HomeMy WebLinkAboutHILLCREST BLK 8 LT 8Municipality of Anchorage
Community Development Department
On-Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • hftp://Www.muni.org/onsite • (907) 343-7904
Well Decommissioning Log
Legal Address,
Subdivision WU64FSr Block Lot
T R Section Lot
On-site Water & Wastewater Program certified contractor performing the well decommissioning:
Name:
Signa re:
IV
Compa
Well decommissioning date Method of decommissioning: AMC 15.55.060L1 a. ❑ b. ❑ c.
Location: Use the space below to provide a drawing of the property showing the following items;
• North arrow
• Decommissioned well,
• Other water wells on the property,
Two separate swing-tie distances for each well shown on the drawing,
Note-The_svdna-tie.distances shall_be measured from either permanent structures or the property corners.
contrary Contrary Ct
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G:\Community Development\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Well Decommisioning form.doc