HomeMy WebLinkAboutDELUCIA LT 28 Municipality of Anchorage
Development Services Department
Building Safe~ Division
On-Site Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Box lg6650 Anchorage, AK 99519-6650
www.cLanchorage.ak, us (907) 343-7g04
Permit Number: ~' ~0~0 t7Lq [
Phone; Num~ of B~rcoms: ~
Township:
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL iNSPECTION REPORT
Pig Number:'
Wastewater System: [] New ~"Upgrade
LEGAL DESCRIPTION
Range: Section:
Well: [] New [] Upgrade
Cia s sift ~atlon(P~dv at e..~ B~C); ~ Total Deplh: Cased to:
/ FL
Yield: ~umpSet a~ FtJ ~...~Ne~t~ove~ou~ FL
SEPARATION DISTANCES
ABSORPTION FIELD
~J~DeepTmnch D ShaflowTre~ch I-1 Bed ~ Mour~l [:] Obher:
Total Depth lmm ~dgina, grade:
Soil Rating: I ,2 GPD/Ft= Ft.
Depth th PiPe b°tt°m from °dg~al g~ FL ~ Ft.
TANK
Gravel depth beneath pipe:
Gravel Length:
Number of li~es:
Septic [] Holding [] S.T.E.P.
[] Other.
To SepticTank Absorption Field Station LiE Holding Tank
BENCH MARK
E&,~&mP
~, .... 17034 Eagle River Loop Road, No. ~
inspections pe~ormea Dy:Ea le River, Alaska ~5~ Dates:
Development S~ces Depa~m[nt Approval
',
PERMIT NO. SW020491 PACE 2 OF 3
iVlunicip, oLi~v o¢ Anchoraae
DEPARTMENT OF HEALTH AND HUN[AN SERVICES
ENVIRONHENTAL SERVICES DIVISION
P,B. Box 196650 eAncho~age, Aicska 99519-C)650e Telephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL LOT 28, DELUCIA S/D
OT
7
LOT
.( .
m EXtsTING
r- 3 BEDROOM
WATER STORAGE TANK(~ 2 NouSE
XLOT 6~ ~ --
~,~- u- /
~ ~NEEDLES
P.I.D, NO. 051-141-20
38 LOT 37
1000 GALLON
SEPTIC TANK
LOT 29
(DIVERTER VALVE)
~'o~
SCALE: 1" = 40'
LOOP
MUNICIPALITY OF ANCHORAGE
Development Sen/ices Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Dec 26, 2002
Expiration Date: Dec 26, 2003
Permit Number: SW020491
Legal Description: DELUCIA LT 28
Design Engineer: 0003 S & S Engineering
Owner Name: Robin Thompson
Owner Address: PO BOX 670094
CHUGIAK, AK 99567-0094
Parcel ID: 051-141-20
Site Address: 022675 NEEDELS LOOP
Lot Size: 15000 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
[] Disposal Field [] Septic Tank [-~ Holding Tank [] Privy
[] Private Well ~ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection: Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By: ~2 ~
Date:
WR#: 020098 PID#: 051-141-20
Date Received: 12-20-02
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Waiver Review~Worksheet
HA#: Permit~: 020491
Engineer: S & S Eneineerin(~
t7034 Eaule River Ioo= Road No. 24 Eaale River., Alaska 99577
Applicant: Robin Thompson
Waiver Requested: 1' separation absomtion,fieldto m'oPoertv line
Criteria: Geology
A. Water Table
B. Soil SorPtion
C, Permeability
D~ Water TableGradient
E, Horizontal Separation
Points:
Total:
Waiver is Granted:
List Conditions or Reasons for above:
Date: ]~- ~-(~-13 ;~,~
Rec~: 029397 Amount: $150 Date Paid: '121.~'/2002
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci,anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/VVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
O
Parcel I.D. i- I
Permit Number
Property owner(s) ~Ob ;~lThOf3"/p:~O/~
Mailing address (1) ~,0, J~oX t~?OC) ~L}-
Mailing address (2) L~I~;A~, /~
Legal description (Lot, Block & Sub'd.) Lo~
Legal description (Section, Township & Range)
Lot Size ~000 Acr~
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Day phone
Zip Code
Number of Bedrooms
[] Well Only []
[] Water Storage []
[] Jacuzzi []
[] Water Softening Unit []
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
S & S ENGINEERING
F.a~le RLver. Alaska 99577
(Signature of property owner or authorized agent)
Permit Fees:
Date of Payment:
Receipt Number:
(Rev. 12/00
Waiver Fees:
Date of Payment:
Receipt Number:
December 19, 2002
ROBERT C. COWAN, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907} 694-1211
HEALTH AUTHORITY
APPgOVALS
SEWER&WATER
MAIN EXTEN$1ON~
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot 28, Delucia Subdivision
SEWER&WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
It is requested that you issue a permit to install a new 1000 gallon HDPE septic tank
and a new trench to serve the existing three bedroom dwelling on the referenced
property. A waiver of one foot is also requested from the proposed trench to the
east property line.
WELL INSPECTION
& FLOWTEST
A test hole was excavated and a percolation test performed. The approximate location of
the test hole is located on the attached site plan. At the time of excavation 11/14/02 no
water was found. After monitoring, ground water was not found.
SITE PLANS
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
areas or drainage patterns by the installation of the proposed septic tank. The installation
of this septic tank will not prevent any future development on any of the adjacent
properties.
ROADDESlGN
If you require additional information, please contact us.
SOILTEST
PE~OOLATION
TEST
Sincerely,
RCC/bjj
Enclosure
STRUCmRN-&
k~EC~IC~-
INSPECTIONS
ON SITE
WA~TEWATER
DISPOSAL SYSTEM
OESIQN
17034 NORTH EAGLE RIVER LooP ~ SUITE 204 ~' EAGLE RIVER, ALASKA 99577
LEONE: LOT 28, DELUCIA
B.J.J./JHM[ R.C.C.
~rin~ DESIG.~'~ITERIA:
.5 BDRJvf' = 450 OPB
SOILfl/= 1.2 GPD/SQ.FT.
17054 EAGLE RIVER LOOP ROAD ~///Q
FT
EAGLE RIVER, ALASKA 99577
PHONE# (907)694-2979
FAX// (907)694-1211
Z
1 0.0' DE;P
6.0' EFF :(
2.5' WID
ITERIA:
LOT 7
S/D
\
LOT
BATE:
12- 19-02
Z
WATER STORAGE TANK
x"~LOT
<
WITH LESS THAN 3 5' OF
COVER REQUIRE INSULATION.
6
ExiSTING
BEDROOM
HouSE
SEPTIC ~'ALNK-
\/
/\
~LES
(TYP.)
40'
LOOP
OBTAIN UT LTY LOCATES
PRIOR ~0 ANY EXCAVATION
LOT 37
/
1' WAIVER
UESTED
LOT
29
Performed For:
Legal Description:
MohictpaltiY o1' Arichoi'age
Development Se~lCes bepadment
BUilding Sa!e{y Dlvtston
on-site Water and WasteWater Program
4700 south BragaW St.
P.O. Box '196650 AnChorage, AK 99519-6650
www.cLanchoraqe.ak.Us
(g07) 343-7904
soils Log - Percolation Test
Slope
.'f;' C ¢,." /\
Date Performed: ''/ ~ IO"~
Site Plan
~ Deplh
(Feet)
20-
cOMMEHTS
WAS GROUND WATER
~.COU.TERE~?
s
IF YES, AT WHAT DI=PTH? O
Depth to Water After
Monitoring? ~'~YE P
Dale: ~'~
Reading Date
PERCOLATION RATE
TEST RUJ~ ~ETWEEN
Gross Time Net Time Depth to Water Net Drop
0 O &,Y~" ~'"'"
io /o lO' ¢
IO i o ~ ¢
(~nutes~nch) PERC H~E DIAMETER ~ ¢
FT AND C FT
PERFORMED BY: ~/~/(-,~ ,~'~¢t¢~,,,'~ -- %~ ~----~ "~~ ~ CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELiNEs IN EFFECT oN THis DATE· DATE:
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER&WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOWTEST
StTE PLANS
ROAD DESIGN
$OtLTEST
ROBERTC. COWAN RE.
ROBERT A. SHAFER, RE.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
REFERENCE: Lot 28, Delucia Subdivision
December 2, 2002
GENERAL:
o
The scope of this project includes the installation of a 1000 gallon minimum
septic tank and installation of a trench to serve the existing three bedroom
residence located on the referenced property.
Construction shall be in accordance with the approved site plan and design
drawings, Municipal permit with any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal Regulations. . '
o
The contractor shall be responsible for obtaining any necessary underground
utility locates.
Unless specifically agreed otherwise, the property owner shall be responsible
for final grading areas subsequently depressed from soil settling.
o
Contractors installing wastewater disposal systems must be certified by the
Municipal Health Department for system installations. Owners installing their
own systems must also receive prior approval from the Municipal Health
Department.
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
D~PO~AL SYSTEM
DESIGN
SEPTIC TANK INSTALLATION:
1. A septic tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two 4" cleanouts for pumping access.
2. The septic tank shall be sufficiently bedded to prevent settling or shifting of
the tank.
17034 NORTH EAGLE RIVER LOOP , SUITE 204 · EAGLE RIVER, ALASKA 99577
Page 2
Lot 28, Delucia Subdivision
December 2, 2002
All standpipes on the septic tank shall extend a minimum of 12 inches above final grade.
Septic tanks installed with less than 4 ft. of cover shall be insulated.
A foundation cleanout shall be installed one to four feet from the building foundation. In
the line between the tank and the leachfield there shall be two adjacent cleanouts (unless
an effluent pumping system exists within the septic tank). These cleanouts shall be
located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line,
shall be to clean toward the leachfield. The second cleanout shall be to clean toward the
septic tank.
Final grading over the septic tank shall be such that a positive slope exists away from the
septic tank.
ABSORPTION TRENCIt/DRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The bottom of the
excavation shall be within 2 inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock)
placement.
o
Once the gravel is installed, the distribution pipe is to be installed level with the
perforations faced downward. Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
A silt barrier must be installed between the final gravel layer and the native soil backfill.
Ensure the silt barrier covers the entire gravel surface before placing backfill.
Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations
shown on the design, and extend a minimum of 12 inches above final grade. The portion
of the monitoring tube extending through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is equivalent to the effective depth of
the gravel as noted on the design.
Backfill over the final gravel layer must not be less than twenty-four (24) inches.
Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The
finish grade over the trench must be mounded to prevent the formation of a depression
after settling.
Page 3
Lot 28, Delucia Subdivision
December 2, 2002
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be constructed by a Municipal approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
Type of Pipe
Cast Iron
ASTM D3034 (PVC)
ASTM FS10 (HDPE)
ASTM D2662 (ABS)
Perforated Solid
Yes Yes
Yes Yes
Yes No
Yes Yes
Use of a type of pipe other than listed above must be approved by the inspecting engineer.
Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or
equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
passing the #200 sieve.
When sand is being used as a filter material, its gradation specifications must conform to
current M.O.A. or D.E.C. requirements, which ever requirement applies.
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the installation of the
wastewater disposal system. These inspections will occur as follows:
Page 4
Lot 28, Delucia Subdivision
December 2, 2002
The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any gravel. A septic tank may be
set in place, but may not be backfilled before this inspection.
The second inspection must be conducted after the placement of the silt barrier,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer
is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-
construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or
control in any way the contractors activities.
The owner shall contract with the contractor to perform the work outlined in these specifications
and plans and in accordance with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be
the owner's representative and will inspect the work as stated above to document the contractors
activities. Final acceptance of the contractors work rests with the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor to
carry out the work in accordance with these conslntcfion documents. S & S Engineering's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incident to this project.
CONTRACTOR / INSTALLER
Municipality of Anci p age .
DeveloPment serviC0s O~j~ii~r~ent
Building Sa!ety Division
On-Site Water and Was[ewa{er Program
4700 Sou{h Bragaw SL
P.O. Box 196650 A'nchorage, Ak: 99519-6650
www.cLanchorage.ak.ds
(907) 34.'i-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWEELING
·
Parcel I.D. O5'(- )~f/ --~0
GENERAL INFORMATION
HAA# /-Tf ,O oo!
Expiration Date: }'- O .-~
Completelegaldescription Lot 28; De'lucia Subdivis.ion
Location (site address or directions) 22675 N¢Pd¢'l '.q 'r,nnp C,h~g-i R~-
Current Property owner(s) Robin Thompson Day phone 688-0480
Mailing address PO Box 670094 Chugiak, AK 99567
Lending agency · DaY phone
Mailing address
Real Estate Agent David Windsor / Remax Day phone 727'3300
Mailing Address 2600 Cordova St. Ste. 100 Anchorage, AK 99503
Unless o~herwise requested, HAA will be held by DSD for pickup.
TYPE OF wAsTEWATER DISPO
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class__
Public Water System
Well
Individual On-site
[] individual Holding tank
[] Community On-site
[] Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based onIy upon the representations given In paragraph 5 by an independent professional civil
engineer registered in the Stale of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs Upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may 6e reissued for a period of up to one year with
valid water samples:) Cedific~tes are valid ~oi' one year for properties served by Class A or B wells ar a public
water s~stem. The Municipality of Anchorage is no[ responsible for errors or omissions in the professional
engineer's work.
4.' STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of ~he validation date shown below. I verify that my investigation,
based or] procedures outlined in the Health Authority Approval Guidelines for this appiication, shows that the
on-site water supply and/or waste, wa[er disposal sy~;~em is(are) safe, funciional and adequate' for the num. bar of
bedrooms and type of structure indicated herein. I further verify thai based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all ~pplicable Municipa~ end S~a[e codes, ordinances,
and regulations in effect at the time of installation.
NameofFirm S & S EnfJ. neerin~; Phone 694-2979
Address 17034 ~, ;gagle ~,iver ~oop S~.e 204 F,~,le ~J. ve~, AE {)9577
Engineer's Printed Name Robert C. C'owan Date //~ /~_~
,~NGINEE~'S :'
DSD SIGNATURE
. ..\/ Approved for
Disapproved.
Conditional approval for
bedrooms. "~ ?:, "-, ""
bedrooms, w~[h the follow~ng stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
IViaintenance Agreements
Supplemental Engineer's Report
Other
Originai CerIificate Dale: /,_ :.? _ ~) :st_..
~B;' ... -:':.':" "~":... "...: ' · '...:,. ~.' .:....'".' ... ".
/
"Pump· on"' evel.at _/Lin.
Datum ../
E. SEPAR,,~TIO'N DISTANCES
SEPARATION DISTAN¢:ES FROM WELL'ON I-OT 'ro~
Sept~ t'~k/l~ .0n~.'lot..."-
Absorption field.on lot /'4~:::)(~:) ~
Cycles tested . "~'~ ':'" Me~.alarm & circuit req[iirements?
in.
Public sewer.~ain.. /N2/~r ....... .'P~lib"~e~et ma'nhblelcleanout ~'.~:".~
~is~tcs~i'~'" n~ : ~ '::'~' ::"H0id5 tan~' ' ' : ~'~:: ~: ..... ?"': .......... ' .....
SEPAR~ION.;~'S}~ANCES)~RoM"sEPYi~i~G TAN~.O.~: L~ TO~'' ". .... '"' :~'~.: ~;: "::~:::~ :'; ~'' '-'.'~.
Building foundation '~" '~' :Prspe~ line ;~ ~ "Absomti~n::'fie~d ~ ~
/ ,. ......
Water main ~ ',~. ~"~...'..'-.';' ;Water sewice line' :.'. ~ ;~:': S~:~c~'~r..: /~'.~
Wells on adjacent.'lo~" t~? ~: '~
SEPARATION' DISTANCE. F~O'MA~SORPTIONFIELD ON'~EOT. TO.: .... .:":"
Prbpe~line S'.'~/v~o) Building foundation ]'~ ~ Watermain ' '"' '~"
- ~ ..... - /..:
wate~'S~ice"li'ne ""../~: ~'~ewater '-:~' ~....,'Dfi~eway,.parkingN~i~ie~tbrage.:.;.,./~:~.~.
-Cu~ai~.~a~~:~:.~:~:w&,A:~...adjA~6~t:.i~: '.:~.~.'~..:..:. :.
F. COMMENTS --: ~' ''~ ~ :~ ~-.: ' ': ....
ENG.iN.EE.R~s, CE.RTiFiCATION- '.'"'".::' ..
G,.
I ce~tify:.~ha~.l,.,have determ~ned'.thr~Ugh::#eld.~n'spe'cti~S:'a/~d'~ .':':~
review OfMunicipai records:tba'~ the abdile :~ystem~.,~rA_i~ ...'. :
conTormance.wi~h,.M~A, FtAA guidel~/~e~"in.~ffect oi~;:~his: datel
Engineer's Printed Name .~ ~.~.~'.
. .. .... . . . ~:~.
Receipt.Number.. ~"':~:~.~t' 4~'
(Rev. 1·2/01)
. .:..:::??.:i'.Dgte,gf-Payment} . . -,
...... Receipt N~tmbe~,. ..... :.... .....
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Water Well Advisorv
Health Authority Approval # 030010
During a recent Health Authority Approval on-site inspection and test of the
potable water supply well on Block , Lot 28 of Delucia subdivision,
the well's productivity was determined to be 0.33 gallons per minute. The
minimum well productivity reqUired by this Department (AMC 15.55) for a
3-bedroom residence is 0.31 gallons per minute. Although the subject well
currently exceeds this minimum requirement, all parties concerned are
advised that the production capacity of the Well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering lawns and
gardens may be required.
This advisory must be attached to all coPies of the subject Health Authority
Approval.
CT&E Environmental Services Inc.
Laboratory Divi~i0n
200 W, Pot~er Drive
Drinking Water Analysis Report for Total Colifo~ Bacteria
Anchorage, AK 99518-1 605
Tel: (907) 552-2343
READ I~$TRUCTION$ ON REP~P~£ SIDE B£FOR~ COLLECT[NE SAM~E ~ Fax: (907) 561 ~5301
MUST BE COMPLETED BY WATER SUPPLZER
o p~ucW~T~aS~S',-~x.~.~ I I I I
~ P~ATE WA~R SYS~M
~ S~d R~ . ~ 5~d Invoice
Ii
13 Send InVoice
SAMPLE DATE:
Month
SAMPLE TYPE:
~ Routine
r~ Repeat Sample (for routine sample
with lab ref. no. ').
D Special Purpose
SAMPLE LOCATION.
Day Year
Treated Water
Untreated Water
TO BE ~OMPLETED BY LABORATORY
Analysisshows this Water SAMPLE ~o be:
~ Sali'sfactory
D Umati.sfactury
n SamPle over 30 hours old, resulte may
. be unreliable
0 Sample too_10ng in transit; sample should
notbe over~g)hours old at examination
to indicate reliable results. Please send
~e,w Sample via special delivery.mail.
Date Received
Time Received
Analysi.s Began
Analytical Me~od:
* Numberofcolonies/100 m].
., Result* Analyst
174
Time Collected
Colleeted
-'h Fbks Jun
Date: Time:
Client notified of unsatisfactory resultS:
Phoned Spoke with
Faxed
Faxed
Time:
Commen~:
BACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-MUG Result: Total Coliform
Membrane Filter: Direct Count
Verification: LTB BGB
Fecal Coliform Confirmation
Final Membrane Filter Results~
E. Coli
.__ Colonies/lO0 mi
COLiFIRM
Collferm/100 mi
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, iLLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA
CLIENT:
APPROVALS
ROAD rlESl(]ll
1ESt
SII1UCIURAL &
lie CI IAI IICAL
ItlSPECIIONS
WELL RECOVERY TEST DATA
WELL LOCATION (legal):
TEST DATE:
WELL DEPTII: f "7--~ !
CASING DEPTIh ~" ~"
TEST PROCEDURE:
t} Draw water down lo pump.
2) Shut pumpofl t5-60
-record lime
-record meier readl.g
3) T.rn pump on. Drawdown.
4) Shut pump off. -r~cord time
-record meier reading
5) Calculale gal.lml,. ~ecover~.
TEST DATA: START TIME:
TRIAL II r'UUP II T~ME
OFF
~ ON /'~.4
OFF
oFF /
OFF /
OFF
3 ON
OFF
OFF
4 ON
OFF
OFi=
ON
OFF
ROBEfl [ C. COWAN, RE.
IIOBEII[ A. SI IAFER, P.E.
CIVIL ENGINEERS
(901) 694-2979
FAX (907) 694-121J
TESTED BY: ~..,~" ~v' ~/-Z~
WELL DRILLER: ~ -- ~J~
DATE DRILLED: /~;;~/.~/- / ~X
[VilSC DATA:
Cashlg Ileiuhl:
Sanllary Seal?
Wires In Co,dull?
Gradh,g O.l(.?
PImIp Deplh:
S alllll)les Taken?
Dale:
STATIC WATER LEVEL: / ~O
METER II GAL/MIN.
/ .
RESULTS: WELL CURRENTLY PRODUCES: ~e =3:::~ ~P/¥')
FLOW RATE NOT GUARANTEED-SUBSEQUENT VARIATIONS.CAN
7034 HOIl111 EAGi E RIVER J OOP ' SI. JIIE 204 - EAGLE RIVER, Al ASEA 99577