The URL can be used to link to this page

Home My WebLink AboutKING (PLAT 67-87) BLK 1 LT 6King Block 1 Lot 6 #014-252-28 Mayor Development Services Department Building Safety Division On -Site Water 6 Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www muni oro/onsite (907)343-7904 Pz09-0715 Pump Installation Log Well Drilling Permit Number: W-D08-03DJ10 Date of Issuc: S -'R -09 Parcel Identification Number: 000 /0 Legal Description Block Lot Property Owner Name & Address: K�r`�- Play l0? -87 ( Brown , Seo4 A- Pm-ir r Ci GL. I D $yso Auadiv%er Place Eir1G:'1(or0.0.2. t4 K 49507 Pump Installation Date: /O Pump Intake Depth Below Top of Well Casing: goo feet Pump Manufacturrcr's Name m \I of 5 Pump Model:_ RLAS �Alq-q" Pump Size Vol hp Pitless Adapter Burial Depth: feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Completion? O Yes O No Method of Disinfection: Comments: Rep l aced PtXMP eys4ern Pump Installer Name: f0%y-\ TialieVtor Company: Ldhea40n L(Jtx4e-r t J05,Trrc, Mailing Address: Po 60 x 8 Ila 18' City: D )as i 11 o- State: PK zip: 99697 Attention: The pump installer shall provide a pump installation log to DSD within 30 days of pump installation. WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological a Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either to, Ib or Ic.) A.D.L. No. la. Borough Subdivision Lot Block Ib. V4 qt rs. Section No. Township N ❑ Range E ❑ Meridian iZLt�L 6 1 _of.of—of� S❑ W❑ Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL: Danmar, builder Address: Street Address and Area of Well Location 2. WELL LOG Feet Below Surface Material Type Top Bottom 4, WELL DEPTH: (final) 5. DATE OF COMPLETION 102 � — --�- — ravel till 0 8 6. ® Cable tool C3Rotory ❑ Driven ❑ Dug ❑ Auger ❑Jetted ❑ Bored ❑ Other: hard pan -silty 18 2 silty clay w/gray gravel 32 70 7.USE: [3Domestic []Public Supply []Industry ❑ Irrigation ❑ Recharge ❑ Commerical ❑ Test Well ❑ Other: boulder 49 53 boulder 53 cemented ravel silt70 6. CAS NG: ❑Threaded ❑welded diam. in. to 83 It, Depth Weight 17 1be./ft. diam. in. to ft. Depth Stickup ft. boulders -cemented ravel H20 75 1 OP 9. FINISH OF WELL: Type: open end Diameter All Slot/Mesh Size: Length: Set between ft. and ft. Backfilling Gravel pack 10. STATIC WATER LEVEL: 62 ft. ❑ Above or n Below land surface Dote Equipment used: Pc?7 C', l.Ti " 11. PUMPING LEVEL below land surface and YIELD ft. after hrs. pumping g.p.m. ft. after hrs. pumping g.p.m. ENVIK ii li'.'._P.IA. - �O E -i, J U N G 12. GROUTING Well Grouted: Elyse ❑ No Material: ❑ Neat Cement ❑ Other: 13. PUMP: (if available) HP Length of Drop Pipe ft. capacity g.p.m. ❑ Subm. ❑ Jet ❑ Centrificol ❑ Other 14. REMARKS: 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Water Temperature _° ❑ F ❑ C This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Vern's Drilling & Enterprises t3_Y > "�.;r t Registered Business Name Contract License Number Address: SRA Box 1 560 Anchorage, Ak 99507 Signed: Date: Authorized Representative Form 02-WWR (11/8I) Copy Distribution: WHITE -State DGGS, PINK -Driller, CANARY -Customer ^ DEPHRTMENT ^ HEALTH AND ENVIRONMENTHL` �!OTECTION STREET, �NCHORHGE/ HK 9��« 264-4720 / '141 1_ ~T' PERMIT NO. ( ) HPPLICANT DHNMHR CONST INC 8]81 POKEY CIRCLE LOCHTION LEGHL 1-6 B1 KING LOT SIZE 12000 SQUHRE FEET MINIMUM DISTHNCE BETWEEN H WELL AND HNY ON—SITE SEWHGE DISPOSHL SYSTEM IS 100 FEET FGR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE 113 25 FEET AND TO H COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED HND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]0 DH -,-'S OF THE WELL COMPLETION OTHER REQUIREMENTS MAY APPLY. SPECIFICHTIONS HND CONSTRUCTIQN ARE HVHILHBLE TD INSURE PROPER INSTALLATION. 10,��1-11: T- QXF :1 fF---Cl= E> FE rmll�l E �� [ CERTIFY THH 1� I FVI FAMILIHR WITH THE RE(.XUIREMENTS FOR ON—SITE SEWERS HND WELLS AS SET FORTH BY THE MUNICIPHLITY OF HNCHORHQE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. __------ ___ HPPLICHNT DHNMH�� CQNST INC ISSUED BY Y �� nz � p�/\ (\\v�`� u/\�[ " Y4. 0 Time APPLIC yT FILLS OUT UPPER HAI" ONLY Property Owner 7�jJi`f/ii;-' -Cir^T/'i % /�'li Phone Time Mailing Address _ ._ f-- Zip Code i Date Buyer ]t _ _ ie Address Zip Code Date n c' Lending Institution -"`,,,;, — ��--� Phone Address e% L- f/ Zip Code Inspector Realty Co. & Agent , _ Phone Address All Zip Code Legal Description 4111A1 Street Location / + Al 1;2 ls. Type of Residence i 04ingle Family ❑ Multiple Family No. of Bedrooms 3 - ❑ Other ( APPROVED BEDROOMS Water Supply Wrndividual En ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. ❑ Community For wells drilled prior to that date, give well depth (attach log if available). ❑ Public Utility DATE Sewer Disposal C c) t'> LCAj— ❑ Individual �9D Year Individual Installed: ❑'"Public Utility PAY ( jti,�ff�� k When Connected to Public Utility: t : '<'.F Date Sewer Installed ❑ Holding Tank ! Ii F1 �`>.<.,, t� �; [ c.<f1 L Septic Tank Size NOTE: THE INSPECTION FEMUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time i Date Date Date Date n c' Inspector Inspector Inspector Inspector ls. ` 1 Field Notes: s? .�U A'} I i r MA �o Q� f A w �� ( APPROVED BEDROOMS - 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CON DITIONA APPROVAL` DATE BY: 0-2 Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received L r'✓> L Septic Tank Size Well to Tank 72023 (31ffiI August 19, 1982 Danmar Construction Inc. 8607 Corrin Drive Anchorage, 7-0: 99507 Subject: Lot 6 Block 1 Ling Sub. Approval. for the individual sewer and water facilities cannot be granted until the follox,•7inq items have been completed: The depression or pit around the well casing needs to be filled with impervious type roil so that it slopes away from the well casing. J The water analysis report needs to be submitted to this 1 fico from the Cham Laky, 5633 n Street, for our review. This department needs to have the document submitted to erify public sewer connection. J Please notify this Department for a reinspection when the noted discrepancies have been corrected. if there are any further questions, please call this office at 264-4720. Sincerely,] Cory Willis, R.S. Cta19/n/ral CHEMICAL & GES OGICAL LABORATORIES -__? ALASKA, INC. EpDEPENpFNT O Rev. 1978 TELEPHONE (907)-279.4014 ANCHORAGE INDUSTRIAL CENTERvo �, 274.3364 5633 B Street Date Collected uae^•�R1e8 Drinking Water Analysis Report for Total Coliform Bacteria o TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY WATER SYSTEM: a.m. - Date Received Time Received p.m. Lab. No. Analysis shows this Water SAMPLE to be: I.D. NO. i ❑ Satisfactory -'� 1.0ml " 0.1ml El Unsatisfactory Water System Name Phone No. - ❑ Sample too long in transit; sample should BEFORE not bb'over 48 hours old at examination Mailing Addr as - r'y , - to indicate reliable results. Please send Confirmatory new sample. City I - ! l ,. .state - _ zip Code 24 Hours ; a r':• 2 Date Received L SAMPLE DATE: i 48 Hours - Mo. Day Year Time: Received SAMPLE TYPE: ❑ Routine ❑ Check Sample (for routine sample El Treated Water with lab ref. t El Untreated Water ❑ Special Purposee SAMPLE Time Collected NO. LOCATION Collected By 2 I f Analytical Method: ❑ Fermentatlon Tube ❑" Membrane Filter Lab Ref. No. Result* Analyst ETI � m FTI *No. of colonies/100 ml. or No. of Positive portions. 06.1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD - Rev. 1978 Date Collected Source - READ INSTRUCTIONS a.m. - Date Received Time Received p.m. Lab. No. Presumptive loml loml loml loml loml 1.0ml " 0.1ml 24 Hours - BEFORE Hours Confirmatory 24 Hours 48 Hours - - EMB Broth 24 hours: Broth 48 hours: COLLECTING SAMPLE Multiple Tube Report: loml Tubes Positive/Total loml Portion. - Membrane Filter: Direct Count Coliform/100m1 Verification: LTB BGB Final Membrane Filter Results _ Coliform/100ml Reported By Date Time- -. .., P_, a.m. p.m. July 1, 134 Ackinso", Oswald A Partners AM: Lewis E. Oickinson, Partocr 009 Cordova $treat Anchoragu, Alasga 00161 Subject: Well Lucatioo, Addition 11, King hubuivislun For icon 0. Sinwons noar "r. uickinsoo� Too Mawr Ancoura2z Aroa boroulk bupar MUL of Bvironvantal QualiV nas rocwivod and reviewed tne plan snowing the proposed sooikpuolic Llass A null site for King Subdivision. We havu on awjQcnians Lu toc prupused lachLiun for this oull SiLu aid would axpacc to ruceive addi- Liunal anjinsuring details aou plans prior to too projecLs construction. Ao nould caution you,'houever, coat tie approved site location in no way approves Lne classification semi-pualic Class A. Tic final approval as Lo classification of this well is strictly haM upon its inter ad use witlin this suDdivisioo and tin numner of consumars aN type of con- sunQrs Vat As w0l will serve. Howdyer, in recent discussions with Hr. Gibbons, we feel is his intended use of this water system will allow Lot wall to ranwin in the sund-public Mass A status. Should you flava any questions rugdrding our Deparument's approval of the proposed site location of this Well, please Contact the undersigned. Sincerely, Rolf Strickland. k.S. kief Saaitar0-i A d, Municipality of Anchorage • '� Development Services Department ` Building Safety Division On -Site Water and Wastewater Program �+ •• 4700 South Bragaw Street P.O. Boz 196650 Anchorage, AK 99519-6650 www. ci.an chorage. a k. us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D. 014-252-28 HAA# 0� Expiration Date: _ / (7 - --Z `i 1. GENERAL INFORMATION Complete legal description Lot 6 Block 1 King S/D Location (site address or directions) 8450 Nadine Place, Anchorage AK 99507 Current Property owner(s) Susie Desiree Cronin Day phone 646-9071 Mailing address Lending agency Mailing address SyVS f genr,y Mailing Address 8450 Nadine Place. Anchorage AK 99507 Day phone 1� �c�eu� NCi�1ZenyS (!eCrDayphone 60-$7a-366( 3 0 Concnr74¢ NuiV 5-k-/00 , C'64fi ilv. I!A — ,/ Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well ®. Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ 3 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 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 one 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. 11M) 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 Eng. Svc. Phone 272-8218 Address P.O. Box 102954 Anch AK 99510 Engineer's Printed Name Steven R. Pannone, P.E. Date Engineers Comments: In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and. septic systems depend on the local soil condition, ground water levels that may fluctuate during the year, and the water usage of the family being served by the system These conditions are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defectg or encroachments. PES can therefore not provide any warranty for future performance nor give any estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized nor will it confer any legal right whatsoever. 6. DSD SIGNATURE 1-10' Approved for -3 bedrooms. Disapproved. ♦� 44 �d 491 •°� ... �.... M :Steven R. •Pannone � No. CE 8149 � Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: �/� Original Certificate Date: -7' �Z cl - O q Expiration Date: Reissue Date: (Rev. 1159) Leg C _. , if A B, or C povide'PGVSID�#_ Weil Log Y " ed 6/23/1982' Sanitary seal Y Wires properly protected Y i 102 ft' "" Cased to 83 ft Casing height (above ground} 24 in. FROIv1 WELL LOG , AT INSPECTCON „ r�y>. 6/23/1982'.. _"7119C2D04�'" ;. . level s 62 63. ft tion Unknowng PTn 3.9' S P m AP,LE RESULTS Other bacteria /100I'M colonies/100,mi Nitrate mg/I colonies )Is: 7/19/2604 Collected by: Laura Pannone LDING TANK DATA ' d' �" Tsize:: gal Number of Compartments . _ Found ' Mean Depression over tank_ High water alarm ping Pumpe ON FIELD DATA d Soil ratinN (�.p.d./ft2 or "7-77 bdrm) _ System type ONS =ft, idth - ft _ ft Gravel_below pipe777, ft Effecfive WVr—ptio ea _ft2 Monitoring tube_ Depression over field �uacy test `" e is (Pa Fail) For bedrooms n absorption field ore test'_ in ter added gal. New depth_ in. ie -`0 min'.,:- Final fluid depth _ in Absorption rate >= g.p.d. "date ation tre ant (past 12 mo) (Y/N & type) If yes give D. LIFT STATION,` Date installed Size j�allons Manhole/Access "Pump on" level at — in"Pump o at in High water alarm level at in Datum / as t�ted Meets alarm & circuit requirements? E. 'SEPARATION DISTANCES SEPARATION DISTANCES FROM"WELL'ON'LOT TO-— . " Septic tank/lift "station on lot NIA On adjacent lots 100 Absorption field on lot N/A On adjacent lots 100+ Public sewer main- 100+ Public se4vefmanhole/cleanout 100+ Sewer /septic service line' 25+ Holding tank 100+". "' SEPARiCFI N DISTANCES FROM`SEPTIC/HOLDING`TANK ON TO: Building foundation Prop rty line Absorption field Water main/Water servic a Surface water Drainage ell n adjacent lots SEPARATION DISTANCE FRO §QRP FIELD ON LOT TO: Property line Bui n foundation Water main Water Service Ii, Surface water Driveway, parking/vehicle storage Curtain ain Wells on adjacent lots F. COMMENTS` G. ENGINEER'S CERTIFICATION ` =��P� •' �s�♦♦j.. I certify that I Piave determined through ifefd inspections and i 49TH �1 review of Municipal records that the above systems are in r ...0 conformance with MOA HAA guidelines in effect on this date ' "` �j`Pi Steven•R Pannone.•�a Engineer's Printed Name Steven R. Pannone. P.E. ` " "" s No cF 8149 / ) ♦♦O ••tr (oil Date ' i / I4! �� r ♦.1o�ESSt�� 22 HAA Fee $ JU / Waiver,Fee $ Date of`Payment CZ -'(fes v Date of Payment Receipt Number �J ° Zi Receipt Number 200 W. Potter Drive inking Water Analysis Report for Total Coliform Bacteria Armh om �'BAK9 3l READ INSTRUCTIONS ON REVERSE SIRE BEFORE COLLECTING SAMPLE MPf Fa DS$ 5301 p PUBLIC WATER SYSTEM I.D. 0 ty L� l SAMPLE DATE:` ® Year SAMPLE TYPE: a Routine o Treated water a Repeal Sample (for routine sample Isb ref. no. ) tom Untreated Water with l Special Purp„, V V j}t Time Colleded SAMPLE LOCATI N Collected 1�� Pleue Mnt 005 Analysis allows this Water SAMPLE to be: !” satisfeotory a Unsatisfactory p Semple over 30 hours old, results may be unreliable t1 Sempie too Ion in ttanait; sample should tptba ovlr$Iours old at ccaminatson to indies a raliable results. Please send new sample via special delivery mail. De" Reeelvei Time Received +ss Analysis Began Analytical Method; d MMtMtnb ha1no filter 104430-A- Result* Analyst Pinks"Jun oemww.DaG.L. Anch Cl Faxed Dat, Time: ,Client notitled of unsatisfactory results: Phoned Spoke with Fsuad Date: _,,,_ Time: BACTERIOLOGICAL WATER ANALYSIS RECORD MMO-MUG Result: Tettl Coliform E. Cali Membrane Filter: Direct Count 4-- g --+—=r & ' rn.L- Colonles7100 mi Verilcation; LTB EGD COLI FIRM zrvm _ ?.X °A°'°°' r° c°°M OB •0therleererle Fecal Couform confirmation Finsl Membrane Filt�`�erR,e,,,su�-�l�.�ts�� Gik.Fi.4 ✓' Coliform!100 ml Reported BY __.`i Date 7'� Time 12.3Y3 hrs 20mments: ME Envirana,entsi 9ereices mC. I 200 Oise Foner Orim, Anchorite, AK 69518•15C5 tl907Y 5628843 t(207)551 --°.30t w,".sosanvironmontelsom t MRe8N 1044348001 :Wet Name Patmone Eng. Srv. ProjeetName/li L6, Bk 1, King SM nest sample JD L6, Bk 1, King SID Matrix Drinking Water IWS1D 0 All Dates/Times are Alaska Standard Time Printed DateMsee 07/22/2004 11:23 Collected Detamme 07/1912004 12:00 Received DateMme 07119/2004 14!55 Technical Director _ StephcgfgMde sample Remarks: V=UT Results PQL Mutts Method Contain ID L1mas Allowable Dae Ddi� Ifut latera Dapartmaat Nitrate -N 0.100 U 0.100 myL EPA 300.0 B (<=10) 07119/04 7JB tiarobiology laboratory Total Coliform 403, No Coli col/100ml, BIr120922213 A (<=I) 07/19/04 DKC \ Municipality of Anchorage • �1 Development Services Department �lBuilding Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St 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 Parcell.D._Ot`i-2s2—z Y-oeo HAAS Expiration Date: / O - '2— GENERAL INFORMATION Complete_ al. description Loi. (D (31 I .Location (site address ordirections) e`'{S o t�,(a Current Property oviner(s) R. Day phone 544— 5q S 2 Meiling address. S u -iJ , Lending agency Day phone Mailing address Real Estate Agent mrt (.0 a ( �. Day phone Z- S - ol/ �( Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well ❑ Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site ❑ Individual Holding tank ❑ Community On-site ❑ Public Sewer kc] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 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) for properties served by a single-famiiy 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 private or Class C well and may be reissued with new water sample results. (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 Municipality of Anchorage is not 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 verify 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. Name of Firm M( rata r I %( , 4 4 crso/rt P� Phone 3gS-33 Address 446 q0 4';,Ao $h on /414 l!- ,(c 9 ,ft -(6 Engineer's Printed Name M eA c t At , Ze I r e vrn P tF. Date 7 4f o Z 5. DSD SIGNATURE ✓ Approved for �_ bedrooms. Disapproved. OF �'X ptE..... !I• •qs� 11 .y MI AEE N. ANDERSON: cc / CE-9�� 9 ��i Conditional approval for bedrooms, with the following stipulations: Additional Comments J=: ON-SITE Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: lir r c iJ Original Certificate Date: (R. OV02) Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program - 4700 South Bragaw SL P.O. Box 196850 Anchorage, AK 99519.8650 www.ci.anchorage.akus (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L a >' ` R f k ( /G, n.+� 5�D Parcel IDM L/ - '212-- e 5 A. WELL DATA Well typerr�o�t Date completed -i ►z L Total depth /O L ft Data of test Static water level It A, B, or C provide PWSID # — Sanitary seat (YIN) Y eels Cased to FROM WELL LOG i, 21 R Wag production U oknowivF ' g.p.m. Well Log (YIN) 'lye Wires properly protected (Y/N) Casing height (above ground) 1- `( in. AT INSPECTION Gy f G. S 9 -p.m. WATER SAMPLE RESULTS: Coliform —$Lcolontes/100 ml. Nitrate J, 2 mg.A. Other bacteria colonies/100 mi. Arsenic: mg A. Date of sample:pv Collected by: Mil( B. SEPTICIHOLDING TANK DATA Tank size ga4 j0parlipM8 ....... ` �. Cteanouts (Y/N) over tank (Y/N) water alarm (YIN) _ Pumper C. ABSORPTION FIELD 12J j� D Iled + Soil rating (g.p.d.Atz or 1eAxirm) — Length R Width R Total depth fL Eff. 1 tion area ft2 ring tube Date of adequacy Fluid depth in test — in. Elapsed — min. Final fluid depth — in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) _ System type Craves below pipe ft. Depression over field For — bedrooms gal. New depth— in. pbon. e>= g.p.d. — If yes give to D: LIFT STATION Date 'Pump on' level at _ in. E. SEPARATION DISTANCES Size in gallons Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on krt Absorption field on lot Public sewer main ta• .I Sewer hreptic service One too /* water alarm level at in. Meets alarm On adjacent lots / uo r f On adjacent lots /ou 1/ - Public /- Public sewer manhole/deanout foo /v< Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Bull n Property line Absorption gel Water main ne Surface water DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Water Service One F. COMMENTS G. ENGINEER'S CERTIFICATION Building foundation Wells on adjacent lots 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 xt+�laei hl dTvs•n Date ?1Y�ai HAA Fee $ 375 - Date 7SDate of Payment 7, 8 - D 2 - Receipt Receipt Number (Rev. 12ro1) Water main Waiver Fee $ Date of Payment Receipt Number parldngIvehide storage E^T7- 30 _ � CA Cr6o' —1� ' _•Tic . cs+c+'r •. 01 �� z, ,, - � Q��IZ T�W",Mw�� c%�ny OKNELLn1 9 V O 30 /o o. 00 E^xr. i I J64-01-52 C6:Shci-R6lrMF EN7WCAN-At SRV /e1 h CUE Environmental Setvlcee Inc. fi.. r��..rrr� r�✓�.rrrwru CUE, Ref.# 1023900001 ClientName AndersenEngtaccdng Project NKUWM h440 Vadetc L 6 133. 1 Being S'O Cikill Sample ID 3450 \Ldre 16 BU: I Bcutg SO alatrlr. Drintirg Watrr Orrlcted By PWSID 0 ixple R-mam.- YT5FISSJI T-515 P.OVU t -W AU IJales/rOne% are Alada Srondatd Tele Porard Date!rimr OV012002 15:42 Collected Mterflne 06/_&2002 15:00 Received D.steffllnc O"IM12002 15:1O Technical Director r� �St�fp�h1en C. Ctk Rtltased By .•fAn�:.:: Pero Me` -s.: f"wa 0.nulu POL upas Stch� Lm• Aa.: Gic Ka:era Department h:tralt -K Mcrobiology Laboratory 'rwal Colifo m 1:.2c01t C.20O rry'L EPA 3WU I, ICI Oi'r-19:02 JD; 108. No Coli con-kinl- SALE:2220 i<Ir O(MrO2 SAP CME Environmental Services Inc. Lhborotory Division reitry�iv�t►�rni�i/�a/rirriirr/r/emir/rirr//ire 200 W. Porter Drive Drinking Water Analysis Report for Total Cv Lilt B1CtCrla Tel. eau, AK 59518.7605 Tel: RE.4D L'v'STELCTIo,VS O.v M,ERSE SrD£ BEFORE COLLECTINGS.•L$IPLE Fax p PUBLIC WATER SYS'rEm I.D.11 tjC PRIVATE NN.ATERSYSTEM � = Se+Id Rerue• M�tit;Cr N , •-raKv Snv46 a.�Fc_33� to c C Sendrnwice Send Retutir ] Send fnymce .VSs) it q0'S ((o 9 CJ FzN;1 ED - SAMPLE DATE: Month Day Ye SAMPLE TY?E ,�}111�_s11Routine Tem MID 4e o RepeuSample(forroutinesam'ler' �"t at »Ith lab ter. no ,- Special Purpose C 1 led SAMPLE LOCATION Conments: TIIM O lec Collected BY P axle Pmt 1 SAMPLE to be: Dl .>�am�:edveE.�d1+b;�s old, -euhs may be unreliable O Sdmp:e too long in :rash; samp.e should not be over?, Ohours old at eaaminat:on I o indicete richabic results. Please send new simpl: via special Csl.very mail. Date RecelcedA/A-%- TimeReeeived �5�� Analysis Began 1-7 i 0�- Analytical Method. Mennrane Filter o MMO-MLO • Number of color, ievl(y17n1. Lab Ref. No. Result* Analyst Wal sent to ADX -C- Aeen Fbks ". C Faxed Dale 7111- Client notified onts�sults: Ploaned Spoke with seen Dac* AEC—) Tx ix BACTERIOLOGICAL RATER ANALYSIS RECORD MstO•MCG Result: Total ColiformE. Cori Menlbsrsee Fiber; Direct Count ! a11 ` ld_ ColoaiewNo ml verHlcatow LTR F,GB COLIFDtH_ r% r'7- r.r ,•. Fecal Coliform CoorsroaVan Real Membrane Filter Results C CoNtortri 100 tn1 Reposed By a Date J Time hn :D •Orh.•fxm• y ZMW= Memhorofma SOSGroap(Socaita Cendra'ade Su,y illaricei ENwIRON6tENTAL FAOJTIES IN ALASKA. CALIFonNIA. FLORIDA, ILLINOIS, MA7YAND, MICHIGAN. MISSOURI, %TN a°PSET. OH10. sVEST YIRC N1A �