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HomeMy WebLinkAboutRACHEL LT 2#015-273-38 a Municipality of Anchorage s e a.r Development Services Department a Building Safety Division Onsite Water &Wastewater Program, 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Page 1 of 3 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: SW040484 PID Number: 015-273-38 Name: JOE NIESPODZIANI Wastewater System: O New ■ Upgrade Address: 11101 CANGE STREET a ANCHORAGE, AK 99516 ABSORPTION FIELD Phone: No. of Bedrooms: (907) 344-2843 5 O Deep Trench ■ Shallow Trench d Bed O Mound 0Other LEGAL DESCRIPTION souRating: 1 2 grad Taw Depth from awes 9 5 MAX spoke. fT. n Block: Lot: Subdivision: Depth to pipe bottom from original grade: grovel ape+ beneath pipe: — 2 RACHEL SEE DWG. rt 2.0 ti Township: Range: Section: — — — rill added abort original grade: growl length: 2 ® 45 (90 TOTAL) SEE DWG. n. rt WELL: O New O Upgrade Crawl width: 5 Number of Knee: Distance between pew.: I — la f>CR It classification PrWo. A&C : Total Depth: Cased To: Total absorption area: Pipe material: D 3034/ F-810 n 642 so. Ft. orales: bad: stalk water Uw : bwlofer. GEG, Ltd. Datakwlaned: 12/13-16/2004 n Yee: Pump set At Casing Height Above ground: TANK „�, ft pt SEPARATION DISTANCES ■septic 0Holding 0S.T.E.P. 0Other T° Septie Absorption Uft Holding bac/Pdvats Manufadwe: ANCHORAGE TANK DepeoitY in goforw: 1500 From Tank Field Station Tank sewer untie Well 100'+ 100'+ — — 25'+ Neatens: STEEL Number of compertmeote: 2 Surface water 100'+ 100'+ — — — LIFT STATION Lot Una 5'+ 10'+ — — — Sit, in galone: Manufacturer: 5'+ 10'+ 'Pump on Mei at: ump oft sue1. oh ter alarm ou Foundation — — — Pomp Moles I InspectionspeAomwd by. Drain NONE KNOW BENCH MARK Remarks: THE OLD SEPTIC TANK WAS ABANDONED PER UPC. Laaatian ono Dwenpeon: BOTTOM OF SIDING (NORTHWEST CORNER) AFTER INSTALLING THE NEW TANK WITH APPROPRIATE GRADE FROM THE HOUSE, COULD NOT GET GRAVITY Assumed EMotiom 100.00 n. FLOW TO THE OLD DRAINFIELD. [NclNelcrsa 4 � QF '•�gS40 Inspections performed by: GEG, Ltd. Dates: 1st 12/13/2004 '....9 ........ ..... 2nd 12/15/2004 , 3rd 12/16/2004 O •.:� Gar ess: Development eryices Department Approval 4peDp E— ti��p0 04 �' • fz�>'1 � �Ao Reviewed and approved by:ate: � �4p derafesslo0\ te12/01) pee Op4��oc� PERMIT NUMBER: AS-BUILT DRAWING PARCEL NUMBER: 015-273-38 SW040484 I \\\EAc AR �\ INSTALLED FLOW SPLITTER NEW DRAINFIELDS L2 BL1 -G- G-G \ - LD DRRAINFIELD ABANDONED ---TH�1 IN PLACE FOR FUTURE USE I_- Sr r-___ �� / \ / NEW SEPTIIC ON TANK / A-T-i3--Fc ALTERNATE SITE WILL STI 1&20 113.Dg 70.00 I I REQUIRE THE USE OF ST2 10.17 121.53171.55 AN ADJANTEK DELI 21.83 18.08 74.84 TREATMENT SYSTEM DBL2 23.48 18.08 74.75 . ~ - / ;'�.::�.. •. • FS 45.85 27.30 82.88 C01 47.11 28.20 83.15 i C .. r' ^... �• .` Mri 44.25 24.87 00.03 CO2 07.88 84.30 96.88 �• \ •'.:'.ISTINC �' �: •. \ _MiT 07.97 64.50 97.09 .• , � ' • �' •�•14 WELL CO3 38.98 40.03 96.88 1 ,� I "1 MT3 157.45141.45 97.48 C04 91.39 69.31 109.27 ; . ��•:.,; ; ,•;.,, • �; Mi4 90.46 88.82 109.59 .• r.. ..'... .:..: t.'. GARAGE i a U I\ \ I 100' WELL RADIUSip DATE, 2/21 /2004 ., • ``� .. DRAWN BY: GARNESS ENGINEERING' GROUP, Ltd. C.J.G. I....:. s�ALE CONSULTANTS & GENERAL CONTRACTORS �r 1 " = 4O, .. ..:.*• 1701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE, AK 99507 ' PHONE (907)337-5179 • FAX (907)318-3246 PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOE NIESPODZIANI (907) 344-2843 1 2 OF 3 , O Gar ess.. 0 °•, CE- 5 LEGAL DESCRIPTION: RACHEL SUBDIVISION; LOT 2, BLOCK 2, �4p�, s� ' •lira? 01F��4o� P��ofessoo, TYPEWORK: AS-BUILT DRAWING OF SEPTIC SYSTEM UPGRADE `"'����``�� PERMITNUMBER: AS -BUILT DRAWING FARDEL ID NUMBER: SW0 SW040484 015-273-38 FINAL GRADE - 99.56-99.72 ST1 ST2 TOP OF INLET - INVERT OF BUNG AT INLET - 94.92 n U NEW 1500 GALLON SEPTIC TANK -TOP OF TANK AT OUTLET - 95.50 INVERT OF BUNG AT OUTLET - 94.75 1 - RK4I. GRADE - Mr CO FINAL GRADE - ORIGM. GRADE 100.97-102.42 ORIGINAL OWE ,B1 100.94-102.79 . 100.99 O I t00A6 • 1 I NRROIDT POIM XNiXES. 6 0 ' riLLTER FABRIC �iRTER FABRIC 5INVERT OF �� ` a"� BOTTOM Of AL 1807700 Of TRENCH (AVG.) - 91.40 VC.) I10' - 91.49 (1V0.) RELATIVE ELEVATION OF BOTTOM OF TEST HOLE - 85.46 (TEST HOLE DRY) DATE: m. 12/22/2( DRAWN BY: GARNESS ENGINEERING GROUP, Ltd.: C.J.G. CONSULTANTS 8 GENERAL CONTRACTORS 3701 E. TUDOR ROAD, SUITE 101 - ANCHORAGE, AK 99507 • PHONE (908357-6179 • FAX (907)338-3266 N.T.S. PREPARED FOR: PHONE NUMBER: PAGE NUMBER: JOE NIESPODZIANI (907) 344-2843 1 3 OF 3 LEGAL DESCRIPTION: RACHEL SUBDIVISION; LOT 2, BLOCK 2, TYPE OF WORK: PROFILE AS -BUILT DRAWING OF SEPTIC SYSTEM UPGRADE v� '`150 I ....... A Gor ess.' -? I-, ,t„o MUNICIPALITY OF ANCHORAGE Development Services Department Onsite Wafer 8 Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519.6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Permit Number: SW040484 Legal Description: RACHEL LT 2 Design Engineer: 0855 Gamess Engineering Group, LTD Owner Name: JOE NIESPODZIANI Owner Address: 11101 CANGE STREET ANCHORAGE. AK 99516-1453 .17tk3p+ 1toBD P-kiUkA 10) Date Issued: Nov 22, 2004 Expiration Date: Nov 22, 2005 Parcel ID: 015-273-38 Site Address: 011101 CANGE ST Lot Size: 28114 SQ. FT. Total Bedrooms: 5 Permit Bedrooms: 5 This permit Is for the construction of. ❑✓ Disposal Field Z Septic Tank ❑ Holding Tank ❑ Privy Private Well ❑ Water Storage All construction must be in accordance with: 1. The attached approved design. 2. All requirements specked 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. 5. The following special provisions. THE NEW PROPOSED DRAINFIELD IS APPROVED TO SERVE 5 BEDROOMS. ANY FUTURE ADEQUACY TESTS FOR THIS 5 BEDROOM HOME NEED TO BE PERFORMED ON THIS NEW DRAINFIELD ONLY. 12)ifloI. 6AImfsS Fv6. G1t•(.,rD Ir -OA besr94 cqh eI/hVgE C>vE Tu ELEWi-rutis. I HE DESr§v Wme- REMAW q S Wr%. T"A/E DEPrq Wrcc. 6E Sk/Ar.cuvtr,p .47- 2.3/ EfffcrrVG f TO c0MpF&$ArE TWE LEN/rrN bVe-ReASED TO SS.S r Gavq. 4' AIF -v Cov�.gmATrup/ 77457 /dOCF- wrct. df SvOrhTTFv '✓�T//E AS-Pvrr..r. V Received By: Issued at Date: - Date: /07% Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 015- 27-1 -? 8 Permit Number Property owner(s) JOE NIESPODZIANI Day phone 344-2843 Mailing address (1) _ 11101 CANGE STREET • ANCHORAGE. AK Mailing address (2) Zip Code 99516 Legal description (Lot, Block & Sub'd.) RACHEL SUBDIVISION; LOT 2, BLOCK 2, Legal description (Section, Township & Range) N/A Lot Size Z Et ll r'I Acres/Sq.Ft. Number of Bedrooms .► S THIS APPLICATION IS FOR: Sewer Only Well Only ❑ Sewer and Well ❑ Water Storage ❑ Sewer Upgrade ❑ THIS PROPERTY CONTAINS: Hot Tub ❑ Jacuzzi ❑ Swimming Pool ❑ Water Softening Unit ❑ Therapy Pool ❑ 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. GARNESS ENGINEERING GROUP, Ltd. Permit Fees: Date of Payment: 111/710 Receipt Number. 0 6 19J Waiver Fees, Date of Payment: Receipt Number. GARNESS ENGINEERING GROUP, Ltd. CONSULTANTS & GENERAL CONTRACTORS November 12, 2004 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, Ak 99519-6650 (907) 343-7904 Ref: Proposed Septic System for Rachel Subdivision; Lot 2, Block 2, To whom it may concern: The existing 4 bedroom house is served by a private well and septic system. The septic system is currently in the state of failure and needs to be replaced. Per the owners request we have designed the new septic system to serve 5 bedrooms. We are proposing to install a 1500 gallon septic tank and 5 -wide trench type drainfield. One test hole was excavated on the property. The drainfield will be designed around the 30 foot radius of this test hole. Comments regarding the design are summarized as follows: 1. SOILS: See the attached logs which shows the soil classifications, groundwater monitoring, and the percolation test results. The insitu sandy soils will act as a sand filter. It is our opinion that an application rate of 1.2 gallons/day/f2 should be used. 2. TRENCH DESIGN: a. Percolation Rate: <1 minutes/inch b. Proposed Application Rate: 1.2 gallons/day/R2 c. Number of Bedrooms: 5 d. Design Flow: 750 gallons per day e. Minimum Absorption Area: 625 R2 f. Total Depth: 9.5 feet (maximum) g. Effective Depth: 3.5 feet (minimum) h. Width: 5 feet i. Reduction Factor: .54 j. Minimum Length: 68 feet long k. Effective absorption area = 630 !12 3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed septic system. 3701 E. Tudor Road, Suite 101 • Anchorage. AK 99507 Ph: (907) 337-6179 • Fax: (907) 338-3246 • Website: gamcssengineering.com 4. TOPOGRAPHY: As can be seen on the attached topography site plan the average slope in the area is relatively flat. In short, there are no slope concerns. We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assistance. NOTE: A site plan drawing, a design drawing, one soil log, and a 7 page construction specification letter which are all part of the design package for this septic system. 3701 E. Tudor Road, Suite 101 ' Anchorage, AK 99507 Ph: (907) 337-6179' Fax: (907) 338-3246 * Website: gamessengineering.com ALLEN S/0; LOT 1, 1 X115 1 I I 1 1 ALLEN �S/D; 1 \ LOT 2. i \ EXISTING \ 4 BEDROOM \ HOUSE, 1 (-SEPTIC I ARaD I ALLEN S/D; I LOT 3, / i \ 1 gEPnC ALLEN S/D;ARLAD LOT 4, T12N, R3W, SECTION 21, LOT 25, N2, T12N, R3W, SEC. 21, / LOT 25, S2, Inn. WEII RADIUS PROPOSED 1 SEPTIC SYSTEM \, �rneTlur. L_ CREAT DANE PARK S/D; LOT 4, r--------------------- ------------ I I 1 SIEFKER 5/D /2; SIEFKER -I SIEFKER S/D /2; /2; LOT A -1 C. I LOT A-fA, LOT A-18, 11/3/2004 Y/] DRAWN 9Y: ��•v�' ... ._ __.. _ C.J.G. GARNESS ENGINEERING GROUP, Ltd. SCALE: nnnnnn CONSULTANTS& GENERALCONTRACTORS 1" = 100 ��,,,, ,,, ,,, ,• ,,,,, ,,,,,,,, 5700 F TIX D PDAD. SDITF 104 • AHrwMAr.F. AK OOS01 • PwmF (W?M?Y .10 • FAX (00)gIRA, 746 PREPARED FOR PHONE NUMBER: PAGE NUMBER: i1 JOE NIESPODZIANI 344-2843 1 OF 2 :,j r ss. LEGAL DESCRIPTION: 'y'�y, E 7953 RACHEL SUBDIVION; LOT 2, BLOCK 2, TYPE OF WORK: '+i`)�dP O\ -•:' SITE PLAN FOR PROPOSED SEPTIC SYSTEM UPGRADE +.`•.,rotesslo^_• Ld /'-... s �• ..,,, , 1 RACHEL S/D; 1 I V . \♦ i LOT 1. I U I/ LLQ CREAT LL1 DANE PARK Z S/D; LOT 2. LLJI Of I 11\ GARAGE % ♦j �� I 11 ♦ i I --J �' I I N i 11 ♦� 1\ ------' i 1 I F- EPTI CSEF4I LLI RACHEL 5/�D; / I I \\ LOT 3, I I I 112TH AVENUE r--------------------- ------------ I I 1 SIEFKER 5/D /2; SIEFKER -I SIEFKER S/D /2; /2; LOT A -1 C. I LOT A-fA, LOT A-18, 11/3/2004 Y/] DRAWN 9Y: ��•v�' ... ._ __.. _ C.J.G. GARNESS ENGINEERING GROUP, Ltd. SCALE: nnnnnn CONSULTANTS& GENERALCONTRACTORS 1" = 100 ��,,,, ,,, ,,, ,• ,,,,, ,,,,,,,, 5700 F TIX D PDAD. SDITF 104 • AHrwMAr.F. AK OOS01 • PwmF (W?M?Y .10 • FAX (00)gIRA, 746 PREPARED FOR PHONE NUMBER: PAGE NUMBER: i1 JOE NIESPODZIANI 344-2843 1 OF 2 :,j r ss. LEGAL DESCRIPTION: 'y'�y, E 7953 RACHEL SUBDIVION; LOT 2, BLOCK 2, TYPE OF WORK: '+i`)�dP O\ -•:' SITE PLAN FOR PROPOSED SEPTIC SYSTEM UPGRADE +.`•.,rotesslo^_• I NOTE:THE-CONTRACTOR SHALL HAVE THE PROPOSED DRAINFIELD 100' WELL RADIUS AND THE NORTH EXCAVATE A TRENCH THAT IS ` LOT LINE ON THE PROSPECT PROPERTY. 9.5 FEET DEEP MAX. BY S FEET \ FLAGGED BY A REGISTERED SURVEYOR WIDE BY 66 FEET LONG. ADD 3.5 PRIOR TO CONSTRUCTION. FEET OF CLEAN WASHED SEWER \ DRAINROCK. EXISTING SEPTIC TANK (:SEPT) TO BE COMPLETELY ABANDONED I TELEPHONE ELECTRIC UNE EXISTING DRAINFIELD GAS UNE \ TO REMAIN FOR ALTERNATE SITE ALTERNATOR FUTURE USE VALVE \ —C C G -- TH/ --- NSTALL DOUBLE -------- n CLEANO +/- / PROPOSED / / 2 1500 GALLON \ SEPTIC TANK J I gym= EXISTING \ I I rI .� ,�• WELL I wLd GARAGE \ \ c~iI 0 v III / I 2004 12 11 0��0 0 ENGINEERINGoRAW/BY:./ F '• F C.J.G/R.A.L. GARNESS ENGINEERING 'f �p GROUP, Ltd. �: pp CONSULTANTS t GENERAL CONTRACTORS SSE: 41" — 4O� „••, •,•• ••, •••,••••• D 3701 F TUOM POAD. SUITF 101 • ANCUOPAGF. A9 99507 • Pu F (901)331-119 • FAX (90))339d]tA O D PREPARED FOR: PHONE NUMBER: PACE NUMBER: Q JOE NIESPODZIANI 344-2843 2 OF 2 pe( y Gar ess! LEGAL DESCRIPTION: p RACHEL SUBDIVISION; LOT 2, BLOCK 2, �� reI`Ilvt `��`'' TYPE OF WORK: 44'cdprof essio�N DESIGN FOR PROPOSED SEPTIC SYSTEM UPGRADE ��Oppp000� ALLEN S/D; T12N, R3W. SECTION LOT 25. N LOT 1, REAT DANE S/D; W7-SE SEPTIC LOT 25. S2, AREA N S/D; 2• ROPOSED EPnc--T T GRADE SE AREA N E%I-,TING 4 PEDFOO NOUS SEPTIC AREA ALLEN S/D; Ll.l LOT 3. RACHEL � LOT CJ Z GREATE PARK R ATLLOT 2• PLO GAFtAC Q `-SEPTIC SEPI P ALLEN S/D;ARSLLL RACHEL S/D; LOT 4, U Z Q U E 12T AV U V/SJEER/D /2; SIEFKER S/D /2; /D /2; LOT A-1C, -1 LOT A-18, DATE: 11 3/2004 o4o�p0 p G \!.O' .••• . , VD DRAWN Y: �:' • • • • • • •. 4 • • • .. 'Q SCALE: 57 F Tkmn. ncF. e5 ooso wo : roen5n-nno • FAX 1oon5. an.n 1 007 Q REPAR ONE NUMBER: PAGE NUM R: A I 44-2843 1 0 3 Q G C 795 :' e`vO oOQJ�e�''•..ILI�.�pQov tSUBDIVION: T 2. 400000�� F. Q W RK: RN FOR PROP ED SEPTI SYSTEM UPGRADE OF OL GARNESS ENGINEERING GROUP, Ltd. A H y0p CONSULTANTS & GENERAL CONTRACTORS Q O 4 — e 0 701 L )IOrM ft l& NII[ 101 • AmC.OW, M. 29]07 • P - (907)N7-4179 • FM- W b • •[BSrtG pr ynwYy;ql Q•' • • • •' • • ' . ' •.. •' .......... SOIL LOG — PERCOLATION TEST 0 LEGAL DESCRIPTION: RACHEL SUBtDMSION; LOT 2• BLOCK 2• 1 r Gar ess, O PERFORMED FOR: JOE NIESPOOZLANI DATE: 11/10/2004 ODp� —79 DEPTHP p�e^�0r'G\ (feet) ___= ORGANICS ro /e sslo TEST HOLE 1 4���000000 LOAM SOIL CLASSIFICATIONS 2 I I / GW =___ ORG I 3 `'= • ^ GP I MLI GM CL I 1 1 4 GC I OL e_e°. o SW MH \� 5 SP CH Sm OH ••: 7 `<•� GROUNDWATER DATE U) )� SP do GP / •: 1 \ :,:.Ljj 8— ORDRY II 11/10/2004off Z' 9 <i I " SITE PLAN o �;� 1'100' to—..:s _. . ,se- DATE e . 11 '• ' .� . TIME (MINUTES) READING (INCHES) 12 ` '•• •. .tii••: so 0 13 •e . :. ,..•. 14 '••' 15 ;...: 1 B.O.I1. 16 17 18 19 PERCOLATION RATE <1 (MIN./INCH) PERC. HOLE DIA. 6 (INCHES) TEST RUN BETWEEN 6.5 FT. AND 7.0 FT. 20 A FOUR HOUR PRESOAK WAS PERFORMED: N YES ❑ NO SOILS LOGGED BY: JODY MAUS PERCOLATION TEST PERFORMED BY: JODY MAUS COMMENTS: THE INSITU SANDY SOILS WILL ACT AS A SAND FILTER. PERFORMED BY GEG, Ltd. I• JEFFREY A. GARNESS• CERTIFY THAT THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: DATE READING CLOCK NET TIME WATER LEVEL NET DROP 11/10/2004 P05550S�PN \N u. ,,r ,, GRE .ER ANCHORAGE AREA BOR JGH ' ~;~') Department of Environmental Quality ~-~' 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION SEPTIC TANK: MAILING ADDRESS_~_~>~I ~..X._~..~.~~ PHONE DISTANCE FROM WELL MATERIAL NUMBER OF COMPARTMENTS INSIDE LENGTH , INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY/f~~) GALLONS. TILE DRAIN FIELD: DISTANCE FROM WELL ,.~.~ NUMBER Of LINES ~' ABSORPTION AREA '~/-.~ ~ DEPTH: TOP OF TILE TO FINISH GRADE I FOUNDATION /'~ '/ ! TOTAL LENGTH NEAREST LOT LINE '~ OF LINES DISTANCE BETWEEN LINES,, W/n TRENCH WIDTH...~__("~N. TOTAL EFFECTIVE SQ. FT. LENGTH OF EACH LINE ~ / DEPTH OF FILTER MATE"IAL BENEATH TILE ~ e-ABOVE TILE ~ IN. WELL: TYPE_D 'II BUILDING FOUNDATION CESSPOOL APPROVED CONSTRUCTION NEAREST NEAREST' LOT LINE SEWER LINE OTHER SOURCES I~DISAPPROVED DEPTH -~'! SEPTIC SEEPAGE TANK , SYSTEM REMARKS DISTANCE FROM: DISTANCES: INSTALLED BY: SEWER LINE DEPTH: REMARKS: Form EQ-032 DIAGRAM OF SYSTEM DATE ~'~-/'~' ~ APPROVED APPLICANT ,RRCHAEL R SIIITH~ SAR BO>,' 1750 LOCATION CRNGE RD LEGAL RACHAEL suBD TYPE OF SOIL ABSORBTION SYSTEM IS: PIT · t-lur-.i I c I Pt:iL I T"-r' O,,F, ;~I'-.i~;H~..-3RF:IGE \ . DEPARTMENT t"""~ HEALTH AND EHVIRONHENTRL/~e. OTECTION 2510 E.'..UDOR RD., ANCHORAGE, AK. ~ WELL AND ON--~<~ I TE SEt-IFA PER£~! PER&~IT"NO. < 762~e ) LOT SIZE 28050 SQUARE FEET MAXIMUH NUMBER OF BEDROOHS = 4 SOIL RATING THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEH IS: DEPTH-- 1P LEI'~IGTH= ~1_ ~---'~X~RI~I%~EL DEPTI I, , ~ THE LENGTH DIMENSION IS THE LENGTH (IN FEET> OF EACH SIDE FOR R SEEPAGE PIT. THE DEPTH OF n TRENCH OR PIT IS THE DISTANCE BETHEEN THE SURFACE OF THE GROUND AND THE BOTTOH OF THE EXCAVATION (IN FEET). THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETHEEN THE OUTFRLL PIPE AND THE BOTTOH OF THE EXCAVATION (IN FEET>. REnU I RED SFPT I C T.~-I. NK S I ZE= ::1.250 ICSI:::::ILI IDr-IS BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUH DISTANCE BETWEEN R WELL AND ANY ON-SITE SEHAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL OR 200 FEET FOR A PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN _-zO DAYS OF THE HELL COMPLETION. SPECIFICATIONS AND CONSTRUCTION DIRGRRrtS ARE AVAILABLE TO INSURE PROPER I NSTRLLAT I ON. PDRrlIT YALID FOR ONE "r'EAI:~: FROrl ISSUE I CERTIFY THAT l: I AH FAHILIRR WITH THE REQUIREMENTS FOR ON-SITE SEHERS AND HELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE I~,~EMODELED TO INCLUDE MORE THAN 4 BEDROOMS. ~.A~ P~CRNT RH~HREL R SMITH '("~ GREATER ANCtlORAGE AREA BOROUgh") Department of Environmental Qua,.ty 3330 "C" Street Anchorage, Alaska 99503 Performed for Legal Descrip-ti on: This form reports: Soils log X ~X " Percolation test Depth Feet 0 4- 5- / o ) 7- 8 - ,'"' 10- 11-' 13- 14- Was ground water encountered? ~-~--~f If yes, at what depth? Reading Date Gross Time Net Time Depth to Water Net Drop Percolation rate minute. · Proposed installat-'T~-n-:' Seepage Pit Drain Field to bottom o-f--pit Uepth of Inlet . Depth or trencI~ ~q-040 (6/?4) ~. -<V . 3-2---7 WELl. PERMIT NO.( ~flCHflEL R SMITH. LOCATION CANGE RD LEGAL L~ RACHAEL SD LOT SIZE ~8050 SQFT NUN I C I Pt:Il Ii.T%-~ OF 8NI~:HORF:IGE DEPARTMENT OF HEALTH fiND ENVIRONMENTAL PROTECTION ~0 C STREET, ANCHORAGE, ALASKA ~74-45~1 ON--~; I TE SEWER PERM I T SPA BOX 1750 3444705 TYPE OF SOIL ABSORPTION SYSTEM... TRENCH NUMBER OF BEDROOMS 4 SOIL RATING, SQFT/BR 150 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYS~TEM IS:DEPTH= 8 LENGT.H,= 75 THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OU~flLL\WIPE fiND THE EXCAVATION BOTTOM F D THE BACKFILLING OF ANY SYSTEM WITHOUT FINAL INS~EC~ON BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE FROM WELL TO tiNy/SEPT,I~C TANK('P~flCKAGE PLANT OR SOIL ABSORPTION SYSTEM IS :!.00 FT FOR A PRIVATE WEEL AND.,,200 FT,,~cOR A PUBLIC WELL WELL :LOGS I'IUST BE RETURNED TO THE DEPARTFIENT WITHIN 30 DAYS OF THE WELL COMPLETION. I CERTIFY THAT I AM FAMILIAR~W ~'H THE\'REQUIR~MENTS/F/OR ON-SITE SEWERS AND WELLS tis SET FORTH BY THE MUNICIPALITY', OF flNCH~C~ flNDTWILL INSTALL IN ACCORDANCE WITH THE CODE. r Size of Casing ~ Depth of Hole~g~feet. Cased to .~ ~ } ' ,, feet. Static water level /~0 feet ~ (below) land sur£ace. Finish o£ well (check one) Open end ~0: Screen ( ): Perforated Describe screen or perforations:, Nell puaping test at--aliGns per (hr) ~ for ~0 ~] £eet 9( dr~..wdoum.£rom static l~el. (). hours }fELL LOG Depth in feet from Give details of formations penetrated, size of ~aterialo ~ .~round surfac~, color~ and hardness. tO H°O d bo., }e '" MUNICIPALITY OF ANCHORAGE of 3 A M M • Department of Health & Human Services p}j DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPR(5OkL OFr,,,r ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # Z)4J _ ; � 7n HAA # a (/ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 2; Rachel Subdivision Location (address or directions) 11101 Canqe Street (b) Property owner HUD #035084 Telephone: (home) Business Mailing Address (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent ASSOCIATED BROKERS/Sandy Address 640 Priest 36th Avenue, Anchorage Alas'ca 99503 Telephone (e) Mail the HAA to the following address: (or check here ID� if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING/694-2979 --- 17034 Eaqle River Loop Road, Suite 204 River, Alaska 99577 2. TYPE OF RESIDENCE Single -Family XX Number of bedrooms a 3. WATER SUPPLY Individual Well 12 Community ❑ Public ❑ Note: If community well system, must have written confirmation from the, State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site 50 Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 F 1 Z abed Mane laflic'Aaal s70-zl l.!oM s,a0au16u0 leuolssa;oad aq; ul suolsslwoaosao.uaao;aIglsuodsaa;ousla6eaogouV;oAl! ledlolunWagl'ponsslsla;eogpooeaao;agMVP azAIeueao suol;oadsulIon ptaoo;ou op SHHC7;o saaAoIdwA -s;uowwinbaa a;e;s pue Ieaapa; uleiaao A;sl;es a;.iapao u suol;n;l;sul bulpuai alai.{; pue sawog ;o saasegoand o; (sa;anoo e se SILO saop SHHG aql 'eilseiV ;o a;e;S ag; ul paaa;s160a aaeu16ua Iei.!olssa;oad;uapu; lriapul ue (q anoge g ydea6eaed ul uanlb suol;e;uosaadaa aq; uodn Aluo poseq pa;eol;laao Ieno.iddV (;!.!oglnV g4leaH s:-,nss! (SHFI(.l) saolnaaS uewnH pue q;Ie0H;o;uaw;aedaQ a6eaogouy;o /(;liedloiunW @q_L :. NOunyo - --- —'-------- -- lenoaddV Ieuo!;!puo-.) ;o swaa.l_ - -_- _--__ -- euol;l uo _ _ PE)AOAddesiG PeAoiddv q swooapaq - - ao; panoaddV 1t1A0HcIdV SHHCI '9 auogdalal ale(] SSG) PPV 17OZ '01% neoal chA1 znq;.3 ,;73e'? ; w.!!d;o auaeN -uol;oadsul slq; }o a;ep ag; uo;oa;;a ul suol;elnEw pue 'saoueulpao 'sapoo e RIS Pc!p led!ownN lie q;lM aouelldwoo ul sl wa;s (s Iesodsip aa;eMa;seM ao/pue /\Iddns aa;eM a;ls-uo aq; 'uol;oadsui pue uol;e6l;sanul (w woa; pue saii; obeaogouV ;o (;lledlolunw ag; woa; poule;qo uol;euuo;ul ag; uo paseq ;eg; (}laan aaq;an; I -ulaaaq pa;eolpul aan;on,i;s;o ads(; pue swooapeq;o Aagwnu aq; ao; a;enbope pue leuol;oun; '),les sl wa;sits Iesodslp .!a;eMa;sum ao/pue Ajddns aa;eM a;ls-uo aq; ;eq; smogs IPAOAddV R;!aog;nV q;IeaH slg;;o uol;e6l;sanui (w;+1g; (;u)n l 'Mol:)q uMogs aiep uol;epljen aq;;o se pue o;aaag pail;;e Ieas Aw Acl pal}lpao sV N011VUYH03N1 (INV VIVO `HOUV3S 3'113 `S.LS31 /SN01103dSN1 ONIOIAONd VYHH ONIa33NION3 "9 MUNICIPALITY OF ANCHORAGE (MOA) ® Health Authority Approval (HAA) ,y CHECKLIST - FEBRUARY 19841 343-4744 —� Legal Description: A. WELL DATA Well Classification ( mQ10- F AA < < �+ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N)—Date Completed Yield q p M Total DepthCased to #Q'I Depth of Grouting Static Water Level In Pump Set At r '� K It Casing Height Above Ground % Sanitary Seal on Casing (Y/N) — Electrical Wiring in Conduit (Y/N) U Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ( C a ; On Adjoining Lots ( E) -f To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots t`» To Nearest Public Sewer Line :7 '_5i f To Nearest Public Sewer Cleanout/Manhole 100 f To Nearest Sewer Service Line on Lot f Water Sample Collected by '4S6 ")1"V'� ; Date Water Sample Test Results L� A ) �n r t9 -C' 1+4 (4 Comments B. SEPTIC/HOLDING TANK DATA Date Installed to - 14 7�Size 1250 No. of Compartments 2 -- Standpipes (Y/N) 14_Air-tight Caps (Y/N) Ll Foundation Cleanout (Y/N) A% Depression over Tank (Y/N) AJ Date Last Pumped 2-�' - ie _ 99 l Pumping/Maintenance Contact on File (Y/N) gSJ /1 ; for 'A Holding Tank High -Water Alarm (Y/N) _�1_l1_ Temporary Holding Tank Permit (Y/N) N SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: i To Water -Supply Well C) To Building Foundation To Property Line To Disposal Field S To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course ®� Comments A) AA ��a I� o r�nC' !-se-i tl(Ge S 72-026 (Rev. 7/88) Front Page 1 of.2 C. ABSORPTION FIELD DATA Soils Elating in Absorption Strata- Date trata ._ C�C��_. Type of System Design Date Installed- -- �� tr__-___ ��_-___- Length of Field _-_Za-� �a n Width of Field _-_ _ __ ? b__-- Depth of Field Gravel Bed Thickness �SL Square Feet of Absortion Area - _ �� Statndpipes Present (Y/N) Depression over Field (Y/N) Date of Last /Adequacy Test - Results of Last Adequacy Test __- VT L Vl C �f �> d- C -d r c) rA/\__ _ SEPARATION DISTANCE-- FROM ABSORPTION FIELD: To Water -Supply Well - _ t_ To Property Line To Building Foundation -__ ___--- __--__ _ __-_____- ___ _To Existing or Abandoned System on Lot __ __ _ ,��ta __--_-______._--- ;On Adjoining LotsTo Waiver Main/Service Line To Cutback (if present) - - To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area f l Comments._ D. LIFT STATION Date Installed Size in Gallons ------___� "Pump On" Level at - --- High Water Alarm Level at --_ Tested for _-____. __ -- --- Meets MOA Electrical Codes (Y/N) Comments Dimensions — Manhole/Access (Y/N) . "Pump Off" Level at ___ Vent (Y/N) - - - -- _ Pumping Cycles during Adequacy Test. "*Check Permitted Bedroom Rating Against HAA Request" k I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect .on>"tf�e) date o`7~,til,is inspection :-ilgned `a?-�• �t e"' yt� �`-Y"' —`+=•tat �hEsv;et-r^� ,,1�" Company -� �7 ------ �nm geer s Seal: Date MOA No. Fleceipt No. ��)_t--` �- �- -- _-_-- Receipt No. -- - --__ - Date of Payment4,_'-�jP__-_ _- Waiver Fee: $ Amount: $ __--_ ___ _ / Date of Payment-_-_ -026 (Rev. 7/813) Back Page 2 of 2 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 --yA -A l9 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) UI C: n �R��ti� (b) Applicant Name 144MRhAt� _�!L — Telephone: Home Business — Applicant Address 1, 10! 4zn9�C_R n c4 oren7f_, /} /T 99S710� _ (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder Q ; Buyer ❑ ; Other ❑ (explain); — (d) Lending Institution wes �-Li,' mcprcqe Telephone ~6' 3 - s 1ssw -- Address __Al(" u• T�cdd� loot ��f%p�a r i%s-o� (e) Real Estate Company and Agent —.C� of 4<&i0t Moe A"nC G *Cl — Address 3uti S /9 re He IrC� f}rt�tioi'RRP Telephone - (f) Mail the HAA to the following address: 1� 46_ �1GST 2. TYPE OF RESIDENCE Single -Family 1W Multi -Family ❑ Other Number of Bedrooms 3. WATER SUPPLY Individual Well l>t Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite $d 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. 7z -02e (11,84) 5. 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. )4 Name of Firm t- 10th* 7"4GAn4ccl 4-tr✓iceJ Telephone S ys--/ � 1. jiC�r�itG/i Q�/ Qermye Address 1 sf 5'30 ac -40 SP /}nc%toratye .4h 99516 Date — A�Ortt & I9W6-'_ . rewitfd VKAe H 198 Per tncPccAon is/Y /Ro' o(efitcichf con.loAwnr daft.( -wn oe�r,nu/ Aw"In Aa✓G tAetn carreclva(i r•ee 1. jiC�r�itG/i Q�/ Qermye /0 y1/ TC 06,1kQ/1� G��for/ Yic�h J'tCt� ACVbtc� f -411 -ed and Q►�folca� �Ie .•lam;., J� a ctlar 2. c)evrtrrr,*o arrrna.1 eAll heowX h`u Wen ll.d eCnt:Q /rwaleGi yi7 olnak� Seal Engineer's � � ..... 49�—"':b :���� �•.. e..... •..e. a ......... 00, e THBODORF F. MOORS fA d� t''•. CE - 35139 6. DHEP APPROVAL Approved for __�` C's bedrooms G�"'z �' Date �' 6 9 Approved — K Disapproved Conditiona Terms of Conditional Approval dhep CAUTION The Muncipality of Anchorage Department of Health 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 DHEP 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. MUNICIPALITY OF ANCHORAGE DEPARTMENT OS Oy PROTECTION DIV OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION HSS TE SI WER ANDEALTH AUTHWATER FACIOLRTYY APPROVAL OF O 264-4720 application Date 1. GENERAL INFORMATION subdivision, section, township, range) (a) Legal Description (include lot, block, _-- Location (address or directions)�� �nG��U� ``d1� ( )�� i)- �e � _ Business arsy'_Telephone:Home — -- Applicant Name fta-sheet ��, ��C..)r06�C (b) qpP n e R f 01 Other ❑ (explain); —� Applicant Address Buyer ❑ ; Owner/builder © ; (c) Applicant is (check one): Lending Institution ❑ ; _ — ac e Telephone t4l�S��rn i I�r � — (d) Lending Institution AA Address`���� '�1 - GG1d C (e) Real Estate Company and Agent _ Address Telephone — -- (f) Mail the HAA to the following address: 2, TYPE OF RESIDENCE ether Multi -Family 13 Single -Family 91 Number of Bedrooms 3. WATER SUPPLY public 11Community 13liartment of Environmental Conservatioi Individual Well ® m, must have'written confirmation from the State Dep Note: If community well syste attesting to the legality and status. 4. SEWAGE DISPOSAL Holding Tank ❑ ER ❑ Community [IHolding Note: If community well system, tment of Environmental Conservati� Onsite must have written confirmation from the State Dep 2-025 (111 attesting to the legality and status. 5. 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 F(u,t1_-0,P Telephone 3 `1s -136-.5- Address f h'.5-30 Echo Sk 4-rg c-11onye %I f,� 9H -S 7( DateAP_$-<«. 9c'C (�ecvmIoeac-ec-d r,)r dcI-6--d: !�. DerresStvn C*_�ceranf Acs �Aic Jee,I(r cin.-( ev &cc,,�o /mv, 5e (cC mccr/ A(I Ir enc( r�cdEcf -� c�-[r-rrin czca.�at->.� j cx / �P 3Y(fPCC �Y Y24 kJ aecY/� r -Y 3. t,UeU GUtrin& WC41be /52uA �" ccs^�"`� Engineer's Seal 6. DHEP APPROVAL G w Approved for 12c4ee— bedrooms by Approved Disapproved jql. Epp mese.. ........oaveeae.�eee .A• ..a°m°s. °.een4e °.eoe..e• THEODORE F. pgppRE e° C --3589 i? Biu `r,` •., e•e ,fit, �Y' Q8 L�3Frt�1z�q�.. Conditional Terms of Conditional Approval V Xl_> LQ L (?tet t ai 94iLef -) CAUTION The Muncipality of Anchorage Department of Health 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 DHEP does this as a courtesy to purchasers of hornes 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. MUNICIPALITY OF ANCHORAGE (MOA) I~,~. HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 2644720 Legal Description: WELL DATA Well Classification Well Log Present (Y/N) ~' Date Completed .~c I~?~" Yield Total Depth ~.~l 'Cased to ~ ~<'t Depth of Grouting ~ Pump Set At c~/1/? I y" Sanitary Seal on Casing (Y/N) If Al B, C, D.E.C. Approved (Y/N) H,A. Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Depression Around Wellhead (Y/N) y- To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole /~, Water Sample Collected by ; On Adjoining Lots ! t9 ' ; On Adjoining Lots ~' To Nearest Public Sewer To Nearest Sewer Service Line on ; Date q ~ Water Sample Test Results ..~_~f-~;~,c.~r~y SEPTIC/HOLDING TANK DATA Date Installed Size Standpipes (Y/N) ~ Depression over Tank (Y/N) ~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) ~0 ~. Separation Distances from Septic/Holding Tank: Air-tight Caps (Y/N) To Water-Supply Well To Property Line ' To Water Main/Service Line Course No. of Compartments ~ Foundation Cleanout (Y/N) Date Last Pumped H,~. ; for H. 4- Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage 72-026[11/84) ' C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (Y/N) N Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation ~ 2 ' Lot N, To Water Main/Service Line hi, .~, ¥~.o Type of System Design Length of Field '~&- ° Depth of Field ~Y ' Gravel Bed Thickness 0"'" Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line ~,3' ' To Existing or Abandoned System on ; On Adjoining Lots · ~..7o t To Cutbank (if present) N, ,4. · To Stream/Pond/Lake/or Major Drainage Course ~m. too To Driveway, Parking Area, or Vehicle Storage Area '~ "/'~ ° D. LIFT STATION /I¢,4. Date Installed Size in Gall(~ns "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (WN) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during 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 _O?"~c- '.-~~ D~te ~'8/~' Company /==~z;'/~ ~c~f ~OA No... Receipt No. ~ Date of Payment ~ .' ~ ' ', ~'~ Engineer's ~al Amount: $ ~ ~eeeeeeleeeeeeeeeeeeeeeeeee~ Page 2 of 2 ....... · 72-0~ (H,'84} NORTHERN TESTING LABURATORIES, INC. 600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99701 907-479-3115 6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99518 907.,14.94t623 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY CLIENT I-I PUBLIC WATER SYSTEM I.D. # ~ PRIVATE WATER SYSTEM NAME Meiling Addre$~ C~ty SAMPLE DATE: Mo. Day Year SAMPLE ~PE: ~ Routine ~ Special Purpose State Zip Code Phone 5' ~1.-z-- I-t ,5-~z- Purchase Order No. I-I Treated Water [] Untreated Water [] Check Sample (for original contaminated sample with lab reference no. Sempe Time 2 4 6 8 9 10 Signature of Representative ~-"~ TO BE COMPLETED BY LABORATORY Received at: [~/Anch. I-1 Fbks. Date Received Time Received Next Sample Due COMMENTS: SATISFACTORY UNSATISFACTORY RESAMPLE OTHER BACTERIA TOO NUMEROUS TO COUNT U R OB TNTC Direct Verification Count LSB BGB Comment~ ?~liform Colonies per 100 mis. Time NORTHERN TESTING LABORATORIES, INC. 60~ UNIVERSFrY PLAZA WEST° SUITE A FAIRBANKS, ALASKA 99709 907~479-3115 6957 OLD SEWARD HIGHWAY, SUITE 101 ANCHORAGE, ALASKA 99518 907.349-8623 Drinking Water Analysis Report for Total Coliform Bacteria TO SE COMPLETED BY CLIENT [] PRIVATE WATER SYSTEM Mailing Ad~i. ess City ' State Zip Code SAMPLE DATE= q j ~'~ Mo. Day Year Phone ,_~ Purchase Order No. SAMPLE TYPE: [] Routine [~"Special Purpose [] Check Sample (for original contaminated Treated Water Untreated Water sample with lab reference no. Sample Time No. Location ~l,~octm:l Collected by '7-£~ / Labor~tory Ref. No. '-J 3 B/ANY._ ~ 4 0.01/~1~ ID ~ 1.0 ,',11~ 10 Signature of Representative FOR i. ABO~ATORY USE ONLY MAIL HOLD FOR FICKUP TO BE COMPLETED BY LABORATORY Received at: [~'Anch. [] Fbks. Date Received Time Received Next Sample Due COMMENTS: SATISFACTORY UNSATISFACTORY RESAMPLE OTHER BACTERIA TOO NUMEROUS TO COUNT S TNTC ~'~' ~lVrl4 Direct 0 C) 0 Verification Final '' ~ ~5 Coliform Colonies per 100 mis. Repgrted_by