The URL can be used to link to this page

Home My WebLink AboutGRANITE VIEW BLK 11 LT 10 Municipality of Anchorage Page [' of ~--~ DEPARTMENT OF HEALTH AND RUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION' P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 - On-Site Wastewater Disposal System and/or Well InspeCtion'Report Permit Number: '~'d'Jcl~'O[iZ' PIDNumber: 'OI~-- Na~.: ~ ~ ~ ~~ Wastewater System: D New ' ~Upgrade Address: t~i ~~ ~ ~L~ ABSORPTION FIELD" Phone: g~_~3~~ IN°'°~edr°°ms: ~ Deep Trench ~ Shallow Trench ~Bed .OMound OOther~ Soll Rat ng' ' Total Depth from origlna~grade: LEGAL DESCRIPTION ~ ..~ '~ ~-~ 5~ Lot: [ ~ Block: Subdiv~ion: Depth to pipe bottom fro~ original gra~e: Gravel depth beneath pipe Township: ~/~ Range: ~t~ JSectio~/~ Fill added above original grade: Gravellength:~, ~ ONew ' 0 uPgra '~ Gravel width" ~/ Number of lines: Disiance ~eiween lines: Classification (Pti, .a~-- T,,~~ FL CasedTo:{.. ' - Ft. ,Totalabsorptionare,:~ ~ ~ SQ. Ft. PIpe material: ~Bi~ From Tank Field Slation Tank Sewer Lines , ~ . ~ I ~ 0 , Surface Lot Size in g~llons: ~~ Line ~1~ ~ t~ ~31~ "Pump on" level ;~lgh. water alarm at: Foundation ~ ~l~ ~?/~ Cudain .~ '/~ ~ 'l~ ~ Electrical Inspections peformed b~ Drain Remarks: ~ 5~ ~ ~ ~ BENCH MARK I Assumed Elevation: Reviewed and approved by: ~ Date: ~-. Permit No. ~ v,J~/~--O Jla. Page . 2, of . Municipality of Anchorage . DEP'~RTMENT OF HEALTH AND HUMAN SERVICES · ~E~VIRONMENTAL SERVICES DIVISION . ' P.O. Box 19665~, Anchorage, Alaska 99519-6650 Telephone: 343-4744 On-Site Wastewa[er Disposal System and/or Well InsPection Repod . Legal Description' u~ ~o~,~ ~*~,~ ~ PIDNo.: / / / ~.~"2'""~'~',~_~_ ~ = ,~.q .........~ ............... ~ .... ./. .~ ........................................ ~ ................ ~ ~"' Permit No. %~ ~ ~ ~) I J Z. Page . 5- of. ~ ~0 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Ins pection Report.'.~ Legal Description: t.~-r o ,~ ~ ~1.3 (~-E. ~/~..~J PtD No.: ~t~ ,. -~C)2.-Z-cJ'. Rick Mystrom, Mayor Municipality of Anchorage Department of Health and Human Services $25 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 June 15, 1995 Jeff Garness, P.E. Alaska Water and Wastewater Services 8471 Brookridge Drive Anchorage, Alaska 99504 Subject: Waiver Request for Lot 10 Block 11 Granite View Subdivision Waiver Request ~WR950023, PID ~014-302-29, SW950112 Dear Mr. Garness: Your request for a waiver of the required 10 foot separation between a septic system and a lot line has been approved. The waived distance is 2 feet from the north property line. This approval applies to the existing septic system lot line separation only. Any future upgrade to the septic system will require all separations be met or another approval from this department. Sincerely, Daniel J. Roth On-site Services ljw ~7 '~ MUNICIPALITY OF ANCHORAG~~ Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR# [~3~2qA~ PID# 014-302-29 HA% Permit Date Received: June 5, 1995 Legal Description: Lot 10 Block 11 Granite View Subd___~ivisiOn Engineer: Jeff Garness, P.E., Alaska Water & Wastewater Services 8471 Brookridge Drive, Anchorage, Alaska 99504 Applicant: Gary & Debra Griffith Waiver Requested: Lot line waiver of 2 feet from the north progerty line. Criteria: 1. Geology: Points: ~ A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: Special Conditions: o 3. Other: Waiver is Granted: .~. Waiver is NOT Granted: List Conditions or Reasons for above: ~6~ B~/=~F~ Date: ~-- /~ ~~f By: /),tm te o Name of Reviewer Rec #: 00947/120 Amount: $ 115.00 Date Paid: June 5, 1995 MUNICIPALITY OF ANCHOP~AGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGP~ADE) PERMIT PERMIT NUMBER:SW950112 DESIGN ENGINEER:ALASKA WATER & WASTEWATER SERVICES OWNER NAME:GRIFFETH GARY THOMAS & OWNER ADDRESS:9120 GRANITE PL ANCHORAGE, ALASKA 99515 PARCEL ID:01430229 PAGE 1 OF DATE ISSUED: 6/13/95 EXPIR3~TION DATE: 6/13/96 LEGAL DESCRIPTION: GRANITE VIEW BLK 11 LT 10 LOT SIZE: 9995 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND t5.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED A_ND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS:~ ~ Rick Mystrom, Mayor Municipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 June 15, 1995 Jeff Garness, P.E. Alaska Water and Wastewater Services 8471 Brookridge Drive Anchorage, Alaska 99504 Subject: Waiver Request for Lot 10 Block 1t Granite View Subdivision Waiver Request ~WR950023, PID ~014-302-29, SW950112 Dear Mr. Garness: Your request for a waiver of the required 10 foot separation between a septic system and a lot line has been approved. The waived distance is 2 feet from the north property line. This approval applies to the existing septic system lot line separation only. Any future upgrade to the septic system will require all separations be met or another approval from this department. Sincerely, Daniel J. Roth On-site Services ljw ~7 Alaska Water & Wastewater Services "Preserving The Last Frontier" Municipality of Anchorage Department of Health and Human Services Division of Environmental Services On-Site Services Section P_O. Box 196650 Anchorage, Alaska 99519-6650 Ref: Septic System Upgrade for Lot 55, Bk 3, Granite View. To whom it may concern; Attached is the application, site plan, and design drawings for the subject septic system upgrade. Comments regarding the proposed system are as follows: !. TRENCH DESIGN: As can be seen from reviewing the attached percolation test results, the soil "perked" at 1.1 minute/inch at the location proposed for the system upgrade. This corresponds to an application rate of 1.2 gpd/ft2. Since the existing home has $ bedrooms, the total design flow is 450 gpd. Based upon this, the minimum amount of absorp~/~br%area is S75 ft2. The proposed trench is 5 feet wide, (.~.1~ feet deeo,~ and 52 fe~t long, providing an t-~absorption 'ar~a of $75 ft . Upon looking at the design drawings you can see that I am requiring the installation of 4 feet of drainrook. The additional 1.9 feet of drainrock (above the 1.2 gpd/ftz soils) is extra depth to mak~ the design more conservative, since there is no room for~future upgrades, without getting waivers to nearby wells. 2. LOT LINE WAIVER: Because of the limited space, it will be necessary to place the trench within two feet of the north property. Per the as-built survey, there are no easements in thls area. The septlo system on the property to the north (lot 11, Bk 11, Granite View) will be only about 12 feet away. Per the as-builts, that septic system is a 10 foot deep trench with 6 foot of drainrock 12'). Based upon these facts, it is my recommendation that the waiver be approved 'For a two foot separation distance. 3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed upgrades. 4. SLOPE CONCERNS: Tile lot is generally flat, therefore, there are no slope concerns. I am unaware of any negative impacts that this installation would impose on adjacent wells, or septic systems. If you have any questions, please call me a 537-6179. Sincerely, , Ow ~e~/, ,nsultant Grif~th2.WPS cio PC~SL,~ ~ PERFORM'~D FOR: . 'Municipality of Anchorage I ~-_"' . ~' .DEPARTMENT OF HEALTH & HUMAN S~RVICES 825 "L" Street, Anchorage, Alaska 99502-0650 . sOiLS LoG - PERCOLATION ;EST LEGAL DESCRIPTION: ~ ~ gjp Township, Ri ige, Section: - ' eLD )E SITE pLAN I . 'ER t4 o ~/~l~' WAS G.OUND WATER ~ ~ J '" ENCOUNTERED? ~:'; ! s IF YES, AT WHAT DEPTH? ~,1~ ~.e~l~c=:~... pO E Grosa Net Depth to Nat Reading Date Time T!m" Water : Drop .~nnnl ATinN RA~E 1.O~5 (minute~ nth) PERC HOLE DIAMETER ' TEST RUN BETWEEN ~I FTAND '-~ · OMMEN S ~ PERFORMEDBY' "'~t~F"' ~/3.~i~:..~ , I ~ ~ ' CERTIFY THAT THIS TE~T WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDE . j ' ,.,~0 It ts the responslbllJty of the owner or bill]der, prior to cOllStrUct, lon, :to proposed, bulld!n~ ~rade r~latlve to' fin. lsbed grade and ut:lltv connectm~s and ~ determhqe tile eXlZ[ence of lilly Inents, COVOB2. I]~, or l'e~brlctlolls which do not appear on the recorded subdivi- sion p/aL z, ,q -,.; ........... 4 ~,i, · . "~V;'¢~',;;'¢.?:¢/' - · · /o////z~-....: :--... · %?,3'~'~:~¢}2~ ..-'. _-~c~w."'~/~/~q'. · - , . .'...~,~,~ ~ · '".:-' . :~ ;....(",.'-.;':)"':....~: ~.... '~, .' .. ' ~'. "::'.. "".." '~ .' '. '2'": :' ..."...-...:'Z. :.Z' :.:'.,':' ?" ,'-e ~,~~;,,.,;, ..; ..... - · '-LOT 8USVEY. Bff~TI~I,,ATIOil--~ ': "..'. .' .~ ,o~ ~ip~ · · · '. Lot Block Anchorooe Recording ~~ --~ *~' --- · ...... ~' ' . ~'z.'--': '-: - --~~". / ~/.Z~_~.(O. I ~ I _/._:_.~=~ ..... I ' .,.-::~?~72 ¢~-I ' °~'~.~.-I -. 4'- ~'~" ~- ......... / / / I '1 / ~. ~os3,oo,,~. ~o It Is the respon,qlbllity of the owner or builder, prior to constrtlet, loI1, to ])roposed building grade relalivo to shed grade and utdi;y connections and ~ cletermh~e the ex:~tcncte oI :thy merits, covermnts, or lesbrlctlons which do not appear on the recorded subdivi- sion plat. ,g&W..'- · - ~ "..~,~-'~^ ~ LOT SURVEY CERTIFICATIOLI- Lot Z~ , Block .~&,~Z-7 ~._~ Z2~ .~_ Anchorege Recording Precinct, Alo~ko LEGEND: (~ Bro:~ C~p MonumGnl .O Iron Pip~ · Stool Pin ~ Survcy Hub &Tock LT_ ,z.'.:c.~u. LC555ZZ ADAMS* CORTHELL* LEE CONSULTING ENGINEERS -- IJE]ILS, FIJIJNDATIEINS, AND MATERIALIJ ij[3X ij4~ FAIRIJANKS TEL. AP-ril 3~ ~961 ~/0 3634 Mr. R. Po House Bo~ IODS Anchorage~ Alaska SUBJECT~ Percolation Test - Granite View Subdivision, Lot I0, Block II Dear Sir= Transmitted herewlfh ere fha results of fha percolation fesf per~ormed in strict accordance wlfh fha method prescribed in fha FHA publicaflon ~In!D~m ~ro~e~y Standards. The fesf was per~ormed In a pre-dug hole et a depth of 5,4 ~ee~ below existing grade. The percolation rate wes I inch per 25 minutes. I~' you have questions regarding fha results o~ this please ~eeI ~ree fo contact fha writer. ANCHORAGE FAIRBAN KS PERCOI_AilON I'EST DATA I.OCATION SKE'FCH APP. 'roPoo. FROST [i[:li[~i~O .....IDA:i~I (~'~6-~":l:i'l~l-E---~'~":F~'lrJ 1 DEPTH T~ HzO NET DROP s ~ f · r_NC.)LA 1 ION RATE LEGEND GRAVEl. SAND SILT CLAY ORGANIC CONTENT PEAT WATER TABLE M¢INROY'S 1335 H~der Box 1021, Anchorage R. P. House 10/3/61 94 Feet 6" Well 0 to 63 63 to 68 68 to 92'6" 92'6" to 94" gravely soil gravel & silt some water cement gravel gravel & water P~nped clear in about 20 minutes ~a~ Ao Ro McInroy MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 01 4-302~29 HAA# 1. GENERAL INFORMATION Complete legal description Lot 10; Block 11; Granite View Subdivision Location (site address or directions) Property owner Mailing address Lending agency Mailin. g address Agent Address 9138 Granite Place Peter Male 9138 Granite Place Anchorage, AK Day phone Anchorager AK 99516 Day phone ..... Da~ phone Unless otherwise requested, HAA will be held for pickup. 2, NUMBER OF BEDROOMS: 3 3, TYPE OF WATER SUPPLY: NOTE: Individual well XX Community well Public water : If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site XX Holding tank Community on-site Public sewer 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#21 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 Firm Address Engineer's signature ALASKA WATER & WASTEWATER GON~tULt'ANi~ ~/~ 6901 DEEIARR ROAD, SUITE 2B ANCHORAGE. ALASKA 99504 Phone Wastewater Consultants, inc. $ ~ Shall be PAID //DO ~ or prior to, closing for the Engineering Services Provided. DHHS SIGNATURE ~ Ap.proved for '7'-~ /~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: 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 orderto 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 engineeFs work. Legal Description: A. WELL DATA Well type PRIVATE Log present (Y/N) Total depth Sanitary seal (Y/N) · OCT 1 Municipality of Anchorage ...... .~ RVICE ~uI~,~ .... DEPARTMENT OF HEALTH & HUMAN SE ~,O~A~ SE~W~ Environmental Services Division .... 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist GRANITE VIEW; LOT 10, BLOCK 11 Parcel I.D.: 014-302-29 94.5' If A, B, or C, attach ADEC letter. ADEC water system number N/A YES Date completed Cased to 94' YES FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~ Date of sample: /~-4~ B. SEPTIC/HOLDING TANK DATA Date installed §/~n./g5 Foundation cleanout (Y/N) Date of Pumping 10/7/99 C. ABSORPTION FIELD DATA Date installed 6/2 !/95 Length 57' Width 10/3/61 Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION 10/3/61 UNKNOWN UNKNOWN g.p.m. YES Nitrate 10/7/99 51' ? 1 g.p.m, Collected by: Other bacteria ~ A.W.W.C., INC. Tank size lnnn Number of Compartments 2 Cleanouts (y/N).YES YES Depression (Y/N) NO Highwater alarm (Y/N) NO Pumper A+ HOME SERVICES Effective absorption area ~ Monitoring Tube present (Y/N)YF~ Date of adequacy test 10/7/99 Results (Pass/Fail) PA~ Soil rating ~or ft2/bdrm) n R - 1.? System type TRENCH 5' Gravel thickness below pipe 6' Total depth 8.5'+ Depression over field (Y/N) NO For ,'~ bedrooms Fluid depth in absorption field before test (in.); 17.5" Immediately after863 gal. water added (in.): 26.5" Fluiddepth 19.5" (ins) Minutes later; 924 Absorption rate = 450+ .q.p.d. Peroxide treatment (past 12 months) (Y/N) NONE KNOWN If yes, give date - 72-026 (Rev. 3/96)* D. LIFT STATION a~~ Date installed Size in g Manhole/Access (Y/N) ~ "Pump oft" level at* High water alarm level at'/ *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 100'+ On adjacent lots 100'+ Absorption field on lot Public sewer main 100'+ N/A On adjacent lots Public sewer manhole/cleanout 100'+ N/A Sewer/septic service line 25% Lift station N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5'+ Property line 5'+ Absorption field 5'+ Water main/service line_ 10% Sudace water/drainage 100% Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line '7 ~1,{~+/ Building foundation 1 O' Water main/service line 10'+ Surface water 100% Driveway, parking/vehicle storage area 10"+ F. Curtain drain ENGINEER'S CERTIFICA~'IO~1~///~/ I certify that l h,~7~7~ d~e~mi~ru En,n r' ~/l '(,] g' ees Name Date NC~NF ~:~C~WN Wells on adjacent lots 100'+ fid inspections and review of Municipal /ines in effect on this date. JEFFREY A. GARNESS HAA Fee $, ~..,.~,¢, D D Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Parcel I.D. # 1o MUNICIPALITY 0FANCHORAGE ,!'.,., ~: . - DEPARTMENT OF HEALTH & HUMAN SERVICES_ Division of Environmental Services On-Site Services Section :: P.O. Box 196650 Anchorage,Alaska 995t9'6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description" Location (site address or directions) ¢~.-~-~ · /~, · prOperty owner Mailing address Lending agency Mai!.ing address Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. . -- ',;:,. .... . -. · ~,.-- L.;-)" . . . : ..._ .:.. F,-;'.?' :-~,~1.~(~ 2. NUMBER OF BEDROOMS: ~ ~ 'p~-V_-u? 3. TYPE OF WATER SUPPLY: :-:~ .~:.. ...................... - . ..... -- ' Individual well Community well .. -: _ ,-.- Public water - 'System, provide' NOTE: If community well written confirmation from State ADEC~_~st- lng to the legality and status of system. - 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site /~ Holding tank'- -' ' ' :--:.-' '-." - -' r-r1 Community on-site ' ":- ' · . ., ..... -_.: . Public sewer ' :, NOTE: If community wastewater system, provide written confirmation from State attesting to the legality and status of system. 72-025(Rev. 1/91} Front MOA~21 DHHS SIGNATURE. Approved for ,/~7 bedrooms. , ., ,, . ,.- ,.. Disapproved. " - Conditional;approval for- '~' -:,;'bedrooms, with the following stipulations: .:'.';.':" · .- c 7"~ .' * : , · .i'.'~ , :~ · .: ' STATEMENT OF INSPECTION BY ENGINEER · As Certifiedby.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 ot~ the date of this inspection. . Alaska Water & N , _. ' ' Wastewater Services ame of ~-irm ~,~-~ RrnnEric~nR Dr. / Phone Address ~ ~ / ,'*"/" I Engineer's signature ... Date Additional Comments """ 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-O25(Re~.1/91) Back MOA~21 Legal Description: ~o'T- A. Well Data Well type D~--~v~-~~-'~-- Log present (Y/N) Total depth Sanitary seal (Y/N) -../.~_ MUNICIPALITY OF ANCHORAGE Municipality of Anchorage ENVIRO~i SERVICES DIVISION· Department of Health and Human Services ? 1995 HEALTH AUTHORITY APPROVAL CHECKLIST RECEIVED ~o> ~.K-.u.~ ~-'~,'~=' ParcelI.D. c::)J,,~-- ~c:)Z.- 7--cJ' If A, B, or C, attach ADEC letter. ADEC water system number ~'J /A Date completed 10/~/~1 Driller casedto crA" m,~o,~ Casing height Wires properly protected (Y/N) ,y ~ c. Date of test Static water level '-~Well flow Pump level1 FROM WELL LOG AT INSPECTION g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I lC) + Absorption field on lot I ~0 Public sewer main · ,~ .......... e line ; On adjacent lots > { oo ; On adjacent lots ~- ~ oo Public sewer manhole/cleanout ~J J~' Petroleum tank ~/,~ WATER SAMPLE RESETS: Coliform Nitrate Date of sample: 7/G/q~'- SEPTIC/HOLDING TANK DATA ~____-~ Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping O ~ J. /~°/r-/d~ Other bacteria Collected by: ~ c..~ . ~,4,1~. Tank size I ooO Compartments ~' FOundation cleanout (Y/N) ~ ~ ~ Depression (Y/N) ~/~ Alarm tested (Y/N) ~ A /~ Pumper ~/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: / / Well(s) on lot lie +-- On adjacent lots ~ To property line 1 2. I--+ Absorption field ~ / ~ t00~ ~J/~ Foundation Sudace water/drainage Water main/service line >-lc)/ 72-026 (W93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Vent (Y/N) ~evel at High water alarm level Meets MOA electrical codes (Y/N) ~ SEPARATION DI~ON TO: ~ ~ On adjacent lots Su~ D. ABSORPTION FIELD DATA ~--~--~ ~_.~ Manufacturer Manhole/Access (Y/N) ~' Level at Date installed G/'~//~'.~' Soil rating (GPD/FF) ' ~ To /- ?-- System type /--~-~--~ / / Total depth Length ~'7 Width ~ Gravel thickness (~ / ~ ' ~ '+ Total absorption area -~ c~ ~ ~-r ~' Cleanout present (Y/N) '"t ~___c~ Depression over field (Y/N) . Date of adequacy test r,J/~- Results (pass/fail) ~J//~ for ~ Bedrooms Water level in absorption field before test /'J/A- After test ~ Peroxide treatment (past 12 months) (Y/N) /',/ /~- If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water > / Curtain drain N/A I On adjacent lots ~ i oo Property line __.~-7 ~ +-- To existing or abandoned system on lot ,z~ Cutbank ~/~ Water mai~se~ice line ~/~ Driveway, pa~in~vehicle storage area ~0 E. ENGINEER'S CERTIFICATION I certi that I have checked, verified, or nformed to all MOA and HAA guidelines in e~e~~a, te of this inspecbbn, fY ..~ ~.'~ OF / [ Sign at ure .- ~ ~E S H~ Fee $ ~ ' ~ Waiver Fee $ Receipt Numar // ~ ~/~70) Receipt Number .... DATE RECEIVED 1'~: " INSPECTION APPOINTMENTS /-/ T, ME T,ME . \ ^ . T,ME ~ / ' ~ ~ ~/' DATE ~- ~ DATE INSPECTOR INSPECTOR INSPECTOR DEPT, OF H~ALTH & MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL P~OTECTION DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 JUL 8 1980 ENVIRONMENTAL SANITATION DIVISION Te,ephone 264-4720 RECEIVED_ REQUEST FOR APPROVAL OF I~DIVIDUAL ~ATER A~D 8E~ER FACILITIES DIRECTIONS: Gomplete all parts on page 1. Incomplete requests will not be processed. P[ease allo~ ten (10) days for processing, 1. PROPERTYO~N~R / ~ ~' ~'~// [ PHONE MAI LING ADDRESS PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION ~ PHONE I MAILING ADDRESS 4. REALTOR/AGENT I PHONE MAILIN6 ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION B. TYPE OF RESIDENCE NUMBER OF~BEDROOMS [] One [] Four [] Other '~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [~ Three [] Six 7. WATER SUPPLY INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. Awell lo§ is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM · ~ iNDIVIDUAL/ON.SITE*~ [] PUBLIC UTILITY //~0/--¢ ~ ~YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY / 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 INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or []Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTAN~ESwELL TO: Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS [~'~APP ROV ED FOR -~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED ~...~~ DATE BY ISAACS PUMPING SERVICE (Norm Tibbetts, Owner) 6218 Quinhagak Street ANCHORAGE, ALASKA 99507 Phone 344-0114 ]087 I ANCHORAGE. ALASKA 99502 I PH 907-279~0483 i TLX. 090-25280 I I I I I I [ TAX I All claims and returned good[ ~IUST be ..... panied by this bill.~h ~'~l~'~-~Oa 1919 SERIES 609 R&NI No. 051001-61 Sanitary Sewer System; Consisting of a it~ Lot 10~ Block 11~ Granite View Sub- Philip Baldner of R&M Consultants con- ystem on the above described property. The test indicates acceptance rates determined under conditions at the time tested. Actual system performance over long periods of time depend on factors which cannot be evaluated by this test thus our office cannot warrant the suitability or fitness of the system for either an extended period of time or for user demand in excess of the expected flow noted herein. Factors affecting system performance include: Actual use demand on the system; Fluctuations in groundwater levels; Physical conditions of the septic tank, leach field, trench or seepage pit and soil. It should be noted that while a septic tank and leach field disposal system is one of the most reliable methods of sewage treatment and disposal it is nearly certain that the leach field or seepage pit will fail sometime during ANCHORAGE FAIRBANKS JUNEAU Ms. Moriarty August 5, 1980 Page 2 the useful life of the structure. Studies indicate leach fields~ trenchs and pits have a life expectancy of ten to twelve years under optimum conditions. All septic systems have a finite hydraulic loading capacity which can be expected to decrease with time. Because the house on the lot is occupied, we assume that the seepage pit was at its normal degree of saturation. During this test the liquid levels in the septic tank and seepage pit were monitored as water was added to the system. The measurements are summarized in the following table: DATA & CALCULATIONS FOR SEEPAGE PIT TEST SUBJECT: 3 Bedroom = 450 GPD Required Flow PROJECT NO. 051001 -61 DATE: July 29, 1980 1. TIME OF PUMPER ARRIVAL: 9:10 a.m. SEPTIC TIME SEEPAGE TIME GALLONS GALLONS GALLONS TIME TANK PIT REMOVED REMOVED ADDED LEVEL LEVEL FROM TANK FROM PIT TO PIT 3.05' 9:05 4.70' 9:05 o 3. 4. 5. 6. 7. 3.05' 9:34 7.20' 9:32 3.05' 9:47 4.90' 9:45 6.95' 9:52 4.90' 9:51 1000 1000 Specific capacity : (1000 gallons/(7.20-4.70ft.)) × (1 ft./12 in.) : 33.33 gal./in. 975 Ms, Moriarty August 5~ 1980 Page 3 DATE: July 30¢ 1980 8. 6.75' 8:31 4.90' 8:33 Effluent acceptance rate based on specfic capacity = (4.9 feet - 4.9 feet) (12 inches/foot) (33.33 gallons/inch) = 0 gallons SEPTIC TIME SEEPAGE TIME CUMULATIVE TIME METER TANK PIT GALLONS ADDED READING LEVEL LEVEL - TO S~EPAGE PIT 10. 6.75' 8:40 4.90' 8:40 0 8:40 6.75' 8:53 4.75' 8:50 50 8:50 6.75' 9:04 4.25' 9:02 100 9:02 6.75' 9:16 4.10' 9:14 150 9:14 6.75' 9:28 4.00' 9:26 200 9:26 6.75' 9:49 4.15' 9:46 250 9:46 * 6.75' 10:12 4.00' 10:11 300 10:11 6.75' 10:33 3.95' 10:30 350 10:30 6.75' 10:49 4.00' 10:47 400 10:47 6.75' 11:07 4.05' 11:05 450 11:05 6.75' 11:25 3.95' 11:22 500 11:22 · Time for well to recover. 11. DATE: July 31, 1980 6.60' 9.10 4.55' 9:08 0 9:08 12. 6.60' 10:25 4.05' 10:27 250 10:23 6.60' 12:01 3.95' 11:59 500 11:55 13. DATE: August 1, 1980 6.75' 9.52 4.85' 9:51 Ms. Moriarty August 5, 1980 Page 4 If the 3 bedroom residence on the property is to house 6 people, the average load on the system can be expected to be 450 gallons per day. During the test, the system accepted 500 gallons in 24 hours on two con- sectutive days with 80% of 500 gallons introducted at the maximum rate the well was able to produce. We can therefore conclude that the system is disposing of effluent at an adequate rate for a 3 bedroom residence. We have appreciated this opportunity to be of service to you. Please contact us if you have any questions concerning this test or if we can be of additional service. Very truly yours, R&M CONSULTANTS, INC. Richard S. Giessel Staff Engineer JC/RG/jh/AT-E 1. Approval requested by: Mailing Address: 2. Property Owner: Mailing Address: GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received July 15, 1976 Time of Inspection Date of Inspection REQUEST FOR APPROVAL OF Pratt INDIVIDUAL SEWER & WATER FACILITIES FOR Conv. Rainier Mortgage Post Office Box 1096 Tacoma, Washiq~ 98401 John & Kathy M Hoke Phone: 344-3198 9138 Granite Place Legal Description: Lot 10 Block 11 Granite View Subdivision Location: 9138 Granite Place 3:15 p.m. 7-16-76 Friday 5. Type of facility to be inspected Single Family 6. Well Data: Individual A. Type C. Construction 7. Sewage Disposal System: On-site system A. Installed C. Septic Tank: D. Seepage Pit: E. Disposal Field: Distances: A. Well to: Septic tank Nearest lot line B. Foundation to septic tank B. Depth No. of bedrooms -3 D. Bacterial Analysis B. Installer 1. Size /OOD 2. Manufactur~r 1. Absorption Area~0'5~x~-c 2. Material Total length of lines , Absorption area , Other contamination , Absorption area , Sewer Lines __ C. Absorption area to nearest lot line EQ-034 (1/74) Paa~ 1 nf twn n~n~¢ MUNICIPALITY OF ANCHORA6E DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTEOTION 2510 East Tudor Road, Anchorage. Alaska 99584 276-2221 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES 1. Type of Inspection: CMRO VA FHA CONV ~' 2. Property Owner: -'~J',-~ k~ q ~ ~,t '1~ ~:)-/~-, 7Y~ ~¢ Jc ¢. Mailing AddreSs: ~ t~f~:~e ¢) , DayPhone: ~V~J~q~ Mailing Address: ~.~ ! 4. Name of Lending Institution: 5. Name of Realtor or Agent: ~ 6. Legal Description: L°'i Location: ~J ~ Phone: Phone: 7. Type of Facility to be Inspected: 8. Water Supply o No. Bdrms. Type of Supply: Public Utility If Individual, number of dwellings presently served If Individual, depth of well Sewage Disposal System Type of System: Public Utility. .Individual Individual (on-site) ~- If Individual, date of installation 72-003(3/76) Page 2 of two pages - Re st for Approval of Individual '~er & Water Facilities Legal Descr~pti0n' ~otlO Block 11 Granite View Subdivision Comments Approved ~ C~ .~~- Disapproved Approval ~Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this 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) ~ · ~ Form Approved FHA FoCal 2573 ~' ' FEDERAL HOUSING ADMINISTRATION ' Budgel Bureau No. 63-R296.8 Re/. Jul~ 1958 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER'SUPPLY AND SEWAGE DISPOSAL SYSTEM INSURING OFFICE ANCHOI~GE, ALASKA PART I.--TO BE COMPLETED BY FHA MORTGAGEE Matanuska Velley B~nk Pouch 7012, Anchorage, Alasks JPROPERTY ADDRESS SERIAL NO. MORTGAGOR OR SPONSOR R. P, House BLOCK NO, LOT NO. TOTAL NUMBER: BASEMENT z i-1 Yes WATER SUPPLY BY: _[~] Public system /[-~ New installation J---1 Community system // /J Con attic or other area be made into additional bedrooms? (If Yes, how many~) '--]Yes No J SYSTEM DESIGNED FOR [~--1 Individual NO. OF BDRMS, GARBAGE DISPOSAl. Yes ]No SEWAGE DISPOSAL BY: --]Public system --]Community system [~ Individual PART II.~TO BE COMPLETED BY.HEALTH DEPARTMENT HEALTH DEPARTMENT INSPECTOR'S SKETCH It.is the opinion of the [] State [~] County __ Local Department of Health that this individual water-supply system [~is [] is not satisfactory as a domestic water supply for the subject property. It is the opinion of the ~1 State [] County [~ Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: J'~ Can be expected to function satisfactorily, and ~ 7 [] Cannot be expected to function ,,~atisfactorily is not likely to create an insanitary condition TIT~E ~ S '~ DATE . ~ S IG~,IAT U..~E ....... , / ~ ~ ~07~ ?he ~e~lfh =~fhoHfy should complete the ~pproprJate opinion statement ~bove ~nd ~x d~te, signature ~nd title Jn the ~p~ces provided. '- ' '.-- Use of the above grid for Health Department Inspector's sit'Ich as well as use of the hack of this form is at the option of the health authority. ....... .¢,~ " -' PAR~ ,h,~'Fb~ USE'~F ~.HA OFFICE TO THE CHIEF UNDERWRITER: [ bare ~e~iewed the ~o~egoing and ~be peninem P~A,CdmpJi~nce [nspe~ion ~epo~, and ~ecommcnd ~bat 'the Individual wa~e~-suppt7 system be considered ~ Acceptable ~ No~ ~ccep~b]e ~wage disposal be consi&~ed ~ Acceptable ~ Not Acceptable. ' DATE SIGNATURE HEALTH AUTHORITY APPROVAL IMI]iIVII)UAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM CHIEF ARCHITECT DEPUTY FOR CHIEF ARCHITECT FHA Form 2573 Rev. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [~ Septic tank. [] Cesspopl. ..Septlcp~ist~nceTank:from Weiii~-~--'O feet. Material ...... "~'~/~-~-~/ ~/'~'~' ~ ~(O 9 ~ ? Number of compartments ~de length ' feet. Inside width, f~et. .Liquid depth, feet. Cesspool: · Distance from: Well, feet; foundation, '"i~- feet; nearest lot line at [] front, [] side, [] rear, feet. Inside diameter, feet. Depth,. feet. Liquid capacity, .gallons. Lining material SECONDARY TREATMENT consists of~Tile disposal field. [] Seepage pits. Other Tile Disposal Field: Distance from: Well, / ~__ _ f~_.et; foundation, ~"~ feet; nearest lot line at [] front, ~.ide, [] rear, ,/() feet. Total length of tile linesI ,-~ 3 ~ feet. Number of lines, ~ ~ . Distance between lines, 7 t/~ ~, feet. Trench width, ~.~ ~ inches. Total effective absi~ 'SPtio0 a~ea in bottom of trenches, '70~ ~quare feet. Length of each line, O t,t,~'~t~ ~0 J ,~. {~bO feet. Dept~-~, top of tile to finish grade, 3 ~1~ inches. Type of filter material: [~ Gravel. [] Broken stone. Other ~)e.s~ ~.,f) Depth of filter material beneath til% ! ~'/ inches. Depth of filter material over tile, ~ -- ~ inches. Seepage Pits: Number of pits Outside diameter, .feet. Depth,. feet. Lining material Distance from: Well, Inspection made by: [] State. Date of inspection feet; building foundation, feet; nearest lot line at [] front, [] si.d~ rear,__ feet. [] County. [~Local Health Authority. ~~-~~'~ REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main, ~ feet. Size of main, ~ .inches. Individual wells ~ are [] are not customary in neighborhood. Give most recent record of failure of well,{ in immediate vicinity to furnish adequate supply of water LotPr°pertieSsize: in neighborhood7 ] feet wide: j~ are [~. ~eonot beingf, eet deep.devel°pedDwellmgWith' bOthset backindividualfrom frontWater'supplyproperty andhne,, sewage-disposal~.~ .~'~'"~ _ feet.Syst6ms: Individual water supply from: ~ Drilled well. [] Driven well. [] Dug well. [] Bored well. Distance of well from: Building foundation, cast iron sewer, ~ seepage pit,. · Well construction: /5-' feet; tile sewer. feet; cesspool, feet; nearest lot line at [~front, f~ side, [] rear, ./tO feet, ~-~'"' ' feet' septic~'ank ~'-'/~ feet; disposal field../0~'~ feet; feet; other sources of possible pollution, feet. Diameter, ~) inches. Total depth, ~q feet. Type of casing, ff/~ DePth of casing, 9~ Approximate depth to pumping level of water in well. ,,~ ~ feet. feet. Approximate yield, -,~" gallons per minute. ~aled wate~ight to depth of ~ feet. Exterior space around casing sealed with: ~ Cement grout. ~ ~ddled clay. ~ Or~na~ backfill. Well cover: ~ ~ncrete. ~ Wo~. ~etal. Openings in well cover watertight: ~ Yes. ~ No. ,urn,: ~ Shallow well. ~ Deep well. Len~h of drop pipe, ~ 7 feet. ~mp capaci~, ~cated in: ~Basement. ~ ~mproom off basement. ~ Pumphouse above ~ound. ~ ~mp pit. ~mproom pro,fly &dined: ~ Yes. ~ No. ~mp m~ting wate~ight: ~ Yes. ~ No. Type of storage: ~ressure. ~ Gravis. Capacity, . . gallons. Has bacteriologist examination of water been made? ~Yes. ~ No. If answer is "yes," give &te~, 19~/ Quali~ of water ~is ~ is not satisfa~o~ for human consumption. Installation ~does ~ does not comply with approved exhibits, ff any. /~ ~% lnsp~ion made by: ~State. ~Coun~. ~c~HealthAu~oriw. ~ ~~ /) Date of inspe~ion ~~ . 19 ~ / ~~ ~ ~ : .gallons per minute. · ~ .! ADH-I~SE-$-FI (t) Lab. No. INDIVIDUAL WATER SUPPLY ALASKA DEPARTMENT OF HEALTH DATE Section of Sanitation and Engineering ACTION ON REQUEST FOR BACTERIOLOGICAL WATER ANALYSIS from the Individual Private Water Supply Oranite View ~abd./Spen serving, was received ~2/1~ ' and examination has been completed. OFFICE Satisfactory ~ Questionable Unsatisfactory Records in this office indicate this Individu~te Water Supply to be of sanitary status. J . Analysis shows this SAMPLE to be Satisfactory. Questionable .Unsatisfactory. If an "Unsatisfactory" or "Questionable" status is indicated above, you should take immediate action as recommended below. 1. Boll or chemically treat your water supply to protect your family tram water-borne diseases as outlined in en- closed leaflet, "Drink It Pure." 2. rmprove your spring -- See bulletin HSE-6-2 3. Improve your cistern -- See bulletin HSE-6-3 4. Improve your dug well--See bulletin HSE-6-4 5. Improve your driven well-- See bulletin HSE-6-5 6. Improve your drilled well- See bulletin HSE-6-6 7. Relocate your well to a safe location in relationship to your sewage disposal system -- See bulletin HSE-15 8. Bottle Broken in transit, please send new sample. 9. Sample too long in translt~ sample should not Be over 48 hours old at examination to indicate reliable results. Please send new sample. 10. Contact your nearest [] Local Health Department or [] Alaska Health Department, Sanitation office for bulletins, consultation, and assistance. 11. This is a surface water source and subject to pollution by man and animals. An approved water supply source should be developed. SANITARIAN'S REMARKS A,D~--HSE-6-FI (e) Out Completely. INDIVIDUAL WATER SUPPLY Section of Sanitation and ~mgineering Request for Bacteriological Analysis Please Look on Reverse of Sheet for S~e Collator,Ion Tnmt. rllction~." 7. !3c ~ ' (Name of person collecting sample) (Date) (Time) Water sample collected from [~'i~ltchen tap; [] Bathroom tap; [] Basement tap; [] Other (list) ................ ;. ........ ...., ................... ~,:......:.::.: ........ ,. ...... :2....,+..~ ...................................... Addr~s premise where source ........................................................ ~...-.~-....-.. .................................................................. (~ame) (Box ~, ov street address) Please place an "X" in the box before i~e~8 which b~g dese~be your watez 8OU~08: ~ell ~ ~ Dug, ~ Driven, ~D~lled, ~ Bored : 8p~i~g, ~ 0i~em, ~ O~er (lis~) ............................................................................................................... ~ Greek, ~ ~ver, ~ Lake, ~ ~ond .................................................................................................................. DUG · o~ ~ Wood, ~ 0on~re~e, ~_~et~l, ~ O~en ~OOA~O~: ~ Zn b~semeng, ~ Basemen~ offset, ~ Under ~o~e, Ogler ................................................ : .................................................................................................................................... o~ ~o~i[~io~ (~[) ............................................................................................................................................. ~R~: Building sewer -- ~-Cast ~on, ~ Wood, ~ Tile, ~ ~bre pipe, ~ Asbestos cement Jolt material ~ ~pe ........................................................................................................................................... GE~R~ ~OR~ON: Does water become muddy or discolored? ~ yes, ~ no ~en? ..................................... v---.: .......................................................................................................... Diameter of well .................. ~.f.~ ............................. depth ........... ~5~ ..................................... feet · ~ ' "';' ......... ................ ........... zz: ..................... ~en~th oe atop pipe ............ ~:2.~;.~. ............................................................................................. ~er depth ~rom boSOm ............................................................................................................ teeg Pump loaagion: ~ ~ well, ~ Offse~ ~ basement, ~ In basemen~ ~ ~ ugi~gy r~m, ~ On ~o~ ot well ~ O~her (l~t) ........................................................................................................ PURPOSE O~ EXAMZ~A~ZO~: Illness suspected? ~ yes, ~-no ~ew souree ot ~upply? ~yes, ~ no Repairs to existing system? ~ yes, ~ no ......... ........... ....................................................................................... PLEASE DRAW A S~TC~ ~ ~E SPACE BELOW. ~IS SK~OH SHOED SHOW ~CATION OF HOUSE, WA'i'~ SUPPLY SOURCE, SEPTIC TANK, SE~R, DRA~ LI~S OR O~ SOURCES OF PO~U~ON ~D DIST~CES BE~N WAT~ SUPPLY SO,CE AND ~ OF ~OVE PAC~I~. SAMPLES MUST BE SUBMITTED IN CONTAINERS PROVIDED BY TH~: ALASKA DEPARTMENT OF HEALTli Anchorng~ A~a~kn cc: SC~O