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HomeMy WebLinkAboutSPENDLOVE VIEW HEIGHTS #2 BLK 4 LT 3pendlove View He40 ights #2 Block 4 Lot 3 #017-401-32 Parcell.D. 017-401-32 01II1t n'l`40 :0. tt� Municipality of A>r� ,Waj# 8-ry On -Site Water and Wastewater Program tiZE;'o (907) 343-7904 3 Ef 1 2 J14 Certificate of On -Site 1. GENERAL INFORMATION Expiration Date: e - C Complete legal description SPENDLOVE VIEW HEIGHTS #2 BLK 4 LT 3 Location (site address) 8700 SPENDLOVE DR ANCHORAGE AK Current Property owner(s) DEAN CAMERY Mailing address Real Estate Agent KATHY FERNENDEZ 2. TYPE OF DWELLING: M Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ❑x Individual x❑ Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water Rvctem ❑ Puhlic Sewer n WaiverNariance request for: NONE q __. nista nce--- Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee Date of Payment cl I I le f!y Receipt Number. b ✓ t �' 1 COSA t« 05t,1 Y 1q �3 Waiver Fee $ Date of Payment Receipt Number Waiver # 5. 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 Certificate of On -Site Systems 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 SPURKLAND ENGINEERING Address 203 W. 15TH AVE.,STE.202A, ANCHORAGE, AK 99501 Engineer's Printed Name LARS SPURKLAND 6. DSD SIGNATURE System #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved Phone 279-3916 Date 9/15/14 OF A4 -r ��„„ SPURKLANO:c�, 15 0 Vs I 1►, pRO�Fe.10 P '� Conditional approval for bedrooms, with the following r'-) By: z A� .�,,� 111 . Original Certificate Date: The nicipality of Fin oraga Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA blue sheet r ( - If more than 1 septic system is on the lot: COSA Checklist # 1 of 1 Structure served by this system 1 Certificate of On -Site Systems Approval Checklist Legal Description: SPENDLOVE VIEW HEIGHTS #2 BLK 4 LT 3 A. WELL DATA Well type PRIVATE Date completed -1977 Total depth 130+ ft. Date of test Static water level Well production If A, B, or C provide PWSID # Sanitary seal (YIN) Y Cased to 40+ ft. FROM WELL LOG WATER SAMPLE RESULTS ft. Coliform NEG colonies/100 mL Nitrate 3.43 mg/L Arsenic ND ug/L Date of sample: 8/25/14 B. SEPTICIHOLDING TANK DATA Tank Type/Material STEEUSEPTIC Tank size 1000 gal. Number of Compartments Parcel ID: 017-401-32 Well Log (YIN) N Wires properly protected (YIN) Y Casing height (above ground) 12+ in. AT INSPECTION 9/12/14 ARTESIAN ft 4.3 �J21111 Collected by: GARNESS ENG Date installed 10/25/1976 Cleanouts (YIN) Y Foundation cleanout (YIN) Y Depression over tank (YIN) N High water alarm (YIN) N Date of pumping 5/28/14 Pumper A+ HOME SERVICES C. ABSORPTION FIELD DATA Date installed 10/1976 Soil rating (g.p.d./ff or felbdrm) 165 System type TRENCH Length 42 ft. Width 3 ft. Gravel below pipe 6.0 ft. Total depth 9 ft. Eff. absorption area 504 fe Monitoring tube Y Depression over field N Date of adequacy test 9/12114 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 450 gal. New depth 13 in. Elapsed Time: 60 min. Final fluid depth 10 in. Absorption rate >= 450 9 p d Any rejuvenation treatment (past 12 mo.) (YIN & type) If yes, give date D. LIFT STATION Date installed "Pump on" level at Datum ril Size in gallons "Pump ofr level at in. Cycles tested Manhole/Access (YIN) High water alarm level at Meets alarm & circuit requirements? _ E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 91' -WR 9200$4 On adjacent lots 1001+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main NA Public sewer manhole/cleanout NA Sewer /septic service line 25'+ Holding tank NA Animal containment areas 50+ Manure/animal excrete storage areas 100'+ SEPTICIHOLDING TANK ON LOT TO: Building foundation 5+ Property line 51+ Water main NA Water service line 10'+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water Service line 10'+ Surface water 100'+(N.O.) Curtain drain 50'+ (N.O.) Wells on adjacent lots 100'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that t have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name LARS SPURKLAND Date 9112/14 COSA brown sheet 10-10-12.doc Absorption field 51+ Surfacewater 100'+ Water main NA g/vehicle Driveway, rkin 50'+ pa storage QF. + �P'14' 1- t, 9s ... ...:..si :..X pfl... PURKLAND;}g� j in. GUY ANCHOR POWER POLE �t C9 dZ^oma rl O m M ZL w w NLo J�SV atom b, W V1 e o L Z Z 11®40' PLAT NO. 76-43 SPENDLCVE VIEW HEIGHTS, ADDN. NO. 2 LCT 3, BLOCK 4 50,132 S.F. SPENDLOVE DRIVE 0 M N 89057'52"E 148.36'(R) N 89047'17"E 147.99'(M) IO >-RETANNG WALL Q� N �(`�WE� 49.7' \ + B \ G, k�x, x II SEPTIC SYSTEM iOa `_'X`X- Vd+:5hoP oA AM a4Rry N 89043'35"E 185.42'(M) N 89056'51"W 185.04 (R) A S— B U I LT I HEREBY CERTIFY THAT I HAVE SURVEYED THE GASTALDI LAND PROPERTY DEPICTED ABOVE AND THAT NO SURVEYING, LLC ENCROACHMENTS EXIST EXCEPT AS INDICATED. JEFF A. GASTALDI, R.L.S. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY EASEMENTS, 2000 E. DOWLING RD., SUITE 8 COVENANTS OR RESTRICTIONS WHICH DO NOT ANCHORAGE, ALASKA 99507 APPS ON THE RECORDED SUBDIVISION PLAT. PHONE 248-5454 UNDER NO CIRCUMSTANCES SHOULD ANY DATA GRID DATE HEREON BE USED FOR CONSTRUCTION OR FOR SW2841 9/17/2014 ESTABLISHING BOUNDARY OR FENCE LINES. ANCHORAGE RECORDING DISTRICT, ALASKA F.B. 2014-04 jos No. SVH234 NOTE: NO CORNERS SET THIS DATE N N BUILDING DETAIL SCALE: 1"=20' ♦♦*hV®®* OF A 1� ♦ a� •,,....... �qs ♦. 1: co : ••• F 0 49T .�.... *•: �....... ........... . •• . ffery A. Gostoldi •� AV I sot �� Air t aA ... a rofessionot �0� Municipality of Anchorage Development Services Department Building Safety Division - On -Site Water and Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING. Parcel l.D. 017-401-32 HAA#LjjQ 0 1 D �2_ % 0 Expiration Date: 117-11-t3 I 1. GENERAL INFORMATION Complete legal description Lot 3, Block 4, Spendlove View Heights Ill Location (site address or directions) 8700 Spendlove Drive Chris Current Property owners) Alexander Da hone 345-2440 Y P .8700..Spendlove Drive, Anchorage, AK 99516 L -Mailing address Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address be held by DSD for Unless otherwise requested, HAA will pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well Q Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sever ❑ The Municipality of Anchorage Development 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) 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 less than 30 days old. (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 S & S ENGINEERING Phone 6 9N— D-cl 7% 17034 No. 204 Address Eagle River, Alaska 99577 Enginoer'sPrintedName .Robert C. Cowan. P.F. Date S-13110/ 5. DSD SIGNATURE L-1000 Approved for 3 Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other BYG�/�� Original Certificate Date: (y (R". II.00) Municipality of Anchorage 4,11 Development Services DepartmentBuilding Safety Division ` on -She Water & Wastewater Program 47W South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.6650 www.d.androrage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: f-07- -3 0 LO C'c y �Pe...awwl V1' "I ")t(' 41"'Parcal ID: 0/7 — q / - 3 Z A. WELL DATA Well type PR,vaTr< If A, B. or C provide PWSID # = Date completed u�K Sanitary seat 0/N) YeE Total depth 301a fl. Cased to FROM WELL LOG Date of test Static water level ft Well production 9•P•m• WATER SAMPLE RESULTS: Coliform o colonies/100 nil. Date of sample: _LIX 4 0 1 Nitrate D-32 mg./I. Well Log (49 N O Wim property Protected &N) Yl S Casing height (above ground) d a '4 M. AT INSPECTION 5-10"1101 A2rlSiw,✓ ft. g.p.m. Other bacteria O colonies/100 ml. Collected by: S & S ENGINEERING 17014 Eapte River Loop Road No, 404 B. SEPTIC/HOLDING TANK DATA iEaple Rkrar, Alaska 99577 Tank Type/Material J0--4 r -- /-S 7 f Date installed l 0%2 S /7 6 Tank size )o e o gal. Number of Compartments " Cleanouts O/N) YE J Foundation cleanout ON) ��_ Depression over tank (YAO L OO High water alarm (Ye ^� U Date of pumping (0/5101 pumper / S AA C- S C. ABSORPTION FIELD DATA Date Installed /0 l Soli rating (g.p.d.1W or lbdrm ! 6S System" T R4wi c (-4 Length y�.= ft. Width 3 ft. Gravel below pipe (0 ft. Total depth 9 ft. Eff. absorption area Soy ftp Monitoring tube ya. ss Depression over field ✓ o Date of adequacy test o 1 Results1PEQFail) PASJ For 3 bedrooms Fluid depth in absorption field before test 3 6 in. Jv ^ ,1L4 Water added .Tc9 gal. New depth Sa In. Elapsed Time: / 3 min. Final fluid depth �Lj in. Absorption rate >= H t o g.p.d. a* AAJ.9.1*64A NQH C -JA WwJ 41/,L4. 47— 7/"f 1-I.44tL Any rejuvenation treatment (past 12 mo.) (Y/N & type) Ivo,vQ_ levo w,. If yes, give date D. LIFT STATION Date installed Size in gallons _ Mar AeeeS ) "Pump on" level at _ in. 'Pump air _ in. High water alarm level at In. Datum _ Cydes tested Meets alarm 6 dreufi requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO Septic tankAlft station on lot 411 T e cu C w q 9a -%"01 "0 adjacent lots _ /00 4 Absorption field on lot /00 On adjacent lots /00 j Public sewer main N 14 r Sewer /septic service fine a S �h Public sewer manhola/deanout N 14 Holding tank n/ / A SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: r . I Building foundation S f Property line S t Absorption field S Water main N /a Water service line /0 > Surface water /00 �.4 Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line /0 4 Building foundation 104 Water main OJ �A r . , Water Service line /0 Surface water /00 a- Driveway, parkirglvehide storage S 0 Curtain drain Wells -on adjacent lots /O 0 I f F. COMMENTS ' 1, G. ENGINEER'S CERTIFICATION is!Zt I certify that I have determined through field inspectlons and y ' review of Municipal records that the above systems are in conformance with MOA HAA guidelines in efled on this date. •• -` i 744 Engineer's Printed Name I UA7- C. CO r++�/r y" . �'- AMP• 90�f R08ERT C. COWAN Date S-�3/�0 / :fly CE -8801 t�� Vti .................•` i HAA Fee $ 300. • , Date of Payment s -/3r �o / Receipt Number 0 0 S It r (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number JUN -01-01 15:09 FROM - CUE Environmental Services Inc. `' �1�• �iir�rrrrrrriirrrri� CT&E ReLp 1012931001 Client Name S k S Engineering ProlectNamv# Spendlove View Hts #2 Client Sample ID Lot 3 Dlock4 Matrix Drinking Water Ordered By PWSID 0 Sample Remarks: T-294 P.02/03 F-846 Client POM Printed Date/rime Collected Datefrime Received Date/Time Technical Director Released By nA 06/01/2001 11:36 05/29/2001 12:30 05/29/2001 14:30 Stephen C. Ede ParameterResuln PQL Units Method Allowable Pup AmIysis - Limits tate Date ]nit Waters Department Nitrate -N Microbiology Laboratory Total Coliform 2.39 0.500 mg/L EPA 300.0 0 0 col/100mL SM 1892228 (<10) 0529/01 SCL 0529/01 KAP JUN -01-01 15:09 FROW CT&E Environmental Services Inc. Laboratory Division T-294 P.03/03 F-846 Drinking Water Analysis Report for Total Coliform Bacteria 200 W Potter orrve tE4DINSTRUMONSOVREV£RS£SID£a£FOR£COLLECT7,V47SAMPLE Anchorage. AK92518.1605 Tel: (9071562.2343 Fax: 1907151111-5301 MUST BE COMPLETED BY WATER SUPPLIER a PUBLIC WATERSYSTEM I.D.0 ,X PRIVATE WATERSYSTEbI Sore Rema• EL SwI farMn ENOIN&MRIN, 17074 Ea le River Loo Road M� s Riva, Alsska 99577 •� h a Sw.dR"whe a Swefn..dae «r SAMPLE DATE: M Month. SAMPLE TYPE: �q Routine O Repeat Sample (Increasing stimplr with lab r*E mg..) a special Purpose 2_:.1 1. M Day Year SAMPLE LOCATION Lor 3 BLe r'k Y fiY*wx4wc Vr4t. P77-A(z- TO BE COMPLETED BY LABORATORY Zlysis shows this Water SAMPLE to be: Satisfactory O Unsatisfactory O Sample over 30 hours old. results may be unreliable O Sample too long in transit; sample should na be over 411 hours old at examination to indicate reliable results. Please send new sample via spaeiAalio mail. Dale Ranived Time Received Analysis 114224 Analytical Method: -fMcmbram Filter Vd MMC .Tr Number orcolonies/1oom1. - - - Resslt• Analyst 11012931 O ' Ttested Water R Unneaad Water Tian Collected Caueen+ ' DP 1XV0A-1 8oe9 C. 11� Ittttt ® rl 4k his Jae ❑ rated Cats Tune Client notined oruasstisfactory remelts: Poo 1pua.ith resod ❑ D= Tuna: BACTERIOLOGICAL WATER ANALYSIS RECORD MMO �IUC Rmla Tim Gllfsrm a Cots Mestkrass Filter. Dkm Coast 0, Caisaiurloo wl Verifications LTD 11GD COLInRW •ren w�r.c�. Feat Ceulbrst Coa11rsuds4 a -rat.. r...m. Final Membrana FUler RMnlra 1 (Caalthrmllee MI Reported 11 - y �S C pace D -nagS „J Ldi�) kn :omments: •V SEM M4m0er el the 203 Grate lsoeldre C4nM4N nae lurv4tttaneal GREA, cR ANCHORAGE AREA BM,,)GH Department of Environmental Quality nNa4 P, 1-: ' 3330 C Street Anchorage, Alaska 99503 —INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME_ -- D-=-arl_t�,itC__•.�l�l..(�J MAILING ADDRESS __ _.__,_�_- PHONE X_ LOCATION X -N c=-hZL/EGAL DESCRIPTION ___(J'e_ ° SEPTIC TANK: DISTANCE NUMBER OF FROM WELL / (yzg- _ MANUFACTURER _- Cg" L __-MATERIAL __COMPARTMENTS / i INSIDE LENGTH____ INSIDE WIDTH _ LIQUID DEPTH _ LIQUID CAPACITY/" ) GALLONS. TILE DRAIN FIELD: l TOTAL LENGTH, f DISTANCE FROM WELL hzr- FOUNDATION ------NEAREST LOT LINE_� _OF LINES NUMBER OF LINES--/-- DISTANCE BETWEEN LINES _.- _TRENCH WIDTH 3 IN. TOTAL EFFECTIVE ABSORPTION AREA �_SQ. FT. LENGTH OF EACH LINE __ - - DEPTH OF FILTER //t�a.0 DEPTH: TOP OF TILE TO FINISH GRADE MATERIAL BENEATH TILE__(" IN. ABOVE TILE IN. WELL: TYPE __._'"� � ' CONSTRUCTION.--_ -----_------DEPTH _—DISTANCE FROM: BUILDING NEAREST NEAREST SEPTIC SEEPAGE FOUNDATION , LOT LINE SEWER LINE , TANK , SYSTEM. CESSPOOL APPROVED_-._ DISTANCES: ___ OTHER SOURCES DISAPPROVED— __ REMARKS INSTALLED BY:fiQ.r�<L?� SEWER LINE DEPTH: PIPE MATERIAL: LOT SLOPE: REMARKS: Form EQ -032 DIAGRAM WSY STEM �f�rr,? t _5 ' r_ I� DATE _!V "GAPPROVED - G. A. A. B. L , L�G i 1 DATE _!V "GAPPROVED - G. A. A. B. L October 2!5j 1977 V' 7 G B 8 Al Aurora Builders Po -ib- evchorTo, Alaoka 99509 "uec III J - -t Per)-, it !.X)iratioll Dcar iiir A nfnrmit is:mef�l ))v thdo tIoPartmolil.- for we'll and/01, ,I e w .4 U 'r 1.1lo-Eallatioll o -In )'c)'- 3 black 4 S*pendlove Vic -,;,y Heic hts sinon the issuo dat- c.;icn.el!j olke 11). tho evc-Int Your still plant to install tha ivell and/or on-sita no"Wer -Vutc,wj, a 5etlircdI . 1-111he. Orl(virull soil -Lont, may bo usoC% to obtrilm a curr(-mi; povyzjit. T U10 X-10111 IUI ' b 10 C TI (117-illorl, a well 1-oc,f Clooartmoll-L'- Oc,) fJ()(-IAIaICIAXI z:'It3 ijjguij n L X You ha -m eilay 'clic above utsitlterp rJ( ase, do not "C-0 cx)vJ-,,w*lL thi,-, ofIlioo humiediately at 204-47210. LOS 4, lljuchllol�,# MlNIMUM DISTHNCE BETWEEN H WELL HND HNY ON ... SITE SEWHGE DISPOSHL SYSTEM IS 100 FEET FOR H PRIYHTE WELL OR 200 FEET FOR H PUBLIC WELL WELL LOGS ARE REQUIRED HND MUST BE RETURNED TO THE DEPHRTMENT WITHIN ]0 L:- F! OF THE WELL COMPLETION. SPECIFICHTIONS HND CONSTRUCTION DIHGRHMS ARE AVAILABLE TO INSURE PROPER INSTHLLHTION ��two owl �* H - "A M L. :1 Q Folio to! CH P -H FE %0 EE 90 �KZZ:11 4 ,,, U AZ H Y� I CERTIFY THRT 1: I HM FRMILIHR WITH THE WELLS HS SET FORTH BY THE MUNICIPHLlTY OF HNCHORHGE 2� I WILL INSTRLL THE SYSTEM IN HCCORDHNCE WITH THE CODES SIMID :~._~_._.~... ... ... �~..... ... ~..... ....... ..... ..... ..... ..... ... ~~�~~...... ..... ... ..... ... ..... �~ HPPLICHNT HURORH CONTR & BLDRS ( ISSUEDBY.. ...... ..... ...... ..... ........ .......... ....... �..... ---- ..... ^..... �..... ..... ..... DHTE....... ..... ..... ... �... �........ ..... �... ..... . n GREA .�R ANCHORAGE AREA BOF .-JGH o )"i b DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO. 3330 "C" STREET ANCHORAGE, ALASKA 99503 T'EF'L EPHON E-2 4=atE4� ) // �u°�xV.ro iW �mw•i �' (/'c.// �C{'/t'� �� ! i(�\ G Ij r:� r7`. v� / APPLICATION AND PERMIT NAME OF APPLICANT _,U '' '/ ��� )'�v J`l �j y / PHONE..Lij%�f MAILING ADDRESS INSTALLATION LOCATION v r4_/o E- '%- __; LEGAL DESCRIPTION _ ice �- l/ 5-'/� L y l d / Y �,; t [. - t/XrefC4 INSTALLATION OF: SEPTIC TANK ____ DATE _-.�l/_ _-1 ?APPLICANT'S SIGNATURE — SEEPAGE PIT_ .-, DRAIN FIELD , OTHER TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH TO BE INSTALLED BY _ SOIL. TEST RESULTS _ NOTE: THIS PERMIT IS 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 SIZE TYPE._ SEEPAGE AREA SIZE TYPE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT --_DRAIN FIELD SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK SEEPAGE PIT TO NEAREST LOT LINE. WELT_ TO SEPTIC TANK DRAIN FIELD WATER MAIN TO SEPTIC TANK DRAIN FIELD _ DRAIN FIELD SEEPAGE PIT ALSO CONSIDER AREA WELLS, SEEPAGE PIT SEPTIC TANK, SEEPAGE PIT —___, DRAIN FIELD TO RIVER, LAKE, STREAM, CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED W17H AIRTIGHT REMOVABLE CAPS. GRAVEL RACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. OR LICENSED DESIGNER DIAGRAM OF SYSTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. DATE _-.�l/_ _-1 ?APPLICANT'S SIGNATURE ) EQ -01 6075) GRE".A ..:.R ANCHORAGE AREA E30R JGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 SEWAGE NAME OF APPLICANT INS TALLATI ON LOCATION LEGAL DESCRIPTION INSTALLATION OF: SEPTIC TANK --� TYPE AND SIZE OF FACILITY TO BE SERVED _ FINANCED THROUGH SOIL TEST RESULTS COMPLETION DATE ANTICIPATED PERMIT NO. �. OOSAL SYSTEM APPLICATION AND PERMIT ' MAILI�G ,ADDRESS PHONE v SEPTI-'- , DRAIN FIELD , OTHER TO BE INSTALLED BY _ NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST 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 SIZE ©C-1 ? ___ TYPE SEEPAGE AREA SIZE TYPE MINIMUM DISTANCES, REQUIREMENTS � DIAGRAM OF SYSTEM FOUNDATION TO SEPTIC TANK _ a FOUNDATION TO SEEPAGE PIT- 3- , DRAIN FIELD _ SEPTIC TANK TO SEEPAGE PIT WALL i SEPTIC TANK •-, __, SEEPAGE PIT DRAIN FIELD TO NEAREST LOT LINE. J WELL. TO SEPTIC TANK ___( SEEPAGE PIT - DRAIN FIELD __ ALSO CONSIDER AREA WELLS. .WATER MAIN TO SEPTIC TANK SEEPAGE PIT _ DRAIN FIELD SEPTIC TANK, l HCS SEEPAGE PIT _-_L_-�, DRAIN FIELD TO RIVER, LAKE, STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON. SEPTIC TANK AND SEEPAGE Pill FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGAR ING NSl'ALLATION. G.A.A.B. OR LICENSED DESIGNER I CERTIFY THAT I AM FAMILIAR WITH. THE REQUIREMENTS OF GREATER ANCHORAGE AREA DESCRIBED SYS91TE`jM IS ly ACCORDANCE WITH SAID CODE. DATE �LJ �' �S__ APPLICANT'S SIGNATURE EQ -016(3-75) ORDINANCE NO. 28-68 AND THIAT TH'E ABOVE MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES}t Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # 1. GENERAL INFORMATION Complete legal description Lo f , II lack S/�cncC�ave 1/1ew Hecyh,b #I 2 E 3 4. Location (site address or directions) 87ao Wde Oue Dr'b{ Property owner R ( i 1 9 (ass e,- Day phone 3'fS- S6 z7 Mailing address geno((aw Dri.�e, Anctior! �, 4 -' 196-101 Lending agency Alf'/ 86(nkr 01 lf(cell_-el Day phone 2s 7 -33Ga Mailing address IS -00 w• genres" g�vo�; r41?cyarayr 995 0�? Agent bar hares Mk SYY7 A - nie/7ax Pr04erllf Day phone 276 - 276' Address 26'00(oro(ava S>� �nc%araye� ,Ak 9`�5"tr3 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water 3 �u NOTE: NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA 021 5. 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 of this Health Authority Approval application 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 Firm1_ faNav Technica 1 Seo-,�tc er Phone 3 yS— 73Sr- Address 11,5-3a Echo S{ Ali c/7oAlt 9 Mj( Engineer's signature 1.�^� me_c 2 Date 3 / (6 /9 Z �t well — Sepf1c. Tan k Se�tacrcefio� o�1r{unGe wo (vee n asd�.0 6. DHHS SIGNATURE X Approved for 3 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments No fE 7'R b L E U M Ph'ODNC TS MAY Se Y "n Ep /A/ 7 -HE 57-48,46E 7H�97- LeoN7-14/Av3 rho;er Ey1,rr1p WTlc The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates 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. 72-025 (Rev. 1/91) Back MOA 421 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: 3 /1 .SDena((auc View tilt, #a Parcel I.D. A. WELL DATA Well type PL"� If A, B, or C, attach ADEC letter. ADEC water system number K• A Log present (Y/N) N Date completed 19 7(5' Driller tA Total depth 13r Cased to >wo'or �edrr»c(i Casing height (2-(I Sanitary seal (Y/N) Y Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: AT INSPECTION 1 / MAY OF ANCHORAGE: AAL SERVICES DIVISION 57' lvi At g.p.m. 7 g.p.m. UnK L.EI V ED Septic/holding tank on lot — 93' to c•�• ; On adjacent lots > (00 Absorption field on lot its, ; On adjacent lots > «` Public sewer main Public sewer manhole/cleanout N, R• Sewer service line > 25" Petroleum tank None .S ecP4 WATER SAMPLE RESULTS: Coliform 0 col /r00 m i Nitrate S•& my (-,e- Other bacteria o [v1 /IC,0ym e Date of sample: 2 / 17 / %Z Collected by: 7-ff Mr,,OrE B. SEPTIC/HOLDING TANK DATA Date installed Ia Tank size 1060 y a ! Compartments — Cleanouts (Y/N) r <<, Foundation cleanout (Y/N) r Depression (Y/N) N High water alarm (Y/N) Date of pumping Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ,� On adjacent lots > (SIS ` Foundation S'O' To property line Ifo —Absorption field (_S Water main/service line > Sri' Surface water/drainage > (00, 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFTSTATION N A. Date installed Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots Date installed Io / ZS/ 76� Soil rating "Pump off" level at — Cycles tested Surface water 16s 0'/r36{rm System type Trench Length `I C. Width 3 Gravel thickness Total depth 9 Total absorption area SO H Cleanouts present (Y/N) r Depression over field (Y/N) N I Date of adequacy test a/ 19 /9 Z Results (pass/fail) Pas./ for 3 bedrooms Peroxide treatment (past 12 months) (Y/N) alone knvw/? o.� If yes, give date N,A. SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ^ IIS Onadjacentlots � loo' Property line 3s' To building foundation 6W' To existing or abandoned system on lot N A, On adjacent lots > 3o ' Cutbank N. A Water main/service line � S-0 ` Surface water > I Go ` Driveway, parking/vehicle storage area > 7S'` Curtain drain None ,�,bser veo,< E. ENGINEER'S CERTIFICATION I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature 91 . Engineer's Name % h eodbra Date 3 / 16 HAA Fee $ %D >✓ Date of Payment Receipt Number Q2 72-026 (Rev. 3/91) Back MOA 21 • Y • R N •�/.%r ................ �t•o•THGODORE F. Y,OOREAr j Cc 9uJ`� ''••...,.•••'� Mir Ossr:AXu_ � Waiver Fee: $ ' -A Date of Payment a 35 Receipt Number 3� Municipality of Anchorage Department of Health and Human Services dl'lh5 Tom Fink, 825 "L" Street Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 April 23, 1992 Ted Moore, P. E. Flattop Technical Services 14530 Echo Street Anchorage, Alaska 99516 Subject: Waiver Request for Lot 3 Block 4 Spendlove View Heights #2 Waiver Request #WR920014, PID #017-401-32, HA920180 Dear Mr. Moore: Your request for waiver of the required 100 foot horizontal separation of a septic system to a private well has been approved. The approved separation distance is 90 feet from the well to the septic tank. This waiver approval applies to the existing septic system to well separation only. Any future upgrade to either will require all separation distances be met or another approval from this department. Sincerely, 9 Daniel J. Roth Civil Engineer On-site Services ljm:#6 Concur: c ihP.E. ohn Sm Program Manager On-site Services MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR#Lj)�qDMj PID# 017-401-32 HA# HA920180 Permit # Date Received: March 20, 1992 Legal Description: Lot 3 Block 4 Spendlove View Heights #2 Engineer: Ted Moore, P. E., Flattop Technical Services 14530 Echo Street, Anchorage, Alaska 99516 Applicant: Bill Blosser Waiver Requested: WEll to septic tank - 90 feet Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D.• Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: Waiver is NOT Granted: List Conditions or Reasons for above: 5 EE .47Ae14Eb Date: 4-2.2-72 By: a eviewer Rec #: 23539 Amount: $ 410.00 Date Paid: March 20. 1992 i I��t����Ek 1��QuEsT i Fold C b7- 3 &-k ¢ SP4E.lnt ULOE VIEA.. H6T3-1121- V A VBR aur ST �'4MOElt t�Y{ 92 001¢ LuAlUAR IREiVLtEST F_Gn _ - (,v ,Ell, _ _Tv_ SFPriC -7WAR Oir _90 fFc7 - - - - 7kr S E Prl c rAaK tM 1A. f r,44 irAo is- T_T 13 A _ G 19EK-R!_ /000- _ GALLON 74pk_ _ _ %ft/t I - .--Teak _x-19 3 _F_I 1TEp_ _ _ FO_R_ KF CH,9NIc G _ Co u. P4 A•10 7"N kO.v_ - - i -1 lav E LL 0.1-r4 — I lllr/4586 - 15 -Ai a _ L, -t t 1,96 el?_TM E S ao. _ _ e T- -L o T-, - iiYfiP - - - - - w E t t l d¢J FOR _ 9 t v c Rlgt._ h -_F- t_t- T-TIY.Qr _ _5 ioV f vu .� �- ;-MAE 54FO.7rEC7 it L b T. _ kcS - ?,-_ �t L oG3 �',9 �` -ALL _ C vA-�i_0_TA'MT- rr�lee JS JNoc,�D - - --APF-4FupT-C AN? _ )90-, T _('04_t"4�.4r-/o_'- T �_ - - - - ROU&Y Ciyt._CLtL.g_rIOAiS-IvolcA-TA rte,6RE __ is -� AePwoel - I'S - uoG/tJ4nlEN7- triTN_B,EQeoeor-AT__- D ,IfFN_19 �.1r�C- �►� 1 ilk --- tFpmock ar 70'r_. _ i E _su,�,r c7--�,�6LC_- - --- - - A/�R_oarr4l}TEL BFr%-EP- lictE w«s un ao,,.,t, l( wduLP- -L+ESD oN ro _ReL i).Pv_ Sl-6Pd-- U -P 9/PaCie_ /S- /mp oev, 35, AALiF_lelp A-ufl 9- A m4 It uI7-PA, -S' - CIVIL & ENVIRONMENTAL ENGINEERING • ENERGY CONSERVATION & ANALVSLS THEODORE F. MOORE, P.B. PH: (907) 345-1355 M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 Dear Sirs: March 18, 1992 14530 ECHO ST, ANCHORAGE, ALASKA 99516 By means of this letter we are requesting issuance of a waiver allowing the existing septic tank on Lot 3, Block 4, Spendlove View Heights, Addition #2 to be 90 feet from the well on the same lot instead of the normally required 100' separation distance. To assist you in your review of this waiver request we are enclosing a site plan which we have prepared, a HAA application and data sheet, and other relevant backup documents from your files. There is no driller's log on file for this well, but a 1977 HAA issued by your office indicates that an approved well was installed, probably in 1976, and that the well has a total depth of 134'. The well is located inside a small shed located north of'the residence. On February 19 we conducted a yield test of the well. We were unable to get the well seal completely off, and there is a plug in the well casing near ground level 12" below the top of the casing, so it was impossible to directly measure either the static water level or the drawdown and recovery. Based on our test data however, we were able to determine both the well yield and the apparent initial static water level as follows: We pumped a total of 1141 gallons of water from the well during the course of the test. The initial pump rate for the fust 274 gallons pumped was 7.6 gpm, however the pump rate for the last two hours of the test slowed to 5.7 gpm, which we assume reflects the actual yield of the well. Multiplying this 5.7 gpm yield times the 181 minutes total time that the pump was running results in a total well production of 1031 gallons, whereas we actually pumped a total of 1141 gallons of water during that period. The 110 gallon difference must reflect water that was stored in the casing above the pump intake, and this represents 110/1.5 = 73 feet of water standing in the casing. Assuming the pump intake is at 130 feet below ground level, then the initial static water level would have been at 57' below ground level, and that is the number we have used in the waiver point allocation described below. According to the GAAB as -built inspection report, the wastewater disposal system was installed on 10/25/76 and consists of a 1000 gallon Greer septic tank followed by 42 lineal feet of soil absorption trench with 6 feet of sewer gravel beneath the distribution pipe. To assess the adequacy of the system we added a total of 1141 gallons of water into the cleanout between the tank and the trench while monitoring fluid levels in the septic tank and in the soil absorption trench. Even though the residence was occupied prior to the test, the absorption trench was able to accept a surge loading of over 1141 gallons without backing up to the level of the horizontal distribution pipe and once the flow of water was stopped the fluid level receded at a more than adequate rate for a 3 bedroom residence. We measured the horizontal separation distance between the well and the septic tank cleanout to be approximately 93', and this waiver request is for 90' to allow for the underground projection of the septic tank closer towards the well. The house sits on a narrow bench which has been carved into the hillside, and the overall topography of the lot slopes down to the southwest at 25%. Thus, the ground elevation at the septic tank is actually 15 feet lower than at the well, and should the septic tank fail or back up and overflow the effluent would tend to flow directly away from the well. By searching in the DHHS microfilm files we were able to locate the enclosed well logs for 3 nearby lots. Based on our review of these logs, we feel that the log for Lot 5, Block 4, Spendlove View Heights #2 is probably the most representative in terms of depths to soil strata. The shallower static water level may be attributable to the well being located further downslope, or else the static water level in the subject well is higher at other times of the year. The following is a breakdown of the waiver analysis points which could be assigned using the ADEC SCRO's waiver analysis guidelines: Category and Description Points Distance to water table (57 feet) 5.37 Soil sorption (assume silty gravel) 2.5 Soil type (assume sandy gravel) 1.5 Water table gradient (assume +10%) 6.0 Horizontal separation (90 feed 2.6 Total 17.97 Based on this analysis and point assignment, it appears that the waiver can be safely granted without concern over contamination of the well by the septic tank, even if it fails. This finding is consistent with the qualitative finding described above based on the slope of the lot. Please give me a call if you have any questions on this analysis or our testing procedure. Sincerely, Ted Moore, P.E. LC . f3if1 Glasser Yo RewluK �,.�, SuNSffINEan 22 IR Y7 AcR65 � _ �c.�T � _ Sur�cst�INr✓'/tCR�s' ... _ .., _ _ _ _ _ � _ 1.07'q/ BLL y SPC-rvDt^rJv� DRIVC- o INB.36' s 0 roy 1006; d;p L I I v S�PrfC TRN/c ( C.d, A41. T174'NCfi I 6 ns 0, 1 �o I I I I N 1 I I 1 1. Ts �I I �I I I I i I , j.oT• 3, 3�-0CK 1Y, $P6NOI,dvE I/IEw NTS. RDDN. Pa 185*.02' c. of a y Flattop Technical Services 14530 Echo Street yoeesmg sem c srsr k. o T 2, C LI'�t y I- 1, L3 y Anchorage, Alaska 9951. F 3, Q `Y, S PEN D 1.D v E U f e W N Ts # a et,�-s .'P. 4 OF A4 "%toWCG C. SEPTfC SYSTEM 0 �•••••.•...•...... �r o} 0. 00 THEOa)n I tOU2E y ¢' c4 Ar �,y.•. �:� ••• •. �; s OWN. 6Y: TCM Tkxk NarE: TH,s is rdoT A SuRVHYt?O PG Ai Ai-✓" G.rJCATraNS ARE APPRoxrrrATR 1 iY -m�. A DIVISION OF COMAIJERCIAL TESTING & ENGINEERING CO. AV .._— e� TELEPHONE (907) 562-2343 5633 B Street LAeORATOflY Ln Anchorage, Alaska 99518 Drinking Water Analysis Report for 1 otal C;oiiforni Bacteria _ TO BE COMPLETED BY WATER SUPPLIER I� TO BE COMPLETED BY LABORATORY G PUBLIC WATER SYSTEM I.D. 4 CYTT 'i E PRIVATE WA'rER SYSTEM "= icc��un %o��nrcR� �vcS 3`'/.i—(35^5 Name V Phone No. /'IS3G C=c�to Sf. M.al:ngAddress - A,,) C / Cr,y ,J Slate Zip Coda SA6APLE DATE: U 2 r ! I Rio. Day Year SAMPLE TYPE: Routine ❑ Check Sample (for routine sample with lab ref. no. j C Treated Water O Special Purpose N Untreated Water SAMPLE Time Collected No. LOCATION Collected By 1 -3�Y SyP't o�(or,�. r/ emu F(fr M? (o. vrrJ„ 2 I 3 I _ 4 5 A.D.E.C. `� C Analysis shows this Water SAMPLE to be: ❑ Satisfactory ❑ Unsatisfactory ❑ Sample too long in transit; sample should not he over 30 hours old at examination to indicate reliable results. Please send now sample via special delivery mail. Date Rccoived I �G7 Time received I � Analytical Method: Membrane f=ilter No. of colonies/100 ml. Lab (def. No. Result* Analyst ETI 4�,DSZ6 m W u m BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS Membrane Filter: Direct Count BEFORE COLLECTING SAMPLE Verification: LSB Fecal Coliform ConFlrmation Final Membrane Ffitor Results Reported By TNTC : Too Numerous To Count 08 d Other Bacteria Coliform/100 mi BGI3 Coliform/100 ml Date PART ONE OF TWO: REMAINDER TO FOLLOW 11V CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 '111, Im) '10 f. F; ',,1. 00 I 'ij -f; j2 ij I.) i, f,AQ Ulk I E I7 J" k J: (IT I I 1i F: i 11 IL«jl-j ffllllllot' `;0 w., nc c 1, jW0 0 d ICY: 1 tern ft'-r If fit, c .1 t S J'Ihrjv�4 11014313SMember of the SGS Group (Socl6t6 G6n6rale do Surveillance) if 1"n 353, 0 ICY: 1 tern ft'-r If fit, c .1 t S J'Ihrjv�4 11014313SMember of the SGS Group (Socl6t6 G6n6rale do Surveillance) GREA,LR ANCHORAGE AREA POFlvjGH 01 IIL rJ _,O I r i. I,, SiPPROVEo DoImirlmentof Environmental G,1 ty 3330 C Street -)fr BY: p,, Alw�ka 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM r NA I PHONE ILI ,ME ''LOCATION y rN r4l� e ol� I SEPTIC TANK: DISTANCE FROM WELL -t- NUMBER OF COMPARTMENTS_ INSIDE LENGTII__. I IQ Ili) 111 -11TH LIQUID CAPAC I TYZC_V� GALLONS. YILE DRAIN FIELD: WDisrANCE FROM WFLI_ ou, J!)P, I o" I T 1. 0 T I- I NF,. TOTAL LENGTH Of LINES NUMBER OF I RF N( If V;II)TIi IN. TOTAL Er-FECTIVE ADSORPTION AREA 1 1 PK; rl I Of LAC 14 L INC :LIf P DEPTH: TOP or TILE TO F FINISH GnA()L 1-i I I ',J 1. A 1 1 ILI AkOVE I ILE IN. --IN 4.!WELLi 4YIJE .CONST $?U(- T Ify I DIrTANCF F At)m WILDING NEAREST "OUNDATION_ LOT LITE. x55pocf 1. 01 IIL rJ _,O I r i. I,, SiPPROVEo NSfALLED BY: : k ;WER LINE Dums --------- — Pl MATERIAL: SLOP[ ,.I PT if Sf_EpAGE IrkrjK SYSTEM __ DIAGRAM WSYSTEKI C t. T -I;,- Ll'. ... '2. 1 Spena.Love Drilled by C.H. SELF j Completed Dec. 27* 19 V 41, 1-e 3 w TIA q, I depth -r I 1 1 4- Nq7-66 1441- I . V " u li`., 1 -1 r u. Gallons per minute ....... 84 w 1.1.,.iStatic level ..............10 feet. 141, lw�Caain- feet a X4 R,'6'6 -3"f eet... topsoil. c;,3-17 feet...zand and gravel. {17-23 feet..sand and gravel. dP3-30 fcct..rocks and gravel. k'� 30-3 5 foet..gravel. feet..pea gravel. "P4!38-70 feet rocks and gravel. f:70-71 feet...sa:id. $1;471 feet..... bedrock. feet -101 .,bedrock. U Ik t114^ 11h /99 v 3471 7 inches. 04 I I I . . . . . . . . . 7 .1 OF AN l4 1 Cii-7. CF HEALTH & EINJRON%",;NITAL PROT ECTION 4 '�A MOP. (IN A '�' V-E-0:113� 1! 41 P6 C -e- ; Xu -/d �A 4. Spena.Love Drilled by C.H. SELF j Completed Dec. 27* 19 V 41, 1-e 3 w TIA q, I depth -r I 1 1 4- Nq7-66 1441- I . V " u li`., 1 -1 r u. Gallons per minute ....... 84 w 1.1.,.iStatic level ..............10 feet. 141, lw�Caain- feet a X4 R,'6'6 -3"f eet... topsoil. c;,3-17 feet...zand and gravel. {17-23 feet..sand and gravel. dP3-30 fcct..rocks and gravel. k'� 30-3 5 foet..gravel. feet..pea gravel. "P4!38-70 feet rocks and gravel. f:70-71 feet...sa:id. $1;471 feet..... bedrock. feet -101 .,bedrock. U Ik t114^ 11h /99 v 3471 7 inches. 04 I I I . . . . . . . . . 7 .1 OF AN l4 1 Cii-7. CF HEALTH & EINJRON%",;NITAL PROT ECTION 4 '�A MOP. (IN A '�' V-E-0:113� 1! 41 P6 C -e- ; Xu -/d �A .......... IN If IMOU2= A AN4 84""7714 "WATUR WELL DRILLED AND CA9111-i OUT TO THE DEPT" OF' tik ll`z- -- THE RATE opt -- PER FOOT. :s4 °IION�'flV,V"ELL GITF. filen_c A sl, ' a f R(jt'Eipa,�r �l' Sa .4, jl 20% f"; ! :4 'R f-i: fkl ? 0 " cAn 4: UUMAt4M 226 to a' flddAtAhnaL kla4m. uAwd 61� A to 6 'gM vtth -130 hjt%'#z la A!8L6- I A" '4- 5 v 1%,i!, 4? K �'pw i t 24 $0 lL All, Foli I )1,112% 00 X,250 .?,e*A: 35500.00 0, I T /ALL LABOR AND MATERIAL FOR COMPLETION Cie SAID D I l"T—m.CHKCK PAYABLE TO RAMPART DRILLING WORKS FOR THE EC 1'•l OF Av,4',711ANK YOU VERY MUCH. ev, BERNIE CLAUS OF RAMPART DPILLINO WOR116 j 4.1, ru4 0-th. SKRVICIK CHAROC 0 F 114% PKR MONTM WILL St: A8111198990 ON PAST out rr-c-,?UNT* twwal t j. . I . ' r ' i .. / .W 'la 7r i 1174 ( pr 1 7� YrrY1iY`i! fok,'13690 S7'AIK I1O1L77CI: .19k A\NcuoRAGEq ALASKA 99iia {�+({ 9iF I f l��ll��"% • i�iiii F; r I tAl, �•';( }} 4 W WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF SO irr.t_ r E D AT THE: RATE OF y2! =' ---. PFR FOOT. {j COTY'OwNER �;�� a�l�s,�1 h�3�5-;z�� s.:.�i. 76g� L 9�'5o7 272-8654 - ; , OF• WELL SITE—f--t-- Zsat- .�-- stab._ � h� �I,;jjj. �CAitON l:LEFt 13�,v>,i� GLata a P .w. ___ —. ? •�ccL U l tl2k.�. 'I LOG. N' (arr.»77� 1Lt ave�bu2don of o.iit�} y.3nur; with canglonc�Jtate �iCn 1� Ao 17 fent.'' % X350' Beditock.Yil ned inuca. a,t.y 2ocl.. &4& 4.eA pvtoduc t ian ih.ow nt- l'el ole. 00 320 to 326 f.ect jhewn Onga.i pe.2 minu,teY+;-ictd. » -- - — .w^ �... / - 7ota.L watet p,Lodatct.Lon ohowj aveL 'Toro I 42 . feet �howo Gn.e i i.'. ,;• jhowld aiAo 4,xfv�ove-wi-Ul u_or_ o? wa.te�t .)tandbiq -(n ccLJ,blq off/' lroi.ton ;u4.01.,in. 24 houA4 of tatta dtaut•�i r.. W One- lla�e 51c(J,netjUiie Pwnp 4houW Ge in�.tat(ed 75 �eeL off/ Gattoct. 3 i�l ga.Go, peg. foot at ;300 fee.t.: 4$0 k ;i I� ti ' 31 1 or�i'. � qal a f tia.t-eA p�toda:,ct ivn An. u 24 hou�t �'me pxma. ;'!.. ry S. MUNICIPAUTY OF ANQ4QRAQE` �`itI i Zaul.l,(nq: I' S73 50.00 DEPT. OF HEALTH I, Y"f 1 '{ !qt fY�Ii I ENVIRONMENTAL PkOTECTIONI i�" hl I C1 IIt �Sa O t tor.! I. S[ a- Glnarl r f J 1.. !lo , 02 Ui C 18 1981;. �(I �r RECEIVED ifi� I `., , 6 it IIf- iiCLUbES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUMOF 73 5i . o0 C4� � �qi f THANK YOU VERY MUCH. . E]E12NII= CLAUS OF RAMPART DRILLING WORKS `1 \ 41 ,5.th 1.C;'/ 3 , 6tRVIC.f; CHnnc;E or 1!n".G f`f:fi MONTH Wll.: ti (' r�,, •f'��I_U`ON 1'A.pi7 DU!'� ASWNT'S--"'""" i c It ifs i IIIT��I'�i,l � I�;s Ilr FYI v L. - DATE RECEIVED I NSPECTION' APPO I NTMENTS STREET LOCATION , TIME TO Q TIME TIME DATE DATE DATE ❑ Two ❑ Five ❑ MULTIPLE FAMILY Three ❑ Six 1 ' -- 1'r1-(�n INSPECTOR INDIVIDUAL* INSPECTOR INSPECTO since June 1975. For wells drilled prior to that date, give well RAGE - depth (attach log if available.) OF 17,-,%1.T i g; MUNICIPALITY OF ANCHORAGEppNI�v� RDEP,�T. DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTj��MENLI ,, ; TLCTION 825 L Street - Anchorage, Alaska 99501 • L/ r 1980 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 RECEIVED ]ECE+` 7ED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHONE MAILING ADDRESS V10 Az("L'Z_ > 4, 0- CI / o nn O C7 O Cl PROPERTY RESIDENT (lf differe from above) T 7 PHONE 2. BUYER pRJ` -zPHONE /C MAILING ADDRESS 3. LENDING INSTITUTION 7 PHONE MAILIN ADDRESS 3'.)- v 1 c " 4. REALOR/AGENT - PHONE -" Z s o MAILING ADDRESS pp 8- S` U n U 5. LEGAL DESCRIPTION 1. o 7- 3 (_ c - -'I' STREET LOCATION , TO Q 6. TYPE OF RESIDENCE NUMBER OF,BEDROOMS ❑ One ❑ Four ❑ Other SINGLE FAMILY ❑ Two ❑ Five ❑ MULTIPLE FAMILY Three ❑ Six 7. WATER SUPPLY INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ❑ COMMUNITY since June 1975. For wells drilled prior to that date, give well ❑ PUBLIC UTILITY depth (attach log if available.) S. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE** � YEAR ON-SITE SYSTEM WAS INSTALLED. ❑ PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6179) 72-010 (Rev. 6/79) THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE ❑ SINGLE FAMILY ❑ MULTIPLE FAMILY NUMBER OF BEDROOMS ❑ ONE ❑ THREE ❑ FIVE ❑ OTHER ❑ TWO ❑ FOUR ❑ SIX 2. WATER SUPPLY ❑ INDIVIDUAL ❑ COMMUNITY ❑ PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM ❑INDIVIDUAL/ON -SITE ❑PUBLIC UTILITY Connection Verified PERMIT NUMBER DATE INSTALLED INSTALLER ❑Septic Tank or ❑ Holding Tank Size: -1 If Tank is homemade give dimensions: SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5. COMMENTS (� C�APPROVED FOR BEDROOMS ❑_, /CONDITIONAL APPROVAL (letter m st accompany certificate) LTJ DISAPPROVED DATE \ _ `-7 Q BY V� 72-010 (Rev. 6/79) V 825 "L„ STREET ANCHORAGE, ALASKA 99507 O[PAHTh.9ENT OF HEALTH AND ENV If MNfvlE N I A L PROTECTION December 12, 1980 David Reisdorf % Nancy Doner Century 21 - Sleeper, Inc. 8050 Old Seward Highway Anchorage, Alaska 99502 Subject: Lot 3 Block 4 Spendlove View Heights Subdivision #2 Approval for the individual sewer and water facilities cannot be granted until the following items have been completed: (1) The water analysis report needs to be delivered to this office from the Chem Lab, 5633 B Street, for our review. (2) A well log submitted to this department for our review. (3) The septic tank pumped with a receipt submitted to this office. (4) An adequacy test needs to be performed on the existing leaching area. This test will determine if the system is adequate according to National Standards. A listing of private firms performing the test is enclosed. This report needs to be submitted to this office for review. If there are any further questions, please call this office at 264-4720. Sincerely, Robert C. Pratt, R.S. Associate Specialist RCP/ljw cc: Spokane Mortgage 3201 C Street 99501 CHEMICAL & GF.. iOGICAL LABORATORIES , i' ALASKA, INC. TELEPHONE (907)-279.4014 ANCHORAGE INDUSTRIAL CENTER —"t•4 274.3364 5633 B Street d `6S. ue4eeroeie9 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY WATER SYSTEM:Analysis shows this Water SAMPLE to be: I.D. NO, Water System Name - Phone No. Mailing Address - City State Zip Code SAMPLE DATE: CD Mo. Day Year SAMPLE TYPE: ❑ Routine ❑ Check Sample (for routine sample with lab ref, no. 1 ❑ Treated Water ❑ Special Purpose ❑ Untreated Water SAMPLE NO. LOCATION 1 2 IL 3 IIIS 4 L� 06.1220 (b) Rev. 1978 Date Collecl READ INSTRUCTIONS Date Racely BEFORE 24 Hours 24 Time Collected Collected By ❑ Satisfactory ❑ 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 Ref. No. Result` Analyst I I m I I � I CD I m -No. of colonies/100 ml. or No. of Positive portions. BACTERIOLOGICAL WATER ANALYSIS RECORD COLLECTING SAMPLE MultipieTube Report:—_ Membrane Filter: Direct Count Verification: LTB _ Final Membrane Filter Results. Reported By _ _Time Received 10M I 10m Source a.m. —p.m. Lab. No. 10m] I 10ml I 1 0.1ml Broth 24 hours: Broth 48 hours: 10ml Tubes Positive/Total 10ml Portions BG Date Time a.m. p.m. ;vILLIAM THACKER, ARCHITECT.' 1344 W. 7th Avenue Ancht, A lass o. 99509 February 4, 1977 Mike Crum Alaska National Bank 3301 'C' Street Anchorage, Alaska 99501 INSPECTION REPORT FOR RESIDENCE CONSTRUCTED FOR MR. & MRS. DAVID REISDORF CONTRACTOR & GENE BROOKS INSPECTING ARCHITECT& WILLIAM THACKER MUNICIPALITY CF ANCHORAGE - DEPT ENVIROIuVI�1 (cCTION EC RECEIVED This inspection was made Thursday morning, February 4, 1977. Present& William Thacker, Gene Brooks and the job foreman. Structure Roof joists 2x8's @ 16"O.C. adequate for 141 span. Ridge beam is shown on the drawings as a 5 1/84'x20". The contractor stated that this beam is a 5 1/8"x16 1/2" GLU-LAM. The depth of this beam should be checked, The contractor had only preliminary drawings which did not show structural sues. I was not able to verify this until the construction drawings were reviewed. Preliminary structural calculations made by me indicate that a 5 1/811x 16 1/2" GLU-LAM would not be adequate for the span and design load. The main floor has 2x10 joists at 1611O.C, for a s. -an of 14 feet with 5/8" T&G plywood sheathing (underlayment in kitchens and baths). I could find no squeaks in the floor and it appears to be well constructed. Diagonal let -in braces were used according to the contractor in the exterior walls to pick up the horizontal shear. This is good practice as the redwood siding might not of itself provide sufficient shear, A GLU-LAM beam that picks up a substantial part of the loft floor load was moved approximately 3 feet .in order that it :iot terminate at a window header. This, however, increases the load on the GLU-LAM under the living area. The living area GLU-LAM is notched over a supporting header. The increased loading on this beam will cause the compression strength perpendicular to the grain to be exceeded. I would recommend February 4, 1971. Inspection Repor_ coni, Page 2 that a steel angle be thru-bolted to both sides of the GLU- TEAM and lagged into the supporting beam. A Silver Metal Products heavy angle HA 37 with 5/8" diameter bolts and lags would be adequate. This is a 34"x 71" angle x 3/16" with 4 - 5/8" diameter holes in each leg, Interior Finish Drywall appears to be good. The wood ceiling and walls are well constructed and tight fitting. Painting of walls and wood trim is good. Items to be completed: but not necessarily limited to the following: Carpet (installation begun) Concrete at rough -in bath Underground electrical service (in summer) Items to be corrected: ,f The balcony railing spacing exceeds the maximum allowable of 8 inches clear. Summary This residence appears to be well constructed. It is, however, not possible to do a thorough inspection of a completed residence. WILLIAM THACKER INSPECTING ARCHITECT William Thacker Architect 1344 West 3rd Avenue Anchorage, Alaska 99501 Mike Crum Alaska National Bank Inspection Report Residence for Mr. and Mrs. Reisdorf Structure The lower level glu-lam beam connection has been completed satisfactorily. Items to be completed Exterior clean up Sealing of exterior wood Underground electric service installation w - g-a'Z<.� , U �a440� WILLIAM THACKER, Architect J �' "M '+F•4N �s�� �"�W✓�'I��� %��r...MA(i���.d �'r104..n.'h✓�'�e✓�gvOriroTiMr h+�Lrr�^"1�^��'4*tKJ^(^'_Y V / '"r'R"'K: •9"!�w�iiri "�� �'GN 1�� y.wlG% ���'f''� rv�'Ga . �`Kme.n''U^' ���. �i Y r J 0 f William Thacker Architect 1344 West 3rd Avenue Anchorage, Alaska 99501 Mike Crum Alaska National Bank Inspection Report Residence for Mr. and Mrs. Reisdorf Structure The lower level glu-lam beam connection has been completed satisfactorily. Items to be completed Exterior clean up Sealing of exterior wood Underground electric service installation The Reisdorf residence appears, according to my inspection of the finished residence, to be of sound construction, with the exception of the items to be completed which are noted above. The finished items and construction are good. y ER'S NAME: I JENTIFICATION NO.- ORIGIN: .— DESTINATION - DATE: J rAuTHOR] Fn ©P GAIT 6+ Cut GI A4, EXCEPTION SYM80L5 - •[•B[NT D.tl[N7[D uO-MOT H-[AT[q w.wUKtl[0 LOCATION SYMBOI.�; fG.•OILID •!1-tltOM[N I.►AO[� 1. ARM [ LlO Au •wU[Tl0 . T- tlU•tlUtlN[D O•[OVt Ito I[C-PAGK[D by TOwN 0 Cu tC•fCwATCH[0 .CN11►[D L.LOO}[ CAAMI[w WORM t. ■OTTON ) wtAw CU •C04ilNTtl Y•C ACw[D p.NAww[D I■0. OVINC0 BY OfO. DIf l90 O}C•BY A}}LN CONOITIOu UNKNOWN NL NILO(V/ OWM[11 1-COwN/w ! MGH/ 1. 6 f10[ OWNER By OWNER [v CARRIER R HOT-,(•_TH[ ORI[}ION 0I Y�OI wYN[OL IN aj-L& 0000 cgM2jrjgN KXCKPT FOR NORMAL WEAR. [. LVT 10. TO• LEPT II v[n[tw ITEM NO. ITEM CONDITION AT DESTINATION — I '�..� 1/5 all- e..(. 61 X (m..C. % e rAuTHOR] Fn ©P GAIT 6+ Cut GI A4, :y 274-4561 ved-Ja,ar4 1�7L nspection 11:00 a.m. spection 1-26-77 Wed. North Phone: Buchholz 2. Property Owner: Aurora Contractors & Builders inc2hone: 349-5128 Mailing Address: _ Box 4-814 99507 3. Legal Description: Lot 3 Block 4 Spendlove View Heights #2 4. Location: 5. Type of facility to be inspected Single Family No. of bedrooms 3 6. Well Data: A. Type _ Individual B. Depth 134' LL C. Construction] _ D. Bacterial Analysis 7. Sewage Disposal System: On—site system A. Installed C. Septic Tank: 1976 1. Size B. Installer D. Seepage Pit: 1. Absorption Area E. Disposal Field: Total length of lines 8. Distances: 2. Manufacturer 2. Material A. Well to: Septic tank , Absorption area Sewer Lines , Nearest lot line Other contamination B. Foundation to septic tank Absorption area C. Absorption area to nearest lot line EQ -034 (1/74) Page 1 of two pages Page 2 of two pages - Re, st for Approval of Individual : er & Water Facilities Legal Description Lot 3 Block 4 5pendlove View Heights #k2 Comments Approved Disapproved — Date 4— y" 77 App al,Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM �'J Unue irlrur-ma Lrun canna _inea in Lnls request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED Date EQ -034 (1/74) 00 UN OF ANCHORAGL `` 11 OF HEALTH & MUNICIPALITY OF ANCHORAGE ® WAL P94'LMiP*FNT OF HEALTH AND ENVIRONMENTAL PROTECTION �St 2510 East Tudor Road, Anchorage, Alaska 99504 276-2221 N 2 419%7.° u REQUEST FOR APPROVAL OF RE.CEI ED INDIVIDUAL SEWER and WATER FACILITIES � �4 1. 9. Type of Inspection: CMRO VA FHA CONV 2. Property Owner: 04J0 .-• ✓{ r"j %..) e —/0 Xv,-' 'L P - /�-�!e, _'j'_ �j�"� r / y3..r Mailing Address: l� dk=%9"� ( �UDay Phone: 3. Name of Buyer: �,7.L„' ri !� /'S Mailing Address: Day Phone: 4. Name of Lending Institution: Mailing Address: (' `•�iw :-�-_ Phone: 5. Name of Realtor or Agent: Fl c"-k','E_ (5✓fl Mailing Address: .i/� ("°.-/- ___— Phone: % ' 6. Legal Description: ;� ! " _ ' �'; r ,:r� z, 'c� ��•=_. /� �0.oy t Location: ( p J t.,fJ72.:i ,Jil 7. Type of Facility to be Inspected:No. Bdrms. 8. Water Supply Type of Supply: Public Utility Individual i -JV +r' If Individual, number of dwellings presently served ell If Individual, depth of well- 9. Sewage Disposal System Type of System: Public Utility Individual (on-site) A If Individual, date of installation 72-003(3/76) 06.1220(a) ;Rev. 1973 DATE ALA' DEPARTMENT OF HEALTH AND SOCIAL Sr :ES DIVISION OF PUBLIC HEALTH INDIVIDUAL AND SEMI-PUBLIC BACTERIOLOGICAL WATER ANALYSIS INDIVIDUAL ❑ SEMI-PUBLIC ❑ CHLORINE RESIDUAL PPM REPORT RESULTS TO I NAME I ADDRESS CITY ADDRESS OF SOURCE ZIP CODE Lab No OFFICE Analysis shows this Water SAMPLE to be: Satisfactory ❑ Unsatisfactory ❑ Questionable ❑ Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. ❑ Bottle broken in transit, please send new sample. SANITARIAN'S REMARKS COMPLETE THIS SECTION locc 1.Occ l.ecc ONLY IF WATER IS AN INDIVIDUAL SUPPLY - SAMPLE COLLECTED BY - - 48 Hours - -- - -- - _ - - -- DATE COLLECTED TIME COLLECTED -- Sample Collected From ❑ Kitchen Tap ❑ Bathroom Tap ❑ Basement Top Brilliant Green ❑ Other (List) 24 Hours Well - ❑ Dug ❑ Driven ❑ Drilled ❑ Bored ther _ .- SOURCE: ❑ Spring ❑ Cistern ❑ Other-----.-- Dug Well or Cistern Construction: - Dug Walls -❑ Wood ❑ Concrete ❑ Metal ❑ Tile Brick or Top - ❑ Wood ❑ Concrete ❑ Metal ❑ Open Top ❑ Concrete - LOCATION: ❑ In Basement ❑ Basement Offset El Under House Elie Yard ❑ Other -- --- _ - - Building Sewer - Septic DISTANCE TO: or Other Drainage Pipe Feet. Tank --Feet. Tile Seepage Coss. - Field - Feet. Pit feet. Pool -_ Feet. Privy _—Feet. Other Possible Sources of Contamination - MATERIAL: Building Sewer- ❑ Cast Iron ❑ Wood ❑ Tile ❑ Fibre ❑ Asbestos' Cement ❑ Plastic Joint Material - Type - - 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 Feet. Offset in In Utility PUMP LOCATION: ❑ In Well ❑ Basement ❑ In Basement ❑ Room — - - v On Top ❑ Of Well ❑ Other - - - PURPOSE OF EXAMINATION: Illness Suspected? ❑ Yes ❑ No - New Source of Supply? ❑ Yes ❑ No Repairs to System? ❑ Yes ❑ No Signature --- 06-1220 rot BACTERIOLOG61. WATER ANALYSIS RECORD Rev. 1973 am READ INSTRUCTIONS Date Received I - �Time Received —Pm. Lab. No. --- ON REVERSE SIDE BEFORE COLLECTING SAMPLE Lactose Broth Iocc locc lace IOcc locc 1.Occ l.ecc 24 Hours 48 Hours - -- - -- - _ - - -- - Brilliant Green 24 Hours 48 Hours EMB Lactose Broth, 24 hrs. 48 Coliform Density MF Results Reported by This analysis indicates Coliform Organisms to be: AGAR Date Absent Present Gram's stain -- (Most probable No. per 100cc) a.m.