HomeMy WebLinkAboutSILVER CREST BLK 2 LT 19liver .Crest
Block 2
Lot t9
#015-062-50
Municipality of Anchorage "' -".
DevelOpment SerVices Department :~ :
Building Safety Division
On-Site Water and Wastewat~r ~rogram, a?O0 $. Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page of
www. d.anchorage.ak.u$ (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number:, ..~ ~ LDz,9_Q q I ~) PIe Numben ,, 0 15- 0G,¢9..-
"'~"' '~o~ t'l~.,-~-{~-e~l WastewaterSystem: DNew ~Upgrade
*~"" W ~1 5 ~ i> ~ ~.~/~ ABSORPTION FIELD
~ ~ Deep T~ ~ $ha~ Tr~ ~Bed ~ M~d D Ot~e~
LEGAL DESCRIPTION ~. ~,,~,,
I- ~ ~,. ~ 0 ~,.
Well: ~ New ~ Upgrade ~,...~n .~.,o.i..,:
O,stan~ be~een I,nes
C:ass,fl~:~on (Private. ~ B. C~ ~ ~l ~ Tolal Dep~: FI. Cited to: FI Tola~ ab~b~ uea ~ Flt P~MatenaL
SEPARATION DISTANCES ~eptic ~ Holding D S.T.E.P. -.... ~ther:
Septic Abso~tion' Lift Holding Pubti~Pdvate M~e~ Caoac,ty
s.,...~.:.,~qo S/o ~'10 X~ LIFT STATION
//k
BENCH MARK
Inspections pegormea by: ~S Dates: 1" tOl*olO~ '"~'""'----*'
2 '1,1
Developmer t Semices Depa~ment Approval ea~
~ :~._ ~-~
Reviewed and approved by: ~ ~ ~ Date: ~
N
'1
27.5'~ BC
31.5; ~ 4,9.5'
m
I
49~h
NEIg ~SlGH: OCTOB~ 3I, 2002
TOBBEN SPURKLAND P.E.
203 Y~ 15171. AVENUE
ANCH. AK. 99501
.£90~) 279-~91e
[ LO1' 19 BI, OCK
722I
SEPTIC SYSTEW AS BUILT
,J)AT*E: NOV. 11, 2002
SHEET: 2/.T GRID: 2u9
PE£NIT # $I,/0204IB PID # 0I$-062-~0 SILO2192,DVG
¥-INCN INSULATION
5 FT
I8 FT
BIOCYCLE
LF,,GEND:
ACI1VATL'D ~UDG~ ~
1250 GAL SEPTIC TANK
1. PRIMARY TREATMENT, SEPTIC TANK
2. AERATION TANK
$. CLARIFICATION TANK
4. DISCHARGE TANK
5. SOIL A~3ORPTION
TOEBEN SPURKI. ANfl P.E. Il
203 P/ISth Ave
II
Ak 99501
LOT 19 BLOCK 2 SILVER CREST
7221 STAMPS ClROIX
BOB JERNSTROM
SEPTIC SYSTEM SCHEMATIC
flATE: NOV. II, 2002
SHEET: 3/'3 GRID: 2439
PERMIT # 21,~08fl418 Piti # fl15-06£-50 $ILO£193.~/G
Dec 2'7 02
12: l?p ,]ERMSTROM EMGIM£ERIHO SRR-IOS2
h~.r' ~.' " .... "
11/4/2002 B:4£ PA~
p.!
Inspection Report
MunlclpaliLy or'Anchorage, Building Safety Division
4700 South Brai;aw
INSPECTION: VO:~CE
Hame
Acldres~
Legal
Subdivision
Co mmenls or Directions
/NSPECTZON: FAX (g07)249-7777
Rrlck's Electric: Bill
722/, STAHPS CI~R
BK 2 LT lg
$ ZLVE P. CREST
[NFO;343-D211
Permit 02-g37&
440-93S1
Phone 34S-2923
%nspect~n Date /,1/5/2002PN
Septic System
inspection ~tro Electrical Relnspectlon N
NO I~ONCOHPI.TAf;CE OBSERVED
CORRECT2ON5 ESSENTZ6,L AS EXPLAZNED BELOW
W~LL RE-EXAHINE AT NEXT []
[] INSPECT[ON
COMMENTS: (for Inspector use only)
DO I~OT CONCEAL UNTIL REINSPECTION
Znspector
MUNICIPALITY OF ANCHORA GE
Development Services Department
On-Site Wafer & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEVVATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Oct 16. 2002
Expiration Date: Oct 16, 2003
Permit Number: SW020418
Legal Description: SILVER CREST BLK 2 LT 19
Design Engineer: 0007 Tobben Spurkland, PE
Owner Name: Bob Jernstrom
Owner Address: 7221 STAMPS CIRCLE
ANCHORAGE, AK 99516-6551
ParcellD: 015-062-50
Site Address: 007221 STAMPS ClR
Lot Size: 51510 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
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. Ail 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 DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel ~.D. D/5-- O~ ;~ - 6 0
Permit Number SW
Property owner(s)
Mailing address (1)
Mailing address (2).
Legal description (Lot, Block & Sub'd.) LC '~' t q
Legal description (Section, Township & Range)
Day phone_ 3q6 -2.:~ 77
Zip Code
LOt. Size
Acre~
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Tt~erapy Pool
Number of Bedrooms q
[] Well Only []
[] Water Storage [-i
[] Jacuzzi'
[] Water Softening Unit
I certify that the above information ~s correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature
property owner or authorized agent) l~
Of
Permit Fees:
Date of Payment:
Receipt Number:
(Rev. 12;00)
Waiver Fees:
Date of Payment:
Receipt Number:
T.SPURKLAND P.E.
203 WEST 15'I'tl. AVENUE SUITE 203
ANCIIORAGE, ALASKA 99501
(9O7) 279-3916
Fax (907)276-6013
October 31, 2002
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage AK. 995169-6650
Subject: SW020418 PID # 015-062-50 Lot 19 Block 2 Silver Crest
Dear Dan;
On October 31, 2002 Dean Construction and Development, a certified septic system installer,
attempted to install the septic system covered by this permit. Ground water was observed at 7 feet
at both end ofthe proposed deep trenches, and consequently the the installation was halted. Buffed
organic matter was also observed. The ground water monitor tube installed in the test hole was still
available and showed no water to a depth of 15 fl. The existing septic tanks have been removed and
replace by a 1250 gallon Anchorage Tank steel septic tank. The owner has decided to leave this new
tank in place and install a "Category II" Advanced Wastewater Treatment System.
The new design, centered on the monitor tube is submitted.
Yours truly,
T. ]? AND P.E.
203 W 15th. Avenue, Suite :203
ANCHORAGE, ALASKA 9950 I
(907) 279-3916
Fax (907)--276-6013
SEPTIC SYSTEM DESIGN
LOT 19 BLOCK 2 SILVER CREST S/D
BOB JERNSTROM
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
Anchorage, Alaska 99519-6650
October 31,2002
We are resubmitting an application for the upgrade of the septic system for this lot. The septic
system design is based on the following:
Ground Water @ 7 ft.
Use Category II System
Soil Rating. From Testhole 08/26/02
<30 rain/in = 2 gal per sq.fl/day
No. of Bedrooms 4
Required Area: 600/2= 300 sq.ft
Use 10x.30 bed
SYSTEM CONFIGURATION
STANDARD BED
TOTAL LENGTH 30 FT
TOTAL WIDTH I0 FT
TOTAL DEPTH 2 FT
ROCK DEPTH .5 FT
INSULATE
COVER 2 PT
SEPTIC TANK BIOCYCLE
The installation of this septic system will not prevent wells and septic systems from being installed on the adjacent
lots.
There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots.
The proposed septic system will not change the general slope of the area. Ponding and/or concentration ofsurface
runoffwill not result from this installation.
P.E.
203 W 15th. Avenue, Suite 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
SEPTIC SYSTEM DESIGN
LOT 19 BLOCK 2 SILVER CREST S/D
BOB JERNSTROM
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
Anchorage, Alaska 99519-6650
October 4, 2002
We are submitting an application for the upgrade of the septic system for this lot. The existing
system, installed in 1978, did not pass a recent adequacy test and must be replaced.
This submittal consists of three (3) drawings showing the present improvements on the lot and the
adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the septic
system is subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet
3/3). Soil logs and percolation tests of applicable test holes are also enclosed. The septic system
design is based on the following:
No Ground Water or Impervious Layer to 17 ft.
Use Standard Trench
Soil Rating. From Testhole 08/26/02
30 rain/in = 0.6 gal per sq.~day
No. of Bedrooms 4
Required Area per Bedroom: 150/0.6 = 250 sq.ft.
Total area required: 250 x 4 = I000 sqft
Test. hole depth 17 feet
Bottom Rock At I 1 feet
Top Rock At 5 feet
Rock Depth 6 feet
Minimum Trench Length I000 / 12 = 84 ft.
Use two trenches each at 50 ft
SYSTEM CONFIGURATION
STANDARD TRENCH
TOTAL LENGTH 50 FT
TOTAL WIDTH 2 FT
TOTAL DEP'H! ! 0 FY
ROCK DEPTH 6 FY
COVER 4 FT
SEPTICTANK 1250 GAL
The installation of this septic system will not prevent wells and septic systems from being installed on the adjacent
lots.
There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots.
The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface
runoffwill not result from this installation.
N
TOBBEN SPURKLAND P.E.
203 W 15TH. AVENUE
ANCH. AK. 99501
¢907~l 27g-391 ·
1,01' 19 BLOCK g Sll, V~£ CREST' $/D
7221 5'T~P$ CIRCLE
SEPTIC SYSTEM DESIGN
DATE: OCT. 4, 2002
SHEET: 1/$ GRID: 2439
PE£HIT SVO2OXXX PIB# XXX $1LO2191.BV6
N
SCALE~ I' = 50 FT,
30 FT LON~
I0 f7
I
I
'1
49~ch
~01q~-N
TOBBEN SPURKLAND~£
203 W 15TN. AVENUE
4NCN. A/(. 99501
(907) 279-3916
LOT 19 BLOCK £ SEVER CREST S/D
722I .TRAMPS ~
SEPTIC SYSTEW DESIGN
DATE: oct. g ~o~
SH£1~'T: 2/3 GRID: ~
PERMIT #VO£O41B PID It ~15-06£-5~ SILO~Ig~,DVG
N
$CALE~ I' = 50 FT, /
I
I
I
I
49th
TOBBEN SPUBKLANO P.E.
203 PI ISTN. AVENUE
.(~OZ) 2~-.~
LOT 19 BLOCK 2 $ILI~R CP~S~ $/D
7221 ST41EPS ~
SEPTIC SYSTEt, t DESIGN
DATE: OCT. 9, 2002
SHEET: 2/3 GRID: 2U9
PEi~IIT #VO2OXXX PID # XXX $1LO2192.BVG
Monitor
Clean
Oean Out
Standard Trenches,
£' Vide
58' Long
11' Deep
6' Sewer rock
5' Cover
Monitor
Clean
Ctean Out
gal Septic tank
208 DIVERTER VALVE
Z £00 FLO~/SPLITTER
NO SCALE
NO SCALE
1250 SEPTIC TANK
BENCH MARK. TOP OF VELL CASING
ASSUMED ELEV, 180.88
TDBBEN SPURKLAND P.E.
E03 V15th Ave
Anchorage Ak 99501
~79-~16
IILOT lg, BLOCK 2 SILVER CREST
7221 STAMPS CIRCLE
~0~ JERNSTROM
SEPTIC SYSTEH SCHEHATIC
])ATE, OCT. ~,, 2002
SHEET, 3/3 GRI~, 2439
PERMIT # S~/02xxx PID# xx SILO21gg. DPtG
Municipality of Anchorage
Developmenl Services Department
Building Safely Division
On-Sde Waler and Waslewater Program
4700 South Bragaw SI.
P.O. Box 1966,50 Anchorage. AK 99519-66,50
www ¢i anchoraqe ak.us
(901) 343-7904
Soils Log - Percolation Test
Slope
Sile Plan
WAS GROUND WATER
ENCOUNTERED?
L
YES. AT WHAT DEPTH') 0
Depth Io Water A~ter I. P
Monitoring? ~"t" E
Oale '[..
DeDIh to
Reading Date Gross Time Nel T~me Wa=e' '.-':: L": :'
ti '1,~, ~t:~'5 ~ I
"50
I
PERCOLATION RATE ,, '~) ~u,ew,~ PERC HOLE C~AMEI'E~ ~
TEST RUN BETWEEN ~ FT AND ~:~ FT
--= ="'" :-".!ED ."J A CCO~DA'"dCE WITH ALt STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE
3~H--28--2803 83:33 PM T SPURKL~ND 987 2?6 6813 P.82
Municipality of Anchorage
Developmeot Services Dep,rtment
BuildtnI Sdc~ Division
On-She Water and Wa~tlwate~ Program
P.O. Box 1~66~0 A~:ho~tge,. AK 99519-6650
(~?) 343°?904
PROPERTY OWNER AGP, EEM~NT FOR THE MAINTENANCE OF AN ON-SITE
WASTEWATER DISPOSAL SYSTEM
This agreement, dated I 12~ o25 , is made between the Municipality of.~nchorage
Development Services Deparunent (DSD) and the prol~rty owner(s) of:
This agreement is made for the purpose of maintaining an on-site wastewater disposal system on
the subject property.
The propert)' owners agree to the following:
Submit to the Municipality of Anchorage,'on an annual basis, an inspection and operation
statement from a registered professional engineer. This inspection and operation statement shall
verify that the engineer has inspected all effluent and air pumps, timers, and alarms, and that ~ny
deficiencies have been repaired and that the system is functioning as designed.
(si )
(Printed Name)
(Signatm'e)
(Printed Name)
The Foregoing lnsu'ument was ackuowledged before`
,
.)
Wc.~mY hand~l~$ealt~
~ot~'s printed ~c)
% MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
!. ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Ancltorage, Alaska 99501 T01ephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELl_ INSPECTION REPORT
T~HONE [] NEW
NAME
1344-0741 ~ UPGRADE
John Shelton __
MAILING ADDRESS
1744 E. 59th Anchorage, Alaska 99507
LEGAL DESCRIPTION
L19 B2 Silvererest Subdivision
LOCATION NO. OF BEDROOMS
Stamps Circle 4
DISTANCE TO: Well 130 ' I Absor~)~o,n area uwelling 16' PERMIT NO. 780696
_vI -- __
I-2 Manufacturer Material No. of compartments 2 each
~< Greer 1500 gallon x 2 3000 total Steel
~ I- Liq. capacity in gallons IF HOMEIVIADE: Inside lengtl~- Width Liquid depth
--, Well .... Dw~l[i'~g PERMIT NO,
9 ~ ~ DISTANCE TO:
O '~ Manufacturer Material Liquid capacity in gallons
12 Well -~;"oundation ~ Nearest lot line PERMIT NO.
~:Z DISTANCE TO; 113~ 30' 14' _ 780696
~ 2 No, of lines Length of each line Total length of lines Trench width Dista,,ce between lines
'~p:~_ ~ 1 85 ' 85 36nches N/A
Material beneath tile 5 Feet-- Tote1 el~f~iv~b.sort~o.n~ area
~F-- ~-op of tile to finish grade
4
Feet
inches
-- -- Length Widtl] Depth PERMIT NO.
,~ t- Type of crib Crib diameter Crib depth Total effective absorption area
LU Well Building fonndation Nearest lot line
'~ DISTANCE TO:
,..I Class Depth Drilie'r Distance to lot line PERMIT NO.
LU Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
Cast
SOIL TEST RATING
200 --
iNSTALLER
H&M Excavating
REMARKS -- ---
2 1500 gallon tanks installed
at owners request. --
?
Lot 19 Block 2 Silvercrest
72-0~3 (Rev, 3/78)
Well Owner
Location
DRILLING, INC.
DRILLING LOG
Use of Well
(address of: Township, Range, Section, if known; or distance main road.
Size of casing · ~' Depth of Hole. 'i i; .': .
" - · ~ feet Cased to it. li,~' 0 feet
Static water level t. ft. (abo~e)- (below) land surface. Finish of well (check one) open end (.
Screen ( ; Perforated ( ).
Describe screen or perforation "/~..
Well pumping test at .~fi gallons per (~9~,)- of drawdown from static level.
(minute) for t hours with I, ,./,
Date of completion
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
);
TO
TO
TO
TO
TO
TO
TO
__ .TO
TO
.TO
TO
TO
~TO
TO
TO
2 -- STATE
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FINE:' '('HE: I'!?,EFI'TOi'"I Ell.::' "!'HI:~: ~i::?:;l.::l:::l"/l'::l"l" :1: L31",I ':: :[ i",l I::'l.ii:E/'f' ::'.
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l.::'(;If;¥FH l.?'r' THE; I'"tUN:!:IZ;I.F'I::II...;I:'f'"r' Ell:' I::lt",ll::)HOl.;;:l.::lGl~l..
~;~:: ;I; I.q ]: L.L. :l. l",l~;'l"l:lt..I... "I"HIE E};"¢:~;TE:t"I ~; N FICCORDI.:'INE:E !.'4 ~ TH TI 'tie
::~:: ;l. I..II"413'E!:~::~;"I'I:::IN[)' 'f'HFI'f' THE O?',I'"':~;~TE %tZI.'.IEr~: :~;h":5"l"lEhl f'lF:l'¢ RE(;¢...l:l.l.:;:l:;
I'::IF'[::'I. 2~"INT ..;l'Ed'"lhl %1 '1t~5[ .'1% h.
4040 "B" STREET,
ANCHORAGE, ALASKA 99503
PHONE; 907-279.258!
Hole No..
Location
Test Hole Field Log
~',,! J
Water Level While Drilling
Water Level After Drilling
Frost ~ ~Z Drill
W.O. No.
Date '-~ -
Logged By (~,~,/
Driller
Weather
C, i-"
. 'Llj
j
, - U r;
1- L0,
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel 1. D. 015-062-50
1. GENERAL INFORMATION
Complete legal description
Silver Crest B2 L19
Location (site address) 7221 Stamps Circle
Current property owner(s)
Mailing address
Real estate agent
Clay Crossett
Kathi Johnson
2. TYPE OF DWELLING:
0 Single Family (w1wo ADU)
1771 Duplex
F-1 Multiple Dwellings (Single Family and/or Duplex)
Expiration Date -
Day phone
Day phone
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
Private Septic
RX
Water Storage
F -I
Holding Tank
R
Community Well
El
Community
F -I
Public Water System
R
Public Sewer
R
Waiver request for:
Received by:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 9 COU/0
Date of Payment
Receipt Number OL42 2-e
COSA# 05C_,Wl�3SQ
Date:
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
Distance:
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT 907-343-7904
On-Site Water and Wastewater Section Fax: 343-
7997
www.muni.org/onsite
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org
Nitrate Advisory
Certificate of On-Site Systems Approval # OSC201330
Subdivision: Silver Crest, Block: 2, Lot: 19
A water sample revealed a nitrate concentration of 5.84 milligrams per liter
(mg/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on
existing health information and can therefore be used to gauge the relative
quality of water from private wells. Since nitrates are known to slowly increase,
we recommend you monitor the water quality. Please see the attached “Nitrate
Fact Sheet” for important information regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On-Site
Systems Approval.
Mailing Address: P. O. Box 196650 * Anchorage, Alaska 99519-6650 * www.muni.org
Nitrate Fact Sheet
From Northern Testing Laboratories, Inc.
Nitrate is a negatively charged compound of nitrogen and oxygen, which is very soluble in water.
Nitrate is not readily filtered or otherwise removed in the soil and can pass rapidly into ground water
wells.
SOURCE: Nitrate is a major component of fertilizer and wastewater. Often the nitrate is in the form of
ammonia or protein first, which through contact with oxygen and certain bacteria, converts to the
oxidized form known as nitrate. Sources of nitrate from wastewater include urea, ammonia cleaners,
food solids, and bacterial cells. It may also result from the breakdown of organic matter buried in the
soil.
TOXICITY: Nitrate is generally not toxic to adults or children over the age of two or three years, but is
associated with a potentially fatal infant disease called methemoglobinemia. In the digestive system of
young children, nitrate converts to nitrite, which can pass through the intestinal wall into the blood
stream. There it combines with the hemoglobin and interferes with the ability of the blood to carry
oxygen. For this reason, methemoglobinemia is referred to as “blue baby” disease. The EPA limits the
concentration of nitrate in public drinking water supplies to 10 mg/L. The standard has been lowered
from a previous level of 45 mg/L set by the US Public Health Service and the World Health Organization.
TREATMENT: due to its solubility in water and negative ionic charge, filtration and other common home
water treatment systems such as softening or iron filtration does not readily remove nitrate. The best
method for limiting nitrate in well water is source control. This can include avoiding overdosing of
fertilizer near the well and maintaining good separation distances between septic tank leach fields and
the well. A special anion exchange filter that contains a media with a strong affinity for negatively
charged ions in water, or by a reverse osmosis treatment system or distillation can remove nitrate.
TESTING: Nitrate analysis is usually done by one of the several “wet chemical” methods using a
spectrophotometer to read the final color endpoint. Specific ion electrodes also can be used to detect
the activity of nitrate in water. This laboratory uses several different wet chemical methods approved
under the public water supply laboratory certification program. They also have test kits available, which
the laboratory uses to perform an inexpensive “screening test”, and with which the homeowner can
monitor the change in nitrate levels from their well. They recommend comparing the test kit results
against a certified analysis from the lab occasionally to verify the accuracy of the kit. We recommend
using a specially prepared bottle that has been rinsed in hydrochloric acid for collecting samples.
Municipality of Anchorage
Development Service$~ Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St. '
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 I.D.
GENERAL INFORMATION
Complete legal description
HAA# '~')q (~ iq' G
expiration Date:_ g- / M '-- ~ ~
Location (site address or directions)
Current Property owner(s)
Mailing' address
LoT Iq, -~!/...0_. e-'-'-51LVF_iLC.~BS"
~o 1~I2.T ~iqgTO..o~ Oa¥ phone
5,'t~- i o,t z.
Lending agency
Mailing address
Day phone
Real Estate Agent
Mailipg Address ..
nless otherwise requested, HAA will be held by DSD for pickup.
NUMBER 'I~F B*EDROOMS: ~
;TYP.E OF WATER SUPPLY:
' Individual Well
..... I_ndividuaj Water.Storage
Community Class,
Public Water System
Day phone
Well
TYPE OF WASTEWATER DISPOSAL:
[~ Individual On-site
.. D~ ........... In_di~idual Holding tank
D Community On-site
[] 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.. Cedificates 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. (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.
S;I'ATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed heret~ 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.
Phone
Name of Firm
Address
Engineer's Printed Name
DSD SIGNATURE
~ Approved for J'~'" bedrooms.
Disapproved.
Conditional approval for --
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
· Septic System Advisory
Well Flow Advisory
X
'Maintenance Agreements '
Supplemental Engineer's Report
Other
By:
Original Certificate Date:
I fl -o u,-
(Rev. 01/02)
Municipali of Anchorage
Development Serwces Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:.
WELL DATA
Well tYPe ~-. _
Date completed . ~/~ ~//~7oc.-'
Total depth. I i ~ fl.
If A, B, or C provide PWSID #. t'~/~
Sanitary seal (WN)__.~_
Cased lo :l ~ -~' ft.
FROM WELL LOG
Date (~f test ~,'~//?
Static water level '
Well production 112
WATER sAMpLE RESULTS: '
Coliform O colonies/100 mi.
Arsenic: ~/ mgJl.
g.p.m.
Parcel ID: 0
Well Log (Y/N)
Wires properly protected (Y'/~)
Casing height (above ground)
AT INSPECTION
7 0 ft.
z.// g.p.m.
B. SEPTIC/HOLDING TANK DATA
Co
Nitrate ~.~ ~ mg./I.
Date of sample: L//~/A j/
Other bacteria N_~ colonies/100 mi.
Collected by: . ~ ~/p~/~ ~J,/,~ ,~
Length '~O
Total depth. ~ ft.
Date installed
Tank Type/Material
Tank size ~/~ gal. Number of Compartments ?
Foundation cleanout (Y/N) ~ Depression over tank (Y/N) t'~
Date of pumping /~T i2-'~l~ Pumper ~
ABSORPTION FIELD DATA
Date installed / I/e ~/o z.. Soil rating (g.p.d./ft2 or ft2/bdrm). ~..
ft. Width J O ft.
Eft. absorption area '~C-O ft2 Monitoring tube .
I~,+ [~¢_.~ I¢,{f Results (Pass/Fail) -'~
Cleanouts (Y/N) \/
High water alarm (Y/N) ~
System type '~ ~ L.~
Gravel below pipe ~), ~ ft.
~'/ Depression over field
For q bedrooms
Date of adequacy test
Fluid depth in absorption field before test C3 in. Water added /'"'gal.
Elapsed Time: "'/min. Final fluid depth 4"/'"in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
If yes, give date
New depth t.~ in.
g.p.d.
De
Se
LIFT STATION i~ . '
Da:to installed ///////~i~...~,
"pump on" level at .~, ~ in..
Size in'gallons, //~ ~
'Pump off" level at /,~ in!
Datum ~. e .~ ~vt; ' .Cycles tested
SEpARATiON DisTANCEs
SEPARATION DISTANCES FROM .WELL ON LOT
Septic tank/lift station On lot I ,~ ~ ' ' ' i, On adjacent lots'
Manhole/Access (Y/N) i ' :l
High water alarm !evel at ~ ~ '.1'~
Meets alarm & circuit ~'equirements?, ~
AbsOrption field on lot: ',
Public sewer main
Sewer/sepbc service ~line
On adjacent lots
~ublic, .~ :,~ sewer. . manhole/clea'r~out.,
Holding tank !'~'//~-..
iSEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Water main
,Water Service line'
,CUrtain drain IA[lo :'
F. COMMENTS
Property linei_ ' "' , Absorption field
Water service line ~-. '~' surface water i
ReceiPt Humber
(ReV. ? 2/0,1:
Receipt Number
Wells on adj ts~ ~ !OO
acentlo "! ~ ,
· ,sEpARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundationi !~'.~ ~'" Water main ,
Surface water': i..-t I o Driv;way. parking/vehicle storage
Wells on adjacefit lots ~')' /o-~.
G. ENGINEER'S CERTIFICA]iON ' , l . '
I Certify that I have determined through field inspeCtions and
· ' reviewofMunicipal re'cords that the above systems are tn l '~ '~:
conformance with 'M°A HAA guidelines in effect on this d~te.=,
,
Engineer's Printed Name ~t ,,, I
,Date i ~ ~_g, hr,, ~ l i,!
HAA Fee $ pil '~//~ .;.----- : I Vaiver Fee $
D~te of Payment it.'//;',~- '~ ''~ J/ " i" ,)al~;,, ~: of, ,Payment
SGS Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
1041880001
Tobben Spurkland P.E.
iLot 19, Block 2, Silver Crest
Lot 19, Block 2, Silver Crest
Drinking Water
All Dates/Times are Alaska Standard Time
Printed Date/Time 04/23/2004 12:18
Collected Date/Time 04/2 1/2004 11:00
Received Date/Time 04/2 1/2004 11:22
Technical Director ~. Steuben O'. Ede
Sample R~marks:
Allo~vable Prep Analysis
Parameter Results PQL Units Method . Container 1D Limits Date Date Init
Waters Department
Nitrate-N
3.86 0.100 mg/L EPA 300.0 B {'<=10) 04/21/04 JJB
Microbiology Laboratory
Total Colif0mn
col/100mL SMI8 9222B A (<=1)
04/21/04 DPT
15 04 ]2:4:3p
Rpr !~ 04 0't:00p
JERNSTROM EHGIHEERIHG
Ka%h~ J Fernend ez
S22-1052
807 273 ?343 p.~
\
~ ~~ ~.....:~ "' " I 'i'
LO r ~9
/
~.. ...~
~.'. EXS~NO '.'1 1 /
__~. -'P~,~ '"M
~:.~::~~{. [,~ k. :: ~;'?"..'. ""'"" "' '.".~x :~_ // ~
~c'oo'oo"c ~-:;~ -~t,-.,,..~, ~'
55.40'
.., ~.r~,,:. C,RCLr
PR-__, .. I ...... ~ H.__ - . ~ ,,.~ . :~ ~ _
~~,~.~-=.-~-~..-~~ c~t~ ~ f~ esto~;~9 ~o~v I~. I~1~ ..
~~~ ~'.~~:~ ~ meats ~l~t ~L~ t~ notc~ /~a~_ ~ ~
-- ' ' · a~a ~ ~
CONS~UCI~N DUR~S-PLANN~S-ENGINEERS ' . mu~ .~'
0
· . St_._R CR__ _L .... I__ · _
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
~_~\,~-I~ ~-~'~,~( ~ HAA# ~c~\(~;¢'1~-~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
(b)
Location (address or directions)
Property owner ~ov! -~¢----~
Telephone: (home) Z?b-/b3~-Business
Mailing Address
(c)
Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent
Address
(e)
Telephone ¢'~ 5 7 -- ~P / ~ ~
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 RESIDE/NCE
Single-Family'~/ Number of bedrooms
3. WATER SUPPLY
Individual Well I~ 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-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.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by mysealaffixed hereto and as of the validation date shown below, Iverifythat my investigation of th is
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 flies 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 / ~/¢,~ e~ ¢ Y-~/,~uC¢ /~. ~b~, Telephone
Address ~ ~-/ ~ ~'~ ~ ~
Seal
6. DHHSAPPROVAL /b/ ~ / / ~-//~/~4~~..,_~,
Approved for ¢ bedrooms
Approved ~ Disapproved Conditional
Terms of Conditional Approval /~,,~ ZJ~"-
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 satisfycertain federal and state requirements. Employees of DHHSdonotconductinspections
or analyze data before a certificate is issued. TheMunicipalityofAnchorageisnot responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88)Back Page 2 of 2
,".¢
A. WELL DATA
Well Classification
Well Log Present (Y/N) ~ Date Completed
Total Depth /{C~///~Cased to //,7. ~, Depth of Grouting
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
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
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
./ /:5 ''p ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed ! ¢/'TF_-. Size ? ¢ [I~c,,'r~ NO. of Compartments
Standpipes (Y/N) y Air-tight Caps (Y/N)
Depression over ']'ank (Y/N)
Pumping/Maintenance Contact on File (Y/N) ~/~'/~
Holding Tank High-Water Alarm (Y/N)
To Water-Supply Well
To Property Line
To Water Main/Service Line
Date Last Pumped
;for J~,/'A-
Foundation Cleanout (Y/N) ~'o ~L /~'00~4 c~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
/p_.¢ _+
_4.'O
To Stream, Pond, Lake or Major Drainage Course
Comments ~0~,4
Temporary Holding Tank Permit (Y/N)
To Building Foundation !/o ¢
To Disposal Field /,2E ~
72-026 (Rev. 7/88) Fronl Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date installed /
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
L o t /"//A
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments "¢: /~,- ,,.,~4 S .~-~, ~/,,,-~¢,.~- /
Type of System Design
Length of Field
Depth of Field //
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line /Z//
To Existing or Abandoned System on
; On Adjoining Lots /¢-e~
To Cutback (if present)
D. LIFT STATION
Date installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA g._u~idetiue~.i.r}.effect on the date of this
Company
Date F ¢~ l/ / 7 7[ ~ ~ ~~~. Engineer's Seal
MO, No. _
Receipt No.
Date of Payment -/~ -- x~ Waivor Foo'$
Amount'S /9~- ~ Date of Pa~me~
72-026 (Rev. 7/88) aaok Page 2 of 2
6751 t}, DIHOND BLVD.
ANCHORAGE, ALASKA 99502-5904
(907) 248"5095
RESIDENTIAl- WELL INSPECTIOIq
LEGAL:
LOCAT I ON:
OWNER:
TYPE OF WEL. L:
D[]NAL.D C,, ROACH
I:::'r:i.w:~L'.c(,,, f:!i:i, ngl¢:., I::'am:i. ].y
WFI._L LOG AVAILABLE: Yes
iNSTALLATIDN REQU:I;REMENTS MET:Y
WELL. YIELD F'R[tM WELL LOG:
F'IJMF' YIEI_D FROM TEST:
5 Ii)al ll3r'~!~ per Minui:c,
I)Af'E OF INSF'ECTIShI:
'rEST PROCEDURE: Well was Fiumped at. a corlsi:.arrt': ratr:.:, wh:L:l.(:i, the
· F~:.,c::d: I:)~:l (3w i':oj] ere cas& rig, At a i]t.tmp:L I]g rate o'f 5 ga;I ]. ohs
I'll:i.l'll.t'J:cL~ 'El]E,water ].c)vE;,t droppJed 'ho (~l(:).I;e(et. a 4: 'l:. ~i, l" :i:!O ifl:i.l'lt.itce~; iD.i;
ptirlll], i r'll.~J i:~lliJ i'"e:lfiai ne(:t a'f; thail 1 ex/el .For i:he (Jt.tl,"at :i or'~ 63~ thE, t6?s'k ,
'T'l'le re~)ccrvc~F'y was mor~itc)rex;.I .For ~2.0 minuti.;<,s~ [)ul'~ing tl'l:i.s time
TEST FOIl E. COL.]: AND ·TOTAL NITROGEN: Water" was 'Lest. l:(,:,d for E. Col :i
a r'i d 'L: (:)'t:. a ]. ~i :L t r oq (.;an (:~l'~ I::'e~l::~ 1 2,~ :1 9 9 :L
E.[](';)l:i. 0,, To't,',al N:i, trogen 2,3 mgl/:L,.
Max,, al:Lowable To'i:a]. Nitr(:)(.:]er] :l.O m~!/:l,.
]'EST RESULTS: 'Fi~ :i. s we 1 1 m(s:,(~ t. s 't:. h m, r' ~.~:,q u i r ~.'.~,me:,n i: s o¥ t h ~::;,
Mun:i. c:i. f:)a]. :i I:y c)',~:
mZ~I_~. L,J__~..I_[__= WIL=[.=. ~O])__U_~_E.. I',IO___R$_ TH~N ;~ ~¢$]=pNs ~ER HINUTE FOR ~.
'l"l"H;~, Iqt.tn :[ c :i. pal r"equ:L rl.:.:>llw~:~r/t'. ~; or wE.:,]. ]. -~:
i::,cH,' [:)(.Zedl'"oclnl l:~6)1"- (:ii:fy', 'l'l~:L S t41.D]. ]. E)>iC:6))E~(::I 'U.J]i ~/~ 1"6,))(:]Eli I'"E.)flll,))l'l'J;.. 'l'hc.~
Ct. ............: ( .... ll~(..Jl[ c)'¢ '['.hi:.? [:l::)FiCl:i.'L::i. clr'l (::)4: i'.'.l'~[.:,
c::(:)l']c:J:i.'(".:i.(::)ll~; a'is (::,'I:; i'..he (:Jay i:[~;,si.'.ed. The
i~:'d::jl.ii-f;e?l .... F,:;.::,c:,d:i. n(;:] i'he we:;,1 1,
8751 ~], DUDNI) BLVD,
(IM;BOR~GE, ALABK/~ 99502-3904
(907} 248-5095
LEGAL:
LOCATION:
OWNER:
RESIDENCE:
WELL:
SEF'TIC SYSTEM ADEQUACY TEST
LC}"F 19 ~ BL[]CI::: 2 S:I:L. VF::-'RCRI:ES'I"
7:772:L STAMI:::'S CI
D[]I'4AL. D C ROACH
S:i. nql e Fam:i. ]. ',/,
E'ri vat~.:~,, []n S:i.
SEPTIC SYSTEM:
F'RE)Iq M/.JN]:CIF:'AL RECORDS,", /!. B(:.:,dro(:m'~ System
"l"F~NK:Gree]r :7. x 1500 Gal.T'wo Comparts.each
ABSOIRI:::"1" I C)N SYS"I'E]'4 ~ "l"r ~-:¢n c h
ABSORF'"[':[i]N AREA: [i5() SCl. F'k.
SI: I I,,, RA"[' I NG: 2()()
:[ NSTALLAT' :[ ON [)A'T'I~ ~ 1978
DATE OF LAS-[' PUMPING: [::el). 1:1.~ 1991 A+ IIomci, Serv:t[::es
DATE: OF TEST: I:::l.:fl':) :I.:L - F:'¢?I::) :18~ :1.991
TEST PROCEDURE: Sys'k[:~:,m was :i.r~;~,pected and me~asur"ed (::n'~ 1:::'(~7~b 1t,,
'T'a:~r~ks were .foLu'ld b~ct'k.h 7 'f(.:~(:e'k o-f (:::ovl:.)r ,':M~d with a ].J. qL{J.(::l level
45 J. ,~ c I~ (.~, s ,, ( :l 5" ) C 1 c::.a r'~ (::)t,I 'k '['. (::) t r [.:e n (::: h w a s 7 'f: e e 4: d e el) a n d (::1 r y
Mor'~i tot LuI::)(~ was 11 .fee?E deep and had a ]. iclui(::l 1 evel c)~: 43 il"~ch'-~
waker ].evels :i.n the I:ank arid the mor~itor tub(~ were mc~n:i.'hored. 'l"he
1. (~2¥'[:r)]. :L Ii 'l;'.he m(::n"l:L 'kol" dropped 1 () i I'ic;:h~:2~4 ~ then (::Jut J ng the n(ex'k 24
(]l"l '1:t'1~:~ :!.3th,, the test was rel:)ea'l:r.._~ci, The water level, i~'~ 'khe moni. ....
(22,, 5) 'Yhe add:i.t:i, c:)l~ o~': 6,:.)C) gal 1. oc~s (:).f t,.~a'l:er c:aused the watc..)r 1 eve].
to:, r:i si.? to 'l:h[;) !a;am~2 l i?vel as I::n~;:,q;orc..y. (3',:.:.!i") Duri ng the next. 24
I'1¢]L~1"~3 'f::hi'e ]. ~;~ve]. dropped 4 inc:h;-:es,,
(::)J"l 'l:h(i.lir ]ll~tlr: ,, apl:n'"ox :i. rna'Eel y lZlCK) gal 1 ohs wc?r'{,2 added to the
w:i.'khout any water .fi. owing bac:k ~n'ko the tanks. The water l~:.~v(a:l. J.~
!:h{:.,:, fr~cn~:i 'kor r"l::)~,~;:, ko a ]. ~::)v(:~,). o'f ',Str';" .~ and did not. L mmi~xdi a'k~:~,l y drol::)..
:;~':C) hoLu,"s :[ Z.T~:J~.)I"' th(:~ walte:~r 1 (:eveZ had dl"Ol:)l::)e(:l 4 ~
TEST REfiLILI': Thi ~ ~;-ys'k(.::,m ri~el.')'k~ '1.:1~[~:, co(::h~:, r" lz~(:lL.t :[ reii~(.~r'd(:.!~ I:]'{:
· 1: t", ~-::~Health ~0 ] c:l ~o(:: J. ~:~CI. S e r v :i. c: ~'..~ ~:~
[}el:)artm(:~:,r'rk o.F 'k. hc.) Mufi:i.c:i.p,'.:dl.J.'ky o.F
LOT 1% ~',LOI?,K 2 SII.VERCREST
PG 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT BY SAHPLZ for Work Order ~ 31896
Date Report Printed: FEB 13 91 @ 15:56
Client Sample ID:LZ9 B2 SILVERCREST POTABLE WATER
PWSID :UA
Collected FEB 11 91 0 13:00 hrs.
Received FEB 11 9i 0 16:25 hre.
Preserved with :AS REQUIRED
Analysis Completed :FEB 13 91
Client Name
Client Acct
BPO ~
Req #
Ordered By
TOBBEN SPURKLAND, P.E.
TOBBENS
PO ~
Send Reports to:
Laboratory Supervisor :STEPHEN C. EDE ~ 1)TOBBEN SPUEELAND, P.E.
Chemlab Ref ~: 910461 Lab Smpl ID: 1 Hatrix: WATER
Allowable
Parameter Tested Result Unite Hethod Limits
NITRATE-N 2.3 mg/1 EPA 353.2 10
Sample ROUTINE SABLE COLLECTED BY: T. SPURRLAND
Remarks:
Tests Performed ' See Special Inst~uetions Above UA=Unavailable
None Detected "See Sample Remarks Above
Not Analyzed LT=Lees Than, GT~Greater Than
"' bAT'~ RECEIVED
· _ iNSPECTiON APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR I NSPEC~~
~UNIcIPALI~ OF ANCHO~GE
MUNICIPALITY OF ANCHORAGE DEPT. OF HEAL'tit &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEOTIO~NviRONMENTAL F;~OTECTIO~
825 L Street - Anchorage, Alaska 99501
(~) ENVIRONMENTAL SANlTATlONTelephone 264-4720 DIVISIONl~ I~FIt , F. AU~ ] ~80,
DIREOTIONS: Complete all parts on page 1. Incomplete requesls will not be processed, Please allow ten (10) days for processing.
1. PROPERTY OWNER
P"OPER~Y RESIDENT Ill different from above) ' , / F ~+O ~¢~ ~. PHONE
2, BUYER ' ' - ~ ~ . PHONE
MAIEINQADD~88. - ,z" "2 · '~ ·
, L ~IN~I T~ T ~ / ~ PHONE
MAIL~GADOR~S ~.~__ / '
STREET LOCATION
6. TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [~ Four [] Other
[] Two [] Five
[] Three [] Six
7, WATER SUPPLY
~ INDIVIDUAL* * ATTACH WELL LOG. A well (os is required for all wells drilled
[] COMMUNITY since June 1975, For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach Icg if available.)
8, 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, 6/79) ~!-~.~
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE F~ THREE [~ FIVE [23 OTHER
r--i MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[~]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or F-I Holding Tank
Size: /.~-O~ If Tank is homemade SOILS RATING
give dimensions: -'~:~('-)
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
[] CONDITIONAL APPROVAl_ (letter must accomp~n~ertificate)
72-010 (Rev. 6/79)
MUNICIPALITY OF ANCHORAGE .... '. ' '
~ DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTECTION k..-..,., _ .' .... .
~tt~'~ ! L~;~,// ENVIRONMENTAL ENGINEERING DIVISION
~ Telephone 264-4720 r ' =
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
MA~ LING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. BUYE~ PHONE
MAILING ADDRESS
~ENDINGINSTITUTION ' PHONE
MAI LING ADDRESS
4. REALTOR/AGENT, ' PHONE
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF R~SIDENCE [~ SINGLE FAMILY
[] MULTIPLE FAMILY
7, WATER SUP. PLY
E~]//INDIVI DUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8. SEWAGE DISPOSAL SYSTEM
I~" I N DIVI DUAL/ON-SITE**
[] PUBLIC UTILITY
NUMBER OF BEDROOIV~
[] One E/~"' Four
[] Two [] Five
~ Three [] Six
[] Other
~ ATTACH WELL LOG. A well log is reauired for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
**If individual/on-siTe, give installation date ,~/~-'~/~ ~¢' .
If system is over two (2) Fears old an adequacy test is required
by this Depar[men[.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78) ~
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE ~NSTALLED
[]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
1
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
~ APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
LEGAL DESCRIPTION
72-010 (Rev. 3/78)