HomeMy WebLinkAboutSPRUCE ACRES LT 14
DEPARTMENT OF HEALTH & HUMAN SERVICES
Div sion of EnvJronmenta Serv ces
'~ On-Site Semites Section
..... -; ~'- --~:?
~ '~ ........ : ............ ~7~ .......
..... CERTIFICATE OF H~LTH AUTHORI~
GENERAL I~FORaATION -'
_COmplete legal description-~_ Lot 14; Spruce A~
:' ,' iPr0P;~wner '??'-J~dY-- Day phone
' -;' - Lend~.ng agency Day phone '.
-' '~:- =~ A~ent ........ StCu6 8~¢~/ R~ Re~ -*-¢ Day phone
? -~'/5;:: ~;(~:~, P Unless}~the~ise:requested~, H~ w~ll be_ ~d~_f~r
..... ~ NUMBER OF BEDROOMS ....... .;~ . ~
_.- NOTE: If commu~ ~ell system, prowde wnffen ¢onfirmation from
: .-..-.. - ~. lng ~ the leg~ and statue of system. , -~j-- "-;~" ''~ "" "'
,4. ~PE OF WASTEWATER.... DISPOSAL: ... : ~ ~ ..;: .-
~ .NOTE:. ~fc~mmum~;~as~e~ate~sys~em~pr~w~rt~nc~nfirmatt~nfr~:¢t~:;,"~?`~
' ' ;:.. affesting m t~ legali~nd Status of system. '
STATEMENT OF INSPECTION 'B~ ENGINEER:,.~.,: .-~-
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Hsalth Authodfy Approval application shows that the on-site water supply.
and/or wastewater dis0osal system is safe, functional and adenuate for the number of bedrooms
and type of structure indicated herein, I turther verify that based on the information obtained from
the Munici pality of Anchorage files and from my inves.ti, gation 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 effecton the date of this inspection.
17034 Eagle Rlve~' Loop Road
Name of Firm
Address
Engineer's signature
6. DHHS SIGNATURE
Approved
for
· --' ~-~ ~ ,', · ':":~:.~'-v
· roved ..- - :, ~x:. ~...-,;:~.::u;.. .: .......... ~.~-
_u: ' _ Dlsapp · · . :w:::. ~,:.~-,-.-.. -...... ,. - .... :: .,,;~: .... ,~ n~, ~:,. ,
-; Condltlonal approval fof:'~'m-' .:v,-.,. - bedrooms, with the followmg~zst~pulabons:,.':.':-F.:`.
~ ~.Additional Comments
Date .2. - /,~ - ~..5~
· The N{bhmlpality o('~.[~c~orsge Department of Health and Human Services (DHHS) issues Health Authority
"~pprova ~rt I caie~'bas~:l only upon the representation~/ given in par~agraph 5 above by an independent
-,pro,fes~,[o~al eq,gl~, r regmtered ~n the State of Alaska· The DHHS does thi~as a courtesy to purchasers of homes
and thei~:t~nding ins{itutions in order to ~tlsht Certain f~ieml and state requirements. Employees of DHHS do not
conduct Inspections or analyze data before a certificate ~s ~ssued. Th.,e MUnmlpallty of Anchorage is not
responsible for errors ~r om~ss~ons ~n the prof~?~onal engineers work, '~, :. ' ~:'
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type
Log present
Total depth
Sanitary seal
If A, B, or C, attach ADEC letter. ADEC water system number
]~'~ Driller
Date completed
Cased to ~'O '~' ' Casing height
W res properly protected (~/N)
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/l~ank on lot /~//,//-
Absorption field on lot /J//~
FROM WELL LOG AT INSPECTION
g.p.m.
; On adjacent lots /~
; On adjacent lots
Public sewer main '~ ~ Public sewer manhol~t
Sewer service line I0 "J- Petroleum tank
~ Nitrate ~gO~ ~7~ Other bacteria
Col~orm
Date installe~ · Tank size Compadments
Cleanouts (Y/N) ~ Foundation c~eanout (WN) .~Y/N)
High water alarm (WN) ~ Alarm~)
Date of pumping ~_ ~er
SEPARATION DISTANCES FR~ _
Well(s) on lot / O~ ~ts ~ndation
To p~;~ __~Bsorption field__ ~ _Water ma~
72-026(~)'F,~t ~ ~E gTz~o ~TrE~ ~b CONTINUED ON BAC GE
~TATION ~
Date inst'alt~ __ Manufacturer
Size in gallons '"'--.. Manhole/Acces~ ~
.~-~--"Pump off" Level at
Vent (Y/N) ~1 at. _
High water alarm level ~__.~-~Cycles tested
Meets MOA electrical codes (Y/N) ,.-.---~_'"'"'"~_
SEPARATION~~STATION TO: ~
.~j~lot"- On adjacent lots Su dace w~.... ~-
D. ABSORPTION FIELD DATA
%._
Da"~'it 'nstalled Soil rating (GPD/FF) System type
Length'"--..~ Width Gravel thickness Total depth /
Total absorption area~ Cleanout present (Y/N) Depre~ (Y/N) _
Date of adequacy test ~ Resulte (pass/fail) f ~o"r Bedrooms
Water level in absorption field before te-"~'~'-%s ~ test
Peroxide treat, ment (past 12 months)(Y/N) ~~/If yes, give date
SEPARATION DISTANCE FROM ABSORPTION~'"'--.~.
Well on lot __~Q.~dlCacent lots ~ Property line
_.To existing or abando~ lot.
To building foundation ~'
On adjacent lots J Cutbank __ Water main/servi~..~
Sudace~~ Driveway, parking/vehicle storage area
Cu~taifi drain ~
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
Signature ~"~¢~/'- ---~,
Engineer's Name
Date
H~ Fee $ ~. ~ Waiver Fee $
Date of Payme~ ~~ ~ Dato o, ~ayment
Receipt Numar ~'~/} Receipt Number
72-026 (~)* ~ck
14:15 COMMERCIAL TESTING ~ 9076941211 N0.636 ~05
CHEMICAL & GEOLOGICAL LABORATORY
A D]VZ$ION OF. COMMERCIAL TESTING & F_NG, FN£EP, J'NG CO.
TELEPHONE (907) $$2-2343
o
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
15~,PuBLIc wATER SYSTEM I'D' # FI t I [ I I
PRIVATE WATER SYSTEM .
SAM~'~ OATE:
~o, Day Year
SAMPLE ~PE:
~ Check SampIe (for routine ~ample
with Jab ref. no. ~ ~ O Treated Water
0 Special Purpose ~ Untreated W~ter
SAMPLE
TO BE coMPLETED BY LABORATORY
Analysis shows this Water SAMP,LE to be;
[] Sample leo long in tr~.nait; sculpin should
lo indiczte reliable tesu~s. Please send
new sample via special delivery mail,
Time Receiv,d / ~
Method: Membrane Filter
A.D.E.C. ~
· No. ofcclonies/100mL I t ~ ~
· ' Result'
i FT-q
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
_COLLECTING S .AMPLE
TNTC = Too Numerous To Count
OB = Other Bacteria
Reported By ,. ,
Coliforft¢100 mi
~2×02/95 14:12 COMMERCIAL TESTING ~ 90?6941211
CT&E Environmental Services Inc.
~ampls R~marks= sAMPLE CObLECTED B¥~ J.W.
Nicrate-N 0.~0 U mg/L ~PA 353.2 10. 02/01/~S ~
DEIPT. OIt [BNVI#O~ME~TAt,
October 26, lg?9
John KILnge=
Sen£or/~dmtn£strattve O£ftcer
Anohorage Water and Sewer Ut£1itles
300~ ~otlc Blvd.
~nchorage~ ~laska 99503
~UBJECT: Plan & Spec££1cetion Review
S78-14-3640, 006515
D-l-1 Trunk
(Your letter 10-19-79)
Dear ~ohn:
~ have rev£e~e~ the plans, specifications, and bid
doc~unents fo~ 2he 8ubJec2 p~o~ect. The se~er project cons~StB
O~ 69ZSLF o~ 16-inch DIP, L,325~ of 12-Snob DIP~ 2~0LgLF of
10-~nch DIP, an~ 162LF o~ 8-~nch D~P, manholes and other
I ~ve no co~en~s or ~eco~enda2~on, conce~n~n9 these
plans and specSf~cations ~hich a~e approved got items of
concern to 2h$8 Dependent.
Please ~o~ar~ cop~es off the hsd tabulations and the
not~ce ~o proceed ~hen available.
Engineer
2.24,0
2.24.4
2.25.0
2.25.1
2.25.2
2.25.2.1
2.25.2
2.26.0
2.27.0
2.27.1
BORING AND CASING (Continued)
the plans), which payment shall include ail payment [or
furnishing, jacking or boring, for installing of casing
vation and backfill where the casing is installed.
and manholes are prohibited without proper protection
against contamintion of the water wells.
Construction= The following are required for the
minimum of four inches (4") of concrete around the Joint
and for a distance of no less then six inches (6") each
direction from the ~oint in accordance with the Sewer
Encaeement Detail shown on Sheet 12 of 12 of Plans for
those Joints falling within a seventy-five foot (75')
radium of any well shown on the plans,
Basis of Payment; These items of wo£K will be incidental
ADDITIVE BID SCHEDULE B
NONWOVEN FABRIC ~ATEHIAL FOR ROADBED
IMaoription~ This item consists o£ lurntehing,
preparation cE backfilled trench and adjacent roadway,
and placing by hand a nonwoven fabric material. The
purpose o£ the material is to distribute the weight of
the gravel overlay section evenly across the fill area
within the traveled roadway,
2.0
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
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner (/~
Mailing Address 82- ¥/ ~,~-.~ /~;,
(c) Lending Institution
Telephone: (home) 3 5'¥-,~ t?'~ Business
,~tc4~,~-,,_~. .4-A- ~-~7
Telephone
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here ~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family E~ Number of bedrooms
3. WATER SUPPLY
Individual Well [] Community [] 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 DISPOSAL
On-site [] Public J~ 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
5. 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 th is
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional ~nd 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.
Name of Firm ~'(¢,/-,,fof, 7"~-c4,~'~r~f £~,,¢~' Telephone ~' Yb-- 13 5-~-
Address I
Date
6. DHHS APPROVAL
Approved for ,..~' bedrooms by
Approved ,.._.-'/~ Disapproved
Terms of Conditiorial Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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.
72-025 (Rev. 7/88) Back Page 2 of 2
~ MUNICIPALITY OF ANCHORAGE (MOA)
(~*,~1(_~-,I Health Authority Approval (HAA)
~ CHECKLIST - FEBRUARY 1984
MUNICIPALITY OF ANCHORAGE 343-4744
ENVlRONMENTALS£RVICESDIVISlON Legal Description: J. of-
SEP 2 7 1989
A. WELL DATA
Well Classification /'~ ~J"E J V E D
Well Log Present (Y/N) ~ Date Completed
Total Depth ~.¢ Cased to ~-s'~' Depth of Grouting
Static Water Level '] E"
Casing Height Above Ground I q"
Electrical Wiring in Conduit (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 ~'la/-J, gf
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At '~ ,~'o '
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
N
; On Adjoining Lots
N,~. ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
.~%, ¢.r ; Date
Water Sample Test Results ~¢ ~.~..¢~ ~y - ~ (o [-/~'~, //o¢/~ ¢
Comments ~W ~f~n~ ~ ~I0 ~1(o~ ~n ~/Zl/~
B. SEPTIC/HOLDING TANK DATA N,~. ( p~hl;c ~t~)
Date Installed Size No. of Compartments
Standpipes (Y/N) Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Foundation Cleanout (Y/N) .
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA /~(. ,/~.
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present)
D, LIFT STATION .N,,4,
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed
Company
Date
MOA No.
Receipt No.
Date of Payment
Amount: $
Receipt No.
72-026 (Rev. 7/88) Back
Seal
Waiver Fee: $
Date of Payment
Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~°~ ~ i~
~~'~"k 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (607) 562-2343 ~o
~ ~..~--,'.',~"....~ FEDERAL TAX 19 # 92-0040440 . ~
ANALYSIS REPORT BY SAMPLE fo~ Work Order- ~ 16883 Date Hepo~t Pzinted: SE? 25 89 .~ 18:35
Client Sampls ID:LOT 14 SPRUCE ACRES
PWSIU :UA
Collected REP 20 89 ~ 14:00 bra,
Heeelved SEP 20 89 ~ 15:10 hrs.
Preserved with :AS REQUIRED
Clier~ Name · FLATTOP TECHNICAL SRV
Client Aect : EDATTOT
P.O.~ NONS RECEIVED
Chs~ab ~e£ ~: 7629 L~b 8~p]. ID: 1 Matrix: WA~ER
~llowabla
?a~a~ete~ Te~ted Result/Units Method Limx~s
HITRATE~N ND(O.IO) [~/1 EP~ 353.2 10
Sample
Ro~azks;
i Testa Performed ~ Ssa Special Instructions Above UA=Unavailable
ND= Hone Detected ** See R~ple Henm~k~ Above
A CHemiCAL ~ OeOLOG~CAL L, Bomromes or ~r~s~, ~yc.
[~l:: :~ .
:A:~% Dr,nking Water Analys,s Report for Total Cohform Bacter,a
TO BE COMPLETED BY WATER SUPPLIER
~ PRIVATE WATER SYSTEM
SAMPLE DATE: ~
MO,
Phone No.
State
Day Year
Zip Code
SAMPLE TYPE:
~ Routine
[] Check Sample (for routine sample
with lab ret. no. )
[] Special Purpose
[] Treated Water
~ Untreated Water
SAMPLE
NO. LOCATION
21 I
3
4
5
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
atisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
n~w sample via special delivery mail.
Date Received
Time Received
Analytical Method: Membrane Filter
* No. of colonies/100 mi.
Lab Ret. No. Result* Analyst
' ~-~ FFd
I
I
I FF~
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Membrane Filter:. Direct Count
Verification: LTD
Final Membrane Filter Results
TNTC = Too Numberous To Count
OB = Other Bacteria
[C~ ~>~t~ Collform/100ml
Date
Time:
a.m.
PART O~'~ OF 'I~EO
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 5633 S Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
TO BE COMPLETED BY LABORATORY
[3 PUBLIC WATER SYSTEM I.D.#
~ PRIVATE WATER SYSTEM
Name Phone No.
Mailing Address
City State
Mo. Day Year
Zip Code
/~aslysis shows this Water SAMPLE to be:
atisfactory
[] 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.
Date Received
Time Received /~'O''~
SAMPLE TYPE:
I~I Routine
[] Check Sample (for routine sample
with lab ref. no. 7~'Z.~ - 7.
[] Special Purpose
[] Treated Water
[] Untreated Water
Analytical Method: Membrane Filter
* No. of colonies/lO0 mi.
SAMPLE
NO. LOCATION
3
i
Time Collected Lab Ref. No. Result* Anff~vst
Collected By
J
J
READ INSTRUCTIONS Membrane Filter: Direct Count
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
~ Co]lforrn/lOOml
Verification: LTB
Final Membrane fl~ter~esulj~_ ,/~//~
Reported
RGB
Cogform/lOOml
TNTC = Too Numberous To Count
Time:
OB = Other Bacteria
Spruce
Lot 14
#014-231-21
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
w,.wv.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING" '
Parcel I.D. ~Y I ¥ -'7_~/ -'7_/
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Current Property owner(s)
Mailing address 7 ~ ¥ q
Lending agency ~,,,( n
Expiration Date: ~. ~' [- O .2.
~,,-~ ~/,'~ Day phone ~ ~- ~OYf~
Day phone
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY:
.Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations 9ivan in paragraph 5 by an independent professional civil
engineer registered in the State of ~aska. Certificates of Health Authority Appraval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a pdvate or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municlpality of AnchoraGe is ncr responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verity that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is(are) 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name0fFirm /'~l~F/~z:'~ "/"~¢J~,~i¢~! _C~,~,- Phone
Address
Engineer's Printed Name '7~ ~'~, ~'o,'~- F:, Iwoo ~c' Date
5.. DSD SIGNATURE
f Approved for '~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: .~'- ~ / - 0 ~
(Rev. 12~x3)
Municipality of Anchorage f~
Development Services Department .... -:
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage. AK 99519-6650
www.ci.oncflorage.ak.us
~07) 343-?~04
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
WELL DATA . ·
Wall type ~'~t If A, B, or C provide PWSID #
Date oompleted ~ J~ 7/,..' , Sanitary seal (Y/N)
Total depth ~.~°fl. .... Cased to~,~') fl.
Date of test
Static water level
Well production
FROM WELL LOG
/~'. A.
fi.
g.p.m.
Parcel ID:
.. Well Log (Y/Id)
Wires property protected
Casing height (above ground)
AT INSPECTION
qO ft.
in.
WATER SAMPLE RESULTS:
Coliform O colonias/100 mi.
Date of sampte: ,.,¢'/~1/OZ
B.' ~EPTIC/HOLDING TANK DATA
.Tank.Type/Material
Tank size gal. : I~lumber of C~lpartments'
Foundation cteanout (Y/N) Depression over tank (Y/N)
High water alarm
Date of pumping. Pumper
C. ABSORPTION FIELD DATA /~j. ~.. ~. ,~.
Date installed
Length fi. W~dih
Total depth __ ft. Eft. absorption area __
Date of adequacy test
Ftuid depth in absorption field before test in.
Elapsed Time: __ min. Final fluid depth
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Soil rating (g.p.d./fl~ or ~redrm)
ft.
~ Monitoring tube __
Results (Pass/Fall) __
Water added gal.
in.
· System type
Gravel below pipe
Depression over field
Absorption rate >=
If yes, give date.
For bedrooms
New depth in.
g.p.d.
O. UFT~rATION J~/. w~-.
Data installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at
Datum Cycles tested
Meets alarm & cimuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
~e~3flc tanldllff station on lot iV./~,
Absorption field on lot
Public sewer main ' """
sewer/septic service line
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
On adjacent lots ~, · IOo '
On adjacent lots '~ I~ ·
Public sewer manhale/cteanout
Holding tank /~/, ,4~. ·
Iv.b.
Building foundation
Water main
Property line
Water se~ice line
Absorption field
8u~ace water
Wells on adjacent lots ' *
SEPARATION DISTANCE '
FROM ABSORPTION FIELD ON LOT TO: N. ,A-,
Property line Building foundation Water main
Water Service IIn~ Surface water "· ' Driveway. paddng/vehide storage
Curtain drain. Walls'on adjacent lots ."
I certify that I have determined through 8eld inspec~ons and
review of Municipal recoils that the above systems ere in
conformance with MOA I-IAA guidelines in effect on this date.
Engineer's Printed Name '~17o ¢:~O ~'( ~ /'-to ¢~ ;--~'
Date ~l'~.v ~ ~¢~O~.
HAA Fee $
Data of Payment
Receipt Number
(Rev. 12/00)
Waker Fee $
Date of Payment
Receipt Number
I~YoZ4-OZ OZ:61~ FI~IrCT&E EflVIL'O~I[MTAL $£V 90T5615301 T-999 P.03/03 F-SZ~
.I .' ~ I: .,'
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CT&E Environmental Services Inc, , ,m.,.,.;,...
. Laboratory Division r.~'.~'.wr.~'/.w'.~'/.m'/.~,//.ar, e,///I.l'///~/f///////f////////~
Drinking Water Ahalysis Report for Total Coliform Bacteria
200 W. Porter Drive
READ INSTRUCTIONal ON KEVERSE SIDE BEFORE COL.[.ECTING 8AMPLE Anchorage, AK 99518-1606
Tel: (907) 562-2343
Fax: (907) 581-5301
MUST SE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY
!:J PUllUC WATER SYSTEM ID# ...... J ..,_~[aly~tJ~,x~v~l~iaWetMSAMPI. Etol:)e:
~/ PmV^TE WATER SYSTEM J
..~ Send Resul~ J-~ Send Invoice
SAMPLE TYPE:
Routine
Repeat Sample
{ref. er to lab no.
[] Treated Water
[] Untrsated Water
~ilytlcalMMhod:
Sent to ADEC:
Client notified of unsatisfactory results:
Date: Time:
YSIS RI~'CORD
MMO-MUG Re~,utt:
Memb~lne REar,
VerfftcaUon: LTB
Fecal Colifm*m Co~f'mTtaUoft:
Final Memb~ne Filter Ref~uEa:
Re~orted By:
Total
f,~ ~1~ MemDer of I~o ~G8 Ca. oup ~ociite Oa~ale ~e S~v~illanCe)
,UA~-24-OZ OZ:51P~ Fi~O~-CT&E ENVIROFI~IiTAL
.~I&K CT&E Environmental Servlce~ Inc.
9OTSG15191
-T-999 -P,~Z/O~ F°SZ9
CT&E RtL# 1022855001
Cllen! Nsme Flattop Technical Sty.
I're]t'~t Name/# Lot 14, Sl~mee Acre
Client Sample Il) Lot 14, Spruce Acre
Matrix Drinking Water
Ordewd By
PwslD 0
$.~mplc P,~marks:
PQL
Uuhs M~h~d
All Date~rlme~ are Al,~kn Standard ']time
PHnted Dnte/Tlme 05/23/2002. I1:16
Collmed Dare,rime 05/21/2002 10:55
0.200 U
I OB, No Cob
0.2.00 m~L EPA ~00.o {<10) 05/21/02
col/lOOm~ SMI$ 9222B
(<!) 05/21/02
'~ INFOnMATIOFI HEREON IS POn THE USE ~c LENO[~
'TIONS SPECIFI(:ALLY TO SHC'*;' ANY C~N~UCTS
~'RIJCTUR~S AND PLA~I'[D LG! LINES OP EA~[NIS A~C ~.:
'10 8E USED EO~ K)SJlIONING ADO(IIONAL
~NC~UNES.
1" = 30'
EASEHEI~TS OF RECORD, oTHER TITAN THOSE
SH09~I Ot~ THE RECORDED pLAT, ARE NOT
S H0t411 I~EI~ON
AS - ~UXLT ( ~0 CORNERS SET THIS DATE )
I hereby certify ch~t I have periormed a ~orcgage~'a
in~p~ccion of the folXovi~g described p£opercy
Lo~ 1l , Spruce Acres Sub,
[nc|wrage Recording Precinct, Alaska and that the
-ments situated thereon are ~lthin the property lines
do not overlap or encroach on the property lying adJac,
thereto, that no improvaaenta on property lying adJace'
thereto encroach on the preaises in question and that
there are no roadways, transaission lines or other vis
ble esseaents on said property.except as indicated her
on. Da~ed at Anchorage, Alaska
this ls~ ,,day of tlove~bo~ 19 89
[~OLT & ASSOCIATES LAHD SURVEYORS /~