HomeMy WebLinkAboutEARL RAY BLK 4 LT 1(1.) OWNER:
Name i s` ` irb t rl No 3`'J
Address
(2.) TYPE OF WORK (check):
New Well 61 Deepening ❑ Reconditioning ❑ Abandon ❑
If abandonment describe procedure in Item 12.
(3.) TYPE OF WELL: (4.) PROPOSED USE (check):
Rotary Air (0- Driven ❑ Domestic ❑ Industrial ❑ Municipal ❑
Rotary Mud ❑ Dug ❑ Irrigation ❑ Test Well ❑ Other ❑
Cable ❑ Board ❑ Thermal: Withdrawal ElReinjection LI
(5.) PASING INSTALLED: Steel ❑ Plastic ❑ Threaded ❑ Welded Q
r
"Diam, from ft. tot r 4 ft. Gauge
"Diam. from ft. to ft. Gauge
LINER INSTALLED:
"Diam. from ft. to . ft. Gauge
(6.) PERFORATIONS: Perforated? ❑ Yes ❑ipNo
FROM
Ch
SWL
Type of perforator used
Size of perforations in. by in
perforations from ft. to
tt..
perforations from ft. to
ft.
perforations from ft. to
ft.
(7.) SCREENS: Well Screen Installed? ❑ Yes OyNo
` 1
Manufacturer's Name
Type Model No.
Diam. - Slot Size Set From ft. to
ft.
Diam. Slot Size Set From ft. to
ft.
(8.) WELL TESTS: Breakdown is amount water level is
lowered below static level
Yield �sf L.J gal./min. with ft. drawndown after hrs.
Yield gal./min. with ft. drawndown after hrs:
gal./min. with drill stem at ft. hrs.
ttgaR1A'S WELL ,&
AQ►� P.O. Box 1992 • Palmer, AK 99645 ��IfIA Completed date:
Y (907) 232-WELL�!
Signedti 11 i-- /
(10.) LOCATION OF WELL:
Borou9h1 - 116---4642-
.Drillerswell number
1/. Y. Section T R W.M.
Tax Lot # _� .. % L 1 . 4 - _. 'e, Z. N ti a
Address at well location:
(11.) WATER LEVEL: Completed Well
Q
Static Level � ft. Below land surface. Date a/ Y:
Artesian pressure lbs. per square inch. Date
(12.) WELL LOG: /
Depth drilled f I t^l ft. Depth of completed well ! ft.
Formation: Describe color, texture, grain size and structure of materials; and
show thickness and nature of each stratum and aquifer penetrated, with at least
one entry for each change of formation. Report each change in position of Static
WaterLevel and indicate principal water -bearing strata.
MATERIAL
FROM
TO
SWL
a
07
T �o
6AAB-Ho-I r, TER ANCHORAGE AREA BORT "M
HEALTH DEPARTMENT
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
NAME
i
LOCATION-�-
SEPTIC TANK:
DISTANCE FROM W
LIQUID CAPACITY
SEEPAGE SYSTEM:
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
MAILING
ADDRESS
LEGAL DESCRIPTION
MATERIAL
Aj31 f
.GALLONS. INSIDE LENGTH._
SEEPAGE PIT:
NUMBER OF PITS % OUTSIDE DIAMETER_ !
LINING MATERIAL �'�'" "'` T"' .— —. DISTANCE FROM
^"9
WIDTH
/ G
PHONE
NUMBER OF A
___COMPARTMENTS C
LIQUID
SIDE WIDTH_ y DEPTH
NEAREST LOT LINE I-) . TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
LENGTH—, DEPTH /
BUILDING FOUNDATION r,
�/ SQ. FT.
TILE DRAIN FIELD:
TOTAL LENGTH
DISTANCE FROM WELL _, FOUNDATION NEAREST LOT LINE , OF LINES ,
NUMBER OF LINES D�,SI 7,4NL 8 TWEEN LINES TRENCH WIDTH IN. TOTAL EFFECTIVE
ABSORPTION AREA SQ. FT. LEN ;T OF EACH LINE_ -`
DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE IN. ABOVE TILE
WELL: TYPE T�T `�� DEPTH -`— , BUILD NG FOUNDATION. �r'DISTANCE FROM�r� SAMPWATELE - , NEAREST
NEAREST SEPTIC %s-' SEEPAGE` 4 OTHER
LOT LINE , SEWER LINE , TANK SYSTEM—/// CESSPOOL — , SOURCES
DIAGRAM OF SYSTEM
DISTANCES: --
31
LAy i L./ %�' T
DATE _ APPROVED —
HEALTH AUTHORITY
GARB -IID -2 CREATE,:. ANCHORAGE AREA. JROUGH Case No.
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NAME OF APPLICANT_
RESIDENCE ADDRESS
MAILING ADDRESS
LOCATION OF INSTALLATIO
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK SEEPAGE PIT.
TO SERVE THE FOLLOWING FACILITY
,DRAIN FIELD
FINANCED THROUGH TO BE INSTALLED BY
PERCOLATION TEST RESULTS ANTICIPATED DATE OF COMPLETION
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS PERMIT TO INSTALL A
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED
SEPTIC TANK SIZE TYPE SEEPAGE AREA
DIAGRAM OF SYSTEM
DISTANCES:
PHONE NO
, OTHER
TYPE
Health Authority I I I I I I I I I I I I I I I I I I I I I I
I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the
above described system is in accordance with said code.
DATE APPLICANTS SIGNATURE
I.0
5
GREATER ANCHORAGE AREA BOROP
HEALTH DEPARTMENT CASE 4 -
327 EAGLE STREET
ANCHORAGE, ALASKA 99501
Performed For ], e.ts� Date Performed 7Q
.,�_� �—,
Legal Description. 3iarn t; Subdivision
E<�1P1_ I�ac.�.itl s a 0H
This Form Reports a: S 1 LO7��� -excalation Tees
Depth
Cr.; t Location Sketch
"
ss Ig or an e SLT w7'
$yp
a
hairline rtss. � grass,
class GL'
Ton plastic in organic
�I
silt. Reddish brown
color TJSCS class SIL,
Sandy silty gravei. n Fai,t
well. graded. V' to 3"
diameter random.. br. to
�
�(
re in color_ USCS GMd
Sandy gravel ® Low s?..lt,
content we_l-1, graded.
Non ��lF.s"r,ac sand becomes
coarse with depth. USCS
�
Class G�1 r
-- 1
Was Ground Water Encountered? kLQ_
If Yes, At What Depth ___
Proposed Instali�tio>n: Seepage Pi X _ Drain "field
Depth Of Inlet Depth To BottomOf P? t Cr 'e rend,—
COMMENTSrPcommen-67117
�q�;�e� bP.i..�roon Contractor states own
� � Pr
plans t(5 -,iKi�i1�m� `�� rs
Test Performed Hg:
Data Certified By:
Date: