HomeMy WebLinkAboutTIMBERLANE PARK #1 BLK 2 LT 5
8~-~14
........... OUT TO THE DEPTH OF 65 i'eet.
PER FOOT. Steel casing seated out to 65'.
PROPERTY OWNER ~;~r.k ordered by p~ll Taylor 244-6233~
UOCATION OF WEkU SlTF Lt. 5 5!k. 2 Sub. Timberlane~~
DRlkkER ~ernie Claus of Kampart Drilling Works
WELL LOG:
0 - 16' SLlty sandy fine gravel. 4u~ clay material.
16 - 44" Coarse gravel. 35% clay.
~: - 62' Hardpan. A cemented gravel.
2ol 5a:,~ona St.
SIX INcH WATER WELL DRILLED
DRILLED AT THE RATE OF
62 - 65' Water bearing fine gravel going into a coarse water bearing gravel
from.63 to 65 feet. This Water Well is producing. 10 gpm, with water re-
covery back up to v~ithin 30 feet oi' surface. 1/2 horsepower submersible
pump should be installed ~ to 8' feet ol'f bottom. Both the water quantity
~. 'cuality are excellent.
· I~t ot Anchorage
~ug~.o'P?~ ? ~.man Services
Dept. Heakn
charge for mobi~zation or de~ob. ;:.:o charge Ior set up.
T~tkl cost of %Tster ~/ell: $24.00 x b5 ~'eet: $1
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF $~ ~ ~bQ).
THANK YOU VERY MUCH.
August 27, 1992
DATF
B~NIE CLAUS OF~WORKS
SERVICE CHARGE OF 1~4% PER NIOI~'TH WILL BE ASSESSED ON PAST DUE ACCOUNTS.
I 2di ka:,~ona St. 9951 ~ ANCltOIIACIIE~ ALASKA
~IX INGH ~AT~R W~LL D~ILL~D .......... OUT TO TH~ D~PTH O~ 6~ ~'eee.
DRILLED AT THE R~E OF ~24 .O0 PER FOOT. Steel casing seated out to 6>'.
PROPERTY OWNER ~}/qrk ordered oy _~11 Taylor 244-6233
LOCATION OF WELL SITF Lt. 5 21k. 2 Sub. Timberlanel
DRILLER ~ernie Claus of Eampart Drilling '~or~s
WELL LOG:
0 16' Si_lty sandy fine gravel. 4u% clay material.
16 - 44" Coarse gravel. 35% clay.
44 - 62' Hardpan. A cemented gravel.
62 - 65' Water bearing i'ine gravel going into a coarse water bearing gravel
from 63 to 65 feet. This ~¥ater Well is producing 10 gpm, with water re-
covery back up to within 30 £eet ol' surface. 1/2 horsepower submersible
pump should be installed ~ to 8 feet oi'f bottom. ~oth the water quantity
quality are excellent.
charge i'or :aobiiization or de,~ob.
charge
· alit ot Anchorage
lYtua~.c,P,.,_ t~ Human Services
Dept. Heatt~ ~-
i'or set up.
Total cost oi k~:eter ;:¥eli: $24.00 x b5 ~'eet: $i,Sbo.oO
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF ~1, ~bU. ~',J
THANK YOU VERY MUCH. ~ ~
B~NIE CLAUS OF RAMPART DRILLING WORKS
A:~gust 27, 1992
DATE
SERVICE CHARGEOF 1'/~% PER MONTH WILL BE ASSESSED ON PAST DUE ACCOUNTS.
PAGE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM PERMIT
PERMIT NUMBER:SW920249
DESIGN ENGINEER:DUMMY COMPANY
OWNER ............. ouT~,~r A
OWNER ADDRESS:743 1/2 WEST 4TH AV
ANCHORAGE,AK 99507
DATE ISSUED: 8/27/92
EXPIRATION DATE:
PARCEL ID:01914228
LEGAL DESCRIPTION: TIMBERLANE PARK #1 BLK
5
2 LT
LOT SIZE: 22263 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
1 OF
8/27/93
DATE .~~
HUMBLE COURT'
0
Io' u'r~ L. ~$~1T.
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 019-142-28
Certificate of On -Site Systems Approval
Expiration Date: J 1 'Z4 2 3
Legal description TIMBERLANE PARK #1 BLK 2 LT 5
Site address 11821 HUMBLE CT
Current property owner(s) ANNE KRANAWETTER
X The On-site system(s) is/are approved for 4 bedrooms
Conditional approval for
Comments or advisories:
bedrooms, with the following stipulations:
Original Certificate Date: 120-2-3
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 ApprovMjune 2022
MUHMPAUT Y OF A' Hi C = J 0 R, A G Em R,
Development Services DepartmentPhone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 019-142-28
Complete legal description TIMBERLANE PARK PHASE1 BLK 2 LT 5
Location (site address) 11821 HUMBLE COURT, ANCH AK
Current property owner(s) KRANAWETTER
2. ON-SITE SYSTEMS SIZED FOR 4 BEDROOMS
Day phone
3. TYPE OF WATER SUPPLY: X 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 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑® AWWTS ❑ Bed ❑ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: M
Distance:
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 $ c� c(g Waiver Fee $
Date of Payment Date of Payment
COSA # 0SG 2,-5 1 1 7 Waiver #
COSA Application_ June 2022
Legal Description:
COSA Checklist
TIMBERLANE PARK PHASE1 BILK 2 LT 5 Parcel ID: 019-142-28
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system _
A. WELL DATA
❑NI Well log is filed with Onsite (or attached)
Date drilled 8/27/92 Total depth 65 ft
Cased to 65 ft
❑N Sanitary seal is functioning correctly
N Wires are properly protected
Casing height (above ground) 24 in.
Date of flow test for COSA 3/14/23
Static water level at beginning of test 12
Comments
B. TANK DATA
Measured operating fluid level in septic tank _
Date of pumping
❑ Required maintenance completed, if AWWTS
Comments:
D. ABSORPTION FIELD DATA
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
Comments/Deficiencies:
COSA Checklist June 2022
Well production at time of test 2.8 gpm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes N No
0 Coliform bacteria is Negative
Nitrate 1.48 m /L ❑ Nitrate less than MRL (ND)
Arsenic
Collected by
Date 4/17/23
g
_ ug/L M Arsenic less than MRL (ND)
MNA
C. LIFT STATION
❑ Required maintenance completed
Age of lift station _ years
Lift station material
Comments:
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
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 _ ft
Neighboring Tank > 100' ❑ Yes if No _ ft
Absorption Field on Lot > 100' ❑ Yes if No _ ft
Community Sewer Manhole/Cleanout > 100'
❑ta Yes if No _ ft
Private Sewer/Septic Line > 25' [C Yes if No _ ft
Holding Tank > 100' ❑ Yes if No _ ft
Neighboring Absorption Fields > 100' Animal Containment > 50' [E Yes if No _ ft
❑ Yes if No _ ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' n Yes if No _ ft Q 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 Surface Water > 100' ❑ 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
F. ENGINEER'S COMMENTS
LOT HAS AWWU SEWER SERVICE
Wells on Adjacent Lots:
Private Wells > 100'
Community Wells > 200'
❑ Yes if No It
E] Yes ifNo_ft
If tank or field is under driveway comment below
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 /in1/2'c /A /r Ac(, <940 h IP C,
Engineer's Printed Name A* l4'A-r, c�
COSA Checklist June 2022
Phone 727-8864
Date 4/2 3
f� ......
f
��. MICH;Cl N. uFB'oCfl .
CE -946,I,
i
i, ( )..e. �21
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY AppROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 019-142-28 ..
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
HAA # ~ ~,~(~.~
Expiration Date:
Lot 5 Block 2 Timberlane Park Phase I
11821 Humble Court, Anchora.qe, AK 99515
Current Property owner(s). Jerry & Shirley Wells Day phone 349-9994
Mailing address 11821 Humble Court, Anchora.qe.1 AK 99515
Lending agency
Mailing address
Day phone
Real Estate Agent Careen Muir ~ Dynamic Properties Day phone 727-2289
Mailing Address 3111 C Street, Ste. 100, Anchoraqe, AK 99503
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
:. Individual Well [] Individual On-site r'-I
· Individual Water Storage [-'1 Individual Holding tank r"]
Community Class Well [-'1 Community On-site r-1
Public Water System _. D Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to home owners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. Certificates are valid for on'e year for properties served by Class A
or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
{Rev, 1 '1/99)
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
based on procedures outlined in the Health Authority Approval Guidelines for 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 applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone EnR. Svc.. Pl~one 272-8218
Address P.O. Box 102954, Anch, AK 99510
Engineer's Printed Name Steven R. Pannone, P.E. Date
' . nductin an adeauacv test, I attempt to prowde a thorough, conscientious _~n,~,~.~l .~ ~ ~
1°f
the test. and seoaration distances measured to readily identifiable features. The operat' ' m ,.- ' "
· ' temsde end on the local soil condition, ground water levels that may fluctuate ' ' _~ '~: ztOTH '~
wells and septic sys p ........... : -~-- ,< -, ..
during the year, and the water usage of the family being served by m.e s~te.n~., s ne. se .c.on~m.uons. ~.e ..... "s ~ ..... :~ .....................
· ntrol of the evaluator of this system· All systems evemuany Xml uno saus~acmry test [c~u, ~,,,~3~t,
· o. uts, .e the co .......... do ,hey a,at there are .o hidden defect ..f ..............
est~. g Y on ~ ·
do no! guarantee luture perlorn~nc~ vsu,~ ~v ..... ', ....... - ~ · ~. ~ ~ e, ..... o i none
., can therefore not rovide any warranty for future performance nor gwe any ~,-0~%Steven R. Pon
°r~r~rt°ea;fh~noe~t]~.,EtShes stem will contiPnrue to meet the operat'°nal requ'rem, en. ts°fth, eAD,E.C°r ~";/~C~"o, No. CE 814g
. e orr is for the sole benefit of the owner listed at)ore. ^nY redance uP ~,~..~..o~,.tt,,~t_~'..,
MOA DSD The content ofth,s r p ........ . ..... vS?,~,;,'~..."'w~'-..~.-'.
or use of this report by any other person or Party is not aumoriz~ nor w,i ~t comer any ~ega~ ngnt 'q~,50 ,;~ ........... ~xt,,~
6. DSD SIGNATURE
Approved for. 14-
Disapproved.,
Conditional approval, for
bedrooms.
bedrooms, with the following stipulations:
Additional comments
., ' ~JJfljj)) ] ] ) ) ) }t
~aintenance Agreements
Supplemental Engineer's Repod
Other
Attachments: HAP, Checklist
Septic System Advisory
Well Flow Advisory
Expiration Date:
(Rev, 11
X
Reissue Date:
Legal Desc'rip!ion:
A. WELL DATA
Bo
Municipality Of Anchorage
Development Services Department
t' i Building Safety Divisionl ', ~
~, on-site water and Wastewater iSrogran~
470OSouth Bragaw Street .
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.an(~horage.ak.u§
(907) 343-7904 "
HEALTH AUTHORITY APPROVAC CHECKLIST
Lot 5 Block 2 Timberlane Park Phase I
SEPTIC/HOLDING TANK iDATA -'
Date installed I Number of CompartmentS, .
Clean0uts , Foundation cle~~ Depression over tank · High water' ~larm
Date of pumping.
ABSORPTION FIELD DATA
Date installed-'~_S~)ilra~i~r~(g.~d./ft2orft2/bdrm)" System type
Length ' ...ft - -. ~i(~b( ft : . Gravel below pipe .... l ft
Total depth ,ft.-. Effective ~ptl~¥~..,~._ ft2 .Monitoring tube Depression °v~r field, ~_.
Date of adeqUacy test ~ . ~Results:(Pas~..~; '_ " --- I_ ~/ -- -~. For '' bedrooms'
Fluid depth in ab~ ;';. '~ in- ~dde~ g~l... ' New depth
~'~.~b >= g~p.d.
.Elapsed Time: 0 min ., , Fin~lfiuid depth .:" in sorptio~
rate
Any rejuvenation treatment (past 12 mo.) (YIN & type) . ' yes, give date
Well type P
Date completed 812711992
If A, B, or C provide PWSID
sanitary seal
Total depth, 65 ft
Cased to 65 ft
FROM WELL LOG
Date of test
Static water level
812711992
30
10
ft
Well production
WATER SAMPLE RESULTS:
Coliform , 0 colonies/100 mi
Date of sample: 6/16/2004
g.p.m -
Nitrate 1.34 mg/I '°, '-"Other bacteria, 0 colonies/100ml
Collected by: Laura Pannone
i
Parcel I.D.: 019-;142.28
Well Log _Y
Wires properly protected v
Casing height (above grout .!) 26~ in.
AT INSPECTION
6116/2004
"40 ft
3.0 g.p.m
(Rev. 11/99)
"D..LIFT STATION
· ': Date installed .... Si'~[ng~ll0ns' ' ,,,. i.:_ ' Manhole/Access
-'--~,,
' "Pump on" level at in"Puml~'~,~t.' :,. ':,'~, ~ , in High water alarm level at in
Datum . ~ qycles test~[~'. '"' ' Meets alarm & circuit requirements?
E. SEPA~TION DIST~CES . ~ ~
Sepfi~ ~an~l~ff statio~ on Io~ ' On ad~
Absorption field on Io~ On ad]acen~ lots
Public se~er main 100+' ' ~ Public sewer manhole~cleanou~ 100+
Fe
Sewer/septic service line 70+ Holding tank
SEPARATION DISTANCES FROM SEpTIC/HOLDING TANK ON LOT TO:
foundation ' ' _"~~e~ line Ab~Orpti0n field
Building
Water main ..... I/~W~service line Surface water
Drainage 'I ~/ells o~,~djacent lots '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: .
'~ i Water main' :'
Property line Building~fouqdation.
water servi~e line~:" ' .' , 'S~~w~r"' ' --... ',
Curtain drain .... We~~nt lots'
!1~
COMMENTS
G. ENGINEER'S CERTIFICATION
DriveWay, parking/vehicle storage.
I certify that I have determined through field inspections and .
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines.in effect 'On this date.
Engineer's Printed Name Steven R. Pannone, P.E.
HAAFoe $ ~0-c~'
Date of Payme,nt 5 - ..
Receipt Number . ~-L//' ~' 7 ~_~'x'
(Rev. 11/99) .. -
Waiver Fee $
Date of Pa~ent
Receipt Num~r
06-22-0~ 0~I~
FI~I-crgE ESI, SGS ENV SE~ICE$
9075~15301 T-828 P.O1/OZ F-762
Laborato Analysts Report
SGS Ret#
ClOne fiamp]¢
MatHz
0
1043375001
Parmone Eng. Srv.
Timber Lane Pa~ke9 Pha~ I
Lo~ ~ BI~ ~
D~g Wa~r
All Dete~q'imes are Al~]~a Standard Time
Prlated Date/Time 06/18/2004 14:41
Cofleeled Dat~fflme 06/1~0~ 1 i :~
~ived Date~lme 06/16~ 12:ll
Unit! Method
,Al, lowabk: . Prep
Cont~r. tr iD I-f~at~ rp~
B (<=101
Toni ColLform
~ol/lO~mL SM20 g22:LB
^ (~11
t;'{~F, ..-.,.,--, ;.1 ~. v,t.,.:. I,,,. ! Lab~ltury~ivi$~: 200 W_~.I aetter Olive.. A~cl
I ~ .~,d ~o ~ I L/.OZ ou~etu i~lllUJ~uuji xel pu'eJq ,,1Pl~Od
.q-L~ a H
~(~ 'd
· : 2.06
S~13(]:'1] ns: ...
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
GENERAL INFORMATION
Complete legal description
HAA #
Location ('site address or directions) ~ )__ ~__c~ ~.___<~
~ ~, ~ ~ ~ ~ Day
Mailing address ~ ~~~~ phone
Lending agency __
Mailing address~ _
Agent _
Address
Day phone_
Day phone _
4. TYPE OF WASTEWATER DISPOSAL:
Unless otherwise requested, HAA will be held for pickup.
Individual well
Publio water ~ _
NOTE: ,fcommunitywellsystem, providewrittenconfirmation;;~;t~A
~ng to the legality and status
of system.
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If Community wastewater system, provide written confirmation from State
attesting to the legality and status of system.
(~ Municipality of Anchorage ~
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: I ,~'; ~ ~;Z- '~--~4,~,~ Parcel I.D. 0 / ~ ~ / ~--,~- - '~ ~
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
Date completed ~/~'1/~Z-' Driller
Cased to
FROM WELL LOG
~ --~ Casing height
Wires properly protected (Y/N)
AT INSPECTION ~
g.p.m, g.p.m, rw'l o
; On adjacent lots z
Date of test
Static water level
Well flow / ~ '~
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
;On adjacent lots
Public sewer, main
Sewer service line
Public sewer manhole/cleanout
Petroleum tank
Nitrate ('2~. ' ~''& Other~acte~a
Collected by:
Tank size Compartments
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Foundation cleanout (Y/N)
Depression (Y/N)
Alarm tested (Y/N) ~
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot On adjacent lots
To property line Absorption field
Foundation
Water main/service line
Surface water/drainage
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
. Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
sEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot '
D. ABSORPTION FIELD DATA
//.-~
Date installed
Length: Width
Total absorption area
Depression over field (Y/N)
Resu'lts (pass/fail)
Peroxide treatment (past 1~ months) (Y/N)
On adjacent lots
Soil rating
Gravel thickness
Surface water
System type
Total depth
Cleanouts present (Y/N)
Date of adequacy test
for
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
If yes, give date
bedrooms
On adjacent lots Property line
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or co~formed to all MOA and HAA guidelines in effect O~ the dale of this inspection.
Signatu re ~ /2L~..~ ,~ u '~'~',
Engineer's Name
Date
HAA Fee $ /
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5533 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS RESIILTS for INVOICB :! 60997
Chemlab Ref.{ 92.6480 Sample { I Matrix: WATER
Client Sample ID : LB B2 TIMBERLANE tl KITCHEN TAP
PWSID : UA
Collected : 11/23/92 @ 15:35 h~s.
Deceived : 11/23/92 6 16:30 hrs.
PreserYed mith : AS REQDIRED
Client Name :A.W. MURFITT CO. INC.
Client A¢¢t :AWMUREI
BPO~ : PO# :NONE RECEIVED
Req~ :
0rde[ed By :BILL TAYLOR
Analysis Completed : 11/25/92 Send Reports to:
Laboratory Supervisor : STEP~N C. EDE lJA.W. M~RFITT CO. INC.
Released By : ~../~~ 2)
Parameter Results Units Method Allowable Limits
NITRATE-N 2.58 mg/l EPA 353.2/300.0 10
Sample ROUTINE SAMPLE COLLECTED BY: DILL TAYLOR COLONY BUILDERS, WITNESSED
Remarks: BY KEVIN BOERMAN.
1 Tests Performed See Special Instructions Above UA=Unavailable
ND= None Detected "See Sample Remarks Above
NA- Not Analyzed LT=Less Than, GT=Greater Than
~SGS Member of the SGS Group (Soci~t~ G~n~rale de Surveillance)