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Home My WebLink AboutSUMMIT ESTATES BLK 1 LT 12Summit Estates Block 1 Lot12 #015-072-30 ~ MUNICIPALITY OF ANCHORAGE ~' ~/ · DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON31TE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHONE ~' [] DEGRAOE LOCATION NO. OF BEDROOMS / PER T NQ, ~. DISTANCE TO: ~Well /~/ ~Abs°rpti°nareaT~~ / D~elii~ F ~¢;~ Ma ~'al No, of compartments /OPO IF HOMEMADE: , ~ Well Owelllng PERMIT NO. ~ Oz DISTANCE TO: O Z ~ Manufacturer Material Liquid capacity in gallons D Well Foundation Nearest lot line/~ / No. of lines], Length of each line Total len~]~?ines Trenc width ~ mop of tile to finish grade~ ,~0' ~inches Distance~nhne Material beneath tile Total efrect~b~orp~ area ~ Well Building foundation Nearest Jot llne ~ DISTANCE TO: m Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIPE MATERIALS INSTALLER ~ ~ ~ REMARKS / : . ~ ~ ~ LEGAL P,F'F'L T CFINT LOCFtT ! CIN L. EGRL. HE,..Itt .... ~. qT L~.Z.' E,.1. SLII,,'hH!T E_,F T'¢F'E F!F '~)!L FEE]F:'F'TI?.~ :,T:, ,~.ll T"X' DF::RII,.4FIEL[:, F'EET SOIL. RFITII..a3 ,::fE, L:g FT,-.'ESg)= '~:¢';1;., . E?:, ~g:s F" -F E-i == THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF' THE TREI,..!CH OR DRRINFIEL ]'PIE DEF:'TH OF1 F! TRENCH OR PiT IS 'THE !}:[STRNC:E BETNEEN THE SURFRC. E OF:' THE GROUND RND THE: E:OTTOM OF' THE EXCF!',/FFrION (IN FEET). THE GRR',,,'EL. DEPTH IS THE MZN!MUH DEPTH OF GRFiVEL. E~ETNEEN THE OUTFRLL P]:F'E laND 'TNE BOT-FOb! OF THE EXCfYFRTION (IN FEET). ,'::'ERI,'IIT ..FFL.~L. RI,,!I HI:IS THE m~:',:,r-,-~.~':,ZFI 'rTY TO :[NF'ORH TF. IS OEF'RF'ThlENT E,t![~'TNr:; !r-lc: iNSTFILLFITION ii,.~E,F'EC:TIOI,.2L':; OF RNY NEIIq r'![...)HCr:J~T TO Ti _... F .r.F-E~.F¥ RN[:, FHr.:. ,.,.--,~'~ .pB'r,:,..~..., F~F._ RESI[:,ENCES THFFF THE !,.!ELL. NIL. t~ ..... EF.,m. MINIMUM DISTFINCE BETFIEEN R P.IELL RND FINk' ON-SITE SEWRGE DISPOSRL.. SYSTEH ZS :LEI8 FEET F'OR FI PRI',,,'RTE NELL OR &'.SC~ TO ;2EIO FEE'I' FROM FI F:'L!E:LIC NELL DEF'END!NG UPON THE TYPE OF PL.IBL.!C I,!ELL MINIMUM DZSTRNC:E; FROM R F'RIYFiTE 14ELL TO FI PRIYRTE SENER LINE IS 25 FEET FIND TO R COHMLINITY SENER LINE IS 75 FEET. FIELL LOGS RRE REQUIRE[:, FINE) MUST BE R. ETURNED TO THE DEF'RRTHEN]" !.41THIN ][:C~ DRYS OF THE HELL COHPLETION. OTHER REQUIREMENTS MRY RF'F'L"r'. SPECZFICFFFIONS FIN[) CONSTRUCTZON DIRGRFIH:B FIRE RVRZLRBLE TO INSURE PROF'ER INSTFE_L.F~TZON. I'"_.I'.:.N ....... F I h '~' THR-F "~,, .......... ,LIEF ........ ~[... ~: ':' f: 1' FtI"I f:rFgM!L. IFIR !,.IlTH THE F4'.EC!I...I!REMEI",ITS FOF.: I..li',l'H:,l ]E C'.[7 '..--;',,;7 ¢1l. '"l.'.~,J.-! .... .¢'-'1::' ': ..... E '! FORTH BY THE i"llJI,.,IICIPRLITY OF' RNC;HOF'.RGE. ;2: I !4ILL INS'I"F!,LL 'I"!-IE SYSTEi'"! IN FICCORDRNCE WITH THE CODES. ]:; ! LINDERSTRI,-.!D THFgT TItlE O!',I-SITE SEt,.IER SYSTEM, i"iFIY REE~.UIF'.E EhlLRRGEHENT iF THE RESIDENCE IS REMO[:,ELE[:, TO INCLLIt}E I."IORE 'T'NflN 2 BE:[:,ROOHS. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR:. '?]-i ~ ~'~AL con st, LEGALDESCRIPTION: L0'F i~ ~ I oR~AN~ 1 7 8 SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 2O WAS GROUND WATER S ENCOUNTERED? QL P E IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time i~llY~, Water Drop PERCOLATION RATE / ~, ~ (minutes/inch) TESTRUN~TWEEN. ~"~''~ FTAND ~ FT COMMENTS -. ~ _~.~-..~6~~ 1, PERFORMED BY: /~,'~/~ ~'~ ~'A [~C/~N~ ,/) '~,~LL~ CE(gTIFIED BY: ~~..~ DATE: 72-008 (6/79) ALASKA ENVIRONMENTAL CONTROL SERVICES, INC. 1200 west 33r~ Avenue Suite B ANCHORAGE, ALASKA 99503 Phone 561-5040 CALCULATED BY DATE CHECKED BY DATE / "= Date Drilled: ' ' Static Water Level Draw Down '~ELL LOG feet feet Gallons Per Minute Total Feet of Uastn~ /03 ~e Material Drilled: to Hefty Drilling S.R.A. Box 1553 H Anchorage ,Alask~ 99507 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# ~)/5'- ~0'7~' ~0 HAA# ~ 1. GENERAL INFORMATION Complete legal description Lot 12; Block 1; Su~it Estates Location (site address or directions) 5411 E. 97th Ave. Anchorage, AK ~tope~ty owner .Cathleen Buczynski [Mailing,addreSS-' 54]~1['.E. 97th Ave. ~.Eei'i.d i r)g agency ..... -: N1,ailing address ;~ Agent Address Day phone 346-3446 Anchorage, AK Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 3 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 4. TYPE OF WASTEWATER DISPOSAL: NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. XXx Individual on-site 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. l/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. S & $ ENGINEERING Name of Firm 1702f4 I~a_are I~Iver Leop I~n*rl kl~ O¢~[ Phone ~-- 2-c7 7 ~ Eagle River, Alasl(a 99577 Address Engineer's signature ~'/~-~~' ~--¢~ Date DHHS SIGNATURE / ' v/ APproved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: 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. Municipality of Anchorage MUNICIPALITY/(~EAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division _[uJ · 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 JUL Health Authority Approval Checklist Legal Description: LeT- 17- G~.~.- ParcelI.D.: O I 5- ~ 0'7 ~ ~.J O A. WELL DATA Well type Log present ~/N) Total depth Sanitary seal If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~///(' / ~ Cased to / o 3 Casing height (above ground) Wires properly protected (~N) FROM WELL LOG AT INSPECTION Date of test Static water level Well production g.p.m. WATER SAMPLE RESULTS: Coliform 0 Date of sample: (~ / ;~O //q B.~HOLDING TANK DATA Date installed (~ ~/~/$"z._ Tanksize Foundation cle~pout~, N) Date of p~mpihg"7/~/'~ ~7 .. C, ABSORPTION FIELD DATA Nitrate ]'oo o Depression (Y/~ Pumper ,~t -j- //a~ ~ ]- '~ ~ Other bacteria 0 Collected by: S & $ ENGINEERING 17034 Eagle River ~.oop Road No. Eagle River, Alaska 99577 Number of Compartments. ~'' Cleanouts (~N). ~u O High water alarm (Y/~ Date installed .. .~ Soil rating (g.p.d./fFo~ ) '7 0 System type 7-~¢.~ Length ~ (.o 0 Width. £' Gravel thickness below pipe ~ (~ Total dePth Effective'absorption area ~'T I 7 ~ Mon~tonng Tube present g/N) ¥ J' Depression over field (Y~) ,/~ rJ Date of adequacy test ~/3/ ~//7 Results(Pass/Fail) /o,~$~- For '~ bedrooms Fluid depth in absorption field before test (in.); 9 ,~ y' Immediately after['` ~'~gal. water added (in.): F u d depth ~) A.'~ (ins) Minutes later:. ~l &" Absorption rate = ~' 5-0 "/' g.p.d. Peroxide treatment (past 12 months) (Y/N) ~'~'"'~ ~:,v0 ~,~/ If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons ~ "Pump on" level at* ...-~-'""'~ "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: '~holding tank on lot /0o + Absorption field on lot ) o o ' '/- Public sewer main On adjacent lots On adjacent lots Public sewer manhole/cleanout Sewer/septic service line ~$- -F Lift station SEPARATION DISTANCES FRO~TI~HOLDING TANK ON LOT TO: Foundation ~ / ~- ! Property line ~' '/~ Absorption field Water main/service line !o /4- Surface water/drainage )00 ~Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / 0 Building foundation ) O Water main/service line Surface water ! O0 ~ Driveway, parking/vehicle storage area Curtain drain lq o ~ ,L k: ,., o ~, ~ Wells on adjacent lots ) 0 0 --/ F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal in conformance with MOA FJAA guidelin~ in effect on this date. Date "~ / ~ / q 7 Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES CERTIFICATE OF INSPECTrON FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date "7/1/~,, ~. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO suBMITTAL) (a) Legal Description (include lot, block, subdivision, sect[on, township, range) · Location (address or directions) (b) Property Owner ~,~.~..~,~,~.[L~ ~., k Mailing Address Telephone; Home Business (c) Lending Institution t~ I,~A~_. Mailing Address (d) Real Estate Company and Agent ~-'~ ~ vi &. ~rJ4 Teiephone '~-,~!~! (e) Address Telephone '~'~ ~ "~ ~ Mail the HAA to the followina address: or: Check here ~ if hold for pick up. List contact person and day phone number below. ,4 /~ /~ TYPE OF RESIDENCE Single-Fami~y~ 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. Page 1 of 2 72*025 fRev 8/861 Front iBuo!ssajoJd aq~ u! 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Xw leql XJIJGA I 'MOlaq UMOqS Olep uo!lep!leA oqi jo se pue ojoJaq psxlJ~e leOS Xw Xq pawpao sV .g MUNICIPALITY OF ANCHO: E ENVIRONMENTAL SEI~VICES Dki~iON A. WELL DATA . J U L 1 2 1988 'RECElYED MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 . Le,,g, al pesj~ription: L~T I~., B~ ): Well Clas~ificaiioh '' Well Log Present (Y/N) Total Depth JIg '~ Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances ~[rom Well: To Septic/Holding Tank on Lot ' To Nearest Edge of Absorption Field on Lot JJ To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments Jf A, B, C, D.E.C. Appro,)ed (Y/N) Date Compiet~d [!~' /~*' '~ ~'' Yield Depth of Grouting J~ Pump Set At ,~ Sanitary Seal 'on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots 'To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date Cb /=-Col,', o./q,~,/I t',l B. SEPTIC/HOLDING TANK DATA Date Installed ~ Size /(J;~l~ No. of Compartments Z"~"~O Standpipes (Y/N) '/"~Y-,~ Air-tight Gaps (Y/N) ~ Foundation Cleanout (Y/N) Depression over Tank (Y/N) ~ Date Last Pumped ~/~/~ Pumping/Maintenance Contract on File (Y/N) ~/~ ;for ~/~ Temporary Holding Tank Permit (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well / O ~ To Property Line ~ ./D TO Water Main/Service Line ~ Course TO Building Foundation To Disposal Field ,7' To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72 026 IRev 8/861 Front C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata J ~(-~ Date Installed ~ '.'/¢~ ' ~ ~ Width Of Field Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well Jl ~ "~. To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parl~ing Area, or Vehicle Storage Area Comments Type of System Design "~,,~ ~."/~ ,/-~l Length of Field ~ ~) Depth of Field '~. ,,,)"""' Gravel Bed Thickness ~ ! Standpipes Present (Y/N) ~" 1~'/~ Date of Last Adequacy Test ~/~,,,¢'.//&~' ~ To Properly Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) D..,FT ST^T,O. N ot l 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) Pumping Cycles during Adequacy Test. Meets MOA Comrdents ** Check Permitted Bedroom Rating Against HAA Request ** I certify th~.t I have checke~, v~rified .,d) conformed to~,OA ~nd HAA guidelines in effect on the date of this inspection. Signed ~./~ Date Company MOA No._ Receipt No. ,.3,d. ¢~ Date of Payment Amount: $ Page 2 of 2 Engineer's Seal 72 028 fRev 81861 Back ~EPARTMENT OF ~EALT~ & ~U~AN SERVICES DIVISION OF ENVIRONMENTAL SERVICES OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date q/~-/~' '7 GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) (b) (c) (d) (e) Location (address or directions) Property Owner Mailing Address Telephone: Home '~,- 7>0,~ Business ,= 97T . Lending Institution ~'~ ~, ~C~_V2-1L [.-~Jg,(-- ~-~ Telephone Mailing Address ~7/0, ~ ~1~ ~O~ Real Estate Company and Agent ~ ~ ~ ~ ~ ~ ~ 0 ~ Telephone ~ ~ ~ / ~ 3~ Mail the HAA to the followin~ address: or; Check here~, if hold for pick up. List contact person and day phone number below. -- TYPE OF RESIDENCE Single-Family ~ Numbsr of BeOrooms 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/~f/'com munity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the regality and status. Page 1 of 2 72-025 fRev 8/861 Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 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 end 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 ins~.~ ..... Name of Firm ~'~--- ~ Telephone ~")~ '''''~ ~/~' Address Date DHHS APPROVAL Approved for '/~-A~c-'~?,~edrooms by Approved Disapproved Conditional Date Terms of Conditional Approval CAUTION 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. Page 2 of 2 72-025/Rev 8/86) Back MUNICIPALITY OF ANCH~~'~I~CIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL $EI~VICESId~/4t~IKTIfli AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 SEP 3 1987 264-4720 Legal Description: L~'T ID.L I~- ~- RECEIVED WELL DATA Well Classification Well Log Present (Y/N) Total Depth t 0._% Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot I ~ J' To Nearest Edge of Absorption Field on Lot ~ ~ ~:~ To Nearest Public Sewer Line N c~ ~ ~ Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments Cased to If A, B, C, D.E.C. Approved (Y/N) Date Completed /~: /,~,; ~., Yield Depth of Grouting N aN Pump Set At "~ oTTO Sanitary Seal on Casing {Y/N) '%// Depression Around Wellhea? (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer hi o Iq ~_. To Nearest Sewer Service Line on Lot ,~ / O ~ ~ ; Date ~/~"7/& '7 ¢'. o.el · B. SEPTIC/HOLDING TANK DATA Date Installed ,¢ '/B',~,~ Size Standpipes (Y/N) "T*b/~ O Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances fron~ Septic/Holding Tank: To Water-Supply Well I o I To Property Line ~'/~ Air-tight Caps (Y/N) To Water Main/Service Line No. of Compartments 'Z-'¢ f-~ ~/' Foundation Cleanout (Y/N) Date Last Pumped 8/P-~/ J'¢~ ;for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field '7 Course No To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026( ! ~/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field ' Square Feet of Absorption Area .'!~/7 Depression over Field (Y/N) Results of Last Adequacy Test '-~.,,~ ~.5 Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot hq o ~ ~., Type of System Design Length of Field Depth of Field '7, Gravel Bed Thickness .-~ Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line __ To Existing or Abandoned System on ; On Adjoining Lots __ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Commants To Cutbank (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested lot Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles (luring Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~ ~ ~ ,uz~-~,t,~¢2 Date / Company MOA No. Receipt NO, //~) 0 ~ ~ ~ // Amount:Date of Payments /~/~¢~ ~' t., .,' . ·. Engineer's Seal Paoe 2 2 ~; '.. Anchorage P.O. B(,..~196650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4111 TONY KNOWLES. MA YO R DEPARTMENT OF HEALTH & HUMAN SERVICES September 11, 1987 Tobben Spurkland, P.E. 203 West 15th Avenue, C Suite 203 Anchorage, Alaska 99501 Subject: Lot 12 Block 1 Summit Estates, Waiver Request WR87-054 Dear Mr. Spurkland: Your request for a waiver of the 100 foot separation required between the well on the subject lot and the leachfield on Lot 10 Block 2 has been granted. This distance has been waived to 98 feet. This waiver is valid for a three bedroom single family dwelling onlyo Sincerely, Stephen S. Morris civil Engineer On-site Ssrvices cc Gus Andress, P.E. On-site and Water Quality Manager '203 W. 15th AVE "C" SUITE 203 CONSULTING ENGINEER TELEPHONE: (907) 279-3916 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 6-6650 ANCHORAGE, ALASKA 99501 AUGUST 31, RECEIVED 1987 SUBJECT: REQUEST FOR WAIVER OF SEPARATION DISTANCES FOR PRIVATE WELL-DRAINFIELD LOT 12, BLOCK 1, SUMMIT ESTATE Gentlemen; We are submitting a request distances stated in Title 18, 80.020 for waivers from the separation Alaska Administrative Code Chapter During an Health Authority Approval inspection it was found that the well on lot 12, Block 1, Summit Estate was 98 feet distant from the drainfield on lot 10, Block 2, Summit Estate. The installation on lot 10 predates the installation on lot 12, which was inspected by a Municipal inspector and approved. ~pparently the inspector failed to check for separation distances between the well and the neighbor's septic system, with the result that the present owner is faced with a code non-compliance not caused by him. This situation is an extension of the situations described by Mr. Lee Browning in a letter to Assemblyman Dyson dated July 14, 1987, where Mr. Browning states that a homeowner should not have to pay for a waiver for a non-compliance problem not caused by him. Basedfee. on Mr. ~Br°wnings~/] ~J~letter ~-~I request,~ a~~e, waiver Yours Tobbeff Spurkland P.E. ~ ~ ~ ~ ANCHORAGE, ALASKA 99501 CONSULTING ENGINEER TELEPHONE: (907) 279-3916 RESIDENTIAL WELL LEGAL: LOT 12, BLOCK 1, SUMMIT ESTATE LOCATION: 5411 E97TH. AVENUE OWNER: JOHN ELDRED TYPE OF WELL: SINGLE FAMILY WELL LOG AVAILABLE: YES INSTALLATION REQUIREMENTS MET: NO. WELL INSTALLED 98 FEET DISTANT FROM DRAINFIELD ON LOT 10, BLOCK 2, SUMMIT ESTATE WELL YIELD FROM WELL LOG: 10 GALLONS PER MINUTE PUMP YIELD: 6-7 GALLONS PER MINUTE DATE OF INSPECTION: AUGUST 28, 1987 TEST PROCEDURE: WELL WAS PUMPED AT A CONSTANT RATE OF 6.7 GALLONS PER MINUTE WHILE THE DRAWDOWN WAS MONITORED WITH AN ACOUSTIC PROBE. THE WELL WAS PUMPED TILL THE DRAWDOWN STABILIZED. AT THE BEGINNING OF THE TEST WATER LEVEL WAS FOUND AT 48 FEET BELOW TOP OF CASING. AFTER 75 MINUTES OF PUMPING THE WATER LEVEL STABILIZED AT 79 FEET. THE WELL WAS PUMPED FOR AN ADDITIONAL 30 MINUTES WITHOUT ANY FURTHER DROP IN WATER LEVEL. A TOTAL OF 750 GALLONS WERE WITHDRAWN. TEST FOR COLIFORMS: WATER WAS TESTED FOR COLIFORM BACTERIA AND NITRATES ON AUGUST 29, 1987. E.COLI 0, NITRATES 0.91mg/1. TEST RESULT: THIS WELL MEETS THE REQUIREMENTS OF THE MUNICIPALITY OF ANCHORAGE. The Municipal requirement for well flow is 150 gallons of water per bedroom per 24 hours.This well surpasses this requirement. The assessment of the condition of this well applies only to the conditions as of this date. The flow rate of the well may change due to subsurface conditions that may not be observed from the surface, and changes in land use and other factors that may impact the conditions of the aquifer ~/r_bf~%~he well. '~'~ ~ ~ A rk~ [~ , ~203W. '~SthAVE "C" SUITE 203 CONSULTING ENGINEER TELEPHONE: (907) 279-3916 SEPTIC SYSTEM ADEQUACY TEST LEGAL: LOT 12, BLOCK 1, SUMMIT ESTATE LOCATION: 5411 E97 TH. AVENUE OWNER: JOHN ELDRED RESIDENCE: SINGLE FAMILY, THREE BEDROOMS WELL: PRIVATE, ON SITE SEPTIC SYSTEM: FROM MUNICIPAL RECORDS: TANK: GREER STEEL, TWO COMP. 1000 ABSORPTION SYSTEM: TRENCH ABSORPTION AREA: 517 SQ. FT. SOIL RATING: 170 INSTALLATION DATE: JUNE 1982 GAL. DATE OF PUMPING: AUGUST 28, 1987. MARX ENTERPRISES DATE OF TEST: AUGUST 28, 1987 TEST PROCEDURE: SYSTEM WAS INSPECTED AND MEASURED. TANK WAS FOUND WITH 4.5 FEET OF COVER AND 48 INCHES OF LIQUID. CLEAN OUT TO TRENCH WAS SIX FEET DEEP.AND DRY. TRENCH SUMP WAS SIX FEET DEEP AND DRY. BOTTOM TWO FEET OF SUMP WAS PERFORATED. 750 GALLONS OF WATER WAS ADDED TO THE TRENCH AT A CONSTANT RATE OF 6.7 GALLONS PER MINUTE WHILE THE WATER LEVEL IN THE TANK WAS MONITORED. 300 GALLONS WERE ADDED TO THE SUMP. AT THE END OF THE TEST NO WATER WAS OBSERVED IN THE SUMP AND THE WATER LEVEL IN THE TANK HAD NOT CHANGED. TEST RESULT: THIS SYSTEM MEETS THE CODE REQUIREMENTS OF THE MUNICIPALITY OF ANCHORAGE. The operational life of all septic systems depends on the local soil conditions, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of this septic system. We can therefore not give any estimate of how long the system will continue to meet t~e,,9¢_erational requi- rements of the Municipality and State. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 · Application Date /~)/'~/~ GENERAL INFORMATION (b) (c) (d) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions),j , 5' ff- ff £- 7 7 ,, ApPlican[ Name ~'~ f--i.~ ~/~ Telephone: Home ~-~O~? Business Applicant. Address ./0/. ',~,* ~z ~, m~ ~ g. 4~¢~7¢ ~r Applidant is (chock ~no): kondm~ Institution ~; Ownar'buildar~; Buyar ~ Othor ~ (axplain); Lending tnstltutjoB . ~ :,' Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family [~Multi-Family [] Number of Bedrooms Other 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 weli system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) ~'~ ENGINEERING FiRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 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 /~-~'~ Date Approved ~ Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of H, ealth and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DI~EP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 (41/84) DEPT. OF HEALTH & ~O E~VIRONMEN'i'AL PROTECqON MUNICIPALITY OF ANCHORAGE (MOA) ,~ nt HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST264_4720'-FEBRUARY 1984 R E C E IV E D Legal Descrip~on: ~/'~. ~/' ~/'~ ~'~ WELL DATA Well Classification We[l Log Present (~N) Total Depth /O:~ r Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit~N) Separation Distances from Well: / To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole ~/~- Water Sample Collected by .~ Water Sample Test Results If A, B, C, D.E.C. Approved (Y/N) Date Complete(:] 7-~'~2- Yield Depth of Grouting Pump Set At Sanitary Seal on Casin~N) Depression Around Wellhead ; On Adjoining Lots /'~2(~ /'~ //~'/"~ '~; On Adjoining Lots /~]2¢7 r-/4 To Nearest Public Sewer To Nearest Sewer Service Line on Lot Date /0~,,~ ~ Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~"~ -~' ~'- Standpipes:N) Depression over Tank (Y~.~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/~-Iolding Tan~l~.. To Water-Supply Well /00 To Property Line ~ t To Water Main/Service Line ~-/0 Course "/-/~20 ! Size /¢¢2/9 No. of Compartments Air-tight Caps(~xl) Foundation Cleanout ((~N) Date Last Pumped /(~) :for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field ¢ '7 To stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72 026(~1/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~- Width of Field ,.~-! l'70 ~ Square Feet of Absorption Area Depression over Field (Y/~ Results of Last Adequacy Test Separation Distance from Absorptio~ Field: To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments r Type of System Design Length of Field ~-,,~ / Depth of Field __ Gravel Bed Thickness ~ ~ Standpipes Present CN) Date of Last Ade..guacy Test / To Property Line __ To Existing or Abandoned System on ; On Adjoining Lots ~-,~,~ To Cutbank (if present) ,,~//~' /O0 '¢ D. LIFT STATION Date Installed Size in Gallons __ "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Corn merits ~M~nhole/Access (Y/N) ~/// "Pump Oft" Level at ' ,/ Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed .~/4/,4~5, ~// Date /f~- ~-- ~'~ Company .I~ ~ - .~ MOA No. Receipt No, ~/--~ ~¢ ~ Date of Payment ///~/~ ~ Amount: Page 2 of 2 72 026 Im~ IWim- L/AI~UH/~I UHII:~, II,lO, LA~-*.TORY I.D. I ~b~(j) ,7127 OLD SEWARD HIGti. kY L_/ ' .ANCHORAGE, ALASKA 99~8 · (907)344-8551 . ' BACTERIOLOGICAL BATER ANALYSIS TO B~ COMPLETED BY WATER SUPPLIER DATE COLLECTED J MONTH DAY YEAR I.D. HO. (PUBLIC SYSTEMS) & I I I I I I NAI~ OF SYSTEM SYSTEM ADDRESS CiTY STATE TIME COLLECTED J TYPE OF SYSTEM ~J ~-1 PUBLIC ~JiNDIVIDUAL CIRCLE CLASS A B C t~iden~al~ TELEPHONE NUMBER ZIP CODE FOR LAB USE ONLY I-) RESUBMIT SAMPLE Sample rejected because: CHECK ONE OR MORE r) Sample too long in transit. Sample should not be over 30 hours. I-J Sample received too late in week [:]Not in proper container rJLeaked out J--) Insufficient information provided. ' LOCATION WHERE SAMPLE WAS COLLECTED · 'COLLECTED BY:(SIGNATURE) tYPE of SAMPLE (CHEEK ONLY ONE THIS COLUMN) ~'DRINKING WATER ~CNECK TREATMENT J-QCHLORINATED J'IFILTERED .~(~O"NTREATED OR OTHER r'l RAW SOURCE WATER F') NEW CONSTRUCTION OR REPAIRS El OTHER(Specify) IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NON-CONFORMING SAMPLE? [~ YES vl~ PREVIOUS COLLECTION DATE ANALYSIS REQUESTED (IF OTHER THAN TOTAL COLIFORM) SEND REPORT TO:(PRINT FU~L NAME,ADDRESS AND ZIP CODE CITY ~LO~9~ STATE A~ ZIP Please read instructions on form~ I-1Other {Specify) RECEIVED FROM RECEIVED BY iF>~),'FF! ~.~(j-!j DATE ~F *.~~~(~ TIME ANALYTICA~HE-F~OD: ~ME~BRANE FILTER (-')FERMENTATION TUBE Date & Time Started Date & Time Completed LABORATORY RESULTS Analyst [] Other Bacteria ~ Test unsuitable because: [] Confluent Growth [] TNTC ~U SATISFACTORY NSATISFACTORY [] BACTERIOLOGICAL WATER ANALYSIS RECORD FOR LAB USE ONLY ~irO'~-L COLIFORMS FECAL COLIFORMS OTHER Membrane Filter: Direct Count ,. Verification: LIB Final Membrane Filter Results Reported By ~ Coliform/lOOml BGB Coliform/lOOml Date Time READ SABLE COLLECTION INSTRUCTIONS ON BACK OF FORM ALASKA T/UIROrlmeTAL CONTROL $1 r lCe$, Inc. ~n§Jnecrin§ 6 ~nui~o,menlel $ludics JOHN ELDRED 1013 E DIMOND 1203 ANCHORAGE ALASKA 99515 SELLER-JOHN ELDRED 10/29/86 JOHN ELDRED 1013 E DIMOND #203 ANCHORAGE ALASKA 99515 60590 LEGAL:SUMMITE ESTATES BLOCK 1 LOT 12 ADEQUACY TEST FOR SEWER SYSTEM ADEQUACY TEST DATE-10/28/86 THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 517 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 900 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A S BEDROOM HOME. SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1000 IS ADEQUATE FOR THIS $ BEDROOM HOUSE. THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON 10/29/86 THIS REPORT DOES NOT VERIFY THE INTEGRITY OF THE PIPING FOR THE WATER SUPPLY OR WASTEWATER SYSTEM. FLOW TEST ON WELL WELL FLOW DATE-lO/28/86 A FLOW TEST WAS PERFORMED ON THE WELL. 900 PUMPED AT A RATE OF 7.5 GPM OVER A DURATION OF THE DRAWDOWN WAS 84 ~ WITH A RECOVERY TIME OF AND THE STATIC WATER LEVEL WAS 48 FEET, THE WELL IS ADEQUATE FOR THIS S BEDROOM HOME. GALLONS OF WATER WAS 2 HOURS. MINUTES ~Jest 33r,J A*lenue, Suite ~, Anchor(iqe, Aloskr~ 99503, (907) 561-50,q0 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH ALr~HORITY APPROVAL CERTIFICATE · General Information Application Date 1 (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name~~~ ~?-5~: Telephone - ~l{~m~ .... Applicants Address ~_~ f/. ~o ./~ ~Zj~ ~q.a ~ Applicant is (check one) Lending Institution ~ ; O~er/builder Business (d) Lendinginstituti6h Address Tele~pe (e) Real Estate Co~ &~Agent __ Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single-Family~'n Number of Bedrooms Multi-Family~--~ Other (describe) 3. Water Supply Individual Woll~ Community~ Publtc~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and statns. Sewage Di~osal , Onsite~ Public~ Community~ Holding Tank~, l Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. l~j~f[Page 1 of 2] 5. Engineerin_~__Firm Providing Inspections, Tests~ File Search, Data and Information 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 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 regula- tions in effect on the date of this inspection. Name Of Firm_ ~'~ ~'?l~ __ Telephon~/-%~?:)~/~ Address__~ ~ ~L~/~.~,/.~{ "~ ~)~z~' ~ ~ Date DHEP Approval Approved for~/~z-~([~/bedrooms Approved . ~_ Disapproved __ (ENGINEER SEAL) Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. T}~ DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP 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. (DHEP SEAL) RR4/eJ/D18 [Page 2 of 2] 7-19-84 WELL DATA ~ Well Classification MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL pROTECTIO~J OCT 1 '1984 ~,','u~" If A, B, or C, D.E.C. Approved(Y/N) Well Log P~esent ~) Date Completed Total Depth /~ / Cased to /~)~ / Static Water Level- ~/~, ~ ~ Pump Set At Casing Height Above Ground ~. ~ / Electrical Wiring in Conduit ) Separation DistanCes from Well: To Septic/Holding Tank on Lot / ~ O / ~ __ Yield ~,~ Dept~ of Grouting /~'/~7'~ Sanitary Seal on Casing ~N) Depression ~ound ~l~ead (Y~ ; On Adjoining Lots .//~/ /O13-'~/~ ; On Adjoining Lots ~-.To Nearest Edge of: Absorption Field on Lot To Nearest Public Sewer Line ~/~' To Nearest Public Sewer Service Line Cleanout/ManhOlesample By ~~_ /t.}/~~' TO Neare. st, Sewer ~t~/~ on Lot Wate~ Coile.cted ~-- Date / Water Sample Test Pesults B. SEPTIC/HOLDING TANK DATA Date Installed ((j/~ ~ Size Standpi~s ~) Ain-tight Caps ~) Foundation Cleanout ~) ~p~ession o~ Ta~ (Y~)~ Date ~st P~d--/~ for /~ P~ing~intenanm Contract on File (Y~)/~/v'; Holding Ta~ High-Wate~ Ala~ (Y~) ~/~.-Te~a~y Holdi~ Ta~k Per~t (Y~) ~/~.- Sep~ation Distan~s f~ ~ptic~olding Ta~: To Water-Supply ~11 j ~0 / ~ To ~o~rty ni~ ~.~/~ To ~ter Main/Se~vi~ Li~ ~ 7 / Course Conlr~nts To Building Foundation ~7/' TO Disposal Field 7,$~ TO Stream, Pond, Lake, or Major D~ainage [Page 1 of 2] Receipt ~ Date Paid: Amo un t: 2-15-84 ALASKA e OIl OnmEnTAL COnTI OL self'c/ICeS, Inc. I~nqineerin§ 6' ~nuironmenlal $1uclies OCT 17 1984 JOHN ALDEN 2804 W NORTHERN LIGHT BLVD ANCHORAGE AK 99503 SELLER - JUDY FRYER BUYER - SUBDIVISION - SUMMIT VIEW ESTA TE5 BLOCK -1 LOT-12 ADEQUACY TEST FOR SEWER SYSTEM THE TYPE OF ABSORPTION SYSTEM IS A TRENDH-.WI~TH AN AREA OF 517 5~FT, THE SYSTEM IS CAPABLE OF ACCEPTIN~r~O GALL~ OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM"ZS-~6OO--G~vqJ_LON5, BASED UPON THE TEST DATA THE SYSTEM I5 ACCEPTABLE FOR _7 BEDROOM HOME. THE SEPTIC TANK WAS PUMPED ON OCTOBER 16 1984 . FLOW TEST ON WELL _t- - ............ THE WELL FLOW RATE W GPM FOR 4 HOURS." SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK[VOLUME OF 1000 I6 ADEQUATE FOR THIS 5 BEDROOM HOUSE. 1200 LUesl 33r(1 Auenue, $oite ~, ]~nchoro§e, Alosko 99503,,(907) 561-5040 '. 5633 ~ Street Drinking W~mr Analysis Repo~ for Total C°lifo~m' Bacteria TO BE COMPLIED ~Y WATER SUPPLIER " TO BE COMPLIED BY ~BORATORY WATER SYSTEM: I I I , I [ I J (*) See h on back ~,s shows th,s Water SAMPLE to be: Mailing ASdress C, Jty State Zip Code MO. Day t Yea~ SAMPLE TYPE: ". ~ Check Sample (for routine sample with lab ref. no, ! ~ Treated Water Untreated Water [] Special Purpose SAMPLE i Time Collected NO. LOCATION I I [] Sami)le too long in transit; sample should not I~e over 30 hours old at examination to indidate reliable results. Please send new sample via special delive~ mail. Date Heceived Time R~celved /S O O · .Analytical Method: -.' [] Fermentation Tube ~ ~.~,.lembrane Filter Lab Fmf. No. Result* Analyst READ INSTRUCTIONS BEFORE oe-12~o Membrane Filter. Direct Count Verification: LTB Final Membrane Filter Results Reporled By BACTERIOLOGICALWAT£R ANALYSIS RECOR{:) COLLECTING SAMPLE ,TNTC-- Too Numerous To Count BG[,. Date Time: Collformll00ml . APPLI(L~.NT FILLS OUT UPPER HA[~/ONLY JPhone Lending Institution Single Family ~ultiple Family NO of Bedroo~ Water Supply ~lndividual ~ A~ACH WELL LOG. A wall log is required for all wells drilled since June 1975. ~ Community ~ ~ ~ For wells drilled prior to that date, give well depth (attach log if available). ~ Public Uglity sewer Oisposal NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date Date Oate Date Inspector Inspector Inspector Inspector RECEIVED ~.-- ~ weml 1o Tank SepUc T~k Size ~ ~0 72.023(3/~) CHEMICAL & GEcrLOGICAL LABORATORIES b-/ ALASKA, INC. TELEPHONE (907)-279,4014 ANCHORAGE INDUSTRIAL CENTER 274-3364 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria TOBE COMPLETED BY WATER SUPPLIER WATER SYSTEM: I.D, NO. ..:, ,--,. / (.}x,u-x,-.,-fl ? Mailing Address City State Zip Code MO. Day Year SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. t 4 5 LOCATION Time Goliected Collected By TO BE CC rvlPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ..['~r'Satisfactory [] Unsatisfactory [] S~mple too long m transit; sample should r~o! De over'48 hours old at examination [o indicate reliable results Please send new samDle. Date Received' ~ Time Received Analytical Method: [] Fermentation Tube ~, Membrane Filter Lab Ref. No. Result* Analyst -~NO of colonles~ 100 mi. or No. of Positive READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 {b) Rev, 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Properly Owd'~r . Address Zip Code Phone Lending Institution Address ~ ~,/~ .~.~"4 'V~ ~ /~ Zip Code Realty Co. & A~n~ ' Phone Zip Code Address Water Supply ~ Community ~ ~-~ ~ ~ ~[ A~ACH WELL LOG. A w~l log is required for all wells drilled si~ce June 1975. For wells drilled prior to that date, give well depth (attach log if available). ~ Public Utility Sewer Disposal ~ Individual ~ Year Individual Installed:__ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSiNG CAN BE INITIATED. Time Time Time Time Date Date Date Date \~..~. OA_~G~. ~ Inspector Inspector Inspector Inspector Field Notes: ~..,~ MUNICIPALITY OF ANCHORAGE E£EIVED ~ ~o~owD