HomeMy WebLinkAboutBURLWOOD TERRACE Block 2 Lot 10Li•( Ck‘E,\( faa,,
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Municipality of Anchorage
Community Development Department
On -Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http:f/wwv.moni,orglonsite • (907) 343-7904
Well Decommissioning Log
Legal Address:
Subdivision iSurlwooe It. reace Block 2_ Lot IC)
T R Section Lot
On Wafer R Wastewater Program fie ad contractor perforr<;ing the well decommissioning:
i
Name Signature: E
I'll"
Company f w P S
Well decommissioning date 3 - 13' i -C Melhed of decommissioning: AMC 15-55.060L1 a. L I b. a C.
Location: Use the space below
• North arrow
• 0econlmissroned well.
• Oihe.- water wells on
• Two separate swing
Note: The swing -tie distances
\it
J
to provide a drawing of the
Ne propeliy.
-(ie distances for each well
shall be measured from
...
properly showing the following items:
shown en the drawing.
ether pern(cru
manent stres or the properly' corners.•1'
f
344
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Ay Developrnent:Moveldpment Serrrces5&wtdmg Sa
PEATER ANCHORAGE AREA BOROUGH
HEALTH DEPA,RD!ENT
327 EAGLE STREET
ANCHORAGE, ALASKA 99501
279-2511
DATE RECEIVED
INSPECT:
TIME:
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
FOR
1. Approval Requested By (2074?()
Address /530 /3 Lc_
Phone
.72-27-7,5// 77-7'/ 3
2. Property Owner ./k)v 5 / X72 Phone
3. Legal Description
0
��uY U ).)
4. Type of Facility to be Inspected I�\
Number of Bedrooms /-16A-) 9 /;ti
S. Well Data:
A. Type
B. Depth
C. Size
D. Construction
E. Bacterial Analysis
STREET: 3'3 3:; L� NtJ
6. Sewage Disposal System:
A. Septic Tank (If homemade, show diagram on back)
1. Size
2. Age
3. Manufacturer
4. Installer
�T
Approval Request for Se ,e & Water Facilities
Page Two
B. Seepage Pit
1. Size
2. Lining
C. Disposal Field
1. Number of Lines
2. Total Length
7. Required Measurements
A. Well to Septic Tank
B. Well to Seepage Pit
C. Well to Sewer Line
D. Well to Property Line
E. Well to Other Possible Contamination
F. Foundation to Septic Tank
G. Foundation to Seepage Pit
H. Seepage Pit to Property Line
8. COMMENTS:
APPROVE
-. ?
DISAPPROVED:
DATE: % •';
DATE:
APPROVAL VALID FOR ONE YEAR FRON DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH HEALTH DEPARTMENT
ED1170
11K-
/
/u1
a
I'mEO
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIfn
(Fill out in Triplicate)
f person requesting appr.val
!kr!' of property! owner
gel rlesrri.ption
},edrr,oms in house �—
tdat�i Analysis:
2 �{ /
a. Bacterial �-/ -767/91- 4/ �CZ4`
b. Detergentl
77.,1.1 data:
333
3755
a.
b. Lel, ti,
:70,24Pk-
c. Casing Sita
d. Distance from well to closest existing or proposed: (-G
1. Sewer lino
2. Septic tank
3. Seepage Area
4. Cesspool'
5. Property Line
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
7. Sewage disposal, system.
a. Age of system
b. Septic tank capacity in gallons
c. Name of septic tank manufacturer
?L -11-6L11"1 41 ( e_(„7(LY
•
1. If "home made" show diagram on reverse side of this form.
d. Disposal field or seepage pit size and type
1. Distance to property line
to house foundation
Perco) ati.cin 're 'St 7es.ults
f. Percolation Test performed by
Use tr.e reverse .side of this form to show diagram. Diagram should include
the fo]]owing information: property lines; well location, house location,
tank Location, disposal area location, location of percolation test,
direction of ground slope.
9. Tie �, r.,r r ;�>n on tis form is true and correct to the best of my knowledge.
Signature of Applicant Date Signed
TO BE FILLED OUT BY HEALTH DEPAPTrIENT PERSONNEL
above described sanitary facilities are hereby approved, subject to the
`ollowing conditions:
Conditions --I
The above described sanitary facilities are disapproved for the following
reasons:
.2
Signature bf Iffie a']
Date
Approval is valid for one year following the date of approval.
CPJ:cw
-„b
_e>
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWAGE AND WATER FACILITIES
(Fill out in Triplicate)
vauw. of person requesting approval
2. kta,sof property- owner
3. description ',9„,?$ / J S-
4. NuMLel. of bedrooms in house
5. Water.. P.nalysis :
a. Bacterial.
b. Detergent
6. Well data:
a. Type
b. Depth
c. Casing Size
4,
d. Distance from well to closest existing or proposed:
1. Sewer line
C'/37ie
o
/
f
----1"-6-L-4-1 7/9//P
2. Septic tank
3. Seepage Area
4. Cesspool'
5. Property Line
6' /
6. Other sources of possible contamination, i.e., creeks, lakes,
houses, barn, drainage ditch, etc.
7. Sewage disposal system.
a. Age of system
b. Septic tank capacity in gallons
c. Name of septic tank manufacturer
1. If "home made" show diagram on reverse side of this form.
d: Disposal field or seepage pit size and type
1. Distance to property line
to house foundation
e. Percolation, Test results
f. Percolation Test performed by •
s?_ Use the reverse side of this form to show diagram. Diagram should include
the fo].].owing information: property .lines;•well location, house location,
c ptic tank location, disposal area location, location of percolation test,
and direction of ground slope.
9. The lifor•u.a+ion on this form is true and correct to the best of my knowledge.
Signature of Applicant Date Signed
La
70 BE FILLED OUT BY HEALTH DEPAFTT1ENT PERSONNEL
The above described sanitary facilities are hereby approved, subject to the
_'ollowing conditions:
Conditions:
the above described
sand
reasons:
facilities are disapproved for the following_
7 I Ld?/WY-1*r
g
Signature of Elfficfi .�• "`
Date
Approval is valid for one year following the date of approval.
CPJ:cw