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MUNICIPALITY OF ANCHORAGE ]
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage< Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL'SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MA'"NG ADORESS
LEGAL DESCRIPTION
LOCATION
DISTANCE Well
TO:
~-~' z Manufacturer
~ I- L q, acity IF HOMEMADE:
Well
DISTANCE TO:
Manufacturer
Well .
DISTANCE TO:
Length bf each line
t/~z .r~,
Top of tile to finish grade
Length Width
Type of crib Crib diameter
DISTANCE TO:
DISTANCE TO:
Well
~epth
Building foundation
Class
IAbsorption area
PHONE
D welli n/~/_,/_~,
Mate~__~
Width
NO. OF BEDROOMS
PERMIT NO. ,.~
No. of compartm~.~s
Liquid depth
/
[~'NEW
E~UPGRAOE
Inside length
Dwelling PERMIT NO.
Liquid capacity in gallons
Material
Foundation z/~f~,/~ Nearest Iot~..~,_line !
Total length of lings I Trench
~ / ' inches
Material beneath tile
~ ~' inches
Depth
Crib depth Total effective absorption area
Building foundation Nearest lot line
Driller
Sewer line
PERM T NO. .
Distance between lines
Total effeetiue absomtion area
PERMIT NO.
Distance to lot line
Septic tank
PERMIT NO.
Absorption area(s)
OTHER
PIPE MATERIALS
SOl L TEST RATING
NSTALLER
REMARKS
DATE
/ 2 o/
LEGAL
!,~: E~: :[ ~.~!!..! (:)L D T.q ): fF. L I~ .3: Fi:
L.::~: ! 3:)[:}KCII~T
[,lf~,l]~l',11...Jt',! hiS'f'Fil"-,!C:l:T E~ETI,.!E[?.N FI t:.!E[.Z fiND f:iN'.:; ON....-S:(TE S[C[,!R(][~: [) :[ :}}~;PO'~;FI!... :~;'.~.'S"['E:Fi i::~;
:![~i((~ TO 2e:.i:;{l Ff~ZT F~:OPI Fi Pt.!BL.IC: !.:.!ELL DEF'END]:NC~ i.]F'ON THE:
OF THE( i~iELL
(:)-t"I,'i[~i:,~: F~:Ei:~:!U ]: I~:EPtEZ,4TS FIFI¥ I::iPPL.¥. SF'[::C: ]: F Z C:[~T :( Cff'~S FIND C;Cff.,I'.~'T'F~:i,.IC;T
ff,ZF! Z L,Fi!~t_ [~: TO ): NSI,.I[;:E F'[;;OF'E[;: :i: i'.,!STFIL. LFt'i" :(
¢ ' DEF'RRTMENT OP HERLTH RND EN',/IRONMENTRL. PROTECTION
, 825 "L / STREET, RNCHORRGE, RK. 9950i
~ ~4 4~ ~E1
L~-~ ..... :. Z TE :SE~ER F'ERf4 J: T'
F'ERMI~- NO. ( ~q'~"-"
' I- ' c ...... cD, 1¢~ ) 2~--'-. 5='.':23: /
, PPLICFINT REtNHJLD THIELE .JR ,_,lC:e, WISTERIR
-,-,
OCRTION LOOKOUT =,,. [.
.EGAL L2 LOOKOUT S,.,"D LOT SIZE 3:2670 SQLIRRE FEET
FYF'E OF :,L IL RBSORBTION SYSTEM I_. TRENCH ~
MRXIMLIH NUflE, EF.. OF BEDRUOM_, - =..~ =,UIL RRTINu (Si.) FT/BR'~= t50
q , c~ RE';ORPTION :¢:,TEH I:..
OF THE _,LIL '-' '-
THE REQUIRE[:,_ I~E - - ~ ~
THE LENbTH BlT'lENS]ON IS THE LENGTH (IN FEET;, OF THE TRENCH OR DRR~NF~ELD.
THE DEPTH OF R TRENCH OR PZT ~S THE D]STRNCE BETWEEN THE SURFRCE OF TFIE
GROUND RND THE BOTTOM OF THE EXCRVRTZON (ZN FEET).
THERE IS NO SET W~DTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE M~N~MUM DEPTH OF GRRVEL BETI.4EEN THE OUTFRL. L P~PE
RND THE BOTTOM OF THE EXCRVRT~ON (~N FEET.':,.
PERMIT RPPL. ICRNT HAS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE
INSTFIL. LRTION INSPECTIONS OF FINY WELLS RDJRCEN'r TO THIS PROPERTY RND THE
NUMBER OF RESIDENCES THRT THE WELL WILL SERVE.
BRCKFILLING OF RN9 SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS
DEF'RRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON--SITE SEWRGE DISPOSRL SYSTEM IS
100 FEET FOR R PRIMATE WELL; OR
150 TO 200 FEET FROM R PUBt. IC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.
OTHER REQUIREMENTS MRY RPPL~. SPECIFICBTtONS RND CONSTRUCTION DI~GRRMS RRE
RYRILRBLE TO INSURE PROPER INSTRLLRTION.
F' E;F-:~"-'t I T E)-::F' ~ F-:ES [:,ECEi'-'IBER _--<t.
I CERTIFY THRT
l: I RH FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH BY THE MUNICIPRLITY OF RNCHORRGE.
~: I WILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
2:: I LINDERSTFIND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE
~'LICRNT R¢~HOLD THIELE J~
ISSUED B ,__~ ...... %~ .................. [:ATE ..................
,~ 3:. c,
~-~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99502 276-222¶
SOILS LOG - PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED:
LEGAL DESCRIPTION:
SLOPE
11
12
13
14-
15---
16
17
18
19
2O
COMMENTS
PERFORMED BY:
WAS GROUND WATER
ENCOUNTERED? ~/'t"~ .
IF YES. AT WHAT
DEPTH?
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inch)
FT AND ~ FT
~
?erfomned for McGhan Construction Oompmny
]egal Description: Lot 2 Block -
Phis For-n reports: SOILS TEST Yes
MUNICI~LITY OF ANCHORAQE
r'''~'x, ,"~"~ DEPT. OF HEALTH &
CONSTRUCTION TEST LAB ~..?IRONMEN1AL P~OTECT]ON
"One Test is worth a Thousand Opinions"
2204 Cleveland Anchorage, Alaska 99503 ~JQL-~-J~f~
RECEIVED
Date Per.~ormed7/23/79
Subdivision Lookout Subdivision
PERCOLATION TEST Yes
Depth
Feet
11
1.5'
--__4'
~~6,perc
Zone
Soil Characteristics
Peat
Dark Bro~.n San.dy Gravel (GP)
Brown Silty Sandy Gravel
(GM)
Bottom of Test Hole
/\
~as Ground Water Encountered Yes
if YES, What depth? 10'
leading Date Gross T~ne I Net TLme Depth to H20
Net
Drainage
7/23/79 ! Sat.
7/24/79 0 ! 10" -
'ercolation Rate
10
2O
50
60 Min.
1"/20 Minute
] 1"
11 3/4"
13 1/4"
13 3/4"
Proposed Installation: SEEPAGE PIT DRAIN FIELD
Depth of Inlet Depth to Bottom of Pit or Trench
IO~4ENTS: 210 -Sq, Ft, drainage area required per bedr~nm
from minus 1.5' to 10'__
_
%
'est Performed by David Pau~ ' ~ %
3/4"
1/2"
1/2"
Data Certified Bv: CONgTp~T~miO~ TEST LAB
Date : 7/24/79
MuNIcIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99502 276-222~'
SOILS LOG- PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED;
LEGAL DESCRIPTION:
3
4
'5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
/oM mo:~2.
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SITE PLAN
PERCOLATION RATE (minutes/inch)
Gross Net Depth to Net
Reading Date Time Time Water Drop
TEST RUN BETWEEN FT AND ~ FT
..1
STATE OF ALASKA
RETURN TO: Division of Geological and C /sicaJ Surveys (DGGS)
· ~ · 3001 Porcupine Drive (TeJep,,~)e: 277-6615) DEPARTMENT OF' NATUP~AL RESOURCES
Anchorage, Alaska 9~501
WATER WELL RECORD
/ , ~J j-,. //~ , y,~? ~.y.' ?' ,,7,~-' ~ ,,~ 7 :~,' <. U.S.G.S. Local
Drilling Company Na~ ' ' ~'~) · ~ "- Drilling Permit No.
Y / / / N/S E/W
Address:
Street Address and Area of Well Location ~? ~,~ /~ ' / ~ / .~
Comp1 et ion
Surface ~ .~'/' ft. '
' - r~.. ' 6. USE: ~Do~stlc ~Public Supp)y
' r' ~ . ~ Threaded ~Welded
~ .... -,. ? ~ =~ 7. CASING: /: ,
8. FiNfSH OF WELL:
[
Type: ~ /. ,,, ..~ '~
. . Slo~/He~h Size: Length:
9. STATIC WATER LEVEL: ?/'~:~ ft.
q~,~ Type of Heasure~nt:
h~/~--~ lO. PU"P'NG LEVEL below land surface
ft. after hrs. pumping
g.p.m.
~II~I~IDA[)~ ~c ~,~O~A~E 11. WELL H~D COMPLETION: ~ In Approved Pit
DEPT. OF HEAITk ~
ENVIRON~ ENTAL PRO"E~IOH ~P~cless Adapter ~ inches above grade
~2. GROUTING: ~eli Grouted: ~ Yes
D~rFI[IrR ii. PU.P: (if available) HP
Type: ~ Sub~rslble ~ Reciprocat lng
~ Jet ~ Other:
15. WATER ~ELL CONTRACTOR'S CERTIFICATION:
Address: ' " :~' -
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL )1~ (~ -- D~ ~Q
OF ON-SiTE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
LOok oUT j LOT
Location (address or directions)
(b) Property Owner ¢'Hh'IA Telephone: Home
Business
Mailing Address
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent
Address
(e)
Telephone '~"/b - 0000
Mail the HAA to the followin(~ address: or: Check her~,~(~,, if hold for pick up.
day phone num Ar bc~ .
List contact person and
TYPE OF RESIDENCE
Single-Family,S,
Number of Bedrooms
WATER SUPPLY
Individual Well~ Community [] Public
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~ 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. 'r
Page 1 of 2 72-025 (Rev 8/86) Front
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e~ep eZAleUe Jo suo!loadsu! ~onpuoo lou op SHHQ ,to seeAoldUUq 's~u@uueJ!nbeJ e~e~s pue leJepe,t u!el~ao A,tsp, es o], Jap Jo
u! suo!ln~p, su! 5u!puel J!eqJ puc s@uJoq ,to s~eseqoJnd o~, Ase~Jnoo e se s!ql seop SHHQ eqj_ 'e:~SelV ,to e~elS eqi u! peJels!f@J
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le^o~ddv A~poq},nv q~leeH senss! (SHHQ) seo!^JeS ueuJnH pu~ q~leeH ;o lueLupedea efe~oqouv ,to /q!led!o!unl~ eqZ
NOIJ. n¥o
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.g
MUNICIPALITY OF: ANCHORAGE MUNICIPALITY OF ANCHORAGE (MOA)
ENVIRONMENTAL SERVICES DJVi$10~EALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
APR ]987 264-4744
Legal Description:
RECEIV[D
WELL DATA
I...OOF..oUT. 50~SDIUI~tOtJ
hOT 2.
Well Classification ';~:2'¢-.~.~ A'~" If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) NO Date ,Completed _OI~J~OLO/~ Yield
Total Depih ~"7 / Cased to xJ_~2o_!Ft~_n Depth of Grouting
Static Water Level ~/ Pump Set At ¢~0¢~
Casing Height Above Ground /~n
Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot 'jrl00
To Nearest Edge of Absorption Field on Lot
; On Adjoining Lots
; On Adjoining Lots + [O0~'
To Nearest Public'Sewer Line '"¢"'/~ ~ To Nearest Public Sewer
Cleanout/Manhole '"P IO0~ To Nearest Sewer Service Line on Lot
Water Sample Collected by C~ ~¢~"'!~y~'f&',,~.. ,'Date 2-.Aj:~/~'7
Water Sample T.e. st Results '"~/~'r"l ~1cc4-~'~
Comments "~Y~'~'~ /¢t'~J-;'{~ 0d~'LJ~'T~'~-~ /(~,J~ CLJ~¢'~ ~'-~l~T~'Z~
B. SEPTIC/HOLDING TANK DATA
Date Installed ~/,~r~ '~ Size J(.00 O ~ No. of Compartments ~'
Standpipes (Y/N) '~/~ LoM¢~ Air-tight Caps (Y/N) k~'~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~0 Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ~ ; for
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well .-~ (od
To Property Line Jr IO f
To Water Main/Service Line ,4"'~,,~ ~
Course 'Jr {~O I
Temporary Holding Tank Permit (Y/N) ~
To Building Foundation
To Disposal Field lO
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026 IRev 8/86) Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absnrnfi,~" Field:
To~
To E
'~¢ / ~;>J~-FJ~J'~Type of System Design ~1¢ ¢1~
Length of Field ~/~ '~
Depth of Field ~ ~
Gravel Bed Thickness ~ '~
Standpipes Present (Y/N)
Date of Last Adequacy Test
ToY .........................
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) I%0'F'
'+l~O'
LIFT STATION
Date Installed __ /;
Size in Gallons __
"Pump On" Level;
High Water Alarm Lew, _
Tested for
Electrical Codes (Y/N)
Comments
__ Dimensions
_ Manhole/Access (Y/N)
__ "Pump Off" Level at
. Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that 12~ave checked, verified, or conformed to all I~IOA and
Signed ~(,..~4¢.~ q/J/~/'~, Date
Company "~~ 4J ¢~ MOA No.
ReceiptNo. ~ ¢ OO/- O O ~ (
Date of Paymen, J~ ~
Page 2 of 2
HAA guidelines in effect on the date of this inspection.
72 026 fRev 81861 Back
Location:
BESSE, EPPS & POI~S
2220 EAST 88 AV~U3E
ANCHORAGE, AK 99507
(907) 349-6451
WATER ~.L TEST
Subdivision:
Block: --
Client's Name:
Address:
Initial Reading ~n Meter:
NORTHERN TESTING LABORATORIES, INC.
2505 FAIRBANKS ST.
ANCHORAGE, ALASKA
907-277-8378
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY CLIENT
!
/'~PRIVATE WATER SYSTEM
SAMPLE DATE:
SAMPLE TYPE:
Routine
[] Special Purpose
Mo. Day Year
PurChase Order No.
Zip Cone
[] Treated Water
[] Untreated Water
Check Sample (for Original contaminated
sample with lab reference no. )
Sample
No,
..,111.
10
Signature of Representative
FOR LABORATORY USE ONLY
TO BE COMPLETED BY LABORATORY
Received at:\ '/~nch. [] Fbks.
Date Received (._3/~, ~/v ~
Time Received
Next Sample Due
/15o
COMMENTS:
SATISFACTORY (~) ~
UNSATISFACTORY U
RESAMPLE R
OTHER BACTERIA OB
TOO NUMEROUS TNTC
TO COUNT
Direct Verification Rnal
C~unt I~B BGB Result* Comment~
*No. of To[~J Coliform Colonies per 100 mi~
:,: ~,-.:, ,.'., ~
DaTe
ISAACS PUMPING SERVICE
(Norm Tibbetts Owner)
6218 Quinhagak Street
ANCHORAGE, ALASKA 99507
Phone 563-3300
All cie, ires and
MUNICIPALITY OF ANCHORAGE
DMSION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General InfoL-,~tion Application Date ~,~ay 14, 1984
(a) Legal [~sc~iption (include lot, block, subdivision, section, township, range)
Lot 2, Lookout Subdivision
LOcation (add, ess or directions)
Upper O'Malley~ Trails End, Longhorn, right on Cobra
(b)
Applicants Nan~ Reinhold Thiele Telephone 346-3417
Applicants Address 8126 Wisteria, Anchorage, Alaska 99502
(c) Applicant is (check on~) iending Institution
Buyer~ ; Other~ (explain);
(d) Lending Institution
Te le pho ne
(e)
Address
I~al Estate Co. & Agent
Address ~/~ ~'/~
2. Type of N~sidence
Single-Family~
Numbe~ of ~edrooms
3. Water Supply
Individual Well~
Multi-Family ~-~ or,her (describe)
Conmunity ~--~ Public
Note: If c~munity well system, must have w~itten confirmation f~cm the State
Department of Environmental Conservation attesting to t~ legality and status.
Is the well adequate for the number of kedrcc~s specified in this HAA (Y/N) y~
4. Sewage Disposal
Onsite ~--~ Public ~ Co~mm/nity ~ Holding Tank ~-~
Is the wastewate~ disposal system adequate for the rumber of bedroons (Y/N)
Yes
[Page 1 of 2]
2-15-84
Engineering Firm Providing Inspections, Tests, Data and Information
I ~'tify that I ha~ ~h~¢ked, verified, c~' c~nfozm'~d to all MDA ~ C.~id~lir~s in
effect on the date of this inspection.
Signed
Name of Firm Co~in & Associates~ Inc. Telephone
Adchzess 1549 E. Tudor~ Suite 204, Anchorage, Alaska 99507
Date May 12, 1984
( ENGINEER SEAL)
6. DHEP Approval
Approved for ,~- bedrocks
App~ove~~ Disapp~o~d ~--~
Terms of Conditional Approval
Date May 12~ 1984
561-6151
The Municipality of Ancho=age Dapa~tm~=nt of Health and Environmmntal Protection dces
not guarantee the continued satisfactory performance of the wate= supply and/or the
wastewate= disposal system. This approval indicates that, as of th~ validation date
sh(Twn above, based on the data and infofmation furnished by an engineer registered in
the State of Alaska, the wate~ supply and wastewater disposal system is safe and func-
tional for the p~nbe~ of b~drcc~s and type of structure indicated°
(DHEP SEAL)
7. Mail the HAA to the following address'.
Call 346-3417 for pickup
KB2/d5/s
[Page 2 of 2]
2-15-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
Lookout Subdivision
MUNICIPALITY OF ,~N~HOI~g~
DEPT. OF HEALTH &
EN¥1RONMENTAL
APR 5
RECEIVED
Lot 2,
Well Classification
Well Log P~esent (Y/N) No
Total Depth 100'
Static Water Level 20'-6"
Casing HeightAboveGround
Elect~icalWiring in Conduit (Y/N)
Date Cc~pleted
Cased toe Unknown
Pump Set At
15"
individual If A, B, o~ C, D.E.C. Approved(Y/N) N/A
Unknown Yield 0 13' do~fn
Depth of Grouting Unknown
Unknown
Sanitary Seal on Casing (Y/N) Yes ~,
Yes Depression Around Wellhead (Y/N) No
Separation Distances from Well:
To 'Septic/Holding Tank on Lot 129' to C.O,~ ; On Adjoining Lots. 1_550.
'~,! · 135'
To Neamest Edge of Absorption Field on Lot~6 /bet~een; On Adjoining Lots
- ," './ t;.U. , --
To Nearest Public Sew~ Line N/A ~' '' To Nearest Public sewer
Cleancut/Manhole N/A To Nearest~' sewer service Line on L°%f°nhous°there sid,
Water Sample Collected By Brust ; Date 5/10/84
Water Sample Test Results satisfactory
Cu~ents
B. SEPTIC/HOLDING TANK DATA
Date Installed .8/1/-79 Size *1000 __ No. of Cu~artments *2
Standpipes (Y/N) Yes Air-tight Caps (Y/N) Yes Foundation Cleanout (Y/N)
Depression ove~ Tank (Y/N) No Date Last Pumped 5/12/84
Pumping/Maintenanoe Contract on File (Y/N)No ; for N/A
Holding Tank High-Water Alarm (Y/N) N/A Temporary Holding Tank Permit~ (Y/N)
Separation Distances from Septic/Holdin~ Tank:
To Water-Supply Well 129' to c.o. To Building Foundation 22'
To Property Line ~,~10' To Disposal Field 16' between C.0.
To Water Main/Service Line on other side TO S~ea~, Pond, Lake, c~ Major Drainage
o~ house
Course N/A,
Yes
N/A
CoNlne~ts *From DHEP Files
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed '8/1/79
Width of Field '5'
Square Feet of Absorption A~ea
Depression over Field (Y/N)
Results of Last Adequacy Test
'210 Type of System Design
Length of Field '91
Depth of .Field *3'
Gravel Bed Thick~ess *6"
*630 Standpipes P~esent (Y/N)
No Date of Last Adequacy Test
satisfactory
Yes
5/12/84
*Trench
Separation Distance from Absorption Field:
To Water-Supply W~ll > 100' To P~operty Line *25'
To Building Foundation > .20' To Existing or Abandoned System cn
Lot N/A ; O~ Adjoining Lots 115'
On other side
To Water Main/Service Line of build. To Cutbank(if present) N/A
To Stream/Pond/Lake/o~ Major D~ainage Co~n~se N/A
To D~iveway, Parking A~ea, o~Vehicle Storage A~ea on other side of building
Counts *From DHEP Files
D. LIF~ STATION NONE
Date Installed
Size in Gallons
"Pump 0~" Level at
High Water AlarmLevel at
Tested for
Electrical Codes(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Me~ets MOA
Corm~ents
Check Permitted Becl~oomRating Against HAA Request 3 Bedrooms
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this~ inspection.
Company CORWIN & ASSOCZATES, INC.
KB1/d5/s
[Page 2 of 2]
Date 5/12/84
MOA No. ST84-038
ENGINEERS
SEAL
2-15-84
MUNICIPALITY OF ANCHORAGE
DMSION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRC/gMENTAL PROTECTION
APPLICATI(~ ~DR F~EALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
App 1 i c a t i on Da t e ~<~ '//z//~24/
Legal Description (include lot, block, subdivision, section, township, range)
(a)
_L°cati°n (add~ess~ '.~.°r directions)~ ~7-,~//2- X~../ /'~ ~-~_.-//~o,-~ /z3~/~7z ~ ~,-~-
(b) Applicants ~ ./~*'~/~ ~/''~ ,~-~'.~'~C~"~.~ ~lepho~ ~q'& ~."')~
(c) appliqant3s (che~) ~nding Institution ~; O~r~uil~ ~;
(d) ~nding Institution ~lepho~
Address
(e)
~al Estate Co. & -AGent
Address
0
0
Te le phone
_Type__of ~sidence
Single-Family ~_~
N~be~ of Bedrooms
Multi-Family
Othe~ (describe)
Wate~ S upj~
Individual Well ~ Community ~ l%~blic ~_.,
Note: If cc~N~nity ~11 system, must have w-~it~n ~nf~tion f~ ~e State
~pa~nt of ~vi~o~ntal Con~rvation attesting to t~ legality ~d status.
Is ~e ~11 ade~ate fo~ the n~ of ~s s~cified in this P~ (Y~])
_Sewg, ~e Dispo~_a__~l
Onsite ~ P~blic ~_-~ Ccratlunity ~ Holding Tank ~
Is the wastewater disposal system adequate fo~ t_he ntmtbe~, of bedrocms (Y/N)
[Page- 1 of 2]
2-15-84
5. Engineerin~q Firm Provid~ctions, Tests, Data and Information
I certify that I have ~cked, verified, or conformed to all YDA ~5%A Guidelines
effect on the date of this inspection.
?
: .. Date . '/
Nam~ of Firm &_~.~ ~-_~_._...I./::.~,.~.~.-. ~- Telephone
( ENGINEER SF~AL)
Terms of Conditional Approval
Conditional~
Date , - .. --
The Municipality of Anchorage Department of Health and Enviro~ntal Protection dces
not guarantee the continued satisfactory 9erfom~mnee of the water, supply and/or the
wastewater disposal system. This approval indicates that, as of the validation date
shc~m~ abo%m, based on the data and information furnished by an engineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and func-
tional for the ~r~er of ked~ccn~ and type of structure indicated.
( ~tEP SEAL )
7. Mail the HAA to the fo].lc~ing addressx
/'
KB2/d5/s
[Page 2 of 2]
2-15-84
A. W~LL DATA
MUNrICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
MUNICIPAUTY OF ANCHOPJkG5
DEPT. OF HEALTH &
ENVi P, Oi',LVyzNTAL p2OJECTION
Well Classification
Well Log P~esent (Y/N)
Total Depth .~ /o S ) caSed to
Static Water Level . JD /- ~"
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on' Lot
If A, B, c= C, D.E.C. Approved(Y/N)
Date Completed
Pump Set At
&.--~.v/d. ,, wz/z Yield
Depth of G~outing. ~/~ ·
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
/ /~ ~.o, ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot/& ~ ~.. , On
To Nearest Public Sewer Line //// To Nea~,est Public Sewer
Cleancut/Manhole /p//~ To Nearest Sewe= Service Lir~ on Lot
Water Sample Collected By
Water Sample Test Results
C<~t~fents
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Size //~ o o
Air-tight Caps (Y/N)
/P/o Date Last Purrg~d
Pumping/Maintenanoe Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) /z//~ Tempo~a~5' Holding Tank Permit (Y/N)
Separation Distanoes from Septic/Holding Tank:
/ ~ C. o, To Building Foundation ~z
To Disposal Field ./J ' ~/~ ~ ~- o.
To Water-Supply Well z/2~
To Property Line ~ /o
To Water .Main/Service Line
corpSe '
0/,/'7, ~7'/;~,r' 5'~% Stream, Pond, Lake, c~ Major D~ainage
[Page i of 2]
2-15-84
C. ABSORPTION FIELD DATA
Soils Pating in Abso~ptiqn Strata
Date Installed--~ ~//~f
Width of Field --~ ~-
Square Feet of Absorption A~ea
Depression ove~ Field (,Y/N)
Type of System Design ~-~ ~u
Length of Field ~ J/
Depth of Field ~ ~ t
Gravel ~d Thick.ss ~ ~ ~'
Stan~i~s ~e~nt (Y~) ~
~te of ~st A~a~ ~st ~/~
Results of Last Adequacy Test ~'~c~/~/S~
Separation Distance from Absorption Field:
To Water-Supply Well .~ /~ ~ ~ To P~operty Line ~ ~-J- /
To Building Foundation ~ ~ ~ / To Existing or Abandoned System on
Lot ~/~ ; On Adjoining Lots
To Wate~ Main/Service Line ~/~/~ ~//~f To Cutbank(if p~esent)
To St~eam/Pond/Lake/c~ Majo~ D~ainage C~se
To D~iveway, Parking A~ea, o~ Vehicle Sto~aGe A~ea
Co~ents , ~ ~-,~ i~>/~ ~-~ ~/
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumpin~ Cycles du~ing Adequacy Test.
Meets MOA
Co~nts
** Check Permitted Bed~ocm Rating Against HAA Request ** ~ ~gd/e~ ~
I certify that I have checked, verified, o~ conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed
KB1/d5/s
[Page 2 of 2]
Date
MOA No.
ENGINEERS
SEAL
2-15-84
MICAL & GEOLOGICAL LABORATORIES'OF ALASKA, INC.
TELEPHONE (907) 562-2343 ANCHORAOE INDUSTRIAL CENTER 5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM: (*) See h on back
I.D. NO.
Water System Name Phone No.
~y : Stat~ 7i~ ~ode
Mo. Day Year
SAMPLE TYPE:
I-1 Routine
r-I Check Sample (for routine sample
i~pelth lab ref. no.
clal Purpose
1~ Treated Water
[] Untreated Water
SAMPLE
NO.
I
I
I
I
I
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY lABORATORY
Analysis shows this Water SAMPLE to be:
[~Satisfactory
[] Unsatisfactory
FI Sample too long in transit; sample should
not be over 30 hours old at examination to
indicate reliable results. Please send new
sam~ple via special delivery mail,
Date Reoe,vec, ~- -/'~- ? ~
Time Received I~.0 0
Analytical Method:
[] Fermentation Tube
J~,Membrane Filter
Lab Ref. No. Result* Analyst
I-FI
I-F1
I-F1
~,No. Of colonies/100 mi. or NO. OI Positive portions.
o~-122o
Rev. 1983
BACTER IOLOO ICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Membrane Filter:. Direct Count
Verification: LTB
Final Membrane Filter Results
TNTC = Too Numerous To Count
BGB
Collform/100ml
Colllormll00ml
Dste .~-//- '~/
Time: /z,~'~ a.m.
825 t "S'I"nEEff
~., 'tGRAGE, ALASKA 99501
(~)07) 264 4i 11
December 31, 1979
Reinhold Thiele, Jr.
8126 Tri-Lake Road
Anchorage, Alaska 99502
Permit ~790563
Subject: Lot 2 Lookout Subdivision
A permit issued by this department for well and/or sewer
system has expired.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal ordinance.
If you have drilled the well a well log should be sent
to this department to document the installation date.
If an engineer has inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files.
If there are any further questions, please contact this
office at 264-4720.
Sincerely,
Les N. Buchholz, R.S. .
Senior Environmental Speci%~l~ist
LNB/ljw
enc: Copy of Permit