total Depth /~'~O~ Casedto "/" ~>>,c-~ IDepth of Grouting Static Water Level ~ ¢'¢" / Pump Set At Casing Height Above Ground /:~-- // Electrical Wiring in Conduit (Y/N) Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Separation Distances from Well: j To Septic/Holding Tank on Lot /' / '~'- ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /(~ ~ ; On Adjoining Lots To Nearest Public Sewer Line /¢~r2"~'-z~ To Nearest Public Sewer Cleanout/Manhole ,./O'D tv' xE To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) ~"~'~¢~ Air-tight Caps (Y/N) Depression over Tank (Y/N) ./$/':> Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /6IO Separation Distances from Septic/Holding Tank: Size / ¢~ No. of Compartments '-- / ~' . Foundation Cleanout (Y,/N) Date Last Pumped .... ~7/~.~%?~7/._~'~' ~?,-/i~ ~ <~ ~) ,,/I/~ ; for Temporary Holding Tank Permit (Y/N) /v/F-) To Water-Supply Well To Property Line To Water Main/Service Line Course /Y o ¢.¢' ./~, To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72 026 fRev 8B61 Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field ~-¢'~'~--~ - Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorpti(~n' To Water-Supply Well To Building Foundation Length of Field ~,/~¢'~¢% ,- Gravel Bed Thickness ~, 4- Standpipes Present (Y/N) Date of Last Adequacy Test TO Property Line O¢"/O' '- 5-~_ /~ -~-'g~u~'7 To Existing or Abandoned System on Lot ',~_o '/;t-Z-'~-f.,7c% ,ro~,~-,,~o,,ce-J; On Adjoining Lots ,,/Oo To Water Main/Service Line To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course /~'2_.) To Driveway, Parking Area, or Vehicle Storage Area ~ O / LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have, checJs.e_d_, verified-, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Company "~C¢~'k,~ f./ux~,,% MOA No.~ 7- ReceiptNo ~- O~/- OO/~ ~ O~. A~TH ~ . 'er ? Engineer's Seal Amount: $ Page 2 of 2 CHEMICAIJ & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 m STFIEET ANCHORAGE, ALASKA 99518 TELEPHONE(907) 562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE Client PO~ : VERBAL Req g: Client Smpl ID: i/4 GRANITE ViEW ~1 Sample Rec'd : JUL 23 87 Ordered By : Send Reports To: PENINSULA ENGINEERS 440 W BENSON STE 206 ANCHORAGE. AK. 99503 Special Instruct: COPIES HELD FOR PICK UP, 1400 7-28-87. COLLECTED 7-22-87 Work Order No. : 1888 Client Account : PENINSP Date Report Printed: JUL 28 87 9 11:26 Released By : 2 ~ Reports Address ~2 Chemlab Ret ¢: 7027 Lab Smpl ID: 1 Matrix: Water All.able Parameter Tested Result/Units Method Limits NITRATE-N ND(O.1) mCI 10 Sample ROUTINE SAMPLE Remarks: ANALYSIS COMPLETED: 7-28-87 LABORATORY SUPERVISOR: STEPHEN C, EDE I Tests Performed ND= None Detected NA= Not Analyzed * See Special Instructions Above ** See Sample Remarks Above LT=Less Than, GT=Greater Than HEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~'*:~-":°""~'~'";'~'"'~ TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER 5633 8 Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: Water System Name I.D. NO. Mailing .A~Jdr ess Cib/ State MO. Day Year ,/,._-.* _ Zip Code SAMPLE TYPE: Routlno Chock Sample (for routine sample with lab ref. no. [3 Special Purpose [3 Treated Water 63 Untreated Water SAMPLE NO. 2 L 3 I LOCATION Time Collected Collected By TO BE COMPLETED BY LABORA'I'ORY Analysis shows this Water SAMPLE to be: ~ Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Dats Received Time Received Analytical Method: [] Fermentation Tube ~Membrane FIItor Lab Ref. No. Result* Analyst J r-F1 J · NO. of coIonfe$/I00 mi or NO OI Positive portions 06.1220 (b) Ray, 1983 BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direct Count Verification: LTB Final Membrane.,P31ter Results Reported Date. Time: TNTC= Too Numerous To Count BGB Coilform/lOOml DEPARTMEK 825 MUNICIPALITY OF ANCItORAGE OF HEALTH AND ENVIRONMEN/ L Street, Ancho):a. ge, 279-25]1, ext. 224 or 225 PROTECTI ON I.~,.t(~ Received: ~_uj:y_ 21, 1977 'ri Time I! 3: ] ~e Date Date Insp Insp REQUEST FOR APPROVAl_, OF INDIVIDUAL SEWER AN]} WATER FACII,ITIES 1. Lending Institution Request: Alaska Pacific Bank Mailing Address: Post Office Box 420 Phone: 276-3110 2. Property Owner: _, J__o_h_nff_A~lv_e__r.a__Shi.~e_r.~ ........................ Phone Mailing Address: Post Office Box 10038 99502 3o Legal, DescriptJ.on: Lot 1 Block 4 Granite View Subdivision 4: Single Family Re~idence: (x) Multiple Family Residence: ( ) NUH't re]'; of BoO'rOOlUS: Three Number of Bedrooms: 5, Well System: Individual well (x) Community/Pub] ic System ( ) Permit ~ Dap'th off Well Well Log on Fi]c ( ) Conotructlon Bacterial Analysis Sewage Disposal System: Permit ~ Septic Tank Size Absorption Area On-site System (x) Public Uti. lity ( ) Ins'called _1_9_7_5_ ........ 7pst~?.; ez ................................... Manufacturor qoils Rate Material 7. Distances: Well to Septic Tank to Sewer' Line Nearest Lot line to Nearest Lot I,ine to Abnoi/DtJ.on Area Absorption A:t:c-a Page Two Depaz"ki~len% of Hea_lJ:h aud ]<_nv'n_ronme~-ka] ProkockJ. on Reqt-iest fo}: Approval of_'[11dJcidtld-I. ~-3cwor and_ W~-t_o~: b,ct. lLl"~ -' i_e: Legal Description: Lot 1 Block 4 Granite View Subdivision Comments; Affadavit Attached: ( )~ Letter Att:ached: ( ) Disapproved: Date: Department WOrksheet: ...... ~UNICIPALITY OF ANCHORAGE ' - '- ...... ~equest for Approval of Individual .~ewer and Water ~'a~J. li~J~es Property Owner: Mailing Address: Name of Buyer: Mailing Address: Lending Institution Mailing Address: Phone: Single Family Residence: (~ Number of Bedrooms: Multiple Family Residence: ( ) Number of Bedrooms: Water Supply: *Individual Well (~ If Individual Well, well depth If Conununity System, name of system Public/Con~nunity System ( ) Sewage Disposal System: On-site System If On-site System, date of installation: (~,~ Public System ( ) ~NOTE: A well log is required on ALI, wells drilled since 6/75. 3/'77 06 12201o) Rev 1973 AL,,.KA DEPARTMENT OF HEALTH AND SOCIAL SE~iCES DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGI CAL WATER ANALYSIS Lab No OFFICE INDIVIDUAL NAME ' ~'~ ADDRESS ADDRESS SEMI.PUBLIC [] CHLORINE RESIDUAL PPM REPORT RESULTS FO Aha ,/sis shows Ihis Woler SAMPLE to be [] Unsohsfoclory [] Queslionoble [] Sumde too ong - transit somD~e shoulc not be ow, r 48 hours o~o et exomlnohon to indi£ole rehoble results. Please send new sample, SANITARIAN S REMARKS _ COMPLETE THIS SECTION ONLY IF W~TER IS ,~h/JNDIVIDUAL SUPPLY . >:¢ SAMPLE COLLECTED BY ~ - ' IT- ~ ,{_/ Sample Collecled F~om ~....Kitchen TOD [] Bolhroom ToD [] Bosemenl ToD [] Other (LlSl) Well- [] Dug [] Drwer [] Drill.~a [] Bored SOURCE; [] Spring [] Cistern [] Olber__ 'Dug Wall or C~slern ConstrucUon: Woll~- [] Wood [~ Concrele [] Meta ~ Tile Brick or Top -- [] Wood [] Concrete [] Mole ~ Open Too [] Concrele LOCATION: [] In Bosemenl [] Bosemenl Offsel [~] Under House [] In Yard [] Olher Building Sewer DISTANCE TO or Other Drainage Pipe Tde Seeoag~ Field _Feet. Pit Other Possible Sources of Contam)nohon MATERIAL: Budding Sewer [] Cos~ Iron E) Ploshc Jotul McJter ) TVDO Cess- _Feet. Pool Feet Priw -eel E] Wood [] Tile E] Fibre [] Asbeslos Cemenl [] Ye~ [].No GENERAL Does Water Become Mudd, or Discolored? When? D ...... ,erofWdl (..~ ': .De.th__ 1(>~') Eom Well Casing PUMP LOCATION [] n Well [] Bosemem [] n Basement [] Roan On Top J J~ Of Well C~ Olher , PURPOSE OF EXAM NAT ON: Illness Suspected? [] ~es [] No -' ~ '~ ' New Sou ce o Supply'~ ~. L [] Yes [] No RepoustoSvs~em? [] Yes [] No Signolure__ \%~ READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE Rev 19/3 48 Houri Brilliant ,Green 24 Hours 48 Hours .--MB BACTERIOLOGICAL WATER ANALYSIS RECORD ,,'"ip' "\ 1 Otc ~cc I Occ I Occ I_Occ _l..Occ _AGAR tMosl probable No. per 100cd !~isk ~anaf~men% ;~enior F, nviron~mmnta! S]?eci~list. i~)t 2 131o~k d Granite View Subdivision John Shiers :£ncluded is ad. di'tional information from t_h<~ o)',~tbuds~.~an Also~ note that ~.~,, Shi;.~r~' neighbor on Lot 3 ~lo~k 4 had a ~:~e].l and sev~r system installed prior %0 ~}~r~ Sb. ie~s o~] Lot 1 Block 4. Mr. Shiers could have inst:alled his we].], in a differ¢-'nt: conffiguration so as to allow more area for ?laco~,~ent of an on-sit:e se~er on Lot 2 [~tock 4. Laws do not state placeI~'~n~t confif~ura'ti~ms for n~ighborin~3 l~roI~er,I~y~ Th(~ I)eparl:n~ank o~ lt~al%h and En~ronmentat J~rogectJ. on does not have final aueho~:ity for ].ot size when subdivisions are approva~. As s%a%cd in encloseS~ o~rrespon~]enoe som~'~ lots a~:e not ~[evelopable un'til ]?ub!ic sewer is avai],~;le~ A holding tank op'tion no lon~jer e~ists since S'hat~ law is }?rohibitinq this method of d, is~?osal. Les N. I~uchholz~ .l~.go S~ior Environemental St?ecialis-~: