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?arcei Identification
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MUNICIPALITY OF ANCHORAGE
/~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIGN
~_,~ ~(. "~lJ II/-'~ENVIRONMENTAL ENGINEERING DIVISION
t 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME [PHONE ~NEW
~AILING ADDRESS
~EGAL DESCRIPTION
pL ik
~DCATION NO, OF BEDROOMS
DISTANCE T0: Well ' Absorption are~ Dwelling ~ PERMIT NO.
Material No. of compartments,~
~ ~ Manufactu ret C~ g~'~ ~s~ '
~ ~ Liq. capacity in gallons Inside length Width Liquid depth
/¢¢~ IF HOMEMADE:
Well Dwelling PERMIT NO.
~ ~ DISTANCE TO:
,J~
O Z ~ Manufacturer Material Liquid c~pacity in gallons
~ ~ Well Foundation Nearest lot li~)e PERMIT NO,
No, of lines t Length Trench width
Total length o~jn%~ Distance between line~
~- Length Width Depth PERMIT NO,
~ ~ Type of crib Crib diameter Crib depth
¢ DISTANCE TO:
M Class Dep~ Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area{s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOIL TEST RATING
-
INSTALLER
REMARKS
2oc< ---
LEGAL
72-0~3 (Rev. 3~78)
MUNICIPALITY OF ANCHORAGE
Department 'f Health and Environmenta Protection
825 ~ Street, Anchorage, AK. ~9501
264-4720
* * * HANDWRITTEN PERMIT * * *
Permit 9~L}.)~Q,~-). WELL~ANDt~J~%~ON-SITE SEWER PERMIT /~C$.~ '
Applicant: _~ ~ [,/~.!"~ (~,~ Mailing Address:
Location: Phone Number:
76 . .../. _ Lot si e:
:Legal
Description:
Type of Soil Absorption System Is:
Trench: ~,-'~Drainfield: Seepage Bed: HoldingL.Tank:
Maximum Number of Bedrooms: Soil Rating(sq.ft/br)
The Required Size ~-~e Soil Absorption System Is:
DEPTH ? LENGTH~~k"~r~//. GRAVEL DEPTH F WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HE)C-D'I'Ma3~ TANK SIZE = /O~C~ GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this departmeni
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 fee!
for a private well or 150 to 200 feet from a public well depending upon the -type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and' wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may re~ire enlargement if
the residence is remodeled to include more that ~ ~ed,~ooms.
Applicant / Date: ~. ~-~//_~
SWP/024(1/81)
s
& ENGINEERS,
INC.
7125 OLD SEWARD HWY.
ANCHORAGE, ALASKA 99503
349 - 6561
S()IL S
9
10
11
I[',
14
15
16
17
20
SITE PI. AN
WAS GROUND WATER
ENCOUNT~RED~
s
o
E
Gross Net
COMMENTS
TEST RUN BETWEEN
,,u
Oeplh iD Net
WRier Drop
I,,.5" 1,5"
FT
APPL! 'NT FILLS OUT UPPER 'ONLY
-ProPerty Owner d /<9~ ~"- ~/¢'./2/~./ &/ Phone
Lending Institution ~¢/¢/ (~ ~/] ¢[/ /¢ Phone
Address Zip Code
Realty Co. & Agent /~/ o ~//- Phone
Address Zip Code
Type of Residence
~ Multipl~ Family No. o~ B~drooms
~ Other
~lndividual ATT~GH WELL LO~, A well Io0 I~ ~quim~ 1o~ ~11 w~ll~ drilled sino~ ~une
~ Community For wells drilled prior to that date, give well depth (attach log If available).
~ Public Utility
Sewer Disposal
~ Individual Year Individual Installed:_
B Public Utility When Connected to Public Utility:
~olding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED.
Time Time Time (~, '~'%;%, \~/
Time
Date
' ~-- "'~ ~ OF HEALTH
,CONDITIONA, A,eOVAL' ~ ~
DATE . ~////~Y~
Soils Rating Date ~wer Inslalled Well To Absorption Area Well Log Received
Well to Tank Septic T~k Size
72-023 (3t82)
CHEMICAL & G LOGICAL LABORATORIES ~" ALASKA, INC.
· TELEPHONE (907)-279,4014 ANCHORAGE INDUSTRIAL CENTER
274-3364 5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
Water System Name " Phone No.
.. ,. ~ .,'ii~
Mailing Address
City State
Mo. Day Year
Zip Code
SAMPLE TYPE:
[-'J Routine
E) Check Sample (for routine
with lab ref. no.
E] Special Purpose
sample
[] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results, Please send
new sample.
Daie Received 'i
Tirne Received
Analytical Method:
[] Fermentation Tube
[] Membrane Filter
Lab Ref. No. Result* Analyst
F-I-]
J t-T-1
I
I
*NO of colonies/lO0 mi. or No of Positive portions.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev, 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collecte¢l Source
ecelved ---- Lab, No,
Presumptive ].Omi 10mi Z0ml 10mi 10mi 1,0mi 0,Zml
24 Hours
48 Hours
Confirmatory
24 Hours
46 Hours
EMB
Multiple Tube Report=
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter Results
Reported By
Broth 24 hours: __Broth 48 houri:
10m1 Tubes Positive/Total 1Omi Portions
Collform/lO0ml
BGB
' Collform/100ml
Dato ~
Time! ' ', __e.m,