HomeMy WebLinkAboutELMORE #1 BLK 5 LT 6Elmore #1 Block 5 Lot 6 #018-172-06 GREC"&ER ANCHORAGE AREA BOUGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME 02"'X -LS ✓���T lb's MAILING ADDRESSZZZd,�K3'7-J--S dIZL�'/� VHONE "A45 LOCATION7292411/21C« Ael/,C��Q"f/OU.UICGALDESCRIPTION Lf •7 D'e� S/D / SEPTIC TANK: DISTANCE s6w SO NUMBER OF FROM WELL'S MANUFACTURER FS//.y(JL� MATERIAL �rVC./-'�`%� COMPARTMENTS INSIDE LENGTH � INSIDE WIDTH -- LIQUID DEPTH — I IQUID CAPACITY IA66) GALLONS. SEEPAGE PIT: / NUMBER OF PITS / DIAMETER " OR WIDTH -9 LENGTH=, DEPTH—!? LINING MATERIAL.? `QNB S/CRIB SIZE: DIAMETER DEPTH DISTANCE FROM: WELL_;d 4 /(�U//£O /f /f TOTAL EFFECTIVE BUILDING FOUNDATION , NEAREST LOT LINE 2G ABSORPTION AREA (WALL AREA) OS U.OifSQ FT. ADDITIONAL ABSORPTION WELL: TYPEZCONSTRUCTION BUILDING NEAREST FOUNDATION LOT LINE CESSPOOL �QIHERSOU APPROVED DISAPPROVED DISTANCES: r/*am) INSTALLED BY: 62/Z .ftyfE�S PIPE MATERIAL: 64T1' -2-'01j LOT SLOPE: REMARKS: ,,jj,C,vC//.off' /S ,A,dGGE (;,EOGt�/Ld ��fE C /lAGfF/!L DATE F W m No. EQ -031 SEPTIC TANK. DIAGRAM OF SYSTEM .SEEfsOG L sr�p/,CH may/ rSr�j'�Jn� —> u e/ r�7 p/,cto SES/o I e4ow TONE. DC7`'&&& APPROVED...L DISTANCE FROM: 1,,eo v5 -x-, n G.A.A.B. 1, T GREATER ANCHORAGE AREA BOROUGH f'aW 4. Q DEPARTMENT OF ENVIRONMENTAL QUALITY PERMITNO._ I1'II�$�e Iqp�) 3330 "C" STREET ANCHORAGE. ALASKA 99303 TELEPHONE 274-456t SEWAGE DISPOSAL SYSTEM — APPLICATION AND PERMIT NAME OF APPLICANT ��J AJMAILING ADDRESS INSTALLATION LOCATION �j�j/— LEGAL DESCRIPTION- —" / T INSTALLATION OF: SEPTIC TANK TYPE AND SIZE OF FACILITY TO BE SEP FINANCED THROUGH SEEPAGE PIT TO BE INSTALLED BY PHONE / DRAIN FIELD OTHER SOIL TEST RESULTS NOTE, THIS PERMIT 15 NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SI2E �'TENTYPE 'fr�~"� SEEPAGE AREA SIZFJ ���'�'� TYPE MINIMUM DISTANCES. REQUIREMENTS FOUNDATION TO SEPTIC TANK s/ FOUNDATION TO SEEPAGE PIT �p0 DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL X$ ' SEPTIC TANK ..J / SEEPAGE PIT Ol42 DRAINFI�L� TO NEAREST LOT LINE. SG SG * J,x!-73 �J/l��j�—� WELL TO SEPTIC TANK MV � �' SEEPAGE PIT �!G_ DRAIN FIELD —r ALSO CONSIDER AREA 4 WATER MAIN TO SEPTIC TANK '��/ SEEPAGE PIT /O DRAIN FIELD SEPTIC TANK. ldD SEEPAGE PIT .LCT. DRAIN FIELD TO RIVER. LAKE. STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSS EXCAVATION S FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. G.A.A.B. OR LICENSED DESIGNER DIAGRAM OF SYSTEM 1 CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28.88 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE APPLICANT'S SIGNATURE A \ / \\ J FORM NO. [001{ 7 I' 0''' ' donsttuctlon gest 1'ai UrCEIce17 _ J. -Ont test is worth a thousand opinions" OCT , _ 1973 Al(', SS*S TUDOR ROAD. ANCNOAAQ9. ALASKA 903O7 • T[tgm"Z 232-0471 U.. • G9[ A I EV A;; 'HC[•.([nn. VG11' r Performed For Mr. Jim Srheffers Date Performed" Oct 3;•.•19'3°.,. Legal nescrirtion: Lot o Bloch r _Subdivision Elmore # 1 This Form Renorts Soils Loa yC3 Percolation Test tenth Feet Soil Characteristics 1 Overburden• Z a _ Coarse Sandy Grsvel 5 '- GW -65 7 — am 141 ;9,9N Was_Cround Water Encountered? NO If Yes. At what Denth? -._ ,— IReadinq Date Gross Time wmm� � Net Time I Depth to H2O Net Dro Foreolation Rate 1linute Prbrosed Installation: Seenaae Pit Drain Field Deoth of Inlet Denih—lo rottom Of Pit Or Trench COJ11sEKTS: fi; By t't. drainnrl, ernn ru,juirt'd n1+r bedroom no bedrock or water table to minus 14 feet list Performed By Jim Mack Data Certified By:Construction Tqv t. Municipality of Anchorage C• _ \ Development Services Department •'"" Building Safety Division \_. On -Site Water and Wastewater Program s r 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 wwv+.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. C9f 4f 17 2 _Q (!5:, HAA Expiration Date: 141,1r_� Jamg j 1. GENERAL INFORMATION !— Complete legal description Location (site address or directions) /'•f Son Tr /-v Current Property owners) 01 a do llepr, n Day phone -,�44 S— G? ;z / Mailing address Lending agency Mailing address Real Estate Agent Mailing Address y33r5 Suns�rnG Cri �„�. 0/9 �_ Unless otherwise requested, HAA will he held byOSD forpickup. Day phone Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY:' TYPE OF WASTEWATER DISPOSAL: Individual Well Individual On-site �[ Individual Water Storage ❑ Individual Holding tank I❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ 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 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of tide (except between spouses) for properties served by a single-family 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 1`//(r4eg&IAArrJrt4er1 P.S-, Phone Address tf(eg0 S ,e_4he ,,' Are//. �.�cGrAA. 9' V(0 Engineer's Printed Name MA rA .1- l'6 Jr 16.6 rl Date 't -.OF A4 7O: MICHAEL N. ANDEMN: 4 S. DSD SIGNATURE �� �.'. ;r9f69 _L�Lf Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory . Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: t mD Original Certificate Date: (R. 01M) 1Vlunicipality of Anchorage • �' Development Services Department Building Safety Division On -Site Water 8 Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www. ci. a n ch o ra g e. a k. u s (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ,F/mo,ev (316 S- Parcel ID: 01 V r 1it A. WELL DATA Well type-RLMJCi Date completed-yL_k-. Total depth to,;, FROM WELL LOG Date of test e Static water level k>3Z ft. Well production O.P.M. WATER SAMPLE RESULTS: If A, B, or C provide PWSID # Sanitary seal (Y/N).1!-L'- Cased to /OS ft. Coliform _colonies/100 ml. Arsenic: _G mg./I. B. SEPTIC/HOLDING TANK DATA Tank Type'Material ro. rr c kcl Well Log (Y/N) /4. Wires properly protected (Y/N) T _ Casing height (above ground) _2f- in. AT INSPECTION ft. -tow( pepth, to 4 1`• / (brow O"n 2 Nitrate 0.3 s kg.11. Other bacteria _ 0 colonies/100 ml. Date of sample: �—/zV,S Collected by: M. k -r N 4 r r•.s•" Date Installed Tank size /Zso gal. Number of Compartments L Cleanouts (Y/N) Y' Foundation cleanout(Y/N)Depression over tank (Y/N) H— High water alarm (Y/N) Date of pumping 7 5/ O Pumper 4 rum a L {-N o ttry r k, PU M rZ111" (Awl J _ C. ABSORPTION FIELD DATA 7� Dateinstalled ry 3 Soil rating (g.p.d./ft2orit=/bdrm) /.? System type �irrl?., () I rc1 er c n}(1 6reo.+J.P 4 Lewgln 1g.0 ft. 1�tidth r D ft. Gravel W... IG�_� ft. Total depthZiDfl. Eff. absorption area _e _y Monitoring tube _Y Depression over field Date of adequacy test Results (Pass/Fail) -P-9-0 For 31 bedrooms y y �� /// Fluid depth in absorption field before teshyA in. Water added gal. New dep.h 340 in. r efA,o Z07 7OR//1 Elapsed Time min. Final fluid depth _ n. / Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) / If yes, give date D. LIFT STATION Date installed Size in gallons "Pump on" level at _ in. "Pumaev8r t _ in. Datum Cycles tested E. SEPARATION DISTANCES (Y/N) High water alarm level at Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT T�rc tga7 c 110"5"- - Septic tank/liti-statiert on lot 9 Is , - On adjacent lots _ iu o '1 Absorption field on lot /toy I} On adjacent lots /Yu ti - Public sewer main _L1 /i¢ Public sewer manhole/cleanout N Sewer /septic service line .5014 Holding tank N lift. SEPARATION DISTANCES FROM SEPTIC/HatDIdG•TANK ON LOT TO: Building foundation t 2 Property line S rP, t Absorption field JI!gA4R /o /ru Water main N /i1 Water service line yv Surface water im o,,#b-- Wells on adjacent lots / b v f SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: in. Property line _ 2b t+ Building foundation Z D r4 Water main WU, Water Service line 5-,0 11 Surface water foo t4- Driveway, parkingtvehicle storage `"t0 Curtain drain 1-1 1A,_ Wells on adjacent lots /n / F. COMMENTS G. ENGINEER'S CERTIFICATION �� Of A r 91� ••••:, i certify that i have determined through field inspections and0-0 h i * review of Municipal records that the above systems are in conformance MOA HAA in 49TH y, • with guidelines effect on this date. / Engineer's Printed Name MIrGIRI N rdiY// �VP;MICHAEL Date �`N./A�NDERSON;� 69 9/'/vS,,.•�ty�..' HAA Fee S 4 3q� Waiver Fee S q Date of Payment _t / t 0r S Date of Payment Receipt Number qt D 73 (.� 0 Receipt Number (Rev. 12101) O O O 0 0 FIA NATRONA AVENUE •----------------------� 1 1 N B9046'30"E 1713.71' 0 B_ GRAVEL. DRIVEWAY — ^ CONC. �D n Ot 3 i BBB Ot G= c F DECK G a D WELL AB.t DECK Id UTILITY CASEMENT v <. OF A *-4 THa S .,�, fid•, C SHANE A. HOLT: �A LS -6914 •• ��G J� fin. o • . dd B 139046'30"W 1713.71' THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPEORMLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND RATTED LOT LINES OR EASEMENTS AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL STRICTURES OR FENCELINES. w 0 O r O 0 R AS -BUILT SURVEY ( NO CORNERS SET THIS DATE 1•.30' 1 HEREBY CERTIFY THAT 1 HAVE PERFORMED A MORTGAGEE'S INSPECTION OF THE FOLLOWING DESCRIBED MORRTY. LOT S. BLOCK 0. ELMORE SUB. ADO'H. W. 1 I 1 1 I ANCHORAGE RECORDING &STRICT, ALASKA AND THAT THE VISILE RAPIIOVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS EXIST OTHER THAN 1OTED. T ANC EASEMENTS OF RECORD. OTHER THAN THOSE SHOWN ON THE RECORDED FLAT, ARE NOT SHOWN HEREONML1 ESS INDICATED I DATED _AUGUS)MOE. ALASKA iM3 ISM_ oAv of Auousr zoos NOTE. Y FENCELINES SHOWN ARE LOCATED APPRO)OIMTELY AND ME NOT TO BE USED TO OETERMINE PROPERTY LINES MOLT LANG SURVEYING )O I, FS II:�N AN OR LOCATE STRUCTURES. TEL. 34613513 ANY PAYING SHOWN WY BE APPROXIMATE DUE TO SNOW CONDITIONS. O 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 Parcel I.D. N �& y % O (0 HAA # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) l -,-r I'D t aAz� ':5-� e:'L� oV. s I n _# / Location (address or directions) (b) Property owner CF '"t��V Telephone:(home) Business Mailing Address (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address Telephone 2-1n — 1�5io 1 Telephone (e) Mail the HAA to the following address: (or check here if hold for pick up.) List contact person and day phone number below: 5 d 5 ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single-Familyl� Number of bedrooms 3. WATER SUPPLY Individual Well Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-sitelA 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. 72 -MS (R«. 7M) 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 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 regulations in effect on the date of this inspection. - Name of Firm 5 & 5 EPIGIN68.oiur. 6 Telephone 6204-'Z G '715 17034 Eagle River Loop Road No. 204 Address Eagle Rival', Date a — Z 6. DHHS APPROVAL Approvedfo4 do bedrooms by """' Date Az ApprovedDisapproved Conditional Terms of Conditional Approval CAUTION 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 Inorderto 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. 12425(R". 7i6a) awt Page 2 of 2 A. MUNICIPALITY OF ANCHORAGE (MOA) • pGtiCN Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 �r,ceP�Ns `5•�,. 343-4744 N� oar' i99� Legal Description: 21 f5;- #�l WELL DATA �?`���� Well Classificat(oh �;�t ��� ` If A, B, C, D.E.C. Approved (Y/N) 2L Well Log Pres� Present (Y,(?cDatee Completed Yield r� •-17 CWrl + Total Depth - )t-. Cased to�1L� r Depth of Grouting Static Water Level 7 Pump Set At N= n Casing Height Above Ground LZ -) Sanitary Seal on Casing (DN) Electrical Wiring in Conduit ON)y Depression Around Wellhead (YAC � SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot On Adjoining Lots To Nearest Edge of Absorption Fie,id] q/n� Lot ) ov f -t ; On Adjoining Lots th To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/ManholeN To Nearest Sewer Service Line on Lot Water Sample Collected by � �I` A I +fir ; Date Y7 Water Saml Comments B. SEPTIC/HOLDING TANK DATA Date Installed Size 11-t5'0 No. of Compartments Standpipes ON) _Air -tight Caps 6?N) Foundation CleanoutON) Depression over Tank (Y16? r -A Date Last Pumped �Z- `; - 66 Pumping/Maintenance Contact on File (Y/N) ; for �— Holding Tank High -Water Alarm [Y/N) 01A Temporary Holding Tank Permit SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: r To Water -Supply Well ori I To Building Foundation To Property Line C To Disposal Field (4 I To Water Main/'Service Line o -+- To Stream, Pond; Lake or Major Drainage Course Comments -V- t �� • � 72-M(R". 7/88( Front Page 1 of 2 C. ABSORPTION FIELD DATA . i . _,.' Soils Rating in Absorption Strata 8�' t« Type of System Design�� Date Installed Length of Field (1 / Width of Field l ( Depth of Field 9 f r j ; Gravel Bed Thickness to Square Feet of Absortion Area !145>e Statndpipes Present6VN) Depression over Field (Y(1q. �� Date of Last Adequacy Test $ " 813 Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well I od t+ To Property Line l o to To Building Foundatiop t To Existing or Abandoned System on N (j Lot f'' ; On Adjoining Lots ( To Water Main/Service Line To Cutback (if present) A To Stream, Pond, Lake, or Major Drainage Course I oo I+ ( To Driveway, Parking Area, or Vehicle Storage Area 80 Comments D. LIFT STATION to Installed Size in "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 Ac "Check Permitted Bedroom Rating Against HAA Request" I certify that I have checked, verified, or conformed to all MOA and HAA guidelines In effect on to of this Inspection. .�•� Signed A ••N. S & 5 ENGINEERING ••e••�s� Company 17034IM-RiVeLoop RaWNci.2101td e �y r Eagle River, Alaska 99577 S. Date �Z�7�o._g jZ ,, •... .. �• • •...».ems y... MOA No.3„A., Receipt No.—.,6�.5--% C Date of Payment x L cyl—i-- Amount: $ / %O -d e t�An�� Receipt No. ' NAINWfi Waiver Fee: $ Date of Payment 72-026 (Rev. T/U) BaCM Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ..o+ .o+.. 5633 8 STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FEDERAL TAX ID N 920040440 ANALISIS REPORT BI SAMPLE fox Mork Order 1 10871 Date Report Printed: DEC 16 88 4 15:21 Client Sample ID:L6, 85 ELMORE Client Nana : S G S ENGINEERING PW31D :UA Client lett : SNSENGP Collected DEC 12 88 4 16:00 his. P.0.1 NONE RLC'D Received DEC 12 88 4 17:00 hrs. Req 1 Pxesared with :4 DEC. C Ordered Ey : RJS Analysis Completed :DEC 14 88 Send Reports to: Laboratory Supei or STIPREN C. EDE 1)S i S ENGINEERING rr Released By : G- Q(�� 2) Special Instruct: Chealab Ref 1: 1699 Lab Smpl ID: 1 Matrix: NATER Allowable Parameter Tested Rault/Onits Method Limits ------------------------------------------------------------------------------------------------------- NITRATE-N 0.29 sq/1 EPA 151.2 10 Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY RJS. 1 TO Pnfoxmed Sa Special Instxuctiona lbove 0A•Onara11ab1e ND- Nona Detected " See Sample Remarks Above NA• Not Analysed LT -Lae Than, CT -Greater Than CHEMICAL & GEOLOGICAL LABORATORIES OFALASKA, INC. = TELEPHONE (907) 562-2343 5633 B Street f Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY 0 PUBLIC WATER SYSTEM I.D.q /�PRI�TER�TE� VName Malling Addr.-/ N City SAMPLE DATE: State Mo. Day Y® SAy1PLE TYPE: /, -Routine U Check Sample (for routine sample with lab ref. no. ) O Treated Water ] Special Purpose Untreated Water 7nalysis shows this Water SAMPLE to be: 7 Y W satisfactory No. ❑ Unsatisfactory ❑ Sample too long in transit; sample should 10 not be over 30 hours old at examination i to Indicate reliable results. Please send new sample via special delivery mail. Zip Code Date Received SAMPLE Time Collected NO. Z� LOCATIQN� Collected By 2 f4ttQ f E 5-40 E/�w 3 1 I 41 I 51 I READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Time Received _ Analytical Method: 1 7 rD Membrane Filter No. of colonies/100 ml. Lab Rel. No. Result* 3�SS- ►I Eo U_J m U m L U I m 1 Analyst ;L6 BACTERIOLOGICAL WATER ANALYSIS RECORD D Membrane Filter. Direct Count '+ O Coillorm/10 ml Verification: LTB r BGB Final Membrane Reported By TNTC = Too Numberous To Count OB = Other Bacteria O Coifform/100ml ! Date 12 Time: a.m. p.m. r- C? Z #1: Time 1. Date 3- Insp Pr ^MUNICIPALITY OF ANCHORAGE DEPARTMEN_ OF HEALTH AND ENVIRONMENT, 1PROTECTION 825 L Street, AnchoraaP. Alaska 99501 264-4720 Date Received: March 15, 1978 p.m. #2: Time jp,Ncin. #3: Time %C;.3C.)c4m r K-78 Friday Date ?,-�� 1A`1;,n�, Date tt\ Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES Lending Institution Request: Alaska State Veteran's Administration Mailing Address: 907 West Northern Lights Blvd. Phone: 2. Property Owner: James E. Schefers Mailing Address: Star Route A Box 325-S 3. Phone: 349-2427 99507 Legal Description: Lot 6 Block 5 Elmore Subdivision #1 4: Single Family Residence: (39 Multiple Family Residence: ( ) 5 Well System: Permit # Construction Number of Bedrooms: Number of Bedrooms: Four Individual Well (K4 Community/Public System ( ) Depth of Well 85' Well Log on File ( ) Bacterial Analysis 6. Sewage Disposal System: On-site System (34 Public Utility ( ) Permit # Installed 1974 Installer Septic Tank Size Manufacturer Absorption Area Soils Rate 7. Distances: Well to Septic Tank to Sewer Line Nearest Lot line to Nearest Lot Line Material 5�i to Absorption Area Absorption Area MUNICIPALITY OF ANCHORAGE Department of Health and Environmental Protection 825 L Street, Anchorage, Alaska 99501 Wuest 264-4720 for Approval of Individual Sewer and Water Facilities 1. Property Owner:— Mailing Address: Sj;A fSoY- 3P5 ---S AAS l+k Phone: 3q9-2297 99Sa7 2. 3. 4. Name of Buyer: ,-.= AIF -= Mailing Address: Phone: Lending Institution: ALASKA SThTE V A Mailing Address: Realtor/Agent: A/a A/F Phone: Mailing Address: Phone: 5. Legal Description: LO% l 0640CA S CLMOf-F- 01- / Street Location: % cZn1 / $ A/,4-7-Pn 44 L iz�lz�-,aR - � c"4z C -Y. ,C, 6. Single Family Residence: Number.of Bedrooms: Multiple Family Residence: ( ) Number of Bedrooms: 7. Water Supply:_ *Individual Well A Public/Community System ( ) If Individual Well, well depth If Community System, name of system 8. Sewage Disposal System: *'On-site System V. Public System ( ) If On-site System, date of installation: *NOTE: A well log is required on ALL wells drilled since 6/75. **If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fee of $25.00 must accompany each request before processing can be initiated. 3/77 rv1 e- Two g Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 6 Block 5 Elmore Subdivision #1 Comments: 1 s Et �. �—r ;:�Wu tj MW C, DbEfl 1000 `'1R AHTS in — 41,. — • 11 .r_ © " Affadavit Attached: Letter Attached: ( ) Approved: Date: .3 Disapproved: Date: Department Worksheet:' f L0 00 C5 z RECEIPT FOR CERTIFIED MAIL -30t SENT TO STREET AND NO. P.O., STATE AND ZIP CODE R[TOAN�1. fhaalb YNere and fate delivered ------ RECEIPT W'tN delivery to addressee only .— .... f. fM.s la.Mla, date and.hero dellvered SERVICES With delivery to addressee only .._........ I Yc1.1AL ucu Tcv teldre eN re4111re ) I PS PearNO INSURANCE COVERAGE NIOYIOEO— (See other side) Apr. 1971 3900 NOT FOR INTERNATIONAL MAIL . CM: un 01480-743 06.1220(a) Rev. 1973 ALASK^EPARTMENT OF HEALTH AND SOCIAL SER' S ' DIVISION OF PUBLIC HEALTH ')! INDIVIDUAL AND SEMI-PUBLIC DATE BACTERIOLOGICAL- WATER ANALYSIS INDIVIDUAL © SEMI-PUBLIC ❑ CHLORINE RESIDUAL PPM REPORT RESULTS TO V ) r NAME .:"9^:a._ i•G{;.tll� - ADDRESS n CITY � I I ` ZIP CODE ADDRESS OF SOURCE COMPLETE THIS SECTION ONLY IF WATER IS AN INDIVIDUAL SUPPLY SAMPLE COLLECTED BY DATE COLLECTED — ) � ) 'A TIME COLLECTED /' I Sample Collected From O Killen lap 0 Bathroom Tap ❑ Basement Top ❑ Otho (Lip) Well— Duo Driven Drilledored '- SOURCE: 8 Cl0 Spring B Cistern r e Otho_ Duy Wel or Cistern Construc6... Wails—❑ Wood Cencrel. Metal iib Brick or Top — ❑Wood 8 Cotterel. a Mpol 8 Open Top 0 Connote LOCATION: 0 In Basement 0 Basement Offset Cl Undo Nouse Oln Yard 0 Other Wilding Sew., Septic DISTANCE 70: or Other Drainage Pipe Feet. Tank Feet. Tile Seepage Cos- ' - field Feet. Pit he. Pool I",. Privy' Feel. Otho Possible Souses of Contamination MATERIAL: Building Sewer - 0 Cost Iran 0 Wood 0 Tile 0 Fibre 0 Asbestos ' 0 Plastic Joint Material - Type Cement GENERAL: Does Water Become Muddy or Discolored? Yes ❑ No When? Diameter of Well Depth Feet. Well Casing Material Diameter Depth Length of Water Depth Drop Pipe From Bottom foot. Offset in In Utility PUMP LOCATION: 0 In Well 0 Ba»men, 0 In Basement 0 Room On Top 0 Of Well 0 Other PURPOSE OF EXAMINATION: Illness Suspected? 0 Yes ❑ No New Source of Supply? 0 Yes 0 No Repairs to System? 0 Yo 0 No Signature READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE lob No. OFFICE Analysis shows this Water SAMPLE to be: 1 ❑ Satisfactory ❑ Unsatisfactory ❑ Questionable Sample too long in transit; somple should not be over IB hours old of examination to Indicators reliable results. Phrase send new sample. ❑ Bottle broken in transit, please send new sample. SANITARIAN'S REMARKS 06 1220 19 3 Rev, 20 ( BACTERIOLOGICAL WATER ANALYSIS RECORD R Dal. Received 7 17 /0 f-- Time Reroived fm_lab. No. r/ Lactose Moth f 10,c 10'c 10'c 10'c 18ce I 1.0'c 1.0cc 2s Now, ) M Noun _ Brilliant Green 2s Hours /8 Noun EMB AGAR lactose BroM, 24 Ms. AB hrs. Gram's ilotn Coliform Density (Mop probobl. No. per, Worst MF Rebs R.",t.d by �/% Date ? K•^7�p—' m. a.m. p. This analysis Indicate, Coliform Organisms to be: Abs�nl t Preunt