HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 4 LT 30
~ ~%/ 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
LEGAL DESCRIPTION
~ DISTANCE TO: IWell ¢ I Absorption are; Dwellir~g~, S.~ PERMIT NO, F~
~ ~ ., -- ,~ i~ Material ~L- No, of compartments ~
Liq. capacity in gallons Inside length Width Liquid depth
/ ~ IF HOME'DE:
~ ~ DISTANCE TO: W°ll Dwelling PERMIT NO.
3: -~ Material Liquid capacity in gallons
~ ~ Z NO, of lines t.engtl~ of eacl~[in~
=~ / ~ Total length oflbl~ Trench widJb~~ Distance between lines ~ '
N ~ ~ ~ Material beneath~il~ Total effective
~ ~'~ ~ inches absorpt~
~ Lengtb Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ m DISTANCE TO: ~uilding foundation Sewer line Septic tank Absorption area]s)
OTHER
PIPE MATERIALS
SOIL TEST RATI
72-013 (Rev. 3/78)
t l"lli!;
Iiii!~l. OI. Ih[I)
I lie
I:::! I",1 E:,
Performed For
Legal qescrintion:
This Form Reports
"Ou~ t~$t h wort~ ~ t~ou~.d opinlon~"
//~ Date Performed
Soils Loo_~_5 Percolation Test
~enth
Feet Soil Characteristics
-- ,:~x~~~ ~
16--
18--
20--
Was Ground Water Encountered?
I~ Yes, At what Depth?
Readinq
Date Gross
Time Net Time
Percolation Rate )tinute
Proposed Installation: Seenaoe Pit
Depth of Inlet Depth
~./~0 ~" ~----~'~ '
Cn~ENTS
{ .
Test Performed
Depth to H20
Net Dro
Drain Field
To Bottom Of Pit Or Trench
.y~ /.2 ,
· :_LT__ ,-
~ELL CONSTRUCTION LOft
Well location: (a(Idress & legal flescliption)~-~'. _~ ~_~E ~-~ Location s~etch or~remarks
Oescribe intervals and size:
Wall~ield tested by (pumping, bailing, air) at ~)
/
lot hours with~(O __It, of drawdown flom static level,
____to
--__to
----to
__to
----to
__to
to
· MUNICIPALITY OF ANCHORAGE /
MUNICIPALITY OF ANCHORAGE DEPT. OF HEA~LTH & J
82B L Street - Anchorage, Alaska 99501 J
ENVIRONMENTAL ENGINEEFIING DIVISION NO / 4 1 78
~/ Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATFR AND S E I 'REF 'J I L IJ gD
DIRECTIONS: Complete all carts on page 1. Incomplete requests will not be processed. Please allow ten (10) davs for processing.
~-. PROPERTY OWNIER PHONE
MAI LI NO ADDR ESS
?
PROPERTY RESIDENT (If different from above]
2, BUYER
~AJLING ADDRESS
PHONE
PHONE
3, LENDING INSTITUTION
MAILING ADDRESS
~ ~AL,TO~/Aa~NT
PHONE
MAILING ADDRESS
I~. "I.'EG'/~L DESCR ~TION
STREET 05 ?ON.,
6, TYPE OF RESIDENCE
~INGLE rAM LY
~ MULTIPLE FAMILY
~ WATER SUPPLY
NUMBER OF BEDROOMS
[] One ~ Four
[] Two [] Five
[] -hree ~] Six
[] Other_
.~" INDIVIDLJAL~
[] COMMUNITY
[] PUBLIC UTILITY
~'. SEWAGE DISPOSAL SYSTEM
.~" 'NDIVIDLJALION-SFr
[] PUBLIC UTI LITY
* ATTACH WELL LOG. A well og is required for all wells drilled
since June 1975. For wells drilled prior t9 that date. qive well
depth (attach ,oc~ if available.) t'~.f}2...~?~.~ ,4~.~j~_ ~ ~.~
* If individual/on-site, give installation date J~ .
If system is over two (2} years old an a~eauacv [esl ~s required
~y tnis Deoartment,
NOTE: THE: INSPECTION FEE MUST ACCOMPANY EACH REQUI=ST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
.... b~,¢E RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE CATE
NSPECTOR INSPECTOR INSPECTOR
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
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or [] Holding Tank
Size: ~,.~ IfTank is homemade: SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Lin~ Nearest Lot Line
Absorption Area to nearest Lot Line
'5. COMMENTS
~--~APP ROV ED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
CHEMICAL 8~ (~EOLOGICAL, LABORATORIF~ OF ALAEKA~ INC.
P.O. BOX 4-1276 ANCHORAGE, ALASKA 99509 484g BUGINESS PABK BLVD.
Drinking Water Analysis Report for Total Coliform ]Bacteria
TO BE COMPLFTED BY WATER SUPPLIER
PUBLIC WATER SYSTEM: ~--I I I I~
I.D. NO.
Pubtic Water System Name
Ma~ltllg Addres~
'~ - io ....
O~y ~
Zip Code
Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no,
~E3>S~ a Purpose
SAMPLE
NO. LOCATION
4 [
[] Treated Water
[] Untreated Water
Time Collected
Collected By
TELEPHONE
(gO7) 2794014
TO BE COMPLETRD BY LABORATORY
LABORATORY:
NAME ,,
: ~ADDRESS~'
CITY
Date Received / //~ ~)/"~
Time Received
Analytical Method:
C) Fermentation Tube
~ Membrane Filter
Lab Fief. No. Result* ,~nalyst
~ FTq
L I :Fq
READ INSTFIUCTIONS
BEFORE
COL. LECTING SAMPLE
Form No. 18-310 (3-78)
O6.1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collected
Oate Received
lOml Tubes PoSitive/Total lOml Portions
