HomeMy WebLinkAboutT12N R3W SEC 29 PARCEL 4C
MRY-5-2015 08:23R FROM:
TO:3437997 P.1/1
Municipality of Anchorage
Community Development Department
On -Site Water and Wastewater Program
4700 Ehore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http.,/hvww.muni.orglonsite • (907)
343-7904
Well Decommissioning Log
Legal Address:
Subdivision Block Lot
T f j R 3 V Section, _ Lot L( L 11400 �up4t�
--
On,sita Water 8 Wastewater Program ceriiged contractor performing the well decommissioning:
Name: �irt y u signature:
Am 1A_ I �� 1f ,,
Company: Am 1A`f I'i�{,r .�1 C
CCII
WBa decommission':ng dare J' 'Pf Ldethod of decommissioning: AMC 15.55.0600 a. ❑ b.0 O.
Location: Use the space below to provide a drawing of the property showing the following Items;
North arrow
• Decommissioned well,
• Other water wells on this property,
• Two seporate ewingdie distances for each *V shown on m@ drawing,
Nota; The swingdle distances shall be measured from either permanent structures or the property corners.
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RL UEST FOR' APPROVAL O[~iiiii
(Fill out in T~iplicate)
flame .of perao~ reques%ing approval ......
Mame of p~ope~ty owne~
Number of bedrooms in house~
a. Bacterial ,
b.
De'te~gent ~ "~', ,
Well data:
c. Casing Size ..
d. D~stance from well 'to closest existing
1, Sewer iine
Ar __ll
5. Property Line
6. O?her sources of possible contamination~ i.e.~ creeks~ lakes,
houses~ barn~ drainage ditch~ etc.
Sewage disposal system.
a. Age of system__~<$.
b. Septic tank capacity in gallons
c, Name of septic tank manufacturer
1. If "home reade" show diagram on reverse side of this form.
Disposal field or seepa~e pit size and type
1. Distance to property line to house foundation
e, Percolation, Test results
f. Percolation 'Pest performed by
Use the reverse side of this form to show diaFpam, Diagmam should include
the foJ]owing information: p~operty lines~.we]iL location, house location,
nap~c tank location, disposal area location, location of percolation test,
ar, d direction of gr'ound slope.
9. The [~[orma~-ion on tbls form is true and correct to the best of my knowledge.
nature Date Si?ned
TO BE FILLED OUT BY HEAl,TH DEPART~!ENT PERSONNEL
~e above described sanitary facilities are hereby approved, subject to ~he
...... ~611owin? conditions: -- ~-
Conditions: ~-)L_~_
The above described sanitary facilities are disapproved for the following
Sign~tore oF~lcral~ ' ,.' Date '!
Approval is valid for one year following the date of approval,
CPJ:cw
fineho~,age~ Alaska 99502
GUBJI:C'i' ~ Pa~o~ ~lC~
W, 209~, H, 209~ E, 200~,
point of be{{tnning
Th~.~ le~er :la to cortifv that public or- ¢omrauntt:y
eeonomteal!V faaatbla to the sub,eat parcel of land.
DAVID R, L, DUffCAN~ H,
l.ied ~.ca 1 B~.reetor
Clifford P. Judktns,, R. ~.
Chi. of Sauttarian
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Tmiplicate)
lla~,~ .of person ~equefitln~ approval__
2.
of property ownep .
~h Numb~,'~f~ bedrooms in house~.
5. WaterAnal~&s' ,.
a. Bacterial
b. Detemgent.~ '"'_' .
Well data:
c. Casing Size
d, Distance from well to closest existing or proposed:
1, Sewer line
2, Sept~ c tank ?,~/ ,
~, Saepa~e Area /~/
4, Cesspool' /C/)O/
5. P~operty L~ne.. ~___.
6. Other sources of possible contamination, i.e., c~eeks, lakes,
houses~ ba~n~ drainage ditch~ etc.
Sewage disposal system.
a. Age of system 3~/~<'
c. Name of septic tank manufacturer
].. If "home made" show diagram on reverse side of this form.
Disposal field or seepage pit size and type
~
1. Distance to ppopePty llne ~O' 3o house foundation.
f. Percolation Test performed by __ ---'
· ,~. Use the reverse aide of this form to show dlaFram, Diagram should include
.the foJ]owil~g ]nformati(.n: p~operty lines~.well location, house location~
~pt~o tank location, disposal area location, location cf percolation test,
aad direction of Fround slope.
9. The h.£ormat~on on thislfor~r is true and correct 'to the best of my knowledge.
TO BE FILLED OUT BY HEALTH DEPARTI~E~'T PERSONNEL
~The above described sanitary facilities are hereby approved, subject to the
]~6]lowin? con,ii, ions:
Conditions:
The above described sanitary facilities {~re disapproved for the following
S~grlature of ~f,f-io~fi'~.~ "' ",,' ;.
Date
Approval .is valid for one year following the date of approval.
CPd:cw