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HomeMy WebLinkAboutEAGLEWOOD #6 TR W 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 Parcel I.D. # ~ g '7 - ~ 5' / - .5-,Z.~ HAA # 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner -~"'-J ,,,..)~.~.z~,~.,~'.~ Day phone( Mailing address ¢~ ~ ~ Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEc attest- ing to the legality and status of system. 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, 1/91) Front MOA #21 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. Name of Firm Address hCOI Engineer's signature DHHS SIGNATURE Approved for 4 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date ///- ¢ - ~' 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. 72-025(Rev, I/91) Back MOA~I ENVIRONMENTAL SERVICES DIVISION Municipality of Anchorage AU$ 0 DEPARTMENT OF HEALTH & HUMAN SERVICES iI~ E CE Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type ~,~> ~,~'~'~' If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) ;~'~'~' Date completed Health Authority Approval Checklist ~c/~-~, ~ x..~..~..~,,~ ,~° ,~x.~_~ Parcel I.D.: Total depth ~. ~'~., ~:~,~. Cased to Sanitary seal (Y/N) Y' Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~ Date of sample: ~/'~'~-'~' ~ B. SEPTIC/HOLDING TANK DATA FROM WELL LOG Casing height (above ground). wires properly protected (Y/N) AT INSPECTION Y /,~, g.p.m. ~' zT/ g.p.m. ~' / Other bacteria Collected by: ,~"~.~ Nitrate Date installed ,~'~) / ¢ ¢',~--' Tank size ,,.~.~2g Foundation cleanout (Y/N) ¢Y Depression (Y/N) A/ High water alarm (Y/N) Date of Pumping '¢'//~ ¢,//¢'~- Pumper ~- ,~.- Soil rating (g.p.d./~ or fF/bdr, m) / ¢'¢ System type ~ ~-h Gravel thickness below pipe f~'Zz. Total depth C. ABSORPTION FIELD DATA Date installed Length ~-~ .~'~ Width Effective absorption area ~',.4"~ ~",,/ Monitoring Tube present (Y/N) /v~ Depression over field (Y/N) .... ~a~e of a~equacy test/~ ~/~L- Results (Pass/Fail) ~ For Fluid depth in absorption field before test (in.); ~ ~ "lmmediately affer4~e gal. water added (in.): Fluid depth o-q ~/~" (ins) Minutes later: / 5'¢'~ Absorption rate = Peroxide treatment (past 12 months) (Y/N) /L/' If yes, give date g.p.d. bedrooms 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) High water alarm level at* "Pump on" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line & o ~'~- On adjacent lots / ~ d '~ ~'~ On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation .x ~' ~'/ Property line ..5'-~ ",~'/ Absorption field ,~-/~'~',.z Water main/service line ~, ~'/Surface water/drainage~'~'~-,~.~,e,~,Welts on adjacent lots ,",~ ~'~---~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /O '~ ~'/'- Building foundation & ~"~'/ Water main/service line Surface water ~-~'~,~' Curtain drain ~'~ ~- ~ ~-'~', Driveway. parking/vehicle storage area ~"~ Wells on adjacent lots ?~ ~) ~,~-~ F. ENGINEER'S CERTIFICATION I certify that I have determined thru in conformance with MOnA HAA guidelines in effect on this date. Signature ~ Date "7/; HAA Fee $ Date of Payment ~'/~ /~'~ Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt, Number Douglas T. Kenley, PE HCOI Box 6034, Palmer, Alaska 99645 (907) 746-10 ~3 . RECEIVED October 28, 1996 Mr. James Cross Municipality of Anchorage Health & Human Services On-site Services NOV 4 1996 Municipality o'[ Anchorage Dept. Hearth & Human Serviee~ Re: Well casing below ground level on property owned by Steven Newcomer located at 9450 Eagle River Lane, Eagle River, Alaska. Legal: Tract W Eaglewood #6 Dear Mr. Cross; This letter is in reference to a conversation with Fred Kenley when he asked your office to inspect the above property, at the owner's request, to determine if the well casing could be left in its present condition. You stated at that time that the top of the well casing would have to be enclosed in a water-tight manhole. A Morris #318131200, 12" diameter, skirted manhole was located and purchased through Alyeska Pump. Enclosed is a data sheet and photograph of the manhole installed. Approximately 5 inches of bentonite was used to accomplish a water-fight seal at the bottom. Mr. Dan Roth commenced the original review for a health authority certificate on the above properff. I request that you now continue the review of the documents submitted. Sincerely, ~----, I '~- l/ ff. : Douglas T. Kenley, PE (y CE #8176 SEP-06-96 FRI 12:12 ¢~LYESKB PUMP & E©UIPMENT FP~X NO, 34450Y2 P, 02 ..... MANHOLE: COYEFt -, Monitoring Well ~anh°le Cover . ~ '- Mode, HE812CS FEATURES * ~" X 1~". (O~her skiK lengths available on request). ~ I - i ested to 55,000 pounds with no distoKion or brea~. (Testing equipment had ~ maximum pressure of 55,000 Pounds.). ' P~nted black inside & outside. , 12 ski~ is unb~ken steel tubing, Fi~nge is Ductile Iron. Cover is Cast Iron. * Ski2 is completeiy welded to the flange on the inside. ' Unit is wate~i bt Wh u ' ...... g , y p t a non-wate~ght cover over a well snd ?K attecung your samples by ground water contamin8t on? I * Hecessed stainless steel bolts and washers. ' Fem"e ~hre,d holes for bolts do not obstruc, 8. open ,~ ' O-ring seal undercover. . ~;r~;4eavy duty lug, prevent unit from tuming or lifting in the ' Unit can be personalized. The Helmet Douglas T. Kenley, PE HCO1 Box 6054, Palmer, Alaska 99645 (907} 746-1075 RECEIVED August 5,1996 Mr. Dan Ro,th Municipality of Anchorage Health & Human Services On-site Services ,AUG 6 1996 Munictpality of Anchorage Dept, Health & Human Services Re: Height of well casing above ground level on property owned by Steven Newcomer located at 9450 Eagle River Lane, Eagle River, Alaska. Legal: Tract W Eaglewood #6 Mr. Roth: This letter is in reference to a conversation with Fred Kenley when he asked your office to inspect the above property, at the owner's request, to determine if the well casing could be left in its present condition. I have enclosed pictures showing the well location and drainage patterns immediately after a rainfall. According to your instructions to Mr. Kenley, enclosed is the application for the Health Authority Certificate, and I request that your office make an inspection of the well casing at your convenience. Sincerely, gouglas T. Kenley, CE #8176 Douglas T. Kenley Civil Engineer State of Alaska C.E. 8176 Legal Description WELL & SEPTIC SYSTEM ADEQUACY TEST Applicant Date of Test' System Data Tank Volume Number of Bedrooms ,,'.,~"Z) ~',,~',~.~ · Absorption System Absorption required (l~"dally flow) / TEST DATA TIME VOL. DIFF. FLOW TANK TUBE DIFF. WELL DIFF. (cjal) (gpm) LEVEL LEVEL LEVEL System Passed "'"' System Failed Comments ,Douglas T. Kenley Civil Engineer State of Alaska C.E. 8176 Legal Description SEPTIC SYSTEM ADEQUACY TEST Applicant Date of TeSt System Data Tank Volume Number of Bedrooms ~.~5,.r'~ ~..~..r'- Absorption System cv',~/~'' ~ Absorption required (1/~/daily flow) ~, ~ ~::~. ~,~. TEST DATA TIME VOL. DIFF. FLOW TANK TUBE LEVEL DIFF. COMMENTS (gals.) (gpm) LEVEL ? ~ ~c ,, ?'~ ~'~" ,-~,~'- e ~ /~-c ~,, ~,' System Passed System Failed Comments , Douglas T. Kenley Civil Engineer State of Alaska C.E. 8176 Legal Description SEPTIC SYSTEM ADEQUACY TEST Applicant Date of TeSt ,.,/~v. y' ,~-v~ /'~'~ System Data Tank Volume Number of Bedrooms Absorption System Absorption required ('l.~aily flow) / TEST DATA TIME VOL. DIFF. FLOW TANK TUBE LEVEL DIFF. COMMENTS (gals.) (gpm) LEVEL ~ ~'"" ~ y~/~. ~"1 System Passed Comments System Failed CT&E Environmental Services Inc. Laboratory Division ~-~'~-~e,~-j-~-~e-~,e~e-~-~-~-f~,,~-a~-jjj~jjjjjjjjjj~f~~~ CT&E Ref.# Client Sample ID Matrix Sample Remarks: 962785.962785001 9450 Eagle River Ln Drinking Water 200 W. Potter Drive Anchorage, AK 99518-1 605 Tel: (907) 562-2343 Fax: (907) 561-5301 Collected Date 07/09/96 Technical Director: Stephen C. Ede Released By Parameter Nitrate-N Total Coti~orm Results QC Qual 0.100 U 0 PQL Units Method ALlowable Prep Analysis Init Limits Date Date 0.100 mg/L EPA 353.2 0 co[/lOOmL SM18 9222B 07/10/96 EMB 07/10/96 TAV U ~ Undetected LT - Less than GT - Greater than D - Secondary Dilution J - Below the calibration range ~ES Member of the SGS Group (Soci~te G~n~rale de Surveillance) ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA CT&E Environmental Services Inc. Laboratory Division r~-~-~-,a-.~-,~,~-.~-~-~-.~-~-~-.~-~-.~-.~j~j~jjjj~j~j~jj~ Drinkin_a Water Analysis Report for Total Coliform Bacteria _~o ,:., o::.~ ~ Anchorage. AK 995~ 8.1605 R_E.q_D L~TRUCTI03~ O.V ~VE~ SIDE BEFO~ COLLECTZVG S.43[PLE T~l: (~07) 5~2-2343 ~ F~x: (~07) 3~i-~30~ / N~'ST BE CO~L=LETED BY W.&~R SUTPL~& TO BE COMPLETED BY L.~O~TORY = Pb~LICWATERSYSTEMLD.~ ~ } J I I J J PRIVATE V;ATER SYSTE.M Send Results ~ Send [nvoice Month Day Year SAMPLE T'zTE: ~ Routine ~ Repeat Sample (for routine sample with lab ref. no. ) Q Special Purpose SAb'[PLE LOCATION Treated %'ater Untreated VVate r Ti me Collected Collected By Date Received Time Received Analysis Began Satisfactor:.' Unsatisfactory Sample over 30 hours old, results ma?' be unreliable Sample too long in transit; sample should not be over 4S hours old at examination to indicate reliab[e results. ?lease send new sample via special de[ivery mail. U/10 Analytical Method: ~ Membrane Filter r~ MMO-M'UG Number ofco[onies,qO0 mi, Lab Ret'. No. Result* I9~. 278S Da::: '"'7-"" ]'-Z-- Time: A/lyst ./un ~ Faxed Client notified of unsatisfactoo' results: Phoned Spoke ~.ith Faxed Date:. Tim:: BACTERIOLOGIC:-~L WATER .--M";.-~LYSIS P. ECORD .'v'I.MO-ML'G Result: Total Coliform Membrane Filter: Direct Count Verification: LTB Fecal Coliform Confirmation Final blembrane Filter Res~/lts BCB E. Coli (~) Colonles/lO0 ml COLWIRM Coliformll00 mi RE/MAX OF EAGLE RIVR P.1 ,,,,, l~100; OF DRILLING ky A 8' L DRILLING COMPANY RE/'HflX OF EAGLE RIVER ?, 01/01 PARCEL: 067-031-52-000-97 CARD: 01 OF 01 RESIDENTIAL SINGLE FAMILY STATUS: RENUMBERED TO/FROM: - - 1 NEWCOMER E S & DONNA E EAGLEWOOD #6 TR W PO BOX 3238 0 VALDEZ AK 99686 3238 SITE LOT SIZE: 189,299 ---DATE CHANGED--- ZONE : R1A OWNER : 06/02/92 TAX DIST: 046 ADDRESS: 07/02/96 GRID : HRA # : NOTES : REF 067-031-01/02 PLAT 92-05 .... DEED CHANGED .... BOOK : 2236 PAGE: 0678 DATE : 02/03/92 PLAT : .................................. ASSESSMENT HISTORY .......................... ---LAND .... BUILDING .... TOTAL--- FINAL VALUE 1994: 58,700 108,300 167,000 FINAL VALUE 1995: 42,600 109,200 151,800 FINAL VALUE 1996: 93,700 99,600 193,300 EXEMPT VALUE 1996: 0 0 0 --EXEMPTION .... ..... TYPE ..... STATE EXEMPT 1996: 0 FINAL VALUE 1996: 193,300 -COMM COUNCIL- NONE PARCEL: 067-031-52-000-97 RESIDENTIAL SINGLE FAMILY 07/03/96 TOPO: EVEN LEVEL UTIL: NONE LIV UNITS: 001 STREET : PAVED PAVED WELL: N TRAFFIC : LOW ACCESS : GOOD WETLANDS : DRAINAGE : GOOD COMMON AREA: % OWNERSHIP: LEASEHOLD : INSP DT: 12/93 LAND ONL 06/92 EXTERIOR MM/YY TYPE AMOUNT SOURCE SALES DATA 1: / 2: / 3: / .................... OTHER BUILDINGS AND YARD IMPROVEMENTS ..................... TYPE QTY YRBLT SIZE GRADE CONDITION CABIN 1 79 768 AVERAGE AVERAGE 444,444 PARCEL: 067-031-52-000-97 RESIDENTIAL SINGLE FAMILY 07/03/96 STYLE : OTHER YEAR BUILT : 1974 TOTAL ROOMS: 07 FULL BATHS : 2 HEAT TYPE : CENTRAL FP: STACKS : EXTRA VALUE: CONDO STYLE: GRADE : AVERAGE STORY HT : 1.0 REMODELED: BEDROOMS : 03 HALF BTHS: 0 HEAT SYST: HOT WATER OPENINGS : EXTRA VAL: CONDO FLR: CST/DESGN: EXTERIOR WALLS: WOOD EFFECTIVE YEAR: 1974 RECREATION RMS: 0 ADD'T FIXTURES: 0 FUEL HEAT TYPE: NATURAL GAS FREE STAND : E-Z SET FIREPL: t CONDO COM PROP: CONDITION : GOOD BASEMENT : 1,288 FIN/BSMT : 952 BASEMENT GAR: CAR TOTAL 1ST FLOOR : 952 2ND FLOOR : 0 3RD FLOOR : 0 AREA: HALF FLOOR: 0 ATTIC AREA: 0 RECROOM AREA: 1904 .............................. ADDITIONAL FEATURES ............................. BASEMENT: 1ST FLOOR: 2ND FLOOR: 3RD FLOOR: AREA: ATTCH/BUILT GAP, AG 720 JWL 03 96 08.16 RE/MA× OF EAG~.E RIVR .... .., . , ....~P..~ ~ .,.~ _ · ~ .. ' ~,~ ~ ~.~ ,,.~z. . .... ~. L ,.. ;,~...: '..':.. . .... ' ~ ...... .;.~.~ FROM W~LL '?/ ~:~ MANUFA~URER'~J ....... MATERIAL~/~)~"~ ._COMPARTMEN .~.~, SEEPAGE PIT: ,, ' NUMBER OF PIT~ / .--. DIAMETER -- LINING MATERIAI-Q~ CRIB SIZE= BuILDiNG FOUNDATION'~ , OR WIDTH.~'''/, LENGTH "v ~"' DEPTH -' .~/ ~ / ... OiAMETER?_Z_-.DEPTH~ DISTANCE FROM: WELL __'/ .TOTAL EFFECTIVE NEAREST LOT LINE__ ABSORPTION AREA (WALL AREA) 7'~" "__SQ, FT. ADDITIONAL ABSORPTION WELL: TYPE " .... :'" ~ '"'OUILDING '..-. /~" · NEAREST ~ . FOUNDATION ., I LOT LINE 9/!f;." '/' ~ ,.CONSTRUCTION-- DEPTH _ DISTANCE FROM*- NEAREST SEPTIC ,./ ,',' SEEPAGE - /.., SEWER LINE ' , TANK '"7./ Y'-,,'", SYSTEM- / ~' I CEE. SPOOL" ,, OTHER SOURCES DISAPPROVED APPROVED-- INSTALLED PIPE MATERIAL' LOT SLOPE~ ,: .4,t' .',.. ..... .,/,, . ,%~' . . ...:?;.~f,...,.'y:.. :i.: REMARKS: ' REMARKS ~ DIAGRAM OF SYSTEM .j JUL 10 '96 08:~ RExM_AX OF EA~LE RIVR " '(' "~ ...... GRE~r,E~ ANCHORAS[ AREA BOROU6H DEPARTMENT OF ~NVIRONMENTAL QUALITY CASE 3500 TUDOR ROAD ANCHOR~SE, ALASKA.. 99502 Pe~foemed For' L, A. ~oa~s:a~[~' D~te Performed ¢/[3/72 Legal Description; Lot Block___Subdlv]s on . . ~Th{s Form Reports $a~]s~g x P-~r'6o]'~]oh T~St .._ ' ' Seward ~eridiaa, T 14 ~, R 1 ~:=fl~iou'i8:~L~'~ 2~.8E I/6 a~ ~ 1/4,'~1/4 Depth Feet Soi]'~haracteristfcs .,,,6i'~ with fine 8~avel at ~a~fi~e $~na 'with silty Band seams Was ~lround Water [~ncounte~ed? no . ~e If Ye~, At What Depth? , = ...... P~rc6'l att on Rate ~ M'i"nute Proposed InstallatiOn: ' Seepage Pit Drain Field Dept,h Of Inlet . "...... Oept~B To-hot, tom of Pit O~:"~ell~h;' COMMENTS: ~' ~ 170 $~uare feet 0 drainage area is ~e~ui~ed .Der ~ad~opm ;::. _ Date:__ O?,J'.lJ~ 10 '9~3, 08:09 RE/MAX OF EAGLE RIVR ~--"~- ' I.-OG OF DRILLING ky A ~ L AI~D~ss ..................................................................... ~,., ,,= ....................................................... ~...~./~ ~-~..LJ.....~...R~: ........ 2~ .............. ..................... DATF~-~NDED .... ~i~u OF FOI~MATI01~ " P.1 ~00; DRILLING COMPANY Eoglewood T act W #067-03! -52 Municipality of Anchorage Development Servlc D paHment Building Safely Division On-Site Water and Waslewa~er Program 4700 South Bragaw SL P.O. Box '196650 Anchorage, Al( 995tg-6650 www.cl.anch0rage.ok.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ParcelI.D.~G'7-- o3j - '1, GENERAL INFORMATION Complele legal description Expiration Date: Tract W, Ea~lewood Subdivision~f~ Location (site address or directions) 9450 Ea~le River Lane Cu~'rent Property owner(s) Mailing address Lending ~ncy'- Tom Higgins Dayphone 696-3396 9450 Eagle River Lane Eagle River, AK 99577 Day phone Mailing address e Real Estate Agent Mailing Address Unless olherwise requested, HAA will be held by DSD for plckup. NUMBER OF BEDROOMS: ~ Day phone 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Commtmity Class~ Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site ~ Individual Holding tank [] Communily On-site [] Public Sewer [] The Municipalily of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given In paragraph $ by an Independent professional civil ~.ngineer registered In the Stale of Alaska. Certificates of Health Authority Approval are required for the transfer of lille (except belween spouses) for proper[les served by a single tamily on-site waslewa[er disposal and/or water m~pply system. DSD also issues HAAs upon request Io homeowners. Certificates of Heallh Authorily Approval are valid [or 90 days from Ihe date of Issue for properties served by a privale or Class C well and may be reissued wilh new waler sample results less than 30 days old. (Certificates may be reissued [or a period of up to one year with valid water somples.) Certificates are valid for one year [or properties served by Class A or B wells or a public water system. The Municipalily of Anchorage Is not responsible~for errors or omissions In the professional engineer's work. 4. STATEMENT OF INSPECTION BY E~IGi~JEER As certified by my seal affixed hereto and as o1' Ihb valldafion date shown below, I veri~y that my Investigation, based on procedures outlined In the Health Authority Approval Guldellnes for this application, shows that the on-site water supply and/or wastewater disposal Sy-~terrJ Is(are) safe, functional and adequale for the number of bedrooms and lype of structure Indicated heraln. I [urEter [,eriry tha~ based on Ihe Information obtained from the Municipality of Anchorage files and from thy Investigation and Inspection, the on-site waler supply end/or waslewater disposal system is(are) In compliance Wilh all applicable Municipal and State codes, ordinances. and regulations In effect at the lime of installation. NameD[Firm S & S En~,ineer~n~ Address 17034 N..Eagle River Loop Rd. Engineer's Printed Name Robert C. Cowan 5. DSD SIGNATURE Approved for ~ Disapproved. Conditional approval t'or bedrooms. - Phone 694-2979 Ea;~le River, AK 99577 Dale 5-/~/0 ~.- .......... ..- ,~, L:-"' ..._-q, '.;;~% ' ,,., .-t:NGINEEP..23 · · ;~, ~I~ (~,L~ .......... %~* ~ bedrooms, with Ihe following stipulations: Additional Comments By: Attachments: HAA Checklist Septic Sys{em Advisory Well Flow Advisory X Maintenance Agreements SUpplemental Engineer's Report Other ,Original Certificate Date: _.9'-"- C/ - 0 ~ Muni¢i_ Hty of Anchorage Oevelop~]~ervices Department On-S~astewatar Program {'/X)O~ erag~w St. P.O. Box l~t~0 .Nlctlorage. AK 99519-6650 w'4N~{L~orage.ak.us HEALTH AUTHORTrY APPROVAL CHECKLIST A. WELL DATA Well type p//./V~ ff A. B, or C provide PWSID iV ~ Date completed :~/'T'~· Sanitary seal (Y/N) FROM WELL LOG Date of test ___~Z.~_..~ ~ Static water level ~-~'~ ft. Well production /,~ g.p.m. Parcel ID: ~'~' O~/' ~'~' we, Log (YtN) ~/ Wires pmpsrly protected fi/N) ~/ Casing height (above ground) --/~--~'~ln. AT INSPECTION 5- '~' g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi. Date of sample: "~(//~,/~ ~"" B. SEPTIC/HOLDING TANK DATA Tank Type/Material ~a/''/c' Tank size /~/-'~'"/.) gal. Number of Compartments Foundation cleanout (y~) Y Depression over tank (Y/N) Dete of pump~g ~/~/o:Z .umber Nitrate 0d~'mg./I. O~er..r~ 0 colonies/100mi. Data installed Cleanouts (Y/N). High water alarm (Y/N) C. ABSORPTION FIELD DATA Date {nstelled B/~'~' Soil rating (g.p.dYl~ ~) /~ I Length ~-~ ft. W.~ ~-~ ft. Total depth/~.~ ft. Eft. absorption area ~ ft2 Monitoring tube . Date of adequacy test 4//~'/02,~' Results(Pass/Fall) Fluid depth in absorption field before lest ~ ~. Water edded.~.~al. Elapsed Time: qQ min. Final fluid depth~ in. Absorption rate Any rejuvenation treaffnent (past 12 mo.) (Y/N a type) W~/llf~' ~V'~4/N/ If yes, give date System type ~J~/'7' Gravel below pipe ,c~ ft. Depression over field /V/ For ~ bedrooms New depth~ in. g.p.d. D. LIFT STATION Date installed 'Pump on" level at / in. Datum / E. SEPARATION DISTANCES Size in gallons 'Pump off' level at Cycles tested !~nhel~ ~'ligh water alarm level at Meets alarm & circuit requirements?. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tanldlifl-atatton on lot Absorption fiald on lat /d(~ Public sewer main Sewer/septic service line ~ /.~- Holding tank SEPARATION DISTANCES FROM SEPTIC/H~wDING TANK ON LOT TO: On adjacent lots On adjacent lots /(2<:2 "~"- Public sewer manhole/deanout in. Building foundation _~ "P- Property line ~ ~ Water main / ~2/-~- Water sen~ce line / ~:) ! . 'f-- Wellson adjacentlots / OO "~' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line, /0 ~ Building foundation ,/~.~ ~' Water Service line ! O ~ ~' sur~ce water / ~2 -~- C . in d ainon adja Absorption field ~ *~- Surface water Watar main /V//,~ F. COMMENTS G. ENGINEER'S CERTIFICATION 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 effec~ on this date. Engineer's Printed Name Data ~/'~/, HAA Fee $ Date of Payment Receipt Number (Rev. 12/00) Waiver Fee $ Data of Payment Receipt Number _,I CT&E Environmental 'Service~ Inc. · 200 W. Poflm Deice · M AK ili11.1~06 )rinkin~, Water Analyszs Report for Total Coliform Bact_ena Td: (907) 5~2.2343 PI. lEK TO BF., C MUST Analysis sh~wl this Wa~r SAMPLE to be:.  UBLIC WATER SYSTLM I~. R/~ATE WATER SYSTEM D~ R~d Tim ~ ~ ApJ~ic~l Methodl "]~.~cmbune Film' ~/O MMO-MUG · NumbeY ofcolofli~/100 mi. t· Analyst a sp~.~ hrpea, ~ T~no co.I Ii ._..__ .,;ks Jun [] Fazed Dm~ CIlem ratified df u~o~ .. BACTERIOLOGICAL WATER ANALYSIS RECORD rC~f RGB , COLIFIRM ,~t~- CT&E Environmental ~lc~ Inc. CT&E Rtr~ 1021931001 Client NLme Project Nsme/~ Tract W. F. allc Wood Client Sample ID Tract W, ,~agle Woo~ Matr~ Dr~king Water Ordered By PWSID 0 Sample All Dates/Times are Alaska Sttndlrd Time Printed Date/Time 04/18/2002 14:28 Collected Date/Time 04/1 f~'2002 15:45 Received Date/Time 04/I~'2002 17:30 Techol~ StOl eu C £de Re~ult3 PQL Nittate-N 0.200 U Allowable Pr~ Anal)'~s Limits D~t¢ D~te Init 0,200 m~/L EPA 300.0 (<10) 04/16/02 JDT M]. c l'ob:J, ol o g~, Labor a to L,"y, Total Coliform 0 col/100r~ SMI8 9222B [<1) 04/16/02 KAP I1' I"~ O0 ~' / / / / // // // .