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I~ERt'"i I T NO.
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STREET., ANCHORAGE., FIK. 9~.
2.64-47:::_'F'~
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[:,RIVE 9950]: 24-~:-5±04_
LOT SIZE 4900E'~ SQLIFIRE FEET
MINIMUM DISTANCE BETWEEN R WELL AN[:, ANY ON-SITE SEWAGE DISPOSFIL SYSTEM IS
100 FEET FOR R PRIYATE WELL OR '150 TO 20F'~ FEET FROM FI PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM [:,ISTRNCE FROM R PRI',,,'FITE WELL TO FI PRIYATE SEWER LINE IS 25 FEET FIND
TO A COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS FIRE REQUIRED AND MUST 8E RETURNED TO THE DEPARTMENT WITHIN ]:0 DRYS
OF THE WELL COMPLETION.
-OTHER REQUIREMENTS MAY FIPPLY. SPECIFICATIONS FIND CONSTRUCTION DIFIGRFIMS ARE
R',,,'FIILRBLE TO INSURE PROPER INSTFILLFITION.
F'EF:~"t I T E::-(}'=" 1] RE'--'] E:.,EE:-E~'-'~E:EF..:
I CERTIFY THFIT
!' I RM FAMILIFIR WITH THE REQUIREMENTS FLR ON-'--.ITE SEWERS FIN[:, WELL~ RS SET
FORTH BY THE MLINICIF'FILITY OF HNCHUF..R=E
.2: I WILL INSTALL THE .=-r=TEM IN ACCORDANCE WITH THE CO[:,ES.
S I GNE[:,:
HFFLI _.HN] ALLEN .-,E~ IELL
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tV1-W DRILLING, Inc. · ;
P.O. Box4-1224 · 1310C International Airport Road
(907) 274-4611
ANCHORAGE, ALASKA 99509
DRILLING LOG
,,i i .... ,~'.,,~i. UseofWe]] ::~' :' '
Well Owner_
Location (address of: Township, Range, Section, if known; or distance main road
Size of casing_ '' Depth of Hole
Static water level "'" ft.
Screen ( ); Perforated
'~' feet
feet Cased to
(below) land surface. Finish of well (check one) open end (
).
Describe screen or perforation :~ j/'
Well pumping test at ,f,:~ gallons per of drawdown from static level.
(minute) for_ '~ .hours with '~," r :
Date of completion ~ ~-; ] ' "'" '
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
TO_ " (L__t; ';.~.:-
.TO.
TO_
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TO
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);
ft.
Ce~iea~e No's. 814 & 9-/.3
3--CONTRACTOR
; '--_ ,/ D~i~E RECEIVED
x INSPECTION APPOINTMENTS
TIME TIME TIME
INSPECTOR INSPECTOR INSPECTOR O_
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCH!ORAGi}
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPL OF
825 L Street - Anchorage, Alaska 99501 ENVIRONM;
uu i o 0 1981
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
" I PHONE
MAILING ADDRESS
PHONE
PROPERTY RESIDENT (If different from above)
A..- ~"'r~'~/, Z~~E~';~---~-~ I PHONE
MAILING ADDRESS
I PHONE
4. REALTOR]AGENI
MAILING ADDRESS ------------
5. LEGAL DESCRIPTION
~TREET LOCATION
6. TYPE OF RESIDENCE
~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OFtBEDROOMS
[] One [] Four
[] Two [] Five
~ Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL~
COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BEDROOMS
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SIX
2, WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3, SEWAGE DISPOSAL SYSTEM
[]INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or E~] Holding Tank
Size: If Tank is homemad~
give dimensions:
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
OTHER
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5, COMMENTS
DATE
E~/APPROVED FOR
~-~ BEDROOMS
CONDITIONAL APPROVAL (letter must accompany certificate)
DISAPPROVED
72-010 (Rev. 6/79)
CHEMICAL & G,,i,_?LOGICAL LABORATORIES F ALASKA, INC.
TELEPHONE (g07)-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.
~ailing Address
City State Zip
Mo. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no. )
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO.
1
2
3
4
5
LOCATION
I /:c (' o,-~,I
I I
l I
I -I
I
Time Collected
Collected ~? .~'
/,~' c~.
TO BE COMPLETED BY LABORATORY
,~.~na ysis shows this Water SAMPLE to be:
_[]_Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 48 hours old at examinauon
to indicate reliable results. Please send
new sample.
Date Received / ~ "'/
Time Received
Analytical Method:
~1 Fermentation Tube
,El Membrane Filter
Lab Ref. No. Result* Analyst
I I
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220
Rev, 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected Source
elved Lab. NO,
Presumptive 10mi 10mi 10mi 10mi 10mi 1,0mi 0.1mi
24 Hours
46 Hours
"onflrmatory
24 Hours
48 Hours
£MB Brotll 24 hours:
Multiple Tube Report;
Membrane Filter; Direct Count
Verification; LTB
Final Membrane Filter Results ' ?
Broth 48 hours..
1Omi Tubes positive/Total 1Omi Portlona
Collform/10Oml
Collform/100ml
Time: e.m.