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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEAl_TH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MAI LING ADDRESS
LEGAL DESCRIPTION
LOCATION
PHONE
~'7 7 -
DISTANCE TO; Well Absorption area
Manufacturer
L q, capac tV n ga on~
IF HOMEMADE:
' ~,~ DISTANCE TO: Well
i~ ~. Manufacturer
'J-r I DISTANCE TO: Well
-z~u"~' z INo.oflines ILengtb of each line
~ength Width
t Type of crib Crib diameter
Well
~ DISTANCE TO;
~ IClass Depth
~ I DISTANCE TO: Building foundation
NO. OF BEDROOMS
PERMIT NO.
Dwelling
Material
Width
No, of coFnpertments
Inside length Liquid depth
Dwelling PERMIT NO.
Material
Foundation Neare~ ['ct line
Total length of lines Trench w dt~
Material beneath tile
Liquid capacity in gallons
PERMIT NO.
Distance between lines
inches
Total effective absorption area
Depth
Crib depth
Building foundation
Driller
Sewer line
inches
PERMIT NO.
_Total effec~tive absorption area
Nearest lot line
Distance to lot line ~0,
I Septic tank ] AbsorpEion ;rea(s)
[] NEW
I~rJC'G R A D E
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
t~
DATE LEGAL
i
APPROVED
72-013 (Rev. 3/78)
Permit
Location: ~----
Leqal Description: (-../., ~.~ ~30~%Y".:('./~1
Type of Soil .Absorption System Is:
-Trench: Drainfield:
Maximum ~Number of Bedrooms:
MUNICIPALITY OF ANCHORAGE
Department ~f Health and Environment~ Protection
825 ~ Street, Anchorage, AK. 99501
264-4720
Mai'ling Address: <' '
Lot -Size:
Seepage'Bed: Holding
soii:Ra~ing sq.ft~b~)
The Required Size of the Soil Absorption System Is:
DEP.TH . .LENGTH GRAVEL DEPTH_ ~ :> , WIDTH
The length dimension is the length(in feet) o.f the. tren'ch.:or drainfield. The
depth of a trench or pit is the distance between the surface of:the ground and
~the bottom 'of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall ~ipe and
the bottom of the excavation(in feet).
* * REQUIRED ,9~E,~II!~:C(HOLDING) TANK SIZE = /~)~ GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
' * * * TWO(2) INSPECTIONS ARE-REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a welt and any on-site sewage disposal system is 100 feet
for-a'private well or 150 'to 200 feet from a public well depending upon the type
of public well. Minimumdistance from a private well to a private sewer line
is 25 feet and to a corm%unity, sewer line is~75 feet. Well logs are required
and must be returned.to this department within 3'0 days of the well completion.
Other requirements may apply. _Specifications and construction diagrams ~re
available to insure proper installation.
* * *-PERMIT EXPIRES DECEMBER 31, 1 9 $ 2 * * *
I certify that:
(1) I am familiar with the.requirements for on-site sewers and wells as
set forth by the Municipality~ of Anchorage~
(2) I will in'stall the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 bedrooms.
Signe~:
Applicant
I/kf*2?t ~" K~. M) "//' , ~' , ..
,; ; ~. ,i/,, .:,2 )
' . '~" MUNItg~PAL[lj'¥ OF ANGH4],..~C.-E
' ~ ~ . ~ 3 ' ,
T~e of S~I ~Vouption ~y~-'
O~f}{ __ - ...... , LE~{GTH '- .... GRAVEL O~]~ -
khe ~tOm O~ the ~avaEioa(in -~eet),
fo~ a ~rlva~ well ?r .~50-b~ 200 ~ee~ fr~ a ~3uhlio well
'+ ..... ~ '~ PERMIT EXPiReS D~CE~RJ~I, .1 9 ~.~
~e% for%h by t-he M~icipali~y ~of ~cho~age.
f~. ~ ,5~'~ ~ Ye~z.:,~3 v ~";,-~. , ,
MUNICIPALITY OF ANCHORAGE
= Health and Environmenta?
Street, Anchorage, AK.
Department *rotection
825 ~3501
264-4720
* * * HANDWRITTEN PERMIT * * *
Permit ~ ~%\~f .... ~~0N-SITE SEWER PERMIT
Applicant: !~['F~7--O ~-- ~_ d~ Mailing Address:
Location: Phone Number:
Legal Description: ~./Q~ /_~ - ~ Lot Size:
Type of Soil Absorption System
Trench: ~ Drainfield: 9 _ Seepage Bed: ~ Holding Tank:~~
~aximum Number of Bedrooms: ~ Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:'
DEPTH .LENGTH . GRAVEL DEPTH .... WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
REQUIRED ST~I:NT-~C(HOLDING) TANK SIZE = ,~D~2~ GALLONS
*
*
*
*
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 2 * * *
I certify that:
(1)I ara familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of A~chorage.
(2)I will install the system in accordance with codes.
(3) I u~erstand that the on-site sewer system may req}~ire enlargement if
th~/~,~id~ence i~ remodeled to include more that 3/b~drooms.
Signe': ~plicant ~YDate: Issued
SWP,/024(1/81)
DEPF1RTMENT ~ ..... HEFILTH FIIqE:, ENYIRONHENTRL. ='OTECTION
825 "'L.." FREET, FINCHORlaGE., ~K. 995e,.
264-4Z2E~
F:'ERHIT NO. ( 8D[~e]6~[~ ) [:,ATE OF ISSUE
mmm klflRNING - DUE TO CHflNG[F,IG REQLI[REI'qENTS THIS PR]NTOLIT h'lflY NOT BE
*:+,* COPY OF' THE OR]G ~ ON~L. PERH~'I" :+:
FtPF'L[CRNT t"'IEL., INC 2C~4 EFIST 5 SUITE 2E14 995C1:t. 276-6858
I...EGRL LOTS t A 2 MT. s~:Z~_ S/D LOT SIZE :I. EI~3C~C~E~ SQIJARE FEET
TYPE OF' SOZL ABSORBT[ON SY~'TEM ZS: ~
MRXIMUM NUMBER OF E,/DE..UH.:, = 3: '~-[L. RATZNG ,::SD~ i-T,. E, F4 .....
]"HE REQL.IZRED, S[~ OF THE SOIl.. RE:90RPTZON S"r'STEM
THE L. ENGTH E:, [ MENS Z ON [5' THE LEhlG'F~[f~ FEET) OF THE TRENCH OR DRRZNFIEL.[:'.
"I"HE E:'EPTH OF FI TRENCH OR PZT ZS THE DISTFIf',ICE BETWEEN THE SLIRFFICE OF THE
GROLINE:, FINE:' TIdE BOTTOr'I OF' THE EXCRVRTZON (ZN FEET).
THERE IS NO SET NIDTH FOR TRENCNES.
THE GRAVEL [:,EPTH ~] 'TP~ ~[.NIMIJM DEF'TH OF GRB'¢EL BETI4EEN THE OIJTFALL. PIPE
DflCKF[LL..ZNG OF FINY SYSTEM W~THOIJT FZf',lR[.. ZNSPECTZON fiND, F]F'F'RC¢,,,'AL. BY
DEPFIR]'MIZNT klZL. L. BE SLIBJEC'F 'FO PROSECUTION.
MINIHIJH E:,ISTlaNCE E~ETHEEN R HELL. AND ANY ON-SZTE SE[,.IflGE [:,ISPOS~I... SYSTEM
:1..5D TO 2ElD FEET FOR FI PUBLIC HELL. E:,EF'ENDZIqG UPON THE TYF'E OF PUBLIC HELL
MZNZMIJH D, IST~NCE FROM FJ PRI',/RTE NELL TO ~ PRIVATE SEHER L..ZNE ~S 25 FEET FIND
'TO FI COhlMIJN]TY SEHER L. ZNE ZS 75 FEET.
NELL. LOGS RRE REQUZRED, FINE..', MUST E:E RETURNED TO TNE DEF'~R'rHENT [,.I~THZN 3:E~ D, FIYS
OF THE I.qE:L..L. C:OHPLET~ON.
OTHER RELqLIZREHENT9 HAY APPLY - SF'ECZFICflTZONS AND CONSTRUC:TZON E:,]flGR~PIS ARE
FI'v'Fi~ L. ABLE TO Z NSLIRE PROPER · Z NS'T'ALLFrl" [ ON
Z CERT~F::Y THRT
::L: Z F:IM FRP'IZLZAR HI]"H TNE REQUZREMENTS FOR ON-S["FE SEHERS RND HELLS AS SET
FORTH B"r' THE MUNZCZPALZTY OF' RNCHORAGE.
;2: I HZ[..L ZNSTFILL THE SYSTEM ZN FICCORDRNCE ['.IZTt"I THE CODES.
]:: I LINDERSTF~N[:, THRT THE ON--'SZTE SEI,',IER SYSTEM MRY REQUIRE ENLARGEHENT ZF THE
RES IE:'EN~ REr~LC~*~E[} TI~f~I;LIJ[)E MORE THAN 3: BED, RCu3MS.
INSF[~~ER :~ 8 '};EWER 2
1.4EL. L INSP El HELl_ LOG [."ATE E1 [:,RILLER
January 4, 1982
N. Sekse & M. Classen
c/o Dresser Atalas
5839 Old Seward
Anchorage, AK 99502
Permit ~810693
Subject: Lt. 1 & 2 Mtn Vale, 1 Residence
A permit issued by this department for a well and/or sewer
system has expired as of December 31, 1981.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log should be sent to
this department to document the installation date.
If an engineer inspected the installation of the on-site
sewer system, please have them send us the as-builts for our
files.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
Pro;~m M~nager~
Sewer and Water Program
Enclosure: Copy of Permit
[::,EF'~IF, TT'ME:NT HEFIL."FH F¢.,E:, EN',,,'! RONME:N"FFIL ..... 3TE:CT ION
8;:...::5 '" L. '" s;-r'REET., FINCHORFIGE., FiK. 9::'35Ed.
2 E; 4 "-' 472 E~
,E:,~ ~'-,,~ ........ :?,:.:,; :E 'T' ~.~': ii~i:.:.:,; E~:: ~....fl E'E F,.,? IL.~t F::~ iC]~i Fi ff:::':~ [:,, E IFTM E: IF;;~: Edl ]1:: '-If-
F:IF'F'[..:[CFtNT N. '.:.:;EKE;E 'J'.. M. I:::LFi'_":i',:F:iEN (:::,-'"E~ [:,Fe.E:'.i~;:'.-:;f:ZR FI"['I._FI:::i:., .58'"'.~:9 OL.E:, '_-,[:..~ , ~,.,.:.-.:bL-::
[ : r:':FIT :[ lin Ct....F!I:;~iK RI:,.
L.E: }RL LT. t&2. M'FN ',,,'FtL. E., '.'L RE:C; I I:::,E:NCE I...OT E; ]: ?E
"r'¢F:'E ,:'F :;,::,~L FIE':-. :F.'F'I-]' :,N :3',:~:T1T:lt IE;: ~ /-//~/J//4.~'~..
h!R:<'rM..M I'*,IUME:EF:'. OF EE'E:,F:'or.:$'I'&.'; = ]:
E';.:IL RF:I'I"INC-i (:5[;:! F:'T,.."E:R)= ~
'T'HEi: F..:E~.E:!IJIRE[:, SIZE OF:' THE '_"SOIL. F:iE:'.E;r'~F?F:'TI"'I'-,~ '.~'T'E;TE:M ]:S:
TFIE: LENGTH [:, I h'IENE; :[' O1",1 I L::; THE LENGTH ,:: I lq FEET > OF THE "I"F.:ENCH OR DRR I lql::: I EL.E:,.
THE [:,EPTH OF t:::I TF..'E:NC;H OF:: PIT :[::5 THE DISTFINCIE E',E:THEEI',I THE SUI:;..'FF:ICE OF THE
GROUI'.,ID RN[:, THE E:OTTOM (:il:::' "FI..'IE E'?:;CFI',,,'FITION ,:: IN FEET).
'I"HERE IE; I'.,IO :7:,ET HI[:,TH F.:OF.': TRE:I",ICHE:E;.
THE GRR',,,'EL. [:, E]::' T FI I::-:; ]"FIE M II',tIMIJi"I [:,EF:'TH O1::: GF..'FI',,,'EL E:ETHEEN "I"HIE OI...rT'FFiL. L P:[F'E
FIN[:, THE BOTTOM OF THE E::.::CF:I',,,'I:::FF 1' ON ,' I N FIE:ET ',
il:x;: E.r:2: ~:;;:., ILJ ][ II:~i:: EE: !E:, ~ "'iF' F!I ~'-¢~ E:::: 2~ :~: ;;~: EE ........ '"~? ~;-DI ~::..2':~ ~:/i~n E3i IF::~ L. L... E::, B.,.~I '.'Z.~;;
PERM :1: T FIF'PL I E:FINT HFIE; THE RE.'.:qPONS; I B ! L I T'¢ 'TO I i'.,IFORM ]"FI I E; [:,EF:'I::iRTMENT Dl..Ir,;l I I'.,!G THE
:r. i'.,I:5]"FILLFIT :1.' ON I NE;,PEC'f'I ON'::; OF Ftl'.,l'¢ I.,.IELI_S Fi[:,JFICENT TO TH Z E; PF.'.OPERT'T' FINE:, THE
NLIMBER OF' RESIB, EI'.,ICES "I"HF:IT TFE: HEI._L HILL E;ER',,,'E.
I
..................... ~:~ .:: ,,lli~l~]~ ]:, ]E P-4] E!:-; F" EE E::: '"'Il"" ][ IIZ) ~'..,,li ~;; ~::::I1 IfiL" E.:E E;:;.". EE ~". tl._l~ % 11~i .". .EEC E:::: .......................
E~FK::I<F :1: LI_ I NC:i OF FII",I'¢ E;'T'E;TE:M H I THOIJT F T I.,tRL I N:SPEC'F I ON I::fl',l[::, RI:::'PREI',/FII... B'T' TH I E;
[:,E:F'F:I!;::TM[!i:I'.,IT 14ILL. BE SUBJECT 'FO F:'ROE;ECUTION.
I'!]: N I MUM I::, I :STFII',IE:E E:E'THEE:N FI klE:L.L FIND FIN'T' ON-'/::; I TE SE.HFIC. iE [:, i :ii;F'O:!!;FIL $'T'E;"I"EM I E;
:;!..EIEI FE]ET FOR FI PRI',/RTE: I.,.IELL. (::iF;'. :l. SEI TO ;;!'EIEI FEET FF:'.OM FI F:'UE',LIE: HI:ELL DEF'EN[:,Ii',IEi
UF:'ON THE TYF'E OF F:'UE:[_.IC I.,.IEL. L.
MINIMUM I}I:.3TI:::INCE FROM FI F'RI',,,'F:ITE I.,.IELI... TO F:I I::'~;.:Ik,'Iq"I"E L:.;EHER LINE IS; 25 F:'E::ET RNI::,
TO FI COMr,ILtNI]"'T' SEHEF.: LII'-,IE I':l 75 F'E:ET.
Eq'IqER REC!LI :[ REi"IEEI'-,ITL5 I"IFW FIPF'L"¢. SPEC:: I F I CRT I Ot",!S FIN[.:, CON:!i!;TF::LK:::T I ON [:,:[ I::IGR. FIMS fiRE
i::~l'v'R I L..Flli::[I_E TO T N'.:.;IJF.:E: PROPER I N:.E;TFtI...LFIT :[ ON.
I CE:I::~:]" :[ F"¢ TFII:::I'F
:1.: I I::IM F:'FIM:[LII::II:;: 14:['1"H THE REQUI'RE:MENTS FOR Oi'-,!-S;:[TE :E;Et.,!ER:~i; F:tI",tE I.,!EEL_L.'.:.'; I::t:.F.'; SET
F:'ORTH E:'T' THE MLII'.,I ]: C I I::'FII._ I ]"'T' OF FII'.,!CHOf;~:RGE.
2: I [,.t ILL I NE;TRL[... THE :.E;"r'S;TE:M I I",l FIE:C:EIR[:'FINCE H I Tlq ]"HE CO[:'E::!i;.
.]:: I UI",I[:,ER:STFII',I[:, THFIT THE ON--'SITE 21EI.,.IER S:,"r'STEH I"IW'/ REC!U:[RE ENL. FII"e. GEME:NT If:' THE
REE; :[ [:,E:NCE I E; F~:EMf:IE:,E:LEI::, TIZI I h,ICLUB, E MORE: THI:::IN 3: E:E:[:,I;?.I]IOMS.
PERMIT NO.
APPLICANT
LOCATION
LEGAL
TAKU CONST CO.
CLARK RD. kO~LE~
L'f.i&2 MT. V~¢ S/D ;
204 E 5TH SUITE 20~ RNCH 276-6858
LOT SIZE 200000 SQUARE FEET
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
i00 FEET FOR A PRIVFITE WELL OR iD0 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DRYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F'E~:M I T E~:"-F" I F-:E5 BEC:Ef-IBER --~i., i_'~- 8~[4
I CERTIFY THAT
i: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
SIGNED:
RF'PLI CANT TRKU CONST
V4. 0
WATER WELL LOG
FOSS DRILLING ASSOCIATED
909 CHUGACH DR. #5?
ANCHORAGE, ALASKA 99505
MUNICIPALITY OF ANCHORAGE
DEPT. OF IX '!TH &
F-NVIRONMENT,&L ;:; 0 [[CTION
AIJ6 7 1980
WELL LOCATION Lots 1 and 2 Mountain Vale Subdivision
SIZE OF CASING 6"
STATIC WATER LEVEL
REMARKS
__DEPTH OF HOLE ~) FT,
17 FT. G, P, M, 20
CASED TO 63 FT.
WITH 34 FT. OF DRAWDOWN.
DATE COMPLETED 6/2~/80
PUMP TO BE SET AT
62~
...0 to 5 ,,,
Or6anic: brown color and soft
5 to 35 Alluvium: grey color, medium hardness
35 to63 Till: grey and hard
to63 Sand and GRavel: brown, with water
to
to
to
to
to
to
to
to
to
to
to
to
¸to
rTime Time
'~'ate Date Date
Inspector Inspector
,nspector
Comments~ ~ b ~-_-- .--6~.. , Conditional Approval
Date Sewer Installed Permit No. Septlo Tank Size
Holding Tank Size
Soils Rating Well To Absorption Area Well Log Received
Well to Tank
APPLIOANT FILL OUT LOWER HALF ONLY
Address /¢() ~ /~¢ ~ ~J ,~,
Realty Co. & Agent ~Od,~ ~/ ~S~-¢~ ~'~C. Phone ,
Street Location ~/~kr ~ 4/
Type~f Residence
~ingle Family
U Multiple Family No. of Bedrooms
~ Other
WatCupply
~ Individual ATTACH WELL LOG. A well log is required for all wells drilled since June
B Community 1975. For wells drill¢¢.priOr to that date, give well depth (attach log If
~ Public UtilitF¢ available.) O~ ~
~ Individual ~-~' '~ ~. ~ ~'~ ~ar Individual Installed:
O Public UfiliW ~ . ~ , ~ ~' ~hen Connected to Public UUliJy:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFOR6 PROO~SSIN~ CAN BE INITIATED.
August 17, ]_9~2
Norman D. Grant, Jr.
P.O, Box 4-1909
Anchorage, AK 99509
Snbjec'L: Lo-I:,~; ] and{ ? '4ouDtain Vole SUbdivi.qio'[~
Approval '{or the individual sewer and water facilities
be gran-P, ed until the foltowinq items have been completed:
0 The top of the well casing sealed with a sanitary seal
that it is wa-her 'tight.
Nxposed qlec%rJ.cn! wires Lo %he we].l lw.}ad ~re in violatioll
Of tt~e ~funicipellhy of Anchorage codes and mu[d% he encased
in conduiL,
'IT}e water analysis report nee({s to be .qubmitted to 'this
office
-.rohl t'}Ie (]hell% Lab, q633 '1'~ ~,hxeet, for our review.
;,d...t].nj 'Lank 1)urn}ed with a
depar%ment.
Install at ].east an additional 1000 gallon holding tank to
give t'he dw(~l, lJ. nga to'hal of at least 2000 gallons t)o].ding
capacity. Prior to this upgrade a permit needs
issued from this departmeut.
° ~Fhe 1000 qn!.lon tank outside the dwelling needs to !)e
sea]ed a'l'. t'he outlet.
3oma method of gettinq 'the sewaqe :from 'h]l{} t~ril]]( tO t'he
pumper 'truok murat be provided to this dei3art, ment for al~prova].,
pant when boldi~q 'tanks are filled and needfl puqpiDq.
l/lease no'hJ.:f~y this Department for a reinspection wb. en. the
uoted discrepancies have been corrected. If -h'0. ere are any.
furtNer questions, please call t,hi?~ office a'h 264-472().
Sincerely,
Cory Wil'].i~, ~. S,
CHEMICAL & G[ LOGICAL LABORATORIES ? ALASKA, INC. ~>
- TELEPHONE (907)-279.4014 ANCHORAGE INDUSTRIAL CENTER ' '
274-3364 §633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
I.D. NO.
Water System Name Phone No,
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.
, I
LOCATION
Time Collected
Collected BY
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
~] Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
[] Membrane Filter
Lab 'Ref. No. Result* Analyst
*No of colonies/~O0 mi. or No of Positive pot[ions
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev, 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
Date Received Time Recelve(J p,m. Lab, No.
3resumptlve ].emi 1Omi ].Omi 1Omi /Oral 1.0mi O,lml
24 Hours
48 Hours
:onflrmatory
24 Hours
,48 Hours
EMB. Broth 24 hours: Broth 48 hours,,
Multiple Tube Report: Z0ml Tubes Positive/Total Z0ml Portions
Membrane FIIter; Direct Count Collform/100ml
Verification: LTB BGB
Final Membrane Filter Results Collform/10Oml
Reported By Date ,
APPLIC/ IT FILLS OUT UPPER HAL ONLY
Property Owner Norman B. Grant, Jr. Phone
Mailing Address Post Office Box 4-1909 Anchorage ZipC0de 99509
Suyer Norman/Joan E. Horii
1408 Nunaka Drive Anchorage 99504
Address Zip Code
Lending Institution National Bank of Alaska Phone
Pouch 7-02-5 Anchorage 99510
Address Zip Code
Really Co. & Agent Nova Real Estate¢ Inc. Phone
Address 859 East Loop Road Anchorage ZipC0de 99501
LegaI Descript~on Lots 1 and 2 Mountain Vale Subdivision
Street Location
Type of Residence
X'~ Single Family
~ Multiple Family No. of Bedrooms. tWO
[] Other
Water Supply
X~ Individual ATTACH WELL LOG. A web log is required for all wells drilled since June 1975.
~ Community For ',,,'ells drilled prior to that date, give well depth (attach log if available).
~ Public Utilily
Sewer Disposal
~ Individual Year Individual Inslalled:
Q Public Ulilily When Connecled Io Public Utilily:
~ ~'~J-loldin g Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST SEFORE PROCESSING CAN BE INITIATED.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
Environmental Sanitation Division
825 L Street · Anchorage, Alaska 99501 · Telephone 264-4720
CERTIFICATE OF INSPECTION
ON.SITE SEWER AND WATER FACILITY
1. Property Owner
Mailing Address
2. Legal'Description
Norman B. Grant, Jr.
Post Office Box 4-1909 Anchorage 99509
Lots 1 and 2 Mountain Vale Subdivision
3. Type of Dwelling
~Single Family
[] Multiple Family
[] Other
· CONDITIONS OF APPROVAL
A holding tank requires routine
pumping.
4. Sewage Disposal
[] Individual
[] Public Utility
~,~olding Tank
APPROVAL FOR
~ BEDROOMS
[] CONDITIONAL
[] DISAPPROVAL
([:~'"APPROVED
5. Water Supply
.,~,~ ndivid ual
[] Pubbc
[] Community (shared)
DATE: /
BY:
1HIS APPROVAL NOT VALID
W~THDUT DEPARTMENT SEAL
WELL LOCATION Lots 1 and 2 Mountain Vale Subdivision
SIZE OF CASING 6" DEPTH OF HOLE. 53 ET, CASED TO
FT. G. P. M. 20 WITH 34
~'7~0~ a ~O~"l / FOSs ~ZZ~O ASSOCiAteS
1~ ' ~CHORAGE, ALASKA 99505
WELL OW~bl~no~&tv ContracLors Industrial,Inc,USE OF
63 'FT.
FT. OF DRAWDOWN.
DATE COMPLETED 6/a5/8o
PUMP TO BE SET AT 62'
0 to..5 .,.
_5 to,35
.35 to 63
to63
,to
to
to
_ to,
~to
to
to
to
Organic: brown color and soft
Alluvium: grey color, medium hardness
Till: grey and hard
Sand and GRavel: brown, with water
825 "L" STREET
ANCHORAGE, ALASKA 99501
(907) 264-4111
GEORGE M. SULLIVAN,
MA YOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECFION
December 31, 1980
Mel, Inc.
204 East 5th Avenue - Suite 204
Anchorage, Alaska 99501
Permit ~ 800660
Subject: Lots 1 and 2 Mountain Vale Subdivision
A permit issued by this department for well and/or sewer
system has expired as of this date.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log should be sent
to this department to document the installation date.
If an engineer inspected the installation of the on-site
sewer system, please have them send us the as-builts for
our files.
If there are any further questions, please call this
office at 264-4720.
Sincerely,
Senior Environ~n~;~"~~ialist
LNB/ljw
enc: Copy of Permit
SWP/057