HomeMy WebLinkAboutKWIK LOG BLK 3 LT 11
Development Services Department
Pudding Safety DIVlsion
.s� Oi-51T2 W at r ,$ Wast --water Frogr _rn
4'00 f ragaw Street �.
,�. ✓=.0.'ox 195650
MafkAegich Anchoroc,e, AK 99519-6650
Mayor vvmm:.mu0i.rrgion,iit
(907; s43-7504
Pump Installation Log
Well Drilling Permit Number: SW_ Date of Issue:
Parcel Identification Number:
Legal Description
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t3-3 J--lI
Pump Installation Date: 6_ 1 2_ 20 1 3
Pump Intake Depth Below Top of Well Casing: C�(� feet
Pump Manufacturer's Name: P e J
Pump Model: S, 0 C- "3 11 12 S
Pump Size /1Z hp
Pitless Adapter Burial Depth: 0 feet
Pitless Adapter Manufacturer's Name:
Pitless Adapter Installer: �-
Well Disinfected Upon Completion? I /I Yes No
Method of Disinfection: T
Comments:
Property Owner Name & Address:
i 'e
LfL
Anchorage Pump & `Nell Service
Pump Installer Name: 330 East 76th Avenue
Anchorage, Alaska 99818
Phone: 907-243-0740
Fax: 907-243-0742
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of piunp installation.
~:'] 2 ~ ~'~_~,~' "~*~w~. ~ U S DEPARTfaENT OF HOUSING AND URBAN DEVELOPMENT x~Budget Bur~ ~o;X63'R029
' ' HEALTH AUTHORITY APPROVAL
) AL WATER SUPPLY AND SEWAG~DI~
INDIVI[ U ~~-~=
j MOaTOA '
Everette M. & ~ry B. Flynn, Jr. ~616 E. 7~nd Avenue, Ancl~orage, Alas~ 99507
~.OCK NO.
j Kwick ~g ~ ~
[ [~ New installation
J~] 'Yes L~JNo no
system
Public ~] ~lnmuni. system
Public system ~] ~mnlunity system ~J Individual 5 ~ Yes J~ N~
-IEALYH DEPARYMEN¥ INSPECTOR'S SKETCH
is/the opinion of the [-j State [~] County Local Department of Health that this individual water-supply system
lyre,
t~ ~s .or satisfactory asa domestic water supply for the subject property ....
is the opinion of the [~l State JTJ County J~ Local Department of Health that this individual sewage-disposal sys-
tom with proper maintenance:
[~i~l Can be expected to fimction satisfactorily, and
is not likely to create au insanitary condition
DATE
[-~ Cannot be expected to function satisfactorily
tiTLE
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