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r bevelopment Services Department
Building Safety Nvision
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Watt A Wastewater Program _ <<
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470 J e
F1mor Road�..� L
F.C. Box 196650
Man', Bagich
Anchoroge, AK 995017
Mayor
www. enuni.crg!Ons; te
(507)343 -?904
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Pump Installation Log
Well .Drilling .Permit Number: Sir_.------
Tete of Issue:
Parcel Identification Numrier: 001-
B2 -9q
1:egai Dewription Frnn�erty OK•ner P- me �� 4.(1 ess:
� �i C �S � Fl z L13,9-1 � c� � .,� .�a v.� �►a c '211Z
Pump Instalkition Tate:
Pump lir_take Depth Lelaw Top of NVell Casirr : f 7 Meet
Puinp Manuhhcture-ys Narne: A V rVj ��,•��a5?rcp
Pump Model: A %!r1 7 V /
Pump Size ha
I'itsess Adapter Burial Di-pth: f feet
j Pitiess Adapter Manufacturer 's -N avte:
Pitless adapter Installer: A)'r-A
-11
Weil 13isiufe.:ted Upon C.onll3letion?. Yes D. ,4o
Method of Nsinfeetion:
9 Curninents.
Ful -tip (installer Name-
t 1
`�,�'i�1�V � t ,�, � � � • � �U bit
p
ttention: The puLnp iuscaller shall provide -- pump insta ile.ticrt Log to ttie DSL') wi8uii 30 days of purnp izs.el'_aticr..
Mark Begich
Mayor
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Rood
P,O. Box t96650
Anchorage, AK 99507
www.munLorq/onsit¢
(907) 343-7904
Pump Installation Log
Well Drilling Permit Number: SW
Parcel Identification Number:
Legal Description
Pump Installation Date:
Date of Issue:
Property Owner Name & Address:
Pump Intake Depth Below Top of Well Casing: [t]~ feet
Pump Manufacturer's Name:
Pump Model: C~tl
Pump Size ] hp
Pitless Adapter Burial Depth: ~ feet
Pifless Adapte~r Manufacturer's Name: /
Pitless Adapter Installer: /
Well Disinfecte~ Upon Completion? ~Yes [] No
Method of Disinfection: ~1 tl I~ G~_].L t~'~",,~
Comments:
Pump Installer Name:
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.