HomeMy WebLinkAboutT15N R2W SEC 25 LT 134
Municipality of Anchorage Page ~--~-. of 2--
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ,~) ~d)~? PID Number:
~/rz.- ~5o~/ Wastewater System: ~New ~ Upgrade
fo~/ ~1~/~ b~ ~: ~/~/~ ABSORPTION FIELD
Phone: (/~-~0~ No. of Bedrooms: ~ Deep Trench a Shallow Trench ~Bed ~Mound aOther
LEGAL DESCRIPTION so,,~.~: ~ GP~/Sq. Ft. TotalDepthfrom~ginalgrade;
I ~ ~ Sectio.~ ,~ Fill added above original grade: Gravel length:
WELL: ~New ~ Upgrade ~/ID ¢~ ~ Ft. /I ' Ft.
Classification~/~(Private'~A'B'C): T~t h:, Ft. Cased~To: Ft. Total absorption~ ~area:~ SQ. Ft. Pipe
SEPARATION DISTANCES ~ s,.t~c ~ Ho~i,.
w~,~~/P~ ~ LIFT STATION
Lot S~e in gallons:
Cu~ain ~//~ ~ Pump Make & Model I Electrical Inspections pedormed by:
Remarks: ~/~ Z~;~ ..~ ~;/~ BENCH MARK
ENGINEER'S SEAL
Inspections pedormed by: ~,~ Dates: 1st ~P~/P~
Department of He d Hu r ices apPrOval
Reviewed and approved by~ -- Date: /
,Permit No. ~'~' ~O~"~ Page
2 of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519 6650 · Telephone: 545 4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: LOT 134 T15N R2W SEC 25
300.60
PID No.:
N 89°50'00'
1250 GAL
B
LQT 134
50' BLM & UTILITY EASEMENT
302,20
N 89°50'00' ~/
ELEVATIONS ~ TOP DF ~"ELL CASING
(NOT ~0 SCALE)
SWING TIES
k-lg = 39.4
B-E = 35.5
C-F = 94.6
D-F = 117.9
SCALE 1"=60'
o~ - MONITOR ~JBE
11-9-95
ENGINEER'S SEAL
'G'- 7 "~
0~w.. cu ~ 3e ..~
............
RECEIVED
~ JUL 1 1 199G
MunJc~pah[y ot Anchorage
~ .~ Dept. Health & Human Services
Zac's Well Drilhng
~ And Pump Service ~
P.O. Box 521068
Big Lake, Alaska 99652
376-0227
r)m, ZH oF wm.r.
sT^Tic
GALS. PER MIN.
SIZIE. OF CASING
KIND-OF FORMATION:
From cY
From /
From ~ ~'
From ~ 7 Ft. to ~/' Ft. ~,~'e7~,o 5 ~o,,~ ,~ From Y~g Ft. to/~'TFt.~7,~i
From ~/
Ft. to qZ Ft.~rz ,4~,c,7'~-L From/¥TFt. to/~/ Ft.d~'~9
Froml7, O Ft. to/7_/ Ft,(~,64q~'a~ae,~g From/&7 Ft. to/?0 Ft. 6tego
CONTRACTOR
PROPOSAL & ACCEPTANCE
4597
TELEPHONE
NAME
ADDRESS
CITY
TELEPHONE
STATE ZIP
PROPOSAL NO. 1PAGE N0. OF PAGES
MATERIAL AND LABOR AS REQUIRED IN ACCORDANCE WITH THE ABOVE
SPECIFICATIONS.
FOR THE
SUM OF DOLLARS S
THE ABOVE PRICES, SPECIFICATIONS AND CONDITIONS ARE SATISFAC-
TORY AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO COMPLETE
THIS CONTRACT AS SPECIFIED. PAYMENT WILL BE MADE AS OUTLINED
AUTHORIZED SIGNATURE
AUTHORIZED SIGNATURE
DATE OF ACCEPTANCE
l'a::~Fa~ .~c4~o i~ !q~nvnt~d P~ner []
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 AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW950287
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAME:BERSON BILL
OWNER ADDRESS:6631 WEINER DR. #F
ANCHORAGE,ALASKA 99502
DATE ISSUED: 9/21/95
EXPIRATION DATE: 9/21/96
PARCEL ID:05131605
LEGAL DESCRIPTION:
T15N R2W SEC 25 LT 134
LOT SIZE: 99752 (SQ. FT.)
NUMBER OF BEDROOMS: 2 THIS PERMIT: 2
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / 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 (iSAACS0) .
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
INSTALL SUFFICIENT AMOUNT OF SPECIFIED PITRUN
TO ENSURE A SIX FOOT (6') SEPARATION FROM BEDROCK.
INSTALL AN IMPERMEABLE MEMBRANE AROUND PERIMETER
OF DRAINFIELD TO ENSURE DOWNWARD MOVEMENT OF
EFFLUENT.
RECEIVED BY: ~ ~ ~ J,. ,'~
DATE:
DATE:
RECEIVED
SEP ~ ~ 1995
Municipality o! Anchorage
Del)t, Health & Human Services
Eagle Ri%, _r
Engineering Services
P.O. Box 773294
Eagle River, Alaska 99577
694-5195 FAX 694—FAXS
To:
S
Date:
Re:
Comments:
Total number of pages Y including this cover sheet.
If you have any questions or if you are missing any pages
please call us at 694-5195.
Total number of pages Y including this cover sheet.
If you have any questions or if you are missing any pages
please call us at 694-5195.
PERFORMED FOR:
LEGAL DESCRIPTION:
2
3
4
5-
7-
8-
I0-
13-
17
19
20
COMMENTS
RECEIVED
$£P 2 2 1995
M ........ ,,- ~, ~.,.~'~.t4p. t~,[pahty of Anchorage
DEPARTMENT OF HEALTH'~&~J~A~J~f~,a~ Services
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
307 /3q
&b,414
Township, Range, Section:
SITE PLAN
SLOPE
WAS GROUND WATER
ENCOUNTERED? /~
DEPTH?,P YES. AT WHAT /A//..~ pO
E
Depth to Water After '2/,~/'~z
MaAitorinD? D~? Date:
Gross Net Depth to Net
Reading Date Time Time ~oW,~ate~r~,,r,~ Drop
~o2,~ o~j~q195
/ ,, ..~:~..c Ig .,.,;~ u~"
PERCOLATION RATE ,~/ ~(minutes/inch) PERC HOLE DIAMETER ~ It .
TEST RUN BETWEEN / /~- FT AND ,~ ~'~- FT
PERFORMED ~: /"/~N I ~/Z,¢E '~"~"CERT,~ THAT TR,S TEST WAS ~ERFORMEO,N
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4185)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
3-
4
7
12
14-
1'/-
20-
COMMENTS
RECEIVED '
Municipality of Anchora~E~P 2 2 1995
DEPARTMENT OF HEALTH &,~UMAN SER~/ICES
.... u~ ~c~ r~cnorage
825 L Street, Anchorageo~.~(~an Service0
SOILS LOG ~ PERCOLATION TEST
Township, Range, Section:
SLOPB
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
$
IF YES, AT WHAT //~/~ ~
DEPTH? p
E
Oeplil Io Water After
Monitoring/ ~Y Date: '~-Y'-sg
N
Reading Date Gross Net Depth to Net
Time Time ~?~a~r~ ~.~ Drop
_~AF. ~ ~/~/9~'
~ ~: ~7 ~a.~',
6 ~,'~ Io ~Y ~%~" ~"
PERCOLATION RATE ~J~ ~3 (m,nutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ FT AND ~ FT
PERFOBMED E¥: A'/JW , z~-~g~ CE.T,~¥ THAT THIS TEST W^S FEB~OB.ED'N
ACCORDANCE WITH ACC STATE AND MUNICIPAL GUIDELINES iN EFFECT ON THIS OATE. DATE:
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
3
4
7
8
g
10
14
17-
:20-
COMMENTS
RECEIVED ..~ ..... ..,. ,..
· SEP 22 1995 ~'~.",~.r.~[~ '":...'~?~.
Mumclpality of Anchora~nic,pallty
~EPART~ENT OF HEALTH & H~~man Servi
825 "L" Street, Anchorage, Alaska 99502-0650
-
Township, Range, Section: 7"/5-,/k/ /~.~-/-t..) rSVp.. ~.~'
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPT.?
SITE PLAN
Gross Net Depth to Net
Reading Date T~me Time Water Drop
~- ~:','~' /0 ~,~ ~ ~" ~ ~"
PERCOLATION RATE ''~' ~' '7 (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~/~ FT AND
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE;
Louis Butera, P.E.
Registered Civil Engineer
September 7, 1995
Jim Cross, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Lot 134, T15N R2W Section 25
Permit Application
Dear Mr. Cross:
The proposed well and septic system will have very limited impact on adjacent properties for the
following reasons:
1. The surrounding lots are large, allowing sufficient room for septic sites.
2. Immediate neighboring septic systems are all +30' distance.
3. ' Reserve space is adequate, due to soil absorption capacity and low bedroom rating.
4. Drainage will not be affected and is not a major consideration in our design.
The proposed area is the only location on the lot that is not restricted by slope or bedrock
outcroppings. If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\G:\WPDOCS\1995\95-O85A.NAR
P.O. Box 773294 · Eagle River, Alaska 99577 · Telephone (907/ 694-5195 . Fax (907) 694-3297
SPECIFICATIONS FOR ON-SITE SYSTEM
LEGAL:
Lot 134, T15N R2W Section 25
09/08/95
Ae
1.
2.
3.
10.
B.
1.
4.
5.
6.
GENERAL
The well and septic plan is for a two bedroom single family residence only.
The drawing and/or site plan shall be a part of this specification.
All materials and workmanship shall meet the Anchorage Department of Health 0VIOA-
DHHS) requirements.
All soil tests are advisory to the design and are to verified or modified in the field by the
Engineer.
All excavations and depths are advisory and are to be verified in the field by the
Contractor to meet MOA-DHHS requirements.
It is the responsibility of the Owner to obtain all necessary permits or easements and to
locate any adjacent multi-family wells.
It is the responsibility of the Contractor to secure all utility locates prior to construction.
The excavation is to be exactly in the area shown on the site plan, any deviation requires
Engineer approval.
It is always recommended that a surveyor locate the nearest lot line position and the
location of any easements.
Any remaining open test hole excavations shall be filled.
SEPTIC TANK/LIFt STATION
Septic tank and lift station shall be 1,250 gallon Orenco/Anchorage Tank model OSI 05-
20-HHF.
Receipt from certified electrician stating the lift station was wired to applicable codes to
be supplied to Engineer.
LEACHFIELD
The leachfield excavation is to follow the natural contour to maintain uniform total depth
of the trench bottom, removing the 1' topsoil layer and placing this on the downslope side
of the excavation
A +6" layer of sandy pitrun material (<5% fines) shall be placed in the excavation as
needed to bring the bottom of the leachfield to 6' above the bedrock level, approximately
at ground surface. The top of the sand layer excavation shall be level, plus or minus 1.5".
1' of sewer gravel shall be placed on top of sand layer with leachpipe buried in gravel with
+2" cover over pipe.
The leach gravel is to be covered with typar fabric material.
A combination of soil and extruded board insulation to a depth of 3' or equivalent is to be
placed over the leachfield with a 3:1 maximum finish slope.
The area over the dralnfield is to be finish graded to prevent ponding of surface water
runoff, with uphill portion contoured into the slope.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH = o ground surface GRAVEL DEPTH = 6" under pipe, 2" over pipe
GRAVEL LENGTH = 75' GRAVEL VflDTH = 5'
SOIL RATING = 0.8 gpd/ft2 BEDROOM CAPACITY = 2
SEPTIC TANK SIZE ---- 1,250 gallons w/lift
Twenty-four (24) hours notice required for all inspections
\1994\95-085A.SPC 1
LOT 1.19
VACANT
300.60
N 89°50'00'' ~/ ~. ~ ,~. I
/' I
' LOT 134
/ .....
............... FILTER * ~ , · .~o 1-1/4' 45" EL
~ 50' BL~ & UTILITY EASEMENT ~ °S~?~oo
30~,~0 ~PRESSURE PIPE CLEANDUT
N 89~50'00' ~
N, FIRELAKE RD.
~ TEST HOLE
· - MONITOR TUBE
NO WELL ON LOT o - SEWER CLEANOUT
NO SURFACE WATER + ~ WELL
PROPOSED LEACHFIELD
NO KNOWN CURTAIN DRAINS -- --- EASEMENT
LEGAL: LOT 134 T15N R2W SECTION 25 ~...,
OWNER: BERSON ~<r" '
CONTRACTOR: N/A ~* '~gTH~ '.
JOB~ 95-085AI DATE: 09/08/951 SCALE 1" = 60' ~- %~,~:~'
~.0. ~ox 77~4 ,,~% ~.... ...'
~, ?o~ss~o~
.EAGLE RIVER
ENGINEERING SERVICES S,E~r.o.
P.O. Box 773294 CALCULATEDSY ~'~/~ DATE
EAGLE RIVER, AK 99577
(907) 694-5195 CHECKED BY DATE
SCALE
0.42 gpm per 1/8" orifice .... '": ...... ": ........
25 gpm + 0.42 gpm = 59 orifices ....
'Spacing = 69' +' 59 orifices = '1.17' or 14"'spacing
\G:\WPDOCS\1995\95-085A.CAL
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502~0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
2
4
§
/--~,~7 /$9
6
7
8
9
10
11
12-
13-
14-
15-
16-
17-
18-
19-
20-
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
DEPTH?
SITE PLAN
Gepll~ lo Waler Alter ~/,s'/'~-~
Monitoring? D~/ Oate:
Grass Net Depth to Net
Reading Date Time Time Water Drop
om' ,,
~ " ,~: ~ 19 ~/ ~11~ ~ ~II~'
PERCOLATION RATE ¢' ~(minutes/inch) PERC HOLE DIAMETER
TES' RUN EETW N / FTAND
PERFORMED BY: ///J"~]~ I ~:~/~'~ ";~-~'-~- CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES iN EFFECT ON THIS DATE, DATE: ' ~" "~; ~ '-~ ~' -'
72-008 (Rev. 4185)
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
f, ,-~9]..~ ):% '. :'
*~'.... ..."~
LEGAL DESCRIPTION:
3
4
5
6
7
8
9
10
11
12
13
14-
15-
16-
17-
19-
19-
20-
COMMENTS
/.- u'7 /$~
t/A IzY / /'-I ~
Township, Range, Section:
SITE PLAN
SLOPE
WAS GROUND WATER
ENCOUNTERED?
I F YES, AT WH AT
Oepth to Water Alter
Gross Net Depth to Net
Reading Date Time TTme Watec Oral3
PERCOLATION RATE /"/J '~-~ (m,nutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN / FT AND ~ FT
PERFO.MED EY: /~'N , Z~/z~SS ~-W-~
~-~- ,% - CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DAT~ ~"-
72-008 [Rev. 4/85)
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:
5
6
7
8
g-
10-
11
13-
14-
15-
16-
17-
18-
19-
20-
Township, Range, Section:
SLOPE
WAS GRouND WATER
ENCOUNTERED?
SITE PLAN
S
DEPTH?
E
0ep[h to Water A~at
Moniloring? ~ I~l~ ~ ':'~'¢'
Gross Net Depth to Net
Reading Date Time Time Water Drop
/ %: $~ /~ ,,,,., ~,~- ut/(/" ~- z.//~,"
PERCOLATION RATE ''~/~' ~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~/~/-~ FT AND ~'~-'~FT
COMMENTS
---; ~ - CERTIFY THAT THIS TEST WAS PERFORMED IN
-p, - b~ ,- ,~-~ ·
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; ~
72-O08 (Rev. 4/85)
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box ??3294
EAGLE RIVER, AK 99577
(907) 694-5195
TI5N P,2W
ction Z5
Lot 134
#051 - 316-05
Mu.iclpality of Anchorage
Development ServiceS' De aHment
Building Safety Division
On-Site Water and Waslewa~er Program
,{700 South Bragaw St.
P.O. Box '196650 Anchorage. AK 995tg-6650
www.d.anchorage.ak.tJs
(907) 3,{3-7g04
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-316-05
1. GENERAL INFORMATION
Complete legal descripfio~ Lo b 134;
[oc~tion (site addres~'o'~ i~irections) 18 310 Iq'.
C.ui'r&nt Property 6wnei'(s) '
"M.a, ili'6g address
Lendin~g~n~y '
Expiration Date: c/. 3, - O..O._
sec 25; T15N; R2W
Fire Lake Ave
Mailing address
Real Estate Agent
Berson
Day phone 694-5050
Ea~]e River. AK 99577
Day phone,
Day phone
Mailing Address
Unless othenWse requested, HAA will be held by DSD for plckup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Communily Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
individual On-site []
Individual, Holding tank
Co,m. mundy On-site
[] Pubhc Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given In paragraph S by an Independent professional civil
engineer registered In the State ot Alaska. Certil~cates of Heallh Authority Approval are required for the transfer of
lille (except between spouses) for propedies served by a single family on-site wastewaler disposal and/or water
supply system. DSD also issues HAAs upon request ~o homeowners. Certificales 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. (Certilica~es may be reissued for a period of up 1o one year wilh
valid water samples.) Certific%les 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 prolesslonal
engineer's work.
4. STATEMENT OF INSPECTION BY EI4GINEER
As certilled by my seal affixed herelo and as o{' Ihb vali(Jation da~e shown below, I verify that my Investlga{loh,
based on procedures outlined In the Health Authorily APproval Guldelines for this applicalion, shows that the
on-site water supply end/or was~ewater disposal Sy~terfl Is(are) safe, functional and adequale for the number of
bedrooms and lype of struclure Indicated herein. I t'urther verify Iha{ based on the Informalion obtained from the
Municipality of Anchorage files and [rom my Investigation and Inspection, the on-site water supply end/or
wastewater disposal system Is(are) In compliance ~vi[h all applicable Municipal and State codes, ordinances.
and regulations In effect at the time of
Nameo[Firm S & S En~fneerfn~
Address 17n~;, ~ ~'~,ql~ ~fver Loop Suite
Engineer's Printed Name Rnh~,r~' c _
5. DSD SIGNATURE
~ Approved for
Disapproved.
Conditional approval for
Phone 69/4-2979
Ea~!eRiver, AK, 99577
Date
bedrooms, with Ihe MIIow'ng sllpulabons:
---
Additional Comments
Altachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
SUpplemenlal Engineer's Report
Other
Original Cedificate Date: ~,.~ - 3 - 0..~.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
w~wv,ci.anchorage.ak.us
(507) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:/-/~'/'
A. WELL DATA
Date completed
Total depth /~(~ ft.
IfA, B, or C provide PWSID # '"-
san =y=e (Y/N) 7'
Parcel ID: ~ ~,.~,~''
(,C~ed to _
FROM WELL LOG
Date oftast /~/~/~"
Static water level "~, / ft.
Well production ~ ~ g.p.m.
War Log (Y/N) '7'
Wires properly protected (Y/N)
Casing helgM (above ground)
AT INSPECTION
"
~' ~' g.p.m.
in.
WATER SAMPLE RESULTS:
Coliform 0 oolonies/150 mi.
Date of sample: ~¥.~a,/O
B. SEPTIC/HOLDING TANK DATA
Nitrate O-.~ 70 mg,/t.
Collected by:
Other bacteria /'/ colonies/lO0 mi.
$ & $ ENGINEERING
i7034 laele Riv~.
F.~e Ri,mr, N~dm
Tank ~'ype/Matertel ~
Tan~ size '~=~=. gal.~ Number of Comparlmente ~-
F0u~daflon deanout (Y/N) ' ~/ Depression over tank (Y/N) .
Ce
Date of pumping "~/~-/~2/ Pumper ~,/~ ~
ABSORPTION FIELD DATA "~
Date installed .~. Soil rating (g.p.d./fl2 or ~/bdrm)
Total depth '~ ft. Eft. absorption area ~"'ft2 Monitoring tube
Date of adequacy test 4//,~/~' Results (Pass/Fail) /~ ~'$
Fluid depth in absorpiton field before test ~ in.
Elapsed Time: // min. Final fluid depth (~
Y
Water added~.~O~gal.
in.
Date installed ~__
Cteanoute (Y/N)
High water alarm (Y/N)
System type ~'//'~,/,.~;~ ~"~'
Gravel below pipe ~7/~"' ft.
Depression over field. /V/
For ~- bedrooms
New depth'% ! in.
Absorption rate >= :~C,4~..~ g.p.d.
If yes, give date ~-'
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
D. UFT STATION
Data installed ~'/~/
'Pump on' level at 4~ .~in.
Datum '~,~/~'/ 7
s ze in gallons
'Pump off' lev~ at Z~. i~in. ,
Manhole/Access. Of/N)
High water alarm level at
Meets alarm & drcult requirements?.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tamP/lift station on lot
Absorption field on lot /("20 /'~-
Public sewer main ~//'~
On adjacent lots
in.
On adjacent lots
Public sewer manhole/cteanout ~/-~
.=,~m~rTseptic service line ~' ~ I'F' Holding tank /~/
SEPARATION DISTANCES FROM SEPTIC/I-~-G TANK ON LOT TO:
Building foundation ~ ''/' Property line ~ ~ Absorption field ~' ~'P'
/,. '~ Sudace water /~) /~-
Water main /.J - Water sewice line ! O t
/
Wells on adjacent lots _~ , ; , '.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 4/~)/,/.- Building foundation //g~:)/v-- Water main '"'//'~'
Water Sewice line / ~'-)/-+ Sudace water / O O '4- Driveway, pafl<Jng/vehicle storage !
Curtain drain ~/J Wells on adjacent lots ~/~O ~-
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspec~ons and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Pdnted Name
Date
HAA Fee S ..3 '7
Date of Payment '~'
Receipt Number
(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number
CE - 8801
CT&E Environmental Services Inc.
200 W. Potter
)ranking Water Analysis Report for Total Colifo~i-~ Bacteria ^~ora~,.
Tel: (907l 561.2343
Send ~esulo ~ Se~ ifl~c~
0 Send
SAMPLE DATE:
Month
SAMPLE ~(PE:
~' Routine
O Repent Sample (for routine tAmple
with lab ref. no. .)
Day Year
Treated WAter
Untreated Water
Time Collacted.
Analysis shows this Water SAMPLE to be:
~ Sallst'Ktory
0 UnsAtisfactorY
SAmple over 30 hou~ o~d, ~ul~ ~y
S~le t~ I~g in ~nsit; s~mple should
not be over~Ou~ old at examination
new s~ple ~a s~ial delive~ mail.
Date R~eiv~ ~
An~ysls ~an ~ ~/~
An~cll Meth~: ~ ~em~e Filt~
~ M~UG
· Numb~ofcolonie~l~ mL
Lab Ref. No. Result*
Sentt~A.~.E.~- A~th fb~ Jun
Analyst
fn~td
. Time:
Client noUfled of unsAtisfActory results:
Spoke ~R.~
Time:
MMO-MUGResult: TotzlCollform £. Cell
.,.~ran..,.- oi~c...t L& O~ ~o ~\', ..
Verification: LTB KGB_ COLIFIRM
lqnat Membrane Filter Results ,--./-~', ~ ·
..po.ed,,, 'A~ ~,,. ~1.o~,.. /,~-
Comments:
~'~d,~ E;~ MambM of the SGS Gro~Jp (SociM6 G6n~'ale de Sur~iUanca)
~$~.. CT&£ E.vtronmental Service, InC.
2/ 3
CT&E Ref.#
CHeat Name
Project Name/#
Clieat Sample ID
Matrix
Ordered By
PWSID
SampleRema~:
102292600!
S & S Engineering
L134 $ec25 TISM R2W
L134 Sec25 TISM R2W
DrinMng Water
All Dare,Times are Alas~ Standard Time
PHnted Date/Time 05/28/'2002 12:06
Cellected Dale/Time 05/22/2002 14:00
Received DaterTlme 05/23/2002 11:20
Technical Director Stepbewe_"%Ede
Released By ~~
Uai~ Method
Allowable Pte~ A~ysis
Limbs D~te Date Init
Nitrate-N
0.370 0.200 rng/L EPA 300.0 (<10)
05,"23/02 .IDT
Hicrobiolog~ L~boratoz7
Total Coliform 4OB, No Coli
col/lOOmL SMI8 922213
05~3/02 KAP