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HomeMy WebLinkAboutWILDWOOD GLEN LT 6Wildwood Glen Lo1- 6 #015-092-73  ~..=/' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL DESCRIPTION ~;~L LOCAT'ON H ~' L L~;J~ ~ ~,STA~CETO: Iw~'' /~, I~o~p~ion~r~2, ~,,~n~ G' ~'  Manufacturor ~(~'e~ Mater,a~ ~o. of c~ar~ments kiq2~~ gallons IF HOMEMADE: Inside length Width ~ff' Liquid depth -- ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O < Manufacturer Material Liquid capacity in gallons ~ Well Foundati~,c Nearest Io~n~ / ~ PERMIT NO'~/ ~ O 6G ,o. o, ,,nw. ,*n,,h o, e. ,i~, ~ot~, ,~o;,i..__~_. ~r~n~h ~i~ '~ ~ Top of tile to finish graOo ¢/ ~ Material beneath tile~,/Z~*incheSlnches T°taieffectiveabs°rpti°narea Length Width D0pth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest ~ot llne ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER INSTALLER REMARKS DATE LEGAL 72-0f3 (Rev. 3/78) six INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF DRILLED AT THE RATE OF ~20o 00 PER FOOT. PROPERTY OWNER /~. ~-o/u~ ?a4F~. 2.43-3137 LOCATION OF WELL SITE DRILLER WELL LOG: O- .... 26 ' 26 .... 83 ' 156--195' Sg.O.q. g.~.a.~e~. $o~e. we~ ma.~w~z.6. 10/o c.~.. /l~ 195 ~fie. e~t ~ood c~.e.a.~ Da/teat. lre.aat/~ 3/4 Ito:o.~e. Co.o,t o~ ~: ~20. O0 X 195 Co4Z o,fi We.U. Se~t: ~20o O0 ~3900.00 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF ~'~.Q~:0.00 DATE. THANK YOU VERY MUCH. BERNIE CLAUS OF RAMPART DRILLING WORKS A/~o~ 78~, 7957 T~. ~ SERVICE CHARGE O F I~% PER MONTH WILL BE ASSESSED ON PAEtT DUE ACCOUNT$. ~PF'L I C:RNT LOCBT I ON LE.~RL " , ~4-4.7~0 PERMIT NO. ( JOHN J. PBYNE 4~,1~ =FENBRD RD HILLSIDE L6 ~ NILDNOOD GLEN LOT ...... 4~.000 _,L-.!UMRE FEET TYPE OF =,uIL RE,=,uRFTI_N S'¢$TEM IS: 'fREN...H MRNIMIJM NI_IflE, ER OF EEDEUOfl=, = 4 cF~IL F. RTI~Iu (~Q F1,-'E,~ .... THE REQLIIRED SIZE OF THE :,IJIL RB=,uRFTI_N _,Y_,TEtl I... [:, E F' T FI1 =._. '=' L E l'-,t ,.3 -1- H =~, '- ---' ...::--- ~_3RFI%,'EL [-" E F' T H == 4- THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETNEEN 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 GRRYEL BETNEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE EXCRVRTION (IN FEET). PERMIT RPFLI_,HNT HFI.o THE RE_-,F.Nc. IE, ILITY TO INFORM THIS DEPRRTMEHT DURING THE INSTRLLRTION INSFEL. TIuN:, OF RNY NELLS RDJRCENT TO THIS ~"n~''- ..... r~.~r~.m.Y FIND THE NUMBER OF RE_,IDENL. E_, THRT THE NELL NILL :,ER,,E. BRCKFILLING OF RN~ SgSTEM NITHOUT FINHL INSPECTION RND RPPROVRL. BY THIS ~DEPRRTMENT NILL BE SUBJECT TO PROSECUTION. MINIMUM DISTBNCE BETWEEN R NELL RND 8N9 ON-SITE SENRGE DISPOSRL SYSTEM IS ±00 FEET FOR R PRIVBTE NELL. OR ~50 TO 200 FEET FROM R PUBLIC NELL DEPENDING UPON THE TYPE OF PUBLIC NELL. MINIMUM DISTRNCE FROM 8 PRIVRTE WELL. TO R PRIVRTE SENER LINE IS 25 FEET RND TO R COMMUNITY SENER LINE IS 75 FEET. NELL LOGS RRE REQUIRED BND MUST BE RETURNED TO THE DEPRRTMEN'T WITHIN ~0 DR~S OF THE NELL COMPLETION. OTHER REQUIREMENTS MR9 RPPL9. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE ~'.BVRILRBLE TO INSURE PROPER INSTRLL. RTION. I CERTIFY THRT 1: I RM FRMILIRR NITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY THE MUNICIPRLIT¥ OF RNCHORRGE. 2: I NILL INSTRLL THE SYSTEM IN RCCORDRNCE NITH THE CODES. ~: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MR¥ REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN 4 BEDROOMS. ' RP~.ICRNT JOHN J. ~ PR'¢NE ' ISSUED B"r' .............. ~ ........ DFITE_-' ...... "/4. 0 PERFORMED FOR: JOH /~ LEGAL DESCRIPTION: ~ ~'~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTIOI~ 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG [] PERCOLATION TEST OATE.ER.ORMED~ /V~AF~ 2 3 9- 10- 11- 12- 13- 14- 15- 16- 17- 18- 19- 20- l- 'Z.. 5fl-,'uD~) 51 UT ~' -/5- 5 I L"T~ SITE PLAN SLOPE ~A~G.OONDWATER No ~ ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date ' Time Time Water Drop NO. 1732-E June 22, 1968 PERCOLATION RATE Iminutes/inch) COMMENTS TEST RUN BETWEEN FT AND FT 72-008 (6/79) 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.bs (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL · FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-092-73 1. GENERAL INFORMATION Complete legal description WILDWOOD GLEN SUBDIVISION; LOT 6 Location (site address or directions) 9740 CONIFER STREET "' ANCHORAGE, AK Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address RONALD & NORMA HALLMARK c/o EVENS DUCLAIR w,/ U.S. INSPECT Day phone Day phone EVENS DUCI.NR w/ U.S. INSPECT Day phone(soo) 872-3660 ext. 529 3650 CONCORDE PARKWAY SUITE 100 * CHANTlU.Y. VA 20151 Un/ess otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-site Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates ef 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 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 er B we/Is or a public water system. The Municipality of Anchorage is not responsible for errors or emissions in the professional engineer's work. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1,310.00 at. or pdor to closing for the engineering services provided. ' 4. STATEMENT OF INSPECTION ElY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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 vedfy 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. NameofFirm ALASKA WATER &: WASTEWATER CONSULTANTS, INC. Phone 3,37-6179 Address 6901DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date Engineer's Comments: In conducting this evaluation, A I/VWC, Inc. affempted 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 encreachments. AWWC, Inc. can therefore not previde 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 other person or party is not authorized, nor will it confer any legal tfght whatsoever. DSD SIGNATURE ,, ~1~/~''~ ~ Approved for ~'~'~/Ofb!drooms. Disapproved. Conditional approval for bedrooms, with the fllowing stipulations: ,,-"DS · WATERA D Attachments: HAA Checklist Septic System Advisory Well Flow Advisory = : WASTEWA1LH ~ : _.. PROGRAM . .. · .... , Manitenance Agreements Supplemental Engineer's Reort Other Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4?00 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 wv~v.ci.anchorago.ak.us (907) 343-7904 Legal Description: A. WELL DATA HEALTH ~,UTHORITY APPROVAL CHECKLIST WILDWOOD GLENN S/D; LOT 6 Parcel ID: Welltype ~v^~[ ffA, B, orCprovldePWSID~ N/A Data completed 4/18/1981 Sanitary seal (Y/N) YES Totaldepth 195 It. Date of test Static water level Well production WATER SAMPLE RESULTS: Cased to 195 It. FROM WELL LOG AT INSPECTION 4/18/1981 5/20/2002 115 .It. 154 10 g.p.m. 7.8 Calllont~ 0 colonies/100 mi. Amenic: .002 mgJL. SEPTIC/HOLDING TANK DATA 015-092-75 Well Log (Y/N) Wlm$ properly protected (Y/N) Casing height (above ground) Nitrate 5.67 mg./L. Other bacteria __ Data of sample: 5/22/2002 Collected by: .It. g.p.m. 0 .colonies/100 mi. AKWWC~ INC. Date installed Soil rating (~r fl~:lrm) 125 Length Width 5 It. Total depth ,~ It. Eft. absorption area 650 It= Monitoring tube YES Date of adequacy test 5/20/2002 Results (Pass/Fall) PASS Fluid depth in absorption field before test 0 in. Water added 628 gal. Elapsed Time: 0 min. Final fluid depth 0 in. A~sorptlon rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN ABSORPTION FIELD DATA 4/2e/tg.~ 65 fl. System type DEEP TRENCH Gravel below pipe 5 It. Depression over field NO For 4 bedrooms 0 'in. g.p.d. Tank Type/Material STEEL Tanksize 1500 gal. Number of Compertments 2 Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO Date of pumping 5/21/2002 Pumper New depth 600+ If yes. give date 12+ in. Datainstafled 4/28/1981 Cleanouta(Y/N) YES H~hwatarelarm(Y/N) N/A A+ SERVICES D. LIFT STATION Date installed Size in gallons ~ 'Pump ~ High wa rte alarm love' at --- .in. ~ Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot100'+ Absorption field on lot, 100'+ Public sewer main N//A Sewer/septic eewice line 25'+ On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cieanout Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation. 5'+ Property line Water main N/A Water service line 10°+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Water service line 10'+ Curtain drain NONE KNOWN F. COMMENTS Building foundation 10'+ Surface water 100'+ Wells on adjacent lots, 100'+ Absorption field Surtace water 5'+ G. ENGINEER'S CERTIFICATION 100'+ Water main N/A Driveway, parking/vehicle storage 10'+ I certify that I have determined through field inspec~ons and review of Municipal records that the above systems am in conformance with MOA HAA guidelines in effect on this date, Engineer's Prin~qd Na~e Data ~ Z,- JE~-rKL'Y A, GARNESS Date of Payment Receipt Number ~ (Rev. 12A711 Waiver Fee $ Date of Payment Receipt Number 05/1__.___~7/02 FRI 09:49 FAX ! 907 762 3189 Jack ;~hlTe £sTa~e ~002 -- NO. 304iIP. ,~t~__ CT&E Environmental Services Inc. CT&E Ref.# Client Name Project Name~ Client Sample ID l%latrlx Ordered By PWSID Sample gcm,~ks: 1022882001 AK Water & Wastewnter Consultants Inc. Wildwood Glenn Lot 6 9740 Con~er St Drinking Water All Dates/Times are Alaskn standard Time Printed Date~flme 05/24/2002 15:18 Collected Date/Time 05/22/2002 10:00 Received Dart/Time 05/22/2002 10:30 Technical Director Released By t~~ Allowable Prep A~alys[s Parnmc~cr Results PQL Un~ Method Limits Date Date Init Met:als Del~&r~nent: Arsenic 0.00200 U 0.00200 mg/L EPA 200.9 (<:0.05) 05/24/02 Namers Department * Nitmte-N $.67 0.200 mg/L EPA 300.0 (<10) 05/22/02 Microbiology Laboratory, Total Coliform 0 col/100mL SMI8 9222D (<1) 05/22/02 JMP SDT KAP CT&E Environmental Services Inc; .' Laboratory Division ~~,~,~,~-~,~,~,~s,~-j~w'~,~,~'~'~ 200 W. Potter Drive Drinking Water Analysis Report for Total Coliform Bacteria ^.c~ore.e. AK sgs~..~ go5 Tel: (9071 562-2343 P~E, dD ,rNsTRf../CT/ON$ OIV REI/£RSE SIDE BE, FORE ¢O1.J.2CTING S/IMPI, E Fax: (907) 561-5301 -- MUST BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY PUmCWATE. svs'rm m # 111111 "1 PRIVATE WATER SYSTEM Send Re~utt~ . I'1 Send tnvolce : ~endResut, ,~ Szndlnv*ict SXMPLE DATE: Month SAMPLE TY~E: ~{, Routine 13 Repeat Sample (for routine sample with lab ret. no. ) n Special Purpose Year Treated Water Untreated Water Time Collected Collected By ' Analysis shows this Water SAMPLE to bce ~,2 ~atisfactoD' . · . '. '. 12 Unsatisfactory . : . . O' Sample over 30 hours old, results may be unreliable ' ' O Sample too long in transit; sample should not be over~l)hours old at examination ......... to indicate r~liablc r~ult~.. Plea~c.scnd ...... new sample ','ia special delivery mail. · Date Received Time Received [0~ C,~ . A~alysls Began Analytical Method: ,",l~Mcmbran6 Filter '0 -MMO-MUG * Number of colonies/100 mi.. Lab Re/No. Result* . Analyst Sent to A.D.E.C. Anch Fbks Jun [] Fazed Client notified of ~ a!-}'-'-~-"~ regultS(' {3 ~'honed Spoke with BACTERIOLOGICAL WATER ANALYSIS RECORD MMO-MUG R.ult: Total Coliform Membrane Filter;. Direct Count Verification: LTB BGB Fecal Coliform Confirmation Final Membrane Filter Results Reported By ~~_ Date F-.. Cotl Colonles/I O0 mi COLIFIRM Collformll00 mi ~qS Member et tho $G$ Grou0 (Socl,t~ G6nir,'. do 5urvoillanc~l MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Divisibn 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 Parcel I.D. # 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Day phone Lending agency Mailing address Agent Address Day phone Day phone. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site , Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-(}25 {Rev, ~/91) Front MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: .Z-,~-~ · ~'.,'~',~.-~,'~-~'~'~,~ zCz-~.~,v' Parcel I.D. A, Well Data Waif type ~'~ Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 Cased to If A, B, or C, attach ADEC letter. ADEC water system number Date completed .~/~,~./z~ -',~4~//~']/ Driller /~-' ' Casing height FROM WELL LOG SEPARATION DISTANCES FROM WELL TO: Wires properly protected (Y/N) AT INSPECTION g.p.m, r~ rn ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout oleum tank Petr Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed ,/~- - ,' :~,, Tank size Other bacteria Cc'/aCted by: ~..~//)~:((~':' Compartments Cleanouts (Y/N) ,Y' Foundation cleanout (Y/N) High water alarm (Y/N) Date of pumping ' ~' 'J SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: To property line /&' '~'' ~"' .., Absorption field .~" / Sudace water/drainage Depression (Y/N) Alarm tested (Y/N) Pumper - -:>-~-&D~ Foundation Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE COMMERCIAL TESTING & ENGINEERING CO. AK DIV CHEMICAL & GEOLOGICAL LABORATORY 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 Mo. Day SAMPLE TYPE: ~Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water ~. Untreated Water SAMPLE No. LOCATION / /) i//,.) 31 "1 TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: E] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable resuJts. Please send new sample via special delivery mail. Time Received /.~, c~) Analytical Method: Membrane FlEer * No. of colonies/100 mi. Time Collected Co"~'ed~7 .Al ^7:-',5"°"'°' , /¢ I /& II Lab Ref. No. Result* A .D.E.C. ~ READINSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direct Count Verification: LSB Fecal coliform confirmation Final Membrane Filter Results Reported By TNTC = Too'Numerous To Count OB = Other Bacteria BACTERIOLOGICAL. WATER ANALYSIS RECORD BGB Coliform]100 mi ~d.. /& ' Date r JUN 0 8 'c)9~' Tim~: [~(~ a.m. ' PART ONE OF TWO: ~SG-I~ r~em~er o~tr,~ s~ REMAINDER TO FOLLOW CT&ERef.# Client Sample ID Matrix Commercial Testing & Engineering Co. Environmental Laboratory Services ~~/~_/~.~%zT.~z~/7.~'~/~ LABORATORY ANALYSIS REPORT 94.2781-3 L6 WII,DWO OD GLENN WATER ClientName KENLEY,P.E., DOUGLAS WORK Order 79200 OrderedBy DOUG KENLEY Printed Date 06/10/94 ~08:37 hrs. Project Name Collected Date 06/07/94 ~12:41 hrs. Project# ReceivedDate 06/07/94 ~16:45 lu's. PWSID UA Technical Director STEPHEN C. EDE Sample Remarks: ROUTINE SAMPLE COLLECTED BY: STUART. QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 4.5 mg/L EPA 353.2/300.0 10 06/08/94 CMR * See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed ,, U = Undetected, Rep erred value is the practical quantification limit. LT= Less Than ~' D = Secondary dilution. GW = C~eater Than 5633 B Street, Anchorage. AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO. UTAH, WEST VIRGI~llA 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 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Locatiqn (add~'ess or directions) , (c) Applicant is'(~ec~ ~ne~; ~end'i'ng Institution B; Owner/builder ~; Buyer B; Other O (explain); (d) Lending lns{i~0tioG · , Ill Telephone ~ Real Estate Compa y g ~ ~ ,e, A, ,e s ' n (f) Mail the HAA to the following address: TYPE oF RESIDENCE Single-Family)~' Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Well J~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL onsiteJ~¢.. Public r"l Community [] Holding Tank I-I Note: If community wail system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) ENGINEERING FIRM PROVID~G INSPECTIONS, TESTS, FILE SEARCH, D~TA AND INFORMATION As cedified 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 flies 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 /~C _~ /'/~C / Telephone Date DHEP APPROVAL Approved for ~"~'~bedrooms by Approved ~ Disapproved Conditional. Date /Z-Z-~-~' Terms of Conditional Approval 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 es 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 err(~rs or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) .MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTEGTION APPLICATION FOR HtltLTH AUTHORITY APPROVAL CERTIFICATE I. General Information Application Date (a) Legal Description (include lot, block, subdivision, section, ~wnship, range) Location (address or directions) Applicants Address (c) Applicant is (check one) Lending Institution ~ ; Owner/builder Buyer ~; Other ~ (explain)~ _~>ccivt ~/' _ (d) L,~ding Institution ~~~~ ,- Tel, hone Address ~J~ ~t ~- (e) Real Estate Co. & Agent Address Telephone Mail the HAA to the following address: ~ype of Residence Single-Family~ Number of Bedrooms Multi-Family~ Other (describe) Wager Supply Individual Well ~ Community ~ Public ~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status° [Page 1 of 2] Sewage Disposal Onsite~ Public~-~ Commuaity~ Holding Tank~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. En~ineerin~ Firm Provldtn8 Inspectfons~ Tests~ File 8earch~ Data and Information As certified by my seal affixed hereto and as of the validation date shown below, verify that my investigation of this Health Authority Approval shows that the o~slta 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 i~formati0n obtained from the ~icipality of ~choraEa files and from my investigation ~d inspection, the o~site ~ter supply and/or ~stewater disposal system Is in compliance ~th ~1 ~ntcipal ~ State codes, ordinances~ a~ tious in effec~ om the date of ~his inspection. ~ ~ ~ ~,,C~F Telephone ~ . U. .., ~ENGINEER DEEP Approval Approvad for Approved bedrooms ~ ..-~.~.,:(i. Disapproved Conditional CAUTION . THE I~JNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIIiO~R~ENTAL PROTECTION (DHE]~) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAG°~PH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA° THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES THEIR LENDING INSTITUTIONS IN ORDER TO -SATISFY CERTAIN FEDERAL AND STATE REQUIRE~ MENTSo EMPLOYEES OF DHEP DO NOT C055~UCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT ~ESPONSIBLE FOR EP/IORS OR OMISSION~ IN THE PROFESSIONAL ENGINEER'S WORK° (DHEP SEAL) RR4/ej/D18 :Page 2 of 2] 7-19-84 ~.j ~j MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) PRow APR J 7 1985 Legal Description: ~/ Well Classification ~'u~/C If A, B, ~ C, D.E.C. Approved(Y~) Well ~ ~esent ~) Date ~leted ~-/~- ~ / Yield Total ~p~ /~ / . Card to /~ ~ ~pth of Grouting Static Water ~1 ~5 ~ ~t At Casing ~ight ~ Ground ~ ~ Sanit~y ~al on Casing ~) Electrical Wiring in Conduit ~) ~ession ~ound ~l~ead (Y~. Sep~ation Distance f~ ~11: ~ To ~ptic/Holding Ta~ on ~t /O~ ~? ~ ; ~ Adjoining Lots /~ To ~arest Edge of ~sorption Field on Lot /0¢ ~ Adjoining ~ts /~ To Newest Public ~ Line ~ To Newest Public Clean~t/Ma~ole ?~/~ To ~est ~r ~rvice ni~ on Lot ~O Wate~ S~le ~llected By ~'~ ~ ; ~te Water S~le Test ~sults SEPTIC/HOLDING TANK DATA Date Installed ~-~-~ [ (Paise. /~OO ~) No. of Ccmpa~tr~nts ~ ~ Standpipe ~) Air-tight Caps ~) Foundation Clea~out ~) ~pression over Ta~ (Y~ Date ~st P~d ~-/~ P~ing~i~tenan~ Con~act on File (Y~) ~/~ ; fo~ ~/~ Holding Ta~ High-Water Ala~ (Y~) ~/~ . Te~ra~y Holdi~ Tank Petit (Y~)/F~ Sep~ation Distance ~ ~ptic~olding Tank: To Water-Supply ~11 [~0' ~ ~To ~ilding Foundation & ~ ~ To ~o~rty Li~ [.~ /~ TO Dis~sal Field ~- i ~ To ~ter Main/Se~vi~ Line ,Q~-~ To S~e~, Pond, ~e, ~ Major ~aina~ Cour~ ~/~ [Page 1 of 2] Receipt Date Paid: Amount: 2-15-84 C. ABSORPTION FIELD DATA Soils P~ting in Absorption Strata Date Installed ~-,~-~ ~/ Width of Field ~ Square Feet of Absorption A~ea~6-oo Length of Field Depth of Field Gravel Bed Thickness >0 Standpipes Depression over Field (Y~ Date?f Last Adequacy Test Results of Last Adequacy Test ,~/D Separation Distant9 from Absorption Field: To Water-Supply Well /61)~ '~ To P~operty Line ,30 -~ To Building Foundation ~o/ (~ To Existing or Abandoned System Lot ~ ; On Adjoining Lots -50 /-/ To Water Main/Service Line ~Z~- TO Cutbank(if present) ~ To Stream/Pond/Lake/or Major Drainage Course To D~iveway, Parking Auea, or Vehicle Storage A~ea /(~/¢ Meets MOA D. LIFT STATION Date Installed Size in Gallons "Pump O~" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Con~ents ** Check Permitted Bedroom Rating Against ~Z Request ** I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. Signed ~ ~, ~-(L Date Company /~ ~l~_ (~,p/ ~u/~$ MOA No. [Pa~ 2 of 2] 2-15-84 ALASKA e nOIROnmellTAL CONTROL ~n§ineerin§ $ ~nuironmenlal atutliea SeR i'CeS, Inc. RUTH PAYNE 4616 SPENARD ROAD ANCHORAGE ALASKA SELLER-SAME APRIL 17 1985 WILL PICK UP FROM OUR OFFICE 50139 LEGAL:WILDWOOD GLEN SUBD/BLOCK i/LOT 6 ADEQUACY TEST FOR SEWER SYSTEM ADEQUACY TEST DATE-APRIL 15 1985 THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 630 SQFT. THE SYSTEM IS CAPABLE OF ACCEPTING 600 GALLONS OF WATER PER DAY. THE SURGE CAPACITY OF THE SYSTEM IS 900 GALLONS. BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A 4 BEDROOM HOME. SEPTIC TANK ADEQUACY THE EXISTING SEPTIC TANK VOLUME OF 1500 IS ADEQUATE FOR THIS 4 BEDROOM HOUSE. THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON APRIL 16 1985 . FLOW TEST ON WELL WELL FLOW DATE-APRIL 15 1985 A FLOW TEST WAS PERFORMED ON THE WELL. 900 GALLONS OF WATER WAS PUMPED AT A RATE OF 6.1 GPM OVER A DURATION OF 2.5 HOURS. THE DRAWDOWN WAS 2.8 ' WITH A RECOVERY TIME OF 10 MINUTES AND THE STATIC WATER LEVEL WAS 125 FEET. THE WELL IS ADEQUATE FOR THIS 4 BEDROOM HOME. MuNICIpALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAl- pROTECTION 1200 UJcsl 33r(I Aacnu¢, Suil¢ ~.Anchoracl¢, Alaska 99503.(907) 561-5040 CHEMICAL & ~L/OLoGICAL LABORATORIE~OF ALASKA, I~ Drinking Water Analysis Report for Total L;OliTorm oau~. ?.. .~ %~, TO BE COMPLIED' BY WATER SUPPLIER TO BE COMPLIED~:-~ORY WATER SYSTEM: City State Zip Code · Day ~-' Ye~ SAMPLE TYPE: 'E~Routlne :'[] Check Sample (for routine sample With lab ref. no. [] Special Purpose I I I I I I I (*) See h on back Analysis shows this Water SAMPLE to be: [] Unsatisfactory [] .Treated Water ~Untreated Water SAMPLE Time NO. LOCATION, . ~ Collected 2 I ~~' 4I I ~I I [] 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. Date Received Time Received Analytical Method: [] Fermentation Tube ~Membrane Filter Lab Ref. No. Result* Analyst I r-I-] I ~-~ I 06-12~0 (~) BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter. Direct Count Collformll00ml Verification: LTB __BGB Final Membrane Filter Re Its ~) Time: TNTC = Too Numerous To Count CoIIformll00ml APPLI ~NT FILLS OUT UPPER H/[~_~ ONLY Buyer Address Zip Code Lending Institution ~,,~/ ~ ~' ' ' ~I~/,,/~X~; ~: 5~'~zX'~ Phone Address Zip Code Realty Co. & A~nt Phone Address Zip Code Type of Resi~nce Water Supply ~ Individual A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. ~ Community For wells drilled prior to lhat date, give well deplh (atl~ch Jog if availabJe). ~ Individual Year Individual Insl~lled:. ~ Public ~tilily When Connecled Io Public Utility: ~ Holding Tank Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: MUNICIPALITY OF ANCHORAGF [~r~'~ ~ DEPT, OF HEALTH ~ ~',~ ENVIRONMENTAL pROTECTION ,, RECEIVED ~APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ( ) DISAPPROVED Soils Rating Date ~wer Installed~ Well To Absorption Area /~ I Well Log Received l ~ / ¢~ / WelltoTank /~ Septic T~k Size ,I ,Time., ,..~ .~rime Date Date Date Inspector Inspector Inspector Comments Conditional Approval Date Sewer InstMled --~T~.~.,~J.~.~ Permit No, Septic Tank Size ..,~ Holding Tank Size /6 Soils Rating Well To Absorption Area Well Log Received Well to Tank AP, PLICANT FILLS OUT LOWER HALF ONLY Property Owner ~o [~.,, .~/ /~,,~,,/' ~,x,-~ Phone Buyer Address ~'~? d E~'~ ! ~-hz~ Phone Lending Institution Address Realty Co. & Agen~ ~ Phone Address Stree, Looat,on Type ~;~f Residence [3 Single Family [] Multiple Family No. of Bedrooms [] Other Water~upply 42] Individual ATTACH WELL LOG. A well log is required for all wells drilled since June [3 Community ~¢1 1975. For wells drilled prior to that date, give well depth (attach log if [] Public Utility . available.) Sewage Disposal .... I~ Individual ' '? Year Individual Installed: [] Public Util!ty When Connected to Public Utility: © Holdin~ ~4nk NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. CHEMICAL & GEO~JGICAL LABORATORIES O~,,~!LASKA, INC. TO BE COMPLETED BY WATER SUPPLIER- ",, "-., ~.o..o. Water System Name /~ ' Phone No. Mailing Address .-.' -' CiW State Zia C~e MO. Day Year SAMPLE ~PE: D Routine D Check Sample (for routine sample with lab ref. no. · ) ~ Treated Water ~ Special Purpose ~ Untreated Water SAMPLE Time Collected NO. LOCATION~--. Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~ Satisfactory [] Onsatisfactory [] Samole too long in transit, samole should not be over 48 hours oK1 al examlna[ion re indicate reliable results Please sene new sample. Date Received /,~ Time Received ,/ .... g Analytical Method: [] Fermentation Tube ~/Membrane F ter Lab Ref. No. / Result* Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 {b) Rev. lg78 BACTERIOLOGICAL WATER ANAL~YSIS RECORD 24 Hours AL~gust 23, 1983 John Jo Ruthye Payne 4616 Spenard Road Anchorage, AK 99503 Subject: Lot 6, Block 1, Wildwood Glen Subdivision Approval for the individual sewer and water facilities cannot be granted until the following items have been completed: o A well log submitted to this office for our files and review. o The septic tank pumped with a receipt submitted to this department° Please notify this Department for a reinspection when the noted discrepancies have been corrected, i~ there are any further questions, please call this o~fice at 264-4720° Sincerely, JR5/ej/E2 Jim Roberts ~ ' ~- · t Specialist Assistant Envl~onmen.al . CHEMICAL & Gi.~ TELEPHONE I907) 562-2343 LOGICAL LABORATORIES~-~F ALASKA, INC. ANCHORAGE NDUSTRIAL CENTER /c~ 5633 B Street~L~ Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: Water~t~m Name Mailing Address liD. NO. Phone NO, State Zip Code City MO. Day Year SAMPLE TYPE: [3/Routine E3 Check Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE Time Collected NO. LOCATION Collected By I TO BE COMPLETED BY LABORATORY Analys~s snows tins Water SAMPLE to be: ~atisfactory [] Unsatisfactory - [] Sample tooqon~iW't?~nsit?s~'~ple'should not De over 48 hours old a[ examination ~o ndicate reliao~e resul[s. Please send new samole. [:)ate Received Time Received /L:'~/~/' Analytical Method: [] Fermentation Tube ..Membrane Filter Lab Ref. No. Result* Analyst I I BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Date ColleCted Source. Presumptive /0mi 10mi 10mi 10mi lOml 1.0mi 0.1mi 24 Hours " 48 Hours