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Home My WebLink AboutMCCARREY LT 6McCarrey Lot 6 #017-092-86 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: -~t.O '~O PIDNumber: d~ Name: ',~¢.,~[¢'~ ~~e~,~' Wastewater System: ~New ~ Upgrade ~: ~1~ ~ /~ ~ ~~ ABSORPTION FIELD Phone:No~ of Bedrooms: , ~ ~--~3~ .~ UeepTrench ~ Shallow Trench ~Bed ~Mound ~Other LEGAL DESCRIPTION sci, Ratingi Total Depth from original grade: t~ ~ GPD/Sq. Ft. ~ ~ Lot: Block: Subdivision: Depth to pipe botto~from original grade: Gravel depth beneath pipe Township: I Range: Section: Fill added above original grade: Gravel le.~ ~ ~ Ft. Ft. WELL: ~New ~ Upgrade Gravel width: Number of lines: Distance between lines: ~ ' Ft, [ ~ Ft. Classificat~n~(Private, A,B,C): Total Depth: ~ Cased To: Total absorption area: Pipe material: ~t %~d: , Static Water Level: Installer: Date installed: Pump Set at: Casing Height Above Ground: Yield: ~¢ GPM ~ Ft. ~ Ft. TANK SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding ~ublic/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~ ~ ~ ~ / Well ~*0 ~ ~ ~ ~'~ Material~ ~ ~ ( Number of Compartments: ~ Surface /~¢¢ /¢0~ ~ ~ ~ Water U FT STATIO NHigh water alarm at: LineL°t ~ /~ Size in gallons: Manufacturer: Foundation /~ ~ ~ "Pump on" level at: "Pump off" level at: Cu rte in Electrical Drain ~ ~/~ Pump Make & Model Inspections performed by: Remarks: BENCH MARK Location and Description: I Assumed Elevation: ENGINEER'S SEAL Inspections performed by: Department of Healthan~ Human~vices approval ~?,.~,y~:~23~Z.L~4~ Reviewed and approved b~~~'-" ~ate: 72-013 (Rev. 9/91) MOA 25 ~0t ,,' ,w \ / / DEPARTMENT OF NATURAL RESOURCI~ DIVISION OF WATER WATER WELt ~1 W~ ~AKE OPmWO TYPE: ~ n ~d ~ ,~K'f~ ".' Oap~ of ope~ng,: , ~ t~ ft ' . ~P ~TAKE D~TH= ....... It H~sepowec .' , :.? PLEASE'MAIL WHITE COPY'OF LO : . ' DNPJOIVI$1ON OF WATER PO BOX772116 :" EAGLE RiVI~R AK 99577-2116 COMMERCIAL TESTING & ENGINEERING CO. s .v'c s Chemlab Ref.~ :93.6738-! Client Sample ID :JOHN C. Matrix :WATER REPORT of ANALYSIS 5633 B STREET ANCHORAGE, AK 99518 TEL: (907) 562-2343 FAX: (907) 561-5301 Client Name :MICHAEL ANDERSON WORK Order :74214 Ordered By :MIKE ANDERSON Report Completed :12/20/93 Project Name : Collected :12/16/93 @ 08:30 hrs. Project~ : Received =12/16/93 @ 14:00 hrs. PWSID :UA Technical Director:STEPHE~ C. EDE . Released By : .~/~ Sample Remarks: SAMPLE COLLECTED BY: UA. QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 1.! mg/L EPA 353.2/300.0 10 12/17 CMR * See Special Instructions Above ** See Sample Remarks Above U = Undetected, Reported value is the practical quantification limit. D = Secondary dilution. ~SGS Member of the SGS Group (Soci(~t~ G(~n~rale de Surveillance) UA = Unavailable NA = Not Analyzed LT = Less Than GT = Greater Than ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA COMMERCIAL TESTING & ENGINEERING CO. ENVIRONMENTAL LABORATORY SERVICES Drinking Water Analysis Report for Total Coliform Bacteria READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING SAMPLE 5633 El STREET ANCHORAGE. AK 99518 TEL: (907) 562-2343 FAX: (907) 561-5301 MUST BE COMI>LETED BY WATER SUPPL/~ER ! [] Send Resul~ [] Send lnvoice SAM:PLE DATE: ~ Month SAMPLE TYPE: [] Routine [] Repeat Sample (for routine sample with lab ref. no. ) ' [] SpecialPurpose SAMPLE LOCATION Year [] Treated Water [] Untreated Water Time Collected Collected By Plcaze Prim TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: 1/,~ Satisfactory [] Unsatisfactory [] Sample over 30 hours old, results may be unreliable [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample ,Aa special delitvery mail. Date Received t ~ /~/I ~, Time Received J t~'O0 AnalysisBegan lZ~(~'t"~ ? [~(D¢~) Analytical Method: "~Membrane Filter ~rn MMO-MUG * Number of colonies/100 mi. Lab Ref. No. Result* Analyst Sent to A.D.E.C. _~am ch ..) Fbks Jun Date: Iq'2D] 0/~-"~ Time: Client notified of unsatisfactory results: Phoned Spoke with [] Faxed Faxed Date: Time: BACTERIOLOGICAL WATER ANALYSIS RECORD MMO-MUG Result: Total Coliform E. Colt Membrane Filter: Direct Count ~ Verification: LTB BGB COLIZ~IRM Fecal Coliform Confirmation Final Membrane Filter Results ReportedB.~/~-~' Y~ Date /2'['~--~"~ Time Colonies/100 ml Coliform/100 ml Corpmnents: ~,,~,~ S~ S Member of the ENVIRONMENTAL SERVICES iN ALASKA, C(~LORADO, UTAH, ILLI PART ONE OF TWO: REMAINDER TO FOLLOW _,,ROLINA December 23,1993 Department of Health and Human Services Anchorage, Alaska Re: Onsite Sewer system design for John Cornelison McCarrey Subdivision Lot 6 Dear DHHS, The original system design called for two trenches 35 feet long, with the top of the pipe being set by the garage slab elevation (basement), however the owner set the residence up higher than expected. This allowed for a deeper trench (8 feet) to be used instead of the 5 foot design. All the soils were well draining SM, GM and SW types with percolation rates 4 min/inch or better, with the silt content being minimal. The GM layer (between 7 and 9 feet) was faster due to the gravel (2 min/inch). This layer got thicker the farther we got away from the test hole, see plan for test hole location. The original design was a 6 bedroom system, however the owner down sized the house to 5 bedrooms. Therefore the tank was sized for the 5 bedroom design (1500 gal) but the field was left at the larger 6 bedroom size due to the fact that the gravel was already purchased and on site. This was all communicated to the DHHS at the time of construction. If you have any questions please call. Sincerely Steven R. Pannone P.E. PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: /V~ r(~'~rt,~,~ ~(4 ~ LO '1L (_.m Township, Range, Section: SLOPE 1 2 3 4 5 6 7 8 9 SITE PLAN 10- 11 12 13 14 15 16 17 18 19 20 WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT ~ DEPTH? p E Depth to Wate~ Alter ~/T Monitoring? N(;, ~-,) Date: V/~i'~ Gross Net Depth to Net Reedin§ D.tO Time (l~t,,~ Time (Nt,.'~ WOtO, Drol~ (,'.~ ~a ID Z ,~ PERCOLATION RATE ~/ lmmutesnnch) PERC HOLE DIAMETER ~ 'g:~ // TEST RUN BETWEEN /g)~' FT AND // FT ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/8,5) PAGE 1 OF 1 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 AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930260 DESIGN ENGINEER:STEVEN R. PANNONE OWNER NAME:CORNELISON JOHN D & MARILYN P OWNER ADDRESS:6948 FAIRWEATHER DR. ANCHORAGE AK 99518 DATE ISSUED: 7/27/93 EXPIRATION DATE: 7/27/94 PARCEL ID:01709286 LEGAL DESCRIPTION: MCCARREY LT 6 LOT SIZE: 50791 (SQ. FT.) NUMBER OF BEDROOMS: 6 THIS PERMIT: 6 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / 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 343-4329 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 RECEIVED B~ ISSUED BY: ~-~- DATE' DATE: April 20, 1992 Department of Health and Human Services Anchorage, Alaska Re: Onsite Sewer system design for John Cornelison McCarrey Subdivision Lot 6 Dear DHHS, This is a request for an onsite sewer permit for a new residence located at the above address. The original soil test done for the subdivision is located where the house will be located, therefore it can not be used. Two new soil test were done showing good soils for an original and a alternate site. The well is located at the South East corner of the property as shown on the plot plan. No impacts to the surrounding properties are foreseen. All have onsite systems already and appear to be performing adequately. The required set-backs and reserve areas are easily obtained due to the large lot size and good soils. The lot footprint is rectangular with the West end pie shaped and the East side being square. The slope is gradual to the East Sincerely ~'6~ O99 9,~ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-06§0 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: ~z'~ ¢'~¢' ~r't'1 ~-~ b LO'IL ~:2 1 2 3 4 5- 6- 7 8 9 Township, Range, Section: SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 20 WAS GROUND WATER ENCOUNTERED? S L IF YES. AT WHAT O DEPTH? p E §np,ll to Water ,ftor ~/~ /~ Monitoring? ~ ~, C~ Date: d ~ Gross Net Depth to Net Reading Date Time ~.1~, ~t~ Time (~4, ~1~ Water Drop ~o lO 2 ,~ ~ io PERCOLATION RATE ff (m,nutes/,nch) PERC HOLE DIAMETER TEST RUN BETWEEN ¢/~/~' FT AND // FT PERFORMED BY: J~/lt ¢' k,,¢l 4,,-,",..o,7 , < 'J¢'/"9~- P'~I ~,t,',.~..-..' CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: (¢2 //~ f'~ /~t ~ 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEER'S SEAL) DATE PERFORMED= LEGAL DESCRIPTION= 1 2 3 4 5- 6 7 8 9 Township, Range, Section: SLOPE SITE PLAN / t~ ~" 10 11 12 13 14 15 16 17 18 19- 20- WAS GROUND WATER o. ENCOUNTERED? s L IF YES, AT WHAT O DEPTH? p E Oaplll lo Water Nter i~/A of Monitoring? /VO. ~,&O. Date: . q~' Gross Net Depth to Net Reading Date Time/_HIw'~ ~ ~ ~0 to PERCOLATION RATE I~'" (m~nutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~-~ FT AND ~ FT 3OMMENTS ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~' fRO ( G ~ 72-008 (Rev. 4/85) '' DEPARTMENT OF HEALTH & HUMAN SERVICES · , . SOILS825 "L" StreeI.LOG Anchorage.__ PERCOLATIoNAIaska 99502-0650TEST 5~FORMED FOR: ~O~ ~ DATE PERFORMED: =GAL DESCRIPTION: JO= d, ~, O~f 50,0. Towns,ID. Range. Section: DEPTH SLOPE SITE PLAN (FEET) O~ I~ Reading Date Time ~N, Time Water Drol~ [I q-/~-'~ o o j ' Zo lo ~.9 ~/ ~ ~ z.s qo rD I 20 ,/d/ ~" ToP PERCOLATION RATE (mmnutes/~ncn) PERC HOLE DIAMETER TEST RUN BETWEEN 3. ~- FT AND L?. ~' FT JMENTS 'ERFORMED BY: /~t ~',~' ~ ~ ~¢,, 5o,",J I ~V~ '~'~h~-- ~Z)~, ~- CERTIFY THAT Tl':ilB TEST WAS PERFORMED IN CCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; Municipality of Anchorage Development Services Department , Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cl.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. O17-092 -86 t. GENERAL INFORMATION Expiration Date: Complete legaldescription McCARREY SUB01V1SION; LOT 6 Location (site address or directions) 6105 EAST 144th AVENUE * ANCHORAGE, AK 99516 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address JOHN AND MARILYNCORNELISON Day phone 6105 EAST 144th AVENUE * ANCHORAGE~ AK 99516 Day phone 345-9557 BONNIE MEHNER w~/ PRUDENTIAL JACK WHITE Day phone 762-3111 3201 C STREET~ SUITE 200 * ANCHORAGE, AK 99503 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: *5 *HOUSE IS ONLY 4 BEDROOMS PER HOM~.OWNER. 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well [] Individual On-site Individual Water Storage r-[ 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 Health Authority Approval (HAA) based only upon the representations given in paragraph 5 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 pdvate or Class C well and may be reissued with new water sample results less than 30 days old. (Cedificates 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 er a public water system. The Municipality et' Anchorage is not responsible for errors or emissions in the professional engineer's work. Note:Alaska Water and Wastewater Consultants, Inc. shall be paid $1,1 l O. OO at, or prior I to closing for the engineering services prey/dod. I 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I varify that my · . investigation, based on procedures outlined in the Health Authodty 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 w/th all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER &: WASTEWATER CONSULTANTS, INC. Address 6901DEBARR ROAD, SUITE 2B * ANCHORACE. AK 99504 Engineer's Printed Name JEFFREY A. GARNESS. P.E. Phone Date 337-6179 Engineer's Comments: In conducting this e~a/uation, AWWC, Inc. attempted to prot, fde 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 watar usage of the fami~ being sen~d by the system. These conditions are outs/de the control of the evaluator of the system. SatisfactoO/ test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. AWWC,, Inc. san therefore not prey/do 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 w/lilt confer any legal right whatsoever. 5. DSD SIGNATURE Approved for 5 bedrooms. Disapproved. Conditional approval for ~: ON-SITE ~ WATER AND bedrooms, with the fllowing stipulatio~ ~ WASTEWATER ~ t PROG~M , ... Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other Odginal Certificate Date: Municipality of Anchorage Development Services Department Building Safety OMsim Or-Site Water & Wastswat~r Program 4700 ~ Omgew b~ P.O. Box 196650 Anchorage. AK 99519-6650 Legal Description: A. 'hEM. DATA Well type pmv^~ Date completed Total depth HEALTH AUTHORITY APPROVAL CHECKLIST IdcCARREY SUBDNISlON; LOT 6 Pamel ID:, 017-092-86 If A. B, or C provide PWSID~ N/A Saraary .e~ (Y/N) YES Casedto 65 f~ FROM Wi=! i LOG 7/4/199`3 7/4/9,3 207 ft. 2.5 Date oftast Static water level Well production g.p,m. WATER ~AM/~LE RESULTS: Coliform ~ colonios/100 mi. well Log (Y/N) Wires properly protected (Y/N) Casing height (above gmuncl) AT INSPECTION 2/2`3/2001 24 .ft. 2.0+/- g.p.m. Ol~er bactarta._~, Date of ~ample: 2/23/2001 Collected by:. AWWC, INC. D. SEPTICJHOLDING TANK DATA Tank Type/Matadal STEEL Tank$1ze 1500 gal, NumberofComperlmente 2 Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO Date of pumping 2/23/2001 Pumper C. ABSORPTION FIELD DATA Date instafled ~o/~6/g~ Length 6O tr. Totaldepth ~s.e ft. Eff, ebsoq~tloneroa 960 ft' Monltodngtube YES Dete of edequacy test 2/2~/200~ Resu~ (P~/Fall) Flulddepthineb~fT)tiontlalclbefomtest 1' in. Wetaredded125-~gal. Any ro]uvenation Imatment (past 12 mo.) (Y/N a type) NONE KNO~ YES YES 18+ .In. __ coionles/lO0 mi. Date Instelled 10/16/199`3 Cleanoute (Y/N) YES High water alarm (Y/N) N/A NORTHLAND PUMPING Depression over tleld NO For 5 bedrooms New depth'~-11 In. *750+ g.p.d. ffyes, ghm date - D. UFT 81'ATIOH Date lostalled. Size In gallons 'Pump on' level et in. 'Pump n, High water alarm level et __ In. Da,~:.a.a.a.a.a.a.a~ Cycles tested Meets eb~nn & circuit requirements? E. SEPARATION DISTANCE~ SEPARATION OI~'I'ANCES FROM WELL ON LOT TO: Septic tank/lilt station on lot lOO'+ Ab~on field on lot 1 oo'+ Public sewer main sewer/sep~¢ sewloe llne 25'+ On adjacent lots I00'+ On adjacent lots 100'~- Public sewer manhole/cteanout Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Properly line Water main 1 o'+ Water sewloe fine. 10'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: At=orptton field, 5'+ Su~tece water. 100'+ Property line 10'+ Water sendce line 10'+ Curtsln drain NONE KNOWN F. COMMENT8 Bulldlng foundation lO'+ Surface water 100'+ Wells on adjacent lots: 100;+ Water main 10'+ Driveway, paddng/vehlcle storage 10'+ G. ENGINEER'~ CERTIFICATION I certify mat I have determined through ~Teld Inspec~N~ and review of Municipal mCOnfS that the above q~'~ems ere/n conformance with MOA HAA guidelines In effect on this date. Englnee;'e Pd:ts~d.N.??. J~.FP ~EY A. OARNESS HAAF.$ Date of Payment <:-~- Recelpt Number /c~O ~' (R.v. 12~0o) Waiver Fee $ Data of Payment. Receipt Number, 1010902001 AK Water&WastewaterConsultants Inc. McCa~ev S/D Lot 6 Drinking Water CT&E Ref.# Client PO# Client Name Prtnted Date/Time 02/27/2001 12:11 Project Name/~ Collected Date/Time 02/23/2001 13:05 Client Sample ID Received DatetTime 02/23/2001 17:00 I~latrlx Technical Director Stephen C. Ede Order. By ~~ PWSID 0 Released By Sample Remarks: Allowable ~ Analysis Parameter Results PQL Units Method Limits Date Date Init Waters Department Ni~t¢-N 0.500 U 0.500 mg/L EPA 300.0 10 max 02/23/01 SCL Microbiolo~y Laboratory Total Coliform 0 col/100mL SMI8 9222B 02/23/01 SKW CT&E Environmental Services Inc. 200 W. Potter Drive Drinking Water Analysis Report for T~tal Coliform BacteriaT.I:~'~"(~O?) se:-2ao^K **s~o-~e06 READ INSTRUCTIONS ON ltEi,~-IL'~F-- SIDE SEFORE COLLECTING &4MPLE Fox: 19071561.5301 MUST Bt= I~OMPLg I gO BY WATER SUPPLIER puB,tc WAT£~ SY~£M ~.D. # IIIIIII P~VATE WATER SYS~M ~H & WASTEWATER , CONSULTANTS, INC. Mouth Day SAMPLE TYPE: O Routine O Repe'a't Sample (for routine sample with lab ref. no. ) n Special Purpose Time SAM PLE LOCATION Collected Treated Water Untreated Water Collected By C~,~, TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~ Safisf~tory O Un~a~sfaotory O Simple over 30 hours old. resulu .may be unreliable n Sample too long in transit: sample should not be ove?~l~ours old at exnmmanon to indicate ~eliable results. Please send new s~mple via special delive~ mail. Date Received Time Received ( -'1 (~ ~ ! / - Analytical Method: '~ Membriz~._Filter / O ' MMO-MUg * Number of colonics/100 mi. Recult· Analyst 10105Ot ,Jch Fbks Jun Due: Time: Client notified of unsatisfactory, resulu: Sp~e wkb Time: BACTERIOLOGICAL WATER ANALYSIS RECORD MMO-MUG Remit: Total CalU'atm g.- C~' Membrane Filter:. Dire~ Count (q~ (~ Coba~:s/lQO mi Verification: LTB BGB COLIFIRM Fetal Coliform Confirmation Final Membrane Filter Rmlts C~ilfnrm/I O0 mi ,,- i~ ~u.~ I~..:.~; of the SOS Grouo ISoc~4t6 G4~a~e d~ Sur~mllor, co) ENVIRONMENTAL FAC:lURES IN ALASKA. CAUFORNLA. FLORIDA. ILUNOIS. MARYLAND. MR:MIGAN. IdI~,~JRL NEW JERSEY. 01410. W~ST V1RGd 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 Parcel I.D. CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~P~ 'Z-~ ~J~ HAA# GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Day phone Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: 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. TYPE OF WASTEWATER DISPOSAL: individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1191) Front MOA #21 · Lue~s/(s .~o sn~s pu~/(uIUBel eq] o~ Bu!~se~ :3.LON JaMeS o!lqnd e~!s-uo ~Junwwoo ~tum, 5u!plOH m,!s-uo lenP!^!pL :'i~SOdSIO ~I3/VM~ S~M .-I0 · Lua~s,~s ~o sneers pue X~!IeBaI ol Bu! -~s~e OBQV a~eT~ LuoJj uo!~eu~J!juoo ue~!Jl~ ep!AoJd 'uJe~sXs Ila/~ /(~ o!lqnd IleM Jnwwoo I~np!A!pUl euoqd ~eO euoqd ~ea :3J. ON :Alddn$ I:EIJ. VM JO 3dA.L :smooaa~a do tt~lalNNN 'pelsenbe.~ es!,~.leq,~o SSelun sseJ PPV ~,uebv --(?,_, .S. ~ - ._% ~ ~ euoqd sseJppe 6U!l!elAl /~oueBe §u!pue-I sseJppe §Uil!elAl JeUMO ,~lJedOJd · dmto!d Joj pleq ~.~j.~/L// ~o.: ~.~e ~ ~ (suo!loeJ!pJo sseJppem,!s) uo!~eoo-1 uop, d!Josep le§el eleldLUoO NOI/~/IN~O-INI 'iVI:I=IN=II9 "1- 5)NI-I-I=IMa A'IlIAIV:I :I'IE)NI$ V I:lO=l -IVAO~tdclV A/II:IOH/rlv HJ.-IV:IH :10 =U.VOI:IIIEI:IO ~ ) (~) #'a'l leOJecl Legal Description: A. WELL DATA Well type Log present (Y/N) Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST (-'o~ ~ Parcel I.D. Total depth Sanitary seal (Y/N) "If .A, B, o~C, attach ADEC letter. ~, '. ~J< ~' !': Date completed Cased to ADEG water system number ?/H [~ ~::) Driller ~ ~-" Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG t' 5'- g.p.m, AT INSPECTION ~ g.p.m. Absorption field on lot Public sewer main SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Sewer service line )'(//~ ; On adjacent lots /~ ; On adjacent lots /OC~ "/' Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform 42 Date of sample: ~q-( Nitrate · 6 / Collected by: Other bacteria m, f,,,,. ( ..,J-,, ~- B. SEPTIC/HOLDING TANK DATA Date installed CO-~,~- ct.'3 Cleanouts (Y/N) ~" High water alarm (Y/N) Date of pumping Tank size 1~'o~ ~ ~ ( Foundation cleanout (Y/N) ~¢,5 Compartments Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line ~-~' Surface water/drainage On adjacent lots /¢c) -/' Foundati~. Absorption field /.~-" Water main/service r'~e /~<~ +- 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level ' _.--'""'"~ Cycles tested Meets MOA electriC__ Manufacturer Man~ ~ "Pump off" level at Surface water D, ABSORPTION FIELD DATA Date installed (~'~ ~ q~ Soil rating [ ~ ~ ~,PP/.-~, ~ System type Length ~(~ · Width '7-"r' Gravel thickness ~o" Total depth Total absorption area C[~O ~_~.'z... Cleanouts present (Y/N) ~/'"'~ Depression over field (Y/N) /'~ o Date of adequacy test (~' Results (pass/fail) /~ ~ for Peroxide treatment (past 12 ~,onths) (Y/N) * /%(0 SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~-- To building foundation On adjacent lots /o~ Surface water /~ ~) Jr- bedrooms If yes, give date Curtain drain ~'/¢ o On adjacent lots /¢¢ ~' Property line /'~" To existing or abandoned system on lot ~'~ ~ Cutbank /ocs 'f Water main/service line ~/'~ Driveway, parking/vehicle storage area / ~ ~- E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this/nspection. Signature~ Engineer's Name Date HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number