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Home My WebLink AboutKIMPTON LT 4 NAME 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 PHONE J~NEW [] UPGRADE MAILING ADDRESS P,O, BoX A-35' °195-e '7 LEGAL DESCRIPTION LOCATION NO, OF BEDROOMS Well DISTANCE TO: ] Manufacturer ILq qapacity in gallons ~ ............ /~0 ,~nu ......... DISTANCE TO: Well Manufacturer I Well DISTANCE TO NO. of IMes [ Length of each Top of tile to finish grade Length ~ ~ Width Ty~of crib Crib diameter we / DISTANCE TO: I [Class Dept~ DISTANCE TO: ~n~fo~d~tio~ Absorption area~_ ~ Dwelling Inside leggth ] Width ~ Dwelling Foundation PERMIT NO. Material Nearest lot line Trench w dth No, of compartments Z._ Liquid depth PERMIT NO. Liquid capacity in gal]ohs PERMIT NO, otal length of lines Distance between lines inches Material beneath tile Total effective absorption area inches Buildinq fou nd~ation Driller /Z Crib depth Total effective absorption area ,~ ~_~ ~. Nearest lot line ~.~- ~er line Distance to lot line PERMIT NO. Septic tank Absorption area(s) OTHER PIPE MATERIALS SOlS TEST RATING NSTALLER REMARKS AL Departmen Health and Environment ~'rotection 825~'Lj Street, Anchorage, AK.~g9501 264-4720 * * * HANDWRITTEN PERMIT * * * Permit ~ ~S~I~ WELL AND/OR ON-SITE SEWER PERMIT Applicant: ,¢3 ~t'-' '~ '"/'--,, Mailing Addres~: / ~. Location: Phone Number: Legal Description: a c/ ~/b~/m/~ i.'~ Type of Soil Absorption System Is: Trench: Drainfield: Seepage Bed: h Holding Tank: Maximum Number of Bedrooms: ,~, Soil Rating(sq.ft/br) DEPTH Lot Size: The Required Size of the Soil Absorption System Is:' ~ LENGTH /~ .. GRAVEL DEPTH / ~2- WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = /D/3'O GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a.well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 1 9 8 3 * * * I certify that: (!) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if t~e~residence is remodeled to include more that 3 be~,ooms. ! Date: ~ ~:>dt .... , ~ [] SOILS LOG ~, ! MUN~CIPALITY OF ANCHORAGE ,,. ':' DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION [] PERCOLATION TEST 82~ L. ~ree~, Anchorage, Alaska 9~501 264~720 : SO~LS LOG- PERCOLATION TEST . ~ -. -'- 7 '- -~~0PE ~ SITE PL~ ' ,75' , '~,, 13 .~ j Gross Not Depth ~o Reading Date Time Time Water Drop t . 1 14 PERCOLATION RATE , , {mlnutes/inchl TEST RUN BETWEEN FT AND __ FT COMMENTS ...... DOC Co. dba SULLIVAN WATER WELLS P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-275~) WNER OF LAND L)/</~, /<'/ ~,~-~ ,a'7'o ,.,d .DDRESS ? ~ ;'.~ o/~ c~ ~-/ C' /"/~ 6 .,~,,% EGAL DESCRI~ION Z ~ ' ~ ~ E~IT NUMBER l DEPTH OF WELL ~:~) ) / STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR c'~ ~ 0 KIND OF CASING ! .?,?! :IND OF FORMATION: rom '~) Ft. to -~ Ft. ¢) c),,,? <' 67d,*",,'~ .~," From rom ~ Ft. to /~ Ft. ,'d<~ ~ ,~'~:'~',?d. From tom t ~ Ft. to ~: C; Ft. ~r/~;,e,~.~f/~j From ,- ,.~. ~ .-~z:c~~ tom ~0 Ft. to [;90 Ft. ,/~<d~,'~ ~:: t:'~; ~ rrom~ tom t'~o Ft. to'/:;~: Ft. <~to~ ~' ~' - - From rom /$-~ Ft. to /~$ ,Ft. ~'/,:,~ <e~<::~ From tom.J(~C, Ft. to /.J:~ Ft. ~/< F" ~3'// C/;~"gA From ~om~.Ft. to Ft, ,Z~,~'~'-.'., ~) 6 '~)~ / g" ~ From romJCr~ FI. to ~')~'Ft. ~.~', eS~~/~o~2cz" From :om Ft. to Ft From tom Ft. to Ft From tom Ft. to Ft From tom Ft. to Ft From tom Ft. to.~.Ft. From ;om Ft. to.~Ft. From :om Ft. to Ft. From~ Ft. to Ft. Ft. to Ft. Ft. to Ft. Ft. to Ft Ft. to Ft, Ft. to Ft. __ Ft. to_ Ft._ Ft. to Ft. __ Ft. to Ft. Ft. to.~Ft. Ft. to Ft. Ft. to__ Ft Ft. to Ft Ft. to Ft. Ft. to Ft. Ft. to.__.Ft. .Ft. to .... Fl'. ISCL. INFORMATION: ,, -' ,,~ k. / '~..~ C DRILLER'S NAME ~'~ ..:.'.-'"-,' '~,. APPLI( NT FILLS OUT UPPER HA[ ,ONLY Property Owner~,,~,,/ Phone -~ ', /~_,~ ,~/ 0 ..... Lending Institution /~....: "~' Address /,~: ' /~ Really ~o. ~ Code Zip Code Zip Code Legal Description ~/¢., ~-' .Z// .,/~/~/~/:~?~.4~' Street Location .!.././//L) F" ?//?/~/~ '"~)" 'i/~ Type of Residence J~] Single Family [] Multiple Family No. of Bedrooms [] Other ZipCode ~.~...5 ~i7 Phone Phone Water Supply ;~ Individual ) .(.~.! . ATTACH WELL LOG. A we~l 10g is required for all wells drilled since June 1975. [] Community {":~5.~ ~ For wells drilled prior to that date, give well depth {attach log if available). [] Public Utility Sewer Disposal E~ Individua~ [] Public Utility [] Holding Tank 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' ~.~,~.~..~.~.~ ES,,,~,~) ~ ~ ~ ~ . ( ~APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED ( )CO.D T=O.*L*,.ROWL* Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received ~8'--~ 3 Well to Tank /~ Septic T~k Size 72-023 (3182) CHEMICAL & G£_.LOGICAL LABORATORIES t>./ ALASKA, INC.~~ -- ~ ; TELEPHoi'~E (9D7) 562-2343 ANCHORAGE INDUSTRIAL CENTER ~~-~"~ 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 City State Zip Code Mo. Day ' ~ Year SAMPLE TYPE: [3 Routine [] Check Sample (for routine sample,~ with lab ref. no. [] Special Purpose [] .Treated Water [] Untreated Water SAMPLE NO. , 2 3 5 I 1 Time Collected Collected By TO BE COMPLETED BY LABORATORY Aha ysis~hows this Water SAMPLE to be: ~] Satisfactory [] Unsatisfactory [] Samole too long in transit: sample should not ee over 48 hours old at examination [o indicate reliable results. Please'send new sardplel Date Received Time Received Analytical Method: [] Fermentation Tube ~.'Memb[ane Filter Lab Ref. No. Result* Analyst I CCi READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-1220 {i~) Rev. 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collected Source Time Receive~l ),rn. Lab. NO. Presumptive 10mi 10mi 10mi 10mi 10mi /.0mi 0.1mi :-%~ HOurs Confirmatory EMB Broth 24 hours: Broth 48 hours: , Multiple Tube Report: 10mi Tubes Positive/Total lOml Portions Membrene Filter: Direct Count , Collform/100ml Verification= LTB, BGB Final Membrane Filter ReSults ~ . .-" ) Collform/lOOml Repor {ed By. -~' · ; " Date -'T 'i eom,