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Home My WebLink AboutROSEWOOD PARK ESTATES BLK 2 LT 8 Municipality of Anchorage Community Development Department On -Site Water and Wastewater Program 4700 Elmore St.. P.O. Box 196650 Anchorage, AK 99519-6650 - http://www.muni.oig/onsite - (907) 343-7904 Well Decommissioning Log Legaldress- SubdiviZ) sion �5f "ica p4e I '/' Block Lot T R Section Lot On-site Water & Wastewater Program certified contractor performing the well decommissioning: Name: Signature: Company: AncharqSe, AK99511 Well decommissioning date Method of decommissioning: AMC 15.55.060 L I a. � b. R C. Location: Use the space below to provide a drawing of the property showing the following items; North arrow • Decommissioned well, • Other water wells on the property, Two separate swing -tie distances for each well shown on the drawing, Note: The swing -tie distances shall be measured from either permanent structures or the property comers. &I 0� 0 U:\Uommuniry UevelopmentWevelopment ServicesXSuilding Safety\On Site Water and WastewateAFormsXClient Forms\Well becommisioning form.doc C-) r ke— I- S Pr,~per ty Owner APPLI --NT FILLS OUT UPPER HAl ONLY JPhone Address Zip Code ~'~ ~ ~ ~ Zip Code Lending Institution Realty Co. & Agent Address Zip Code Zip Code ~Phone Phone Legal Description ]~.0 -I ~': ~Lo~4~- ~ Street Locaticn ~:, '}d.~.~) ~ ~ ~ L~ Type of Resi~nce ~ Single Family ~ultiple Family No. of Bedroo~ ~/ ~ Other Water Supply pudividual mmunity bric Utility Sewer Disposal dividual ublic Utility olding Tank ATTACH WELL LOG. A wail log is required for all wells drilled since June 1975· For wells drilled prior to that date, give well depth (attach log if available). Year Individual Installed: When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED, Time Time Time Time Date Date Date Date Inspector Inspector Inspector Inspector Field Notes: MUNICIPALITY OF ANCHORAGE c.,'' RECEIVED (~ *CONDITIONS OF APPROVAL APPROVED BEDROOMS ( ) DISAPPROVED ( ) CONDIT[ONA~ APPRO~/AL* Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size CONSTRUCTION AND OPERATION CERTIFICATE ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION PUBLIC WATER SYSTEM APPROVAL TO CONSTRUCT Plans for the construction of ~ ~ , public water system located , Alaska, submitted in accordance with 18 AAC 80.100 approved. conditionally approved (see attached conditions). 3Y TITLE nave been reviewed .and are DATE If construction has not started within two years of the approval date, this certificate is void and. new plans and specifications must be submitted for review and approval before construction. APPROVED CHANGE ORDERS bnange (contract order no. or descr: ptive reference) /~pproved by Date The "APPROVAL TO OPERATE" section must be completed before any water is made available to the Fiublic. APPROVAL TO OPERATE The construction of the public water system was completed on ? ~ · ~ [date). The system is hereby granted interim approval to operate for 90 days following the completion date. BY TITLE DATE As-built plans submitted during the interim approval period, or an inspection by the Department has confirmed the system was constructed according to the approved plans. The system is hereby granted final.approval to operate., , /- ' BY :' TITLE DATE CHEMICAL & GI~,~LOGICAL LABORATORIES ~ 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: I.D. NO. Water System Name Phone No Mailing Address _ Zip Code City SAMPLE DATE: MO. State . Day Year SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE 3 Time Collected Collected By TO BE COMPLETED BY LABORATORY Aha ysis shows this Water SAMPLE to be: ~'i' Satisfactory [] Unsatisfactory .~J Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Date Received Time Received Analytical Method: [] Fermentation Tube ~ Membrane Filter Lab Ref. No. Result* Analyst I I r-[-I I I READ INSTRUCTIONS BEFORE COLLECTING SAM PLE 06-1220 (b) Rev. ].978 BACTERIOLOGICAL WATER ANALYSIS RECO RD Date Collecte~l Source =resumptlve ~.Oml 10mi /Omi 1Omi 1Omi 1.0mi O,lml 24 Hours 48 Hours "onflrmatorY 24 Hours 48 Hours EMB Multiple Tube ReDort: Membrane Filter: Direct Count Verification: LTB Final Membrane Flitter R~esults Broth 24 hours: Broth 48 hours: 10mi TUlles Positive/Total 10mi Portions Collform/100ml BGB Collform/100~l Date '- * Time- a.m.