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Home My WebLink AboutBURLWOOD TERRACE BLK 23 LT 9LoT' Municipality of Anchorage Community Development Department On-Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904 Well Decommissioning Log Legal Address: Subdivision �,',kPW--"J Block 2� Lot T R Section Lot �� j �J` qt' On-site Water & Wastewater Program certified contractor performing the well decommissioning: Name: 1 � 4,4 I� Signature: Company: �P.D. BO112130 Attefivra '4e, AX99511 Well decommissioning date Method of decommissioning: AMC 1, 5.060Ll a. ❑ b. ❑ C. Location: Use the space below to provide a drawing of the property showing the following items; • North arrow • Decommissioned well, • Other water wells on the property, • Two separate swing-tie distances for each well shown on the drawing, Note: The swing-tie distances shall be measured from either permanent structures or the property comers. G:\Community Development\Development Services\Building Safety\On Site Water and Wastewater\I-ormskUkent t-orms\Well Uecommisiomng torTn.doc - GREATER ANCHORAGE AREA BOROUGH i Department of Environmental Quality .~]/~ /~ 3500 Tudor Road· Anchorage, Alaska 99507 279-8686 tt~ Date of Inspection "/ ''z "' ~ REqU_ST FOR ,~PPROVAL OF , ~"~ ,'~> I~ZVlDUAL S~ER & ~A~R FACILITIES 1. Approval Requested Address: Phone 5 Type of Facility to be Inspected: , ,~ Number of Bedrooms: A. Installed B. Installer C. -Septic Tank: 1. size 2. Manufacturer D. Seepage Pit: 1. Size 2. Material E. Disposal Field: Total Length of Lines Distances: o A. Well To: Septic Tank , Absorption Area , Sewer Lines · Nearest Lot Line , Other Contamination B. Foundation to Septic Tank Absorption Area C. Absorption Area to Nearest Lot Line .. Ae~e~t for Approval of Ir Pag~ Two 9. Comments: Yidual Sewer & Water Facilitie.~ AppzN~va] Valid for One Year From Date Signed Greater Anchorage Area Borough, Department of Environmental Quality DIAGRAM OF SYSTEM I certify that the information contained in this request for approval to be a true and accurate representation of the subject sewer and water facilities located ~t: Signed Date ~lai~. of property, owner Numb~ ~6 l~d~.oom$ in house r.,-,'/ REQUEST FOR APPROVAL OF / INDIVIDUAL SEWAGE AND WATER FACILITIES (Fill out in Triplicate) ' ~lame.-of person requesting approval . ~¥~.2~i?_ .~ Wate~ Analysis: Well data: b. Depth_ c. Casln~ Size_ (,.)ii ds Distance from well to closest existing or proposed: 1. Sewer llne q ~ ~ I 3, 5. 6. Septic tank _ 7 I , Seepage Area . Cesspool'__ ~ .' Property Line_~30 Other sources of Possible contamination, i.e., c~'eeks, lakes, houses, barn, dralna[e ditch, etc.... MO [3~ · 7. Sewage disposal system. a. Age of system b. Septic tank capacity in gallons,,, ~-~ . c. Name of septic tank manufactu,~,~.r. ~' 1. If "home made" show dlaFPam on reverse side of this fomm. d" Disp°sal field °P seepaae Pit size ~d t~e - ~. Distance to p~ope~ty llne Q-_ I t to house foundation · e, Percolation~ Test~'esults f. Percolation Test performed by Use the reverse side of this form to show diafram. Diagram should include .the foilowing information: p~operty lines~.well location, house location, ~ptic tank location, disposal area location, location of percolation test, and direction of ground slope. The information on this form is true and correct to the best of my knowledge. Sif~frure of AppiicAn~ D~ Si~n~d ' TO BE FILLED OUT BY HEALTH DEPAP, T~.~ENT PERSONNEL he above described sanitary facilities are hereby approved, subject to the .......... ~'llowing cond~ions: ..... Conditions: The above described sanitary facilities are disappr~oved for the following reasons: Appro al ~s valid for one year following the CPJ: cw date of approval. HA Form 2573 ~ Form Approved R~v. July 1958 FEDERAL HOUSING ADMINISTRATION "-'", Budget Bureau No. 63-R296.8 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM PART I.--TO BE COMPLETED BY FHA INSURING OFFICE MORTGAGEE SERIAL NO. MORTGAGOR OR SPONSOR PROPERTY ADDRESS BOOHBR~ Cho.z*les R, & $L13~ R. I. of Tudor on Chz*ls~lo St.~ ~3 mi. $.E. Can attic or other area bo mad& into TOTAL NUMBER: BASEMENT ~] ~%]ew installation additional bedrooms? LIVING UNITS BEDROOMS SATHS (If Yes, how WATER SUPPLY BY: SYSTEM DESIGNED FOR D Public system ~ Community system I~ Individual NO. OF BDRMS. GARBAGE DISPOSAL SEWAGE DISPOSAL BY: I-I blic system I--I mmunity system Individual I I--I Yes No PARt II,--tO gE COMPLETED BY HEALTH DEPARtMENt HEALTH DEPARTMENT INSPECTOR'S SKETCH I I I ~ J r ~' ~. ir : , it -,* I : '%1/ i ' ; i r ~.a ' i \ , Il I .u i , :,g. , . 't 2' { '. ,I[ :{ ' .r'.' ~': : '" ' ~,' , ~." d" ~ i , ,,t,i~ -'.~ '~ , ~' ;' -'~, I'~ i : II I I i II ~ ]1 I I i ~ I It is the opinion of the [--] State [--] County [-~ Local Department of Health that this individual water-supply system [~ is [~ is not satisfactory as a domestic water supply for the subject property. It is the opinion of the [--] State ['--1 County ~ Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: [Can be expected to function satisfactorily, and I~ Cannot be expected to function satisfactorily is not likely to create an insanitary condition DATE SIGNATURE TITLE _ ,, /NOTE: The health authority should complete the appropriate opi statement above an x date, slgnatur nd title in the spaces provided. Use of the above grid for Health Department Inspector's skor' as well as use of the back of this form is at the option of the health authority. PART III.~FOR USE OF FHA OFFICE TO THE CHIEF UNDERWRITER: I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that'the Individual water-supply system be considered [--] Acceptable I~ Not Acceptable Sewage disposal be considered [] Acceptable [] Not Acceptable. DATE SIGNATURE Jl CHIEF ARCHITECT r~l DEPUTY FOR CHIEF ARCHITECT · ,~ HEALTH AUTHORITY APPROVAl, INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM FHA Form 2573 Rev. July 1958 REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SYSTEM PRIMARY TREATMENT consists of [~ Septic tank. Septic Tank: Distance from well, 7~ feet. Material Total liquid capacity, ~ Inside length,?a~[l~_feet. Inside width, Cesspool: Distance from: Well, feet; foundation, Inside diameter, feet. Depth, [] Cesspool. gallons. Capacity inlet comp~artment, feet. Liquid depth, 51~41'11t feet; nearest lot line at [] front, [] side, [] rear, feet. Liquid capacity, gallons. Lining material SECONDARY TREATMENT consists of [] Tile disposal field. Tile Disposal Field: Distance from: Well, Total length of tile lines~ Trench width. Length of each line Type of filter material: [] Gravel. [] Seepage pits. Other gallons. Number of compartments feet. feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet. feet. Number of lines Distance between lines, .feet. inches. Total effective absorption area in bottom of trenches, square feet. feet. Depth, top of tile to finish grade, inches. [] Broken stone. Other. inches. Depth of filter material beneath tile, inches. Depth of filter material over tile, N tuber of pits/ . Outside diameter, feet. Depth, feet. Lining material Distance from: Well, _~! feet; building foundation, ~ feet; nearest lot li~ at I-I front, [] side, [] rear, 11 Inaction made by: [] State. [] County. [] Local Health Authority. Inspected by Date of inspection ~ ~ , 19 ~1 (TITLE) REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM Distance to nearest public water main, ~ feet. Size of main, ~ inches. Individual wells [~ are [] are not customary in neighborhood. Give most recent record of failure of wells in immediate vicinity to furnish adequate supply of water Properties in neighborhood [~are [] ot being developed with both individual water-supply and sewage- Lot size: ~1~ feet wide, i~n d~osal systems. feet deep. Dwelling set back from front property line, feet. Individual water supply from: [l~ Drilled well. [] Driven well. [] Dug well. [] Bored well. Distance of well from: Building foundation, _ ]~ feet; nearest lot line at [] front, ,~'side, [] rear, ~ cast iron sewer, feet; tile sewer, .feet; septic tank,.___~} .feet; disposal field, seepage pit, .feet; cesspool, ~ feet; other sources of possible pollution, feet. Well construction: Diameter, & inches. ~i'otal depth, 1~0 feet. Type of casing,, t._~.~ ~l~-%pth~ of casing, Approximate depth to pumping level of water in well, ~' ~ feet. Approximate yield, gallons per minute. Sealed watertight to depth of ~' I~ feet. Exterior space around casing sealed with: [] Cement grout. ~Puddled clay. [] Ordinary backfill. Well cover: [] Concrete. [] Wood. ~ Metal. Openings in well cover watertight?~es~ ~ No. ~umu: [] Shallow well. ~l~Deep well. Length of drop pipe, ~ ~} feet. Pump capacity, ~on, s peLm~ute. Located in: [] Basement. [] Pumproom off basement. [] Pumphouse above ground, r-n ~ it ~l~l~l~ Pumproom properly drained: [] Yes. [] No. Pump _rno~rlling watertight: [~Yes. [] t'~o~~ ~[1~ Type of storage: ~gPressure. [] Gravity. Capacity gallons. feet, feet; d~Ias bacteriological examination of water been made? [~es. [] No. If answer is "yes," give date ~ I~ 19 ~uality of water [~lgis [] is not satisfactory for human consumption. Installation [] does [] does not comply with approved exhibits, if any. //~'-) . / Inspection made by: [] State. [] County. [] Local Health Authority. ~ I~ ~1 Inspected by ' '- Date of inspection 19 (TITLE) *t~llMtet Inf~,~tle. h.mldm4 I~/I.~l~'t~ ~4' U. S. GOVERNMENT PRINTING OFFICE: 1957 O-F--4~TO$8