HomeMy WebLinkAboutT12N R3W SEC 15 LT 85
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
POBox 1ysn5o 47uoElmore Road
Anchorage, Alaska sg51o'0OoO Phone: 904 Fax: (807)343-7gnr
xxp,0"ww.mvniom/onsite
On -Site WastewaterDisposal System Permit
Permit Number: OSP201280
Work Type: Septic Upgrade
Tax Code Number: 01505333000
fl �
Site Legal Address: / ,��,"
Site Mailing Address:
Owner: Springer Charles
Design Engineer: SARNESSENGINEERING GROUP LTD
This permit is for the construction of:
R1 Disposal Field 10 Septic Tank El Holding Tank 11 Privy
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
8/14/2020
8/14/2021
r_1 Private Well M Water Storage
All construction shall beinaccordance with:
1 . The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
VVaetavvator Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3 The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.G5.Provide notification bycalling (BO7)343-7QO4(24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall boeither:
a. Opened and Closed onthe same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: ,___�
Date:
5
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Fax: 907- 343-7997
On -Site Water & Wastewater Program
Mayor Ethan Berkowitz
On -Site Sewer/Well Permit Application
For A Single Family Dwelling
Parcel I.D. 015-053-33
Property owner(s) C/O CONTRACTOR (ARM SERVICES) Day phone 907-317-9433
Mailing address 9840 JUPITER DRIVE "ANCHORAGE, AK
Site address 9840 JUPITER DRIVE 'ANCHORAGE, AK
Legal description (Sub'd, Block & Lot) T12N, R3W, SEC 15, LOT 85
Legal description (Township, Section & Range)
Lot Size
APPLICATION IS FOR:
(® all that apply)
Absorption Field
Septic Tank
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
Sq.Ft. Number of Bedrooms 5
APPLICATION IS AN:
Initial ❑
Upgrade
Renewal ❑
THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR:
N/A
TYPE OF DEWELLING:
Single Family (SF)
(w/wo ADU)
Duplex (D) ❑
Multiple Dwellings ❑
(SF and/or D)
Distance: -
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd.
(Signature of property owner or authorized agent)
Permit/Rush Fees: _ _
Date of Payment: %
20,20 COUID
Receipt Number: O � O 1 G
Permit No. 05P20128
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
(Rev. 01 /11)
UARNE,SS EINGINFERINU, Ltd Anr e)).
ENGINEERING SALES � CONSULTING Alwb..,...rjD� ;,r
October 191', 2020
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Change Order for T12N, R3W, Sec 15, Lot 85 — OSP201280
To whom it may concern:
The current design calls for a maximum excavation depth of 9 feet, however, the existing cleanout at the
end of the trench is approximately 5.8' below grade. During the initial layout we became concerned the
proposed drainfield could not be installed to the north, without exceeding a maximum depth of 9 feet
below original (not existing) grade. The proposed design change calls for a 5 -wide trench with 0.5 feet of
effective to limit the drainfield depth. It should be noted that an exploratory hole was excavated northeast
of the existing monitoring tube and northeast of the existing cleanout (see attached 40 scale). It was
noted that there is approximately 2-5 feet of fill, reducing in depth to the north; therefore, we do not
believe that the existing drainfield was "over excavated" (MT at 11.16' below grade), given the significant
amount of fill adjacent to the drainfield.
We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems.
If you have any questions, please contact us at 337-6179. Thank you for your assistance.
ly,
E., M. S.
3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259
Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201280, Deb Wockenfuss, 08/14/20
DESIGN CRITERIA:
NUMBER OF BEDROOMS: 1 BEDROOM UPGRADE (5 TOTAL)
GALLONS PER DAY (GPD): 150+ GPD
PERCOLATION RATE/S: <l MIN/INCH
PROPOSED APPLICATION RATE: 1.2 GPD/FT
MINIMUM DRAINFIELD SQ.FT.: 125 FEET'
DRAINFIELD DESIGN:
MAXIMUM DEPTH: 9 FEET BELOW ORIGINAL GRADE (NOT EXISTING GRADE)
WIDTH: 5 FEET
LENGTH: 30 FEET
M.O.A. APPROVED SAND FILTER: N/A (NATIVE SOIL)
EFFECTIVE: 0.5 FEET
REDUCTION FACTOR: N/A
ACTUAL SQ.FT.: 150 FEET' (650 FEET TOTAL)
�i
EXTEND EXISTING DRAINFIELD BY 30 FEET TOTAL -
(INSTALL CO & MT @ NORTHEAST END OF TRENCH)
\� EXPLORATORY HOLES -
1 ° SEE ATTACHED LETTER
r FLAT
tea— FLAT
r FLAT 15,
�� 15 o CC
% T
MT a
DOCUMENTED \
LOCATION OF 1994
BY TOKEN
SPURKLAND, P.E.
�/RESERVE
EXISTING 1,000 GALLON
STEEL TANK TO BE
TANK• WITH DBL CO'S PRE & POST TANK '
DECOMMISSIONED PER UPC
SITE WILL REQUIRE
ADVANCED TREATMENT
GEG, Ltd. HAS AN 8 PAGE SPECIFICATION LETTER
THAT PERTAINS TO THIS DESIGN. BY PROCEEDING
FORWARD WITH THIS INSTALLATION, THE
ENGINEER, WELL DRILLER, CONTRACTOR AND
PROPERTY OWNER AGREE THAT THEY HAVE
READ THESE SPECIFICATIONS AND AGREE TO
ACCEPT THE TERMS AND CONDITIONS OUTLINED.
RESERVE DESIGN CRITERIA:
NUMBER OF BEDROOMS: 5 BEDROOM UPGRADE
GALLONS PER DAY (GPD): 750+ GPD
PERCOLATION RATE/S: <1 MIN/INCH
PROPOSED APPLICATION RATE: 4 GPD/FT
MINIMUM DRAINFIELD SQ.FT.:150 FEET
*CAT 11 ADVANCED TREATMENT
RESERVE DRAINFIELD DESIGN:
MAXIMUM DEPTH: 9'
WIDTH: 5 FEET
LENGTH: 30 FEET
M.O.A. APPROVED SAND FILTER: NIA (NATIVE SOIL)
EFFECTIVE: 0.5 FEET
REDUCTION FACTOR: N/A
ACTUAL SQ.FT.: 150 FEET
NOTE: CONTRACTOR SHALL HAVE THE
T12N, R3W, SEC15, LOT 84 WELL RADII ON LOT 83 AND 85, AND THE
VACANT WEST LOT LINE FLAGGED PRIOR TO
CONSTRUCTION.
APPROXIMATE BOUNDARY OF WETLANDS PER MOA MAPPING
T12N, R3W, SEC15, S2,SE4, SW4, NW4
VACANT
WETLANDS
OF
,ff
_ 77 77
~�
2
GA ISIS E GI I G G OLTP, Ltd ........ ....... .............
t = f 44.:. .:4..
ENGINEERING SALES= CONSULTING r` f s, ti 3 ..0
/
3701 E. TUDOR ROAD, SUITE 101 . ANCHORAGE, AK 99507 • PHONE (907) 337.6179' FAX (907) 338.3246 • WEBSITE. � .aamessenaineenno.com .rrcr :.,.,..•h ........... •.................
PREPARED FOR: PHONE NUMBER:
ARM SEPTIC SERVICES 907-317-9433
PROJECT/LEGAL DESCRIPTION:
T12N, R3W, SEC 15, LOT 85
TYPE OF WORK:
�,_ DESIGN OF SEPTIC TANK UPGRADE
PAGE NUMBER: o (.f et�lrey A'-Gaaiess
2 OF 2 *♦�'%I�f CE -7953
1 `
DRAWN BY: ♦�♦��� .,i J�k; , ZD,.�•���1
AV
D.J.G./PNB
LICENSE♦ Fp /��JJ','pp11 •......... ••'P�
DATE: ff,oy` `t,t�� -
10/16/2020 9AECC884 I --
PROPOSED GREER 1,500 GALLON HDPE SEPTIC
1 °
TANK• WITH DBL CO'S PRE & POST TANK '
/
a��
r•
--DRIVEWAY a,
_�.." %�,, :�:•-'tir.
'ti's•.
o ST
OMH
�:';�;..•
•SHED
EXISTING =.: :• i•''r �•
r••'.•�''•
BEDROOM HOUSE
/�/
APPROXIMATE BOUNDARY OF WETLANDS PER MOA MAPPING
T12N, R3W, SEC15, S2,SE4, SW4, NW4
VACANT
WETLANDS
OF
,ff
_ 77 77
~�
2
GA ISIS E GI I G G OLTP, Ltd ........ ....... .............
t = f 44.:. .:4..
ENGINEERING SALES= CONSULTING r` f s, ti 3 ..0
/
3701 E. TUDOR ROAD, SUITE 101 . ANCHORAGE, AK 99507 • PHONE (907) 337.6179' FAX (907) 338.3246 • WEBSITE. � .aamessenaineenno.com .rrcr :.,.,..•h ........... •.................
PREPARED FOR: PHONE NUMBER:
ARM SEPTIC SERVICES 907-317-9433
PROJECT/LEGAL DESCRIPTION:
T12N, R3W, SEC 15, LOT 85
TYPE OF WORK:
�,_ DESIGN OF SEPTIC TANK UPGRADE
PAGE NUMBER: o (.f et�lrey A'-Gaaiess
2 OF 2 *♦�'%I�f CE -7953
1 `
DRAWN BY: ♦�♦��� .,i J�k; , ZD,.�•���1
AV
D.J.G./PNB
LICENSE♦ Fp /��JJ','pp11 •......... ••'P�
DATE: ff,oy` `t,t�� -
10/16/2020 9AECC884 I --
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201280, Deb Wockenfuss, 08/14/20
NOTES:
THIS DRAWING SHALL NOT BE
MODIFIED FOR USE AS A PLOT PLAN
MEAS: MEASURED, PREVIOUS SURVEY
COMPLETED BY LCG LANTECH,
AUGUST 25,1994
REC: RECORD INFORMATION, MOA
GRID 2436, DATE OF 4/7/1986
LOT 84
S900 00'00"W 330.06' (REC)
LOT 83
S89'0 5859"W 329.921 (MEAS)
279.92 ...
..........
t
.................. 00.—
"E
....................... ...... ...............
........................ ..'..'.'..'.`.'.'.•..'.'.....•......'.'.'.'....... ............. .......
.............. ..............
.......... ... ....................................
....................... ....................................................................
....................... ...................................................................
....................... .................................................... ..............
LOT 85 10
.......... ...................................................................
.................. * - * .... - " - '' 2
......... ..... .................................................................
.......... ................ ............ "" ........................
. ........ ................ .......... ............
G E N E RATO R/ ................
.0- 0
............................................. I
..................................................•I ............
< UTILITY BOX
UJ W
....................................................
................................ Uj
.....................
CO (5) * ....................
....... ......................
....................... HE 13.2' z in
....................•.'.•.•.•..•.•.'.•.'.•.•.•.'.'..'.'..•...Uj
CO (2) .................
.............. ....................<
.. ........ 0 ....................
LO U-)► 0
LOT 86 '-0 72.91 13.3' cc
0
Uj G n w
Uj
8.1' z -
c *NOW"UJ 00.
CN z
LO U.)
0
0 UlW
0
U) C:) RETAINING WALL Uj
C:)
C/)
M
b
Ln Ln
280.00
S890 5455"W 330.001 (MEAS)
1 900 00'00"E 330.061 (REC)
250 H Street
LEGAL DESCRIPTION:
Anchorage, Alaska 99501
ADDRESS: 9840JUPITER DRIVE PARCEL #: 015-053-33-0
LOT 85
AS- Elk U I L T
SURVEY CERTIFICATION: LCG LANTECH, INC HAS CONDUCTED A PHYSICAL SURVEY OF THE
Survey Department
T1 2N, R3W SEC 15
PROPERTY AS SHOWN ON THIS DRAWING AND CERTIFIES THAT THE IMPROVEMENTS
Phone 562-5291
---
SITUATED THEREON ARE WITHIN THE PROPERTY LINES AND NO ENCROACHMENTS EXIST
Mainline
LEGEND:
OTHER THAN NOTED.
Phone 243-8985
DRAWN DATE:
07/21/2020 WORK ORDER:
20052
CO (2)
....... Asphalt
AECC 668
DRAWN BY:
ADS/SC PLAT:
NONE
CLEAN OUT
= Concrete
EXCLUSIONARY NOTE: IT IS THE OWNERS' RESPONSIBILITY TO DETERMINE THE EXISTENCE
WATER WELL
OF ANY EASEMENTS, COVENANTS, RESTRICTIONS OR RIGHT-OF-WAY TAKINGS WHICH DO
MONOMMONN�
CHECKED BY:
SC GRID:
SW2436Overhang
NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. UNDER NO CIRCUMSTANCES
FENCE —X—X
SHOULD ANY DATA HEREON BE USED FOR CONSTRUCTION, FOR ESTABLISHING PROPERTY
SCALE:
1 40' FB/PG: 818/5
REF: 20021-583
Wood Deck
LINES, OR FOR PLOT -PLAN PURPOSES.
Municipality of Anchorage Page
DEPARTMENT OF HEALTH AN[) HUMAN SFRVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 995'19-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ,~,'e~ D ~E~ RID Number: ~)~'-
Name:Wastewater System: ~New D Upgrade
Address:
~.o,~ ~o~o ABSORPTION FIELD
Phone: ~ No of B~ooms: ~Deep Trench E] Shallow Trench D Bed ~ Mound D Other
Lot: Bloc~: Subdivision: Deplh Io pipe botlom Irom original grade: Gravel depth benealh pipe
¢
Township: [ Range: [ Section: Flit added above original grade: Gravel length:
WELL:~New ~ Upgrade Gravel width; ~ Ft, {I -- Ft.
Classification (Private, A,8,C): Total Depth: Cased TO: Tolal absorption area: Pipe material:
Date Drilled: Static Water Level: Insta~l~ Date installed:
Yield:[ Pump Set at: [ Casin9 Height Above Ground:
TANK
SEPARATION DISTANCES ~Septie n Holding n S.T.E.P.
TO Septic Absorplion Li/I Holdin9 Public/Pdvalo Manufacturer: ~. Capacity in gallons:
From Tank Field SIaUon Tank SewerLines .~'r~& / ~ K
su~o~ ' LIFT STATION
Water ~
Curtain Pump Make & Model IElectrical Inspections performed by:
Remarks: BENCH MARK
Location and Description:
Department o~ Hoalth and Human Services approval '
Reviewed and approved by:
72-013 (Rev. 9/91) MOA 25
25 0 £5 50 75 JO0 125 150 ,
TOBBEN SPURKLAND P.E. II
II
20-~ W I~TH, ~,VENUE
ANCH. AK. 99501
(907~ 279 59~6
9840 ,JUPITEf¢ DA;IVE
CHAR'LES SP£INOE£
SEPTIC SYSTEM ASBUILT
DATE: OC[Ofl£R 26, 1994
SHEET: 2/J GRID: 2456
9 ~eep \ ~
5 ~e~/er' ~.oclc ~
~' ~ove~~
Cleonouts
/
//- Honi't om
89. I
b Pt of' £epLic Rocl~ - -
ND SCALE
95. ~
,0
u
1750 ~ol, sep'h¥ ~ont<
tTOHBEN SPURKLAND P.E.
205 W15th Ave
Anchorooe Ak 99501
279-,~976
BLkl LOT 85 S£C. 15 T12N
9840 JUNIPER DRIVE
CHARLES SPRINGER
SHEET: 5/5 GRID: 2456.[
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUNLAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF 1
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT ~ER:SW940353
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:MITCHELL-SPRINGER LIVING TRUST
OWNER ADDRESS:9840 JUPITER DR
ANCHORAGE, ALASKA 99516
DATE ISSUED: 9/21/94
EXPIP~ATION DATE: 9/21/95
PARCEL ID:01505320
LEGAL DESCRIPTION: T12N R3W SEC 15 LT ~ 85
LOT SIZE: 78607 (SQ. FT.)
~ER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST ]BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHOR_AGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18A3~C80) .
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 (24 }{OURS)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM U-NDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
ISSUED BY: (~
T.SPURKLAND P.E.
203 W 15th. Avenue, Snite 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6{113
SEPTIC SYSTEM DESIGN
BLM LOT 85 SEC. 15 T12N R3W
CHARLES M. SPRINGER
No Ground Water or Impervious Layer to 15 ft.
Use Standard Trench
Soil Rating. From test 3/31/94
> 1 min/in - 1.2 gal / sq. ft.
See Sieve Analysis
No. of Bedrooms 4
Required Area per Bedroom: 150/1.2 - 125 sq.ft..
Total Area Required 4 x 125 = 500 sq. fl..
Finish Floor Elevation 99.4
Ground Elevation at Absorption Field 98+-
TestholeTotal Depth 15
Less 6 feet 9
l,ess 3 feet Cover 6
Rock Depth 5
Length of Trench 500 / 2x 5 = 50 [FT,]
SYSTEM CONFIGURATION
STANDARD TRENCH
TOTAL LENGTIq 50 FT,
TOTAL WIDTH 2 FT.
TOTAL DEPTH 9 FT.
ROCK DEPTIt 5 FT.
COVER 4 FT.
SEPTIC TANK 1250 GAL.
The installation of this septic and well system will not prevent wells and septic systems from being
installed on the adjacent lots.
There are no developed of natural surface / sub surface drainage courses on this or the adjacent lots.
The proposed septic system will not change the general slope of the area. Ponding and/or
concentration of surface runoff will not result from this installation.
Septic System Design
BLM Lot 85 Sec. 15, TI2N, R3W
LL:ll 75 t: t
O
>7?
250 300
/" nO 8 od lOO O0
LLII 83 ?~,41: 1"
i~ RlPO, O0 I
UNflEVELBPEP
LIlT 77
L/Il 84 V,4£ANI
TF1BBEN SPURKLAND P.E.
I
ANCH. AK, 99501
~07~
LET U5 SEE i5 TI£N
9,940 JUPIIER flI~IVE
£HARL ES -cPBIN6ER
REPLA CE~,t~N T
PRI$IARY TRENCH
?ENCH -
~ell PROPOSED
PROPOSED DRIVEWAY
25 0
SPURKLAND P.E.
203 W 15TH. AVENUE
ANCH. AK. 99501
. f907/ 279-z~916
/ /~? 85 S£L' 1S ?l£N
9840 JUPIIE,q D£[VE
£HA,qL/'£ SP£IN~E£
SEPTIC SYSTEM DESIGN
DATE: AU/JUST 1,9, I994
SHEET: 2/5 GRID: 2436
C/eon
5O
S tondord lrenah:
50' Lon9
9' Deep
,5' Se~er rocl~
3' Cover
1
NB SCALE
TOBBEN SPUP/(ZAND P.E.
205 ~/15th Ave
~,%~?~. _. A~ 99~o,
LOT 85 SEC. 15 T12N f13P~
9840 JUN/PER DRIVE
CHARLES SPRINGER
SEPTIC SYSTEM DESIGN
DATE; AUGUST 18, 1994
SHEET: 5/5 GRID: 2456
PERFORMED FOR:
LEGAL DESCRIPTION:
2
10
14
20
Municipality of Anchorage
DEPARTMENT OF IdEALTII & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG --- PERCOLATION TEST
SLOPE
WAS GROUND WATER ~ ~
ENCOUNTERED? 1'~L
DATE PERFORMED
Township, Range, Section:
S
L
tfionitorin§? ---~--~'i~ Date:
Readin9 Date
SITE PLAI~
/'ERCOLAIIONRATE ~J__ (nl,nutes/mch) PERC HOLE DIAMETER __
/
TEST RUN BETWEEN ~ _FTAND..~ /~FT
COMMENTS
PERPORMEO,~Y: _ t, ~ , '~', ~
CERTIFY THAT TNIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATEANDMUNICIPALGUIDEL[NESiN EFFECTON THIS DATE. DATE:
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
10
11
12
13
14
15
16
17
18
19
2O
1
2
3-
4
5
6
7
8
9
Muoicipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" StreeL Anchorage, Alaska 99502-065:,
SOILS LOG -- PERCOLATION TEST
COMMENTS __
f¥O L~
DATE PERFORMED:
TowRship, Range. Section: ~'~'~,(7~SiTE PLAN
SLOPE
Del]Ih lo W~lcr Aller
Monitoring?
S
L
O
P
E
Reading
Time
Net Depth to
Time Water
Net
Drop
PERFORMED BY:
ACCORDANCE WITH ALL STA rE AND MUNICIPAL G~IIDELINES IN EFFECT ON
72-008 (Rev. 4/85}
CERTWY THAT THIS TEST WAS PERFORMED IN
DATE:
SUBDIVJelO~
S'rATE OF ALASKA
OF NATURAl.
DFPARTMENT
DIVISION OF WATER ".;'
WATER WELL RECORD .'~
4~£OHON I'OWN ~II'IP
/?.
WELL OWNER:
n~l Color
top I-1oround surlaoe
D0pth
Ftorn TO
WELL DEPTH;
Depth of hole: /~ ~) ft
Depth of oesln'~~:ft
DEPTH T0 STATIC WA'I'~R LEVELI
.. ~'?'? ft below E'~ top of oeslog
Date: ..4/ ~..~/... ~/, .... /.,-,
DATE,
, El
METHOD OF DRILLING: j-~' alr rot,ry [] 'eeble ~t~I':
[~ other
USE OF WELt.= ~]' domestic [] lrrlgeUon I~ mOblt6~ .'
r-i public supply
CASING STICK. UP: ft, Diem:
Cee ng
WELl. INTAKE OPENING TYPE; ,r~ open end E~,~
[] parfereted [] open hole ;
Depths of openings:
to ______~__ ft
SCREEN TYPE: . Diem:
Slot/Mesh Size:
GRAVEL PACK TYPE:
Volume used;
GROUT 'TYPE:
D0pth: from .......... ft to
DEVELOPMENT ME tOD:
Duration:
PUMPING LEVEL AND YIELD:
, /-~ ~P ft after umpln[
PUMP INTAKE DEPTH: . ...... ft
W~LL DISINFECTED UPON COMPLE?ION?
Dopth to top:
Volume:
, ~FORMATION:, · ~ REMARKS:
,! .--.- . ~., , :...
/X..'"' .......
', :,i,'~;~'4..~:,/', ...~/' ~ ..... ~j~ ~ .... ~ /r2. ~.~." '?~/ PL~A.,E MAIL WHITE COPY OF
~ ~ ~~~c Date ' DNRIDIVISION OF WATER '~ :, :'
PO BOX 772116
EAGLE RIVERAK 99577.2~