HomeMy WebLinkAboutHILLSIDE NORTH #1 LT 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
. Environmental Health Division
/' 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
,~me DISTANCES
I~(C_,,~4.~,~141~) A.J~UIS~z~, ~ ~ SEPTIC ABSO,PTION
~ .... TANK FIELD WELL
~6A~.~SC.~,T~O. LOT LINE ~ ~ O ~ / O
Township, Range, Section
~ /~ ~ ~ ~ ~ ~ ~ dr,veway,AS'BUILTwaterDIAGRAMbodies, etc.)(Sh°w location of well. septic system, property lines, foundat,on.
TANKS N
~anulactu~er Capacity ~n gallons
Material No of Compa,me%ts
TYPE OF SYSTEM .......
P~o
~TRENCH ¢ BED ~ W. DRAIN S OTHER P',~OI~
Depth to pipe bottom from Total depth from original grade ~j .~
original grade ~ / FI / ~ FT
Fill added above original grade Gravel depth beneath p~pe
Gravel length Gravel width
Total ~bsorphon 8re~ Dist~noe between lines
Number o~ lines Soil rating Pipe material
~ PRIVATE ~ OTHER (Identifv) -
installer I Date Installed: ~ /
/¢
O¢ & ~ ¢~2" inspections Pe~rmedby: '
~ I ~ ' 4 cen~atthi~inspection was pedormsd ac6ord'ng to all
1'1 :il T
Da'Le Issued: ()8/29/88
E.n q :i. r",ee l" Designed
Name: RICHARD NEUBAUEI::~
AddPess: 284:1. DEDARI::( RD.
ANC, HL,]I.,~A.:~I:::. ~ AK 795()8
Day Phone?
2.64- 16()()
F:'a ~" c e 1 I ('.t: ()41-031-66
Lo'i:. Legal." Sul::~cli¥isic~nu FIIL. L..SIDE NORTH $t:]. Lot: 1
Sect i on ,", 6 ]'ohq'~sh :i. p: l:;;~lxl Range ."
Lo'L Size 7869:3 (sq. Ft. of ac:r'es)
Max Bedvoc)m~: 'T'his l:::'~,PFr~it: 4 ']"orA1 Capac:::i.'Ly: 4
B 1 C)C: k Il ....
ii~l!L]:~'l"IL] ]"ANK: I~lin:i, mum 'Lo'Lal sept:(c t. ank capacity: 1,25} gal:l, orH~,, Each sept:i,c
rani.:: mus'L have at ].eas'L 2. compar"Lments. Depth to 'Lop eF sept:Lc tank(~) ,::: 4.0
~' ~}:~et I e, (,,IL~ .L i (...> i F~SL~ 1 at i c)g'~ oveP tam I< ( s ) .
I NS'T'ALI... I:::'ER ENG I NEERS A'T"TA'I"E:HED DES I GN, 'I"I::~ENE:H LENG'T'H TO BE! 2. :!. '
NO'T' I FY DHHS F'R I OR TCI EAC, H I NSF'EC"F I ON ,, PHONE ::~J;Zl. 3-'468:1. AI:::'TEI::~
NORMAl... WORKING HOURS,, "['!'"1]: !~'3 I":'EIRMIT IS ISSUED I::'OR A SIN['3L.E F:'AMtLY
RE!!i)IDENCE ONLY AND EXPIRE,S
I, I am fami].iar' w:i.'Lh the Pequivements ~'ov on.....s:i, te: sewer's and wells as set
£orth by the? Murl:[cipa!ity oF Anchc.mage (MOA) and the State oF A:l. aska~
~?.. I ~i].l install the system in accordance ~i'th all MOA codes and r, egulations,
and :i.n compliance w:i. th the design c~iter, ia o[ t..h:i.s per, m:i.t.
3. I ~J.].:l. adhere to all MOa and State of Alaska requirements l'ov t. he set back
d:i. stances ~'vom any exist:Lng well., wast. ewateP disposal system
4,, I under'st~r~d~at this pe:,r'mit :i.s val:Ld For' a maximum oF 4 I:)edr'oom~,, I
also under~nl~ 'tlnat., t.~e cap~c:i.'Ly oF the {otal system is 4 I::)edvooms ~n<::l
(O~,nev) RICHAI::~D NEtJ[~UER
.... DA]"E:
1201 RAMONA ST. 99515
$1XINCH WATER WELL DRILLED .......... OUT TO THE DEPTH OF 410 feet.
DRILLED AT THE RATE OF ~22.00 PER FOOT (Steelcasing driven and seated
'into bedrock at 160 feet.
PROPERTY OWNER Dr. Richard Neubauer 337-8572 264-1600
LOCATION OF WELL SITE
DRILLER Bernie Claus of RAMPART DRILLING WORKS
WELL LOG:
0- t8'
26 - 85'
Lt. 1 Hillside North Sub. (Stucka~ain Heights) Anch.
Silty sandy ~ravel. 30% clan material.
A wet fine ~ravel.
Coarse gravel. 20% clay binder.
DEPT. OF HEALTH &
ENVIRONMENTAL pRO~:ECTION
85.- 123' Hardpan. A cemented gravel. Thin areas of fine sand. Boulders!
123 - 158' Silty coarse gravel. 40% clay material. Goin5 into a'broken
bedrock material from 151 - 158'. (A weathered broken bedrock.)
158 - 410' Bedrock. A sedi-metamorphic rock.
3/4 gpm of water yield showing between 277-281 foot level. Total water
production by 355 feet indicated just two gpm. Both areas of water yield
coming out of a granular type rock. Between 387-392' water production im-
prove by'about two & one half gpm additional flow. This new area of water
is coming out of a porous type rock, and may improve in yield various times
of the year. (During run off in springtime & also during wet years.) The
winter months will slow production down somewhat, as well as dry years.
Total water production now is close to five gpm, with a slow down of four+
gpm after several hours pumping. 260 feet of water standing off bottom. One
horse submersible pump should be installed about twenty feet off bottom. The
water should pump 100% clear in a day or two from that depth. Intermediate
pumping pneumatically for two days showed good clarity in water.
'COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
Charge for ~O0-feet, plus 40-feet on separate initial drilling. ($22.00 per ft.)
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF
Credit to the Neubauer account: $2,580.00 .Total cost: $9,680.00
THANK YOU VERY MUCH. Pay:$7,100.O0
No additional drilling charges.
BERNIE CLAUS OF RAMP/~kRT DRILLING WORKS
L,'.:~ t. Size:,
N,:a;< ~i~:~,cl r' ,:;:*, c:, m'~.::. ~ Th i
~c;r'.t.h by t.h,:<, ]'.'h..u-'~:i.c::i. pa:l. ity ~:~!' (.'.~nc:h,:::~r,:aDe (MO¢:'~) ,.'~t'~cl the Stat.(~:~, c)f
2,, I will :i.r~ir, t.~al! t.h~.:.'.~ sy~r~:x.~,m in ~:~tcccmc!anc~:~, ~.~:i.t,h all tvtO(.~ c:c~de~s and
~.?,.r"~d :i.n c:cm~i::)I:i, ance~ ~,,~it.h t.l"~:~, d~.:~,~i~:i, gr'~ cP:i.t.s~r'i~:~ (::){' this p~+:~,rm:~.t.,,
...................... v~ .................. I ........................................................................................................................................ 'l-'"T'" ..................................
•
• •76 e`
•- Municipality of Anchorage �V ...„/„Avii.,
ii.
\ ) On-Site Water and Wastewater Program -" 4 'nil 1..-i:
(907) 343-7904 E DEC 2 8 Ai *Y
siY
Certificate of On-Site Systems ApprovaN
Parcel I.D. 041-031-66 Expiration Date: 3 ---: 1 - ( CJ
1. GENERAL INFORMATION:
Complete legal description Hillside North#1; Lot 1
Location (site address) 9681 Middlerock Road*Anchorage,AK 99507
Current Property owner(s) Eleanor Ryan Day phone 333-4905
Mailing address
Real Estate Agent Bethany Mehner-Weiser Day phone 223-1632
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ® Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: c/' Date: /7;//f
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ nc. Waiver Fee $
Date of Payment 19421g/1? Date of Payment
Receipt Number 06 (�4 Receipt Number
COSA# abcti16 -?, 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: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road,Suite 101-Anchorage,Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: !2.-/Z44/11—
In
conducting this evaluation,GEG provided an engineering evaluation of the well and/or septic system o`er , /
in accordance with the guidelines and regulations established by the Municipality of Anchorage and p�C O..•. .61%
industry practices. The reported results describe the condition of the system/s on the date/s of the if.,„;.
4:%k /) "1"--
i
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or � ^ , A•• T I %1 • QO
encroachments may exist that were not identified during the evaluation. The operational life of all wells / * ,
and septic systems depend upon a variety of variables, including but not limited to, soil conditions, v
groundwater levels (that may fluctuate during the year), quality of construction (materials and
workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and j -. VA
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the Q - f :y A Gam-ss•
fi system/s;therefore, GEG makes no warranty(express or implied) regarding the future performance of v0 CE-79 •• e`,
the well or septic system. GEG makes no representation whether an alternative well or septic system VQ 9's
can be installed on the property in the event either of the current systems fail to perform adequately in Q4 e, �. . AP
the future. The content of this report is for the sole benefit of the person/party that retained GEG to �\\eapro{esstoncQ�
perform the evaluation. Reliance upon the information provided in this report by any other person or ��OO400��
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
#AECC884
6. DSD SIGNATURE
System #1 Approved for f bedrooms
System #2 Approved for bedrooms
Disapproved `` \-\( OF y
Conditional approval for bedrooms, with the follow*stip ti
G,•
S Lc.' ��C i S �9 ecty-s � = W�TERA MD �`
� A
tT U`Pt i 20 e vs WASTEWATER
,�, PROORRM
SERv�G
=y: - ,/�� Original Certificate Date: 2-` 2-x- 1 7
The Municipality of Anchorage 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_10-10-12.doc
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: Hillside North #1; Lot 1 Parcel ID: 041-031-66
A. WELL DATA *Assumed cased to bedrock
Well type Private If A, B, or C provide PWSID# N/A Well Log (Y/N) Yes
Date completed 3/20/1990 Sanitary seal (Y/N) Yes Wires properly protected (Y/N) Yes
Total depth 410 ft. Cased to *158 ft. Casing height (above ground) 12+ in.
FROM WELL LOG AT INSPECTION
Date of test 3/20/1990 12/12/2017
Static water level 150 ft. 161.1 ft.
Well production 5 g.p.m. 3.4+ g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 ml. Nitrate ND mg./L. Collected by: GEG. Ltd.
Arsenic: ND ug./L. Date of sample: 12/12/2017
B. SEPTIC/HOLDING TANK DATA29 YEAR OLD STEEL SEPTIC TANK IS
APPROACHING THE END OF ITS USEFUL UFE
Tank Type/Material Septic/Steel Date installed 9/17/1988
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Yes
Foundation cleanout (Y/N) Yes Depression over tank (Y/N) No High water alarm (Y/N) N/A
Date of pumping 11/04/2017 Pumper Isaacs Pumping Service
C. ABSORPTION FIELD DATA *Below Existing Grade
Date installed 9/17/1988 Soil rating (g.p.d./ft2Kt2/bdrrr) 125 System type Deep Trench
Length 25 ft. Width 3 ft. Gravel below pipe 14 ft.
Total depth *21+ ft. Eff. absorption area 700 ft' Monitoring tube Yes Depression over field No
Date of adequacy test 12/12/2017 Results (Pass/Fail) Pass For 4 bedrooms
Fluid depth in absorption field before test **10 in. Water added**806gal. New depth **20 in.
Elapsed Time: **30 min. Final fluid depth **13 in. Absorption rate>_ **600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &type) None Known If yes, give date —
*Monitoring tube extends approximately 12.26 feet into 14 feet of effective drainrock.
**At the start of the test, 208 gallons of water were introduced into the drainfield causing
a 10 rise of liquid level in the MT; The liquid level stabilized at this level for the remainder
of the adequacy test (598 additional gallons added with no rise, 806 gallons total).
D. LIFT STATION
Date installed Size in gallons Manhole/Access(Y/N)
"Pump on" level at in. "Pump off" level at '• '• a er alarm level at in.
' •• Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field *5'
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water **100' Driveway, parking/vehicle storage 10'+
Curtain drain None Known Wells on adjacent lots 100'+
F. COMMENTS
*5 feet from edge of ST2 to edge of cleanout at west end of trench.
**Physically measured exactly 100' from edge of cleanout to edge of stream during the adequacy
test (attached survey shows approximately 96 feet)
ooaop \0
G. ENGINEER'S CERTIFICATION 4c..- °...
���
. 00
I certify that I have determined through field inspections andff' . IF v
*. O
review of Municipal records that the above systems are in 0 (� �*-- V
conformance with MOA COSA guidelines in effect on this Q
date. f 51,A. G• :ss.: p
Engineer's Printed Name JEFFREY A. GARNESS Q c' •
9 1.z., '0
O��SfP .. z JO- .,4'0
De ��
Date 121Z� 04 dprofession
�.k000o��
#AECC884
(Rev.11/05)
LOT 5
Id82'00'oo"E 15.91' Fit..-is.a 0
0•
I4‹..., .6. /
WOOD STORAGE .' ••••
A...
r-c �� �.
t„ WOOD BRIDGE
IF LOT1< .r
I
I DETACHED �' ,.r LOT4
GARAGE I •• ar?.� 'r. +5.
Ln -' CULVERT :•
ro .r`-
c� (lyp)
c'' EXISTING :;
HOUSE J'1 ' ' °'
MA iii / 7 CLEAN OUTS
VW
CV / CENTERLINE- fir'L) a
Z OF :�
l/.
STREAM
�„ PaE BASEMENT •-,
LOT 2 'c O4. .%295.78'
lik.
O
-.....s.„:"
/PCODaCK ROA ,
`
fo`
oma° _
'/`�
r�,o
,
S75 O 4e. SCALE 1"=50` \I
�sAoF �� 4 30.7'
ta t!k
0:17..7C,Pa.', .. i.C,Q`Dtot NOTES:
...-
/1\ ~ V 6 0' 8'0 1. THIS DRAWING SHALL NOT BE MODIFIED FOR
$%(2,... G}9 tt 2 STORY to USE AS A PLOT PLAN WITHOUT THE EXPRESSED
�' cQi HOUSE WRITTEN CONSENT OF LCG LANTECH.
p elk 4 Q 6,0 6.0' 2. SNOW AND ICE MAY CONCEAL MINOR SURFACE
e '•,STEVEN CALLA MAN:• 2
FEATURES.
Vl 1 k�'ofe,,;flno�tia BUILDING DETAIL I v U
vpodc SCALE 1•a 27
PARCEL N: 041-031-86-000 IC
SURVEY CERTIFATION:LCG LANTECH,INC HAS CONDUCTED A PHYSICAL SURVEY OF
ORDERED BY: LINDSAY CROSS THE PROPERTY ASSHOWN ONTHIS RMAY.INOAND CERTIFIES THAT THE
IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY UNE9 NID NO
LEGAL OESCRIP1I0N: ADDRESS: 9681 MIDDLEROCK RD. ENCROACHMENTS EXIST OTHER THAN NOTED.
AS-BUILT EXCLUSIONARY NOTE IT IS THE OWNERS RESPONSIWLRY TO DETERMINE TIE
LOT 1 EXISTENCE OF ANY EASEMENTS,COVENANTS.RESTRICTIONS OR RONTOF•WAY
TAKINGS MII4 CN 00 NOT APPEAR ON THE RECORDED SUSDIVS0CN PLAT UNDER NO
HILLSIDE NORTH ADDITION#1 CIRCUMSTANCES SHOULD ISFY DATA HEAEON SE USED FOR CONSTRUCTION.FOPt
IRCUMST' 8S'a1DISFYDATAHEAEGNSEU`EDFORCONSTRUCT,a+'FOP`
EST ABL SHIRO PROPERTY LNES,OR FOR PLOT-PIAN PURPOSES
LEGEND
260 H Street ® Gravel y r� I;
Ancllnrape A Ia5ka 9950 I wn7ER Y.,a PIPE .,� :tl :I CIIJI:iI
a - J FENCE --x—X—
DRAWN Ey llepartlTUTIt DRAWN OATS 12121/2017 WORK ORDER:17124
Phone 562-5291 --
...,.__
�' 1 i' 1 Inc Malnhne —DRAWN BY: AP PLAT: 83 ___._..... .,
Phone 243-89E5 CHECKED SY: SC OR10:� SIW2143
au�iiLec(uu enyinPtui'9 �wtveytng SCALE: AS SHOWN FBdPG:8OBJ21 22 Ft FS90L250C
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # kc"~Ll \ - f-'G'L,\ - ic~ir~ HAA# ~°~,~-~L°
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (inclu.de 10t, block, subdivision, section, township, range)
St T
Location (address or.directions)
(b) Property owner ~//~¢ff"~ ~/ECC~CfCK" Telephone: (home),-~.-~- ~'O~Business
(c) Lending Institution TelePb°ne
Mailing Address
(d) .Real Estate Company and Agent
Address
Telephone
(e)
Mail the HAA to the following address: (or check here i-1, if hold for pick up.)
List contact person and dayp~one number below.:
2. TYPE OF RESIDENCE
Single-Family~ Number of bedrooms ~
3. WATER SUPPLY
Individual Well,,~ Community []
Public
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DI..SPOSAL
On-siteX~ 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 my seal affixed hereto and as of thevatidationdateshown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is Safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
~a,u$¢. f~4~. Telephone ,.~f/~.-?..¢.~o ,/ ~ ~ ?o?o~
Name
of
Firm
Address 9 ~,0 / /5 ~,~// ~/~/.~ ¢.~ Dr. ~ ,4 c. .~ ~'Jo lC ~ ~'-/~
Date
6. DHHS APPROVAL
Approved for/z~e~,/~Sedrooms by
Approved ~-//~ ~ Disapproved
Terms of Conditional Approval
Conditional
Date
The MunicipalityofAnchorage 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 inordertosatisfycertain federal and state requirements. Employees of DHHSdonotconductinspections
or analyze data before a certificate is issued. The MunicipalityofAnchorageisnot responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LJ I~IL~,StDE ~a.j ~,~-'FtLIJ ~?~ Parcel I.D.
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water ~.~tem number
Date completed ~ -'/'o ~'"'~ ~ Driller
.Cased to / ~, ~ Casing height '-~
Y '~ Wires properly protected (Y/N) ~'
FROM WELL LOG
'5 -'/o
Date of test
Static water level
Well flow 5
Pump level :37 o
g.p.m.
AT INSPECTION
~, 'L~, ~'/?..- i~gN~C~pALtTY OF ANCHORA~
SEPARATION DISTANCES FROM WELL TO:
+ / COt
Septic/holding tank on lot
Absorption field on lot .+ too
I
Public sewer main + I po
~- (00~
Public sewer service line
WATER SAMPLE RESULTS:
Coliform O
Date of sample: ~, Z,~, q' ~
Nitrate
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
~ I00
.-t l O--~ t
-~ lO0
ool
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed ~)' ~' ~'~'~l'7~{~' Tank size I'Z.5'o Compartments
Cleanouts (Y/N) ~' Foundation cleanout (Y/N) ~ ~ Depression (Y/N)
High water alarm (Y/N) 14 Alarm tested (Y/N) ~
Date of pumping
/v
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot -t, too On adjacent lots
To property line +' ~ o t & ~ + ~0
Absorption field Water main/service line
Surface water/drainage
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK pAGE
ION
Date install'eft-. Manufacturer ~
Size in gallons ~ Manhole/Ac~
Vent (Y/N) ~
"Pump ~ ~ "Pump off" level at
High water alarm level Cycles tested
Meets MOA electrical codes ~
·
OM LIFT STATION TO:
W. eYc~n lot On adjacent lots
D. ABSORPTION FIELD DATA
Date installed ?- ~'~/ ~/'(~ ~
Length Z,3- ~ Width
Total absorption area 7 c~o
DepressiOn over field (Y/N)
Results (pass/fail) l¢~55
Peroxide treatment (past 12 months)
Soil rating /~-~' System type 1')(~t~
Gravel thickness I + f Total depth
Cleanouts present (Y/N)
Date of adequacy test
for ~-o~
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot + ~' f¢~
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots -¢ /o-o ' Propertyline
To existing or abandoned system on lot
Cutbank + led / Water main/service line
Driveway, parking/vehicle storage area 4- 5o
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA
Signature
Engineer's Name
Date
date of this inspection.
HAA Fee $ //~'~f ~'-5~¢'
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
NORTHERN TESTING LABORATORIES, INC.
3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 · FAX 456-3125
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 · FAX 274-9645
Constructing Engineers
9601 Buddy Werner Drive
Anchorage AK 99516
Attn: A1 Landers
Report Date: 08/26/92
Date Arrived: 08/25/92
Date Sampled: 08/23/92
Time Sampled: 1400
Collected By: CH/MW
Our Lab #:
Location/Project:
Your Sample ID:
Sample Matrix:
Comments:
Al19894
L1 Hillside Add #1
Water
MDL = Method Detection
Limit
Flag Definitions
B = Below Regulatory Min.
H = Above Regulatory Max.
E = Below Detection Limit
Estimated Value
Date
Method Parameter Units Result Flag MDL Analyzed
EPA 353.3 Nitrate-N mg/1 <MDL 0.1 08/25/92
Reported By: Su;an
Microbiology Supervisor
-Q.:c. Zo %. :- -- / / 7 ~_
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1-3