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HomeMy WebLinkAboutUS SURVEY 3043 LT 28B-20(01,-S1 arr ss Lt0 M DRILLING, Inc P. O. Box 4-1224 • 1310C intnatiortal Airport Road •, (907) 2744611 • ANCHORAGE, ALASKA 99509 • DRILLING LOG Well Owner Gets Me ine 3 4Lise of Well Dente5 Li Location teddies% .of: Township, Range, Section, if known; or distance main road: Lot 28-B" GirdwOod Sioaring _Depth of Rale 73 s ." fret Cased to_. i3 3t, n a feet Static wsterilivel-IL__--it. (NA) (below) lend surface. Finish of well (check one) open end ( Scrsen ( ); Perforated( Describe screen or perforition Well pumping test at. _i_gallons per (b% (minute) for_L___Iimws with1307, of drewdown from static lova • . Date of completion_ 7 /11 /S D WELL LOG Depth in feet from ground surface Give details of formations penetrated, size of material, col and hardness Ta_7_7 TO 511 Organic Silty gray clay with gravel is!- CC Boulder I 55: it 6T0T° :46 y c lay witheravel irtt. '2ro 73' clav & rrtivelL TO TO_ TO • < Sandy gravel ti water ZS Cams& t4,t ELT: 2.. 2 —STATE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW930341 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:MEINEL GENE E OWNER ADDRESS:8741 PKUTO DRIVE ANCHORAGE, AK. 99507 ,~PAG~ DATE ISSUED: 9/03/93 EXPIRATION DATE: PARCEL ID:07506124 LEGAL DESCRIPTION: US SURVEY 3043 LT 28B 1 OF 9/03/94 1 LOT SIZE: 31185 (SQ. FT.) NUMBER OF BEDROOMS: 2 THIS PERMIT: 2 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM 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 (iSAAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: THIS WELL WAS DRILLED ON 7/31/80 WITHOUT A PERMIT. LOG WAS SUBMITTED ~T,H T~EX~w~'~PERMIT APPLICATION. RECEIVED BY: THE WELL DATE: DATE: / 'Ray. 7) ,c 190 sco'oN 3000 XVI t 2 Q mr mAj ADD' «w z. K "•!„:1R1': Y Tz K° Ls-- Indicate North w -J J m w E E 0 t 2? (jui7b,t. $ SURVEY 3043 ---;., .t , \ , , _.." ------.1-_ int KA '\ a \ OA D . ; ?I 11 \ __. . ..... . 4.."""'"flw GI 11011111•••• tt 11! " a Municipality of Anchorage On -Site Water & Wastewater Program (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 075-061-97 Expiration Date: / a- — g r t5 1. GENERAL INFORMATION Complete legal description Location (site address) Current Property owner(s) Mailing address Real Estate Agent U.S. SURVEY 3043; L288-2 1535 ALYESKA HIGHWAY ROBERT WILLIAMS 1535 ALYESKA HIGHWAY Day phone 850-264-5968 REBECCA W/ GLACIER CITY REALTY 2. TYPE OF DWELLING: ▪ Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System W aiverNariance request for: 2 Day phone 783-1910 TYPE OF WASTEWATER DISPOSAL: Individual On-site ❑ ❑ Individual Holding tank ❑ ❑ Community On-site ❑ Public Sewer Distance: — Received COSA to be released to the engineer, unless otherwise requested by the engineer. Date: 4/1/2g//S COSA Fee $ 6 24-- DateDate of Payment cl —1-15 Receipt Number 0354.3G COSA# ©J Cl 6! / Waiver Fee $ Date of Payment Receipt Number Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, 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. 1 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 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 *ANCHORAGE, AK, 99507 ee'' Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date n 13) /1S Engineer's Comments: In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the systemls on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend on a variety of variables including, but not limited to, soil conditions, groundwater levels (that may fluctuate dudng the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and ere outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an akemative wellorseptic system can be installed on the property in the event either of the current systems fail. The content of the report is for the sole benefit of the person/party who retained GEG. Reliance upon the information provided in this report by any other person or party, including but not limited to subsequent property purchasers, is not authorized. In short, GEG disavows any legal duy to anyone other than the person/patty who paid for this report. 6. DSD SIGNATURE System #1 Approved for 2 bedrooms. System #2 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: 1F/ • '-arness ? i C 53 •��°F'ESSO ��..vt�;\\```0 (n1 tt1)ff1/4 oro ON-SITE t' WATER AND WASTEWATER;it.- �p PROGRAM By: Original Certificate Date: cl - it The icorage Develop,emt Services Division (DSO) issues Certificates of On -Site Systems Approval (COSA) based only upon the rep -s> -. atrons given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTCHMENTS: COSA Checklist Septic System Advisory Well Flow Advisory (Rev. 10/12/12) Nitrate Advisory Arsenic Advisory Other If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: U.S. SURVEY 3043; L288-2 A. WELL DATA Well type PRIVATE Parcel ID: 075-061-97 If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 7/31/1980 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 73 ft. Cased to 73 ft. Casing height (above ground) 12+ in. FROM WELL LOG Date of test 7/31/1980 Static water level 18 ft. Well production 5 WATER SAMPLE RESULTS: Coliform 0 colonies/100 mf. Arsenic: ND ug./L. B. SEPTIC/HOLDING TANK DATA Tank Type/Material Date installed Tank size gal. Number of Compartments _ Cleanouts (YIN) Foundation cleanout (Y/N) _ Depression over tank (Y/N) _ High water alarm Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d.ft2orft2/bdr System type Length ft. Width ft. Gravel below pipe ft Total depth ft. Eff. absorption -a__ ft2 Monitoring tube_ Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absor. '.n field before test _ in. Water added _gal. New depth __in. AT INSPECTION 8/19/2015 56.7 ft. gpm 5.8 gpm Nitrate 0.330 mg /L Collected by: GEG. Ltd. py tip Date lnl'F�u- of sample: 8/19/2015 & 8/25/2015 PUBLIC Elapsed T min. Final fluid depth _ in. Absorption rate >_ rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date g.p.d. D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N "Pump on" level at in. "Pump off" level - High water alarm level at in Datu Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankfift station on lot N/A On adjacent lots Absorption field on lot Public sewer main N/A *50'+ Sewer /septic service line **UNK Animal containment areas 50'+ 100'+ On adjacent lots 100'+ Public sewer manhole/deanout *50'+ Holding tank N/A Manure/animal excrete storage areas SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Absorption field Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIE i o OT TO: Property line B 100'+ undation Water main Water service line Surface water Driveway, parking/vehide storage drain Wells on adjacent lots F. COMMENTS *GRANDFATHERED—WELL AND SEWER INSTALLED PRIOR TO 1983. *NO REQUIRED SEPARATION DISTANCE UNTIL 1983 G. ENGINEER'S CERTIFICATION 1 certify that 1 have detemrined through field inspections and review of Municipal records that the above systems am in conformance with MOA COSA guidelines in effect on this date. Engineer's Printed Name JEFFREY A. GARNESS 6131/15 - Date (Rev. 11/05) / ~ ~ ~ ' ~ 20' ~OAa TO PRAC~CE LAND SURVEYING IN THE STATE OF ALASKA AND ~AT THIS PLAT ,**~ n~ REPRESENTS A SURVEY MADE BY ME LOT 28B-1 AND LOT 28B-2 oR UNDER ~Y DIRECT SUPERVISION AHD USS 50~3, GIRDWOOD ,A~SKA THAT ALL DIMENSIONS AND OTHER DETAILS ARE CORRECT AS OF SEPT. 15. Igg2. WITHIN NE 1/4, S.18. T. ION.,R.2E., S.M., AK. 8741 PLUTO DR. J ANCHORAGE, A~SKA 99507 12/21/92 ADMJ ADM 1"=60' 1 12/21/92 CHANGE IN INTERIOR LOT BOUNDARIES AOtd ADM ~ REV. NO. DATE: REVISIONS ORA~ CHECK 92002 92002AB 1OF1 • Municipality ofAnchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.akus (907) 343-7904 • CERTIFiCATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY L)WELLING Parcel I.D. D 7$ — O C/ — `l 7 • 1. 'GENERAL INFORMATION -Complete legal description HAA # • (D � O Expiration Date: / 0 -17 - 0 3 Lot 28B-2; U.S. Survey 3043 Location (site address or directions) Nile 1.5 Alyeska Highway, Girdwood Current Property owner(s) Mawret w; 11 i ams Day phone 7817_126_0 _ ' Mailing address Lending agency Mailing address Real Estate Agent S-A K w ti r r t Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: �! PO Box 798 Girdwood, AK 99587 Day phone Grog&& t1 Gy 3. TYPE OF WATER SUPPLY: ' Individual Well Individual Water Storage Community Class Well Public Water System Day phone 7x..3 ` 13 7 TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer 1216)1262115111101 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (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 Health Authority Approval Guidelines for this application, 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 s S F.ngi nonring Phone 694-2979 Address17014 N. Eagle River Loop Ste. 204 Earle River, AK 99577 Engineer's Printed Name Robert C. Cowan Date 7 //y/o j l,C.............. Ay 1trii?f ;NEER' //.. r! . c.,Ar 7e�\ IOBERT C. COWAN J j 5. DSD SIGNATURE c� CE.8801 .k. V.V. Approved for .2. bedrooms. I trf �=; •....,.,„.•'•;'f���:.� Disapproved. '•�:.�x.i.”- Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: •I/h I a (Rev. 01/02) Original Certificate Date: 7 ' % 7 O 3 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.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:Lcr ?B -a V.S. S'RviY 3o f3 Parcel ID:O7S-O6J-97 A. WELL DATA Well type r.e, 4rt If A, B, or C provide PWSID # Well Log (Y r o Date completed "•x'181 Sanitary seal (IN) Yd- f Total depth / Pi+ ft. Cased to 10 ft. FROM WELL LOG Date of test ' Static water level Well production WATER SAMPLE RESULTS: ft. g.p.m. Coliform 0 colonies/100 ml. Nitrate e2.36- mg./I. Arsenic Date of sample: 7/60 3 B. SEPTIC/HOLDING TANK DATA la 41a-/ L Tank Type/Material Date installed Tank size .gal. Number of Compartments Cleanouts (Y/N) r Foundation cleanout (Y/N) ^ Depression over tank (Y/N) _ High water al_ /N) Date of pumping '` Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft2 or ft2i• . m) _ System type Length ft. Width ft. Gravel below pipe ft. Total depth ft. ` Eff. abso = on area 112 Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail) For _ bedrooms Fluid depth in ab - . tion field before test _ in. Water added_ gal. New depth_ in. Elapsed e: ` min. Final fluid depth _ in. Absorption rate >= g.p.d. rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date Wires properly protected 6N) Y,cJ Casing height (above ground) fa- + in. AT INSPECTION 74/a3 11)- ft. y.6 g.p.m. Other bacteria colonies/100 ml. Collected by: S & S ENGINEERING -T7034-lagte-RIvsrtoop-Road No. 204 $,f w ER Eagle River, Alaska 99577 D. LIFT STATION Date installed Size in gallons "Pump on" level at _ in. "Pump off" level . in. Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 1414 On adjacent lots Absorption field on lot d (4 On adjacent lots "1/A Public sewer main 9 7 Manhole/Access (Y/N High water alarm level at Meets alarm & circuit requirements? A/ fA 3F - Public sewer manhole/cleanout 9'7 Sewer /septic service line Holding tank A/ /A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line Water main Water service line Wells on adjacent lots SEPARATION DISTANCE FROM ABSORP FIELD ON LOT TO: Absorption fi Property line :uilding foundation ace water Water main Water Service lin- Surface water Driveway, parking/vehicle storage Cu rain Wells on adjacent Tots F. COMMENTS C-AANDFArN4,146 WE“. A. ,E.A- /NSTAt•t.Jt0 I'araR TO FAL, k_� z`r G. ENGINEER'S CERTIFICATION I certify that t have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAAAguidelines in effect on this date. pbgt.t7 C, Cow,,-' 7/(y/o .3 Engineer's Printed Name Date ..r HM Fee $ Date of Payment Receipt Number (Rev. 12/01) ••7 �r y toy /s3. 0 ROBERT C. COWAN �Q 0 • CE - 8301 - & • .. .0 _ e. Waiver Fee $ h,� .�:;;';.,;':6' Date of Payment Receipt Number 7-10-03; 5:5OPM: SCS Ret:aw Client Name Project Name/# Client Sample ID Matrix 1034017001 S & S Engineering Lot 28B-2 US Survey 3043 Lot 28B-2 US Survey 3043 Drinking Water ;907 5615301 # 2/ 3 AU Dates/Times are Alaska Standard Time Printed Date/Time 07/10/2003 14:55 Collected Date/Time 07/06/2003 14:00 Received DatefTime 07/07/2003 14:30 Technical Directo Stephen C de Rekase Sample Remarks: Parameter Waters Department Nitrate -N Qualifiers Results 0.302 0 Microbiology Laboratory Total Coliform PQL Allowable prep Analysis Units Method Container ID Limits Date Date hit 0.100 rnp/L EPA 300.0 B (<=10) 07/08/03 JJB col/100mL SM189222B A (<=1) 07/07/03 JS i Parcel I D # MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 075S '96/ - q1 1. GENERAL INFORMATION Complete legal description HAA # OFilac' lnlc U.S. Survey 3043 Lot 288-2 Location (site address or directions) A/yeeaa Hwy. G.Lrdwood, AK Property owner Gene Me-Lne/ Day phone 786-8455 Mailing address 5960 Longoria Ciao -ft Anchorage, AK 99504 Lending agency Day phone Mailing address Agent Dave S Judy Batten/ Remax ob A/yeaaa Day phone 783-2010 Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water 3 XXX NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer XXX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA#21 5. 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 of this Health Authority Approval application 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 5 & S ENGINEERING 17034 Eagle River Loop Road :Co. 204 Address Eagle River, hake:7 7 Engineer's signature Phone 6 al'/- 2-49 7 j Date 9 IC' �r•A 8801` / '4 . � ♦ G,a 6. DHHS SIGNATURE Cc°Sl''"C'.., X Approved for 1 bedrooms. - Disapproved. Conditional approval for bedrooms, with the following stipulations: By. Additional Comments Date CAUTION The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their fending institutions in order to satisfy certain federal and state requirements. Employees of DHHS 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. 72-025 (Rei. 1/91) Back MOA #21 MUNiCJRALITh OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION Municipality of Anchorage AUG 2 1 199 DEPARTMENT OF HEALTH & HUMAN SERVICES p Environmental Services Division RECELY 825 L Street; Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist t7 Legal Description: Lo T a 7 8 - a U- S - Su/et/4.y Parcel I.D.: 0 1 5- - "( fiS A. WELL DATA Well type PRivk7E If A, B, or C, attach ADEC letter. ADEC water system number Log present I( f/N) YES' Date completed '7 / 3118-0 Total depth ) 3 Cased to 7 3 e Casing height (above ground) t 1 Sanitary seal (QYN) Y 6 S Wires properly protected &N) V€-� FROM WELL LOG AT INSPECTION Date of test 7 ( 3//PO $1r3 /9 Static water level f V S'6 ` .z Well production S g.p.m. } g•p•m• itesrm.tr@.D- ay Pv,HP 8r Pc.JItia,„/(- WATER SAMPLE RESULTS: Coliform 0 Nitrate O. 3 t r Other bacteria Date of sample: / / 3 ) q G Collected by: B. SEPTIC/HOLDING TANK DATA P vet r C '4 4., S & S ENGINEERING 17034 Eagle River Loop Roar, Ms. 294 Eagle River, Alaska 99577 Date installed Tank size Number of Compar Cleanouts (Y/N) Foundation cleanout (YIN) Date of .ing C. ABSORPTION FIELD DATA, ession (Y/N) High water alarm (Y/N) Pumper ('UBLIt C Sewt2. Data installed Soil rating (g.p.d./ft2 or ft2/bdrm) System type Length+ Width . , Gravel thickness below pipe otal depth Effective absorption area' ' Monitoring Tube present (Y/ Depression over field (Y/N) Date of adequacy test Results (P• : ail) For bedrooms Fluid depth in absorption field before tes , Immediately after gal water added (in.): Fluid depth (ins _ utes later: Absorption rate = g.p.d. Peroxide trea (past 12 months) (Y/N) If yes, give date 6 (Rev. 3/96)* D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) Pu vel at* "Pump off' level at* High water alarm lev- - * *Datum Cycle E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot N 4 On adjacent lots 'v/A Absorption field on lot Ai/4 On adjacent lots ti /a Public sewer main 7C Public sewer manhole/cleanout � 9 Sewer /septic service line a S" Lift station PI/4 9(- \,J&"- /},v4 £t i 4 1Msr4'-c- 4 P4162, ro 19 b'3 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation Property line Absorption field Water main/service line Surface water/drainage Wel SEPARATION DISTANCE FROM ABSORPTION FIELD Property line Bu' oundation TO: acent lots Water main/service line Surface water Driveway, parking/vehicle storage area Curt rain Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal recordte. in conformance witA Hguidellies in effect on this date. i C r^ f4( Signature Engineer's Name nt.614.2r C. C dw�th/ /2 /9G Date s are Ci'P'y CE -8801 /4• r se t14\31OF "c1J\t.C7 • 13 ROBERT C. COWAN /e HAA Fee $ Date of Payment Receipt Number (/z//r,c 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number CT&E Ref.# Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID 0 Released By CT&E Environmental Services Inc. Laboratory Division nanism arAr ®.a®�®v®.row®.cy�vrArAnan rs.aarassaramt 963765002 S & S Engineering N/A L28 B-2 U.S. Survey 3043 Drinking Water 200 W. Potter Drive Anchorage, AK 99518-1605 Tel; (907) 562-2343 Fax: (907) 561-5301 Client PO# Printed Date/Time Collected Date/Time Received Date/Time Technical Director Sample Remarks: 08/19/96 16:05 08/13/96 16:00 08/14/96 10:05 Parameter Nitrite -N Nitrate -N Total coliform Results PQL Allowable Prep Analysis Units Method Limits Date Date Init 0.100U 0.100 mg/L EPA 353.2 0.315 0.100 mg/L EPA 353.2 0 0 col/100mL SM18 92226 08/15/96 ESC 08/16/96 ESC 08/14/96 TAV 0 SGS Member of the SGS Group (Societe Generale de Surveillance) ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA