HomeMy WebLinkAboutMCMAHON #1 BLK 3 LT 29
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
PNoNE-Oq-?I
NAME
MAI LING ADDRESS
LEGAL DESCRIPTION
DISTANCE TO: Well
Manufacturer
Liq. capacit
IF HOMEMADE:
Absorption area. Dwelling ~ ~) ~
'~ qO ':Material. ·[
Width "[~
Inside lengt~h{ Cl
Dwelling~'~ ~
DISTANCE TO:
Manufacturer
DISTANCE TO:
Material
~.)(~ ¢ Foundation Nearest Io~t_l;~...~) {
Length of each ,engt h~f~n~s Trench wid~ ~inches
Material beneath tile
Depth
Top of tile to finish grade
inches
NO. OF BEDROOM~L.~-
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMIT I~' ~t~(~ll,t,~ ~' ~ l~
Distance betweeRJines
Total effective./~.~rptJon area
PERMIT NO.
Type of crib
Crib diameter Crib depth
Well Building foundation
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO.
Sept c tank Absorpt on area(s)
DISTANCE TO:
DISTANCE TO:
Depth Driller
foundation Sewer line
OTHER
PiPE MATERIALS
OLA~
SOl L TEST RATING
INSTALLER
REMARKS
DATE LEGAL
THE L. ENG'!"H !}!'HEN'.:;ION iF~ TF!r:E LENi:YI"H ,::IN FEET) OF THE TRENCH E',R
THE DEF:'TH OF FI TREFqCH OR Pi'F Z.S:; 'THF.] [:,ZSTF!i"4CE E:ETHEEN THE ~;U.F.'.FFiCE OF' THE
[iiROI..iN[) R.N[:, THE E~OTTCihl OF THE E',:.::CFi'v'F:FFIC!N <!N
THERE IS NO ."{IET i.,.!]:[>]"I.-t F'OR 'T'RENCHE:5.
'T'HFJ GRW,/EL_ [>EF'TH i:5 THE l'"lL,"i'.~):HLJ.:-""i DEPTH.: OF:: CiF:R',/EL. DETi,.IEEN THE OLFFF'FIL.L. F'!PE
Fi,.ND THE E':EF:.:"TOH O,r.:: THE EZCF:¢,/FFF):OF~ (IN
T F '/.q E'
CONSULTING GEOLOGIST
BOX 476-M, STAR ROUTE a * ANCHORAGE, ALASKA 99507' · PHONE 344-7071
SOILS LOG
Performed for ~~ ~~ ~l?_e 5 Date
Location ~ S ~ ~ ~_.-X2>' ~_o_~~ ~
Soil Type Water Level
Remarks
0
~.0
.14
16
18:
20
Total Depth of Excavation
Groundwat er
~'~ot Reached
Depth, if Reached
Classification Method
~'-Visual
( ) Sieve ~alysis
()
Bedrock
~-~'Not Reached
Depth, if Reached
Gary F. Player, Consulting Geologist
WELL OWNER
LOCATION Z ~
WATER WELL LOG
FOSS DRILLING
1336 Ingra Street
Anchorage, Alaska 99501
SIZE OF CA~ING/~ J/DEPTH OF HOLE 7~ ~T.
STATIC WATER LEVEL ~ FT.
FEET OF O~OWN.
DATE COMPLETED~-~/- 7 ~
Pu~P TO BE SET AT ~ &
FT.
~to_2g
___to
, to
__t 0
tO
__to
tO
to
__to
to
to
to,,,
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.q o.,m A V c
MUNICIPALITY OF' ANCHORAGE
DEPARTMENT OF HEALTH~ ENVIRONMENTAL PROTECTION '
825 L Street - Anchorags, Alaska 99501
ENVIRONMENTAL E'NGINEERING DIVISION
Telephon~ 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACl ~1~1 ES;
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing,
I, PROPERTY OWNER ~ ~ PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2, BUMER
MAILING ADDRESS
3.
MAILING
5. LEGAL DESCRIPTION
;TREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One ~ Four
'~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
[] Other
7. WATER SUPPLY
~. 'INDIVIDUAL* *ATTACH WELL LOG, A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTILITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
~. INDIVIDUAL/ON-SITE** **lfindividual/on-site, give installation date ~ ¥ ]~Tg
If system is over two (2) years old an adequacy test is required
[] PUBLIC UTI LITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED ,
INSPECTION APPOINTMENTS""
TIME TIME . TIME
DATE DATE DATE
INSPECTOR INSPECTOR I NSP ECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [~ ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] IN DI VI DUAL/ON -SITE DATE I NSTALLE D
[]PUBLIC UTILITY
Connection Verified INSTALLER
E~l~ptic Tank or E~Holding Tank
Size: I ~,,..~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL.,~,~.~ _0
4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line I Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
~ APPROVED FOR ,~. BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Ti~j~
LEGAL DESCRIPTION
72-010 (Rev, 3/78)
. ; :) ,~ ,~
Date ,'
ALASKa- 'ARTMENT OF HEALTH AND SOCIAL ST~-~CES
DIVISION OF PUBLIC HEALTH
Lab. No.
BACT E R I O LOG I CAU'"WATE R
ANALYSIS
Office
PLEASE MAIL RESULTS TO:
NAME ~.'"" ' ' < ' ~
ADDRESS ' "-~ : "'
ZIP CODE
Sample collected by
Phone No. - '
Date Collected · Time
Sampling Address
Specific place of collection
REASON FOR SAMPLE SUBM/SSION:
[] Illness suspected
[] Health Regulated Establishment
[] Other ~ v..',
WATER SAMPLE SOURCE
~] 'Well Type of casing ((:~'
[] Improved (Enclosed, Covered ) Spring
[] Surface (Reservoir, stream, lake)
[] Holding Tank
[] Other
Analysis shows this WATER SAMPLE to be:
[]'Satisfactory
[] Unsatisfactory
[] Questionable [] submit other sample
[] Sample too long in ~mnsit to indicate reliable results.
Sample should'not be over 48 hours old at ~ime of
examinatio~.
[] Bottle broken or leaked in transit.
[] Other
SANITARIAN'S REMARKS
Sanitarian's Signature:
~EAD INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b) BACTERIOLOGICAI- WATER ANALYSIS RECO)RD
Rev. 1978
Date Collected / !~ ~ "'/' Source
7 /.:) fi-f::~ ~.-) . C' .'~,a.:m. :: ~..
' Date Received -' ~ime Received -,' p,m. Lab. No.
Presumptive 10mi 10mi 10mi 10mi 10mi 1.0mi 0.1mi
2~ Hours
Confirmatory
48 Hours ,:
EMB ~? .~ ' / B$oth 24 hours: Broth 48 hours:
Multiple Tube Report: ~' /~'~ 10mi Tubes Positive/Total 10mi Portions
Membrane Filter: Direct Count, ~ Coliform/100ml
Final Membraiie~ Bilter Results ~ / /" ~_ y /., ~
Reported By ~ z f . Date ~/.9// /. 4f
