HomeMy WebLinkAboutLITTLE BEAR BLK 2 LT 4
PERM I T
RPPLICANT ED RINNER
LOCRT I ON B~'~LH _.E
'- ;'' , - -l-'
LEGAL L. 4 B2 LITTLE BEAR SUBD
[:,EPRRTMENT.' c HEALTH FIN[:, EN',,,' ! RON',IENT? 1. F E I EL: ~ I JN
25±0 E. TUDOR RD.., RNCHOF.'FIGE, IRK. >.:.~507
276-222'_1.
8)]:10 I.,.IELL_,LE~ r':F'd
LOT SIZE 8400 %6dJRRE FEET
MINIMUM DISTRNCE BETWEEN A WELL AND ANY ON-SITE SEHAGE DISPOSAL SYSTEH IS
±EIEl FEET FOR R PRIVATE WELL OR 200 FEET FOR A PUBLIC NELL
WELL LOGS RRE REQUIRED AND MUST 8E RETURNED TO ]"HE DEPARTMENT I,.IITHIt",t 3:6 [:'FLYS
OF' THE WELL COMPLETION.
SPECIFICFITIONS RND CONSTRUCTION DIAGRAMS FIRE AVAILABLE TO INSURE PROF'ER
INS'FRLL. ATION.
I CERTIFY THAT
1: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WE/.,.L.S RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
...... ...................
RPPLICRNT ED RINNER
ISSUED E:~r __DFITE ...... ~ ..........
F'EF.:M I "1" NO.
I)EPRRTHEN'T ,...F HEFIL.]]~'t Rlql} E:N'v'IROt'-,IHENTRL. ,RO"f'EC:]-'ION
;~i'.5::l..E~ E. TLI[:,OR F.:[.':,.., RNC:HOF-,'FIGE., RK.
~..-.11 EL:-': L. ILF" .LFZ D-T-.: ~"""I] ][: ']1 ....
,:1 '?G]~::i.:~:.~ .'.', [:,FITE OF
C: C) F:"
F:IPt::'I... ]: CRbtT
I.... O Ii:: FI T I Ii) N
L.E)]iI::I L
B~EP~:' BEFIR F'LFICE:
L4 E!:2 LITTLE E',E:FtI~E: Si..J[EID
::}.':}7:::I.E~ 14EL..L.."SL, E'~-' CC)LII:~:T
L.O'T' ::]; I ZE
8,~:!.~Z~E'~ SI]:!LtlaRE FEET
HIi'qlHIjM [:,tSTFINCE 8E'I"t.,IEEN f:l I.,.IEL.L FINE:, F:IN'.? ON-SITE SEI.,.IFIGE: [:,ISF'OE;F:IL S"r'STEM ]:'.':T,
2.~ZiE~ F:EE'T' F:'OR R PF.'.:[VF!TE 14ELL OR ~:'('.:~ FEET F"OF.':
NELL. LOGS F:IRE RELT!LIIF.'.E[:, F:IN[:, HIJS]" DE.. RETLtRI',IE[:, TO THE [:,EPFIRTMEN'T' !-,.ti:THIN ]i:E~ [:,FI"?'.'.C,
OF TIdE I-,.tELL COHF:'L.E'T'ION.
SPEC :1: F I CFIT :[ Ob,IS F'tN[:' C:ONSTRUC:T I ON [:' :[ RGRRHS F:IRE FI',,,'FI .): LFtE'4...E 'T'O ]: N:E;L.tI:RE F:'I:;~:OPER
]: NS'1"FtL..LR T ]: ON.
t CERTIF:'Y THFIT
::L: I f:lt"l FFiMII._iRR WiTH THE RE~L::IUtREHENT'S FOR: ON-S;]:TE :E;Et4ER'.E; RN[:, 14ELL.:E; FIS SET
FORTH r:?'.r" THE HUN I C I I::'RL I T"r' OF:' FIt",!CHOF..'FIGE.
2: 1i: t4tL. L. :[t',IS'T'FIL. L '1"HE S"r'STE:H :I:N FIC:COI';-:[:'FINCE b.l:["l"H THE CO[:'F.T.S.
'.E; 11: GNEi}:
I:::IF:'PL I CFINT El::' R I
:11 :E;'.'~i;IJEE:' B"r'. .................................................................................... L}FITE ..................................................
:[ I",I:L':F'ECT I ON H :i: STOF.:"r' '- S:;Eb. IEF.: & E~ SEI'tEF:: 2
b. IIEL.t..' I F,ISP E~ !.,.IELL. LOG [:,FI'I"E ~:.~ [:,R ]: L.I...E:.R
Z
Z
0
#i: Time
Date
Insp
,~=,MUNICIPALITY OF ANCHORA ~.~
DEPARTMEi OF HEALTH AND ENVIRONMEh PROTECTION
u4
70
825 L Street, Anchoraae. Alaska 99501
264-4720
9:30 a.m. #2: Time
Date Received:
September 19, 1977
#3: Time
9-27-77 Tuesday Date
Date
Prat% Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request:
Mailing Address:
2. Property Owner:
Mailing Address:
Alaska National Bank of the North
3301 C Street, Calais II
L.J. Sebring
Star Route A Box 1540C 99507
Phone:
Phone: 344-3069
3o Legal Description: Lot 4 Block 2 Little Bear Subdivision
4:
o
o
Single Family Residence: (
Multiple Family Residence:
Number of Bedrooms: Three
Number of Bedrooms:
Well System:
Permit #
Individual well (x) Conmmnity/Public System ( )
Depth of Well Well Log on File ( )
Construction
Bacteria]. Analysis
Sewage Disposal System:
Permit #
Septic Tank Size
Absorption Area
On-site System ( ) Public Utility ~)
Installed Installer
Manufacturer
Soils Rate Material
Distances: Well to Septic Tank
to Sewer Line Nearest Lot line
to Nearest Lot Line
to Absorption Area
Absorption Area
Pa~3e T-~o
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water FacilitSes
Legal Description: Lot 4 Block 2 Little Bear Subdivision
Cor~merlt s:
Affadavit Attached
Disapproved:
Letter Attached: ( )
Date:
Department Worksheet:
'- ' MUNICIPALITY OF ANCHORAGL ' ' "'' ' ' ·
i'~ IDepartment of Health and Environmental Protection' ,'
~//~~ i ' 825 L Street, Anc!}orage, Alaska 99501 .... "~
~[t~W~} 279-2511, e~t. 224, 225 ~'~:'' V i?:!i
Facilities
· ~ ~-~-~-r~/equest for Approval of Indlvzdual Sewer and Water
m
Property Owner:
Phone:
Name of Buyer:
Mailing Address:
Phone:
Lending Institut~ion: ~. ~ Y~/~'
Mailing Address: ~/~/_---f ~.~/~'~_z~~~ ~ Phone:
Realtor/Agent: ~(~r ~~
Mailing Address:
Phone:
Legal Description:
Street Location:
Single Family Residence:
Number of Bedrooms
Multiple Family Residence: ( ) Number 6f-Bedrooms:
Water Supply: *Imdividual Well (~ Public/Community System (
If Individual Well, well depth ~
If Co~mmunity System, name of system
Sewage Disposal System: On-site System ( ) Public System
If On-site System, date of installation:
*NOTE: A well log is required on ALL wells drilled since 6/75.
3/77
06~122~0)' Rev. 1973
DATE
ALA . DEPARTMENT OF HEALTH AND SOCIAL S' ',CES
DIVISION OF PUBLIC HEALTH
INDIVIDUAL AND SEMI-PUBLIC
BACTERIOLOGICAL WATER ANALYSIS
Lab No.
OFFICE
INDIVIDUAL []
NAME
SEMI-PUBLIC [] CHLORINE RESIDUAL PPM
REPORT RESULTS TO
', ;-~ ).
ADDRESS
CITY
ADDRESS
OF SOURCE
ZIP CODE
COMPLETE THIS SECTION
ONLY IF WATER IS AN iNDIVIDUAL SUPPLY
SAMPLE COLLECTED BY -" · !" /":'~
DATE COLLECTED ) : ~ ' TIME COLLECTED / ' ~'i~J
Sample Collected From ~[~] Kitchen Tap [] Bathroom Tap [] Basement Tap
[] Other (Hst)
Well- [] Dug [] Driven [] Drilled
SOURCE: [] Spring [] Cistern [] Other__
Dug Well or Cistern Construction:
Walls--[] Wood [] Concrete [] Metal
Top -- [] Wood [] Concrele [] Melal
LOCATION:
[] In Basement [] Basement Offset
'? E]ln Yard [] Other
Building Sewer
DISTANCE TO: or Other Drainage Pipe Feet.
' Tile Seepage Cess~
Field Feet· Pit Feet. Pool __
Other Possible
Sources of ContaminaHon
MATERIAL: Building Sewer - [] Cast Iron [] Wood [] T~le
[] Plastic Joint Material - Type
GENERAL: Does Water Become Muddy or Discolored?
When?
[] Bored
[] Tile Brick or
[] Open Top [] Concret~-
[] Under House
Septic
· Tank Feet.
Feet. Privy __. Feet.
[] Fibre [] Asbestos
Cement
[] Yes [] No
Diameter of Well Depth P~et.
Well Casing
Material Diameter Depth
Length of Water Depth
Drop Pipe From Bottom Feet.
Offset in In Utility
PUMP LOCATION: [] In Well [] Basement [] In Basement [] Room
On Top
[] Of Well [] Other
PURPOSE OF EXAMINATION: Illness Suspected?
New Source of Supply? [] Yes [] No
READ INSTRUCTIONS
ON
REVERSE SIDE
BEFORE
COLLECTING SAMPLE
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
[] Questionable
[] Sample too long in transit; sample should not be over 48
hours old at examination to indicate reliable results. P/ease
send new sample.
[] Bottle broken in transit, please send new sample.
SANITARIAN'S REMARKS
[] Yes [] No
Repairs to System? [] Yes [] NO Signature
o,s-],~2o (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1973
'' ~ : i" Time Received ~' , am ~ '
Date Received ~ ~ : ~ .pm Lab./ No. -
Lactose Broth 10cc 10cc 10cc 10cc 10cc 1.0cc 1.0cc
24 Hours
48 Hours ........... "
Brilliant Green ,
24 Hours
48 Hours
EMB AGAR
Laclose Broth, 24 hrs. 48 hrs. Gram's stain
Coliform Densily (Most probable No. per 100cc)
MF Results
Reported by ?':-~ '
This analysis indicates Coliform Organisms to be:
Date, . "' j' p.m,