Loading...
HomeMy WebLinkAboutFISCHER BLK 2 LT 1C · .~IUNICIPALITY OF ANCHORAGE (' · · DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION ! 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE r--IuPGRADE MAILING ADDRESS LEGAL DESCRIPTION L lc r~ ~z. Cd¢~ LOCATION NO. OF BEDROOMS D,STA,CE,O: Iwe'' I Ag° t'onar" PE,M,TNO. L~"~c~ar~nga"°n' '~"OME~OE= ,n.de,e.gth Width Liquiddeptb I~,o~ Well Dwelling PERMIT NO. DISTANCE TO: O :~ ~ Ma~lufacturer Material Liquid capacity in gallons ~ Well F°undati°ne"~.O) I Nearestlot~_t~l~ / PEHMIT NO. ~[~ No.DISTANCE TO:of lines , Length ~(~h,~ne Total len~ Ii/les-- L~Tren~) /' ' inches To talOec/~e~sorption Distance between lines ~ I- Top of tile to finish grade (~ / Material beneath tile area ¢~ ~ inches Length Width Depth PERMIT NO. ~1- Type of crib Crib diameter Crib depth Total elf active absorption area u~ Well Building foundation Nearest lot line ~ DISTANCE TO: -I'a ~'.lass Depth Driller Distance to lot line PE~,~I~Nc)O.~,~_ {~.t~ ud Building foundation Sewer line Septic tank Absorption area(s) ~: DISTANCE TO: OTHER PIPE MATERIALS SOIL TEST RATING 1[O ~ INSTALLER ~ -- REMARKS 724)13 (Rev. 3178) PERMIT NO. r'lU~-i I C I PRL I t'q OF F:II'-Ii~HORF:IGE DEPRRTME~T OF HEBLTH Rr'~D E~VIROrlMEr~TBL PROTECTIOr.~ 825 'L' STREET, Ar~CHORRGE, A~. 99501 264-472~ NELL 8~4D Ot4--SItE SEI4ER PERMIT RPPLICRNT LOCRTIOr~ LEGRL MT. EHTERPRISES BIRCH LIC B2 FISHER SR8 BOX i582-N LOT SIZE ~44 0491 70000 SQURRE FEET TYPE OF SOIL RBSORBTIOr. I SYSTE{'I IS: TRENCH MRXIMUM NUMBER OF BEDROOMS = 4 SOIL RRTING (SQ FT?BR>= ilo THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS: DEPTH= ~-2 LE[~GTH= 5~ GRRVEL DEPTH= 4 THE LENGTH DIMEHSION IS THE LENGTH (IH FEET> OF THE TRENCH OR DRRIHFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRr'~CE BETWEEH THE SURFRCE OF THE GROUND Rr'~D THE BOTTOM OF THE EXCRVRTION (IN FEET>. THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MIHIMUM DEPTH OF GRRVEL BETHEEN THE OUTFRLL PIPE Rr'~D THE BOTTOM OF THE EXCRVRTIOr~ (Ir~ FEET>. REQUIRED SEPTIC t~( SI;~- E= 1250 GBLLO~S PERMIT RPPLICRNT HRS THE RESPOr~SIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTRLLRTIOr.~ INSPECTIOr~S OF 8NY WELLS RDJRCEHT TO THIS PROPERTY RND THE NUMBER OF RESIDEr~CES THRT THE WELL WILL SERVE. TL-IO ,~ 2 ) I I'-,ISPECT I 0~4S FIRE REQLm I RED BRCt(FILLING OF RHY SYSTEM WITHOUT FIHRL INSPECTIOr.~ Rr~D RPPROVRL BY THIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTRr'~CE BETWEEN R WELL R~'~D R~Y ON-SITE SEWRGE DISPOSRL SYSTEM IS i00 FEET FOR R PRIVRTE WELU OR 150 TO 200 FEET FROM R PUBLIC ~lELL DEPENDING UPOt~ THE TYPE OF PUBLIC WELL WELL LOGS RRE REQUIRED R~'~D MUST BE RETURNED TO THE DEPRRTMENT WITHIH ~0 DRYS OF THE WELL COMPLETIOr~. OTHER REQUIREMErITS MRY BPPLY. SPECIFICRTIOHS RND COtISTRUCTION DIRGRRMS RRE RVRILRBLE TO INSURE PROPER INSTRLLBTIOt~. PERr'l I t E×P I RES DECEMBER _'~%1 ~ ::Lg?~©. I CERTIFY THRT l: IRM FRMILIRR WITH THE REQUIREMENTS FOR Or'l-SITE SEWERS Rr'~D WELLS RS SET FORTH BY THE MUNICIPRLITY OF R~CHORRGE. 2: I WILL IHSTRLL THE SYSTEM I~RCCORDR~CE WITH THE CODES. ~: I U~'~DERSTR~ID THRT THE Ot~-SITE SE~ER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE RESIDENCE IS~ODELED TO~LU[~ MORE THR~ 4 BEDROOMS. J ISSUED BY DRTE V1.2 PERFORMED FOR: LEGAL DESCRIPTION: 2 3 4- 5- 7- 9 10 11 13. 14. 15- 16- 17- 18- 19- 20- COMMENTS SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch ~0, ,A~d~, A~a*ka gg602 276-2221 n PERCOLATION TEST SOILS LOG -- PERCOLATION TEST DATE FERFOR,.D: '~ /~'0 /9 ~ SLOPE SITE PLAN IF YES, AT WHAT DEPTH? WAS GROUND WATER ENCOUNTERED? i i Li J Gross Net Depth to Net Reading. Date Time Time Water Drop PERCOLATION RATE (mlnute~llnch) TEST RUN BETWEEN , FTAND FT 72-008 (7/76) WATER WELL LOG FOSS DRILLING 1336 Ingra Street Anchorage, Alaska 99501 LOCATION -~' ' ' ' SIZE OF CA~ING~2~DEPTH OF HOLE~PT. CASED TO i~T~ STATIC WATEH LEVEL / ~ PT. YIELD_~GAL.PER.~IN. W tn ~ FEET OF DRAWDOWN. REMARKS DATE 'CO~PLETED~PU~P TO BE SET AT~ ___~o to tO__ to__ .__tO__ tO___ tO____ tO___ MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 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 lot. block, subdivision, section, township, range) LOT IC: BLOCK 2: F/6ch~ SubdZui6/0n LocatiOn (address or directions) 5301E~6t 100th Aue~zz~, (b) Property owner _Tcut~ Ce~z,~ Telephone: (home) $46-1444 Business MailingAddress ~.~0! E~,,+ 100,f'lt Au~_~ A~,/tn~z?. A,~z~ 99~I~ (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent RE/MAX P~OPERTZES,ZNC. A'I'TN= Caro~ K,~o~e Address ~600 Co~dou~ S~. Su.,~¢ I00 Ancho,'[a.~e~ A~,~6~zct 99503 Telephone ~7~ --f7~I (e) Mailthe HAAtothefollowing address:(orcheck here ~Xifholdforpick up.) Listcontactperson and day phone numberbelow: $ & S ENGINEERING 17034 Ea_~le R~ver L~o? Road ~,~_ ~_~ Eagle River, Alaska 9957~ 2. TYPE OF RESIDENCE Single-Family r~ Number of bedrooms ~ 3. WATER SUPPLY Individual Well,~ Community CI Public [] Note: If community well system, must have written confirmation from the State Depart~nent of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site,~t; Public [] 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. 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~s Health Authority Approval 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 Date Telephone :~ & .5 ENGINEERING 17034 Eagle R~ver L~ Re&ENo. 2 Eagle River, Alaska 9957/ 04 Approved '~'"""~ Disapproved- Conditional Terms of Condi!ional Approval ' ,/~2~ 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. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) Heal, th~, ~,~orlly Approval (HAA) OCT Z 8 1989 Lega~ Description: ~ A. WELL DATA ' RECEIVED - Well Classification . -~' ~ lc ~ ~rY.,; I~/ If A. B. C. D.E.C. Appr0~;ed (.y/N) Well Log Present (Y/N~ ~/' i DateC~ompleted "~-I~- ~''~::~ Yield .~.O ~'~ TotalDepth ~ 'Casedto f' ~r~4 Depth of Grouting Static Water Level ~. Casing Height Above Ground 'Electrical Wiring In Conduit (Y/N) Pump Set At ~)~- / Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot / OO To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line .'.)/~ To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments f- ; On Adjoining Lots ! / /Oo ~ ; On Adjoining Lots To Nearest Public Sewer ~.,~ ,~ ~,)~:~'~o~ ;Date . B. SEPTIC/HOLDING TANK DATA ., - Date Installed ~-~-'~'Size__L,~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: ~ I' To Building Foundation /' To Disposal Field '" ' Foundation Cleanout (Y/N) DateLastPumped I O - II~ - ; for f,) F Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line' To We,~c=ta3~/Service Line To Stream: Pond, Lake or Major Drainage Course Y ~2~'~ (..,. 7~) F,o-~ Page .1 of 2 C. ABSORPTION FIELD DATA ~' * / .' ~ // Soils.atinginAbsorptionStrata ~ Type of System Design '~"~Jc.~ ' ' Date Installed / ,Width of Field · Square Feet of Absortion Area Depression 0v. er Field (Y/N) Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ( ~c, I'/' "~/ Length of Field Depth of Field ~ Gray,vel Bed Thickness · '~/~ ~ StatndpipeS' P~'esent (Y/N) fJ Date Of Last Adequacy Test F To Property Line To Building Foundation Lot /'J/~ To Water Main/Service Line ./¢2 ~ P' To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments · ~ ~ ' To Existing or Abandoned System on ; On Adjoining Lots: ;~ O · 4- To Cutback (if present) ~J~j ~ ,,o~- ¢~ ~.~'~ D. LIFT STATION 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 hace 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. c>-~//'/'~/ Date of Payment Amount: $ Receipt No. ~ Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ANALISI$ hEPO~T E! SAMPLE for Work Order ! 17456 Date Report Printed: OCT 16 E9 ! 09:22 Client Sanple I0:L13, 82 - EAgL 8II Collected OCT 10 89 ! 16:15 hre. ~ecelved OC~ 11 89 ! l~:O0 hrl. Preserved with :AS REQUIRED CLient lcct: P.O.! ~gE REC£IVEO ~eq I Ordered S7 lnalyels Completed :OCT 11 89 Send 8eports to: leleaeed ~7 : ~ d. ~ 2) Special HOLD EOB PICEDP. Instruct: Chaalab ~ef I: 7999 Lab Smpl ID: I }{atrlx: lllo.able Parameter Tested ~esult/Unlte ~thod Limits 0.92 ~/l Sample EOUTINE SAMPLES. SAMPLES COLLECTED 8I R.g.S. Tests Performed ' See Speciel Instructions Above UA-Unaveilable None Detected "See Sample ~emarks Above Not Analyzed LT-Less Than, CT-Greater Than CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (90'7) 562-2343 5633 B Str.eet Anchorage, AlasKa 99518 Drinking Water Analysis Report for Total Cohform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY PUBLIC WATER SYSTEM I.D.# PRIVATE WATER SYSTEM Name Mailing Add~ess Phone NO. S & S ENGINEERING 17034 Eagle Rivet' L~p Roa,] NO~204 Eagle River, Alaska 99577. City State Mo. Day Year Zip Code SAMPLE TYPE: ~ Routine iD Check Sample (tot routine sample with lab ret. no. iD Special Purpose ) iD Treated Water CI Untreated Water SAMPLE NO. LOCATION 31 I S I Time Collected Date Received Time Received Analytical Method: uSlS shows this Water SAMPLE to be: tisfactory satisfactory 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. Membrane Filter · No. of coloniesll00 mi. Lab Ref. No. Result* 7999 Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter. Direct Count Verification: LTB BGB__ Final Membrane Filter Results Reporled By ~""~-~.o .~-'-~'~ ,Date Time: p.m. 'TNTC = Too Numberous To Count OB = Other Bacteria ,~t MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date "' GENERAL INFORMATION (a) Legal Description (incl~ude lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name~/.,! ..'~. ~'-'~'-'~-~ z/-- Telephone: Home .77-.~': -- :~/'?.~ Business (b) Applicant Address ._..~2~c/' .,.--.:-'~-*~,,-; ~' ~';~'*/~ ~ ~. (c) Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~; Other ~ (explain); (d) Lending Institution , Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the f~llowing address: 2. TYPE OF RESIDENCE Single-Family/[~' Multi-Fami!y/[] Other Number ol Bedrooms WATER SUPPLY Individual Well/~]' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite,~ Public I-I Community [] Holding Tank I-I Note:Ill community well system, must have written confirmation from Ihe State Department of Environmental Conservation attesting to the legality and status. 72-025 (11~84) Page 1 of 2 ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ·, As certified by my seal affixed hereto and as of Ihe validation date shown below. I verify that my investigation of this Health '. Authority Approval 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 liles and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with ali Municipal and State codes, ordinances, and regulations in effect on the date of t,f,f,f,f,f,f,f,f~,~ion. Name of Firm~ Date Approved for /~d.~- bedrooms by/,/j 7~il/-v'~.~:~[''~c'~'' &C.'(.[__ Date Approved 'X Disappr°ve~d Conditionalt Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 {11/84) MUNICIPALITY OF ANCHORAGE (MO~,i HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 WELL DATA A4UNICIPALITY OF ANCHORAG~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION JUN 0 9 Legal Description: ~-- Well Classification ~- ,,~'//--~ If A, B, C, D.E.C. Approved (Y/N) / we, Log Pre nt ' ) Date Comp*eted Total Depth. ~-~'~/ / Cased to ~/ Static Water Level Casing Height Above Ground Electrical Wiring in Conduiti~.N) Separation Distances from Well: Depth of Grouting Pump Set At ~'~'"..~' / Sanitary Seal on Casing~) ~/~'.~' : / / Depression Around Wellhead (Y~.~Z~'/~ To Septic/Holding Tank on Lot /~.,~ ~ ; On Adjoining Lots f~,~ /...4. _ To Nearest Edge of Absorption Field on~ot _,/~ ;On Adjoining Lots To Nearest Public sewer Line /,~././~/.?'/ To Nearest Public Sewer Cleanout/Manhole /~..~//,~'~ ~ To Nearest Sewer Service Line on Lot ~. Water Sample Collected by ~/~/.',''~,d~''~'-4 ~/ ; Date Water Sample Test Results .~l'"/ Comments ~ ~~ ~/~ ~* ~- B. SEPTIC/HOLDING TANK DATA Date Installed -~'--~'~'~'-- ~'~ Standpipes ~N) Depression over Tank Pumping/Maintenance Contract on File (Y/N)/~z ; for Holding Tank High-Water Alarm (Y/N) ,~ Tempora~ Holding Tank Permit (Y/N) ~paration Distances from ~ptic~olding Tank: To Water-Supply Weft ~ ' ~ To Building Foundation To Prope~y Line _~¢ /~ TO Dispo~l Field ~' To VJ-~.. M_L~/~ice ~.ne ~ ~ Comments ~ ~ ~ Size /,,~...;'*Z~ No. of Compartments Ai~.~.~t~ Caps~'~'N) ~/z~'~. Foundation Cloanout~N) /~ _ / Date Last Pum~d ~ --~ ~ To Stream, Pond, Lake, or Major Drainage Page I of 2 ', 72-026{ 11~S4 ) ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~'/~'~ ~z.r.~.'.,.o/.p~,~,~' Type of System Design Date Installed ~'- ..,,~2~' ~ ,~',~'~ / / To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~"c'~ To Cutbank (if present) .~-,~x~- .~"~,,,~-',~"~"7""' Length of Field ~"~'"~' Width of Field --q'>~'// Depth of Field Gravel Bed Thickness Square Feet of Absorption Area "~./'/~",,~' '-~'~"~/ Standpipes Presenld~q Depression over Field (Y~ ,/~/,~ Date of Last Adequacy Test Results of Last Adequacy Test ~'~ ~F'/I,~-.;~-v~' Separation Distance from Absorption Field: To Water-Supply Well /~4~' /--~"' To Building Foundation ,~Z~ / Lot ,,f~,z,--~ ~F~,-~,~--.~--~"' To ~a~e~..Mem/.Se~ice Line ,~' / To Stream/Pond/Lake/or Major Drainage Course To Driveway. Parking Area. or Vehicle Storage Area D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump oIr' Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request Signed.I certify that,L~ave_~l~,.~ ~checked' verified, or conformedDate to all~O~l/~'and HAA guidelines in effect on the date of this inspection. Company ~JL~'~¢l~g~0'0~ MOANo. Receipt .o. ~d~,~ Date of Payment Amount: $ ~ ~,cz.~..~ Page 2 of 2 2220 EAST 88 A~"JE A.N~IO~ulc~, AK 99507 (907) 349-6451 W~ ~LT~ subdivision: Lot: Block: Client's Name: Address: Tester: Initial Reading ~n Metar: ~ ~.F~-~/ Production Pate: GP~ 24-Hour Capacity Callons BESSE, EPPS & 2?20 EAST 88 AV~:US A.¼(~IO~A~, AK 99507 (907) 349-~451 % Subdivisio.:Lot: Block: Client's Name: Add~-ess: Tester: Reading cn Metar: f TIME CPM ~ VOLUME . /~ ;/~ _~ ~ ~ ~ ./// '~. /~ ~uction ~te: 1.~ c~ 24-Hour ca~cit~, IqZOc.~no~ ANCHORAGE CESSPOOL PUMPING ANCHORAGE CESSPOOL PUMPING Alaska Pumping P. O. Box 110232 ANCHORAGE, ALASKA 99511-O232 2415 NORTHERN TESTING LABORATORIES, INC. ~00 UNNI[RSr~Y PLAZA WEST, SUIT~ A FA~RBANK$o ALASKA 99709 ~07479-3115 ~7 OLD SEWARD HIGHWAY. SUiT~ 101 ANCHORAGE, ALASKA ~$18 ~07-349-8623 Drinking Water Analysis RepOrt for Total Coliform Bacteria TO BE COMPLETED BY CUENT i ' I-IPUBLIC WATER SYSTEM I.D. ~ [] PRIVAT~ WATER SYSTEM SAMPLE DATE: ~' ,-~ Mo. Day Purchase Order No. SAMPLE TYPE: ~t~urine pecial Purpose [] Check Sample (for original contaminated sample with lab reference no. FI Treated Water /[~Untreated Water 3 J 4 5 6 7 8 10 Signature of Representative uUN 0 9 ~o,~,.. FOR LASORATORY USE ONLY PICKUP TO BE COMPLETE~ BY LABORATORY Received at: I~r Anch. [] Fbks. Date Received ~-~/-.-~'/~'~" Time Received /,~- ~/5 Next Sample Due COMMENTS: SATISFACTORY O U N S ATIS FACTO RY U RESAMPLE R OTHER BACTERIA OB TOO NUMEROUS TNTC TO COUNT *No~ ~o~v~liform Colonies per 100 Reportedj~y '"//.,~/' mis. Time · APPLIC""NT FILLS OUT UPPER HAI"'",ONLY Pfo~_,,-rty bwner /.~,,~.,~/~ ~,--~.~ ~* ~ ~ ~ ~ ~one ". Addres; Lending Institution ~/ ~ ~/. ~. Phone Address Really ~. & A~nt / Phone Address Type of Resl~nce ~ing/e Family ~ Multiple Family No. of ~ Other Water Supply ~divtd~l A~ACH ~LL LOG. A w~l log Is ;~ulr~ for all wel~s drl~ed aince June 1975. ~ ~mm~lty For ~ells ~lll~ prior to fha date, give well depth (attach I~ If available). ~ Public Utility Sewer Disposal ~ndlvld~l Year lndlv~ual tnstalled: ~ Public ~lllty When ~ecled to Public Utility: ~ Holding Tank NOTE: THE INSPE~ION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Tim~'~ Da,. Da,. Da,e Field Notes: (~PPROVED BEDROOMS ~ ~CON DI~IONS OF APPROVAL ( ) CONDIT~NA~ APPROVAL* ~ DATE ~ ~ ~ Soils Rating Date ~wer Install~ Well To ~sorptlon Area DIRECTIONS/MAP TO PROPE~ TO BE INSPECTED NOTE: ,~e sure to put color of the dwelling or. .other identifying landmarks that will insure the inspector to locate the correct property to be inspocted. Accurate dlrecti'ons with landmarks will save time and not cause delays in a possible re-scheduling of an appointment. / /  TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER ·" *. · : 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER / SYSTEM: I.O. NO. dj ~ lin ~ L~ /'' Water System Name P~ofle No. SAMPLE DATE: ~ ~/F'~T~. Mo. Day /,. yea~ SAMPLE TYPE: /'// le ~ ~' ' "": -~' ' C~RouUne (' ~" / " O Ch~k ~pte (for murine ~p with I~ mr. no. " ' m~ , - ~ D Untreat~ Water /': TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: n satisfactory ~;~'-n sa t is~ [] Sample too long in transit: sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. , ~ . ', Date Received ~, Time Received //,~'0 I~ Analytical Method: I:,,, ~,,~ Fe~entatlon Tu~ , ~ ~ ~ ~mbrane Filter ~b Ref. N~. Rssult' , 'iFA ~"~ ~ ,' ' ~ ~*:' ' ':*' :-'- ..... ee-t~2o (~) - . BACTERIOLOQK:AL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE CHEMICAL ~c GI.~. OGICA£ LABORATORIES 0" ALASKA, INC. Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER SAMITE NO. I 4 i WATER SYSTEM: Wa~er System N~me ~W SAMPLE DATE: ~ ~~ SAMPLE ~PE: D Routine ~ Ch~k ~le (for with I~ mr. ilo. TO BE COMPLETED BY LABORATORY Analysis shows ~his Water SAMPLE to be: ,,~ Satisfactory [] Unsatisfact?y - [] Sample too iong;in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send / / "/ '~'( Time Received '/ Analytical Meth~: 4 ~ Fe~entatlon Tu~ ~,~- ~'Membrane Filter ~b Ref. No. Result* A~lyst · ................ M-t220 I~l ....... BAC'TERIOLO~ICALWATER ANALYSIS RECORO - '- .... READ INSTRUCTIONS BEFORE COLLECTING SAMPLE MUNICIPALITY OF ANCHORAGE DEPT. OF H~ALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEI~;~I~)NM£NTAL P.~OT~TION 82~ L Emro * Amh~a~e. AIm~* SSS01 ENVIRONMENTAL ENGINEERING DIVISION NOV 1 3 1978 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND S DIRECTIONS: Complm ~dl i~r~s on pa~e 1. Im.mlMm mqu~m witl nm be pr==m.~,';~i~_~l~ .. , .... 1. PROPERTY OWNER / ~ ~ / MAILING ADDRESS PROPERTY RESIDENT (It d;ff~r~t from MAILING ADORESS PHONE PHONE PHONE LENDING INSTITUTION MAILING ADDRESS PHONE MULTIPLE FAMILY [] Three [] Six 7, WAT,~R ~PLY "~DIVIDUAL° I--] COMMUNITY I--] PUSUC UTI'LITY ~. EEWA~GE O~)~;AL SYSTEM ,,[~ND] VI DUA L/ON-SITE * * [] PUSLIC UTILITY · ATTACH WELL LOG, A w~ll log is required for all w~lls drilled since June 1976. For wells drilled prior to that date, give well depth (attach log if available.) ( "~ ~ **if individual/on-site, give installMion date / ~ . If system is over two (2) years old an adequacy te~ is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN RE INITIATED. 72.010(3178) 1' THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED ' ' INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS ]--I SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO r--I FOUR [] SIX 2. WATER SUPPLY PERMIT NUMBER [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED I--I PUBLIC UTILITY Connection Verified INSTALLER C-}Septic Tank or [] Holding Tank~.z.~ Size: /' ~ ~ If Tank is homemade SOILS RATING t ! give dimensions: TYPE OF TANK MANUFACTURER ~_~. ~.~._~ TOTAL ABSORPTION AREA MATERIAL S. COMMENTS [] CONDITIONAL APPROVAL (letter must accompany certificate) [~' DISAPPROVED DATE BY (Title) 72-010 (Rev, 3/78) C~-~- It GEOLOGICAL LABORATORE,8 OF ALA8KA. INC. P.O. BOX 4-1276 ANCHORAGE, ALASKA 99509 4649 BUSINESS PARK BLVD. · Ddnking Water Anab/s~s Report for Total .Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TELEPHONE (907) 279-4014 TO B~: COMPLETED BY LABORATORY PUBLIC WATER SYSTEM: LD. NO. 'c~~.~_ ~ .,,.~.' PulMk: WMec SyatMn Neme Mo. Day Year SAMPLE ~PE: ~ Routine ~ Check Sample (for routine sample with lab ref. no. ) ~Speclal Purpose Zip Code [] Treated Water r-I Untreated Water LABORATORY: NAME Date Received Time Received ~ '~ "~ O Analytical Method: [] Fermentation Tube t~Membrane Filter SAMPLE NO. LOCATION -. '1 Time Collected Collected By 4'1 ' Rev.]978 Lab Ref. No. Result* ,,~alyst 3ACTERIO LOG ICAt. WATER.ANALYSIS RECORD READ INSTRUC~I ~ONS BEFORE COLLECTING SAMPLE Form No. 1~310 (3-78) "r,m.7 t /~OU ~m.