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HomeMy WebLinkAboutT15N R1W SEC 30 LT 53T15N RlW Sec 30 Lot 53 x#051-293-36 2012 permit not constructed. Municipality of Anchorage Community Development Department Page 1 of 3 On-Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: None PID Number: 051-293-36 ❑✓ New ❑ Upgrade Name: Paul and Kathy Mallory ABSORPTION FIELD ❑ Deep Trench ❑✓ Shallow Trench [—]Bed []Mound Address 15894 South Birchwood Loop Chugiak, AK 99567 ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 2 1.2 GPD/SF 5.3 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 3.3 Ft. Gravel depth beneath pipe 2.OFt. Subdivision Block Lot 53 Fill added above original grade 0 Ft. Gravel length 36 Ft. Township Range Section 15N 1 W 30 Gravel width 5Ft. Beds: Number of Lines Distance between lines I Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between trendies I From Tank Field Tank Line 257 Ftp One Ft. well 70" 84" N/A NIA >25' TANK O Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Klondike Concrete Capacity I 1,000Gal. Surface water >100' >100' NIA N/A Material Number of compartments Lot Line >5' >10' N/A NIA Concrete Two NA Foundation >5' >10' N/A N/A LIFT STATION Manufacturer Capacity Curtain Drain None Noted - Gal. I I IN Remarks ""See Waiver. Systems ndocumented. Pump on level at in. Pump off level at in. High water alarm at in. Measurements Determined from Field Investigation and Owner Furnished Information. Pump make and model Electrical Inspections performed by Installer PIPE MATERIAL Housetotank D3034 Tank to drainfield D3034 James Polyefko/Tim Montgomery Drainfield F810 CO/MT D3034 Inspector AH - Field Investigation BENCH MARK (Assumed elevation) 100.Oft Inspection ., 8/12/11 8/26/11 Location and description dates: 2nd a" 9/21/11 a'" Yurt Finished Floor Slab. COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL �Amok t1blihill1 Conditional Approval: Date T �..................... MICHAEL E. ANDERSON : 4? R %'.• LE - 4381 Approve Date +'t\POFEW ispecnon nepory 1-i-t2mc Municipality of Anchorage Page 2 of 3 DEVEOPMENT SERVICES DEPARTMENT 4700 South Bragaw Street Anchorage, AK 995196655 - 343-7904 PID No. 051-293-36 LOT 45 DRIVEWAY TO SOUTH LOT BIRCHWOOD LOOP 46A � 5 89'37'14"E 329.67' C) C7 0 O O STEEL FENCE 0LOT 53 � Do C = 109,860 S. F. D (n SHED C CD YURT LOT C 52A O n z G 30.0' ]3.5• FCO p cz 29.2' m .. GRAV-EL C3/MT 52 zs.t• n.o• �� :. r---�----- Z DRNEWAY., i a \ Of LIGHT, 'POLE \\ Sj \\ P0ic 0 Taln�Cn z ® i o u o N ExV'e1,iln9 I ! N N W OVERHEAD ELECTRIb, LINES W N \/ ? \ \ LOG CABIN / (P LOT -- 52C I I I Existing Irrigation Well � I cW ! oA � to 0 o N 89-4,3'22-W 330.49' LOT 56B LOT o LOT 56A OF r��O+♦♦♦ 1 . P............ ':♦ �...,. ..,49th / PLAN AS BUILT ' ��`° ' ♦�'; MICHAEL,E. ANDERSON SCALE 1" = 50' ♦♦1�T�n •, No. CE-43at�i ♦♦♦ ��pROFESSIONP���• Municipality of Anchorage Page 3 of 3 DEVEOPMENT SERVICES DEPARTMENT 4700 Elmore Road Anchorage, AK. 99519-6655 - 343-7904 On -Site Wastewater Disposal System or Well Inspection Report Permit Number: None PID No. 051-293-36 7 N lUl.b N / N 1,000 Gallon Septic Tank 972 x 9-21-11 W (Trench Length) NOTE: Trench Depth Could Only be Verified to 2' Below the Distribution Line. Owner States Trench is 4.5' Below Line. PROFILE AS -BUILT No Scale Municipality of Anchorage Development Services Division On -Site Water and Wastewater Program **** VARIANCE/WAIVER REVIEW **** Waiver#: OSV141255 COSA#: Permit#: PID#: 051-29336 Legal Description: T15N R1 W Sec30 Lot 53 Engineer: Anderson Engineering Applicant: Paul and Kathy Mallory Your request for a waiver of thesequired 100 feet horizontal separation from the absorption field to the private well has been approved. The approved separation distance is 84 feet. Your request for a waiver of the required 100 feet horizontal separation from the septic tank to the private well has been approved: The approved separation distance is 70.0 feet. This waiver approval applies to the existing septic system only. Any future upgrade to the on- site wastewater disposal system will require all separation distances be met or another approval from this department. ❑ The affected adjacent property owner(s) have been given a 7 day notice regarding this waiver. n Notarized letter(s) of non -objection have been received from the owner(s) of the affected adjacent property. 0 Adjacent properties are not affected by this waiver. ....... •.............a........... .■•i....•... ••. a ....•.•. u. ................... Waiver is Granted: X Waiver is not Grant : Date: Approved by: arae of Reviewer ..._............................................ . ..M....:...■... ..... ....■....... ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 : 677-7766( February 10, 2015 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: T15N, R1W, Section 30, Lot 53 Septic Tank to Well Encroachment Waiver Dear Onsite Services Engineer: 4111629— 711 -?AY Allogaol-)LG osQryiass 0,5sI a93,3(P The existing septic tank on Lot 53 of Section 30, T15N, R1 W is located 70' from the existing well on the lot. In addition, the southwesterly corner of the absorption trench is 84' from the well. The lot has been operating in this configuration for many years and recent water tests show no presence of nitrate/nitrite content in the well. A waiver is therefore required to allow the tank to remain in its current location less than 100' from the well. The septic tank is constructed of concrete and appears to be water tight. It was uncovered and inspected in August of 2012 and found to be structurally sound and water tight.. The tank is located down slope from the existing well and any effluent that might surface from the septic tank or absorption trench would flow away from the well and toward the front of the lot. The surface grade is 7% away from the well. Surface effluent contamination of the well is virtually impossible. Underlying soils on the lot are silty gravels (GM) based on documentation completed during the verification of the suitability of the septic tank and the inspection of the absorption trench. The well on this lot is 61' deep with water infiltration at 35' below the surface. It was probably drilled in 1973 when the original buildings on the lot were constructed. It is unknown whether the lot was ever placed in service as no septic system or sewer service to the buildings originally constructed on the lot could be found. In addition, no information regarding the well can be found, but an inspection was recently completed and as built documentation prepared. Owner provided information indicates the well and initial placement of the septic tank was made in 1973 at the request of the Seventh Day Adventist Church. The overwhelming justification for the issuance of a waiver between the well and the T1 5N R1 W SEC 30 Lot 53 February 10, 2015 Page Two septic system is the water quality results. No detection of nitrate or nitrite content was found in the water. No coliform, bacteria or arsenic was found either. We are confident based on the long term performance of the existing septic tank and absorption trench and the water quality from the well that contamination from the septic system is not likely. We therefore recommend that the waiver allowing the existing septic tank to remain 70' from the well and the absorption trench 84' from the well be granted. ADEC POINT ANALYSIS Bottom of Tank to Highest Water Table — 8' 1.00 Points Soil Absorption Type — Sand/Gravel w/Silt 2.50 Points Permeability — Silt or Sandy Gravel 2.00 Points Water Table Gradient - +7% 5.90 Points Horizontal Separation — 70' 1.80 Points TOTAL POINTS 13.20 No Bacteriological Pollution Possible, but Chemical Pollution Possible but Unlikely from Household Chemicals. Sincerely, 1v 1^� Z Michael E. Anderson, P.E. ARCTIC PUMP & WELL INC. �yry Jim Sullivan PO HoxAK 97 AK 1 Y Eagle River, 99577 mr�t (907) 688-2510 (907) 258-2510 (907) 745-2510 auwCa,,eci.net Pump Installation Log Well Drilling Permit Number: SW Parcel Identification Number: Date of Issue: Arctic Pump & Well, Inc. Page I of I Legal Description:T15N Rl W S30 Property Owner Name & Address: Lot:53 Paul Mallory Block: 15894 S Birchwood 1p QQSF7 Pump Installation Date: 4-28-12 Pump Intake Depth Below Top of Well Casing: 54 Feet Pump Manufacturer's Name: Tait Pump Model: 5P37 Pump Size: 1/2 hp Pitless Adapter Burial Depth: feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: NONE Well Disinfected Upon Completion? Yes Method of Disinfection: Chlorine Comments: 9.5 static 2'stick up 15' casing Water infiltration 35'and 41' 61' Total depth Pump Installer Name: Arctic Pump & Well, Inc. Arctic Pump & Well, Inc. Page I of I i SGS Ref.# 1142975001 Client Name Anderson Engineering Project Name/# 15894 S. Birchwood Loop Client Sample ID 15894 S. Birchwood Loop Matrix Drinking Water Printed DateTime Collected Date/Time Received Date/Time Technical Director 07/15/2014 9:14 07/08/2014 19:00 07/09/2014 9:07 Stephen C. Ede Sample Remarks: E. Coli Negative 1 100mL SM21 9223B A 07/09/14 MEV Allowable Prep Analysis Parameter Results LOQ Units Method Container ID Limits Date Date Init Metals by ICP/MS Arsenic ND 5.00 ug/L EP200.8 C (<10) 07/09/14 07/10/14 EAB Waters Department Total Nitrate/Nitrite-N ND 0.100 mg/L SM21 450ONO3-F B (<10) 07/11/14 CDE Microbiology Laboratory E. Coli Negative 1 100mL SM21 9223B A 07/09/14 MEV Total Coliform Negative 1 100mL SM21 9223B A 07/09/14 MEV 15894 Birchwood Loop Road Septic System The history of the septic system is as follows. In 1973 the 1000 gallon dual compartment tank was installed for the Seventh Day Adventist Church by the late James Polyefko, a licensed septic system installer in the Eagle River/Chugiak area. The tank was manufactured by Klondike Concrete with reinforced concrete. There are two concrete lift off access holes in the top, each 2' x Tin size. Each compartment has a 6" above ground pump out. The drain field was upgraded in 1993 by the owner Tim Montgomery who at the time worked for Strata Construction. During his tenure with the company he installed over 20 septic systems. He was assisted by his father Bill Montgomery who was a licensed septic installer in the area for many years. The drain field he installed is a 5 foot wide trench, 36 feet long. There is 4 1/2' to 5' of sewer rock beneath the standard ABS perforated drain field pipe. The drainpipe was covered with 6" of sewer rock and then covered with Typar to prevent introduction of dirt into the drainfield. The Typar was then covered with dirt to a depth of 3 1/2'. Before the septic tank was connected to the Mallory home, it was fully excavated, inspected for leakage, pumped and cleaned. There was no evidence of leakage, cracks or other defects. When JR Septic pumped the exposed tank, the technician was impressed with the condition of the tank. The ABS drainpipes going from the residence to the tank are insulated with 8" of foam board above to prevent freezing and two clean outs are installed in the drain pipe, one in the house and one outside. Hook up to the tank was performed by Pomeraning Excavation. The system has been in continuous use for three years with no issues whatsoever, and the well test was clean both before the purchase of the property and again at the application of this waver. There is no indication the log cabin ever had plumbing. The owner states that no septic system ever served the log cabin. No septic system other than the one shown on the drawing could be found on the lot. The Septic Tank was constructed in 1973 by Klondike Concrete. At that time Klondike was an approved septic tank supplier and concrete tanks were in use throughout Anchorage. It was uncovered and inspected and found to be watertight and structurally sound. It is more than 40 years old and still sound verifying it was constructed to adequate standards. The aforementioned information was obtained from both field inspections and in discussions with the current owner. We cannot guarantee the information from the owner or previous owners is accurate. � F, Michael E. Anderson, P.E. OF 4E1 E. ANDERSON :,2 CE -4381 2® r-11 -t5'. ��d ec 30- On -Site Wastewater Disposal System Permit MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Permit Number: OSP121134 Tax Code Number: 05129336000 Work Type: Septic Upgrade Permit Effective Dates: June 25, 2012 to June 25, 2013 Design Engineer: ANDERSON ENGINEERING Subdivision: T1 5N R1 W SEC 30 Site Legal Address: T15N R1 W SEC 30 LT 53 G:0755 Owner/Address: MALLORY PAUL & KATHY 15894 SOUTH BIRCHWOODLP CHUGIAK AK 995676954 Site Mailing Address: 15894 S BIRCHWOOD LOOP RD, Chugiak Lot Size in Sq Ft: Total Bedrooms: This permit is for the construction of: ,,,ent c, I)eparr.ment 108900 3 Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Special Provisions: 1. The wells are not documented and are not eligible for COSA approval without further investigation and possible upgrade. 2. Proposed system too deep for soils information submitted. The Engineer needs to do an additional perc test in the GM layer prior to the construction of the septic field. Please submit stamped and signed results with the As -built Inspection Report. If the results require a design change, construction of the system will stop pending On -Site review and approval. Received By: Issued By: Date: Date: e, r Z MUNIUPAUTY OF A HCHORAGE Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program Mayor Dan Sullivan ON-SITE SEWER/ WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-293-36 Property owner(s): Paul and Kathy Mallory Mailing address: 15894 S. Birchwood Loop Chugiak, AK 99567 Site address: Same Day phone: 444-5978 Legal description (Sub'd., Block & Lot): P.LM Lot 53, Section 30, T1 5N, R1 Legal description (Township, Range & Section) _ Lot Size: 108,900 S.F. Number of Bedrooms Three (3) THIS APPLICATION IS FOR: THIS APPLICATION IS AN: (® all that apply) Absorption Field X Initial EJ Septic Tank X Upgrade X Holding Tank ❑ Renewal ❑ Privy ❑ Private Well ❑Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: Waiver Fees: _ Date of Payment: r!n!l3 jc.� Date of Payment: Receipt Number: ()M55Receipt Number: Permit No. QSPl,) / (3L/ Waiver No. C:\Users\AndEng\DesktopWike\T15N JohnsonTermitApplication Lot 102.docC:\UsersWndEng\Desktop\Mike\T15N JohnsonTermit Application Lot 102.doc ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 677-7766 (FAX) June 12, 2012 Municipality of Anchorage Development Services Department On -Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: BLM Lot 53, Section 30, T15N, R1 Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer: The owner of BLM Lot 53 intends to construct a new three-bedroom home on the lot at some point in the future. They are currently living in a yurt on the property. The existing septic tank and a section of the existing absorption trench fall within the 100' protective well radius. We are therefore requesting a permit be issued for the construction of a new well and septic system to accommodate the home that will be constructed outside the radius. The attached Site Plan and backup documentation identify the location and configuration of the existing and proposed septic systems along with the wells on the Two wells currently exist on the lot with the second used entirely for landscaping purposes. Drainage arrows are shown on the site plan showing the grade and direction of flow on the lot. The drainage pattern will not be changed as a result of this project. The test holes placed on the tract in the area of the absorption trenches indicated clean gravel (GP/GM) material with some silt. The percolation rate of the soil was determined to be 2.4 minutes per inch. No groundwater was found during the placement of the test holes but was noted at 12' below the surface during the monitoring period. An application rate of 1.2 gallons per day per square foot was used in the design of the absorption system. We are proposing to place a new 1,000 -gallon septic tank and 2- 20' long by 5' wide by 4' effective depth absorption trenches to treat and dispose of the effluent generated in the house. The elevation of the distribution line in the absorption trenches will be 2' below the surface and the total depth will be 6'. A minimum of 3' of fill or 2" of insulation and 2' of fill will be placed over the absorption trench and 4' over the septic tank. The ground surface on the lot in the area of the absorption trench slopes to the northwest at 7%. The new trenches will be constructed parallel with the contours of the BLM Lot 53, Section 30, T1 5N, R1 W June 12, 2012 Page Two slope as much as possible in conformance with Municipal requirements. The new septic system will be constructed a minimum of 100' from all wells and any surface water and 10' from the proposed and existing water services in the area. If the system is constructed in accordance with our design the following statements apply: 1. The system, if constructed as designed, will have no adverse impact on the wells in the area or those to be constructed in the future. 2. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. 3. The system, if constructed as designed, will have no adverse impact on reserve space, either surface or subsurface, on any lots located in the area. 4. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. The current drainage pattern will be maintained. Sincerely, -P-4'6'L' E- C - �' Michael E. Anderson, P.E. Attachments W 0- :�• 49th••••••: MICHAEL E. ANDERSON k. NO. CE -4381 14. f fWESSICt�iO —I Ln �O 0 D C —I 7 D � C cn 0 z (n C CO CO�5 0 C 00 - o mCj) r O 0 C un 0 M O i M Ln rnG y z z Existing Irrigation Well LOT 45 14"E 329.67' LOT 53 109,860 S.F. / DRIVEWAY TO SOUTH BIRCHWOOD LOOP 20.2'x20.4' SHED STEEL FENCE 2-20' Long x 5' Wide x 4' Effective Depth Absorption Trenches _ co ` Co MT OVV C( _Co®MTTHSFSV / / / / GRAVEL___ DRIVEWAY - _ \ \ c LIGHT POLE Septic \ \ / ALTERNATE SITE \\ / f Advontex Treatment System with 13' Long x 5' Wide x 4' Effective Depth Absorption Trench. I Exist Exist' I ® I �\ / ttTRIIC \ �\ 13.6'x17' LOG CABIN \ \\ 4)0 "+,,,r, \ USeas fcta�e. / per M� ' t ' L GEND I------��/ MT - Monitor Tube NOTE' FCO - Foundation Clean Out I No Areas of Excessive Slope or Surface TH - Test Hole CO - Clean Out Water ore Within 100' of An Part of the I Y FDV - Flow Diverter Valve I New Septic System. No Wells or / Wastewater Systems on Adjacent Lots / Conflict with the Proposed Septic System. N 89'43'22"W 330.49' LOT 56A SCOPE OF WORK Expose Existing Septic Tank and Verify Suitable for Relocation. Decommission Absorption Trench in Accordance with Municipal Code. Relocate Septic Tank and Construct 2-20' Long x 5' Wide x 4' Effective Depth Absorption Trenches. Place Flow Diverter Splitter Valve to Insure Even Flow. SITE PLAN SCALE 1" = 50' LOT 46A LOT 52A N O O N N W rr W W N N LOT 560 �:• ••; . ®�: ;z}1 AV49th /. j}}, ...... �......n..,.,. i ................................................ MICHAEL E. ANDERSON f No. CE -4381 :�Zi AV "'k -Zj -1 Z,••••' �FaC'i ♦� �z)�R�FESSI4��i��• LOT 52C LOTI1 BLM LOT 53, SECTION 30, T15N, R1 W DESIGN FACTORS: SYSTEM REQUIREMENTS: Three Bedroom Home 5' Wide Trench System Perc. Rate: 2-5 Min./Inch 1,000 Gallon Septic Tank Application Rate: 1.2 GPD/SF 4' Drainfield Rock 3 Bedrooms X 150 GPD/1.2 GPD/SF(Application Rate) = 375 SF Absorption Area 375 SF/5 SF/LF-.5 (Red. Factor) 37.5 LF Trench Length THEREFORE: Construct 2-20' Long x 5' Wide x 4' Effective Depth Aborption Trenches at the Location Shown. Flow Line Elevation in Trench to be 2' Below Original Ground Surface. Total Depth to be 6' Below Existing Ground. Provide 3' of Cover Over Trench and 4' Over Tank or Provide 2" of Insulation and 2' of Cover. Maintain 10' Separation From Water Services in the Area. Place Flow Splitter Valve to Insure Even Flow to Each Trench. Natural Backfill 1'6" Geotextile Fabric 6" 0 4" Perforated PVC (Holes Down) MI 5' Drainfield Rock TYPICAL DEEP TRENCH SECTION (NO SCALE) NOTE: Grade Area Over Trench to Drain Away. Minimum 6' Separation From Bedrock. Minimum 4' Separation From Groundwater. Minimum 100' Separation From Private Wells in the Area. Minimum 100' Separation From Surface Water or Streams. Minimum 10' Separation From Water Service Line. *•— -44� ar �y , .: 49th ..... 79- -. Michael E. Fu ►,ted,, : No. CE4381 ��� ♦����;;OFES S=� ��• Municipality of Anchorage Development Services Department Building Safety Division • �r On -Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www.ci.anchoraoe.ak.us (907) 343-7904 a MICHAEL F_ d>,t DWS"ON r8 Soils Log - Percolation Test Performed For: {� V K WO�2-C/ Date Performed: !V T Legal Description: Section 30 T1 5N. R1 W. Lot 53 _ Township, Range, Section: 1- 2- 4- 5- 6- 7- 10- 11- 12- 13- 14- 15- 16- 17 18- 19- 20- Depth (Feet) G L ,,)rze Tian T 6 YA._�j - 64k A, V-A roll WAS GROUND WATER Date ENCOUNTERED? No Depth to Water s IF YES, AT WHAT DEPTH? XXX L Depth to Water After P — Iv P Monitoring? E Date: Z I Reading Date Gross Time Net Time Depth to Water Net Drop �Iv II �3�1?. tiv a A i,w 4: I � fr /V mw 13•��3�3 � ��p to '' .S1 II•� .I I� I u PERCOLATION RATE (minuteslinch) PERC HOLE DIAMETER 7 " TEST RUN BETWEEN FT AND' ;L• J�r;_ FT COMMENTS TEST CAVITY was presoaked prior to Percolation - PERFORMED BY: A. Harala I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Jim Sullivan PO Box 770197 Eagle River, AK 99577 5IS ' HR (907) 688-2510 1 �1739! (907) 258-2510 (907) 745-2510 � an w',%,Llci.net Well Drilling Permit Number: SW Parcel Identification Number: Date of Issue: Arctic Pump & Well, Inc. Page 1 of I Legal Description:T15N RlW S30 Property Owner Name & Address: Lot:53 Paul Mallory Block: 15894 S Birchwood 1p QQ567 Pump Installation Date: 4-28-12 Pump Intake Depth Below Top of Well Casing: 54 Feet Pump Manufacturer's Name: Tait Pump Model: 5P37 Pump Size: 1/2 hp Pitless Adapter Burial Depth: feet Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: NONE Well Disinfected Upon Completion? Yes Method of Disinfection: Chlorine Comments: 9.5 static 2'stick up 15' casing set into bedrock Water infiltration 35'and 41' 61' Total depth Pump Installer Name: Arctic Pump & Well, Inc. Arctic Pump & Well, Inc. Page 1 of I