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HomeMy WebLinkAboutNULUKATAK LT 4 ['~f~=~,/¢ DRILLING, Inc. P.O. Box 110378 e 10330 Old Seward Highway (907) 349-8535 ANCHORAGE, ALASKA 995I 1 87-178 Well Owner Susan Burgess DF, ILLIN® L©G Use of WeD Location (address of: Township, Range, Section, if Imown; or distance main road L4, ;~ulukatak Subdivision Domestic Size of casing. 6" Depth of Hole. Static water leveL2_¢)~_~ ft. (~) 310' feet Cased to 77' feet (below) land surface. Finish of well (check one) open end ( Screen ( ); Perforated ( Describe screen or perforation_b_3~c_kfj.J~_d, !v~._pea ?ravel Well pumping test at-- ~ gallons pei· (i~) (minute) for /,~. of drawdown from static level. Date of completio, ~/ 4~'/://:',~_//¢2 ); XX~i'4" PVC liner 10'-310'-,perf below 150', annulus 310'-120' & w/cement grout //'27~'/. 120' to lC hours ~vith ·/"1//. ft. WI]LL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, color and hardness O__TO 2 Ca~s i_~ s t ickup -__2__TO. 67 _ 67 TO 6g - 6g TO. 841 _. 8 Q~_TO 90 _ 99_TO 31_0 TO TO ..... TO. .TO.___ _TO_ --. _TO. _TO~ TO . ~_%_i¢_t in g. hole ~l~e_r__b_e~%ing formation--now filled w/bentonite slurry ~r~a~4n ~e_dr_ock--_s~o~e fr&ctures--some seepage . _~%o_j~_cn bedrock--less tha~ 1/2 GPM ;Gray bedrock--check water lew~l @ 160'--1/2 GPM Check water ~ 3].0'--made 13' in 15 min. t, AUNICIPALITY OF ANcHORAG~ ENV~P, ONKAI!NIAL pROTECIION 1WWWA Certified Contractor i -- CUSTOMER P.O. Box 110378 · 1~)'330 Old Seward H[gh~ay (907) 349-8535 ANCHORAGE, ALASKA 99511 Well Owner Susan Burgess DRILLING LOG UseofWe]] Domestic Loeat~ ~ddress of: Township, Range, Section, if known; or distance main road // L47 Nulukatak Subdivision Size of casing 6" Depth of Hole 310 ' feet Cased to 7 7 ' feet Static water leve t. (I~?': fbelow) land surface. Finish of well (check one) open end ( ); Screen ( ); Perforated .( ,~rv, ). '.:~'4" PVC liner 10'-310'--perf below 150', annulus Describe scr~n or perforatio~ :~{ ] ] od; w/poa gravel 310'-120' & w/cement ffrout Wen pumping test at ~ gafi~'~s p%~ (hour) (m~ute) for ~ hours with ~r ~ 120' f[.o 10' of ~awdo~ from s~tic ~el,:~ . Date of completion 71 ~:f?r~;' ~ ~ Depth in feet from ~ ~: ;':' :~ greed surface G~d~t~? 6f formations penetrated, size of material, color and hardness [,E~'tSn~' hole . .:~'O~':~:~:~baarin[: f~ation--now filled w/bentonite slurry _ O _TO 2 _ 2 _TO 6 7 _ '~ O 6,~ ~TO 80 _ ~,q TO _ 9Q_TO __.TO, ___.TO, 90 k--less than 1/2 GPM 3]0 ~: 160'--1/2 GPM ;r~'~made 13' in 15 min. .TO. __.TO __.TO. .TO .TO __.TO. (/, iNWWA Certii~ecl contractor Certificate No's. 814 & 973 2 -- STATE W'~ For ............................................. ~ .... :: ............. :~ ......................................... Location ..... ~)~'.V ~.' ~ .~. ~.~. ~.~ ...... ~., ........... ~..~...~ ............................................ · /'- ./~:', ........ Date completed ....... ,., ...... ~.:.z.: ........................................................... Depth of well .. ,2'] ...~...~ ........................................................... Size of casing. ~ ~ '~.. Distance to water ...... ~ ...................................................................................... '.':: ~ 3.]';: .' Dist~ce to water while pumping z/~ .............. ~ ...................................... at rate of .............. ~'.~ .......................... gallons per hour. --:.(:; Formation I from I to ./ DE~A DRILLING COMPANY SR^ BOX 394 B ANCHORAGE. ALA$:<A 99~O7 MUNICIPALITY OF ANC~ORAID~ DEPT. OF HEALTH & ENVIRONMENTAL PRbTEC]' ON ~UL 2 0 1987 RECEIVED Well Log Location ~.~l'.~k.cl.~.ct[q ~b, L. o-t': ...................................... Date completed ....... :...../...~:..:. ,./...'.".: ............... ~:,... 7..?.,.. (2:'..': ~..0. ..................................... Depth of well .... '- / ...~.../ .......................................................... Size of casing. ~ x_-- ~ Distance to water ....... ../..~ ...................................................................................... Distance to water while pumping ........................................................ at rate / ~' "'1 of .............. e.g.~ ........................... gallons per hour. 'V ,/ Formation l irom DELTA DRILLING COMPANY SRA BOX 394 B ANCHORAGE, ALASKA 99S07 SUBJECT -RETURN TO ~ SlONED $1~ND PARTS 1 AND 3 INTACT DATE / POLY PAK (50 SETS) 4P472 Municits ,lit¥ P.o. O~ (907) 343-4200 Anchorage MATON K 'O 'L':'S'yoR DEPARTMENT OF HEALTH & HUMAN SERVICES X 196650 ANCHORAGE, ALASKA 99519-6650 July 22,1987 Ms. Susan Burgess c/o Marston Real Estate 2804 W. Northern Lights Blvd. Anchorage, Alaska 99519 Ms. Burgess, Following a complaint of elevated nitrate levels in the well water for Lot 4 Nulukatak Subdivision, this office began a preliminary investigation to determine the extent of contamination in the areao > To date our findings would indicate that the contamination is limited to the well on Lot 4. Though current nitrate levels are below the EPA maximum contaminate concentrations we suggest the well's casing and pitless be checked for soundness and leakage. If these are found to be in sound condition and no source of contamination can be proven then drilling a new well would seem the most appropriate coarse.of action. At this time we are continuing our inVestigation in an effort to discover a p©ssible source of contamination. If the situation should change we will notify you as soon as possible. Until then I am including a copy of the test results we have to date for your information. si erely, Daniel N. Belles DHHS On-site Services cc Marston Real Estate DHHS files J ELEV. ASSUMED I~.C.~ON.$E I =500.00 1:50 TH AVl~. SURVEYOR'S CEFITIFICAT~. :...,-.. hereby certify that I have eurveyed ,,he. property '' described hereon, and that the improvements situated ; , . the[ach are located as shown on ,hi9 plat, and that there .,,' are no roadways, or other visible easements on propert~ except ~ indicated hereon. :' ":' '.:.. : ~'/~,~ ~1, . _ . . ASBUILT BUll_DING LOCATION ' "LO~T 4 NULUKATAK SUBDIVISION " A.N. OOARD BOX 4691, ANCHORAGE,AK. 99509 DATE ;,J2 OEC. 1982. SCALE: I'% 40' ,~. ~'~:~.<~ MUNICII~ALI'i-Y OF ANr;HQRA(;t~ ~: ~'~'~ ~;, DEPARTMENT OF HEAl_TH ~ ENVII~ONMENTAI. PI-~O'rEc~ iON '~Ju ENvIRQNMENI'AL ENGINEERING DIVISION '%:~~ 825 L Sl'rect - Anchorage. Alaska 9950'1 Telmfl~onr~ 264-4720 -- ON-SITE SEWAGE DISPOSAl_ SYSTEM AND/O~ WELL iNSPECTION REPOI~T LOCATION -- I ¢' ~ ~ J NO. OF BEDROOMS ~ ~ / / ~e~l '~ '_ ' I ~bsorption area u / DISTANCE TO: ] ' O ~ ~ [ I ~ /Manufacturer ~ .... IMat~rial ~ , ;-%o-~m6.rtm;.~ ~ ~1. cal)a~~ IF HOMEMADE' ~e length -. ?~(hh [LiquM d,:pth - ~m~ I DISTANCE TO~ I Dwellin~ ~ [PERMIT NO. ~ F j Top of tile to finish ~r~d~ t /' _ M~oriat beneath tF~ ~ - ~Z lq:oral eFf~?(ve absorption area ~ j DISTANCE TO: Buil~n~Ldatf°n Sewer hn. OTHER PIPE MATERIALS INSTALLER REMARKS DAT? LEGAL PE.]RM I 'T' NO. F F L I ..PINT LOCRTI ON I..EI]RL FSIR TRFI[:,E CFIRPENTR'?' :I.]:OTH FIVE,..'UPF'ER [:,E LOT 4 NJLLIkR'TRK t"ILIIi%It I C: I F 'IL I T"r' ElF FIi'-.iC:H( --'.'Ft ,SE misdeal~"-/'~/?(/~0'~'~ [:'EF'FtRTME:NT ElF HERLTH FIND EN',,,'IRONMENTFtL PF.:uTECTION ..... STREE.T'., RNCHORFIGE., FIK. 9'95C'tL ~ ~: 425 SOUTH BF.H.~HLI 99504 LOT SIZE T%'PE OF SOIL RBSORPTION _S_,TEM IS: ]F..ENCH .--, ,- ~-"'m'::'~?=. 52_ RRE FEET MRXIMUM NLIMBER OF BEDROUM_, = 4 SOIL R. RTING ,,SQ FT,..E,R.,= ~.~i.,~ THE REQIJ I F..E[., '~' TM '" ¢ ~ --,I~..[:. OF;' THE =,Kill.. FIBSORPTION S%'STEM IS: lC E.F FH-- 1~2~ LEl'46'"rH= 29 i_-,Rt;! ,,, EL [:, E F:' -r H ---= ]'HE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT tS THE DISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET), THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETHEEN THE OUTFRLL PIPE FIND THE BOTTOM OF THE EXCBVRTION (IN FEET). F'ERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPBRTMENT DURING THE INS]'RL. LRTION INSPECTIONS ElF RN¥ NELL. S R[:,JRCENT TO THIS PROPERTY RN[:, THE NUME:ER OF RESIDENCE'=; THRT THE HELL HILL ~';ERVE. TI--JC, ,:: 2: ::, I r-4_c-.;F'E£:T I Cil'-,l"=; I=IRE REGiIB I RE[) BRCKFILLING OF RN'T'-¢-%TEM HITHOUT FINRL IN.~,FEL.,TION RND RPPF,'OVRL B'¢ THIS [:,EPRRTMENT WIt_L BE SLIBJECT .T'O PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE -;ENRGE DISPOSAL SYSTEM IS iOE~ FEET FOR R PRIVRTE HELl_ OR '150 TO 200 FEET FROH R PUBLIC WELL DEPENDING UPON THE T'T'PE OF PUBLIC WEI_L MINIMUM DIS.T'RNCE FROM R PRIVR,T'E HELL TO B PRIVRTE SEWER LINE 1S 25 FEET RND ]'0 R COMMUNIT%' SEWER LINE IS 75 FEET. WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN }0 DFWS OF THE HELL COMPLETION. OTHER REQUIREMENTS MR'¢ RPPI. b'. SPECIFICRTIONS RND CONSTRUCT'ION DIRGRRMS RR.E R',,,'RILRBLE TO INSURE PROPER INSTFILLRTION. F EF~.J I I T E::-::P ][ RES E)ECEf~IBEF.: I CERTIFY THRT :1.: I RH FRMILIRR !4ITH THE REQLIIREI"~ENTS FOR ON-SITE SEHERS RND WELLS RS SET FOR. TH BY THE MUNICIPRI..ITY OF RNCHORRGE. 2: I NILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. 2: I UNr)ERSTRND THRT THE ON-SI.T'E SEWER S'-r'STEM MR¥ REQUIRE ENI.FtRGEMENT IF THE RESIDENC'E IS REMODEL. ED TO INCLUDE MORE THRN 4 BEDF..bOM_. E; I GNEP: ............................................... RF'PLICRNT FRIR TR¢~DE CRRF'ENTRb' I SStJED B%'. ,PATE.~..:Z~:.~ V4, El PERI,IIlT NO. FIPPL. ICFtNT :P~-C'.:' ir -i-v O,.c(ca ~"a C !9 ~ r] -(- v ,. TYPE OF SOIL PIE:SORBTION SYSTEM LOT SIZE ~"/, ~')7~ SQUARE FEET I',IRNIMUM I'.IUHBER OF BEDROOMS SOIL RATING (SQ FT/BR)= ~ ~ THE REQUIRED SIZE OF THE SOIl_ ABSORPTION SYSTEM IS: [)EEPTFI= ~O LEN~3TH= ~ ~ GRR%~EL. [}~EPTf~= 6 THE LENGTH DIMENSION IS THE LENGTH (IN [=EEl') OF THE TRENCH OR DRFIINFIELD. THE DEPTH OF FI TRENCH OR PIT IS THE DISTFINCE BETWEEN THF SLIRFACE OF THE GROLIND FIND~ THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRR',?EL DEF'TH IS THE MINIMLIM DEPTH OF GRPIVEL BETlqEEN THE OLITFF'ILL PIPE AND THE BOT]'OM OF THE EXCFIVFITION (IN FEET). [~:E_- ti3 Ell I F:: ELL-;,, :SEF'T I C/: -FFIP-.~I-~. S I ZE= j }_ .c) C I]I::IL_L.I]I'-IS PERMIT FIPPLICFINT HFIS THE RE_,PCN_IBILITY TO INFORM THIS DEPARTMENT D. RING THE II,~STALL. PITION IN.qF'ECTIOI,~S OF F1NY NELLS ADJFtC. ENT TO THIS PROPERTY AND THE 4JMEER OF RESIDEI,qCES THFIT THE WELL WILL SERVE. T I-,~ Em ( L--::_ .':., I f-~ S F' [~: (] T I ~3 ?-.~ ~ R R E F-' IE C~ LI I R E [:. E:ACKFILLINO OF ANY SYSTEM NITHOLIT FINAL INSPECTION BPI[) AF'PROVPIL BY THIS DEPRR'FMEN'F NILL BE qLIBJECT TO FRO.:,EC. UTION. MINIMLIM DISTAHCE BETNEEN PI WELL AND aNY ON-SITE SEWPIGE DISPERSAL SYSTEM IS :1.00 FEET FOR R PRIVATE NELL~ OR ~.50 TO 200 FEET FROM FI F'UBLIC 14[:LL DEPENDING LIPON THE TYPE OF PUBLIC NELL WELL [.0OS FIRE RED. UIRED AN[) MUST BE RETURNED 'I"O THE DEPARTMENT NITHIN ZO DRYS OF' THE NELl_ COMPLETION, OTHER REQUIREMENTS MAY APPLY. SPECIFICPITIONS FIND CONSTRUCTION DIAGRRI,dS ARE RVPIILABLE 'TO INSURE PROPER INSTALI_RTION. PERI'-1 :[ T E~::F' 1: RE2; [])ECEMBE:[4: ._-'~:-'.:1 .... ::I..L~. 80 I CERTIFY THAT fi.: I RI,q FPIMILIPIR 14ITH THE REQUIREMENTS FOR ON-SITE SEt,lEAS AND I,IEI_I_S AS SET FORYH BY THE MUNICIPPILITY OF RNCHORRGE. 2: I PIILL INSTFILL THE SYSTEM IN ACCORDANCE NITH THE CODES. Z: I UNDERSTAND THRT ]HE ON-sZ'rE SENER SYSTEM MAY RE6~UIRE ENLFIRGEMENT IF THE RESIDENCE IS REMODELED TO INCLLIDE MORE THRN~ EEDROJM:). .......................... VL3... '2 SOILS LOG PERFORMED FOR: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Aleska 99502 276-222~ SOILS LOG - PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2o [] PERCOLATION TEST DATE PERFORMED: ~"¢ //~ / ~ SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE '~, ~in~¢~ TEST RUN BETWEEN U PERFORMED BY: ~~ CERTIFIED BY: 72 008 (7/76) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH 0 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SiTE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include 10t, block, subdivision, section, township, range) Location (address or directions) "~- Telephone: Home ~--¢" 7- ¢".'¢'?f~ Business (b) Applicant Name Applicant Address (c) Applicant is (check one): Lending Institution []; Owner/builder,~,; Buyer []; Other [] (explain); __ (d) Lending Institution Address Telephone (e) Real Estate Company and Agent Address 'Telephone (f) Mail the HAA to the follpwjng address: , ,:_-._:.: .,. t 2. TYPE OF RESIDENCE Single-Family~l~ Multi-Family [] :' N~;mber of Bedrooms 4' Other WATER SUPPLY Individual We[l~ 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~ Public[] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attestin9 to the legality and status, Page 1 of 2 72-025 {11184) ~ jo ~ ')tJo~ sjaau!Sua leuo!ssajoJd eqh u! suo!ss!uJo Jo s JO J JO JO; alq!suodsaJ hou s! @6eJoqouv jo Xi!led!o!un~ OH1 'penss! s! eheo!J!poo e oJolaq ehep @zXleue JO suo!hoadsu! honpuo3 ]ou op doriC] $o saoXolduJ=j 'shuouJeJ!nbeJ ahehs pue leJapej u!eHoo Xls!hes oh ]opJo u! suo!hnH]su! 6u!puol J!@qh pue souJoq jo sJoseqo]nd oh XseHnoo e se s!q~ saop clOHQ eql 'e~lSel¥ lo a~ehS oqh u! peJe]siSaJ ]aau!6uo leuo!ssoloJd huepuadapu! ue Xq e^oqe g qde~Se]ed u! uo^!L5 suo!he]ueseJdoJ eqh uodn XlOlOS paseq so]eo!H:ploo le^oJddv XH~oqlnv qhleaH senss! (d3HQ) uo!~oeioJd lelUeLUUO~!^u:-] pue qHeoH ;o hUOLUpedeE] a6eJoqouv ;o Xh!led!oun~ eql NOl±n¥o leAoJddv leUO!h!puoo ~o smJOl leUO!l.!puoo poAoJddes!(3 pe^oJddv ~,/~ o_.~-/";%.~, ouoqdalal ¢~'~--~t~ w4!_t ~o OWeN 'uo!loedsu] s!ql uo loeNe ul suo!~elnOeJ pue 'seoueulpJo 'sepoo e~e~S pue led!o!un~ lie ql!~ eoue!ld~oo u! s! ~e~s~s lesods!p ~o/pue ~lddns ~ele~ eHs-uo eq~ 'uo!loedsu! pue uo]~6l~seAu! ~ ~oJj pue seIN eSeJoqouv jo ~!led!o!un~ eql ~oJj peu!elqo uo!le~oju! eq~ uo peseq leq~ ~JHeA ~eq~nj I 'u!eJaq peleo!pu! eJnlonJ~s e~en bepe puc leUOiloun~ 'ejes s! ~e~s~s lesodslp ~e~e~e~se~ ~o/pue ~lddns ~ele~ el!s-uo eq~ ~eq~ s~oqs leAmddv ~lHoq~nv qlleaH s!q~ ~o UO!~BS[]SOAU! X~ ~eq~ XJ!JOA I 'MOIOq UMOHS olep uo!lep!leA aq~ $o se pue o~oJaq pax!j~e leOS X~ Xq pa!jiUao sV NOI~OJNI QN~ VZVQ 'HOMV~S ~qld 'SZS~Z 'SNOIZO~dSNI 9NIQIAO~d ~MIJ 9NI~NIgN~ WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) ~.,¢,HE~'~AUTHORITY APPROVAL (HAA) .~ oi ~i~ .:5,~;'I''CHECKLIST - FEBRUARY 1984 ,,~i,,~\\, ~ ~:~::.t ~' 264-4720 .. ~C~ ..~.~¢~.~ ~ ".,.~¢' J~'~::)~' Legal Description: ~ r~ ~ ~ Well Classification Well Log Present Y~I) Date Completed Total Depth ,.~/~O · Cased to Static Water Level /-.'~ ~ Casing Height Above Ground Electrical Wiring in ConduitCN) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Man hole ,'~ Water Sample Collected by Water Sample Test Results If A, B, C. D.E.C. Approved (Y/N) ,~/,~1 / Depth of Grouting !~//,'~, Pump Set At ~/~ Sanitary Seal on Casing~N) Depression Around Wellhead (Y~ ; On Adjoining Lots · /~ ~ ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ~f" f~/f~'¢;'~ ;Date ¢ - ~[':/- ~'~' Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes~rN) _ Air-tight CapsgN) over Tank (Y~ Depression Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) '~// Separation Distances from Septic/Holding Tank: Size I,~"~"'° No. of Compartments Foundation Cleanout (Y,~ Date Last Pumped ;for Temporary Holdin9 Tank Permit (Y/N) To Water-Supply Well /(25" ! To Property Line /O To Water Main/Service Line Course /<~' To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed (~ r'~¢'~':~'O Width of Field ~ Square Feet of Absorption Area Depression over Field (Y~ Results of Last Adequacy Test Separation Distance from Absorption Field: Type of System Design Length of Field ~-~ Depth of Field Gravel Bed Thickness Standpipes Present t~N) Date of Last Adequacy Test To Property Line 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 To Existing or Abandoned System on ; On Adjoining Lots .,~--o To Cutbank (if present) ! D. LIFT STATION sDi~ / Dimensions ,w~/, ~ Manhole/Access (Y/N) "Pump On" Level at ~ "Pump Off" Level at High Water Alarm Level at ~__ Vent (Y/N) . Tested for ____ ~~during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** Signedl certifythat I~d~r conformed to. Date all MOAand/~ "//-~'?HAA guidelines in effect on the date of this inspection. Company ,/'¢~¢'t~-,~ MOA No. Receipt No. t/ ~ O / O O ~ Date of Payment ./¢///¢/'~"~-- Amount: $ Page 2 of 2 72-026 {11/84) /~ C_.HEMICAL ?_ ?_E__OLOGICA_L LABORATORIES OF ALASKA, INC. ~,,~-~,~.'o;,,~,~.',E~,,~ FEDERAL TAX ID # 92-0040440 ACHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER ..,~PRIVATE WATER SYSTEM Name Phone No. Mailing ,~ddress Cily State Mo. Day Year Zip Code SAMPLE TYPE: ~t/Routine -© Check Sample (for routine sample with lab ref. no. [] Special Purpose __.) [] Treated Water ~¢Untreated Water SAMPLE Time Collected NO. LOCATION Collected By 4I J TO BE COMPLETED BY LABORATORY Date Received Time Received Analytical Method: Analysis shows this Water SAMPLE to be: ~ Satisfactory E~] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Membrane Filter No. of colonies/100 mi. Lab Ref. No. Result* I I FF1 I I Fi] Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE TNTC OB Membrane Filter: Direct Count Verification: LTB Final Membrane Filter Results _ ReportedBy~ ~ ~ = Too Numberous To Count = Other Bacteria BGB Coilform/100ml Ooilform/100ml Time:_ APPLI(' AlT FILLS OUT UPPER HAl ONLY Buyer Address Zip Code Realty Co. & A~nt Phone Address Zip Code Ty~ ~esi~nce ~Single Family ~ Multiple Family NO. of Bedrooms ~ Other ~dividual 1~4~ ~c-~ &%~ ATTACH WELL LOG. A w~l log is required for all walls drilled since June 1975. ~ Community For wells drilled prior to that date, give well depth (attach log if available). ~ Public Utility Sewer Disposal Cdividual Year Individual Inslalled: ~ :-L~ ~ 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 Dale Inspector Inspector Inspector Inspector '-/ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CO N D ITIO N A L ,~ P P RO,.V,A L,' BY: Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received 72-023 {3/821