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Development Services Department ` ffkk Phone: 907-343-7904
On -Site Water & Wastewater Section `�__"� Fax: 907-343-7997
Well Drilling Permit Number:
Parcel Identification Number- 015JV- 07
Date of Issue:
Legal Description
TH
Block
Lot Pro ertV Owner Name & Address:
�Gf(D'lZGta ��✓
G
Pump Installation Date:
Pump Intake Depth Below Top of Well Casing: feet
Pump Manufacturer's Name:G`-''
clelj
Pump 14•lodel• _ (/C/
Pump Size: Z.- hp
Pittess Adapter Burial Depth: feet
Name:-
Pitless Adapter Manufacturer's
Pitless Adapter Installer:
I
' fected U on Com letion? � Yes 0 No
Well Disinfected p
Method of Disinfection: VI,f
Comments:
Pump Installer Name ANCHORAGE WELL & PUMP SERVICE
7640 King Street
Company: Anchorage, AK 99518
PH: (907) 243-0740
Mailing Address:
Cit�r State- Zip:
Attention: The pump installer shall provide a pump installation tog to On-site within 30 days of pump installation.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
82-5 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAI LING AD D~ESS,,-)/,~
LEGAL DESCRIPTION
LOCATION
DISTANCE TO:
PHONE ~i~KN EW-
pl:l~--/l ~/ [] UPGRADE
Manufacturer
o jinish grade
i-
Length
IF HOMEMADE:
Well
L~.O
sh Pine
Width
NO. OF BEDROOMS
Absorp~n/area I Dwelling, ~,.,~ ~/'/' ~ P~CF~-'~ NO,
/
/
Material No. of~mpa~tments
Inside length / Width Liqui~ de/ ~th
Dwelling PERMIT NO.
Material Liquid capacity in gallons
Foun~on ~ /'~ot IJ~e PERMIT
Total lenflt~d lines / Trend~ width
inches Distan~en lines
Material beneath tile ~/ Total effe~ve absorption area-
Depth PERM T NO.
Type of crib Crib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
Class Depth Driller Distance to lot line PERMIT NO.
DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE ~,/ATE_R.L~A. LS~ -, ~ .
I NSTAL~I_ER
REMARKS
DATE LEGAL
F'EI:4.:I"t 1_' "I"
FtF'F'L I CRi'-,H'
LOC:RT I Oi",t
LEGRL
SRFI BOX 82FI
~,.I R f;-:R Et'.,I OL:SON
ORTH SD
LO]" 40RTH S[:,
'T"r'PE OF SOIl_ FIE:SOF.:F'TION S"r'STEH IS: TF..'ENCH
LOT SIZE '.924ES.'_:J'.9 '::;QLIRF?.E FE]ET
MRXII"'ILIH I",ILIHBER OF E:EI::,ROOHS = 2
SOIL RFITING ,::SQ FT,.."BR)= 288
TFIE REQUIRED :E;IZE OF THE SI]IL FIE,'SOF.'.F'TIOIq S'.r'STEH IS:
lEE, E~] F' T ~-11 .... ::EL ;;7.-2 L. E 1'-4 l]~ If" ~--il -== ;5 :_:: ,]'i F'-.;: F; %," E L_ [) E-; F' "f- IF-Il
THE LENGTH DIi'"IENt_:;IC~N IS THE L. ENG'FH ,'IN FEET) OF ]'PIE TRENCH OR DF.'.FIII'.4FIEL[:,.
THE [:,EPTH OF FI TRENCH OF.: PIT IS THE [:,ISTF¢4CE BETNEEN THE SUF.'.FFIE:E OF ]"HE
GF,'OUi'.~[:, FIN[:, ']'FIE BOTTOM OF ]"HE EXCR',,,'FITION ,::IN FEET).
THEF:-tE.[ IS NO SE]" I.,.II[.,]"H Ft]R 'I"RENCFIES.
THE GF.:F¢,,,'EL DEF'TFI IS THE MINIHUH [:,EF'TH OF GRFI',,,'EL BETI.4EEN TFtE OLH'I.--FII_.L F'IPE
FIND ]"FIE BOTYOH OF' ]"HE E:*:',E:FI',,,'RTION ,::IN FEET).
F:'ERHI T FIPPL I CFINT FIRS THE F.:ESPONS IE',I L I T"r' TO INFORM THI'_5 DEPRRTi"IENT [:,LIF4:II'.,IG THE
Ii",IS]-'FIL. LRTIOI",I INSPEE:TIONE; OF RN"r' !.4ELLS R[:'JRCENT TO TFIIS F'ROF'EF4'.T'¢ RNI]:' THE
NUMBER OF RESIDENCES TFIRT THE NELL !.,.IIL. L SER',,"E.
.................. ']1'- lt.,,..lt C" "::: ;:~: ::" :.t: ~"-.~ %:]; F' EE¢::: ]~ Z C" l'"~i ::.:; F~ 1t':: E 'F-.'. t!:-: "]:.~ Ut ][ I1~: E [::
E',RCI<FtL[..ING OF RN"r' S'¢STEM !,.IITHOUT FII",IRL. II",ISF'ECTION RN[:' RPPRO","RL. B"¢ THIS
[:'EPRRTMEi",IT !,.I ILL. E',E SUE',JEE:T TO PROSECUT 101",1.
I"IIi'.~IHIJH I::,ISTi~INCE E:ETNEEN Ft I.,.IELL t::fl",l[)I:II'.,t'T' ON-E;IT[E SEI.4RGE [:,ISF'OSFIL S"r'S"FEI'"I IS
:£CIE1 FEET FOR FI F'RI',,,'RTE NELL OR 2t. 5E1 TO 2~Et(Zl FEET F'F.'.OM FI PUBLIC I,.tEL. L DEPENDING
UF'ON THE T'¢F'E OF PUBLIC I.,.IEL. L
MII",IIHLIM DZSTFtNC:E FROI'I R F'F.:Z',,,'RTE NELL "FO FI F'F.'.I',,,'F]TE SEI.,.IIER LINE IE; 25 FEET FIND
TO R COHHUNIT'¢ SENER LINE IS 75 FEET.
I.,.tELL. L.O(:iS RRE REL.-~UIF.".E[':, F:INC, MUST BE RETIJRI",IED TO THE [:,EF'RRTME]qT NITHIN /~:C'~ [:'R"r'S
OF TFIE 1.4ELL COMPLETION.
O]"HEF.'. RE6'!LIIF.:EMENTS I"'IFW RF'F'L'-r'. SF'EC:IFICR'rIONS FIN[:, CONSTRUCTION DIFIGRRi"IS RF.'.E
FP,,'Fi]:L. FtBLE TO INSIJF.:F F:'ROPER INSTR[..LF~TION.
I C E R'T I F'"'¢ T H FIT
:1..: I RH FF~I',IZL. IFIR NITFI THE RE6~UZREMENTS FOR ON--.SZTE SENERS FIND L,.IEI~L.S RS SET
FORTH 8,¢ THE I',ILINZCZF'RLZT'¢ CF RN]H]RFI3E
;2: Z P.tZL. L ZNSTFILL THE S?STE]',I ZN F~CCORDRNC:E I.,IZTFI THE CODES.
2:: ~ UNDERSTFIN[:, TFtFFr' TFIE ON-SZTE 2~;EI.4ER S¥STEH t','IW¢ RE6~UZF?.E ENI.~RRGEMENT IF THE
RES Z[:,ENCE ZE; REMODEL. ED TO INCLUDE MORE 'f'HRN 2: BEDROOHS.
FIPPL. ZCRNT I.,.IRRREN OLSON
":..':.. F'[" E ~ ........ [:,RTE_. .-~- - ~ '"1~.. ~::'~_
MUNIClPAI. ITY OF ANCHORAGE
DEPARTIVI[-'NT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, A!aska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERPORME FOR: rer
LEGAL DESCRIPTION:
2
veto/
6
7
8
9
SLOPE
SITE PLAN
....... 10
11
....... 12
13
14
15
16
17
18
19
20
COMMENTS
PERFORMED BY:
72-008 (6/79)
~ \I~NCOUNTERED?
dr q brclom .~* 'v
~ ~' ~ ~ln3 IF YES, AT WHAT
DEPTH?
/
0
p,
E
Gross Net Depth to Net
Reading Date
Time Time Water Drop
JHzO to'.i ~1 ....
~ f~ :06. ,~'~/ ,
PERCOLATION RATE ~"0 (minutes/inch)
TEST RUN BETWEEN ~-~ FT AND ~' '~'~ FT
0 0 0 0 0 0 0 0 0 0 0 0
Es
P~oper ~'y Owner
Mailin¢ Addrs~s
APPLIC
FILLS OUT UPPER HAL ONLY
ZiD Code
Phone~
,Z p Coda
Lending Institution
Address ..
. ' Zie Code
Realty Co. & Agent
Address
Legal Description
Streel Location
Type of Residence .~" Single Family
I~ Multiple Family
~ Other
Water Supply
[~f~divid ual
~ Community
(~ Public Utility
Zip Code
Phone
Phone
,;-, , .... ',
ATTACH WELl_ L~G. A well log is required for all wells drilled since June 1975.
For wells drilled prior to thai date, give well depth (attach log if available).
Sewer Disposal
(~4'~dividual
~ Public Utility
~ Holding Tank
Year Individual Installed:
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUES'r BEFORE PROCESSING CAN BE INITIATED.
Time
Time
[)ate [)ate
Inspector Inspector
Time ~£.~
Date
InspOr
APPROVED BEDROOMS
) DISAPPROVED
'CONDITIONS OF APPROVAL
DEPT. OE HFALi-tl &
ENVIRONM2N rAL PROTECTION
LEIVF. D
Soil8 Rating
Date Sewer Installed
Well To Absorption Area
Well to Tank /;'
Log Received
Septic TaJrk Size /' ¢ /j 0