HomeMy WebLinkAboutNEWLAND BLK B LT 3
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Municipality of Anchorage
Community Development Department
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
Well Decommissioning Log
Legal Address:/t
Subdivision Jun -'J Block, Lot
T R Section Lot
On-site Water & Wastewater Program certified contractor performing the well decommissioning:
Nam ) , 7G,-)
Companny�
Signature:
Well decommissioning date 6 Method of decommissioning: AMC 1 5.55.060L1 a. ❑ b. ❑ C
Location: Use the space below to provide a drawing of the property showing the following items;
• North arrow
• Decommissioned well,
• Other water wells on the property,
• Two separate swing -tie distances for each well shown on the drawing,
Note: The swing -tie distances shall be measured from either permanent structures or the prooerty corners.
J,
R.
G:\Community Development\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Well Decommisioninq form.doc
~o~da to vevi~ ~ th~ ~etu~e (s) is ~ i~ not ~1~ and
~'u~ 30, tB76.
!970
Subdivision
The Creator ¢¥,lchorage Aroa
took (:our (4)
October 7, 1970. 'l-he results ~,iere received on (')ctober
9~ 1970 anti are sat:i.s.i[actory.
5bmercl. y ~
CLIFI:OIiD P. , ,,,:c !i.5o
^dministrative Director
linvironmcntal l-fealth SUF, ervisor