HomeMy WebLinkAboutWOOLEVER BLK 2 LT 2 J'OOL. '06
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
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
_ [] UPGRADE
NAME
LEGAL DESCRIPTION
LOCATION
DISTANCE TO:
Manufacturer
Liq, capacity in gallons
~ O~;) O IF HOMEMADE'.
DISTANCE TO: Wel~___~_~_
Manufacturer
No. of lines ~ I Length of .ach li~.~
Top of tile to finlsh grade
Length Width
Material
N~are~t lot line ~ ~
Tr e nth w~t h~.~ inches
Foundation
Type of crib
DISTANCE TO:
Total length of Id~(~)_¥
Material beneath tile
Depth
Crib depth
Building foundation
Driller
inches
NO. OF BEDROOMS
PE M,T NO. 180 , 54.
No, of compartments
PERMIT NO.
Liquid capacity in galloas
PERMIT NO, ~.~
Distance betwee,1 lines
Total effective a~¢~c~ti~.on area
PERMIT NO.
Total effective absorption area
Nearest lot line
Distance to lot line
DISTANCE TO: Building foundation Sewer line Septic tank
OTHER
PIPE MATERIALS
SOIL TEST RATING
REMARKS
DATE
LEGAL
72-013 (Rev, 3/78)
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Al&~ka 99§02 276-222I
SOILS LOG - PERCOLATION TEST
PERCOLATION
'rEST
PERFORMED FOR:
LEGAL D E S C R I P'¥ I O N: ___Ljc~.7~._~_~..~.).~. k'- ~-
1
2
3
4
6~
7-
8
9
lO
11
12-
13-
SLOPE SITE: PLAN
14-
15-
16-
17
18
19-
20-
Reading
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
(minutes/inch)
· TEST RUN BETWEEN ........ FT AND -- ,.-- FT~ I I
P~RFOR~ED BY:
72-008 (7/76)