HomeMy WebLinkAboutTELAQUANA HEIGHTS LT 11T
laquana
ights
11
#001-201-11
~iI
Iii
FAX NO, :9~7 345 0202
3ul.28 2~9 8S:4JPM Pi
Alpine Drilling & Enterprises
Property Owner Name & Address: Sam & Beth Rose
Well Log
Permit Number: #SW0900O9 Date of Issue: 5~-27-09
Date Started: ~ Date Completed: 7-10-09
Legal Description: Telaquana Hieght$ Lot ~ 1 -
Parcel Identification Number: 00%20%1
Is well located at approved permit location? x '4Yes [~] N
Method of Drilling [] air rotary [] cable tool
Casing type: steel
Wall Thickness: ,25 inches
Diameter: _5 inches Depth: 382 feet
Liner Type:
Diameter: ~ inches Depth: ~ feet
Casing stickup above ground: _2 feet
Static water level (from ground level): 5_Lfeet
Pumping level: 380 feet after
_2 hours pumping 20 gpm
Recovery.. Rate: 20 gpm
Method of Testing: .a/r
Well Intake Opening TyPe:
x Open End [] Open Hole
[] Screened Start feet Stopped_ _ feet
[] Perforations Start feet Stoppe, d ~ feet
Grout Type: .bentonite ~ Volume: 2 bgs
Depth: Start 0 feet Stopped ? feet
177?2 Clarke Circle
Anchora~ ,Alaska 995?5
Borehole Data: Depth (ft)
Soil Type, Thickness & Water Strata From To
Stick-up 0 2
Silty sand 2 33
clay 33 189
silt moist I89 259
gravelly sandy silt 10 gpm won't clear 259 264
silty clay 264 3 78
water sand & gravel 3 78 382
Pump: Intake Depth ~ feet
Pump size ~ hp Brand Name
Well Disinfected Upon Completion? x Yes [] No
Method of Disinfection: chlorine tablets
Comments:
Well Driller:
Alpha.Drilling &,En~rprises
POBox 110496
AnchorageAK995t]
Mark Begich
Mayor
Development Services Department
Building Safety Division
On-Site Water & Wastewate~ Program
4700 Elmor¢ Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orq/onsite
(907) 343-7904
Pump Installation Log
Well Drilling Permit Number: SW
Date of Issue:
Parcel Identification Number:
Replacement Only: YES NO
Legal Description
Lot 11, Telequania Heights
Pump Installation Date: 09/01/2009
Pump Intake Depth Below Top of Well Casing: 310 feet
Pump Manufacturer's Name: Myers
Pump Model: 2NFL75-5
Pump Size 3/4 hp
Pitless Adapter Burial Depth: 12 feet
Pitless Adapter Manufacturer's Name: Harvard
Pitless Adapter Installer: n/a
Well Disinfected Upon Completion? [] Yes [] No
Method of Disinfection: Recirc
Comments:
Property Owner Name & Address:
Sam Rose
Pump Installer Name:
Aarow Pump & Well Service LLC
PO Box 110496,Anchorage, AK. 99511
(907) 346- 9355
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
Apr.26. 2010 1'59PM Garness Enaineerina Group, Ltd, No,8612 P. 4
Aarow Pump & Well Service LLC
(907)346-9355
Well Abandonment
Lot 11 Telequania Heights
Water well approx. 15' west of entry way was pumped full of grout from the bottom up
and a steel cap welded on top of casing. Well cut off7' below grade.
Brian R. Wille
Aarow Pump & Well Service LLC
SGS Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
1104401001
Garness Engineering Group, Ltd
Telequana Hts Lot 11 Hose
Telequana Hts Lot 11 Hose
Drinking Water
?
Printed Date/Time 08/31/2010 12:05
Collected Date/Time 08/25/2010 9:10
Received Date/Time 08/25/2010 9:40
Technical Director Stel~hen C. Ede
Sample Remarks:
Parameter
ResdlB
LOQ
Units Method
Allowable Prep Analysis
Container ID Limits Date Date
Init
Metals by ICP/MS
Arsenic
Waters Department
Total Nitrate/Nitrite-N
ND
5.00
0.100
ug/L EP200.8
mg/L SM20 4500NO3-F B
C (<10) 08/26/10 08/30/10 KDC
(<10) 08/25/10 AYC
Microbiology Laboratory
E. Coli
Total Coliform
Negative
Negative
100mL SM20 9223B A
100mL SM20 9223B A
08/25/10 DLC
08/25/10 DLC
SGS ReL# 1104402001
Client Name Garness Engineering Group, Ltd Printed Date/Time 08/31/2010 12:06
Project Name/# Telequana Hts Lot 11 Kitchen Collected Date/Time 08/25/2010 9:12
Client Sample ID Telequana Hts Lot 11 Kitchen Received Date/Time 08/25/2010 9:40
Matrix Drinking Water Technical Director Stel}hen C. Ede
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date init
Metals by ICP/MS 5.27
5.00 ug/L EP200.8 A (<10) 08/26/10 08/30/10 KDC
Apr,t6, 2010 l'59PM Garness Enaineering Group, Ltd, No,8612 P, 2
SCS Rd,# 1094743 O01
Client Name Gamess Engineering Group, Ltd Printefl Date/Time 09/23/2009 17:30
Project Name/# Tclequana tits L11 Collected Date/Time 09/08/2009 I3:10
Client Sample ID Telequana I-Its Lot ] 1 Received Date/Time 09108/2009 13:32
M~trix Drinking Water Technical Director Stenhen C, Ede
Sample Remarks;
Allowable Prep Analyui.q
Parameter Re~ultq PQI, Units Method Container ID Limit.q Date Dale
Arscnic
16.4 n 5,00 ug/L EP200.8 C
09/14/09 09/16/09 NRB
Total Nkrateaqqitrite-N
ND 0. I00 mg/L SM204500NO3-F B (<10) 09/13/09 LCE
~iCrobiology ~aho~atorir
Colony Count 4
Total Coliform 0
Fee,al Coliform 0
cot/100mL SM209222B A (<200) 09/08/09 DLC
col/100mL SM20 9222B A (<1} 09t08/09 DLC
col/100m[, SM20 9222B A (<I) 09/08/09 DLC
Volatile Pue[s Depa~tmant
Gasoline Range Organics ND 0.100
Benzcne ND 0,500
]'oluene ND 2.00
Ethytbcnzene ND 2,00
o-Xylene ND 2.00
P & M -Xylene ND 2.00
4-[-lroll~ofluorobcnzelle <.surr:-- J 00
1,4-Difluorobcnzene <,surr> 106
mg/L AKIOI O
ug/L SWg021B D
usa, SWS021B D
ug]L SW8021B D
ug/L 8W8021B D
ag/L SWg021B D
% AKI01
% SWS02IB
D 50-150
D 80-120
09/18/09 09/19/09 KPW
09/18/09 09/19/09 KPW
09/18/09 09/19/09 KPW
09/18/09 09/19/09 KPW
09/18/09 09/19109 KPW
09/'~8/09 09/f9109 K.PW
09/18/09 1'19/19/09 KPW
09/18/09 09/19/09 KPW
Seanivolatile Otqanie Fuels
Diesel Range Organles ND 0.800
mg/L AK102
G
09/11/09 09/21/09 KDC
Apr,26. 2010 2'OOPM Gsrness Enaineerina Group, Ltd. No,8613 P. 1
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i
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MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WATER SUPPLY PERMIT
Upgrade
Date Issued: May 21, 2009
Expiration Date: May 21, 2010
Permit Number: SW090069
Legal Description: TELAQUANA HEIGHTS LT 11
Design Engineer: 0855 GARNESS ENGINEERING GROUF
Owner Name: SAM & BETH ROSE
Owner Address: 11712 CLERKE CIRCLE
ANCHORAGE, AK 99515-
Parcel ID: 001-201-11
Site Address: 002263 KlSSEE CT
Lot Size: 0 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
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.
5. The following special provisions.
!WELL DECOMMISSIONING PAPERWORK TO BE BE SUBMITTED.
Received By;.
Issued By;.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw St.
P.O. Box 196650
Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERHIT ,b, PPLICATION
FOR ~, SINGLE FAHILY DWELLING
Parcel I.D.
Property owner(s) ~AM ~ BETH ROSE
Day phone 223-5324
Mailing address 11712 (;LERKE CIRCLE *ANCHORAGE. AK
Site address
Zip Code 99515
Legal description (Sub'd, Block & Lot ) TELEOUANA HEIGHTS. LOT 11
Legal description (Township, Section & Range)
Lot Size ~-~, ~ Sq. Ft.
Number of Bedrooms
THIS APPLICATION IS FOR ( [] all that apply):
THIS APPLICATION IS AN:
Absorption Field [] Initial []
Septic Tank [] Upgrade []
Holding Tank [] Renewal []
Privy []
Private Well []
Water Storage []
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.
GARNESS ENGINEERING CROUP~ Ltd.
Permit/Rush Fees: ~ ~')0
Receipt Number: (~ ~ Z ~ ~) ~
(Rev. 11/05)
Waiver Fees:
Date of Payment:
Receipt Number:..
GARNESS ENGINEERING GROUP, Ltd.
~., ,~ .......... = CONSULTANTS & GENERAL CONTRACTORS ~ ' :~ ~-:~.~ :' ':'.;- '~ ~'~'~ ::
May 18, 2009
Municipality of Anchorage
Development Service Department
On-Site Water & Wastewater Progmm
4700 Bragaw Street
P.O. Box 196650,
Anchorage, Ak 99519-6650
(907) 343-7904
Ref: Proposed Well Upgrade for Telequana Ileights Subdivision; Lot !1,
To whom it may concern:
In recent months the existing well that serves the subject property has been under close examination and found
to be contaminated with heating oil. GEG and the homeowners have been working closely with the ADEC
Spill Response Team as well as the ADEC Contaminated Sites Division, taking every precaution necessary to
protect public health. It has been decided through conversations with Todd Blessing at ADEC that 3
monitoring wells will be drilled and monitored, soil samples will be taken and examined for GRO, DRO, &
BTEX. At this time we are proposing to decommission the existing well and drill a new well per MOA
standards. Attached is a site plan showing neighboring lots and separation distances from the proposed site.
We are unaware of any adverse impacts that the proposed well would have on existing wells.
If you have any qt
;tions, please contact us at 337-6179. Thank you for your assistance.
,E., M.S.
3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507-1259
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.gamessengineering.com
ILO~K 2, LOT lA
TELEQUANA HTS.
BL~K 2. LOT ~ , ~ u. I
I
SAM · BETH ROSE 223-5524 1 OF 1
SITE P~N 4/23/09
/ /
APPROXIMATE LOCATION OF
PREVIOUSLY REMOVED
HEATING OIL TANK,
REMOVED BY CHUCKS
BACKHOE SERVICES.
KISSE£ CT
wm._~
EXISTING HOUSE
SEWER UNE
LOCATION
BLOCK gA. LOT
12
/
/
/
/
gA. LOT
SEWER UNE
LOCATION
GARNESS ENGINEERING GROUP, Ltd.
~ ~, CONSULTANTS & GENERAL CONTRACTORS
PREPARED FOR: IPHONE: NUMBER: I PAGE NUMBER:
SAM & BETH ROSE 223-5324 1 OF 1
L[GAJ. DESCRIPTION: DRAWN BY:
TELEOUANA HEIGHTS; LOT 11 PNB
Pt'P[ OF WORK: DATE:
SITE PLAN 4/23/09
Lot
Block
SERVICE COII~:I.CTIOII RECORD
Subdivision or
Property Owner.~' ~",., .~:
Address
. . o'~"~'.,
Water Size Permit Yes
Sewer t -~ Size ~' ' ~ermit Yes
Date
Inspectm'
Contr.
No ~
'OCATIO~I SKETCII
P P P P P P ~ P P P P ~
Municipality of Anchorage
Development Services Department
CERTIFICATE
FOR A
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
/
(907) 343-7904
OF ON-SITE SYSTEHS APPROVAL
SINGLE FAMILY DWELLING
Parcel I.D. 001-201-11
1. GENERAL INFORMATION
Expiration Date: i ~-- (:~ -/ O
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
TELEQUANA HEIGHTS LOT 11
2265 KISSEE COURT *ANCHORAGE, AK 99517
SAM ROSE Day phone
2263 KISSEE COURT *ANCHORAGE, AK 99517
223-5524
Day phone
Day phone
Unlesso~erwi~e¢equeste~ COSA willbeheldbyDSD ~rpickup.
2. NUMBEROF BEDROOMS: 4
3. TYPEOFWATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well · Individual On-site []
Individual Water Storage [] Individual Holding tank []
Community Class Well [] Community On-site []
Public Water System [] Public Sewer ·
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems
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 samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not 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 the validation date shown below, I verify that my
investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this appfication,
shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Phone 357-6179
Address ,3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Date
o
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
ON-SITE
WATER AND
other person or party is not authorized, nor will it confer any legal right whatsoever.
DSD SIGNATURE
Approved for t-IL'
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
WASTEWATER : _:
PROGRAM
...
Attachments: COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
.., .
(Rev. 11105)~/"
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
.j/~'~'~'(--~'~ Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
CHECKLIST
Legal Description:
TELEQUANA HEIGHTS LOT 11
Parcel ID: 001-201-11
WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A
Date completed 7/10/09 Sanitary seal (Y/N) YES
Total depth 382 ft. Cased to 382 ft.
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
YES
YES
24+ in,
FROMWELL LOG
Date of test 7/10/09
Static water level 51 ft.
Well production 20 g.p.m.
AT INSPECTION
NEW WELL
g.p.m.
WATER SAMPLE RESULTS:
Coliform - 0 colonies/100 mi.
Arsenic: 14.5 ug./L.
SEPTIC/HOLDING TANK DATA
Nitrate ND mg./L. Other bacteda
Date of sample: 8/25/2010 Collected by:
PUBLIC SEWER
0 colonies/100 mi.
GEG Ltd.
Tank Type/Material
Date installed
Tank size __gal.
Foundation cleanout (Y/N)
Date of pumping
ABSORPTION FIELD DATA
Date installed. -
Number of Compartments Cleanouts (Y/N)
Depression over tank (Y/N) __ High water ala~N~ Pumper
Soil rating (g.p.d./ft2or ft2~em type
Length ft. Width J ' ft. Gravel below pipe ft.
Total depth ft. Eft. absorption~~ ft2 Monitoring tube Depression over
field
Date of adequacy test _...-/ Results (Pass/Fail) __ ___ For bedrooms
Fluid depth in abso~'f~d before test in. Water added_ gal. New depth in.
Elapse_ min. Final fluid depth in. Absorption rate >= g.p.d,
A~ ne ation treatment (past 12 mo.) (YIN & type) yes, give
If
date
D. LIFT STATION
Date installed
"Pump on" level at in.
Datum f Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons Manhole/Access (Y..(_Y_~ ~
"Pump off" leveLaL-------fl'~'--'-', High water alarm level at
Septic tank/lift station on lot N/A
Absorption field on lot N/A
Public sewer main 75'+
Sewer/septic service line 25'+
Animal containment areas 50'+
in.
Meets alarm & circuit requirements?
On adjacent lots N/A
On adjacent lots N/A
Public sewer manhole/cleanout 100'+
Holding tank N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER
Building foundation
Property line
Absorption field
Water main Water service line. Surface water
on adjacent lots ~
Wells
SEPARATION DISTANCE FROM ABSORPT~ TO:
Property line _ ~undation~: Water main
~'"'"~Surface water ' Driveway, parking/vehicle storage
~ Wells on adjacent lots
F. COMMENTS
G. E~"NE'ER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Arsenic Advisory
Certificate of On-Site Systems Approval # 101198
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
11 of Telequana Heights Subdivision. This inspection revealed an arsenic
concentration of 14.5 micrograms per liter (ug/L) for the property's well
water sample. The Environmental Protection Agency (EPA) has established
a maximum contaminant level (MCL) of 10.0 ug/L for public drinking water
systems. While private wells are not subject to this regulation, EPA
standards are based on existing health information and can therefore be used
to gauge the relative quality of water from private wells. Information on
arsenic is available from the On-Site Water and Wastewater Program
website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
FHA Form 2573 FEDERAL HOUSING ADMINISTRATION Budget Bureau No, 63-R296.§
Rev. July 1958
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PAR'[ I.--TO BE COMPLETED BY FHA
INSURING OEFICE MORTGAGEE ~SERIAL NO.
/melm~'~q~ A],il~ka Xat~l. mtaT. ~ o£ A!aska ~ ~mholral~T 60e00G!65
MORTGAGOR OR SPONSOR PROPERTY ADDRESS
SUBDIVISION NAME BLOCK NO. 1 LOT NO.
TOTAL NUMBER:
LIVING UNITSI ~EDROOMS . -B~'JHS
J
WATER SUPPLY BY:
[~ Public system
SEWAGE DISPOSAL BY~
[~' Public system
BASEMENT
] New installation
Can attic or other area be made Into
additional bedrooms?
{if Yes, ho~' manyg)
[~] Yes [~] No ~.
[~] Cotnmunity system
] Cominunity system
r~[-] htdividual
~'] Individual
SYSTEM DESIGNED FOR
PART II.~TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
It is the opinion of the [] State County [] Local Department of Health that this individual Water-supply
[~is [] is not satisfactory as a domestic water supply for the subject property,
It is the opitfion of the [] State
tern with proper maintenance:
~-~Can be expected to function satisfactorily, and
is not likely to create an insanitary conditiot .~_ t~g0/(-*F"._
[] County [] Local Depar!ment of Health that this individual sewage-diapc i sys-
[-'1 Cannot be expected to function satisfactorily
NOTE: The health ciuthorlty should complete the appropriate opinion statement ~bove and a~x dote, signature and IDle in tho
spaces provided.
PART III.~FOR USE OF FHA OFFICE
TO THE CHIEF UNDERWRITER~
I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that'the
Individual water-supply system be considered r'~ acceptable [-'] Not Acceptable
Sewage disposal be considered [] acceptable [] ~Not ~ceptable.
DATE
SIGNATURE
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
] CHIEF ARCHITECT
] DEPUTY FOR CHIEF ARCHITECT
FHA Form 2573
R~v. July 1958
:ol~ta jo Xlddns o;~nbapu qs!uJnj m ~!up!^ a]~!pamtu! u! $11ota jo aJnl!eJ jo pJoao: luoaa: 1som
'pootl~oqq~}ou u! A~umolsn~ lou aJu [] o:e [] SllOax lUnpD}pui
W:IISA$ Alddfl$'tFllVA6. 1VrIQIAIQNI~NOI13:IdSNI lO liiOdtit
WtlSAS 1V$OdSlO':lOV/V~aS lVflQIAIQNI~NOIJ,33dSNI 40 J. tlOdltJ
15 July ~959
Federal, Housinl5 A&ntuistratio~
l~ox 779
Auchorege, Alazke
,~erial No. 60,-0061~.5
~elequaue HeiEhts~ l,ot 11
You will note ~hat the installed sewer l~e ~uns along the
easement oi this property° The 8~p~ic t~ and cesspool ~e~a
put in in 1958. There i~ a possibllil:y~hat ~he se~a~e dtspesal
sy~temtaay eaui~e a nuisance in the future. The decision to
require a connection to the sewer outiall rests with you.
JL~:pb
Joa L. t~lker
ADH-HSE.6.FI
Out Completely.
-~_~~ WATER SUPPLY
A]hASKA DEPARTMENT OF HE/HYI'H
Section of Sanitation and Engineering
IiPlease Look on Reverse of~
Sheet for Sample Collection[
Request for Bacteriological Analysis l. ab. No..._
.?
......................................
Name and type of :tabllshment using tl~Js wate!: ................ .D..:~:...~. .................. ~....~....e...... f ................... (.~)......~..
p~ ,/./2~ , ~ Sekool, C~, Hpspltal, Camp, or. linear Establishment
Location of this water ~upp~.......~-""..~.~..~...~....~:e.~:..~..~~......:.".~.C~/~....~<(.~"~...~......-e~.......~...: ........
Street, ltlghway~llepost, Town
Report should be mailed to ..-~...~ ................... owner, . ...................................... manager
Name ........... .......... Name Manager ..................................................................................
Addres .............. ............................. Address ..................................................................................
tr '5
Town ........... 6o.~.~2 .............................................. Town .................................................................................
Please place an "X" e box bef 1
.'~.trF/t&e bo: ore terns which best describe the water supply sampled.
Collection Point.( ~[Kitchen tap, [] Bathroom tap, [] Basement tap, [] Utility Room tap, [] Other (list)
Source: [] Drilled Well, [] Driven Well, [] Dug Well, []Bored Well, [] Spring, [] Cistern,
[] Stream, [] Lake, [] River, [] Pond, [] Other (list) ........................................................................
Well or Cistern
Co~mtructlon:
Well L~catton:
Treatment:
Pump Location:
Distance to
Pollution:
Type Sewer:
G~neral Information:
Walls ~ [] Wood, [] Concrete, [] Metal, [] Tile, [] Brick or Concrete Block
Top --[] Wood, [] Concrete, [] Metal, [] Open Top
Diameter .................... inches, Depth .................... feet; Drop pipe length .................... feet.
Depth of water in well .................... feet.
[] In Basement, [] Basement offset, [] Under building, [] In Yard, [] In '0'tility Building,
[] Other (list) .....................................................................................................................................................
[] Yes, [] No. If yes, give type of treatment: [] Chlorination, [] Softening,
[] Iron removal, [-I Other (list) ...................................................................................................................
[] In well, [] Offset in basement, [] Utility room, [] On top of well cover, [] Other (list)
Any sewer or drain .................... feet Septic tank .................... feet
Other source (list) ..................................................................................................................................... feet
[~ Cast iron, [] Wood stave, [] Cement rtl.e, [] Other (list) ............................................................
Does Water become muddy or discolored? [] Yes, [] No. If so, when ............................................
Is water suspected as source of Illness? [] Yes, [] No. If yes, then describe Illness ..................
PLEASE DRAW A SKETCH IN THE SPACE BELOW. SKETCH SHOULD SHOW LOCATION OF HOUSE, WATER
SUPPLY SOURCe, SEPTIC TANK, SEWE~, DRAIN LIN'ES OR OTHE/~ SOURCES OF POLLUTION AND DISTANCES
BETWEEN WA~*E~R~qU~PLY A/qD ~ OF ~OVE FA~IL/~TI~. USE BACK SIDE IF MORE SPACE NEEDED,
SAMPLES MUST BE SUBMITTED IN CONTAINERS PROVIDED BY ~HE ALASKA DEPARTMENT OF HEALTH
ADH-HSE-6-F 1 ([)
(6-58 iOM)
INDIVIDUA/~ WATER SUPPLY
~//~ '//y//.97~r///a~ / ALASKA DEPARTMENT OF IIEALTH
Section of Sanitation and Engineering o~q.~c~
ACTION ON REQUEST FOR BACTERIOLOGICAL WATER ANALYSIS
Bout;h{:en~,z'al Regiona.~
Your receot request for an analysis of a sample
frotn tile individual Private \Vater Supply
serviw,Ohi:Ll~g~alt DI'~V~ ~' ___was
received 7/q/59 and
1999
Anohorage,
examination has heeu completed.
Records in this ollice indicate this individual Private Water Supply to be of F/--.Satisfactory.-- Qnestiouable ..... Unsatisfactnry
sanitary status.
Analysis shnws this SAMPLE to be t_.-~ SatisfactmT Questioaable __ .Unsatisfactory.
If an "Unsatisfactory" or "Questionable" status is indicated ahove, you should take immediate action as recommended below.
1. Boil or chemically treat your water supply to protect your family from water-borne diseases as outlined in eu-
closed leaflet, "Drink It Pure."
2. ImProve your spring--See bulletin HSE-6-2
3. Improve your cistern--See bulletin HSE-6-3
4. Improve your dug well- See bulletin HSE-6-4
5. Improve your driven well--- See bulletin HSE-6-5
6. Improve your drilled well---See bulletin HSE-6-6
7. Relocate your well to a safe location iu relationship to your sewage disposal system--See bulletin HSE-15
8. Bottle broken in transit, please send new sample.
9~ Sample too long in transit; sample should not be over 48 hours old at examinatiou to indicate reliable results.
Please send new sample.
~ 10. Contact your nearest ~ Local Health Department or [] Alaska Health Department, Sanitation office for
bulletins, consultation, 8ud assistance.
1L This is a surface water source and subject to pollution by man and animals. An approved water supply source
should be developed.
SANITARIAN'S REMARKS
$ig,tattz c _ ~ ~