HomeMy WebLinkAboutKASILOF HILLS BLK 2 LT 16Kosiloff
Block 2
Lot 16
#015-161-30
~/1 , .......... Building Safety Dw
.... · .. . . ~, ,. P~m ............ ~.~.~ ..
. , -. . ..., , · (90~34~7904, .
: ....... CERTIFICATE OF H THAUTHORI ' '"
· " FbR'A',S NGLE FAMilY DWELUNG
~ ._om..~.e .e.a .es~.a~n:,- ......... · -, , ....
Lom~on (s~te a~dress or ~re~ons)': 8701 Shebanof Agenue '~nchorage,.AK99516~3~4
iling ~dd ~'s · ' ' ' ' ' '"'
Ma re Same as Above ~. - , ,.. ,.....;. ,... ,-,'- :. ,.: ,:, , - ,.
Lending agency/' ...
Mailing'addre~..:.. ': ....!" ,, ....
Real Estate Agent .....
Mailing 'Address
' *: '-,',=' "',' ' Day PhOne ,.'.t':, , ? :'
.... Day pho/~e ....
; "~*.: -'.: · . "i*~. ;.'!' ...... ' .....
Unless otherwise rcquest~d, ' HA~ will be DHH~ for p k HA~ picked up by: ~ '
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:: . -
Individual Well []
Individual Water Storage ~ []
Community Class Well
[]
Public Water System []
TYPE OF WAS'i'EWATER DISPOSAL:
Individual On-site ~' []
· 'ln~ivid6al H~lding t~nk. []
Community On-site DD
Public Sewer,
The Municipality of Anchorage Dev~lopment 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 Io home owners. Certificates of Health AuthodtyApproval are
valid for 90 days from the date of issue for properties served by a pdvate or'Class C well and may be reissued with
new water sample results less Ihan 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.
' 5, STATEMENT OF INSPECTION BY ENGINEER ;;'~;, :' ;.'--..;, '.. ,,'" ,-.
.... .. ~ ?. ,.. ~.'._~?r.'~ '..~..~ .~.' · ~ '.,. .' .,~ -.' .. ;' /.!-':.,':.: . .,.
, . - . ' :"' ~'.. '~,, ~,.;', "~' ',',:.i..~.;,'.'"~.>,,'',... ":.~ ". :"-:~'.~ ,; <,-. -.. .' ~., :L:,4 .,'~ .. ,-''~
; ' ': .'.. las ~difi~ ~.~y ~1 a~ he~0 and as of the ~lrid~ 9~date.~.~low,'l ye~.that my.in~igation '~" .
. ':. ',"~ '0n ~u~ o~tlin~ in'the, H~' ~fity'A~y~ 'G.ui~li,e~ f~ ~is' Heaah A~ho~'App~v?
' .'. '. '..' apHi~tion :s~ ;~at :th6 ~n-{~e Water ~upply an~or,wa~6water,dis~l S~aem :is ~fe,. fun~i0nal and
. · '... '.info~atioh .'o~in~'~m th~',Muhid~l~'o[ An~h6mge file,:and from' my in~6aigai6n'ahd, lh~ion,.the
:." .. '" 'on-~' ~ater' ~y ~0~at~r'd ~1 ~y~e~' is in'~mplian~ ~h al ap~ ~e'Muni~ pa 'and; ".'
.. ~; ,. > State ~es, o~man~,,'a~ r~ul~bons In effe~ at the bm~ 0f In~al~abon:,.: :, ':..:...; ~ ,, :. , ~ ..
': ' ,-;NameofF~PannoneEng. Svc.~.....' '..'. .. r~..'...., ... '~Phone-272~218 .....
~Address-P.ObBox-1029~ch,:AK99510' '/:"' : .~ "' ' , ; : '. ; ,~.';',', -.' . , :
, Eng~neeCs Pnnted Name. ~even R. Pannone, P.E. . -'..'.: .: .... . :;.; Date '.: 511712001 ;.'
~lls~c~s~on~el~l~ndbo~F~ds~t~lcvcls~t~yflud~tc .. '~t · '~0~' '~
'. - r~Its do not g~t~ fut~ ~o~ of~e ~t~'nor do ~ ~t~ ~t ~e are ~o · - · ~~~[: ...............
: h~dd~dcf~orm~c~.P~efomnotpro~d~any~tyforfut~om~ ' ~.~Steven R...Ponqoneff~ '
: , n~givc~ymS~fhawlofig~&~m'Si wndn~1om~t~e0~do~Ir~of~' ~.', ~d'CE,8149
' ~ ' ' Disapp, rov~d.:' ,' '~: ":' ' "' - , , -
· 'Conditional appro~,al for
Additional Comments
bedrooms, with the following stipbl'a, tions:..
,t~H(¢~((tf(f~,.,./
~:- WATERAND -~ m~
= · PROG~M ·
Attachments: HAA Checklist
Septic System Advisory
Well Flow Advisory
Expiration Date: ~ - ~,~
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~ ~.~ ~- ~) I
Reissue Date:
Municipality of Anchorage
Development Services Department
Building Safely Division
On-Site Water and Wastewater Program
4700 South Bregmv Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(g07) 343-79O4
HEALTH AUTHORITY APPROVAL CHEcKLIsT
Legal Description:
A. ~ DATA
Well type Pl~ate
Date comp~ated 6/9/1983
Total depth 230 fl
Date of test
Static water level
Well production
Lot t6 Block 2 Kasilof Hills
If A, B, or C provide PWSID It
Sanitary seal Ye,
Cased to ~Q ft
FROM WELL LOG
6/9/16~13
~
g.p.m
WATER SAMPLE RESULTS:
Coliform ~ .colonies/100 mi
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Parcel I.D.: 015-161-30
Well Log Yes ·
Wires pmpedy protected Yes
Casing heigM (above ground) 12+ in.
AT INSPECTION
6/1612001
g.p.m
Nitrate _' ?~.~mg/! ~ Other becteri~ ~ ~lonies/100 mi
co,,...
Tank TypeJMaterlal Greer/SteeI
Date installed 6/16/1983 Tank size 1000 gal Number of Compartments 2
Cleanouts YeS ' Foundation cleanout Yes Depression over tank No High water alarm [No
Date of pemping' 6/i'1/2001 Pumper Northland Pumoil~q
C. ABSORPTION FIELD DATA
Date installed 6/16/1983 ' Soil rating (g.p.d./ft= or ft=/bdrm) 90 System type Trench
Length 32 ft WKtth ~ ft Gravel below pipe 4:~ ft
Total depth 49" * ft ' Effective absoq~ area ~[[9~ ft= Mortifying tube Yes Depression over field No
Date of adequacy test ~/16/2QI)1 Results (Pass/Fail) Pass For.3. bedrooms
Fluid depth in abseq~tion field before test J~/In" .. Water edded450 gal. New depthiDrY i~.
Elapsed Time: .Q min Fin,al= fluid, depth. Dry in Absoq~tion rate >= 460+ g .p.d..
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date
(Rev. 11,99)
D. UFT STATION
. * Date installed
'Pump on' level at
Datum
Size in gallons
in'Pump off' level' at
Cycles tested.
in
Manhole/Access,
High water alarm level at
in
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot IDS"
Absorption field on lot 128'
Public sewer main N/A
On adjacent lots 1gO+
On adjacent lots lIDO'+
Public sewer maflhole/cleanout
Sewer/septic sewice line NIA Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 67.$1' * ' Properly line 10'+ 'Absorption field
Watermain N/A Water sewice line ~i~ o cewater 100'+
Drainage 100'+ Welts on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+
Water Service line 25'+
Cmlain drain 100'+
Building foundation 87.6'
Surface water lID0'+
Wells on adjacent lots lIDO'+
Water main
Driveway, parking/vehlcie storage ~0'+
F. COMMENTS
*Insulation over entire field. **Well to Tank Waiver on File
G. ENGINEER'S CERTIFICATION
revfew of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone. P.E.
Date rd1?/01 :
0,o
Date of Payment ,,~'/t 7LO (
Receipt.umbe,
(Rev. 1 !,'ge)
WaiverFee$.
Date of Payment
Receipt Number
~ CT&E Envlronm~nl~l~
T-g44 P.OZ/03 F-3&T
ClOt PO~
i~rl~t~d Dsl~i'l~ 0~/22J2001 11'.29
Cot~ed !~['1~ 0~17/2001 11:25
Ra~t~d D~'l'i~ 05/17~001 12:00
0.$00 U
0.$00 z'~JL EPA 300.0 ~<10) 05/17/01 SCL
0 m~loon-,L L~{I~ 9222B
200 W
Drinking Water Analysis Report for Total Colifom Bacteria
MU~T ~ CO~ BY WA~ SUPPLER ] TO BE C'OM~E~D BY ~T~Y
I ~D ~ I0~ v I I A~lcal Melh~: ~M~ Filt~
L'
~ ..... ~sult* Analyst
SA.~Li: LOCATION
tl Treated Waler
0 Untreated W~r
Tiros Collemd
BACTERIOLOGICAl. WATER ANALYSIS P.~,CORD
MMO. MUG ~ull~ To~I Col~orm ~. C~
V~-if~sflOOl LTn BOB COLIFLRM
Fecal ~ollform Ceaflrmalloa
Final Membrane Fires' P. tsu lu CeUform/l~l mi
i~l~ MII~YM~ of Ihl il3J Oro(~ (~ocilhi ~MMrlM de Sur~llinC4)
EI'~fqO~AEh'TAL FACIUT. IE6 IN AI.A~ICA. C. AU~ORNIA. FLORIDA. ILI.~0~. MA~Y1J, ND. MICHIGAN. M~SOL~I. NEW .K~SEY. OHIO. WEST
ALASKA ENVIRONP~.NTAL
CONTROL SERVIC , INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO
CALCULATED BY_
CHECKED BY_
SCA~E ./
OF
DATE
DATE --
:%
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description:
/~,
Well Classification ~)~/~"'¢'FE'~' '- If A, B, C, D.E.C. Approved (Y/N)
Well Log Present CN) Date Completed ~¢- ~)~¢'--~ '~ Yield
Total Dept.h ,~----'30 ~,O Depth of Grouting
Cased to
Static Water Level -0 ~*Oo ~"""
Casing Height Above Ground /, ~"
Electrical Wiring in Conduit(~N)
Separation Distances from Well:
To Septic/Holding Tank on Lot ~'/~'
To Nearest Edge of Absorption Field on Lot /2-'¢'/"
Pump Set At /1/~_~¢
Sanitary Seal on Casingl~N)
Depression Around Wellhead (YI~
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Line ~"/~ To Nearest Public Sewer
Cleanout/Manhole _ ,,(-/'/,g To Nearest Sewer Service Line on Lot _
Water Sample Collected by ,~d.~ /¢, ~---~/,~,4/ ; Date ~-/~
Water Sample Test Results
B'. SEPTIC/HOLDING TANK DATA
Date Installed
StandpipesON) Air-tight Caps CN)
Depression over Tank (Y(N~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) _
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~'
To Property Line
To Water Main/Service Line
Course
Size ~/~'~ (~/~- No. of Compartments
Foundation Cleanout ~')N)
Date Last Pumped .
;for
Temporary Holding Tank Permit (Y/N)
_ To Building Foundation
To Disposal Field
Comments
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ -/(~' "~
Width of Field -~ /
Square Feet of Absorption Area
Depression over Field (Y~,~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
./.
To Water Main/Service Line ,'~///~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field -~ ~ I
Depth of Field ~" ~"-
Gravel Bed Thickness
Standpipes PresentCN)
Date of Last Adequacy Test
To Property Line /0
To Existing or Abandoned System on
; On Adjoining Lots
~//~utbank (if present)
Comments
LIFT STATION /~//~
~ Dimensions
Size in Gallons ~ Manhole/Access (Y/N)
"Pump On" Level at ~ "Pump Off" Level at
High Water Alarm Level at -~.~..~Vent (Y/N)
Tested for ____ ~ during Adequacy Test, Meets MOA
Electrical Codes (Y/N) ~
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I h~v~ch,~ked,/erified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~"~,~'~ (-" /""//~ Date
Company ~ MOA No.
Receipt No. ~%~/~
9 M .,.
Date of Payment ¢:~'~ "u~-¢
Amount:
Page 2 of 2
72-026 (11/84)
MUNICIPALITY 017 ANCHORAGE
DIVISION OF ENVIRONMENTAL" t~ALT11
DEPARTMENT OF H~ALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR ~ALTH AUTHORITY APPROVAL CERTIFICATE
1o General Information
Application Date
(a) Legal Description (include lot, blocks subdivi~sion, section: tewnship, range)
/~7~ ?~ ~z,..~ ~ i~.>51~,/;~ /~'L~ ~ 'Yi':,~-' ,~6~7 .~ ,f' g~
Location (address or directions)
~,~ ~> L~ 5 Tale_phone }Iome Business
(b) Applicants Name ~5~[%pc:/C ~,:'- '' ~
Buyer F~:: ; Other ~ (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Coo & Agent
Address
Telephone
(f) Mail the HAA to the following address:
T_~e~ of Residence
Single-Family,S.
Number of Bedrooms
Water Sup 1p~-
Multi-Family
,3
Other (descrioe)
Community ~ Public
Note: If community well system~ must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
.S e. wag~
Note: If communi~:y well system, must have ~r~itten coofirmatlon from the State
Department of Environmental Conservation attesting to the legality and status°
[Page 1 of 2]
Engineering Firm Providing Inspections, Tests. File Searchz Data and Information
e
Approved for ~_~
Approved
As certified by my seal affixed hereto and as of the validation date showm 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 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 regula--
lions in effect on the date of this inspection.
Disapproved
Terms of Conditional Approval
Col d ltional
..... CAOTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND EI,~fIROhT,~;TAL
(DHEP) ISS~S I~T~ AUT'HORITY ~PROV~ CERTIFICATES BASED ~. UPON
ATIONS GIVEN IN PARAG~PH 5 ABO~ BY ~ INDEPE~E~ PROFESSIONAL ENGIi. P3gR
IN TI~ STATE OF ~AS~. T~ DHEP DOES ~IS AS A COURTESY TO P~CHASERS
THEIR ~NDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAl. ~D STA~
MENTS. ~PLO~ES OF DHEP DO NOT CO~UCT INSPECTIONS 0R ANalYZE DA~
CERTIFICATE IS ISSI~D. T~ M~ICIP~ITY OF ~CHORAGE IS NOT N~SPONSiBI~
OR OMISSIONS IN Tt~ PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/eJ/D18
[Page 2 of 2]
7-19-.g4
. ClIEMICAL & GEOLOGICAL.LABORATORIES-OFALASKArINC.'
.... ..:./ Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPUER TO BE COMPLETED BY LABORATORY
WATER SYSTEM: { ,'1 I t I I
-
'~~,7~.-~," .~z.,-,,',~_.~..- .~--
SAMP~ ~PE:
~Utl~
~k ~ple (for ~tlne ~ple ~.Treat~ Water
- with I~ mi. no., 'J ~UntreMed Water
~1
3
Analysis shows this Water SAMPLE to be:
[~,~atistactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination to
indicate reliable results. Please send new
sample via special delivery mall.
Time R~elved I ~- ~ O ~
Analytical Method:
D Fermentation Tube
F1 Membrane I:llter
Fief. No. Raault° Analyst
.,IL-j:]
BACTERIOLOGICAl- WATER ANALYSIS RECORD
_READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
ColllormllO~ml
Membrane Fillet Direct Count
.,BGB
TNTC = Too Numerous To Count
ColllormllOOml
POUCI-I 6-.050
ANCHOFIAGE. AI_ASKA 99502-0650
(907) 264-4111
DEPARi'MENT OF FIEALTH AND ENVIRONMENTAL PROTECTION
August 26, 1985
Mr. Alan Wien
Alaska Environmental Control
Services, Inc.
].200 West 33rd Street, Suite B
Anchorage, Alaska 99503
Subject: Waiver of separation disitance between well and septic tank,
August 23, 1985. Lot 16 Block 2 Kasilof Hills Subdivision.
Dear ~,~r. Wien;
The waiver granted on August 23, 1985 for Lot 16 Block 2 Kasilof Hills between
the well and septic tank is to 98 feet only.
Sincerely,
Stephen S. Morris
Civil Engineer
On-site Services
S S M / p ah
POUCH6-655
DEPAflTMENT OF I;IEALTH AND ENVI[1ON~','IENTAL PROTECTION
August 23, 1985
Jeff Weiss
8701 Shebanoff
Anchorage~ Ak 99516
Subject: Lot 16 Block 2 Kasiloff Hills Subdivision.
Dear Mr. Weiss;
This Department hereby waives the separation distance from the well
and septic tank on Lot 16 Block 2 Kasiloff Hills Subdivision. Yhis
waiver is valid for a three (3) bedroom dwelling only.
Sincerely,
Stephen S. Morris
Civil Engineer
On-Site Services
SSM/pah
ALASKA ClILIIROFImSF1TAL COFITROL SCRUICSS, IFIC.
August 19, 1985
Municipality of Anchorage
Department of Health & Human Services
825 L. Street
Anchorage, Ak. 99501
Re: Kasilof Hills Block 2, Lot 16
On 8/16/85 we performed a HAA on the above referenced lot. It
consists of a 3 bedroom house with individual private well &
septic system. From the HAA, the separation d{stance from the
well to the septic tank is 98 feet.
The slope of the land slopes away from the well towards the
septic tank and beyond. The well is 230 feet deep. Due to
the depth of the well and the slope of the land, we request a
waiver be granted to reduce the required separation distance
to 98 feet. If you have any questions, feel free to contact
US,
Sincerely,
Alan Wien
Engineer Technician
1200 LUesl 33rd Aueaue. Suile B · Anchoraqe. Alaska 99503.(907) 581-50~10
MUNICIPALITY OF ANCHORAGE
· DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO'i'ECTION
~ ~ ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
"~AME
PHONE [] NEW
.l-e/; /-/ ?4e-2 /FG []UPGRADE
'~AI L] NG ADDRESS
LEGAL DESCRIPTION
l Well Absorption area Dwelling PERMIT NO,
~ ~ Manufacturer Material No, of compartments
Liq. capacity in gallons Inside length Width Liquid depth
-- /(~ IF HOMEMADE:
_~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO,
~] ~ ~ Manufacturer Material ~iquid ca;)acity in gallons
Q Wall Foundation Nearest lot line ~ PER~IT NO,
~Z DISTANCE TO: ttOf I'tl
:j ~ ~ No. of lines / Length of each line~ 2' Total length of lines
~' ~ ~ ~ Top of t~to finish grade / Material beneath tile Total effective absorption area
~ength Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ DISTANCE TO: Well Building foundation Nearest lot line
~ Class Depth Driller Distance to 10t line PERMIT NO,
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
~NSTALLER
APPROVED / DATE LEGAl_
72-013 (Rev. 3t78)
DEF'FIF::TMEi'.,IT 0r: I-~IEPII_'I"H I::IN[:, EN',,,' I I:,::Cd'.,ff"tEt'-,ITF:II_. F'[;u'Z 'rE ': T I ON
· "L FIN,::HORn,: E, al,,::. '3S
2 '6 4- 4 7' ;::4 0
lb,..ll ET L_ ti .... FI IP41 LC..::, Cn ~'-41 -- "Z:~; Z T' El
,' P,E: ~.:t2G'3 ',
LI3C:I.~TICtI'-~
I_.EGFIL.
JEFF H. ~,.IE
LCIT ±d; E:LK '2-_" KFISILI}F IqII_,LS LOT '_:;I;.ZE
TI'r'PP] IZIF SOIL FIE:SI]RF'TIOI'.,I S'¢'-:;TEH IS: TF-:EI",!CH
3:4 4'- 21:7:'5 ti)
'9 '9 '9 S '/:) SI';:[I..FIRE FEET
1H,',Ii~l It NUI'"IE:ER Cli,:' E:EE:,F.:C~OHS =
SClIL. F.:FITING I::SI;! F'F,.."BF.:::,= S,E~
TFIE REI:;!IJIF.:ED SIZE FF THE SOZL. 14E ...... F..F [I1'31'.,I S"rl:~'.';TI-_-I'"I I:.','
'T'HE L. ENGTH DIMENSION IS THE LENGTH ,:.'IN FEET) I]IF TI,-IIE TRENCH I]IR [)RF:III',!FtEL.[:,.
THE [:,EPTI,-I OF FI TRENC:H OF.! PIT IS THE DISTFd'.,IP:E BE"I"I,qEEN TI,-tE SUF.:FRCE OF "r'HE
PiF.'.OUiqD FINE:, THE BOTTOM OF' "rFIE ENCFIVFiTIOI'.,I (II'.,I FEE]").
]"HERE IS NO SET I.,.II[:,TFI P'OF.: TF.:ENCI,-IES.
THE GF.:FI',,,'EL DEF'TH IS ]'I,-IE MINIHIJM E:,EF'TFI OF- GF.:FIVEL BETt,.IEEI'.,I -rl,4t:z OUTFFILL. F'ZF'E
FIND TI,-II:T. E~OT"I"OH OF: THE E,'.'-,h2FI',,,'FIT:[OI'.~ (IN F'EET).
I::'ERHIT PFFL] ..HlltT FIFIS 'THE RE'::.:F'ON'5't:EILI"F'-? TO INFI]l:;.ff"l THIS E:,EF'FIR]"HEI'.,IT DLIRING TI-..IE
ZNSTFIL. LFITICd'.4 II',t=,FEL. IILd,I_-, FIF_ FINh.' NELL':; RI}JFIE:ENT TO THIS FF,.UFEF..]"" ' "'"'~ FII'..I[:, I-'HE
NLI"'IIF,'ER OF' RESI[:,Ei'.I]ES THFIT 'THE I.,.IELL. 14ILl_ SER',,,'E.
P',FIC:I<FIL. L. ING OF' FIN'¢ S"r'STEM I.,.IITHOUT FINRL. INSF'E--TI. Cd",I FIND hlFFF. _' IL'" Bh" TI"I.IS
[:'EPFIRTMEN]" klILL. BE '.~t IE .'fEE T TF~ f:'ROSECUT I
I'"IINII.II.UM [:'IS'TFII",IC:E BETNEEN FI klEI._L FII"~D Fli",l"r' ON-SIT[:[ .SENFIGE [:'ISF'OSI::tL S"r'STEH IS
:LE~E~ FEET FOR FI PRI'v'FiTE NELl... OR 21..5E~ TO 200 FEET FROM FI PUBLIC 14ELL. DEF'EN[:'Ii",IG
UPOI",I I-PIE T"r'F'E OF F'UE:LIC: I.,.IELL.
I'"IINIMUH DISTFINC:E FROM FI F'RI',,,'FITE I,.IEI...L TO FI F'I~:I',,,'FITE SEb. IER LINE IS 2:5 FEE'T' FINE:'
T'O FI E:OHHIJNIT"r' :..=,EI...IER LINE IS }-'5 FEET.
I.,.IEL. L. LOGS FIRE F.:EI_::!UIF.:ED FINE:' MI.JST BE F:'.ETLIRNED TI] THE DEF'FIF?.TMENT !,.IITHIN .~:E~
OF THE 14ELL C:OI¢IPLETIOI'-,I.
OTHER REQUI REHE;I",ITS I'IFI"? FIPPL'¢. SPEC:IFIC:P~TIONS FINE:' CONSTt:;;:UE:TI ON [:'II:IGF.:P'IMS FIRE
F:I",,'PtIL. RE:I_E ]"O INSLII~!E PROPER INSTFILLRTION.
I CERT IF"T' THI::IT
iL: I FIf'I FFII.'IILIRR 1.4ITH THE REQUIREMENTS FOR ON-SITE SEI.qERS FINE:, t.,.IELL. S F:IS SET
F'ORTFI B"r' THE I"I.I...IN I C l PI:IL I T"r' OF FII".ICHOF.:RGE.
:2: I 1.4IL. L IIqSTFILL THE S'¢'-'3TEH IN FICCOF.:DFINE:E 14ITFI THE CODES.
.7..':: I UN[:'ERSTFIN[:, TFIFtT THE OI",I-SITE SEI4ER S"r'S]"EM MFI"r' R. E6.!UIRE ENLRRGEME:N]" ]:1::' THE
F::ES I [:'ENF:E I S REMQ[:'ELE[:, TO I I",IC:L JDE I"ICIF.':E THFIN 3: E:E[:'ROCd"I::~;.
//
I S:E;, .IED ~---.[:'f: TI ._ ",,'4. (.'.t
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99,501 264-4720
SOILS LOG - PERCOLATION TEST
/,~' SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
5
6
7
8
9
12
13
,14
15-
16-
17
18
19
2O
COMMENTS
PERFORMED BY:
72-008 (6/79)
DATE PERFORMED:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND
M__ FT
RETURN TO: Division of Geological and G 'slcaJ Surveys (DGGS)
3001 Porcupine Drive (Telep...ne: 277-6615)
Anchorage. Alaska 995OI
WATER WELL RECORD
~ATIOH OF WELL ] Please complete either la, lb, or lc.
U.S.G.S. Local Ilo.
Drilling Permit No.
A.O.L. NO.
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
la. Borough i Subdivision Lot Block lb. Fraction
.&~ch L I Iq ~ I / / /
lc. Distance and Olrection From Road l~tersectrons
t~aSl!Of [Jll.s
Street Address and Area of Well Locatlom
2. WELL LOG
Material Type
ravo]~-lonses ball
oeoomposeo bec Pock
black Pock
gPay black rock~wn.}_te
'-~-~ fractuPed
Feet Belo:~
Surface
15. WATER WELL CONTRACTOR'S CERTIFICATION:
I Tol.ln s h i p Range Me r i d I a n
N/S
3. OWNER OF WECL: Je£f ','J~]~-' ....~'~'
Address:
4. WELL DEPTH: (completed) Surface Elevat ion D~e] of
~C~b'e t~O' :~-~?tRotary []Driven C]oug
E~ Auger O Jetted C3 ~ored [~ Other:__
6, USE:X~DomestJc [--]Public Supply [~ Ind,stry
C]trrJg~tion ,[~Rech~rge [~Commr¢ial
7. CASING: ,~] Threaded ~ded
6 in. to 60 ft. Oepth Weight ---
in. to ft. Depth
8. FINISH Or WELL:
Slot/Mesh Size: Length:
S~t bet~n ft. and
Fittings:
fi:.
STATIC WATER LEVEL: Pt,
~Above []]Below land surface
Type of Measurement;
I0. PUMPING LEVEL below land surface
ft, after __hrs. pumping ~r~___ g.p,m,
ft, after hrs. pumplng ---- g,p.m.
11. WELL HEAD COMPLETION:
{~]Pitless Adapter
C] In Approved Pit
inches above grade
Mater~al: il]Hca t Cement L~ Other:
PUMP: (If available) HP
Length of Drop Pipe ---- Pt. capacity -- -- g.p.n
Type: [~ Submersible E~] Reci proca t ing
C] Jet [-]Other:
14. REMARKS:
Water Temperature:
This well was drilled under my jurisdiction and this report is true ~o the best of my knowledge and bellef:
Registered ~ Name Contract L~cen~mbeF
c,;~,, p, .~ ~560 Anchoz~e Ak 99502
Signed: Date: ~
Property Own, er
Mailing Address
Buyer
Address
Lending Institution
Address
Realty Co. & Agent
APPL r*NT FILLS OUT UPPER HA'
____~.~' Zip Code
Zip Code
ONLY
Address
Phone
Zip Code
Phone
Legal Descriptio~r ,,] ? //~]
Street Locaticx~ L
Type o!..,ReEidence
I~"'¢Sin gle Family ::,_
[~ Multiple Family No. of Bedrooms
~ Olher
L4.'"lndividual ATTACH WELt. 1.O(3. A well log is reqeired for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach log if available).
[] Public Utility
Sewer [)~sal / f,/ ,,f/ z,
~ndividual Year Individual Installed:__ /
L~ Public Utility When Connected to Public Utility;
~ Holding Tank
NOTE: TNE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Tin',e
Date Date Data Date
Inspector Inspector Inspector Inspector
Time
(,~) APPROVED BEDROOMS ) DISAPPROVED
'CONDITIONS OF APPROVAL
Soils Rating
Date Sewer Installed
Well TO Absorption Area
Welf to Tank
Well Log Received
Septic Ta~k Size
72.023 (3 82!
ACHEMICAL & GE ~OGICAL LABORATORIES 'ALASKA, INC ~~. ~
TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTER
5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
[/? . ,.O. NO.
×[./~..-¢;- :)_ ;,
Water System Name Phone No,
Mailing Address
City State Zip Code
MO. Day Year
SAMPLE TYPE:
r~ Routine
[] Check Sample (for routine sample
with lab ref, no,
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO, LOCATION
I
Time Collected
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[~l"Satisfactor¥
[] Unsatisfactory
[] 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
Analytical Method:
[] Fermentation Tube
[] Membrane Filter
Lab Reft No. Result* Analyst
L I
· NO of colonles/100ml or No. of PoslhVeportions
READINSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collecte~ Source
Date Received Time Received p,m, Lab, No,
~esumptlve 10mi 10mi lOml 10mi 3,0mi 1,0mi 0,1mi
24 Hours
48 Hours
Confirmatory
24 Hours
,48 Hours
EMB. Broth 24 houri=
Multiple Tube Report=
Membrane Filter= Direct Count
Verlflcstlom LTB / ~
FiniI MembraneFIIter R!¢Ulis; ;~ ,~
RIported By ¢~<; ~;' / '<- ,,
Broth 48 hours; ,
lOml Tubes POlltlve/Total lOml Portlonl
Collform/ZO0ml
BGB