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HomeMy WebLinkAboutSIEFKER TR 16 W2.IZA .. 1O `-,=-`i't-A V f y'1 Ci t MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. GAABHDi GP"kTER ANCHORAGE AREA BOROI'e H HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME F?� ` � ,5 _ ADDRESS S' /Lam c2, 1 % PHONE LOCATION � 7-- �"'L � � IcC1LEGAl DESCRIPTIONAU Z-- LoT L% SEPTIC TANK: [D `- (, DISTANCE FROM WELL-NUMBER ELL MATERIAL �,° ° ! L C' -COMPARTMENTS LIQUID LIQUID CAPACITY L ( GALLONS. INSIDE LENGTH 7 INSIDE WIDTH DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS -OUTSIDE DIAMETER OR WIDTH /� LENGTH /7 DEPTH , LINING MATERIAL 0—,iI, : 1JC 'R�lL0C-VC1C7C7 / f DISTANCE FROM WELL BUILDING FOUNDATION— NEAREST /_ NEAREST LOT LINE— `�-� TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) SQ. FT. TILE DRAIN FIELD: TOTAL LENGTH DISTANCE FROM WELL FOUNDATION NEAREST LOT LINE OF LINES , NUMBER OF LINES _DISTANCE BETWEEN LINES TRENCH WIDTH IN. TOTAL EFFECTIVE ABSORPTION AREA SQ. FT. LENGTH OF EACH LINE DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE WELL: TYPE D ✓telL� f ', / DEPTH_, DISTANCE FROM BUILDING FOUNDATION. e WATER �� SAMPLE NEAREST NEAREST LOT LINE 4 SEWER LINE, / SEPTIC TANK �. SEEPAGE✓� SYSTEM l OTHER _ C CESSPOOL SOURCES_ DISTANCES: GA^B-HD-2' GREATEI, ANCHORAGE AREA -)ROUGH Case No.�_ } t HEALTH DEPARTMENT 327 Eagle St. Anchorage, Alaska 99501 279-2511 SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT NAME OF APPLICANT a 6- MAILING ADD HESS _SZ r e2/% J19�PHONE NO. RESIDENCE ADDRESS NLOCATION OF INSTALLATION -74 All-6- LEGAL l:tLEGAL DESCRIPTION W c '7 / G S; .f l(e r Sic k APPLICATION TO INSTALL: SEPTIC TANK ✓ , SEEPAGE PIT I-�' , DRAIN FIELD _, OTHER TO SERVE THE FOLLOWING FACILITY FINANCED THROUGH 5 o I t_. RlR-n0-LAi-1Q=N TEST RESULTS THIS IS TO SERVE AS DISTANCES: -ed vi c e» L e; .t -t TO BE INSTALLED BY s' I- Ac ANTICIPATED DATE OF COMPLETION Lcc v /fIZ BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT , PERMIT TO INSTALL A AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED SEPTIC TANK SIZE -TYPE SEEPAGE AREA DIAGRAM OF SYSTEM Health Authority TYPE I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the above described system is in accordance with said code. DATE ✓� APPLICANTS SIGNATURE 21 J2,&eL ^-"��- zy GREATER ANCHORAGE AREA BOROUGH Department of Environmental Quality 3330 "C" Street, Anchorage, Alaska 99503 274-4561 Date Received l -t g' , - Time of Inspection Date of Inspection REQUEST FOR APPROVAL OF INDIVIDUAL SEWER & WATER FACILITIES t FOR 1. Approval requested by: Mailing Address: )/o ��� /�17�� Phone: 2. Property Owner: Phone: Mailing Address: _ 3. Legal Description: Z6k ZI may, �Ct /�QGI , GC2 4. Location: ��/G c,•�J �,f-f ��,�iU � O�7 l/� 5. Type of facility to be inspected ��, P No. of bedrooms D /� 6. Well Data: A. Type B� Depth C. ConstructionD. Bacterial Analysis 7. Sewage Disposal System: A. Installed � B. Instal lert,� //I� zQ.A.�i_� C. Septic Tank: 1 Size 2. Manufacturer l-.��-��4�-µ� k"? QJ1�.2. D. Seepage Pit: 1. Absorption Area 40-0ZI 2, Mate rial��� E. Disposal Field 8. Distances: Total length of lines A. Well to: Septic tank_, Absorption area /&0 Sewer Lines Nearest lot line, Other contamination B. Foundation to septic tank Absorption area C:�� C. Absorption area to nearest lot line 6 EQ -034 (1/74) Page 1 of two pages Page 2 of two pages - Re ;t for Approval of Individual Legal Description �12k vz- 112/o� Comments Approved Disapproved 2r & Water Facilities Z, Date %d Approval,Valid for one year from date signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM PA i VV A � , I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities and these facilities are operating satisfactorily. SIGNED EQ -034 (1/74) Date �.uxnan v� 9 , GREATER ANCHORAGE AkLlf, BOROUGH Department of Environmental Quality 3330 "C" St., Anchorage, Alaska 99503 s 274-4561 REQUEST FOR APPROVAL, OF INDIVIDUAL SEWER & WATER FACILITIES 1. Type of Inspection: CMRO VA FHA —w C 0 N V 2 2. Property Owner: . � uG �iC //1/'5 Mailing Address: � _ Y_ Day Phone z_lvr o-/,y�_' 3. Name of Buyer: Mailing Address: � Day_ Phone_ --- 4. Name of Lending Institution: /von Mai ling Address: P h o n e 5. Name of Realtor or Agent: Mailing Address :��07 Phone7I: 6. Legal Descrip Location: VA a 0 FW Type of Facility to be inspected: No. _Bdrms. Water Supply Type of Supply: Public Utility Individual X If Individual, number of dwellings presently served If Individual, depth of well Sewage Disposal System Type of System: Public Utility Individual (on-site) �( If Individual, date of installation REQUEST FOR APPROVAL OF If'f'y INDIVIDUAL SEWAGE AND WATER FACILITIES J ( Fill out in `i'rIplicate) _ Name .of person requesting approval ence Ka 2 , Name of 3. Legal de 4, Numb-er,.ot-bedrooms in house.:—/ 5. Water -Analysis: a. Bacteria.1 b. Detergent 6, Weal data: a. Type b. Depth -7 c. Casing Size (!1 d, Distance from well to closest existing or proposed: 1. i Sewer line ,Z� . /_ 2, �r Septic tank l0 , 3. Seepage Area 4, Cesspool' , 5. Property Line , 6. Other sources of possible contamination, i.e., creeks, lakes, houses, barn, drainage ditch, etc. , 7. Sewage disposal system, "i f a. Age of system b. Septic tank capacity in gallons c, Name of septic tank manufacturer 1. If "home made" show diagram on reverse side of this form. d; Disposal field or seepage pit size and type, 1, Distance to property line____(J to house foundation �\ Percolation Test results^� i"' Percolation Testerformed b p Yt- Usethe reverse,side of this foram to show dial=ram. Dialrram should include he following information: property li.nes;.wel.l location, house location, Septic tank location, disposal area location, location of percolation test, anj direction of ground slope. y 9. The l formation .on this form is true and correct to the best of my knowledge. S I`nature of Applicant �'� Date Signed 4 TO BE r1LLED OUT BY HEAL'T'H DEPARTMENT PERSONNEL above described sanitary facilities are hereby approved, subject to the *.he P61lowing condeft- ons: Conditions: P ED The above described sanitary facilities are disapproved for the following reasons: of '57-177-1Dawel(' ` 1 is valid for one year following the date of approval, CPJ:cw U 39 e 0, OR, MEN19 aery dab � � O d• _©N � AC4 < O® N in 40O@ Q � N Him n ro k o QQ ©®©@ 00 U S R sJ/V V ,7 . N N fn pn f0 Z 0�' ll1 wo d b m_ mm < In m < NJ in O <Go` 39 e 0, OR, MEN19 aery dab � � O d• _©N � AC4 < O® N in 40O@ Q � N Him n ro k o QQ ©®©@ 00 U S R sJ/V V ,7 . N N fn pn f0 b A m_ mm < In m < in < m m in < N_ m N_ in O <Go` O p C