HomeMy WebLinkAboutKOBUK TR BMark Begich
Mayor
Development Sewices Department
Building Sefety Division
On-Site Water & Wastewater Program
4700 Elmo~e
P.O, ~ox 196650
Anchorage, AK 99507
www.muni.orq/o~ite
(~7) 343-79~
Pump Installation Log
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Well Drilling Permit Number: SW
Date of Issue:
Parcel Identification Number:
Legal Description
Pump Instillation Date:
Property Owner Name & Address:
JJ ~.~.t Hv[D~,,O ~..0 .
Pump' Intak~e Depth Below Top of Well Casing: 0'O feet
Pump~Manu, facturer's Name: ~V~.~O~
Pump'Model:
PumpSize /O hp
Pitless Adapter Burial Depth: /t9 feet
Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer:
Well Disinfected Upon Completion? ~Yes [--] No
Method of Dislnfection:
Comments:
Pump Installer Name: ~Je}¢ ~ 0~ ~, t~,~'l ~; &
.~ll~erage Well-& Pump Serv!ce,
330 East 76th Avenue
~chorage, AK 99518
Phone: 907-243-0740
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
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.