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HomeMy WebLinkAboutSOUTH LAKEWOOD HILLS BLK 2 LT 4South Lokewood Hill Block 2 Lot 4 #015-511-27 Department of Health and Human Services 825 'L' Street P.O. Box 196650 Anchorage, Alaska 99519-6650 ,t~ck M~rort/ hit p://www.¢l.I ach orage.i kA~ Mayor Permit Number:, #SW.~90154 Date of !~a-e: EvIa/99. .Parcel ld|'-fifi~'~!!n~ ~h~r~ D1~51~-27 ~te S~: ~ Date CompleX: 3-1~0 Is well I~t~ at approved ~it I~tlon? ~ Y~ ~ No ~ ~crlpt~ ' S. L~w~ Hill~ ~lk ~ ~ 4 ' Pm~ ~er Name & Addr~: Randy Wolf. 6740 O'Malley Road e Data: stick-up organic & silt gravel g/-avelly silt sandy gravel ssgravelly silt silt gravelly silt . silty sandy water& gravel water sand & gravel gravelly silt Depth'(fO RECEIVED I AR 28 2000 · Municipality gl Anchorage Oept. Health & Human Services ""' ":',!' 'Method of Dn'lllu cable tool · Easihgtype: steel... '0 2 .. WallTlfidkness: f025 inches 2 4 -Diameter: _6inches Depth: 242 feet -4 . 11 .. LluerType: .... Diameter: ineh~s ' ' Depthi ~ feet :1I .63 Casing stickup above ground: _2 feet 63 '67 87 "121 Static water level (fxom ground level):-132 feet · Pumping level: 240 feet after .121 167 _2 hours pumping '/00 +-gpm 167 210 'Recovery Rate:... '/00. + gpm... ~. %.:. ,.. 210 225 Method of Tesfing:air//ft ;....... 225 .237 Well la enln . · 237 242 'D Open End [] Olxm Hole · J--J S cu'~med Start ,feet-Stopped feet "' .~:~] P,.-~orations Start 225 feet Stopped 237 feet 'Grout~l'ype: bentonite fi 8 'Volume: ~ bgs Depth: , : Start 0 feet Stopped: feet Pump! Intal~c D=pth feet Pump size ~ hp Brand Hame '.Well Disinfected Ul~n compl~fion? [] Yes [] No · .Method ofDisiafectioa:. ~or/ne tablets 'Comments: Well Driller:· 'AlpifeD.?ylin~ Epteq~ses. ......... , ..... .,,., Anchocage AK 99511 Attention: The welldritler -'..~:: t~ovide a i, vell log to the property owner withla ~0 days of completion and the property MUNICIPAUTY OF ANCHORAGE Department of Health end Human Services On-Site Services Program 825 L Street. Room 502 P.O. Box 196650, Anchorage. AK 99519-6650 (907) 343-4744 ON-SITE WATER SUPPLY PERMIT Renewal Date Issued: Jun 18, 1999 Expiration Date: Jun 17, 2000 Permit Number: SW990154 Legal Description: ,SOUTH LAKEWOOD HILLS BLK 2 LT 4 , Design Engineer. 0000 None Required Owner Name: Randall Wolf Owner Address: 6740 OMALLEY ROAD ANCHORAGE, AK 99515-0000 Parcel ID: 015-511-27 Site Address: 006740 O'MALLEY RD Lot Size: 35000 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage 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 Ddnking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction dudng freezing weather must be either. A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: PAGE 1 OF 1 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 SYSTEM (UPGRADE) pERMIT PERMIT NUMBER:SW970138 DESIGN ENGINEER:DUMMY COMPANY OWNER N~LME:WOLF RANDALL C & CARLA L OWNER ADDRESS:6740 O'MALLEY ROAD ANCHORAGE, ALASKA 99516 DATE ISSUED: 6/17/97 EXPIRATION DATE: 6/17/98 PARCEL ID:01551127 LEGAL DESCRIPTION: SOUTH LAKEWOOD HILLS BLK 2 LT 4 LOT SIZE: 35000 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: 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 (18AAC80). 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 SANE DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS ISSUED BY: ~2~,~,~/' DATE: / 7- f 7 % C 5TAT'~. /oZ. mi 0 ID Gerald ¥. Randall Jr. ~ NO, ~053.S ~' EXCLtlSlgfl 1IOTE: II Is the resp~qslbllily lO detclmine~ On Ihs recorded subdivision pJaJ, SEPTIC TANK: Distance fmom well ~ ~,,,~atePial ,~-~<'~ ..N~eP of compartments , / .... Liquid eapaeity,,~)~, ~Eallons, Inside tenEth ~,Inside width Liquid depth,, d~a~teP~ oP SEEPAGE SYSTEM: Seepage Pit: Nu~eP of Pits ~ ,,,qutside ' ' width ...... , lenEth , depth ~ , lining material ~'~f2~ Dish.ce from well /~, buildln~ fo~da~ion ,, nearest lo~ line :~ ToTal effective absorption area (wall a~a),, '>()~?, sq. T~_~ DR6!~ ..F~: Distance from well , foundation ~ , nearest lot line Total lenEth of lin%s, Nu~er of lines Distance between lines Trench width~ in.' TO~al effec~xve' absorption area ..... sq. ft. LenEth of each line Depth: Top of ~iie to finish Erade , Depth of filter ~erial beneath tile in. Above tile WELL: Type~'~'~/~., depth. , distance from buildin8 fo~datlon ..... , nearest lot line .... , nearest sewer line, , septic tank , seepaEe system cesspool , other sources , DISTANCES: DIAGRAM OF SYSTEM DATE: APPROVED Health Authority 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. # 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) ( (b) Property owner Mailing Address (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone '~7~' - ~-"76~ / (e) Mail the HAA to the following address: (or check here [~, if hold for pick up:) List contact person and day phone number below: / 2. TYPE OF RESIDENCE Single-Family ~ Number of 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 th legality and status. SEWAGE DISPOSAL On-site [] 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 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 F~/'/~/~ 7~c4n; ~/ ~ Telephone Address I~b-3~ ~ ~ J Date ~cem~ ~0 I~ ~, .... ---~;-' -~ Engineer's Seal 6. DHHS APPROVAL Approved for ~ bedrooms by Approved ~ Disapproved Terms of Conditional Approval Conditional Date 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 Mun ici pality of Anchorage is n et responsible for errors or omissions in the professional engineer's work. 72-025 (Rev 7/88) Back Page 2 of 2 PAL TY OF ANCHORAGE (MOA) '°'!^(Fiea th Author ty Approval (HAA) (~HECKLIST - FEBRUARY 1984 A. WELL DATA 343-4744 Legal Description: Well Classification ~r~ f'/¢' ~' If A. B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) /%/ Date Completed ~ 1~'7 Yield I~¢~ "~'¢¢¢ Total Depth 1~,5" Cased to ? ¥~" Depth of Grouting /%,4, Static Water Level /'f '~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot 81' ~I~ 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 ,5~-/'~z~c~"/'Or'v' Comments /4~f~f~ ¢,~f'cf' Pump Set At ~r)~' ~r ~ Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) N c, o. ; On Adjoining Lots ~18' ~ ¢,,~ ;OnAdjoiningLotsT-~O~ To Nearest Public Sewer Cleanout/Manhole ;Date TIC/HOLDING TANK DATA ' Date Installed I~ Size ~ f No. of Compartments Standpipes (Y/N) Y' Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) N, ,4. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: Foundation Cleanout (Y/N) IV Date Last Pumped I ~/' I'/' / ~'~' ; for N,/¢. Temporary Holding Tank Permit (Y/N) To Water-Supply Well ~' To Property Line ~ ~5- To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments IX/eli- ..¢'~'1¢ ~q-c To Building Foundation To Disposal Field 72-026 (Rev 7/88) Front Page 1 of 2 C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed I ~ ~ Width of Field N,/t-. Square Feet of Absortion Area ~00 Depression over Field (Y/N) 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 Comments_ ~t~-~orif~ ~fc~7 O. LIFT STATION N, Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Type of System Design Length of Field Depth of Field II Gravel Bed Thickness 7' Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line ~ To Existing or Abandoned System on ; On Adjoining Lots ~ .?~ ~ To Cutback (if present) ~ [00~ Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA ,g.~.~eg~p~es in effect on the date of this nspect on ..¢~" ~rx~':: ~ ~ ~ ......... ¢.,.~ ........ ............... ~ Engineer's Seal Date Dec~o~r ~ tv~ :~ / . ~ ~-. ' MOA No. ~-0~ ~__ ~ ~ ¢ (%.rt'.,.o[:,,~{; ~ ~,,~ool~E -' l~ ~c _ ~ ~¢/o 0 .. , ,, . '~ '~'~otcs,~;~r,'~,:~ ;~:? Receipt No. ~,P ~ ~u / ~ ~/ Receipt No._ ~:~ _ Date of Payment /~ -~- ~ ~ Waiver Fee: $ ' Amount: $ /~(2- ~)~ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. /~'~¢~ 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343 FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order # 10915 Date Report Printed: DEC 19 88 @ 12:59 Client Sample ID:L14, B2 LAKEWOOD HILLS PWSID =UA Collected DEC 14 88 @ 13:55 ks. Received DEC 14 88 @ 15:00 Preserved with :N DEG. C Client Name : FLATTOP TECHNICAL SERVICE Client Acct: FLATTOT P.O.~ NONE REC'D Req # Ordered By : T. MOORE Analysis Completed :DEC 16 88 Send Reports to: Laboratory SupervisJ~']:STEPHEN C. EDE i)ELATTOP TECNNICAL SERVICE Special -- [/ ............... Instruct: Chemlab Ref #: 3723 Lab Hmpl ID: 1 Matrix: WATER Allowable Parameter Tested Result/Units Method Limits NITRATE-N ND(O.lO) mg/1 EPA 353.2 10 Sample ROUTINE SAMPLE Remarks: SAMPLE COLLECTED BY T.M. 1 Tests Performed See Special Instructions Above WA=Unavailable ND= None Detected ** See Sample Remarks Above NA= Not Analyzed LT=Less Than, GT=Greate~ Than ACHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER ~ PRIVATE WATER SYSTEM ~-(~{4¢/~ 7~c/o,~ ~'c¢d' :e~'~'(c e¢ Name Phone No. Mailing Address ~ City State Zip Code Mo. Day Year SAMPLE TYPE: [-~ Routine L3 Check Sample (for routine sample with lab ref. no. Lq Special Purpose Treated Water Untreated Water SAMPLE Time Collected NO. LOCATION Collected By 3 I I 4 I J 5 I J READ INSTRUCTIONS BEFORE COLLECTING SAMPLE TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~ Satisfactory [] Unsatisfactory [] Sampletoo long intransit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received /~ ~//¢~' ~ Time¢ Received J~'"~ Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Result* I , I l-lq J ~ Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count ~'~ Coilformli00n~t' Verification: LTS ,,~ Final Membrane F~iltel Resets _ / BGB. ~) Coilformll00mt Time: '/~ a.m. TNTC = Too Numberous To Count OB = Other Bacteria 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 .o~./,9 / ~ 7 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) d'7 ¥~ o ' t--tN Ih~7 Applicant Name ~¢? ,/'~"~"~ Telephone:Home Applicant Address ~'7 ~¢~' ~2 ' ~f/1~ ~/ (b) Business --~-~ ""~ ~ (c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain); (d) Lending Institution Address ~0i~ (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family I~ Multi-Family [] Number of Bedrooms .~ Other WATER SUPPLY Individual Well [] Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attestin9 to the legality and status. 4. SEWAGE DISPOSAL Onsite [] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attestin9 to the legality and status. Page 1 of 2 72 025 (11/84) 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 ~'f~z/L.,x~/~ '~¢~ n ~'cc~( ,.~'~r¢'c.,~'c.~ Telephone ~ ~,~- I~.~ Address ~ ~ c~o~/¢ t Engineer's Seal Approved for ~ bedrooms by Date 2 -- ¢~ ~ 7 Approved ~ Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipaiity 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) WELL DATA ~ MUNICIPALITY OF ANCHORAGe: MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL SERVICES DIVISION HEALTH AUTHORITY APPROVAL (HAA) FEB 1987 CHECKLIST - FEBRUARY 1984 264-4729 Legal Description: ~ O ~ ~'¢.~ Rt~;¢F'lf~ ~F'D Well Classification Well Log Present (Y/N) Total Depth I~,~~ ~¢,,¢" Cased to Static Water Level iq ¥ i Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E.C. Approved (Y/N) Date Completed ~g¢7 Yield Depth of Grouting Pump Set At &,~ I~¢ ;~. i~ Sanitary Seal on Casing (Y/N) ~' Depression Around Wellhead (Y/N) To Nearest Edge of Absorption Field on Lot ~ To Nearest Public Sewer Line ; On Adjoining Lots ~' ,¢¢'~:~ ; On Adjoining Lots ~ I~¢ To Nearest Public Sewer Cleanout/Manhole N,/). To Nearest Sewer Service Line on Lot Water Sample Collected by T~I~ ; Date '2. Water Sample Test Results .~c~'.~.~, ~_~ .- ~ ~,~j~,.~¢ Or ~ Comments ~ ~" i;m,'~ ~t ~f~ ~ i~,~ ~',~ B. SEPTIC/HOLDING TANK DATA Date Installed I;~ ~'~' Size ~'~ ~(~/ No. of Compartments ~ Standpipes (Y/N) ~' Air-tight Caps (Y/N) Y Foundation Cleanout (Y/N) N Depression over Tank (Y/N) ~/ Date Last Pumped lO/~¥ /~¢' Pumping/Maintenance Contract on File (Y/N) I~l~ ft ; for ~,~ Holding Tank High-Water Alarm (Y/N) i~t,/4 Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ~¢'l ~ To Property Line '~ Z-~' To Water Main/Service Line ~f,/~. Course ~' t~O ~ To Building Foundation ;~ ~ To Disposal Field '~l ~ To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72 026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field _ Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field ('~¢~'~'~ Depth of Field ~ If Gravel Bed Thickness ? ~ -&.,,, If- Standpipes Present (Y/N) Date of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot To Property Line ~¢' 3,5'¢ To Existing or Abandoned System on ; On Adjoining Lots To Water Main/Service Line NC/¢-. To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area M~¢" Comments [~o,~o~ ~ ~e~ LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I cartify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~"~-~"'~"'~"~'~'- ~."~.,¢-¢-~4._ Date ~/'¢/~ 7 Company 1='(-¢~t~'/a "r'~,c~,,¢,~ca/ .~4.~ MOA NO. Receipt No. ~E Date of Payment: Amount: $ Page 2 of 2 72 026 (11/84) Engineer's Seal 7i27 OLD SEWARD HIGHWAy ' ' ' # ....,0.~/ .ANCHORAGE, ALASKA 99518 (907) 344=8551 BACTERIOLOGICAL MATER ANALYSIS TO BE COMPLETED BY MATER SUPPLIER DATE COLLECTED I TIME COLLECTED I TYPE OF SYSTEM MONTH DAY YEAR I I.D. MO. (PUBLIC SYSTEMS) CIRCLE ~LA~ I , I I I I I I A B C ~ResiJ~nti~ NAME OF SYSTE~ TELEPHONE NUMBER SYSTEH ADDRES~ CITY LOCATION ~HERE S~MPLE ~S COLLECTED ""COLLECT[D BY: (~IGNATURE) ZIP CODE ~YPE OF SAMPLE (CHECK ONLY ONE THIS COLUMN) [] DRINKING WATER ~CHECK TREATMENT F'tCHLORINATED F-)FILTERED ~UNTREATED OR OTHER [] RAW SOURCE WATER r-) NEW CONSTRUCTION OR REPAIRS [] OTHER(Specify) ~ IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NON-CONFORMING SAMPLE? [] YES ~NO PREVIOUS COLLECTION DATE ANALYSIS REQUESTED (IF OTHER THAN TOTAL COLIFORM) SEND REPORT TO:(PRINT PULL NAME,ADDRESS AND ZIP CODE NAME ADDRESS CITY ~~ STATE b~ ZIP FOR LAB USE ONLY [] RESUBMIT SAMPLE Sample rejected because: CHECK ONE OR MORE []Sample too long in transit. Sample should not be over 30 hours. )']Sample received too late in week []Not in proper container []]]Leaked out [] Insufficient information provided. Please read instructions on form. []]Other (Specify) RECEIVED FROM 'l~] fl)O0~., RECEIVED BY ,~f)]~] T~t~ DATE ~- ~-~ ~/ TIME AN~AL METHOD: ~IMEMBRANE FILTER E]FERMEUTATION TUBE Date & Time Started Date & Time Completed ~ I~';~ '' " ~(.), LABORATORY R~SULTS_.. [] Other Bacteria ~ Test unsuitable because: [] Confluent Growth [] TNTC ~/ SATISFACTORY U.SATISFACTO~Y [] BACTERIOLOGICAL WATER ANALYSIS RECORD FOR LAB USE OMLY ')~r/ TOTAL COLIFOPJqS "-) FECAL COLIFORMS r--] OTHER Membrane Filter: Direct Count Verification: LTB Final Membrane Filter Results Reported By BGB Date Time Coliform/lOOml Coliform/lOOml READ SAIIPLE COLLECTION INSTRUCTIONS ON BACK OF FORM MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT. ©F i: ALT i & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE~NMF-N],,:,_ ~ .CTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION FEB P, !JT0 Telephone 264-4720 DEC I~ I\1 ~; J~ IRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. PROPERTY RESIDENT (If different from above) PHONE PHONE PHONE PHONE ~J~..15' LEGAL ESCRIPTI N ~Z ~ 6. TYPE OF RESIDE~-CE - -- ~ - NUMBER OF BED~OO~S ' ~'~ ~'1 I ~/ [] One [] Four [] (~qer . I ~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [~ Three [] Six WATERRS~S PPLY I~' INDIVI DUAL* * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY since June lg75. For wells dr~illed_~pri_~o~ to that date, give well [] PUBLIC UTI LITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** **If individual/on-site, give installation date If system is over two (2) years old an adequacy test is required [] PUBLIC UTI LITY by this Department, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72~)10(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOI NTM ENTS TIME TIME TIME DATE DATE DATE I NSP ECTOR ~ NSP ECTOR [NSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] F~VE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED E3 PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER I~INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER [~]Septic Tank or [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line I WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS [~'~PPROVED FOR .¢ BEDROOMS [~] CONDITIONAL APPROVAL (letter must accompany certificate) ~- DISAPPROVED ~C: ~:::~ DATE...~:~ --'~l ~ ~--~'- O~I~,- r~ <~ BY (Title)(~.(~ . ~.~ LEGAL DESCRIPTION 72-010 (Rev. 3/78) #1: Time Date Insp ,~ MUNICIPALITY OF ANCHORAG=-, DEPARTM ~ OF HEALTH AND ENVIRONMEI ~L PROTECTION 825 L Street, Anchorage. Alaska 99501 264-4720 Date Received: February 1, 1978 /C):~ ,~rY/. ~2: Time #3: Time Date Date Insp Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES Lending Institution Request: Alaska Statebank Mailing Address:310 East Northern Lights BoulevardPhone: 279-7637 344-3144 Property Owner: Hannah Masonry Construction Mailing Address:Star Route A Box 34-C 99502 Phone: Legal Description: Lot 4 Block 2 South Lakewood Hills Subdivision Single Family Residence: (x) Number of Bedrooms: Three Multiple Family Residence: ( ) Number of Bedrooms: Well System: Permit # Construction Individual Well (x) Community/Public System ( ) Depth of Well Well Log on File Bacterial Analysis ( ) 6. Sewage Disposal System: On-site System (x) Public Utility ( ) Permit # Installed /~F Installer Septic Tank Size ~)~O Manufacturer Absorption Area Soils Rate Material 7. Distances: Well to Septic Tank to Absorption Area to Sewer Line Nearest Lot line Absorption Area to Nearest Lot Line Page T.~.3 ~ Department of Health and Environmental Protection Request for Approval of Individual Sewer and Water Facilities Legal Description: Lot 4 Block 2 South Lakewood Hills Subdivision Comments: Affadavit Attached: Approved: ~_C~, ~ Disapproved: Letter Attached: ( ) Date: Date: Department Worksheet: (el]elsod Snld) ~tO~--'ll¥1Ai 03l.*111~i33 ~]0:1 ldlq33, P MUNICIPALITY OF ANCHORAG~ Department oS Health and Environmental Protection 825 L Street, Anchorage, Alaska 99501 · ~Kequest ~or Approval o~ ina v · ~ ~ Property Owner: Hgnna~rnction . Mailing Address: ST, RT, A, Box ~a4-C, Anchora&e~ AK q9502Ph°ne: 3;!1!-3]~!~!· Name of Buyer: SAME Mailing Address: Phone: Lending Institution: Alaska Statebsmk Mailing Address: ~10 ~., Northern Lights Blvd.~ AnchoragePh°ne: Alaska 99~03 279-7637 Realtor/Agent: NOEE Mailing Address: Phone: Legal Description: Lo~ 4, Block 2, South Lakewood Hills Street Location: N~ 0'F~tley Road, Anchorage, Alaska e Single Family Residence: Multiple Family Residence: (X) Number of Bedrooms: 3 ( ) Number of Bedrooms: Water Supply: *Individual Well If Individual Well, well depth If Community System, name of system ~) Public/Con, unity System ( ) Sewage Disposal System: *~n-site System If On-site System, date of installation: (X) Public System *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 ~efore ~rocesslng can be initiated. 3/77