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HomeMy WebLinkAboutPURINGTON LT 9Onsite File Purington Lot 9 #008-032-25 ]Vi-W DRILLING, Inc. P.O. Box 10-378 0 10300 Old Sewara H~ghwa, (907) 349-8535 ANCHORAGE, ALASKA 99511 DRILLING LOG Well Owner Lou±s Di.O~LP~8~L Use of Well Dommastic Location (address of: Township, Range, Section, if known; or distance main roa& Size of casing ~"_ Depth of ttole_ 82' feel Cased '._,. (:;0. /' fuct Static water level 3~..'___ft. ~4Ib'~} (bclow))and suriacu. Finish of wc. lJ luheck one) Screen ( ); Perforated ( ). cd,eh enci ( x ); Describe screen or perforadm~_ . .... \Veil pumping test atl,zq_. 5 §allons per :(,~m2x) (minute) for ii hours with ~05% X~ of drawdown from static level. Date of eomp]etion WELL LOG Depth in feel from ground surface MUNICIPALITY OF ANCHORAGE DPT Cc [':'LT'! p- Give details of formations lie mtrated, size of material~t,~7_,.,eoitor a;4d~;~,~]dnessh~ m~,- Ca sJ_n~ Sr 5 c_k:up _~$ihL~Lao s e G~ava], _ __1~ 0 _33 --Sil_[-y~Har. d dlan 3~8_._T0 46 Si1 tbt_Cr2~cl 46. TO 61 RECEIVfr D _~Siltv~IkTr d Pan ....... ...... TO. TO. _ _ _TO S,/a t er__ _Grs xm]_ . i -- CUSTOMER PERMIT NCL :'F'LICFINT LOIJIS C [:,IONIL-L]E COI-,tST C: J.:t~:LE~ 1.4. E, TH tfq. C~5 OCFIT I ON .EGRL LT. 9 F'UF.:INGTON S,.."[:, LOT SIZE 274-;?985 :'.a.~999 SL.]URRE FE:ET /,IINIMUM [:,I:STRNC:E BETI,.IEEN FI HELL RN[:, lal'.4'T' ON-SITE SEI.4RGE [:,ISPOSRL S"r'STEM tL."r.~E~ FEE]" FOR R PRIVRTE I.,.IEL. L OF.': ±SE~ TO 2C~E.~ FEET FROM R PUBLIC HELL [:'EPEN[:'ING I...IPON THE ]'"r'F'E OF PUBLIC HELL MINIMUM [:'IS]'FINCE FROM R PR I ',,,'RTE WELL TO IX PRI',,"RTE SEI.4ER LINE IS 25 FEE]" laND TO FI COMMIJNI]""r' SEHER LINE IS 7,5 FEET. HELL LOGS RF.:E REQUIRE[:' RN[:' MLIST BE RIETIJRNE[:' TO THE [:'EF'RF.:TMEIqT HITHIN OF THE HEL. L COMPLETION. O]"HEI;.: REQUIREMENTS MR'T' RPPL"r'. SF'ECIFIClaTIONS laN[:, CONSTRUCTION DIRGRFIMS FIRE R',,,'RII..FIBLE TO INSURE PROF'EF.: INS'FRt. L. RTION. I CERTIF'¢ THFIT 1: I FIM F:RMILIFIR I.,.IITH ']'PIE: REQUIREMENTS F'OR ON-SITE SEWERS FINE:, 1.4EL. LS FIS SE]" FOR'f'H 8"r' THE MUNICIPRLIT'T' OF RNCHORRGE. 2.: I t.4IL:LI~TFILL ~E ~%TEM Il',' .FIC:C2R~;SI"'a THE CODES. ',,,' 4. El () 0') V! I? 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WELL DATA Well log is filed with Onsite (or attached) Date drilled 7/1/1982 Total depth 82 ft Cased to 80.7 ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) 28 in. Date of flow test for COSA 8/20/24 Static water level at beginning of test 26 ft. Well production at time of test 4+ gpm Water storage tank volume NONE gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date 8/20/24 Comments __________________________________________________________________________________ B. TANK DATA – PUBLIC SEWER Measured operating fluid level in septic tank Date of pumping Required maintenance completed, if AWWTS Comments: C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA - PUBLIC SEWER Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field. Per record drawings, field is insulated. Monitor tubes go to bottom of effective. If not, state depth into effective Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Adequacy test date Results Pass Fluid depth prior to test in Water added gal New fluid depth in Elapsed time min Final fluid depth in Absorption rate gpd FIELD STATUS – POST RECOVERY Effective depth (per record drawings) in Effective depth used in Effective depth remaining in Comments/Deficiencies: COSA Checklist WELL ONLY.docx E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100’ Yes if No NA ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No NA ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft N/A – Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Tank to Property Line > 5’ Yes if No ft Field to Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If tank or field is under driveway comment below F. ENGINEER’S COMMENTS G. CERTIFICATION & STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm FIRST WATER CONSULTING Phone 907-350-9566 Engineer’s Printed Name CURTIS HUFFMAN, PE Date 9/6/2024 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory for current or future occupants or guarantee that no unseen encroachments, deficiencies or discrepancies exist can be given by First Water Consulting & 9/6/24 ��/�UMCP " U T Y OF As HCH0F QZAGE Development Services Department I Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 008 032 25 1. GENERAL INFORMATION Complete legal description PUR . INGTON LOT 9 Location (site address) 4128 BRANTLEY Current property owner(s) Hugo Mailing address Real estate agent 2. TYPE OF DWELLING: Df Single Family (w/ADU) Duplex Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 Expiration Date: ,Z - q r zo ZZ Day phone Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well 0 Private Septic Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer �C] Waiver request for: NO N E Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Q Waiver Fee $ Date of Payment ��(�Z I Date of Payment Receipt Number --D 22Z--1-0- Receipt Number COSA # 0 5 C 2 1 1,6 50 Waiver # 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm C&M ENGINEERING Address 20182 TULWAR Engineer's Printed Name CHARLES BALZARINI 6. DSD SIGNATURE System #1 Approved for -13— bedrooms System #2 Approved for bedrooms Disapproved Phone 8545558 Date 10/28/21 OF A�gsjl �,o!'c.• 9 �� ,;�e *: 49 TH •.* CHARLES G BALZARINI -;eF`•• CE -13854•0` PROFESSIONA�'.0,� Conditional approval for bedrooms, with the following stipulations: t( OF n 6- -C SITE Ger: g WATER AND z= PROGF.AM C� )SElllll\���� By: Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other COSA Checklist blue sheet COSA Checklist Legal Description: PUR .INGTON LOT 9 Parcel ID: 008 032 25 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system 1 A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 711182 Total depth 82 ft Cased to 80.7 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) +12 in. Date of flow test for COSA 10/28/21 Static water level at beginning of test 25 ft. Comments Well Only, No Septic Well production at time of test +5.5 gpm Water storage tank volume NA gallons Well disinfected for coliform test? ❑ Yes ❑ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by C.Balzarini Date of Sample 10/28/21 B. TANK DATA C. LIFT STATION Age of tank(s) years ❑ Required maintenance completed Tank type/material Age of lift station years Measured operating fluid level in septic tank Lift station material ❑ Standpipes/foundation cleanout per record drawing Comments: Date of pumping D. ABSORPTION FIELD DATA Which system tested (date installed) Adequacy test date ❑ ALL standpipes present per record drawing Results ❑ Pass For bedrooms Total measured depth from grade ft (max) Fluid depth prior to test in Measured depth to pipe invert from grade ft (min) Water added gal ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state New depth in depth into effective Elapsed time min ❑ Code -required soil cover over field Final fluid depth in ❑ System presoaked Absorption rate gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) date of test) _ Gallons introduced gallons If yes, enter date Comments/Deficiencies: well Only, No Septic COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ❑ Yes if No Community Sewer Manhole/Cleanout > 100' If absorption field is under driveway comment below ❑ Yes if No ft M Yes if No ft Neighboring Tank > 100'✓❑ Yes if No ft Private Sewer/Septic Line > 25' ❑✓ Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' ❑✓ Yes if No ft Neighboring Absorption Fields > 100' Animal Containment > 50' ❑✓ Yes if No ft ❑✓ Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' MYes if No ft 0 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots: Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft - - Water Main > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' ❑ Yes if No ft If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots: Water Main > 10' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS Well Only, No Septic G. ENGINEER'S CERTIFICATION 1 certify that l have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date.. 10/28/21 COSA Checklist yellow sheet 0 Assw 001 CO 49TM ../ CHARLES G BALZARINI CE -13854 pROFESSIONP • Municipality of Anchorage On -Site Water and Wastewater Program -_ (907) 343-7904 Certificate of On -Site Systems Approval Parcel I.D. 008-032-25 Expiration Date: 1 " _ -20-z 1. GENERAL INFORMATION: Complete legal description PURINGTON; LOT 9 Location (site address) 4128 Brantley Place *Anchorage 99508 Current Property owner(s) Franceda Veal Day phone Mailing address Real Estate Agent 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual ❑ Individual Water Storage ❑ Holding Tank ❑ Community Class_Well ❑ Community ❑ Public Water System ❑ Public Sewer WaiverNariance request for: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Z'aO Date of Payment Z�iriA2 I Receipt Number __00 ylc( Cr COSA# dsG2\ 1937 Date: Waiver Fee $ _ Date of Payment Receipt Number Waiver # 6 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm: Garners Engineerinq Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. 6. DSD -�--IGNATURE System #1 Approved for bedrooms System #2 Approved for bedrooms Disapproved Conditional approval for bedrooms, #AECC884 with the follctt/g p � A nn Tin J � J 1 "'))M) ;JI Original Certificate Date: P-3 "ZC9Z� The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist_ Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other J -)A COSA CheckUs't Legal Description: PURINGTON; LOT 9 If more than 1 septic system on loft: COSA Checklist # of A. WELL DATA © Well log is filed with Onsite (or attached) Date drilled 7/1/82 Total depth 82 ft Cased to 80.7 ft 01 Sanitary seal is functioning correctly IM -1 Wires are properly protected Casing height (above ground) 12+ in. Date of floe. 'test for COSA 7/10121 Static water level at beginning of test 27 ft. Comments IS. TANK DATA Age of tank(s) years Tank 'type/material I'V1easured operating fluid level in septic tank ❑ Standpipes/foundation cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA Which system tested (date installed) ❑ ' ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) ❑ N/A — pressurized field ❑ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Code -required soil cover over field System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Comments/Deficiencies: COSA Checklist vellow sheet Parcel ID: 008-032-25 Structure served by this system Well production at time of test 6.6+ gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes Al No Coliform bacteria is Negative Nitrate mg/Litrate less than MRL (ND) Arsenic ug/L [ rsenic less than MP,L (ND) Collected by GEG, LTD Date of Sample 7/13121 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date Results ❑ Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ❑ Yes NSA Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft ❑ Yes if No Neighboring Tank > 100' ❑✓ Yes if No ft Private Sewer/Septic Line > 25' ❑ Yes if No Absorption Field on Lot > 100' ❑ Yes if No NSA ft Holding Tank > 100' ❑7 Yes if No Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ❑✓ Yes if No Q Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' ❑ Yes if No ft Q Yes if No From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No. Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots: ❑ Yes Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No. Water Main > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No_ Water Service Line > 10' ❑ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) ft ft ft ft ft ft ft Building Foundation > 10' ❑ Yes if No ft if absorption field is under driveway comment below Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots: Water Main > 10' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Surface Water> 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records tha6 the above systems are in conformance with MOA COSA guidelines ih effect on this date. COSA Checklist yellow sheet `7.1.1 r... �. V .Z y. U ,J Garn ss. �/ L1� vArofessio�\ #AECC884 Zr,2D 22.0 rA0(n E c/) cnDm cn Omzz -iZO� D O O X°moo m §z0�o NOzm -' zz=o I1 0mmo ---- 0 0 ON O 0 m� j os a m = D z VJf� MM E. am N -i (D CJ N C S 22.0 _,CCD0 m CYm a O O -n O CDa x c I:..,.. n o m m m Q S N N N CD 2O N (p D) CD N C = j d O a m = Q VJf� MM m 0 z. o n o " W m �. c m o CD co C _. cCD CD a @ O CTI 0 EK acs 3.0 t�D 0 @ 3No-a N r,J + N _ o p m (D �a S b a n 9 o o ! 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O c (p .Z1 Dl "O N p O ro ro c)@ 0 N y 7 3 m .� ....�� m ro S. �m o°N a co 7C3 mac `moo .-> a m -- N ao N D cn c 3-0 3 an d m 3 ;7 w � ID Cn D' N (D in-' = o•: � as tCD CL i ox Ln. zSp v5 0= (D 0 � � =,3m (D N (Da 7• o' (D m (p S D m (D o o m mcr��' ocn So�o��(u o(n fD U) O y (n N a z ,� p (D nc m Cr (D O (� o re 0 'a - m y 0 «N o D CO o- ID m� � ro to N m o 0. c � m am e m d o ¢ai U) a �' cn �. r C° O i- C� I- 0 N 00006'00" w u� 22.0 O O O d O I:..,.. n Q 3 v !� cD d O Q O � � � v CD �. i. _ i @ Q. t�D 0 @ O I d C7 r- m QO 26.0 r� ; 00 Un CD CD 22.0 O d I:..,.. n 3 !� cD d O (' O � •-19. • cn 00 i. _ i @ Q. yi N 0 @ O I d r� ; 00 Un CD CD 22.0 N 00006'00" w 50.00 O d BRANTLEY PLACE co 4�11 00 {n 17 DO, 00 R I NC; 0 N NO 9A 9 N I rk APPLI¢ NT FILLS OUT UPPER HA~ ONLY Address Zip Code Lending Institullon Phone Address Zip Code Realty Co. & Agentz~2,- ~-- ;.~ ?~'~ , ~ / ~ ~ Phone Legal Description//~..o ~- 'J ~.L-~"* / ~-L~--/ .7~, ,, ~2 Street Locati~ )~/.~j'{ f /~-/ ', Type o~ Resi~nce  Single Family Multiple Family No. of Bedroo~ ~ Other Water Supply .~ Individual A~ACH WELL LOG. A w~l Icg is required for all wells drilled since June 1975. ~ Community For wells drilled prior to that date, give well depth (attach Icg if available). ~ Public Utility Sewer Disposal ~ Individual Year Individual Installed:  Public Utility When Connected to Public Utility: Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Date / ~.- .- / '~ .- ~ -~ Date Date Date Inspector Inspeclor Inspector Inspector ,~C4~' -- (-~ ~)'-IG%~ ,~L~ E?',, ~'~ ...... ~U~ .... ~ ~v ~ ANCHORAG~ DFPT Cc :':'LT~ RECEIVED (~) APPROVED BEDROOMS ~ 'CONDITIONS OF APPROVAL ~ ~ ~s,..~ov~ ~ } CON~T~ON*~*..RO~' Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received Well 1o Tank Septic T~k Size 72-023