HomeMy WebLinkAboutKASILOF HILLS BLK 4 LT 13Onsite File yo- MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 hftp://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP241385 Work Type: Septic Renewal Tax Code Number: 01513119000 Site Legal Address: KASILOF HILLS BLK 4 LT 13 G:2541 Site Mailing Address: 10111 Kasilof BLVD, Anchorage Owner: HARTMANN SUSAN A & ZACHARY D Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft: Total Bedrooms: 11 /22/2024 11 /22/2025 32147 Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance 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 Wastewater 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 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Tij /- o P_ c, r Date: 1° Issued By: Date: 4 MUNICIPALITY OF Community Development Department Development Services Division On -Site Water & Wastewater Program Phone: 907-343-7904 Fax: 907-343-7997 ON -SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 015-131-19 Property owner(s) Zachary & Susan Hartmann Day phone Mailing address 3842 Wesleyan Drive, Anchorage, AK 99508 Site address NHN Kasilof Blvd Legal description (Sub'd., Block & Lot) Kasilof Hills Block 4 Lot 13 Legal description (Township, Range & Section) Lot Size 32,147 _Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (Z all that apply) Absorption Field rx-j Initial 171 Single Family (SF) El Septic Tank nx Upgrade 1771 (w/wo ADU) Duplex (D) ❑ Holding Tank ❑ Renewal nX Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: A q5- Waiver Fees: Date of Payment: G- Date of Payment: Receipt Number: Receipt Number: Permit No. 0-5 Waiver No. Permit App_'-'- : - :-'.,'c ; November 20, 2024 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Kasilof Hills Block 4 Lot 13 Septic System Permit Dear On-Site Services Engineer: The permit for the construction of a well and septic system on Kasilof Hills Block 4 Lot 13 has expired. A site visit was conducted and there have been no substantial changes to this lot or to the surrounding area since the permit was originally issued. The current design and permit conditions meet all code requirements. We therefore request the renewal of the permit for the well and septic system on this lot. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241385, Curtis Townsend, 11/22/24 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP221164 Work Type: Septic Initial Tax Code Number: 01513119000 Site Legal Address: KASILOF HILLS BLK 4 LT 13 G:2541 Site Mailing Address: 10111 Kasilof BLVD, Anchorage Owner: ESSLINGER GEORGE G Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date Expiration Date Lot Size in Sq Ft: Total Bedrooms: enC n v Department 6/14/2022 6/14/2023 32147 Q Disposal Field Q Septic Tank Holding Tank Privy Private Well Water Storage All construction shall be in accordance 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 Wastewater 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 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Issued By: Date: Date: 0 Community Development Department ` Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWERIWELL PERMIT APPLICATION Parcel I.D. 015-131-19 Property owner(s) Crown Pointe Homes Day phone 907-727-5259 Mailing address 3350 Midtown PI, Anchorage, AK 99503 Site address NHN Rezanof Cir. Legal description (Sub'd., Block & Lot) Kasilof Hills 134 L13 Legal description (Township, Range & Section) Lot Size 32147 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑x Initialx❑ Single Family (SF) x❑ (w/wo AD U) Septic Tank ZUpgrade ElDuplex ElHolding (D) Tank ElRenewal El Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: -f-591 Waiver Fees: Date of Payment: J a 9 OP a Date of Payment: Receipt Number: Q5 15 5b Receipt Number: Permit No. Waiver No. Permit App_'-'-:- ._..:c May 24, 2022 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Kasilof Hills B4L13 Septic system design Dear On-Site Services Engineer: The owner of the above lot intends to build a 4-bedroom home on the property, so we are submitting this permit application for the construction of a new septic system. The attached site plan identifies the location of the home as well as the existing well, septic location and alternate site. No conflicts exist between this proposed system and any other well or septic system, whether on this lot or adjacent lots. The ground surface on the lot slopes toward the road steeply near the front of the lot, the proposed septic system is located where slopes are much milder. There are slopes greater than 25% within 35 feet downslope of both the primary and alternate site. However, we have provided a slope cross section that demonstrates the effluent will not daylight down grade from the drain field if the proposed design is followed. Elevations are included on the site plan showing the grade and direction of flow. Stormwater drainage will not impact this septic system. The new trench will be constructed parallel to the slope as much as possible. Wells on this and adjacent lots are shown. The new system will be a minimum of 100’ from all wells and surface water, and more than 5’ away from the septic tank. The alternate site is located more than 6’ away. Please refer to the attached test hole logs, plan, and profile pages for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221164, Deb Wockenfuss, 06/14/22 ALTERNATE SITE: 20' LONG x 5' WIDE 0.5' EFFECTIVE DEPTH ABSORPTION TRENCH W/ 2' SANDLINER MAINTAIN 6' SEPARATION Benjamin Schiller CE 12592R EGISTEREDPROFES S I O N ALENGINEER 1"=50' CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND 2CO MT TH#1 KASILOF HILLS, BLOCK 4 LOT 13 FEET 0 50 100 ≥6' FCO NOTE: NO SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC SYSTEMS.KASILOF BLVD.4-BDRM HOME 6/14/22 REZANOF CIR.10' UT I L I TY EASEME NT 1180 1170 1190 1200 1210 1220 1230 MT CO CO 1250-GAL SEPTIC TANK W/20" MANWAY 2- 60' LONG x 5' WIDE 0.5' EFFECTIVE DEPTH ABSORPTION TRENCH W/ 2' SANDLINER MAINTAIN 6' SEPARATION MT CO MT CO FS ≥10' EXISTING SEPTIC SYSTEM DECOMMISSION EXISTING TANK PER U.P.C Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221164, Deb Wockenfuss, 06/14/22 TYPICAL TRENCH SECTION (NO SCALE) NOTES: 1. GRADE AREA OVER TRENCH TO DRAIN AWAY 2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2' WITH 2" OF INSULATION 3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY Benjamin Schiller CE 12592R EGISTEREDPROFE S S I O N ALENGINEER4" PERFORATED PVC (HOLES DOWN) DRAINFIELD ROCK 5' 6" 6" 2' DESIGN FACTORS:SYSTEM REQUIREMENTS: 600 GPD PEAK FLOW PERK RATE: .51 MIN/IN APPLICATION RATE: 1.0 GPD/SF 5' WIDE TRENCH TRENCH SYSTEM 1250 SEPTIC TANK BOTTOM OF TRENCH: 7.0' BELOW GRADE FLOW LINE ELEVATION: 6.5 ' BELOW GRADE TOP OF TRENCH: 0.5 ' ABOVE GRADE 600 GPD / 1.0 GPD/SF /5' WIDE *1 RED. FACTOR (0.5' EFF. DEPTH) = 120' TRENCH 6/1/22 GEOTEXTILE FABRIC 6" 6' KASILOF HILLS, BLOCK 4 LOT 13 MOA APPROVED SAND Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221164, Deb Wockenfuss, 06/14/22 0' 5' 10' 15' 20' 25' 30' 35' 40' 45' 50' 55' 60' 65' 70' 1165 1170 1175 1180 1185 1190 1195 1"=10' ORIGINAL GRADE ALTERNATE SITE SLOPE CROSS SECTION 530' 535' 540' 545' 550' 555' 560' FEET 0 10 20 KASILOF HILLS, BLOCK 4 LOT 13 46% AN G L E OF EF FL UE N T INF LUE N CE FO R PRI M A R Y SITE 6' 6' 46% AN G LE OF EF F L U E N T INF LU E N C E FO R PRIMAR Y SITE 46 % AN G L E O F EF FL U E N T INF LUE N CE FO R AL T E R N AT E SITE Benjamin Schiller CE 12592R EGISTEREDPROFES S I O N ALENGINEERJun 14, 2022 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221164, Deb Wockenfuss, 06/14/22 LEGAL DESCRIPTION: PERFORMED FOR: DATE: PARCEL ID#: SOILS LOG AND PERCOLATION TEST 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 DEPTH (feet) TEST HOLE 1 DATE READING START TIME NET TIME (minutes) DEPTH to WATER NET DROP PERCOLATION RATE: (MIN/INCH) (inches)(inches) DATE OF MONITORING WAS GROUND WATER ENCOUNTERED? DEPTH TO WATER AFTER MONITORING IF YES @ WHAT DEPTH? .51 5/6/22 1 2 3 4 5 6SP (WITH COBBLES) Professional Engineers Stamp: YES KASILOF HILLS B4 L13 5/06/22 015-131-19 CROWN POINTE HOMES 4:251 2 3 4 5 6 0 4:27 4:30 4:34 4:37 4:42 1' OB 1:56 Benjamin Schiller CE 12592R EGISTEREDPROFE S S I O N ALENGINEER6/1/22 PERC TEST LOCATION TECHNICIAN: L.TIDWELL 6 13.0' 13.0' 5/19/22 COMMENTS: 6" DIAMETER TEST HOLE PRESOAKED PRIOR TO TESTING SITE PLAN 6 USCS SOIL CLASSIFICATION WAS VISUALLY DETERMINED GM 0 2:25 6 6 0 2:55 6 6 0 2:58 6 6 0 3:02 6 6 0 3:07 6 6 TH1 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221164, Deb Wockenfuss, 06/14/22 P. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE XNEW C- /4 CC A)5'_r �I?Q160AU tj- •- �Oq-o ED UPGRADE MAILING ADDRESS O JS 0 10.3 i.3 'G A Alcaomca A i 9 SI j LEGAL DESCRIPTION i ' /3 AL - r 4- KA_5;L01= A J'I ; i.e, -ti 2 A" 3 LL) .3 z.. Z LOCATION NO. OF hAS /Logi= BLV 1 BROOMS DISTANCE TO: ,tel Absorption area �•f� f; Dwelling PE5V NO. v %���7j�OStl�� % _Y azQ Manufacturer yy�� 10 AA)Q4 Mater' I No. of co artments LU I.- �G4F L C4 Liq..capacity in gallons IF HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. O F Manufacturer Material Liquid capacity in gallons 0 w= DISTANCE TO: Well �(,sp7 f .11 Foundation 1'RG1"'GS /, Neares I t lige V% PER IT NO. 40 7/® J LL z No. of lines LengthLength of e� hiline Total lengLh of fines Trench 1th 1E Distance between lines H z w { 3� 33 — 16, inches /�/ Q Top of tile to finish ra a � Material beneath the ,� Lj- Total of cti a ab �ption area i O} inches &0 Length Width Depth PERMIT NO. w c7 Q F- as W Type of crib Crib diameter Crib depth Total effective absorption area LU DISTANCE TO: Well Building foundation Nearest lot line Class Depth Driller Distance to lot line PERMIT NO. -� T l.ti' Lu DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS C s 'r IROAJ o..?0:3 SOIL TEST RATING P i� INSTALLER GM C REMARKS .j 1ENLAIC--4-RI�, C )A)SdK E a 6 Zrev Xrev MCA S - ©2 4 kL ILL �r ?Ooo,)7s 6 vul APPROVED DATE LEGAL t- 13 1-r,,wco>'= ti -'as 'T > ZeV�', :31,) skrc 2 Z /L-UlJ (Hev. J/78) PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT PHONE: �X 11"'040, :1 m-ne" ���IF-,,".���� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L �TREET, ANCHOR�GE� AK 99501 264--4720 IF;" ;R�!: ��..... 4L-.. IF 840710 08/21/84 BECHAROF CONSTR" P O BOX 111394 ANCHORAGE, AK 99511 349-4O40 LEGAL DESCRII , . ,: SUBDIVISION KASILOF HILLS LOT: 13 BLOCK: 4 SECTION: 1 Al. TOWNSHIP: 12N RANGE: 3W LOT SIZE: 32147 (SQ "FT" OR ACRES) MAX BEDROOMS: 3 Listed below are the options available to you in designing your septic system. Choose the option bestfits your �^..... ..... ~�_��~~�~�~_�__��~�� site" ~���D h, 0 C:::�K-1, IJ!'N ]I,'. P"ll DEPTH TO^ PIPE BOTTOM (FT ) 6 0 ' ^ `` 60 GRAVEL DEPTH (FT.) 4~0� 2"0 TOTAL DEPTH (FT") 10.0'/ 8"0 GRAVEL WIDTH F. 2^5 YY 5"0 GRAVEL LENGTH(FT ) 32, 0/' , 2 35"0 GRAVEL VOLUME (CU^YDS.) 13.3 " 16^2 TANK SIZE (GALS) 1,000^0 ** J. ^ 0 SOIL RATING (SQ, FT" /BR> 83 83^ 83 ** TANK MUST HAVE AT LEAST TWO COMPARTMENTS I c�rtiI*y that: 1" I am with the requirements f,or on~site sewers and wells as s�t �orth by the of Anchorage (MOA) and the State of Alaska" 2" I will install the system in accordance with all MOA codes and regulations, and in with the design criteria of' this permit" 3. I will adhere to all MOA and State of Alaska requirements for the set back distances from any existing well, wastewater disposal syste0 or public sewerage system on this or any adjacent or nearby lot. 4" I understand that this permit is valid for a w',ximum bedrooms and any enlargement 1,1jil1 require an additional ' per(nit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS~BUILTS WILL N CTRICAL INSPECT1ON REPORT; AND (3) THE ELEC ICENSED ELECTRICIAN" SIGNED � ..... ..... .. ..... .... _.... ....... __���_ APPLIC��ff�~^�ECHAROF CONS�," �r ° ISSUED BY DATE: ........... .... ... .....��� �������....... ^^.... . L SOILS LOG MUNICIPALITY OF ANCHORAGE I/• +.f DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION 825 L. Street, Anchorage, Alaska 99501 264-4720 TEST SOILS LOG — PERCOLATION TEST PERFORMED FOR: S"'MDATE PERFORMED: --Io LEGAL DESCRIPTION:_ t-oc_jL �ot 17j rpT� SLOPE SITE PLAN 1 � ,t 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18- 19. 20 ' i— G 1l1/ S+ c+11 500%��I �:•���� Gp I—aT-S 6F co c" -- Etl" Q'a 0,4 QQ5 Sol",e s; l+ w�t� Sze WAS GROUND WATER n I S its �� ENCOUNTERED? d L O P IF YES, AT WHAT E DEPTH? 6' ` Pe�I' Ihck"'— COMMENTS so f 46/;' Reading Date Gross Net Depth to Net Time Time l� Drop / Z y Ifo '30 _ /Oy vy Z 15 t z� /Uva y � ZI So • Zb Reading Date Gross Net Depth to Net Time Time Water Drop / Z y Ifo '30 _ /Oy vy Z z� /Uva y � ZI So • Zb PERCOLATION RATE 1.6 (minutes/inch) TEST RUN BETWEEN 8 Z FT AND C FT PERFORMED BY: [zicy /1/0/- .ST 8 �/ 01 5Z CERTIFIED BY: 72 -008 (6/79) DAT= - MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG ❑ PERCOLATION TEST PERFORMED FOR: -36-tyL F!!i es DATE PERFORMED: v'j LEGAL DESCRIPTION:_ has L) --K- L[ / z:' -1- 3 SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 - 18• 19- 20 - ML OTS Or Svc' I �rne2� i WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? C E Reading Date Gross Time Net Time Depth to Water Net Drop c I.4Af Reading Date Gross Time Net Time Depth to Water Net Drop I PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND .FT COMMENTS 1-0/ PERFORMED BY: �„ -u f `�y ST 6ya zSL CERTIFIED BY: 72-008 (6/79) DATE: G; ER AINCHORAGE AREA BOROUGH, DEPARTMENT OF ENVIRONMENTAL QUAL',v CASE # 3500 TUDOR ROAD ANCHORAGE, ALASKA 99502 Performed For Ellett Gross Time Net Time �Denth to H2O I Net Dron I k/. Se-o-tt- Date Performed ) Z Legal Descri nti on : Lot l'3 Bl ock.�/_Subdi vision ��/of N; Its This Form Renorts Soils Log x Percolation Test Denth /-�L 0 Y, I Feet Soil Characteristics 2 — S W . Welk f (-j V4 -Son _ y Ila ri i 5 E ►� • k -�- rnu a ! ! i 7 — 9 — 10 — Was Ground Water Encoun If Yes, At what Depth? I_;--�--j-- It �I red? no Reading Date Gross Time Net Time �Denth to H2O I Net Dron I ' I I j Percolation Rate Minu—ti� Proposed Installation: Seena Depth of Inlet r.0mr^ENTS : T�Sf hal* Test Performed By kJa,, � S it Drain Field l_ . To lay e e al How AS"4o, "a,-taC---1 i f ed By Date: WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological a Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either to, Ib or Ic.) A.I) I N„ IajBorough Subdivision Lot Block Ib. 1/agIrs. Section No. TownshipNED Range E[:] Meridian —of—of—of _ S� W❑ Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL Address: Street Addracs and Area of Well Location 2. WELL LOG Feet Below Surface 4. WELL DEPTH: (final) 5. DATE OF COMPLETION Material Type To Bottomft. — — - 6. Cable tool Q Rotary Driven Dug E]Auger Jetted Bored Other: 7. USE: E] -Domestic Public Supply E] Industry El Irrigation Ej Recharge E] Commerical El Test Well Ej Other: streaks ,cit tx'aae of 8. CASING: E] Threaded .Welded diam. in. to ft. Depth Weight Ibs./ft. "t` len se f whi t r r+ ,' C_- diam. in. to ft. Depth Stickup ft. 9. FINISH OF WELL; Type: ' "' "' Diameter: Slot/Me'sh Size: Length: Set between ft. and ft. Backfilling Gravel pack 10. STATIC WATER LEVEL: j }}, Above or Q Below land surface Date Equipment used: �` t ( ) F 200 11 . PUMPING LEVEL below land surface and YIELD ft. after hrs. pumping g,p,m, ft. after hrs. pumping g.p-m, MUNICIPALITY OF ANCHORAGE 12. GROUTING Well Grouted: Yes E] No Material: E] Neat Cement Other: DEPT. OF H TH & 13. PUMP: (if available) HP — 8 Length of Drop Pipe ft. capacity g.p•m• Subm. Jet Centrifical ❑ Other --_—_—. 14. REMARKS: 16. WATER WELL CONTRACTOR'S CERTIFICATION: 15. Water Temperature ° F C This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Registered Business Name }. Contract License Number Signed: Date: Authorized Representative Form 02-WWR (11/81) Copy Distribution: WHITE -State DGGS,. PINK -Driller, CANARY -Customer cn cn r ° z °