HomeMy WebLinkAboutUS SURVEY 3043 LT 66EOnsite File
US Survey 3043
Lot 66E
#075-061-70
111,mm :1m I ultuwu: *rnuso
1201 Ramona St. 99515 ANCHORAGE, AILASkA
344-7714
SIX INCH WATER WELL. DRILLED
OUT TO THE DEPTH OF 60 feet.
DRILLED AT THE RATE OF t23.0J PER FOOT.
PROPERTY OWNER
Steel casing seated to. sixty feet.
teen Fotchkiss 783-2331 '(Girdwood, Ah)
•
LOCATION OF WELL SITF Lt. Blk. Sub.
.4
DRILLER Bernie Claus of Rampart Drilling Works.
WELL LOG: '
0 - 16' Silty sandy clay with 33% gravel, plus several boulders.
16 - 51'• Fardpan. A cemented gravel. (Glacial silt/till)
51 - 6J' Silty sandy water bearing material Eoing.into a good coarse water
bearing gravel (57' to 6J1). Also drilled out to 65'feet, however, it is a
very fine water bearing material going into glacial material. The good
water in coarse gravel is 57' - 6J'. Water production is at 10 gpm, with
33 feet of water standing off bottom. SubmersfSl'e°••pump should be installed
down to 52 to 55 feet. 1/3 or 1/2 horsepower, 230v pup.
This Water Well has been paid in full.
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. .
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF
THANK YOU VERY MUCH.
BERNIE CLAUS OF RAMPART DRILLING WORKS
DATF August 10, 1992
. SERVICE CHARGE 0 F 1y,% PER MONTH WILL BE ASSESSED ON PAST DUE ACCOUNTS.
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 SYSTEM PERMIT
PERMIT NUMBER:SW920084
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:HOTCHKISS DEAN HOWARD &
OWNER ADDRESS:BOX 1105
GIRDWOOD, ALASKA 99587
DATE ISSUED: 5/19/92
EXPIRATION DATE: 5/19/93
PARCEL ID:07506170
LEGAL DESCRIPTION: T10N R2E SEC 17/18 LT 66E OF
USS 3043
LOT SIZE: 18477 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
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 (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
2.
OF WELL.
RECEIVED BY:
OBSERVE SETBACKS TO SEWER SERVICE LINE (25'), SEWER
MAIN (75') AND SEWER MANHOLES (100').
SUBMIT WELL LOG TO DHHS WITHIN 30 DAYS OF COMPLETION
ISSUED BY:
DATE:
DATE:
Municipality of Anchorage
On -Site Water & Wastewater Program
(907) 343-7904
CERTIFICATE OF ON—SITE SYSTEMS APPROVAL
Parcel I.D. 075-061-70
1. GENERAL INFORMATION
Complete legal description US SURVEY 3043 L66E
Expiration Date: /02 - / 7
Location (site address) 1454 ALYESKA HWY *GIRDW00D
Current Property owner(s) CHUN ANN E REVOCABLE TRUST Day phone
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
In Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well Li
Public Water System [
WaiverNariance request for:
Received by:
COSA to be released` to the engine�r. unless at se requested by the engineer.
CCEPTE
um, Par sac animal D
SEP 1 0 2014
TYPE OF WASTEWATER DISPOSAL:'
Individual On-site ❑
Individual Holding tank ❑
Community On-site 0
Public Sewer
Distance: —
COSA Fee $ 6 -2A -
Date
2`a
Date of Payment al t i l o'1
Receipt Number D 1(04 1 61/4
Waiver Fee $
Date of Payment
/ Receipt Number
COSA # 1917& N i tqT ? Waiver #
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, 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. 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 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
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 8 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
other person or party is not authorized, nor will it confer any legal night whatsoever.
6. DSD SIGNATURE
System #1 Approved for bedrooms.
System #2 Approved for bedrooms.
Disapproved.
Conditional approval for
By
Date t!,J
bedrooms, with the following stipulations:
Original Certificate Date:
/19
The . Icipa " o 7=" r9,".ge Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations 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. 11/05)
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: US SURVEY 3043 L66E Parcel ID: 075-061-70
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 8/10/1992
Sanitary seal (Y/N) YES
Total depth 65 ft. Cased to 60 ft.
Wires properly protected (Y/N)
Casing height (above ground)
FROM WELL LOG AT INSPECTION
1-7-
/2
Date of test 8/10/1992 08 014
Static water level 35 ft. 34 ft.
Well production 10 g.p.m. 6.18 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0
Arsenic:0 n ug./L.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
colonies/100 ml. Nitrated 3�t9ng./L. Collected by: GEG. Ltd.
Date of sample: 08/27/2014
PUBLIC SEWER
Date installed
Tank size gal. Number of Compartments Cleanouts (Y/N)
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./ft2or ft2/bdrm System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eff. absorption - - ft2 Monitoring tube Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorp geld before test in Water added _ gal New depth in.
Elapsed Ti min. Final fluid depth in. Absorption rate >= g p d.
Ar ejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
YES
24+ in.
D. LIFT STATION
Date installed Size in gallons
"Pump on" level at in. "Pump off' level
Datu
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
N/A
N/A
Manhole/Access (Y/N
High water alarm level at in
Cycles tested Meets alarm & circuit requirements?
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
75'+
Sewer /septic service line 25'+
Animal containment areas 50'+
On adjacent lots
On adjacent lots
N/A
N/A
Public sewer manhole/deanout 100'+
Holding tank
N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD
PUBLIC SEWER
Absorption field
Property line Buildi
ndation
Water service line Surface water
Curta
T TO:
Water main
Driveway, parking/vehicle storage
m Wells on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that I have determined 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
00/4
Date
(Rev. 11/05)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 995196650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON—SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 0? s- 061- 9 0
1. GENERAL INFORMATION
Complete legal description
Location (site address)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
U.S.S 3043; LOT 66E
COSA# OCf 0 3 ? 3
Expiration Date: 1 —' / 9 - l O
1454 ALYESKA HIGHWAY • GIRDWOOD, AK • 99587
RICK LUEBKE
Day phone 301-7017
1454 ALYESKA HIGHWAY • GIRDWOOD, AK • 99587
Day phone
ERIN EKER W/ DYNAMIC PROPERTIES Day phone 2307266
118 MONARCH MINE RD • GIRDWOOD, AK • 99587
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
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 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 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
3701 E. TUDOR ROAD, SUITE 101 " ANCHORAGE, AK 99507
JEFFREY A. GARNESS, P.E.
Address
Engineer's Printed Name
GARNESS ENGINEERING GROUP, Ltd.
Engineer's Comments:
In conducting this evaluation, GEG, MD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines It 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
other person or party is not authorized, nor will it confer any legal right whatsoever.
Phone 337-6179
Date ID) 1409
0
5. DSD SIGNATURE
Approved for 3 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the filming stipulations:
E-79 3
tol lS. cado
O Pro fession°�
0
��400000�
440
P•ON ITE
• I,•
WASTEWATERWATERAND . =
PROGRAM
•oi1rr J
sui 1111110 \
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Bv:
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
(Rev. 11105(
Original Certificate Date: / O - / - 0 9
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: U.S.S. 3043; LOT 66E
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A
Date completed 8/10/1992 Sanitary seal (Y/N) YES
Total depth 65 ft Cased to 60 ft
FROM WELL LOG
Date of test 8/10/1992
Static water level 35 ft.
Well production 10 g.p.m
WATER SAMPLE RESULTS:
Coliforme colonies/100 ml. Nitrate. D 7%mg./L.
Arsenic: A) n ug./L. Date of sample: 9/25/2009
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal Number of Compartments
Parcel ID: 0 el 0 3 7 7
Well Log (Y/N) YES
Wires properly protected (Y/N) YES
Casing height (above ground) 12+
AT INSPECTION
9/25/2009
34 ft.
7.78 g.p.m.
Foundation cleanout (Y/N) _
mping
C. ABSORPTION FIELD DATA
Date installed
Length ft
Total depth
in.
Other bacteria 0 colonies/100 ml.
Collected by: GEG Ltd.
Date installed
C
PUBLIC SEWER
ver tank (Y/N)_ High water alarm (YIN)
Pumper
Soil rating (g.p.d./ft'or ft'/bdrm)_
Width ft.
Monitoring tube
Results - - ail)
_ in Water added
Final fluid depth_ in.
ft Eff. absorption area
Date of adequacy test
Fluid depth in absorption field befo
Elapsed Time:
ft'
(PUBLIC SEWER
System type
Gravel below ' ft
Depression over field
For bedrooms
gal. New depth in.
Absorption rate >_ • g p d.
juvenation treatment (past 12 mo.) (Y/N & type) If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at in
Datu Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons Manhole/Access (YIN
"Pump off' leve High water alarm level at in.
Meets alarm & circuit requirements?
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
N/A
N/A
75'+
Sewer /septic service line 25'+
Animal containment areas 50'+
On adjacent Tots
On adjacent Tots
Public sewer manhole/cleanout
Holding tank
N/A
N/A
100'+
N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation
Water main
0
Property line
Water service li
Absorption field
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water service line
F. COMMENTS
Building foundatio
Surface water
Wells on adjacent Tots
PUBLIC SEWER
u ace water
Water main
PUBLIC SEWER
ay, parking/vehicle storage
G. ENGINEER'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
Date 101100q
JEFFREY A. GARNESS
00
COSA Fee $ I/7 6' / Waiver Fee $
�O
Date of Payment ,ys1 0 l Date of Payment
Receipt Number O S 3 02-0 Receipt Number
(Rev. 11/05)
?SP
LOT GGE=/5,772 SF.
LOT
660
'LOT
5
-LOT
DATE
Lot 66 E , Block
11 S Surveti 3043
Anchorage Recoragg District, Alaska k n-324)
1_OT SURVEY CERTIFICATION
1 hereby artily that I have surveyed the property Moto end deealbed
hereon, end that the Mpre.ew.nte situated thereon re •ltNs the prop-
erty erae end do eat overtop es esraoah on adjacent property end tbat
a inctra .este 06 odloo°nt property arlap or encroach as 1M prealee°
N question end that Man ere ea roadways, utility lime, wither N.IbIs
easeemeete on said property newt se Indicated hereon.
4
secs Or. .4
•..sushi
CO •. •f- e
i*%'1'_•J t s*I
•
1W • •...4
i%i R.L. Button : 1ji
c
I m, lsnn;Sr i
•
as pl tK t mooed
s e• swot shown M°°eao velem tshown es • j.,0,6,••••»•••••00 as,
otherwise sated. , AOFESSiDtlhI-‘�
LEGEND ��,���.�`
�
O Brags or kart pip AAlumin/orum tenor monument recovered 05-23-08
red
O 2 x 2 hub ti tock recovered
• 5/8"x 50N rebar set this survey
—x— Fence Lids (Approx. Location)
Stole /erroY�.J �^,
Ret 454
Date
0523Q3 '
Prepared by:
(9071279-62X
R. L. BUTTON
Registentd Land Surveyor
5/9 W. EighthAvi. Anchorage A/asko9950/
F.B. No.
05-048
Property of: Rick Luebke
Municipality of Anchorage
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.ak.tis
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY,AI PROVAL
FOR A SINGLE FAMILY•DWELLING
HM# • • .- H140/0 a39
Parcel I.D. b7S-OL ( -70
..
Expiration Date: /0 - /7- b
1.' GENERAL INFORMATION U 5S
Complete legal description '• L04- ttet - 30143
• • Location (site address or directions)
".Current Property owners) 1 1 \(t rc -t 41 le -r Day phone �1 cS3 —1)9 Q81
'=4Aailing address GA fa (.0 Qsi g521)7 - r P.O.a rx
Lending agency
- Mailing address
Real Estate Agent %twtL. ANie.t?
., l�nitef • Day phone .7g 2—antD
Mailin-g-Address P. O, Bn\ /bat\) Gnrcimnpri °fl 5$7
Unless otherwise requested, HAA will be held by DSD for pickup. r 14 ,._ — 7f', t /0 1
Day phone -
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
A
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
0
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 private or Class C well and may be reissued with
new water sample results less than 30 days old. (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, 1 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.
S & S ENGINEERING •
Name of Firm 170:4 tagla Riv,v „•r Roa i'4"r201
Address Eagle River, Alaska 99577
Engineer's Printed Name n%I k e. COu?&
Phone &`f`/-7.979
Date 7/3/6(
A. iC 9r.tZllt1.
r'y'•�(9!!
iY I E�R 4;3\
/! y� t ROEERT C. COWAN Cr
%\\ CE•8801
5. DSD SIGNATURE ° !
1/•.' Approved for 2— bedrooms._��;;�•�,,►
Disapproved.
Conditional approval for bedrooms, with the following stipulations: �itittlftffrrry�ff
O,
` : WATER : WaON SITEAND •.'
y :
:WASAR
•
PROGRAM :
Additional Comments
'JJ l aiEjjj)sel ) )
By:
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
(Rev. 12CC)
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: — / 7- 0
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6850
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOT 66 t
A. WELL DATA
Well type PRwfTl
Date completed `aI iq 2
Total depth 60 ft.
U_S. SvevLy
3093
If A, 6, or C provide PWSID #
Sanitary seal ®/N)
Cased to fo O ft.
FROM WELL LOG
Date of test T//0 2..
Static water level
30 ft.
Yt s
Well production / 0 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml.
-)/a./o/
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank.Type/Material
Tank size gal.
Nitrate Q_S"
Collected by:
Parcel ID:
wen Loge1N) Y E S
Wires properly protected®N) Y E T
Casing height (above ground) L/ i+ -in.
AT INSPECTION
7/.i./o
3 3 ft.
1.3 g.p.m.
X LI "'Tea BY p'^' P
mg.!). Other bacteria 0 colonies/100 ml.
5 & 5 ENGINEERING
i t?Sa lagta RIyar Loup Read Na 203
PAL( c St w32 Eaglet Riwr, Alaska 99377
Date installed
Number of Compartments _ Clean
Foundation cleanout (Y/) _ Depression over tank (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed SoU rating (g.p.d ft2/bdrm)
Length ft.
Total depth ft. Eff. abs • •• on area ____ft'onitoring tube
water alarm (Y/N)
ft.
Date of adequacy test Results (Pass/Fail)
Fluid depth in abso
Elapsed Ti
on field before test _ in.
System type
Gravel below pipe ft.
Depression over field
For _ bedrooms
New depth_ in.
Water added_ gal.
min. Final fluid depth _ in.
Any r enation treatment (past 12 mo.) (Y/N & type)
Absorption rate >=
If yes, give date
g.p.d.
D. LIFT STATION
Date installed Size in gallons Man
'Pump on" level at _ in. `Pum
Datum Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/ q
Absorption field on lot W / k
Public sewer main S '"1
i
Sewer /septic service line XS- 't
in.
/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
On adjacent lots W,A
On adjacent lots N �A
Public sewer manhole/deanout / 0 0 ''-
Holding tank s"/ 4
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: QUI t31 c.
Building foundation Property line _
Water main Water service line
Wells on adjacent lots
SEPARATION DISTANCE FROM ION FIELD ON LOT TO:
Absorptio
Property line Building foundation
Water Service III : Surface water
Curtai I • ain Wells on adjacent Tots
SEwE2
urface water
Water main
Driveway, parking/vehicle storage
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through held inspections and
review of Municipal records that the above systems am in
conformance with MOA HAA guidelines in effect on this date.
Roit•t% C. C8 hotter
-7(3/0/
Engineer's Printed Name
Datear
CE-ISOW AN
8801
ft
(, r
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
Waiver Fee $
Date of Payment
Receipt Number